Health Profile for the East of England 2021

Overview

This report is a comprehensive review of health in the East of England region and builds on the findings of the Health Profile for England (HPfE) 2021 (1).

This report includes a set of important health-related topics based on the Health Profile for England. It highlights the universal impact of COVID-19 as well as presenting inequalities between the least and most deprived areas, and variation in health behaviours seen in each region in England. As we move into the post pandemic and recovery phase there are emerging opportunities to sustainably tackle the historical and emerging challenges through the Levelling Up and soon to be published Disparities White Papers. Action will be supported via greater integration between the NHS and social care enabled by the development of Integrated Care Systems.

The data in this report provides evidence of the impact of COVID-19 on life expectancy, increasing risk factors in our population and the impact on the determinants of health which will have an enduring and long-term impact on the health of our population. Healthy life expectancy at birth had started to decrease or level off in most regions before the pandemic. This represents an increasing number of years lived in poor health, resulting in a reduced ability to work, a reduced sense of wellbeing and an increased need to access services. In all regions obesity was the largest risk factor contributing to morbidity. Smoking and diabetes were the second and third largest contributors although their placing varied in different regions.

In many areas we have seen a widening of inequalities between the most and least deprived areas. The harms to health are not uniform, data in this report tells a compelling story about widening health inequalities and variations in health behaviours. There are also areas of improvement, the proportion of mothers smoking at the time of delivery and antibiotic prescribing both continue to decrease.

Taken together, this data confirms that we are now observing the direct and indirect impacts of the COVID-19 pandemic on all parts of society, with many chronic health conditions worsening and most historically disadvantaged areas being further so. This has resulted in greater health need and widening health inequalities in all parts of the nation. The findings reinforce the need for targeted increases of clinical and preventive service recovery programmes with a resolute focus on secondary prevention called for in the NHS Core20Plus5 approach to reducing health inequalities. As we have learned throughout the pandemic the nature and scale of the challenges cannot be met by any single agency. We must harness the full potential of our newly transformed public health and health care systems, guided by the new national strategies and frameworks, working closely with our partners in place, and engaging and mobilising local communities. Ultimately, this data confirms areas for system-wide prioritisation, mobilisation and action.

Key messages in the East of England

• the East of England is currently home to 6.3 million people, with approximately one third living rurally. The region has some of the most affluent localities in the country and the most deprived. The population in the East of England is projected to grow, with over a quarter of residents aged over 65yrs by 2043
• the East of England experienced its largest COVID-19 wave in January 2022. Throughout the pandemic COVID-19 cases, mortality and excess mortality have impacted some populations more than others. The wider impact of the pandemic on public health in the region is predicted to be far reaching; however, for many areas of public health, data is not yet available, or it is too early to evaluate this impact fully
• prior to the COVID-19 pandemic (1981-2020) there was a slowing in life expectancy improvement. From 2019-2020 there was a decrease in life expectancy and an increase in all age and premature (<75yr) mortality and for both males and females. The life expectancy gap between those living in the most and least deprived areas for males has increased, with heart disease being the largest contributing condition
• before the pandemic, childhood obesity continued to increase with one in five children aged 4-5yrs and one in three of Year 6 students classified as overweight or obese.
• before the pandemic healthy life expectancy had started to decrease for both male and females in the East of England. The most common contributing conditions included lower back pain, type 2 diabetes, depressive disorders, and headache disorders
• the proportion of people in the East of England who reported that they smoked had decreased to 13.7% before the pandemic. This proportion is significantly higher for those from manual occupations or those with mental health conditions. Smoking was also the leading behavioural risk factor contributing to morbidity in the region
• employment in the East of England rose between 2011/12 to 2018/19; however, it decreased during the pandemic. The gap in males and females in employment in the East of England is now wider than it is nationally
• child poverty in East of England local authorities ranged from 16-39% before the pandemic, while 72% of reception aged children had reached a good level of development

Introduction

This profile brings together data and knowledge to give a broad picture of health in the East of England. The report provides a regional view of health and indicators presented in the Health Profile for England 2021 (1), first produced by Public Health England (PHE) in 2017.

As the first edition of the Health Profile for East of England region, the report includes public health intelligence about prevalence, regional trends, local authority comparisons, and health inequalities. The interactive charts and interpretation are grouped into the following sections:

• overview of the population of the region

• COVID-19

• mortality and life expectancy

• child health

• adult health

• risk factors associated with ill health

• the wider determinants of health

• health protection issues

Summary points are included at the beginning of each section, followed by detailed analysis and charts.

The data and evidence in the report are provided to support policy makers and practitioners, to inform health improvement activities and support a reduction in health inequalities.

Supporting information

Charts in this report follow a standard format, with 3 sections for each topic area:

Headline - overall data for the key indicator used in East of England, usually as a trend over several years. Regions are defined as Government Office Regions (GORs). Where this isn’t possible other geographical region definitions are used as indicated in the supporting information.

Inequalities - how the indicator varies between different groups in East of England, by protected characteristics such as age, sex and ethnicity or categories of socioeconomic deprivation where possible. Some inequalities information presented at national level in the Health Profile for England 2021 is not available at regional and sub-regional level.

Sub-regional comparison - headline information on the indicator variation is presented at the Upper Tier Local Authority (UTLA) level. UTLAs affiliated with the government region are shown unless stated otherwise. UTLA codes and boundaries are subject to change pending the data released.

It is not always possible to use the same indicator for the headline, inequalities and sub-regional comparisons within each topic area.

This report builds on the methodology used in the Health Profile for England 2021, with minor amendments to enable regional and sub-regional comparisons, and to account for methodological changes that have occurred since the publication of the Health Profile for England 2021. Further information on methods, data and definitions is available here. Of note, the health profile of the East of England is based on Government Office Regions - as such Milton Keynes is excluded unless otherwise specified.

Data may have been updated and available in the charts below, therefore the information in the text may be subsequently out of date.

Overview of the population of East of England

The East of England is home to 6.3 million people(2). The population is forecast to grow by 8.7% (548k) over the next two decades. Much of the projected growth will be in older age groups. By 2043, 25.6% of the East of England population are projected to be aged over 65 years (3).

The East of England is a diverse region where one person in three lives in a predominantly rural community (4). Among those aged 65 years and over, this rises nearer to one person in two (4). At the time of the 2011 Census, the largest ethnic groups in the region were recorded to be White British (82.6%), White Other (4.5%), Indian (1.5%), Black African (1.2%) and Pakistani (1.1%) - with other minority ethnic groups each making up 1% or less of the total population (5). The proportion of the local population from ethnic minorities (including white minorities) varied from 3.4% in parts of Norfolk to 55.4% in Luton (5). In 2019, the East of England overall had the third highest GDP per capita in England, after London and the South East (7). Within the region, there is significant variation in economic prosperity and deprivation. The region is home to the locality classified as having the highest level of deprivation in England and also localities classified among the least deprived (8). The region has a number of deprived coastal communities with poor health outcomes (9). The challenges faced by those living in deprived coastal communities were highlighted in the Chief Medical Officer 2021 annual report (10).

Overview of the East of England region. (A) NHS STPs (coloured regions) and CCGs (green borders, labelled) within the Government Office Region (burgundy border). (B) National IMD quintile of LSOAs within the East of England. Source: Index of Multiple Deprivation 2015-2019 dashboard(6). Note Some areas within the East of England PHE centre (2019) and sub-regional NHS geographies sit outside of the Government Office Region used in this report.

COVID-19

Overview

This section examines the direct impact of the COVID-19 pandemic on health with analysis of COVID-19 cases, vaccination rates, death rates involving COVID-19 and excess deaths during the pandemic up until 31st December 2021.

COVID-19 cases

In the East of England at the end of December 2021, 1,237,572 confirmed cases of COVID-19 had been reported (11). The region’s highest 7-day average case rate, based on reported positive COVID tests, occurred in December 2021 at 1815.4 cases per 100,000 population that week - over twice the peak observed in January 2021. This late 2021 spike peaked in January 2022 (11). Variations in case rates are influenced by both variations in uptake and reporting of testing in addition to changes in the spread of infections.

Figure 1b shows COVID-19 has had a greater impact on some groups than others. During the period March 2020 to December 2021 the cumulative age-standardised COVID-19 case rates in the East of England were:

• higher in females than males at 20,089 per 100,000 population compared to 18,450 per 100,000
• highest in people aged 25-49 years at 24,303 per 100,000 population
• lowest in the White ethnic population at 18,627 per 100,000 population
• lowest in least densely population areas
  
• higher in the least deprived decile (Figure 1b)
• the local authorities with the highest cumulative rates over this period were Thurrock, Luton, and Southend-on-Sea, shown in figure 1c

Health Profile for England 2021 headlines

England had experienced 2 main waves of cases by the end of June 2021 (11). The first wave took place in spring 2020 and the second from autumn 2020 to spring 2021. The timing of the second wave varied throughout the country and cases in regions in the north of England were relatively high in October and November 2020, while in regions in the south of England case rates increased later in December 2020 and January 2021 (11).

Figure 1 - COVID-19 cases

Figure 1a - Trends

Source: UKHSA COVID-19 dashboard Date accessed: 02/03/2022 Note: Source data are updated daily and historic data may be revised. Download data

Figure 1b - Inequalities

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Figure 1c - Local Authority

Source: UKHSA COVID-19 dashboard Date accessed: 23/02/2022 Note: Source data are updated daily and historic data may be revised. Download data

Deaths involving COVID-19

By the end of December 2021, there were 16,991 deaths registered for people from the East of England where COVID-19 was mentioned on the death certificate. This equates to an age-standardised rate of 257 deaths per 100,000 population (12). The region’s highest 7-day average number of deaths was reported in January 2021 with 189 deaths (11).

Figure 2b shows that there are wide inequalities in death rates involving COVID-19. The cumulative age-standardised mortality rates in the region were:

• 1.7 times higher in males (330 per 100,000 population) compared with females (200 per 100,000 population)
• highest in people aged over 85 (4,147 per 100,000 population)
• 2.1 times higher among those living in the most deprived localities in the region (409 per 100,000 population) compared with those living in the least deprived localities
• higher in Asian / Asian British, Black / Black British, Mixed / Multiple and Other ethnic groups (relative to those from White ethnic populations
• higher in more densely populated areas
• highest in Thurrock and Luton where cumulative age-standardised deaths rates to the end of December 2021 were 444 per 100,000 and 442 per 100,000 respectively. Figure 2c shows those rates were 2.6 times higher than that observed in the local authority with the lowest COVID-19 death rate for this period, Cambridgeshire

Health Profile for England 2021 headlines

Inequalities in death rates from COVID-19 largely reflect inequalities in COVID-19 case rates. However, they are also influenced by differences in survival following COVID-19 infection. During the first wave of the pandemic in England, people aged over 80 years were 70 times more likely to die from COVID-19 once infected, compared with those aged under 40 years (77). Survival was higher in females than males, and after controlling for age, deprivation and pre-existing health conditions, survival among many ethnic minority groups remained lower than the White group. The Bangladeshi ethnic group had the poorest survival and had 1.88 times the odds of dying once diagnosed than the White ethnic group. The Pakistani, Chinese, and Black Other ethnic groups had 1.35 to 1.45 times the odds of dying once diagnosed and the Indian group 1.16 (78). The possible reasons for these differences and further interpretation of ethnic inequalities in COVID-19 mortality rates are discussed in depth elsewhere (45, 46).

Figure 2 – COVID-19 deaths

Figure 2a - Trends

Source: UKHSA COVID-19 dashboard Date accessed: 02/03/2022 Note: Source data are updated daily and historic data may be revised. Download data

Figure 2b - Inequalities

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Figure 2c - Local Authority

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Excess mortality during the COVID-19 pandemic

Excess mortality is an estimation of the number of additional deaths that occur as a result of an event or health crisis. It compares the number of deaths from all causes (the all cause mortality) in a given time period, with what would be expected to have occurred in the absence of the event or health crisis. Consequently, in this case, it captures deaths caused both directly by COVID-19 and indirectly from other causes related to COVID-19. Figure 3a shows the weekly number of excess deaths in the East of England between 27 March 2020 and 31 December 2021. Overall, during this period, the cumulative all cause deaths were 1.09 times higher than expected in the region as a whole, totalling 10,190 excess deaths (13).

Figure 3b shows inequalities in excess mortality within the region:

• for females, excess deaths were observed in all age groups. This is in contrast to most other regions where deaths in females under 24 were lower than expected. For males aged under 24 there were fewer deaths than expected, with increases observed in all other age groups
• no clear pattern was observed between deprivation quintile and number of excess deaths
• for both males and females, excess deaths were highest in those from Mixed ethnic groups
• highest levels of excess deaths were seen in Thurrock, Luton, Bedford and Central Bedfordshire. Excess mortality over time for each local authority can be found on the OHID excess mortality tool
• the East of England saw a shift in the location of deaths away from hospices, and a large increase in the number of deaths at home

Health Profile for England 2021 headlines

Across England overall, there was an association between deprivation and excess mortality, with a ratio of 1.17 in the most deprived areas and 1.13 in the least deprived areas (1). As with the regional figures, this takes existing inequality in mortality by deprivation into account, so this greater excess mortality in deprived areas is an indication that COVID-19 has exacerbated existing inequalities by deprivation. Further analysis has shown that among Black and Asian groups excess mortality in those aged under 75 did not vary by deprivation and was high across all deprivation groups. This indicates that the excess mortality in those aged under 75 in the Black and Asian groups cannot be explained by deprivation and other factors play a role (79).

Figure 3 – Excess deaths

Figure 3a - Trends

Source: OHID Excess mortality in England dashboard Date accessed: 07/02/2022 Download data

Figure 3b - Inequalities & UTLA

Source: OHID Excess mortality in English regions dashboard Date accessed: 07/02/2022 Download data

COVID-19 vaccinations

In the East of England region, by the end of December 2021, of those over 12 years old, 82.4% (4,832,380 people) had received 1 dose, 76.5% (4,484,444 people) had received 2 doses and 57.3% (3,356,790 people) had received 3 doses (11). Figure 4b shows that there have been significant variations in adult uptake of the first 2 doses up to 31 December 2021 (under 18s not present in data):

• higher among people born in the UK (89%) compared with those non-UK born (79%)
• higher among people whose main language is English (89%) compared with people whose main language is not English (72%)
• higher among females (90%) compared with males (87%)
• at 92% among people with a disability that slightly limited day-to-day activities and 90% among people with a disability that limited day-to-day activities a lot
• lowest in areas with high levels of multiple deprivation, with 82% of people in the most deprived areas in the region having had two doses compared with 92% of people in the least deprived areas
  
• lowest in people identifying as Black Caribbean (65%) and highest in those identifying as White British (90%)
• highest among homeowners at 92%
• highest among people identifying as Jewish at 93% and lowest among people identifying as Muslim at 75%
• 87% among urban populations compared to 92% among rural
• highest in those in higher managerial and professional occupations (93%) and lowest in those that had never worked or were long-term unemployed (72%)

Figure 4c shows that at the local authorities level, by the end of December 2021, uptake of two COVID-19 vaccinations was recorded at 60% in Luton, 63% in Peterborough and 68% in Thurrock. Highest levels of uptake were recorded in Norfolk and Suffolk both at 81%.

Figure 4 – COVID-19 Vaccinations

Figure 4a - Trends

Source: UKHSA COVID-19 dashboard Date accessed: 02/03/2022 Note: Source data are updated daily and historic data may be revised. Download data

Figure 4b - Inequalities

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Figure 4c - Local Authority

Source: UKHSA COVID-19 dashboard Date accessed: 02/03/2022 Note: Source data are updated daily and historic data may be revised. Download data

Mortality and life expectancy

Life expectancy

Figure 5a shows trends in life expectancy at birth for each year from 1981 to 2020. For much of the decade prior to the pandemic, the East of England had mirrored national trends with a slowing in improvements in life expectancy year on year. From 2019 to 2020, life expectancy fell from 80.7 to 79.6 years for males and from 84.1 to 83.5 years for females.

The slope index of inequality (SII) is a measure of the social gradient in an indicator and shows how much the indicator varies with deprivation (Figure 5b). It takes account of inequalities across the whole range of deprivation within England and summarises this into a single number. The measure assumes a linear relationship between the indicator and deprivation (12). The higher the value of the SII, the greater the inequality within an area.

• the inequality gap widened in life expectancy for males from 2019 to 2020 from 7.5 to 8.1 years
• over the same period, the gap for life expectancy in females showed no change at 6.3 years

At local authority level in 2020, life expectancy for females was lowest in Luton at 81.4 years and highest in Suffolk at 83.9 years. Life expectancy for males was lowest in Thurrock at 75.9 years and highest in Central Bedfordshire at 80.7 years (Figure 5c).

Figure 5 – Life expectancy

Figure 5a - Trends

Source: OHID Public Health Outcomes Framework Date accessed: 10/06/2022 Download data

Figure 5b - Inequalities

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 02/03/2022 Note: SII = Slope Index of Inequality. See data and definitions document for more details. Download data

Figure 5c - Local Authority

Source: OHID public health profiles Date accessed: 02/03/2022 Download data

Breakdown of trends in life expectancy by age or cause of death

This section examines which age groups and causes of death have contributed to the trend in life expectancy or inequalities in life expectancy presented earlier. Figure 6a shows a breakdown of the change in life expectancy by year in the East of England between 2017 and 2020 according to age group or cause of death. A positive value for a cause of death or age group means that reductions in the mortality rate in that group acted to increase life expectancy. A negative value means that an increase in the mortality rate in that group acted to decrease life expectancy.

In Figure 6a, between 2018 and 2019, most causes of death show positive values, similar to England overall. This means that death rates from these causes reduced, contributing to an increase in life expectancy. Between 2019 and 2020, mortality from COVID-19 contributed to a reduction of 1.1 years for males and 0.8 for females.

In terms of inequalities, Figure 6b shows the contribution of either age or cause to the gap in life expectancy between the most and least deprived and how this has changed over the pandemic:

For males:

• in 2020, the 70-79 age group contributed the largest number of years to the difference between the most and least deprived groups at 2.1 years
• there has been an increase in the contribution to the gap in life expectancy in 01-09 and 30-89 age groups in 2020 compared to 2019
• COVID-19 contributed 0.8 years to the difference in life expectancy between the most and least deprived groups
• heart disease was the largest cause of the difference in life expectancy between the most and least deprived groups at 1.3 years. This has increased over the course of the pandemic

For females:

• in 2020, the 70-79 age group contributed the largest number of years to the difference between the most and least deprived groups at 1.8 years
• there has been an increase in the contribution to the gap in life expectancy in 40-49, 70-79, 90+ age groups in 2020 compared to 2019
• deaths where COVID-19 was mentioned contributed 0.6 years to the difference in life expectancy between the most and least deprived groups
• heart disease, other circulatory conditions and chronic lower respiratory disease were the next largest single causes of the difference in life expectancy between the most and least deprived groups at 0.6 and 0.8 years

Addressing inequalities in these diseases would have a substantial impact on reducing inequalities in life expectancy.

Figure 6 – Breakdown of trends and inequalities in life expectancy

Figure 6a

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Figure 6b - Inequalities

Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data

Trends in mortality and leading causes of death

Figure 7a shows trends in age-standardised mortality rates at all ages and aged under 75 for people in the East of England region from 2001 to 2020:

For males:

• the all-age mortality rate increased from 1,018.9 per 100,000 population in 2019 to 1,144.4 in 2020
• the under 75s mortality rate increased from 352.8 per 100,000 in 2019 to 394.2 in 2020
• in 2020 the leading cause of death for all ages was COVID-19. In those over 80 was dementia and Alzheimer’s. In those aged 35 to 79 the leading cause of death was heart disease. In the youngest age group, 20-34, suicide and injury was the leading cause of death (Figure 8a)

For females:

• the all-age mortality rate increased from 761.9 per 100,000 in 2019 to 826 in 2020
• the under 75s mortality rate increased from 234.7 per 100,000 in 2019 to 244.1 in 2020
• in 2020, the leading cause of death for all ages and those over 80 was dementia and Alzheimer’s. In those aged 65-79, it was lung cancer. From 35 to 64 the leading cause was breast cancer. In the youngest age groups, 20-34, suicide and injury was the leading cause of death (Figure 8a)

By deprivation:

• the under 75s mortality rate is strongly linked to deprivation decile with the rate in the most deprived decile 3.5 times higher than the least deprived decile (Figure 7b)
• between 2020 and 2021, the largest increases in mortality were seen in the most deprived deciles in the region although none of the year on year changes were statistically significant (Figure 7b)
• deaths by cause and deprivation decile are shown in Figure 8b. Deaths where COVID-19 was mentioned anywhere on the death certificate are excluded. Further details are available from the OHID Wider Impacts of COVID-19 tool

By local authority (Figure 7c):

• for females, no local authority in the East of England recorded a significant change in under 75 all cause mortality between 2019 and 2020
• for males, significant increases in under 75 all cause mortality were recorded in Thurrock and Luton

Figure 7 – All cause mortality

Figure 7a - Trends

Source: Office for National Statistics: Nomis Date accessed: 02/03/2022, OHID analysis of Office for National Statistics data Date accessed: 02/03/2022 Note: Nomis data used from 2013 onwards; PHE analysis used for 2001 to 2012. Download data

Figure 7b - Inequalities

Source: OHID analysis of Office for National Statistics mortality and population data Date accessed: 02/03/2022 Download data

Figure 7c - Local Authority

Source: Office for National Statistics: Nomis Date accessed: 02/03/2022, OHID analysis of Office for National Statistics data Date accessed: 02/03/2022 Note: Nomis data used from 2013 onwards; PHE analysis used for 2001 to 2012. Download data

Figure 8 – Leading causes of death

Figure 8a

Females

Males

Source: Office for National Statistics Nomis Note: Age groups should be compared with caution as there are many more deaths in older age groups than in younger age groups. Download data

Figure 8b - Inequalities

Source: OHID Wider Impacts of COVID-19 on Health (WICH) tool Date accessed: 07/02/2022 Download data

Figure 8c - Local Authority

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020. Date accessed: 18/08/2022 Download data

Child health

Overview

Every child having a good start in life is the foundation for the future health and wellbeing of England’s population. This section presents some key indicators of child health: birthweight, infant mortality, early child development and child obesity. The data includes the pre-pandemic period and 2020/21, where available.

Low birthweight

Low birthweight (less than 2500 grams) is measured as a proportion of all live births (excludes still births). Figure 9a shows that between 2006 and 2020, the proportion of babies born at full term with a low birthweight showed a fluctuating but largely stable year on year trend. Through this period, the proportion of babies born at full term with a low birthweight in the East of England has been lower than the England proportion. Figure 9b shows that in 2020, among local authorities in the region, the highest proportion of low birthweight babies was in Luton at 4.7% followed by Peterborough at 3.5%.

Health Profile for England 2021 headlines

In England, the last two decades have seen overall improvements in babies born with a low birthweight, infant deaths and child development. However, in the years leading up to the coronavirus pandemic improvements slowed down (37).

Figure 9 – Low birthweight

Figure 9a - Trends

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Figure 9b - Local Authority

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Infant mortality

Infant mortality covers all deaths within the first year of life. The majority of these are neonatal deaths which occur during the first month and the main cause is related to prematurity and preterm birth, followed closely by congenital anomalies (74). Figure 10a presents trends in infant mortality rates from 2001 to 2003 until 2018 to 2020. They are presented on a three-year rolling average basis to smooth out variation.

• although there was some fluctuation in the underlying trend, overall the rate of infant mortality in the East of England decreased from 4.5 deaths per 1000 live births in 2001-03 to 3.4 per 1000 in 2013-2015. Between 2013-15 and 2018-2020, the infant mortality rate has shown relatively little change and was again 3.4 per 100 live births in 2018-20
• in 2018-2020, Luton had the highest rates of infant mortality while no local authorities had infant mortality rates that were statistically better than the East of England rate (Figure 10b)

Figure 10 – Infant mortality

Figure 10a - Trends

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Figure 10b - Local Authority

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Child development

Starting primary school is a significant milestone in a child’s educational journey. Language and communication skills are fundamental to young people’s potential development and achievements later in life (14). Being able to express themselves, interact with peers and make themselves understood helps to build a child’s confidence and boost their self-esteem (15). Inadequate communication skills can lead to poorer adult outcomes in literacy, mental health and employment (16).

In the academic year 2018/19, 82.7% of children achieved at least the expected level of development in communication and language skills at the end of Reception year, an improvement since 2012 (17).

Inequalities

Figure 11b shows:

• Fewer boys than girls achieved the expected level of development, 65.9% compared with 79% in 2018/19 (Figure 11a)
• Among UTLAs, the proportion of children achieving the expected level of development in 2018/19 ranged from 67% in Peterborough to 72% in Essex

COVID-19 impact on child development

Due to the pandemic, data on child development at the end of Reception year was not reported for the academic year September 2019 to July 2020. In March 2020, Early years settings were closed to most children, with only children from key workers and vulnerable families eligible to attend (around 7% of children aged 2 to 4), although not all eligible children attended (18).

The full impact of the pandemic on Early Years development may not be known for some time; however, recent research suggests that a lack of social activities and interactions that would normally have helped to prepare children for the start of school may have impacted school readiness. For example, the Education Endowment Foundation (EEF) found that out of the schools surveyed, 76% reported that children who started school in the Autumn 2020 term needed more support than children in previous cohorts. Almost all schools indicated that they were concerned about pupils’ communication and language development (96%), personal, social and emotional development (91%) and levels of literacy (89%) (19). How these short and longer term impacts will vary across the region and impact existing inequalities is unclear. Preliminary reports suggest that without corrective action recent progress made in reducing inequalities in educational attainment will be lost (20, 21).

Figure 11 – Child development

Figure 11a - Trends

Source: OHID Child and Maternal Health Profile Date accessed: 31/03/2022 Download data

Figure 11b - Local Authority

Source: OHID Child and Maternal Health Profile Date accessed: 31/03/2022 Download data

Childhood obesity

Obesity in childhood can result in the early onset of cardiometabolic, respiratory and musculoskeletal conditions, as well as adverse psycho-social outcomes and an increased risk of living with obesity and associated mortality and morbidity later in life (22). Reducing the rates of childhood obesity presents a significant public health challenge.

In the academic year 2019 to 2020, data from the National Child Measurement Programme (NCMP) showed that 9% of children aged 4 to 5 (Reception year) in the region were obese and 21.8% were overweight or obese (23). This increases to 19.1% of children aged 10 to 11 years (Year 6) being obese, up from 16.9% in 2009 to 2010. 32.7% of children in Year 6 were reported to be overweight or obese (23). COVID-19 disruption to schools heavily impacted the NCMP, particularly at lower level geographies where observed differences may be due to differences in measurement rather than actual differences in child obesity.

Inequalities

Figure 12 shows:

• in Reception and Year 6, children in the most deprived areas were more than twice as likely as children in the least deprived to be obese
• in Reception and Year 6, levels of obesity are higher among boys than girls
• among local authorities in 2019/20, levels of obesity among children in Reception year ranged from 7% in Cambridgeshire to 9% in Luton and Peterborough. Among Year 6 children, levels of obesity were again lowest in Cambridgeshire (15%) and highest in Luton (27%)

COVID-19 impact on child obesity and physical activity

The latest findings from the National Child Measurement Programme (NCMP) suggest that obesity has increased across all regions in both Reception age children and children in Year 6 (24). A link between weight gain and out of school time in the school holidays has previously been demonstrated (25). Closure of schools, sporting and leisure facilities, park facilities and recreational areas, together with an increase in screen time over the pandemic period may have led to a reduction in physical activity in children and young people (26).

A recent Sport England survey estimates that physical activity has dropped relative to pre-pandemic levels with an estimated 94,000 fewer active children and young adults nationwide (27). White children and children from the least deprived families were most likely to be active (27).

The East of England was the only region to report a statistically significant decrease in the number of active children in 2020/21 relative to 2017/18 (-2.2%) and has the second lowest rate of active children (43.2%) (27). Within the region, Thurrock had the lowest rates of active children (36.8%) and the highest rates of inactivity with 48.2% of children having less than 30 minutes of physical activity a day, whilst North Hertfordshire and East Hertfordshire had the lowest rate of inactivity (22.3%) and highest rate of active children (52.9%) respectively. Watford saw the biggest increase in physical inactivity levels relative to 2017/18 with 15% more children being inactive (27).

Figure 12 – Child obesity

Figure 12a - Trends

Source: OHID Child and Maternal Health Profile Date accessed: 31/03/2022 Download data

Figure 12b - Local Authority

Source: OHID Child and Maternal Health Profile Date accessed: 31/03/2022 Download data

Other indicators of child health

Smoking, drinking and drug use

In 2018, 5% of girls and 3% of boys aged 11-15 reported currently smoking in the East of England, the combined rate of 4% is slightly below the national figure of 5% (33). Prior to the pandemic, in England smoking among teenagers had been reducing (from 19% to 5% between 2000 and 2018), while drug use had increased from 2016 to 2018 (33). The East of England had the lowest rates of pupils trying drugs (21% relative to the national rate of 24%), with 15% having taken drugs within the year (33). Alcoholic drinking rates were similar to the national picture with 9% of pupils within the East of England reporting drinking within the last week relative to 10% nationally (33).

Mental health and wellbeing

One national survey comparing aspects of mental health found that in 2020 one in six (16.0%) children aged 5 to 16 years were identified as having a probable mental disorder, increasing from one in nine (10.8%) in 2017 (34,35). In 2021, 39.2% of children (6-16 years old) and 52.5% of young adults (17-23 years old) reported experiencing mental health deterioration since 2017, whilst 21.8% and 15.2% experienced improvement, respectively. Those with a probable mental health disorder were more likely to say lockdown had made their life worse and to struggle with sleep. Sleep difficulties were lower but still high in those unlikely to have a mental disorder with over 25% of children and over 50% of young adults reporting sleep difficulties in 3+ nights of the last 7 days (34,35).

It is highly probable that the pandemic may have had a profound effect on the life of children and young people, not least through isolation and interruptions to education among many other factors. However, data is not yet available, or it may be too early to assess the longer-term impact of these factors on the mental health of children and young people.

Hospital admissions for injury

Data on hospital admissions for injury among children aged 0-14 years for 2010/11 to 2020/21 are shown in Figure 13. Over this period, the rate of admission among children in the East of England is consistently lower than the England rate. Central Bedfordshire, Hertfordshire, Norfolk and Suffolk all have rates above the East of England rate.

Hospital admissions for self-harm in ages 10-24 in 2020/21 data in the East of England region (374.7 per 100,000) were significantly lower than the England value (31). Peterborough and Suffolk have the highest levels of self-harm in this age group in the East of England (607.6 and 546.2 per 100,000) whilst Thurrock and Luton have the lowest levels (277.7 and 277.8 per 100,000) (32).

Pregnancy

Figure 14 shows that in the East of England, the proportion of people reporting that they were smokers at the time of delivery has decreased from 13.4% in 2010/11 to 9.0% in 2020/21. There is variation in smoking rates during pregnancy within the region, ranging from 5.8% in Central Bedfordshire in 2020/21 to 13.4% in Norfolk. Inequalities in risk factors during pregnancy have been observed nationally:

• in 2018 to 2019 obesity levels in early pregnancy in deprived areas (28.5%) were almost double the least deprived (15.1%) (29)
• smoking in early pregnancy in deprived areas (24.0%) was more than 5 times that of the least deprived (4.3%) in 2018/19
• smoking at the time of delivery remained higher in deprived areas nationally (11.7% in the most deprived compared with 7.2% in the least deprived) (30)

In 2019, in the East of England, the under 18s teenage conception rate was continuing to decline at 13.9 per 1,000. However, nationally the rate in the most deprived areas (20.6 per 1,000) was more than double the least deprived (8.3 per 1,000) (31).

Previous reports, prior to the pandemic, demonstrated nationwide inequalities in many other aspects of children’s health (28).

Health Profile for England 2021 headlines

Wide inequalities are apparent across all indicators of child health presented (1, 37). In 2019, in the most deprived areas, the proportion of term babies with a low birthweight, the infant mortality rate and the prevalence of obesity in children aged 4 to 5 and 10 to 11 years was more than double the least deprived. In 2018 to 2019, 23.4% of children aged 5 years had dental decay, and the prevalence was almost 4 times higher in most deprived areas than in the least deprived areas. For those indicators with data available by ethnicity (low birthweight, infant deaths, dental decay, obesity) inequalities by ethnic group are present (86, 37).

Preliminary data that covers some of the pandemic period suggests that the proportion of babies born with low birthweight and the infant mortality rate has not changed significantly since the start of the pandemic (37). Comparable data on child obesity or child development are not available for the pandemic period, but there is evidence of a reduction in physical activity and that children who started school in Autumn 2020 needed additional developmental support compared with children in previous years. The hospital admission rate for extraction of teeth due to dental decay in children reduced in 2020 and in children up to the age of 5 was half that seen in previous years (97). This may indicate that more children are living with severe dental decay as a result.

Figure 13 – Injuries resulting in hospitalisation

Figure 13a - Trends

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Figure 13b - Local Authority

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Figure 14 – Smoking in pregnancy

Figure 14a - Trends

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Figure 14b - Local Authority

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Health in adults

Overview

Good health is vital to maintaining quality of life in adults and has wide ranging benefits.

Figure 15 shows variation in healthy life expectancy:

• for females, healthy life expectancy has decreased by 1.9 years between 2010-12 to 2017-19. Over the same period, the average number of years of life lived in poor health has increased from 17.4 years to 19.7 years
• for males, healthy life expectancy has decreased by 0.3 years between 2010-12 to 2017-19. Over the same period, the average number of years of life lived in poor health has increased from 15.3 years to 16.1 years

Factors contributing to morbidity in the East of England are lower back pain, depressive disorders, type 2 diabetes and headache disorders. Self-reported adult mental health scores have increased with people reporting higher anxiety, lower self-worth, increased low happiness and increased low satisfaction.

Suicide and self-harm vary greatly across local authorities in the East of England region. The suicide rate for the East of England is above the national rate.

Figure 15 – Healthy life expectancy

Figure 15a - Trends

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Leading causes of morbidity

The Global Burden of Disease GBD, uses years lived with disability (YLDs) to attribute the burden of morbidity. YLDs is a measure of morbidity that combines the prevalence of each disease with a rating of the severity of its symptoms (excluding death itself), to give an overall measure of the loss of quality of life. Figure 16a identifies the most common causes of morbidity in 2019 according to GBD, as measured by age-standardised YLDs per 100,000 population. It also shows the change in YLDs since 1990. Change over time needs to be interpreted with caution as this may reflect changes in methodology and categorisation. Overall, the top three leading causes of morbidity in the region in 2019 were low back pain, depressive disorders, and headache disorders.

• for men, the top 3 were low back pain at 942.7 years lived in disability per 100,000 population, type 2 diabetes at 676.0 years and depressive disorders at 614.7 years
• for women, the top 3 were low back pain at 1,274.3 years lived in disability per 100,000 population, headache disorders at 935.4 years and depressive disorders at 832.0 years
• type 2 diabetes showed the largest change over time for both sexes. At 676.0 years lived in disability per 100,000 population up from 273.8 per 100,000 in 1990 from males and to 512.4 years lived in disability per 100,000 population up from 225.8 per 100,000 in 1990 for females

At local authority level, the largest variation is estimated to be in morbidity due to type 2 diabetes which ranged from 446 YLD per 100,000 population in Suffolk to 733 YLD per 100,000 in Peterborough (Figure 16b).

Figure 16 – Leading causes of morbidity

Figure 16a

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020. Download data

Figure 16b - Local Authority

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020. Download data

Mental health and wellbeing

According to the GBD in 2019, mental health conditions, such as depression and anxiety, accounted for 7.3% of total morbidity in the East of England region (36).

Figure 17a shows trends in wellbeing up to 2020/21, measured by four indicators, anxiety, low happiness, low life satisfaction and low worthwhile feelings. In the East of England in 2020/21:

• 23% of the population reported feeling anxious
• 9% of the population reported feeling low happiness
• 5.3% of the population reported feeling low satisfaction
• 4.2% of the population reported feeling low worthwhile

Figure 17 – Mental health and wellbeing

Figure 17a - Trends

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Figure 17b - Local Authority

Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data

Figure 18a illustrates that the rate of hospital admission for self-harm in the East of England has shown a slight upward trend over the last decade and in 2021/21 was 162.8 per 100,000 population. Figure 18b shows that rates in the East of England have been consistently lower than the England rate and are consistently higher among females than males. The highest rate of admission in 2018/20 is seen in Cambridgeshire with the lowest rate in Hertfordshire.

Figure 18a also shows that the rate of suicide in the East of England has increased from 8.9 per 100,000 population in 2010-12 to 10.8 per 100,000 in 2018-20. At local authority level in 2018-20, rates of suicide were higher among males than females. Rates of admission are generally higher for females compared to males for self-harm, whereas suicide follows the opposite trend. At local authority level, Cambridgeshire has the highest rate of emergency hospital admission for self-harm at 244 per 100,000 and Southend-on-Sea the highest rate of suicide at 13 per 100,000.

Figure 18 – Suicide and Self-harm

Figure 18a - Trends

Source: OHID Public health profiles , Suicide Prevention Profile Date accessed: 31/03/2022 Download data

Figure 18b - Local Authority

Source: OHID Public health profiles , Suicide Prevention Profile Date accessed: 31/03/2022 Download data

Health service contact during the pandemic

Data on admissions to hospital during the pandemic for causes other than COVID-19 may help to understand the potential broader impacts of the pandemic on future health. A range of measures relating to use of health care services through the pandemic period can be found in the OHID Wider Impacts of COVID-19 tool. This shows that emergency admissions to hospital in the East of England were lower in 2020 compared to 2019 and reached the largest fall seen in April 2020. By April 2021 emergency admissions were similar to the 2019 pre-pandemic period. Elective admissions in 2020 also fell compared with 2019. Rates of admission showed a steady increase throughout the first part of 2021 (37).

Health Profile for England 2021 headlines

The reduced admissions, GP consultations, A&E attendances and health seeking behaviour observed during this period (37) may be a factor in the increase in deaths at home presented earlier. They may also represent missed opportunities to provide secondary prevention treatment to patients, such as blood pressure and cholesterol control, and may also result in an increase in long-term health complications.

Dementia and Alzheimer’s disease

As presented earlier in the report, dementia and Alzheimer’s disease is a leading cause of death, and despite not featuring in the leading YLDs, dementia is a significant cause of ill health in the East of England region. Emergency admissions for dementia and Alzheimer’s disease reduced across all regions in England when comparing 2021 to 2019. The East of England region had a reduction of 17.1% compared to the 2019 baseline, above the England rate (-15.7%)(37).

Cancer

The total number of new cancer diagnoses in April and May 2020 was around a third lower than the previous months of 2019. A decrease in new cancer diagnoses was observed for breast, prostate, colorectal and lung cancers as shown in Figure 19a. This data is from the East of England - North and East of England - South cancer alliance 2020 boundaries which deviate from the Government Office Region boundary. Further regional breakdowns by ethnicity and IMD are available here.

Figure 19 – Cancer incidence

Figure 19a - Trends

Source: National Cancer Registration & Analysis Service Date accessed: 07/02/2022 Note: Data based on Cancer Alliance 2020 geographies. See data and definitions document for more details on mapping alliances to Government Office Regions. Download data

Risk factors associated with ill health

Overview

Risk factors play an important role in determining whether a person becomes ill, at what age, and the associated effect on quality of life. The Global Burden of Disease (GBD) divides risk factors into 3 main groups: behavioural, metabolic, and environmental & occupational. These are underpinned by the broader social and economic risk and protective factors that shape people’s lives such as education, income, work and social capital. The next section of this report presents these wider determinants and examines the contribution that these risk factors make to morbidity and mortality, using GBD data. Trends and inequalities in some of the risk factors making the largest contribution are examined.

The prevalence of risk factors contributing to ill health in the East of England varies across local authorities. In the East of England overall, the proportion of adults who smoke has decreased and was estimated to be 13.7% in 2019, In the same year, 23.1% of adults reported that they drank more than 14 units of alcohol per week, 67.3% of adults were physically active completing 150 minutes of activity each week, 62.3% of adults were overweight or obese, and 56.7% ate the recommended five-a-day of fruit and vegetables.

Health Profile for England 2021 headlines

The prevalence of ‘increasing and higher risk’ drinkers went up in April 2020 and remained above pre-pandemic levels until June 2021 (39). There has also been a reduction in physical activity levels, particularly in Black and Asian groups and lower socioeconomic groups (88, 89). There has been an increase in the number of people trying to quit smoking during the pandemic with over a third of smokers attempting to quit in the 3 months up to June 2021. Data on the impact of the pandemic on adult obesity is not yet available (37).

Leading risk factors

Figure 21a shows trends in smoking prevalence, obesity and hypertension (high blood pressure). Within the East of England:

• tobacco and alcohol use were the behavioural risk factors contributing the most to morbidity in the region (Figure 20a) whilst tobacco and diet were the behavioural risk factors making the biggest contribution to mortality in the East of England region (Figure 20b)
  
• high blood pressure and high blood glucose were the risk factors that contributed most to mortality in the region (Figure 20b). High body mass index and high fasting plasma glucose made the largest contribution to morbidity in the region (Figure 20a). Although calculated independently, these risk factors are connected and individuals often have more than one risk factor influencing their health and wellbeing
• tobacco use is an important risk factor contributing to cardiovascular disease (e.g. heart and circulatory conditions), cancer and chronic respiratory disease (Figure 20b) all of which are listed as leading causes of death in the region (Figure 8a)

Health Profile for England 2021 headlines

Inequalities in risk factor prevalence contribute to inequalities in ill health and mortality. For example, inequality in smoking prevalence by deprivation is a large determinant of the inequalities in mortality and life expectancy. In 2019, smoking prevalence remained much higher than average in some groups, for example, people in manual occupations (23.2%), people with a long-term mental health conditions (25.8%), deprived areas (16.9%), and the Mixed ethnic group (19.5%) (39). The prevalence of ‘increasing or higher risk’ drinking was greatest in the highest household income group at 34.8%. The prevalence of obesity in adults was higher in the most deprived than least deprived areas, and there were wide inequalities in the proportion of adults meeting recommended level of physical activity and fruit and vegetable consumption (39). Health Survey for England evidence suggests that the prevalence of multiple risk factors is higher in men, the White ethnic group, lowest-income households, most deprived areas, and people with long-term health conditions (80).

Smoking

Recent methodological changes mean the current prevalence from the Annual Population Survey cannot be reliably compared to previous years, but according to previous surveys in the last two decades smoking rates have been decreasing (85).

• figure 21a shows that the East of England adult smoking prevalence was 13.7% in 2019
• smoking prevalence remains much higher than average in some groups, including among people in manual occupations (25.1% were estimated to be smokers) in 2019 (38) and those with a mental health condition (23.9%) (38). Prevalence is also higher in areas with high levels of deprivation - with the most deprived decile having a smoking prevalence over 1.5 times higher than in the least deprived (38)
• figure 21b shows smoking prevalence was highest in Peterborough at 18.8%. Only Hertfordshire was statistically significantly below the regional rate in 2019 and 2020 (38)

Alcohol

Increasing and high-risk drinking is defined as drinking more than 14 units per week.

• in the East of England in 2019, estimates from the Health Survey for England suggested that 22% of males and 10% of females reported drinking between 14 and 50 units of alcohol a week (classed as increasing risk drinking) with a further 4% of males and 2% of females drinking more than 50 units a week (higher risk) (39)
• two local authorities significantly deviated from the regional rate of adults drinking over 14 units per week in 2015/18 (22.8%): Thurrock (11.6%) and Cambridgeshire (28.7%) (40)
• the number of deaths related to alcohol in the region was 2,048 in 2020, which represents a 32.4 per 100,000 population rate and is significantly lower than the England rate (40)

Drug use

Pre-pandemic survey-based estimates for recent drug use in England vary year on year (41). 9.4% of people aged 16 to 59 reported using any drug in the last year in 2019 to 2020. Rate of deaths due to drug misuse continues to be highest among those born in the 1970s.

• in 2019/20 it was estimated that 8.7% of 18-59 year olds in the East of England used illicit drugs within the last year, below the national rate of 9.4% (75)
• this rate has remained consistent in the region since the mid-90s, though there has been a shift from amphetamine use in the mid-90s to powder cocaine (75)
• in 2018-20, the rate of death due to drug misuse in the East of England was 3.7 per 100,000 population, lower than the England rate (42). At a local authority level in the same period, rates ranged from 2.9 per 100,000 in Central Bedfordshire to 5.7 per 100,000 in Southend-on-Sea (a rate for Thurrock could not be reported) (42)

Physical activity

In 2019/20, 67.3% of adults in the East of England were physically active (undertaking at least the recommended level of 150 minutes of moderate intensity physical activity or equivalent per week). This is significantly higher than the England percentage (73). At local authority level, physical activity levels ranged from 57.7% in Luton to 71.5% in Cambridgeshire (73)

Health Profile for England 2021 headlines

England level findings in 2020/21 from Sport England uncovered wide inequalities in physical activity in adults. The proportion was lower for: people who are in routine/semi-routine jobs and those who are long-term unemployed or have never worked (52%); living with a disability or long-term health condition (45%); and Asian (excluding Chinese) (48%) and Black (52%) ethnic groups (89).

Diet

The proportion of the population meeting the recommended five-a-day on a ‘usual day’ in the East of England was 56.7%; higher than the England rate of 55.4% in 2019/20 (44).

Health Profile for England 2021 headlines

Differences in drinking patterns by age and income were observed. ‘Increasing or higher risk’ drinking was highest in the 55 to 64 age group, with the lowest rates among younger age groups, under 25s, as well as those aged 75 or over. Prevalence of ‘increasing or higher risk’ drinking was greatest in the highest household income group but greater harm, such as hospital admissions for alcohol-related conditions in 2018 to 2019, were more than double that in the least deprived areas, the gap has only slightly narrowed since 2010/2011 (81). This inverse relationship between consumption and harm is often referred to as the ‘alcohol harm paradox’. Attempts to understand this have suggested interactions with other behaviours such as smoking, poor diet and exercise, among the reasons why alcohol-related harms are greater in more deprived areas (82) to patients with issues such as blood pressure and cholesterol control, and may also result in an increase in long-term health complications. The recommended five-a-day is lower for people who were unemployed (45.2%), living with a disability (52.1%), working in routine and manual occupations (45.8%), Asian (47.2%), Black (45.7%), or living in the most deprived areas (45.7%)(83).

Obesity

In the East of England region, in 2020, 64.0% of the population was classified as obese or overweight. Figure 21a shows this has remained similar since 2015 and is similar to the England rate (39). Figure 21b shows Thurrock has the highest levels of adults classified as obese or overweight (76.3%) whilst Peterborough has the lowest (60.7%).

Health Profile for England 2021 headlines

As with other risk factors, there are inequalities in adult obesity prevalence by age, sex and deprivation. The Health Profile for England 2021 reported that in 2019 it was lowest in those aged under 25 with a gradual increase by age group up to ages 65-75 after which prevalence decreases. This pattern was seen for both males and females (39). Obesity prevalence was lowest in the least deprived areas and highest in the most deprived, with a clearer gradient for females than males. The impact of the pandemic on adult obesity levels is not known but given the changes in other risk factors presented (diet, physical activity and alcohol) it is possible there will be an increase in obesity and a widening of inequalities (39).

High blood pressure (Hypertension)

Figure 21a shows the registered prevalence of high blood pressure in the East of England region in 2020/21 was 14.3% higher than the England rate of 13.9% (47). NHS Digital have stated that changes in QOF during the pandemic mean that indicator data may be inaccurate for the 2020/21 reporting year, and comparisons with data from previous years could be misleading. There is some variation by local authority with Luton and Peterborough having the lowest prevalence (12%) whilst Norfolk has the highest (16%) but this variation could also be related to better diagnosis rates in the GPs (Figure 21b)

The indicator discussed only includes recorded prevalence of hypertension, so may not reflect true prevalence in the population. The Office for Health Improvement and Disparities (OHID) cardiovascular disease prevention packs contain estimates of the hypertension prevalence including those that are undiagnosed (91). These figures include both adults with blood pressure higher than 140/90 mmHg, and those with blood pressure below this limit who report taking medication to lower their blood pressure.

Blood glucose

Increased blood glucose levels may lead to diabetes and can increase the risk of heart disease and stroke, kidney disease, vision and nerve problems. A blood glucose level that is above normal but not in the diabetic range is referred to as Non-Diabetic Hyperglycaemia (NDH). As people with NDH often exhibit few or no symptoms it is often undiagnosed, though rates of diagnosis have increased since the establishment of the Diabetes Prevention Programme (48, 49). Currently 4.9% of people in England have an NDH diagnosis (49, 50).

• within the East of England NHS commissioning region, NDH registrations varied from 1.7% (Southend CCG) to 6.5% (Norfolk and Waveney CCG). Rates of detection of NDH may not reflect the prevalence of the condition and are heavily influenced by screening rates (50)
• the proportion of people offered the national diabetes prevent programme that do not decline varied from 9.9% (Norfolk and Waveney CCG) to 33.6% (Bedfordshire, Luton and Milton Keynes CCG) (50)

Figure 20 – Leading risk factors

Figure 20a - Morbidity

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020. Download data

Figure 20b - Mortality

Source: Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020. Download data

Figure 21 – Risk factors

Figure 21a - Trends

Source: Wider Impacts of COVID-19 on Health: Wellbeing and behavioural risk factors , Wider Impacts of COVID-19 on Health: Hypertension QOF Date accessed: 31/03/2022 Download data

Figure 21b - Local Authority

Source: Wider Impacts of COVID-19 on Health: Wellbeing and behavioural risk factors , Wider Impacts of COVID-19 on Health: Hypertension QOF Date accessed: 31/03/2022 Download data

Wider determinants of health

Overview

The wider determinants of health are a diverse range of social, economic and environmental factors which influence people’s mental and physical health across the life course (51). Inequalities in these factors are an important driver of the inequalities in risk factors and health outcomes presented earlier in this report. This section presents some key indicators for a range of wider determinants of health including the built and natural environment, education, employment and income, and communities and social capital.

Health Profile for England 2021 headlines

The Health Profile for England 2021 outlined evidence that the COVID-19 pandemic has had a substantial impact on employment patterns and opportunities. There is evidence that the economic impacts of the pandemic affected young people disproportionately. At the end of January 2021, the take up rate of eligible employees that made a claim to HMRC under the furlough scheme was highest in those aged under 18 (34.5%) and those aged 18 to 24 (21.1%)(37). There has also been a decline in the number of 16 and 17 year olds in employment, from 22.5% in the 3-month period March to May 2020, to 13.9% in the comparable period in 2021. In November 2020 the arts, entertainment and recreation industry and the accommodation and food service industry had the highest percentage of employees on furlough leave at 33.6% and 21.9% respectively (37). These are industries with a high proportion of the workforce who are relatively young.

The built and natural environment

The quality of the built and natural environment such as air quality, quality of and access to green spaces and housing quality affect health. Poor housing has a negative effect on our physical and mental health, particularly for older people, children, disabled people and individuals with long-term illnesses.

• homelessness and the use of temporary accommodation remain at high levels in England (52). In the East of England region, the rate of statutory homelessness was 2.4 per 1,000 in 2017/18 (53) whilst households with dependent children who are owed a duty under the homeless reduction acts accounted for 10.3 per 1,000 in 2020/21 (54)
• fuel poverty is now measured by the new Low Income Low Energy Efficiency (LILEE) statistic (55). A household is defined as fuel poor if it has income (after accounting for fuel costs) below a certain level and a low energy efficient home. In 2019 13.2% of households were estimated to be in fuel poverty (54)
• living in a greener environment can promote and protect good health, aid recovery from illness and help with managing poor health. Greenspace can help to bind communities together, reduce loneliness, and mitigate the negative effects of air pollution, excessive noise, heat and flooding (76)

Employment

Good employment improves health and wellbeing across people’s lives, boosting quality of life and protecting against social exclusion. Figure 22a shows the trend in employment rates for males and females in the East of England and England between 2011/12 to 2020/21. During this period, rates of employment for males in the region rose from 79.5% in 2011/12 to a period high of 83.1% in 2018/19. Rates of employment for females showed a similar trend rising from 68.8% in 2011/12 to 73.8% in 2018/19. Employment among both males and females in the region has fallen over the last two years. Rates of employment in the East of England have been consistently higher than the England rate but the difference for females has narrowed in 2020/21.

• the gap in employment rate between males and females is larger in the East of England (9.1%) than it is nationally (7.4%) in 2020/21 and has widened compared to the previous year

• at local authority level, employment rates in 2020/21 varied from 70.3% in Luton to 84.3% in Bedford

Figure 22 – Employment

Figure 22a - Trends

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Figure 22b - UTLA

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Income

Many physical and mental health outcomes improve incrementally as income rises (56, 57). Income is related to life expectancy, disability-free life expectancy (57), and self-reported health (58). The relationship operates through a variety of mechanisms. Financial resources determine the extent to which a person can both invest in goods and services which improve health and purchase goods and services which are bad for health. Low income can also prevent active participation in social life and day to day activities, affecting feelings of self-worth and status (59). It can also influence health through feelings of shame, low self-worth and exclusion (60).

The Minimum Income Standard (MIS) is defined as not having enough income to afford a ‘minimum acceptable standard of living’, based on what members of the public think is enough money to live on (61). Figure 23a shows in 2018/19, 27.7% of the population of the East of England region did not reach the MIS. Figure 23b shows Child poverty rates were highly variable across the region ranging from 16% to 39%.

Figure 23 – Minimum income standard

Figure 23a - Trends

Source: Joseph Rowntree Foundation Households below a Minimum Income Standard: 2008/09 - 2018/19 Date accessed: 31/03/2022 Download data

Figure 23b - Local Authority

Source: After housing cost childer poverty rate estimates, Loughborough University 2019-20 Date accessed: 31/03/2022 Download data

Education

Educational attainment is strongly linked with health behaviours and outcomes. Better-educated individuals are less likely to suffer from long-term diseases, to report themselves in poor health, or to suffer from mental health conditions such as depression or anxiety (62). Education provides knowledge and capabilities that contribute to mental, physical, and social wellbeing. Educational qualifications are also a determinant of an individual’s labour market position, which in turn influences income, housing and other material resources associated with health.

In the East of England in 2018/19, one child in four did not reach good level of development at the end of reception year (72.3%). Among children receiving free school meals the percentage achieving a good level of development drops to 1 child in 2, lower than the England rate (54.6%) (63). In 2020, the percentage of 16 to 17 year olds who are not in education, employment or training (NEETs) for the East of England region was 4.3% (63).

Health protection

Overview

Health protection issues include the prevention and control of all types of infectious diseases and chemical and environmental threats to the health of the population. Over the past century, there has been a considerable reduction in the number of deaths from infectious diseases. However, the COVID-19 pandemic has demonstrated how threats from new infectious diseases can emerge and will continue to do so as a result of a whole range of global factors. Environmental threats include factors such as air pollution, climate change and flooding. Climate change is a risk to health both nationally and globally. It affects all aspects of our everyday life and our environment, including the places we live, the air we breathe, as well as our access to food and water (64).

It is not possible to cover all health protection issues in this report. This section presents specific information on air pollution, sexually transmitted infections, tuberculosis (TB), vaccinations and vaccine preventable infections, and Antimicrobial resistance (AMR).

Air pollution

Air pollution can contribute to cardiovascular and respiratory conditions and shorten lives. It is estimated that long-term exposure to the air pollution mixture in the UK has an annual effect equivalent to 28,000 to 36,000 deaths (68). The Health Profile for England 2021 highlighted that the highest exposures were generally in busy, urban environments, often with high levels of deprivation, contributing to health inequalities (1).

• by 2019, man-made fine particular matter levels of air pollution were 9.7\(\mu g/m^{3}\) in the East of England region compared to 9.0\(\mu g/m^{3}\) for England
• the regional trend between 2011 and 2020 has been decreasing, from 9.8 \(\mu g/m^{3}\) to 7.2 \(\mu g/m^{3}\) (Figure 24a)
  
• the region’s highest annual fine particle level between 2011 and 2019 occurred in 2011, 2013 and 2016 (9.8\(\mu g/m^{3}\)) (Figure 24a)
• there is wide variation within the region in mean fine particle matter air pollution with high levels observed in Luton and Thurrock (Figure 24b)

Health Profile for England 2021 headlines

The highest air pollution exposures have been in deprived urban environments therefore contributing to health inequalities. Social restrictions implemented during the pandemic meant that there were fewer vehicles on the roads. Motor vehicle use fell dramatically during the first (March 2020) and third (January 2021) national lockdowns in England, but by the end of July 2021 were similar to previous years (37). This reduction in vehicle use may have had a favourable impact on air pollution levels.

Figure 24 – Air quality

Figure 24a - Trends

Source: OHID Wider Determinants of Health Date accessed: 31/03/2022 Download data

Figure 24b - UTLA

Source: OHID Wider Determinants of Health Date accessed: 31/03/2022 Download data

Infectious diseases

Prior to the pandemic, the incidence of many infectious diseases such as TB had been declining, but disproportionately impacted more deprived or inclusion health groups. In 2019, the incidence of TB was higher in people born outside of the UK, particularly those of Indian, Pakistani or Black African ethnicity, than in people born inside the UK (1). It was also higher in the most deprived than the least deprived areas and more than a fifth of UK born cases had a known social risk factor such as homelessness or drug use. Preventable bacterial sexually transmitted infections (STIs) such as chlamydia and gonorrhoea had been increasing prior to the pandemic (1).

Impact of the pandemic on infectious diseases, vaccines and vaccine preventable infections

The level of testing for, or detection of, many infectious diseases such as TB and STIs decreased during the pandemic, which may reflect a real decrease in incidence due to social distancing measures or may reflect a reluctance to be tested or reduced access to testing. In addition, the health profile of England 2021 highlighted a reduction in MMR (measles, mumps, rubella) vaccine uptake in parts of 2020.

Vaccination uptake rates generally in winter 2020 to 2021 were higher than they had been in previous years due to increased efforts to reach as many people as possible and increased awareness due to the COVID-19 pandemic.

• in 2020/21, 90.4% of children in the East of England had received two doses of the measles, mumps and rubella (MMR) vaccine by the age of 5 years (66). Across the region, uptake varied from 82.5% in Luton to 92.8% in Norfolk

• flu vaccination coverage in the over 65s was 81.8% in 2020/21 in the East of England. This exceeded the national benchmark and the national rate for the first time (65). Prior to the pandemic uptake rates were 10% lower

• over the last 10 years, Flu vaccination rates in at-risk individuals in the East of England has been below the national rate. Despite increasing by 10% to 52.8% in 2020/21 the East of England region still fell short of the national goal of 55% coverage (65)

Sexually transmitted infections

The epidemiology of sexually transmitted infections (STIs) has changed markedly over the last two decades, reflecting changes in demographics, individual behaviours, surveillance techniques, diagnostics and treatments. There has been a continued decline in the rate of new HIV diagnoses (69) due to a combination of testing, pre-exposure prophylaxis, rapid linkage to treatment and support for those diagnosed with HIV to attain viral suppression. There has also been a decline in the rate of genital warts following the introduction of the HPV vaccination programme (Figure 25a).

• the diagnostic rates per 100,000 for chlamydia (aged 25+), gonorrhoea and syphilis had been increasing in the East of England region between 2012 and 2019 (Figure 25a). The diagnostic rate per 100,000 for genital warts has been decreasing since 2012. 2020 saw a decline in the detection rates of all STIs (70)
• diagnostic rates per 100,000 in the East of England region are 140, 56, 41, 5.2 for chlamydia (aged 25+), gonorrhoea, genital warts and syphilis respectively in 2020 compared with 171, 101, 48.6, 12.2 for England (Figure 25a)
• there is wide sub-regional variation in the diagnostic rates of STI in the East of England region. chlamydia (aged 25+) diagnoses are most common followed by gonorrhoea, Genital wards and syphilis (Figure 25a)
• the local authority with the highest chlamydia diagnostic (aged 25+) rate per 100,000 in the East of England region is Peterborough (a diagnostic rate of 239.7/100,000), the lowest is Central Bedfordshire (a diagnostic rate of 96.7/100,000) (Figure 25b) (70)
• the local authority with the highest gonorrhoea rate per 100,000 in the East of England region is Peterborough (a diagnostic rate of 104.6/100,000), the lowest is Suffolk (a diagnostic rate of 36.1/100,000) (Figure 25b) (70)
• the local authority with the highest genital warts rate per 100,000 in the East of England region is Southend-on-Sea (a diagnostic rate of 52/100,000), the lowest is Central Bedfordshire (a diagnostic rate of 26.2/100,000) (Figure 25b) (70)
• the local authority with the highest syphilis rate per 100,000 in the East of England region is Luton (a diagnostic rate of 15/100,000), the lowest is Norfolk (a diagnostic rate of 3/100,000) (Figure 25b) (70)

Health Profile for England 2021 headlines

The measures taken to control the COVID-19 pandemic resulted in a drop in the number of people accessing services. Reduced demand for these services during this time may have been influenced by compliance with social distancing measures and changes in risk perception and behaviour, but may also indicate undetected infections. The full impact on infection transmission and long-term health outcomes will take time to emerge and evaluate (84).

Figure 25 – Sexually transmitted infections

Figure 25a - Trends

Source: Sexual and Reproductive Health Profiles Date accessed: 31/03/2022 Download data

Figure 25b - Local Authority

Source: Sexual and Reproductive Health Profiles Date accessed: 31/03/2022 Download data

Tuberculosis

The number of new cases of tuberculosis (TB) has fallen dramatically in England over the last century (71). Figure 26 shows:

• by 2019, the incident rate per 100,000 of Tuberculosis (TB) was 6.3 in the East of England region compared to 8.4 for England
• the regional trend between 2011 and 2019 has been decreasing, with the 2020 figures similar to 2000
• the region’s highest incidence over the last 20 years occurred in 2011 (9.2 per 100,000)

Health Profile for England 2021 headlines

The rates of TB are higher in people born outside of the UK, particularly those of Indian, Pakistani or Black African ethnicity, than in people born inside the UK (90). It was also higher in the most deprived than the least deprived areas and more than a fifth of UK born cases have a known social risk factor such as homelessness or drug use (90).

Figure 26 – Tuberculosis

Figure 26a - Trends

Source: OHID TB Strategy Monitoring Indicators Date accessed: 31/03/2022 Download data

Antimicrobial resistance

Antibiotic-resistant bloodstream infections rose by an estimated 32% between 2015 and 2019 in England (72). Figure 27a shows the trend in the rate of antibiotic prescribing in primary care in England between 2015 and 2020. Antibiotic prescribing in primary care is often measured in STAR-PU, which are weighted units to allow comparisons adjusting for the age and sex of the population. It shows that the rate of antibiotic prescribing in primary care in the East of England has fallen every year, with the largest drop between 2019 and 2020.

• in 2020, the indirectly standardised antibiotic prescribing ratio is higher in the East of England (0.83) region compared to England (0.75), a statistically significant difference
• the regional trend between 2016 to 2020 has been decreasing from 1.14 to 0.83
• figure 27b shows there is variation within the region in primary care antibiotic prescribing
  
• 6 local authorities (Cambridgeshire, Central Bedfordshire, Essex, Peterborough, Southend-on-Sea, Suffolk) are significantly higher than the regional rate
• 4 local authorities (Bedford, Hertfordshire, Luton, Norfolk) are significantly lower than the regional rate
• 1 local authority (Thurrock) is not significantly different to the regional rate

Figure 27 – Antibiotic prescribing

Figure 27a - Trends

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Figure 27b - Local Authority

Source: OHID Public health profiles Date accessed: 31/03/2022 Download data

Conclusions

The 2021 Regional Health Profile for the East of England builds on the comprehensive snapshot of the nation’s health presented by the National Health Profile for England, providing a regional perspective on the issues highlighted nationally to enable local decision-making that benefits the health of the local population.

The Regional Health Profile presents data on how the COVID-19 pandemic has affected health and well-being in the region. The full impact of the pandemic on health in the region is not yet known but evidence from national analysis has shown that the pandemic has had a disproportionate impact on many who already face disadvantage, replicating existing inequalities and in some cases, increasing them. Action to address inequalities in health and promote equitable health gain for all is a key priority.

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