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Overview

This report is a comprehensive review of health in the North West 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.

Introduction

This profile brings together data and knowledge to give a broad picture of health in the North West. 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 Health Profile for North West 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:

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 in their policy areas.


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 North West, usually as a trend over several years. Regions are defined as government regions. 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 North West, 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

Key Findings

This report provides a comprehensive look at the state of health in the North West. The structure of the report follows that of the National Health Profile for England and looks to mirror the layout. Where key findings from the national report are relevant to the North West situation or where there is an absence of regional data England values are used but this is highlighted in the text and references.

Like in previous Health Profile for England reports, this update looks at a range of population health data, such as smoking and obesity, but it also provides an early summary of the impact of the COVID-19 pandemic on many aspects of health inequalities.

Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. There are many kinds of health inequality, and many ways in which the term is used. This means that when we talk about ‘health inequality’, it is useful to be clear on which measure is unequally distributed, and between which people.

Here we look at 5 important points the report makes about how the nation’s health has been affected directly and indirectly by the pandemic.

Mortality was higher than previous years

In 2020, COVID-19 was the leading underlying cause of death among males, replacing heart disease, and the second largest cause of death among females after dementia and Alzheimer’s disease. By the end of December 2021, 23,865 deaths had been registered with COVID-19 mentioned on the death certificate among residents in the North West.

Between 21 March 2020 and 31 December 2021, deaths were 1.16 times higher than expected across England, based on data for the previous 5 years.

Deaths were higher than expected in all age groups over 25 years but were particularly high in those who live in deprived areas (1.20 times higher for men and 1.19 for women) and in the Black population (1.74 times higher for men and 1.55 for women), reflecting the disproportionate impact of the pandemic on these groups.

Dementia deaths increased, and diagnoses declined

Dementia and Alzheimer’s disease remained the leading cause of death in North West in females and the third largest in males.

In 2021, there were around 5,500 fewer people aged 65 and over with a diagnosis of dementia compared with the previous year. Although increased mortality among people with dementia during the pandemic may be a factor, this is also likely due to reduced access to services where diagnosis takes place.

Health services were not used as much

During the pandemic, hospital admissions, A&E attendances and the number of GP consultations were all down, particularly in the first wave of the pandemic.

Surveys show that half of people with a worsening health condition between May 2020 and January 2021 did not seek treatment, most commonly because they did not want to put pressure on the NHS or were concerned about catching COVID-19.

This has meant that new diagnoses for some diseases this year were considerably down compared with previous years. This includes cancer, for which there were 18% less diagnoses between April and December 2020 than in the same months in 2019, a larger reduction than seen nationally.

This reduced contact with health services may mean that preventative treatment has been missed but could also lead to long-term health complications and an increase in deaths in the future, meaning that we can still expect to see the impact of COVID-19 in years to come.

Children’s development may have suffered

Children’s education has been severely disrupted during the pandemic. From 23 March 2020 until June 2020, most schools in England were closed to children other than those with parents who were key workers or who were classed as vulnerable.

While the full impact of the pandemic on child health and development is still not known and will not be known for some time, initial studies suggest that children who started school in the Autumn 2020 term needed additional support when compared with children in previous academic years and that learning has suffered to some degree for most pupils and year groups, particularly primary and more disadvantaged students.

Almost all schools have indicated that they are concerned about young pupils’ communication and language development, personal, social and emotional development and levels of literacy as children were not experiencing the social interactions that they usually would, such as play dates and interacting with grandparents.

Increased alcohol consumption among heavy drinkers likely drove a rise in alcoholic liver deaths

There has been an unprecedented increase in alcohol-specific deaths (deaths which were caused by alcohol use), mainly due to increased alcoholic liver disease mortality. In 2020, alcohol-specific deaths increased by 20% compared with 2019. Although alcohol-specific mortality rates have been increasing in recent years, this represented a significant acceleration in the upward trend.

A recent PHE report monitoring alcohol consumption and harms during the pandemic noted that the increase in alcoholic liver disease mortality was “likely to be due to increased consumption among an already at-risk group of heavy drinkers”.

Increased mortality has impacted on life expectancy

The high number of deaths due to COVID-19 caused life expectancy in England to fall in 2020, by 1.5 years for males to 77 years and 1.2 years for females to 81 years. This is the lowest life expectancy since 2009 for males and 2008 for females.

The pandemic has exacerbated existing inequalities in life expectancy by deprivation to the largest we have seen in two decades, which is as far back as our data goes. The gap between the most and least deprived areas in the North West in 2020 was 12.5 years for males, 1.3 years larger than in 2019, and 10.8 years for females, 0.9 years larger than in 2019.


Introduction to the North West

The North West is a geographically diverse area with stunning coastline, national parks and areas of outstanding natural beauty. The urban centres are concentrated around the cities of Liverpool and Manchester. Geographically the North West is the 6th largest of the 9 regions, however it has the 3rd highest regional population.The North West is often considered three subregions with their own unique cultures. To the north are Lancashire and Cumbria, to the south and east is Greater Manchester, and to the south and west are Cheshire and Merseyside.

There are 2 national parks within the North West, the Lake District and Peak District which crosses the border into the Midlands, 3 World Heritage sites and 3 areas of outstanding natural beauty.

The region is home to 7,341,200 residents, and the population is growing. Overall the population within the region experience worse than national average outcomes, such as lower life expectancy, higher levels of poverty and deprivation. However, there is significant variation within the region.

Life expectancy for females in the North West is 81.7 years and for men 77.9 years (2018-20), below England’s average life expectancy for (83.1 years , and 79.4 years respectively).From birth, men living in the North West can expect to live 60.2 years disability free and for women the figure is 59.1 years (2018-20).

The elderly population within the North West (18.7% are aged 65 and over) are mostly concentrated in the rural county areas with the larger urban areas of Manchester, Liverpool, Preston and Lancaster having younger populations.


COVID-19

Introduction


England had experienced 2 main waves of cases by the end of June 2021. 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 to the south of England case rates increased later in Decembers 2020 and January 2021.

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 impacted the North West severely. As of 31 December 2021, the North West had the highest cumulative COVID-19 case rate of all 9 regions in England and the highest total number of deaths. The impact of COVID-19 is ongoing and it is likely that the elective healthcare backlog, educational impact and wider indirect consequences of the pandemic will take some time to quantify and address.


COVID-19 cases

By 31 December 2021, 1,743,857 confirmed cases of COVID-19 had been reported in the North West. The region’s highest 7-day average case rate occurred in December 2021 at 2,470.4 cases per 100,000 population. The impact of COVID-19 was not equally distributed, and some groups have been more affected than others. The data is influenced by testing strategies and not everyone has access to the same level of testing throughout the pandemic. In the early stages of the pandemic testing was limited to healthcare and care home settings. Regular testing was required in some high-risk settings, education, care and healthcare establishments although universal testing was available, many people would only get tested if they had symptoms or were identified as a contact of an individual who had tested positive. The increased testing in NHS, care home and student populations may have detected more cases in those groups leading to an overrepresentation of these groups in the data.

Sex: recorded COVID-19 cases were statistically significantly higher in females (23,788 per 100,000) than males (21,459 per 100,000 population).

Age: recorded COVID-19 cases were statistically significantly higher in the 0-24 years (24,538 per 100,000) and 25-49 years (22,299 per 100,000 population) age groups.

Deprivation: the relationship between COVID-19 cases and deprivation isn’t linear although statistically significantly higher rates are more prominent in the more deprived deciles (decile 1 being the most deprived and decile 10 being the least deprived). Deprivation deciles 3, 4 and 6 through to 10 have cases rate statistically significantly higher than the North West average. Deprivation decile 5 is the only decile that has a statistically significantly lower case rate than the regional average. Deprivation decile 9 has the highest case rate: 23,461 per 100,000.

Ethnicity: COVID-19 case data is available for broad ethnic groups. The other ethnic group category had the highest case rate (27,526 per 100,000) and was 1 of 3 categories with rates statistically significantly higher than the regional average (22,676 per 100,000), Asian/Asian British (23,323 per 100,000) and Black/Black British (27,076 per 100,000) were the other 2.

Population density decile: COVID-19 case rates were statistically significantly higher in deciles 3-9. In deciles 1 (the most densely populated) and 10 (the least densely populated) rates were significantly lower than the regional average. Low rates in the most densely populated areas are unexpected and are potentially caused by lower uptake of testing in those areas, more investigation is required to better understand the cause.

Local authority: Figure 1c shows that the local authority with the highest COVID-19 case rates in the North West was Knowsley at 27,103 per 100,000 population, significantly higher than regional average. As at the end of December 2021, Knowsley had the highest 7-day rolling rate at 2,875 per 100,000 population

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


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 [2]. 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 [3]. The possible reasons for these differences and further interpretation of ethnic inequalities in COVID-19 mortality rates are discussed in depth elsewhere [4,5].


By 31 December 2021, 23,865 deaths were registered with COVID-19 mentioned on the death certificate in North West. The region’s highest 7-day age-standardised mortality rate occurred in April 2020 at 194.3 deaths per 100,000 population that week. Figure 2b shows some of the wide inequalities in death rates involving COVID-19 and the cumulative age-standardised mortality rates in the region between March 2020 and December 2021.

Sex: the cumulative mortality rate in the North West was statistically significantly higher in males (431.4 per 100,000 population) than females at (266.1 per 100,000 population)

Age: age-standardised mortality followed a strong age gradient with the highest rates observed in the oldest age bands. In people aged 85+ the age standardised mortality rate was at 4,982.6 per 100,000 population. Mortality rates were statistically significantly higher than the regional average in the 65-74, 75-84 and 85+ years age groups.

Deprivation: cumulative age-standardised mortality from COVID-19 follows the deprivation gradient with the highest mortality rate in the most deprived decile (decile 1, 513.5 per 100,000) and the lowest in the least deprived decile (decile 10, 198.0 per 100,000). Cumulative age-standardised mortality rates were statistically significantly higher than the North West average (337.7 per 100,000) in deprivation deciles 1 to 5, not significantly different in decile 6 and statistically significantly lower in deciles 7-10.

Ethnicity: the highest cumulative age-standardised mortality rates are observed in the Asian/Asian British (724.2 per 100,000) and Black/Black British (696.5 per 100,000). Both ethnic groups had statistically significantly higher rates than the North West average (337.7 per 100,000).

Population density: the cumulative age-standardised mortality rate pattern when viewed by population density is similar the deprivation pattern. The highest rates are in the most densely populated areas (decile 1, 484.4 per 100,000). The 4 most densely populated areas have statistically significantly higher mortality rates than the regional average (337.7 per 100,000) and the 3 least densely populated deciles have mortality rates statistically significantly lower than the regional average.

Local authority: there is significant variation at the local authority level with the highest cumulative age-standardised morality rate being almost double the lowest. By the end of December 2021 Blackburn and Darwen had the highest age-standardised morality rate (487.8 per 100,000), Cheshire East has the lowest with an age-standardised morality rate of 250.2 per 100,000 over the same period.

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 a measure of how much higher all-cause mortality was in the pandemic period than would have been expected, based on previous years, had the pandemic not occurred. These figures account for inequalities prior to the pandemic and therefore demonstrate the disproportionate direct and indirect impact of the pandemic specific groups. Figure 3b shows that between 27 March 2020 and 31 December 2021, the cumulative all-cause mortality ratio was 1.16 higher than expected compared to the baseline period, 2015 to 2019.


There was an association between deprivation and excess mortality, with the ratio 1.17 in the most deprived areas and 1.13 in the least deprived areas. 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 [6].


Sex: the cumulative excess mortality ratio was higher in males (1.16) and females (1.14) than the baseline expected.

Age: in most age groups the excess mortality ratio was higher than expected. In males the highest excess mortality ratio was in the 50-64 years age group (1.28), in females the 25-49 years age group (1.22) had the highest excess mortality ratio. Males aged 0-24 years had a lower than expected excess mortality ratio (0.92).

Deprivation: the excess mortality ratio in both males and females followed a similar pattern with the highest ratio seen in the most deprived quintile and the lowest ratio in the least deprived quintile. Quintile 1 (the most deprived) had a ratio of 1.2 for males and 1.19 for females, both higher than the respective averages for their sexes. In the least deprived quintile the excess mortality ratio for males was 1.13 and for females 1.08, both lower than the regional sex specific averages.

Ethnicity: the excess mortality ratio varied notably between ethnic groups. The highest ratio was in the Black ethnic group for both males (1.74) and females (1.55). The lowest ratio for males was in the mixed ethnic group (1.06) and for females in the White ethnic group (1.13).

Local authority: 12 of the 23 local authorities in the North West had excess mortality ratios in excess of the regional average (1.16). The highest was Blackburn and Darwen with a ratio of 1.23. Two local authorities, Cheshire East and Halton, both had the joint lowest excess mortality ratio (1.08), although both were in excess of the baseline period.

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 North West, by the end of December 2021, 5,513,718 of the population had 1 COVID-19 vaccination dose, 5,071,600 had 2 doses and 3,603,074 had 3 doses. Figure 4b shows that there has been variation in uptake of 2 doses of COVID-19 vaccine (OHID COVID-19 dashboard), but this variation may not be statistically significant.

Country of birth: COVID-19 vaccine uptake in the North West was higher in people who were born in the UK (85.7%) compared with those born in the outside UK (77.6%).

English language proficiency: 85.6% of people whose main language is English had received two doses of COVID-19 vaccine compared with 73.0% for those whose main language is not English.

Sex: vaccine uptake was higher in females (86.6%) than males (83.3%)

Disability: people whose day-to-day activities are limited a little (89.5%) had the highest uptake of 2 COVID-19 vaccinations compared with those whose activities are limited a lot (87.7%) or those whose activities are not limited (84.4%).

Deprivation: uptake of 2 COVID-19 vaccinations followed the deprivation gradient with the people living in the most deprived quintile having the lowest uptake (74.7%) and people living in the least deprived quintile having the highest uptake (92.1%).

Ethnicity: ethnicity was noted nationally as a factor in COVID-19 vaccination uptake which is reflected in the data. People in the Black Caribbean (62.1%) and Black African (65.7%) ethnic groups had the lowest uptake. People in the White British (86.7%) and Indian (84.4%) ethnic groups had the highest uptake in the North West.

Housing tenure: people living in owned housing in the North West had the highest vaccination uptake (89.4%). The percentage of people living in rented accommodation, both private-rented (75.3%) and social-rented (73.3%) had the lowest uptake rates.

Religion: people who stated that they were or Hindu (89.7%) faith had the highest COVID-19 uptake (of 2 vaccines) in the North West. The lowest uptake was found in those of Muslim (72.1%) faith.

Rural-urban: rural communities (91.5%) in the North West had higher uptake rates than people living in urban area (84.2%).

Socio-economic class: investigating the data by socio-economic class showed that people who had never worked or were long-term unemployed (64.4%) had the lowest uptake of 2 COVID-19 vaccines. The highest uptake was in the higher managerial, administrative and professional category (91.4%).

Local authority: regardless of whether uptake of 1, 2 or 3 COVID-19 vaccines was considered a similar pattern emerged in the North West, with Cumbria consistently having the highest uptake (88.2%, 82.9% and 65.3% respectively) and Manchester having the lowest uptake (66.5%, 59.2% and 34.7% respectively).

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

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

Introduction

This section examines trends and inequalities in all-cause mortality, mortality from leading causes of death and life expectancy. It presents data for the pre-pandemic period, and 2020 data where it is available.

Life expectancy

Figure 5a shows trends in life expectancy at birth from 2001 to 2019 have increased for both males and females in the North West, although life expectancy in the North West has been below the national average throughout that period. Compared with 2019, life expectancy fell in 2020 by 1.5 years for males to 77 years and 1.2 years for females to 81 years. The fall in life expectancy represents widening inequalities in health outcomes.

Deprivation: Life expectancy at birth fell in every deprivation decile in both males and females between 2019 and 2020 as shown in Figure 5b. Life expectancy for females declined the most in deprivation decile 2 at 79.0 years down to 76.9 years, a decrease of 2.1 years. The largest fall in life expectancy for males was also in deprivation decile 2, a decrease of 2.2 years, from 74.8 years down to 72.6 years.

The slope index of inequality (SII) is a measure of the social gradient in an indicator and shows how much a health outcome varies with deprivation. 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 [7]. The higher the value of the SII, the greater the inequality within an area. Within the North West in 2020 there was a difference of 12.5 years between the most and least deprived males in the region, an increase of 1.3 years compared with 2019. In females the gap between those living in the most and least deprived deciles in the North West was 10.8 years in 2020, an increase of 0.9 years compared with 2019.

Local authority: Figure 5c shows variation in life expectancy at birth for males and females for each local authority in the North West. Life expectancy for females in the North West demonstrates a similar pattern to males where the majority of local authorities have a significantly worse life expectancy than the England average. Life expectancy for women in Cheshire East and Trafford is significantly higher than the England average. In Cheshire West, Stockport and Cumbria there is no statistically significant difference to England.

Life expectancy was significantly lower in 2018-2020 compared with the national average for males in the majority of North West local authorities. Only Cheshire East and Trafford have a significantly better average life expectancy than the national average.

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

Child health

Introduction


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.


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: low 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 is associated with an increased risk of infant mortality, developmental problems in childhood and poorer health in later life [8, 9]. Nationally, the rate of low birth weight is positively correlated with deprivation and increases as deprivation increases [10].

In the North West Figure 9a shows that the proportion of babies born at full-term with a low birth-weight decreased from 3.1% to 2.7% between 2006 and 2020. The proportion has decreased to be statistically significantly lower than the England average in 2020 for the first time in data available on OHID Fingertips which starts in 2006.

Local authority: Comparisons available in Figure 9b show that in 2020, of the 23 North West local authorities, 2 local authorities had a statistically significantly higher proportion of babies with low birthweight. The proportions ranged from 4.8% to 1.7%, against the regional average of 2.7%.


The Health Profile for England examines inequalities in low birth weight at England level. In 2018 the proportion of babies born at full-term with a low birthweight in the most deprived areas was more than double the proportion in the least deprived areas, as measured by the relative index of inequality (RII). The RII is a summary measure of inequality. It measures the relative difference between the most and least deprived areas and is presented as a ratio. For low birthweight the RII is 2.2, meaning that the level in the most deprived areas is 2.2 times higher than the least deprived. Analysis by deprivation back to 2010 shows that this inequality remained broadly similar. The analysis for April 2020 to March 2021 suggests that these inequalities have remained throughout the pandemic.


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 pre-term birth, followed closely by congenital anomalies [11].

Figure 10a shows the trends in infant mortality for the North West and England. In the North West, the rate of mortality fell from 5.7 per 1,000 live births in 2001-03 to 4.2 per 1,000 live births 2013-15. The rate subsequently increased until 2016-18 which was followed by a further period of de-crease. In the most recent data available, 2018-20, the mortality rate is 4.3 per 1,000 live births.

Local authority: comparisons available in Figure 10b show that out of the 23 local authorities in the North West, Oldham and Manchester have statistically significantly higher rates of infant mortality than the North West average, while Trafford and Cheshire West and Chester have statistically significantly better rates than the North West average.

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 [12]. Being able to express themselves, interact with peers and make themselves understood helps to build a child’s confidence and boost their self-esteem [13]. Inadequate communication skills can lead to poorer adult outcomes in literacy, mental health and employment [14].

Figure 11a shows that the percentage of children achieving a good level of development by the end of Reception between 2012/13 and 2018/19. The percentage of children achieving a good level of development has improved in both males and females, but the rate of improvement has slowed in recent years.

Sex: in the North West and nationally fewer boys than girls achieved the expected level of development (62.2% compared with 75.9%). The same sex pattern can be seen in the England data, but the percentage of males and females achieving a good level of development is lower in the North West compared with England.

Local authority: Figure 11b shows that 6 of 23 of North West local authorities have a statistically significantly higher percentage than the North West average, namely in Trafford, Warrington, Cheshire East, Cheshire West and Chester, Bury and Cumbria. Conversely, 6 out of 23 North West local authorities have statistically significantly lower levels of school readiness than the North West average.

National data in the Health Profile for England shows that a clear gradient can be seen between child development and deprivation with 77.7% children living in the most deprived areas achieving the expected level compared with 87.0% of those living in the least deprived areas.

Covid 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 continuing to attend (around 7% of children aged 2 to 4 years) [15]. Outside formal early years settings, young children may also have experienced a lack of social activities and interactions that would normally have helped to prepare them for the start of school, such as with grandparents and via play dates.

Although the full impact of the pandemic on early years development will not be known for some time, a study carried out by the Education Endowment Foundation (EEF) found that out of the schools in England surveyed, 76% reported that children who started school in the autumn 2020 term needed more support than children in previous cohorts. Almost all surveyed schools indicated that they were concerned about pupils’ communication and language development (96%), personal, social and emotional development (91%) and levels of literacy (89%) [16].

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

Prevention and treatment of childhood obesity presents a significant public health challenge. Obesity in childhood can result in the early onset of cardio-metabolic, 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 [17].

Figure 12a presents data from the National Child Measurement Programme (NCMP) from 2006/07 to 2019/20. Data from the shows that the prevalence of obesity in the North West is higher than the national average in both males and females in Reception and Year 6.

Reception: obesity in Reception aged females in the North West was static between 2006/07 and 2014/15 but has subsequently been in an upwards trajectory. In 2019/20 10.9% of boys aged 4 to 5 years (Reception year) in the North West were obese compared with the national average of 10.1%. In girls the same age, 10.6% are obese which is also higher than the national average of 9.7%.

Year 6: in Year 6 prevalence of obesity in males and females has been increasing since the NCMP programme first started. The rate of increase had been broadly similar to the national average. However, in the most recent year the gap has increased between the North West and England and there are now higher rates of obesity in both male and female Year 6 pupils. 2019/20 saw the largest increase in females (an increase of 1.2 percentage points to 20.2%) compared with the national average for Year 6 females of 18.4%. In Year 6 males the increase in 2019/20 was the joint highest (1.5%, the same as 2014/15 to 2015/16) and now stands at 25.3% compared with the national average of 23.6%.

Local authority: NCMP data on obesity at Reception and Year 6 for some local authorities were supressed and therefore cannot be reported on. 2019/20 data available at the local authority level is presented in Figure 12b. In the North West 4 local authorities have a prevalence of obesity statistically significantly higher than the regional average in Reception aged children (10.8%): Halton (14.3%), Knowsley (13.8%), Blackpool (12.6%) and Manchester (11.9%). 2 local authorities have a prevalence of obesity in Reception aged children statistically significantly lower than the regional average: Warrington (8.5%) and Trafford (7.2%).

In the Year 6 age group, the prevalence of obesity is substantially higher than the Reception age group. In 2019/20 the North West prevalence of obesity is 22.8%. 8 local authorities have prevalence rates statistically significantly higher than the North West. The highest 2 are Blackpool (28.6%) and Manchester (27.3%). 8 local authorities also have rates statistically significantly lower than the regional average.


Deprivation: Based on the national 2019/20 NCMP data, children in both Reception and Year 6 in the most deprived areas were more than twice as likely as children in the least deprived to be obese.

Ethnicity: There are also inequalities by ethnic group. Black African ethnic groups had the highest prevalence in children aged 4 to 5 years (15.9%) and children aged 10 to 11 years (30.5%). All Black ethnic groups and mixed race Black ethnic groups reported on in the NCMP data in Reception and Year 6 age groups had significantly higher rates of obesity compared with the national average. Bangladeshi and Pakistani children also had significantly higher rates of obesity in both age groups.


Covid impact on childhood obesity

The latest findings from the NCMP suggest that obesity has increased across all regions in both Reception age children and children in Year 6. A link between weight gain and out of school time in the school holidays has previously been demonstrated [17]. Closure of schools, sporting and leisure facilities, park facilities and recreational areas, together with an increase in screen time over the pandemic period have led to a reduction in physical activity in children and young people [18]. Recent Sport England survey estimates the percentage of children aged 5 to 16 years undertaking 60 minutes of activity a day has fallen from 45.3% in 2018/19 to 44.0 in 2020/21.


Recent evidence from Sport England suggest that in England, there has been a reduction in physical activity in boys, and an increase in physical activity for girls during the pandemic in England. Evidence also suggests the differences by deprivation have widened.


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

The Health Profile for England 2019 demonstrated inequalities in many other aspects of children’s health prior to the pandemic. This section looks at some of these.

Injuries resulting in hospitalisation: Figure 13a shows the trend for hospital admissions for unintentional and deliberate injuries in children (aged 0-14 years) between 2010/11 and 2020/21. For the North West the crude rate has reduced from 152.9 per 10,000 in 2010/11 to 100.5 per 10,000 in 2020/21. The rate has consistently been higher than England (75.7 per 10,000 in 2020/21).


Prior to the pandemic, in England smoking among teenagers had been reducing, while drug use had increased. The proportion of children aged 15-year-olds who reported they were regular smokers decreased from 12% to 5% between 2010 and 2018. Lifetime prevalence of drug use among school pupils aged 11 to 15 years increased sharply between 2014 and 2016, even accounting for a methodological change, but then remained level up to 2018 at 24%. This survey data is not available at a regional level.


Obesity in early pregnancy: mothers who are obese have increased risk of complications during pregnancy and birth. Babies born to obese women also have a higher risk of adverse health outcomes including stillbirth, congenital abnormalities, and subsequent obesity. In 2018/19 there was significant variation in the proportion of obesity in early pregnancy among local authorities in the North West. The North West (23.6%) had a statistically significantly higher proportion of obesity in early pregnancy than England (22.1%). 11 local authorities had statistically significantly higher rates than the proportion for England. Halton (29.1%), Blackpool (28.5%) and Wigan (27.0%) had the highest rates in the region. Stockport (20.1%) and Trafford (19.0%) had a statistically significantly lower proportion of obesity in early pregnancy than England.

Smoking in early pregnancy: smoking in pregnancy has well-known detrimental effects for the growth and development of the baby and health of the mother. Smoking during pregnancy increases the risk of premature births, miscarriage, stillbirth and perinatal deaths, complications in pregnancy, low birthweight and the child developing other conditions in later life. In 2018/19 there was significant variation in the proportion of smoking in early pregnancy among local authorities in the North West. The North West had a statistically significantly higher proportion of smoking in early pregnancy than England (14% compared with 12.8%). 13 local authorities had statistically significantly higher rates of smoking in early pregnancy than the proportion for England. Blackpool (29.1%), Liverpool (21.5%) and Knowsley (19.2.0%) had the highest rates in the region. 4 local authorities had a statistically significantly lower proportion of people smoking in early pregnancy than England: Cheshire East (11.7%), Bury (11.1), Stockport (10.8) and Trafford (6.3%).

Smoking at the time of delivery: Figure 14a shows the trend in the proportion of mothers smoking at the time of delivery. In the North West the proportion has reduced from 17.8% in 2010/11 to 11.0% in 2020/21. The North West has had a consistently higher proportion of mothers smoking at time of delivery compared with England but the gap has been narrowing. Figure 14b shows that in 2020/21 there was significant variation in smoking at the time of delivery among local authorities in the North West. 6 local authorities were significantly worse when compared with the regional proportion, 6 local authorities significantly better, and 11 local authorities were not significantly different when compared with the regional proportion.

Dental decay: in the North West, 31.7% of children aged 5 years had experience of visually obvious dental decay The North West had the highest percentage of children aged 5 years with visually obvious dental decay and was statistically significantly worse than England. In 2018/19, 13 local authorities had statistically significantly higher rates than England (23.4%). The top 3 were Blackburn with Darwen (50.9%), Oldham (43.2%) and Rochdale (40.7%). Note that there were 3 local authorities for which no data was available for this indicator.

Teenage conceptions: looking at the trend for 1998 to 2019 the rate of teenage conceptions for the North West has steadily decreased from 50.3 per 1,000 in 1998 to 19.4 per 1,000 in 2019, although and the rate has been consistently statistically significantly higher than the rate for England. There is significant variation in the under 18s conception rate for local authorities in the North West in 2019. 13 local authorities are statistically significantly worse, 8 not statistically significantly different and 2 statistically significantly better than the England rate.

Covid impacts on other indicators of child health

One national survey comparing aspects of mental health found that in 2020, 1 in 6 (16.0%) children aged 5 to 16 years were identified as having a probable mental disorder, increasing from 1 in 9 (10.8%) in 2017. When compared with those unlikely to have a mental disorder, children and young people with a probable mental disorder were more likely to say that lockdown had made their life worse with 54.1% of children aged 11 to 16 years, and 59.0% of young people aged 17 to 22 years stating this, compared with 39.2% and 37.3% respectively.

The pandemic has had a profound effect on the life of young people, through isolation and interruptions to education. Some of these effects will be longer-term and data is not available to measure them yet. The impact on education and employment among young people is covered in the wider determinants section of this report.

You can find out more about Child and Maternal Health from OHID Fingertips public health profiles.


Wide inequalities are apparent across all indicators of child health presented. 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.

Preliminary data that covers some of the pandemic period suggest that the proportion of babies born with low birthweight and the infant mortality rate has not changed significantly since the start of the pandemic. 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. 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

Introduction

As well as life expectancy (how long the population could expect to live), it is also important to consider the quality of life or length of time spent in good health. This is referred to as healthy life expectancy. Healthy life expectancy is not yet available for the years covering the pandemic.

Figure 15a shows that for females healthy life expectancy has improved by 0.4 years between 2010-12 and 2017-19. Overall life expectancy for females in the same period has increased 0.5 years. This means that the average years of life lived in poor health in females has increased from 19.9 years in 2010-12 to 20 years in 2017-19.

For males, in 2017-19 healthy life expectancy has improved by 0.7 years. Overall life expectancy in the same period for males has increased by 0.8 years increasing the average years of life lived in poor health to from 16.6 years in 2009-11 to 16.7 years in 2017-19.

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 1990 and 2019 according to GBD, as measured by age-standardised YLDs per 100,000 population. It also shows the change in YLDs since 1990.

Overall, the top 3 leading causes of morbidity in the North West in 2019 were lower back pain, depressive disorders and headache disorders.

Sex: for females, the top 3 causes of morbidity in 2019 were lower back pain at 1,306 years lived in disability per 100,000 population, headache disorders at 932 years and gynecological diseases at 864 years. In males, the top 3 were low back pain at 960 years lived in disability per 100,000 population, diabetes mellitus at 724 years and depressive disorders at 611 years.

Diabetes mellitus showed the largest change over time in both females and males, but change over time needs to be interpreted with caution as this may reflect changes in methodology and categorisation.

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 Global Burden of Disease, in 2019, mental health conditions such as depression and anxiety accounted for 14.1% of total morbidity in the North West.

Figure 17a shows trends in wellbeing up to 2020/21, measured by 4 indicators: anxiety, low happiness, low life satisfaction and low worthwhile feelings.

Anxiety: the percentage of people self reporting anxiety in the North West and England decreased from 2011/12 to 2018/19. Since then, the proportion has been increasing steeply and in 2020/21 25.7% of the North West reported feeling anxiety, compared with 24.1% for England.

Low happiness: the percentage of people self reporting a low happiness score in the North West and England decreased between 2011/12 and 2018/19. Since then, the proportion of people reporting low happiness has been increasing and in 2020/21 10.3% of the North West reported low happiness, compared with 9.2% for England.

Low satisfaction: the percentage of people self-reporting low satisfaction in the North West decreased between 2011/12 and 2017/18. In England the period of decrease continued for an additional year until 2018/19. In the North West since 2017/18 the proportion has been increasing and in 2020/21 7% of the residents reported feeling low satisfaction, compared with 6.1% for England.

Low worthwhile: the percentage of people reporting a low worthwhile score follows the same pattern as the indicators above with a decrease both regionally and nationally followed by an increase in the last few years. In 2020/21, 5% of the North West respondents stated they felt low worth compared with 4.4% in England.

Local authority: the results at local authority level are similar. For self-reported anxiety only 2 local authorities have values statistically significantly different from the North West (25.7%). Wirral (32.4%) has a statistically significantly higher percentage of people and Lancashire (21.9%) has a statistically significantly lower percentage.

For self-reported low happiness there is slightly more variation. Again Wirral (14.9%) report a statistically significantly higher percentage than the North West (10.3%) and 3 local authorities report statistically significantly lower values than the region: Lancashire (7.0%), Blackburn and Darwen (7.3%) and Stockport (7.5%).

Data for self reported low satisfaction and low worthwhile scores are poorly populated at the local authority level.

Figure 17 – Mental health and wellbeing

Figure 17a - Trends
<b>Source:</b> <a href = 'https://fingertips.phe.org.uk/public-health-outcomes-framework#page/0/gid/1000042/pat/15/par/E92000001/ati/6/are/E12000004/yrr/1/cid/4/tbm/1' target = '_blank'> OHID Public Health Outcomes Framework </a> <b>Date accessed:</b> 31/03/2022 <a href = 'https://fingertips.phe.org.uk/static-reports/health-profile-for-england/Data/North_West_017a_mental_health_and_wellbeing.csv' target = '_blank'><b>Download data</b></a>

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 shows that trends in emergency hospital admissions for self-harm ranged from 253.2 per 100,000 in 2010/11 to 225.0 in 2020/21. Rates of emergency admission for self-harm have continuously been higher in the North West than in England. Trends for suicide have remained consistent, from 10.8 per 100,000 in 2010-12 to 10.7 in 2018-20. Over time the gap between the North West and England has narrowed and in the most recent period (2018-20) the North West has a suicide rate only slightly higher than England.

Local authority: rates of admission are generally higher for females compared to males for self-harm, whereas suicide follows the opposite trend. At local authority level, St. Helens has the highest directly standardised rate for self-harm in females at 534.0 per 100,000 and Blackpool has the highest directly standardised rate of suicide for males at 26.9 per 100,000.

Figure 18 – Suicide and Self-harm

Figure 18a - Trends
Figure 18b - Local Authority

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

Dementia and Alzheimer’s disease

According to the Global Burden of Disease, Alzheimer’s disease and other dementias accounted for 1.2% of total morbidity (years lived with disability) in the North West in 2019 and (as discussed earlier in the report) are a leading cause of death.

In the North West the recorded prevalence of dementia for people of all ages was 0.7% in 2020/21. For people aged 65 years and older recorded prevalence was 4.0% in 2020. The dementia 65+ estimated diagnosis rate for the North West was 65.9% in February 2022, compared with the England value of 61.7% (not statistically significantly different).

Cancer

According to the Global Burden of Disease, cancers accounted for 2.17% of total morbidity (years lived with disability) in the North West in 2019 and (as discussed earlier in the report) are a leading cause of death.

Figure 19a shows that the trend in new cancer diagnoses for all sites combined and the four main cancers (breast, prostate, colorectal and lung) declined in March 2020. Cancer diagnoses began to increase again as the COVID-19 pandemic progressed. The total number of new cancers diagnoses in April and May 2020 were around a third lower than in the earlier months of 2020. By September 2021, diagnosis rates of new cancers had not yet returned to pre-pandemic levels in the North West. This applies to the 4 main cancers and all sites combined.

Health service contact during the pandemic


The reduced admissions, GP consultations, A&E attendances and health seeking behaviour observed during this period 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.


Emergency hospital admissions (all cause) decreased in the North West from 11.4 per 1,000 in January 2020 to 7.1 per 1,000 in April 2020. In comparison, in April 2021 emergency hospital admissions had increased to 10.3 per 1,000. The latest data for July 2021, shows hospital admissions are statistically significantly lower still than pre-pandemic at 10.4 per 1,000.

Hospital outpatient attendances in the North West followed a similar trend falling from 152.6 per 1,000 in January 2020 to 73.3 per 1,000 in April 2020. By April 2021, the rate has increased back to a rate of 139.6 per 1,000. The most recent data for July 2021 shows that hospital outpatients attendances are still statistically significantly lower than pre-pandemic levels at 141.1 per 1,000.

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

Introduction

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 and 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. These wider determinants are discussed in the next section of this report. At the time of writing GBD 2019 results for regions and local authorities were available but update is due early 2022. This section focuses on behavioural and metabolic risk factors in adults. It 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.


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 in England remained much higher than average in some groups. For example, people in manual occupations (23.2%), people with a long-term mental health condition (25.8%), deprived areas (16.9%), and the Mixed ethnic group (19.5%).

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. Health Survey for England evidence suggest that 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.


Leading risk factors

The risk factors making the biggest contribution to mortality in the North West region are tobacco, high blood pressure, diet and high blood glucose. These also make a significant contribution to morbidity along with high body mass index (or obesity), alcohol, drug use and occupational risks. Please note that the disease burden attributable to specific risks are independently calculated for each risk factor. Risk factors attributed to YLDs or deaths cannot be summed together.

Smoking

The latest Annual Population Survey (APS) estimates shown in Figure 21a suggest that the percentage of adults smoking has declined in England and the North West. The most recent smoking prevalence in adults data from 2019 show that 14.5% in adults in the North West smoke compared with 13.9% for England.

Inequalities: smoking prevalence remains much higher than average in different groups. Among people in manual occupations, 22.9% were estimated to be smokers in 2020, higher than the general population estimate of 13.4%. National smoking prevalence inequalities data shows that smoking prevalence in adults in most deprived decile (15.5%) is almost 2 times higher than in the least deprived (9.2%). Prevalence is also higher in those with a long term mental health condition: in 2019/20 the prevalence was 27.8% compared with 15.1% in the general adult population. Please note that this data comes from the GP Patient Survey whereas previous data comes from the Annual population Survey and therefore the values are different.

Local authority: Figure 21b shows smoking prevalence data by local authority in 2019. 5 local authorities have a statistically significantly higher percentage of adults smoking that the North West average (14.5%). The local authority with the highest percentage was Blackpool at 23.4% and the lowest proportion (9.1%) was found in Trafford.

Recent methodological changes mean that current prevalence from the APS cannot be reliably compared with previous years, but according to previous surveys in the last two decades smoking rates have been decreasing. Other data sources suggest that this trend continues. There is evidence of an increase in the rates of people attempting to quit smoking during the pandemic. Although the rates have fluctuated, quit rates remained consistently higher than in 2019. Analysis of Opinion and Lifestyle Survey suggests that across all regions the latest smoking prevalence is lower compared with 2019, London being the only exception.

Alcohol

Increasing and high-risk drinking is defined as drinking more 14 units per week and up to 35 units for women and up to 50 units for men. In 2019 the prevalence of ‘increasing or higher risk’, in the North West was 26.9%.

Local authority: Health Survey for England estimates for local authorities in 2015-18 show variation in the North West. The local authority with the lowest percentage drinking more than 14 units a week was Knowsley (17.6%), with the highest being Cheshire West and Chester (30.4%). No local authority had a significantly lower rate than the England average and 3 had statistically significantly higher rates than England.

The number of deaths related to alcohol in the North West was 3,247 in 2020, which represents a rate of 45.7 per 100,000 population and is statistically significantly higher than the England average.


HPfE 2021 reported differences in drinking patterns by age and income. ‘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 [19]. This inverse relationship between consumption and harms 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 [20] to patients, such as blood pressure and cholesterol control, and may also result in an increase in long-term health complications.


Drug use

Pre-pandemic survey-based estimates for recent drug use in England vary year-on-year. 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 continue to be highest among those born in the 1970s. In the North West region the rate of deaths due to drug misuse was 7.1 per 100,000, and significantly higher compared with the England average.

An investigation of local authority data shows a significant degree of variation. In the 2018-20 data Blackpool (22.1 per 100,000) had the highest rate of deaths due to drug misuse and Cheshire East the lowest (3.3 deaths per 100,000).

Physical activity

The definition of being physically active is taking at least the recommended level of 150 minutes of moderate intensity physical activity or equivalent per week. In 2019/20, 63.9% of adults (19+ years) were physically active in the North West, statistically significantly lower compared with the England proportion of 66.4%. There was variation by local authority, with 14 local authorities in the North West having a proportion of physically active adults (19+ years) statistically significantly lower than the proportion for England.

In contrast, adults (19+ years) doing less than 30 minutes of moderate intensity physical activity or equivalent per week are classified as physical inactive. In 2019/20, 25.2% of adults (19+ years) in the North West were physically inactive, statistically significantly higher compared with the England average of 22.9%. The percentage of the population (19+ years) who were physically inactive in 12 North West local authorities is statistically significantly higher than the England value.


As with children, England level findings in 2020/21 from Sport England uncovers wide inequalities in physical activity in adults. The proportion was lower for people who have 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 (48%) and Black (52%) ethnic groups.


Diet

The proportion of the population meeting the recommended ‘5-a-day’ on a ‘usual day’ was 51.2% in the North West region. This is lower than the England average of 55.4% in 2019 to 2020. There is significant variation by local authority in the North West. The majority (15 out of 23) of local authorities have a statistically significantly lower proportion of people meeting the ’5 a day recommendation2, only 1 has a significantly higher proportion.

HPfE 2021 reported wide inequalities at England level. The recommended 5-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%), and those who were Asian (47.2%), Black (45.7%), or living in the most deprived areas (45.7%).


Obesity

Figure 21a demonstrates that in the North West region, the levels of obesity and overweight have risen between 2015 and 2019, with the rate currently at 65.9% in 2019 and significantly higher compared with the England average.

Local authority: Figure 21b shows the variation by local authority. 7 local authorities in the North West have a statistically significantly higher percentage of their adult population who were overweight or obese than the North West percentage. Knowsley (74.0%), Wigan (73.7%) and Wirral (71.8%) had the highest percentage in the North West in 2020/21, and Cheshire West and Chester had the lowest (60.2%).


As with other risk factors, there are inequalities in adult obesity prevalence by age, sex and deprivation. HPfE reported that in 2019 it was lowest in those aged under 25 years with a gradual increase by age group up to ages 65-75 years after which prevalence decreases. This pattern was seen for both males and females. 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 we will see an increase and a widening of inequalities.


High blood pressure

Figure 21a shows that the prevalence of high blood pressure (hypertension) in the North West has shown little change between 2015 (14.4%) and 2020 (14.6%). There was some variation by local authority for 2020/21, as shown in Figure 21b. The highest prevalence of hypertension was for the Blackpool at 17.9% and the lowest for Manchester at 10.0%. However, this indicator only includes diagnosed prevalence.

The Public Health England (PHE) CVD Prevention Packs show the percentage of the estimated hypertension prevalence which has been diagnosed. In 2019/20 this ranged from 61.4% in Morecambe Bay CCG to 76.3% in Blackpool CCG.

Once diagnosed it is important that a patients’ blood pressure is managed. Again, there was variation in management across the region, ranging from 64.4% of hypertension patients treated to target in South Sefton CCG to 75.1% in Salford CCG in 2019/20.

Blood glucose

Analysis from 2015 estimated that there were approximately 657,000 people across the NHS North West region with Non-Diabetic Hyperglycaemia (NDH). Within the North West NHS commissioning region, NDH registrations vary from 3.3% (Greater Preston CCG) to 9.6% (Wigan Borough CCG and Bury CCG). Rates of detection of NDH may not reflect the prevalence of the condition as they are heavily influenced by screening rates (50).

The NHS Diabetes Prevention Programme (NHS DPP) delivers evidence based behavioural interventions that can prevent or delay the onset of Type 2 diabetes in adults who have been identified as having NDH. For the NHS North West region in 2020/21, 23.7% of those registered with NDH had been offered a place on an NHS DPP course. In 2020/21 values ranged from 0.3% in Bolton CCG to 55.1% in Heywood, Middleton and Rochdale CCG.

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
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

Introduction

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 [21]. 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.

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 also 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.

Fuel poverty: fuel poverty is now measured by the new Low Income Low Energy Efficiency (LILEE) statistic. 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. According to this measure in 2019 the North West was ranked in the middle of English regions (4/9) for proportion of fuel poverty but had a greater percentage of households defined as fuel poor (14.5%) than the England average (13.4%). The proportion for local authorities in the North West ranges from 10.9% in Cheshire East to 19.8% in Manchester.

Natural environment: living in a greener environment can promote and protect good health, aid recovery from illness and help with managing poor health. Green space can help to bind communities together, reduce loneliness, and mitigate the negative effects of air pollution, excessive noise, heat and flooding [22].

Homelessness: homelessness and the use of temporary accommodation remain at high levels in England (106). According to this measure the rate of households owed a duty under the Homeless Reduction Act in the North West in 2020/21 was - 11.9 per 1,000 households. This is statistically significantly higher than the national rate of 11.3 per 1,000 households.

Employment


HPfE 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%). There has also been a decline in the number of 16 and 17 years 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. These are industries with a high proportion of the workforce who are relatively young.


Good employment improves health and wellbeing across people’s lives, boosting quality of life and protecting against social exclusion.

In the North West, employment had been increasing up to 2019/20. However, within the first year of the pandemic, employment had shown a downturn. Compared with England as a whole, the North West has consistently had lower employment rates. As shown in Figure 22a there are also differences between males and females in the region. The percentage of females in employment has historically been lower compared with males and ranged from 64.3% in 2011/12 to 70.6% in 2019/20. During the first year of the COVID-19 pandemic (2020/21) the percentage of females in employment decreased to 69.8%. For males, the percentage in employment increased from 72.0% in 2011/12 to 79.2% in 2019/20. In 2020/21 the proportion of males classed as employed decreased to 76.6%.

Local authority: Figure 22b demonstrates the inequality in employment rates at local authority level across region. In 2020/21 3 local authorities had employment rates in people aged 16-64 years that were statistically significantly higher than the North West rate (73.2%), Warrington (79.8%), Cheshire West and Chester (79.3%), and Wigan (77.4%). 4 local authorities had a percentage of the 16-64-year-old population in employment statistically significantly worse than the North West percentage with the remaining 16 not being statistically different to the regional value.

Source: PHE Public Health Outcomes Framework Download data

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 [24, 25]. Income is related to life expectancy, disability free life expectancy [26], and self-reported health [27]. 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 [28]. It can also influence health through feelings of shame, low self-worth and exclusion [29].

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 [30]. Figure 23a shows the trend in the North West for the MIS in children and all ages between 2016/17 and 2018/19. The percentages of individuals in the North West not reaching MIS is stastisically higher in the North West compared with England. In the North West in 2018/19, 31.8% of the population did not reach the MIS. The percentage is higher in children (48.0%).

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 [31]. 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 [32].

Level of development at the end of Reception year In the North West by the end of reception, 68.9% of children are achieving a good level of development in 2018/19. This is statistically significantly lower than the England value of 71.8%. In the North West, there were statistically significant differences between the sexes. 75.9% of female and 62.2% of male children were achieving a good level of development at the end of reception. In 2018/19 at local authority level the majority of local authorities in the North West (15 out of 23) had a significantly worse proportion of children achieving a good level of development at the end of Reception. Only 2 local authorities had a significantly higher proportion than the England average: Trafford and Warrington.

GCSE results (Attainment 8) Attainment 8 measures pupil’s results in 8 GCSE-level qualifications. The average ‘Attainment 8’ score for pupils in North West was 49.6 out of 90.0 in the 2019/20 academic year, lower than the score for England (50.2 out of 90.0). A difference between the sexes was apparent with an average score for females in the North West of 52.6 out of 90.0 and a score for males of 46.7. At local authority level the average score ranges from 37.8 per 90.0 for Knowsley to 60.2 out of 90.0 for Trafford. The data also shows that the average Attainment 8 score for pupils in the 2019/20 academic year varied by ethnic group. Pupils from the Chinese ethnic group had the highest average Attainment 8 score out of all ethnic groups (68.2 out of 90.0). White pupils had the lowest score (49), followed by Black pupils (49.3).

Not in education, employment, training, or whose activity was not known (NEET) In 2020, 5.3% of young people aged 16 to17 years in the North West were not in education, employment, training or whose activity was not known (NEET). This is significantly better than the England value of 5.5%. A statistically significant difference between sexes was also observed, with 4.4% of female and 6.2% of male young people age 16 to17 years classified as NEET. There was a large variation between local authorities in the North West in 2020. Blackpool (8.9%), Liverpool (8.4%), Knowsley (7.9%), Manchester (7.6%), Salford (6.1%) and Lancashire (5.8%) all have a statistically significantly higher proportion when compared with the England average (5.5%).

Health protection

Introduction

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 [33].

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).

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. 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.

Impact of the pandemic on infectious diseases

The level of testing for 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. In addition, as demonstrated by the reduction in MMR (measles, mumps, rubella) vaccine coverage, childhood vaccinations were also interrupted during the pandemic while flu vaccination coverage was considerably higher than previous years. Flu vaccine uptake in England from 1 September 2020 to 28 February 2021 was 80.9% for patients aged 65 years and over compared with 72.4% in 2019 to 2020.

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 [33]. Figure 24a shows the trend in the level of air pollution from man-made fine particulate matter for the North West and England. The trend between 2011 and 2020 has been variable, with a peak during 2016. In 2020, the level of air pollution from man-made fine particulate matter was 6.1µg/m3 in the North West compared with 6.9µg/m3 for England. The concentration of fine particle matter has been consistently lower in the North West compared with England.

There is some variation in levels of mean fine particulate matter air pollution across the local authorities in the North West (Figure 24b). In 2020, with more rural areas like Cumbria (4.0 µg/m3), Cheshire West and Chester (5.4 µg/m3), Lancashire (5.5 µg/m3) and Cheshire East (5.6 µg/m3) and having a lower mean concentration of fine particle matter compared with urban areas like Liverpool (7.3 µg/m3) and Manchester (7.0 µg/m3).


HPfE 2021 highlights that the highest air pollution exposures have been in deprived urban environments therefore contributing to health inequalities. During the pandemic, up to July 2021, there were fewer vehicles on the roads, which had a favourable impact on air pollution levels. Social restrictions implemented during the pandemic meant that there were fewer vehicles on the roads, as people were asked to stay at home, which had a favourable impact on air pollution levels. Motor vehicle use fell notably 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 [34].

Social restrictions implemented during the pandemic meant that there were fewer vehicles on the roads, as people were asked to stay at home, which had a favourable impact on air pollution levels. Motor vehicle use fell notably 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 [34].


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

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 [35] 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.


Chlamydia

Figure 25a includes a chart showing the trend in diagnostic rates for chlamydia (aged 25+ years) between 2012 and 2020. In the North West rates rose from 154.5 per 100,000 in 2012 to 191.6 per 100,000 in 2019, before declining in 2020 to 133.7 per 100,000.

Figure 25b includes a chart showing the variation in chlamydia diagnostic rates for local authorities in the North West for 2020. The local authority with the highest chlamydia diagnostic (aged 25+) rate per 100,000 in the North West is Manchester (296.4 per 100,000) and the lowest is Bolton (67 per 100,000).

The trend in detection rates for chlamydia (aged 15-24) for the North West has been less clear compared with diagnostic rates for chlamydia (aged 25+ years). In 2012, the detection rate for chlamydia (aged 15-24 years) was 2,361 per 100,000, the detection rate in the North West gradually declined to 2,003 per 100,000 in 2019 and fell sharply in 2020 to 1,249 per 100,000.


HPfE 2021 reported that 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 [36].


Gonorrhoea

Figure 25a includes a chart showing the diagnostic rates for gonorrhoea in the North West between 2012 and 2020. Rates for gonorrhoea rose from 44.5 per 100,000 in 2012 to 97.7 per 100,000 in 2019; before declining to 65.6 per 100,000 in 2020.

Figure 25b includes a chart showing that in 2020 the local authority with the highest gonorrhoea diagnostic rate per 100,000 in the North West was Manchester (296.4 per 100,000), the lowest was the Cumbria (18.6 per 100,000).

Genital warts

Figure 25a includes a chart that shows the diagnostic rates for genital warts between 2012 and 2020. In the North West the rate declined between from 147.3 per 100,000 in 2012 to 45.5 per 100,000 in 2020.

Figure 25b includes a chart that shows that in 2020 the local authority with the highest genital warts diagnostic rate per 100,000 in the North West is Manchester (91.4 per 100,000) and the lowest is Cheshire West and Chester (20.7 per 100,000).

Syphilis

Figure 25a includes a chart showing that in the North West the diagnostic rate for syphilis increased from 5.5 per 100,000 in 2012 to 13.6 per 100,000 in 2019; before declining to 9.6 per 100,000 in 2020.

Figure 25b includes a chart that shows that in 2020 the local authority with the highest syphilis diagnostic rate in the West was Manchester (32.6 per 100,000), and the lowest was St Helens (2.8 per 100,000).

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


HPfE 2021 reported that 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. 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.


The number of new cases of tuberculosis (TB) have fallen notably in England over the last century. Figure 26a shows the trend in TB incidence (new cases per 100,000 population) between 2000 and 2020. In the North West there has been a steady decline in the TB incidence rate since 2011, generally mirroring that seen for England. In 2020, the incidence rate was 6.2 per 100,000 in the North West compared with 7.3 per 100,000 for England.

Figure 26 – Tuberculosis

Figure 26a - Trends

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

Vaccines and vaccine preventable infections

As a result of effective vaccination programmes the incidence of many diseases has reduced significantly over time and the importance of vaccination in controlling infectious diseases is highlighted by the COVID-19 pandemic as discussed earlier.

Influenza vaccination uptake rates 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. Influenza vaccine uptake in GP registered patients from 1 September 2020 to 28 February 2021 in England was 80.9% for patients aged 65 years and over compared with 72.4% in 2019 to 2020, and 53.0% for patients aged 6 months to under 65 years in one or more clinical risk groups compared with 44.9% in 2019 to 2020 [37]. As a consequence of this and the social distancing measures introduced for the COVID-19 pandemic, influenza and other seasonal respiratory viruses were much lower in 2020 to 2021 than in other seasons.

Advice from the Joint Committee on Vaccination and Immunisation (JCVI) on routine childhood immunisations stated that children should continue to receive vaccinations according to the national schedule during the COVID-19 pandemic [38]. Measles is a highly infectious disease which can only be controlled by vaccination. People who have not received 2 doses of the MMR (measles, mumps, rubella) vaccine are at risk of developing measles. In 2020/21 only 86.6% of children in England aged 5 had received the 2 doses.

Monthly monitoring of MMR vaccination coverage shows that the measures implemented to manage the pandemic have impacted vaccination uptake. MMR (first dose) monthly vaccine coverage estimates measured at 18 months of age from 2019 to 2021, show a decrease from April 2020. The largest decreases were seen in data for August to November 2020, reflecting a decline in uptake within the cohort of children who would have been eligible for the vaccine during the March to May 2020 lockdown. In May 2021, 86.4% of infants were vaccinated with MMR (first dose) by 18 months of age. This is a 1.7 and 1.5 percentage point reduction on May 2019 and May 2020 respectively.

Antimicrobial resistance

Antibiotic-resistant bloodstream infections rose by an estimated 32% between 2015 and 2019 in England. Figure 27a shows the trend in the rate of antibiotic prescribing in primary care in the North West and England between 2015 and 2020. Antibiotic prescribing in primary care is often measured as an indirectly standardised ratio per STAR-PU (STAR-PUs 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 North West and England has fallen every year, with the largest drop between 2019 and 2020. In 2020 the indirectly standardised ratio per STAR-PU in the North West was 0.87 compared with 0.75 for England.

There is regional variation in primary care antibiotic prescribing. 15 local authorities have rates significantly higher than the North West average and 6 statistically significantly lower.

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 Health Profile for England has provided a comprehensive snapshot of the nation’s health, updating many indicators presented in previous reports. The report has also provided an early summary of the impact of the COVID-19 pandemic on many aspects of health and health inequalities.

The report has highlighted how the direct impact of COVID-19 pandemic has disproportionally affected people from ethnic minority groups, people living in deprived areas, older people and those with pre-existing health conditions.

There have been substantial indirect effects on children’s education and mental health, and on employment opportunities across the life course, but particularly for younger people working in sectors such as hospitality and entertainment. In addition, it is clear that access and use of a range of health services has been disrupted during the pandemic and the long-term effects of this is not yet realised.

Data on many aspects of health during the pandemic are not yet available but will be added to the Wider Impacts of COVID-19 on Health (WICH) monitoring tool where possible and summarised in future Health Profile for England reports. Continued monitoring of the indirect impacts of the pandemic on the nation’s health and health inequalities will remain a priority.

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