Health Profile of the South West of England 2021
Overview
This report is a comprehensive review of health in the South 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 agenda 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 continues to decline and antibiotic prescribing both continue to decrease.
Introduction
This profile brings together data and knowledge to give a broad picture of health in the South West. The report provides a regional view of health and indicators presented in the Health Profile for England 2021, first produced by Public Health England (PHE) in 2017(1).
As the first edition of the Health Profile for South 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:
overview of the population of the region
COVID-19
mortality and life expectancy
child health
adult health
risk factors associated with ill health
the wider determinants of health
health protection issues
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.
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
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 South West, usually as a trend over several years. Regions are defined as Government Office Regions (GORs). Where this isn’t possible other geographical region definitions are used as indicated in the supporting information.
Inequalities - how the indicator varies between different groups in South 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.
Overview of the population of South West
The region is home to 5,731,100 residents, and the population is growing (2). Overall the population within the region tends to experience better than national average outcomes, such as higher life expectancy and lower levels of poverty and deprivation. However, there is significant variation within the region, with some communities and populations experiencing significant challenges (3).
Life expectancy
Life expectancy in the South West is 83.8 years for females and 80.1 years for males, which is better than England’s average life expectancy for women (82.6 years), and better for men (78.7 years) (2020). From birth, men living in the South West can expect to live 65.2 years in good health (rather than with a disability or in poor health) and for women the figure is 65.0 years (3).
Age Structure
22.4% of the South West region population is over 65, mostly in the shire county areas with the larger urban areas of Bristol, Plymouth, Swindon, Bournemouth and Bath Spa having younger populations closer to the England average (4). The region has a greater proportion of the over 65 population living alone than the national average (5). The proportion of population 85 or over is higher than the England average generally, except for the larger urban areas (Bristol, Plymouth and Swindon) which are similar to the national figure (6).
Ethnicity
From the 2011 census, the proportion of white people in the region was 95.4% with Asian/Asian British being the second highest proportion at 2.0%. The proportion of white people in the region is high compared to the England average of 85.4% (7).
Key features of the region
The South West of England is a beautiful scenic region with open moorland, sandy beaches, urban centres and rural communities. It is the largest of England’s nine regions, covering Cornwall in the south through to Gloucester in the north. Large cities include Bristol, Cheltenham, Exeter, Plymouth and Swindon. There are two national parks within the South West, Dartmoor and Exmoor, four World Heritage Sites and areas of outstanding natural beauty.
The region’s population is served by:
1 Ambulance provider, SWAST
5 Police force areas
6 Fire & rescues services
15 Upper tier local authorities and 25 district authorities
7 Integrated Care Systems
19 Hospitals with an A & E
1,192 GP practices
11 Prisons
1,859 Primary schools
322 Secondary schools
Picture of health: An intelligence framework for the South West
The South West also produces an interactive dashboard Picture of health: An intelligence framework for the South West (8). This is a resource which provides our updated place-based regional health needs assessment to help identify regional priorities by providing a snapshot of key public health indicators including analysis of causes of mortality by age group, deprivation, and demographics. This tool can be used with local authority JSNAs which provide greater granularity of data and information.
Key Findings
Much of the data in this report describes the impact of the pandemic on the population of the South West and their health outcomes. It also provides insight into how the pandemic may have exacerbated existing conditions.
The blog that accompanied the release of the Health Profile for England: 2021 identified 5 important points about how the population’s health has been affected directly and indirectly by the pandemic (9). This report has highlighted similar issues within the South West:
1. Mortality was higher than previous years
COVID-19 featured in the top five leading causes of deaths for both men and women with over 8,000 deaths registered in the South West with COVID-19 mentioned on the death certificate by the end of 2021
Compared to death rates in previous years, deaths among men were 1.08 times higher during the pandemic and 1.07 times higher in females
Excess deaths across all age groups led to a significant reduction in life expectancy of 0.5 years for males and 0.7 years for females in 2020
Within the region, Bristol and Swindon were two of the areas that the life expectancy was significantly lower in both males and females. This may be driven by the higher death rates and excess deaths seen among those in more deprived areas and in certain ethnic groups who have greater levels of representation in these areas
2. Diagnosis rates fell considerably for dementia, cancer and sexually transmitted diseases
In the South West region, there was a decline in the estimated dementia diagnosis rate between 2019 and 2021 equating to 3,059 fewer dementia diagnoses being made
During the period between April to July 2020, new cancer diagnoses dropped significantly in the South West before returning to pre-pandemic levels from December 2020
Sexually transmitted infections (Gonorrhoea, Chlamydia, Genital Warts and Syphilis) all had large falls in diagnosis rates in 2020 despite continual increases in the diagnosis rates of Gonorrhoea, Chlamydia and Syphilis between 2012 and 2019
3. Health services were not used as much, but vaccination uptake has increased
Emergency hospital admissions from all causes dropped to 22.3% in the first quarter of 2020/21 and the elective hospital admissions for all causes dropped to 60% in the first quarter of 2020/21. They remain below pre-pandemic levels
Data that measured the number of first treatments for cancer over the pandemic shows in the South West region, there was a deficit of 2,987 new treatments between March 2019 and September 2021
There was, however, an increase in influenza vaccination uptake rate in the South West region particularly in those over 65 years old from 73.7% in 2019/20 to 82.8% in 2020/21, higher than the target of 75%
In children, the Measles, Mumps and Rubella (MMR) vaccination rate saw a slight increase in uptake from 93.0% in 2018/19 to 93.3% in 2020/21. Almost all the South West areas reached the 95% target rate for two doses by the age of 5 with the exception of Swindon and Bristol
4. Children’s health and development may have suffered
Despite a lack of data, initial studies suggest that 76% of 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
Childhood obesity in the South West continues to increase in the region with 9.3% of boys and 8.9% of girls aged 4 to 5 (Reception year) in the region being obese. Despite being lower than the England average, obesity remains a concern. Recent evidence shows that measures taken during the pandemic have further limited physical activity in children, which may exacerbate these health issues in the South West
5. Mental health and wellbeing were greatly affected by the pandemic
A significantly higher proportion of people in the South West self-reported high anxiety scores, low worthwhile scores, and low happiness scores in 2020 compared to the previous year
This may be attributed to a range of social and environmental factors that came about or that were exacerbated due to the pandemic, including lockdowns with prolonged isolation, the death of loved ones, job security concerns, loss of employment, financial concerns, poor health or health concerns
Employment in the South West fell by 1.8 percentage points in males and by 1.1 percentage points in females in 2020/21
COVID-19
Introduction
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.
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. National research highlighted that 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 (10). 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 (12). The possible reasons for these differences and further interpretation of ethnic inequalities in COVID-19 mortality rates are discussed in depth elsewhere (13,14,15).
Detailed analysis and charts
COVID-19 cases
In the South West, at the end of December 2021 (Figure 1a):
just over 980,000 confirmed cases of COVID-19 had been reported
the region’s highest 7-day average case rate occurred on 29 December 2021 at 12,117 cases per 100,000 population that week. The number of cases on that day was 14,467
Evidence on inequalities in COVID-19 cases and deaths has emerged throughout the pandemic. As in the rest of the country, in the South West, the cumulative age standardised case rates per 100,000 population in the region have significantly differed by age, sex and ethnicity (Figure 1b):
case rates were higher in females (18,084) than males (16,457) per 100,000 population
rates were significantly higher in age groups 0 to 24 years (23,124) and 25 to 49 years (21,351) per 100,000 population, compared to older age group
case rates are significantly higher in the most deprived decile (18,077 per 100,000 population) compared to the South West average (17,303)
lowest case rates were in mixed/multiple ethnic groups (15,896 per 100,000 population), and white (16,897) but significantly higher than the South West average in any other ethnic group (25,642), black/black British (20,413), and Asian/Asian British (19,101)
cases were significantly lower in the least densely population areas compared to more densely populated areas
Across Local Authorities (Figure 1c) the cumulative case rates were generally highest in: Bristol and Bournemouth, Christchurch and Poole, and lowest in Cornwall & IoS and Devon.
- the three highest cumulative rates per 100,000 population were in Bristol, Bournemouth, Christchurch and Poole and South Gloucestershire and lowest in Dorset, Devon and Cornwall and the Isles of Scilly
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
Deaths involving COVID-19
At the end of December 2021 (Figure 2a):
there were 8,374 deaths registered with COVID-19 mentioned on the death certificate in the South West region (17)
the region’s highest 7-day age-standardised mortality rate occurred in January 2021 at 103 deaths per 100,000 population that week
There are wide inequalities in death rates involving COVID-19 and the cumulative age-standardised mortality rates in the region (Figure 2b):
were significantly higher in males than females, with the rate of 191 in males compared to females at 115 per 100,000 population
increased with age and were significantly higher in the over-65 age groups. The highest death rate was in the 85+ age group at 2,733 per 100,000 population, approximately 4 times higher than for these aged 75-84
were in line with the national findings, death rates were significantly higher in the two most deprived deciles - cumulative age-standardised mortality rates in the most deprived decile was 221.5 per 100,000 compared to 138.9 per 100,000 in the least deprived area
were significantly higher than the South West average in the any other ethnic group (347 per 100,000 population) followed by black/black British (258 per 100,000 population) and Asian/Asian British (247 per 100,000 population). The white ethnic group had a significantly lower rate (143 per 100,000 population)
deaths were significantly higher in the more densely populated areas
Cumulative Age-standardised COVID-19 mortality rates per 100,000 were highest in Bristol, Bournemouth Christchurch and Pool and Swindon and lowest in Dorset, Torbay and Devon (Figure 2c).
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
Excess mortality during the COVID-19 pandemic
National data has shown that 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 (18).
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.
Inequalities are illustrated in Figure 3b, with excess mortality:
1.08 times higher in males and 1.07 times higher in females
higher than expected in age groups over 25, with the highest excess deaths in those aged 85+
1.09 and 1.03 times higher in males and females than expected in the most deprived areas compared to 1.13 and 1.11 times higher in males and females in the least deprived areas
highest in other ethnicity group, with males 1.3 times higher and females 1.8 times higher than expected
for those dying in a hospice, rates were 0.76 times lower than expected rates
highest at local authority level in Bournemouth, Christchurch and Poole (1.1 times higher), Bath and North East Somerset (1.1 times higher) and Bristol (1.1 times higher).
Note: Value for Cornwall have been combined with Isles of Scilly
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
By the end of Dec 2021, 4,240,109 (80%) of the South West population aged 18 and over had received 2 doses (19). Figure 4a shows overall uptake of each dose. However, as Figure 4b shows, there has been variation in uptake by:
country of birth - with just over 10 percentage point difference for those born in the UK compared to those non-UK born residents
English language proficiency - 90.5% for those whose main language is English compared to 71.6% for those for whom English is not their main language
sex - 88.6% of males had received 2 doses of the vaccine compared to 91.1% of females
those who report having some level of disability had similar uptake levels
deprivation - 93.1% in the 5th least deprived areas compared to 84.4% in the 5th most deprived areas
ethnicity - vaccination rates were lowest in black Caribbean (67.6%) and black African (70.5%) ethnic groups, and highest in white British (91.0%)
household tenure - with highest uptake of vaccination in those who owned their own house (93.0%) and lowest for those living in social rented accommodation (80.8%)
religion - the lowest vaccination rate for those describing themselves of Muslim faith (75.1%) compared to 92.3% for those who identified as of Christian faith
rural/urban population - vaccination rate of 89.1% among urban populations compared to 91.8% among rural
socio-economic classification - lowest in those classed as never worked and long-term unemployed at 73.8%, and highest in those describing themselves as working in higher managerial, administrative and professional occupations (93.4%)
Figure 4c shows data at local authority level. The lowest rate of vaccination uptake was in Bristol and the highest was in Dorset.
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
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.
Detailed analysis and charts
Life expectancy
In the South West region, life expectancy at birth from 2001 to 2020 in general has steadily increased for both males and females (as shown in Figure 5a). However, in 2014 to 2015 there was a decrease in life expectancy for both males and females. Compared to 2019, life expectancy also fell in 2020 by 0.5 years for males to 80.1 years and by 0.7 years for females to 83.8 year, however, this was less of a decrease than seen in England.
Figure 5b shows life expectancy reduction between 2019 and 2020 by deprivation deciles. Life expectancy is highest for both males and female in the least deprived decile of the population, and lowest in the most deprived decile. The reduction in life expectancy is observed regardless of deprivation or sex.
Figure 5c shows differences in life expectancy by local authority. Life expectancy was significantly lower in 2020 for females in Bristol (82.5), Plymouth (82.4) and Swindon (83.2). Life expectancy was significantly lower for males in Torbay (77.9), Bristol (78.6) and Swindon (78.8).
Note: Value for Isles of Scilly have not calculated due to small numbers.
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 (Figure 5b). The measure assumes a linear relationship between the indicator and deprivation (39). The higher the value of the SII, the greater the inequality within an area. Within the South West region in 2020 there was a difference of:
7.0 years between the most and least deprived males in the region, an increase of 0.1 years compared to 2019
5.4 years between the most and least deprived females in the region, a decrease of 0.1 years compared to 2019
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
Breakdown of trends in life expectancy by age or cause of death
The change in life expectancy over the pandemic has been attributed largely to COVID, accounting for an overall reduction of 0.6 years in males and 0.7 years in females in the South West region (Figure 6a).
Figure 6a shows deaths by age and gender and illustrates how deaths among those aged 40 and over had a negative effect on life expectancy over the pandemic. In previous years, improvements in life expectancy among these age groups had been contributing to an increase. Males aged 80 to 89, females aged 70 to 79, 80 to 89 and 90+ made the greatest contribution to a decrease in life expectancy (-0.15 years).
Figure 6b shows the contribution of either age or cause of death to the gap in life expectancy between the most and least deprived and how this has changed over the pandemic:
For males,
in 2019 the greatest contribution to inequalities in life expectancy was made by mortality in those aged 60-69 and 70-79
there has been an increase in the contribution to the gap in life expectancy for both the 40-49 and 50-59 age groups in 2020 compared to 2019
in 2020, the 60 to 69 age group contributed the largest number of years to the difference between the lowest and highest deprivation deciles at 1.8 years
in 2020, COVID-19 contributed 0.4 years to the difference in life expectancy between the lowest and highest deprivation deciles
in both 2019 and 2020, heart disease was the largest cause of the difference in life expectancy between the lowest and highest deprivation deciles at 1.1 years
accidental poisoning was is also notable for its large contribution to inequalities in both 2019 and 2020
For females,
in 2019 the greatest contribution to inequalities in life expectancy was made by mortality in those aged 60-69
there has been an increase in the contribution to the gap in life expectancy in most age group from 10-19 to 70-79 in 2020 compared to 2019 (slight decrease for those aged 60-69)
in 2020, the 70 to 79 age group contributed the largest number of years to the difference between the lowest and highest deprivation deciles at 1.5 years
in 2020, COVID-19 contributed 0.2 years to the difference in life expectancy between the lowest and highest deprivation deciles
in 2019 chronic lower respiratory disease was the largest cause of the difference in life expectancy between the lowest and highest deprivation deciles at 0.8 years, reducing to 0.6 year in 2020. In 2020 the largest differences were observed in deaths categorised as ‘Other’ (0.8 years) and lung cancer (0.8 years)
Addressing inequalities in these diseases would have a substantial impact on reducing inequalities in life expectancy.
Figure 6 – Breakdown of trends and inequalities in life expectancy
Figure 6a
Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data
Figure 6b - Inequalities
Source: OHID COVID-19 Health Inequalities Monitoring for England (CHIME) tool Date accessed: 23/02/2022 Note: Source data are updated monthly and historic data may be revised. Download data
Trends in mortality and leading causes of death
Figure 7a shows trends in age-standardised all cause mortality rates for All ages and for those aged under 75, for both males and females in the South West from 2001 to 2020. Trends in both were generally decreasing over the 20 years. However:
for males:
the All-age mortality rate increased from 1,025.0 per 100,000 population in 2019 to 1,098.3 in 2020
the Under 75s mortality rate increased from 354.7 per 100,000 in 2019 to 372.8 per 100,000 in 2020
for females:
the All-age mortality rate increased from 738.8 per 100,000 in 2019 to 791.4 in 2020
the Under 75s mortality rate increased from 223.4 per 100,000 in 2019 to 239.1 2020
Figure 7b shows data for the most recent years (2020 and 2021) for under 75 years by deprivation decile:
deciles 1 to 4 (most deprived) were significantly higher than the South West average in both 2020 and 2021
the greatest increase between 2020 and 2021 was also observed in the most deprived deciles
Figure 7c shows data for 2019 and 2020 by local authority:between 2019 and 2020, the under 75s mortality rate increased for most local authorities, although this was not statistically significant
the highest mortality rates are observed in Bristol, Bournemouth, Christchurch and Poole, Plymouth, Swindon and Torbay
Note: Values for Isles of Scilly have been combined with Cornwall.
Figure 8a shows the five leading causes of death in each age group over 20 in 2020, based on the number of deaths by underlying cause, for females and males separately. Deaths in children and those aged under 20 are not included in this chart as the number of deaths is small and the leading causes vary from year to year.
Figure 8a refers to deaths registered in 2020. Sudden deaths, those where the cause is unclear and those suspected to be due to certain causes, such as suicide or drug poisonings, can only be registered after referral to a coroner and sometimes an inquest is required which may take months or even years to conclude (20). Although the full impact of the pandemic will not become clear for some time, coroners have reported pressure on the system which may have resulted in lengthier registration delays than previously (21). This may impact on the pattern of leading causes of death presented for 2020:
for males the leading cause of death for All ages was heart disease, and this was also the case for those Aged 50 to 64 and 64 to 79. For those Aged 80 and over the leading cause was dementia and Alzheimer’s disease, the same as for females. In those Aged 35 to 49 it was Accidental poisoning. In the youngest age group, 20 to 34, Suicide and injury/poisoning of undetermined intent was the leading cause of death, the same as for females
for females the leading cause of death for All ages and Aged 80 and over was dementia and Alzheimer’s disease. In those aged 50 to 79 it was lung cancer, and for those aged 35 to 49 was breast cancer. In the youngest age group, 20 to 34, suicide and injury/poisoning of undetermined intent was the leading cause of death
The data in Figure 8b shows data for cancer, dementia & Alzheimer’s disease, circulatory disease and respiratory disease by deprivation decile, and show data combined for 2015-2019 and 2020:
the inequality gradient was observed for all conditions (rates highest in the most deprived decile, decreasing as deprivation decreases), although this is less clear for dementia and Alzheimer’s disease
mortality rates reduced slightly between the two time periods for all conditions except dementia and Alzheimer’s disease where the pattern was less clear possibly as a result of the large number of COVID19 deaths in 2020
Figure 8c shows local authority comparisons of age-standardised rates of years of life lost (YLL) from the four leading groups of causes of death. Years of life lost are estimated by multiplying the number of deaths by the maximum global life expectancy for each age and sex, and then summing to get the total number in each area. The rates of YLL for:
Alzheimer’s disease and other dementias were similar across all local authorities. Females consistently had higher rates than males
Cardiovascular disease were highest in Torbay for both males and females
Chronic respiratory disease were highest in Bristol for males and in Plymouth for females
Cancers were highest in Torbay for males and in Bournemouth for females
The directly standardised rate of mortality for people aged 65 and over with dementia shows that:
in 2019 was 770 per 100,000 in the South West and is lower than the England average (849 per 100,000)
at local authority, the highest rate was in Swindon at 909 per 100,000, while the lowest rate was in Cornwall and Isles of Scilly at 674 per 100,000
deaths from dementia and Alzheimer’s disease has decreased from 2015 to 2019 at 110.4 per 100,000 to 2020 at 107.7 per 100,000 (22)
Figure 7 – All cause mortality
Figure 7a - Trends
Source: Office for National Statistics: Nomis Date accessed: 02/03/2022, OHID analysis of Office for National Statistics data Date accessed: 02/03/2022 Note: Nomis data used from 2013 onwards; PHE analysis used for 2001 to 2012. Download data
Figure 7b - Inequalities
Source: OHID analysis of Office for National Statistics mortality and population data Date accessed: 02/03/2022 Download data
Figure 8 – Leading causes of death
Figure 8a
Females
Males
Source: Office for National Statistics Nomis Note: Age groups should be compared with caution as there are many more deaths in older age groups than in younger age groups. Download data
Figure 8b - Inequalities
Source: OHID Wider Impacts of COVID-19 on Health (WICH) tool Date accessed: 07/02/2022 Download data
Child health
Introduction
In England the last two decades have seen overall improvements in child health, with a reduction in babies born with a low birthweight, infant deaths and improved child development. However, in the years leading up to the coronavirus pandemic, improvements had slowed down.
Low birth weight increases the risk of childhood mortality and of developmental problems for the child and is associated with poorer health in later life. At a population level there are inequalities in low birth weight and a high proportion of low birth weight births could indicate lifestyle issues of the mothers and/or issues with the maternity services. The Health Profile for England: 2021 found that 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). Low birth weight (less than 2500 grams) is measured in full term babies and expressed as a proportion of all full term live births only (excludes still births)(1).
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 rates in the least deprived areas. 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.
Every child having a good start in life is the foundation for the future health and wellbeing of England’s population. This section presents some key indicators of child health: Birthweight, infant mortality, early child development and child obesity. The data includes the pre-pandemic period and 2020/21, where available.
Low birthweight
Figure 9a shows that:
the proportion of babies born at full term with a low birthweight remains between 2.5 and 2.7% in the South West
the proportion remains lower than the England average of 2.9%
Figure 9b shows that:
- by local authority, in 2020 both Bournemouth, Christchurch and Poole and Bristol had a significantly higher proportion of babies with low birth weight compared to the South West average
Note: Values for Cornwall have been combined with Isles of Scilly.
Figure 9 – Low birthweight
Figure 9a - Trends
Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data
Infant mortality
Infant mortality covers all deaths within the first year of life. The majority of these are neonatal deaths which occur during the first month and the main cause is related to prematurity and preterm birth, followed closely by congenital anomalies (23).
The full impact of the pandemic on the infant mortality rate is not yet known, however the latest data suggest that there has been little change. In general rates have been decreasing over the last 20 years, although this has plateaued since 2014.
Figure 10a shows:
- in the South West region, the rate of mortality fell from 4.6 per 1,000 live births in 2001-2003 to 3.6 between in 2013-2015 and it remained at this level up to 2018 to 2020. The region is still lower than the national average of 3.9 per 1,000
Figure 10b shows:
- that for 2018-20, local authorities in the South West have similar rates to the South West average
Note: Values for Cornwall have been combined with Isles of Scilly.
Figure 10 – Infant mortality
Figure 10a - Trends
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 (24). Being able to express themselves, interact with peers and make themselves understood helps to build a child’s confidence and boost their self-esteem (24). Inadequate communication skills can lead to poorer adult outcomes in literacy, mental health and employment (24).
Figure 11a shows that:
in the South West, in the academic year 2018/19, 78.4% of girls and 65.5% of boys achieved at least the expected level of development in communication and language skills at the end of Reception year. This is very similar to England
the percentage of children achieving a good level of development has been improving since 2012/13
The South West has historically shown higher rates than England, this gap has narrowed over time and rates are now similar to England.
Figure 11b compares local authorities for 2018/19 showing:
- better than South West average rates in Bournemouth, Christchurch and Poole, North Somerset and South Gloucestershire. Significantly lower rates were observed in Bristol, Cornwall and Plymouth
Figure 11 – Child development
Figure 11a - Trends
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 (26).
Figure 12a shows that:
in the South West, in the academic year 2019/2020, data from the National Child Measurement Programme (NCMP) showed that, 9.3% of boys and 8.9% of girls aged 4 to 5 (Reception year) in the region were obese, slightly lower than the England average
among pupils aged 10 to 11 years (Year 6), 20.2% of boys and 15.6% of girls were obese, also lower than the England average
Figure 12b shows that:
by local authority in 2019/20, Gloucestershire, Plymouth, Somerset and Swindon had a significantly higher prevalence of obesity in Reception children compared to the South West
for Year 6 children, Bristol, Gloucestershire, Swindon and Torbay were significantly higher
Note: Values for Cornwall have been combined with Isles of Scilly and Bath and NES value supressed due to incompleteness of data source.
Figure 12 – Child obesity
Figure 12a - Trends
Source: OHID Child and Maternal Health Profile Date accessed: 31/03/2022 Download data
Other indicators of child health
From England level data we know that hospital admissions of children and young people (under 25 unless otherwise stated) for asthma, diabetes, epilepsy, gastroenteritis (0 to 4 years), lower respiratory tract infections (0 to 4 years) and following accidents, were generally below average for 2018 and 2019.
Injuries resulting in hospitalisation
Figure 13 shows data for hospital admissions caused by unintentional and deliberate injuries in children (aged 0-14 years). Figure 13a shows that:
trends for admissions have been steadily decreasing both in the South West and nationally
since 2015/16, rates have been decreasing much more slowly in the South West
rates in the South West are now higher than England
Figure 13b shows:
considerable variation across the local authorities in the South West
significantly higher admission rates in Devon than the South West average
Note: Values for Cornwall have been combined with Isles of Scilly and Gloucestershire data is not on fingertips due to data quality reasons.
Figure 13 – Injuries resulting in hospitalisation
Figure 13a - Trends
Source: OHID Public health profiles Date accessed: 31/03/2022 Download data
Smoking in teenagers
Prior to the pandemic, in England smoking among teenagers had been reducing, while drug use had increased. The proportion of 15-year-olds who reported they were regular smokers decreased from 12% to 5% between 2010 and 2018 (30). Lifetime prevalence of drug use among school pupils aged 11 to 15 increased sharply between 2014 and 2016, even accounting for a methodological change, but then remained level up to 2018 at 24% (31). This survey data is not available at regional level.
Smoking in pregnancy
Previous reports have also demonstrated inequalities in many other aspects of children’s health (32), including during pregnancy. Smoking in early pregnancy in most deprived areas was more than 5 times in the least deprived (33). Data on maternal smoking (Figure 14a) shows that:
- in the region, the proportion of mothers smoking at the time of delivery has decreased from 13.5% in 2010/11, to 10.3% in 2020/21. Rates in the South West are slightly higher compared to England
Figure 14b shows that in 2020/21:
prevalence of smoking at time of delivery varied across local authorities
Cornwall had a significantly higher prevalence of smoking at time of delivery (15.8%) than the South West average
Note: Values for Cornwall have been combined with Isles of Scilly.
Figure 14 – Smoking in pregnancy
Figure 14a - Trends
Source: OHID Public health profiles Date accessed: 31/03/2022 Download data
COVID-19 impacts on other indicators of child health
One national survey comparing aspects of mental health found that in 2020, 16.0% children aged 5 to 16 years were identified as having a probable mental disorder, increasing from 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 11 to 16 year olds, and 59.0% of 17 to 22 year olds stating this.
The pandemic has had a profound effect on the life of young people, for example through isolation and interruptions to education. Some of these effects will be longer-term and data are 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.
Health in adults
Healthy Ageing
As well as reporting total life expectancy, 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. The difference between total life expectancy and healthy life expectancy represents the number of years lived in poor health, usually (though not always) occurring in the final years of life. Figure 15a shows that for the South West region:
for males, in 2017/19 total life expectancy was 80.4 years, an increase of 0.5 years since 2010/12. However, 0.4 of these additional years were in poor health, with healthy life expectancy only increasing by 0.1 year over the time period
for females, in 2017/19 total life expectancy was 84.1 years,an increase of 0.4 years since 2010/12. However, the number of years of health life expectancy actually fell from 65.7 years in 2010/12 to 65.0 years in 2017/19, while the number of years lived in poor health increased by 1.1 year over the time period
although in 2017/19 total life expectancy for females was 3.7 years longer than for males, men actually had a slightly longer healthy life expectancy than women (65.2 v. 65.0 years). On average, the longer total life expectancy for females is thus entirely comprised of additional years of life lived in poor health
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 uses years lived with disability (YLD) to reflect the burden of morbidity (34). YLD is a measure of morbidity that combines the prevalence of each disease with a rating of the severity of its symptoms (excluding death itself), to give an overall measure of the loss of quality of life. Figure 16a identifies the most common causes of morbidity in 2019 according to GBD, as measured by age-standardised YLD per 100,000 population. It also shows the change in YLD since 1990. Change over time should be interpreted with caution as this may reflect changes in methodology and categorisation. Overall, the top 3 leading causes of morbidity in the South West region in 2019 were lower back pain, depressive disorders, and headache disorders. However, for:
Males; the top 3 leading causes of morbidity (as measured by YLD) in 2019 were lower back pain causes (939.4 YLD per 100,000 population), diabetes mellitus (638.0 YLD) and depressive disorders (614.3 YLD). Diabetes mellitus showed the largest increase between 1990 and 2019 with a 148% increase over the period (from 257.7 to 638.0 YLD)
Females; the top 3 leading causes of morbidity (as measured by YLD) in 2019 were lower back pain (1,295.7 YLD per 100,000 population), headache disorders (935.8 YLD) and depressive disorders (831.2 YLD). Diabetes mellitus again showed the largest increase between 1990 and 2019 with a 128% increase over the period (from 204.5 to 466.0 YLD)
Figure 16b shows that similar patterns of morbidity are seen across the local authorities in the South West.
Figure 16 – Leading causes of morbidity
Mental health and wellbeing
According to the Global Burden of Disease, in 2019, mental health conditions such as depression and anxiety, accounted for 2.7% and 1.4% respectively of total morbidity in the region (35).
Figure 17a shows trends in wellbeing between 2011/12 and 2020/21, measured by four indicators; anxiety, low happiness, low life satisfaction and low worthwhile feelings. In the South West region:
21.1% of the population reported feeling anxiety in 2019/20, this rose to 23.4% in 2020/21
8.1% of the population reported feeling low happiness in 2019/20, this rose to 8.7% in 2020/21
4.4% of the population reported feeling low satisfaction in 2019/20, this rose to 5.3% in 2020/21
3.8% of the population reported feeling low worthwhile in 2019/20, this rose to 4.4% in 2020/21
Amongst local authorities in the South West region in 2020/21 there was considerable variation, as shown in Figure 17b:
anxiety scores across all local authorities ranged from 19.8% in Dorset to 27.7% in Torbay
low happiness score was highest in North Somerset (11.1%) and lowest in Dorset (6.2%)
low life satisfaction scores ranged from 3.9% in Wiltshire to 7.9% in Bristol (although some local authorities did not have data for this indicator)
comparisons of the low worthwhile score across the South west are difficult, as many local authorities have missing data due to small sample size
Note: Values for Isles of Scilly are missing in data source.
Figure 17 – Mental health and wellbeing
Figure 17a - Trends
Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data
Source: OHID Public Health Outcomes Framework Date accessed: 31/03/2022 Download data
Suicide and Self-harm
Figure 18a shows that:
trends in emergency hospital admissions for self-harm in the South West increased from 223.0 per 100,000 in 2010/11 to 249.4 per 100,000 in 2020/21. Since 2010/11, rates have consistently been higher than the England average
trends for suicide have shown a slight upward trend, increasing from 10.9 per 100,000 in 2010/12 to 11.6 in 2018/20 and decreased slightly during 2018/19 and 2019/20. As for emergency hospital admissions for self-harm, rates have consistently been higher than the England average
Figure 18b shows that:
for South West local authorities in 2020/21, Swindon (407.0 per 100,000) has the highest rate of emergency admissions for intentional self-harm while Devon (210.4 per 100,000) has the lowest rate
for South West local authorities in 2020/21, Torbay (18.8 per 100,000) has the highest suicide rate while South Gloucestershire (8.0 per 100,000) has the lowest rate
as with the national picture, females have consistently higher rates of emergency admissions for self-harm whilst the reverse is true for suicide rates
Note: Values for Cornwall have been combined with Isles of Scilly.
Figure 18 – Suicide and Self-harm
Figure 18a - Trends
Source: OHID Public health profiles , Suicide Prevention Profile Date accessed: 31/03/2022 Download data
Health service contact during the pandemic
Data on admissions to hospital during the pandemic for causes other than COVID-19 can help to understand the potential broader impacts of the pandemic. The Health Profile for England: 2021 report provides a national interpretation of a variety of metrics describing trends in the health service contact over the pandemic (1).
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.
Dementia and Alzheimer’s disease
As discussed earlier in the report, dementia and Alzheimer’s disease is a leading cause of death, and despite not featuring in the leading YLDs, dementia is a significant cause of ill health in the South West. A particular commitment of the NHS in the 2014-15 mandate was to increase the number of people living with dementia to have a formal diagnosis, so their carers and healthcare staff can provide timely interventions and improve outcomes. As not all people with dementia have a formal diagnosis, the indicator ‘estimated dementia diagnosis rate (aged 65 and over)’ was created to compare the number of people estimated to have dementia with the number of people diagnosed with dementia (aged 65 and over). The target was to increase the estimated dementia diagnosis rate to 66.7%:
- in the South West region, over the pandemic, there was a decline in the estimated dementia diagnosis rate, from 61.8% in 2019 to 57.7% in 2021. This equates to 3,059 fewer dementia diagnoses
Care plan reviews are an important aspect of dementia care and the Quality and Outcomes Framework (QOF) target is that 75% of people with a dementia care plan get a review in the preceding 12 months:
- in the South West region, during the pandemic, there was a decline in dementia care plans being reviewed in the last 12 months from 75.7% in 2019/20 to 37.8% in 2020/21. This equates to 21,547 fewer dementia care plans being reviewed. This trend is also seen in the figures for England which decreased from 75.0% in 2019/20 to 39.7% in 2020/21
Cancer
Cancers do not feature as leading causes of YLDs in the GBD data presented above but are a significant cause of ill health and mortality in the South West region.
Figure 19a shows that, since January 2018, the trend for new cancer diagnoses for all sites combined, and the four major sites: breast, colorectal, prostate, and lung, was steady until the first COVID-19 restrictions in March 2020. During the period between April to July 2020, new cancer diagnoses for all sites combined had dropped significantly. Since December 2020, new cancer diagnoses for all sites had returned to pre-pandemic rates with minor fluctuations. Similar trends were observed for the four major cancers.
Data that measured the number of first treatments for cancer over the pandemic shows in the South West region, there was an estimated deficit of 2,987 new treatments between March 2019 and September 2021 compared to baseline activity in the previous 2 years (36).
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, and an update is due early in 2022 (37). 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. Where data are not available at regional or local authority level, for example on inequalities, the report makes references to England level findings.
Leading risk factors
Morbidity
Figure 20a shows that for the South West in 2019:
the behavioural risk factors having the largest effect on years of life lived with disability (YLD) were tobacco use (5.5 YLD) and alcohol use (3.5 YLD)
the metabolic risk factors having the largest effect on years of life lived with disability (YLD) were high body-mass index (overweight/obese) resulting in 6,2 YLD and high fasting plasma glucose (diabetes) with 5.5 YLD
although calculated independently, these risk factors are connected, and individuals often have more than one risk factor
Mortality
Figure 20b shows that for the South West in 2019:
the behavioural risk factors having the largest effect on mortality (expressed as age standardised percentage of all deaths) were tobacco use (17.6%) and dietary risks (12.1%)
the metabolic risk factors having the largest effect on mortality (expressed as age standardised percentage of all deaths) were high systolic blood pressure (hypertension) representing 12.3% of all deaths and high fasting plasma glucose (diabetes) with 11.5% of all deaths
although calculated independently, these risk factors are connected, and individuals often have more than one risk factor
Smoking
There is evidence of an increase in the rates of people attempting to quit smoking during the pandemic (39). 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. Figure 21 shows that:
the smoking prevalence in 2019 among adults was 14.0% in the region, higher than the national average of 13.9%
by local authority, in 2019, Plymouth had the highest percentage of adults who currently smoke (18.5%) and Dorset the lowest (10.1%) - see Figure 21b
there is thought to be a biological link between smoking and lower back pain and further information can be found here
Note: Values for Isles of Scilly have been supressed due to small numbers.
Alcohol
The Health Profile for England (HPfE) 2021 reported differences in drinking patterns by age and income (1). ‘Increasing or higher risk’ drinking (defined as drinking more than 14 units per week and up to 35 for women and 50 units for men ) 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. However. indicators of harm, such as hospital admissions for alcohol-related conditions in 2018 to 2019, were more than double in the most deprived areas compared to the least (40). The gap has only slightly narrowed since 2010/2011 (40). 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 (41).
Drug use
Pre-pandemic survey-based estimates for recent drug use in England vary year-on-year (42). 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 (42). The data shows that:
regional differences are significant - North East had the highest rate of deaths due to drug misuse and London the lowest (9.9 and 3.5 deaths per 100,000 respectively in 2018-20)
in the South West region, the rate of deaths due to drug misuse was 5.5 per 100,000
of local authorities in the South West, Plymouth had the highest rate of deaths from drug misuse (9.4 per 100,000) and South Gloucestershire the lowest rate (3.3 per 100,000)
Physical activity
As with children, England level findings in 2020/21 from Sport England uncovers wide inequalities in physical activity in adults (43). Those who are classed as physically active are those who undertake at least the recommended level of 150 minutes of moderate intensity physical activity or equivalent per week. The proportion of inactive people was lower for people who are employed in routine/semi routine jobs, 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 60.1% in the South West region, higher than the England average of 55.4% in 2019 to 2020 (44). The local authority in the South West with the highest proportion of its population eating the recommended number of portions was Bath and North East Somerset (65.8%) and the lowest was Plymouth (52.0%).
Obesity
As with other risk factors, there are inequalities in adult obesity prevalence by age, sex and deprivation (1). Health Profile for England reported that in 2019 prevalence was lowest in those aged under 25 with a gradual increase by age group up to 65-75 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 likely we will see an increase and a widening of inequalities.
Long-term trends show an increase in adult obesity in England, although with some fluctuation year to year. In 2019, obesity prevalence was highest in the North East (34.0%) and lowest in London (23.4%).
Data for the percentage of adults classified as overweight and obese, in figure 21 (a) and (b), show that:
in the South West region, the levels of obesity and overweight are similar to England, and have remained relatively static between 2015 (61.1%) and 2019 (62.0%)
levels of overweight and obesity varied by local authority across the South West, ranging from 52.5% for the Isles of Scilly up to 67.5% for Plymouth
High blood pressure
High blood pressure, or hypertension, rarely has noticeable symptoms (45). But if untreated, it increases the risk of serious problems such as heart attacks and strokes. Adults with blood pressure higher than 140/90 mmHg, plus those reporting taking medication to lower their blood pressure are classified in the Quality Outcomes framework (QOF) as having high blood pressure (Hypertension). Figure 21a shows that there was little change in the trends in QOF prevalence of high blood pressure (hypertension) between 2015 and 2020. There may have been some decrease in the diagnosis of hypertension due to limited GP appointments during the pandemic. These QOF data shows that:
the registered prevalence of high blood pressure (hypertension) in the South West region has decreased by 0.2% between 2019 and 2020
the latest diagnosed prevalence in the South West region is 14.8%
there is considerable variation across South West local authorities where the percentages with high blood pressure range from 10.3% in Bristol to 18.1% in Dorset
Blood glucose
Increased blood glucose levels may lead to diabetes and can increase the risk of heart disease and stroke, kidney disease, vision and nerve problems. A blood glucose level that is above normal but not in the diabetic range is referred to as Non-diabetic hyperglycaemia (NDH). Whilst we have no regional data, it is estimated that approximately 5 million people in England have diabetes (46,47).
Figure 20 – Leading risk factors
Figure 20a - Morbidity
Figure 21 – Risk factors
Figure 21a - Trends
Source: Wider Impacts of COVID-19 on Health: Wellbeing and behavioural risk factors , Wider Impacts of COVID-19 on Health: Hypertension QOF Date accessed: 31/03/2022 Download data
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 (48). 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. Homelessness and the use of temporary accommodation remain at high levels in England (49):
- in 2020/21, 1.5 per 1000 population were living in temporary accommodation within the South West region, lower than the national average of 4.0 per 1000 (50)
Fuel poverty is now measured by the new Low Income Low Energy Efficiency (LILEE) statistic (51). A household is defined as fuel poor if it has income (after accounting for fuel costs) below a certain level (living in a property with a fuel poverty energy efficiency rating of band D or below) and a low energy efficient home. These data shows that:
in the South West region, 10.6% of households were living in fuel poverty in 2019, which is lower than the England figure (13.4%) (52)
according to the Annual Fuel Poverty statistics report 2022, in 2020, the South West had the second highest median floor area (86m2 ) which drives the highest median fuel costs (£1,274) and had the highest average fuel poverty gap of £287 in England
Green Environment
Living in a greener environment can promote and protect good health, aid recovery from illness and help with managing poor health. Greenspace can help to bind communities together, reduce loneliness, and mitigate the negative effects of air pollution, excessive noise, heat and flooding (53). The Monitor of Engagement with the Natural Environment (MENE) survey collected information on the utilisation of outdoor space for exercise/health reasons between 2009 and 2019 (54).
Regional level data is available for 2015/16, it shows that in the South West region, 17.4% of residents visited the natural environment for health or exercise purposes over the previous seven days, similar to the national average of 17.9%.
Employment
Good employment improves health and wellbeing across people’s lives, boosting quality of life and protecting against social exclusion.
Health Profile for England: 2021 outlined evidence that he COVID-19 pandemic has had a substantial impact on employment patterns and opportunities (1). 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 (55).
For the South West, employment had been increasing in recent years, up to a peak in 2018/19 for males when 82.4% were in employment, and up to 2019/20 for females when the employment rate was 76.7%. Compared to England as a whole, the South West has always had higher employment rates over the period 2011/12 to 2020/21.
Figure 22a also shows that:
employment rates have historically been lower for females compared to males, ranging from 69.0% in 2011/12 to 76.7% in 2019/20 for females in the South West, and from 78.1% in 2011/12 to 82.4% in 2018/19 for males
employment rates for both males and females in the South West fell during the first year of the Covid pandemic (2020/21). During this period employment fell by 1.8 percentage points for males (from 81.7% to 79.9%), and by 1.1 percentage points for females (from 76.7% to 75.6%)
Figure 22b shows variation in employment rates in 2020/21 between local authorities in the South West. It shows that:
- Torbay (74.7%) had the lowest level of employment of all local authorities in the South West, while North Somerset (82.2%) and South Gloucestershire (81.8%) had the highest levels of employment
Note: Value for Isles of Scilly is missing in the data source.
Figure 22 – Employment
Figure 22a - Trends
Source: OHID Public health profiles Date accessed: 31/03/2022 Download data
Figure 22b - UTLA
Source: OHID Public health profiles Date accessed: 31/03/2022 Download data
Income
Many physical and mental health outcomes improve incrementally as income rises (56, 57). Income is related to life expectancy, disability free life expectancy, and self-reported health (58,59). 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 (60). It can also influence health through feelings of shame, low self-worth and exclusion (60).
The Minimum Income Standard (MIS) is defined as not having enough income to afford a ‘minimum acceptable standard of living’, based on what members of the public think is enough money to live on (61). Figures 23a & b show that in 2018/19:
26.4% of the population of the South West region did not reach the MIS, lower than the national average of 29.4%
39.6% of children in the South West were living in households that did not meet the MIS, which is also lower than the national average of 42.3%
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
Education
Educational attainment is strongly linked with health behaviours and outcomes. Better-educated individuals are less likely to suffer from long term diseases, to report themselves in poor health, or to suffer from mental health conditions such as depression or anxiety (62). Education provides knowledge and capabilities that contribute to mental, physical, and social wellbeing. Educational qualifications are also a determinant of an individual’s labour market position, which in turn influences income, housing and other material resources associated with health:
- in the South West, 72.0% of children achieved a good level of development at the end of reception in 2018/19, which is similar than the England value (71.8%) (63). As the most recent data is shown for 2018/19, we cannot see the impact the pandemic may have had on levels of school development at a regional level
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 (64).
It is not possible to cover all health protection issues in this report. This section presents specific information on air pollution, sexually transmitted infections, tuberculosis (TB), vaccinations and vaccine preventable infections, and AMR.
Air pollution
Air pollution can contribute to cardiovascular and respiratory conditions and shorten lives. It is estimated that long-term exposure to the air pollution mixture in the UK has an annual effect equivalent to 28,000 to 36,000 deaths (65).
Figure 24 presents the annual concentration of human-made fine particulate matter, adjusted to account for population exposure. Fine particulate matter is also known as PM2.5 and has a metric of micrograms per cubic metre (\(\mu g/m^3\)). Figure 24a shows that:
the regional trend between 2011 and 2019 was around \(7 \mu g/m^3\) for each year and was always lower than the national average
during the first year of the pandemic, 2020, the man-made fine particulate matter level of air pollution fell to \(6.2 \mu g/m^3\) in the region
In the South West, there is wide regional variation in mean fine particle matter air pollution as shown in Figure 24b:
- Bristol (\(7.5 \mu g/m^3\)), South Gloucestershire (\(7.1 \mu g/m^3\)) and Swindon (\(7.4 \mu g/m^3\)) all had fine particle matter higher than regional average which was (\(6.2 \mu g/m^3\))
Figure 24c shows the areas of the country with the highest concentration of human-made fine particulate matter (PM2.5) levels in 2019. The highest exposures were generally in busy, urban environments, often with high levels of deprivation, contributing to the health inequalities presented in this report.
Health Profile for England: 2021 highlights that the highest air pollution exposures have been in deprived urban environments therefore contributing to health inequalities (1). During the pandemic 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 dramatically during the first (March 2020) and third (January 2021) national lockdowns in England, but by the end of July 2021 usage was similar to previous years (55).
Figure 24 – Air quality
Figure 24a - Trends
Source: OHID Wider Determinants of Health Date accessed: 31/03/2022 Download data
Figure 24b - UTLA
Source: OHID Wider Determinants of Health Date accessed: 31/03/2022 Download data
Infectious diseases
Prior to the pandemic the incidence of many infectious diseases such as TB had been declining, but disproportionately impacted more deprived or inclusion health groups. In 2019, the incidence of TB was higher in people born outside of the UK, particularly those of Indian, Pakistani or black African ethnicity, than in people born inside the UK. It was also higher in the most deprived compared to 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 or detection of many infectious diseases such as TB and STIs decreased during the pandemic, which may reflect a real decrease in incidence due to social distancing measures or may reflect a reluctance to be tested. 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.
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 (134) due to a combination of testing, pre-exposure prophylaxis, rapid linkage to treatment and support for those diagnosed with HIV to attain viral suppression. There has also been a decline in the rate of genital warts following the introduction of the HPV vaccination programme (Figure 25a).
Health Profile for England: 2021 reported that the measures taken to control the COVID-19 pandemic resulted in a drop in the number of people accessing services (1). 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 (66).
The diagnostic rates per 100,000 for Chlamydia (aged 25+), Gonorrhoea and Syphilis had been increasing in the South West region between 2012 and 2019. The diagnostic rate per 100,000 for Genital warts has been decreasing since 2012. 2020 saw a decline in the detection rates of all STIs (66). Figure 25a shows:
- diagnostic rates per 100,000 in the South West region are 107, 39, 48.6 and 6.8 for Chlamydia (aged 25+), Gonorrhoea, Genital Warts and Syphilis respectively in 2020. These are lower than the England rate, with the exception of Genital Warts, which have a similar rate of diagnosis
Figure 25b shows that:
for local authorities, there is wide regional variation in the diagnostic rates of STI in the South West region. Chlamydia (aged 25+) diagnosis are most common followed by Gonorrhoea, Genital Warts and Syphilis
the local authority with the highest Chlamydia diagnostic (aged 25+) rate per 100,000 in the South West region is Bristol (a diagnostic rate of 225.1/100,000), the lowest is Dorset (a diagnostic rate of 55.4/100,000)
the local authorities with the highest Gonorrhoea rate per 100,000 in the South West region were Bristol (a diagnostic rate of 80.5/100,000) and Bournemouth, Christchurch and Poole (a diagnostic rate of 79.9/100,000), the lowest are Cornwall and Dorset (both with a diagnostic rate of 19.0/100,000)
the local authority with the highest Genital Warts rate per 100,000 in the South West region is Plymouth (a diagnostic rate of 86.0/100,000), the lowest is North Somerset (a diagnostic rate of 25.0/100,000)
the local authority with the highest Syphilis rate per 100,000 in the South West region is Bristol (a diagnostic rate of 17.8/100,000), the lowest is Somerset (a diagnostic rate of 2.1/100,000)
the value for the Isles of Scilly is zero
Figure 25 – Sexually transmitted infections
Figure 25a - Trends
Source: Sexual and Reproductive Health Profiles Date accessed: 31/03/2022 Download data
Tuberculosis
The number of new cases of tuberculosis (TB) have fallen dramatically in England over the last century (67). Figure 26 shows that since 2000 incidence of TB has been consistently lower in the South West than in England and that more recently (since 2011) there has been a steady decline in the incidence rate (new cases per 100,000 population) in both England and the South West. a noticeable exception to this was 2019, where there was a sharp increase from 2018 in the South West and a slight increase in England.
Health Profile for England: 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 (1). It was also higher in the most deprived compared to 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.
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 vaccine coverage in those over 65 years of age in the South West region increased from 73.7% in 2019/20 to 82.8% in 2020/21, higher than the benchmark of 75% (68)
for those who are at greater risk of developing serious complications if they catch flu, the coverage was 57.2% in 2020/21, higher than the benchmark of 55% and higher than the England average of 53% (69)
at local authority level, all areas in the South West in 2020/21 achieved the goal of 75% coverage among those aged 65 and over (70). Only Torbay (54.8%), Cornwall (54.2%), Bournemouth, Christchurch and Poole (52.9%), Plymouth (52.3%) and Bristol (52.3%) did not achieve the goal of 55% for at risk individuals (71)
Note: to view this data, please click on the underlined links.
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 old in one or more clinical risk groups compared with 44.9% in 2019 to 2020 (138). As a consequence of this and the social distancing measures introduced for the COVID-19 pandemic influenza-like illness was much lower in 2020 to 2021 than in other seasons (70).
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 (71). 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 2019 to 2020 86.8% of children aged 5 had received the 2 doses, a slight decline from previous years (72).
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 (72, 73):
population vaccination coverage for one dose of MMR by age 2 in the South West region is higher than England average (90.3%), but has been following a steady trend from 2015/16. This had increased slightly to 93.3% in 2020/21, however the national benchmark is 95%
population vaccination coverage for 2 doses by age 5 had also fallen to around 93.0% from 2016/17 to 2019/20 but increased to 93.3% in 2020/21. This remains lower than the target of 95%
at local authority level, in 2020/21, Wiltshire (95.7%), Plymouth (95.2%), Dorset (95.1%) and Bath and North East Somerset (95.1%) all achieved the goal of 95% coverage of 1 dose by age 2. Bristol (88.6%) was the only area not to have achieved 90% coverage
in 2020/21, there wasn’t any area in the South West that had achieved 95% target vaccination for two doses by age 5. Swindon (89.2%) and Bristol (85.4%) achieved less than 90% coverage
Antimicrobial resistance
Antibiotic-resistant bloodstream infections rose by an estimated 32% between 2015 and 2019 in England (74). Antibiotic prescribing in primary care is often measured in STAR-PU, which are weighted units to allow comparisons adjusting for the age and sex of the population.
Figure 27a shows the rate of antibiotic prescribing in primary care in England and the South West has fallen every year, with the largest drop between 2019 and 2020. In the region, this fell from 0.9 per STAR-PU to 0.8 in 2020 - lower than the target of the mean England prescribing in 2013/14 (the threshold is 1.161 items per STAR-PU, the England 2013/14 mean performance value). At local authority level, all areas had fallen below the 2013/14 England mean target for prescribing. However, there is still some regional variation, with Plymouth and Torbay both above 0.8 per STAR-PU (Figure 27b).
Figure 27 – Antibiotic prescribing
Figure 27a - Trends
Source: OHID Public health profiles Date accessed: 31/03/2022 Download data
Conclusions
The 2021 Health Profile for the South West region has provided a comprehensive snapshot of the region’s health. 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 (11). 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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