UK health performance: findings of the Global Burden of Disease Study 2010

Summary

Background

The UK has had universal free health care and public health programmes for more than six decades. Several policy initiatives and structural reforms of the health system have been undertaken. Health expenditure has increased substantially since 1990, albeit from relatively low levels compared with other countries. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to examine the patterns of health loss in the UK, the leading preventable risks that explain some of these patterns, and how UK outcomes compare with a set of comparable countries in the European Union and elsewhere in 1990 and 2010.

Methods

We used results of GBD 2010 for 1990 and 2010 for the UK and 18 other comparator nations (the original 15 members of the European Union, Australia, Canada, Norway, and the USA; henceforth EU15+). We present analyses of trends and relative performance for mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 259 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to the UK. We assessed the UK's rank for age-standardised YLLs and DALYs for their leading causes compared with EU15+ in 1990 and 2010. We estimated 95% uncertainty intervals (UIs) for all measures.

Findings

For both mortality and disability, overall health has improved substantially in absolute terms in the UK from 1990 to 2010. Life expectancy in the UK increased by 4·2 years (95% UI 4·2–4·3) from 1990 to 2010. However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates, and life expectancy in 1990, and its relative position had worsened by 2010. Although in most age groups, there have been reductions in age-specific mortality, for men aged 30–34 years, mortality rates have hardly changed (reduction of 3·7%, 95% UI 2·7–4·9). In terms of premature mortality, worsening ranks are most notable for men and women aged 20–54 years. For all age groups, the contributions of Alzheimer's disease (increase of 137%, 16–277), cirrhosis (65%, −15 to 107), and drug use disorders (577%, 71–942) to premature mortality rose from 1990 to 2010. In 2010, compared with EU15+, the UK had significantly lower rates of age-standardised YLLs for road injury, diabetes, liver cancer, and chronic kidney disease, but significantly greater rates for ischaemic heart disease, chronic obstructive pulmonary disease, lower respiratory infections, breast cancer, other cardiovascular and circulatory disorders, oesophageal cancer, preterm birth complications, congenital anomalies, and aortic aneurysm. Because YLDs per person by age and sex have not changed substantially from 1990 to 2010 but age-specific mortality has been falling, the importance of chronic disability is rising. The major causes of YLDs in 2010 were mental and behavioural disorders (including substance abuse; 21·5% [95 UI 17·2–26·3] of YLDs), and musculoskeletal disorders (30·5% [25·5–35·7]). The leading risk factor in the UK was tobacco (11·8% [10·5–13·3] of DALYs), followed by increased blood pressure (9·0 % [7·5–10·5]), and high body-mass index (8·6% [7·4–9·8]). Diet and physical inactivity accounted for 14·3% (95% UI 12·8–15·9) of UK DALYs in 2010.

Interpretation

The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action. Further progress in premature mortality from several major causes, such as cardiovascular diseases and cancers, will probably require improved public health, prevention, early intervention, and treatment activities. The growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response.

Funding

Bill & Melinda Gates Foundation.

Introduction

There are several reasons to expect the UK to set a standard for health that other countries might struggle to match. For six decades, the UK has provided universal free health care, comprehensive primary care, an organised network of secondary and tertiary hospital services, and broad public health programmes. Since 1990, the UK Government has introduced public health measures for tobacco control,¹ immunisation,2, 3 cancer and non-cancer screening,⁴ and reduction of salt in foods;⁵ has undertaken substantial reform of all aspects of the health system, including management of cancer; and has increased health expenditure as a percentage of gross domestic product from 6·8% in 1995, to 9·6% in 2010.⁶ A major focus on a reduction in waiting times for diagnosis and elective procedures substantially decreased the backlog of elective procedures.7, 8 In 1999, the National Institute for Health and Clinical Excellence (NICE) was established to provide evidence-based guidelines for prevention, diagnosis, and treatment of major causes of disease and ill health and to disseminate standards for quality of care.⁹ Various types of incentive schemes have been tried to expand coverage of some key preventive interventions in primary care.¹⁰ Finally, major structural changes in hospital organisation and management and in resource allocation have been progressively adopted, implemented, and revised.11, 12, 13

Although the underlying social, economic, and physical environments remain important factors influencing health outcomes, it is nevertheless important and timely to investigate whether these UK investments in health care and public health have been followed by the expected improvements in health. If not, the data might suggest what more can and should be done to improve population health. Health policy has been devolved to the four nations of the UK. In April 2013, a new system for public health and health care in England will be implemented; Scotland, Wales, and Northern Ireland have different arrangements. For example, Public Health Wales was created in 2009 to protect and improve the health and wellbeing of the population of Wales. In England, various new organisations are being launched, such as the National Health Service (NHS) Commissioning Board, Public Health England, Health Education England, and local clinical commissioning groups.¹³ In addition to the health-service changes, substantial public health responsibilities and funding are being transferred from the health service to local governments in England, with the stated aim of addressing underlying problems more effectively, including the social determinants of health.

These new arrangements could provide new opportunities for information and intelligence—eg, results of research into patterns of disease, injury, and leading risk factors—to influence policy and strategy much more directly. Research is also now embodied as a core function of the NHS,¹⁴ and knowledge and intelligence is a core function of Public Health England. Some commentators, nevertheless, have raised concern that these changes in England could have adverse effects on universal access to care and ultimately health.15, 16, 17

There have been several enquiries into the patterns of health loss and trends in the UK. The 2011 English Chief Medical Officer's report² provided an authoritative assessment of many dimensions of health in England. Nolte and colleagues¹⁸ examined avoidable mortality in the UK, and others investigated the contribution of different risk factors to mortality trends.19, 20, 21, 22, 23, 24 Lyons and colleagues²⁵ reported the UK burden of injuries. The newly released Global Burden of Diseases, Injuries, and Risk Factors Study 2010²⁶ (GBD 2010) provides an opportunity to go beyond these studies and comprehensively examine the leading causes of disease burden and how they are changing. Consistent definitions, data sources, and methods were used in GBD 2010 to examine health loss from 291 diseases and injuries and 67 risk factors or risk factor clusters for 187 countries.26, 27, 28, 29, 30, 31, 32, 33 A key strength of GBD 2010 was that change in patterns of health could be studied not only for premature mortality, but also for leading causes of disability. Furthermore, because the study assessed the same set of causes for all countries, it provides a convenient and appropriate platform for benchmarking performance. Benchmarking has two dimensions: to examine levels of health across several countries, and investigate and compare changes over time within each country. Both can help to put the UK health achievements in context and suggest areas of opportunity for improvement.

This report draws on a specific interrogation of the GBD 2010 data to examine three crucial areas: the patterns of health loss in the UK; the leading preventable risks that explain some of these patterns; and how UK outcomes compare with a set of comparable countries in the European Union and elsewhere in 1990 and 2010.