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Health inequalities within Herefordshire

Version 2.0, April 2013

1

HEALTH INEQUALITIES WITHIN HEREFORDSHIRE

Public Health Department, April 2013

KEY FINDINGS

The ‘gap’ in life expectancies between the best and worst performing population deciles in Herefordshire currently equates to 6.2 years for males and 5.9 years for females.

Females living in the least deprived areas of the County can expect to live an additional 7.2 years of healthy life (ie free of disability) on average compared to residents of the most deprived areas, and males an additional 6.6 years.

Herefordshire residents living in the most deprived areas are 33% more likely to die of cancer than those in the least deprived areas.

Herefordshire residents living in the most deprived areas over 60% more likely to die of coronary heart disease than those in the least deprived areas.

Herefordshire residents living in the most deprived areas over twice as likely to die prematurely (under 75 years) of cerebrovascular disease than those in the least deprived areas.

Rates of hospital admission from cerebrovascular disease are significantly high in national terms across most deprivation quintiles of the County.

Herefordshire residents living in the most deprived areas are around 65% more likely to die of chronic lower respiratory disease than those in the least deprived areas.

Smoking related mortality rates are over 40% higher among the most deprived population quartile than in the County overall.

Adults (35+ years) residing in the most deprived areas are a third more likely to be admitted to hospital as a consequence of their smoking than the population of Herefordshire overall.

Alcohol related hospital admission rates are over 40% higher among the most deprived population quartile than in the County overall.

Young people (under 18 years) living in the most deprived areas are over twelve times more likely to be admitted to hospital as a direct consequence of their alcohol consumption than those living in the least deprived areas of the County.

Herefordshire residents living in the most deprived areas are around 30% more likely to be admitted to hospital due to an accident than those in the least deprived areas.



2

INEQUALITIES IN LIFE EXPECTANCIES

The association between deprivation and poor health outcomes is well recognised, affecting both life expectancy at birth and disability-free life expectancy (DFLE) at birth. As demonstrated in the recent Marmot Inquiry1 people living in poorer areas experience shorter lives and spend more of their shorter lives with a disability. Such associations are often discussed in relation to areas with marked levels of deprivation, income inequalities or health inequalities, but can have a lower profile in relatively affluent areas with less obvious inequalities. Herefordshire generally does not experience widespread deprivation – just 5.8% of the County population lives in the most deprived quintile of population nationally, and the County enjoys higher than average life expectancy and disability-free life expectancy at birth. Similarly inequalities in local health outcomes - as measured by the Slope Index of Inequality for Life Expectancy 2006-10 - are lower than for England. However, even within this context the effects of deprivation produce demonstrable inequalities - in parts of Herefordshire with greater proportions of income-deprived residents those residents generally have a shorter average life expectancy at birth and spend a greater part of that life expectancy with a disability when compared with residents of less deprived areas. Figure 1 demonstrates the relationship between life expectancy at birth and deprivation by gender across the Herefordshire population. Figure 1: Life Expectancy at Birth, by Deprivation Decile

Life Expectancy by Deprivation Decile 2006-10: Herefordshire

68

70

72

74

76

78

80

82

84

86

88

Lif

e E

xpec

tan

cy (

Yea

rs)

M 80.6 81.1 78.8 79.1 79.2 79.3 80.9 79.1 76.1 74.9

F 84.4 85.1 83.4 86.0 83.5 84.4 84.3 83.1 81.8 80.1

10 least

deprived9 8 7 6 5 4 3 2

1 most

deprived

Source: Public Health Observatories of England As deprivation increases between the least deprived decile of the County’s population and the most deprived decile, so life expectancy generally falls. This ‘gap’ in life expectancies

1 Fair Society Healthy Lives. The Marmot Review, February 2010.

http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf.

http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf



3

between the best and worst performing deciles currently amounts to 6.2 years for males and 5.9 years for females. The decline in life expectancy is notably and consistently sharp for both males and females through the three most deprived population deciles. Life expectancies at birth data published by the Public Health Observatories of England indicate contrasting trends in the slope indices of inequality (SII) for life expectancy – the difference in life expectancy at birth between the most and least deprived areas within the County (Figure 2). Figure 2: Slope Index of Inequality for Life Expectancy Trends

Slope Index of Inequality for Life Expectancy -

Herefordshire Trend

-2.0

0.0

2.0

4.0

6.0

8.0

10.0

Slo

pe I

nd

ex o

f In

eq

uali

ty (

Years

)

Male 5.5 5.6 4.8 4.9 4.1 4.8

Female 2.6 1.9 2.4 2.9 3.2 4.1

2001-05 2002-06 2003-07 2004-08 2005-09 2006-10

Source: Public Health Observatories of England

The SII for males has fallen – though inconsistently - from 5.5 years in 2001-05 to 4.8 years in 2006-10. The SII for females has risen steadily since 2002-06 from 1.9 years to a current figure of 4.1 years in 2006-10. It should be noted that though these shifts are not statistically significant, they are potentially indicative of a widening of the inequality gap among the County’s female population over recent years to the extent that inequalities in female life expectancy are almost of the same order as for males. These respective local trends are depicted against equivalents from a peer group of most similar PCTs in Figures 3a and 3b. Figure 3a shows the slight and inconsistent reduction in the local male slope indices of inequality against higher but leveling SII in the comparator group.



4

Figure 3a: Slope Index of Inequality for Male Life Expectancy Trend Slope Index of Inequality for Life Expectancy -

Males Trend

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0S

lop

e I

nd

ex o

f In

eq

uali

ty (

Years

)

Herefordshire 5.5 5.6 4.8 4.9 4.1 4.8

Peer Group PCTs* 5.7 6.0 6.3 6.6 6.6 6.6

2001-05 2002-06 2003-07 2004-08 2005-09 2006-10


Figure 3b shows the sharp increase in the local female slope indices of inequality against stable SII in the comparator group. Figure 3b: Slope Index of Inequality for Female Life Expectancy Trend

Slope Index of Inequality for Life Expectancy -

Females Trend

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Slo

pe I

nd

ex o

f In

eq

uali

ty (

Years

)

Herefordshire 2.6 1.9 2.4 2.9 3.2 4.1

Peer Group PCTs* 4.1 3.7 3.8 3.7 3.8 4.0

2001-05 2002-06 2003-07 2004-08 2005-09 2006-10


* Peer Group PCTs comprise the four most similar PCTs around the country: Shropshire County, Somerset,

East Riding of Yorkshire and Lincolnshire Teaching based on the most recent ONS Health Area classification.



5

Healthy or disability-free life expectancy (DFLE) provides a measure of the balance

between length and quality of life. Disability-free life expectancy measures disability by

looking at reported limitations in day to day activities such as work, school and leisure

activities. The General Household Survey has included such questions in certain years for

65+ year olds. Figure 4 demonstrates the inequalities in DFLE experienced within the

population of Herefordshire. Figure 4: Disability-Free Life Expectancy, by Deprivation Quintile

Disability Free Life Expectancy by Deprivation Quintile (IMD2004)

1999-2003: Herefordshire

52

54

56

58

60

62

64

66

68

70

DF

LE

(Y

ea

rs)

DFLE Male 64.7 65.0 62.8 58.9 58.1

DFLE Female 68.6 68.0 66.7 62.8 61.4

1 least deprived 2 3 4 5 most deprived

Source: ONS

Females living in the least deprived areas of the County can expect to live an additional 7.2 years of healthy life (ie free of disability) on average compared to residents of the most deprived areas. Similarly males living in the least deprived areas of the County can expect to live an additional 6.6 years of healthy life on average. A local application of the methodology used by the Marmot Inquiry has produced findings for Herefordshire consistent with national results at Middle Super Output Area (MSOA) level. MSOAs - of which there are 23 in Herefordshire - are geographically defined areas similar in socio-economic terms and typically consisting of approximately 7,500 residents. Figure 5 shows average life expectancy at birth and disability-free life expectancy at birth plotted against the percentage of the population that is income deprived in each Herefordshire MSOA area. Linear regression analysis is used to describe the relationship between the predictor variable (income deprivation) and the response variable (life expectancy).



6

Figure 5: Life Expectancy and Disability-Free Life Expectancy at Birth by MSOA

Life Expectancy and Disability Free Life Expectancy at birth (Persons)

at MSOA level 1999-2003

58

60

62

64

66

68

70

72

74

76

78

80

82

84

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

% Income Deprived (IMD2004) at MSOA level (Private Households)

Lif

e E

xp

ecta

ncy (

Years

)

LE (years) DFLE (years)

Linear (LE (years)) Linear (DFLE (years))

PENSIONABLE AGE INCREASE 2026-2046

Source: Public Health Dept, NHS Herefordshire Locally, the proportion of residents in private households experiencing income deprivation (the ‘x’ axis in Figure 5) varied by MSOA from 5.3% - 24.9%. Average life expectancy at birth (the ‘y’ axis in Figure 5) ranged from 77.1 years to 82.1 years across Herefordshire’s 23 MSOAs for the period 1999-2003. Similarly, average disability-free life expectancy at birth ranged from 59.7 years to 68.2 years. For every 10% increase in the percentage of the population experiencing income deprivation there was an approximate 2 year reduction in average life expectancy at birth, but a 4.5 year reduction in average disability-free life expectancy at birth. This means the gap between life expectancy and disability-free life expectancy at birth is greater in the more deprived MSOAs as illustrated by the widening gap between the respective pink and black linear regression lines in Figure 5. For example, people living in one of the most deprived MSOAs in Herefordshire have an average life expectancy at birth of 78.0 years but on average will spend 17.8 years of it with a disability, yet people living in a less deprived MSOA have a very similar average life expectancy at birth of 78.2 years but spend considerably more of it without a disability – on average 12.9 years. The planned future pensionable age increases between 2026 and 2046 are represented in Figure 5 by the shaded bar. In only one MSOA does the average disability-free life expectancy for 1999-2003 exceed the future upper pensionable age limit of 68 years, and in the most deprived MSOA average disability-free life expectancy is eight years less than the upper pensionable age. As a rural county Herefordshire has small ‘pockets’ of deprivation within MSOAs. If we were able to undertake this analysis for these neighbourhoods we would expect the association to be even more marked; such areas experiencing even shorter average life expectancy at birth and spending an even greater part of it with a disability. However, life expectancy data is not published below MSOA level currently.



7

INEQUALITIES IN HEALTH OUTCOMES

By dividing the Herefordshire population into quartiles according to residence-based deprivation scores (IMD2007 or IMD20102 depending on data source) and measuring health-related activity within each quartile, it is possible to illustrate the relationship between deprivation and health status within the County across a range of disease or condition groups. It should be noted that the composition of deprivation quartiles will have changed to some extent between the IMD releases of 2007 and 2010, though the effect on quartile rates is considered to be minimal. Where the following analysis looks at hospital admissions of Herefordshire residents, it covers both elective and non-elective admissions to all providers and the time period covered varies with source. All mortality analysis is again residence-based and covers the years 2007-11; the most recent five-year period for which data is fully available

Cancer Standardised all age cancer mortality rates in the most deprived quartile of the population are the highest in the County (Figure 6.1). They are significantly higher than rates in the least deprived quartile with the mortality rate ratio between most and least deprived quartiles being 1.33, ie people residing in the most deprived areas are 33% more likely to die of cancer than those in the least deprived areas.

Figure 6.1: All Age Cancer Mortality, by Deprivation Quartile

Directly Standardised Mortality Rate by Deprivation Quartile (IMD2010)

2007-11 pooled: Cancers (ICD10 C00 - D48)

0.0

50.0

100.0

150.0

200.0

250.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 149.5 160.8 142.1 199.0 161.1

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL

Source: Public Health Dept, Herefordshire PCT

2 IMD: Indices of Multiple Deprivation commissioned by the Department of Communities and Local Government.



8

Standardised rates of premature (aged under 75 years) cancer mortality are notably higher in areas of the County experiencing greater deprivation as shown in Figure 6.2. The most deprived population quartile has a rate of premature mortality 1.44 times greater than that experienced by the least deprived quartile and a significantly higher rate than the County overall. Figure 6.2: Premature Cancer Mortality, by Deprivation Quartile

Directly Standardised Premature Mortality Rate by Deprivation Quartile

(IMD2010): Cancers (ICD10 C00-D48) 2007-11 pooled

0.0

50.0

100.0

150.0

200.0

DS

R p

er 1

00,0

00 p

op

ula

tio

n

DSR 90.5 99.6 93.4 130.1 102.3

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


Unlike local mortality rate variations, no discernible correlation exists between hospital

admission levels and deprivation (Figure 6.3). Every population quintile within the County

has a significantly high standardised admissions ratio (SAR), ie admission levels

consistently exceed those expected given the age and sex structure and deprivation status

of each population quintile. Indeed, he least deprived quintile has a significantly higher

SAR than the most deprived, possibly indicating problems with access to healthcare

services among the most deprived



9

Figure 6.3: Standardised Admissions Ratio (SAR) for Cancer, by Deprivation Quintile

Standardised Cancer Admission Ratios by Local Deprivation Quintile

(IMD2007) 2005/06-2009/10

0

20

40

60

80

100

120

140

SA

R (

Ex

pe

cte

d =

10

0)

SAR 119.3 105.7 112.1 121.0 109.2

Q1 Least deprived Q2 Below average Q3 Average Q4 Above average Q5 Most deprived

Source: Dr Foster Intelligence



10

Coronary Heart Disease (CHD)

The most deprived quartile of Herefordshire’s population has a standardised all age CHD

mortality rate which is significantly high compared to the County as a whole (Figure 7.1),

and exceeds the rate in the least deprived quartile by over 60%, ie the rate ratio between

the most and least deprived quartiles is 1.62. Mortality rates in the least deprived quartile

(Q1) and Quartile 3 are significantly lower than in Herefordshire overall.

Figure 7.1: All Age CHD Mortality, by Deprivation Quartile


2007-11 pooled: CHD (ICD10 I20 - I25)

0.0

20.0

40.0

60.0

80.0

100.0

120.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 62.8 76.3 60.8 102.0 73.7

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


Within Herefordshire the rates of premature mortality due to coronary heart disease vary

markedly with deprivation levels (Figure 7.2). The most deprived population quartile has a

rate of premature mortality 2.37 times greater than that experienced by the least deprived

quartile and a significantly high rate relative the County overall.



11

Figure 7.2: Premature CHD Mortality, by Deprivation Quartile


(IMD2010): CHD (ICD10 I20-I25) 2007-11 pooled

0.0

20.0

40.0

60.0

80.0

DS

R p

er

100,0

00 p

op

ula

tio

n

DSR 23.8 37.0 25.9 56.3 34.5

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


There is no discernible correlation between CHD-related hospital admission rates and deprivation (Figure 7.3). Every population quintile within the County has a significantly low standardised admissions ratio (SAR), ie admission levels are consistently lower than expected given the age and sex structure and deprivation status of each population quintile. The SAR of the most deprived quintile is not significantly different from that of the least deprived. Figure 7.3: Standardised Admissions Ratios (SAR) for CHD, by Deprivation Quintile

Standardised CHD Admission Ratios by Local Deprivation Quintile

(IMD2007) 2005/06-2009/10

0

20

40

60

80

100

SA

R (

Ex

pe

cte

d =

10

0)

SAR 77.8 74.8 68.5 67.4 79.9





12

Cerebrovascular Diseases

Standardised mortality rates in each quartile of Herefordshire population are broadly similar and do not appear to correlate strongly with deprivation (Figure 8.1). The rate ratio between the most and least deprived quartiles is 1.12. Quartile 3 has a significantly low rate of mortality relative to the County overall. Figure 8.1: All Age Cerebrovascular Disease Mortality, by Deprivation Quartile


2007-11 pooled: Cerebrovascular Diseases (ICD10 I60 - i69)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 51.6 51.9 41.0 57.8 50.4

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


Within the County rates of premature mortality due to cerebrovascular disease vary significantly between most and least deprived communities (Figure 8.2). The most deprived population quartile has a rate of premature mortality 2.18 times greater than that experienced by the least deprived quartile.



13

Figure 8.2: Premature Cerebrovascular Disease Mortality, by Deprivation Quartile


(IMD2010): Cerebrovascular Diseases (ICD10 I60-I69) 2007-11 pooled

0.0

5.0

10.0

15.0

20.0

25.0

30.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 8.3 7.7 11.0 18.1 10.9

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


No discernible correlation exists between hospital admission levels due to cerebrovascular

disease and deprivation (Figure 8.3). Most deprivation quintiles have a significantly high

standardised admissions ratio (SAR) ie admission levels are predominantly higher than

expected given the age and sex structure and deprivation status of each population

quintile within the County. SARs are not significantly different between the most and least

deprived quintiles.

Figure 8.3: Standardised Admissions Ratios (SAR) for Cerebrovascular Disease, by Deprivation Quintile

Standardised Cerebrovascular Disease Admission Ratios by Local

Deprivation Quintile (IMD2007) 2005/06-2009/10

0

20

40

60

80

100

120

140

SA

R (

Ex

pe

cte

d =

10

0)

SAR 125.1 124.1 106.7 124.3 116.7





14

Respiratory Diseases

Standardised mortality rates from chronic lower respiratory disease in the most deprived quartile of Herefordshire are the highest in the County at around 27 deaths per 100,000 population compared to 17 deaths per 100,000 in the least deprived quartile – a rate ratio of 1.65 (Figure 9.1). This indicates that people residing in the most deprived areas are 65% more likely to die of chronic lower respiratory disease than those in the least deprived areas and that this variation is statistically significant. Figure 9.1: All Age Chronic Lower Respiratory Disease Mortality, by Deprivation Quartile

Directly Standardised Mortality Rates 2005-09: Chronic Lower Respiratory

Disease (ICD10 J40-J47) by Deprivation Quartile (IMD2007)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Rate Ratio (most to least deprived) 1.65

DS

R p

er

100,0

00 (

ES

P)

DSR 16.5 23.4 19.7 27.3 21.1

Q1 least deprived Q2 Q3 Q4 most deprived ALL


Within the County rates of premature mortality due to chronic lower respiratory disease increase with deprivation and are again significantly higher in the most deprived quartile (Figure 9.2). This quartile has a rate of premature mortality 2.19 times greater than that experienced by the least deprived quartile.



15

Figure 9.2: Premature Chronic Lower Respiratory Disease Mortality, by Deprivation Quartile


(IMD2010): Respiratory Diseases (ICD10 J40-J47) 2007-11 pooled

0.0

5.0

10.0

15.0

20.0

25.0

30.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 7.8 6.3 10.1 17.1 9.8

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


No discernible correlation is apparent when looking at hospital admission levels due to

respiratory disease in relation to local deprivation (Figure 9.3). Admission rate ratios vary

little across the County. Admission levels are generally lower than expected given the age

and sex structure and deprivation status of each population quintile and the SAR of the

most deprived quintile is not significantly different from that of the least deprived.

Figure 9.3: Standardised Admissions Ratios (SAR) for Respiratory Disease, by Deprivation Quintile

Standardised Respiratory Disease Admission Ratios

by Local Deprivation Quintile (IMD2007) 2005/06-2009/10

0

20

40

60

80

100

120

SA

R (

Ex

pe

cte

d =

10

0)

SAR 91.8 88.5 85.8 84.2 98.3





16

Smoking-related conditions

The relationship between deprivation and smoking-related morbidity is well-documented.

The methodology employed to measure smoking-related mortality is derived from a

document produced by the Health and Social Care Information Centre entitled 'Statistics

on Smoking: England'. It measures all mortality in England among adults aged 35 and over

from a range of diseases including various types of cancer, respiratory diseases,

circulatory diseases and some diseases of the digestive system.

The methodology is based on smoking-related percentages - ie the proportion of deaths

occurring in a population that can be attributed to smoking for each smoking-related

condition defined in terms of ICD10 codes. It can be used to adjust whole mortality

numbers for the proportion of each death that can be attributed to smoking and so

estimates the number of deaths that can be considered ‘smoking-attributable’, by gender.

For example, a death from lung cancer (ICD10 C33-C34) counts for 0.87 of a smoking-

related death among men and 0.74 among women.

Significantly high rates of mortality are experienced in the most deprived quartile of the

Herefordshire population as illustrated in Figure 10.1 below. The mortality rate ratio

between most and least deprived quartiles is 1.56 and adults residing in the most deprived

areas of the County are over 40% more likely to die as a result of smoking than the

population of Herefordshire as a whole.

Figure 10.1: Smoking-Related Mortality, by Deprivation Quartile

Directly Standardised Mortality Rate by Deprivation Quartile (IMD2010):

Smoking-Related 2007-11 pooled

0.0

50.0

100.0

150.0

200.0

250.0

300.0

DS

R p

er

10

0,0

00

po

pu

lati

on

(3

5+

ye

ars

)

DSR 152.7 161.0 140.1 238.4 168.8

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


Rates of premature smoking-related mortality are shown in Figure 10.2. Again mortality in

the most deprived quartile is significantly high when compared to both the least deprived

quartile - a rate ratio of 1.83 - and the population of the County overall (1.53).



17

Figure 10.2: Premature Smoking-Related Mortality, by Deprivation Quartile


(IMD2010): Smoking-Related 2007-11 pooled

0.0

50.0

100.0

150.0

200.0

DS

R p

er

100,0

00 p

op

ula

tio

n (

35+

years

)

DSR 77.1 85.3 76.6 141.3 92.2

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


Hospital admissions caused by smoking are measured in a very similar way, though the

basket of relevant disease groups is slightly wider and includes additional conditions to

which smoking is considered an attributable factor, such as hip fractures among those

aged 55+ years and age-related cataracts.

Figure 10.3 depicts the variation in smoking-related hospital admission rates across the

County. The standardised rate of admission in the most deprived quartile of population is

40% greater than in the least deprived quartile and adults living in the most deprived areas

can be said to be a third more likely to be admitted to hospital as a consequence of their

smoking than the population of Herefordshire overall.



18

Figure 10.3: Smoking-Related Hospital Admission Rates, by Deprivation Quartile

Directly Standardised Smoking-Related Admission Rates 2010/11 by

Deprivation Quartile (IMD2007)

0.0

500.0

1000.0

1500.0

2000.0

DS

R p

er

100,0

00 p

op

ula

tio

n (

35+

years

)

DSR 1049.7 988.5 1011.3 1475.0 1105.3

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL




19

Alcohol-related conditions

As with smoking it is possible to measure the proportion of hospital admissions occurring

in a population that can be attributed to alcohol consumption. The methodology adjusts

whole admission numbers (across a wide range of alcohol-related conditions defined in

terms of ICD10 codes) for the proportion of each admission that can be attributed to

alcohol consumption and so estimates the number of admissions that can be considered

‘alcohol-attributable’, by gender and age. For example, an admission due to fibrosis and

cirrhosis of the liver (ICD10 K74) counts for 0.77 of an alcohol-related admission among

men aged 16-24 years but just 0.38 among women aged 75+ years.

Figure 11.1 illustrates a distinct relationship between higher levels of deprivation and

higher alcohol-related hospital admission rates. Significantly high standardised rates of

admission are observed in the most deprived quartile of Herefordshire – 44% greater than

admission levels across the entire County. The admission rate ratio between the most and

least deprived quartiles is 1.95, ie a person residing in the most deprived quartile of the

County is almost twice as likely to be admitted to hospital due to alcohol consumption as

someone resident in the least deprived quartile.

Figure 11.1: Alcohol-Attributable Hospital Admission Rates, by Deprivation Quartile

Directly Standardised Alcohol-Attributable (NI39) Admission Rates 2010/11

by Deprivation Quartile (IMD2007)

0

500

1000

1500

2000

2500

DS

R p

er

10

0,0

00

Po

pu

lati

on

DSR 1084.2 1330.3 1333.8 2117.0 1466.6

Quartile 1 least

deprivedQuartile 2 Quartile 3

Quartile 4 most

deprivedALL

Data Source: Hospital Episode Statistics (HES) Analysis: Public Health Dept, Herefordshire PCT

In the most deprived quartile of the County over 30% of alcohol-attributable admissions in

2010/11 were among those aged less than 45 years (Figure 11.2). This compares to less

than 10% of admissions from the same age group in the least deprived quartile. Across

Herefordshire around 7% of alcohol-related admissions were in those aged under 25

years; however in the most deprived quartile under 25s accounted for 14% of all alcohol-

related admissions.



20

Figure 11.2: Alcohol-Attributable Hospital Admissions, by Age Band & Deprivation Quartile

Alcohol-Attributable Admissions 2010/11 by Age Band & Deprivation Quartile (IMD2007)

13.5

5.4

4.0

2.3

6.8

16.1

9.6

11.1

7.6

11.4

31.0

31.6

32.2

24.8

30.0

38.6

52.8

52.4

65.4

51.4

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

most deprived Quartile

Quartile 3

Quartile 2

least deprived Quartile

County

% Admissions by Age Band

0-14 years

15-24 years

25-44 years

45-64 years

65+ years


There is an even more pronounced association between higher levels of deprivation and

higher alcohol-specific hospital admission rates (Figure 11.3). The range of diagnoses

considered to be alcohol-specific includes acute conditions that typically arise from

excessive alcohol consumption exclusively eg ICD10 codes K70 (alcoholic liver disease)

and ICD10 K292 (alcoholic gastritis). Significantly high rates of admission are observed in

the most deprived quartile of the County – 86% greater than admission levels across all of

Herefordshire. The admission rate ratio between the most and least deprived quartiles is

3.95 – a resident of the most deprived areas of the County is almost four times as likely to

be admitted as a direct consequence of their alcohol consumption than a resident of the

least deprived areas.



21

Figure 11.3: Alcohol-Specific Hospital Admissions, by Deprivation Quartile

Directly Standardised Alcohol-Specific Admission Rates 2010/11


0

100

200

300

400

500

600

700

800

DS

R p

er

100,0

00 P

op

ula

tio

n

DSR 166.7 310.0 269.6 659.1 354.1

Quartile 1 least

deprivedQuartile 2 Quartile 3

Quartile 4 most

deprivedALL


Figure 11.4 demonstrates that across Herefordshire the 45-64 years age band represents

the largest proportion of alcohol specific admissions (40%). Of particular concern is the

proportion of these admissions occurring in young people (under 25 years). In the most

deprived areas 15% of alcohol specific admissions are accounted for by this age group

compared to 7.6% in the least deprived areas. Indeed, over 50% of all alcohol-specific

admissions from the most deprived areas are accounted for by the under 45 years age

groups. Interestingly in the most deprived areas only 10% of alcohol specific admissions

are in those aged 65 and above, but this proportion rises to 36% in the least deprived

areas.



22

Figure 11.4: Alcohol-Specific Hospital Admissions, by Age Band & Deprivation Quartile

Alcohol-Specific Admissions 2010/11 by Age Band & Deprivation Quartile (IMD2007)

3.2

3.7

2.1

2.6

12.0

7.4

11.3

7.6

10.3

35.0

25.2

20.6

21.7

28.0

39.6

37.0

46.8

34.8

39.9

10.2

26.7

19.1

35.9

19.2

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

most deprived Quartile

Quartile 3

Quartile 2

least deprived Quartile

County

% Admissions by Age Band

0-14 years

15-24 years

25-44 years

45-64 years

65+ years


Alcohol-specific admissions often reflect the effects of binge drinking among young people

eg ICD10 codes F10 (mental and behavioural disorders due to use of alcohol) and ICD10

X45 (accidental poisoning by alcohol).

Amongst those aged under 18 years the provisional crude rate of alcohol-specific hospital

admissions in Herefordshire is 81.7 per 100,000 population in 2010/11, compared to an

average rate of 85.3 per 100,000 over the previous three years (2007/08 – 2009/10).

However there is extreme variation in rates of admission of young people within the

County, ranging from 12.2 admissions per 100,000 in the least deprived quartile to 148.3

per 100,000 in the most deprived quartile (Figure 11.5). This equates to an admission rate

ratio between most and least deprived neighbourhoods of 12.2.



23

Figure 11.5: Alcohol-Specific Hospital Admissions under 18 years, by Deprivation Quartile

Alcohol-Specific Admission Rates under 18 years 2010/11


0

20

40

60

80

100

120

140

160

Cru

de R

ate

per

100,0

00 P

op

ula

tio

n

Crude Rate 12.2 68.6 87.6 148.3 81.7

Q1 least deprived Quartile 2 Quartile 3 Q4 most deprived ALL




24

Accidents

Standardised mortality rates for accidents are highest in the most deprived quartile of

Herefordshire, although not statistically significantly so (Figure 12.1). The mortality rate

ratio for accidents of 1.46 between most and least deprived quartiles, ie people resident in

the most deprived areas are 46% more likely to die as a result of an accident than those in

the least deprived areas

Figure 12.1: All Age Accident-Related Mortality, by Deprivation Quartile

Directly Standardised Mortality Rates 2005-09 Pooled: Accidents

(ICD10 V01-X59) by Deprivation Quartile (IMD2007)

0

5

10

15

20

25

30

35


DS

R p

er

100,0

00 (

ES

P)

DSR 18.2 25.6 23.9 26.6 23.4



Within Herefordshire rates of premature mortality due to accidents do not vary significantly

(Figure 12.2). The most deprived population quartile has a rate 1.38 times greater than

that experienced within the least deprived quartile.



25

Figure 12.2: Premature Accident-Related Mortality, by Deprivation Quartile


(IMD2010): Accidents (ICD10 V01-X59) 2007-11 pooled

0.0

5.0

10.0

15.0

20.0

25.0

30.0

DS

R p

er

10

0,0

00

po

pu

lati

on

DSR 13.6 17.8 16.2 18.8 16.6

Q1 least

deprivedQ2 Q3

Q4 most

deprivedALL


The most deprived quartile of the County’s population has a standardised emergency hospital admission rate that is significantly higher than all other population quartiles (Figure 12.3). The admission rate ratio between the most deprived quartile and the least deprived quartile is 1.31.



26

Figure 12.3: Emergency Accident-Related Hospital Admissions, by Deprivation Quartile

Directly Standardised Emergency Admission Rates 2005/06-2009/10 Pooled:

Accident-Related (ICD10 V01-X59) by Deprivation Quartile (IMD2007)

0.0

200.0

400.0

600.0

800.0

1000.0


DS

R p

er

100,0

00 (

ES

P)

DSR 707.9 750.8 735.4 928.1 781.2



If you need help to understand or interpret this document please call Peter Stebbings, Public Health Dept., Herefordshire Council on 01432 261998 or e-mail [email protected] April 2013

[email protected]

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