Issue of the month – December 2018: Burden of Disease

Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Reference: Lancet 2018; 392: 1647-61. Published Online October 26, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32207-4  

Previously, estimates of the global burden of disease (GBD) have been undertaken for the UK in 2010, and for nine regions in England in 2013; this 2016 update has been conducted for England, Scotland, Wales and Northern Ireland, and for 150 English local authority areas.

The leading causes of years of life lost (YLLs) in the UK were ischaemic heart disease, lung cancer, cerebrovascular disease, chronic obstructive pulmonary disease (COPD) and dementia.

The most common causes of years lived with a disability (YLDs) were low back and neck pain, skin conditions, migraine, depressive disorders, and sense organ diseases.

Although the all-cause age-standardised YLL rate was highest in Scotland and lowest in England, the age-standardised YLD rate was highest for England and lowest for Wales. England had the highest YLD rates for low back and neck pain, skin conditions, and sense organ diseases; anxiety was highest in Northern Ireland, attributed to the socioeconomic legacy of the Troubles.

Except for dementia and breast cancer, men had higher rates of YLLs than women for each of the leading conditions, whereas with the exception of sense organ diseases, falls and drug-use disorders, women had higher rates of YLDs for each of the leading causes. Of note is that self-harm was the third highest cause of YLLs in men but fourteenth in women.

Across England, there is a two-fold variation in the YLL rate between the most-deprived local authorities and the least-deprived local authorities.

One of the main concerns for the authors is the slowdown in improvements to life-expectancy since 2010 in the UK, an observation that has also been seen in the USA, Canada, Australia and most countries in Europe. They believe it is important to understand the nature of this change in more detail in order to inform health and social care policy, priority setting, prevention, planning and research.

Of greater concern, however, is the fact that in England, Wales and Northern Ireland the burden of disease from years lived with a disability is greater than that for years of life lost, and people, even if living longer, are living with one or more long-term non-fatal conditions that are disabling and which make increasing demands on health and social care services. For individual people and the population as a whole this shift has profound consequences.

Although Steel at el hint at elements of population healthcare, such as the need for health services to recognise that prevention is a “core activity rather than an optional extra” or that resource allocation needs “to continually adapt to the increasing burden from non-fatal conditions”, there is no mention let alone recognition of the need to employ the evolving paradigm of increasing value in healthcare, with value being the result of outcomes over resource use.

Value-based healthcare – encompassing personal value, population value and technical value – would provide a useful approach to addressing the issues raised by the changing burden of disease for the four UK health services.

When examining the data for years lived with a disability, the leading causes fall into six programme budget categories: problems of the musculoskeletal system, problems of the skin, neurological, mental health disorders, problems of vision and problems of hearing, of which mental health disorders followed by musculoskeletal and neurological have the greatest annual expenditure. Although Steel et al mention that the “quality and capacity of local services” is one of the population-level factors that could affect the trends in mortality for specific conditions, there is little further analysis of the potential application of burden of disease data to the planning and delivery of health services; the authors’ focus is primary prevention and the leading attributable risk factors, many of which may have more effect on years of life lost than years lived with a disability.

When caring for people in need with disabling conditions, the questions health services need to ask are:

• Within each programme budget category, have we identified the value obtained from each of the interventions commonly used to care for the population in need?
• In the musculoskeletal programme, are we offering people with low back or neck pain the options for high-value intervention to address the problem bothering them most and affecting their daily lives?
• Are we reducing the use of low-value interventions in the musculoskeletal programme and shifting resource into higher value interventions and/or high-value innovations?

Such shifts in resource use within a programme budget would help to reduce the years lived with a disability.

The global burden of disease data, however, could also be used to guide shifts in resource use across programme budgets, a potentially contentious and much more difficult task than shifting resource within a programme budget. In conjunction with other information sources, the burden of disease data could act as an evidence base for English local authority areas to take account of differences in demography, socioeconomic conditions and need in local populations when considering potential resource shifts across programmes.

While the burden of disease data show that two-thirds of the improvements in premature mortality can be attributed to population-wide decreases in smoking, cholesterol and blood pressure, it remains important to continue to work on the remaining third, attributed to “improved therapies”, especially if the improvements are focused on improving value in healthcare for populations in need, and especially for populations with long-term non-fatal conditions.

This month’s issue of the month was brought to you by Erica Ison, 3V’s Senior Project Lead.