DFLE adds a dimension of quality of life to LE estimates, providing users with a summary measure of population health. DFLE can be used as a high level outcome to monitor health improvement, effects of policy change at national and local level, and to support service planning across sectors, such as health, benefits and pensions.
This bulletin updates a previous article and presents the second in a series of annual estimates of LE and DFLE at age 16 across English regions and LADs, for men and women during the period 2007-09. Estimates for men and women at age 65 are also provided in the accompanying dataset Sub-national Disability-free life expectancy : England, 2007–2009 (249.5 Kb Excel sheet)
Health expectancies (HEs) provide estimates of the length of life spent in favourable and unfavourable health states, thereby adding a quality dimension to LE. DFLE is calculated using self-reports of activity limiting illness from survey data, and is therefore a measure of functional health status, which has relevance for fitness for work and independent living. DFLE divides expected years of life into those spent living with and without a limiting long-standing illness or disability (LLSI). It is important to track the rate of improvement in DFLE against the improvement in LE as this has implications for the duration of time that, on average, people will live in a favourable state of functional health.
Health inequalities have enormous social and economic costs. The recent Strategic Review of Health Inequalities in England post-2010 (Marmot, 2010) clearly highlights these and illustrates the likely benefits that would be realised if everyone experienced the same health as those in the most advantaged areas. The Review makes a compelling case for monitoring these inequalities more frequently at sub-national geographical scales to determine whether these inequalities, and their associated social and economic costs, are narrowing, persisting or widening over time. This information is useful to enable monitoring of policies designed to achieve health improvement among the worst performing areas on measures of health outcome fastest, thereby reducing the scale of the health gap between areas with advantaged and disadvantaged populations.
A substantial body of literature demonstrates significant geographical differences in HEs, and that these are strongly associated with the relative level of deprivation experienced by the area (Bajekal et al., 2002; Bissett, 2002; Bajekal, 2005; ONS, 2007; Rasulo et al., 2007; Olatunde et al., 2010; Smith et al., 2010a,Smith et al 2010b; White and Edgar, 2010; ONS, 2012).
In a recent article: Disability-free life expectancy: comparison of sources and small area estimates in England, 2006-08 we explored the potential of the ONS Annual Population Survey (APS) to produce estimates of DFLE for men and women; firstly at the national level and then by increasingly detailed sub-national levels in England. In this bulletin we update these analyses, presenting figures for men and women at age 16 for the period 2007-09. Note: assessment of change between 2006-08 and 2007-09 cannot be made as these periods contain overlapping years of both disability and mortality data. Valid comparisons of change over time both within and between areas can only be made using distinct (non-overlapping) periods of data.
The dataset that accompanies this release Sub-national Disability-free life expectancy : England, 2007–2009 (249.5 Kb Excel sheet) also includes estimates for men and women at age 65. In addition, the findings of this release will be further illustrated using Interactive maps of LE and DFLE at age 16 and 65 for men and women across lower tier LADs in England for the periods 2006-08 and 2007-09
ONS has produced a range of health expectancy statistics and this bulletin represents the second annual release reporting analyses of inequalities in DFLE by administrative geographical area in England in the 21st century. The statistics presented in this bulletin are currently undergoing evaluation for National Statistics accreditation. Further information about this process can be found at Guidance-about-assessment
For further information about ONS sub-national health expectancies, please visit our website at Subnational Health Expectancies.
DFLE is an important metric in the assessment of health and social care needs, and the monitoring of policies designed to reduce health inequalities. Since estimates of DFLE give an indication of the likely proportion of the working age population fit for work at a given age, they also have relevance for the analysis of the viability of increases to the state pension age. As such, estimates of DFLE are used to support policy development in the Department of Health, the Department for Work and Pensions and the Department for Environment, Food and Rural Affairs. DFLE at age 65, in the form of healthy life years, is also a European Community Health Indicator (ECHI).
The data in this bulletin and comparative figures for men and women at age 65 are available in the associated dataset Sub-national Disability-free life expectancy : England, 2007–2009 (249.5 Kb Excel sheet)
With the exception of London, estimates of LE and DFLE were higher in the southern regions and lower in the northern regions of England, see table 1.
LE at age 16 was lowest in the North West where men could expect to live a further 61.2 years and women 65.4 years; the figures for the North East were similar at 61.3 years and 65.4 years respectively. By contrast LE at age 16 was more than two years higher in the South East (the region with the highest LE) at 63.9 years for men and 67.7 years for women.
The contrast in DFLE between the north and south of the country was more pronounced than LE. There was a clear divide between the north/midlands and the south of England. For men, DFLE was significantly lower in the North East, North West, Yorkshire and the Humber, East Midlands and West Midlands than in the East of England, London, South East and South West. For women, the picture was similar with the exception of London where DFLE was not significantly lower than in the West Midlands.
Overall, DFLE was significantly lower in the North East than in any other region, at 45.3 years for men and 45.9 years for women. By contrast, DFLE was highest in the South East at 51.5 years and 52.3 years respectively. This suggests that, on average, men and women in the North East will experience activity limiting illness or disability before the official state pension age, while those in the South East will achieve the state pension age before onset of activity limiting illness or disability.
In terms of the proportion of life spent free from a limiting illness or disability from age 16, men in the South East can expect to spend around 80 per cent of their remaining lives disability-free compared with only 74 per cent in the North East. For women, these figures were around 77 per cent in the South East compared with approximately 70 per cent in the North East. Thus men and women in the South East can expect to spend 6 to 7 percentage points more of their already longer lives in a better functional health state than their counterparts in the North East, benefiting both in absolute and relative terms.
Comparing figures between men and women, it is notable that DFLE was significantly lower for men across all regions with the exception of the North East.
|English region||LE||DFLE||Lower 95 per cent confidence interval||Upper 95 per cent confidence interval||Percentage of life spent disability-free|
|Yorkshire and The Humber||62.1||46.9||46.5||47.3||75.6|
|East of England||63.8||50.8||50.3||51.2||79.5|
|Yorkshire and The Humber||66.0||48.1||47.7||48.6||72.9|
|East of England||67.4||51.7||51.3||52.1||76.6|
Within each region, the performance of LADs on measures of LE and DFLE varied. However, as at the regional level, a clear north–south divide in this distribution was present, with LADs in the south generally performing better than those in the north.
For men and women, the majority of the LADs with the lowest estimates of DFLE were in the north of the country, with five of the bottom 10 in the North West region. By contrast, the ten LADs with the highest estimates of DFLE for men were all in the south and east of the country, (table 2). For women the pattern across regions was less regular; the majority of the LADs with the ten highest estimates of DFLE, were situated in the South East and South West, but LADs from the East Midlands and Yorkshire and The Humber were also represented, see table 3.
For men, LE at age 16 was lowest in Blackpool at 58.3 years. At the other end of the scale LE was ten years higher in Kensington and Chelsea at 69.0 years. For women, LE was lowest in Halton at 63.7 years and almost ten years higher in Kensington and Chelsea at 73.2 years.
Compared with LE, the gap in DFLE at age 16 between the best and worst performing LADs was much greater; 17.4 years for men and 18.2 years for women.
For men, DFLE was lowest in Newham at 40.2 years, suggesting only two-thirds of remaining life will be spent disability-free on average. Conversely, men living in Chiltern could expect a further 57.7 years, (around 88 per cent of remaining life) spent disability-free,
|LAD||English region||LE||DFLE||Lower 95 per cent confidence interval||Upper 95 per cent confidence interval||Percentage of life spent disability-free|
|North West Leicestershire||East Midlands||62.8||41.0||37.8||44.2||65.3|
|Hartlepool UA||North East||60.0||42.5||40.9||44.1||70.8|
|Barnsley||Yorkshire and the Humber||60.8||42.5||41.0||44.1||69.9|
|South Oxfordshire||South East||64.3||55.8||53.3||58.2||86.7|
|Uttlesford||East of England||64.8||55.9||53.5||58.3||86.3|
|Reigate and Banstead||South East||64.5||56.0||53.4||58.5||86.8|
|East Devon||South West||65.1||56.2||53.9||58.6||86.3|
|Vale of White Horse||South East||65.3||56.4||53.9||59.0||86.4|
|Kensington and Chelsea||London||69.0||56.8||53.7||59.8||82.2|
|Mole Valley||South East||64.8||56.9||54.0||59.9||87.9|
|Surrey Heath||South East||64.8||57.0||53.9||60.2||88.0|
For women, DFLE was lowest in Burnley at 41.3 years, representing around 64 per cent of remaining life disability-free, and highest in Richmondshire at 59.5 years, (around 88 per cent of remaining life spent disability-free)
|LAD||English region||LE||DFLE||Lower 95 per cent confidence interval||Upper 95 per cent confidence interval||Percentage of life spent disability-free|
|South Derbyshire||East Midlands||66.2||41.3||37.7||45.0||62.4|
|North West Leicestershire||East Midlands||66.6||42.5||38.8||46.2||63.8|
|County Durham||North East||65.2||43.1||41.7||44.5||66.2|
|North Dorset||South West||69.0||57.1||54.1||60.1||82.7|
|Epsom and Ewell||South East||69.8||57.4||53.3||61.4||82.2|
|South Northamptonshire||East Midlands||68.3||57.8||54.4||61.1||84.6|
|Surrey Heath||South East||68.2||58.3||54.8||61.8||85.5|
|West Devon||South West||68.6||58.4||54.8||61.9||85.1|
|East Devon||South West||68.3||58.6||56.3||61.0||85.8|
|Richmondshire||Yorkshire and the Humber||67.4||59.5||56.4||62.5||88.2|
In figures 1 and 2, the contrast between the north and south of the country is clearly evident for both sexes. LADs across the country were ranked according to estimated DFLE and divided into fifths. The darkest shade represents the bottom 20 per cent of areas (less than 46.4 years for men and less than 47.5 years for women) and the lightest shade represents the top 20 per cent of areas (52.7 years or more for men and 53.8 years or more for women). Interactive versions of these maps are also available online
Women can expect to live longer than men in all LADs. In the majority of areas, women could also expect to live for longer without a LLSI or disability. The greatest differences in DFLE between men and women were in Chichester and Gravesham. In Chichester, women could expect 7.3 years more life free from a LLSI than men. This means that women could expect on average approximately 12.5 years with a LLSI, for men this figure was 15 years. Looking at the relative rank of DFLE across LADs, women in Chichester had a rank of 27 out of 324 compared to a male rank of 205, see table 4. For Gravesham the gender differential was also 7.3 years with women spending around 15 years with a LLSI or disability compared to men who could expect to spend around 18 years with a LLSI or disability. However, the female DFLE rank in Gravesham was only 120, with the size of the gender differential largely explained the low rank on this measure among males who were ranked at 299 out of 324.
In approximately one-third (105) LADs, DFLE for men was higher than for women, the LAD with the largest DFLE gender difference in favour of men was East Cambridgeshire where men could expect to spend 5.5 years longer than women free from a LLSI or disability. In this area, women could expect to spend on average approximately 20 years with an LLSI or disability compared with only 11 years for men. Interestingly in this LAD the female DFLE rank was 228 out of 324. For men, the equivalent rank was 33. This gender difference is therefore driven by high ranking among males on the DFLE measure.
|England||years, relative rank|
|LAD||English Region||DFLE difference (Women - Men)||Male DFLE rank (value)||Female DFLE rank (value)|
|Chichester||South East||7.3||205 (48.3)||27 (55.6)|
|Gravesham||South East||7.3||299 (44.6)||120 (51.8)|
|East Cambridgeshire||East of England||-5.5||33 (54.1)||228 (48.6)|
In conclusion, estimates of LE and, more prominently, DFLE show a clear north–south divide. In particular, estimates of LE and DFLE are higher, by region and by LAD, in the South West, South East and East of England than in the North East, North West, Yorkshire and The Humber and the East and West Midlands.
Previous research has demonstrated a clear relationship between health and area based deprivation, however defined. Recently ONS showed that LE and DFLE are substantially lower in the most deprived neighbourhoods and that for females, in particular, there is a trend towards increased inequality between the least and most deprived areas over time (ONS, 2012). These estimates support the scale of inequality found previously by administrative geography (Smith et al., 2010b, ONS, 2006) and cohere well with estimates released previously comparing areas by level of area deprivation. The Index of Multiple Deprivation (IMD) 2010 (Communities and Local Government), classifies areas based on different domains of deprivation including income, employment, health, crime, education, barriers to housing and living environment. The patterns of deprivation across England according to IMD 2010 are consistent with the findings of this bulletin in that those LADs situated in the north of England, and in London, which contain some of the most disadvantaged populations on this index also have the lowest estimates of LE and DFLE. However, estimates by geographical area are subject to internal and international migration and economic cycle effects, which can compound the scale of inequality as healthier populations are able and willing to move area for economic and social reasons, thereby changing the socioeconomic composition of areas through selection. It is not possible in this bulletin to quantify the likely impact of migration on estimates of DFLE.
While both life expectancy and DFLE are improving over time for all areas, a sizeable gap persists, suggesting scope for considerable improvement in DFLE among the worst performing LADs through concerted local action across the domains identified in the Department of Health’s Public Health Outcomes Framework (Department of Health, 2012).
The data used in calculating the prevalence of self-reported limiting long-standing illness or disability was obtained from the Annual Population Survey (APS) and aggregated over a three year period (2007–09) to achieve sufficiently large sample sizes to enable meaningful statistical comparison. The prevalence of limiting long-standing illness or disability among males and females resident in private households in England was compared across regions and lower tier LADs which include Unitary Authorities, London boroughs, metropolitan districts and non-metropolitan districts in England, but excludes the City of London and Isles of Scilly. DFLE was then calculated using the Sullivan method which combines prevalence data with mortality and mid-year population estimates over the same period and geographical scales to calculate estimates of LE and DFLE at age 16 and at age 65 by sex (Jagger, 1996). Estimates for males and females at birth cannot be calculated from the APS as survey questions are only asked of those aged 16 years and older.
The results in this bulletin, including equivalent results for 2006-08 can be found on the ONS website at: Subnational Health Expectancies
DFLE at a given age for a specific period and population, such as men and women at age 16, residing in private households in LADs in 2007-09, is an estimate of the average number of years a person would live without a limiting long-standing illness or disability if he/she experienced the specified population’s age-specific mortality and LLSI or disability rates for that time period throughout the rest of his/her life.
The figures reflect the mortality and health status of a population in a given time period rather than those born in an area. It is not therefore the number of years that a person will actually expect to live in the various health states, both because the death rates and health status rates of the specified population are likely to change in the future and because some of those in the specified population may live elsewhere for part of their lives.
Health expectancies are indicators of health status that take into account differences in the age structures of populations. Results are comparable by age, sex and between specified populations.
Bajekal M, Purdon S, Woodgate-Jones G and Davies S (2002) ‘Healthy life expectancy at Health Authority level: comparing estimates from the General Household Survey and the Health Survey for England.’ Health Statistics Quarterly 16 pp 25–37.
Jagger C (1996) ‘Health Expectancy Calculation by the Sullivan Method: A Practical Guide’, NUPRI Research Paper Series No 68, Toyko.
Smith MP, Olatunde O and White C (2010a) ‘Monitoring inequalities in health expectancies in England – small area analyses from the Census 2001 and General Household Survey 2001–05’ Health Statistics Quarterly 46 pp 53–70.
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