title: Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
abstract: BACKGROUND
  In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond.
  
  
  METHODS
  We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters.
  
  
  RESULTS
  Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]).
  
  
  CONCLUSIONS
  Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation and Public Health England.
authors.affiliation: Public Health England, London, UK; University of Manchester, Manchester, UK. Electronic address: john.newton@phe.gov.uk.
authors.forename: John N
authors.initials: JN
authors.lastname: Newton
authors.affiliation: University of Oxford, Oxford, UK.
authors.forename: Adam D M
authors.initials: AD
authors.lastname: Briggs
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Murray
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Dicker
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Foreman
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Haidong
authors.initials: H
authors.lastname: Wang
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Mohsen
authors.initials: M
authors.lastname: Naghavi
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Forouzanfar
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Summer Lockett
authors.initials: SL
authors.lastname: Ohno
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Ryan M
authors.initials: RM
authors.lastname: Barber
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Theo
authors.initials: T
authors.lastname: Vos
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Stanaway
authors.affiliation: Public Health England, London, UK.
authors.forename: Jürgen C
authors.initials: JC
authors.lastname: Schmidt
authors.affiliation: Public Health England, London, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Hughes
authors.affiliation: Public Health England, London, UK.
authors.forename: Derek F J
authors.initials: DF
authors.lastname: Fay
authors.affiliation: Public Health England, London, UK.
authors.forename: Russell
authors.initials: R
authors.lastname: Ecob
authors.affiliation: Public Health England, London, UK.
authors.forename: Charis
authors.initials: C
authors.lastname: Gresser
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McKee
authors.affiliation: London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
authors.forename: Harry
authors.initials: H
authors.lastname: Rutter
authors.affiliation: Public Health England, London, UK; Centre for Infectious Disease Epidemiology and MRC Clinical Trials Unit, London, UK.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Abubakar
authors.affiliation: INDOX Cancer Research Network, Oxford, UK; John Radcliffe Hospital, Oxford, UK; Green-Templeton College, University of Oxford, Oxford, UK.
authors.forename: Raghib
authors.initials: R
authors.lastname: Ali
authors.affiliation: Population Health Research Institute, Hamilton, ON, Canada; MRC-PHE Centre for Environment and Health, London, UK; St George's, University of London, London, UK.
authors.forename: H Ross
authors.initials: HR
authors.lastname: Anderson
authors.affiliation: University of Birmingham, Birmingham, UK.
authors.forename: Amitava
authors.initials: A
authors.lastname: Banerjee
authors.affiliation: Clinical Trials Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Derrick A
authors.initials: DA
authors.lastname: Bennett
authors.affiliation: King's College London Dental Institute, London, UK.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bernabé
authors.affiliation: Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
authors.forename: Kamaldeep S
authors.initials: KS
authors.lastname: Bhui
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Stanley M
authors.initials: SM
authors.lastname: Biryukov
authors.affiliation: Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
authors.forename: Rupert R
authors.initials: RR
authors.lastname: Bourne
authors.affiliation: Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.
authors.forename: Carol E G
authors.initials: CE
authors.lastname: Brayne
authors.affiliation: University of Liverpool, Liverpool, UK.
authors.forename: Nigel G
authors.initials: NG
authors.lastname: Bruce
authors.affiliation: University of Leicester, Leicester, UK.
authors.forename: Traolach S
authors.initials: TS
authors.lastname: Brugha
authors.affiliation: Great Ormond Street Hospital for Children, London, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Burch
authors.affiliation: University of Liverpool, Liverpool, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Capewell
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Casey
authors.affiliation: University of Cambridge, Cambridge, UK.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Chowdhury
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Coates
authors.affiliation: MRC Lifecourse Epidemiology Unit, University of Southampton, Southhampton, UK.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Cooper
authors.affiliation: St George's, University of London, London, UK.
authors.forename: Julia A
authors.initials: JA
authors.lastname: Critchley
authors.affiliation: Guy's and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Paul I
authors.initials: PI
authors.lastname: Dargan
authors.affiliation: University of Liverpool, Liverpool, UK.
authors.forename: Mukesh K
authors.initials: MK
authors.lastname: Dherani
authors.affiliation: Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Elliott
authors.affiliation: MRC-PHE Centre for Population Health, School of Public Health, Imperial College London, London, UK.
authors.forename: Majid
authors.initials: M
authors.lastname: Ezzati
authors.affiliation: Public Health England, London, UK.
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Fenton
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Maya S
authors.initials: MS
authors.lastname: Fraser
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Fürst
authors.affiliation: Public Health England, London, UK; Department of Primary Care and Public Health, Imperial College London, London, UK.
authors.forename: Felix
authors.initials: F
authors.lastname: Greaves
authors.affiliation: School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Green
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: David J
authors.initials: DJ
authors.lastname: Gunnell
authors.affiliation: Public Health England, London, UK; Ulster University, Coleraine, Northern Ireland.
authors.forename: Bernadette M
authors.initials: BM
authors.lastname: Hannigan
authors.affiliation: International Foundation for Dermatology, London, UK.
authors.forename: Roderick J
authors.initials: RJ
authors.lastname: Hay
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA; Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.
authors.forename: Simon I
authors.initials: SI
authors.lastname: Hay
authors.affiliation: University College London, London, UK; Farr Institute of Health Informatics Research, London, UK.
authors.forename: Harry
authors.initials: H
authors.lastname: Hemingway
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Heidi J
authors.initials: HJ
authors.lastname: Larson
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: Katharine J
authors.initials: KJ
authors.lastname: Looker
authors.affiliation: University of Liverpool, Liverpool, UK; Aintree University Hospital NHS Foundation Trust, University of Liverpool, Liverpool, UK.
authors.forename: Raimundas
authors.initials: R
authors.lastname: Lunevicius
authors.affiliation: Farr Institute, College of Medicine, Swansea University, Swansea, UK.
authors.forename: Ronan A
authors.initials: RA
authors.lastname: Lyons
authors.affiliation: Queen Mary University of London.
authors.forename: Wagner
authors.initials: W
authors.lastname: Marcenes
authors.affiliation: Department of Health Sciences, University of York, York, UK; Adolescent Health Research Unit, University of Cape Town, Cape Town, South Africa.
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Mason-Jones
authors.affiliation: Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK; Institute of Health and Society, Newcastle University, Newcastle, UK.
authors.forename: Fiona E
authors.initials: FE
authors.lastname: Matthews
authors.affiliation: Cancer Epidemiology and Population Health, King's College London, London, UK.
authors.forename: Henrik
authors.initials: H
authors.lastname: Moller
authors.affiliation: West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK.
authors.forename: Michele E
authors.initials: ME
authors.lastname: Murdoch
authors.affiliation: University of Oxford, Oxford, UK.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Newton
authors.affiliation: London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Pearce
authors.affiliation: University of Oxford, Oxford, UK.
authors.forename: Frédéric B
authors.initials: FB
authors.lastname: Piel
authors.affiliation: University of Liverpool, Liverpool, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Pope
authors.affiliation: George Institute for Global Health and Division of Cardiovascular Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
authors.forename: Kazem
authors.initials: K
authors.lastname: Rahimi
authors.affiliation: Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, Imperial College London, London, UK; Mid Sweden University, Sundsvall, Sweden.
authors.forename: Alina
authors.initials: A
authors.lastname: Rodriguez
authors.affiliation: British Heart Foundation Centre on Population Approaches for NCD Prevention, University of Oxford, Oxford, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Scarborough
authors.affiliation: Institute for Health Metrics and Evaluation, Seattle, WA, USA.
authors.forename: Austin E
authors.initials: AE
authors.lastname: Schumacher
authors.affiliation: University of Edinburgh, Edinburgh, Scotland; Northumbria University, Newcastle upon Tyne.
authors.forename: Ivy
authors.initials: I
authors.lastname: Shiue
authors.affiliation: Farr Institute of Health Informatics Research, London, UK; London School of Hygiene & Tropical Medicine, Oxford Martin School, University of Oxford, Oxford, UK.
authors.forename: Liam
authors.initials: L
authors.lastname: Smeeth
authors.affiliation: Public Health England, London, UK.
authors.forename: Alison
authors.initials: A
authors.lastname: Tedstone
authors.affiliation: NHS England, Leeds, UK; Imperial College Healthcare NHS Trust, London, UK; Imperial College London, London, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Valabhji
authors.affiliation: University of Nottingham, Nottingham, UK.
authors.forename: Hywel C
authors.initials: HC
authors.lastname: Williams
authors.affiliation: King's College London, London, UK.
authors.forename: Charles D A
authors.initials: CD
authors.lastname: Wolfe
authors.affiliation: Royal Cornwall Hospital, Treliske, UK.
authors.forename: Anthony D
authors.initials: AD
authors.lastname: Woolf
authors.affiliation: Public Health England, London, UK; London School of Economics, London, UK; University College London, London, UK.
authors.forename: Adrian C J
authors.initials: AC
authors.lastname: Davis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death / Q000639:trends; D004739:England / Q000453:epidemiology; D005260:Female; D006304:Health Status; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D008017:Life Expectancy / Q000639:trends; D015993:Life Tables; D008297:Male; D011204:Poverty Areas; D015995:Prevalence; D012307:Risk Factors