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Chapter 10 Descriptive Analysis of Geographic Variations in Adult Mortality by Cause of Death Chapter 10 Descriptive analysis of geographic variations in adult mortality by cause of death Justine Fitzpatrick, Clare Griffiths, Mike Kelleher and Stan McEvoy Geographic Variations in Health Chapter 10 Chapter 10 Descriptive analysis of geographic variations in adult mortality by cause of death Summary 10.1 Introduction • Scotland, Wales and Northern Ireland had higher all-cause There has been a long-standing interest in geographic mortality rates than England for most age groups studied inequalities in mortality and reducing such inequalities is high and analysis of regional all-cause mortality within England on the current Government’s agenda.1, 2, 3, 4, 5 The report to the shows that regions in the north had higher mortality than Prime Minister by the Cabinet Office, entitled Sharing the the southern regions. Nation’s Prosperity,6 produced in December 1999, also focused on inequalities and drew attention to a north-south divide in • There were substantial differences in all-cause mortality mortality - with higher mortality in the north of England, rates by local authority within countries and regions. Wales, Scotland and Northern Ireland, and lower mortality in Authorities with the highest rates tended to be located in the south of England - but also pointed out that within each urban and industrial areas. region and country there are local authorities which have • Males aged 45-64 in London had much lower rates for mortality levels that are higher than the United Kingdom ischaemic heart disease mortality given the pattern for all average and local authorities with lower than average mortality. causes of death. Drever and Whitehead7 and Charlton8 showed that within • The pattern for cancer and lung cancer mortality was very England and Wales, local authorities that had the highest similar to that for all causes of death. mortality tended to be urban areas, particularly those with purpose-built inner city estates and deprived industrial areas. • There was no clear north-south pattern in colorectal cancer Both rural and prosperous areas tended to be the most healthy mortality and local authorities with high rates were less and also made the biggest health gains during the 1980s. concentrated in urban areas than for other causes of death. Recent work from the New Policy Institute and the Joseph • There was little geographic variation in mortality from Rowntree Foundation9 found that of all the local authorities breast cancer and little variation in prostate cancer within Great Britain with mortality rates more than 10 per cent mortality by country. However, within England it was the greater than Great Britain as a whole, more than a quarter were southern regions and local authorities with characteristics in Scotland, just under half in the north of England and just associated with affluence that experienced the highest rates. under a quarter in London. None were located in the south of 10 • There was no north-south pattern in all-age mortality England (outside London). Shaw and colleagues have used from infectious diseases. London had particularly high parliamentary constituencies to illustrate inequalities in mortality from both respiratory and infectious diseases. mortality by area. They found that the six constituencies within Great Britain with the highest mortality under age 65 were • The geographic pattern of mortality from infectious located in Glasgow, and only one from the highest 15 was disease varied considerably by age group. The pattern for outside Scotland or the north of England. Of the 15 areas with those aged 65 and over was very similar to the pattern for the lowest under-65 mortality rates, only one, Sheffield Hallam, all causes of death. was located outside the south of England. • Areas with high mortality rates from accidents were less This chapter provides further evidence of geographic inequalities concentrated in urban areas than for all causes of death. in mortality at country, region and local authority level during Those areas classified as Remoter Rural had the highest the 1990s, expanding on previous work by including data for mortality. the whole of the United Kingdom. It looks at the patterns for both males and females separately, and focuses specifically on • Areas with high mortality rates from suicide were largely particular age groups if the geography of mortality in that age confined to Scotland, Wales, the North West, London and group is different from the geography of all-age mortality. the south coast of England. • Areas with high mortality from drug-related poisonings As well as all-cause mortality, this chapter examines geographic were largely confined to inner London, Glasgow and variation in mortality from particular causes of death. The Manchester. following additional underlying causes of death are examined: • Circulatory diseases (ischaemic heart disease and stroke) • Areas with high mortality rates from alcohol-related deaths • Cancers (all cancers, lung, breast, prostate, colorectal) were largely confined to Scotland, London and Manchester. • Respiratory diseases 248 Geographic Variations in Health Chapter 10 • Infectious diseases For both males and females, within England, there was evidence • Accidents of a clear north-south divide in mortality. Regions in the north • Suicide had high mortality and regions in the south had low mortality • Drug-related poisonings and alcohol-related deaths for all ages, 45-64 and those aged 65 and over. The North East and the North West were the regions with the highest mortality These causes were identified using the International Classificiation and the South East, South West and East of England the regions of Diseases, Ninth Revision (ICD9). They were chosen for two with the lowest mortality in these age groups. The only major reasons. Either they are included as areas for health improvement exception to this was that males in London, who had lower in the Government’s strategy for health in England, Saving Lives: mortality than the United Kingdom as a whole at all ages and at Our Healthier Nation,1 and are subsequently identified in the ages 65 and over, had higher than average mortality at ages 45- recently published NHS Plan,2 and the strategy for Scotland 64. For boys and girls aged 1-14, Yorkshire and the Humber had Towards a Healthier Scotland,3 or they account for a large the highest mortality rate. proportion of total deaths every year. We have ensured consistency in definitions between countries as far as possible throughout Although there was a steady decline in all-age mortality and in this chapter, but differences in coding of cause of death may the mortality of those aged 45 and over in every country and contribute to some of the variations seen between countries. region between 1992 and 1996, the geographic differences described above were maintained throughout the period. The The recently revised ONS classification of local authorities11 North East had the largest percentage decline in all-age mortality (presented in chapter 4 of this volume) is used as an indicator of of the regions of England and the South East the smallest for the characteristics of areas and mortality rates for groups of both males and females, so a small narrowing of the differences authorities with similar characteristics are presented. The relative between the regions was seen. The differences between the contribution of country and region of location and the ONS countries remained relatively stable over this period. classification to differences in mortality rates by local authority is assessed for each cause of death using analysis of variance. For all countries there was also a decline in mortality for boys and girls aged 1-14 over the 1992 to 1996 period (Figure 10.1 We have used age-standardised mortality rates throughout this and 10.2). For both males and females there was an overall chapter, unless otherwise stated. When presenting trends, we have narrowing of the difference between countries of the United used 3-year moving averages to smooth out yearly fluctuations in Kingdom. For the regions of England, the mortality rates for the data. Consequently trends are shown for 1992 to 1996 children aged 1-14 were very variable over time and no real throughout the chapter. Maps have been used to describe the data trend was apparent. at local authority level and a guide to how they have been constructed can be found in Appendix A. For males aged 15-44 the country-level pattern of mortality was the same as for all ages (Table 10.1). All countries except England had higher mortality than the United Kingdom rate. 10.2 All-cause mortality For females, although the overall pattern was the same as for all ages with Scotland, Wales and Northern Ireland having This section looks at variations in all-cause mortality by country, higher mortality than England, Scotland was the only country region of England and local authority in the United Kingdom. to have a rate significantly higher than the United Kingdom rate (Table 10.2). Variations between countries and regions Tables 10.1 and 10.2 show age-standardised mortality rates for Figures 10.3 and 10.4 show age-specific mortality rates for males and females respectively, over the period 1991 to 1997, males and females aged 15-44 by country and 5-year age for countries of the United Kingdom and regions of England. band. For males in the youngest two age groups shown here For both males and females, there was substantial geographic (aged 15-19 and 20-24) Northern Ireland and Scotland had variation in mortality, between both the countries of the United similar mortality rates, with Northern Ireland’s rate being Kingdom and the regions of England. slightly higher, continuing the pattern seen in children for males. Wales had higher mortality than England in the 15-29 Males in Scotland, Wales and Northern Ireland had higher age groups, but its rates were similar at ages 30-44.
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