1. Scottish Burden of Disease study (SBOD) Managing national and local area needs
Dr. Ian Grant | Grant Wyper | Jacqui McGinn | Dr. Diane Stockton 4th Health & Social Care Gathering, 19 September 2018, Dundee

2. Workshop overview Overview and national summary Ian Grant
Using burden of disease estimates in local areas
Grant Wyper
Case study: West Dunbartonshire HSCP
Jacqui McGinn
Discussion: Ideas / reflections on local area use
All delegates
Impact, influence and future research
Diane Stockton

3. Overview and national summary

4. Why are we carrying out this study?
Low life expectancy (LE) in Scotland which is improving very slowly
Even slower improvements in healthy LE
We are living longer but spending more time in ill-health
Global Burden of Disease (GBD) estimates are modelled
Are they good enough for local planning?
Data informed decision making
Policies and interventions targeted where they can have the most impact
Comprehensive local estimates to empower informed local decision making

5. Why measure burden in this way?
Causes of disease and injury are complex
Heterogeneity (acute, chronic, episodic, or a mixture!)
Outcomes (fatal, non-fatal, or a mixture!)
Traditional measures don’t allow for level comparisons
Incidence, prevalence, mortality, bed days, length of stay etc.
e.g. depression vs. Lung cancer
Use of established traditional measures to ensure morbidity and mortality are counting the same thing
Health loss characterised in terms of years lost due to early death and ill-health

6. Disability-Adjusted Life Years (DALY) = Years of Life Lost (YLL) + Years Lived with Disability (YLD)
Mortality estimate
Used with LE tables to estimate the potential lost from dying early (time lost)
Years Lived with Disability (YLD)
Morbidity estimate
Adjusts for how debilitating a condition is (time lost)

7. SBOD 2016 publication – socioeconomic inequalities
SBOD 2015 illustrated what conditions are affecting the population the most
SBOD 2016 improved on initial estimates, revised estimates (used more relevant data sources, updated model assumptions)
SBOD 2016 sought to look at inequalities across socioeconomic groups
Implications for national and local planning
What we already know
Lower LE in most deprived areas
Multi-morbidity is more prevalent in early in life in the most deprived areas
The conditions which people suffer from vary by their socioeconomic status
What is the effect of this on DALYs, YLL and YLD?
Report Reference –

9. Key results – Burden by deprivation

10. Key results – Burden attributable to differences in life circumstances

11. Key results – Relative outcomes between poorer and wealthier areas

12. Key messages – Different areas have different priorities

13. Using burden of disease in local areas

14. Using SBOD to empower local decision making
Estimates of DALYs, YLD, YLL and deaths available (end of Sept)
by local authority (32); gender (2) ; age-group (5)
By disease groups (21), closely linked with service groups
Rates per 100,000 population (directly age-standardised) and numbers
Deaths and YLL estimates
As observed within local area – ill-defined deaths redistributed to more meaningful causes
YLD estimates
As expected within local area
Wide-range of data sets used in national estimates that weren’t available, or powered for analysis at local level e.g. national surveys, GP practice consultations
YLD rate for each SIMD decile (10), gender (2) and age-group (20) stratification for each disease (132) was applied to the population of the local authority
National estimates are highly stratified, therefore local area estimates are highly appropriate
Pilot work on 17 long-term conditions in NHS Lanarkshire indicated estimates were very similar to observed local data

15. YLD (non-fatal burden)
Mapped geographical variation in burden
EASR per 100,000 population – area rates have been standardised for age and gender differences
DALYs (full burden)
YLD (non-fatal burden)
YLL (fatal burden)

16. Tabulated geographical variation in burden (EASR per 100,000 population)
Local authority
DALY
YLL
YLD
Glasgow City
30,359
17,427
12,932
West Dunbartonshire
29,067
16,359
12,708
Dundee City
28,357
16,045
12,312
North Lanarkshire
27,820
15,376
12,444
Inverclyde
27,463
15,019
12,445
North Ayrshire
27,034
14,560
12,474
East Ayrshire
26,759
14,511
12,249
Renfrewshire
26,273
14,315
11,958
Clackmannanshire
25,821
13,788
12,033
South Lanarkshire
25,626
13,700
11,926
South Ayrshire
24,961
13,128
11,832
Falkirk
24,932
13,276
11,656
Na h-Eileanan Siar
24,766
12,767
12,000
Fife
24,443
12,798
11,645
Aberdeen City
24,410
13,620
10,790
West Lothian
24,160
12,463
11,697
Midlothian
23,934
12,217
11,717
Dumfries and Galloway
23,840
12,053
11,787
Argyll and Bute
23,501
12,115
11,386
Angus
23,212
12,015
11,197
Shetland Islands
22,916
12,317
10,599
Highland
22,662
11,347
11,315
City of Edinburgh
22,649
11,803
10,846
East Lothian
22,409
11,253
11,156
Stirling
22,395
11,438
10,956
Scottish Borders
22,269
11,039
11,230
Moray
22,141
11,319
10,822
Perth and Kinross
21,456
10,650
10,806
Aberdeenshire
21,264
10,947
10,317
Orkney Islands
20,999
10,153
East Dunbartonshire
20,481
10,111
10,370
East Renfrewshire
20,331
10,108
10,223
DALYs
Highest: Glasgow City, West Dunbartonshire, Dundee City
Lowest: East Renfrewshire, East Dunbartonshire, Orkney Islands
49.2% increase in DALY rate in area with lowest to highest
YLL
Lowest: East Renfrewshire, East Dunbartonshire, Orkney Islands
72.4% increase in DALY rate in area with lowest to highest
YLD
Highest: Glasgow City, West Dunbartonshire, North Ayrshire
Lowest: East Renfrewshire, Aberdeenshire, East Dunbartonshire
26.5% increase in DALY rate in area with lowest to highest
Equates to an excess of ~10 days lost each year

17. Variation in area burden by cause groups
Stark differences observed across both YLL and YLD
DALY, YLL and YLD trends are similar (in terms of rank)
Need to look to see what diseases groups are causing these differences

18. YLD (non-fatal burden)
Variation in area burden by cause group
YLD (non-fatal burden)
YLL (fatal burden)

19. Summarising local variation
Focus on absolute difference to incorporate the ‘weight’ of the total burden of each disease group
What disease groups are driving non-fatal and fatal differences?
YLL rate range
Cancer, cardiovascular disease and substance use disorders
YLD rate range
Mental health disorders and substance use disorders
Excess non-fatal health loss (local authorities with lowest and highest rates)
Mental health: excess of 5 days (25-44 years); 7.3 days (45-64 years)
Substance use: excess of 4.9 days (25-44 years)

20. Variation – local authorities vs. SIMD decile areas
Area with lowest EASR
Area with highest EASR
Local authority variation masks scale of inequalities highlighted from SIMD decile area findings

21. Accessing local area SBOD estimates (end of September)
ScotPHO website –

22. Local case study: West Dunbartonshire HSCP Jacqui McGinn Health Improvement and Inequalities Manager

23. Why use burden of disease?
To provide a framework and focus for the strategic needs assessment and forthcoming WDHSCP Strategic Plan
To enable longer term planning for future service delivery taking into consideration demographic changes and changes to public spending and policy

24. Policy drivers

27. Strategic Needs Assessment – How?
‘Population view’; demographic changes, socio-economic factors, risk factors combined with trends in health status and disease patterns over time
National Services Scotland: Local Intelligence Support Team
Scottish Burden of Disease Team

28. West Dunbartonshire Health & Social Care Partnership Burden (DALYs) by disease group (2016)

29. Categories with largest overall burden
Cancer
Mental health and substance misuse
Cardiovascular disease

30. Key issues
The population in West Dunbartonshire is ageing rapidly with a high burden of disease likely to increase the complexity of individual needs
The falling working age population will be a major issue in planning sustainable services in the face of the rising burden of disease and concentration of need
The HSCP need to shift from silo planning to whole system approach to planning given the implications above for both the costs of services and revenue generated

31. Burden of Disease SWOT analysis

32. Strengths
Contributes to longer term strategic planning due to projections
Based on internationally and nationally recognised methodology
Visual impact of national and local illustrations
Ranking enables focus and prioritisation particularly in relation to prevention
Impact of physical and mental long term conditions is clear

33. Weaknesses
Understanding of terminology with range of people and partners e.g. burden/DALYs
Local variance of some categories e.g. self harm and interpersonal violence.
Burden of disease data availability e.g. national versus local

34. Opportunities
Development of focused preventative strategies at a local level by the HSCP and community planning partners based on projected burden and harm e.g.

35. Threats Balance between the here and now and the future No “quick fix”
Understanding multi-morbidity
Investment versus disinvestment
Resource allocation and whole system planning

36. SBOD workshop breakout session

37. SBOD workshop breakout session
Small group discussions, summarised presentation via flipchart
1) How would you envisage using these estimates in your local areas?
2) What other information would be helpful to know? e.g.
Disaggregating burden by geography (e.g. locality)
Disaggregating the burden of disease groups (e.g. depression, neck and lower back pain)
Estimates of prevalence
Reflections from case study

38. Impact, influence and future research

39. SBOD local uses to date Pilot projects Local needs assessments
West Dunbartonshire HSCP
Clyde Gateway
NHS Greater Glasgow & Clyde
NHS Lanarkshire LTC project
Fife ADP
Local needs assessments
Workforce planning

40. Wider implications for policy and planning
Huge opportunity for preventative public health
A large proportion of the disease that leads to illness and early death is preventable
If levels of health in Scotland matched our least deprived populations, we would have one of the lowest health loss of any developed country
Preventative action around our mental health
focus on the wider determinants of health (employment, income, place, education)
Policies and actions around substances that harm our health (alcohol, poor diet, cigarettes, drugs)
focus on cost, availability and acceptability to have a significant impact
Self-management of conditions, through the effective use of technology to slow progress of disease, is also essential to reduce burden on health and care services (e.g. for COPD, heart conditions, diabetes and hypertension).
Workforce and services should be proportionate to need, and this varies by condition.

41. Future research 10-year projections Other work streams
“What if” scenario planning (e.g. increasing rates of obesity)
Projection of past trends of prevalence and mortality
Changes in population
Other work streams
How much burden is amenable to intervention? (How much of the impact of low socio-economic position on the Burden of Disease in Scotland is mediated through behavioural pathways?)
What interventions are cost-effective (Health economics work)
Burden of multi-morbidity (identifying the most debilitating clusters of diseases)
How can we support you?

42. SBOD study team NHS Health Scotland:
Diane Stockton, Elaine Tod, Gerry McCartney
Information Services Division:
Ian Grant, Grant Wyper, Oscar Mesalles-Naranjo, Colin Fischbacher
Reports and data: Twitter: