Statistics on Public Health, England 2021

The statistics included in this release are intended to be the latest available annual figures from a range of data sources.

The report provides commentary on hospital admissions for diseases, injuries and conditions that can be attributed to:

• alcohol consumption.
• drug misuse including related mental health and behavioural disorders and poisoning by illicit drugs.
• obesity
• smoking.

The data in this section comes from NHS Digital’s Hospital Episode Statistics.

Data is also presented on smoking attributable deaths.

This publication also presents information on prescriptions items for drugs used to:

• treat alcohol dependence.
• treat obesity and.
• smoking cessation pharmacotherapies.

Several measures of the affordability and expenditure on alcohol and tobacco are also included.

Additionally, the report provides links to information relating to:

• alcohol use and misuse drawn from a variety of sources including alcohol-specific deaths, drinking behaviours among adults and children and road casualties involving illegal alcohol levels.
• drug misuse among both adults and children from a variety of sources, including previously published information from datasets and surveys such as the National Drug Treatment Monitoring System and the Crime Survey for England and Wales.
• smoking by adults and children drawn together from a variety of sources such as the Health Survey for England and Adult Smoking Habits.

This data quality statement aims to provide users with an evidence-based assessment of the quality of the statistical output included in this publication.

It reports against those of the nine European Statistical System (ESS) quality dimensions and principles appropriate to this output.  The original quality dimensions are:

1. Relevance.

2. Accuracy and reliability.

3. Timeliness and punctuality.

4. Accessibility and clarity.

5. Coherence and comparability.

These are set out in Eurostat Statistical Law, however, more recent quality guidance from Eurostat includes some additional quality principles on:

6. Output quality trade-offs.

7. User needs and perceptions.

8. Performance, cost and respondent burden.

9. Confidentiality, transparency and security.

In doing so, this meets NHS England's obligation to comply with the UK Statistics Authority (UKSA) Code of Practice for Statistics , and the following principles in particular:

• Value pillar, principle 1 (Relevance to Users) which states “Users of statistics and data should be at the centre of statistical production; their needs should be understood, their views sought and acted upon, and their use of statistics supported.”
• Value pillar, principle 2 (Accessibility) which states “Statistics and data should be equally available to all, not given to some people before others. They should be published at a sufficient level of detail and remain publicly available.”
• Quality pillar, principle 3 (Assured Quality) which states “Producers of statistics and data should explain clearly how they assure themselves that statistics and data are accurate, reliable, coherent and timely.”
• Trustworthiness pillar, principle 6 (Data governance) which states “Organisations should look after people’s information securely and manage data in ways that are consistent with relevant legislation and serve the public good.”

This dimension covers the degree to which the statistical product meets user needs in both coverage and content.

This publication is considered to be of particular interest to central and local government, the NHS and independent sector providers in England and to English NHS commissioning organisations. However, data and findings are likely also to be of interest to a much broader base of users and are widely reported in the media.

This dimension covers, with respect to the statistics, their proximity between an estimate and the unknown true value.

This report is a National Statistic and is produced according to the Code of Practice for Official Statistics.

Most of the information in this report has been previously published. The sources of the information are trusted sources; the majority being either National or Official Statistics. Most sources referenced in this report include a Methodology section for further information.

Hospital admissions data

The data presented in this report are for inpatients only and therefore does not reflect all hospital activity. This should be considered when interpreting the data as recording and clinical practice may vary over time and between regions.

Drug misuse note: some caution is necessary when looking at these data as, drug misuse may only be suspected and may not always be recorded by the hospital and, where drug misuse is recorded, it may not be possible to identify which drug(s) may be involved.

Further general information on HES data processing and data quality, including specific known issues can be found here:

The processing cycle and HES data quality

COVID-19 and the production of statistics: Due to the coronavirus illness (COVID-19) disruption, it would seem that there is some effect on the quality and coverage of some of our statistics in relation to the 2020/21 period. It is known that many hospitals are reporting zero or significantly less activity across one or more datasets for March 2020 onwards. The HES data in this publication relates to 2019/20, therefore, the end of the reporting period for this publication includes some of the pandemic period but this is estimated to have a negligible impact on the data.

Prescription data

Data on the number of prescription items and Net Ingredient Cost (NIC) for drugs prescribed for obesity or to help people stop smoking, give a measure of how often a prescriber writes a prescription. It is not an ideal measure of the volume of drugs prescribed as different practices may use different durations of supply. The NIC is the basic cost of a drug as listed in the Drug Tariff or price lists; it does not include discounts, prescription charges or fees.

Some prescriptions are recorded against non-CCG cost centres, and include trusts, councils and private companies. This data is included in the national total but will not be allocated to a CCG.

There is no information on drugs supplied direct to patients without prescriptions. Services such as Family Planning Clinics, Out of Hours services, Patient Group Directions, Minor Ailment Schemes can supply direct to patients and do not record these supplies in national datasets.

Obesity note: NHS Prescription services have coded Mazindol within BNF section 4.5 Drugs used in the treatment of obesity, but as prescription data has no information as to why it was prescribed it cannot be stated it was definitely used for the treatment of obesity in this instance. Consequently Mazindol has been excluded from prescribing data since 2012. The number of data items affected is very small and has a negligible effect on the totals overall.

Survey data

Some of the information signposted to in the report is taken from survey data. Sometimes the mode of data collection used in a survey can have an impact on how respondents answer the questionnaire. For example, surveys conducted via a face-to-face interview such as the Health Survey for England (HSE) provide an opportunity for an interviewer to use a computer to record the respondent’s answers which will improve the quality of the data by ensuring all the questions are completed and not allowing any invalid or inconsistent answers. By comparison data collected via a self-completion online survey or paper form such as the Smoking, Drinking and Drug Use amongst Young People (SDD) survey will have none of these inbuilt validations.

Face-to-face interviews also provide an opportunity to guide the respondent through any interpretation issues, which is more difficult in a non-face-to-face interview.

Both modes however may suffer from respondents being tempted to give answers which are considered to be more socially acceptable. This could occur either through the surveys being completed in the home when other family members are present, or through the interviewer being present at a face-to-face interview. This effect is reduced in surveys such as SDD which is conducted in schools in exam conditions.

Obesity note: HSE does include some information such as height and weight (and therefore BMI), and blood pressure which are measured by a nurse and therefore not affected in the same way as the respondent’s answers.

Timeliness refers to the time gap between publication and the reference period. Punctuality refers to the gap between planned and actual publication dates.

This combined publication is intended to be fully refreshed annually and presents or signposts the most up-to-date information available based on a quarterly review.  It is initially based on the content transferred from the publications below before being updated during 2023:

• Statistics on Alcohol
• Statistics on Drug Misuse
• Statistics on Obesity, Physical Activity and Diet
• Statistics on Smoking

The publication of these reports were delayed due to the coronavirus pandemic (COVID-19) requiring changes to NHS England’s statistical production schedule.

Accessibility is the ease with which users are able to access the data, also reflecting the format in which the data are available and the availability of supporting information. Clarity refers to the quality and sufficiency of the metadata, illustrations and accompanying advice.

The report is accessible on the NHS England (NHS Digital) website in HTML format. All tables in the report are provided in Excel format and as csv files, as part of the government’s requirement to make public data accessible.

Coherence is the degree to which data, which have been derived from different sources or methods but refer to the same topic, are similar. Comparability is the degree to which data can be compared over time and domain.

Hospital Admissions

Alcohol-related

Alcohol-related hospital admissions have been estimated by applying alcohol-attributable fractions (AAFs) to Hospital Episode Statistics (HES) data. AAFs are the proportion of disease cases that can be attributable to alcohol. In 2020 new AAFs were calculated based on updated alcohol consumption rates and the latest evidence linking alcohol consumption to disease outcomes. 

Alcohol-attributable fractions for England: an update

Alcohol-related hospital admissions in this report use the new set of AAFs, and so differ from previously published data. Time series comparisons are based on the new AAFs but data is only available from 2016/17.

The “broad” measure of alcohol-related hospital admissions is more dependent on the use of secondary diagnoses than the “narrow” measure. Consequently increases for the "broad” measure may be due to improvements in the recording of secondary diagnoses and the “narrow” measure is a better indicator of changes over time.

Drug-related

Where drug-related mental and behavioural disorders were a factor

There is continuing evidence that recording of secondary diagnosis codes is improving over time, which may have contributed (though not fully) to the increases seen over the last ten years for this measure. This is demonstrated by looking at year on year increases in the mean number of secondary diagnosis codes that were applied to these admissions, as shown below.

Due to poisoning by drug misuse – break in time series 2012/13

Table D.4.1 (within the excel data tables) presents a time series of hospital admissions with a primary diagnosis of poisoning by drug misuse (controlled substances). In 2012/13 the ICD 10 code T40.4 was updated to include the prescription drug Tramadol, which at the time was not classified as a controlled substance. As such code T40.4 was initially excluded from the measure from that time. However, a 2014 amendment to the Misuse of Drugs Act added Tramadol as a controlled substance, and so code T40.4 has now been restored to the analysis for the full time series. However, this does create a break in the time series in 2012/13, with the change to code T40.4 adding a significant number of admissions: T40.4 admission count in 2011/12 = 283; in 2012/13 = 3,342.

Smoking attributable

HES data is available from 1989-90 onwards.

Changes to the figures over time need to be interpreted in the context of improvements in data quality and coverage (particularly in earlier years), improvements in coverage of independent sector activity (particularly from 2006-07) and changes in NHS practice.

Obesity related

Changes to the figures over time need to be interpreted in the context of improvements in data quality and coverage, improvements in coverage of independent sector activity and changes in NHS practice.

Improved use of secondary diagnosis codes

There is continuing evidence that recording of secondary diagnosis codes is improving over time, which may have contributed (though not fully) to the increases seen in ‘admissions where obesity was a factor’ over the last ten years. This is demonstrated by looking at year on year increases in the mean number secondary diagnosis codes that were applied to these admissions as below.

Changes to recording of gastric band maintenance

Practices vary between hospitals as to whether gastric band maintenance procedures (introduced as a specific OPCS-4.5 code from 2009/10) are recorded as being carried out in outpatient or inpatient settings. As the data presented in this report are for inpatients only, inconsistencies over time have contributed to the changes seen in recent years. Time series data that excludes maintenance and revisional procedures, (thus removing the effect of these varying recording practices) is shown in Table 4.1 (Primary bariatric surgery).

Most providers record none or very few gastric band maintenance procedures as inpatient admissions, but the changes known to us that have a significant effect on the national totals are as below. Though this affects all the obesity related admissions measures (with the exception of primary bariatric surgery), it is less significant in the ‘admissions where obesity was a factor’ measure (Tables 3.1 and 3.2), as bariatric surgery represents a much smaller part of that data (less than 1% in 2017/18).

Please note, the figures quoted are for episodes involving gastric band maintenance where there was no primary bariatric surgery in the same episode (as those that also had a primary bariatric surgery procedure code would be included in the counts regardless).

2013/14

Between 2009/10 and 2012/13 Derby Hospitals NHS Foundation Trust (RTG) recorded around 750 to 1,250 obesity related admissions per year involving gastric band maintenance. In 2013/14 and subsequent years this number was zero or close to zero. In 2013/14 this change represented around half of the decrease in the national bariatric surgery figures (-1,640 overall).

Between 2009/10 and 2012/13 King’s College Hospital NHS Foundation Trust (RJZ) recorded around 250 to 400 obesity related admissions per year involving gastric band maintenance. In 2013/14 this number dropped to 53, and just 2 in 2014/15. They have since recorded around 100 per year.

2015/16

From 2015/16 Heart of England NHS Foundation Trust (RR1) has recorded around 300 to 400 obesity related admissions per year involving gastric band maintenance, compared to close to zero prior to 2015/16. In 2015/16 this change accounted for around three quarters of the increase in the national bariatric surgery figures (+406 overall).

Changes to procedure codes effecting the bariatric surgery time series

In 2012/13, changes were made to give a standard definition of “bariatric surgery” using the same methodology as Healthcare Resource Groups (HRGs). The new HRGs were created in 2011/12 Reference Costs collection as a result of work between the National Casemix Office at NHS Digital, the British Obesity and Metabolic Surgery Society (BOMSS) and the Chapter F Digestive System Expert Working Group (EWG). This definitional change has a minimal effect on the previous years’ data; between 20 and 30 cases a year from 2009/10 onwards when OPCS 4.5 and 4.6 codes were used, following on from the introduction of a specific code for maintenance of gastric band in OPCS-4.5 in 2009/10. Appendix B shows the current list of OPCS codes included in the definition of bariatric surgery.

More information on the change of codes in 2012/13 is included in the methodological change notice at:

http://content.digital.nhs.uk/media/13556/Statistics-on-Obesity-Physical-Activity-and-Diet-England-2014/pdf/MethChange201402_SOPAD.pdf

In 2016/17, the National Casemix office updated the definition above to remove 2 previously included OPCS codes, and so the data in this publication has been updated to reflect this, creating a break in time series from 2016/17. Based on data in recent years (2015/16 to 2017/18), the change reduces the total by between 250 and 320 records per year.

More information on the change of codes in 2016/17 is included in the methodological change notice at:

https://digital.nhs.uk/binaries/content/assets/website-assets/publications/publications-admin-pages/methodological-changes/methchange20190205_sopad.pdf

Changes to the calculation of hospital admission rates

Admission rates per head of population were changed in the 2017 report to be age standardised based on the European Standard Population. Prior to 2017, these rates were not standardised. More information is available from the methodological change notice at:

http://content.digital.nhs.uk/media/23838/Announcement-of-methodological-change-to-Statistics-on-Obesity-Physical-Activity-and-Diet-England---2017/pdf/MethChange20170316_SOPAD.pdf

Other HES data issues

2016/17

Around one third of all records for Nottingham University Hospitals Trust were submitted to the Hospital Episode Statistics database without patient identifiers such as postcode. This means it was not possible to assign a Local Authority or Clinical Commissioning Group of Residence to these admission records, so they will not appear in the tables. This will mainly affect the Nottingham and Nottinghamshire areas with a smaller impact on surrounding areas and the East Midlands and England totals.

This dimension describes the extent to which different aspects of quality are balanced against each other.

The sources used in this report include provide information on methodology which will contain specific information about trade-offs. Further details are available in the Appendices.

In addition, HES data quality information, including details of trade-offs, is available here for admissions information presented in this publication:

The processing cycle and HES data quality

This dimension covers the processes for finding out about users and uses and their views on the statistical products.

In 2015 a consultation was carried out to gain feedback on how to make the report more user-friendly and accessible while also producing it in the most cost-effective way.

Findings of the 2015 Consultation

In response to the feedback received, the format of the report was changed for the 2016 report.

This publication has been created following a further user consultation conducted in 2022 to gain feedback on how to make the report more user-friendly and accessible while also producing it in the most cost-effective way. The proposal adopted was to combine the four compendia publications, listed below, into this single publication:

• Statistics on Alcohol
• Statistics on Drug Misuse
• Statistics on Obesity, Physical Activity and Diet
• Statistics on Smoking

Findings of the 2022 Consultation

NHS England is keen to gain a better understanding of the users of this publication and of their needs; feedback is welcome and may be sent to [email protected].

This dimension describes the effectiveness, efficiency and economy of the statistical output.

All data used within this report is either already published or is part of an existing dataset. Therefore, there are no data collected specifically for this report.

The procedures and policy used to ensure sound confidentiality, security and transparent practices.

Some of the data contained in this publication are National or Official Statistics. The code of practice for statistics is adhered to from collecting the data to publishing. The code of practice for statistics is available at:

Code of Practice for Statistics

Details of the relevant NHS Digital procedure and policy information can be found below:

NHS Digital Statistical Governance Policy

NHS Digital Freedom of Information Process

NHS Digital Statement of Compliance with Pre-Release Order

NHS Digital Disclosure Control Procedure