Healthy Life Expectancy Measurement in Scotland

Institute and Faculty of Actuaries
HEALTHY LIFE EXPECTANCY MEASUREMENT IN SCOTLAND

Author(s): A. S. Macdonald, J. Straughn and M. Sutton
Source: British Actuarial Journal, Vol. 12, No. 2 (2006), pp. 327-394
Published by: Cambridge University Press on behalf of Institute and Faculty of Actuaries
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B.AJ. 12,II, 327-394(2006)

HEALTHY LIFE EXPECTANCY MEASUREMENT IN SCOTLAND
By A. S. Macdonald, J. Straughn and M. Sutton
[Presentedto theFacultyof Actuaries,20 February2006]
ABSTRACT
Health expectancy(HE) was onlyrecentlyestimatedforthe Scottishpopulation(Clark et al. ,
2004). The estimateswerebased on Sullivan'smethod,applyingthemorbidityprevalencein each
age group to the expectednumberof years lived,to obtain the expectednumberof years lived
in good health.First,we comparetheseestimateswitha wide rangeof estimatesin respectof the
restof the United Kingdom and the (pre-accession)countriesof the European Union. We find
thatScotland's HE is relativelylow, especiallyformen. Second, we examinedata comprisingthe
responsesto the 1998 ScottishHealth Survey,linkedto the hospitalrecordsof the respondents
from 1981 to 2004, and death records from 1998 to 2004, with HE measurementin mind.
measureof HE, the linkagepresents
Althoughtimespentin hospitaldoes not give a satisfactory
a rare opportunityfor statisticalanalysis of surveyrespondents'mortalityand morbidity.We
show the resultsof survival analyses, quantifyingthe effectiveness
of various definitionsof
'unhealthy'as predictorsof futuremortalityand morbidity.The resultssuggestthatenumerating
recent serious hospital episodes mighthelp to predict futurepatternsof demand for acute
services.
KEYWORDS
Health Expectancy; Hospital Episodes; LifeExpectancy; ScottishHealth Survey
CONTACT ADDRESS
Angus Macdonald, Department of Actuarial Mathematics and Statistics and the Maxwell
Institutefor MathematicalSciences,Heriot-WattUniversity,EdinburghEH 14 4AS, U.K. Tel:
+44(0)131-451-3209;Fax: +44(0)131-451-3249;E-mail:A.S.MacdonakKgma.hw.ac.uk
1. Introduction
1.1 Background
The Facultyof Actuariesin Scotlandcelebratesits 150thanniversary
in
2006. As partof theprogramme
of eventsto markthe occasion,Faculty
Councildecidedto sponsora researchprojectwhichshouldfocuson the
mutualinterests
oftheprofession
and thepolicy-making
bodiesin Scotland.
At about the same time,the Information
ServicesDivision(ISD) of the
ScottishExecutivewas completing
the firstreporton HealthExpectancy
(HE) in Scotland(Clarket al, 2004),and thisworkidentified
severalkey
the results.Moreover,
questionswhose answerswould help to interpret
327
328
inScotland
Measurement
HealthyLifeExpectancy
instruments
the HE estimateshad also
verylike thoseused to construct
beenthebasis forlinkingthehospitalrecordsof individualpeople
recently
have
intoa longitudinal
data setspanningmorethan20 years.Researchers
of
HE
on
that
better
estimates
longitudinal
longrecognised
depend collecting
data, but verylittlesuitabledata exist.The factthatsuchdata have been
of healthservice
developedin Scotlandis a resultof the relativestability
decisionsmadeover20 years
overseveraldecades,and far-sighted
provision
collectionof healthstatisticsand the
ago, whichled to the systematic
ofwhatevolvedintoISD.
establishment
and longitudinal
data led to thechoiceof
Thiscombination
of topicality
HE as thesubjectoftheFaculty'sresearch
project,whichwas commissioned
in the formof a collaborationbetweenthe Departmentof Actuarial
theHealthEconomics
at Heriot-Watt
Mathematics
and Statistics
University,
ResearchCentreat the Universityof Aberdeen,and with the active
ofISD.
involvement
PuttingScottishHE into its propercontextraises severalquestions,
of Clarket
thepublication
as researchpriorities
identified
byISD following
al (2004).First,thereis theapparently
simplequestionofwhereScotland,or
different
leaguetableof
partsof Scotland,are placed in theinternational
whichmaybe revealed,
methodological
HE; but,inexplaining
anydifferences
questionsarise. Most HE estimatesto date have reliedon a verysimple
approachcalled Sullivan'smethod,whose chiefvirtueis that it can be
compiledquicklyand simply,using existinglife tables and population
Its drawbackshavelongbeenrecognised.
However,bettermethods
surveys.
data - a laborioustaskwhichis only
relyon thecollectionof longitudinal
to bearfruit.
nowbeginning
The project,and this paper, have two parts. First, we presentan
international
comparisonof HE in Scotland and in other European
otherpartsof theUnitedKingdom.Second,we carry
countries,
including
ofHE basedon a uniquedata setcompiledby
outa preliminary
investigation
ISD, namelythe near-complete
linkageof the responsesmade by the
includedin the 1998 ScottishHealthSurvey(SHeS) withtheir
individuals
hospitalrecordssince 1981. It is clear that the hospitalrecordsadd a
longitudinalcomponentto the surveydata which would be used in
or not,thiswillhelp
and thequestionis whether,
HE estimates,
conventional
ofHE.
definition
to forma moreobjective
1.2 Whatis HealthExpectancy?
Life expectancy
(LE) has been estimatedin manycountriesfor many
years,beingeasilycomputedusingnormalcensusand/ordeathregistration
in the 20th century(at least in the
data. It has increasedsignificantly
the
to
questionof whatqualityof lifemay be
developedworld),leading
Healthexpectancy
lived.
extra
in
the
(HE) is a measureof
years
experienced
ofyearswhicha personmaybe
thenumber
thisqualityoflife;ifLE is simply
329
inScotland
Measurement
expectedto spendalive,HE is thenumberofyearswhichtheyare expected
thisleads to thequestionof
to spendin a stateof good health.Naturally,
Someauthorshave
whatdetermines
whether
one is 'healthy'or 'unhealthy'.
bothmentaland
definedgood healthas freedom
fromlong-term
disability,
physical,whileothershave confinedit to mean the abilityto undertake
ofdailyliving.As wewillseelater,HE is acceptedas a genericterm
activities
thefullrangeof definitions
forLE adjustedforhealthstatus.The
covering
HE
LE
between
and
is
andis notyetat all clear:
relationship
disputed,
thatincreasedLE was
(a) Gruenberg
(1977) and Kramer(1980) contended
and disease.
merelya resultof a prolongedperiodlivingwithdisability
etal (1991)as the'expansion
Thisconceptwas formalised
byOlshansky
of morbidity'
characterised
hypothesis,
by a declinein theratioof HE
to LE.
thattheprolonging
oflifewouldresultin a
(b) Fries(1980,1989)suggested
of morbidity,
since,assumingthatthetimingof morbidity
compression
eventscouldbe postponed,
theonsetofdiseaseswouldbe confined
to the
finalyearsoflife.
of
(c) Mantn(1982) suggestedthata slowingdown in the progression
diseasewouldlead to a dynamicequilibrium,
a simultaneous
increasein
LE as wellas in unhealthy
between
years.Thus,an inverserelationship
and morbidity
mortality
mightdevelop,but, at the same time,the
disabilities
wouldbe lesssevere.
experienced
wereveryattunedto thedebate,and subsequently
shifted
Policymakers
theirfocusto usingHE ratherthan LE as primaryindicatorsof health.
Researchers
haveresponded
to thisdemandforHE estimates,
notonlyat the
nationallevel,butalso sub-nationally
and bysocioeconomic
groups.Robin
& Ritchie(1993) reportedthatHE estimateshad been made forsome49
countries,the earliestin Europe beingin France (Robin et ai, 1986),
followed
byEnglandandWales(Bebbington,
1988)andtheNetherlands
(van
Ginneken& Bont,1989;van Ginnekenet al., 1991). Robin& Romieu
that13 ofthe15 countries
in theEuropeanUnionhad
(1998)laterreported
calculatedHE estimates,
and thatchronological
seriesexistedforDenmark,
Finland,France,Germany,theNetherlands,
Spain,Swedenand the U.K.
WithintheU.K., however,
HE estimates
wereavailableonlyforEnglandand
WalesuntilClarketal. (2004)published
estimates
forScotland.
An international
of Scottishpopulationhealthwas previously
comparison
undertaken
withcauses
byLeonetal. (2003),butusingLE estimates
together
of death and ill-healthas healthindicators.They found that, among
womenhadtheworsthealth,andamongEuropean
Europeanwomen,Scottish
men,Scottishmenhad thesecondworst.It is againstthisbackground
that
we hope thatthe presentstudycan shedmorelighton the healthof the
Scottishpopulation,
to itshealthcare
and,in so doing,be moreinformative
The studyis presentedas follows.Section2 examinesthe
policymakers.
330
inScotland
Measurement
different
methodsused to estimateHE. Section3 reviewswhatis known
about HE in Scotland,whichis mostlydue to Clark et al. (2004); then
Sections4 to 7 attemptto relatetheseto othernationaland sub-national
we compareScottishHE withmosthighly-standardised
studies;in particular
in Section5. In Sections8 and 9 we describethe
availableEuropeanfigures
SHeS and itslinkageto hospitalrecords;and in Sections10 to 11 we explore
Our conclusions
aspectsof thesedata as theymayrelateto HE estimation.
areinSection12.
2. Definitionand Estimationof Health Expectancy
2.1 BasicIdea ofHealthExpectancy
as:
oflifeat age x maybe written
Thefamiliar
expectation
(1)
ex= f tPxdt.
Jo
themodelin
To justify
thename'expectation',
we,ofcourse,shouldspecify
The simplest
whichthisis indeedtheexpectedvalueof a suitablequantity.
is to adoptthe'alive-dead'model
waywhichpointsus in therightdirection
in Figure1. Supposethata personis in statej at age x; then,for
illustrated
to havevalue one if the
each statek in themodel,definetheindicatorIJxkt
Thisfamily
personis in statek at age x + t,andto havevaluezerootherwise.
of stochasticprocessesdefinesthe individual'slifehistory(actuallywith
ofthemodel).
herebecauseofthesimplicity
someredundancy
thata personin statej at age x is in state
to be theprobability
Definepjxkt
= 1]= E[Ijkt].The timespentin
= P[Ijkt
k at age x + i. That is that pjxkt
statekis:
r ltdt
(2)
du
dt= pikt
El"F it dt'= E[Ijkt]
jT
j
(3)
Jo
valueis:
whoseexpected
0 = Alive
1 = Dead
withforce
ofan individual,
modelofthemortality
Figure1. A two-state
ofmortality
fit
Measurement
inScotland
In particular,
thetimespentalive,ifaliveat age x, is thefamiliar:
331
(4)
Tx=rzdt.
Jo
We notethatTx,therandomfuturelifetime,
is oftentakenas thestarting
pointin defininga survivalmodel. Its expectedvalue is, by definition,
E[7^]= ex,andwe seethatthisagreeswith:
- E[i~]dt= pZdt
j~
e[jT IZdt] jf
(5)
in our
because,clearly,tpxin traditionalnotationis the same as pxt
notation.
The advantageof thisformulation
is thatit extendswithno further
work
to a modeldefining
two or morestatesof health,of whichthesimplestis
in Figure2. Equations(2) to (5) remainequallyvalid(and also if
illustrated
we expandthemodelto severalstatesof health),althoughtheusefulness
of
randomtimesbetweeneventsis muchless,and we drop7^ and itsanalogues
fromnow on. Equation(4) definestherandomtimewhichwillbe spentin
and equation(5) is theexpectedtimewhichwillbe
good healthin future,
spentin good healthin future.This is the simplestexampleof a quantity
called'healthexpectancy',
whichwewillcall HE forshort.
The definition
of HE is not completeuntilthe precisemeaningsof
'healthy'and 'unhealthy'are fixed,and then the questionof actually
HE dependson obtaining
relevant
data.Perhaps,notsurprisingly,
estimating
0 = Healthy
^-
IM>i(t) i
' /xio(i) '
1 = Unhealthy
/*02(*)'^
y
V>n(t)
2 = Dead
modelofstatesofhealth
Figure2. A three-state
332
Measurement
inScotland
thedefinitions
of 'unhealthy'
whichare used in practiceoftenfollowthose
whencomparing
impliedbyreadilyavailabledata,whichcanleadtoproblems
HE estimates
fromdifferent
studies.
2.2 Sullivan
's Method
If we startwiththelast expression
in equation(5) and makethetrivial
observation
that:
00
f/oo
PZdt=
.A) ^LîpZ
Pxj + PxJ
+ p^dt
(6)
where:
of beingalive at timet (in otherwords,
+ Vx'tis the probability
(a) Pxt
thetraditional
tpx);and
thatsomeonealiveat timet is in good
is theprobability
+ Px!f)
(b) Pxt/(Pxt
health;
thenwe have thebasis of Sullivan'smethod(Sullivan,1971)of estimating
HE. The life table probabilities
(a) above are fairlyeasily available at
in goodhealth(b) abovecan
nationaland regionallevel;and theproportion
or otherwise.
healthsurveys
frompopulation-based
be estimated
In practice,abridgedlifetablesare oftenused (five-year
age groupsare
in good healthoverthesameage
proportions
common),withtheestimated
groups,and, in life table terms,the procedureis describedas follows.
age groups:
Supposethattheabridgedlifetablehas n-year
livedbetweenages x and x + n
(a) The expectednumberof person-years
isnLx.
in age groupx to x + n,also
unhealthy
proportion
(b) Denotetheestimated
as
thisis simplyestimated
as
calledthemorbidity
Usually
nx.
prevalence
to thenumber
classedas unhealthy
theratioofthenumber
surveyed.
livedbetweenages x and
(c) The expectednumberof healthyperson-years
x + nmaybe denotednHLx,andis nLx{'- nx).
(HE) at age x maybe denotedhex,by analogy
(d) The healthexpectancy
withex,and is then(J2y>x
nHLy)/lx.
fromzx,
Olderactuarialreaderswillrealisethatif n = 1 thennxdiffers
in
thecentralsicknessrate,onlyin thatthelatteris conventionally
expressed
unitsofweeks:
zx= S2.18/07x+t/x+dt
Measurement
inScotland
333
sickat age x + 1 (see Hooker& Longley-Hook,
wherefx+tis theproportion
the definition
of HE just givenamountsto the expected
1953). Similarly,
while
presentvalue of an annuityof one per annum,payablecontinuously
with
interest
of
0%.
healthy,
2.3 TheMulti-State
Method
The chiefdrawbackof Sullivan'smethodis thefactthatit uses current
rates(thenx).The disadvantages
ofdoingso havebeen
morbidity
prevalence
rehearsedin severaldifferent,
but related,fields,includingthe actuarial
(IP), insurance(CMIB, 1991)and thestudyby
studyof incomeprotection
healtheconomists
of futurelong-term
care costs(Bone et al, 1995).Stated
thetransition
intensities
are thesimplequantitieswhich
(thefijk(t))
briefly,
drivethemodel.The current
rates
are complicated
outcomesof
prevalence
thepast history
of transition
intensities.
of
If, as is oftenrealistic,
patterns
healthhave changedin thepast and maychangein future,
the transition
intensities
For example,new
usuallyhave the mostdirectinterpretation.
treatments
ofheartdiseasemayreducetheincidence
ratesofheartattacksby
of thosewho havehad heartattacks
10%,buttheeffecton theprevalence
thepopulation
dependson howthissimpleoutcomeworksitswaythrough
overtime.Therefore,
transition
intensities
are muchmoresuitableobjectsof
ofpopulation
health.
studyiftheaimis to makelong-term
projections
The use of a multi-state
has
method,therefore, nothingto do with
- Sullivan'smethodwas
themodelwithinwhichHE is estimated
specifying
- but with
most conveniently
describedin a multi-state
framework
the
transition
intensities
as
theparameters
to be estimated.
Given
targeting
estimates
oftransition
intensities,
finding
occupancy
probabilities,
prevalence
ratesand expectedvalues(includingHE) is merelya matterof numerical
computation.
A mostimportant
of 'unhealthy'.
partof themodelis stillthedefinition
If thisconceptremainstiedto theresponseto a surveyquestion,we would
haveto imaginebeingable to poll therespondent
continuously,
askingfrom
moment
to moment
ifhe or shefeltwellor not.Thisis neither
practicalnor
doesit respondadequatelyto thecriticism
ofHE estimates
basedon current
methodis viewedas
rates,givenabove. Rather,themulti-state
prevalence
an opportunity
to changethe definition
of 'unhealthy'to one based on
suchas a recordof illnessor disability.
objectivestatistics,
Thus,themost
naturalkindof studyto use withthemulti-state
approachis a longitudinal
theseare expensive
and timeconsuming
to carryout,
survey.
Unfortunately,
so are notcommon;thelack of longitudinal
data meansthatfewpublished
studieshave used thismethodology,
fewerthanthosewhich
considerably
haveusedSullivan'smethod.
2.4 OtherMeasuresofHealthExpectancy
Equations(5) and (6) are obtainedfromthe simplestpossiblemodelof
inScotland
Measurement
good and bad healthand a weighting
systemwhichattachesweightone to
timespentin good healthand weightzero to timespentin bad health.An
statesbetween
obviousextension
is to definea largernumberofprogressive
will
some
health
and
death
cite
(we
exampleslater).Supposethatthere
good
are m+ 1 suchstates,withstatezero representing
good healthand statem
death.By assigninga scorewkto presencein statefc,running
representing
fromone whenin good health(w0= 1) to zero whendead (wm= 0), we
life expectation(HALE), also called a qualityobtaina health-adjusted
life
(QALE):
adjusted expectation
334
fe=m
/oo
Ut.
X>W
*=0 ^
(8)
In fact,in someschemesstatesof healthmaybe assigneda weightwk< 0,

'worsethandeath'.
representing
2.5 Definitions
ofHealthStatus
Here we summarisebrieflythe commonnotionsof 'good' and 'bad'
health,and associatedterminology
(and the manyacronyms).These are
closelytiedto theformsofdatawhichhavebeencollectedfromtimeto time.
countries
in different
studiesor in different
definitions
The use of different
about
raises
serious
comparability:
questions
clearly
healthdataare:
ofcollecting
(a) Themajormethods
and
(1) bysurvey
questionnaire;
andso on.
ofdiseaseincidence,
hospitalisations,
(2) fromregistries
fromthe
(b) An exampleof healthquestionsin a surveyis thefollowing,
GeneralHouseholdSurvey(GHS) inGreatBritain:
(a) "Over the last 12 monthswouldyou say yourhealthhas on the
wholebeengood,fairly
goodornotgood?
have
Do
illness,disabilityor infirmity?
By
long-standing
any
(b)
you
thathas troubled
I meananything
youovera periodof
long-standing
timeorthatis likelyto affect
youovera periodoftime.Ifyes:
with
matter
is
the
What
you?
(1)
(2) Does this illnessor disability(Do any of these illnessesor
inanyway?"
limityouractivities
disabilities)
measuresof health status.
Questions(a) and (b) capturedifferent
theirgeneralhealth;a
about
feel
individuals
how
asks
Question(a)
iftheresponseis 'good' or 'fairly
as healthy
regarded
personis normally
health(SAH). Question(b) establishes
good'. It measuresself-assessed
illness(LI) and,ifone exists,
thepresenceor absenceofa long-standing
or not;in otherwordsthepresenceor
itis limiting
whether
(ofactivities)
illness(LLI).
absenceofa limiting
long-term
335
inScotland
Measurement
is independence
measureof disability
(c) Another,
arguablymoreobjective,
in respectof activitiesof dailyliving(ADLs). A typicallistof ADLs
ofBritish
Insurers
foruse
bytheAssociation
mightbe thatrecommended
in connection
withlong-term
care insurance,
namely:washing,dressing,
toiletting,
Dependencein anyone of
mobility,
feedingand transferring.
to perform
it withoutsomedegreeof help,
these,meaningan inability
wouldbe elicitedby surveyquestions.However,theapparently
greater
of thismeasureis largelylostwhencomparing
HE estimates,
objectivity
because thereare many different
lists of ADLs, and variationsin
about them.It seemsto be commonin
questionselicitinginformation
studiesof HE to regarddependence
in just one ADL as defining
poor
carecoststypically
use dependence
health,whereasstudiesof long-term
in two or moreADLs as a threshold,
and long-term
care insurance
in threeor moreADLs as a criterion
for
policiesmayuse dependence
thefullsumassured.
claiming
as measured
(d) Yet anothermeasureis aimed at cognitiveimpairment,
StateExamination
by scoreson standardtestssuchas theMini-Mental
(MMSE), in contrast with functionalimpairmentmeasured by
ADLs.
(e) Almostanymeasureofhealthwhichcan be devisedand measuredgives
riseto a formof HE, which,of itself,is a broadratherthana specific
term.Robinet al (1995) classified
variousdefinitions
in theliterature,
fromtheInternational
Classification
ofDiseases(ICD), diseaseincluding,
freelifeexpectancy
and dementia-free
lifeexpectancy;
and, fromthe
International
Classification
of Impairments,
Disabilitiesand Handicaps
lifeexpectancy,
lifeexpectancy,
(ICIDH), impairment-free
disability-free
andhandicap-free
lifeexpectancy.
Thisresearch
on harmonisation
helped
to pave the way forthe firstpublicationof HE estimatesforall 191
WHO membercountries
in 2000.Thiswas based on disability-adjusted
lifeexpectancy,
wheredifferent
healthstatesare weighted
on a scale of
zero(dead) to one (fullhealth).Full detailsare in Matherset al (2000a,
2000b).
(f) HE basedon SAH or LLI or ADL questionsare examplesof 'disabilityfreelifeexpectancy'
(DFLE). It remainsthemostcommonconceptof
HE inusetoday.
For convenience,
we listbelowtheabbreviations
in commonuse, which
wewillusefreely:
ADL Activity
ofdailyliving
DFLE Disability-free
lifeexpectancy
HALE Health-adjusted
lifeexpectancy
(Section2.4)
HE
Healthexpectancy
LE
Lifeexpectancy
LI
illness
Long-term
336
inScotland
Measurement
illness
LLI
Limiting
long-term
stateexamination
MMSE Mini-mental
(measuring
cognitive
impairment)
lifeexpectancy
(Section2.4)
QALE Quality-adjusted
health.
SAH Self-assessed
2.6 Communal
Adjustments
theGHS) sampleonlythepopulationof
Manyhealthsurveys(including
If so, theyexcludethepopulationof
therein.
or
dwellers
households
private
such as nursinghomes,
persons living in communalestablishments,
hospitalsand the like. We should expectthe prevalenceof
psychiatric
to differfromthat in respectof private
in such institutions
morbidity
is sometimesmade. This
a 'communaladjustment'
households,therefore
to be estimated,
livingin each typeof accommodation
requiresthenumbers
ofmorbidity
made,and thetworesultsto be
prevalences
separateestimates
intoan appropriate
combined
averageHE measure.
weighted
theuse of
of data limitations,
because
If thisprovesimpractical,
perhaps
HE inthe
overstate
will
in
the
found
themorbidity
slightly
survey
prevalences
is likelyto be small- in respectof Scotland,
wholepopulation.The effect
itto be 0.3 years(males)and0.2 years(females),
Clarketal (2004)estimated
to comparability.
at birthandat age 65 - butitis anotherhindrance
Studies
HealthExpectancy
2.7 Comparing
Different
The life table approach (Sullivan's method)appears to allow easy
betweengendersand socioeconomic
of HE estimates
groupsas
comparison
well as betweencountries(Jagger,1997). In practicethismay not be so,
whichmay be used (see Section2.5).
definitions
becauseof the different
Buratta& Egidi (2003) identifiedmethodsof data collection(mainly
At a
and registry
interviews
data) as a secondobstacleto comparability.
for
a
make
can
and
difference,
detailedlevel,interview
techniques protocols
of
in
structure,
procedures
replacement
size,
sample
survey
example respect
referenceperiod, timingof interview,correction
for non-responses,
andmodeofinterview.
andinconsistent
formissing
responses,
procedures
& Lopez(1996)reported
and
Chen
&
Murray
(1992)
Furthermore,
Murray
and observed
between
differences
cross-cultural
self-reported
significant
by the World Health
disabilityand poor health.This was corroborated
inthecomparability
severelimitations
(WHO), whichidentified
Organisation
healthstatusdata fromdifferent
of self-reported
populations,even when
troublesome,
wereused.Thisis particularly
andmethods
instruments
identical
becausewe mightexpectthatresultsfromEnglandand Scotlandwouldbe
comparableif thesamehealthsurvey(GHS) wereused.The same
directly
be
might hoped for the European countrieswhich participatein the
HouseholdPanel. If thisis not thecase, differences
EuropeanCommunity
to measureandto rectify.
willarisewhichwillbe verydifficult
inScotland
Measurement
3. PublishedEstimatesI: Scotland
337
In thissectionwe will describethe HE estimateswhichhave recently

becomeavailableforScotland.Full detailscan be foundin Clark et al
(2004). In Sections4 to 7 we comparethesewithestimates- official,
- in respectof theU.K. and Europe.
and otherwise
national,sub-national
Thethorny
issueofcomparability
meansthatwe haveto payattention
to the
detailsofthemethodologies.
3.1 Official
HealthExpectancy
Estimates
The official
HE estimates
forGreatBritainare publishedannuallybythe
OfficeforNationalStatistics
described
(ONS), whichusesthemethodology
et
al.
by Kelly
(2000),namelySullivan'smethodappliedto abridged(fiveyear age groups) nationallife tables fromthe Government
Actuary's
whichwillbe described
in
(GAD), witha communal
Department
adjustment
Section4. Morbidity
ratesare takenfromappropriate
prevalence
responses
to thehealthquestionsasked in the GHS (quotedin Section2.5(b)). The
GHS samplesapproximately
eachyear.
25,000privateresidents
Whilequestion(b) was askedof everyone
livingin a household,
question
(a) was askedonlyof thehead of thehousehold,whohad to be at least 16
forSAH insteadof
yearsold.Hence,an agegroupof16to 19wasconstructed
the15to 19agegroupintheLLI. Itwasassumedthatthemorbidity
prevalence
forageszeroto 15was thesameas thatobservedforages 16to 19.
Since 2004, separate officialHE estimateshave been available for
Scotlandand England.The latterare providedby theONS and theformer
wereproducedbyClarketal (2004),usingthesamemethods(and thesame
sourceof morbidity
and were
data), butmakingno communaladjustment,
of thisomissiondependslargelyon
publishedby theISD. The significance
the extentto whichdisabilityrateswithincommunalestablishments
vary
fromthoseof thegeneralpopulation.Using2001 censusdata, Clarket al
thecommunal
(2004) showedthattheimpactwas verysmall;by excluding
HE estimates
bothat birthand at age 65 wereoverstated
adjustment,
by0.3
See Table 1 forthe
yearsand 0.2 yearsformalesand females,respectively.
results
forScotland.
outcomeis thatformales,LE at birthhas
Perhapsthe most striking
increasedby4.6 yearswhileHE based on LLI has hardlychangedat all. If
thisis trulyrepresentative,
thenit impliesa markedexpansionofmorbidity.
However,thisis notseento thesameextentforHE (SAH), or formenat age
65,orforwomen.
3.2 Estimates
BasedontheScottish
Household
Survey
Clark et al (2004) also estimatedHE forScotlandfor2000 usingthe
ScottishHouseholdSurvey(SHoS). Thisaskedthefollowing
questionabout
LLI:
338
Measurement
inScotland
Table 1. Official
estimates
ofhealthexpectancy
forScotland;for
estimates
for1999to 2000basedon theScottish
Health
convenience,
Surveyarealso shown
Atbirth
LE
Year
MF
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
68.7
69.1
69.3
69.6
69.9
70.0
70.1
70.5
70.3
70.7
71.2
71.4
71.6
71.4
72.1
72.1
72.1
75.1
75.4
75.3
75.7
75.9
75.8
76.3
76.6
76.6
76.2
77.1
77.2
77.4
76.9
77.7
77.7
77.9
HE(LLI)
MF
57.9
58.4
57.5
57.1
58.3
58.7
57.6
56.9
56.0
57.8
57.3
59.5
57.7
56.0
58.2
59.6
57.7
61.0
60.6
60.5
61.5
61.1
61.4
60.8
59.0
59.8
62.3
61.1
61.9
61.3
59.7
60.5
60.1
60.0
Atage65
HE (SAH)
MF
MF
62.6
62.8
63.7
64.0
63.7
64.3
64.2
65.0
64.6
65.3
65.7
65.6
66.0
64.4
64.6
64.7
65.7
LE
65.9
67.0
66.2
66.5
65.2
67.5
67.7
66.6
68.2
68.7
68.0
67.9
67.6
68.1
67.5
67.8
69.1
12.1
12.3
12.3
12.5
12.5
12.5
12.6
12.9
13.0
12.7
13.2
13.4
13.4
13.1
13.7
13.7
13.9
HE (LLI)
MF
HE (SAH)
MF
16.1
16.1
15.9
16.2
16.6
16.3
16.4
16.7
16.7
16.3
17.0
17.0
17.1
16.6
17.3
17.2
17.5
7.8
7.9
7.2
7.3
6.9
7.0
6.3
6.1
7.3
7.5
8.5
8.1
7.9
7.2
8.3
8.8
7.5
8.7
8.8
7.9
8.8
9.2
9.3
8.6
7.5
8.3
9.5
9.7
9.6
9.6
9.0
9.4
8.9
9.6
10.0
9.5
9.6
10.3
9.9
9.7
9.6
10.1
10.4
10.7
11.3
11.0
11.4
10.4
10.8
10.9
11.4
12.1
12.8
11.8
12.3
12.1
12.9
12.1
12.0
12.5
12.5
13.6
13.5
13.3
13.2
13.3
12.3
13.7
60.1 61.1
65.2 68.2
14.3 17.6
9.6
9.9
11.4 14.7
73.3 78.7 58.9 62.6

SHoS 73.0 78.4 53.8 56.9
Source:Clarketal (2004).
65.3 67.3
64.3 66.7
14.8 17.9
9.3
9.6
11.3 12.2
14.5 17.6
7.6
8.8
11.3 13.1
72.6 78.2
ofHE at age 65 forScotland,basedon independence

Table2. Estimates
inADLs fromtheGHS
Year
1980
1985
1994
1996
1998
Source:Clarketal (2004).
LE
MF
12.1
12.5
13.7
13.9
14.3
16.1
16.3
17.3
17.5
17.6
DFLE
MF
11.6 14.6
11.6 14.6
12.6 15.0
12.0 14.8
12.6 16.0
healthproblem
has anylongstanding
illness,
eachofthepeopleinthehousehold
"whether
can do? By
or thekindofworkthatyou/they
thatlimitsyour/their
or disability
activity
whichhas a
I meana physicalor mentalimpairment,
as opposedto ill-health,
disability
on theirabilityto carryout normalday to day
adverseeffect
and long-term
substantial
activities."
Measurement
inScotland
^
^H
^H
^H
^H
^H
^H
^H
^H
^H
^H
o
o
o
&
i/-i C^
SO J
tin OOOOoOOOOiostÔSoOON'HOONd
*^
<J *
a
o
PQ
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EC
Z
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n r^
vovooo^ôvoo'oodôo^
fOfNqTtfsinrtO'nqa;^^^^
Pi ^ôoooôoô^ôasoooo
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rj- vq
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t
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f**"- f*** OQ
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t^ r*^r^ c^ ^^ ^*
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339
Measurement
inScotland
340
v'~!
rj^ô'rMio<oô''-;'t>oo()ooh;WO'trjina'OM-V3rjrj-yoo'
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^^
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II I
341
HealthyLife ExpectancyMeasurementin Scotland
The SAH question in the SHoS is identicalto that asked on the GHS: as
usual responsesof 'good' or 'fairlygood' are classifiedas healthy.The results
are also shown in Table 1. Comparison withestimatesbased on the official
methodologyshows that the resultsare reasonablyclose for HE based on
forHE based on LLI. This impliesthatpeople
SAH, but alarminglydifferent
reportmoreLLIs underSHoS thanunderGHS.
3.3 EstimatesBased on ActivitiesofDaily Living
HE based on independence in ADLs has also been estimated for
Scotland,usingtheGHS (Clark et al (2004), see Table 2).
3.4 Sub-NationalHealth ExpectancyEstimates
Clark et al. (2004) also used the SHoS in three analyses of HE at a
disaggregatedlevel. Two looked for geographical variation and one for
socio-economicdifferences:
(a) LE and HE were estimatedfor 1999 to 2000 in respectof each of the 15
NHS Health Boards in Scotland, see Table 3. This showed some
strikingly
largevariations.Table 3 showsthedifferences
betweenthebest
and worst regions under each measure. Those for HE greatlyexceed
those for LE, in some cases being nearly double. Greater Glasgow is
worst under eight measures, its ex-industrialneighbour Lanarkshire
under three,and they share one. The differences,
especially of HE at
birth, dwarf the improvementsin national HE achieved over the
preceding20 years(Table 1).
(b) A similarpatternwas revealed by estimatesin respectof the 32 Local
Council Areas (LCAs), see Table 4. The differences
wereslightlygreater,
but Glasgow City and North Lanarkshirebetweenthemwere worst or
worstequal under11 measures(Inverclydeaccountingformale HE (LLI)
at age 65).
(c) The socioeconomic study estimated HE by area deprivation for
Scotland, with mortalitydata fromthe 2001 census. We describe this
morefullyin Section7, whereit can be comparedwitha similarstudyin
England.
4.
Published Estimates II: Official Estimates in England and

Great Britain
Great Britain comprisesthe countriesof England, Wales and Scotland.

Most of the available estimatesare for Great Britainas a whole,
although
they have often been attributedto England and Wales by authors. HE
estimatesare now available forEngland and Scotland
separately,but not for
Wales. OfficialHE estimatesforEngland alone were firstproducedin 2004.
inScotland
Measurement
forEngland;for
ofhealthexpectancy
Table5. Official
estimates
thetableshowsthedifferences
convenient
(HE England)minus
comparison,
in
and
2001
when
1999
just(HE England)is
(HE Scotland),except 1997,
forLE)
shown,initalics(similarly
342
At age 65
At birth
LE
Year
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
MF
1.98 1.64
2.02 1.96
1.99 1.78
1.89 1.71
1.97 1.95
2.05 1.58
1.89 1.50
2.35 1.66
2.15 2.23
1.88 1.51
1.97 1.68
1.99 1.58
2.51 2.32
1.96 1.60
2.21 1.80
2.40 1.69
74.7679.76
2.39 1.69
75.28 80.10
2.32 1.64
75.97 80.60
HE(LLI)
MF
-0.06 0.93
1.12 0.51
1.64-0.21
0.50 0.52
0.15 0.22
0.71 0.02
1.30 1.44
2.59 1.26
1.10-0.94
2.02 0.82
-0.07-0.06
1.96 0.58
3.43 1.99
1.23 1.24
-0.43 1.46
HE (SAH)
MF
1.92-0.02
1.31 1.12
1.27 1.22
1.64 2.44
1.29 0.44
1.39 0.16
0.68 1.42
1.33-0.19
0.84-0.42
0.64 0.46
0.72 0.96
0.67 1.24
2.21 0.78
1.88 1.20
1.98 1.10
59.2160.79 67.33 69.00

60.3162.59
66.87 69.19
60.84 62.86 67.31 69.04
LE
MF
0.77 0.94
0.85 1.24
0.78 1.07
0.84 0.72
0.94 1.09
0.94 1.08
0.83 0.94
0.88 1.02
1.29 1.51
0.90 0.87
0.85 1.02
0.92 0.91
1.40 1.56
0.88 0.88
1.08 1.13
1.03 0.87
15.1418.49
1.01 0.98
15.53 18.76
0.99 1.07
16.06 19.17
HE (LLI)
MF
-0.23-0.19
0.41 0.71
0.21-0.03
0.71-0.34
0.68-0.40
1.11 0.08
1.26 1.01
0.31 0.44
0.50-0.53
-0.44-0.40
-0.14-0.20
0.09-0.09
0.94 0.54
0.17 0.19
-0.35 0.74
HE (SAH)
MF
0.59-0.80
0.50 0.24
-0.16-0.17
0.28 0.00
0.70-0.64
0.77 0.24
0.36 0.39
0.21-0.19
0.20 0.06
-0.33-0.82
-0.12-0.38
-0.52-0.13
0.62 0.00
0.32-0.26
0.50 0.86
8.40 9.50 11.86 13.25

8.84 10.04
11.66 13.26
8.94 10.22
11.72 13.33
Source:ONS and GAD.
as a three-year
Note thattheyare presented
movingaverage,reportedas
to thecentralyear.1
applying
The officialHE estimatesfor Great Britainand England includea
based on the 2001 census. Morbidity
communaladjustment,
currently
healthquestion2
to therelevant
the
from
was
calculated
responses
prevalence
This
of personslivingin communalestablishments.
and the enumeration
in
communal
of
numbers
to
the
ratewas applied
peopleliving
(estimated)
in respectof bothSAH and LLI measureseventhoughit is
establishments,
ofan LLI.
basedon thepresence
for
Table 5 shows,not theabsolutevaluesof theLE and HE estimates
1 With a few
exceptions:no surveywas conductedin 1997 or 1999, so estimatesfor 1997 are
based on 1996 and 1998,whileestimatesfor1999 are based on 1998 and 2000.
1 The health
questionin the2001 censuswas: "Does thepersonhave any long termillness,neaitn
problemor handicap whichlimitshis/herdaily activitiesor the work he/shecan do? Include
problemswhichare due to old age."
inScotland
343
Measurement
Table6. Official
estimates
ofhealthexpectancy
forGreatBritain;for
convenient
thetableshowsthedifferences
(HE GreatBritain)
comparison,
minus(HE Scotland),exceptin 1997,1999and2001whenjust(HE Great
forLE)
Britain)is shown,initalics(similarly
Atbirth
LE
Year
MF
HE(LLI)
MF
Atage65
HE (SAH)
MF
1981
1.76 1.44 -0.29 0.81 1.63-0.26
1982
1.80 1.75 0.78 0.31 1.03 0.82
1983
1.78 1.57 1.26-0.49 0.95 0.78
1984
1.67 1.51 0.19 0.23 1.32 2.07
1985
1.76 1.76 -0.10-0.06
0.97 0.05
1986
1.83 1.40 0.49-0.27 1.14-0.16
1987
1.68 1.33 1.03 1.16 0.43 1.12
1988
2.13 1.47 2.26 0.93 1.03-0.38
1989
1.94 2.05 0.75-1.21 0.53-0.59
1990
1.67 1.32 1.68 0.53 0.36 0.28
1991
1.77 1.50 -0.37-0.32
0.54 0.67
1992
1.77 1.39 1.57 0.35 0.40 0.96
1993
2.27 2.12 3.01 1.71 2.00 0.46
1994
1.71 1.40 0.82 0.92 1.55 0.90
1995
1.97 1.61 -0.74 1.09 1.63 0.81
1996
2.15 1.49
1997 74.51 79.57 58.8160.42 66.8568.68
1998
2.14 1.49
1999 75.02 79.61 60.2762.23 66.5368.82
2000
2.04 1.44
2001
75.7080.40 60.5062.72 67.0268.83
Source:ONS andGAD.
LE
MF
0.67 0.82
0.75 1.11
0.68 0.95
0.74 0.61
0.84 0.98
0.85 0.96
0.73 0.82
0.77 0.90
1.18 1.38
0.78 0.75
0.75 0.91
0.81 0.79
1.28 1.43
0.76 0.76
0.97 1.01
0.91 0.75
15.0218.38
0.88 0.86
15.40 18.63
0.87 0.93
15.9419.03
HE (LLI)
MF
-0.33-0.30
0.26 0.58
0.04-0.16
0.53-0.44
0.49-0.51
0.97-0.10
1.14 0.84
0.21 0.30
0.42-0.63
-0.54-0.52
-0.20-0.32
-0.01-0.21
0.83 0.40
0.03 0.02
-0.50 0.54
HE (SAH)
MF
0.44-0.92
0.36 0.12
-0.28-0.30
0.16-0.10
0.51-0.80
0.64 0.07
0.22 0.19
0.09-0.32
0.07-0.07
-0.44-0.93
-0.16-0.53
-0.57-0.28
0.54-0.16
0.21-0.45
0.38 0.65
8.26 9.31 11.69 13.12

8.79 9.80 11.53 13.08
8.81 10.07 11.62 13.17
betweentheEnglishand Scottishestimates,
for
England,butthedifference
easiercomparison.(In thoseyearsin whichdirectcomparisons
cannotbe
Table 6 showsthe
made,we do showtheabsolutevaluesforcompleteness.)
differences
betweentheestimatesforGreatBritainand forScotland.Not
thegeneralpatterns
inbothtablesaresimilar.
surprisingly,
Scotland'smortality
is consistently
above England's,as is well known,
butitsmorbidity
is not.However,thedifferences
betweentheHE estimates
in thetwocountries
fromyearto year,whichis probably
varyconsiderably
just samplingvariancein the GHS fromyearto year(see Section6.1 for
further
comment
on this).
The ratioof healthexpectancy
to lifeexpectancy
(HE /LE forshort)is
oftenusedto comparestudies.Highervaluesindicatemorehealthy
yearsand
a relatively
shorter
of morbidity,
decline;risingvaluesindicatecompression
valuesindicateexpansion.
Table7 showstheratio:
falling
344
Measurement
inScotland
Table7. Ratioof(HE/LE Scotland)/(HE/LE England)for1981to
estimates
1995,basedon official
Atbirth
Year
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
HE(LLI)
MF
1.030
1.009
1.000
1.018
1.026
1.017
1.004
0.988
1.011
0.991
1.029
0.994
0.975
1.006
1.038
1.006
1.017
1.027
1.014
1.022
1.020
0.995
1.001
1.045
1.006
1.023
1.011
0.997
1.000
0.999
Atage65
HE (SAH)
MF
0.998
1.008
1.009
1.001
1.008
1.007
1.016
1.013
1.017
1.017
1.016
1.017
1.001
0.998
1.000
HE (LLI)
MF
1.022
1.009
1.005
0.986
1.019
1.018
0.998
1.025
1.036
1.013
1.008
1.002
1.019
1.003
1.007
1.094
1.012
1.033
0.968
0.980
0.914
0.882
1.024
1.033
1.126
1.082
1.057
0.979
1.043
1.124
HE (SAH)
MF
1.082
0.989
1.070
1.083
1.115
1.056
0.931
1.008
1.157
1.096
1.083
1.063
1.032
1.030
0.984
1.000
1.016
1.079
1.038
1.003
0.995
1.028
1.047
1.081
1.100
1.075
1.120
1.045
1.034
1.032
1.129
1.056
1.081
1.043
1.123
1.045
1.023
1.077
1.087
1.119
1.091
1.064
1.094
1.072
0.996
HE/LE forScotland
HE/LE forEngland
it
forthoseyearswhenthecomparison
can be made.Perhapssurprisingly,
tendsto exceedone, especiallyforwomenand at age 65, indicating
the
oppositeofwhatmightusuallybe assumed.
5. PublishedEstimatesIII: Official Estimatesin Europe
inEurope
Estimates
5.1 Harmonisation
ofHealthExpectancy
different
countriesin Europe developed different
Not surprisingly,
could
and definitions
to measurehealth,so thatHE estimates
instruments
for
fora commonframework
not be comparedconsistently.
Suggestions
healthwithinthe EuropeanUnion date back to 1985,when
monitoring
the
formeasuring
DFLE was retained
bytheWHO as one oftheindicators
the
In
the
1990s
AH'
in
'Health
for
of
European
Europe.
regionalobjectives
Commissionset up a series of workingparties on health data and
HealthMonitoring
and in June1997theEuropeanCommunity
information,
Its objectiveswereto measurehealthstatusin
was established.
Programme
to monitorhealth programmesand actions,and to
the Community,
and supportnational
to allow comparisons
healthinformation
disseminate
wouldbe builtwitha focus
policies.It was agreedthatthesetof indicators
Measurement
inScotland
345
on thenationalexperiences
of the Europeancountries,
but in conjunction
withotherinitiatives,
suchas WHO's ICD, as faras possible.To thisend,
Euro-Reves
was askedto setup a coherent
setofindicators
fortheEuropean
Union. Euro-Revesidentified
the followingfivehealthdomains:chronic
functional
restriction;
morbidity;
activityrestriction;
perceivedhealth;and
mentalhealth.(See Robinetal, 2000)
Robinet al (1998) publishedDFLE estimatesfor 12 countriesin the
E.U. usinga commondataset.Theywerebased on Wave 1 (1994) of the
HouseholdPanel(ECHP), whichaskedthefollowing
EuropeanCommunity
healthquestion:
"Are you hamperedin yourdailyactivities
by any chronic,physicalor mentalhealth
illnessordisability?"
problem,
The possibleresponses
were'yes,severely',
'yes,to someextent'and 'no'. In
the1994wave,60,822households(all privateresidences)
weresurveyed
and
Lifetablesweretaken
129,877adultsaged 16 and overwereinterviewed.
fromEurostat1994(exceptforItaly,forwhichonly1993datawereavailable).
The morbidity
was
prevalenceof thoselivingin communalestablishments
takento be the same as that of the generalpopulation,and morbidity
of 1%was assumedbelowage 16.
prevalence
Two levels of disabilitywere analysed:DFLE based on all levels of
disability('yes, severely'and 'yes, to some extent');and severeDFLE
were that
(SDFLE) based on 'yes, severely'only. Generalobservations
differences
at birthbetweenbestand worstcountries
werefouryearsforLE,
eightyearsforDFLE and fiveyearsforSDFLE (menand women),whileat
in LE, DFLE and SDFLE werethreeyearsforwomen
age 65 thedifferences
and two yearsformen.(Note thatthe reportdid not tabulateresults,so
thattheyarenotpresented
here.)
Greekmenhad thehighestLE and DFLE at birth,Frenchwomenhad
thehighest
LE and Greekwomenthehighest
DFLE. Francehad thehighest
LE at age 65 and Luxembourg
thehighestDFLE. For men,Luxembourg
had thehighest
SDFLE bothat birthand at age 65,whileforwomenIreland
andSpainwerehighest
at birthandat age 65,respectively.
different
FollowingRobinet al (1998),but withslightly
methodology,
EuroStatnowpublishesDFLE forall E.U. countries.
Tables 8 and 9 show
estimates
for1995to 2003 based on Waves2 to 8 of theECHP (2002 and
2003aretrend-based
datafromNewCronos(MPROB)
projections).
Mortality
wereused to createabridgedlifetables(five-year
age groups).Morbidity
prevalenceat ages 16 to 19 was assumedto applyto ages 15 to 19, and
thatof the oldestage groupobservedwas assumedto applyat
similarly
belowage 16 was assumedto be halfthat
higherages.Morbidity
prevalence
at ages 16to 19.
Italy,Spain,Belgiumand Greecehad thehighestDFLE at birthforboth
inScotland
346
Measurement
Table8. FemaleDFLE at birthinEurope,1995to 2003;italicised
figures
HE estimates
theofficial
areestimated
orprovisional;*
forcomparison
basedon the
basedon theLLI questionintheGHS, andtheestimate
of
SHoS, arealso shown;thefinalcolumnshowstheHLE estimate
theWHOt
1995 1996 1997 1998 1999 2000 2001 2002 2003
68.0 68.5 69.0 69.6 73.5
Year
Austria
71.3
61.1
61.1
68.2
61.3
62.2
68.4
60.8
57.4
63.3
64.3
69.4
67.6
72.1
61.4
60.7
69.5
61.8
61.3
69.1
61.9
56.8
63.2
64.6
68.2
66.9
72.9
60.2
62.2
69.3
61.9
61.2
68.8
60.4
56.9
63.3
64.5
68.8
66.5
73.0
59.4
62.7
69.2
61.0
60.8
...
...
61.1
62.2
62.6
...
...
...
62.6
57.0
62.7
62.9
66.4
60.7
...
62.4
64.3
69.2
68.5
61.1
57.7
62.5
64.5
69.6
68.3
60.7
57.6
63.1
64.3
68.7
65.4
61.3
58.3
62.8
64.3
68.3
70.0
62.1
63.1
67.7
70.5
61.5
60.5
68.4
61.2
61.8
71.3
61.4
60.4
68.2
60.0
61.2
...
60.4
61.2
OfficialGB
...
60.8
61.6
OfficialEngland
...
60.1 60.0
OfficialScotland
SHoS(LLI)
* Source: Eurostat.
t Source: 2004 World Health Report.
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Netherlands
Portugal
Spain
Sweden
UnitedKingdom
69.0
61.0
56.8
63.7
64.5
68.5
65.9
73.9
59.3
61.8
69.9
61.9
60.9
69.2
61.9
56.5
63.9
64.7
68.4
65.4
74.4
58.8
61.8
70.2
62.2
60.9
WHO
2002
73.3
71.1
73.5
74.7
74.0
72.9
71.5
74.7
72.6
71.1
75.3
74.8
72.1
fromRobinet al. (1998) in

menand womenin 1995to 2001.This differs
revealedby these
thatFrancefareslesswell.However,thegrossdisparities
of about 15 yearsbetweenItalian and
studies- such as a difference
Finnishwomen - have raised questionsabout theirreliability.(See
thesedifferences
Shapiro,2005, forexample).To put thisin perspective,
betweenthebest
are similarto thedifferences
betweentwoentirecountries
and worstLCAs in Scotland,whichare verymuchsmaller(henceestimates
should suffermore samplingerror) and have known socioeconomic
makedifferences
characteristics
plausible.One oftheother
which,arguably,
carriedout by the WHO.
that
is
studies
comparative
majorinternational
butare of theHALE type,so
are notbasedon LLI questions,
Its estimates
but we
thattheyare not directly
comparablewiththeEuroStatestimates,
showthemanywayin thefinalcolumnsofTables8 and 9, to makethepoint
So, althoughtheEuroStat
thattheydo notshowthesamelargedifferences.
be treatedwithsome
still
should
estimatesare the mostconsistent,
they
caution.
forGreatBritain,Englandand
estimates
We havealso showntheofficial
347
Measurement
inScotland
Table9. Male DFLE at birthinEurope,1995to 2003;italicised
figures
HE estimates
orprovisional;*
forcomparison
theofficial
areestimated
basedon theLLI questionintheGHS, andtheestimate
basedon the
of
SHoS, arealso shown;thefinalcolumnshowstheHLE estimate
theWHOf
Year
1995 1996 1997 1998 1999 2000 2001 2002 2003
Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Netherlands
Portugal
Spain
Sweden
UnitedKingdom
60.0
63.3
61.6
...
60.0
60.0
65.8
63.2
66.7
61.1
59.6
64.2
62.3
64.1
61.7
54.6
59.6
60.8
66.9
64.0
67.4
62.1
58.2
65.1
62.2
66.5
61.6
55.5
60.2
61.9
66.4
63.2
68.0
62.5
59.3
65.5
62.1
60.9
63.4
63.3
62.4
55.9
59.2
62.1
66.5
64.0
67.9
61.9
59.1
65.2
61.7
60.8
63.6
66.0
62.5
55.8
60.1
62.3
66.7
63.9
68.7
61.6
58.8
65.6
62.0
61.2
64.6
65.7
62.9
56.3
60.1
63.2
66.3
63.3
69.7
61.4
60.2
66.5
63.1
61.3
64.2
66.6
62.2
56.7
60.5
64.1
66.7
63.3
69.8
61.9
59.5
66.0
61.9
61.1
60.6
60.8
OfficialGB
58.9
...
58.8
OfficialEngland
59.2
...
59.2
OfficialScotland
59.6 57.7
...
SHoS(LLI)
* Source: Eurostat.
t Source: 2004 World Health Report.
...
...
60.1
60.3
60.3
...
...
...
58.9
53.8
60.5
60.8
65.6
66.9
62.8
57.0
60.4
64.4
66.7
63.5
70.4
61.7
59.7
66.6
62.4
61.4
66.2
67.4
63.0
57.3
60.6
65.0
66.7
63.4
70.9
61.7
59.8
66.8
62.5
61.5
WHO
2002
69.3
68.9
68.6
68.7
69.3
69.6
69.1
68.1
70.7
69.7
66.7
69.9
71.9
69.1
Scotland,fortheyearswhentheyare available,and the Scottishestimate

for2000basedon theSHoS.
In respectof men, Scotlandand Englandjoin Finland,France and
Portugalin a groupwiththelowestDFLE, based on theofficialestimates,
but not those supplied to Eurostat. Among women, Denmark,the
Netherlands
and SwedenreplaceFrancein a somewhatlargergroup.Most
theScottishestimates
for2000,basedon theSHoS,
however,
conspicuously,
arelow,infactbelowanyestimates
fromfiveyearsbefore.
More recentlythe European Health ExpectancyMonitoringUnit
fundedfrom2004to 2007,withtheaim
(EHEMU) has beensetup,initially
ofproviding
"... a centralfacility
fortheco-ordinated
analysis,interpretation
and dissemination
of life and health expectanciesto add the quality
dimension
to thequantityof lifelivedby theEuropeanpopulations."(See
the EHEMU websiteat www.hs.le.ac.uk/reves/ehemutest/index.html.)
In
Robinetal. (2004)reviewed
theECHP methodology
particular,
and,inJuly
andAugust2005,EHEMU releaseddetailedreports
on eachofthecountries
discussedabove.
348
HealthyLifeExpectancyMeasurementin Scotland
Austria
Belgium
Denmark
Finland
France
Germany
Greece
<q _
1980
1985
-O-O--$
-0-O
<>
-*- Scotland
-+ England
Ireland
Italy
Netherlands
Portugal
Spain
Sweden
1990
1995
*^-
2000
Year
Figure3. Ratio of HE /LE estimatesforfemalesin Scotland,Englandand

13 European countries;U.K. figuresare based on theofficialestimates,
European figuresare fromEHEMU based on EuroStatestimates
5.2 Is thereCompression
or ExpansionofMorbidity?
Given a measureof HE, the trendin the ratio HE /LE (the proportionof
total lifelivedin 'good health') is oftentakenas a measureof compressionor
withcaution. If
expansionof morbidity,althoughit needs to be interpreted
HE/ LE =1.0 while LE plummeted,this would probably not indicate a
successful health policy. Figure 3 shows this ratio for females, for 13
European countriessince 1995, and for Scotland and England since 19801981 and until2000-2001.Figure4 showsthesame formales.
First, note that Scotland and England are rather similar; neitherhas
consistentlyhigherHE /LE. Both appear to be trendingslightlydown until
1995, although the isolated values reportedsince then are higher.If the
unusually low ratios for Finland are discounted, Scotland and England
have ratios among the lowest in Europe. Jagger(unpublishedmanuscript)
studied the HE/ LE ratio at age 65, and found some countriesin which it
had increased by 5% or more between 1995 and 2001, suggesting
compressionof morbidity,some countriesin which it had declined by 5%
349
inScotland
Measurement
s -I
*.++*?*?
LU
Austria
Belgium
Denmark
Finland
France
Germany
Greece
<o
^
O-0--$-
-^-O
-O-
-*- Scotland
-+ England
Ireland
Italy
Netherlands
Portugal
Spain
Sweden
1980
1985
1990
1995
2000
Year
formalesin Scotland,Englandand
Figure4. RatioofHE/LE estimates
13Europeancountries;
arebasedon theofficial
U.K. figures
estimates,
arefromEHEMU basedon EuroStatestimates
Europeanfigures
or more, suggestingexpansionof morbidity,
and some countriesin
In aboutthesameperiod,basedon official
between.3
Scotlandand
estimates,
Englandwouldbe inthelastgroup.
6. PublishedEstimatesIV: Other Studies in the United Kingdom
6.1 EarlierEstimates
BasedonLLI Survey
Responses
The earliestHE estimatesforEnglandand Wales4wereby Bebbington
data. HE
(1988),basedon theLLI questionin theGHS and OPCS mortality
was estimated
for1976,1981and 1985.Bebbington
added
results
for
(1991)
3 Therewasno
between
theresults
formenandforwomen.
consistency
theestimates
are applicableto GreatBritainas a whole,but Bebbington
Strictly
speaking,
(1988)assumedthattheyareequallyapplicableto EnglandandWales.
inScotland
350
Measurement
ofHE forGreatBritainbasedon theGHS
Table 10. Earlyestimates
Scottish
theofficial
illnessquestion;forconvenience
limiting
long-standing
arealso shown
estimates
Year
Bebbington
(1991)
LE
Age
1981
1985
1988
1991
1992
1994
70.0
12.5
71.1
13.1
71.9
13.4
72.4
13.7
73.2
14.2
73.7
14.5
74.2
14.8
At birth
Age 65
At birth
Age 65
At birth
Age 65
At birth
Age 65
At birth
Age 65
At birth
Age 65
At birth
Age 65
76.1
16.6
77.1
17.1
77.7
17.3
78.1
17.6
78.7
17.9
79.2
18.3
79.6
18.6
62.0
8.6
60.9
8.5
61.9
9.2
61.2
8.8
58.3
7.1
58.7
7.9
58.8
7.9
58.5
7.6
58.3
7.1
58.7
7.9
58.8
7.8
58.5
7.5
59.9
7.9
59.7
7.9
Official
Scotland
Bebbington&
Darton (1996)
MF
MF
MF
MFMF
1976
Bone
et al. (1995)
58.4
7.1
58.7
7.9
58.9
7.9
58.5
7.6
59.9
8.0
59.7
7.9
59.2
8.5
62.0
8.6
61.0
8.5
61.9
9.2
61.2
8.7
63.0
9.8
61.9
9.5
62.1
8.7
61.0
8.6
61.9
9.3
61.2
8.8
62.8
10.1
61.9
9.5
62.2
9.8
58.4
7.9
58.7
7.0
56.0
7.3
59.5
8.1
57.7
7.9
59.4
8.5
61.0
8.8
61.4
9.3
59.8
8.3
61.9
9.6
61.3
9.6
61.7
9.6
The estimates(see Table 10)

a communaladjustment.5
1988,introducing
overtheperiod,HE was stable.Bebbington
showedthat,whileLE improved
has resultedin theexpansionof
(1988) concludedthatimprovedmortality
morbidity.
thestudyto 1991and 1992(see Table 10) but
Boneet al (1995)extended
communaladjustment.6
used a different
Takingthetrendsin LE and HLE
less
was
obvious,exceptformalesat age 65.
morbidity
expansion
together,
& Darton
series
the
1994
to
(see Table 10),Bebbington
However,byadding
for
almost
was
accounted
in
LE
increase
observed
the
that
concluded
(1996)
totallyby yearsof ill health.Note thattheyused yetanothercommunal
had a very
communaladjustments
It is clearthatthedifferent
adjustment.
smallimpact.
We haveaddedtheofficialScottishestimates
(basedon LLI) to Table 10
doesnotstrongly
fortheyearsforwhichtheyare available.The comparison
lower
or
lower
much
is
consistently thanit is in
suggestthatHE in Scotland
is
5
Table
with
The
Roughlyspeaking,it
interesting.
comparison
England.
5 Persons
living in communal establishments,such as geriatricwards, psychiatrichospitals,
foryoungerhandicappedpersons,were assumed to be disabled,
nursinghomes,and institutions
such as hotelsand acute hospitalwards,wereassumed
whilepeople stayingin otherinstitutions,
to sharethepopulationprevalenceof morbidity.
The 1991censusincluded,lor thehrsttime,theLLI question,allowingme moroianyprevalence
to be founddirectly,thenestimatedindirectlyfor
of thesepersonsin communalestablishments
1976, 1985, 1988 and 1992.
S
-m- -m- -w
. t
t*
351
Table 11. Estimatesof HE at age 65 forGreat Britainbased on the
independencein ADLs fromGHS
Year
Bone
et al (1995)
LE
MF
1976
1980
1985
1991
1994
12.5
12.9
13.3
14.3
14.8
MF
16.5
16.9
17.3
18.1
18.6
11.0
11.8
12.3
14.3
...
Bebbington&
Darton (1996)
MF
13.0
15.0
15.5
16.9
...
Scotland
MF
11.6
12.1
14.4
14.2
11.6
11.6
14.6
14.6
13.5
15.6
12.6
15.0
happens thatthreeout of the fiveyears studiedwere those in whichScottish

HE was relativelyclose to EnglishHE, whichseemsto be thechance resultof
thesamplingvariabilitysuggestedby Table 5.
Bebbington(1992) estimatedHE using data from the OPCS disability
surveys.He argued that,whilethesemightbe superiorto estimatesbased on
the GHS, the GHS has a strongappeal because it reveals long-termtrends.
The OPCS surveys sampled some 100,000 private and 2,000 communal
residentsthroughout
GreatBritainin 1985to 1988.Over21,000wereidentified
as having disabilities,were interviewed,and the responses were classified
fromone to tenusingtheICIDH scale,7witha classificationof sevenor over
indicatingsevere disability.He found that, as people age, the remaining
numberof yearswithoutdisabilityfalls rapidly.The DFLE at birthformen
was 63.6 yearswithoutany disabilityand 70.0 yearswithoutseveredisability,
out of a total LE of 71.7 years (for women these were 66.5 years and 74.5
out of 77.5 years). Bebbingtonthereforeemphasisedthe
years respectively,
of
the
definitionof disabilitywhen making comparisonswith
importance
studieswhichuse a singlelevelof disability.
6.2 NationalEstimatesBased on ActivitiesofDaily Living
Bone et al (1995) also estimatedDFLE forpersonsaged 65 and over for
1976, 1980, 1985 and 1991, using a definitionof disabilitybased on the
followingADL data takenfromthe GHS (exceptfor 1976,whenthe Elderly
Home Surveywas used): bathing;gettingout of bed; feeding;and going to
the toilet. The communal adjustmentwas based on the U.K. Disability
Surveys1985-1986. DFLE increased steadilyfor men and women, a trend
corroboratedby Bebbington& Darton (1996), see Table 11.
We have added the Scottishestimatesof DFLE based on ADLs (Clark et
7 Introducedin 1980
by the WHO, the ICIDH scale goes beyond the ICD by categorisingthe
consequences of disease. The following activities are covered: locomotion; reaching and
stretching;dexterity;personal care; continence; seeing; hearing; communication;behaviour;
intellectualfunctioning;
consciousness;eating,drinkingand digestion;and disfigurement.
inScotland
Measurement
352
al , 2004,see also Table 2) to Table 11. Thereis no veryconsistent
pattern
comparedwiththoseforEnglandandWales.
to those
of morbidity,
TheseHE estimates
contrary
suggestcompression
based on LLI. Bone et al (1995) whicharguedthatthismaybe relatedto
increasedawarenessof ill healthcoupledwithimproveddiagnosis,causing
undertheLLI measure.
a higher
degreeofsickness
peopleto self-report
6.3 Estimates
LifeExpectation
ofHealth-Adjusted
HE estimatesfor Great Britainhave been based mainlyon questions
healthstatusas 'good' or
dichotomise
askedin theGHS, whicheffectively
'bad'. Bebbington
(1992) used the OPCS disabilitysurveysto rate health
& Darton(1996)
and estimateHALE, whileBebbington
statesby severity
and
the
U.K. Omnibus
the
estimated
EuroQolScale8
QALEs, using five-point
based on LLI,
estimates
than
were
The
results
higher
significantly
Survey.9
ofmorbidity.
a lessseveredefinition
thattheweights
represented
implying
6.4 HealthExpectancy
Impairment
Allowing
forCognitive
MRC-CFAS10(2001) chose 15,000personsaged 65 and overat random
to estimateHE based on
interviewed)
(80% of whomwere successfully
health
and
functional,
problems.Functionalabilitywas
cognitive physical
based on a scale of zero to 18 for ADLs, 11 and above indicating
was based on an MMSE scoreof less
Cognitiveimpairment
impairment.
than 18, whilephysicalhealthproblemswereself-reported,
excludingany
Men at age 65
as a riskfactorfordementia).
relatedto cancer(notregarded
couldexpectto live83.1%oftheirremaining
yearswithphysicalillness,but
and 3.7% withcognitive
impairment
impairment
only7.5% withfunctional
womencan expectto live a
(women:86.7%, 14.7% and 6.8%). Therefore,
ofanykindthancan
oftheirliveswithimpairments
muchhigherproportion
to thelast few
confined
are
and
functional
but
impairments
men,
cognitive
yearsoflife,giventhenatureoftheseillnesses.
Data
BasedonLongitudinal
6.5 Estimates
ofHealthExpectancy
HE
estimation
at
first
the
made
Bone et al (1995)
usingU.K.
attempt
8 The
selfcare,usualactivities,
pain/
EuroQolscalerateshealthstatusin respectof mobility,
andanxiety
discomfort
/depression.
9 In theU.K. Omnibus
wereaskedabout
households
some6,000adultslivingin private
Survey,
and
2 = someproblems;
levels:1= no problems;
withthreeresponse
thefiveEuroQolqualities,
tobed.
orconfined
3 = extreme
problems
10MRC-CFAS
(Medical ResearchCouncil CognitiveFunctionand AgeingStudy),is a
and ageing.The six
dementia
between
function,
cognitive
studyoftherelationship
longitudinal
Oxfordand Liverpool,
areCambridgeshire,
Newcastle,
involved
Nottingham,
centres
Gwynedd,
a mixofurbanandruralareas.It is a two-wave
(withwavestwoyearsapart),tworepresenting
withtheinitialsampleofindividuals
aged65 andovertaken
survey,
prevalence
stagepopulation
in 1991.
353
Measurement
inScotland
life table (Ledent, 1980;
longitudinaldata. They createda multi-state
Longitudinal
Studyof Activity
Rogerset al, 1990) usingtheNottingham
andAging11
(MMAP) data
(NLSAA) and MeltonMowbrayAgingProject12
for 1981, 1985 and 1988, and the followingindicatorsof healthstatus:
mentalimpairment;
vision and hearingimpairment;
urinarycontinence;
physical disability and mobility impairment;self-perceivedhealth;
the subjects
depression;and global health.The initialsurveysdistributed
betweeninitialstates'healthy'and 'unhealthy'
foreach indicator.
Piecewise
models
were
fitted
to
x
and
s
sex
to
obtain
exponentialregression
age
smoothed
transition
rates:
In/(s,
+ ij(x)+ yij(s).
x) = ot!j
(9)
Whiletheauthorsreported
theresultsforeach definition
of 'unhealthy',
they drew no generalconclusions.Instead, they suggestedthat: "No
data of the rightkindexistin thiscountry(the U.K.) at the
longitudinal
nationallevel."
Sauvagetet al (2001) updatedBone et al (1995), usingdata fromthe
MeltonMowbrayHealthChecks13and a multi-state
lifetable methodto
calculate:(a) active life expectancy,
based on independence
in all the
ADLs: mobilityaroundthe home;gettingin and out of a chairand bed;
feeding;dressing;bathing; and using the toilet; and (b) cognitive
lifeexpectancy
based on a scoreof sevenor less fromthe
impairment-free
information
/orientation
subsetof theCliftonAssessment
Procedures
of the
Elderly.
The resultswerethata man aged 75 could expectto spend49% of his
but only 7.7% withcognitive
remaininglife withan ADL impairment,
At olderages men are
(women71% and 6.6%, respectively).
impairment
worse off;for men (women)the expectedproportionof total LE with
is 14.5%(8.3%) at age 80, 20.5%(8.7%) at age 85 and
cognitive
impairment
30.4% (11.1%) at age 90. This is the oppositeof whatmighthave been
basedon theMRC-CFAS study.
expected
11The
and Agingconsistsof peoplelivingin the

Nottingham
Longitudinal
Studyof Activity
FPC lists.1,042peoplewereinterviewed
in
community,
aged65 andover,fromNottinghamshire
1985andfollowed in 1989(response
rate88%).
12The Melton up
twocross-sectional
and intermediate
MowbrayAgingProjectcomprises
surveys
in theLathamGeneralHealthPracticein MeltonMowbrayand surrounding
areas.
follow-up
The firstsurveyin 1981included1,203peopleaged 65 and over.The secondin 1988included
fromthe1981sample.At theintermediate
1,579personsaged75,440 ofwhomweresurvivors
in 1985,602outof651 survivors
follow-up
and
aged75 and overwereinterviewed.
Community
institutionalised
wereincluded.
persons
Healthcheckswereintroduced
in 1991,as partofa U.K. requirement
forall personsaged75
andovertobe givenan annualcheck-up.
inScotland
Measurement
354
6.6 Remark
in
The studiesmentionedabove do not all have directcounterparts
of
suitable
on
the
lack
et
al
Bone
Scotland- the comments
(1995)
by
data applyequallyto Scotlandand England- butwe include
longitudinal
studiesof considerablesize, but with
themto illustratehow different
results.Overall, the
can lead to conflicting
different
methodologies,
in Scotlandand
estimates
HE
on
the
official
national
based
of
comparisons
are the most
in
the
estimates
and
on
the
EuroStat
E.U.,
England,
not least because theycome close to providingcomparable
informative,
series.
chronological
7. PublishedEstimatesV: Sub-National Estimatesin the United
Kingdom
in Section3.4, threedisaggregated
We mentioned,
surveysof HE in
Scotlandby Clarket al (2004); one byNHS Boards,one by Local Council
index.
Areas,andonebydeprivation
(2003) foundthatonlyCanada, Englandand Wales,France
Bebbington
and Spain activelyproducedsub-nationalestimates(all using Sullivan's
mightcause Sullivan'smethodto break
method).He arguedthatmigration
to attracthealthymigrants(possibly
tend
areas
as
down, healthy
may
/southdivideinEngland).
thenorth
explaining
for
Table 12 showstheresultsof theanalysisof HE by area deprivation
of
the
the
results
13
shows
Table
and
previous
England(Bajekal,2005),
analysisforScotland,basedon theSHoS (Clarketal, 2004):
(a) Bajekal (2005) calculateddeprivationscores for the 8,595 electoral
wardsin Englandusing1991censusdata and the Carstairs& Morris
Wardsweregroupedintodecilesin orderof
index.14
(1991) deprivation
HE for1994to 1998(to
he estimated
these
groupings,
Using
deprivation.
of 'healthy':(1) responses
coincidewithHSE data) withtwodefinitions
scale of SAH 1994to 1999,
of 'verygood' or 'good' on thefive-point
1996to 1999only,which
LLI
from
free
of
and
whichhe calledHLE;
(2)
betweenthemostand leastdeprived
he termedDFLE. The differences
areas at birthwereverylarge:forHLE, 16.9 yearsformenand 16.8
yearsforwomen;and forDFLE, 12.4yearsand 9.9 years,respectively.
inLE at birth
differences
inexcessofthecorresponding
Thesearegrossly
thishides
for
3.2
men
and
However,
for
women).
years
(threeyears
wards,HLE
facts.Forexample,inthemostdeprived
evenmorealarming
14This indexwas
indicators:
via the following
developedin Scotland,and ratesdeprivation
activemenseeking
work;
fromClassIV or V; economically
headedbyan individual
households
accommodation.
absenceofa car;andovercrowded
inScotland
Measurement
On
o
o
OOs^rÔN^t-^t-Ôr^
vsfc oorôNoNoNooooô
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&
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ooôâjqt^îôin1^
ôvor^rôoooooooo
v2
,*
tÔOOoONO-^^fSoio
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00
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355
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cd
r^pprÔNc^r-rô-siOTt
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(
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e
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r- r- r- oo oo
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r;ooTtTj-ovqp^qoNTtp
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in mio ^'o
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51
i
^
I
in Tt m m ^H c/3
356
Measurement
inScotland
at birthwas about22 years(men)and 26 years(women)less thantotal
inHE at age 65 weremuchsmaller,
LE. Thedifferences
HE by area deprivation
forScotland,also
(b) Clarket al (2004) estimated
index.
data weretaken
the
Carstairs
&
Morris
(1991)
Morbidity
using
data fromthe2001census.Theyalso
fromthe2000SHoS and mortality
usedsimilarmeasuresofhealthas Bajekal(2005),butgroupeddata into
smaller
grouping,
quintilesinsteadof deciles.Because of the different
the difference
wereobservedthanin England.Specifically,
differences
betweenthemostand leastdeprivedquintilesforLLI and SAH at birth
was 13.0yearsand 11.1yearsrespectively
(females),and 14.6yearsand
17.4years(males).
with
to comparedirectly
Otherstudiesrelatingto Englandare difficult
becausetheyclearlyshowthedifficulties
Scotland,buttheyare of interest,
cause.
datadefinitions
whichlackofconsistent
Bebbington(1993) was the firstto quantifydisparitiesin HE across
regionalboundariesin Britain,findingthat a man born in South-East
Englandcouldexpectto liveup to 5.3 morehealthyyearsthanone bornin
For women,thedifference
thenorth(basedon theOPCS disability
surveys).
was 3.8 years.
/southdividewas also observedby Bone et al (1995), who
This north
HE estimatesby StandardRegionsand Regional
undertooksub-national
Health Authority(RHA) areas in England and Wales, using the LLI
in HE at birth
questionin the 1991census.Theyfoundthatthedifference
between(regions)Wales and the South-Eastwas as muchas six yearsfor
wereevengreaterin termsof
menand 4.7 yearsforwomen.The differences
thelowestHE of 60.4 yearsfor
RHA, withWales and Northern
recording
HE was
forfemales.The highest
malesand 64.7and 64.8years,respectively,
inSouthWestThames,66.9yearsformalesand70.0yearsforfemales.
Bisset(2002)found,in NationalHealthService(NHS) regionsin England
betweenLE and HE was increasing,
and Wales, that:(1) the difference
and (2) as in earlierstudies,HE was
an expansionof morbidity;
suggesting
in
thosein thesouth.Similarfindings
than
NHS regions
lowerin northern
at theRHA level.
wereobserved
groupsof men by
(1993) also definedthreesocioeconomic
Bebbington
class
and managers),
withclassII (employers
classI (professionals)
grouping
IV
class
and
HIM
with
class
IHN (skillednon-manual)
(skilledmanual),
so
to
hard
too
were
Women
V
class
with
classify,
(unskilled).
(semi-skilled)
in HE betweenthetop and bottom
At age 20, thedifferences
wereomitted.
groupswerenineyears(based on the LLI questionin theGHS) or seven
surveys).
years(basedon OPCS disability
Melzeret al (2000) triedto extendtheseresultsusingthe MRC-CFAS
and
women.TheygroupedclassesIII, IV and V together,
data, including
as thepresenceof mentalor physicaldisability
defineddisability
(based on
inScotland
357
Measurement
ADLs) or both.Theyfoundthatmenin theuppersocioeconomic
groups
had higherLE and DFLE, but that DFLE for womendid not differ
between
socioeconomic
classes.
significantly
issues
have
also
been exposed in these and other
Methodological
studies.Bisset(2002) suggested
thatthemainimpediment
to
disaggregated
suchestimates
wasthelackofsufficient
datato produce
producing
morbidity
reasonableconfidence
and recommended
threesolutions,
intervals,
namely:
the
width
of
the
thenumberof
(1) increasing
(2) increasing
age intervals;
data formalesand females.15
yearsof data; or (3) combining
Bajekalet al
(2002) followedthisapproachto compareestimatesbased on GHS with
thosebased on theHealthSurveyforEngland(HSE), grouping
GHS data
for1992to 1998andHSE datafor1994to 1999,at nationalandRHA levels.
werehampered
Theyused the SAH measureonly.However,comparisons
in particular,
theHSE offered
fiveresponses
to theSAH
byinconsistencies;
three(theScottishHealthSurvey,
considered
questionwhiletheGHS offered
in thenextsection,also offers
fiveresponses),
and theGHS usesa reference
butthereis nonein theHSE. As a result,theydefined
periodof 12 months,
in
health'
three
different
'good
ways,whichincluded75%, 88% and 94% of
the relevantresponses,and at least showedthe resulting
measuresto be
correlated.16
highly
8. The Scottish Health Survey
8.1 Introduction
The ScottishHealth Survey(SHeS) is an initiativeof the Scottish
andwasundertaken
Executive,
bytheJointHealthSurveyUnitinorder,inter
alia, to providedata on Scottishhealthand to monitortrendsin population
healthovertime,and to enabletheestimation
ofprevalence
ratesof specific
conditions
and comparisons
of different
The firstsurveywas in
sub-groups.
here.Information
was
1995,andthesecondin 1998,and thelatteris relevant
betweenApril 1998 and March 1999, using a
gatheredcontinuously
combination
of interviewer-administered
and nursevisits.17
questionnaires
15In her
ofeightNationalHealthService(NHS) regions,
shecombined
fouryearsof
investigation
datatocreatetwoseparate
attheHealth
epochs,1992to 1995and1995to 1998.Forherinvestigation
oneepoch,1992to 1998,andcombined
malesandfemales.
Authority
(HA) level,sheformed
At thenationallevel,HE at birthwas 73.0,68.4and 59.3years,movingfromtheleastto the
moststrict
definitions
of'goodhealth',andthecorresponding
inHE between
differences
thebest
andworstRHAs were17 years,12 yearsand 11 years,respectively;
definition
of
thus,a stricter
in HE. Grouping
theRHAs intoquintiles
'goodhealth'leadsto a smallerdifference
confirmed
thenorth
/south
dividefoundbyotherauthors
(exceptforinner-citv
London).
Thereis no singlesurvey
date,buttherecordscontainthedatesuponwhicheachpersonwas
interviewed.
We willreferto 'survey
date'in thefollowing
forconvenience,
butwe actuallyuse
the exactinterview
date foreach person.Thus,we may be aggregating
resultsforpersons
thesameage 'at thesurvey
nominally
date',whosecalendaragesmaydiffer
byup toa year.
358
Measurement
inScotland
statusand
The resultsincludeinformation
on demography,
socioeconomic
resultsfrommedicaltests.The 1998surveyincluded14,000individuals
aged
twoto 74 years,ofwhom9,000wereaged 16to 74 yearsandwereconsidered
to be adults.The samplewas takenfromthe Postal AddressFile (PAF),
26 eachmonth
wheresampleaddresseswereselectedfrom312postalsectors,
duringthe12-month
survey
period.
in the 1998surveyis thattheresponseshave beenlinkedto
Our interest
thusproviding:(a) the
some of the medicalrecordsof the participants,
healthdata.
in
and
a
1998-1999;
(b)
longitudinal
surveyresponses, snapshot
itis knownas theSHeS-SMRdata).
We willcallitthe'linkeddata' (officially
werelinkedwiththeir
of8,305oftheadultssurveyed
To createit,responses
recordsof acute hospitaladmissions(SMR01), psychiatricadmissions
(SMR06) and deaths,datingback to 1981
(SMR04), cancerregistrations
and up to March2004.18Of the8,305adultsavailableforlinkage,331 may
fromScotlandduringthelinkageperiodand weredropped,
have migrated
leaving7,974(3,507malesand 4,467 females).The workwas carriedout
byISD.
totheHealthQuestions
8.2 Responses
in twohealthquestionsin the 1998SHeS,
interested
We are particularly
whichmaybe usedto estimateHE. The generalhealthquestion(SAH) was
as follows:
Wouldyousayitwas:
(a) "How is yourhealthingeneral?
(1) verygood
(2) good
(3) fair
(4) bad
(5) verybad."
Thisis notthesameas theSAH questionaskedin theGHS and theSHoS;
it offersfive responsesinsteadof three.We will see later that these
in theHE estimates.
are reflected
differences
However,thequestionis very
in
are summarised
closeto thataskedon theHSE in England.The responses
Table 14.
ofoneormoreLLIs wasas follows:
to thepresence
Thequestionrelating
or infirmity?
Bylongillness,disability
(a) "Do youhaveanylong-standing
a periodoftimeor
over
has
troubled
that
I
mean
you
anything
standing
thatis likelyto troubleyouovera periodoftime."
(1) Yes
(2) No.
18
ExceptSMR06 records,onlyup to December2001.
359
inScotland
Measurement
Table 14. Responsesto thegeneralhealthquestioninthe1998Scottish
HealthSurvey
SAH = 1,2
Age group
Males
Females
SAH = 3
SAH = 4, 5
Males
Females
Males
Females
Total
Males
Females
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
128
158
254
291
322
286
238
230
203
170
168
129
141
230
314
400
403
334
270
319
226
229
256
212
30
20
37
62
57
52
58
54
81
77
84
78
24
35
43
65
65
58
72
86
76
108
103
108
0
3
7
13
9
20
21
28
39
42
27
31
0
6
8
19
16
22
28
33
48
31
42
37
158
181
298
366
388
358
317
312
323
289
279
238
165
271
365
484
484
414
370
438
350
368
401
357
Total
2,577
3,334
690
843
240
290
3,507
4,467
(b) "What (else) is the matterwithyou?", the answerto whichcould

includeup to sixillnesses.
wereasked:
Finally,respondents
limityouractivities
inanyway?"
(c) "Does thisillnessor disability
Yes
(1)
(2) No.
orinfirmity?"
(d) "Do youhaveanyotherlong-standing
illness,disability
(1) Yes
(2) No.
A personis said to havean LLI iftheyanswer'yes' to parts(a) and (c) of
thequestion.Table 15 summarises
thenumberofpeoplewithan LLI, those
withnon-limiting
illness
and those withno long-standing
long-standing
illnesses
at all.
Parts(b) and (d) of theLLI questionaskedrespondents
whatwas wrong
withthem.Respondents
couldlistmorethanone illness.Interviewers
coded
theseresponses
invalidresponses,
usinga listof45 illnesses.Afterdropping
we wereleftwith5,400Lis, reported
by3,484people(about 1.6illnessesper
as limiting.
person),ofwhich3,217wereregarded
Table 16 showsthe diseaseswhichaccountforthe largestnumbersof
reportedLis, and, foreach of them,the numberswhichare reportedas
Men suffered
mostfromheartproblems,hypertension,
limiting.19
asthma,
back problemsand problemsof the bones,musclesand joints.
arthritis,
19
Respondentsmay reportmorethanone LI, so thetotalsin Tables 15 and 16 willdiffer.
360
Measurement
inScotland
Table 15. Responsesto thelong-standing
illnessquestioninthe1998
Scottish
HealthSurvey;respondents
mayreportmorethanoneLI, but
at
ofpeoplereporting
we showthenumbers
havebeenremoved,
duplicates
leastoneLI or LLI
No LLI
LLI
Total
No LI
Males
Females
Males
Females
Age group
Males
Males
Females
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
8
20
37
65
54
73
79
90
124
134
118
110
16
33
48
92
91
85
113
142
141
140
162
163
26
24
54
56
66
58
55
59
54
53
57
54
31
31
41
64
69
56
59
67
67
87
79
79
124
137
207
245
267
227
183
163
145
102
104
74
118
207
276
328
324
272
198
228
142
139
160
115
158
181
298
366
387
358
317
312
323
289
279
238
165
271
365
484
484
413
370
437
350
366
401
357
Total
912
1,226
616
730
1,978
2,507
3,506
4,463
Females
intheSheS,andthe
illnesses
Table 16. Numbersofreported
long-standing
to be limiting
ofthosereported
numbers
Females
Males
Disorder
Cancer
Diabetes (ine) hyperglycaemia
Otherendocrine/metabolic
on/nerves
Mental illness/anxiety
/depressi
Otherproblemsof nervoussystem
Poor hearing/deafness
Heart attack/angina
/highblood pressure/bloodpressure
Hypertension
Otherheartproblems
Bronchitis
/emphysema
Asthma
Otherrespiratory
complaints
Stomachulcer/ulcer(nes)/abdominalhernia/rupture
Otherdigestivecomplaints
Complaintsof bowel/colon
Arthritis/rheumatism/fibrositis
Back problems/slippeddisc/spine/neck
Otherproblemsof bones/joints/muscles
Skincomplaints
Other
LI
LLI
LI
LLI
29
96
44
101
85
56
128
130
127
57
154
57
76
54
49
209
217
197
72
372
13
31
19
81
65
25
99
30
91
42
55
38
32
17
22
168
158
152
16
205
60
95
135
187
93
41
129
190
78
73
242
67
79
56
119
444
223
222
90
467
25
27
39
143
84
20
97
47
51
58
108
38
32
25
65
345
172
180
31
271
Measurement
inScotland
361
Womenweresimilar,butasthmaand arthritis
are muchmoreproblematic.
Table 16 also showsthe extentto whichpersonsfindparticularillnesses
As expected,
backproblems
and otherproblemsofbones,
arthritis,
limiting.
and
and
heart
were
considered
morelimiting
than
muscles,
joints
problems
asthmaor hypertension.
Asthmais by farthecommonest
cause of an LI
amongyoungpeople.
8.3 HE Estimates
Using the 1998 populationand deathsforScotland(the same as were
used in estimatesbased on the GHS), HE estimatesfor Scotlandwere
calculatedusingdifferent
definitions
ofhealthand arepresented
in Table 17,
along withthosebased on the SHoS (Clark et al (2004) forcomparison.
Notethatdatawerenotavailablebelowage 16intheSHeS, so themorbidity
forages zeroto 15 was assumedto be thesameas thatforages
prevalence
16 to 19. Similarly,
ratesat agesabove74 wereassumedto be the
prevalence
sameas thoseforages70 to 74. Thethreedefinitions
are:
(a) HE (SAH = 1,2): 'good health'= responses'l=very good' or '2 = good'
to theSAH question.
(b) HE (SAH = 1,2,3):'good health'= responses'l=very good', '2 = good'
or '3 = fair'to theSAH question.
illnessofanykind.
(c) HE (LLI): 'goodhealth'= no limiting
long-standing
The majorfeatureof theseestimates,
as notedbeforein respectof those
basedon theSHoS, is theverylow HE basedon LLI, and basedon SAH in
theSHeS ifresponse3 ('fair')is classedas bad health.Thisis similarto the
in reconciling
HE basedon the
problemthatBajekalet al. (2000) reported,
GHS andon theHSE.
The estimatesbased on LLI in the SHeS are not quiteas low as those
Table 17. Healthexpectancy
estimates
basedon the1998Scottish
Health
estimates
for1998andthose
Survey(SHeS), comparedwiththeofficial
basedon the2000Scottish
HouseholdSurvey(SHoS); theSHeS offered
five
to theSAH question,
whiletheSHoS offered
three
responses
At birth
Age 65
MF
Study
Official
Official
HE measure
SAH
LLI
65.2
60.1
68.2
61.1
11.4
9.6
14.7
9.9
SHoS
SHoS
SAH
LLI
64.3
53.8
66.8
57.0
11.3
7.6
13.2
8.9
SHeS
SHeS
SHeS
SAH 'good' = 1,2, 3

SAH 'good' = 1,2
LLI
68.7
54.3
57.0
74.1
59.4
58.9
12.6
8.0
7.9
15.7
10.6
9.8
MF
362
Measurement
inScotland
in two
based on LLI in the SHoS, but theyare quite close. Therefore,
thismeasurehas suggested
thattheScottishpopulationhas
separatesurveys
extremely
poorhealth.
9. Linkage of the Scottish Health Surveyto Scottish Medical
Records
Records
9.1 LinkageofHospitalandSurvey
withtheNHS
allocatedto everyone
registered
Usingtheuniqueidentifier
fromits recordsof hospital
in Scotland,it was possibleforISD to extract,
episodesin Scotland,a completesequenceof data foreach personin the
surveyavailableforlinkage(see above),goingback to 1981.Each hospital
and detailedinformation
episodeconsistsof an admissionand a discharge,
on the reasonforadmission(usingICD diseasecodes) and the treatment
given.The linkeddatabasecontainsthe7,974SHeS records,and detailsof
admissions
29,744 acute hospitaladmissions(SMR01), 807 psychiatric
(SMR04), 627 cancers(SMR06) and 416 deaths,a totalof 39,568records.
1,978personshad no medicalor deathrecordduringtheentireperiod1981
to March2004,leaving5,996personswithat leastonesuchrecord,averaging
to note thatthereare no deaths
about fiverecordseach. It is important
forlinkage.The
before1998,becausebeingaliveat thesurveyis a condition
effect
ofthiswillbe discussedlater.
the linkeddata. We see that threepersonswere
Figure5 represents
twoofwhichendedin death
ofeightlifehistories,
in
SHeS
out
the
sampled
beforethesurveydate,so couldnot be included.One of thelivessampled
afterthesurvey,anotherbeforethesurveyand the
had hospitaltreatment
theeventof
Thefigure
thirdbothbeforeandafterthesurvey.
onlyrepresents
it
and
of
admission
the
times
on
conditional
discharge;
that,
samplingand,
the rich ancillarydata recordedin respectof these
does not represent
events.
The potentialvalue of the linkeddata lies in the fact that theyare
theonlylongitudinal
studyofhealthdatain Scotlandwhichwillbe
currently
the linkageto hospitalrecordshas been
that
Now
updated.
continually
Thus,it offers
made,future
episodesand deathscan be addedperiodically.20
the
into
in
real
as nearlyas possible
time,
changinghealthof the
insights,
the
undertook
we
is
This
investigation
following
preliminary
why
population.
ofthedatainthisstudy.
of timessincethelast
thedistributions
Figure6 shows,forillustration,
the
at
event
serious(ICD codes)hospital
surveydate,forthosewhohad had
20When it becomes
available, the ScottishLongitudinalSurvey(SLS) will sample 5% of census

records,linkingthe 1991 and 2001 censuses and hospital records.The methodologywhichwe
discusshereshouldalso be applicableto theSLS.
363
inScotland
Measurement
8
i***- wt-%
6
5
4
*- i
3 - *- i
2
XH
1981
h-O
1998
XH
2004
ofthelinkeddataset;horizontal
lines
Figure5. Graphicalrepresentation
thelifehistories
ofeightpersonsin 1981to 2004;thevertical
line
represent
in
in
the
Health
those
included
the
1998
Scottish
represents
Survey;
survey
areindicated
bywhitecirclesinthesurvey
year,whiledeathsareindicated
byblackcircles;personstwoandsixdiedbefore1998,so couldnotbe in
thesample,whilepersonsfour,fiveandeightwere(randomly)
notsampled;
inrespectofpersonssampledwehaverecordsofall hospitaladmissions
to thesurvey;
(cross)anddischarges
(vertical
line)as wellas theresponses
inrespectofpersonsnotsampledwehaveno data
on LI and LLI status.Personsreporting
episodes,depending
poorerhealth
do tendto have had a morerecenthospitalepisode,but thisshouldbe
withcaution,sincetheseare distributions
conditional
on having
interpreted
survived
to thesurvey
date.
9.2 UsingHospitalEpisodestoDefineGoodandBad Health
Not all hospitaladmissionssuggestthata seriousor limiting
illnessis
to the measurement
of HE,
present.If the linkeddata are to contribute
seriousadmissionswhichare more likelyto be associatedwithsensible
definitions
of'bad health'mustbe distinguished
fromlessseriousadmissions:
364
Measurement
inScotland
Men,Good Health
S -
Women, Good Health
-i
'II111111im:11
111[TKJTrm
0
1000
2000
3000
4000
5000
6000
7000
1000
2000
3000
4000
5000
Time to Last HospitalEpisode
Men, Poor Health,No LLI
Women, Poor Health, No LU
-1r
n
8-
6000
7000
8-
III I I I rn-TTr-^-n
..I I I I rThhTUnr-^
^
0
1000
2000
3000
4000
5000
6000
7000
3000
4000
5000
6000
7000
6000
7000
Men, Poor Health,WithLLI
Women, Poor Health,WithLU
"In
in
8-
8-
8-
1000
2000
3000
"
"T^-n_
0
2000
88-
8-
1000
4000
5000
6000
7000
||0
1000
2000
3000
4000
5000
oftime(indays)sincelastserious(ICD codes)
Figure6. Distribution
recordat thesurvey
onhavingone,anddepending
on
date,conditional
hospital
thepresence
orabsenceoflong-standing
andlimiting
illnesses
long-standing
Measurement
inScotland
365
(a) The linkeddata includethe ICD codes associatedwiththereasonfor
admission,and thisis an obvious(and universal)choice.We classified
ICD codes dependingon the extentto whichdiseasesmightbe selflimiting.21
(b) A second, and potentiallymore useful,approach was Healthcare
ResourceGroup(HRG) codes assignedto SMR01 episodes.The codes
ofthediseaseand on thetreatment,
and are
dependbothon theseverity
onto
a
numeric
scale
In
the
we
mapped
representing
severity.
study define
a serioushospitalepisodeas one witha HRG valueofat least1.1,to be
consistent
withtheuseoftheHRG codesin a relatedprojectwithinISD.
forpsychiatric
we assumedall
admissions,
Lackingsimilarinformation
suchepisodesto be serious.A drawbackof theHRG codesis thatthey
are onlyassignedto episodesfromApril1997.Hence,anyuse ofearlier
episodesmustrelyon theICD codes.
The HRG codes are more discriminating
than the ICD codes; more
episodesaredeemedseriousunderthelatter.For example,all diseasesofthe
circulatory
systemare deemedseriousunderthe ICD coding,including
heartdisease,hypertensive
diseaseand so on; notall
disease,cerebrovascular
equallyseriousin fact.The HRG code picks out diseasesneedingmore
intensive
forexample,a hearttransplant
treatment;
(HRG value 18.05)or
cardiac arrest(1.20) would be seriousundereitherdefinition,
while an
admissiondue to hypertensive
disease has HRG value 0.68 or 0.80,
on severity,
so wouldonlybe seriousunderourICD classification.
depending
Wherepossiblewe use the HRG codes, and whenwe cannotwe use the
ICD codes as a proxy.We can be reasonablysurethattheymeasurethe
same qualitieshowever.If efCDis the total numberof seriousepisodes
suffered
post-survey
by the ithpersonundertheICD coding,and i[CDthe
accumulatedtimein hospital;and if efKGand i"RGare thecorresponding
= 0.72 and
quantitiesunderthe HRG coding,we findthatCov[e1CD,
eHRG]
= 0.92.
Cov[ICD,
iHRG]
9.3 ModelsBasedontheLinkedData
The firstquestionto examineis whatusefulmodelsmaybe suggested
to
accountforthedata generated
by thesurveymembers,
giventhelinkageto
theirhospitalrecords.By 'useful' we mean havinga bearingon the
21The diseases
as non-limiting
wereICD9 codesstarting
with001 to 039 (infectious
regarded
240 to 279 (endocrine,
diseases)except042 - HIV, 210 to 239 (non-malignant
neoplasms),
metabolicand immunity
nutritional,
of diabetes,630 to 677
disorders)
exceptcomplications
of pregnancy
and childbirth),
740 to 999 (congenitalanomalies,childhood
(complications
conditions
and ill-defined
and thesupplementary
V101to V85 and E800
conditions),
categories
to E999. The ICD codeschangedin April1996,and afterthatwe usedtheequivalent
ICD 10
codes.Wearenotawareofa better
butthiswouldbe usefulfuture
work.
categorisation,
366
Measurement
inScotland
estimation
of HE. The multiple-state
formulation
seenbeforeseemsto offer
somepossibilities,
thequestionbeingwhatcriterion
of good healthto use.
structure
on the
However,thelinkageto theSHeS imposesa veryparticular
data whichhas consequencesforthe estimation
of HE. In the following
example,we supposethatthe relevantsurveyresponseis the presenceor
absenceof an LLI, thoughthiscould be replacedby any othermeasure
quantified
bytheSHeS.
A suitablemodel is specifiedin two parts: eventswhichhappen at
whichmaybe collectedwhenone
randomtimes;and additionalinformation
illnessbeginswe may
oftheseeventsoccurs.For example,whena long-term
recordtheillnessor accidentwhichcausedit. Suchancillary
data,collected
ofsucha process,if
wheneventsoccur,are oftencalled'marks'.The history
consistsof thetimesand typesof all
we are able to observeit completely,
between
and the associatedmarks.Thereis a difference
past transitions
state
thecurrent
stateofa process(forexample,a person'scurrent
knowing
of health,but not theirpast medicalhistory)whichwe denote, and
as well,whichwedenoteT'
thepasthistory
knowing
of poor healthis limitinglongthe criterion
that
7
indicates
(a) Figure
are denoted^(x). We denote
termillness(LLI), and the intensities
at timet T'u.
stateat timet Q'u and itshistory
itscurrent
of
successive
8
hospital admission and
spells
(b) Figure
represents
at
and
are
denoted
The
intensities
discharge.
ju]Tp(x) thestateandhistory
timet are denoted(ft*9and ôsp, the latterincludingknowledgeof
diagnosisandtreatment.
whatthe linkeddata provide.Let S be the
We can now stateprecisely
0 = No LLI
-^-
| /ôi 'x) I
1 /4LI(*)'
/4LI(^'
1 - LLI
-7
'
'''x)
2 = Dead
illness(LLI)
long-term
Figure7. A modeloflimiting
inScotland
Measurement
i
1
0 = N()tin
Hospital
<'"
1 jiSH*).!*
^
'"#*(*)
'
1 = In
Hospital
-7
367
1
'
2 - Dead
Figure8. A modelofhospitalepisodes;associatedwitheachhospital
episodearetwomarks,diag- diagnosisand treat= treatment
over 12
surveydate (ignoringfornow thatthe surveywas administered
months)and let T be thelatesttimeforwhichwe havehospitalrecords.The
information
whichwe haveis G'u and ôsp. Thisis lessthanwe wouldlike
to have; in keepingwiththe attemptto defineHE by way of a modelof
healthstates,we would like to observeT^ and ôsp, but we cannot.
we musttakecareto allowforthesampling
schemewhennecessary.
Further,
The subjectswereselectedforthe surveyrandomly(up to stratification),
butconditional
on thembeingalive to be surveyed.
The randomsampling
meansthatit is reasonableto assumethatall thedifferent
lifehistories
are
but
the
be
in
need
to
alive
1998
to
be
means
mutually
independent,
surveyed
thatthe analysisof hospitalepisodesbefore1998 is conditionalon that
outcome.Thispointis crucial.The sampling
was donerandomly
in 1998,so
thehospitalrecordsafterthattimeconstitute
a prospective
study,whereas
thehospitalrecordsbeforethattimeconstitute
a retrospective
study.
It is reasonableto assume that the two processesabove (and others
to SAH, LI orADLs) aredependent,
so that,ifanyofSAH, LI, LLI
relating
and ADL impairment
mightoftenbe associatedwiththeneedforhospital
thehistory
ofhospitalepisodesis drawnin too. Suchdependence
treatment,
meansthat,in theabsenceofall theinformation
whichwe mightdesire,each
about theothers.The
partof themodelmayprovideindirectinformation
inanywayinestimating
HE?"
questionis: "Can thisbe exploited
10. Features of the LinkedData
its generalfeatures,
we mayask threereasonably
Apartfromexploring
offera useable
sharpquestionsof the linkeddata: "Does hospitalisation
368
Measurement
inScotland
8 I" i
'.
W
CL
!:
S?.
&
x
'
x
2
2-
x i
l":
8 - i
d
T
-
*-
*-
L-j
10
r-
20
30
40
50
60
70
80
Age
serioushospitalepisodein 1997to
Figure9. Annualratesofonsetoffirst
as onewithan HRG scoreof
a seriousepisodeis defined
2004,forfemales;
1.1 ormore
a new definition
of HE?";
of 'good' and 'bad' health,therefore
definition
ofthesurvey
used
"Is thepasthistory
at thesurvey
datepredictive
responses
in the conventional
definition
of HE?"; and "Are those same responses
offuture
healthandmortality?"
predictive
to hospital,and thestartofa spell
In thissection,'onset'meansadmission
the
the modelmeansestimating
in stateone of Figure8. Parameterising
datashouldbe used
intensities
transition
Strictly,
onlythepost-survey
4SP(X)in thistask.The reasonis thatsubjectshad to be aliveat thesurveydateto
couldcalculateoccurrence
be included,so whilewe certainly
exposurerates
whichwe
the
be
would
not
data,
estimating
parameters
they
pre-survey
using
want. The use ofpre-survey
data,therefore,
oughtto be limitedto possible
22To
it helpsto lettheintensities
dependon calendartimeas well
expressthismoreprecisely,
data
as on age,i.e. $sp(*, 0- Tnenan occurrence
exposurerateof onsetbasedon pre-survey
of/4rP(*
wouldnotbe an estimate
0 ûtf:
date| Onsethasjustoccurred]
to survey
P [Surviving
hosp
'
^ (X')X
to survey
P [Surviving
date]
369
inScotland
Measurement
I
-
CO
N -
^-
!:
5.
* i
:
'
1 1- i
:
_ :
Lj
i
10
x
-
.
I
.
I
.
I
,I
.
I
.
I
.I
20
30
40
50
60
70
80
Age
serioushospitalepisodein 1997
Figure10. Annualratesofonsetoffirst
to 2004,formales;a seriousepisodeis defined
as onewithan HRG score
of 1.1 ormore
of the surveyresponses.However,we have calculatedonset
explanations
ratesfromthefirsttimewhentheHRG codeswereavailable,namelyApril
we do includea smallpre-survey
is small.
1997,therefore
period.Theeffect
9
and
10
show
rates
of
onset
in
of
Figures
($TP(X) Figure8) firstserious
hospitalepisodesforfemalesand males,forage groupsten to 14, 15 to
20,. . . , 75 to 79. Those in the lowestage groupare based on verysmall
and we disregard
them.Here'serious'is defined
as an episodewith
numbers,
an HRG scoreof 1.1 or over.The use of thefirstepisodeimpliesthatthe
ofignoring,
forthemoment,
thepossibility
ofrecovery
surveyhas theeffect
and further
wouldbe
episodes,whichtherefore
impliesthattherates/Ssp(X)
are so high
higher.Evenso, it is evidentat oncethatonsetrates,so defined,
thata veryhighproportion
ofthepopulationwouldfallunderthisdefinition
ofdisability
deathswhilehealthy,
bylatemiddleage. For example,ignoring
about40% ofwomenwouldbe so disabledbyage 35,70% byage 55 and95%
will not lead to a satisfactory
by age 75. This meansthathospitalisation
definition
of the HE, unless recoveries(discharges)are also taken into
account.
370
Measurement
inScotland
However,the averagelengthof a serioushospitalepisode(HRG>1.1)
was only8.36 days,and each personsurveyed
suffered
an averageof 0.56
of a serioushospital
suchepisodesup to 2004.So, althoughtheprobability
eventis veryhigh,the timespentin hospitalis likelyto be short.The
as timespentinhospital,HE
combined
effect
is thatif'bad health'is defined
is practically
the same as totalLE. We did estimateHE on thisbasis by
than99% ofLE.
Sullivan'smethod,
anditwasuniformly
greater
We concludethatanymeasureofHE in whichhospitaladmissions
playa
directroleas 'onset'of bad healthmustassociate,witheach admission,a
The linkeddata
timespentin bad healthotherthanthetimeuntildischarge.
do not includeany such intervaldata. It is possiblethat wideningthe
medicalrecords,suchas thoseof generalpractices,
linkageto non-hospital
frombad to good health,butthisis
intorecoveries
wouldgivemoreinsight
thattheonsetof bad healthshouldbe
It is perhapsinevitable
speculative.
becausethatis whenpeopleaskforhelp;itis much
easyto observe,
relatively
harderto observewhenpeoplestopneedinghelp.The linkeddata succeed
of acuteservicesin managed
in doingso becausetheymeasurethedelivery
not
do
same
the
token,
but,
capturethebroadernotionsof
they
premises, by
ofHE.
mostconceptions
goodhealththatunderlie
chosenperiodof bad
We have no groundsforassociatingan arbitrarily
The most
health(forexample,a year)witheach serioushospitalepisode.23
we mightlearnis whataveragelengthofhospitalstaywouldequateHE, so
withHE basedon SHeS, SHoS or GHS surveydata,whichseems
measured,
a poor returnfromsuch a data set. Insteadwe proposeotherlines of
investigation.
11. LinkingPre-Surveyand Post-SurveyEvent Histories
Periods
andPost-Survey
11.1 Pre-Survey
and postThe surveydividesthe period 1981 to 2004 into pre-survey
and/or
surveyperiods.A naturalquestionis: "Whatdo thesurveyresponses
the
about
us
tell
no
histories
life
(hospitalepisodesonly, deaths)
pre-survey
be
It
and
admissions
lifehistoriespost-survey
might
deaths)?"
(hospital
date mightbe chosento define'pre' and 'post',
thatanyarbitrary
thought
especiallyone whichwould allocatemoreyearsto 'post'. This is not so,
and
also divides1981to 2004intoperiodsofretrospective
becausethesurvey
The
alike.
not
treat
we
which
opportunity
observations,
may
prospective
23The idea of
linkingtogetherreasonablycontiguousperiodsof bad healthis appealing at first,

but thenwe mustask: "When does a periodof bad healthend, ifanotherhospitaleventdoes not
come along to keep it going?" Thus, we have to introducean arbitrarylimitto periods of bad
healthto make up forthe absence of any signalthatit has ended. This is equivalentto choosing
an arbitraryperiodof bad health.
inScotland
371
Measurement
to a health
presentedby the linkeddata, to followup the respondents
surveyfor a lengthyperiod,is unique in Scotland and very unusual
anywhere.
11.2 Post-Survey
Mortality
We have about six yearsof follow-upsincethe survey,on a properly
basis, so that we can undertakestandardsurvivalanalysis,
prospective
on the surveyresponses.We can targettwo events:survival
conditioning
untildeath;or survivaluntilthefirstserioushospitalepisode,sincebothare
inthlinkeddata.
estimates24
Figure11 showsKaplan-Meier
(and 95% confidence
intervals)
of theprobabilities
of surviving
aliveup to 2,142days(5.9 years)sincethe
on SAH responses,
forage groups45 to 54, 55 to 64
surveydate,depending
and 65 to 74,formales(left)and females(right).Notethattheverticalscales
are notthesamefordifferent
age groups,whichformtherows.Numbersof
deathsat ages20 to 44 didnotsupportsimilarestimates.
As an example,considermalesaged 65 to 74 (bottomleftplot).The three
linesnearthetop are theestimated
survivalprobability
(middleline)and its
and
lower
95%
confidence
formenin good SAH, whogave
intervals,
upper
responses1 or 2 to theSAH question.The steeplyfallinglineslowerdown
are the corresponding
quantitiesformen in poor SAH. Each plot in the
figureincludesa p-value,theresultof a log-ranktestforlack of difference
betweentwosetsofcensoreddata. In manycases thep-valuesconfirm
what
is obviousto theeye.
Thereis a striking
reversalbetweenthe relativeprospectsof men and
womenbetweenages 55 to 54 and 65 to 74. At theyoungerages unhealthy
womenhaveworsemortality
thanmen,at theolderages it is theotherway
much
even
round,very
so,
thoughthenormalrelationship
alwaysholdsfor
menandwomeningoodhealth.
It is conventional
and oftenusefulto includeconfidenceintervalsin
graphsof thiskind,but in our case we have eitherquitewidelyseparated
estimates
withverysmallp-values(as formalesaged65 to 74) or elsecloser
estimates
withlargerp-values,but overlapping
confidence
intervals
(as for
malesaged 45 to 54). Therefore,
intervals
ofteneither
showingconfidence
restatesthe obviousor leans ratherheavilyon thep-valuesto interpret
a
cluttered
picture.
An alternative
of thesamedata is shownin Figure12. The
presentation
24The
Kaplan-Meier estimateis similar to the empiricalsurvival function(1 - FT(t)), where

F(t) is the empiricaldistributionfunctionof T, the random time untildeath, but it allows for
censoring(the fact that not all death timesare observed). Given that 331 SHeS subjects who
mighthave migratedwere excluded fromthe linked data, we assume that observationof time
untildeathis censoredonlyby the linkagestoppingin 2004. If otherunobservedexitsare present
in thedata, theseestimateswill be overstated.
Measurement
inScotland
372
Males, Age at Survey45-54

-
8 J
*-
_"~~
1~
*** "*"
I-i
w-i~
1
|
500
1
|
Wo
_^^.
-
_ _ _
S.
%
o
P=0
d n t
0
~-_
*
*
SAH Score 1.2
- - SAHScore3.4.5
j
500
,
1000
|
1500
Days Since Survey
1000
500
1500
2000
Days Since Survey
'
""
^__
0
2000
p=o
->,.*-...
SAH Score 1.2

- - SAH Score 3.4.5
Days Since Survey
' ' ^
*"""*
d 1
I
1500
~ n
*
-_
m
"
d T
2000
,,
fc-
l_""""k
3d"
1000
Females, Age at Survey55-64
----
S_
500
y ^
1500
1000
500
"*
S
d
SAH Scored
- - SAH Score 3.4.5
SAH Score 1,2

- - SAH Score 3.4.5
8 I '-
~"* '
~* ' x
m
^
_
m "" - *?-w- 1____^'.~s- *-n
p = 0.0086
>
p= 16-04
.,
-
Days Since Survey
8.
%
o
__
""
2000
1500
o
d
i~
i
Days Since Survey
8 |
I-
1000
*
* -
SAH Score 1,2

- - SAH Score 3.4.5
1-
'
, .
p = 0.0481
*"
i.
*~
I
,
2000
,_
"
o 1 |
0
p= o
SAH Score 1
- - SAHScore3.4.5
|
500
|
1000
|
1500
I ' '
2000
Days Since Survey
ofsurvival
estimates
post-survey
probabilities
Figure11. Kaplan-Meier
on self-assessed
health,
confidence
95%
intervals),
depending
(with
vertical
the
that
note
as
classified
4
5
and
of
health';
'poor
3,
responses
scalesarenotthesameforall age groups(rows)
373
inScotland
Measurement
Females,Age at Survey45-54
Males,Age at Survey45-54
s
I
p= 0.0481
g.
I
|
p = 1e-O4
g_
SAH Score 1.2

- - SAH Score 3.4.5
SAH Score 1.2

- - SAH Score 3.4,5
d
d
0
500
1000
o)
h>rw_^
rp^
_^
is";-::Kr:"-^.,.
' ""'.
is8-
"'""--.
J::"fe:;
*k-~
p = 0.0086
".."
"....
SAH Score '2

- - SAH Score 3,4,5
,n
5
:A
.
'
".
...
"
' .
1
il"
a
n "
%"
P= 0
500
1500
1000
500
2000
p=o
500
':-.."''';...
SAH Score 1.2

SAH Score 3,4,5
1000
Days Since Survey
....._
' .
'...""
1500
1500
2000
Females, Age at Survey 65-74
Males, Age at Survey 65-74
S"
1000
DaysSince Survey
Days Since Survey
SAH Score 1,2

~ - SAH Score 3,4,5
I?
o
? .
2000
1500
Days Since Survey
8 J
1000
500
2000
1500
Days SinceSurvey
2000
"
1
d
P=o
SAH Score 1,2

SAH Score 3,4,5
500
1000
1500
2000
Days Since Survey
ofsurvival
estimates
post-survey,
probabilities
of3, 4 and 5 classified
as
on
self-assessed
health,
depending
responses
to
thedottedlinesshowthesurvival
unhealthy;
probabilities
corresponding
oftheupperKaplantwo,three,fourandfivetimestheforceofmortality
Meierestimate;
intervals
95% confidence
at thelongestdurationare
indicated
or triangles
notethat
bycrosses(higher
estimate)
(lowerestimate);
theverticalscalesarenotthesameforall age groups(rows)
inScotland
Measurement
Kaplan-Meierestimatesare shown withouttheirconfidenceintervals,
exceptat the longestduration(righthand side) where95% confidence
intervalsare indicatedby crosses (higherestimate)or triangles(lower
to
The dottedlinesshowthesurvivalprobabilities
estimate).
corresponding
of theupperKaplantwo,three,fourand fivetimestheforceof mortality
Thismakesit easyto assesstheimpactofa factorsuchas
Meierestimate.25
For
different
levelsof SAH in termsof multiplesof the bettermortality.
close
to
suffer
55
to
64
with
SAH
in
12
men
very
aged
poor
example, Figure
doublethemortality
ratesof menof thesameage withgood SAH. The pthe
values are stillshown.On balance,we preferthisway of illustrating
data.
resultsif response3 to the SAH
Figure 13 shows the corresponding
in
thanbad health.Figures11 and 13
rather
is
included
good
question('fair')
at ages45 to 54, buttheyshowthattheSAH question
are hardto interpret
at ages over
ofshortand medium-term
is quitestrongly
mortality
predictive
55. Recall(Table 17) theverygreatrisein HE basedon SAH ifresponse3
given'poor health'
('fair')was classifiedas 'good health'.Whilemortality
and
the
is
not
in
it
is
worse
so,
13,
'poorhealth'group
greatly
Figure
clearly
is quitesmall.
reversalof men's and women's
above on the striking
We commented
relativepositionsshownby Figure 11. Figure 12 puts this into some
ratesabout
At ages55 to 64,menwithpoorSAH havemortality
perspective.
twicethoseofmenwithgoodSAH, afterabouttwoyears.Womenwithpoor
ratesfarinexcessoffivetimesthoseofwomen
havemortality
SAH, however,
55
to
withgood SAH. At ages
64, menand womenare not so different.
thatallocatingresponse3 ('fair')to one
13
with
Comparison Figure suggests
forwomenaged 55 to 64, or that
or otherhealthstatusis veryinfluential
womeninthisage groupgivingresponses1 or2 hadverylowmortality.
of HE usedmostoftenin
to thedefinition
Figure14 (whichcorresponds
to havepredictive
theU.K.) showstheLLI-baseddefinition
qualitiessimilar
whichis consistent
but less discrimination,
to the SAH-baseddefinitions,
inTables14and 15.
ofresponses
withthenumbers
survival
Figures15 and 16 show,for males and femalesrespectively,
serious
of
a
occurrence
the
hospitalepisode(ICD
given prior
probabilities
1981andthesurvey.
between
time
or
500
within
1,500
any
days
days,
coding)
Onlyage groups55 to 64 and 65 to 74 are shown,and notethattheyform
withno
thecolumnsin thesegraphs.Of 416 deathsin thedata,83 occurred
of which33 had no seriousepisode
seriousepisode(HRG) post-survey,
374
25Actuarieswill be familiarwiththe common

of ratingrisks
practicein insuranceunderwriting
as +X% of the mortalityrates of some standard life table. This is verysimilar,except that,
we assess the higher
insteadof holdingto a singlestandardrate (force)of mortalitythroughout,
riskwithrespectto thelowerriskin each particularcase.
375
inScotland
Measurement
Males,Ageat Survey45-54
g j
ra
: : :: :>--^--"---T^ ^ *- ;
s.
:;.
""
p = 0.4677
8
SAH Score 1,2,3

- - SAH Score4,5
500
SAH Score 1,2,3

SAH Score4,5
500
1000
2000
1500
Days SinceSurvey
Days Since Survey
..'....
p = 0.0151
ie .
P= 0
2000
1500
1000
' ''*
|-
R.
'.
. . .
.."..
SAH Score 1,2,3

SAH Score 4,5
'
'
'"' ''"*
P=
" "
"..."*
-.
SAH Score 1,2,3

SAH Score4,5
'.
"
5
"'.
2.
o T-i
0
1
500
1
1000
1
1500
'"'
1
2000
S-~
'
|
0
|
500
- I
p=0
n _
--
'"
.
'
' .
SAH Score 1.2,3

SAH Score4,5
500
1000
1500
|
1500
1
2000
'
2000
p i
'
'
'*
A
'>- i '*
'- *
''.
^,~v.'i. , "
x-..,
'<
'
_
Days Since Survey
1
1000
Days Since Survey
Days SinceSurvey
1
s
;::- :
o
0
"::::V: [[.'.';
R-
R.
^'
':..':..'""* |
s -
,Y~'T~r~
I
5
~|
I
I
'
? "
p= 0
--
'-s.
'
x-..
SAH Score 1,2,3

SAH Score4,5
500
1000
1500
2000
Days Since Survey
ofsurvival
estimates
probabilities
post-survey,
as
on
self-assessed
of4 and 5 classified
health,
depending
responses
to
unhealthy;
probabilities
corresponding
oftheupperKaplanfourandfivetimestheforceofmortality
two,three,
Meierestimate;
intervals
at thelongestduration
are
95% confidence
indicated
crosses
or
note
estimate) triangles
(lowerestimate); that
by
(higher
theverticalscalesarenotthesameforall age groups(rows)
376
Measurement
inScotland
----
ETj^-.
_~1
p = 0.006
NoLLI
- - WithLLI
g _
d
500
,,,,
8 -
p = 0.001
NoLLI
- - WithLLI
g
d
1000
1500
2000
500
Days SinceSurvey
8 J
I
|
'
..
p = 0.0069
"
NoLLI
WithLLI
R-
I s.
m--'
:

"..."'..
1000
1500
"
NoLLI
WHhLLI
S 0
2000
500
.* j
p= 0
NoLLI
- - WithLLI
s-
":
:.'".
500
1000
*/'.
"-.
1500
Oays Since Survey
1500
2000
'"...
2000
'. -.**V.i s^ . ^
p = 2e-04
Ih-
'.."*.
-..
0
"'
"
"~^^-s^^
. '
1000
. I
''.':."-
"..
DaysSinceSurvey
- J
"
../:
A

p= 0
DaysSinceSurvey
2000
.......%~
..d
500
1500
in-rU
i s.
' .
...'
1000
Days Since Survey
Mates, Age at Survey 55-64
^^
-;
;:
'
* I
'...
NoLLI
--WithLLI
'-.
..
500
1000
1500
2000
Day*Since Survey
estimates
ofsurvival
probabilities
post-survey,
on thepresence
or absenceofa limiting
illness;the
depending
long-term
to two,three,
dottedlinesshowthesurvival
corresponding
probabilities
fourandfivetimestheforceofmortality
oftheupperKaplan-Meier
areindicated
confidence
intervals
at
the
95%
estimate;
longestduration
by
notethatthevertical
crosses(higher
ortriangles
estimate)
(lowerestimate);
scalesarenotthesameforall age groups(rows)
311
inScotland
Measurement
Age at Survey 55-64
-I.
"k---',^
p= 0
..
':..
1000
500
1500
Age at Survey 66-74
,,
No SeriousEpisodes500 Dayspre-Survey
- - With
SeriousEpisodes500 Dayspre-Suivey
2 -
--TrTtZI
P = 0.001
, _
2000
o J
p=o
p=o
, _
No Serious Episodes 1500 Days pre-Survey

WithSerious Episodes 1500 Days pre-Survey
500
1000
1500
2000
500
Age at Survey 55-64
500
1000
1500
DaysSinceSurvey
1500
.'..'
p = 0.0065
No SeriousEpisodespre-Survey
- - With
SeriousEpisodespre-Survey
0
1000
2000
Age at Survey 65-74
p = 8e-04
-
q _j
DaysSinceSurvey
'
'"."'.
No Serious Episodes .1500 Days pf-Survey '

WithSerious Episodes +500 Days p%-Surve
DaysSinceSurvey
"
2000
Age at Survey 65-74
Age at Survey 55-64
1500
1000
500
DaysSinceSurvey
>V-'
"'..
..=...
No SeriousEpisodes500.Pays pre^Sijrvey
- - WithSeriousEpisofes500-Oays
A
pre-Suryey
DaysSinceSurvey
iS _
'^v^
2000
"-. .
-A
NoSeriousEpisodespre-Survey .
- - With
".....
500
1000
1500
2000
DaysSinceSurvey
ofsurvival
estimates
probabilities
post-survey,
on theduration
at thesurvey
datesincethelastserioushospital
depending
episode(formales,ages55 to 74); thedottedlinesshowthesurvival
to two,three,fourandfivetimestheforceof
probabilities
corresponding
95% confidence
intervals
at
estimate;
mortality
thelongestduration
areindicated
ortriangles
estimate)
bycrosses(higher
notethattheverticalscalesarenotthesameforbothage
(lowerestimate);
groups(columns)
inScotland
Measurement
378
8J
Age at Survey 55-64
_
|
'
' .
p = 6e-04
E _
8J
-mj- ^T"
500
1000
1500
-^)r_"
'
'
' . .
..
^
A
'
No SeriousEpisodes500 DaysfJre-Survey
- - WithSeriousEpisodesKWDayspr-Surwey
'-. . A
p = 0.0046
~
=>
No SeriousEpisodes500 Dayspre-Survy
- - WHhSeriousEpisodes500 Dayspre-Survey-
Age at Survey 65-74
g
0
2000
500
d"
"
'"..'""*
p= 0
}C
No SeriousEpisodes1500Dayspre-Survey
- - WWh
SeriousEpisodes1500Dayspre-Survey
1000
500
..
jg
0
2000
1500
1000
500
No SeriousEpisodespre-Survey
_ _ With
.
0
500
1000
1500
DaysSinceSurvey
2000
Age at Survey 65-74
p 0.0291
1500
DaysSinceSurvey
Age at Survey 55-64
'
'.
':.....
"'
.-...
No SeriousEpisodes1500Days pro-Survey
- - WMh
p8e-O4
R o
DaysSinceSurvey
!C _
2000
Age at Survey 66-74
Age at Survey 65-64
1500
1000
DaysSinceSurvey
DaysSinceSurvey
..
""
"'
. .
;.
*
No SeriousEpisodespre-Survey :
- - WithSeriousEpisodespre-SurMey '
P 0.0484
"
g _
2000
500
1000
1500
2000
DaysSinceSurvey
ofsurvival
estimates
post-survey,
probabilities
datesincethelastserioushospital
at
the
duration
the
on
survey
depending
ages55 to 74); thedottedlinesshowthesurvival
episode(forfemales,
corresponding
probabilities
at
intervals
95%confidence
estimate;
mortality
or
crosses
areindicated
triangles
estimate)
thelongestduration
(higher
by
scalesarenotthesameforbothage
notethatthevertical
(lowerestimate);
groups(columns)
inScotland
Measurement
379
S |
8-
so J I
11
'
1000
2000
3000
4000
5000
6000
Time Since Last Serious HospitalEpisode (Days)
lastserioushospital
oftime(days)between
Figure17. Distribution
episodeanddeath,forthe383(outof416) deathswhichwereprecededby
suchan episode
at death,of the
either.Figure17 showsthedistribution,
(ICD) pre-survey
timesincethepreviousseriousepisode,wheretherewas one.
It is as expectedthata priorepisodeincreasesrisk;butwhatis ofinterest
is thecontrastwithself-reported
health.Comparing
thetwosetsof figures,
we see thatthesexdifferences
notedaboveare muchlessstrong,
thoughnot
in thewayin which
absent.Thiscouldbe causedby differences
completely
menand womenself-report
theirhealth,whichwouldsuggestthathospital
do
a
more
measure.
episodes give
objective
Althoughthe existenceof a hospitalepisode is predictiveof future
the extentto whichthe durationsinceit occurredis predictive
mortality,
variesgreatly
withage. At ages 55 to 64 durationis strongly
for
predictive,
menandwomen,butat ages65 to 74 itmakesrather
littledifference.
Actuariesare familiarwithselectlifetables,whichreflectthe factthat
someonewhohasjust beenacceptedforlifeinsurance
willhavegivensome
evidenceofgoodhealth,and themortality
ofsuchpeoplewill,for
experience
some time,be betterthan average.In the U.K. it has been commonto
assumethatthiseffect
willwearoffaftertwoor fiveyears,althoughin the
380
inScotland
Measurement
UnitedStatesof Americait is commonto assumemuchlonger' select'
theselection
effect
is,
periods.WhatFigures15and 16showis howpersistent
extends
over
17
that
the
years.
given
pre-survey
period
shortfollow-upperiod;it sufficesto extract
Six yearsis a relatively
patternsforolderage groups,but not foryoungerage groups,and this
particular
samplehas yetto age intotheoldest-oldage groups.Therefore,
as timepasses,
survival
analysismayyieldmoreandmoreusefulinformation
andas morerecordsarelinkedto thedata.
11.3 Post-Survey
Morbidity
The other'survival'eventwhichis accessiblethroughthelinkeddata is
serioushospitalepisode.Except
a post-survey
thetimeuntilfirstsuffering
we
eventratherthantheeventofinterest,
thatpriordeathis nowa censoring
can estimate'survival'probabilities
just as before.Figures18 to 22 show
of HE basedon SAH: thatbasedon LLI;
theresultsforthetwodefinitions
and the durationat surveysince a previousseriousepisode,males and
to Figures12 to 16. Note thatin
These correspond
females,respectively.
are defined
events
21
22
serious
and
byICD codes,while
pre-survey
Figures
- is defined
theeventbeingstudied- thefirstseriouseventpost-survey
by
HRG codes.
ourpreferred
The mostobviousfeatureis thatall of the measuresof healthin the
thanof
of futuremorbidity
discrimination
surveyprovidea muchstronger
ratesare low
futuremortality,
especiallyat ages 45 to 54, wheremortality
4 and
is at olderagesfortheSAH (responses
Thepossibleexception
anyway.
measure.
5 only)
featurein Figures18 to 20 is theextentto whichmenand
One striking
of
womenare similarat ages45 to 64, butat ages 65 to 74 theimplications
LLI and SAH) reduceforwomen,but
health(including
poor self-reported
of womenin poor and
increaseformen;thatis, themorbidity
experiences
men diverge.This sex
of
those
while
close
health
up,
good self-reported
is notquiteso apparentwhenthebaselinemeasureofhealthis the
difference
seriousepisode.
timesincethelastpre-survey
thedurationsincea previousserioushospitalepisode
As withmortality,
moreat ages55 to 64 thanat ages65 to 74.
matters
Comparingsurvivalto firstseriousepisodewithsurvivaluntildeath,the
forthosein the adverseriskgroups,have a
of the former,
probabilities
at about1,000daysafterthesurvey,
out
of
curiousfeature flattening slightly
serious
recent
a
with
men
for
episodeat thetimeof thesurvey,
especially
4 and 5 only).A possiblereasonis a selection
and forpoorSAH (responses
a seriousepisode.
intheperiodfollowing
effect
inScotland
Measurement
11.4 Implications
forHealthExpectancy
sinceClarket
featureof theScottishHE estimates
A clearand troubling
basedon
estimates
low
al. (2004)publishedthemhas beentheexceptionally
381
inScotland
Measurement

i
p J
_| ta^^
:
t':
i':
:
%-:::
'"ÎS::;
x
v
i'
;-:--.- a;:;.->-,,.
I
P=0
<o
d-
--
"
SAH Score 1.2

SAH Score 3.4.5
3-L,
500
1000
'..
..
*-..
'-.a
'*'.
..
500
SAHScreU1"'S
SAHScore3.4.5 ,..
500
1000
-.,
"
X*V"
""A
1500
2000
'
" -
--
500
p=oV;'>vs x-..
--
SAHScore "l'V,
SAHScore3.4'5. '
500
1000
;.7^_
1500
DaysSinceSurvey
1000
1500
*
.
's ,
r-
2000
1000
1500
2000
DaysSinceSurvey
5"
"'..,
SAHScow li S *'*'.
"*', SAHScore3.4.5 ,
v..
DaysSinceSurvey
*;
--
*%
-....%
,.
DaysSinceSurvey
DaysSinceSurvey
*-
SAH Score 1,2

SAH Score 3.4.5
S-L,
2000
1500
--
n _
o
r- J
P=0
o
ci-
x
'
'*. .A
2000
p=v''v*'
d-
--
SAHScorrfv'V..
V>
SAHScore3.^
'
500
1000
^'"%~-^
' ^
*v%
1500
2000
DaysSinceSurvey
oftheprobability
ofsurviving
freeofa
estimates
on self-assessed
serioushospitalepisode(HRG codes),depending
health,
of3,4 and 5 classified
as unhealthy;
thedottedlinesshowthe
responses
survival
to two,three,fourandfivetimesthe
probabilities
corresponding
forceofonsetoftheupperKaplan-Meier
intervals
95% confidence
estimate;
areindicated
or
bycrosses(higher
estimate)
note
that
vertical
the
scales
are
not
same
for
the
(lowerestimate);
triangles
all age groups(rows)
382
Measurement
inScotland
: t?: ^JS^^T^
i' '"*%::::
h: - v::::^'
Ij: - '"^::-*
--
3.
SAHScore1,2,3
SAHScore4.5
""V. ..
5-j
500
1000
1500
--
j.
SAHScore1.2,3
SAHScore4.5
v "^-^
..v
5 -j
2000
500
DaysSinceSurvey
2 _rr~
*"'"
1000
1500
2000
DaysSinceSurvey
q _r- --
* I !' -^xxX'-?;^.....4
I !" -':'>.--'i-;:>
d
"
SAHSco>6.1.2V
V.
- - SAHScored
' %%
0 H_1
0
!
500
!
1000
*-
X.
S.
=_,
1500
i_
,
2000
"
SAHScore>,3V
- - SAHScore
4,5' '_
H_j
0
,
500
DaysSinceSurvey
0'
--
SAHSCore-V. X
X -
Vv^
::S^^- -^
SAHScW^XV;^
500
1000
1500
Days Since Survey
i,
1500
1-- ,
2000
DaysSinceSurvey
N-^
^S
,
1000
! s-
V*s%"
2000
Is-
"
w
--
p.ox<v-v-^--^
1
SAHScore '3' *v
SAHScore4.5 V. X^
500
1000
^^.x
^.
^-"::^ -1500
2000
Days Since Survey
estimates
oftheprobability
ofsurviving
freeofa
on self-assessed
health,
of4 and 5 classified
as unhealthy;
thedottedlinesshowthe
responses
to two,three,
fourandfivetimesthe
survival
probabilities
corresponding
intervals
forceofonsetoftheupperKaplan-Meier
95%confidence
estimate;
crosses
or
areindicated
estimate)
by
(higher
scalesarenotthesamefor
notethatthevertical
(lowerestimate);
triangles
all age groups(rows)
383
inScotland
Measurement
Female, Age at Survey 45-54
^v^X'""
* I
"
p=
--
'.
-..
-..,-,;
500
..
1000
"'
-,...
'."*^>_
o"
p= 0
m'
NOLLI
--WithLLI
5-1
0
500
."
^v ..,
'">,
-^
'<>
1500
I
*
"A
2000
'., %'" ^^*x.. ..
o .
500
1000
A".
5-1
0
500
'..
W^-%
V...
'
-. '
'
'
. "V-V"-."
1500
1000
2000
DaysSinceSurvey
*' * "*-..&
1500
DaysSinceSurvey
:''
NoLLI
- - WWILLI
'.'
2000
1500
1000
p= 0
d"
DaysSinceSurvey
--WithLLI
V.
-.,
500
a. o"
"A
.",
'-.,
..
'-,.
1000
'....
'""*
.,.
*<
DaysSinceSurvey
S"
'"^j
NO"-1-1
- - WithLLI
DaysSUKSurvey
v.
p=o
._
2000
1500
"'l>>^"N'%"-^.-J
"
'.*"-'..
MOLLI
WithLLI
2000
--WithLLI
500
V.v
1000
'-^
Vs
1500
2000
DaysSinceSurvey
ofsurviving
freeofa
estimates
oftheprobability
or
on thepresence
lines
show
the
survival
absenceofa limiting
the
dotted
illness;
long-term
probabilities
corresponding
onsetoftheupperKaplan-Meier
95% confidence
intervals
at the
estimate;
areindicated
ortriangles
estimate)
longestduration
bycrosses(higher
notethattheverticalscalesarenotthesameforall age
(lowerestimate);
groups(rows)
384
Measurement
inScotland
Age at Survey 65-64
p=0W
Age at Survey 65-74
^..
NoSeriousEpisodes500-Bayspre-WYev a
- - With
SeriousEpisobw500 D^ gre-Suvey
0
500
1000
1500
p=0
'>,'-,;'
No Serioteptedd
SOObayCpre^vrveV-"
- - With
Iw^SuNy
Serk)us^tâ^Days
2 "
2000
500
1000
1500
DaysSinceSurvey
DaysSinceSurvey
Age at Survey 55-64
Age at Survey 65-74
2000
li- ^s^vj l!; 'lôi
';
,
,..
- - NoSenousEpisooeîSOOOy^pre-Survey-With
SeriousEpisodesta^Day puB-Survey
5"
0
500
1000
1500
~ d
2000
- 0
-::v.;-,,
**-:.- 'A
No SeriousEp&Qd& V500Da>e-Survey
WtthSertousEpsode^jWlLpayspVsurvey
500
DaysSinceSurvey
Age at Survey 55-64
r--
--,
500
",
1000
1500
DaysSinceSurvey
1500
2000
Age at Survey 65-74
'
No SeriousEpisodespre-Sbn/ey*'.. .
- - WithSeriousEpisodespre-Surtey. " **- .
,
d"
1000
DaysSinceSurvey
2000
q j
s-
'
/',,
-V.
No SeriousEpisdes,pre^9uiyey' "
- - WithSerious
"""- ..
Episodes'pie^Surv^
w "
d
0
500
1000
1500
2000
DaysSinceSurvey
estimates
oftheprobability
ofsurviving
freeofa
on theduration
at the
datesincethelastserioushospitalepisode(formalesaged55 to 74);
survey
to two,three,
probabilities
corresponding
fourandfivetimestheforceofonsetoftheupperKaplan-Meier
estimate;
intervals
areindicated
95%confidence
bycrosses
notethatthevertical
scales
or triangles
estimate)
(lowerestimate);
(higher
arenotthesameforbothage groups(columns)
385
inScotland
Measurement
Age at Survey 65-74
Age at Survey 55-64
3- -
*-'-T s" p''N^
X:<
500
1500
1000
2000
500
p-
-v'V.%
500
1000
1500
2000
500
p=0
5-
No Serious Episodes pre-SurveV" -

WithSerious Episodes pre-Survey
20
500
1000
Days Since Survey
1500
2000
Age at Survey 65-74

i
''-...
"v-s
1500
1000
DaysSinceSurvey
Age at Survey 55-64
'''
No SeriousEpisedesHpo Dayfê^Survey
WithSeriousEpisodeî5b6^Dayspr^Buwey..
DaysSinceSurvey
2000
s"
No SeriousEpisodes1500Day*p-SurVey
With
1500
Age at Survey 65-74
Age at Survey 55-64

q J
2 -
1000
DaysSinceSurvey
DaysSinceSurvey
3-
v---
No Senous Epso('500Ddys.pre-Suivey
A
- - With
SeriousEp6.odeHQ0
iDays>a-ûrvey
No SeriousEpisodes500ftys prtf^jrvey A
- - WithSeriousEpisodes
500 Daysfe-S'uHey..
g -
p= 0
5"
2000
'*'''
'
No Serious EpJsoe&Dre^SiirveV" *. v
v- . .
WithSerious Episode^re-Survey
..
0
500
1000
1500
2000
Days Since Survey
freeofa
estimates
oftheprobability
ofsurviving
on theduration
at the
females
55 to
date
since
the
last
serious
(for
aged
survey
hospitalepisode
to two,
74); thedottedlinesshowthesurvival
probabilities
corresponding
fourandfivetimestheforceofonsetoftheupperKaplan-Meier
three,
95% confidence
intervals
areindicated
estimate;
by
crosses(higher
or triangles
notethatthevertical
estimate)
(lowerestimate);
scalesarenotthesameforbothage groups(columns)
386
inScotland
Measurement
Table 18. Responsesto theself-assessed
healthquestioninthe1998
Scottish
HealthSurvey,
a limiting
bypersonswhoreported
long-standing
illness
LLI and
SAH = 3,4, 5
LLI
Age group
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
Males
8
20
37
65
54
73
79
90
124
134
118
110
Total
912
LLI and
SAH = 4, 5
Males
Females
Males
Females
16
33
48
92
91
85
113
142
141
140
162
163
6
11
17
38
22
41
48
63
98
101
83
85
8
17
27
42
57
52
80
90
101
97
113
110
0
3
5
10
8
20
18
28
39
41
24
29
0
3
8
17
16
20
28
33
47
28
39
35
1,226
613
794
225
274
Females
basedon SAH are notso extreme,

LLI. Estimates
exceptundertheSHeS, if
as unhealthy,
is
counted
to
the
SAH
3
and, as
question
response ('fair')
Tables14and 15 show,ifthisis done,thenthenumbers
poorSAH
reporting
and an LLI are verysimilar.The questionsare: (a) "Are thesemeasures
and (b) "Do theygenuinely
consistent?"
pickouta groupofpeoplewithpoor
healthoutcomes?"The analysesof thissectionmay help to answerthese
questions:
questionswereansweredconsistently
(a) It is obviousthat,if thedifferent
in Section11
described
and morbidity
bythesamepeople,themortality
wouldnot dependon whichquestionhad been asked.Table 18 shows
bad healthunder
an LLI also reported
howmanypersonswhoreported
theSAH question.Therewas substantial
overlapifresponse3 ('fair')was
countedas bad health,and onlya smalloverlapifit was not.Therefore
betweenFigures12 and 14, and evenmoreso between
the similarity
thatresponses
and
18
3, 4 and 5 to theSAH question
20,suggests
Figures
an LLI. This supportsthe
measureverymuchthe same as reporting
reachedbyBajekaletal (2002).See theendofSection7.
conclusion
(b) Our survivalanalysesshowthatthehealthquestionsalmostuniversally
of future
HE are strongpredictors
used in surveysaimedat estimating
This is, of course,theassumption
and morbidity.
underlying
mortality
theiruse,butit is unusualto be able to measureit,becausemosthealth
haveno follow-up.
surveys
measureof HE fromhospital
to forma conventional
Whileit is difficult
inScotland
387
Measurement
recordsalone, we have shownthat the riskof futurehospitalepisodes,
is quitestrongly
therefore
use of healthservices,
predicted
by theexistence
on age) durationsince,a serioushospitalepisode.Rather
of,and (depending
HE framework,
a
than forcingthe hospitaldata to fitthe conventional
of the populationaccordingto the recenthistoryof
simpleenumeration
measuresof the riskof
hospitalepisodes,combinedwithage-dependent
subsequent
hospitalepisodes,mightserveto predictchangesin demandfor
services
overtime.
12. Conclusions
We reviewedwhatis knownabout HE in Scotland,whichis largelythe
oftheofficial
estimates
basedon
reportbyClarket al (2004).Comparisons
theGHS withEnglandor GreatBritainshowthatScottishHE is worseon
average,butthattheratioofHE to LE is similar;ifScotsbecomeunhealthy
sooneron average,thentheyalso die sooneron average.However,this
statement
about averagesdoes not implythattheindividuals
who become
soonerarethesameas thosewhodie sooner;longitudinal
data are
unhealthy
neededto examinethisquestion.
definitions
Comparisons
beyondtheU.K. are hamperedby thedifferent
of healthused in different
countries.Since 1995,a reasonablyconsistent
at the
approachhas been takenwithinthe E.U. (pre-accession)
countries,
levelof officialstatistics,
and estimates
of HE can be ranked,witha good
deal of cautionbecauseof possibleculturaldifferences
in responding
to the
samequestion(indifferent
estimates
areoutsidethis
languages).The Scottish
commonframework,
but, withthatadditionalcall forcaution,theyfall
verynearthebottomoftheEuropeanleagueformen,and in thebottomhalf
forwomen.The trendin theratioof HE to LE place Scotlandand England
in the middleof Europeancountries,beingnot among those reporting
of
expansionofmorbidity
(at birth),noramongthosereporting
compression
However,the trendin Scotlandand England,whichhas been
morbidity.
observed
formuchlongerthaninEurope,maybe slowlydeclining.
Our exploration
of thelinkeddata (theScottishHealthSurveyresponses
in 1998-1999
linkedto therespondents'
hospitalrecordsduring1981to 2004
and deathregistrations
of
during1998to 2004) showedthattheoccurrence
serioushospitalepisodesis not rareby late middleage. For HE estimates,
we do needa sensibledefinition
of recovery
froma spellof bad
therefore,
healthinitiatedby hospitalisation.
Dischargefromhospitalwill not do,
becausemoststaysin hospitalare veryshort;thisleadsto HE whichis over
99%ofLE. Hospitalrecords
wouldbestbe supplemented
byotherlongitudinal
datato estimate
HE.
However,the linkeddata gave us a rare opportunity
to studythe
and morbidity
of individualsurveyrespondents,
mortality
morbidity
being
388
definedby the firstserious hospital episode afterthe survey.We confirmed
the qualitativeeffectof self-assessedbad healthon mortalityand morbidity,
whichwas as expected,but we wereable to quantifyit also in simplesurvival
analyses. This led us to suggestthat a national or regionalenumerationof
recenthospitalepisodes, suitablyclassified,mightbe used as a predictorof
futuredemand.
In the course of thisresearchwe investigatedsome topics whichhave not
foundtheirway into this account, and we noted some interesting
questions
forfuturework.Principally,we thinkthatsurvivalanalysisfroma surveyor
census baseline will be a usefultool in future,especiallyonce the Scottish
LongitudinalSurvey is available, and our simple analyses could then be
greatlyrefinedusingthelargerand longerdata set.
Acknowledgements
We are gratefulto the Faculty of Actuaries in Scotland and to the
Research SteeringCommitteeof the Actuarial Professionfor the funding
whichsupportedthisproject.We particularlywishto thankDr Marion Bain,
Medical Directorof ISD, forhelpingto identifythe topic. We would like to
thankDavid Clark, AndrewElders and Dr Rod Muir of ISD formuchhelp
at variousstages.
References
Bajekal, M, Purdon, S., Woodgate- Jones, G. & Davies, S. (2002). Healthylifeexpectancy
at Health Authoritylevel: comparingestimatesfromthe General Household Surveyand
theHealth SurveyforEngland.Health StatisticsQuarterly,16, 25-37.
Bajekal, M. (2005). Healthy life expectancyby area deprivation:magnitudeand trendsin
England 1994-1999.Health StatisticsQuarterly,25, 18-27.
Bebbington, A.C. (1988). The expectationof life withoutdisabilityin England and Wales.
Social Sciencein Medicine,27, 321-326.
Bebbington, A.C. (1991). The expectationof life withoutdisabilityin England and Wales:
1976-1988.PopulationTrends,66, 26-29.
Bebbington, A.C. (1992). Expectation of life withoutdisabilitymeasured from the OPCS
disabilitysurveys.Studieson Medical and PopulationSubjects,54, 23-32.
expectancyin Great
Bebbington, A.C. (1993). Regional and social variationsin disability-free
consensusachievedandfuture
Britain.In Calculationofhealthexpectancies:harmonisation,
perspectives.Ed. Robin, J.-M., Mathers, CD., Bone, M.R. & Romieu, I. Coloque
INSERM/John LibbeyEurotextLtd., 226.
health
Bebbington, A.C. (2003). Sub-nationalvariationsin healthexpectancy.In Determining
expectancies.Ed. Robin, J.-M., Mathers, C. & Jagger, C. JohnWiley:London.
Bebbington, A.C. & Darton, R.A. (1996). Healthy life expectancyin England and Wales:
recent evidence. Discussion Paper 1205, Personal Social Services Research Unit,
Universityof Kent.
Bisset, B. (2002). Healthy life expectancyin England at subnational level. Health Statistics
Quarterly,14, 21-29.
Bone, M.R., Bebbington, A.C., Jagger, C, Morgan, K. & Nicolaas, G. (Eds.) (1995).
Healthexpectancyand itsuses. HMSO, London.
inScotland
Measurement
389
Buratta, V. & Egidi, V. (2003). Data collection methods and comparabilityissues. In

Determininghealth expectancies. Ed. Robin, J.-M., Jagger, C, Mathers, CD.,
Crimmins,E.M. & Suzman, R.M. JohnWiley.
Carstairs, V. & Morris, R. (1991). Deprivationin Scotland.AberdeenUniversityPress.
Clark, D., McKeon, A., Sutton, M. & Wood, R. (2004). Healthy life expectancyin
Scotland.InformationServicesDivision,National Health Scotland.
CMIB (1991). ContinuousMortalityInvestigationBureau ReportNo. 12. Faculty of Actuaries
and Instituteof Actuaries.
Fries, J.P. (1980). Aging, natural death, and the compressionof morbidity.New England
JournalofMedicine,31, 407-428.
Fries, J.P. (1989). The compression of morbidity:near or far? New England Journalof
Medicine,67, 208-232.
Gruenberg, E.M. (1977). The failureof success. Milbank Memorial FoundationQuarterly/
Healthand Society,55, 3-24.
Hooker, P.F. & Longley-Cook, L.H. (1953). Life and other contingencies,Volume 1.
CambridgeUniversityPress.
Jagger, C. (1997). Health expectancycalculationby Sullivan'smethod:a practicalguide. EuroREVES, Montpelier,France.
Kelly, S., Baker, A. & Gupta, S. (2000). Healthy life expectancyin Great Britain, 19801996, and its uses as an indicatorin the United Kingdom Governmentstrategies.Health
StatisticsQuarterly,
1, 32-37.
Kramer, M. (1980). The rising pandemic of mental disorders and associated chronic
diseases and disabilities. Acta Pschiatrica Scandinavica, 62 (Supplement 285), 285297.
Ledent, J. (1980). Multistatelifetables: movementversustransitionperspectives.Environment
and PlanningA, 12, 533-562.
Leon, D., Morton, S., Cannegieter, S. & McKee, M. (2003). Understanding
the healthof
Scotland'spopulationin an international
context:a reviewof currentapproaches,knowledge
and recommendations
for new research directions.London School of Hygiene and
Tropical Medicine.
Mantn, K.G. (1982). Changing concepts of morbidityand mortality in the elderly
Healthand Society,60(2), 183-244.
population.MilbankMemorialFundQuarterly/
Mathers, CD., Sadana, R., Salomon, J.A., Murray, J.L. & Lopez, J.D. (2000a). Healthy
life expectancy in 191 countries, 1999. World Health Report 2000, World Health
Organization,Geneva.
Mathers, CD., Sadana, R., Salomon, J.A., Murray, J.L. & Lopez, A.D. (2000b).
Estimationof DALE for 191 countries:methods and results.Global Programmeon
EvidenceforHealth Policyworkingpaper No. 16,World Health Organization.
Melzer, D., McWilliams, B., Brayne, C, Johnson, T. & Bond, J. (2000). Socioeconomic
status and the expectationof disabilityin old age: estimatesfor England. Journalof
and Communitv
Epidemiology
Health. 54. 286-292.
MRC-CFAS (2001). Health and ill-healthin the older population in England and Wales: the
Medical Research Council cognitivefunctionand ageing study. Age and Ageing,30,
53-62.
Murray, C.J.L. & Chen. L.C (1992). Understandingmorbiditychange. Population and
DevelopmentReview,18, 481-503.
Murray, C.J.L. & Lopez, A.D. (Eds.) (1996). The global burden of disease. Harvard
UniversityPress.
Olshansky, S.J., Rudbery, M.A., Carnes, B.A., Cassel, C.K. & Brody, J.A. (1991).
Trading off longer life for worseninghealth: the expansion of morbidityhypothesis.
JournalofAgingand Health,3(2), 194-216.
Robin, J.-M., Colvez, A., BucQUET, D., Hatton, F., Morel, B. & Lelaidier, S. (1986).
L'esprancede vie sans incapaciteen France en 1982. Population.6. 1025-1042
Robin, J.-M. & Ritchie, K. (1993). Measuring changes in population health through
390
Measurement
inScotland
lifeexpectancycalculation:what have we learntand whereshould we go?

disability-free
Presentedto theIUSSP Conference,Montreal,August 1993.
Robin, J.-M., Romieu, I., Cambois, E., van de Water, H.P.A., Boshuizen, H.C. &
Jagger, C. (1995). Global assessmentin positivehealth.Contributionof theNetworkon
Health Expectancy and the Disability Process to the World Health Report 1995:
BridgingtheGaps, World Health Organization,REVES paper No. 196,INSERM.
Robin, J.-M. & Romieu, I. (1998). Health expectanciesin the European Union: progress
achieved.REVES paper No. 319, INSERM.
Robin, J.-M., Romieu, I., Jagger, C. & Egidi, V. (1998). Health expectancies in the
European Union, the European CommunityHousehold Panel: data analysis, REVES
oaoer No. 320. INSERM.
Robin, J.-M., Jagger, C. & Edidi, V. (Eds.) (2000). Selection of a coherentset of health
indicators.Euro-REVES, Montpellier,France.
life expectancy
Robin, J.-M., Jagger, C, Clavel, A. & Romieu, I. (2004). Disability-free
(DFLE) in E. U. countries
from 1991 to 2003. European Health ExpectancyMonitoring
Unit.
Rogers, A., Rogers, R.G. & Belanger, A. (1990). Longer life but worse health?
and dynamics.The Gerontologist,
measurement
30, 640-657.
life
Sauvaget, C, Jagger, C. & Arthur, A. (2001). Active and cognitiveimpairment-free
expectancies:resultsfromthe Melton Mowbray 75+ healthchecks. Age and Ageing,30,
509-515.
Shapiro, J. (2005). Problems of comparabilityin ECHP-derived health expectancy:causes,
cures,policyoptions.Presentedto theEPUNet-2005 Conference,Colchester.
Sullivan, D.F. (1971). A singleindex of mortalityand morbidity.HMSA Health Report,86,
347-354.
in liteexpectancytreeot disability
van Ginneken, J.K. & Bont, J.T. (1989). Sex differentials
in the Netherlandsin 1981-1985.Presentedto the InternationalPopulation Conference,
InternationalUnion forScientificStudyof Population,New Delhi.
van Ginneken, J.K.S., Dissveldt, A.G., van de Water, H.P.A. & van Sonsbeek, J.L.A.
(1991). Results of two methodsto determinehealth expectancyin the Netherlandsin
1981-1985.Social Scienceand Medicine,32, 1129-1136.
Measurement
inScotland
391
ABSTRACTOF THE DISCUSSION

fortheFacultyof
The President
(Mr H. W. Brown,F.F.A.): This is a ratherspecialmeeting
becauselast yearthe Facultydecidedthatwe wouldsponsorsomeresearchinto
Actuaries,
in Scotland.We commissioned
measurement
thisresearch,
and I am
healthylifeexpectancy
to welcomeProfessor
Mrs Jennifer
delighted
AngusMacdonaldof Heriot-Watt
University,
oneofthemainresearchers,
andProfessor
MattSuttonfromtheInformation
Services
Straughn,
I hopethatmuchof
DivisionoftheScottish
andalso oftheUniversity
ofAberdeen.
Executive,
theinformation
andresearch
whichhasbeencarriedoutwillbe helpful
to theScottish
Executive,
Parliament.
and,indeed,totheScottish
Professor
A. S. Macdonald,
F.F.A. (presented
theresearch
in depth.In orderto avoid
findings
of whatappearsin thepaper,onlyadditionalmaterialis includedin thisabstract.):
repetition
Manyof you who are presentmusthave spenta careerof 40 or moreyearsin thecityof
without
in thesamelocationas possiblyone of the
thatyouwereworking
Edinburgh
realising
besthealthdatabasesin theentireworld,theInformation
ServicesDivisionof theNational
HealthService(ISD), whichis locatedcurrently
at theGyle.Thisis partlybecauseofthelength
oftimeforwhichtheISD has beenoperating.
Its predecessor,
theHealthServicesResearchand
to theScottish
Unit,wassetup in 1965as partoftheCivilService.It wastransferred
Intelligence
HealthServicein 1974,and it has recently
movedto newoffices
at theNHS ScotlandHQ, at
fortheNHS in Scotlandforpolicymakers,
GyleSquare.It collectsandanalyseshealthstatistics
and has doneso fora verylongtime.As ISD's ownwebsitesays,butit is no exaggeration:
"Scotlandhas someof the besthealthservicedata in the world.Few othercountries
have
information
whichcombines
nationalcoverageand theabilityto
highqualitydata,consistency,
linkdata to allowpatient-based
analysisand followup. ... Scotlandhas becometheenvyofthe
world."So, weareverylucky,indeed,to be abletocollaborate
witha bodysuchas theISD, and
it has beenverystimulating
to workwithmembers
of theISD, Professor
Suttonin particular.
Howvaluableitwouldbe ifthisprojectforthe150thanniversary
oftheFacultyofActuaries
was
notthelast suchcontactwhichwe had withISD on matters
of sharedinterests,
butthefirst
suchcontact.
Professor
J. J. McCutcheon,
F.F.A.: I congratulate
Professor
Macdonaldforgivingus a very
lecture
and fortheclarity
withwhichhe presented
fascinating
quitecomplexdata.I shouldalso
liketo congratulate
Mrs Straughn
and Professor
Suttonfortheirmajorcontributions
to this
work.
I was interested
in theEuropeancomparisons
on healthy
lifeexpectancy,
as shownin Tables
8 and9. I thinkthattheBritish
datawerebasedon theGeneralHouseholdSurvey.
Presumably
thesurveys
intheotherEuropeancountries
formed
a rather
Were
disparate
groupofdocuments.
thesortof questionswhichwerebeingasked?
you able to reconcilereasonably
satisfactorily
Howdidyoureconcile
thedifferent
fromthevariouscountries?
questions
MrsJ. Straughn
We havefocusedon theestimates
(a visitor):
becausewe
provided
byEurostat,
founditquitedifficult
to reconcile
theanswersto thequestions
fromthedifferent
in all
surveys
theEuropeancountries.
The estimates
in Tables8 and 9 are basedon Eurostat,
exceptforthe
at thebottom
ofthetablesforGreatBritain,
comparison
figures
EnglandandScotland.
Professor
McCutcheon:
Is it possiblethatin theEuropeanUnion,through
someform
Eurostat,
ofstandardisation
be attempted?
might
Professor
Macdonald:It has alreadyhappened.
Thefigures
whichwe werereporting
werebased
on questionswhichare thesame,insofaras theycan be thesame,havingbeentranslated
into
different
languages.
392
Measurement
inScotland
I shouldliketo congratulate
Professor
McCutcheon:
theFacultyCouncilforhavinghad the
but
visionto commission
thisresearch.
It willbe ofinterest
to manymembers
oftheprofession,
and themedicalprofession.
sociologists
clearlyalso to thoseinmuchwiderfields- politicians,
Thisis a pieceofresearch
whichis goingto develop,andwe shouldbe pleasedthatwe havegot
theballrolling
here.
ofISD, butcurrently
I am a doctorin publichealthmedicine,
Dr R. Wood(a visitor):
formerly
lifeexpectancy
in thecalculation
oftheoriginal
ofLothianNHS Board.I was involved
healthy
in calculating
I knowthat,as academics,the authorsare interested
estimates.
healthylife
Sullivan'smodel.I was
modelratherthanusingthetraditional
usinga multi-state
expectancy
as to how,inthe
difference
inyouropinionas to whether
itwouldmakea qualitative
interested
on an
thehealthof thepopulation
in monitoring
theresults.I am interested
end,we interpret
or expansionof
compression
ongoingbasis, and in questionslike: "Are we experiencing
difference
itwouldmakea qualitative
inyouropinionas to whether
I wasinterested
morbidity?"
tothosetypesofhighlevelinterpretation.
is possibly
not
Professor
Macdonald:I thinkthattheareawhereit wouldmakemostdifference
at a givenpointin time,but in
or lifeexpectancy
of healthexpectancy
in themeasurement
of
The drawbackof themethodbased on thecurrent
intothefuture.
prevalence
projections
inthepast,andhowthose
havebeenchanging
abouthowthings
illnessis thatitrevealsnothing
of
if you wereto makeprojections
In particular,
intothefuture.
changeswillflowthrough
abouthow thebasic
eitherhealthstatusor mortality,
youwouldwantto makeassumptions
ofthemodelwouldchange,namelytheratesat whichpeoplefallsickand recoverfrom
drivers
sickness,and then see how the prevalenceswould developas a consequenceof those
assumptions.
suchas
to havingrepeated
Dr Wood:Do youthinkthatit is farsuperior
measures,
prevalence
basedon that
Arepredictions
youwouldhave,forexample,in theGeneralHouseholdSurvey?
modelpredictions?
notas goodas multi-state
Macdonald:The problemwiththe GeneralHouseholdSurveyis thatit does not
Professor
If itwereto do that,thenitwouldgivea wayto estimate
followthesamegroupofindividuals.
ofthatkind.Thishaspanel
TheMRC CFAS studyinEnglandis exactly
measures.
thetransition
at different
justsurveying
pointsoftime.However,
data,butthesamepeoplewereinterviewed
measures
to estimatetransition
different
groupsof livesfromtimeto timeis not sufficient
properly.
in the
M. Sutton(a visitor):Justto add to whathas beensaid,we are interested
Professor
does
randomcross-sections
Justcharting
individuals.
healthstatesofparticular
between
mobility
it is thesamegroupof
and aboutwhether
ofindividuals
aboutthemobility
nottellus anything
is a stateinto oroutofwhich
ill-health
orwhether
whichweareobserving
individuals
repeatedly
it is interesting
or forintervention,
it is formonitoring
Whether
peopleare movingfrequently.
seemsto changetheirstateofillforwhichnothing
itis a groupofindividuals
to knowwhether
If thelatteris thecase,
is a stateforwhichthereis a lotoffluidity.
ill-health
healthor whether
intervention.
for
more
to
be
there
onemight
potential
expect
whichcould
F.F.A.:Is thereanyaspectoftheworkwhichyouhavepresented
Mr R. R. Ainslie,
whohavea medical
forapplicants
in particular
lifeinsurance
be usedto improve
underwriting,
discussed?
oftheillnesses
history
on theuse ofhealth
Macdonald:Othershereare better
Professor
placedthanI am to comment
has a bearingon
It certainly
suchas insurance
interests
servicedata bycommercial
companies.
ofan
thepresence
If youcan clearlyidentify
are interested.
aboutwhichinsurers
thequestions
hospitalor medicalrecordsin therecentpast,or eventhefarpast,then,as
through
impairment
Measurement
inScotland
393
whichhas predictive
value forfutureillnessor
we showed,you have quiterichinformation
mortality.
Professor
Sutton:Thesemeasureswhichare givingus thequantification
of healthexpectancy
seemto be crude,verysimplewaysto capturedifferences
in healthstatesbetween
individuals.
Whatcomesoutas verystriking
is howgoodtheyareat predicting
outcomes.
individual
The surveyitselfis incredibly
rich,withmoremedicaland moreclinicalinformation
evenmeasuresof blood pressureand the contentsof blood. Yet, it is actuallythissimple
of outcomessuchas futurehospitaladmissionsor
questionwhichis the strongest
predictor
That is probablya partialanswerto yourquestion,but whatappearsto be an
mortality.
extremely
simplequestion(and it obviouslydoes not takelongto answerit) is an incredibly
of futureoutcomes- muchbetter,indeed,thanmoredetailedclinical
powerful
predictor
assessments.
Dr D. J. P. Hare,F.F.A.:In termsof makingfinancial
senseof thefuture,
to whatextentwill
thisworkhelpto improve
theprojections
ofhealthservice
demandgoingforward?
I do notknow
howsophisticated
thecurrent
are in termsof numbers
of hospitalbeds,consultant
projections
andsimilar
buthavewehelpedto improve
themforthefuture?
matters,
availability
in thedata whichwe havealready,buttheyare notcomplete.
What
Also,we are fortunate
otherdatashouldbecollected
inthefuture,
andhoweasyis ittoarrange
forthattohappen?
ProfessorSutton:Projectingfuturedemand is certainlya priorityfor the NHS. My
ofthestudieswhichhavebeencarriedoutto dateis thatthereis muchfocuson
understanding
whether
suchas is givenin thepaper,arewhat
population
ageingand theassociatedmodelling,
areimportant.
mostofthestudiesseemto showthatitis thedesiretodo morewhichis
However,
thefactorwhichmatters
themost.So, in a sense,ifyouwantto planfuture
services,
youneed
to understand
whattheNHS wantsto do forindividuals,
anditis technological
changewhichis
themaindriveroffuture
demandsforhospitalisation.
Thatis notto saythattheageingofthe
or thehealthstatusof thepopulation
at particular
butthe
population
ages are notimportant,
of whatis happening
to thehealthserviceis just doingmoreformore
reallybig explanation
individuals.
It is technological
thanpopulation
changerather
changewhichseemsto be themore
important.
Mr G. M. Murray,
McCutcheon's
firstquestion.Like
C.B.E., F.F.A.: I linkbackto Professor
withthe unexpected
differences
betweenItaly and
manypeople here,I remainintrigued
ourperceptions
oftheunhealthy
Latinsandthehealthy
Scandinavia,
Scandinavians!
overturning
Do thehealthcostsin thesetwocountries,
or anyotherdata whichare availablefromthem,
backup thefigures
whichyou have,or weretherealreadysurprises
in thesecountries
which
couldnotbe explained?
Professor
Macdonald:I agreethatthedifferences
are surprising.
It is wellknownthatthereare
cultural
differences
inhowpeoplereport
themselves
tobe ingoodorbad health.Thenthereis the
is used, it is translated
into different
simplefactthat,even thoughthe same instrument
andmaybe administered
inslightly
different
languages
ways.
Mr Murray:Do youfeelthatthereshouldbe a correlation
between
certainnationalstatistics
whichwouldbackup yourfigures
castdoubton them?
or,alternatively,
Professor
Macdonald:That is an interesting
statistics
told thesame
question.If expenditure
thenthatwouldseemtobe a robustconclusion.
storyas thesestatistics,
ThePresident
(Mr H. W. Brown,
F.F.A.):I wouldliketo thanktheauthorsforproducing
such
an excellent
Macdonaldforhispresentation.
No doubt,oncewe havehad
paper,and Professor
timetodigestthepaper,wemaywellcomebackwithsomefurther
questions.
394
Measurement
inScotland
It wouldbe a shameifeverything
stoppedhere,and I hopethatwe can takeon movingthis
butfora numberof
so thatit is forthebenefit,
notjust of theactuarialprofession,
forward,
otherusersinScotland.

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Institute and Faculty of Actuaries

HEALTHY LIFE EXPECTANCY MEASUREMENT IN SCOTLAND

B.AJ. 12,II, 327-394(2006)

' /xio(i) '

In fact,in someschemesstatesof healthmaybe assigneda weightwk< 0,

In thissectionwe will describethe HE estimateswhichhave recently

73.3 78.7 58.9 62.6

ofHE at age 65 forScotland,basedon independence

f-^. f"-*. f"^.

f*** f*** f*** **.QQ

r^ r^ ^* r^*c^ r^-*t^ ^^ r****

^-v tu, oooNosaooNoN^âddooooôNo^KK-ûooooK

Published Estimates II: Official Estimates in England and

Great Britain comprisesthe countriesof England, Wales and Scotland.

59.2160.79 67.33 69.00

60.84 62.86 67.31 69.04

8.40 9.50 11.86 13.25

Source:ONS and GAD.

8.26 9.31 11.69 13.12

fromRobinet al. (1998) in

1995 1996 1997 1998 1999 2000 2001 2002 2003

Scotland,fortheyearswhentheyare available,and the Scottishestimate

Figure3. Ratio of HE /LE estimatesforfemalesin Scotland,Englandand

The estimates(see Table 10)

happens thatthreeout of the fiveyears studiedwere those in whichScottish

and Agingconsistsof peoplelivingin the

(b) "What (else) is the matterwithyou?", the answerto whichcould

SAH 'good' = 1,2, 3

available, the ScottishLongitudinalSurvey(SLS) will sample 5% of census

Women, Good Health

Time to Last HospitalEpisode

Time to Last HospitalEpisode

Men, Poor Health,No LLI

Women, Poor Health, No LU

Men, Poor Health,WithLLI

Women, Poor Health,WithLU

Time to Last HospitalEpisode

Time to Last HospitalEpisode

Time to Last HospitalEpisode

Time to Last HospitalEpisode

linkingtogetherreasonablycontiguousperiodsof bad healthis appealing at first,

Kaplan-Meier estimateis similar to the empiricalsurvival function(1 - FT(t)), where

Males, Age at Survey45-54

SAH Score 1.2

Days Since Survey

Days Since Survey

Males, Age at Survey65-74

SAH Score 1.2

Days Since Survey

Females, Age at Survey55-64

SAH Score 1,2

Days Since Survey

Males, Age at Survey55-64

Days Since Survey

SAH Score 1,2

Females, Age at Survey45-54

Females, Age at Survey65-74

Days Since Survey

SAH Score 1.2

SAH Score 1.2

SAH Score '2

SAH Score 1.2

Females, Age at Survey 65-74

Males, Age at Survey 65-74

f* f* f* .QQ

r^ r^ ^* r^c^ r^-t^ ^^ r****