Public Health Outcomes Framework (PHOF 2024)

NI = National Indicator

Data source	Indicator	Published	Publication Quarter
PHM	Life expectancy at birth	✔	Q3
	Healthy life expectancy at birth	✔	Q3
	The gap in life expectancy at birth between the most and least deprived	✔	Q3
	The gap in healthy life expectancy at birth between the most and least deprived NI	✔	Q3
	Premature death from key non communicable diseases	✔	Q1
	Deaths from injuries	✔	Q1
	Deaths from road traffic injuries	✔	Q1
	Suicides	✔	Q1
PEDW	Hip fractures among older people	✔	Q1
NSW	Mental well-being among adults NI	✔	Q4
	The gap in mental well-being between the most and least deprived among adults	Data not available	N/A
	People able to afford everyday goods and activities NI	✔	Q4
	A sense of community NI	✔	Q4
	People who volunteer NI	✔	Q4
	People feeling lonely NI	✔	Q4
	Adults eating five fruit or vegetable portions a day	✔	Q4
	Adults meeting physical activity guidelines	✔	Q4
	Adults who smoke	✔	Q4
	Adults drinking above guidelines	✔	Q4
	Working age adults in good health	✔	Q4
	Working age adults free from limiting long term illness	✔	Q4
	Life satisfaction among working age adults	✔	Q4
	Working age adults of healthy weight	✔	Q4
	Older people in good health	✔	Q4
	Older people free from limiting long term illness	✔	Q4
	Life satisfaction among older people	✔	Q4
	Older people of healthy weight	✔	Q4
SHRN/HBSC	Adolescents of healthy weight	✔	Q3
	Physical activity in adolescents	✔	Q3
	Adolescents who smoke	✔	Q3
	Adolescents using alcohol	✔	Q3
	Adolescents drinking sugary drinks once a day or more	✔	Q3
ONS	Teenage pregnancies	✔	Q2
LFS/APS	People in education, employment or training NI	✔	Q4
	Gap in employment rate for those with long term health condition	✔	Q3
VPDP	Vaccination rates at age 4	✔	Q3
HBMD	Smoking in pregnancy	✔	Q4
NCCHD	Low birth weight NI	✔	Q3
	Breastfeeding at 10 days	✔	Q3
Data not identified	Mental well-being among children and young people NI	Data not available	N/A
	Gap in mental well-being among children and young people	Data not available	N/A
SW	Children living in poverty	✔	Q2
FPF	Young children developing the right skills NI	Data not available	N/A
WED	School leavers with skills and qualifications NI	Data not available	N/A
Data not identified	School leavers with essential literacy and numeracy skills	Data not available	N/A
HLCC	Quality of housing NI	✔	Q1
DEFRA	Quality of the air we breathe NI	✔	Q1
CMP	Children age 5 of healthy weight	Data not published yet	N/A
WDS	Tooth decay among 5 year olds	Data not available	N/A

 

 

Domains
Overarching outcomes
Living conditions that support and contribute to health now and in the future
Ways of living that improve health
Health throughout the life course

 

 

All the data presented in this reporting tool are for Wales residents, and the geographies within the 7 Welsh Local Health Boards and 22 Local Authority areas.  

NHS Wales health boards:	Local authorities (LA’s) in Wales:
Aneurin Bevan University Health Board (UHB)	Blaenau Gwent Caerphilly Monmouthshire Newport Torfaen
Betsi Cadwaladr UHB	Conwy Denbighshire Flintshire Gwynedd Isle of Anglesey Wrexham
Cardiff and Vale UHB	Cardiff Vale of Glamorgan
Cwm Taf Morgannwg UHB	Bridgend Merthyr Tydfil Rhondda Cynon Taf
Hywel Dda UHB	Carmarthenshire Ceredigion Pembrokeshire
Powys Teaching Health Board (THB)	Powys
Swansea Bay UHB	Neath Port Talbot Swansea

 

Some indicators are split into 2011 urban and rural classification.  Settlements that fall outside of more than 10,000 resident population are categorised as rural.

Further developments to the tool in the latter end of 2023 aims to split indicators further into sub-local authority geographies include upper, middle and lower super output areas.

 

 

National Survey for Wales:

The NSfW involves around 12,000 people each year and covers a broad range of topics. The main purpose is to provide information on the views and behaviours of adults in Wales.

Data presented in the tool is by financial year, although presented in the trend tab, direct comparisons over time are not possible due to the significant change in methodology each year. Additionally, not all questions were asked during each survey period. 

Useful links

• Introduction and survey methodology
• Terms and definitions
• Technical information
• Results viewer by year

 

Patient Episode Database for Wales:

The Patient Episode Database for Wales (PEDW) comprises records of all episodes of inpatient and day case activity in NHS Wales hospitals. Hospital activity for Welsh residents treated in other UK nations (primarily England) is also included.  The data is collected and coded at each hospital. The records are then electronically transferred to Digital Health Care in Wales, who validate and merge into the main database.

From 2019/20 onward, there was a reduction in total emergency admissions due to the Covid-19 pandemic.  This should be given due consideration when analysing trends in hip fracture admissions among older people.

Please note that there is an issue with diagnostic coding in several health boards. Table 1 illustrates how the missing codes are distributed by financial year and health board, as at August 2022. Counts of specific diagnoses will be underestimated, but to an unknown extent, therefore caution should be exercised when interpreting trends for these health boards. Additionally, where the percentage of missing diagnoses is over 20%, the value has been suppressed.

Table 1 Missing diagnostic codes, emergency admissions (excluding transfers) by area and financial year

Area	Financial year	Missing records
Aneurin Bevan UHB	2017/18 2018/19 2019/20 2022/23	14% 11% 11% 12%
Cardiff and Vale UHB	2011/12 2022/23	19% 20%
Cwm Taf Morgannwg UHB	2019/20	11%
Hywel Dda UHB	2017/18 2019/20 2020/21	10% 15% 12%
Swansea Bay UHB	2022/23	16%
Blaenau Gwent	2017/18 2018/19 2019/20 2022/23	10% 13% 12% 14%
Caerphilly	2017/18	10%
Cardiff	2011/12 2012/13 2021/22 2022/23	23% 11% 10% 23%
Carmarthenshire	2017/18 2018/19 2019/20 2020/21	16% 10% 21% 14%
Ceredigion	2019/20 2020/21	14% 22%
Merthyr Tydfil	2019/20	14%
Monmouthshire	2017/18 2018/19 2019/20 2022/23	16% 14% 13% 15%
Neath Port Talbot	2022/23	17%
Newport	2017/18 2018/19 2019/20 2022/23	20% 12% 12% 12%
Rhondda Cynon Taf	2019/20	14%
Swansea	2022/23	16%
Torfaen	2017/18 2018/19 2019/20 2022/23	16% 15% 13% 15%
Vale of Glamorgan	2011/12 2022/23	11% 16%

 

Useful links

ICD-10 codes

NHS Wales Data Dictionary

PEDW Publications Table

 

Life expectancy (LE)/ Healthy life expectancy (HLE) at birth:

The PHM is used to calculate Life expectancy (LE) at birth, it is an estimate of the average number of years that newborn babies could expect to live, assuming that current mortality rates for the area in which they were born applied throughout their lives.  It is calculated using the abridged life table method which is the preferred method of the Office for National Statistics (ONS).  As all LE calculations are based on current mortality rates, average life expectancy will change over the course of a lifetime irrespective of other factors.  These should therefore be considered as comparative population measures of mortality during a period of time rather than as predictions of actual individual life expectancy.

Healthy life expectancy (HLE) is an estimate of the average number of years that newborn babies could expect to live in good health, assuming that current mortality rates and levels of good health for the area in which they were born applied throughout their lives.  Healthy Life Expectancy is calculated using the Sullivan method which is the preferred method of the ONS for calculating healthy life expectancy at birth.  Its calculation involves combining health status data from the Annual Population Survey (APS) and Census with the mortality and population data used for LE.    ‘Healthy’ was judged to be a response of very good or good to the APS question asking those aged between 16 and 85 “How is your health in general; would you say it was … Very Good, Good, Fair, Bad, Very Bad”.

 

Adjustments are applied to prepare the APS data for the Sullivan method which use the Census health data, these include:

• • Imputation of health prevalence for age groups not available in the APS (children under 16 years and adults over the age of 85). 
  • Using regression analysis to smooth fluctuations in the subnational health prevalence.

Imputation is also needed where for a particular breakdown:

• • there was no valid response to the good health question in a breakdown.
  • the prevalence of good health was 0, regardless of how many respondents there were who weren’t in good health.

Life Expectancy releases and their different uses.

 

Annual Population Survey (APS), ONS

The APS is used to estimate the following proportions;

• Labour market status of those in full-time education;
• Labour market status of those in part-time education;
• Full-time and part-time employment of those in Work Based Learning, who are employed;
• Employer sponsored 'off-the-job' training for those in employment.

Welsh Government Lifelong Learning Wales Record (LLWR)

The LLWR is used to estimate the following proportion:

• Labour market status of those engaged in Work Based Learning.

These proportions are then applied to the numbers known to be in education, work-based learning and the total population to derive estimates of participation by education and employment.  For Work Based Learners, the labour market status at the start of the learning programme collected via the LLWR is used with the addition of some APS data to estimate the proportions in full-time and part-time employment.

As the data comes from a survey, the results are sample-based estimates and are therefore subject to differing degrees of sampling variability, i.e. the true value for any measure lies in a differing range about the estimated value.

Data is published annually, 2020 data is provisional at this point.  The dataset can be accessed via stats wales.

 

Conception statistics (ONS)

Conception statistics are estimates of all pregnancies of women usually resident in England and Wales.  Figures are derived from maternity, birth and abortion notifications. As there are legal requirement to record this data, it is one of the most reliable data sources available. This dataset combined with the ONS mid-year population estimates is used to estimate conception rates per 1,000 females (15-17 year olds) in Wales.

Quality and methodology information

User guide to conception statistics

Dataset

 

Public Health Mortality

Public Health Mortality (PHM) is a dataset containing each individual death of a resident that is registered in the particular year. Individual records for death registrations are sent on a weekly basis from the Registrars’ offices across England and Wales to the Office for National Statistics (ONS). The ONS collates and validates the data. The data are based on the underlying cause of death e.g. if an individual dies from pneumonia but had been made vulnerable to that disease by end-stage cancer, then cancer (rather than pneumonia) is recorded as the underlying cause of death.

There have been revisions to the manner in which the death certificates are translated by the ONS into International Classification of Diseases codes (10th revision). These changes mean that unrevised data are not comparable across years. The main change relates to the rules that govern which cause of death detailed on the death certificate is selected as the underlying cause. Comparability ratios have not been used in these analyses and therefore caution should be exercised when interpreting trends.

Cause of death is based on the medical certificate of cause of death. This is completed by the certifying doctor for about three quarters of deaths and by a coroner for the remainder. Most of the deaths certified by a coroner do not involve an inquest or any suspicion of violence, but are referred to the coroner because they were sudden and unexpected, or because there was no doctor in attendance during the deceased’s last illness. There will be a long delay in registering a small number of deaths for which a coroner’s ruling is required e.g. suicide, homicide, undetermined intent.

Please note that suicides have been counted by date of registration. There is a known delay between date of occurrence and the date of registration; further delays are likely as a result of the coronavirus pandemic. Please be aware that data is likely to be incomplete, particularly for the most recent periods.  See ONS for more information:

Impact of registration delays on mortality statistics in England and Wales - Office for National Statistics (ons.gov.uk)

 

Hazards and licences data collection, Welsh Government (WG)

Assessments under the Housing Health and Safety Rating Systems (HHSRS) may be carried out for a number of reasons. For example, an HHSRS assessment is carried out when licensing a house in multiple occupation or when a complaint about a property is received from the occupier or a neighbour. Whilst it can cover all residential premises, it is more commonly used to assess standards in private rented housing.  Dwellings can be assessed more than once during each reporting period. 

 

The quality of housing indicator is defined as the percentage of assessments which are free from category 1 hazards according to the Housing Health and Safety rating system hazards.  Category 1 hazards are those that provide the greatest risk to occupants. As this is sourced from the annual housing hazards and licences data collection it does not cover all dwellings but just those that are assessed by local authorities.

 

Note that, due to the Coronavirus (COVID-19) pandemic in 2020, data on housing hazards and licences in Wales for 2019-20 were not collected.

 

Data

Quality report

Data collection

 

Department for Environment Food and Rural Affairs (DEFRA) & UK Air Information Resource (AIR)

Air Quality Exposure Indicators - average NO2, PM2.5 and PM10 concentrations across local authority areas and health board areas, derived from modelled data for each square kilometre in Wales, measured in µg/m3 (DEFRA data).

Each year the UK Government’s Pollution Climate Mapping (PCM) model calculates average pollutant concentrations for each square kilometre of the UK. Each year the Pollution Climate Model (PCM) which underpin the background maps is refined and improved (to account for latest available science and understanding e.g. changes in emissions factors, improved activity data etc.). These method changes are usually only applied in the latest year's figures.  

The model is calibrated against measurements taken from the UK’s national air quality monitoring network.  The Welsh Government has used this published data to assign a concentration of NO2, PM2.5 and PM10 to each residential dwelling in Wales based on which square kilometre of Wales it sits in. 

For each census output area (statistical geographic units comprising around 150 properties), the pollutant concentrations associated with each dwelling within it were averaged to give an average NO2, PM2.5 and PM10 concentration across the census output area.

The quality of air we breathe indicator in this tool is defined as the annual average nitrogen dioxide (NO₂) concentration levels at residential dwelling locations (µg/m³).

 

Air Quality in Wales

Data

 

National Community Child Health Database (NCCHD)

The National Community Child Health Database (NCCHD) includes details relating to maternal and child health related indicators such as births, immunisation screening, safeguarding children and breastfeeding.    

Each of the seven health boards in Wales has a Child Health System database which they manage locally. Anonymised records for all children born, resident or treated in Wales and born after 1987 are collated from each of the local databases each quarter to create the NCCHD.

The statistics relate to live births born to Welsh residents during the relevant calendar year. The analyses are for live births only and do not include stillbirths. However, births occurring in Wales (whether to Welsh or non-Welsh residents) can also be counted by the NCCHD.

The ‘low birth weight’ and ‘breastfeeding at 10 days’ indicators are created using this dataset.

Breastfeeding data has been suppressed if it is less than 80% complete.  The data is not robust enough to provide trend charts.

To note breastfeeding also includes chestfeeding.

 

School Health Research Network (SHRN)

The School Health Research Network (SHRN) is a partnership between Welsh Government, Public Health Wales, and Cardiff University established in 2013. They aim to improve young people’s health and wellbeing in Wales by working with schools in both primary and secondary education to generate and use good quality evidence for health improvement. This includes surveys, capturing key health and wellbeing metrics. These metrics are referenced in many national policies and strategies, including the Whole School Approach to Mental Health and Wellbeing (2021) and Estyn’s Healthy and Happy Report (2019).

Since 2017, all mainstream secondary schools in Wales have become registered SHRN members with over 90% of schools completing SHRN’s Student Health and Wellbeing Survey in 2021/22.

 

Calculation of healthy weight indicator:

Characteristic	“Under/Normal” BMI range
11 year old, male	<=20.89
11 year old, female	<=21.20
12 year old, male	<=21.56
12 year old, female	<=22.14
13 year old, male	<=22.27
13 year old, female	<=22.98
14 year old, male	<=22.96
14 year old, female	<=23.66
15 year old, male	<=23.60
15 year old, female	<=24.17
16 year old, male	<=24.19
16 year old, female	<=24.54

 

 

 

Maternity Indicator Data set (MIds)

Statistics on smoking at birth are limited by the way in which the data is collected.  If carbon monoxide (CO) monitoring is not available, data reliability is dependent on the mother self-reporting accurate information. CO monitoring has largely been suspended since the COVID-19 pandemic began, so data for 2020 and 2021 is mainly self-reported.

E-Cigarette use should not be recorded in this data item and would not be detected by a CO monitor; however, in practice some mothers may self-report as a smoker if they use e-cigarettes and be incorrectly recorded as a smoker.  Likewise, some mothers who do smoke may self-report as a non-smoker and be incorrectly recorded as a non-smoker. 

In 2021, 82% of records had valid data recorded at the Wales level.   This was largely due to Hywel Dda health board not supplying any smoking at birth data, while there was only 68% complete data for Cwm Taf Morgannwg.  There were also low levels of completeness in 2020 for Hywel Dda (30%), Cwm Taf Morgannwg (70%) and Powys (76%).  However, in all years prior to 2020, more than 90% of records had valid data for smoking status at birth, across nearly all health boards.

Full details of every data item available on both the Maternity Indicators dataset and National Community Child Health Database are available through the NWIS Data Dictionary.

More detailed information on the sources of data and analyses in this statistical release are provided in the quality report.

Stats Wales data.

 

Households Below Average Income (HBAI)

Households below average income (HBAI) statistics are based on the Family Resource Survey (FRS), which captures detailed information on income, employment, education level and disability from over 16,000 households in the United Kingdom, with around 900 households in Wales each year. HBAI statistics are used to provide estimates of the percentage of children living in low-income households, measuring both relative and absolute income. The children in poverty indicator presented in PHOF uses relative low income, which measures the number and proportion of children (aged 0-15) in households below 60 per cent of the UK average income, after housing costs are paid. Percentages are calculated using ONS mid-year population estimates.

Both financial year-end (FYE) 2021 and FYE 2022 FRS data were impacted by the Covid-19 pandemic, which resulted in a change in methodology from face-to-face interviews to telephone interviews. These changes resulted in FYE 2021 data sample with fewer renters, households with children and respondents educated below degree level, when compared to FYE 2020. Data quality checks for FYE 2022 suggest that levels of bias in the data are lower than FYE 2021, having less influence on the statistics. It should be noted that FYE 2021 is excluded from the analysis, with 3-year rolling averages including FYE 2021 using two data points only.

Further information on the impact of the Covid-19 pandemic on HBAI statistics can be found in the FYE 2022 technical report.

 

COVER - National childhood immunisation uptake data

Analysis is carried out by the preventable disease programme and communicable disease surveillance centre. The number of children who received the scheduled vaccinations detailed above is divided by the number of children aged 4 multiplied by 100. This measure is calculated using appropriate booster immunisation or final course doses. Figures are calculated for children living and resident in Wales as at the end of March in each year.

Latest quarterly data report.

Immunisation and vaccines resource page.

 

Other key data sources:

Welsh Index of Multiple Deprivation 2019 (WIMD) (used to calculate fifths of deprivations).  It is the Welsh Government’s official measure of relative deprivation for small areas in Wales.  It is made up of eight separate domains/types of deprivation.

ONS Mid-year estimates (MYE) are the official source of population sizes, produced annually, covering populations of local authorities, counties, regions and countries of the UK by age and sex.  This data source is used as the denominator when calculating crude and age-standardised rates.

Please find guidance on how to interpret the following terms used in the tool:

• Confidence intervals

Confidence intervals are indications of the natural variation that would be expected around a rate and they should be considered when assessing or interpreting a rate. The size of the confidence interval is dependent on the number of events occurring and the size of the population from which the events came. Generally speaking, rates based on small numbers of events and small populations are likely to have wider confidence intervals. Conversely, rates based on large populations are likely to have narrower confidence intervals. In the PHOF reporting tool we use 95 per cent confidence intervals. This represents a range of values that we can be 95 per cent confident contains the ‘true’ underlying rate. Comparisons are often made between two or more estimates, for example between different areas or time periods (Figure 1). Sometimes in such cases statistical testing is undertaken by comparing the confidence intervals of the estimates to see if they overlap. Non-overlapping confidence intervals are considered as statistically significantly different (Figures 1a & 1b). Whilst it is safe to assume that non-overlapping confidence intervals indicate a statistically significant difference, it is not always the case that overlapping confidence intervals do not (Figure 1c). A more exact approach is to calculate the ratio of the two estimates, or the difference between them, and construct a test or confidence interval based on that statistic. Such methods are not covered in this technical guide, but can be found in a standard textbook.

Figure 1. Using confidence intervals for making comparisons a) & b) Non- overlapping confidence intervals are considered as statistically significant c) Overlapping confidence intervals do not always indicate a difference that is not statistically significant

 

• Local and national deprivation fifths

  The Welsh Index of Multiple Deprivation (WIMD) is an official measure of relative deprivation for small areas in Wales and a National Statistic. It identifies areas with the highest concentrations of deprivation. Ranking these areas, and dividing them into five equally sized groups produces fifths of deprivation.

  For all national level analysis and most of the analysis at health board and local authority, fifths are calculated at the Wales level (national fifths). There are some indicators where local fifths are used, specifically the life expectancy and healthy life expectancy. Local fifths differ from the national fifths in that the five equal bands of deprivation are recalculated just for the small areas within each health board and local authority boundary, rather than inheriting the national fifths. This is useful for a more localised approach to producing health expectancies.

• Revised European Standard Population 2013 is a hypothetical population structure used in the weighting of mortality or incidence data to produce age-standardised rates (ASR’s).

• National Indicators (NI) represent the outcomes for Wales, demonstrating progress towards seven well-being goals. There are 50 NI's in total, ten are reported in the Public Health Outcomes Framework.

 

The Evidence Service produces systematic reviews, evidence maps and rapid summaries, on various health topics, which may support findings in this tool.

What’s available in other UK nations?

Across the UK nations there are similar tools to the Welsh Public Health Outcomes Framework, none of which are wholly comparable.

In England, the Public Health Outcomes Framework (PHOF) is made up of four domains and is produced by the Office for Health Improvement & Disparities. The domains making up the English PHOF include wider determinants, health improvement, health protection and healthcare and premature mortality. Almost 200 indicators populate the domains, most, but not all differ from those presented in the Welsh version.

Northern Ireland don’t produce a Public Health Outcomes Framework. However, they have developed a Public Health strategy called ‘Making Life Better a whole system strategic framework for Public Health’. The strategy is broken into six themes, including ‘giving every child the best start, equipped throughout life, empowering healthy living, creating the conditions, empowering communities and developing collaboration.

Scotland don’t produce a Public Health Outcomes Framework, however Public Health Scotland and its predecessor bodies have adopted outcome planning approaches across national policy and as such have produced National Performance Framework and National health wellbeing and outcomes framework, both include public health outcome indicators.

 

Stakeholder engagement

Public Health Wales works closely with stakeholders from local public health teams and Welsh Government to produce this reporting tool. Developed in an agile way, we meet our stakeholders regularly to agree how the reporting tool looks, is navigated and indicators are broken down.

We’re always trying to improve the reporting tool, and so any feedback can be emailed to Observatory.AnalyticalTeam@wales.nhs.uk.

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APS (Annual Population Survey - managed by ONS)                    

CDSC (Public Health Wales Communicable Disease Surveillance Centre)         

CMP (Child Measurement Programme - managed by Digital Health Care Wales)

DEFRA (Department for Environment, Food and Rural Affairs - managed by WG)

DHCW (Digital Health and Care Wales)                    

FPF (Foundation Phase Framework - managed by Welsh Government)  

HBMD (Health Board Maternity Dataset - managed by DCHW)                        

HBSC (Health Behaviour in School-aged Children study)                       

HLCC (Hazards and licences data collection - managed by Welsh Government)

LFS (Labour Force Survey - managed by ONS)                            

NCCHD (National Community Child Health Database, managed by DHCW)         

NSW (National Survey Wales - managed by Welsh Government)                     

ONS (Office for National Statistics)                     

PEDW (Patient Episode Database Wales - managed by DHCW)                       

PHM (Public Health Mortality - managed by ONS)                        

SHRN (School Health Research Network)                          

SW (StatsWales - managed by Welsh Government)                    

VPDP (Vaccine Preventable Disease Programme - managed by CDSC)

WDS (Welsh Dental Survey - managed by Welsh Oral Health Information Unit)

WED (Welsh Examinations Database - managed by Welsh Government)