North Wales Neurosciences Review Implementation
Neuro-Rehabilitation Workstream
1. Purpose
The purpose of this report is to outline the preliminary work that has been
conducted to date to develop the neuro-rehabilitation workstream of the North
Wales neurosciences review. This has included a series of meetings with
stakeholders to build understanding of the current neuro-rehabilitation care
pathway, help define the key issues and explore perspectives on these
issues. This has been used to inform the development of a project initiation
document (PID). The PID describes how the schedule for this workstream will
ensure the timescales for the overall neurosciences project are met. The
phase 1 report on the current service will be delivered by March 31st 2009.
The phase 2 report will be delivered by 30th April 2009 in line with the overall
neurosciences review implementation schedule.
2. Gathering Intelligence
In order to develop a robust project plan, a series of meetings have been held
with stakeholders by the project lead and project manager, to gather
information on the existing pattern of services, to identify key issues that need
to be addressed in order to improve neuro rehabilitation services to implement
the Steers review recommendations, and to develop the project plan.
A series of meetings have been held with the following individuals and
centres:
Dr Carolyn Young, Walton Centre for Neurology and Neurosurgery
Dr Colin Pinder, Clatterbridge Hospital Neuro-Rehabilitation Unit
Dr Rudi Coetzer, North Wales Brain Injury Team
Dr Matt Makin, Palliative Care Consultant
Mr Kevin Thomas, MND Association
Dr Bob Rafal, University of Bangor
A meeting with the ‘Steers’ review team took place on 13th February and the
opportunity was taken to understand the team’s thinking about the perceived
needs for N Wales and models of future service provision that could be
considered from England.
A further meeting with Dr Anne Chamberlain (Steers Review Member) and
clinical colleagues in Leeds has been organised for 6th March 2009.
A number of individuals (appendix1) have been indentified with particular
interest and expertise in this area of work and it is intended to hold 2
stakeholder meetings in March and April to sign off the Project plan, further
develop current knowledge of services, needs and identify the gaps, and
develop options for the development of services to meet the identified need. A
final meeting is planned for July to agree the final report for submission to the
Project group
1
3. Neurorehabilitation
3.1 Prevalence
A study by Drs Elliston and Rodgers in 1996 identified 242 people at that time
in N Wales who had suffered significant brain injury. (Representing only 25%
of the expected number predicted from national rates)
A study in 1997 by the All Wales Steering Group (Severe head injuries
rehabilitation) estimated that there were some 1,000 survivors of brain
trauma with long term disabilities living in the North Wales community.
Bob Rafal (2002) estimated that from all three DGHs some 35-45 patients per
annum could access an N Wales Rehabilitation Unit with lengths of stay in the
range of 6 weeks to 3 months.
3.2 In Patient Care
The Walton Centre provides a limited rehabilitation service for patients
admitted and treated through to their service and provides a service for all
types of acquired brain who can benefit from its service including trauma,
tumour, infection, younger stroke patients and neurological conditions.
The service is commissioned by HCW.
Table 1 Contract value and activity
Contract Value
2008/9
£18,946
Contract
Baseline
Activity
38 bed days
2007/8
2006/7
-
91 bed days
91 bed days
Actual Activity
6 bed days to
month 9
22 bed days
-
The Clatterbridge Hospital provides a service for referrals from North Wales
Trusts and the Countess of Chester. The service is commissioned by
Flintshire LHB on behalf on N Wales.
Table 2 Contact Value and Activity
Contract Value
2007/8
Contract
Baseline
Activity
13 patients / 938
bed days
£390,884
Actual Activity
7 patients, 227
bed days
For all Welsh patients discharged from the Clatterbridge service since 2001/2
(65 patients), average length of stay was 63 days (ranging from 7 days to 427
days). Further information is provided in appendix 2.
2
Criteria for admission for rehabilitation from Clatterbridge:



be medically/surgically stable
the WNRU consultant considers that, at the time of assessment a
formal structured rehabilitation programme at WNRU has the potential
to improve the patient's functioning.
have specific goals for rehabilitation
neurological conditions can include:





brain injury from any cause e.g. trauma, infection, after neurosurgical
intervention and other cerebrovascular event
patients with multiple sclerosis and other demyelinating conditions
patients with acute demyelinating polyneuropathy
patients with intracranial tumours who are currently neurologically
stable
patient with spinal cord injury from medical cause
In the three North Wales DGHs the following arrangements are in place for
ABI patients;

Wrexham Maelor Hospital-No dedicated rehabilitation beds for ABI.
Patients admitted to 20 bed stroke rehabilitation ward for intermediate
rehabilitation.

Glan Clwyd Hospital-No dedicated ABI rehabilitation beds for ABI.
Patients managed by orthopaedic service.

Ysbyty Gwynedd-No dedicated ABI rehabilitation beds. Patients
managed on Tegid ward by stroke rehabilitation team. A number of
community hospitals have consultant beds and these are also used for
continuing rehabilitation of ABI patients.
Identifying patients admitted to the three DGHs is problematic and a
search was undertaken of patients with the following diagnostic codes.
Table 3 Diagnostic Codes for ABI
Diagnosis
Traumatic brain injury
Intracerebral Haemorrhage
Anoxic Brain Damage
Meningitis
ICD10 Code
SO6.0 to SO6.9
I61.0 to I61.9: I62.0 to I62.9
G93.1
G00.0 to G00.9; G01; G02.8; G03.0
to G03.9
G04.0 to G04.9; G05.0 to G05.8
I67.1
I60.0 to I60.9
Encephalitis
Cerebral Aneurysm
Subarachnoid Haemorrhage
The table in Appendix 3 shows patients admitted in 2007/8 to Wrexham
Maelor, Ysbyty Glan Clwyd and Ysbyty Gwynedd with the above diagnoses
and with a length of stay greater than 30 days.
3
The data indicates that there were 64 patients in total with a combined length
of stay of 4299 bed days. On the assumption that all these patients would be
appropriate for admission to an in-patient neuro-rehabilitation unit, this unit
would require approximately 11 to 12 beds.
Note that this analysis is preliminary only. Further work will be conducted to
provide a more accurate estimate of need for neuro-rehabilitation. Some of
the patients in this sample may not be appropriate for admission to a neurorehabilitation unit. It is also possible that some patients may be discharged to
community hospitals prior to 30 days and thus not captured in this data.
3.3 Community Brain Injury Service
The North Wales Brain Injury Service provides a multidisciplinary community
based service of low intensity, long-term rehabilitation to individuals of any
age with moderate to severe acquired (non-progressive) brain injuries
including trauma, cerebro-vascular accidents, tumours, CNS infections and
younger stroke patients.
Table 4 New Referrals between 1st January 2008 and 31st December 2008
Total referrals received
174
Total appropriate referrals (accepted)
163
Total non-appropriate referrals (not
accepted)
Of the appropriate referrals:
TBI referrals
Non-TBI (e.g. stroke, tumour,
infection)
Not yet coded
11
59
70
34
Table 5 Staff Establishment (Feb 2009)
Professional Group
Neuropsychology
Consultant Neuropsychologist
(Head of Service)
Neuropsychologists
Psychology
Clinical psychology trainees
Assistant Psychologists
Neurology
Consultant Neurologists
Neuropsychiatry
Consultant Neuropsychiatrist
Physiotherapy
Physiotherapist
Technical instructor
Occupational Therapy
Occupational Therapists
OT students
SLT
SLT
Social Worker
Social Worker
Social worker student
4
WTE
1
3
1
2
0.8
0.2
1
1
1.78
0
1
1
0
Medical
Admin
Registrars/Medical students
Admin manager
Admin and reception
1
1
1.6
3.4 Key Issues Identified
The key neuro rehabilitation issues identified to date include:





The need to map the current pathway for patients discharged from the
Walton Centre many of whom are discharged to the care of DGHs
rather than to a neuro-rehabilitation service able to meet their needs
The need to map/describe the service provided by DGHs to acquired
brain injury patients, to quantify this services in terms of patient case
mix and resource
The need for an agreed definitions set for key terminology relating to
the neuro-rehabilitation pathway
The need to develop a neuro-rehabilitation care pathway for North
Wales, including the key interfaces with other services (e.g. neuropsychiatry, palliative care, acute care)
Quantifying the need for neuro-rehabilitation, and capacity required to
meet that need, is not straight forward. There is no specific code for
neuro-rehabilitation. Patients are spread across many different
locations within the DGHs. A triangulation approach is required that
utilises diagnostic coding, academic research into incidence of ABI,
and the views of clinicians to help verify estimates. Preliminary data is
included above.
4. Palliative Care
The work stream will focus on the needs of patients with ‘rapidly progressing
neurological diseases’ and the interface with ‘neuro rehabilitation’.
The main clinical condition in the above is Motor Neurone Disease (MND),
Multiple Sclerosis (MS) and Parkinson’s disease (PD).
Applying figures quoted in Jader (Jader, L. An Overview of Neurological
Disorder in Wales. Neuroepidemiology 2007; 28: 65-78) for Wales to North
Wales 2007 population estimates, it is estimated that there are at least 664
cases of multiple sclerosis, 40 cases of motor neurone disease and 1063
cases of Parkinson’s disease in North Wales. Tables and Figures Nos 1, 2
and 3 in Appendix 4 show average numbers of deaths per year in North
Wales Counties and across Wales for these three diseases for the period
1996-2006.
For MND diagnosis typically occurs at the Walton Centre for Neurology and
Neurosurgery. 6 monthly neurology outpatient appointments continue at
Walton unless patients seen at local DGHS by visiting Consultant.
The Walton Centre has an established multidisciplinary clinic for newly
diagnosed patients with MND providing assessment and advice following
diagnosis, including Specialist Nurse, Physiotherapist, OT, S&LT, Welfare
Rights and MND Association Regional Care Development Adviser.
5
An informal multidisciplinary team has been established in the former Conwy
& Denbighshire NHS Trust area since 2006. Cases are discussed on a bimonthly basis, identifying future needs and timely, sensitive intervention. St
David’s and St Kentigern’s hospices provide day care.
In the former NE Wales Trust area the majority of patients with rapidly
progressing MND are referred to Specialist Palliative Care Services.
Nightingale House Hospice offers day care and out patient therapy
assessments.
Gaps in Current Service Provision include:









Delays in diagnosis
Fragmentation of services
Duplication of referrals
Assessment and provision of equipment
Inequitable access to services (specialist advice and equipment)
Respite and home care
Communication between agencies
Coordination and anticipatory care
No Systematic care plan
Following discussion with Dr Makin and Kevin Thomas it became clear that a
detailed process mapping exercise to understand the journey for MND
patients has been produced.
The key opportunity for the workstream is to develop a pathway for patients
with rapidly deteriorating neurological conditions and the interface with
rehabilitation services.
5. Continuing Health Care
Where patients have a ‘primary health need’ the NHS is responsible for
funding their health care wherever it is met. There are a number of patients
with acquired brain injuries that the NHS is funding their care in private
institutions. An analysis of the number, costs and type is being prepared by
the 6 N Wales LHBs.
Conwy LHB funds placements at the following institutions:
i) Hafod y Green – Nursing home providing long term care for Acquired Brain
Injury clients. Currently 6 clients, 4 joint funded with CCBC.
ii) Eithinog (Leonard Cheshire Disability) (Dual registration care home for
Acquired Brain Injury clients). Currently 11 patients, 4 jointly funded with
CCBC.
Total Conwy LHB projected costs in 2008/9 £507,376.
6
6. Project Arrangements
6.1 Project Manager
Luke Archard, Assistant Commissioner for Long Term Conditions and
Neurosciences, Health Commission Wales, has been allocated a day a week
by Health Commission Wales to provide project management support to Wyn
Thomas, project lead.
6.2 Project Initiation Document
A PID has been developed for the neuro-rehabilitation workstream. The
document outlines specific objectives for the neuro-rehabilitation workstream
as follows:

To identify and acquire the key service data and information required to
develop and evaluate a range of options for the organization and
delivery of neuro-rehabilitation services for North Wales.

To develop a long list of options for the organization and delivery of
neuro-rehabilitation services for North Wales.

To develop and apply a criteria for evaluating the long list of options in
order to select a short list for full option appraisal.

To conduct an option appraisal and to identify the most appropriate
model for the provision of neuro-rehabilitation services for North Wales.

Develop a pathway for the care of patients across North Wales with
rapidly progressing neurological diseases e.g. motor neurone disease

To identify the key issues relating to the interfaces between neurorehabilitation and other services, including acute care for head injured
patients, neuro-psychiatry services, continuing care and palliative care,
and to address these within the option appraisal.
A series of meetings of the neuro-rehabilitation workstream Project Board will
be held to direct the work. These meetings will be combined with workshops.
The key actions to be achieved in each project meeting are set out below:
Meeting 1 (March
2009)





Key Actions
Finalise and agree Project Initiation Document
Agree Project Board ToR
Agree work plan and timescales. Establish leads
and terms of reference for project working
groups to develop the products.
1st draft phase 1 report discussed. (To be
signed off virtually by Project Board by March
31st).
Hold workshop to identify current patient
pathway and service gaps
7
Meeting 2 (Week
beginning 13th April
2009)



Meeting 3 (Week
beginning 6th July
2009)


Workshop to develop the long list of options for
phase 2 report. Selection of short-list. (Phase 2
report completed following this meeting.
Signed-off virtually by Project Board by 30 April
2009)
Develop and agree criteria and weighting
system for option appraisal to inform 3rd phase
report
Agree date and format of option appraisal
workshop (to be held in June)
Discuss and agree 3rd phase report (product 3)
Discuss and agree costed implementation plan
(product 4)
7. Appendices
Attached are preliminary data and information to feed into the phase 1 report.




Appendix 1 proposed project board membership
Appendix 2 estimated number of patients with ABI admitted to North
Wales DGHs in 2007/8. Implications for capacity of a neurorehabilitation unit for North Wales.
Appendix 3 Data on patients discharged from Clatterbridge.
Appendix 4 Data on MND, MS and PD patients across N Wales
8
Appendix 1
Proposed Board Members
Name
Wyn Thomas
Dr Rudi Coetzer
Dr Bob Rafael
Iwan Bonds
Dr Giles Harborne
Dr Nigel Martin
Iain Mitchell
Pam Lewis
Lowri Welnitschuk
Angela Jones
Ian Langfield
Dr John Hindle
Brian Pickles
Helen Spellman
Huw Thomas
Professor Peter
Madison
Dr Martyn Bracewell
Chris Jones
Professor Carolyn
Young
Dr Colin Pinder
Dr Jenny Thomas
Dr David Abankwa
Role in project
Organisation
Chair of Project Board and
local commissioner
Conwy LHB
Expertise in neurorehabilitation and knowledge
of current North Wales
service
Expertise in neurorehabilitation and knowledge
of current North Wales
service
Financial oversight
North Wales Trust
University of Bangor
NHS Trust
Expert in neuro psychiatry
and knowledge of current
North Wales Trust
North Wales service
Palliative Care
Nightingale House Hospice
Expert in therapy services
and knowledge of North
North Wales Trust
Wales
Expert in therapy services
and knowledge of North
North West Wales NHS Trust
Wales
Continuing Care
North West Wales NHS Trust
Palliative Care
North West Wales NHS Trust
Service Group
HCW
Commissioner
Expertise in rehabilitation
North West Wales NHS Trust
and Parkinson’s disease
Planning expertise and links
with Llandudno Hospital
Conwy LHB
project
Voluntary sector expertise
Leonard Cheshire Disability
and head injury services
Patient and Public
N/A
perspective
Expertise in rheumatology
NWW Trust
and rehabilitation
Expertise in neuro
University of Bangor
rehabilitation
Patient and Public
Conwy CHC
perspective
Independent expert in
Walton Centre for Neurology and
rehabilitation medicine
Neurosurgery
Independent expert in
Clatterbridge Hospital, Wirral
rehabilitation medicine
NHS Trust
Independent expert in
Rookwood Hospital, Cardiff and
rehabilitation medicine
Vale NHS Trust
Independent expert in
Abertawe Bro-Morgannwg
rehabilitation medicine
University NHS Trust
Kevin Thomas
Patient perspective
Luke Archard
Project Management
Support
Welsh Neurological Alliance
HCW
9
Position
CEO
Consultant Psychologist North
Wales Brain Injury Service
Professor of Clinical
Neuroscience and
Neuropsychology
Management Accountant
Chief of Staff (Mental Health
Services)
Asst medical Director
Director of Therapy Services
Head of Therapy Services
Senior Nurse
Senior Nurse
Commissioner for
Neurosciences
Consultant
Project Manager Llandudno
Hospital Review
Head of Acquired Brain Injury
Division
Retired CEO GHA
Retired Consultant
Rheumatologist
Senior Lecturer
Chief Officer
Consultant in Rehabilitation
medicine
Consultant in Rehabilitation
Medicine
Consultant in Rehabilitation
Medicine
Consultant in Rehabilitation
Medicine
North Wales Care
Development Officer
Assistant Commissioner for
Neurosciences
Appendix 2
Admissions of Welsh Patients to Clatterbridge NRU 2001/2 to 2008/9
Year
2001-2
2002-3
2003-4
2004-5
2005-6
2006-7
2007-8
2008-9
Grand
Total
Admissions
1
11
10
13
8
10
3
14
70
Diagnoses of Welsh patients admitted to Clatterbridge NRU between
2001/2 and 2008 /9
Diagnosis
Brain Stem Infarct
Cerebellar infarct
CVA/TBI
GBS
Hydrocephalus, syringomyelia
Hypoxic Brain injury
ICH
ICH, Hydrocephalus,
antiphospholipid syndrome
Meningioma
MS
Peripheral Neuropathy
Post. Fossa epidermoid cyst
SAH
Spinal cord Contusion
Spinal cord infarct
Spinal cord tumour
Stroke
TBI
Not recorded
Grand Total
10
Number of
Patients
1
1
1
2
1
1
10
1
1
5
1
1
6
1
1
1
3
27
5
70
Appendix 3
Patients with an acquired head injury cared for in North Wales DGHs 2007/8
Site
Name
Wrexham
Maelor
Hospital
Diagnosis Text
LoS
Patients
40
1
44
54
71
1
1
1
1
Acute disseminated encephalitis
Acute disseminated encephalitis
Total
Cerebrovascular disease, unspecified
Cerebrovascular disease, unspecified
Total
Intracerebral haemorrhage in
cerebellum
Intracerebral haemorrhage in
cerebellum
Total
Intracerebral haemorrhage in
hemisphere, sub cortical
Intracerebral haemorrhage in
hemisphere, sub cortical
Total
Intracerebral haemorrhage,
intraventricular
Intracerebral haemorrhage,
intraventricular
Total
Intracerebral haemorrhage,
unspecified
Intracerebral haemorrhage,
unspecified
Total
Other intracerebral haemorrhage
Other intracerebral haemorrhage
Total
Other specified cerebrovascular
diseases
Other specified cerebrovascular
diseases
Total
Subarachnoid haemorrhage from
anterior communicating artery
11
3
142
1
1
39
55
1
1
2
118
1
1
32
44
47
55
70
71
80
165
1
1
1
1
1
1
1
1
34
58
8
1
1
2
35
43
1
1
2
35
69
1
1
Subarachnoid haemorrhage from
anterior communicating artery Total
Subarachnoid haemorrhage,
unspecified
Subarachnoid haemorrhage,
unspecified
Total
Subdural haemorrhage (acute)(non
traumatic)
Subdural haemorrhage (acute)(non
traumatic)
Total
Traumatic subarachnoid haemorrhage
Traumatic subarachnoid haemorrhage
Total
Traumatic subdural haemorrhage
2
91
93
2
58
1
119
1
1
39
61
62
64
184
1
1
1
1
1
1
Traumatic subdural haemorrhage
Total
Total
Ysbyty
Glan
Clwyd
1
1
5
2172
31
51
1
32
66
1
1
1
36
2
1
Cerebral aneurysm, non ruptured
Cerebral aneurysm, non ruptured
Total
Cerebrovascular disease, unspecified
Cerebrovascular disease, unspecified
Total
Diffuse brain injury
Diffuse brain injury
Total
Encephalitis, myelitis and
encephalomyelitis, unspecified
Encephalitis, myelitis and
encephalomyelitis, unspecified Total
Focal brain injury
Focal brain injury
Total
Intracerebral haemorrhage in
hemisphere, sub cortical
Intracerebral haemorrhage in
hemisphere, sub cortical
Total
Intracerebral haemorrhage,
unspecified
12
1
46
1
37
1
1
1
33
1
1
35
45
48
56
124
1
2
1
1
1
Intracerebral haemorrhage,
unspecified
Total
Intracranial injury, unspecified
Intracranial injury, unspecified
Total
Other intracranial injuries
Other intracranial injuries
Total
Other specified cerebrovascular
diseases
Other specified cerebrovascular
diseases
Total
Subarachnoid haemorrhage,
unspecified
Subarachnoid haemorrhage,
unspecified
Total
Subdural haemorrhage (acute)(non
traumatic)
Subdural haemorrhage (acute)(non
traumatic)
Total
Total
Ysbyty
Gwynedd
46
117
6
1
1
38
2
1
1
53
1
1
116
1
1
35
1
1
1014
19
128
1
69
128
1
1
1
Cerebrovascular disease, unspecified
Cerebrovascular disease, unspecified
Total
Diffuse brain injury
Diffuse brain injury
Total
Intracerebral haemorrhage in
cerebellum
Intracerebral haemorrhage in
cerebellum
Total
Intracerebral haemorrhage in
hemisphere, cortical
Intracerebral haemorrhage in
hemisphere, cortical
Total
Intracerebral haemorrhage,
unspecified
Intracerebral haemorrhage,
unspecified
Total
Other intracerebral haemorrhage
Other intracerebral haemorrhage
Total
Other specified cerebrovascular
diseases
Other specified cerebrovascular
diseases
Total
13
2
50
1
1
91
1
1
32
87
1
1
36
69
2
1
1
2
32
135
1
1
2
Subarachnoid haemorrhage from
basilar artery
Subarachnoid haemorrhage from
basilar artery
Total
Subdural haemorrhage (acute)(non
traumatic)
Subdural haemorrhage (acute)(non
traumatic)
Total
Traumatic subarachnoid haemorrhage
40
1
95
1
121
1
1
Traumatic subarachnoid haemorrhage
Total
Total
Grand
Total
14
1
1
1113
14
4299
64
Appendix 4
Table 1:
Parkinson's disease mortality, European age-standardised rate (EASR) per 100,000
North Wales Local Authorities, all persons, 1996-2006
Average
deaths per
year
Local Authority
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Wales
Crude
rate per
100,000
EASR
per
100,000
95%
LCL
95%
UCL
Compared to
Wales
No sig. difference
No sig. difference
No sig. difference
No sig. difference
No sig. difference
No sig. difference
5
11
13
7
8
8
7.1
9.2
11.6
8.0
5.2
6.3
3.3
4.1
4.1
3.3
3.1
3.5
2.5
3.4
3.4
2.6
2.5
2.8
4.6
5.1
5.0
4.3
4.0
4.4
205
7.0
3.6
3.5
3.8
Source: O NS (ADDE, MYE)
Figure 1:
Parkinson's disease mortality, European agestandardised rate (EASR) per 100,000, ranked North
Wales Local Authorities, all persons, 1996-2006
Source: ONS (ADDE, MYE)
95% confidence intervals are shown around the EASR
EASR
14
Crude rate
12
Rate per 100,000
Wales EASR = 3.6
10
8
6
4
2
Source: NPHS
Table 2:
15
Gwynedd
Conwy
Wrexham
Isle of
Anglesey
Denbighshire
Flintshire
0
Multiple sclerosis mortality, European age-standardised rate (EASR) per 100,000
North Wales Local Authorities, all persons, 1996-2006
Average
deaths per
year
Local Authority
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Wales
Crude
rate per
100,000
EASR
per
100,000
95%
LCL
95%
UCL
Compared to
Wales
No sig. difference
No sig. difference
Sig. high
No sig. difference
No sig. difference
No sig. difference
2
2
3
2
2
3
2.3
1.5
2.7
1.9
1.2
2.0
2.0
1.3
2.1
1.6
1.1
1.8
1.1
0.8
1.4
0.9
0.7
1.2
3.3
2.1
3.1
2.6
1.8
2.6
46
1.6
1.4
1.3
1.5
Source: O NS (ADDE, MYE)
Figure 2:
Multiple sclerosis mortality, European agestandardised rate (EASR) per 100,000, ranked North
Wales Local Authorities, all persons, 1996-2006
Source: ONS (ADDE, MYE)
95% confidence intervals are shown around the EASR
EASR
4.0
Crude rate
3.5
Rate per 100,000
3.0
2.5
Wales EASR = 1.4
2.0
1.5
1.0
0.5
Source: NPHS
Table 3:
16
Conwy
Isle of
Anglesey
Wrexham
Denbighshire
Gwynedd
Flintshire
0.0
Motor neurone disease mortality, European age-standardised rate (EASR) per 100,000
North Wales Local Authorities, all persons, 1996-2006
Local Authority
Average
deaths per
year
Isle of Anglesey
Gwynedd
Conwy
Denbighshire
Flintshire
Wrexham
Wales
Crude
rate per
100,000
EASR
per
100,000
95%
LCL
95%
UCL
Compared to
Wales
No sig. difference
No sig. difference
Sig. high
No sig. difference
No sig. difference
No sig. difference
2
3
5
2
4
4
3.2
2.6
4.8
2.2
2.5
3.0
2.0
1.9
2.8
1.5
2.0
2.4
1.3
1.3
2.1
0.9
1.4
1.7
3.3
2.7
3.9
2.4
2.8
3.3
79
2.7
2.0
1.8
2.1
Source: O NS (ADDE, MYE)
Figure 3:
Motor neurone disease mortality, European agestandardised rate (EASR) per 100,000, ranked North
Wales Local Authorities, all persons, 1996-2006
Source: ONS (ADDE, MYE)
95% confidence intervals are shown around the EASR
EASR
6
Crude rate
4
Wales EASR = 2.0
3
2
1
Source: NPHS
17
Conwy
Wrexham
Isle of
Anglesey
Flintshire
Gwynedd
0
Denbighshire
Rate per 100,000
5