The Cost of Alcohol to the North East Economy

Transcription

1 The Cost of Alcohol to the North East Economy Introduction In 2008 The Centre for Public Health at Liverpool John Moore s University updated a 2003 Cabinet report 1 on the costs associated with alcohol misuse. This provided a more up to date estimate covering three broad cost areas of healthcare, crime and productivity. The new calculations put the cost of alcohol misuse to society at 17.7bn to 25.1bn per year with the cost approximately broken down as follows: 2.7bn cost to the NHS to 15.1bn cost for licensing and alcohol related crime to 7.3bn in costs to the workplace and wider economy 4 The costs across the three areas were ranging in the years that they represented so using HM Treasury deflators 5 it was possible to adjust the figures so that they all represented 2008/09 prices. This increased the overall cost to 18.3bn bn and breaks down as follows: 2.9bn cost to the NHS 9.1 to 15.1bn cost for licensing and alcohol related crime 6.4 to 7.9bn in costs to the workplace and wider economy Using the methodologies behind the three main studies 1,2,3 that contribute to the above figures it has been possible to produce cost estimates at more local levels across the North East. Wherever possible the most recent figures and research from national sources have been incorporated in an attempt to provide an up-to-date estimate for the cost of alcohol abuse across the North East Localities. The methodology behind this process is included at the back of this document it must be noted that there is a degree of uncertainty in the local figures given that they have been derived from national research, this is reflected in the overall cost ranges provided. However, best use has been made of available evidence and research and there is an intention to update these estimates as and when new data becomes available. 1 Prime Minister's Strategy Unit (2003). Alcohol misuse: How much does it cost? London: Cabinet Office. 2 Health Improvement Analytical Team. (2008) The cost of alcohol harm to the NHS in England. London: Department of Health. 3 Alcohol Consultation. (2008) Safe, Sensible, Social Consultation on further action Impact Assessments. London: Department of Health. 4 Prime Minister's Strategy Unit (2003). Alcohol misuse: How much does it cost? London: Cabinet Office adjusted to 2006/07 prices

2 Summary: Cost of Alcohol to the North East Previously, an attempt was made by Balance to break the national costs down to the local level by simply distributing on a per capita basis. For example, the North East accounts for approximately 5% of the national population, therefore 5% of the cost. This exercise gave the following totals for the North East as a whole: 142.8m cost to the NHS 430.5m to 715.8m cost for licensing and alcohol related crime 320.8m to 396.6m 6 in costs to the workplace and wider economy ( 894.1m 1,255.2m regionally) Using updated figures and more appropriate methods of distributing national costs to the regional level has resulted in the following breakdown: 224.8m cost to the NHS 360.6m to 598.7m cost for licensing and alcohol related crime 377.7m to 466.7m in costs to the workplace and wider economy ( 963.1m 1,290.2m regionally) 422.2m (37.5%) 224.8m (20.0%) 479.6m (42.6%) NHS Crime and Licensing Workplace and Wider Economy (Mid-point of lower/upper estimates used for illustration) The costs to the NHS have increased by over 57% which was widely expected given that the North East has higher than average numbers of people drinking at increasing and higher risk, a larger than average dependent population and also a rate of alcohol related hospital admissions that was over 42% higher than the national in 2008/09 7. The costs for alcohol related crime and licensing have actually reduced in this estimate based on the fact that there are generally lower levels of crime in the North East compared to the rest of the Country. In particular the levels of alcohol 6 An earlier Balance document entitled The Cost of Alcohol to the Economy incorrectly placed this figure at m as a result of using weights basing the national figure being for England and Wales instead of for just England. Therefore the North East actually receives a larger share of the cost than given by the previous estimate. 7 Local Alcohol Profiles for England 2009, 2

3 attributable crime were some 16% 8 lower than the national based estimates provided by the North West Public Health Observatory. The costs to the workplace and the wider economy have also increased by over 20% on the back of the fact that the North East has a higher proportion of increasing and higher risk drinkers when compared to the rest of England. 8 Local Alcohol Profiles for England 2009, 3

4 Overall Cost of Alcohol to the Regional Localities The overall cost of alcohol abuse varies quite widely across the localities mainly as a consequence of differences in population size. The table below shows the breakdown of cost across the three main areas. Where an upper and lower estimate has been calculated from the national figure an average of the two has been used, (see Appendix A for detailed figures). Cost in millions for 2008/09 prices Area NHS Crime and Licensing * Workplace and Wider Economy Total County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East Region , National Total 3, , , , *National figure supplied is for England and Wales To provide a more meaningful comparison between local areas, the total cost has been broken down per head of population for England or England and Wales where appropriate. As a result the North East has a per capita figure of 437 which is only 1.8% above the national figure of 430, there are however large variations across the localities. As can be seen in the following chart Middlesbrough has the highest overall cost at 650/head of population, Newcastle has the next highest figure at 513/head, followed by Hartlepool at 487/head. The areas with the lowest costs per head are the larger rural Counties of Durham and Northumberland at 394 and 353 respectively. The subsequent sections of this report provide further detail about the overall costs attributable to the NHS, crime and the wider economy. 4

5 Cost of Alcohol to Society per Head of Overall Population in the North East Localities County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East Region National Average 5

6 The Cost of Alcohol. To the NHS The cost of alcohol to the NHS is broken down into nine areas as follows: Hospital inpatient & day visits Hospital outpatient visits Accident and emergency visits Ambulance services NHS GP consultations Practice nurse consultations Dependency prescribed drugs Specialist treatment services Other health care costs (See Appendix B for a full locality breakdown of costs for each of these areas) Looking at the cost of alcohol to the NHS for each of the localities shows a different picture when compared to looking at the costs overall. Similarly to before, a cost per head of population has been calculated so that differences between localities can be directly compared, as detailed in the following chart. Cost of Alcohol to the NHS per Head of Overall Population in the North East Localities County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East Region England 6

7 For the overall cost of alcohol, the North East figure was only marginally higher than the national and a number of the North East localities actually had a lower figure per head compared to the national average. However, calculating the cost to the NHS shows the North East average to be 29% higher than the national figure with each and every one of the localities having a cost per head higher than the national. The locality with the highest cost per head is Newcastle at 94, closely followed by Gateshead at 93 and North Tyneside at 92, these figures being 39%, 38% and 36% respectively higher than the national. The locality with the lowest cost per head is Stockton at 80, however, this figure is still some 19% above the national average. Caused by Crime and Licensing The cost of alcohol caused by crime and licensing is broken down into three main areas: Cost of alcohol related crime o General offences that are estimated to be attributable to alcohol o Alcohol-specific offences and their estimated cost to the criminal justice system o Issuing of Penalty Notices for Disorder for alcohol misuse and alcoholrelated crime and disorder Cost to licensing authorities o Shortfall between cost and money made from licensing Cost to licensee o Applying for licensing o Licensing fees (See Appendix C for a full locality breakdown of costs for each of these areas) The cost is comparatively low in the North East given that there are generally lower levels of crime than there are nationally. Expressing an average of the upper and lower costs on a per capita basis for the North East gives a total of 186 per head which is some 16% lower than the national cost of 223. Middlesbrough is the locality with the highest average cost per head at % above the national rate. The high cost estimate experienced in Middlesbrough is due to using the number of alcohol related crimes from the NWPHO alcohol profiles as a weighting factor where Middlesbrough is ranked 15 nationally out of 152 areas. The locality with the lowest cost per head is Northumberland at 125, followed by North Tyneside at 149 with these costs being 44% and 33% lower than the national total respectively. 7

8 Cost of Alcohol Caused by Crime and Licensing per Head of Overall Population in the North East Localities County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East Region England and Wales To the Workplace and Economy The cost of alcohol to the workplace and economy is broken down into three main areas: Lost output due to absenteeism Lost output due to reduced employment Lost output due to premature death (See Appendix D for a full locality breakdown of costs for each of these areas) The cost to the workplace and economy is comparatively higher in the North East than it is for the rest of the nation. Expressing an average of the upper and lower costs on a per capita basis for the region gives a total of 164 per head which is some 18% higher than the national figure of 139. Middlesbrough is the locality with the highest cost per head at 182 with Newcastle being the second highest at 181. These figures are respectively 31% and 30% higher than the national average. The locality with the lowest cost per head is Darlington at 136 which is slightly lower than the national figure. 8

9 Cost of Alcohol Caused to the Workplace and Economy per Head of Overall Population in the North East Localities County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East England 9

10 Methodology for NHS Costs The methodology for this section of the costs is based around updates to the Department of Health The cost of alcohol related harm to the NHS document 9. Updated figures from national datasets have been included where available and all cost figures have been inflated to 08/09 prices using GDP deflator figures 10 published by the HM Treasury. Several of the NHS cost areas use a 2006 estimate of higher-risk drinkers that has been derived from ONS research 11 and 2006-based ONS population estimates. To provide a breakdown at a local level it was necessary to use 2005-based synthetic estimates of the percentage of higher risk drinkers 12 which have then been applied to the most recent 2008 ONS population estimates. At the national level this actually reduces the number of higher risk drinkers from 2,653,545 to 2,103,124, the reduction at the local level however cannot be determined. Observing the reduction in the national figure however suggests that as a result some of the costs to the NHS described earlier may be on the conservative side. Hospital inpatient & day visits The Department of Health document uses hospital admissions costs derived from Healthcare Resource Group (HRG) codes to provide an estimate of the cost of alcohol abuse. As an HRG code is available for each alcohol attributable hospital admission it was possible to add up all of the relevant costs to arrive at a grand total using 2007 admissions data. It was however not possible to replicate this exercise at the local level so aggregated alcohol related hospital admissions for 2008/09 from the North West Public Health Observatory were used instead. The 2008/09 local level admissions data 13 is provided for 10 different disease groups of: Alcohol specific (Acute) Alcohol specific (Chronic) Alcohol specific (Mental) Accidents & Injury (Acute) Cancer Cardiac arrhythmias Digestive (Chronic) Hypertensive (Chronic) Other diseases Violence (Acute) 9 Health Improvement Analytical Team (2008). The cost of alcohol harm to the NHS in England. London: Department of Health Office for National Statistics, Smoking and drinking among adults, Local Alcohol Profiles for England 2009,

11 Updated average cost figures for each type of admission 14 were then applied to the totals for each area to arrive at a total cost for each of the different disease groups. Hospital Outpatient Visits The Birmingham Untreated Heavy Drinkers project recruited 500 untreated heavy drinkers in 1997, and has tracked them (though interviews, questionnaires and so on) up to the Wave Four report, which was published as BUHD (2004) 15. The 2004 report discusses the cohort s use of hospital-based services, including outpatient attendance, and finds that the cohort are twice as likely to use A&E and/or outpatient services in the past three months (relative to the general population). Using the 2008 GLF (the successor to the GHS) the average number of outpatient attendances per year was 1.12, therefore the excess usage of 1.12 attendances per annum in the higher risk group can be attributed to alcohol consumption (although confounding factors may also play a role). It is assumed here that heavy drinkers are the same as higher risk drinkers, so using the NWPHO 16 local level synthetic estimates for higher risk drinkers the average number of alcohol related outpatient attendances was calculated by applying the GLF rate to the local number of higher risk drinkers. PSSRU (2007) 17 cites a national average cost of for adult outpatient attendances 18, as with most figures from PSSRU (2007), this is in 2006/7 prices. This figure was therefore adjusted to a 2008/09 price of and multiplied by the number of alcohol related attendances in each locality to give the overall cost. A&E Attendences Cabinet Office (2003) commissioned a MORI poll of Accident and Emergency staff, asking them what percentage of visits they thought were related to alcohol consumption. The resulting central estimate was that 35% of visits were alcoholrelated. Although this survey is now becoming out of date, alcohol-related demand for Accident and Emergency services is not thought to have decreased since the survey was carried out; it is likely a conservative estimate of the current situation. A&E attendance figures at the North East level for 2009/10 were taken from the Department of Health website 19 and then distributed out across the localities on a per capita basis using 2008 ONS population estimates. 14 Cost figures have been derived by the Department of Health Analytical team using average length of stay and HRG cost codes for different alcohol related disease types. 15 BUHD (2004), Dalton, Orford, Webb and Rolfe, Birmingham untreated heavy drinkers project: report on wave four. Commissioned by the Department of Health. See 16 See 17 Personal Social Services Research Unit (2007), Unit costs of health and social care, Weighted average of all follow-up attendances (adult), Page 99. See 18 This figure is derived from reference costs and reports on NHS Trusts and Primary Care Trusts. 19 See AccidentandEmergency/DH_

12 PSSRU (2007) 20 finds a national average cost of 84 for a lower-cost A&E investigation, and 111 for a high cost investigation 21. The arithmetic average of the two was used in the original study (i.e per visit). Inflating this cost to 2008/09 prices gives a total of per investigation which was then applied to the number of alcohol related A&E attendances for each locality. Ambulance Journeys The finding from the aforementioned MORI poll is also applied here, implying that 35% of ambulance journeys are alcohol-related. Ambulance Services figures at the North East level for 2008/09 were taken from the NHS information website 22. The overall North East figure of attendances was then distributed across the localities on a per capita basis using ONS 2008 mid-year population estimates. PSSRU (2007) 23 estimate a national average cost of 6.70 per minute of an emergency ambulance journey, and 6.80 per minute of a paramedic unit s journey. Both costs take account of equipment / vehicle costs, building costs, salaries / wages and overheads. Taking an arithmetic average of these costs and applying the average journey time of 44.4 minutes yields an average cost of per journey in 2006/07 prices. Inflating this to 2008/09 prices results in a cost of per ambulance journey which was then multiplied by the number of alcohol related journeys in each of the localities. GP Consultations Cabinet Office (2003), through personal communication with the authors of the Birmingham Untreated Heavy Drinkers project, obtained an estimate that 22% to 35% of the cohort s GP visits were alcohol related 24. An arithmetic average of these figures 28.5% - is used in the calculations below 25. The General Lifestyle Survey (2008) shows that on average people visit their GP a total of five times a year. Using the NWPHO 26 local level synthetic estimates for higher risk drinkers the average number of alcohol related GP visits was calculated by applying the GLF rate to the local number of higher risk drinkers, and it was then assumed that 28.5% of these visits were alcohol related. 20 Op cit. High cost investigation and Lower cost investigation, Page Again, these figures are derived from reference costs and reports on NHS Trusts and Primary Care Trusts. 22 See 23 Op cit. Cost per minute, Page Op cit. Annex, Page xi and xii. 25 Cabinet Office (2003) instead presented a range. 26 See 12

13 PSSRU (2007) 27 identifies a cost of 34 per 11-minute GP consultation session, including qualification costs and direct care staff costs 28 as well as salary on-costs and overheads. This cost is in 2005/6 prices as it has not yet been possible to agree an appropriate inflator. The aforementioned generic Hospital and Community Health Services (HCHS) pay and prices index (as set out in PSSRU (2007) 29 ) is therefore used to uprate the cost by 4.56%, yielding a cost of per consultation session. To bring the cost in line with the rest of this report it was further inflated to a 2008/09 price of and then multiplied by the number of alcohol related GP visits for each of the localities. Practice Nurse Consultations It is assumed that the above estimate of 28.5% of heavy drinkers GP appointments being alcohol-related is also applicable to practice nurse appointments. The General Lifestyle Survey (2008) shows that on average people visit a practice nurse twice a year. Using the NWPHO 30 local level synthetic estimates for higher risk drinkers the average number of alcohol related practice nurse visits was calculated by applying the GLF rate to the local number of higher risk drinkers, it was then assumed that 28.5% of these visits were alcohol related. Again, PSSRU (2007) 31 supplies a relevant cost of 9 per consultation in 2006/7 prices, including qualifications, salary on-costs and overheads. Inflating this to 2008/09 prices gives a cost of 9.49 per visit which was then multiplied by the number of alcohol related consultations for each locality. Specialist Alcohol Treatment Services A significant portion of specialist alcohol treatment services are provided by voluntary and other organisations that are independent of the NHS, although NHS provision is still notable. Cabinet Office (2003) cites a paper by Alcohol Concern (2002) 32, which used a survey methodology to assess then-current expenditure on specialist alcohol treatment services. In this instance the figures for the North East localities have simply been obtained by breaking down the national cost based on weighting by dependent population 33 and then inflating to 2008/09 prices. There is an intention to eventually update the 27 Op cit. General practitioner unit costs. Page These are included on the basis that both qualification costs and direct care staff costs form part of the full marginal costs incurred by alcohol-related GP consultations. This differs slightly from Cabinet Office (2003), which did not include the latter. 29 Op cit. Page See 31 Op cit. Page Alcohol Concern (2002), Report on the mapping of alcohol services in England. Commissioned by the Department of Health. See 33 Figures of dependent population taken from Department of Health Ready Reckoner tool which uses findings from the 2007 Adult Psychiatric Morbidity Survey 13

14 specialist treatment figures with costs supplied directly by local commissioning bodies in the North East. The cost of other alcohol-related healthcare usage The original Department of Health report details a number of other areas that were considered in the overall costs to the NHS: counselling sessions visits from a community psychiatric nurse sessions with a health visitor cost of other professionals In this instance the figures for the North East localities have simply been obtained by breaking down the national cost based on weighting by higher risk population and then inflating to 2008/09 prices. 14

15 Methodology for Crime and Licensing Costs The methodology for this section of the costs was derived from the Department of Health Safe, Sensible, Social Consultation on further action Impact Assessments document 34 which provided national cost figures for England and Wales. The costs of alcohol-related crime in this paper were calculated in three parts: the costs associated with general offences that are estimated to be attributable to alcohol alcohol-specific offences and their estimated cost to the criminal justice system costs associated with the issuing of Penalty Notices for Disorder for alcohol misuse and alcohol-related crime and disorder (See Appendix 2 of the original document for full details on methodology) Using the numbers of alcohol related crimes taken from the Local Alcohol Profiles for England 35 it was possible to break the overall cost of crime down to the local level for the North East. However, the profiles gave a national figure for England whereas the costs were for England and Wales, therefore it had to be assumed that this crime rate would be the same for England and Wales. Using 2008 ONS population estimates the England crime rate was applied to the England and Wales population to estimate the number of crimes for England and Wales resulting in a figure that would be in line with the rest of the areas. Each of the localities was next given a weighting of the national number of crimes and was then multiplied by the national cost to give the final figure for each locality. To breakdown the licensing costs that were included in the Department of Health document, weights were calculated for each locality by using 2009 licensing figures from the Department of Culture Media and Sport 36. The weighting for each locality was then multiplied by the national cost to give a figure for each locality. 34 Alcohol Consultation. (2008) Safe, Sensible, Social Consultation on further action Impact Assessments. London: Department of Health. 35 Local Alcohol Profiles for England 2009, 36 See ns/6387.aspx 15

16 Methodology for Costs to the Workplace and Economy The methodology for this section of the costs was derived from the 2003 Cabinet report 37 Alcohol misuse: How much does it cost? which provided national cost figures for England. All of the costs in the original report have been updated to 2008/09 prices so that they are comparable to the NHS and crime costs in this document. The costs to the workplace and economy were split into three areas: lost output due to absenteeism lost output due to reduced employment lost output due to premature death (See p28 onwards of the original document for full details on methodology) Lost output due to absenteeism Estimating production (lost output) costs due to absenteeism may be achieved by calculating the number of working days lost due to alcohol misuse and valuing them using the average costs of an employee, after taking into account employers costs such as national insurance contributions, pension contributions etc. Accounting for part-time and full-time employment rates and assuming that rates of absenteeism were the same among full and part-time employees it was found that in 2001 nearly 11 million (10,988,096) days were lost in England among alcohol dependent employees due to alcohol misuse. This implies that the total cost of absenteeism (including employer costs) due to alcohol misuse in England is 1.2 billion ( 1,213,631,951) in 2000/01 prices. The original document calculated a lower estimate of output lost due to alcohol dependent employees. However, it was deemed fairer to use the number of higher risk drinkers from the Local alcohol Profiles 38 as a weighting upon which to break the costs down to the local level as dependent drinkers were more likely not to have a job in the first place. Given that the North East proportionally has a much larger dependent population than anywhere else in the country using this as a weighting could result in an overestimation of costs. A higher estimate is also calculated aiming to take into consideration that sickness absence due to alcohol misuse may also occur among non-dependent drinkers because of hangovers or other temporary alcohol-related short ailments. Therefore the higher estimate of lost output used both the number of increasing and higher risk drinkers as a weighting to break the cost down to the local level. 37 Prime Minister's Strategy Unit (2003). Alcohol misuse: How much does it cost? London: Cabinet Office. 38 Local Alcohol Profiles for England 2009, 16

17 Both the upper and lower cost estimates also take into account the employment rates of the localities, these were taken from the most recent data from the Annual Population Survey 39 (October 2008-September 2009). The proportion of increasing and higher risk drinkers in the localities were applied to the number of employed working age population across each of the areas. These totals were then assigned a weight of the national figure that could then be multiplied by the total cost. This method will have a fairly wide degree of accuracy given that synthetic estimates of increasing/higher risk populations have been combined with findings from a sample survey. It was however deemed important that differing employment rates were taken into account in the estimate as generally the rates are lower across the North East than they are nationally, their exclusion would result in an inflated cost for each locality. Lost output due to reduced employment In a manner similar to that of the calculation of the alcohol related absenteeism costs it is found that heavy male drinkers (50 plus units a week) spend an average of 11.4 days per annum out of employment. As before two estimates were presented in the original document, a low and a high. It was assumed that being a heavy drinker leads to a considerable reduction in the probability of working by about 7 percent. This translates into a total of 15,039,659 days of non-employment per year among heavy male drinkers and a total cost of 1.7 billion ( 1,726,053,577). The estimate accounts for full-and part-time employment rates in the economy and employer costs but as explained above excludes female dependent drinkers. To acquire a higher estimate the female heavy drinkers were also included in the original calculation. As the Local Alcohol Profiles for England only provide an overall rate for higher risk drinkers and not individual ones for males and females just the overall rate had to be used as a locality weighting on both the upper and lower estimates. As before, the higher risk rate was applied to the number of people employed in each of the localities and the calculated total was used as a weighting factor of the national figure. Lost output due to premature death If all these premature deaths could be prevented or at least deferred until the proper time as indicated by UK life expectancy tables, then society would gain the value of the output they would produce in the current and future working years. To distribute the national costs down to the local level the numbers of alcohol specific deaths for each locality were taken from the Local Alcohol Profiles for England and used as a weighting of the national total. It was decided to use alcohol specific instead of alcohol attributable deaths given that a large proportion of alcohol attributable deaths are accounted for by the older age groups who wouldn t be a part of the labour market. 39 Data for APS taken from 17

18 Appendix A Overall Cost of Alcohol to Society Cost estimate in millions 08/09 prices Area NHS Crime and Licensing * Workplace and Wider Economy Total Lower Upper Lower Upper Lower Upper County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East , England 3, , , , , , , * National figure supplied is for England and Wales 18

19 Appendix B Overall Cost of Alcohol to the NHS Cost estimate in millions, 2008/09 prices Area Hospital inpatient & day visits Directly attributable Partially attributable Hospital outpatient visits Accident and emergency visits Ambulance services NHS GP consultations Practice nurse consultations Dependency prescribed drugs Specialist treatment services Other health care costs Total County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East England , ,

20 Appendix C Overall Cost of Alcohol Caused by Crime and Licensing Cost estimate in millions, 2008/09 prices Area Alcohol Related Crimes Licensing Authorities Cost to Licensee Total Lower Upper Lower Upper Lower Upper Lower Upper County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East England and Wales 8, , , ,

21 Appendix D Overall Cost of Alcohol to the Workplace and Economy Cost estimate in millions 08/09 prices Area Lost output due to absenteeism Lost output due to reduced employment Lost output due to premature death Total Lower Upper Lower Upper Lower Upper Lower Upper County Durham Darlington Gateshead Hartlepool Middlesbrough Newcastle North Tyneside Northumberland Redcar and Cleveland South Tyneside Stockton Sunderland North East England 1, , , , , , , ,