Why have improvements in mortality slowed down?

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Until recently, mortality rates in England and Wales had been falling steadily. However, since 2011, the rate of improvement has slowed and trends in mortality have become more erratic (Figure 1). Strikingly, a sharp rise in mortality in 2015 meant that life expectancy at birth actually fell, before it recovered in 2016. What is causing these changes in the long-term trend?

Two factors are uncontested. The first is the slowing of mortality improvements is principally the result of changes in mortality among older people. Put simply, more older people – particularly older women – than expected given historical trends are dying. The second is that flu contributed to excess deaths in some years, notably 2015 and also in 20171, although the scale of its impact is disputed. Beyond this, views about the underlying factors are hotly contested.

Several researchers cite the impact of austerity, which some claim has resulted in tens of thousands of ‘extra’ deaths.2345 Their conclusions are based on statistical analyses examining associations between mortality trends on the one hand, and external factors such as the slowing of NHS spending, cuts in social care budgets, increases in delayed discharges and reductions in benefits on the other.

However, this interpretation has been challenged, mainly on the grounds that association doesn't prove causality,678 with some arguing that because pensioners have, in fact, been better protected from spending cuts than other groups, austerity cannot be the reason for the change in the long-term trend. Alternative explanations suggested include: a ‘cohort effect’ with gains from, eg reducing smoking, largely already realised; or that older people may be succumbing to more complex and multiple long-term conditions.

Then, there is the influence of statistical artefacts – for example, trends can look different depending on the period over which they are measured9 – and, more fundamentally, the calculation of mortality rates10 is affected by changes in population size and structure and whether these have been suitably adjusted for. 

With such a long list of possible explanations, what are we to believe? Understanding the reasons for recent trends in mortality among older people is largely – but not solely – the key to understanding what's happening. But disentangling the effects of the many different factors affecting older people's mortality is immensely challenging. Co-morbidity and frailty makes it difficult to establish cause of death reliably. Changes taking place simultaneously in external factors such as austerity and declining NHS performance – which could itself reflect pressures such as seasonal flu outbreaks – must also be accounted for.

But UK trends are not unique and similar changes are being seen in other European countries. Six of the largest EU countries (France, Germany, Italy, Poland, Spain, UK) saw a fall in life expectancy for both men and women between 2014 and 2015, and female life expectancy at birth fell in 23 of the 28 EU countries, while male life expectancy at birth fell in 16 EU countries.11 The European mortality monitoring network attributed excess mortality in Europe in the winters of 2015, 2016 and 2017 to flu, and the particular strain prevalent (A(H3N2)).12

However, while these fluctuating trends in mortality are not unique to the UK, the slowdown in mortality improvement has been more pronounced here than in other European countries. And this when life expectancy in the UK is already lower than in many comparable European countries.

Attempts at explaining the changes in the long-term trend must address several questions including:

  • why are post-2010 mortality trends (both between and within years) more erratic than in preceding decades?
  • why are similar patterns seen in many European countries?
  • why is the slow-down in mortality improvement in the UK worse than in other European countries?
  • why is it worse in older women than older men?

The debate has become unhelpfully polarised. In our view, single explanations are unlikely to provide the answer; it is more likely that many factors are at play. The gravity of recent trends in mortality warrants a comprehensive and objective review, especially given our poor standing in European life expectancy league tables. The review should be set in the wider European context, which has received inadequate consideration thus far. The starting point should be to ensure that the underlying data is robust; the Office for National Statistics and Public Health England have a key role to play in assessing the possibility of data-related or analytical bias in the figures.

The King’s Fund and the Health Foundation are in discussion with some of the leading figures in this debate. Our aim is get an overview of what is currently known, outline what further work needs to be done, and advise on the steps governmental and statutory agencies should take to keep these trends under review in the longer term.

  • 1. ONS. Excess winter mortality in England and Wales: 2016 to 2017 (provisional) and 2015 to 2016 (final). 2017. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2016to2017provisionaland2015to2016final
  • 2. Hiam L, Dorling D, Harrison D, McKee M. Why has mortality in England and Wales been increasing? An iterative demographic analysis. Journal of the Royal Society of Medicine 2017; 0(0) 1–10. DOI: 10.1177/0141076817693599 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407517/pdf/10.1177_0141076817693599.pdf
  • 3. Green MA, Dorling D, Minton J, Pickett KE. Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients? J Epidemiol Community Health 2017, doi:10.1136/jech-2017-209403. http://jech.bmj.com/content/71/11/1068.long
  • 4. Loopstra R, McKee M, Katikireddi SV, Taylor-Robinson D, Barr B and Stuckler D. Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007–2013. J R Soc Med 2016;109: 109–116. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4794969/pdf/10.1177_0141076816632215.pdf
  • 5. Watkins J, Wulaningsih W, Da Zhou C, et al. Effects of health and social care spending constraints on mortality in England: a time trend analysis. BMJ Open 2017;7:e017722. doi:10.1136/bmjopen-2017-017722. http://press.psprings.co.uk/Open/november/bmjopen017722.pdf
  • 6. Fordham R, Roland M.  Expert reaction to paper on health and social care spending and excess deaths in England. 2017 http://www.sciencemediacentre.org/expert-reaction-to-paper-on-health-and-social-care-spending-and-excess-deaths-in-england/
  • 7. Milne E (letter). Mortality in England - erroneous attribution of excess winter deaths to underlying trend. Journal of the Royal Society of Medicine; 2017, Vol. 110(7) 264–268. DOI: 10.1177/0141076817703865.
  • 8. Steventon A. Can you really link delayed discharge to mortality? The evidence is far from clear. Blog, The Health Foundation, 2017. http://www.health.org.uk/blog/can-you-really-link-delayed-discharge-mortality-evidence-far-clear
  • 9. Milne E. Why the "120,000" deaths claim is unsupportable. 2017. https://eugenemilne.com/2017/11/17/why-the-120000-deaths-claim-is-unsupportable/
  • 10. Newton J, Baker A, Fitzpatrick J, Ege F. What's happening with mortality rates in England?  Public Health England, July 2017. https://publichealthmatters.blog.gov.uk/2017/07/20/whats-happening-with-mortality-rates-in-england/
  • 11. Newton J, Baker A, Fitzpatrick J, Ege F. What's happening with mortality rates in England?  Public Health England, July 2017. https://publichealthmatters.blog.gov.uk/2017/07/20/whats-happening-with-mortality-rates-in-england/
  • 12. Vestergaard LS et al. Excess all-cause and influenza-attributable mortality in Europe, December 2016 to February 2017. Eurosurveillance, Volume 22, Issue 14, 06 April 2017. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22766

Comments

sharon paterson

Position
retired a/e nurse,
Comment date
30 November 2017

I have felt for a long time that the continued upward trend in survival rates among the elderly would start to decline-largely because the population that had lived through the dietary deprivations of the Second World War, with reduced consumption of sugar and many other restrictions would probably be replaced by younger, less fit-eg. obese , and less active ageing people. I accept that smoking would go against this trend [ people were ignorant of the risks to health ],but fewer people had cars, so walked more, and generally, everyday living was just more physical.

pamela ellis

Position
retiired,
Comment date
02 December 2017

I have spent since 2012 investigating my mother's death,because the Trust will not give me any information of my mother's last hours, or the statements they secreted away in Freedom of Information. I have found out the conspiracy between the Trust, PHSO, CQC, CORONER AND POLICE. The research and my findings are truly frightening of what can happen to our elderly when in hospital. I found out mum was deliberately not given medical care and they admitted it - neglected from the outset, even though I was with her every afternoon and evening. They have not told me why my mother was chosen to neglect. ALL AN ABSOLUTE DISGRACE. ALSO THE MORTALITY REVIEW WAS NOT DONE CORRECTLY. I BELIEVE THERE IS A CULLING OF THE ELDERLY. They have also taken my life - while I still strive for the truth. Pamela Ellis

Ruth Nitkiewicz

Position
Information Specialist,
Organisation
The King's Fund
Comment date
04 December 2017

Hi Pamela,

I'm so very sorry to hear about the loss of your mother. You may wish to contact the Patients Association, an independent charity that can provide assistance regarding your concerns for your mother's care, including advice about lodging a formal complaint. Their helpline number is 020 8423 8999, or you can email them directly at helpline@patients-association.com.

I hope this information helps Pamela.

Warmest regards,
Ruth Nitkiewicz
The King's Fund

Toni Williams

Position
Consultant in Public Health,
Comment date
04 December 2017

Another key question that in my opinion needs to be addressed by analysis of PHE/ONS data is one of inequalities and whether the same trends in mortality are observed across all deprivation quintiles.

judith shamian

Comment date
04 December 2017

You also have not kept up with the nursing staffing levels and credentials as recommended by evidence. Increased nursing hours and increased educational levels of nurses been demonstrated consistently to reduce morbidity and mortality. Dr. Linda Akien is one of the few that researched this area.

david r

Position
management consultant,
Organisation
PACG
Comment date
04 December 2017

would be interesting to see the same info for the other big european countries. where do the UK lines buck the overall trend? this would indicate that it is stuff we are doing in the UK. where do the uk lines resemble those of germany et al? this would indicate it is wider trends at work.

at the moment it looks very much like the 2010-11 date of the change of govt (and the pay cap, and consequent increase in churn in staff in posts) caused a lot of the flattening off... if i had to guess.

M and F show same pattern, so it isnt just due to noise in the data.

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