The Commissioner: Winter, deaths and inequality

Covering unexpected wobbles in life expectancy a couple of years ago, it struck me that the phrase “life expectancy” is a bit misleading.

It is often treated as an unquestionable statistic based on some incredible insight into the future – perhaps from an algorithm so powerful it has developed the necessary foresight, or handed down from a mysterious external presence.

In fact, “period life expectancy” – the figure that is often discussed and was the basis of recent analysis by Sir Michael Marmot’s team – does not even involve any expert prediction or debate.

It is simply based on death rates by age now, not in future – ie: it shows how long people would live, if they carried on dying in the same way people are dying currently. Which is highly unlikely.

This doesn’t mean the recent wobbles in life expectancy – slowing of improvement and even some falls – are not important or concerning.

It does mean at a superficial level, the reason is no great mystery. There were many more deaths in some recent years than before, and many more than expected if previous trends had continued.

I covered them at the time: through 2012 and into 2013, then at the end of 2014 and particularly in 2015; there were surges in deaths sufficient to record very unusual increases in age-adjusted mortality rates in 2012 and 2015. They were highlighted by a small group of people, particularly Blackburn public health director Dominic Harrison, to very little initial interest or welcome in officialdom.

Period life expectancy is reported in overlapping multiyear periods, to iron out blips and fluctuations in deaths, and these surges in deaths were big enough and sustained enough to knock it off the previous trend for four overlapping three year periods: 2010-12; 2011-13; 2012-14; and 2013-15.

A winter issue?

The causes of the shifts in deaths and mortality remain unclear and disputed. Public Health England admits they are unknown, but points particularly to weather; flu and problems with the flu vaccine in winter 2014-15; and to fluctuations in deaths in the quickly growing older age groups.

This is not only a winter issue and the surges in deaths ran beyond winter – but a lot of it was, unsurprisingly, at that time of year.

Recent discussion has pointed to “austerity” as a cause, whether manifested in funding of the health and care system, other services, personal financial strife, employment or other social determinants of health.

Internal work at NHS England in 2014 (it has kept well away from the issue in the years since) looked at a slowdown in the long term improvement of deaths “amenable to healthcare” – also linked to the surges of deaths in 2012-13 and 2015. It noted the change “may reflect the recent economic challenges facing the NHS and a period of sustained flat real term investment in the NHS”.

A study by Mr Harrison, Martin McKee and others said pressure in health and care services may be a cause, as has work by reputable management consultancy 2020 Delivery.

It is widely accepted that a combination of demand/activity growth (generally linked to the number of older people); severe cuts to social care and support services; and very constrained capacity in the NHS are causing major operational problems. We know that ill, vulnerable and older people are often not being looked after very well particularly in winter. It hardly seems surprising then if this has hit outcomes, including death.

This is also perhaps a reminder of what should be the core of the “seven day services” debate – what is the round the clock, round the calendar, ability of the health and care system to respond well to whatever is thrown at it?

And a reminder that the backdrop to the issue – as with several of today’s big policy problems – is the incredible extension of life in previous decades.

Another accepted fact – rehearsed in the annual excess winter deaths statistics and cold weather plan – is that there are many excess deaths each winter and that plenty are, at least theoretically, avoidable.

An inequalities issue?

Sir Michael and others who have raised these issues in recent years have also linked them to austerity beyond health and care services, to wider determinants of health and to social inequality.

Again the link to the recent patterns is uncertain but there are some things that are widely accepted.

The annual (and uncontroversial) cold weather plan is clear things like housing, heating, social support and financial means are factors in excess deaths. There is no disputing that areas with high health need have generally seen the deepest cuts to care and support services. More wealthy people and families are generally less reliant, if at all, on council funded care services that are faltering.

Of the many other potential causes in the frame for the unexpected mortality patterns, one is that rapid recent gains in cardiovascular disease mortality (particularly via smoking rates) are coming to an end. Fine – but there is still significant variation in cardiovascular mortality, and it is a bigger cause of early death among the poor. Interestingly, NHS England has turned its gaze back to heart attacks and stroke in recent weeks.

On a similar note, there is debate about whether England and other rich nations are reaching, for the time being at least, the limits of human longevity. But there is significant variation within the UK – we could pull our average up a long way by reducing health inequalities, including poor outcomes for people with certain disabilities, or some ethnic groups, for example.

Also, Sir Michael has pointed to other developed countries ahead of the UK and still improving – shouldn’t we at least try to chase them?

Finally, some people feel that in the population as in hospital, death is not a very useful indicator. Public Health England prefers to spotlight the 20 year wealth gap in healthy life expectancy – how long you live in good health, rather than how long you live.

Closer to home for the NHS in winter, there are significant deprivation gaps across many familiar measures: emergency admissions, emergency hospital bed days, and access to a GP. As David Buck at the King’s Fund highlighted recently, these gaps seem to be growing, not shrinking.

Update 13 October: Coincidentally, Greg Fell, Sheffield public health director, published a great blog yesterday considering the reasons for the wobbles in life expectancy and healthy life expectancy.