BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k4050 (Published 27 September 2018) Cite this as: BMJ 2018;362:k4050 by Veena S Raleigh, senior fellow at the Kings Fund
The stalling of improvements in life expectancy in the UK since 2011, highlighted again in the most recent data,1 has prompted much comment and speculation about the causes. Longevity is the ultimate measure of health, and the flatlining of life expectancy after decades of steady improvement has unsurprisingly led to calls for action.2 The Department of Health and Social Care has belatedly commissioned a review by Public Health England (PHE).
The negative effect of post-2008 “austerity” on health, social care, and other public spending is cited as a potential cause in studies examining temporal associations between mortality trends and markers of NHS performance and public spending.34567 Other features of this complex mortality story also warrant consideration, including the parallels with what’s happening elsewhere.
Several high income countries have seen a slowdown in longevity improvements since 2010.89 As in the UK, the slowdown is greater at older ages, especially among women, and is driven by some similar causes of death (although the contribution of opioids to falling life expectancy in 2015 and 2016 is so far unique to the US).8 Two parallel but distinct developments warrant further consideration: an underlying deceleration in the rate of improvement affecting most ages, and periodic mortality peaks—mainly affecting older people—that compound the general slowdown.
The decelerating rate of improvement in mortality from cardiovascular disease is a substantial contributor to the steady slowdown in longevity improvements.89101112 The underlying causes are unclear and could include changes in risk factors such as obesity and diabetes and the diminishing effects of primary and secondary prevention strategies. In the UK, improvements have also slowed for several other causes of death—for example, chronic respiratory disease. Adding to the complexities of interpreting changes in cause of death is the rising proportion of deaths attributed to dementia and Alzheimer’s disease (resulting partly from diagnostic and coding changes), many of which are associated with other conditions.
Alongside this general slowdown are annual fluctuations in mortality, notably the sharp fall in life expectancy in many European countries in 2015 (which was greater in France, Germany, and Italy than in the UK), with a recovery in 2016.8 Such large, abrupt, and widespread increases in mortality followed by a recovery are unprecedented in recent years and suggest a common cause. Deaths from respiratory disease had an important role.8 The mortality monitoring agency EuroMOMO (www.euromomo.eu) reported excess winter deaths in 2015 across much of Europe, including the UK. Most of these were in older people and were attributed largely to flu, based on corroborative information on morbidity, the flu strain in circulation, and low efficacy of the vaccine.1314 The pattern of excess winter deaths reported for other years is also similar across much of Europe and points to the role of flu, pneumonia, and respiratory disease more generally in some years.
Understanding the underlying causes
In summary, the general deceleration in mortality improvements in many high income countries since 2010 has been compounded by periodic bad winters. The slowdown has different components, affecting different age groups and sexes differentially,10 but with some similarities across countries. Austerity probably hastened and caused some deaths in the UK, especially among elderly people. It doesn’t explain why similar mortality trends are seen elsewhere, and why the slowdown in, for example, Germany, Sweden, and the Netherlands—which experienced little austerity—has been greater than in Greece, Spain, Portugal, and Ireland, where austerity was most severe. The causes are likely to be multifactorial and need further deconstruction.
Unpacking the causes of the multiple concurrent changes is complex but essential for tackling the underlying drivers. Learning from international experience should be part of this. Furthermore, analyses that aggregate multiple years mask annual fluctuations in mortality that are key to understanding what’s happening in both “good” and “bad” years. For example, just as 2015 was a “bad” year in many countries, life expectancy in several countries including the UK increased sharply in 2014. This was possibly aided by 2014 being a benign year for flu, as reported by EuroMOMO.
Looking ahead, PHE and EuroMOMO report substantial excess winter deaths for 2017-18, largely attributable to flu, and deaths from flu and pneumonia were at or above epidemic threshold for 16 weeks in the US last winter, one of its longest flu seasons.15 Like 2015, 2018 could be a poor year for some countries, including the UK.
Annual mortality changes therefore need closer scrutiny, as do secondary causes of death—for example, comorbidities associated with dementia deaths and cardiovascular and other deaths precipitated by acute respiratory infections. The dataset for England linking hospital patient records with mortality records16 could provide additional, valuable insights into comorbidities and causes of death, including by deprivation level. The effect of widening inequalities on the mortality slowdown also needs closer examination. Timely analysis of such factors should become routine for PHE and the Office for National Statistics (ONS).17
The UK’s life expectancy is below that of many comparator countries, especially for women, for whom there has been no improvement since the slowdown started in 2011. Inequalities are widening, and the UK’s healthcare expenditure and resources are below those of comparator countries. Beyond learning from international patterns, PHE and ONS need to examine urgently why the UK’s life expectancy is falling further behind—including through collaboration with international agencies where appropriate.