Discussion and implications

What does the analysis tell us?

The improvements in mortality that have been seen over many decades in the UK have slowed or stalled since around 2011. While this slowdown is widespread among comparable high-income countries, it has happened at a greater rate in the UK than most others. As the UK does not compare well in terms of its absolute level of life expectancy, this is particularly concerning.

The population-level trends in the UK, which are driven by the older age groups as this is where most deaths occur, mask worrying trends in certain segments of the population. Women have a lower life expectancy than most comparable countries, and improvements have completely stalled in recent years, in particular in the most deprived areas, as too have improvements in mortality for the under 50s. In this respect, the UK differs from other European countries, where improvements continue to be seen in the younger adult population. This trend is being driven by deaths defined as ‘external causes of death’, including increases in drug-related deaths and suicides in the under 50s, with Scotland seeing rates of drug-related deaths that are comparable to the USA and Canada, which are a result of the opioid crisis in these countries. The increases in England and Wales however also need monitoring and urgent action to prevent further worsening.

Significant differences in mortality exist in the UK by socioeconomic deprivation, and these inequalities have been increasing over the period of the slowdown. While improvements in life expectancy have continued in the most advantaged groups, they have completely stalled in the most disadvantaged. This is widening the gap in life expectancy – in contrast to the narrowing observed prior to 2010. Inequalities also exist by geography, with differences in mortality rates and life expectancy across the UK constituent countries.

Understanding the factors shaping these trends will require an explicit focus on inequalities and subgroups of the population and those trends which, if left unaddressed, could increase mortality and inequalities. These include, but are not limited to:

  • obesity: the earlier onset of obesity and its associated comorbidities, and the widening inequalities in childhood obesity
  • smoking: the wide inequalities that persist and contribute to inequalities in mortality
  • misuse of alcohol and drugs: in particular in disadvantaged groups in parts of the UK.

Trends in mental health have rarely been mentioned in the debate about mortality stalling and demand more attention. Worsening mental health would be expected to affect several causes of mortality across the population. In particular, there needs to be a critical look at the role poor mental health may be playing in the cause of deaths that are found to be behind the stalling of improvements in life expectancy for younger adults.

The population’s health and mortality – and inequalities in these – are driven by social, economic, environmental and commercial conditions: the ‘wider determinants’ of health. These have complex interrelationships and act together to influence health. Thus, the slowdown – and in some cases complete stalling – of improvements in mortality in different population groups is not driven by any single causal factor. As there is no single cause for the slowdown, there will be no single solution – improvement will require a whole-government approach to the wider determinants of health.

What does this mean for government policy?

A healthy population is essential for other aspects of social and economic progress – as recognised by the Ageing Society Grand Challenge in the English government’s Industrial Strategy: to ensure that people can enjoy at least five extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest.

Indeed, a population’s health outcomes can serve as a success measure for government policy – in parallel to, and on an equal footing with, measures of GDP. Given the long lead-in time between decisions that shape people’s health and their impact on outcomes, viewing health outcomes in this way would precipitate an approach to policymaking that is more future focused and takes a broader, longer-term view of the action needed to improve the health of the population.

The UK has a good starting point. The independent ONS, which is responsible for collecting, analysing and disseminating statistics about the UK population, society and economy, ensures the provision of reliable and independent data. The public health bodies across the UK governments can provide expert advice on the action required. However, there is a lack of clarity over where responsibility lies to act and an absence of the necessary levers and mechanisms for identifying and taking aligned action across government.

If UK governments are serious about addressing the situation, particularly for the most affected and most vulnerable groups, this will require an independent body with responsibility for:

  • regular and consistent analysis of the factors that influence mortality in different population groups, and the complex interrelationships between these
  • regular and consistent independent tracking of future opportunities and risks to people’s health, to understand what is likely to influence mortality trends in the future
  • public reporting of these trends on a regular basis, in an accessible and understandable format.

To drive the action needed, accountability structures and mechanisms for cross-government action and long-term decision making are needed. The Health Foundation’s recent report on embedding long-term action for health across the whole of government suggested a number of mechanisms for achieving this, one of which was an independent or semi-independent public body, able to scrutinise government policy and provide independent, expert analysis. The model for this could be based on examples such as the Future Generations Commissioner in Wales, the Children’s Commissioner for England and the Office for Budget Responsibility for the UK. Such a body could be responsible for the timely monitoring of data on mortality and drivers of mortality, and communication to policymakers, together with commentary on the policy action needed.

No government wants to see life expectancy of its population fall. However, the risk of this happening – particularly within specific subgroups of the population – is very real and will only be prevented through coordinated, wide-ranging, long-term action led from the centre of government.

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