Introduction

 

The Health Foundation aims to improve the health of people in the UK by learning what works to make people’s lives healthier and improve the health and care system. Mortality rates, and the length of time that people live in good health, are critical measures of how well a country is doing. Mortality rates in a population are driven by a broad range of factors, which are largely outside the control of individuals. The strongest influences on people’s health are the social, economic, commercial and environmental conditions in which they live: the ‘wider determinants of health’. Thus, governments need to be accountable and responsible for creating the conditions that can enable everyone to live healthy lives.

Tracking and understanding trends in mortality sheds light on the impact of national and local policies and can inform future planning. A better understanding of the drivers of mortality and inequalities in life expectancy will point to where action needs to be taken, what should be monitored to help foresee future changes in mortality, and what care needs may arise.

There is growing concern about recent mortality trends in the UK. The improvements seen over many years are slowing and even stalling in some segments of the population. Attempts to understand what is happening have led to extensive debate about the causes, but few widely accepted answers. While this is perhaps not surprising given the complexity of the factors shaping people’s health and mortality rates, it is important to build a fuller analysis of the factors behind these changes and whether these trends are likely to continue in the future.

There is no single lens through which to understand and interpret trends in a nation’s mortality. Changes over time are important, but so too are the absolute and relative differences between countries and groups (as defined by geography, sex, ethnicity or socioeconomic status) within a country.

Given that the UK has a lower life expectancy than many countries considered to be comparable in terms of their population structure and socioeconomic circumstances, getting to grips with what is happening is particularly important (Figure 1). As Figure 1 shows, women in the UK are doing particularly badly, both in terms of their absolute life expectancy of 83.1 years (in 2017), which puts them towards the bottom of the rankings, and that they fell down the rankings between 2000 and 2017 (indicated by the distance between the blue and red dots in Figure 1). Only the USA remain significantly lower than the UK at the end of this period. While Denmark sits below the UK in terms of absolute life expectancy, women in Denmark have experienced a much greater improvement over the 21st century, and have caught up with the UK. The picture for UK men relative to other countries is better, but there is still much room for improvement from their 2017 level of 79.5 years.

Figure 1: Changing period life expectancy at birth by sex: selected countries, 2000–2017

Source: OECD, Health indicators dataset.

In response to the debate about mortality trends, the Health Foundation commissioned a team at the London School of Economics (LSE) and Vienna Institute of Demography (VID), led by Professor Michael Murphy, to carry out a literature review of previous research, plus new analyses into mortality trends. The aim was to provide an in-depth picture of what is happening, and a comprehensive critical assessment of the multiple potential drivers of recent trends. The research is the first in a series of research commissions over the coming years to explore current and underexplored population health issues.

Building understanding about mortality trends and drivers is particularly relevant to two large programmes of work at the Health Foundation, both of which aim to inform a long-term approach to improving health and care in the UK:

  • the Health Foundation’s ‘Healthy Lives’ long-term strategy to improve people’s health in the UK, which aims to focus policy attention on the wider determinants of health and support long-term action on these to improve health and address inequalities
  • a new specialist unit being set up by the Health Foundation working with academic partners across the UK to provide independent projections, research and analysis to help ensure the long-term sustainability of health and social care in the UK. The aim of the unit is to bring about more evidence-based policymaking and a shift in focus towards long sustainability.

This briefing paper is based on the research by Murphy et al. but also draws on other sources, including the review of mortality trends the Department of Health and Social Care commissioned Public Health England to carry out in 2018, and Health Foundation analysis. The Public Health England review was carried out in parallel with the early stages of this research and is referenced in this briefing and full research report by Murphy et al. This briefing focuses on themes of particular interest to the Health Foundation. The full report is available online from the LSE.

Over the 20th century in the UK, mortality rates fell in both sexes, at all ages. Successive cohorts born over this period experienced improvements in survival (Figure 2, which includes cohorts born in the recent past, for which the dashed portion of the survival curves are projections based wholly on assumptions). Of those born around the beginning of the 20th century (1905 cohort), 62% survived to age 60, increasing to 89% of those born mid-century (1955 cohort). This was due to a combination of reasons. Big gains were made in infant survival in the first half of the 20th century, followed by advances in infectious disease control that helped to increase survival rates throughout adult life. In more recent decades, improvements in cardiovascular disease (CVD) mortality through a combination of health care improvements, reductions in smoking and occupational changes have helped improve the proportion of cohorts reaching older ages, with the majority of further improvements in survival rates for younger cohorts anticipated to continue at older ages in future.

Figure 2: Survival curves: England and Wales, selected cohorts 1905–2005

Source: ONS, 2016-based England and Wales lifetable.

Note: - - - denotes projection.

These improvements in mortality led to improvements in life expectancy (derived from mortality data, see definitions in section 2) throughout the 20th century and into the first decade of the 21st (Figure 3). This has been the case in all UK constituent countries, although it is notable that absolute life expectancy differs between countries, England and Wales having the highest life expectancy throughout the period, followed by Northern Ireland, and life expectancy being lowest in Scotland.

Since 2010–2011, mortality improvements have significantly slowed or completely stalled in both sexes and in all constituent countries of the UK, and socioeconomic inequalities in mortality have been reported to be widening. In addition, high mortality in 2015 compared with 2014 caused the largest fall in period life expectancy since the early 1970s. Questions have been raised by academics, policymakers, actuarial analysts and public health experts about the factors that have caused such an apparent deterioration in mortality trends, and about the extent to which the changes are temporary or likely to continue. Finding answers to these questions will have important implications for future policy, pensions and service planning. It will also help to identify action required to foresee and minimise further slowdown or stalling of mortality improvements and widening of inequalities in life expectancy.

Figure 3: Period life expectancy at birth: constituent countries of UK by sex, 1950–2016

Source: Human Mortality Database; calculations by Murphy, Luy and Torrisi.

What is driving these changes?

There has been insufficient reflection on the complexity of the drivers of mortality trends in the academic and media debate. Conflicting views have been expressed about the relative importance of potential underlying causes. Some contributors to this debate have focused narrowly on the recent changes, without setting the trends in a longer-term or global context. Others have conflated the longer-term trend of stalling improvements in mortality with the observed peaks in mortality, particularly the high levels of excess winter mortality in 2015 and 2018. Most have taken a very narrow view of drivers, addressing them in isolation, and much of the debate on links to austerity has been limited to health and social care cuts. In some cases, attempts have been made to estimate exactly how many deaths may have been attributable to austerity, without always being entirely clear how these estimates were reached or the justification for assumptions made.

The evidence base is therefore limited and inconclusive. The recent Public Health England review of trends in mortality in England concluded that rather than being attributable to any single cause, the slowdown in improvement is likely to be the result of a number of factors operating simultaneously across a wide range of age groups, geographies and causes of death. The Health Foundation concurs with the conclusions of the Public Health England report. A deeper recognition and understanding of the complexity of the factors shaping mortality is now essential if effective policy and action to improve mortality and reduce inequalities are to be identified.

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