Until recently the trend in mortality over the last 100 years in England had been relatively clear: since World War 1 every decade has seen people living longer than before. But since 2011 improvement in mortality rates and life expectancy in England has slowed down considerably for both men and women. For some age groups, and for some parts of England, improvement has stopped altogether.
There has also been an increase in the number of deaths in some recent winters. Excess winter deaths in 2017 to 18 were the highest in over 40 years.
To understand what is happening, PHE were commissioned by the Department of Health and Social Care (DHSC) to undertake a review of trends in life expectancy and mortality in England, with a particular focus on the number of deaths in some recent winters and the slowdown in mortality improvement. This review has now been released.
So what are the factors behind these trends?
A slowdown in improvement in mortality rates for heart disease and stroke
Reductions in mortality from heart disease and stroke, which are leading causes of death, have historically driven improvements in life expectancy. Since 2011, there has been a slowdown in improvement in mortality rates for these causes which has therefore had a large impact on the trend in life expectancy. This slowdown has also been seen across many other countries.
Over 84,000 people die from heart attacks or strokes each year, and one in four of these are happening in people less than 75 years of age. Up to 80% of these premature heart attacks and strokes are avoidable and this highlights the importance of focusing on preventative interventions such as stopping smoking, getting more physically active and lowering blood pressure and cholesterol levels.
Stepping up efforts to reduce the risk of heart disease and stroke will also mean addressing the underlying wider determinants of health.
Increases in winter deaths
There was a large increase in the number of deaths in the winters of 2014 to 15, 2016 to 17 and 2017 to 18. These increases were also seen across many other European countries and coincided with circulation of the flu subtype A(H3N2), known to predominantly affect older people. The review also shows that, in 2015, hospital admissions for flu increased at the time of the mortality increase.
The flu vaccine is one of the most effective ways of preventing flu although vaccine effectiveness has varied in recent years. Recent evidence of reduced flu vaccine effectiveness in older people has led to changes in the type of vaccine offered to this group.
There has been a substantial shift in the age structure of the population in recent decades: the number and proportion of people at older ages has increased. There are likely to be more people living with dementia and other long-term conditions that may make them particularly vulnerable to the effects of flu and other winter risk factors, and who may be particularly reliant on health and social care services.
Although respiratory diseases, including flu, are one of the leading contributors to excess winter deaths, there are also more deaths from heart disease and stroke and dementia in the winter months.
Low temperature can be a risk to all age groups, but risks are greatest in older people and young children. People with conditions like dementia are also at risk as they may be less aware that they need to change their behaviour to stay warm.
Recent winter peaks in mortality have contributed to the slowdown in mortality improvement since 2011. However, the review found that improvement in mortality rates for the non-winter months has also slowed in recent years.
No improvement in death rates in young adults
While flu, heart disease and stroke have partly determined the trend in mortality rates in older adults, other causes of death have influenced the trend in younger people.
Mortality rates among younger adults made almost no positive contribution to trends in life expectancy between 2011 and 2016, despite making small positive contributions in earlier years. The cause of death that had the biggest negative impact was accidental poisoning, with 70% of these deaths due to drug misuse and 10% due to alcohol.
Inequality in life expectancy has widened, and since 2010 to 2012 improvement in life expectancy has been slower in the more deprived areas than the less deprived areas of England. In addition, female life expectancy in the most deprived areas has actually decreased. Therefore, the causes of the slowdown in improvement are having the greatest impact in the more deprived areas.
What conclusions can be drawn?
The main findings from the review suggest that the overall slowdown in improvement is due to factors operating across a wide range of age groups, geographies and causes of death. It has also been seen, to some extent, in many other countries. However, it is not possible to attribute the recent slowdown in improvement to any single cause and it is likely that a number of factors, operating at the same time, need to be addressed.
The review summarises work done by others on the association between changes in health and social care provision and trends in mortality. This is one area where further work would be required to understand any potential causal mechanisms which may be operating within England and across different countries.
The analysis shows the importance of stepping up efforts to reduce the risk of heart disease and stroke and address the increase in deaths due to accidental poisoning in younger age groups.
The review also highlights the need to support the most vulnerable, particularly older people, to reduce the impact of poverty, cold winters, and diseases such as dementia and flu.
In the future
According to the Health Profile for England 2018, the slowdown has not been observed for long enough for statistical analysis to determine whether it will continue. The future trend is uncertain for both sexes but PHE will continue to closely monitor trends in mortality rates and life expectancy in England.