Increase in life expectancy in England has halted, new figures show
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3473 (Published 18 July 2017) Cite this as: BMJ 2017;358:j3473
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In the BMJ 22 July 2017 page 129 in seven days in medicine Gareth Iacobucci refers to the dwindling resources available to the NHS. He writes, “We have made a political decision to reduce the proportion of our national income that goes into public expenditure”. For many people this affects the standard of treatment they can expect form the NHS. Iacobucci also writes that leading causes of death are dementia and Alzheimer’s disease. The insoluble dilemma is that if we find an answer to these two diseases, something else will kill us. Life, as we understand it, is a uniformly fatal disease, and we naturally find that unacceptable.
Joseph Lister discovered the beneficial effects of Carbolic Acid in preventing post operative sepsis and his first article on this, ‘On a New Method of Treating Compound Fracture, Abscess, etc., with Observations on the Conditions of Suppuration’ was published in The Lancet, 1867, Vols i and ii. The paper deals with the stormy course and eventually successful outcome of several cases of surgical sepsis. The careful application of nitric acid and then carbolic acid was practised with wonderful results but with no idea of the microscopic cause of the suppuration. The reception by other surgeons of his antiseptic method was sluggish and sceptical to say the least, as Sir Rickman Godlee’s biography of his uncle, Lord Lister, makes clear’. (Lord Lister by Sir Rickman John Godlee, Bt. Third Edition, Oxford at the Clarendon Press 1924)
Pasteur made clear the bacterial cause of putrefaction and laid the basis for aseptic surgery replacing Lister’s antiseptic technique. Today this is universally accepted but life still remains a fatal disease and we are faced ever more uncomfortably with this fact, even if less terrifying than the suppuration of Lister’s day.
Bacteria are microscopic at one level but beyond them lies the even more mysterious ultra-microscopic quantum world. Resuscitation techniques have made near death experiences (NDE’s), or in other words the experience of ‘life’ after death, more common, but as in Lister’s day his reports of the effects of antiseptics were met with scepticism, so are today’s reports of NDE’s, and thus have little influence on medical practice. The study and increasing understanding of the nature of ultra-microscopic structure of the brain itself may help to undermine this scepticism and make it easier view death as non fatal and less terrifying.
Sir John C. Eccles in his short book ‘How the SELF controls ITS Brain’. (Springer-Verlag 1994) and especially in chapter 9 by him and F. Beck, (a quantum physicist and Head of the Theoretical Nuclear Physics at the Technical University of Darmstadt) makes clear the quantum world is not subject to entropy, the second laws of thermodynamics. Eccles and Beck suggest that consciousness, the formation of the will, is the product of the quantum receptors in the cerebral cortex, linking the entropic world of the physical brain with the timeless, space-less and ‘energy free’ quantum world, or in more ordinary language the spiritual world, which we experience after death of the body. With death we become like photons, our ‘mass’ disappears and we become subject to the laws of probability and timelessness. As Schrödinger points out the ‘ψ’ (psi) wave function needs to be multiplied by its conjugate, before it enters existence. Up until then, like Schrödinger’s cat, its existence is a balance of probabilities. When people leave their bodies it is not possible to say of what they are made. They seem to be made of pure consciousness, a state of perfect health without bodily aches or pains, a wonderful solution to the problems of the death of the body faced by the creaking apparatus of the NHS. It just needs to be more widely believed, and the consequences applied.
Competing interests: No competing interests
We must applaud Prof. Sir Michael Marmot and his team for highlighting the inevitable result of austerity and unforeseen cuts seen in the NHS and social care funding. This comes at a time when the NHS has been considered to be the overall best health system. Ironically, it struggled in achieving an acceptable rank in health elated outcomes.
A toxic mix of reduced funding, increased demand and recruitment issues across the National Health Service will have its consequences. In our endeavour to achieve an increasingly difficult task of 'making do' with the resource we have, the commissioners are left with no option but to reconfigure the services. Often, this means reducing capacity, rationing and/or provision of service with less skilled workforce. This can be easily supported by rewritten contract specifications and key performance indicators which assure quality at a very superficial level, if at all, and may or may not have any meaningful relationship to the delivery of care. The life expectancy does not tend to be one of them and, sadly, harm is not always measurable.
The public is consulted but can be consulted in a way that may or may not provide the real picture of the future of that service. The funding squeeze experienced by the health services also has a disproportionate impact on deprived areas as per the inverse care law. This appears to be exacerbating the inequalities that already exist. Life expectancies in these deprived communities already are lower than the rest of country, and it is a gross injustice and shameful to let these inequalities get worse.
Competing interests: A GP partner in one of the very deprived areas of the country. Vice chair, South Durham Health CIC - a GP federation of 23 practices. Vice chair, County Durham and Darlington LMC. A GP trainer and appraiser
Re: Increase in life expectancy in England has halted, new figures show
Iacobucci1 and Public Health England2 recently reported that the trend of increasing life expectancy has slowed and highlighted possible links to austerity. Whilst there is no indication of the statistical significance of the turnover in this trend2, even if we accept it on face value, it still leaves the question of what do we really mean by life expectancy?
Life expectancy indicators can easily be misunderstood. They are created by taking account of the mortality rates today and asking, if they didn’t change, how long would a child born today live. As such it does not actually represent the number of years a person could expect to live, but reflects mortality among those living in a specific area and time-period3. Therefore, it is simply a summary population health measure giving an overview of the current mortality of an area. It is this subtle distinction that is often missed and one that makes life expectancy estimates not particularly helpful to health and social care planners.
An alternative approach might be to look at trends in the actual ages people die and project them forward. This is different to life expectancy in that the age of death is a real measurement of a persons end state incorporating their whole life experience, whereas the life expectancy estimate is simply a number representing a snapshot of the current health of the population. If life expectancy increases then we can say the current overall health of the population today has increased, but not that we would realistically expect a child born to live any longer. However, a projection of the average age of death would incorporate historical data and use it to estimate future trends.
We have used ten years of mortality (2006-2016) and demographic data to estimate and model trends in the average recorded age of death, taking into account expected deprivation and sex inequalities. We then use this model to project the average age of death into the future to give a more easily interpretable estimate of the likely burden of an aging population on health and social care services.
Looking at the data, we find that, across the Dorset, Bournemouth & Poole authorities (population of around 750,000), the average age of death has been steadily increasing over the last 10 years and is higher for women (83 years) than men (78 years). Additionally, there exists a gap in the average age of death between the most and least deprived areas (9 years for men, 6 years for women). There has been little change in this gap from 2006 – 2016.
After applying a simple linear regression model, we are able to confirm the significance of the above findings. We also uncover and quantify an interaction between males and deprivation, indicating deprivation has a more profound effect on men (13 years between most deprived males and least derived females). Examining the data-model residuals, we note they are not significantly different from zero (R2=0.92), indicating the model fits the data well and allowing us to project the average age of death into the future. By 2036 we estimate a female and male average age of death at 88-82 years and 85-79 years respectively (least to most deprived quintile, 95%CI±2 years). The most recent data from PHE4 suggests that, across Dorset, Bournemouth & Poole, the average life expectancy at 65 is 19 and 22 years for males and females respectively. This gives a theoretical life expectancy of 84 for males (dying in 2034), compared to a projected average age of death of 81, and 87 for females (dying in 2037) with a projected average age of death of 86.
The average age of death is in essence a retrospective health measure representing the impact a lifetime of accumulated risks/behaviours and the associated social-demographic status has on a populations final years. This suggests that without the possibility of social-mobility, of those spending most of their time in more deprived areas, the impact of deprivation on health will be felt most severely by men. Any policies that increase poverty and further restrict social-mobility will only serve to exacerbate this phenomenon. In this respect, we are in agreement with Marmot on the potential harmful effects of austerity.
Finally, this alternative average age of death population health indicator is potentially more easily interpretable and meaningful to health and social care planners than the traditional life expectancy measure.
Yours faithfully,
David Lemon & David Phillips
Public Health Dorset
References
1. Iacobucci, G. Increase in life expectancy in England has halted, new figures show. BMJ 2017;358:j3473
2. Public Health England, Health profile for England, July 2017, https://www.gov.uk/government/publications/health-profile-for-england
3. ONS, National Life Tables, United Kingdom: 2012-214, 2017 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...
4. Public Health England, Public Health Outcome Framework, http://www.phoutcomes.info/
Competing interests: No competing interests