Intended for healthcare professionals

Feature Data Briefing

Death: avoiding the unavoidable?

BMJ 2016; 354 doi: (Published 14 September 2016) Cite this as: BMJ 2016;354:i4912
  1. John Appleby, chief economist
  1. Nuffield Trust, London W1G 7LP, UK
  1. john.appleby{at}

John Appleby examines the trends in death rates and what might lie behind them

What, as the leaders of the People’s Front for Judea could have asked, has healthcare ever done for health? The answer, as the Judean People’s Front have said is, quite a lot actually. But could it do more? According to the latest figures on deaths avoidable or amenable to current healthcare technologies the answer is yes. In 2014 an estimated 116 500 deaths (nearly a quarter of all deaths) in England and Wales could possibly have been avoided through health or public health interventions.1 This is now the second year in a row in which observed avoidable deaths have slightly increased—bucking a trend (apart from 2008) since 2001 (fig 1). Is this chance variation or the start of a new trend, one perhaps also reflected in a noticeable increase in overall deaths in 20152?


Fig 1 Trends in deaths that are avoidable, preventable, or amenable to healthcare intervention: England and Wales 20014-15 1

Part of the explanation for these increases is changes in the population and its demographic structure. Death rates (as opposed to absolute numbers) fell continuously between 2001 and 2013, although there was a very small, statistically insignificant rise in 2014.

What causes of death count as avoidable (or preventable or amenable) is not fixed. Various lists have been proposed—for example, Nolte and Mckee’s.3 Changes by the Office for National Statistics in the definition of avoidable deaths for 2013 and 20144 have also contributed to the apparent recent increases in deaths—the effect was statistically insignificant for avoidable deaths and a subset considered preventable but significant for those considered amenable to healthcare intervention.

Definitions aside, as is true of virtually every aspect of health and healthcare, estimates of avoidable deaths reveal wide variations across subgroups, regions, and countries. There were around 6000 years of life lost to avoidable causes of death for males in 2014, compared with around 4000 for females (fig 2), the difference largely due to cardiovascular diseases and injuries. And the north-south divide (or more accurately, above and below a line from Bristol to the Wash) once again is evident in a 1.5-fold difference in avoidable death rates between the south east and north east of England (fig 3).


Fig 2 Years of life lost from avoidable causes of death by sex and cause, adjusted for age, England and Wales, 20141


Fig 3 Age standardised avoidable deaths per 100 000 population by sex, region, and avoidable, preventable, and amenable causes, England and Wales, 20141

Internationally too, there are big differences in observed avoidable death rates—around fourfold at the extremes, between France and Estonia, based on 2007 figures (fig 4).5 Compared with other countries in the Organisation for Economic Cooperation and Development, the UK ranks 19th (out of 31).

More parochially, whether the observed increase from 2014 to 2015 in avoidable death rates represents a turning point remains to be seen. But as the Office for National Statistics has pointed out in relation to the 5.6% increase in overall deaths from 2014 to 2015,2 with older people making up an increasing proportion of the population the expectation is that this (and possibly the turn in avoidable deaths) presages further increases in future.

ONS definitions of deaths that are avoidable, preventable, and amenable to intervention

  • Amenable— a death is amenable (treatable) if, in the light of medical knowledge and technology at the time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided through good quality healthcare

  • Preventable mortality—a death is preventable if, in the light of understanding of the determinants of health at time of death, all or most deaths from that cause (subject to age limits if appropriate) could be avoided by public health interventions in the broadest sense

  • Avoidable mortality—All those defined as preventable, amenable (treatable), or both, where each death is counted only once; where a cause of death is both preventable and amenable, all deaths from that cause are counted in both categories when they are presented separately


Fig 4 International comparisons of avoidable deaths, OECD countries, 20075


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