Rise in mortality in England and Wales in first seven weeks of 2018
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1090 (Published 14 March 2018) Cite this as: BMJ 2018;360:k1090
All rapid responses
In an editorial in March, we raised concerns that more than 10,000 extra deaths had occurred in the first 7 weeks of 2018, compared to the average of the last 5 years.(1) As mentioned in a previous rapid response,(2) Jeremy Hunt was asked on 20th March 2018 in the House of Commons: ‘During the first seven weeks of 2018, 10,375 more people died in hospital than in the same weeks in the previous five years…Why did all these extra deaths occur?’
The Secretary of State for Health and Social Care replied:
‘As the hon. Gentleman will know, these figures cover England and Wales. He will also know that they do not take account of changes in population or changes in demography, so we use the age-standardised mortality rate, which, according to Public Health England, has remained broadly stable over recent years.’(3)
The response from a spokesperson for the Department of Health and Social Care to our concerns when the excess deaths had reached 20,000(4) on 8th May 2018 was similar:
“We keep all research in this area under review, but the ‘age standardized mortality rate’ - which has been broadly stable in recent years - is considered a much more reliable measure, as this type of research doesn’t take into account fluctuations in population numbers and the ageing population.”(5)
The Quarterly Mortality report from the Office for National Statistics (ONS) published on Monday confirms our fears.(6) It states:
‘The age-standardised mortality rate for deaths registered in Quarter 1 2018 was 1,187 deaths per 100,000 population – a statistically significant increase of 5% from Quarter 1 2017 and the highest rate since 2009’.
Figure 1 from ONS shows how remarkable this is:
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...
The ASMR has risen by 5%. So, once again, we repeat: how many deaths will it take for the Government to take note?
References:
1. Hiam L, Dorling D. Rise in mortality in England and Wales in first seven weeks of 2018. BMJ 2018;360:k1090 https://www.bmj.com/content/360/bmj.k1090
2. Hiam L, Dorling D. Re: Rise in mortality in England and Wales in first seven weeks of 2018. BMJ 2018;360:k1090 https://www.bmj.com/content/360/bmj.k1090/rr-4
3. House of Commons Hansard. Topical Questions, 20 March 2018. https://hansard.parliament.uk/commons/2018-03-20/debates/3E71DB83-CDBA-4... (accessed 19 June 2018)
4. Hiam L, Dorling D. Re: Rise in mortality in England and Wales in first seven weeks of 2018. BMJ 2018;360:k1090 https://www.bmj.com/content/360/bmj.k1090/rr-8
5. Iacobucci G. Government must investigate rising excess deaths in England and Wales, experts warn. BMJ 2018;361:k2127
6. Office for National Statistics. Quarterly Mortality Report, England: January to March 2018. 18 June 2018. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 19 June 2018)
Competing interests: No competing interests
It may be relevant in relation to the concerns of Lucinda Hiam and Danny Dorling [1] to return to Donaldson et al's [2] answer to a query of Tony Delamothe published on Christmas Eve 2009:-
"The official estimate of influenza mortality is produced by the
Health Protection Agency. It is derived from excess all-cause death
registrations in the winter. When the number of all-cause death
registrations rises above an ‘expected’ level in a given week, this excess
is counted. The estimates for the last five years in England & Wales
are: 1965 (2004-05 winter season), 0 (2005-06), 0 (2006-07), 426 (2007-
08), and 10351 (2008-09) . The highest estimate in recent years was for
the 1999-2000 ‘flu season, at 21,497.
"This method has its limitations. It captures the numbers of deaths
‘above expected’, but does not examine causation directly....
"A second estimate of ‘flu deaths is found in the annual mortality
statistics produced by the Office for National Statistics. These
statistics record the underlying cause of death. They are based on all
registered deaths, based on the information on death certificates. The
number of deaths for England & Wales with an underlying cause of
influenza (ICD-10 code J10-J11) for the four recent calendar years are: 39
(2008), 31 (2007), 17 (2006) and 44 (2005)..."
It looks as if the Department of Health have never been on solid ground in explaining fluctuations in the death rate on influenza, which according to death certificates may also never have been very great. The comforting aspect of this is that what Hiam and Dorling are drawing attention to is possibly not new - perhaps we have just have had a a few years in which we have escaped the effect. On the other with the Department of Health having failed to provide any causal explanation of these fluctuations we still do not why they happen or know how they could possibly be avoided. Of course, it could become another issue if these high mortality rates continued throughout the whole of 2018.
[1] Hiam L, Dorling D, 'Rise in mortality in England and Wales in first seven weeks of 2018.' 360:doi 10.1136/bmj.k1090
[2] Donaldson et al, 'Author's response' BMJ Rapid Responses, 24 December 2009, https://www.bmj.com/rapid-response/2011/11/02/authors-response-17
Competing interests: No competing interests
Not for the first time I have to point my finger at NHS ENGLAND.
They adopt facultative blindness and deafness when they are confronted with embarrassing questions.
But the questions won’t go away.
Similary I accuse NHS England of ignoring the Lyme Disease questions from VIRAS (please see the rapid responses).
And NHS England ignore the questions on imm and vac raised by many, including myself.
Competing interests: No competing interests
I share the concerns of Hiam and Dorling [1,2] both about the unaccountable phenomenon they describe and the lack of official response. On a parallel basis I have recently been trying to draw attention to the catastrophic explosion of Special Educational Needs and autism among pre-school and school age children across the UK and have been met with similar silence [3,4,5, 6,7].
[1} Hiam L, Dorling D, 'Rise in mortality in England and Wales in first seven weeks of 2018.' 360:doi 10.1136/bmj.k1090
[2] Hiam L, Dorling D, 'Re: Rise in mortality in England and Wales in first seven weeks of 2018', 8 May 2018 https://www.bmj.com/content/360/bmj.k1090/rr-8
[3] John Stone, 'Re the NHS must prioritise health of children and young people - what about autism', 19 March 2018, https://www.bmj.com/content/360/bmj.k1116/rr
[4] John Stone, 'The government must face up to the autism pandemic, and so must the RCPCH', 26 March 2018, https://www.bmj.com/content/360/bmj.k1116/rr-0
[5] John Stone, ' Re: The government must face up to the autism pandemic, and so must the RCPCH', 1 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-2
[6] John Stone, 'The hidden crisis - where are the government and RCPCH, and what is their explanation?' 6 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-4
[7] John Stone, 'The worst figures of all - 600% rise in additional support in a decade in Scottish schools', 13 April 2018, https://www.bmj.com/content/360/bmj.k1116/rr-5
Competing interests: No competing interests
We recently wrote an editorial in the BMJ repeating many previous calls for an investigation into rising deaths in England and Wales.(1) By week 7 of 2018, 10,000 more people had died than the average of the last five years. We showed that neither ‘flu, nor cold weather appeared to be the main cause.
The latest Office for National Statistics data on weekly provisional deaths in England and Wales sadly provide little reassurance of this being a ‘blip’ as some have suggested. By the end of week number 16 (week ending 20 April), 20,215 more people have died than the average for the last 5 years.(2) Yet, still, no action taken or even mention of a possible investigation has been heard from the Department of Health and Social Care. How many deaths will it take for the Government to take note?
References:
1. Hiam, L. Dorling, D. Rise in mortality in England and Wales in first seven weeks of 2018. BMJ 2018;360:k1090
2. Office for National Statistics. Weekly provisional deaths for England and Wales. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (last updated 1 May 2018; accessed 7 May 2018)
Competing interests: No competing interests
Hiam and Dorlings [1] editorial and analysis is a welcomed contribution and timely prompt to keep the focus on the worsening health outcomes across England and Wales. Whilst evidence suggest life expectancy is likely to reduce for men and women in the United Kingdom (UK) [2], alongside a rise in infant mortality in the poorest families [3], it is critical attention remains focused on a key potential cause, austerity driven policy measures, especially for those in poverty.
One element of maintaining health outcomes for the population is a substantial Public Health programme to tackle the rise and financial burden of lifestyle related diseases such as obesity. Part of this programme, would be underpinned by the promotion of physical activity and healthy lifestyles. Sport is one possible vehicle for the promotion of physical activity, healthy and active lifestyles [4, 5, 6]. Yet within England, sport and leisure services and in turn opportunities have received unprecedented funding cuts [7].
Budgetary constraints in local authorities between 2008-onwards have subsequently resulted in an expenditure decrease for non-discretionary services including sport development and community recreation. This area of expenditure forms one component of sport-related services and primarily focuses on raising participation in ‘hard-to-reach’ groups. Research by Widdop et al [8] found that policy goals associated with raising and widening participation were not met to any significant degree between 2008 and 2014 as participation levels have changed little for lower income ‘hard-to-reach’ groups. These outcomes are potentially in part due to austerity measures reducing local authority expenditure.
As noted earlier, sport and physical activity can help contribute to reduced lifestyle related diseases and in turn, the associated financial burden of such diseases for the National Health Service. The economic constraint because of austerity driven policy measures by local authorities, not only appears to illustrate an example of a false economy, but also suggests that the cuts hit those in poverty most. Taking stock, as western countries seem to be recovering from the 2008 economic recession [9], austerity policies are still very much in place, and their impact will most likely continue to influence the lives of people, especially those in poverty, long after such policies are relaxed [10]. As such, there is little doubt that this editorial and analysis serves as welcomed encouragement for additional multidisciplinary research into the impact of austerity driven policies, now and into the future, especially for underserved groups such as those in poverty.
References –
1. Hiam L, Dorling D. Rise in mortality in England and Wales in first seven weeks of 219. BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1090 (Published 14 March 2018) Cite this as: BMJ 2018;360:k1090
2. Dorling D., Gietel-Basten S. Life expectancy in Britain has fallen so much that a million years of life could disappear by 2058. Why? The Conversation, 29 Nov 2017. https://theconversation.com/life-expectancy-in-britain-has-fallen-so-muc...
3. Taylor-Robinson D, Barr B. Death rate now rising in UK’s poorest infants. BMJ2017;357:j2258. doi:10.1136/bmj.j2258
4. Parnell D, Pringle A, Zwolinsky S, McKenna J, Rutherford Z, Richardson D. Reaching older people with physical activity delivered in football clubs: The reach, adoption and implementation characteristics of the Extra Time programme. BMC Public Health 2015; 15: 220.
5. Milanović Z, Pantelić S, Čović N, et al. Broad-spectrum physical fitness benefits of recreational football: a systematic review and meta-analysis British Journal of Sports Medicine 2018. doi: 10.1136/bjsports-2017-097885
6. Hunt K, Wyke S, Gray CM, et al. A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. The Lancet 2014;DOI: 10.1016/S0140-6736(13)62420-4
7. Parnell D, Millward P, & Spracklen, K. Sport and austerity in the UK: An insight into Liverpool 2014. Journal of Policy Research in Tourism, Leisure and Events 2015; 7(2), 200–203;DOI: 10.1080/19407963.2014.968309
8. Widdop P, King N, Parnell D, Cutts D, & Millward P. Austerity, policy and sport participation in England. International Journal of Sport Policy and Politics 2017; 10(1) 7-24; DOI:10.1080/19406940.2017.1348964
9. Cantillon B, et al. 2017. Children of austerity: impact of the great recession on child poverty in rich countries. Published by The United Nations Children’s Fund and Oxford University Press.
10. Haudenhuyse H. The impact of austerity on poverty and sport participation: mind the knowledge gap. International Journal of Sport Policy and Politics 2017; 10(1) 203-213; DOI:10.1080/19406940.2017.1406975
Competing interests: No competing interests
Let us gather (at modest cost to the public) the best minds in British Public Health (I'll give you the list) so that we (sorry, they) can point out where the government is going wrong; all free from political bias (don't worry, I've checked) although it might be suggested it was us (sorry, them) who got us here in the first place.
Competing interests: No competing interests
Working as a GP in the most deprived practice in Sheffield we see the effects of austerity and poverty first hand. Surely increasing inequalities and poverty are the drivers of the increased mortality rates highlighted by Dr Hiam and Prof Dorling? I thank them for this excellent Editorial which adds to the evidence we need to highlight the challenges for our vulnerable patients.
Our Health visitors and District Nurses (crucial in any primary care team but even more so for deprived communities) have been taken out of our practices. No longer can we easily have our team meetings with trusted colleagues or those 'kettle' conversations so valuable to maintain our resilience and share knowledge. We are struggling to get help from specialist mental health services as their budgets have been cut. We need trauma therapists for our patient's complex problems resulting from violence and abuse not just CBT. We would welcome investment in our 'Team' approach so crucial when working in deprived areas.
Sexual health and contraception clinics have been closed. We would welcome research on the effect of this on teenage and unwanted pregnancies - surely a false economy if not morally wrong? Due to increasing workload we are struggling to maintain continuity for our patients: again a false economy.
The misery of the increased rates of physical health problems and early death due to poverty are desperately sad for our patients and at times overwhelming for us to help reverse. There is so much evidence already about the causes of health inequalities and description of their effects, what we need now are funds to support communities suffering from poverty and a health select committee could explore solutions rather than just looking for the causes ... don't we know them already?
Competing interests: No competing interests
On 20th March 2018, speaking in the House of Commons, Dr Paul Williams MP referred to this editorial. He asked the Secretary of State for Health and Social Care, Jeremy Hunt, ‘why did all these extra deaths occur?’.1 Mr Hunt replied:
"As the hon. Gentleman will know, these figures cover England and Wales. He will also know that they do not take account of changes in population or changes in demography, so we use the age-standardised mortality rate, which, according to Public Health England, has remained broadly stable over recent years.1"
To take each point in turn, firstly, the Secretary of State is correct: these figures do cover England and Wales. However, this distinction is trivial. If the figures for weekly provisional deaths by ‘region of usual residence’ are used, the total for Wales is 5,841 for weeks 1-7 of 2018, and the average for the last 5 years 5166.2 England deaths, therefore, are 88,149 compared to a 5-year average, without Wales, of 78,449. This gives an extra 9,700 deaths in England. These Office for National Statistics (ONS) data are available to the Secretary of State and his advisors if they wish to know about trends solely in England.
Secondly, a change in population or demography does not happen suddenly. However, we agree it would be useful to examine the age-standardised mortality rate. Given the gravity of the concerns raised, we hope Public Health England will urgently calculate this, using the ONS projection of the population at risk in 2018,3 to compare what was expected in 2018 to what has been seen. We do not believe this will alleviate our concerns. The ONS projections do not include a sudden very large influx of elderly people, and there is no evidence that this has occurred.
Finally, last week saw publication of statistics not only raising the alarm at mortality rates in adults, but also in infants. Infant mortality has risen two years in a row.4 This confirmed the concerns first raised by Taylor-Robinson et al in 2017,5 and re-iterated in their rapid response.6 Among countries of the European Union, between 1990 and 2015 the UK dropped from 7th place to 19th for neonatal mortality, and from 9th to 19th for under-five mortality.7
Infant mortality is rising, life expectancy is stalling, and there have already been 9,700 extra deaths above what is usual in England in the first 7 weeks of 2018. This leaves us wondering—what will it take for the Government to investigate? We hope the Secretary of State for Health will significantly and urgently re-consider his response.
References:
1. House of Commons Hansard. Topical Questions, 20 March 2018. https://hansard.parliament.uk/commons/2018-03-20/debates/3E71DB83-CDBA-4... (accessed 21 March 2018)
2. Office for National Statistics. Weekly provisional deaths https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 21 March 2018)
3. Office for National Statistics. Principal projection – England and Wales Summary. 26 October 2017. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigrati... (accessed 21 March 2018)
4. Office for National Statistics. Child mortality in England and Wales: 2016. 14 March 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 21 March 2018)
5. Taylor-Robinson D, Barr B. Death rate now rising in UK's poorest infants. BMJ (Clinical research ed) 2017;357:j2258. doi: 10.1136/bmj.j2258 [published Online First: 2017/05/13]
6. Taylor-Robinson D, et al. Death rate continues to rise for poorest infants in England and Wales. BMJ 2018;360:k1090
7. Office for National Statistics. UK drops in European child mortality ranks. 13 October 2017. https://visual.ons.gov.uk/uk-drops-in-european-child-mortality-rankings/ (accessed 21 March 2018)
Competing interests: No competing interests
Re: Rise in mortality in England and Wales in first seven weeks of 2018. Further comments
This article elicited a dozen responses. But no action by Her Majesty's Govt.
Now Hiams and McKee have published (8 March), an opinion piece, and in reply Prof Caan has eloquently sketched the picture fifty years ago - a picture I remember.
It should be clear to the observers of society that we as a nation are failing the poor, the weak, the disabled. Until we improve the social determinants of health, morbidity and mortality cannot get better.
Neither the Chancellor of the Exchequer, nor the Local Authority Chief Executives will open their tight fists.
Who should prod the Local Authorities? Their directors of public health.
If the local authority does not listen and act? The director should go public.
Do we see the directors doing this job? No.
Competing interests: No competing interests