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
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
The figures by Hiam and Dorling confirm the fears I have working at the coalface of General Practice.
The NHS is being pushed to breaking point.
Following chronic underfunding of services and gradual erosion of the good will of NHS staff we are now seeing the impact in these figures.
As waiting times in primary and secondary care increase patients are often sicker when they are eventually seen.
From my patients I hear of negative experiences in hospital not because staff don't want to care but because at times they are so stretched they are unable to do their jobs well.
We shouldn't be surprised that at some point if we provide the NHS with less resources the outcomes will get worse.
I hope the government can see the connection and the need to provide adequate resources to allow all NHS staff the ability to provide the great care we all aspire to provide
Competing interests: No competing interests
Dear Dr Godlee,
Last year we raised concern about the rise in infant mortality in England and Wales in a letter to the BMJ.(1) The latest data released by the ONS this week shows that infant mortality has risen for the second year running.(2) In 2016 there were 2651 infant deaths, compared to 2578 and 2517 in the preceeding two years. The statistically significant increase in infant mortality rate from 3.6 to 3.8 deaths per thousand live births over these two years (p-value = 0.037) is explained by the 5.3% increase in infant deaths, rather than by any change in the denominator which showed only negligible change.
It is critical to understand the social patterning of the recent changes in IMR in order to take appropriate public health action. Our analysis shows IMR has continued to rise particularly in the poorest children, whilst remaining stable in the most advantaged groups, further widening inequalities (Figure 1, link below). We know that infant mortality is associated with social disadvantage, and that the risk factors for high IMR such as smoking in pregnancy, low birthweight and obesity are also socially patterned, with higher risk in more disadvantaged populations.
IMR is used internationally as an indicator of the comparative wellbeing of nations. It is sensitive both to the socio-economic conditions affecting women of childbearing age and children; and the quality and accessibility of services for families. IMR continues to improve in most rich countries, with recent data showing that in countries such as Japan and Finland the IMR has dipped to only 2 per thousand.(3) In Liverpool, where some of us work, the infant mortality rate is now an unacceptable 6.8 - more than twice as high as London's average.
We echo the call of Hiam and colleagues for an urgent investigation into the causes of rising mortality in the UK.4 Poverty is on the increase and projected to get worse, 5 whilst services that support "giving every child the best start in life" are simultaneously being cut. (6, 7) The weakened social protection safety net is a plausible explanation for rising IMR among the most disadvantaged infants in England and Wales. Survival for the most vulnerable children among us will continue to be jeopardized unless policy makers take concerted action to improve the conditions for children to survive and thrive.
Figure 1. Infant mortality rate (95% confidence interval) by socio-economic classification 2008-2016. Link here:
https://www.dropbox.com/s/ro703io2d9h6qth/IMR_2016_NSSEC.pdf?dl=0
Data source: ONS. For the purposes of the analysis we have grouped IMR for joint registrations by NS-SEC groups into professional (1.1, 1.2, 2), intermediate (3,4) and manual groups (5 and below, including unclassified). In 2011, NS-SEC was rebased on the new Standard Occupational Classification (SOC2010). Up until the 2011 data year, ONS published child mortality and birth statistics by NS-SEC using the father's NS-SEC, but from 2012 onwards this was based on combined parents NS-SEC.(1)
References
1. 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]
2. Office for National Statistics. Child mortality in England and Wales: 2016. Statistical Bulletin, 2018.
3. World Bank. DataBank: Mortality rate, infant (per 1,000 live births), 2018.
4. Hiam L, Dorling D. Rise in mortality in England and Wales in first seven weeks of 2018. BMJ (Clinical research ed) 2018;360:k1090. doi: 10.1136/bmj.k1090 [published Online First: 2018/03/16]
5. Browne J, Hood A. Living Standards, Poverty and Inequality in the UK: 2015-16 to 2020-21: Institute for Fiscal Studies, 2016.
6. Browne J. The impact of austerity measures on households with children: Institute for Fiscal Studies, 2012.
7. Taylor-Robinson, D, Lai E, Rutherford C. Bigger cuts to Sure Start children's centres in more disadvantaged areas. BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5332
Competing interests: No competing interests
The authors are over selective with their comparisons in order to emphasise their view that England is experiencing a unique phenomenon of rising mortality. The 2018 data for England and Wales is compared to the previous five years (2013 to 2017), during which time Scotland has seen a significant increase in deaths, and a fall in male life expectancy. Eurostat report a fall in life expectancy across Europe between 2014 and 2015, affecting most member states, and the USA has witnessed two years of falling life expectancy. A general increase in mortality across the western world might deserve more robust analysis.
Competing interests: No competing interests
In their response, Pebody et al point their fingers at influenzal infections. May I request them:
1. To tell us why they believe that the GPs would overlook infuenza infections in causing deaths in the elderly?
2. To tell us if they have ‘sentinel practices ‘ taking speicmens for infuenza virus identification in the country?
Thank you
Competing interests: No competing interests
Hiam and Dorling report a rise in mortality in the first seven weeks of 2018 in England and Wales compared to the previous five seasons (1). They discount influenza as an important explanatory factor.
As explained in one of their references, PHE’s weekly mortality surveillance is set up to detect and report acute significant excess mortality and results are published weekly(2). Excess mortality is defined as a significant number of deaths reported over that expected for a given point in the year and is calculated using the standardised EuroMoMo algorithm developed as part of a European network (3).
Seasonal increases in mortality are seen each winter in England and Wales. Further peaks of mortality occur in some winters, most commonly due to factors such as cold snaps and increased circulation of respiratory viruses, in particular influenza (4).
During the winter of 2017-18 England experienced intense influenza activity, with circulation of both influenza A(H3N2) and influenza B. GP consultations and hospital admissions due to influenza peaked at their highest rate since 2010/11 (5). Statistically significant excess all-age, all-cause mortality by week of death was seen for the period from week 50 2017 to week 4 2018 (2). The editorial notes that the increase in deaths in 2018 cannot be due to flu as the proportion of deaths caused by respiratory disease was not unusually high. However, respiratory disease, at or around the time of death, is not always recorded as the underlying cause of death. In addition, as was the case in 2015, deaths from other causes increase at the time of circulating influenza and the impact of flu is seen across a range of causes of death (6).
This excess in late 2017/early 2018 was seen both in adults 15-64 years of age and those >65 years of age and coincided with the period of peak influenza circulation. The size of the increase is similar to what was seen during the 2016/17 winter, but has not yet reached the levels seen during the 2014/15 season. During each of these three winters we saw the circulation of influenza A(H3N2), whose impact is recognised to be particularly high in the elderly. A number of other European countries have had a similar experience this past winter, supporting our belief that this excess was largely attributable to influenza (7). At the end of each winter further analysis is done to estimate the contribution of flu to all-cause mortality, independent from cold weather and other seasonal contributions.
Next winter, the NHS will be recommending the use of adjuvanted influenza vaccines for >65 year olds. Adjuvanted vaccines are recognised to provide higher effectiveness compared to non-adjuvanted vaccines in this population, and should therefore mitigate against a similar scale of increase in future.
(1) Hiam L, Dorling D. Rise in mortality in England and Wales in first seven weeks of 2018. BMJ 2018;360:k1090 doi: 10.1136/bmj.k1090
(2) PHE weekly all-cause mortality surveillance https://www.gov.uk/government/statistics/mortality-weekly-all-cause-mort...
(3) EuroMoMo standardised algorithm. http://www.euromomo.eu/methods/methods.html
(4) Green H, Andrews N, Fleming D, Zambon M, Pebody R. Mortality Attributable to Influenza in England and Wales Prior to, during and after the 2009 Pandemic. PLoS One. 2013; 8(12): e79360. Published online 2013 Dec 11. doi: 10.1371/journal.pone.0079360
(5) PHE weekly influenza report – week 11 report https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
(6) ONS report https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...
(7) European mortality bulletin week 10, 2018, http://www.euromomo.eu/
Competing interests: PHE is a member of the EuroMoMo network
Re: Rise in mortality in England and Wales in first seven weeks of 2018
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