We are all living longer.  Life expectancy is increasing year on year.

This has become such a ubiquitous news story over the last few years that no-one ever seems to question the concept of an ever ageing population.  While I am not disputing that there has been an increase in life expectancy I am sceptical about some of the claims made, and I am even more sceptical about the way they are used to justify Health policy decisions.

In an ideal world we would like to believe that politicians sit down with Senior Clinical Advisors and Civil Servants, work carefully to identify how to improve how NHS outcomes and efficiency, and then devise strategies using clear evidence and expert reference groups.

In fact this is a pretty rare occurrence, and this style of technocratic policy making is well out of fashion across the political spectrum.  We are sick of experts.

Mostly policy formulation is a massive noisy clamour of ideas. An almost inseparable mass of journalists, lobbyists, SPADs, hobby horse riders and politicians generate a huge number of policy options.  Whoever gets the Ministers ear and can generate sufficient excitement in the papers gets their idea adopted.

Problems are used to justify pre-determined solutions, rather than solutions created to solve problems.  Data is retro-fitted to solutions.  Andrew Lansley in the British Journal of Nursing defended his plans to outsource care to the private sector as reforms to address an ageing population.

“Caring for the ageing population and covering the annual £600m of new drug treatments mean NHS costs are rising at an unaffordable rate and underline why we need to rethink how the system works”

In fact these were solutions heavily promoted by lobbyists looking for a problem to pin themselves too. Having been generous in my praise of Norman Fowler last week I think I am allowed to call Lansley a total muppet.

When we look at the ONS data it doesn’t really support my cynicism. Life expectancy is still rising,  and mortality rates are falling.   Comparing 2003 to 2015 Mortality Rates are 20% lower. 

Lots of people have explanations why the figures are improving. Personally I think that there are 3 broad reasons:

1. A cohort effect – my Grans generation grew up before the NHS, by Dad’s generation lived all their lives with comprehensive state funded Healthcare. 
2. A treatment effect – new drugs and treatments have extended peoples life span, Statins, for example
3. A life style effect – smoking rates have plummeted, for example

Generally the popular press like to emphasise the treatment effect because they are lazy and they can fill masses of column inches by reprinting press releases from big Pharmaceutical companies.   The Daily Mail is the worst offender for this, but most newspapers are guilty to an extent.

The life style effect is harder to quantify because we have to balance out the positive effects on health (huge reduction in smoking, smaller reduction in alcohol consumption), with the negative – obesity levels are still too high and are wiping out too many of the gains made by other public health improvements.

All of this looks like to directly contradicts one of the other most prevalent claims being made in the media – Austerity Kills.  Austerity stories fall into 2 categories; those which deal with individual cases, and those which deal with the impact of austerity on the whole population.

Having worked for the NHS, Department of Health and DWP I can assure you that stories of individual hardship caused by Government Welfare Reforms are true.  Maybe not all of them, but there are clearly individual cases where lives have been shortened, or made unnecessarily harsh due to poor Government policy decisions.   Decisions about Welfare Reform were taken without any consideration of the impact on individuals or on the NHS as a whole.

It seems shocking that any Government should make a decision that shortens anyone life, however lots of decisions are made every year, often with popular support from the public that increase Mortality and Morbidity

For example – we could increase our Cancer survival rates if we disinvested in expensive end of life last chance drugs and spent the money instead on improved access to Diagnostic Tests.  We have known this for a very long time, however it is politically very difficult to achieve.  Pharmaceutical Companies who sell expensive last chance drugs find it easy to get journalists to put their case across, local MPs don’t want to be seen to be withdrawing care, and boring stuff like faster diagnostic access or awareness campaigns to get people to present earlier are easier to cut. The movement of Public Health services to Local Authorities, where they can be more easily cut, has made things worse.   We can measure the impacts of these poor policy choices by comparing deaths over time, or to other countries. 

It is harder however to start and quantify the impact of Austerity at a whole population level, even though instinctively I believe that there has been a significant negative effect.  If you take a population on a low income and you make them poorer, less securely housed and colder in winter time then you will increase their Healthcare Resource Utilisation rate and their mortality rate.

If our overall health statistics are getting better how do we quantify the excess deaths from Austerity?  Is the overall population effect of Austerity a myth?

Going back to the ONS graph we can see a slight uptick on the right hand side.  Deaths increased between 2014 and 2015 for both sexes.  This is pretty unusual.  Since 1995 this is the first increase for men, and the 4th for women – and each of these previous increases were much smaller.  The overall mortality rate increased from 953 deaths per 100,000 population in 2014, to 993 deaths per 100,000 population in 2015.  Total deaths increased by 5.6%, from 501,424 deaths in 2014 to 529,613 deaths in 2015.  

Partly this could be explained away as a bigger population, with more older people having more deaths in winter time.  The increase was concentrated in the first 3 months of the year, which would suggest that this is a short term effect like a virulent Flu or a harsh winter rather than a longer term Austerity effect.

A recent paper in the BMJ compares the ONS data to an alternative view of mortality from the Faculty of Actuaries.  This is a much less well covered source, but has a massive impact on our lives.  It is the actuarial models which determine how much you have to put into your pension, and it is their data which is used by big Companies to justify closing their final salary pension schemes.

Their model of morality showed that mortality improved by 2.2% pa for women and 2.6% pa for men between 200 and 2011. From 2011 onwards the improvement in mortality stopped for men, and got worse for women. 

Had the continued on their trend they would be 11% lower for men now than they are.

The actuarial data shows that the recent decline is not a short term event, driven by a one off event like a virulent flu strain, or a harsh winter.   This is a medium to long term decline. The co-incidence that these dates map exactly to changes in NHS expenditure and the introduction of Austerity measures is hard to ignore.

This starts to give an indication of the likely scale of the impact of Austerity on life expectancy.   Lives are being shortened, or at least improvements in mortality are stopping, and it is hitting women harder than men.

This isn’t the same scale of Public Health catastrophe that has hit Non-Hispanic White Americans without a College Degree that Deaton and Case identified, and which I wrote about last time.

https://jon-chadwick.com/2017/07/01/guns-and-drugs-with-david-wojnarowicz-norman-fowler-klaus-nomi-and-donald-trump/

It does however give us a clear early warning that the improvements in Public Health that we have experienced in our lifetimes are being undone by economic policy decisions in the same way they were in America.

Just like the USA the people who are being affected are being excluded from the debate about policy.   There is plenty of chatter about Social Murder on Social Media, but largely this blots out the voices of the people who living shorter lives rather than making them louder.   If we don’t find a way to represent people in these debates, or give them a voice to challenge preconceptions then maybe an angry orange faced politician will come along who will.

There is of course a silver lining to this rather doomy data.   

The private sector companies who closed their pensions schemes or cut benefits due to an ageing population have received a £28bn improvement in their pension liabilities as a result of declining mortality.   

I am sure that the big companies who are benefiting will use these funds to improve pension schemes, won’t they?

Sources

https://www.nao.org.uk/wp-content/uploads/2004/03/0304364.pdf

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/provisionalanalysisofdeathregistrations/2015

http://adc.bmj.com/content/early/2015/01/07/archdischild-2014-307151

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/201415provisionaland201314final

http://www.bmj.com/content/357/bmj.j1946

https://www.actuaries.org.uk/documents/summary-cmi-working-paper-97-cmi-mortality-projections-model-cmi2016

https://www.actuaries.org.uk/learn-and-develop/continuous-mortality-investigation

http://www.theactuary.com/news/2017/03/slowdown-in-life-expectancy-could-cut-pension-deficit-by-28bn/