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Focus: The mysterious death rate spike

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LGC examines claims that funding pressures caused a spike in death rates

The death rate spike in 2015, when about 30,000 more people died in England and Wales than in the previous 12 months, marked the largest year-on-year rise in mortality since the second world war – but has so far remained unexplained.

Research published last month attempted to address this deficit in understanding of the statistical anomaly, which included a mortality spike in January that constituted 10,479 more deaths than the monthly average between 2006 and 2014.

The analysis, published in the Journal of the Royal Society of Medicine and conducted by experts from Blackburn with Darwen BC, the London School of Hygiene & Tropical Medicine and Oxford University, ruled out data distortions and the impact of cold weather or influenza as the main contributors to the spike, which affected predominantly older people with dementia.

The authors decided that, based on current evidence, well-publicised pressures on the health and social care system linked to funding cuts were the likely cause.

It is unlikely that any increases in ehalth funding to cope with those extra pressures were sufficient to meet demand

Peter Goldblatt, UCL

The researchers made it clear that the study was not conclusive and called for more analysis to be undertaken.

But the findings prompted a robust response from the Department of Health which was unusually personal in rubbishing the work of respected institutions as a “triumph of personal bias over research”.

Dominic Harrison, director of public health at Blackburn with Darwen and one of the authors of the report, rejected the department’s claims. 

Mr Harrison pointed to a report published last year by Public Health England which found life expectancy had fallen in 43% of local authority areas for people over 85 during 2012 -14.

But even outside the corridors of the DH, not everyone working within public health was convinced by the researchers’ hypothesis.

Newcastle City Council’s director of public health Eugene Milne highlighted what he described as “fundamental errors” in the analysis.

As well as voicing statistical concerns, he said the paper’s first graph, which was used to show the reversal of a long-term downward trend in mortality rates in 2010 as austerity took hold, was wrongly labelled.

He said rather than using ‘age-standardised’ death rates, which are adjusted to take account of population changes within different age groups, it actually showed ‘crude’ death rates which only look at the overall number of deaths.

He said this undermined the research as the age-specific curve showed “a plausibly sustained downward trend” in death rates to 2014.

The researchers have since accepted that the graph was wrongly labelled and are due to publish a clarification.

But they say the age-adjusted graph, which LGC was asked not to publish before it is printed in the Journal of the Royal Society of Medicine, shows the abrupt halt in falling death rates followed what had been an even more rapid improvement before 2010 than the crude data had shown.

The authors add that they are confident that the error identified in their analysis “does not make any material difference to the conclusions drawn”.

David Conrad, a public health consultant currently based at Hertfordshire CC, also urged a degree of caution over the findings of the research.

He said the suggestion that funding pressures in health and social care explained the sharp rise in mortality was “one hypothesis which may warrant further investigation”.

Mr Conrad added that while local analysis using Hertfordshire data showed a similar spike in deaths in the first weeks of 2015, this had not been replicated in provisional data for 2016.

He said: “This finding does not suggest that the 2015 spike marks the beginning of a new trend of increased mortality resulting from the ongoing funding pressures, although one would want to wait until the analysis was done with finalised data for the whole of England before leaping to any conclusions.”

Mr Conrad said one theory was that a less effective influenza vaccine could have been a major contributor to the spike that year.

However he added that as influenza vaccines were an international issue, with the same vaccine being used across borders, Hertfordshire had analysed French data which showed no similar spike in that country in the opening weeks of 2015.

Peter Goldblatt of University College London’s Institute of Health Equity said the larger numbers of people with dementia dying in 2015 did indeed imply a “huge resource pressure”.

He added: “It is a fair comment then to say it is unlikely that any increases in health funding and the planning that you need to cope with those extra pressures were sufficient to meet demand.”

Dr Goldblatt also said there are long-term questions over why the UK continues to have higher levels of winter deaths than comparative countries.

If the government or the Care Quality Commission don’t know at what point cuts might generate avoidable mortalities that is problematic

Dominic Harrison, report co-author

He speculated that lower death rates in Sweden could be due to better quality housing and a stronger welfare system, while France has strong healthcare provision.

The research warned that the increase in the mortality rate appears to have repeated itself in 2016, albeit with further data needed before a complete analysis could be conducted.

And Mr Harrison says early data shows a statistically significant spike in the opening weeks of 2017.

He warned that there is no standard measurement under current regulation of the whole health and social care system for assessing the impact of interrelated services failing at the same time.

Mr Harrison added: “If ministers, the government or the Care Quality Commission don’t know at what point cuts might generate avoidable mortalities that is problematic because it makes the regulatory system part of the problem.”

David Buck, senior fellow in public health and inequalities at The King’s Fund, said there is unlikely to be a single cause of the spike.

But he called for the DH and Public Health England to “urgently” investigate the 2015 figures.

Mr Buck added: “It is critical to understand whether deterioration in the performance of the health and social care system is a symptom of wider causes of potentially avoidable mortality, or a leading cause itself.”

Despite the government’s initial dismissal of the findings of the research, pressure could mount on the DH to rethink its stance.

Conservative chair of the health select committee Sarah Wollaston has said the DH “needs to look at the research very carefully”.

If the two recent high profile cases of Mary Muldownley and Teresa Dennett, who are believed to have died waiting for intensive care beds, prove not be isolated incidents political pressure on the government could increase.

If this were to happen, the debate could move from a discussion over the validity of statistics to establishing whether current funding priorities across the health and social care system are literally a matter of life and death.

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