Life expectancy for elderly people

Before 2012, life expectancy for elderly people was rising at an almost constant rate each year with some acceleration in the period immediately prior to 2011. This can be seen clearly in table 1, showing the change between consecutive 3-year averages (to smooth annual fluctuations). A very similar trend is seen for men and women and for life expectancy as measured from either age 65, age 75 or age 85. In every case, what had been consistent improvements declined markedly after ‘2008–2010’ and ‘2009–2011’. Given the consistency of the earlier trends, this reflected a marked increase in death rates in 2012. Worryingly, in the most recent period, in the oldest groups. there were actual declines. The worsening of life expectancy for women over 85 years was first raised as an issue of immediate concern over 3 years ago,12 yet it received little attention then and little since, despite becoming much worse year on year.

Table 1 shows that there is no sign at all of the deceleration slowing down. What started in 2012 worsened dramatically in 2015, when deaths rose by 5.6%—the largest annual percentage increase since the 1960s.13 While there has been a slight recovery in the most recent data, the improvements are still less than half the size of those observed up until 2010/11. To explore this further, we now compare observed life expectancy with predicted trends calculated using regression techniques or ‘expected’ life expectancy.

Trends in life expectancy for the over 65s

The over 65s have borne the brunt of the deceleration in life expectancy gains. We have shown this in the crude differences in life expectancies and now examine the gap between expected life expectancy, if trends up to 2009–2011 had continued, and observed life expectancy, using data reported by the ONS, for people of ages 65, 75 and 85 years (figure 2).14 Note the axes in figure 2 do not start at zero.

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Figure 2

Life expectancy at different ages, England and Wales.

The gap between the expected and the observed values varies from 0.49 years in women at age 65 years to 0.20 years in men at age 85 years.

However, it is not the slowing that is the most concerning. Although that should be considered an amber warning light, demanding investigation at least, any reversal in life expectancy should be considered a red danger sign. This can now be seen clearly for three groups following the change between 2012–2014 and 2013–2015. For female life expectancy at 75 years, there was a fall from 13.11 to 13.09 years; for women at age 85 years, a fall from 6.85 to 6.80 years and for male life expectancy at 85 years, a fall from 5.85 to 5.84 years. Life expectancy was not ‘continuing to increase’ for everyone at the time the DoH’s made its assertions.

A temporary change?

Politicians’ attempts to reassure the public that these changes are only temporary may be overly optimistic. Table 2 presents the same data but only reports changes between non-overlapping 3-year periods. The changes in the first two periods are very similar. In every case, there were rapid improvements in life expectancy for elderly people, which either stayed the same or improved slightly until 2012. Then, in the most recent 3-year period, the improvement for men from age 65 has more than halved (0.65 to 0.27). That for women aged 65 has reduced to just a quarter of what it had been (0.55 to 0.13). The most recent changes are worst for the very elderly (who are presumably the most frail or otherwise disadvantaged and potentially most susceptible to what is causing this recent trend). For men, aged from 85, the most recent improvement (0.02 years in 3 years) is a tenth of the previous rate of improvement. For women aged from 85, what had been a greater rate of improvement than among men of the same age (0.17 and 0.22 years) suddenly became a fall in life expectancy after 2011.

The final column in table 2 shows the very latest data made available in September 2017. It compares 2011–2013 with 2014–2016 and shows that there has been no end to the slowdown in improvements. The latest provisional weekly deaths for England and Wales from January to October 2017 show a crude increase of 15 605 deaths compared with the average of the corresponding weeks over the past 5 years.15

There is, therefore, no sign yet that the pattern that emerged in 2012, and which worsened in 2015, is temporary. Evidence from a longer period in the USA shows that there are no grounds for confidence that such deceleration in improvements, or even declines, will be as short-lived as some policy makers in the UK seem to assume.

The fact that the changes have systematically harmed women more than men, and the very elderly more than the younger elderly, suggests that it is those who have less access to resources of all kinds that have been hardest hit. Elderly women are far more likely to live alone and to be poor as compared with elderly men. People aged over 85 tend to be more frail, and, crucially, more likely to be dependent on a well-functioning health and social care system. As a Professor of Biogerontology has recently suggested ‘…it can be argued that the oldest people are highly vulnerable and that excess deaths among them – from underfunded services – are a major cause of the stalled life expectancy increases’.16

The search for causes

Any very large change in mortality trends must be taken extremely seriously. Life expectancy is the most important social statistic that any country produces about itself and it is often an early sign of wider societal problems, as in the former USSR in the 1980s17 or in the USA more recently. American life expectancy at birth stalled between 2010 and 2014 and, in 2015, actually declined, with rising rates from causes that have been described as ‘deaths of despair’18 concentrated among the poor in states that had experienced the greatest economic and social decline.19 This has political consequences; those counties in which life expectancy stagnated or declined experienced the largest increases in Republican votes in the 2016 Presidential election.20

Some other European countries have seen slowing of improvements in life expectancy but, crucially, not all, and not to the extent seen in England and Wales. Whether comparison of the economic choices made by those countries whose life expectancy has continued to improve, such as Norway and Finland, to those who have seen stalling, such as France21 and Germany, may help understand this remains to be seen, although some caution is required given differences in recording of deaths occurring among people temporarily abroad, a particular issue for older people from some Northern European countries. For now, we are only able to hypothesise.

Our previous search for causes of these reversals in trends in England considered the possibilities of data artefact; environmental events such as war, natural disaster or unusually cold weather; influenza and failings of the health and social care system.

One argument sometimes advanced is that, in the UK, life expectancy is reaching a theoretical maximum, so some slowing in the rate of improvement is inevitable. Yet, other countries, such as Japan, show that the UK is still far from what can be achieved with existing knowledge. Moreover, the overall slowing conceals how life expectancy is actually falling in some parts of England.22 Influenza is likely to have played some role, but even if it did, questions remain as to why, as with excess winter mortality, people living in the UK seem to have been more likely to die from it than in some other European countries. Importantly, others have suggested that influenza may be overstated as a cause of otherwise unexplained premature deaths, at least in the USA,23 where reversals in life expectancy have been similarly poorly addressed.24

Those most affected by the rise in mortality and stalling, and in some cases reversing, of life expectancy, the elderly, are also the group most reliant on a well-functioning health and social care system. In the context of the relentless underfunding of the health and social care system since 2010, we pointed to evidence that suggested a possible link between these two factors, requiring urgent review. As long ago as February 2014, we wrote that ‘The 2012–2013 rise appeared to be more of a trend’ and suggested austerity as the mostly likely immediate cause.12 Subsequent research noted how the narrowing gap in life expectancy between the most and least deprived local authorities, which coincided with the government strategy to reduce inequalities that ended in 2010, began to widen between 2012 and 2015.25

There are alternative suggestions, including a possible infective agent other than influenza.26 However, the main debate is about whether it is still too early to conclude that what is observed is the beginning of a trend that should cause concern. The situation is complicated by delays in publication of detailed data and questions of how it should be interpreted.7 In July 2017, Public Health England reviewed possible causes, including population changes and influenza, including international comparisons, concluding there was not enough evidence as yet to show a change in trends.27 Yet, as noted above, the Institute and Faculty of Actuaries disagrees and has revised its projection of life expectancy downwards, reducing predicted pension liabilities by billions of pounds.8 Furthermore both the life expectancy data released by ONS in September 2017 and the continued high raw death counts (recognising the need for more detailed analysis when the necessary data on deaths by detailed age category become available), adds more weight to the argument that we have now seen enough to know that something very important has changed.  

It is essential, for many reasons, that the divergent views over what the causes might be are resolved. The answer has implications for fiscal, health and social policies, among many others. Most recently, Sir Michael Marmot has called for an urgent investigation into whether spending cuts are impacting length of life, with evidence that they have already impacted on quality of life.28 Other research has found a link between cuts in payments to pensioners and mortality29 and delay in National Health Service discharges and mortality.30 Most recently, research implicated ‘spending constraints’ as contributing to 45 368 (95% CI 34 530 to 56 206) extra deaths from 2010 to 2014, compared with pre-2010 trends, predominantly in people aged over 60 years and living in care homes.31 Correlation is not proof of causality, as all epidemiologists know. However, in the absence of a clear explanation or simple research method that could confirm a causal relationship between underfunding and increased mortality, simply dismissing the possibility is not justifiable. Correlation is not always coincidence.

All this strengthens the case for inquiring into a possible relationship between underfunding and mortality. The need for answers is now even more urgent than it was last year, given the likely impact of Brexit on government finances and the threat to recruitment of health and social care staff already being experienced.32 The question then is who should do this inquiry? Researchers can, and must contribute to the analyses, but the questions raised go beyond what can be answered by demographic analyses, raising important political issues. However, researchers, whether in non-governmental organisations or universities, lack the power to require production of the necessary data to answer the key questions.

Once, questions of this nature might have been addressed by a Royal Commission, but these have gone out of favour and, anyway, they would have to be convened by ministers who show little inclination to do so in this case. The urgency of finding an answer suggests that public inquiries, such as those into the Iraq War or Bloody Sunday, are unlikely to be appropriate or speedy. The one body that does have the legitimacy to conduct such an inquiry, coupled with the necessary powers to summon witnesses and require data to be made available, is parliament, with the health committees of the Commons and the Lords providing the obvious mechanisms.