Abstract
Hiam et al. discuss a rise in mortality in England and Wales in 2015 1 and its potential causes. 2 After discounting other potential explanations, they conclude that ‘…the evidence points to a major failure of the health system, possibly exacerbated by failings in social care’. 2
The age-standardised mortality rate has actually generally been decreasing in England in recent years (Figure 1, which includes data for 2016) despite an increase in 2015 and the upward trend in the number of deaths. Public Health England has been examining recent mortality trends and can offer some additional points which may help readers interpret these data.
Number of deaths and age-standardised mortality rate, England, 2001–2016.
Hiam et al. found an excess of 33,798 deaths in 2015, compared with 2014, but largely dismiss population age structure as an explanation. Milne suggests an alternative figure of 21,231. 3 The authors have clarified the reason for the discrepancy and there are clearly a number of ways to examine the impact of age structure on the excess. As 2014, had relatively low mortality rates, we compared 2015 with 2010–2014 instead. We applied single-year age-specific death rates for 2010–2014 combined, to the population in 2015 to calculate expected deaths in 2015. Using this approach, observed deaths in 2015 were just over 5000 higher than expected for women and there were no excess deaths for men. Much of the increase in the number of deaths in 2015 (at least when compared with 2010–2014) is therefore explained by population growth and aging.
The mortality increase between 2014 and 2015 was not limited to England. Among the 28 European Union member states, life expectancy in 2015 at the age of 65 years fell in 25 states for women and in 21 for men. 4 The factors that caused the increase in mortality rates in England in 2015 also appear to have affected other countries at the same time.
Hiam et al. play down the impact of influenza. A study of 14 European countries found excess mortality in those aged 65+ years between December 2014 and February 2015 that was higher than the previous four winters and which coincided with increased influenza detection. 5
An analysis of hospital admissions of people aged 75+ years who died in 2015 (using linked data) shows that the proportion admitted for flu/pneumonia increased early in the year, with a distinct spike in January (Figure 2). Clearly, flu was having a significant impact at the time when most excess deaths occurred.
Primary diagnosis of last emergency admission if within one week of death or died in hospital, by month of death, aged 75+ years.
As Hiam et al. acknowledge, we cannot yet reach a firm conclusion about what caused 2015’s increase in mortality. As we have reported before, there has been a flattening off of the rate of reduction in the age-standardised mortality rate since 2011, when compared with the downward trend seen in the 10 years up to 2011. 4 While flu may help explain the spike in 2015, and population ageing contributes to the upward trend in the number of deaths, further work is required to investigate the apparent change in underlying trend in the age-standardised mortality rate, with a view to identifying causes.