Priorities for DHSC: death, taxes, and what mortality data tells us about the NHS

In 1984, the introduction of the Office of Health Economics’ “Understanding the NHS in the 1980s” publication stated:

“The ageing of the population has required more of [the NHS’s] energies to be focussed on the difficult health problems associated with the chronic, disabling diseases of later life… Such trends have led a number of commentators to believe that the NHS has reached a crisis point. Some even suggest that it is near to collapse.”

More than forty years later, any publication on the NHS could include the exact same introduction. But looking back, what can we learn about how the NHS, and society as a whole, has coped with death and the aging process? And what does this mean for the Department of Health and Social Care (DHSC) as it absorbs the responsibilities of NHS England?

Data suggests we have certainly got better at treating, and surviving, disease

Mortality for children aged 0-10 is around 25% of what it was in 1980-82, meaning that 3 in 4 deaths are now being avoided. This is an enormous success and it seems certain that substantial advances in treatment for children with rare and complex diseases will have heavily contributed to this. The second age group with big improvements in survival are people aged 60-80: again one might put this down to advances in treatment for the most common causes of avoidable death, such as cancer, heart disease and stroke.

Equally interesting, however, are the age groups where mortality is close, or equal, to 1980-82. These fall into two groups: males (and only males, more on that later) aged 25-40 and people aged over 90. For both of these groups, medical advances in treatment of disease make little difference. For young adult men, all the most common causes of death are societal, not medical. In order they are: suicide, accidental poisoning, traffic accidents, homicide. For the very elderly, all the advances in medical treatment of the last 40 years have served to prolong life, only to a point.

Mortality rates for females are not the same, although trends since 1980 are not hugely different. As we might expect given different life expectancy, at all ages women are less likely to die than men. But the degree of difference changes dramatically at different ages (see chart). Specifically, young men are more than 2.5x as likely to die as women the same age. This is not a story of genetics or ill health, but of societal challenges and inequality. A higher proportion of deaths in young females are due to medical reasons and accordingly the mortality rate for this group as fallen by at least 20% since 1980.

So what does this all mean for the NHS for the next 40 years and the long-term priorities for DHSC?

Returning to the statement made by OHE in 1984, perhaps this is not quite so true today. Yes, an aging population continues to put pressure on a capacity-constrained health system. But increasingly as a society our health needs are much more complex than can fit within a purely “see and treat” medical model. Young people, and young men in particular, need support long before the health service is required.

This requires investment in prevention, and sharing of scarce budgets with local authority teams responsible for wider determinants of health such as education, social services and housing. This data shows that we have got no better in 40 years at providing this support and it cannot be acceptable for this to continue for the next 40 years.

For the very elderly, again this is not simply a health service question. Primary care will always have a vital role to play in the final years of someone’s life. But so will social care and the wider care sector. The better we get at treating “avoidable” deaths, the more important it becomes to invest in infrastructure and services for people at an age at which death is unavoidable.

It remains to be seen what last week’s announcement that DHSC will absorb the responsibilities of NHSE will mean, and the impact that the workforce cuts will have. But one potential upside is closer integration between health and social care teams and programmes, all within DHSC. In the long-run it is this integration, as much as short-term priorities of A&E performance and the elective backlog, which will determine the success of the expanded Department.