Did funding cuts in health and social care budgets lead to excess mortality in England? The devil is in the detail

Research into the impact of austerity in health and social care on mortality has been the subject of much attention and discussion. While it’s instinctive to link austerity with poorer health outcomes, especially for more vulnerable people, does the latest research establish a clear causal relationship?

In Effects of health and social care spending constraints on mortality in England: a time trend analysis, Watkins et al. examined age-standardised trends in mortality rates for England. In the 2001-10 period, absolute deaths decreased by an average of 0.77% a year; followed by an increase of 0.87% for 2011-14. In their research, the authors calculated the difference between mortality predicted using 2001-10 data to that observed in 2011-14, which translated into 45,368 excess deaths.

Austerity and mortality

The researchers attributed the excess deaths to changes in funding for health and social care services. Based on the anticipated growth in funding, they estimated a further 152,141 excess deaths from 2015 to 2020. By assuming that these estimated associations continue, they find that persisting austerity will be responsible for the early deaths of thousands of people.

Though certainly thought provoking, it is worth asking whether the findings of this study are robust enough to establish a clear link between excess deaths and austerity in the NHS and social care? We must consider, especially, that other European countries are showing similar mortality patterns. For instance, Germany and Austria also reported higher levels of standardised mortality in 2013 compared with 2011. Neither country has undergone anything like the fiscal tightening seen in the UK since 2010.

Trends in mortality rates are complex. More research needs to be done to disentangle the complex relationships between health and social care funding, population health and mortality. Based on the evidence presented in this paper, we would encourage caution before making potentially misleading conclusions.

The researchers’ analysis only considered gender, age or place of death, and did not include the complex factors behind individual deaths. The study would benefit from more patient-level information, including determinants of mortality, such as the number of underlying diseases that are likely to change over the years. For example, not accounting for the occurrences of aggressive strains of flu last winter would introduce bias into the analysis, and would mean these deaths were attributed to the  tightening of health and social care budgets at that time.  

The authors present a continuous downward trend in the future mortality per head, which was calculated based on the reductions in mortality observed from 2001 to 2010. Assuming this trend was to continue, mortality would be zero by around 2050. While UK mortality rates are above those in some other countries, we cannot expect that they will continue to fall at the same rate indefinitely.

The authors acknowledge that there are significant limitations to their research and other possible explanations for these patterns. A simultaneous increase in austerity and mortality does not necessarily mean that the former causes the latter.

Mortality out of hospital

The paper also identifies a rise in mortality in care homes and at home, and links this to a lack of social care funding. However, their analysis shows that more individuals are surviving the initial hospital stay. This could be interpreted as a positive sign of improved in-hospital quality of care, but it may also mean that hospitals are more likely to transfer patients into care home settings or hospices (eg in instances where death is deemed unavoidable).

For many, the thought of dying inside a hospital is undesirable, and it has been an NHS strategy to reduce hospital deaths in end of life care since 2008. (A National Audit Office report from 2008 highlighted that there was no clinical need for 40% of people who died in hospital to be in-patients.) So, the findings of this study may be reflecting improvements in end-of-life care – but surviving the initial hospital stay does not necessarily mean the patient is not going to die following discharge. Every hospital visit is linked to significant amounts of physiological and psychological strain, and this may impact on the chances of full recovery, especially for older people. Unfortunately, the authors of this study did not explore causes of death any further.

This study raises important questions about the possible impacts of austerity on people’s health. The increase in mortality we have experienced in recent years needs to be understood. This is important, partly because our health care systems are continuing to experience significant rises in demand, through an ageing population living with long-term diseases. Demand and cost pressures exceed the additional resources that the health care system is set to receive even after the Chancellor’s budget announcements.

Although we should not draw too many firm conclusions from the evidence in this paper, it shows signs of trouble that deserve further research, using better data.

Rocco Friedel is a Data Analyst and Toby Watts is a Senior Economics Analyst for the Health Foundation.