UK mortality trends and international comparisons

Findings from new research and implications for the UK government

A wide range of evidence shows that the UK’s health is fraying. Improvements in life expectancy have stalled, a growing number of people are expected to live in ill health, and deep inequalities in health persist between the poorest and wealthiest communities.

Mortality rates are a well-recognised indicator of a population’s health and wellbeing, and are a useful metric for comparison. International comparisons can help us understand whether these challenges are unique to the UK and – crucially – where there might be room for improvement. 

In 2019, David Leon (and colleagues at the London School of Hygiene and Tropical Medicine) compared trends in mortality in England and Wales over the period from 1990 to 2016 with mortality trends in 22 other high-income countries. This study highlighted that:

• the slowdown in improvements in mortality rates in England and Wales in the 2010s was more marked than in peer countries
• female mortality rates in England and Wales were consistently higher than in peer countries throughout the whole period
• there was an emerging trend of worsening mortality rates among 25–49-year-olds in the UK, compared with the same age group in peer countries. 

To further understand and benchmark trends in mortality rates in the UK against those of peer countries, the Health Foundation funded the team that carried out this 2019 research to update their analysis to include more recent data; expand the scope to focus on all nations and regions in the UK; and explore the specific causes of death driving these trends.

This new research – published as two outputs on the London School of Hygiene and Tropical Medicine website and on the medRxiv preprint server for health sciences – highlights the size of the challenge facing the UK in its mission to create ‘a fairer Britain, where everyone lives well for longer’.

In this briefing we summarise and contextualise the main findings of the commissioned research. We look at overall male and female trends in mortality, differences between UK nations and regions, trends across age groups and trends in specific causes of death. We conclude by considering actions that the UK government could take to begin to address these challenges. 

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a) Mortality trends in the UK since 1990 
b) How UK mortality trends have changed relative to peer countries 
c) Mortality in the four UK nations: trends and international comparisons 
d) Differences in mortality rates across England 
e) UK mortality trends across age groups 
f) International comparisons of mortality rates across age groups 
g) Causes of death for people aged 25–49: changes over time and relative to peer countries 
h) Deaths of despair: UK trends and geographic inequalities

a) Mortality trends in the UK since 1990

Between 1990 and 2023, mortality rates declined for both males and females in the UK. However, most of this improvement was achieved prior to the early 2010s. The improvement was more rapid for males: between 1990 and 2011 the female mortality rate decreased by 30% (from 1,228 deaths per 100,000 down to 857), while the male mortality rate decreased by 38% (from 1,936 deaths per 100,000 down to 1,197).

Between 2011 and 2019, the rate of improvement slowed, with the female mortality rate decreasing by only 5% and the male mortality rate decreasing by 7%. Mortality rates then increased in 2020 because of the pandemic. As of 2023, the UK male mortality rate was 1,165 deaths per 100,000 and the female mortality rate was 843 deaths per 100,000 – largely recovered from the peak during the pandemic but still higher than before the pandemic. Analysis of 2024 data suggests mortality rates might now be back to pre-pandemic levels. 

The UK’s slowdown since the early 2010s compares poorly with international peers and masks concerning trends within different UK population groups. 

b) How UK mortality trends have changed relative to peer countries

Trends in mortality rates in the UK differ from trends in most peer countries, where the slowdown in improvements in mortality rates in the 2010s were less pronounced (Figure 1).

There are some differences in how the UK compares with peers between male and female mortality rates. As shown in Figure 1, while in 1990 the male mortality rate in the UK was 5% higher than the median of peer countries, by the early 2010s it was in line with the median. 

On the other hand, the UK’s female mortality rate stayed 4–13% higher than the median throughout the 1990s to the early 2010s, meaning the UK has always performed worse than the median of peer countries in terms of female mortality rate. The subsequent plateauing of mortality rates in the UK in the 2010s for both sexes (as other countries improved at a faster rate than the UK) has led to a significant widening of the gap to the median. As of 2023, UK mortality rates were 14% higher than the median for females and 9% higher for males. In both cases, the gap to the median was higher in 2023 than in 1990.

As shown in Figure 2, the difference in trends between the UK and peer countries translated into a relative deterioration of the UK’s position between 1990 and 2023. In 1990, the UK had the 7th highest male and female mortality rate out of 20 countries (excluding Japan and Ireland, because data are not available for the three time points included in this chart). By 2011, the male mortality rate had improved (11th highest) while the female mortality rate stayed fairly similar (6th highest). By 2023, following the slowdown in improvements in mortality rates, the UK position deteriorated for both, with the UK having the 6th highest male mortality rate and 4th highest female mortality rate. 

c) Mortality in the four UK nations: trends and international comparisons

The broad trend for mortality rates in each of the four nations (Scotland, Northern Ireland, Wales and England) mirrored the trend for the whole of the UK, including the plateauing seen in the 2010s.

However, there are stark inequalities observed between nations. Out of the four nations, male and female mortality rates were the lowest in England in 2021 (below country level, the latest data available in this research are from 2021). Female mortality rates were 6% higher than England in Northern Ireland, 10% higher in Wales and 20% higher in Scotland. Male mortality rates were 4% higher than England in Northern Ireland, 7% higher in Wales and 17% higher in Scotland.

These inequalities are reflected in varying differences to the median of peer countries. As shown in Figure 3, as of 2021, Scotland had a female mortality rate 36% higher than the median and a male mortality rate 25% higher. In comparison, England’s mortality rates were 13% (female) and 7% (male) higher than the median. When compared with peer countries, Scotland has the second highest mortality rate (after the US) for both males and females.

In every year since 1990, the female mortality rate in every UK nation has been higher than the median of peer countries. In contrast, for the male mortality rate, there have been years where in England and Wales the rate was at or below the median. For Scotland and Northern Ireland, the male mortality rate was above the median every year since 1990.

d) Differences in mortality rates across England

Looking at England as a whole can mask the stark inequalities in health that exist between regions. In 2021, mortality rates were more than 20% higher in the North West and North East compared with the South West for females and males. The regions with the highest and lowest rates are shown in Table 1.

Comparing the mortality rates of England’s regions to the median of peer countries exposes the extent of geographic inequalities (Figure 4). In 1990, London, the South and East of England had mortality rates very similar to (or lower than) the median of peer countries – in blue (or white) in Figure 4. In contrast, the West Midlands, Yorkshire and the Humber and regions in the North of England already had mortality rates higher than the median in 1990 – in red in Figure 4.

Mortality rates in all regions worsened compared with the median between 1990 and 2021, with stark inequalities remaining. Female and male mortality rates in the North East changed from 19% and 14% higher than the median in 1990 to 30% and 17% higher than the median in 2021. Female and male mortality rates in the South West changed from 4% and 7% lower than the median in 1990 to 5% higher and 3% lower than the median in 2021. This is shown in Figure 4 with the red areas getting darker and the blue areas getting lighter.

e) UK mortality trends across age groups

Mortality rates improved for all age groups in the UK between 1990 and 2019. However, the extent of the improvement varied across different age groups. Mortality rates improved the most for the 0–24 age group: they decreased by 47% for females and 54% for males. They improved the least for the 25–49 age group: they decreased by around 20% for both men and women. In line with the general trend, most of the improvements occurred between 1990 and the early 2010s, with all age groups plateauing in the 2010s. However, the 25–49 age group was the only one that experienced a worsening of mortality rates, increasing by 6% between 2012 and 2019 for both men and women. All age groups experienced an increase in mortality rates during the pandemic. 

f) International comparisons of mortality rates across age groups

As shown in Figure 5, between 1990 and 2019 mortality rates significantly worsened compared with the median of peer countries for people aged 0–24 and people aged 25–49. However, the worsening was much sharper for people aged 25–49. The mortality rate for women aged 25–49 worsened from being roughly the same as the median of peer countries in 1990 to being 37% higher in 2019 and 46% higher in 2023. Likewise, the mortality rate for men aged 25–49 worsened from being 10% lower than the median in 1990 to 28% higher than the median in 2019 and 31% in 2023. In addition, while the worsening relative to peers commenced in the early 2010s for most other age groups, it started in 1990 for mortality rates of those aged 25–49 and was further exacerbated in the 2010s. 

These findings underline the significance of the worsening UK position relative to peer countries for this age group. Out of the 21 other countries included in this study, 19 showed a decline in mortality rates similar to the median. Only Canada and the US experienced – similar to the UK – a shallower decline and then a worsening in mortality rates in the 2010s. 

Figure 6 highlights the deterioration in mortality rates for the 25–49 age group compared with peer countries across the UK. In 1990 regions in the South – apart from London – had mortality rates at or below the median of peer countries, while northern regions had mortality rates higher than the median. By 2021, mortality rates had worsened compared with peers in all nations and regions, with stark inequalities remaining. For example, for women aged 25–49, Scotland’s mortality rate was 20% higher than the median in 1990. By 2021, the rate was 113% higher. Within England, for men aged 25–49, the North East went from a mortality rate 7% lower than the median in 1990 to a rate 113% higher in 2021.

g) Causes of death for people aged 25–49: changes over time and relative to peer countries

The main three causes of death for people aged 25–49 in the UK in 2019 were:

1. Cancers (36% of total deaths for women and 17% for men)
2. Deaths from external causes, ie injuries, accidents and other external hazards (21% of total deaths for women and 38% for men)
3. Circulatory diseases (13% of total deaths for women and 18% for men).

Mortality rates for these three causes have evolved differently over time.

While mortality rates for cancer and circulatory diseases improved between 2001 and 2019, mortality rates from external causes deteriorated, particularly since the 2010s. The female mortality rate from external causes worsened from around 13 deaths per 100,000 in 2001 to around 19 per 100,000 in 2019 – an increase of approximately 40%. The male mortality rate from external causes deteriorated from 49 deaths per 100,000 to 57 per 100,000 in 2019 – a 16% increase.

Note: data prior to 2001 have been excluded because changes to how causes of deaths are classified means there is greater uncertainty for data up to 2001. Data since 2019 have also been excluded due to the lack of comparable data and challenges in interpreting trends in mortality for specific causes of death during the COVID-19 pandemic.

As shown in Figure 7, between 2001 and 2019 the UK position relative to peer countries deteriorated for all three of these main causes of death. For cancers and circulatory diseases, mortality rates in peer countries improved more rapidly than in the UK. The difference in trends is even starker when looking at external causes. As mortality rates increased for the UK, they decreased for the median of peer countries – so while in 2001 the UK was doing better than the median of peer countries, by 2019 the reverse was true.

As shown in Figure 8, for external causes, in 2001 the UK male mortality rate was 17 deaths per 100,000 lower than the median and the female mortality rate was 6 deaths per 100,000 lower than the median. From 2013 for males and 2014 for females the UK started doing worse than the median. In 2019, the male mortality rate from external causes in the UK was 19 deaths per 100,000 higher and the female mortality rate was 7 deaths per 100,000 higher. 

This means that – compared with the median of peer countries – the mortality rate from external causes in the UK changed from being 30% lower for women and 26% lower for males in 2001 to being 57% higher for females and 51% higher for men by 2019.

As a result of these trends, deaths from external causes explain 78% (for women) and 69% (for men) of the divergence in mortality rates from the median of peer countries over the period from 2001 to 2019. Deaths from cancers explain 17% (for women) and 15% (for men) of the divergence from peers, while deaths from circulatory diseases explain just 3% of the divergence for women and 6% for men. 

In addition to the three main causes of death, deaths related to alcohol, drugs or suicide (or undetermined intent) – commonly referred to as deaths of despair – are of particular public health interest as they are notably related to socioeconomic factors. In what follows, we delve deeper into trends for each of these three causes of death.

As shown in Figure 9, UK mortality trends between 2001 and 2019 differ across these three causes of death. Drug-related mortality rates experienced a sharp increase. Mortality rates for suicide and deaths of undetermined intent also increased – although not as much as drug-related deaths. On the other hand, alcohol-related mortality rates plateaued for women and even declined for men between 2009 and 2019. 

Compared with the median of peer countries, the UK’s drug-related mortality rate has got substantially worse. In 2019, the UK mortality rate was more than three times higher – for both men and women – than the median of peer countries. The UK also deteriorated relative to the median for deaths from suicide and undetermined intent (but did not deteriorate for alcohol-related deaths). 

As a result, drug-related deaths contribute substantially to the divergence in mortality rates for people aged 25–49 from the median of peer countries over the period from 2001 to 2019. They explain 42% of the divergence in the female mortality rate and 28% of the divergence in the male mortality rate. Suicide and deaths of undetermined intent also contributed towards the divergence (17% for women and 20% for men). Alcohol-related mortality did not contribute to the divergence.

h) Deaths of despair: UK trends and geographic inequalities

Within the UK, there are substantial differences in drug-related mortality rates and in the growth in these rates over the period considered. Scotland has the highest rates for both men and women and is the nation that experienced the steepest growth in drug-related mortality over this period, as shown in Figure 10. As of 2019, drug-related mortality rates were around 4 times higher in Scotland than in England for both men and women.

While drug-related mortality rates in Northern Ireland are lower than Scotland, there has also been substantial growth there since 2001, with faster growth since 2011. Geographic inequalities for alcohol-related mortality and mortality from suicide and deaths of undetermined intent exist, but they are less pronounced than for drug-related mortality. Northern Ireland has the highest rates for male and female mortality from alcohol-related conditions, almost twice as high as England. While Scotland has the highest rates for female and male mortality from suicide and undetermined intent, 1.9 times (women) and 1.7 times (men) as high as England.

Within England, there are stark geographic inequalities in drug-related deaths. As shown in Figure 11, in 2019 the drug-related mortality rate for those aged 25–49 in the North East was 3.5 times higher for men and almost 4 times higher for women than in London.

Figure 11 also highlights how geographic inequalities have increased between 2001 and 2019. In the North East, drug-related mortality rates increased by almost 300% for women and 120% for men, and in the West Midlands by 156% and 96%. On the other hand, rates barely changed in London and the East of England. 

Geographic inequalities also exist for alcohol-related mortality and deaths from suicide (and deaths from undetermined intent), although they are slightly less stark than for drug-related mortality. In 2019, alcohol-related mortality rates were around 3 times higher in the North East than in London. Female mortality from suicide and undetermined intent was 2.4 times higher in Yorkshire and the Humber than in London, and male mortality from suicide and undetermined intent was 2.8 times higher in the North East than in London. 

The research highlights several concerning trends:

• Improvements in UK mortality rates slowed significantly in the 2010s, more so than in most other high-income countries.
• The UK’s female mortality rates have been consistently poor compared with peer countries. For every year between 1990 and 2023, the female mortality rate in the UK was 4–16% higher than the median of other high-income countries
• There are stark inequalities across UK nations, with Scotland having mortality rates 17–20% higher than England. There are also stark inequalities between regions within England, with mortality rates in the North East and North West being 20% higher than in the South West.
• The worsening of the UK position relative to peers has been especially marked for people aged 25–49. As of 2023, the 25–49 female mortality rate was 46% higher than the median of peer countries, while the 25–49 male mortality rate was 31% higher.
• Much of the worsening UK position for the 25–49 age group between 2001 and 2019 was driven by deaths from external causes. Drug-related deaths also played a key role – these accounted for 42% of the worsening for women and 28% for men.
• There are stark inequalities in drug-related deaths across the UK, with Scotland having drug-related mortality rates 4 times higher than England and the North East of England having drug-related mortality rates 3.5 (men) to 4 times (women) higher than London.

The fact that the UK is performing worse than many other high-income countries suggests that improvement is both possible and urgently needed. Improvement efforts should begin with a thorough understanding of the underlying causes, which are multiple, complex and interrelated. The next section explores some of these potential causes, drawing on existing research.

There is a strong link between living standards and health, as access to adequate income and other financial resources is crucial to securing many of the building blocks of health, including good-quality housing and healthy food. Over the past two decades, the UK has experienced a period of economic stagnation and falling living standards. While all high-income countries have faced similar challenges, the UK appears to have been particularly adversely affected. Between 1995 and 2007, median working-age incomes rose by over 40%. However, between 2007 and 2019 they grew by just 6%, placing the UK among the slowest growing countries.

Besides differences in overall economic performance from other countries, there are large and persistent gaps in income between nations and regions within the UK. For example between 2004 and 2019, while average incomes in London rose by 7%, average incomes in Yorkshire and the Humber fell by 2%. The UK has the highest income inequality of any major European economy. 

Beyond the impact of economic growth and living standards, public investment in prevention is key to good health. This includes not only preventative services within the NHS, but also wider public services and infrastructure investment, as our health is shaped by a broad and complex range of influences, including good quality and affordable housing and access to safe green spaces and clean air. However, continued pressure on the NHS and wider public services has often meant a greater focus on tackling acute need and less investment in prevention. Examples include the failure to shift NHS spending towards community services and prevention, as well as difficult local government finance settlements meaning acute need has to be prioritised. In England, there have also been reductions in local public health services and cuts to Sure Start funding, despite evidence of significant improvements for young people and their families across a range of outcomes. 

This research shows drug-related deaths are a key contributor to the divergence in mortality rates for people aged 25–49 from peer countries. This underlines the link between socioeconomic background and health, as well as the key role of prevention in improving health outcomes.

Economic deprivation and social exclusion are strongly associated with drug-related harm. The highest proportion of drug-related deaths in the UK occurs in areas of greatest neighbourhood deprivation, with unemployment, homelessness and poor mental health highlighted as important risk factors at an individual level. The voluntary and community sector plays a key role in addressing these problems but are struggling due to funding pressures and the impact of inflation on their costs.  

Addressing the scale of the shortfall in the nation’s health cannot be achieved by any single government department or policy alone. This is why the UK and devolved governments must take cross-sector approaches with a sustained and long-term commitment to improving health and reducing inequalities. We do not seek to set out detailed policy recommendations in this briefing, and approaches and delivery mechanisms will vary between nations. We do, however, set out broad areas of focus that could drive progress.

The UK government’s mission-driven approach has the potential to deliver improvements to the health of the population through better coordination and integration across government departments, and through enabling a firmer focus on longer term outcomes. Yet there has been a lack of progress to date. The government should focus attention and policy action by setting and monitoring a goal to improve the nation’s health and reduce health inequalities over the next decade and beyond. The contribution to improving health needs to be a stated ambition for all policies, from welfare reform to industrial strategy, from health care to housing strategy.

Turning around the deep-seated socioeconomic deprivation and health inequalities affecting large parts of the UK will require sustained action over time. This includes boosting local economies that have experienced long-term decline.

Policy opportunities and solutions to prevent the early onset of ill health and slow the progress of diagnosed conditions already exist. Such policies include: 

• developing a clear strategy to tackle health inequalities, learning (where appropriate) from the evidence of what we know worked in the 2000s, and ensuring a focus on the wider determinants of health
• reducing income poverty through the forthcoming child poverty strategy and welfare reform
• addressing ill health in the working-age population and its consequences for economic growth by helping people with health conditions stay in or return to employment, following the approaches recommended by our Commission for Healthier Working Lives
• applying population-level approaches to leading risk factors of avoidable ill health, including smoking, alcohol use, poor diet and physical inactivity
• ensuring local government is adequately resourced to provide preventative services, and changing how resources are allocated to ensure more investment is targeted towards the most deprived areas
• orienting health and care services to prevention, increasing the share of funding that goes to primary, community and preventative services, and taking a long-term approach to investment in prevention. 

A concerted effort is also needed to address the stark and concerning trend in drug-related deaths, particularly in Scotland and the North East of England. 

The issues behind the UK’s fraying health and deep inequalities have developed over decades and signify the repeated failure to prioritise prevention. Sustained action over the long term is needed to reverse these trends. A different future is possible, but only with bold and concerted action led by the UK government and devolved administrations.