In 2015, the UK suffered one of the largest rises in overall mortality measured since reliable annual records were first collected of the population in the late 1830s. What has taken place in Britain recently has few precedents since the 1930s and the Second World War.1 To discover the reasons why there might be a fall in life expectancy among the elderly in England now, we need to look for where a similar fall has occurred in the past.
One such spike in mortality rates occurred in the early 1950s. It took just four months, in the midst of Britain’s post-war austerity period from December 1952 to March 1953, for some 12,000 residents to perish in what was then modern London’s most deadly civilian disaster. The initial public reaction was to attribute the deaths to air pollution. At the time, most Londoners kept warm by burning dirty coal. Cool air had settled over the Thames Valley in early December 1952 and did not move for weeks. The air turned thick with smog. In one week alone 4703 people died, many more than the 1852 people who had died during the same week the previous year.
In early 1953, a Member of Parliament put this episode into context when he asked the Minister of Housing, Harold Macmillan:
Does the minister not appreciate that last month, in Greater London alone, there were literally more people choked to death by air pollution than were killed on the roads in the whole country in 1952?
* This chapter is a revised and updated version of D. Dorling, ‘Why are the old dying before their time? How austerity has affected mortality rates’, New Statesman, 7 February 2014. A fully referenced version with all the evidence known to this author and available from early 2014 is available at: www.dannydorling.org/?page_id=3970
Macmillan may well have appreciated the likelihood that it was the smog, but he was also averse to spending more on making smokeless fuel available for the poor at a time of austerity. He ordered that an official government report be conducted; it conveniently proposed the hypothesis that influenza had caused all the excess winter deaths. Many MPs and the public remained suspicious. They did not think it had been just another outbreak of flu. They agitated and, within three years, laws had been passed requiring the burning of cleaner, more expensive coal in cities such as London.
There are clear parallels with the current spike in mortality rates and the 1953 smog. Public Health England’s explanation for the current rise in the death toll has been to assert that ‘influenza has contributed significantly’. However, the rise in 2015 does not have the characteristics of previous cold weather snaps and influenza epidemics. It is austerity that is linked most closely with the rising old-age mortality and its timing coincides with the population reporting worse health and rises in mortality over several years. Influenza is an easy scapegoat.2
Between 2008 and 2013, public sector cuts led to some 483,000 old and disabled people in the UK either losing their care support or becoming no longer eligible to claim it. According to the Personal Social Services Research Unit, the ‘reductions … are particularly acute for older people’. By 2014, there were millions fewer social care visits a year to the elderly than took place five years before. These were visits to elderly people who would have been assessed as vulnerable, visits that could result in the carer setting in motion a course of action leading to the prevention of an unnecessary death. The big cuts to visits came after the general election of May 2010, and became deeper each year after that.
In July 2013, an internal Public Health England report was leaked by the Health Service Journal. In a repeat of events six decades earlier, the report revealed that, ‘since December 2012, both male and female mortality are estimated to have increased’. This was no normal increase; and for the group most severely affected – the very elderly – death rates, already unusually high during most of 2012, were reported to be rising. It is important to point out that the deathly consequences of the cuts were becoming apparent so early on. What the Public Health England report found was shocking. Here, in its own words, is what it said:
When we focus on mortality over 75, we observe rapidly increasing mortality for both males and females, presenting throughout 2012, and continuing into 2013. Female 12-month mortality3 over 75 is currently higher than in any year since 2009; and April 2013 saw a particularly sharp increase. Worryingly, female 75-plus mortality trends appear to have been worse in the Spearhead areas.4
In plain English what this means is that elderly people in the UK in 2012 and 2013 were dying a few weeks and in some cases a few months earlier than they had been before. The next year, 2014 was also bad compared to the improving trend which had existed from 1990 through to 2010, but it was what occurred in late 2014 and through many months of 2015 that was most shocking.
Spearhead areas are some of the poorest parts of the country. They are those places that had the highest premature mortality rates in the very recent past, and were targeted by the last Labour government for special intervention to try to bring down health inequalities in England. However, by 2015 the rise in death rates among the elderly was occurring across the UK and in early 2016 some of the highest elevated rates were in the South of England. These rises may have been so widely ignored because the deaths were of people in old age who would be expected to ‘die anyway’ just a few years later. But if we look back to what was known in 2013 we can see that an opportunity to properly address the issue was missed.
According to the leaked Public Health England report, by mid 2013 there had been, ‘if anything, a further deterioration in mortality compared with that observed [in the same period in 2012]’. The number of excess deaths in England in 2012–13 had been 23,400 (5 per cent) above Office for National Statistics (ONS) expectations. However, a seemingly unperturbed anonymous official reacting to the story told the Health Service Journal that ‘if increased mortality continues through 2013 and into 2014, there will have to be more detailed consideration’.5
In early 2015 there was a 5 per cent rise in total mortality in absolute numbers in England and Wales compared to 2014. In Scotland the rise was nearer 9 per cent. This was unprecedented. No public officials spoke out at a national level as this became evident in January, February and March 2016. They muttered about waiting for the 2015 population mid-year estimates, to be published by July 2016, before pronouncing, as if they thought some unnoticed mass immigration of the very elderly might have occurred. But at least by then the picture should be clear, or so we thought. And at least by then a choice would be made regards emergency funding of the services required in winter 2015/16, of the nurses, of visits to pensioners, of pensioner benefits. To not do would be choosing to let the cull continue. More and more academic papers began to be published in 2015 and early 2016 demonstrating that the geography and social association with austerity was so high that this clearly was not due to some new especially virulent strain of flu.
How did Public Health England react to its internal report being leaked? It shot the messenger. On 15 August 2013 the Orwellian-styled ‘chief knowledge officer’ of Public Health England issued an open letter suggesting there had been methodological weaknesses in the leaked internal report and explaining that: ‘The analyst was therefore asked to stop circulating the reports.’ The reports stopped. But the deaths didn’t. And the need to explain the increase remained. The chief knowledge officer’s letter was accompanied by a new, eight-page Public Health England report – Excess Winter Mortality 2012–13 – which did not explain why there were any methodological weaknesses in the original internal report, but said instead that ‘the temporal coincidence with influenza A(H3N2) across the UK and Europe suggests that influenza has contributed significantly’. And that influenza was ‘a major explanatory factor’.6
Contrast the official message (that it’s probably just mostly flu) with what was proved in the leaked internal reports. Those reports showed that the long-term trend in England of many years of falls in mortality coupled with rises in life expectancy appeared to have been halted in 2012; and that the situation was deteriorating throughout 2013. It was hard to know what to believe. Then the ONS produced its own report in November 2013 which showed the scale of excess deaths to be even greater.7 The ONS report said it was not necessarily because the winter of 2012/13 had been cold that death rates had risen among the elderly. The government statisticians explained that during the exceptionally cold winter of 2009/10, the number of excess winter deaths had been ‘similar to years with mild winters’. Thus, it is not so much the cold as the extent to which people can afford to heat their homes, and probably much else, such as whether they are visited that matters. According to the ONS, in 2012/13 there had been a 29 per cent increase in deaths, compared to 15.5 per cent the previous winter, with roughly 31,100 more people dying than the average for non-winter months. It highlighted that the great majority of these untimely deaths occurred among people over the age of 75. The ONS also cast doubt on flu being the main cause of the spike, saying: ‘Influenza activity in 2012/13 was relatively low.’ In the final version of the report that was later posted on the web this sentence read: ‘Influenza activity in 2012/13 was relatively low, but activity was prolonged and reached levels higher than those seen in 2011/12.’8 The officials stuck to their flu explanation for as long as possible.
The one thing we can now be sure of is the chief reason for the spike in deaths in 2012/13 was not flu. Researchers David Stuckler and Martin McKee had already determined that the rise was not due to influenza and pneumonia. They estimated that influenza and pneumonia respectively contributed only 5.8 and 3.5 per cent of the rapid absolute increase in elderly mortality in the UK since early 2012. The European Centre for Disease Control also announced that the UK had one of the lowest reported intensities of influenza across Europe in winter 2012/13.9
People may in future decades look back at the huge increase in deaths among the elderly from 2012 to 2016 and be amazed that the authorities initially just blamed the cold weather. They might reflect on the fact that there is no large rise in mortality when flu hits countries like Norway and Sweden because of their much better funded health and social service systems.
Cold weather is no excuse for more deaths. We know that countries with frequently low winter temperatures, such as Finland and Germany, where most housing has adequate insulation and heating, have very low rates of excess winter mortality. We have to search for more clues. Maybe, as the price of fuel for cars rises, we pay fewer visits to elderly relatives? There are many factors that matter, but the timing suggests it is the cuts, austerity and not all being in it together that matter most this time.
In 2014, I wrote that it will be those who are poorer and living in poorer areas who will comprise the majority of the prematurely dead, and who will comprise the majority of the thousands more who will die between now and May 2015, should the situation not improve. These are the last of all those people who, in their millions, voted for Labour in the landslide election victory of 1945. This is the generation that experienced post-war austerity – now being killed by post-crash austerity. Ironically given their old age, many will have been or become middle class during the 1960s and 1970s and may well have voted Conservative in the fatal 1979 general election which ushered in three decades of rising inequality and public service cuts.
The most deadly violence is quiet violence, violence that kills you softly. The middle class mass-murderer Harold Shipman killed his elderly and mostly female victims with the quiet violence of a lethal injection. For an action to be described as violent it is often required that there be an intention to hurt, to damage or to kill. If you know that what you are doing or choosing not to do will result in harm that increases mortality, then you are acting in a violent way (see also Vickie Cooper and David Whyte’s Introduction to this book). It may be 30 years or more before the official documents are released to reveal what officials actually knew in 2011, 2012 and 2013.
In 1953, 60 years ago, when it began to emerge that people were dying in numbers who would not normally die, Londoners knew it was the smog. Their MPs knew too, but the Conservative government of the day and its housing minister, Harold Macmillan, did not want the hassle of having to sort out the problem of urban air pollution. The similarities with the British Prime Minister David Cameron are shocking, but the death toll today is far higher. David Cameron left office in June 2016 with UK life expectancy falling. No other post-war prime minister has achieved such a terrible outcome. It is hard not to conclude that patricians had again viewed the rising deaths among the elderly as a price worth paying for the greater good of ‘balancing the books’ and making Britain ‘great’ again, ready to win that ‘global race’. Along the way, thousands will have to shiver in the cold or receive increasingly inadequate care in their old age as budgets are slashed. Over recent years, as the 1 per cent has become ever richer, the poorest have had their income or benefits cut even further. Most of the poor who do get to 65 then do make it to age 80 or 85, however, and it is those age groups that have seen the greatest rises in deaths in recent years. You reap what you sow.10
Websites were last accessed 19 August 2016.
1. See rapid response of 29 July 2016 to the British Medical Journal editorial on the deaths, available at: www.bmj.com/content/354/bmj.i3697/rapid-responses
2. D. Dorling, ‘Austerity, rapidly worsening public health across the UK, and Brexit’, Political Insight blog, Political Studies Association, 11 July, available at: www.psa.ac.uk/insight-plus/blog/austerity-rapidly-worsening-public-health-across-uk-and-brexit-0
3. The 12-month mortality rate measures the death rate of a specified age population in a given period of twelve months.
4. www.newstatesman.com/politics/2014/02/why-are-old-people-britain-dying-their-time
5. The quote appears in the version of my original New Statesman article which is available at: www.dannydorling.org/?page_id=3970. This article gives 32 references including: D. West, ‘EXCLUSIVE: unexpected rise in deaths among older people’, Heath Service Journal, 25 July 2013, available at: www.hsj.co.uk/news/exclusive-unexpected-rise-in-deaths-among-older-people/5061540.article#.UoyrZtK-06Y
6. Public Health England, Excess Winter Mortality 2012–13, London, 2013, available at: www.gov.uk/government/publications/excess-winter-mortality-2012-to-2013
7. Office of National Statistics, Excess Winter Mortality in England and Wales, 2012/13 (Provisional) and 2011/12 (Final), London, 26 November 2013, p.5, available at: www.ons.gov.uk/ons/rel/subnational-health2/excess-winter-mortality-in-england-and-wales/2012-13--provisional--and-2011-12--final-/stb-ewm-12-13.html
8. The final version is available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2013-11-26
9. European Centre for Disease Control (ECDC), Influenza in Europe, Season 2012–2013, Latest Surveillance Data Reports, Solna, Sweden, 2013, available at: http://ecdc.europa.eu/en/publications/Publications/influenza-season-risk-assessment-europe-2013.pdf
10. See: Hiam, L., Harrison, D., Dorling, D., McKee, M. (2017) Why has mortality in England and Wales been increasing? An iterative demographic analysis, Journal of the Royal Society of Medicine, http://dx.doi.org/10.1177%2F0141076817693599 and Hiam, L., Harrison, D., Dorling, D., and McKee, M. (2017) What caused the spike in mortality in England and Wales in January 2015?, Journal of the Royal Society of Medicine, February 17th, http://dx.doi.org/10.1177%2F0141076817693600