The recent article in the BMJ purporting to show the negative effects on mortality in England of funding ‘constraints’ on health and social care has excited considerable attention (if not by the BBC). In this blog I precis the article in the hope of encouraging more people to read the original.
The authors note that the NHS in England saw a real terms annual increase in public healthcare spending of 1.30% between 2010 and 2014 (compared with an historical annual growth of around 4%). But during this period, ‘demand and healthcare cost inflation have increased, with a growing and ageing population, in addition to new treatments and technologies’. A funding gap – between what is needed and what is available – is predicted by 2020/2021, ‘unless major changes are implemented’.
Real terms adult social care spending decreased by 1-19% annually between 2010 and 2014 (after correcting for inflation) (compared with an annual increase of 3.17% between 2001 and 2009). This has important ramifications: it has for example prevented the discharge from hospital of frail patients to means-tested home care and care home accommodation. There is now a considerable supply-demand mismatch.
The question the authors ask themselves is: have these funding constraints impacted on mortality?
The study design and sets of measures deployed cannot be satisfactorily summarized here (I would end up merely reproducing the authors’ own concise, technical account).
Among their findings:
- 8184 higher than ‘expected’ number of deaths in 2012, and 18,324 in 2014 (plus, similar results for men and women);
- care home and home deaths were, respectively, the first and second contributors to ‘excess’ deaths;
- higher than expected deaths were restricted to those over 60;
- £10 per capita declines in real public expenditure on health (PEH) and real public expenditure on social care (PES) were associated with increases of 0.19 and 5.10 care home deaths per 100,000 in England, respectively. For PES, this association held for at least two years after the 2010 spending constraints, while for PEH it became weaker. Further analyses suggested that these increases were independent of macroeconomic forces like unemployment and pensions;
- the number of NHS hospital and community nurses and social care clinical support staff were each associated with care home mortality, alleviating the relationship between real PES per capita and care home mortality in lag years 1 and 2, suggesting that these staff numbers were significant mediators of the spending-mortality relationship;
- the number of nurses, but not of clinical support staff, seemed to be a mediator of the relationship between spending (both PEH and PES) and home mortality rates for lag years 1 and 2; and the number of nurses appeared to be the sole mediator of the relationships between PEH per capita and care home mortality;
- projections comparing two observational bases (2001-2010 and 2009-2014) yielded an additional 152,141 deaths from 2015-2020 using the 2009-2014-based projection when compared with the 2001-2010-based projection;
- to close this mortality gap, on top of the health and social care budget, as of the end of 2016, the aggregate spending and efficiency combinations would involve an additional £27.56 billion for a conservative 0% annual efficiency increase; an additional £27.26 billion for a moderate 1% annual efficiency increase; and an additional £23.03 billion for an ‘aggessive’ 3% annual efficiency increase; and with no additional spending, closure of the mortality gap by 2020 would require an annual efficiency increase of 10.79%.
In sum, the authors claim that their study demonstrates that recent constraints in PEH and PES spending in England were associated with nearly 45,000 higher than expected numbers of deaths between 2012 and 2014. Continuance of these trends, even when factoring in the increased planned funding as of 2016, suggests that approximately 150,000 additional deaths may arise between 2015 and 2020 (and around 120,000 excess deaths from 2010-2017). Those aged 60+ were more susceptible to excess mortality. By setting, deaths at care homes and at home contributed most to the mortality gap, while hospital mortality was lower than expected. This most likely reflects relative spending cuts. It also probably reflects the recent drive to move patients with poor prognoses and those who have reached their ceiling of care away from the hospital environment. It is relevant to note too that social care is means tested and often delivered privately, without universal coverage.
Three policy implications are noted. First, having demonstrated that decelerated increases in PEH and PES in England may have adversely affected population mortality as demand increased and health care costs rose above inflation, the authors stress that the delivery of universal coverage must be adequately financed if it is to remain viable. Second, having shown that the elderly population and those in care homes were especially vulnerable to recent financial changes, targeted interventions to ensure adequate management of these patient groups are recommended (including funding increases in social care as well as rises in nursing numbers). And third, and most significantly, having considered future financial scenarios, the authors insist on the urgency of additional funding if further ‘excess’ mortality is to be avoided.
I have a few comments to add. First, I am grateful to the authors for their study, and the care they took – in design, measurement, analysis and reporting – to ensure the credibility of their research. I hope they will think my summary is accurate, as far as it goes. Second, I have long detected a tendency among epidemiologists (and quantitatively-inclined sociologists who have been too long in their company) to embrace forms of neo-positivism that tacitly assume definitive, even proven conclusions. They will protest, but I believe it is implicit in their research rationales, this urge to ‘wrap things up’. The authors of the BMJ paper are commendably cautious, but they too belong in this camp. Intimating the possibility of proof is a hostage to fortune: it is to open oneself to accusations of failure. It is far better, as well as sounder, to set one’s findings in the context of total research in the field in question. This brings me to my third comment, that the total research in ‘this field’ – ethnographic and qualitative as well as quantitative – makes it clear beyond reasonable doubt: (a) that austerity kills, and (b) that the post-2010 deepening of health and, in particular, social care funding ‘cuts’ make their contribution.
I have in previous blogs taken issue with epidemiological studies, most often – he was down the road from me at UCL after all – those conducted or cited by Michael Marmot. I should reiterate that I value such work and fully respect their authors, none more than Michael; and insofar as they allow for the predictive power so necessary for effective interventions, I applaud them. My qualification is that if it is explanatory power we are after, then more and different is required. Moreover explanatory progress might reasonably be expected to refine our predictive capabilities. And to maximise explanatory power is to take research in the round. What the BMJ paper under consideration here does is add grist to the mill of our understanding of the nature of the causal linkages between health care provision and longevity in an era of austerity unprecedented in modern times. We already know that austerity impairs and kills, and a good deal about the generative mechanisms involved, social as well as psychological and biological.
Watkins, J et al (2017) Effects of health and social care spending constraints on mortality in England: a time trend analysis. British Medical Journal 2017;7:e017722.doi:10.1136/bmjopen-2017-017722