AGING FEBRUARY 15, 2014
It took just four months, 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 4,703 people died, many more than the 1,852 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?” Macmillan may well have appreciated the likelihood that it was the smog, but he was also averse to spending more on smokeless fuel 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.
A half-century later, a study was published in an academic journal which demonstrated that only a very small fraction of the deaths in the months after the 1952/53 smog could have been attributed to influenza. Another 8,000 Londoners died early because of the delayed effects of smog rather than the flu. The deaths had initially been blamed on flu; that misconception was later shown to have been caused by a Conservative government trying to save money and avoid having to take action.
The 1953 smog matters today. It tells us what ministers and their officials are capable of. In 2012 and 2013, government influence and lack of action, rather than external factors beyond its control, again might have contributed to a rise in deaths. Again the deaths are taking place at a time of austerity and again the government of the day would prefer to be able to point the finger at some “influenza-like illness”–blame the cold when it wasn’t that cold–rather than a cause that it could tackle. This time it is austerity itself that is being blamed, but no one is quite sure whether more people are dying now because they cannot afford to heat their homes or because they are getting worse care when elderly. There might even be an unrecognised “time bomb” suddenly reducing the generation’s life expectancy, as cigarettes did in the past and obesity might do in future; but it seems unlikely. All we do know is that more people were dying in 2012 and 2013 than in previous years.
We also know that recessions are not usually linked with rising mortality. In the past, numbers of deaths often fell during recessions as fewer people worked in dangerous industries due to lay-offs. More recently, falls in road-traffic accidents were recorded during the early years of the recession that began in 2008, as fewer people could afford to drive. But today appears to be different, or at least different for the elderly.
Between 2008 and 2013, 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.” There are now millions fewer social care visits a year to the elderly than took place five years ago. These are 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 that leads to the prevention of an unnecessary death. The biggest cuts to visits came after the general election of May 2010.
Last July an internal Public Health England report, entitled Weekly and Monthly Provisional Figures on Deaths Registered in England and Wales; Outline of Reported Deaths in 2013 to Week Ending 5th July, 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.
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 mortality 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.”
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. It was in some of those poorest areas that the greatest absolute increases in mortality among the elderly were first beginning to be reported by the summer of 2013, but excess deaths had been occurring throughout the previous 12 months. We now know that, among women, this resulted in a drop in life expectancy after age 65 between 2011 and 2012.
The Health Service Journal explained to its readers, mostly health-service workers and researchers, that as a result of the increase in deaths among elderly people 2012 had been the first year in which overall all-age mortality had increased since 2003. Back then, the rise had been followed by a very steep reduction in deaths the following year, which rebalanced the long-term trend back towards a steady fall in mortality and a rise in life expectancy. The 2003 increase was a quickly reversed blip. The 2012-2013 rise appeared to be more of a trend.
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 2012-2013 had been 23,400 (5 percent) above Office for National Statistics (ONS) expectations. However, and seemingly unperturbed, an 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.”
Apportioning a rise in mortality on the grounds of each event having some particular and singular cause isn’t always helpful, but neither is inaction. Six months ago the government and its agents were prepared to wait another 18 months before acting. But then the Health Service Journal did not just publish the story, it leaked the entire original report. Consequently, the responsible body was suddenly forced to become a little more responsible. So, 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 that there had been methodological weaknesses in the leaked internal report and explaining: “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 2012-2013–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.”
Contrast the official message (that it’s probably just mostly flu) with what was proved in the leaked internal reports, which 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. And the scale of excess deaths was shown to be even greater.
The ONS report said it was not necessarily because the winter of 2012/2013 had been cold that death rates had risen among the elderly. The government statisticians explained that, during the exceptionally cold winter of 2009/2010, 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. The ONS reported that in 2012/2013 there had been a 29 percent increase in deaths, compared to 15.5 percent 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. This is now a greater number of unexplained excess deaths than all those attributed to the 1952/53 smog.
The ONS also cast doubt on flu being the main cause of the spike, saying: “Influenza activity in 2012/13 was relatively low ...”
The one thing we can now be sure of is that the chief reason for the spike in deaths in 2012/2013 was not flu. David Stuckler, a research fellow based at Oxford University, and Martin McKee, of the London School of Hygiene and Tropical Medicine, have already determined that the rise is not due to influenza and pneumonia, two possible causes that, they estimate, contributed only 5.8 and 3.5 percent of the rapid absolute increase in elderly mortality in the UK since early 2012. The European Centre for Disease Prevention and Control also recently announced that the UK had one of the lowest reported intensities of influenza across Europe in winter 2012/2013.
It is not just cuts to local social services that are known to coincide with the rising deaths. The deliberate disorganization into which the National Health Service and its monitoring bodies were plunged following the introduction of the Health and Social Care Act 2012 may need to take part of the blame when the final autopsy is carried out. It will be far more than the surveillance and “knowledge” functions of the old NHS that will have suffered so much recently as a result of NHS “reform.” The NHS is now worse equipped to know what is happening to public health.
The 2012 “reforms” allowed family doctors more choice as to which patients they might wish to treat. This is not about growing patient choice, especially for the least vocal and most feeble of the elderly. NHS privatization may already be playing a part in this saga, most clearly because the 2012 act’s implementation focuses clinicians’ minds elsewhere. The Health Secretary, Jeremy Hunt, also appears to have had his mind on things other than the rising numbers of deaths. However, recently, he has started personally phoning NHS hospital bosses in areas that miss their prescribed targets, an action described as an “obsession,” “crazy” and “hindering.”
Simon Wessely, the head of the department of psychological medicine at the Institute of Psychiatry, King’s College London, who is also a practising clinician, put it like this: “It is hard to think of a single policy that will do more to extend the health gap between rich and poor than Hunt’s latest plans. GP practices are going to be rated on a scale of one to four. Guess who won’t be seen by the top-scoring practices: those who can’t travel very far, because of a medical condition or because they don’t have transport; those ill-informed about how to play the system; those mentally troubled, or with learning difficulties or dementia. Guess who will be seen: the affluent, information-rich and mobile.”
The recent increase in deaths among the elderly in England has been so great that, by winter 2013, the ONS announced an overall decline in life expectancy over age 65 as measured against previous expectations. The Guardian reported this as a drop of 2 percent in post-retirement UK life expectancy compared with the 2010-2011 projections, and raised the idea that this coincides very closely with the roll-out of the incoming 2010 Conservative-led coalition government’s unprecedented programme of cuts to local authorities as well as cuts to numerous social support schemes, housing and welfare payments.
To find sustained absolute rises in mortality for specific age groups, you have to look back to the 1930s.
What has taken place in Britain recently has few precedents. To find sustained absolute rises in mortality for specific age groups in Britain nationally (outside of wartime), you have to look back to the 1930s. To discover the reasons why there might be a fall in life expectancy among the elderly in England now, the best idea is to look for where in the rich world a similar fall has occurred in the past. The closest precedent to what is happening in the UK can be found in what happened in the United States under the last Republican regime. It was in the final year of George W. Bush’s welfare-cutting presidency, during 2008, that Americans’ life expectancy fell for the first time in 15 years. The very elderly (85-plus) were worst affected.
The announcement in July 2011 that the UK’s largest private care home operator, Southern Cross, was about to go bankrupt and might need to close all 752 of its homes was unlikely to have had just a minimal effect on the health of its elderly and frail customers. But that threat to care homes was made possible only by the coalition government’s failure to intervene at an earlier stage. The BBC posted the report that the 31,000 residents of Southern Cross care homes were at risk of eviction as “business” news, rather than a health story.
In 2012, a review of the effects on health of involuntary nursing-home relocation was released by the Personal Social Services Research Unit. It showed that ill-planned relocations were particularly stressful, being linked to worse survival rates. It also found that relocation, especially from inadequate and poor care, could improve survival. Where the situation became worse there were increased falls, depression, pressure sores, hospital transfers, prescription of antipsychotics and reduced cognition, communication and social functioning.
There are many factors other than a flu epidemic that could have contributed to the upturn in death rates among the elderly in Britain since early 2012. Reduced visits by social services, forced home moves due to cuts, and less medical attention can all increase unexpected deaths among the elderly. At the other extreme, it is possible that, as the pound fell in value, more frail expat pensioners had to return to Britain from overseas, including some recently mocked for complaining about losing their winter fuel allowances.
One thing we do know: almost all of the excess deaths have occurred since the start of the coalition government in May 2010. Widening health inequalities, which were instigated during Margaret Thatcher’s tenure as prime minister, had continued to grow throughout the New Labour years, although for all of those years poor people’s health did improve–just not as fast as for the rich–in all but one location. The only place where falls in life expectancy were reported to be occurring before 2010 was poorer neighborhoods of Glasgow.
The Spearhead areas of England, mostly northern cities and ten inner-London boroughs, were first identified in 2004 using information on deprivation and mortality from cancer and heart disease as well as life expectancy to determine where people face the greatest health challenges. It was in those places that elderly death rates rose the most in 2012. Next, in 2013, mortality rates for elderly people across most of the country were also found to have been rising.
People may look back at the huge increase in deaths among the elderly and be amazed that the authorities initially just blamed the cold weather. It should soon become clear that a very large number of the additional deaths of people aged over 85 were in residential care homes that were adequately heated. We already know that a significant part of the rise in the mortality rate is due to many more recent deaths attributed to dementia, not normally associated with cold. But how does an elderly person beginning to suffer from dementia cope as personal services are cut back and more information is disseminated online?
By November 2013 the NHS was giving out this advice to the elderly on the internet:
If you are 65 or over, it is important to spend most of your time in a warm environment during the winter months. There are a number of things you can do to cope in cold weather. Keep your main living room at around 18-21°C (65-70°F) and the rest of the house at least 16°C (61°F). If you can’t heat all the rooms you use, heat the living room during the day and the bedroom just before you go to sleep. Make sure you are receiving any benefits you are entitled to, such as the winter fuel payment and cold weather payment. Regular hot drinks and eating at least one hot meal a day will help keep energy levels up during winter and keep your body warm. Finally, make sure you get the seasonal flu jab.
On fuel poverty the advice simply read: “. . . commentators across the political spectrum have suggested that there is a link between fuel poverty (the inability to keep a home warm at an adequate level because of a low income) and excess deaths. This potential association was not examined in the ONS report.” Just because it was not examined does not mean it did not matter. The author of the NHS advice was Bazian, “an Economist Intelligence Unit business” health-care company. It works for the government as part of the expanding private sector. Now even bland advice is subcontracted out.
So what is the government itself doing? It has asked the big energy companies if they would please not increase fuel bills by much until after the May 2015 election. However, it has also ensured that there is about to be a great reduction in the number of people who are cold, especially among the elderly. Unfortunately no one will feel the difference, other than the statisticians. This is because the numbers of people living in fuel poverty are being reduced from 3.2 to 2.4 million simply by changing the definition of fuel poverty. Before, if you spent more than a tenth of all your income on fuel for heating you were fuel-poor; now you must also be below the official poverty line. Have a few pennies just above that and no matter what you spend to keep warm you are not fuel-poor. The actual change being proposed is not necessarily disingenuous; but it could have been made in a way that did not result in a sudden reduction in the headline figure.
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.
Sixty years ago, in 1953, when it began to emerge that people were dying in numbers that 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. Macmillan became foreign minister in April 1955 and chancellor just before Christmas that year. His career, propelling the country towards the Suez crisis, and then telling the public they had never had it so good when eventually he became prime minister, was more important to him than a few thousand people dying before their time.
During 2013 it became hard not to conclude that patricians again view 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. In recent years, as the 1 percent has become ever richer, the poorer you are, the more your income or benefits have been cut. It is the frail and elderly who are most likely to be too weak to get to food banks, not to mention too old to face the shame of what is, in effect, begging for food.
In place of many actual visits from carers and medics, the state now employs private companies to advise elderly patients by putting instructions on the internet. Most over-85s have no internet access. It is blaming the victim to say that they should make sure they have at least one hot meal a day to keep warm and turn the heating up for a short while before they get into bed, only to spend the rest of the night breathing increasingly cold air into their lungs as their core body temperature falls. Electric blankets help if you are not incontinent, but elderly people often have to get out of bed several times a night.
It was almost certainly not flu. It may not even mostly have been the cold. The winter of 2009/2010 was colder than our recent winters, yet far fewer died then. It is hard to believe that it is not the rising callousness of our age which, in so many ways, is driving growing numbers of elderly people to die earlier than expected. Life expectancy in the UK remains below that of most other western European countries and for our poorer older groups it would now appear to be falling.
The government said that it would look after pensioners. It brought in the so-called triple lock on state pensions and protected the free bus pass, but it has not looked after all pensioners equally. It will be those who were poorer and lived in poorer areas who will have made up the majority of the prematurely dead, and who will make up 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 that landslide election victory of 1945.
Danny Dorling is the Halford Mackinder Professor of Geography at the University of Oxford. His latest book, All That Is Solid: the Great Housing Disaster, will be published by Allen Lane on February 27.
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