Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007-2013

The impact of the English national health inequalities strategy on inequalities in mortality at age 65: a time-trend analysis

BACKGROUND

During the 1997-2010 Labour government, several policies were implemented to narrow health inequalities as part of a national health inequalities strategy. Many of these policies are likely to have had a disproportionately large impact on people aged 65 and over. We aimed to understand the association between the health inequalities strategy period and inequalities in mortality at age 65-69.

METHODS

We use population at risk and mortality data covering 1991-2019 to calculate mortality rate at age 65-69 at the Local Authority level. We use the 2019 Index of Multiple Deprivation to examine geographical inequalities. We employ segmented linear regression models with marginal spline terms for the strategy period and interact these with an indicator of deprivation to understand how inequalities changed before, during and after the strategy. The reporting of this study adheres to STROBE guidelines.

RESULTS

Mortality rates in each deprivation quintile improved continuously throughout the period of study. Prior to the programme (1991-9) there was no significant change in absolute inequalities. However, during the strategy (2000-10) there was a significant decrease in absolute inequalities of -9.66 (-17.48 to -1.84). The period following the strategy (2011-19) was associated with a significant increase in absolute inequalities of 12.84 (6.60 to 19.08). Our results were robust to a range of sensitivity tests.

CONCLUSION

The English health inequalities strategy was associated with a significant reduction in absolute inequality in mortality age 65-69. Future strategies to address inequalities in ageing populations may benefit from adopting a similar approach.

Is Austerity Responsible for the Stalled Mortality Trends Across Many High-Income Countries? A Systematic Review

This article systematically reviews evidence evaluating whether macroeconomic austerity policies impact mortality, reviewing high-income country data compiled through systematic searches of nine databases and gray literature using pre-specified methods (PROSPERO registration: CRD42020226609). Eligible studies were quantitatively assessed to determine austerity's impact on mortality. Two reviewers independently assessed eligibility and risk of bias using ROBINS-I. Synthesis without meta-analysis was conducted due to heterogeneity. Certainty of evidence was assessed using the GRADE framework. Of 5,720 studies screened, seven were included, with harmful effects of austerity policies demonstrated in six, and no effect in one. Consistent harmful impacts of austerity were demonstrated for all-cause mortality, life expectancy, and cause-specific mortality across studies and different austerity measures. Excess mortality was higher in countries with greater exposure to austerity. Certainty of evidence was low. Risk of bias was moderate to critical. A typical austerity dose was associated with 74,090 [-40,632, 188,792] and 115,385 [26,324, 204,446] additional deaths per year. Austerity policies are consistently associated with adverse mortality outcomes, but the magnitude of this effect remains uncertain and may depend on how austerity is implemented (e.g., balance between public spending reductions or tax rises, and distributional consequences). Policymakers should be aware of potential harmful health effects of austerity policies.

Influenza: cause or excuse? An analysis of flu's influence on worsening mortality trends in England and Wales, 2010-19

BACKGROUND

England and Wales experienced a stagnation of previously improving life expectancy during the 2010s. Public bodies cited influenza as an important cause.

SOURCES OF DATA

We used data from the Office for National Statistics to examine mortality attributed directly to influenza and to all influenza-like diseases for the total population of England and Wales 2010-19. Several combinations of ICD-10 codes were used to address the possibility of under-counting influenza deaths.

AREAS OF AGREEMENT

Deaths from influenza and influenza-like diseases declined between 2010 and 2019, while earlier improvements in mortality from all causes of death were stalling and, with some causes, worsening. Our findings support existing research showing that influenza is not an important cause of the stalling of mortality rates 2010-19.

AREAS OF CONTROVERSY

Influenza was accepted by many as an important cause of stalling life expectancy for much of the 2010s, while few in public office have accepted austerity as a key factor in the changes seen during that time.

GROWING POINTS

This adds to the mounting evidence that austerity damaged health prior to COVID-19 and left the population more vulnerable when it arrived.

AREAS FOR DEVELOPING TIMELY RESEARCH

Future research should explore why so many in public office were quick to attribute the change in trends in overall mortality in the UK in this period to influenza, and why many continue to do so through to 2023 and to deny the key role of austerity in harming population health.

Frailty before and during austerity: A time series analysis of the English Longitudinal Study of Ageing 2002-2018

BACKGROUND

Frailty is characterised by a reduced resilience to adversity. In this analysis we examined changes in frailty in people aged 50+ before and during a period of austere public spending in England.

METHODS

Data from the English Longitudinal Study of Ageing 2002-2018 were analysed. Associations between austerity and frailty were examined using (1) Multilevel interrupted times series analysis (ITSA); and (2) Accelerated longitudinal modelling comparing frailty trajectories in people of the same age in 2002 and 2012.

RESULTS

The analysis included 16,410 people (mean age 67 years, 55% women), with mean frailty index score of 0.16. Mean scores in women (0.16) where higher than in men (mean 0.14), and higher in the poorest tertile (mean 0.20) than the richest (mean 0.12). In the ITSA, frailty index scores increased more quickly during austerity than before, with the additional increase in frailty 2012-2018 being similar in magnitude to the difference in mean frailty score between people aged 65-69 and 70-74 years. Steeper increases in frailty after 2012 were experienced across the wealth-spectrum and in both sexes but were greater in the very oldest (80+). In the accelerated longitudinal analysis, frailty was lower in 2012 than 2002, but increased more rapidly in the 2012 cohort compared to the 2002 cohort; markedly so in people aged 80+.

CONCLUSION

The period of austerity politics was associated with steeper increases in frailty with age compared to the pre-austerity period, consistent with previously observed increases in mortality.

Social security cuts and life expectancy: a longitudinal analysis of local authorities in England, Scotland and Wales

BACKGROUND

The UK Government's 'welfare reform' programme included reductions to social security payments, phased in over the financial years 2011/2012-2015/2016. Previous studies of social security cuts and health outcomes have been restricted to analysing single UK countries or single payment types (eg, housing benefit). We examined the association between all social security cuts fully implemented by 2016 and life expectancy, for local authorities in England, Scotland and Wales.

METHODS

Our unit of analysis was 201 upper tier local authorities (unitary authorities and county councils: 147 in England, 32 in Scotland, 22 in Wales). Our exposure was estimated social security loss per head of the working age population per year for each local authority, calculated against the baseline in 2010/2011. The primary outcome was annual life expectancy at birth between the calendar years 2012 and 2016 (year lagged following exposure). We used a panel regression approach with fixed effects.

RESULTS

Social security cuts implemented by 2016 were estimated to be £475 per head of the working age population in England, £390 in Scotland and £490 in Wales since 2010/2011. During the study period, there was either no improvement or only marginal increases in national life expectancy. Social security loss and life expectancy were significantly associated: an estimated £100 decrease in social security per head of working age population was associated with a 1-month reduction in life expectancy.

CONCLUSIONS

Social security cuts, at the UK local authority level, were associated with lower life expectancy. Further research should examine causality.

Evolução da estrutura e resultados da Atenção Primária à Saúde no Brasil entre 2008 e 2019

Resumo Descreve a evolução da estrutura e resultados da Atenção Primária à Saúde (APS) no Brasil, entre 2008 e 2019. Foram calculadas a mediana de variáveis como: despesa per capita em APS por habitante coberto, cobertura da APS e as taxas de mortalidade e internações por condições sensíveis à atenção primária (CSAP) de 5.565 municípios brasileiros estratificados segundo porte populacional e quintil do Índice Brasileiro de Privação (IBP) e analisada a tendência mediana no período. Houve aumento de 12% na mediana da despesa em APS. A cobertura da APS expandiu, sendo que 3.168 municípios apresentaram 100% de cobertura em 2019, contra 2.632 em 2008. A mediana das taxas de mortalidade e internações por CSAP aumentou 0,2% e diminuiu 44,9% respectivamente. A despesa em APS foi menor nos municípios com maior privação socioeconômica. Quanto maior o porte populacional e melhores as condições socioeconômicas dos municípios, menor a cobertura da APS. Quanto maior a privação socioeconômica dos municípios, maiores foram as medianas das taxas de mortalidade por CSAP. Este estudo demonstrou que a evolução da APS foi heterogênea e está associada tanto ao porte populacional como às condições socioeconômicas dos municípios.

Evolution of the structure and results of Primary Health Care in Brazil between 2008 and 2019

Abstract This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.

Bearing the burden of austerity: how do changing mortality rates in the UK compare between men and women?

Background

Mortality rates across the UK stopped improving in the early 2010s, largely attributable to UK Government’s ‘austerity’ policies. Such policies are thought to disproportionately affect women in terms of greater financial impact and loss of services. The aim here was to investigate whether the mortality impact of austerity—in terms of when rates changed and the scale of excess deaths—has also been worse for women.

Methods

All-cause mortality data by sex, age, Great Britain (GB) nation and deprivation quintile were obtained from national agencies. Trends in age-standardised mortality rates were calculated, and segmented regression analyses used to identify break points between 1981 and 2019. Excess deaths were calculated for 2012–2019 based on comparison of observed deaths with numbers predicted by the linear trend for 1981–2011.

Results

Changes in trends were observed for both men and women, especially for those living in the 20% most deprived areas. In those areas, mortality increased between 2010/2012 and 2017/2019 among women but not men. Break points in trends occurred at similar time points. Approximately 335 000 more deaths occurred between 2012 and 2019 than was expected based on previous trends, with the excess greater among men.

Conclusions

It remains unclear whether there are sex differences in UK austerity-related health effects. Nonetheless, this study provides further evidence of adverse trends in the UK and the associated scale of excess deaths. There is a clear need for such policies to be reversed, and for policies to be implemented to protect the most vulnerable in society.

Investigating the impact on mental wellbeing of an increase in pensions: A longitudinal analysis by area-level deprivation in England, 1998-2002

In 1997 approximately two million people aged 60 years or over were living poverty in the UK. In 1999 the UK Government raised real pension incomes of low-income pensioners by around a third through the introduction of the Minimum Income Guarantee (MIG). This study explores the implications of this change for pensioners' mental wellbeing with a focus on differences by area level deprivation in England. We explore mental wellbeing outcomes of 205 men (750 person-year observations) and 367 women (1,336 person-year observations) of state pension age from scores on the General Health Questionnaire from the British Household Panel Survey using a panel difference-in-difference estimation procedure. We compare the mental wellbeing of pensioners receiving MIG to that of low-income pensioners not claiming MIG, from 1998 to 2002. To investigate differences by area deprivation we use quintiles of the of the distributions of the 2000 and 2019 local-authority-level English Index of Multiple Deprivation. Models controlled for age, marital status and year. Between 1998 and 2002, 136 (38%) of low-income women and 57 (28%) of low-income men in the sample were claiming MIG at any one time. Income increased by 31% for men and 22% for women. There was no change in mental wellbeing for women but we found an improvement for men overall and for men living in the most deprived areas, in the latter case with a decrease of the GHQ-12 score of 2.43 points (95% CI: -5.49, 0.02). This estimate was similar across all measures of deprivation, and across both years of IMD. This study provides tentative evidence that the increase in pension income in England for low-income pensioners contributed to a reduction of inequalities in mental wellbeing for men. This needs to be considered in terms of future state pension policies.

Cuts to local government spending, multimorbidity and health-related quality of life: A longitudinal ecological study in England

BACKGROUND

Population health has stagnated or is declining in many high-income countries. We analysed whether nationally administered austerity cuts in England were associated with prevalence of multimorbidity (individuals with two or more long-term conditions) and health-related quality of life.

METHODS

We conducted an observational, longitudinal study on 147 local authorities in England. We examined associations of changes in spending over time (2009/10-2017/18), in total and by budget line, with (i) prevalence of multimorbidity, 2+ conditions (2011/12-2017/18), and (ii) health-related quality of life (EQ-5D-5L) score (2012/13-2016/17). We estimated linear, log-log regression models, incorporating local authority fixed-effects, time-varying demographic and socio-economic confounders, and time trends.

FINDINGS

All local authorities experienced real spending cuts, varying from 42% (Barking and Dagenham) to 0·3% (Sefton). A 1% cut in per capita total service expenditure was associated with a 0·10% (95% CI 0·03 to 0·16) increase in prevalence of multimorbidity. We found no association (0·003%; 95% CI -0·01 to 0·01) with health-related quality of life. By budget line, after controlling for other spending, a 1% cut in public health expenditure was associated with a 0·15% (95% CI 0·11 to 0·20) increase in prevalence of multimorbidity, and a 1% cut in adult social care expenditure was associated with a 0·01% (95% CI 0·002 to 0·02) decrease in average health-related quality of life.

INTERPRETATION

Fiscal austerity is associated with worse multimorbidity and health-related quality of life. Policymakers should consider the potential health consequences of local government expenditure cuts and knock-on effects for health systems.

FUNDING

Medical Research Council.

Overall mortality trends in Greece during the first period of austerity and the economic crisis (2009-2015)

OBJECTIVES

The economic crisis and the resulting austerity in Greece led to a drastic reduction in healthcare spending, which has been assumed to have impacted people's health. This paper discusses official standardized mortality rates in Greece between 2000 and 2015.

METHODS

This study was designed to analyze population-level data and collected data from the World Bank, the Organisation for Economic Co-operation and Development, Eurostat, and the Hellenic Statistics Authority. Separate linear regression models were developed for the periods before and after the crisis and were compared.

RESULTS

Standardized mortality rates do not support a previously reported assumption of a specific and direct negative effect of austerity on global mortality. Standardized rates continued to decrease linearly, and their correlation to economic variables changed after 2009. Total infant mortality rates show an overall rising trend since 2009, but the interpretation is unclear because of the reduction in the absolute number of deliveries.

CONCLUSIONS

The mortality data from the first six years of the financial crisis in Greece and the decade that preceded do not support the assumption that budget cuts in health are related to the dramatic worsening of the overall health of the Greek people. Still, data suggest an increase in specific causes of death and the burden on a dysfunctional and unprepared health system that is working in an overstretched manner trying to meet needs. The dramatic acceleration of the aging of the population constitutes a specific challenge for the health system. HIPPOKRATIA 2022, 26 (3):98-104.

Glossary: economics and health

As we emerge from the COVID-19 pandemic, there is an increasing focus on how the economy is rebuilt and the impact this will have on population health. Many of the economic policy proposals being discussed have their own vocabulary, which is not always understood in the same way within or between disciplines. This glossary seeks to provide a common language and concise summary of the key economic terminology relevant for policymakers and public health at this time.

Excess mortality in Glasgow: further evidence of 'political effects' on population health

OBJECTIVES

The aim of the study was to update previous analyses of 'excess mortality' in Glasgow (Scotland) relative to the similar postindustrial cities of Liverpool and Manchester (England). The excess is defined as mortality after adjustment for socio-economic deprivation; thus, we sought to compare changes over time in both the deprivation profiles of the cities and the levels of deprivation-adjusted mortality in Glasgow relative to the other cities. This is important not only because the original analyses are now increasingly out of date but also because since publication, important (prepandemic) changes to mortality trends have been observed across all parts of the United Kingdom.

STUDY DESIGN AND METHODS

Replicating as far as possible the methods of the original study, we developed a three-city deprivation index based on the creation of spatial units in Glasgow that were of similar size to those in Liverpool and Manchester (average population sizes of approximately 1600, 1500 and 1700 respectively) and an area-based measure of 'employment deprivation'. Mortality and matching population data by age, sex and small area were obtained from national agencies for two periods: 2003-2007 (the period covered by the original study) and 2014-2018. The rates of employment deprivation for each city's small areas were calculated for both periods. Indirectly standardised mortality ratios (SMRs) were calculated for Glasgow relative to Liverpool and Manchester, standardised by age and three-city deprivation decile. For context, city-level trends in age-standardised mortality rates by year, sex and city were also calculated.

RESULTS

There was evidence of a stalling of improvement in mortality rates in all three cities from the early 2010s. After adjustment for area deprivation, all-cause mortality in Glasgow in 2014-2018 was c.12% higher than in Liverpool and Manchester for all ages (SMR 112.4, 95% CI 111.1-113.6) and c.17% higher for deaths under 65 years (SMR 117.1, 95% CI 114.5-119.7). The excess was higher for males (17% compared with 9% for deaths at all ages; 25% compared with 5% for 0-64 years) and for particular causes of death such as suicide and drug-related and alcohol-related causes. The results were broadly similar to those previously described for 2003-2007, although the excess for premature mortality was notably lower. In part, this was explained by changes in levels of employment deprivation, which had decreased to a greater degree in the English cities: this was particularly true of Manchester (a reduction of -43%, compared with -38% in Liverpool and -31% in Glasgow) where the overall population size had also increased to a much greater extent than in the other cities.

CONCLUSIONS

High levels of excess mortality persist in Glasgow. With the political causes recently established - the excess is a 'political effect', not a 'Glasgow effect' - political solutions are required. Thus, previously published recommendations aimed at addressing poverty, inequality and vulnerability in the city are still highly relevant. However, given the evidence of more recent, UK-wide, political effects on mortality - widening mortality inequalities resulting from UK Government 'austerity' measures - additional policies at UK Government level to protect, and restore, the income of the poorest in society are also urgently needed.

Causal impact of social care, public health and healthcare expenditure on mortality in England: cross-sectional evidence for 2013/2014

OBJECTIVES

The first objective is to estimate the joint impact of social care, public health and healthcare expenditure on mortality in England. The second objective is to use these results to estimate the impact of spending constraints in 2010/2011-2014/2015 on total mortality.

METHODS

The impact of social care, healthcare and public health expenditure on mortality is analysed by applying the two-stage least squares method to local authority data for 2013/2014. Next, we compare the growth in healthcare and social care expenditure pre-2010 and post-2010. We use the difference between these growth rates and the responsiveness of mortality to changes in expenditure taken from the 2013/2014 cross-sectional analysis to estimate the additional mortality generated by post-2010 spending constraints.

RESULTS

Our most conservative results suggest that (1) a 1% increase in healthcare expenditure reduces mortality by 0.532%; (2) a 1% increase in social care expenditure reduces mortality by 0.336%; and (3) a 1% increase in local public health spending reduces mortality by 0.019%. Using the first two of these elasticities and data on the change in spending growth between 2001/2002-2009/2010 and 2010/2011-2014/2015, we find that there were 57 550 (CI 3075 to 111 955) more deaths in the latter period than would have been observed had spending growth during this period matched that in 2001/2002-2009/2010.

CONCLUSIONS

All three forms of public healthcare-related expenditure save lives and there is evidence that additional social care expenditure is more than twice as productive as additional healthcare expenditure. Our results are consistent with the hypothesis that the slowdown in the rate of improvement in life expectancy in England and Wales since 2010 is attributable to spending constraints in the healthcare and social care sectors.

COVID-19: decision-making in public health

Against a background of stalling UK life expectancy, the COVID-19 pandemic necessitated a different way of working for public health to respond quickly to new and many demands. At the same time, public health teams had to ensure they did not concentrate on the immediate crisis at the expense of mitigating longer-term impacts of the pandemic. This was, and is, a major challenge with additional demands on an already hard-pressed workforce. This paper discusses the experience of a local public health department in responding to the pandemic and raises four key areas that influenced decisions and need to be considered in future. These are care homes issues, addressing all four harms of the pandemic, lessons for behaviour change and the need to strengthen Scotland's public health workforce.

Association between disability-related budget reductions and increasing drug-related mortality across local authorities in Great Britain

BACKGROUND

Drug-related mortality in the UK rose markedly after 2012. Here we test the hypothesis that cuts to disability-related spending were associated with increased drug-related mortality across local governments in Great Britain.

METHODS

We regressed changes in drug-related death rates (years 2010-12 versus 2015-17) on local government disability-related budget reductions, adjusting for a range of regional, demographic, and economic factors. Budget reductions are captured with a combined measure of financial losses due to Incapacity Benefit and Disability Living Allowance reforms, expressed in pounds sterling per capita, per year. 364 local authorities across England, Scotland, and Wales were included in the study.

FINDINGS

Greater budget reductions were associated with greater increases in drug-related death rates. In the unadjusted model, each £100 per capita budget reduction was associated with an increase in drug-related death rates of 3.30 per 100 000 population (95% CI: 2.43 to 4.17). The magnitude of the association increased after adjusting for region and demographic factors (b = 4.84; 95% CI: 3.26 to 6.43). The association remained statistically significant after adjusting for a full set of controls, including baseline and trends in unemployment rates, median hourly pay, and gross disposable household income per capita (b = 4.41; 95% CI: 2.57 to 6.24).

CONCLUSION

Deeper cuts to local government spending in Great Britain in the 2010s were associated with larger increases in drug-related deaths.

Local government funding and life expectancy in England: a longitudinal ecological study

Background

Since 2010, large reductions in funding for local government services have been introduced in England. These reductions in funding have potentially led to reduced provision of health-promoting public services. We aimed to investigate whether areas that showed a greater decline in funding also had more adverse trends in life expectancy and premature mortality.

Methods

In this longitudinal ecological study, we linked annual data from the Ministry of Housing, Communities, and Local Government on local government revenue expenditure and financing to 147 upper-tier local authorities in England between 2013 and 2017 with data from Public Health England, on male and female life expectancy at birth, male and female life expectancy at age 65 years, and premature (younger than 75 years) all-cause mortality rate for male and female individuals. Local authorities were excluded if their populations were too small or if changes in boundaries meant consistent data were not available. Using multivariable fixed-effects panel regression models, and controlling for local socioeconomic conditions, we estimated whether changes in local funding from 2013 were associated with changes in life expectancy and premature mortality. We included a set of alternative model specifications to test the robustness of our findings.

Findings

Between 2013 and 2017, mean per-capita central funding to local governments decreased by 33% or £168 per person (range –£385 to £1). Each £100 reduction in annual per person funding was associated over the study period 2013–17 with an average decrease in life expectancy at birth of 1·3 months (95% CI 0·7–1·9) for male individuals and 1·2 months (0·7–1·7) for female individuals; for life expectancy at age 65 years, the results show a decrease of 0·8 months (0·3–1·3) for male individuals and 1·1 months (0·7–1·5) for female individuals. Funding reductions were greater in more deprived areas and these areas had the worst changes in life expectancy. We estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women. Overall reductions in funding during this period were associated with an additional 9600 deaths in people younger than 75 years in England (3800–15 400), an increase of 1·25%.

Interpretation

Our findings indicate that cuts in funding for local government might in part explain adverse trends in life expectancy. Given that more deprived areas showed greater reductions in funding, our analysis suggests that inequalities have widened. Since the pandemic, strategies to address these adverse trends in life expectancy and reduce health inequalities could prioritise reinvestment in funding for local government services, particularly within the most deprived areas of England.

Funding

National Institute for Health Research (NIHR) School for Public Health Research, NIHR Applied Research Collaboration North East and North Cumbria, NIHR Applied Research Collaboration North West Coast and Medical Research Council.

The changing health needs of the UK population

The demographics of the UK population are changing and so is the need for health care. In this Health Policy, we explore the current health of the population, the changing health needs, and future threats to health. Relative to other high-income countries, the UK is lagging on many health outcomes, such as life expectancy and infant mortality, and there is a growing burden of mental illness. Successes exist, such as the striking improvements in oral health, but inequalities in health persist as well. The growth of the ageing population relative to the working-age population, the rise of multimorbidity, and persistent health inequalities, particularly for preventable illness, are all issues that the National Health Service (NHS) will face in the years to come. Meeting the challenges of the future will require an increased focus on health promotion and disease prevention, involving a more concerted effort to understand and tackle the multiple social, environmental, and economic factors that lie at the heart of health inequalities. The immediate priority of the NHS will be to mitigate the wider and long-term health consequences of the COVID-19 pandemic, but it must also strengthen its resilience to reduce the impact of other threats to health, such as the UK leaving the EU, climate change, and antimicrobial resistance.

Impact of the Economic Crisis on Endocarditis Mortality in Spain: A Nationwide Study

Economic recession has dire consequences on overall health. None have explored the impact of economic crisis (EC) on infective endocarditis (IE) mortality. We conducted a retrospective, nationwide, temporal trend study analyzing mortality trends by age, sex, and adverse outcomes in patients diagnosed with IE in Spain from 1997 to 2014. Data were divided into two subperiods: pre-EC (January 1997-August 2008) and post-EC (September 2008-December 2014). A total of 25 952 patients presented with IE. The incidence increased from 301.4 to 365.1 per 10 000 000 habitants, and the mortality rate rose from 24.3% to 28.4%. Those aged >75 years experienced more adverse outcomes. Complications due to sepsis, shock, acute kidney injury requiring dialysis, and heart failure increased after the EC onset, and expenditures soared to €16 216. Expenditure per community was related to mortality (P < .001). The EC resulted as an independent predictor for mortality (hazard ratio 1.06; 95% confidence interval 1.01-1.11). Incidence and mortality rate in patients with IE after the onset of the EC have increased as a result of rising adverse outcomes despite an overall increased investment.

Outsourced austerity or improved services? A systematic review and thematic synthesis of the experiences of social care providers and commissioners in quasi-markets

Social care services are commonly delivered by a combination of for-profit, public, and non-profit sector providers. These services are often commissioned in quasi-markets, in which providers from all sectors compete for public service contracts. The outsourcing of social services to private providers has resulted in a predominantly for-profit provision. Despite the rationale that open bidding facilitates better services and improved consumer choice, the outsourcing of social care has been criticized for prioritising cost-efficiency above service quality and effectiveness. However, the experiences and perspectives of those operating within quasi-markets (providers and commissioners) are poorly understood. To address this gap, we systematically identified, appraised, and thematically synthesised existing qualitative research on social care commissioners and providers (for-profit, public, and non-profit) published in the last 20 years (2000-2020). Twenty-six studies examining the perspectives of social care providers and commissioners relating to the quasi-market provision of social care were included. The synthesis demonstrates consistent concern among non-profit and public providers with regard to spending cuts in the care sector, whereas for-profit providers were primarily concerned with creating a profitable market strategy by carefully analysing opportunities in the commissioning system. All provider types described flaws in the commissioning process, especially with regards to the contracting conditions, which were reported to force providers into deteriorating employment conditions, and also to negatively impact quality of care. These findings suggest that in a commissioning environment characterised by austerity and public budget cuts, it is insufficient to assume that increasing the market share of non-profits will alleviate issues grounded in insufficient funding and flawed contracting criteria. In other words, no ownership type can compensate for inadequate funding of social care services.

Why were there 231 707 more deaths than expected in England between 2010 and 2018? An ecological analysis of mortality records

BACKGROUND

Policy responses to the Global Financial Crisis emphasized wide-ranging fiscal austerity measures, many of which have been found to negatively impact health outcomes. This paper investigates change in patterns of mortality at local authority level in England (2010-11 to 2017-18) and the relation with fiscal austerity measures.

METHODS

Data from official local authority administrative records are used to quantify the gap between observed deaths and what was anticipated in the 2010-based subnational population projections. Regression analyses are used to explore the relation between excess deaths, austerity and wider process of population change at local authority level.

RESULTS

We estimate 231 707 total excess deaths, the majority of which occurred since 2014-15 (89%) across the majority of local authorities (91%). Austerity is positively associated with excess deaths. For working age adults, there is a clear gradient to the impact of austerity, whereas for older adults, the impact is more uniform.

CONCLUSIONS

Fiscal austerity policies contributed to an excess of deaths for older people and widened social inequalities for younger populations. These results call for an end to all austerity measures and require further research into areas with the highest total excess deaths as a priority following the COVID-19 pandemic.

Inequalities in health-related quality of life: repeated cross-sectional study of trends in general practice survey data

BACKGROUND

After decades of steady progress, life expectancy at birth has stalled in England. Inequalities are also rising, and life expectancy has fallen for females living in the most deprived areas. However, less attention has been given to trends in other measures of population health, particularly health-related quality of life (HRQoL).

AIM

To examine trends and inequalities in HRQoL in England between 2012 and 2017.

DESIGN AND SETTING

The authors used nationally representative survey data on 3.9 million adults to examine HRQoL (measured by EQ-5D-5L overall score, plus each of the five health domains - mobility, selfcare, usual activity, pain/discomfort, and anxiety/depression).

METHOD

The study explored trends across time, and inequalities by sex, age, and deprivation.

RESULTS

Although HRQoL seemed steady overall between 2012 and 2017, there is evidence of increasing inequality across population subgroups. There was a rise in sex disparity over time, the female-male gap in EQ-5D-5L increased from -0.009 in 2012 to -0.016 in 2017. Trends for the youngest females and those living in the most deprived areas were of the greatest concern. Females in the most deprived regions suffered a 1.3% decrease in HRQoL between 2012 and 2017, compared with a 0.5% decrease for males. The key contribution to the decline in HRQoL, particularly in females, was a 1.5% increase in reported levels of anxiety/depression between 2012 and 2017.

CONCLUSION

Developing interventions to address these worrying trends should be a policy priority. A particular focus should be on mental health in younger populations, especially for females and in deprived areas.

Deterioration, drift, distraction, and denial: How the politics of austerity challenges the resilience of prison health governance and delivery in England

Extant scholarship has demonstrated that macroeconomic austerity disproportionately harms marginalised end-users. Its impact on the governance and delivery of health provisions on such individuals, however, has received less attention. Drawing on interviews with 27 policy elites involved with England's prison health policy, interviewees perceive that austerity policies have shaped and constrained the prison health system through the politics of deterioration, drift, distraction, and denial. The deterioration of the prison workforce size has been linked to diminished prisoner access to healthcare, attendant with an increased number of riots, assaults, acts of self-harm, and suicides. Concurrently, the microeconomic structure of organised crime is filling the void in prison governance, thus conducing to heightened abuse of psychoactive substances, as well as a surge in associated medical emergencies and violence. Successful prosecution of prior sexual offences, continued incarceration of those imprisoned for indeterminate sentences, and harsh sentencing practices have created policy drift, unremitting overcrowding, and reinforced excessive dependency on prison healthcare resources. The rapid turnover of justice ministers and intensified push for prison privatisation have enabled widespread distraction. Moreover, despite well-documented crises besetting English prisons, politicians seemingly remain in a state of denial. Preventive imprisonment, recurrent spending, and enhanced financial and political accountability measures are necessary to mitigate the effects of austerity and germane policies fomenting inimical impacts on England's prison health system.

Spatio-temporal model to estimate life expectancy and to detect unusual trends at the local authority level in England

OBJECTIVES

To estimate life expectancy at the local authority level and detect those areas that have a substantially low life expectancy after accounting for deprivation.

DESIGN

We used registration data from the Office for National Statistics on mortality and population in England, by local authority, age group and socioeconomic deprivation decile, for both men and women over the period 2001-2018. We used a statistical model within the Bayesian framework to produce robust mortality rates, which were then transformed to life expectancy estimates. A rule based on exceedance probabilities was used to detect local authorities characterised by a low life expectancy among areas with a similar deprivation level from 2012 onwards.

RESULTS

We confirmed previous findings showing differences in the life expectancy gap between the most and least deprived areas from 2012 to 2018. We found variations in life expectancy trends across local authorities, and we detected a number of those with a low life expectancy when compared with others of a similar deprivation level.

CONCLUSIONS

There are factors other than deprivation that are responsible for low life expectancy in certain local authorities. Further investigation on the detected areas can help understand better the stalling of life expectancy which was observed from 2012 onwards and plan efficient public health policies.

Changing mortality trends in countries and cities of the UK: a population-based trend analysis

OBJECTIVES

Previously improving life expectancy and all-cause mortality in the UK has stalled since the early 2010s. National analyses have demonstrated changes in mortality rates for most age groups and causes of death, and with deprived populations most affected. The aims here were to establish whether similar changes have occurred across different parts of the UK (countries, cities), and to examine cause-specific trends in more detail.

DESIGN

Population-based trend analysis.

PARTICIPANTS/SETTING

Whole populations of countries and selected cities of the UK.

PRIMARY AND SECONDARY OUTCOME MEASURES

European age-standardised mortality rates (calculated by cause of death, country, city, year (1981-2017), age group, sex and-for all countries and Scottish cities-deprivation quintiles); changes in rates between 5-year periods; summary measures of both relative (relative index of inequality) and absolute (slope index of inequality) inequalities.

RESULTS

Changes in mortality from around 2011/2013 were observed throughout the UK for all adult age groups. For example, all-age female rates decreased by approximately 4%-6% during the 1980s and 1990s, approximately 7%-9% during the 2000s, but by <1% between 2011/2013 and 2015/2017. Equivalent figures for men were 4%-7%, 8%-12% and 1%-3%, respectively. This later period saw increased mortality among the most deprived populations, something observed in all countries and cities analysed, and for most causes of death: absolute and relative inequalities therefore increased. Although similar trends were seen across all parts of the UK, particular issues apply in Scotland, for example, higher and increasing drug-related mortality (with the highest rates observed in Dundee and Glasgow).

CONCLUSIONS

The study presents further evidence of changing mortality in the UK. The timing, geography and socioeconomic gradients associated with the changes appear to support suggestions that they may result, at least in part, from UK Government 'austerity' measures which have disproportionately affected the poorest.

Trends in life expectancy and age-specific mortality in England and Wales, 1970-2016, in comparison with a set of 22 high-income countries: an analysis of vital statistics data

BACKGROUND

Since 2010, the rate of improvement in life expectancy in the UK has slowed. We aimed to put this trend in the context of changes over the long term and in relation to a group of other high-income countries.

METHODS

We compared sex-specific trends in life expectancy since 1970 and age-specific mortality in England and Wales with median values for 22 high-income countries (in western Europe, Australia, Canada, New Zealand, Japan, and the USA). We used annual mortality data (1970-2016) from the Human Mortality Database.

FINDINGS

Until 2011-16, male life expectancy in England and Wales followed the median life expectancy of the comparator group. By contrast, female life expectancy was below the median and is among the lowest of the countries considered. In 2011-16, the rate of improvement in life expectancy slowed sharply for both sexes in England and Wales, and slowed more moderately in the comparator group because of negative trends in all adult age groups. This deceleration resulted in a widening gap between England and Wales and the comparators from 2011 onwards. Since the mid-2000s, for the first time, mortality rates in England and Wales among people aged 25-50 years were appreciably higher than in the comparator group.

INTERPRETATION

Although many countries have seen slower increases in life expectancy since 2011, trends in England and Wales are among the worst. The poor performance of female life expectancy over the long-term is in part driven by the relative timing of the smoking epidemic across countries. The previously overlooked higher mortality among young working-age adults in England and Wales relative to other countries deserves urgent attention.

FUNDING

None.

Modifiable risk factors for 9-year mortality in older English and Brazilian adults: The ELSA and SIGa-Bagé ageing cohorts

To quantify and compare 9-year all-cause mortality risk attributable to modifiable risk factors among older English and Brazilian adults. We used data for participants aged 60 years and older from the English Longitudinal Study of Ageing (ELSA) and the Bagé Cohort Study of Ageing (SIGa-Bagé). The five modifiable risk factors assessed at baseline were smoking, hypertension, diabetes, obesity and physical inactivity. Deaths were identified through linkage to mortality registers. For each risk factor, estimated all-cause mortality hazard ratios (HR) and population attributable fractions (PAF) were adjusted by age, sex, all other risk factors and socioeconomic position (wealth) using Cox proportional hazards modelling. We also quantified the risk factor adjusted wealth gradients in mortality, by age and sex. Among the participants, 659 (ELSA) and 638 (SIGa-Bagé) died during the 9-year follow-up. Mortality rates were higher in SIGa-Bagé. HRs and PAFs showed more similarities than differences, with physical inactivity (PAF 16.5% ELSA; 16.7% SIGa-Bagé) and current smoking (PAF 4.9% for both cohorts) having the strongest association. A clear graded relationship existed between the number of risk factors and subsequent mortality. Wealth gradients in mortality were apparent in both cohorts after full adjustment, especially among men aged 60-74 in ELSA. A different pattern was found among older women, especially in SIGa-Bagé. These findings call attention for the challenge to health systems to prevent and modify the major risk factors related to non-communicable diseases, especially physical inactivity and smoking. Furthermore, wealth inequalities in mortality persist among older adults.

Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled study

BACKGROUND

Universal Credit, a welfare benefit reform in the UK, began to replace six existing benefit schemes in April, 2013, starting with the income-based Job Seekers Allowance. We aimed to determine the effects on mental health of the introduction of Universal Credit.

METHODS

In this longitudinal controlled study, we linked 197 111 observations from 52 187 individuals of working age (16-64 years) in England, Wales, and Scotland who participated in the Understanding Society UK Longitudinal Household Panel Study between 2009 and 2018 with administrative data on the month when Universal Credit was introduced into the area in which each respondent lived. We included participants who had data on employment status, local authority area of residence, psychological distress, and confounding variables. We excluded individuals from Northern Ireland and people out of work with a disability. We used difference-in-differences analysis of this nationally representative, longitudinal, household survey and separated respondents into two groups: unemployed people who were eligible for Universal Credit (intervention group) and people who were not unemployed and therefore would not have generally been eligible for Universal Credit (comparison group). Using the phased roll-out of Universal Credit, we compared the change in psychological distress (self-reported via General Health Questionnaire-12) between the intervention group and the comparison group over time as the reform was introduced in the area in which each respondent lived. We defined clinically significant psychological distress as a score of greater than 3 on the General Health Questionnaire-12. We tested whether there were differential effects across subgroups (age, sex, and education).

FINDINGS

The prevalence of psychological distress increased in the intervention group by 6·57 percentage points (95% CI 1·69-11·42) after the introduction of Universal Credit relative to the comparison group, after accounting for potential confounders. We estimate that between April 29, 2013, and Dec 31, 2018, an additional 63 674 (95% CI 10 042-117 307) unemployed people will have experienced levels of psychological distress that are clinically significant due to the introduction of Universal Credit; 21 760 of these individuals might reach the diagnostic threshold for depression.

INTERPRETATION

Our findings suggest that the introduction of Universal Credit led to an increase in psychological distress, a measure of mental health difficulties, among those affected by the policy. Future changes to government welfare systems should be evaluated not only on a fiscal basis but on their potential to affect health and wellbeing.

FUNDING

Wellcome Trust, UK National Institute for Health Research, and Medical Research Council.

Financial debt amongst older women in the United Kingdom – shame, abuse and resilience

Long-term poverty, precarious employment, low pay, the increased pension age and real-term reductions in welfare benefits, including bereavement allowances, have brought into focus the financial vulnerability of many older women aged 55 years and older in the United Kingdom. In this article, survey data were analysed alongside evidence from observations of debt support meetings and interviews with older women who were receiving debt advice from a support charity. The findings suggest that older women were more likely to have financial problems than older men, particularly those women who were living on low incomes and who were separated or divorced. Following the breakdown of a relationship, many older women were at increased risk of more debt and bankruptcy, particularly those aged between 55 and 64 years and those in routine and semi-routine occupations. Many women had kept their financial problems hidden due to fear and shame whilst bringing up their children and some had been subject to coercive control and economic abuse by their former husbands or partners. It is important that any pension reforms, changes to minimum wage rates, and new divorce and domestic abuse legislation and welfare policies take account of the circumstances of separated, divorced and widowed older women. More financial support and advice needs to be provided to older women facing financial difficulties.

Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study

INTRODUCTION

Mortality rates in many high-income countries have changed from their long-term trends since around 2011. This paper sets out a protocol for testing the extent to which economic austerity can explain the variance in recent mortality trends across high-income countries.

METHODS AND ANALYSIS

This is an ecological natural experiment study, which will use regression adjustment to account for differences in exposure, outcomes and confounding. All high-income countries with available data will be included in the sample. The timing of any changes in the trends for four measures of austerity (the Alesina-Ardagna Fiscal Index, real per capita government expenditure, public social spending and the cyclically adjusted primary balance) will be identified and the cumulative difference in exposure to these measures thereafter will be calculated. These will be regressed against the difference in the mean annual change in life expectancy, mortality rates and lifespan variation compared with the previous trends, with an initial lag of 2 years after the identified change point in the exposure measure. The role of underemployment and individual incomes as outcomes in their own right and as mediating any relationship between austerity and mortality will also be considered. Sensitivity analyses varying the lag period to 0 and 5 years, and adjusting for recession, will be undertaken.

ETHICS AND DISSEMINATION

All of the data used for this study are publicly available, aggregated datasets with no individuals identifiable. There is, therefore, no requirement for ethical committee approval for the study. The study will be lodged within the National Health Service research governance system. All results of the study will be published following sharing with partner agencies. No new datasets will be created as part of this work for deposition or curation.

Contextualising the pervasive impact of macroeconomic austerity on prison health in England: a qualitative study among international policymakers

BACKGROUND

Prisons offer the state the opportunity to gain access to a population that is at particularly high risk of ill-health. Despite the supportive legal and policy structures surrounding prison rehabilitation, the oppressive nature of the austerity policy in England threatens its advanced improvement.

METHODS

Using grounded theory methodology, this is the first interdisciplinary qualitative study to explore the impact of macroeconomic austerity on prison health in England from the perspective of 29 international prison policymakers.

RESULTS

The far-reaching impact of austerity in England has established a regressive political system that shapes the societal attitude towards social issues, which has exacerbated the existing poor health of the prisoners. Austerity has undermined the notion of social collectivism, imposed a culture of acceptance among prison bureaucrats and the wider community, and normalised the devastating impacts of prison instability. These developments are evidenced by the increasing levels of suicide, violence, radicalisation and prison gangs among prisoners, as well as the imposition of long working hours and the high levels of absenteeism among prison staff.

CONCLUSIONS

This study underscores an important and yet unarticulated phenomenon that despite being the fifth largest economy in the world, England's poorest, marginalised and excluded population continues to bear the brunt of austerity. Reducing the prison population, using international obligations as minimum standards to protect prisoners' right to health and providing greater resources would create a more positive and inclusive system, in line with England's international and domestic commitments to the humane treatment of all people.

Mortality in working-age population during the Great Recession and austerity in Spain

OBJECTIVE

To analyze the mortality trend in Spain before, during and after the economic crisis and austerity policies in the working-age population.

METHODS

From 2005 to 2016 we calculated the annual all-cause mortality rate and the annual mortality rate from the main causes of death in the population aged 15 to 64. We also estimated the linear trends in mortality rates during four time intervals-2005-2007 (before crisis), 2008-2010 (first part of the crisis), 2011-2013 (second part of the crisis and implementation of austerity policies) and 2014-2016 (after the crisis)- by the annual percentage change (APC).

RESULTS

The all-cause mortality rate in men and women showed the greatest decline in 2008-2010 and the smallest decline in 2014-2016. The decline in 2011-2013 was higher than in 2014-2016. The APCs in 2005-2007, 2008-2010, 2011-2013 and 2014-2016 were -2.8, -4.1, -3.0 and -1.5 in men and -1.0. -2.1, -1.1 and -0.6 in women, respectively, although the APC in 2014-2016 in women was not significant. In 2014-2016, cancer mortality showed the largest decrease, mortality from cardiovascular diseases (men), respiratory diseases and traffic accidents reversed and showed an upward trend, and the downward trend in mortality from infectious diseases and digestive diseases was equal to or greater than that observed before the crisis.

CONCLUSION

The decline in all-cause mortality in the working-age population during the economic crisis and the introduction of austerity measures was greater than that observed before and after the economic crisis. The slowing of the decline after the crisis was due to the reversal of the trend in mortality from cardiovascular and respiratory diseases.

Scaling up: The politics of health and place

Research into the role of place in shaping inequalities in health has focused largely on examining individual and/or localised drivers, often using a context-composition framing. Whilst this body of work has advanced considerably our understanding of the effects of local environments on health, and re-established an awareness of the importance of place for health, it has done so at the expense of marginalising and minimising the influences of macro political and economic structures on both place and health. In this paper, we argue that: (i) we need to scale up our analysis, moving beyond merely analysing local horizontal drivers to take wider, vertical structural factors into account; and (ii) if we are serious about reducing place-based health inequalities, such analysis needs be overtly linked to appropriate policy levers. Drawing on three case studies (the US mortality disadvantage, Scotland's excess mortality, and regional health divides in England and Germany) we outline the theoretical and empirical value of taking a more political economy approach to understanding geographical inequalities in health. We conclude by outlining the implications for future research and for efforts to influence policy from 'scaling up' geographical research into health inequalities.

Socioeconomic disparities in life expectancy gains among retired German men, 1997-2016

Background

Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above.

Methods

Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change.

Results

Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement.

Conclusion

Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.

Effects of restrictions to Income Support on health of lone mothers in the UK: a natural experiment study

BACKGROUND

In the UK, lone parents must seek work as a condition of receiving welfare benefits once their youngest child reaches a certain age. Since 2008, the lower age limit at which these Lone Parent Obligations (LPO) apply has been reduced in steps. We used data from a nationally representative, longitudinal, household panel study to analyse the health effects of increased welfare conditionality under LPO.

METHODS

From the Understanding Society survey, we used data for lone mothers who were newly exposed to LPO when the age cutoff was reduced from 7 to 5 years in 2012 (intervention group 1) and from 10 to 7 years in 2010 (intervention group 2), as well as lone mothers who remained unexposed (control group 1) or continuously exposed (control group 2) at those times. We did difference-in-difference analyses that controlled for differences in the fixed characteristics of participants in the intervention and control groups to estimate the effect of exposure to conditionality on the health of lone mothers. Our primary outcome was the difference in change over time between the intervention and control groups in scores on the Mental Component Summary (MCS) of the 12-item Short-Form Health Survey (SF-12).

FINDINGS

The mental health of lone mothers declined in the intervention groups compared with the control groups. For intervention group 1, scores on the MCS decreased by 1·39 (95% CI -1·29 to 4·08) compared with control group 1 and by 2·29 (0·00 to 4·57) compared with control group 2. For intervention group 2, MCS scores decreased by 2·45 (-0·57 to 5·48) compared with control group 1 and by 1·28 (-1·45 to 4·00) compared with control group 2. When pooling the two intervention groups, scores on the MCS decreased by 2·13 (0·10 to 4·17) compared with control group 1 and 2·21 (0·30 to 4·13) compared with control group 2.

INTERPRETATION

Stringent conditions for receiving welfare benefits are increasingly common in high-income countries. Our results suggest that requiring lone parents with school-age children toseek work as a condition of receiving welfare benefits adversely affects their mental health.

FUNDING

UK Medical Research Council, Scottish Government Chief Scientist Office, and National Health Service Research Scotland.

Does domiciliary welfare rights advice improve health-related quality of life in independent-living, socio-economically disadvantaged people aged ≥60 years? Randomised controlled trial, economic and process evaluations in the North East of England

BACKGROUND

There are major socio-economic gradients in health that could be influenced by increasing personal resources. Welfare rights advice can enhance resources but has not been rigorously evaluated for health-related impacts.

METHODS

Randomised, wait-list controlled trial with individual allocation, stratified by general practice, of welfare rights advice and assistance with benefit entitlements, delivered in participants' homes by trained advisors. Control was usual care. Participants were volunteers sampled from among all those aged ≥60 years registered with general practices in socio-economically deprived areas of north east England. Outcomes at 24 months were: CASP-19 score (primary), a measure of health-related quality of life; changes in income, social and physical function, and cost-effectiveness (secondary). Intention to treat analysis compared outcomes using multiple regression, with adjustment for stratification and key covariates. Qualitative interviews with purposive samples from both trial arms were thematically analysed.

FINDINGS

Of 3912 individuals approached, 755 consented and were randomised (381 Intervention, 374 Control). Results refer to outcomes at 24 months, with data available on 562 (74.4%) participants. Intervention was received as intended by 335 (88%), with 84 (22%) awarded additional benefit entitlements; 46 did not receive any welfare rights advice, and none of these were awarded additional benefits. Mean CASP-19 scores were 42.9 (Intervention) and 42.4 (Control) (adjusted mean difference 0.3 [95%CI -0.8, 1.5]). There were no significant differences in secondary outcomes except Intervention participants reported receiving more care at home at 24m (53.7 (Intervention) vs 42.0 (Control) hours/week (adjusted mean difference 26.3 [95%CIs 0.8, 56.1]). Exploratory analyses did not support an intervention effect and economic evaluation suggested the intervention was unlikely to be cost-effective. Qualitative data from 50 interviews suggested there were improvements in quality of life among those receiving additional benefits.

CONCLUSIONS

We found no effects on health outcomes; fewer participants than anticipated received additional benefit entitlements, and participants were more affluent than expected. Our findings do not support delivery of domiciliary welfare rights advice to achieve the health outcomes assessed in this population. However, better intervention targeting may reveal worthwhile health impacts.

Randomised controlled trial with economic and process evaluations of domiciliary welfare rights advice for socioeconomically disadvantaged older people recruited via primary health care (the Do-Well study)

Background

Welfare rights advice services are effective at maximising previously unclaimed welfare benefits, but their impact on health has not been evaluated.

Objective

To establish the acceptability, cost-effectiveness and effect on health of a domiciliary welfare rights advice service targeting older people, compared with usual practice.

Design

A pragmatic, individually randomised, parallel-group, single-blinded, wait-list controlled trial, with economic and process evaluations. Data were collected by interview at baseline and 24 months, and by self-completion questionnaire at 12 months. Qualitative interviews were undertaken with purposive samples of 50 trial participants and 17 professionals to explore the intervention’s acceptability and its perceived impacts.

Setting

Participants’ homes in North East England, UK.

Participants

A total of 755 volunteers aged ≥ 60 years, living in their own homes, fluent in English and not terminally ill, recruited from the registers of 17 general practices with an Index of Multiple Deprivation within the most deprived two-fifths of the distribution for England, and with no previous access to welfare rights advice services.

Interventions

Welfare rights advice, comprising face-to-face consultations, active assistance with benefit claims and follow-up as required until no longer needed, delivered in participants’ own homes by a qualified welfare rights advisor. Control group participants received usual care until the 24-month follow-up, after which they received the intervention.

Main outcome measures

The primary outcome was health-related quality of life (HRQoL), assessed using the CASP-19 (Control, Autonomy, Self-realisation and Pleasure) score. The secondary outcomes included general health status, health behaviours, independence and hours per week of care, mortality and changes in financial status.

Results

A total of 755 out of 3912 (19%) general practice patients agreed to participate and were randomised (intervention,n = 381; control,n = 374). In the intervention group, 335 participants (88%) received the intervention. A total of 605 (80%) participants completed the 12-month follow-up and 562 (75%) completed the 24-month follow-up. Only 84 (22%) intervention group participants were awarded additional benefits. There was no significant difference in CASP-19 score between the intervention and control groups at 24 months [adjusted mean difference 0.3, 95% confidence interval (CI) –0.8 to 1.5], but a significant increase in hours of home care per week in the intervention group (adjusted difference 26.3 hours/week, 95% CI 0.8 to 56.1 hours/week). Exploratory analyses found a weak positive correlation between CASP-19 score and the amount of time since receipt of the benefit (0.39, 95% CI 0.16 to 0.58). The qualitative data suggest that the intervention was acceptable and that receipt of additional benefits was perceived by participants and professionals as having had a positive impact on health and quality of life. The mean cost was £44 per participant, the incremental mean health gain was 0.009 quality-adjusted life-years (QALYs) (95% CI –0.038 to 0.055 QALYs) and the incremental cost-effectiveness ratio was £1914 per QALY gained.

Conclusions

The trial did not provide sufficient evidence to support domiciliary welfare rights advice as a means of promoting health among older people, but it yielded qualitative findings that suggest important impacts on HRQoL. The intervention needs to be better targeted to those most likely to benefit.

Future work

Further follow-up of the trial could identify whether or not outcomes diverge among intervention and control groups over time. Research is needed to better understand how to target welfare rights advice to those most in need.

Trial registration

Current Controlled Trials ISRCTN37380518.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 3. See the NIHR Journals Library website for further project information. The authors also received a grant of £28,000 from the North East Strategic Health Authority in 2012 to cover the costs of intervention delivery and training as well as other non-research costs of the study.

Evaluating effects of recent changes in NHS resource allocation policy on inequalities in amenable mortality in England, 2007-2014: time-series analysis

BACKGROUND

Health investment in England post-2010 has increased at lower rates than previously, with proportionally less being allocated to deprived areas. This study seeks to explore the impact of this on inequalities in amenable mortality between local areas.

METHODS

We undertook a time-series analysis across 324 lower-tier local authorities in England, evaluating the impact of changes in funding allocations to health commissioners from 2007 to 2014 on spatial inequalities in age-standardised under-75 mortality rates for conditions amenable to healthcare for men and women, adjusting for trends in household income, unemployment and time-trends.

RESULTS

More deprived areas received proportionally more funding between 2007 and 2014, though the reorganisation of commissioning in 2012 stalled this. Funding increases to more deprived local areas accounted for a statistically significant reduction in inequalities in male amenable mortality between local areas of 13 deaths per 100 000 (95% CI 2.5 to 25.9). Funding changes were associated with a reduction in inequalities in female amenable mortality of 7.0 per 100,000, though this finding did not reach significance (p=0.09).

CONCLUSION

Current National Health Service (NHS) resource allocation policy in England appears to be contributing to a convergence in health outcomes between affluent and deprived areas. However, careful surveillance is needed to evaluate whether diminished allocations to more deprived areas in recent years and reduced NHS investment as a whole is impacting adversely on inequalities between groups.

Trends in gender and socioeconomic inequalities in mental health following the Great Recession and subsequent austerity policies: a repeat cross-sectional analysis of the Health Surveys for England

OBJECTIVE

It is known that mental health deteriorated following the 2008 global financial crisis, and that subsequent UK austerity policies post-2010 disproportionately impacted women and those in deprived areas. We aimed to assess whether gender and socioeconomic inequalities in poor mental health have changed since the onset of austerity policies.

DESIGN

Repeat cross-sectional analysis of survey data.

SETTING

England.

PARTICIPANTS

Nationally and regionally representative samples of the working-age population (25-64 years) from the Health Survey for England (1991-2014).

OUTCOME MEASURES

Population-level poor mental health was measured by General Health Questionnaire-12 (GHQ) caseness, stratified by gender and socioeconomic position (area-level deprivation and highest educational attainment).

RESULTS

The prevalence of age-adjusted male GHQ caseness increased by 5.9% (95% CI 3.2% to 8.5%, p<0.001) from 2008 to 2009 in the immediate postrecession period, but recovered to prerecession levels after 2010. In women, there was little change in 2009 or 2010, but an increase of 3.0% (95% CI 1.0% to 5.1%, p=0.004) in 2012 compared with 2008 following the onset of austerity. Estimates were largely unchanged after further adjustment for socioeconomic position, employment status and household income as potential mediators. Relative socioeconomic inequalities in GHQ caseness narrowed from 2008 to 2010 immediately following the recession, with Relative Index of Inequality falling from 2.28 (95% CI 1.89 to 2.76, p<0.001) to 1.85 (95% CI 1.43 to 2.38, p<0.001), but returned to prerecession levels during austerity.

CONCLUSIONS

Gender inequalities in poor mental health narrowed following the Great Recession but widened during austerity, creating the widest gender gap since 1994. Socioeconomic inequalities in poor mental health narrowed immediately postrecession, but this trend may now be reversing. Austerity policies could contribute to widening mental health inequalities.

The National Health Service (NHS) in 'crisis': the role played by a shift from horizontal to vertical principles of equity

Explanations of the state of 'crisis' in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be 'failing' and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.

Austerity and health: the impact in the UK and Europe

Austerity measures—reducing social spending and increasing taxation—hurts deprived groups the most. Less is known about the impact on health. In this short review, we evaluate the evidence of austerity’s impact on health, through two main mechanisms: a ‘social risk effect’ of increasing unemployment, poverty, homelessness and other socio-economic risk factors (indirect), and a ‘healthcare effect’ through cuts to healthcare services, as well as reductions in health coverage and restricting access to care (direct). We distinguish those impacts of economic crises from those of austerity as a response to it. Where possible, data from across Europe will be drawn upon, as well as more extensive analysis of the UK’s austerity measures performed by the authors of this review.

The epidemiological transition in Eastern and Western Europe: a historic natural experiment

Background

The continent of Europe has experienced remarkable changes in the past 25 years, providing scope for natural experiments that offer insight into the complex determinants of health.

Methods

We analysed trends in life expectancy at birth in three parts of Europe, those countries that were members of the European Union (EU) prior to 2004, countries that joined the European Union since then, and the twelve countries that emerged from the Soviet Union to form the Commonwealth of Independent States (CIS). The contribution of deaths at different ages to these changes was assessed using Arriaga's method of decomposing changes in life expectancy.

Results

Europe remains divided geographically, with an East-West gradient. The former Soviet countries experienced a marked initial decline in life expectancy and have only recovered after 2005. However, the situation for those of working ages is little better than in 1990. The pre-2004 EU has seen substantial gains throughout the past 25 years, although there is some evidence that this may be slowing, or even reversing, at older ages. The countries joining the EU in 2004 subsequently began to see some improvements in the early 1990s, but have experienced larger gains since 2000.

Conclusions

Europe offers a valuable natural laboratory for understanding the impact of political, economic, and social changes on health. While the historic divisions of Europe are still visible, there is also evidence that individual countries are doing better or worse than their neighbours, providing many lessons that can be learned from.

Making the most of natural experiments: What can studies of the withdrawal of public health interventions offer?

Many interventions that may have large impacts on health and health inequalities, such as social and public health policies and health system reforms, are not amenable to evaluation using randomised controlled trials. The United Kingdom Medical Research Council's guidance on the evaluation of natural experiments draws attention to the need for ingenuity to identify interventions which can be robustly studied as they occur, and without experimental manipulation. Studies of intervention withdrawal may usefully widen the range of interventions that can be evaluated, allowing some interventions and policies, such as those that have developed piecemeal over a long period, to be evaluated for the first time. In particular, sudden removal may allow a more robust assessment of an intervention's long-term impact by minimising 'learning effects'. Interpreting changes that follow withdrawal as evidence of the impact of an intervention assumes that the effect is reversible and this assumption must be carefully justified. Otherwise, withdrawal-based studies suffer similar threats to validity as intervention studies. These threats should be addressed using recognised approaches, including appropriate choice of comparators, detailed understanding of the change processes at work, careful specification of research questions, and the use of falsification tests and other methods for strengthening causal attribution. Evaluating intervention withdrawal provides opportunities to answer important questions about effectiveness of population health interventions, and to study the social determinants of health. Researchers, policymakers and practitioners should be alert to the opportunities provided by the withdrawal of interventions, but also aware of the pitfalls.

Why is life expectancy in England and Wales 'stalling'?

Several independent analyses, by both epidemiologists and actuaries, have concluded that the previous rate of improvement of life expectancy in England and Wales has now slowed markedly, and at older ages may even be reversing. However, although these findings have led the pension industry to reduce estimates of future liabilities, they have failed to elicit any significant concern in the Department of Health and Social Care. In this essay, we review the evidence on changing life expectancy, noting that the problems are greatest among older women. We then estimate the gap between what life expectancy is now and what it might have been had previous trends continued. At age 85, the gap is 0.34 years for women and 0.23 for men. We argue that recent changes cannot be dismissed as a temporary aberration. While the causes of this phenomenon are contested, there is growing evidence to point to the austerity policies implemented in recent years as at least a partial explanation. We conclude by calling for a fully independent enquiry to ascertain what is happening to life expectancy in England and Wales and what should be done about it.