Effects of health and social care spending constraints on mortality in England: a time trend analysis

Abstract

Objective: Since 2010, England has experienced relative constraints in public expenditure on healthcare (PEH) and social care (PES). We sought to determine whether these constraints have affected mortality rates.

Methods: We collected data on health and social care resources and finances for England from 2001 to 2014. Time trend analyses were conducted to compare the actual mortality rates in 2011-2014 with the counterfactual rates expected based on trends before spending constraints. Fixed-effects regression analyses were conducted using annual data on PES and PEH with mortality as the outcome, with further adjustments for macroeconomic factors and resources. Analyses were stratified by age group, place of death and lower-tier local authority (n=325). Mortality rates to 2020 were projected based on recent trends.

Results: Spending constraints between 2010 and 2014 were associated with an estimated 45 368 (95% CI 34 530 to 56 206) higher than expected number of deaths compared with pre-2010 trends. Deaths in those aged ≥60 and in care homes accounted for the majority. PES was more strongly linked with care home and home mortality than PEH, with each £10 per capita decline in real PES associated with an increase of 5.10 (3.65-6.54) (p<0.001) care home deaths per 100 000. These associations persisted in lag analyses and after adjustment for macroeconomic factors. Furthermore, we found that changes in real PES per capita may be linked to mortality mostly via changes in nurse numbers. Projections to 2020 based on 2009-2014 trend was cumulatively linked to an estimated 152 141 (95% CI 134 597 and 169 685) additional deaths.

Conclusions: Spending constraints, especially PES, are associated with a substantial mortality gap. We suggest that spending should be targeted on improving care delivered in care homes and at home; and maintaining or increasing nurse numbers.

Keywords: PYLL; expenditure; health care; life expectancy; mortality; social care; spending; time trend.

Figure 1

Time trend projections of age-standardised death rate (ASDR) per 100 000 individuals. ASDR (left hand y-axis) and the difference in the number of deaths between actual and predicted mortality (right hand y-axis) per year from 2001 to 2014 are shown. The black and blue lines represent actual ASDR for the 2001–2010 and 2011–2014 periods, respectively. The red line represents predicted ASDR using 2001–2010 as an observation base while the 95% CIs are denoted by the beige-coloured area. The grey bars denote the differences between the number of deaths observed and the number predicted for 2011–2014 where positive values correspond to excess deaths and negative values represent lower than expected deaths. Error bars represent 95% CIs. *p<0.05; **p<0.01; ***p<0.001.

Figure 2

Numbers of excess or lower than expected deaths for each place of death. Separate time trend analyses comparing actual to predicted mortality from 2011 to 2014 were conducted using mortality data categorised by place of death. Contributions from each place of death are colour coded. Data are shown for mortality rates for all ages (top panel), those under 60 (middle panel) and those 60 years or over (bottom panel). *p<0.05; **p<0.01; ***p<0.001.

Figure 3

Additional spending needed to close the 2020 mortality gap. Data are shown for PEH (blue) and on top of that, PES (beige), in real terms according to 2014/2015 prices. Actual out-turn data are shown for 2001/2002 to 2014/2015. However, for 2015/2016 to 2020/2021, the budgeted total Department of Health expenditure limit is shown for PEH. For PES, data are based on the continuation of −2.25% annual percentage change in core PES in 2014/2015 supplemented by the potential revenue from the adult social care precept for council tax. Additional spending needed to close the projected mortality gap for each year from 2015 to 2020 is shown as color-coded dotted lines for three different scenarios, each of which assumes different annual efficiency improvements. The additional annual spending numbers with associated 95% CI are shown as bar plots for each scenario. PEH, public expenditure on healthcare; PES, public expenditure on social care.