Forecasting the future is inherently difficult. And given the NHS’s size and the multitude of factors affecting both service performance and patient outcomes, making predictions about the health service is particularly challenging. With the privilege of hindsight, we can reflect on some instances where goals were just too optimistic to be met, like the commitments to trusts returning to financial balance in year. At other times, apparently very high targets have actually been achieved – such as the push to limit waiting times to 18 weeks. So what would it take to achieve the headline ambition of the NHS Long Term Plan?
A bold ambition
NHS England’s press release led with the prediction that the Plan would “save up to half a million lives”, a number picked up by the media. The statement goes on to say the “latest technology… coupled with early detection and a renewed focus on prevention [will] stop an estimated 85,000 premature deaths each year” including saving 55,000 more cancer patients’ lives annually.
A death is deemed as:
■ amenable (treatable) if all or most deaths from that cause could be avoided through good quality healthcare (e.g. those caused by complications during birth)
■ preventable if, all or most deaths from that could be avoided by public health interventions in the broadest sense (e.g. from alcohol related diseases)
■ avoidable if preventable, amenable (treatable) or both. Because many deaths are both, this is less than the sum of the two categories.
On first inspection, these figures look demanding. Based on recent and historic Office for National Statistics (ONS) figures, around a quarter of deaths in England – in the region of 110,000 a year – are avoidable, either through better healthcare or healthier public behaviours (see box). Of these only around 60,000 could be avoided through healthcare.
But single comparisons rarely give the entire picture and performance will be influenced not only by the scale of the action taken but also by the definitions used to measure it. So what do we need to assume and what needs to happen if these laudable ambitions are to be met?
How performance is measured will be a key factor, with the definition used to classify a ‘life saved’ having a large bearing on the number achieved. NHS England shared some details with us about how they added together figures from expert groups to reach their figure – and we can see there are indeed different definitions of avoided deaths at work.
NHS England focus on those that are alive, counting the number of times a life is saved, whereas ONS focus on those that have died and instead count how many of these deaths could have been avoided. A person could be saved from both suicide and cancer, and count twice in NHS England’s sums but only reduce the national statistics by one.
NHS England also count people who survive for five years after diagnosis of cancer as being lives saved. But not all these people, sadly, will live much longer. Performance against this measure could improve purely through earlier diagnosis without actually prolonging lives although, of course, earlier diagnosis can contribute to better outcomes. The impact on the rate of deaths, which is what national statistics will show, would be less than the impact on five year survival.
A growing and aging population might also help to make the target more manageable by increasing the number of lives to potentially save. While England’s population is only expected to grow by around 5% to 2028, the number of people aged over 75 is predicted to increase by around 30%. It is unclear quite how this will affect the number of potentially avoidable deaths but with increased prevalence of disease in this older population, there may be greater scope for life-saving interventions. However, progress here would require turning around a situation where life expectancy for these groups has recently been stalling.
Taking a closer look at the largest component within the overall figure – saving 55,000 more cancer patients’ lives annually – gives an indication of the potential effect of an aging and growing population. ONS estimated around 140,000 deaths from cancer in England in 2017. However, based on numbers from a 2016 study there could be an estimated 160,000 deaths from cancer in 2028.
This also demonstrates the importance of the definition of ‘lives saved’. If NHS England used the ONS definition of avoidable deaths, about a third of deaths would need to be avoided to meet the 55,000 lives saved. But the ONS deemed only around 36% of cancer deaths in 2016 were avoidable (see chart), so the goal would be equivalent to the total estimated number of avoidable cancer deaths. Including increasing five year survival rates in the definition obviously changes the picture.
Action on over 75s
NHS England might also be identifying some causes of death as avoidable when the ONS would not. For most causes of deaths, the ONS exclude people 75 and over from their count of avoidable mortality. The majority of this cohort have three or more conditions on their death certificate making it difficult to estimate ‘avoidability’ of deaths. But, while not including them in their estimates, the ONS do recognise some conditions in the avoidable mortality definition may be effectively treated at older ages and so it would be right for NHS England to seek to include them in its calculation. This is a material consideration – around three-quarters of all deaths are for people aged 75 and over. The difficulty is that we don’t have a national statistical benchmark for knowing how avoidable their deaths are.
Best in class
International data on avoidable deaths, using OECD criteria similar to those of the ONS, suggests the NHS would have to become a world-beater to save half a million lives. The available data show we already have fewer avoidable deaths than average for EU countries, and matching the performance of the very best for preventable (Italy) and amenable (France) mortality would represent 28% and 33% falls, respectively – well short of what is required. On cancer, matching the best performance from a European country (Finland) within the data on deaths from cancer would represent a 21% fall.
Within England, reducing the nation’s average to that of the best performing region (East of England) in 2013 would only have resulted in around a 12,000 fall (11%) in deaths deemed avoidable in the ONS’s estimates. This suggests every area would likely have to increase its performance considerably – just matching the current best is unlikely to be sufficient.
What the data can tell us is the importance of wider initiatives to improve health if something like this target is to be achievable. Nearly half of avoidable deaths are not considered amenable to healthcare but instead require broader prevention. Indeed, last year the WHO made a plea for more ambition tackling non-communicable diseases, such as strokes and most heart diseases, for which a person’s background, lifestyle and environment are risk factors. Their report challenges European countries to work on broader prevention in order to reduce premature mortality from such diseases by at least 45% by 2030. Against this ambition, the Plan’s goal looks rather conservative.
In this light the commitments in the Plan to use funding to support, for example, smoking cessation, obesity reduction and even cleaner air programmes are promising. Yet the NHS itself has relatively few levers over public health. The main budgets for it held by councils are being sharply cut, and services like police and education are under serious pressure. And these factors tend to determine health outcomes over a timescale of decades – longer even than a long term plan looks ahead.
The detailed “bottom up” approach NHS England explained to us, with efforts to prevent double-counting between the effect of different initiatives, is reassuring. And as we have seen, different definitions will lead to quite different numbers.
That said, we think it essential that NHS England are fully transparent and publish the calculation and its methodology. Health service managers and researchers need to understand their implications and what is required. Transparent publication would also help in judging performance later so there was no confusion or misunderstanding about the difference between ‘avoidable deaths’ (the international currency) and the goal of ‘lives saved’ that NHS England has set out.
But, whatever the definition, as my colleague John Appleby previously highlighted, avoidable deaths are worth being concerned about. So I’ll be keeping tabs on performance with a keen eye. And fingers crossed.
Palmer B (2019) “Can the Long Term Plan really save half a million lives?”, Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/can-the-long-term-plan-really-save-half-a-million-lives