Future inequalities in life expectancy in England and Wales
Authors: John N Newton
Journal: The Lancet (2015)

Recent international trends in life expectancy tell a remarkable story of improvement.1Oeppen J Vaupel JW Broken limits to life expectancy.Science. 2002; 296: 1029-1031Crossref PubMed Scopus (1571) Google Scholar In England, life expectancy from birth has doubled since 1840 and, from 1982 to 2012, has increased by about 8 years for men (from 71·3 years to 79·2 years) and 6 years for women (from 77·3 years to 83.0 years).2Office for National StatisticsNational life tables, United Kingdom, 2011–2013. Office for National Statistics, Newport2014Google Scholar This most recent change equates to more than 6 h of life expectancy gained per day survived for men, and more than 4 h for women. Historically, improvements in life expectancy were achieved through reductions in infant and child mortality,1Oeppen J Vaupel JW Broken limits to life expectancy.Science. 2002; 296: 1029-1031Crossref PubMed Scopus (1571) Google Scholar whereas, from 1981 to 2012, life expectancy at 65 years improved by 41% for men and 24% for women in England; and even at 85 years, by 34% for men and 27% for women.2Office for National StatisticsNational life tables, United Kingdom, 2011–2013. Office for National Statistics, Newport2014Google Scholar For men, 39% of deaths in the UK now occur at ages older than 85 years, and 52% occur at these ages in women, increased from 14% for men and 31% for women in 1981.2Office for National StatisticsNational life tables, United Kingdom, 2011–2013. Office for National Statistics, Newport2014Google Scholar In low-mortality countries such as England, summary mortality statistics therefore mainly track changes in the common pathologies of old age.3Bongaarts J Trends in causes of death in low-mortality countries: implications for mortality projections.Popul Dev Rev. 2014; 40: 189-212Crossref Scopus (22) Google Scholar Life tables have been used since the 1840s to describe geographical inequalities in health. These life tables generally correlate strongly with area deprivation,4Griffiths C Fitzpatrick J Geographic inequalities in life expectancy in the United Kingdom, 1995–97.Health Stat Q. 2001; 9: 16-28Google Scholar although migration has an effect.5Norman P Boyle P Rees P Selective migration, health and deprivation: a longitudinal analysis.Soc Sci Med. 2005; 60: 2755-2771Crossref PubMed Scopus (235) Google Scholar Unfortunately, improvement in overall life expectancy has not led to commensurate reductions in levels of inequality. The range of life expectancy at birth in England across its districts increased for males, from 8·3 years in 2008 to 8·7 years in 2012, although it did fall for women from 7·3 years to 6·4 years.6Office for National StatisticsLife expectancy at birth and at age 65 by local areas in England and Wales, 2011–13. Office for National Statistics, Newport2014Google Scholar At a regional level, inequalities have reduced for men, for whom the range between regions fell from 2·7 to 2·4 years, but no change occurred for women, for whom the equivalent range remained at 2·4 years. On a positive note, the gap between men and women at a national level has progressively narrowed from 5·9 years in 1982 to 3·8 years in 2012. Statistics on period life expectancy combine age-specific mortality data into a single summary statistic that is meaningful to almost any audience. Pitfalls exist, however. No one actually experiences period life expectancy.6Office for National StatisticsLife expectancy at birth and at age 65 by local areas in England and Wales, 2011–13. Office for National Statistics, Newport2014Google Scholar Just as the satellite navigation system in your car tells you how long the journey to an airport would take with present traffic conditions, but not with the ones that you will actually encounter, period life expectancy is a notional construct based on present age-specific mortality patterns. In reality, people contribute to death statistics as members of birth cohorts living through different periods at different ages.7Holford TR Understanding the effects of age, period, and cohort on incidence and mortality rates.Annu Rev Public Health. 1991; 12: 425-457Crossref PubMed Google Scholar Period life expectancy statistics therefore tell us a lot about present mortality experience, but rather little about future expectations. Life expectancy at birth has been projected to 2062 for England,8Office for National StatisticsHistoric and projected mortality data from the period and cohort life tables, 2012-based, UK, 1981–2062. Office for National Statistics, Newport2013Google Scholar but the uncertainty range is huge. At best, the life expectancy of men could be 92·6 years and 95·1 years for women, but, at worst, it could be 81·9 years for men and 85·5 years for women. The main estimate is in the middle and represents substantial flattening of present rates of improvement. In The Lancet, James Bennett and colleagues9Bennett JE Li G Foreman K et al.The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting.Lancet. 2015; 386: 163-170Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar have used elaborate Bayesian models to analyse present mortality patterns in England and Wales. They then forecasted life expectancy to 2030 for 375 districts. Their models take separate account of age, cohort, period, and geography; the one that performed best emphasised the effect of cohort. One of the many benefits of this approach is that it makes few, if any, assumptions about trends in mortality. It allows for non-linear trends of the sort that might be expected to follow known patterns of, for example, smoking in past decades. The model output is more optimistic than official figures. By 2030, life expectancy is predicted to reach 85·7 years (95% credible interval 84·2–87·4) for men and 87·6 years (86·7–88·9) for women. The sex gap would be reduced to just 1·9 years as mortality is likely to continue to improve more for middle-aged and old men than it will for women. At district level, the range between local areas in 2012 is already equivalent to the gap between the UK and countries like Sri Lanka or Nicaragua.10WHOWorld health statistics 2014. World Health Organization, Geneva2014Google Scholar The model predicts increasing inequality within England and Wales, with the difference between the 1st and 99th percentiles rising from 6·1 years (5·9–6·4) to 8·3 years (6·8–9·7) for men, and from 5·6 years (5·3–6·0) to 8·3 years (7·1–9·4) for women. These results raise important questions about what constitutes an adequate response to such worsening inequality in terms of both policy and service provision. Measures to control smoking remain important, but addressing so-called proximal risk factors (such as use of tobacco and alcohol, and diet) cannot be expected to achieve much unless the social and economic determinants of these behaviours change.11Marmot M for the Commission on Social Determinants of HealthAchieving health equity: from root causes to fair outcomes.Lancet. 2007; 370: 1153-1163Summary Full Text Full Text PDF PubMed Scopus (528) Google Scholar For health services, the issue is one of equity not equality—the health of the disadvantaged should not be further diminished by prevention and treatment services that are inadequately adapted to their various situations and needs. Clearly, many predictions of trends in life expectancy from the past century were substantially wrong.1Oeppen J Vaupel JW Broken limits to life expectancy.Science. 2002; 296: 1029-1031Crossref PubMed Scopus (1571) Google Scholar In the 1970s, Omran's12Omran AR The epidemiologic transition. A theory of the epidemiology of population change.Milbank Q. 1971; 49: 509-538Crossref Scopus (1953) Google Scholar view of the epidemiological transition was that mortality would stabilise once infectious diseases had been overcome and mortality was dominated by the effects of what he called “degenerative disease and man-made diseases”, such as cardiovascular disease and cancers. Many authorities at that time assumed an upper limit for life expectancy at birth of 75 years,1Oeppen J Vaupel JW Broken limits to life expectancy.Science. 2002; 296: 1029-1031Crossref PubMed Scopus (1571) Google Scholar which now seems extraordinarily naive. The fact that life expectancy has continued its upward trajectory more or less unchecked is widely attributed to a profound and abrupt decline in mortality from cardiovascular diseases. Bongaarts3Bongaarts J Trends in causes of death in low-mortality countries: implications for mortality projections.Popul Dev Rev. 2014; 40: 189-212Crossref Scopus (22) Google Scholar ascribed two-thirds of the recent fall in deaths in 15 low-mortality countries to a reduction in cardiovascular deaths. As a result, cancer is now twice as important as a cause of death in these countries as it was 50 years ago. Sustained improvements in life expectancy have transformed the age profile of countries like England, with implications for health and care services, fiscal policy, the insurance market, and commerce generally. Old people of the future will need to be healthier and more independent than those using services nowadays, otherwise those services could be overwhelmed. Aggressive and timely management of disability, and a positive approach to promotion of health for old people, could still achieve the resilience and capability needed. Reliable estimates of future life expectancy trends are therefore in great demand. Bennett and colleagues9Bennett JE Li G Foreman K et al.The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting.Lancet. 2015; 386: 163-170Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar have arguably developed to its limit the use of existing overall mortality data as a method for prediction of future mortality. The next stage is to model trends in cause-specific mortality for the common causes3Bongaarts J Trends in causes of death in low-mortality countries: implications for mortality projections.Popul Dev Rev. 2014; 40: 189-212Crossref Scopus (22) Google Scholar, 13Mathers CD Loncar D Projections of global mortality and burden of disease from 2002 to 2030.PLoS Med. 2006; 3: e442Crossref PubMed Scopus (7566) Google Scholar and, even better, to add trends in causes attributable to important risk factors. Peto and colleagues14Peto R Lopez AD Boreham J Thun M Heath Jr, C Mortality from tobacco in developed countries: indirect estimation from national vital statistics.Lancet. 1992; 339: 1268-1278Summary PubMed Scopus (1098) Google Scholar have developed a robust method for estimation of numbers of deaths attributable to smoking, which probably peaked in England for men in about 1980 and for women in 2010. Other attributable risks are technically more difficult to estimate but these will become increasingly important to estimate as the effect of smoking falls. In the end, projections are derived from known data and remain susceptible to Hume's problem of induction. We implicitly assume that the future will be like the past in a predictable way, otherwise even the best model is of no value. Unfortunately, experience suggests that the future is often rather different from the past in really quite unpredictable ways. Extrapolation beyond the data remains a risky and uncertain business. I am employed as Chief Knowledge Officer by Public Health England. The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecastingPresent forecasts underestimate the expected rise in life expectancy, especially for men, and hence the need to provide improved health and social services and pensions for elderly people in England and Wales. Health and social policies are needed to curb widening life expectancy inequalities, help deprived districts catch up in longevity gains, and avoid a so-called grand divergence in health and longevity. Full-Text PDF Open Access