The nearness to death effect and why NHS pressures are going to intensify

Rodney P Jones
January 2019

Nearness to death effectSo, what have deaths to do with capacity pressures? There is a very simple answer: the nearness to death effect. The nearness to death effect has been documented for around four decades and shows that healthcare demand escalates with nearness to death and not with age, per se (Payne et al, 2007). Around half of a person's lifetime hospital inpatient admissions and bed occupancy is compressed into the last year of life (Hanlon et al, 1998). Hence, the marginal changes in deaths are intimately linked to the marginal changes in medical admissions (Jones, 2018a). If you ignore the nearness to death effect, you get the entirely false impression that it is all of those older people consuming the resources.For those who have been in the ambulance service for many years, have a moment's reflection around how Figure 1 may have influenced the marginal changes in the proportions of male and female ambulance journeys, especially since 2003. I think you have probably gathered the point.However, the issue regarding older people consuming all of the resources is addressed in Figure 2 where the age at death in 1974 is compared with that in 2017. Deaths in 1974 have been adjusted down to the same total as in 2017. As can be seen, in 1974, the bulk of deaths occurred below the age of 80; while in 2017, it is above age 80. The age of death has increased; hence, the nearness to death effect makes it seem that older people are clogging up the ambulances, etc. Nothing has changed. It has always been that the dying people (in their last year of life), irrespective of their age, drive the marginal pressures on NHS capacity.Figure 2.Age at death in 1974 compared with that in 2017Clearly, non-end-of-life NHS demand pressures are also age-related and Figure 3 attempts to disentangle how many admissions in the medical group of specialties may be a result of each source. Figure 3 makes such an estimate by assuming that every person has seven admissions (emergency and elective, including day case) in the last year of life. As is demonstrated, the proportion of admissions which are end-of-life-related rises with age except in the oldest old (age 90+). It is likely that the number of admissions in the last year of life may vary with age (especially in the oldest old). However, the principle is that the total admissions, ambulance journeys etc, rise in proportion to the speed of change in the population age-structure, relative to the rate of change in deaths.Figure 3.Calculated proportion of all admissions in England in 2017/18 which may be related to the end of lifeRegarding the rate of change in deaths, between 1991 and 2011, deaths in the UK were decreasing by around 4940 per annum. However, since 2011, they have been increasing by around 8840 per annum, and deaths have continued to increase throughout 2018 (Jones, 2018b). Hence, the end-of-life-based winter pressures in 2018/19 will indeed be worse than ever before—irrespective of whether or not there is an influenza outbreak! Influenza would only make a bad situation worse.

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