Six decades of universal free health care, the introduction of widespread public health initiatives (e.g., tobacco control, cancer screening, and immunization), and substantial increases in health expenditure have failed to improve the UK's health outcomes or longevity ranking against the average of 14 other original members of the European Union, Australia, Canada, Norway, and the USA (EU15+) over the past 20 years.
The startling findings, published Online First in The Lancet, reveal that despite life expectancy increasing by 4.2 years over the last two decades, the UK's pace of decline in premature mortality has persistently and significantly fallen behind the average of EU15+, and concerted action is urgently needed.
Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), Chris Murray, from the Institute for Health Metrics and Evaluation, University of Washington, USA, and colleagues analysed patterns of ill health and death in the UK, calculated the contribution of preventable risk factors, and ranked the UK compared with a group of high-income countries with similar levels of health expenditure in 1990 and 2010. Only in men older than 55 years has the UK experienced significantly faster drops in death rates compared with other nations over the last 20 years. The UK ranking in premature mortality rates for adults aged 20 years has worsened substantially. This is in part because of dramatic increases in drug and alcohol use disorders, which were ranked as two of the least important causes of death in this age group in 1990 (ranked 32nd and 43rd respectively), rising to sixth and 18th place in 2010.
Overall, the eight leading causes of death in the UK have changed remarkably little in the last 20 years, with ischaemic heart disease, chronic obstructive pulmonary disease (COPD), stroke, lung cancer, and lower respiratory infections remaining in the top five.
By comparison, there has been a startling increase in the contribution of Alzheimer's disease (increase of +137%; rising from a rank of 24th to 10th), cirrhosis (+65%; 14th to 9th), and drug use disorders (+577%; 64th to 21st).
In 2010, the UK had significantly lower premature mortality from diabetes, road injuries, liver cancer, and chronic kidney diseases than the average for EU15+. However, it has not kept pace with other nations (and still has death rates significantly above the average of EU15+) for ischaemic heart disease, COPD, lower respiratory tract infections, breast cancer, other heart and circulatory disorders, oesophageal cancer, congenital abnormalities, preterm birth complications, and aortic aneurysm.
What is more, disability is causing a much greater proportion of the burden of disease as people are living longer, but spending these later years with more health problems compared to 20 years ago. In 2010, mental and behavioural disorders (predominantly depression, anxiety, drug and alcohol use, schizophrenia, and bipolar disorder), and musculoskeletal disorders (mainly lower back pain and falls) were responsible for more than half of all years lived with disability in the UK.
Explanations for the UK's worsening relative performance confirm the harmful effects of tobacco smoking (that remains the nation's leading risk factor for ill-health responsible for 11.8% of the disease burden in 2010), followed by the rising burden of high blood pressure (9%) and obesity (high body mass index; 8.6%). Also important are risk factors involving poor diet and low physical inactivity, which collectively account for 14.3% of disease burden, and the increasing effect of alcohol. The findings are released as UK Health Secretary Jeremy Hunt launches a new strategy to tackle premature mortality and cardiovascular diseases.
According to Murray, "Further progress in premature mortality from several major causes, such as cardiovascular diseases and cancers, will probably require improved public health, prevention, early intervention, and treatment activities. The growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response." Writing in a linked Comment, Edmund Jessop from the UK Faculty of Public Health in London, UK points out, "The UK has done very well in the past 20 years in many areas. As Murray and colleagues show, mortality has reduced and several aspects of diet have improved, with drops in disability-adjusted life-years for all dietary risk factors examined. The UK has stronger tobacco control than does any other country in Europe, and we continue to enjoy some of the safest roads in Europe."
But he cautions, "There is still plenty of room for bold action by politicians and the body politic: plain packaging for cigarettes, minimum pricing for alcohol, banning of trans fats, improved control of hypertension, and attention to psychiatric disorders. Alternatively, the UK can continue to languish at the bottom of European league tables."
In an Editorial accompanying the publication, Dr Richard Horton, Editor in Chief of The Lancet, describes the study as "an independent scientific report card on decades of NHS reorganisations that have often had more to do with political ideology than sound evidence." He adds that, "The GBD results do not by themselves offer definitive prescriptions for the predicaments they describe. And they do not provide a simple verdict on the performance of the UK health system. But they do offer a quantitative means to monitor measures of health and disease and to enable more rational review and discussion of health priorities. This work is an important step forward for health policy."
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