Tracking Changes in the Causes of Death in England and Wales

Causes of Death: A Study of a Century of Change in England and Wales

OHE’s health and health care statistics service long has been respected as a source of reliable data.  In an OHE Briefing just published, OHE uses this data to take a closer look at what has been responsible for changes in the causes of death in England and Wales.

We are living longer. In his well-known research, Thomas McKeown found that life expectancy in England and Wales increased by around 30 years between 1901 and 1971. He attributed that primarily to a reduction in deaths from infectious diseases, the result of improvements in nutrition, safer water and better sanitation, and changes in personal behaviour.

This new OHE Briefing, which extends McKeown’s analysis to 2007, finds that mortality continued to decline after 1971. It tells a different story, however, about changes in the causes of death. Between 1971 and 2007, only about 20% of the reduction in age-standardised mortality rates in England and Wales is attributable to reductions in infectious diseases. This in part is because some illnesses have all but disappeared—for example, cholera, diarrhoea, dysentery and respiratory tuberculosis[1].  But it is due mainly to marked declines in deaths from other causes.

It is striking that almost 20% of the decline in mortality during 1971-2007 is the result of lower age-standardised mortality rates for just one cause of death—cardiovascular disease.  This is despite an increase in incidence rates for that disease. Innovation in health care has been important; for example, the first beta blocker was marketed in the UK in 1965, offering the first truly effective medical treatment for the disease. The authors note, however, that other factors that also have had an important effect, including lifestyle changes.

The OHE Briefing highlights some diseases for which age-standardised mortality rates in recent years have risen. For example, between 1997 and 2007, mortality rates increased for diseases of the digestive system, including fibrosis and cirrhosis of the liver. According to the authors, “This may indicate that whereas, in the past, changes in sanitation and other public factors outweighed effects from personal behaviours, in the current day negative personal behaviours can increase the risk for both morbidity and mortality from certain diseases (e.g. obesity and diabetes)”.

At the same time that life expectancy has increased, so has the number of individuals living with chronic disease. Not surprisingly, the percentage of the population reporting chronic ill health has increased the most for those aged 65 and over—from 53% in 1972 to 63% in 2007.

Both declines in mortality and increases in morbidity will have important implications for health and health care for many decades to come.

Download Baillie, L. and Hawe, E. (2012) Causes of death: A study of a century of changes in England and Wales. 53. OHE Briefing. London: Office of Health Economics.


[1] OHE’s first publication, in 1962, focused on tuberculosis and the challenges of conquering it. For an overview of that and a more recent, 1996, publication by OHE, click here.



Recent Statistics on Orphan Approvals in Scotland and England

In October 2009, the OHE published research that compared access to orphan medicinal products (OMPs) in selected European countries.  At the request of the UK Orphan Medicines Industry Group [1], OHE recently updated to May 2011 some of the data included in that research.  Using the same methodology, this new analysis focuses on decisions taken on orphan drugs by the Scottish Medicines Consortium (SMC) and the National Institute for Health and Clinical Excellence (NICE).  Included are the 74 orphan indications approved by the European Medicines Agency (EMA) up to May 2011.

Decisions by the SMC

The SMC has issued 55 decisions for the 74 orphan indications.  Because of resubmissions and reviews for some, a total of 69 decisions have been published.

As figure 1 shows, companies most often submitted full submissions for OMPs to the SMC.  Compared to non-orphan products, the proportion of non-submissions is slightly higher, perhaps because the expense of HTA may be prohibitive relative to the prospects for approval.  Abbreviated submissions were less frequent for OMPs, possibly because OMPs are more likely to be new molecules/active substances.

Figure 2 shows that rejection is more likely for orphan than for non-orphan indications. (Note that ‘not recommended’ includes products that were automatically rejected by SMC because the manufacturer did not make a submission to it.)  Of the total number of orphan rejections (43), 29% were due to non-submissions (12). For the remaining 31, the key reason for rejection stated in the SMC’s Detailed Advice Documents (DADs) was lack of economic evidence (‘economic case has not been demonstrated’); this means that the cost per QALY estimate was too high, or the model involved too much uncertainty, or no cost effectiveness model was provided. In 20 of these 43 rejected submissions, the clinical evidence was considered sufficient.  For the remaining 23 rejected submissions (more than half of the rejections), the level of clinical evidence available at the time of the review was considered by SMC to be inadequate.

Four of the decisions classified as ‘restricted’ in the DADs are effectively recommendations because the restriction coincides with the licence, i.e. the ‘restriction’ is that the medicine can be used only by a specialist in the relevant medical area.

To limit the analysis to one SMC decision per orphan indication, only the most recent submission is included in figure 3.  This shows approval was unrestricted for 10 orphan products and restricted for 14.  Thirty-one orphan products were not recommended.

As part of the submission, manufacturers supply details about the budgetary impact expected during the first and the fifth years after launch. These estimates may include the number of patients receiving treatment. Table 1 summarises statistics for patient numbers extracted from the 41 submissions that included this information.

Table 1. Range of reported patient numbers per indication (total indications = 41) Year 1 Year 5
Average across indications 29 43
Minimum 1 2
50 percentile 12 25
Maximum 179 179


NICE Decisions on OMPs[*]

NICE has assessed nine indications for orphan conditions:

  • azacitidine for mylelodyplastic synromes
  • imatinib for gastrointestinal stromal tumours and leukaemia
  • lenalidomide for multiple myeloma
  • sorafenib for RCC and hepatocellular cancer
  • temsirolimus for renal cell cancer (RCC)
  • trabectedin for ovarian cancer and soft tissue sarcoma

In four of the nine indications (temsirolimus and sorafenib, for both indications, and trabectedin for ovarian cancer), the overall decision was to not recommend use of the medicine. In three instances (imatinib, for both indications, and lenalidomide), the decision was to restrict use to a subgroup within the licensed indication. In two cases (trabectedin for soft tissue sarcoma and azacitidine), the treatment was recommended for use subject to a Patient Access Scheme.

Two NICE Technology Appraisals for other products were initiated, but not completed either because the NHS had already decided on treatment protocols (pulmonary arterial hypertension) or the drug (nilotinib) was considered in tandem with other treatments.

[*]This section was updated with new data on 9 January 2012.

Contact Martina Garau at the OHE with questions or for additional information.


[1] ​The Orphan Medicines Industry Group (OMIG) consists of orphan drug manufacturers that are members of the Association of the British Pharmaceutical Industry (ABPI).


New OHE Guide to UK Health Statistics

The OHE Guide to UK Health and Health Care StatisticsJust released is the new OHE Guide to UK Health and Health Care Statistics, which provides both reliable up-to-date statistics and a basic guide to finding and using health statistics for the UK and, to some extent, other OECD countries.

Health statistics are essential to making decisions about the allocation of limited health care resources, affecting the health of both individuals and entire populations.  With the publication of so much data in both hard copy and on the Internet, locating and accurately collating data sets can be a daunting task.

According to Emma Hawe, the lead author of the OHE Guide, ‘It is not surprising to find a maze of statistical information available in a variety of formats from different sources, both official government data and unofficial collections from the voluntary or private sectors. The OHE Guide cuts a path through this maze.’

As an aid in gathering and accurately using health information, the OHE Guide helps to answer these questions:

  • Where do I look?
  • What sorts of statistics do government and non‐government bodies produce?
  • What do they cover?
  • How/where do I find them?
  • If I find them, how do I use them or where can I get help and advice?

The OHE Guide consists of four sections plus a glossary and references:

  • Population statistics provides a description of demographic issues; population estimates and projections; mortality statistics and summary measures, including life expectancy and standardisation techniques; and the collection and use of morbidity and lifestyle statistics.
  • Health care expenditure describes total public and private expenditure on health care in the UK, the structure and financing of the UK’s National Health Service (NHS), and the costs of various activities.
  • Hospital activity and workforce provides a detailed account of NHS data collection concentrating mainly on hospital activities, waiting times and workforce.
  • Family health services includes details about NHS Family Health Services for primary care, encompassing general medical, pharmaceutical, dental and ophthalmic services.

Each section includes tables and figures of important up-to-date statistics, discussion of issues that are common for that type of data, and notes about the key sources of information used by OHE.  Information on methods used for collating and presenting reliable data also are offered where appropriate.

The pdf version of the OHE Guide is available for download, free of charge, from the OHE website.

Download: Hawe, E., Yuen, P. and Baillie, L. (2011) OHE guide to UK health and health care statistics. London: Office of Health Economics.