Young adult premature death on rise in northern England
More young adults are dying prematurely in the north than the south of England, and the gap is increasing, according to a study from the Universities of Manchester and York. In 1965, there were 8% more deaths amongst 25-34 year olds in the north than in the south. This gap fell to 2.2% in 1995, but rose to 29.3% in 2015. For those aged 35-44, the gap was 21% in 1965, 3.3% in 1995 and almost 50% in 2015. The reasons for the trend are unclear, but the authors of the study are calling for greater investment in the north.
We examined long-term trends in mortality in the North and South of England, focusing on the age groups most affected by northern excess mortality. Between 1965 and 2010, national mortality declined while the northern excess remained consistent for most age groups. Among adults aged 25–44, however, northern excess mortality increased sharply from the mid-1990s onwards due to a stall in the North of the long-term decline in mortality. By 2012, following the Great Recession of 2008–2009, four decades of declining premature mortality in both North and South England had stalled, a pattern not seen following earlier recessions.

This study analysed mortality data over five decades for England's population, enabling differences in long-term trends between North and South to be examined in full. Measuring inequalities between two large, meaningful geographies of around 25 million people each allowed us to minimise the effects of errors in population estimates, and more precisely to examine age group specific mortality. While the classification of smaller geographies into North or South is to some extent arbitrary, it reflects boundaries of administration and political responsibility, as well as established social, economic and cultural divisions. This dichotomous approach does not, however, allow us to account for heterogeneity within each region. Within the South for example, London concentrates political and economic resources. We have not examined causes of death, which limits the conclusions we can draw about the underlying drivers of the disparities, although the relative ranking of causes of death for different age groups is the same across all regions of the country. 21 We also have not measured the changes over time in potential social, economic, behavioural and demographic determinants (eg, migration, smoking rates and unemployment), as this was beyond the scope of the study. Finally, in our analysis of recessionary periods we have not examined other periods of economic or social insecurity.

Interpretation of findings

In common with other advanced industrial nations, mortality rates consistently fell across all regions of England in the second half of the 20th century and the first decade of the 21st. Premature mortality rates in the North steadily converged on—but remained substantially higher than—rates in the South throughout a period that included three recessions and multiple changes in political administration, with a total of 23 years of Labour and 22 years of Conservative government. However, the same uniform pattern of converging mortality was not apparent in all age groups. For the 25–34 and 35–44 age groups there were distinct phases: between 1965 and 1985, mortality rates fell more quickly (from a higher baseline) in the North, closing the North-South gap to 12% in the 35–44 age group and completely in the 25–34 age group. This was followed by a decade when the long-term decline in mortality rates among young adults halted nationwide, with little change in regional disparities. However, from the mid-1990s northern excess mortality increased by 25 percentage points in the 25–34 age group and by 23 percentage points in the 35–44 age group. Underlying this rapid divergence was an increase (ages 25–34) or plateauing (ages 35–44) of mortality rates in the North at the same time as mortality rates in the South started to decline again. Because deaths in the under 45s are relatively uncommon, these patterns are concealed in whole population mortality rates, which are dominated by older age groups. However, the consequences for the population, in terms of years of life lost, are grave.

Prior to the Great Recession of 2008–2009 there were no obvious effects of recessionary periods on either long-term trends in mortality or on inequalities in mortality between North and South, even in the working age population. For example, the divergence in mortality rates for young adults between North and South began in 1995, 4 years after the 1990–1991 recession, and continued for another decade through a period of sustained economic growth. It is possible, however, that overall mortality figures conceal different trends for specific causes of death; analyses of previous economic crises found that increases in cardiac deaths were counterbalanced by reductions in respiratory deaths.22

During the 2008–2009 recession, there was again no obvious change in underlying trends in mortality, but from 2012 the historical decline in under 75 mortality rates plateaued in both the North and the South. Within the under 75s, this overall pattern is reflected equally in North and South England for the 25–34 and 45–54 age groups; however, for the 35–44 age group the gap is widening due to a decline in mortality post-2012 not seen in the North. It remains to be seen whether the overall plateauing is a transient phenomenon, or whether years of improving premature mortality are fading and existing wide regional disparities are persisting or worsening.

The extended period of austerity following the 2008–2009 recession has raised concerns about detrimental impacts on population health,23 particularly the health of disadvantaged socioeconomic groups and more economically precarious regions.18 However, the divergent trends in mortality we noted in the 1990s and early 2000s suggest that inequalities can increase rapidly during periods of sustained economic growth. Similar patterns have emerged in the USA (and have been similarly concealed by overall mortality patterns), where mortality rates in white non-Hispanic women aged 45–54 started to increase in the late 1990s.24

Explaining the rapidly widening divide in young adult mortality between North and South over the past two decades will require detailed analysis of specific causes of death and the plausible explanations, including epidemiological, social, economic and migratory factors. The most common causes of death in this age group are suicide, poisoning, land transport accidents and liver disease. Over the age of 40, other causes become increasingly common; ischaemic heart disease in men and breast cancer in women.21 The recent rises in mortality rates noted above in the USA were driven by rapid increases in suicide, poisonings and chronic liver disease—increases that were heavily concentrated in less educated populations.24 In the UK, suicide rates declined nationally throughout the 1990s and 2000s, but this general fall may have concealed different regional and socioeconomic trends. The rapid increase in suicides from 2008, and its concentration in areas of high unemployment, suggests that already wide health inequalities affecting England are worsening.18 The age-standardised rate for alcohol-related deaths in the UK has increased since 1994. Although the rate peaked in 2008 and has subsequently fallen, the 2014 rate is still higher than that observed in 1994.25

Some commentators on the nation's growing inequalities conclude that the transition from premature mortality driven by infectious diseases in the Victorian era to chronic diseases today means that the era of effective state intervention—which included the great public works of sanitation, housing reform, immunisation and universal healthcare—is past, and that responsibility for addressing current disparities now lies with the individual.26 Following this logic, the government would do no more than provide education and some behavioural nudges, particularly in the case of the violent and self-destructive causes of premature mortality that afflict young and middle-aged adults. However, the strong social and geographical patterning of trends in premature mortality points to structural defects that lie beyond the control of the individual, demanding collective action and a strong policy response.

Future policies may be distracted from addressing inequalities due to the pan-regional nature of the apparent plateau in declining premature mortality and the reversal of declining elderly mortality.27 Doing so would ignore the persistent North-South divide and the potential population health gain from addressing it effectively.