Background

The Secretary of State for Health and Social Care announced in January 2023 that the Department for Health and Social Care will develop and publish a Major Conditions Strategy. The strategy will “set out a strong and coherent policy agenda that sets out a shift to integrated, whole-person care, building on measures that we have already taken forward through the NHS Long Term Plan”. An interim report was published in August 2023.

The strategy identifies 6 major conditions: cancer, cardiovascular disease, dementia, mental ill health, musculoskeletal disorders and chronic respiratory disease. Information is presented here for 4 of the major conditions; cancer, cardiovascular disease, dementia and respiratory disease. Causes of death, recorded on death certificates, often will not identify people who die with a mental health issue or musculoskeletal problems as they may not directly contribute to the person’s death. Consequently, deaths from these two major conditions are not addressed directly here.

The purpose of this factsheet is to describe patterns of care near the end of life related to the 4 major conditions. It includes experimental statistics describing the number of deaths, the number of hospital admissions in the months before death and the place of death.

The major condition groups are here defined broadly to capture the impact of these conditions on people at the end of their life and include both chronic and acute conditions. A brief description of how underlying cause of death is determined from the death certificate is included in the Supporting information section together with the definition of how the underlying and contributory causes of death were used to identify people living with major conditions. In this factsheet

A person is described as dying “of” a condition if it is the underlying cause of death recorded on the death certificate, and dying “with” a condition if it is a contributory cause of death only.

More detailed data is available in the accompanying spreadsheet which includes more detailed information by specific underlying causes of death within the major conditions, age, sex, socio-economic deprivation and ethnicity.

Main findings

Characteristics of those who died

In 2022

Table 1 and Figure 1 show that in their final months before death, many more people are living with cardiovascular disease, dementia and respiratory disease than would be suggested by underlying cause of death alone. For example, about 2 times more people who died with than died of respiratory disease.

Counting people by underlying cause of death will underestimate the number of people living with these conditions near the end of their life. A better estimate uses both the underlying cause of death and the contributory causes of death. However, this is still an underestimate of people living with these conditions prior to death as it only counts people for whom the doctor recorded these conditions as contributing to the death.

The underlying and contributory causes of death for any individual may encompass several of the major conditions. Consequently, while any one person will only be counted in a single underlying cause of death group, a person may be counted in up to 4 contributory cause of death groups. Due to this double counting, it would be wrong to add together counts that include people by their contributory causes of death.


Table 1: Number and percentage of people who died of or with 4 major conditions, England 2022

Number of deaths
Deaths with the condition as Cancer Cardiovascular Dementia Respiratory Any of the four conditions
Underlying cause of death 139,622 131,278 63,883 59,475 394,258
Only a contributory cause of death 19,473 123,951 29,483 112,810 82,138
Underlying or contributory cause of death (total) 159,095 255,229 93,366 172,285 476,396
Percentage of all deaths
Deaths with the condition as Cancer Cardiovascular Dementia Respiratory Any of the four conditions
Underlying cause of death 26% 24% 12% 11% 73%
Only a contributory cause of death 4% 23% 5% 21% 15%
Underlying or contributory cause of death (total) 30% 47% 17% 32% 88%


Figure 1: Number of people who died of or with 4 major conditions, England 2022


The deaths in each major condition group vary by demographic characteristics. For example;

  • people who died of cancer are on average the youngest, 43% of people who died of cancer were under 75 years compared to 31% of all deaths

  • among people who died of dementia, 64% were female and 36% male compared to 49% female and 51% male for all deaths. They are also the most elderly with 67% aged 85 years or older compared 40% of all deaths

Table 2 and Figure 2 show the 4 major conditions are the underlying or contributory cause of death for the overwhelming majority of deaths (at least 80%) in each of the categories within sex, age, ethnicity and socio-economic deprivation.


Figure 2: Percentage of people who died of or with 4 major conditions by demographic group, England 2022

Age

Sex

Ethnicity

Socio-economic deprivation


Table 2: Number and percentage of people who died of or with 4 major conditions by demographic group, England 2022

Age
Under 75 75 to 85 85 or older
Distribution of all deaths by age group
Number of deaths (any cause) 167,335 157,321 213,971
Percentage of all deaths 31% 29% 40%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 116,833 122,830 154,595
Percentage of all deaths in this age group 70% 78% 72%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 142,482 147,556 186,358
Percentage of all deaths in this age group 85% 94% 87%
Sex
Female Male
Distribution of all deaths by sex
Number of deaths (any cause) 266,038 272,589
Percentage of all deaths 49% 51%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 195,142 199,116
Percentage of all deaths in this sex 73% 73%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 232,901 243,495
Percentage of all deaths in this sex 88% 89%
Ethnicity
Asian or Asian British Black or Black British Mixed White Other ethnic group Not known
Distribution of all deaths by ethnic group
Number of deaths (any cause) 16,309 8,564 2,239 482,117 1,795 27,603
Percentage of all deaths 3% 2% 0% 90% 0% 5%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 11,107 5,966 1,405 353,358 1,235 21,187
Percentage of all deaths in this ethnic group 68% 70% 63% 73% 69% 77%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 14,288 7,481 1,787 426,752 1,514 24,574
Percentage of all deaths in this ethnic group 88% 87% 80% 89% 84% 89%
Socio-economic deprivation
1 Most deprived 2 3 4 5 Least deprived
Distribution of all deaths by deprivation quintile
Number of deaths (any cause) 109,103 106,696 110,812 109,829 102,187
Percentage of all deaths 20% 20% 21% 20% 19%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 78,137 77,590 81,538 81,292 75,701
Percentage of all deaths in this deprivation quintile 72% 73% 74% 74% 74%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 95,840 94,266 98,293 97,423 90,574
Percentage of all deaths in this deprivation quintile 88% 88% 89% 89% 89%


Time spent in hospital

Among the people who died in 2022

Figure 3 shows the variation in the total time spent in hospital for inpatients during their final 6 months of life. This will, for some people, be a total time over multiple admissions. The distribution is highly skewed with and for most people their length of stay is not close to the average length of stay.The figure also shows


Figure 3: Variation in the time spent in hospital during the last 6 months of life, England 2022

This graphic includes data for 371,594 people who were seen in hospital as an inpatient at any time during their final 6 months. It excludes 167,033 people who were never an inpatient during their last 6 months of life. Among those seen in hospital, nearly 15,300 were only seen in admissions with no overnight stay (zero days).


Table 3: Time spent in hospital in the months before death for people who died of 4 major conditions, England 2022

During 6 months before death
Measure Cancer Cardiovascular Dementia Other Respiratory All deaths
People with at least 1 hospital admission 113,326 81,044 33,804 97,283 46,137 371,594
People admitted as a percentage of all deaths 81% 62% 53% 67% 78% 69%
Total days in hospital (millions) 2.4 1.8 0.8 2.4 1.0 8.4
Range of time in hospital for people with at least 1 admission
Median 15 13 17 16 14 15
Range for middle 50% (interquartile range) 7 to 28 4 to 31 6 to 34 6 to 34 5 to 31 6 to 31
During 3 months before death
Measure Cancer Cardiovascular Dementia Other Respiratory All deaths
People with at least 1 hospital admission 103,123 74,015 29,235 91,187 43,617 341,177
People admitted as a percentage of all deaths 74% 56% 46% 63% 73% 63%
Total days in hospital (millions) 1.8 1.3 0.6 1.8 0.8 6.4
Range of time in hospital for people with at least 1 admission
Median 13 11 14 14 12 13
Range for middle 50% (interquartile range) 6 to 25 4 to 25 6 to 29 5 to 29 5 to 25 5 to 26

The 25th percentile is the value at which 25% of the data lie below that value. The median is the value at which 50% of the data lie below that value. The 75th percentile is the value at which 75% of the data lie below that value. The interquartile range is between the 25th percentile and the 75th percentile.


Emergency hospital admissions

In the 12 months October 2021 to September 2022

Table 4 shows that;

Table 4: Emergency admissions and time spent in hospital following emergency admission by age, England for the 12 months October 2021 to September 2022

Number of admissions
Under 75 years 75 to 84 years 85 years or older All ages
Number of admissions (millions) 4.2 1.0 0.7 5.9
Admissions involving people in the last year of life (millions) 0.3 0.3 0.3 0.9
Percentage of all admissions that involve people in the last year of life 8% 28% 42% 15%
Days in hospital
Under 75 years 75 to 84 years 85 years or older All ages
Total days in hospital (millions) 15.7 8.3 7.7 31.7
Days in hospital involving people in the last year of life (millions) 3.0 3.2 3.8 10.1
Percentage of all days in hospital that involve people in the last year of life 19% 39% 50% 32%


Emergency hospital admissions in the final 3 months of life

During the final three months of life for people who died in 2022

Figure 4 and Table 5 show that of the 4 major conditions, people who died of cancer or respiratory disease were more likely to have had an emergency admission in the 3 months prior to their death than people who died of cardiovascular disease or dementia.


Figure 4: Percentage of people who have emergency hospital admissions during the final 3 months of life for people who died of 4 major conditions, England 2022


Table 5: Emergency hospital admissions during the final 3 months of life for people who died of 4 major conditions, England 2022

Cancer Cardiovascular Dementia Respiratory All deaths
Number of emergency hospital admissions 157,597 97,771 36,973 63,352 486,673
Proportion of people with at least 1 emergency hospital admission 70% 53% 43% 71% 61%
Proportion of people with 3 or more emergency hospital admissions 10% 4% 2% 7% 6%


Place of death

The condition(s) people live with as they approach the end of their life can affect where they are cared for and where they ultimately die. Table 6 presents data on where people died by the major condition they died of. It includes both the number of deaths and percentage of deaths that occur in each setting, it shows

Place of death varies by specific underlying cause of death within the major condition groups, Figure 5 shows for example,

Table 6: Place of death for people who died of 4 major conditions, England 2022

Number of deaths
Place of death Cancer Cardiovascular Dementia Respiratory All deaths
Care home 17,433 19,221 40,167 7,066 110,459
Home 52,880 46,269 9,715 13,898 154,693
Hospice 20,327 1,437 405 848 25,349
Hospital 46,211 60,194 12,962 37,016 233,928
Other places 2,771 4,157 634 647 14,198
Percentage of deaths
Place of death Cancer Cardiovascular Dementia Respiratory All deaths
Care home 12.5% 14.6% 62.9% 11.9% 20.5%
Home 37.9% 35.2% 15.2% 23.4% 28.7%
Hospice 14.6% 1.1% 0.6% 1.4% 4.7%
Hospital 33.1% 45.9% 20.3% 62.2% 43.4%
Other places 2.0% 3.2% 1.0% 1.1% 2.6%


Figure 5: Place of death for people who died of 4 major conditions, England 2022

By major condition

Cancer

Cardiovascular

Dementia

Respiratory


Local considerations and additional resources

Commissioners and service providers should review the data presented in this factsheet alongside several other data and intelligence tools and reports. They should also consider using locally produced data on specialist palliative care and social care services. We have provided information on the main supporting resources in this section.

Major conditions strategy

This government report sets out the case for change and strategic framework for the final strategy.

Additional data on the major conditions include the Office for Health Improvement and Disparities profiles

and the recently published Premature mortality in adults with severe mental illness (SMI)

Additional data on palliative and end of life care can be found in our Palliative and End of Life Care Profiles. The data on these profiles are grouped into topics and includes: needs assessment, care homes and community, hospital care, place of death, mortality, dementia, and underlying cause of death. The data are shown for multiple geographies. You can also find our two other factsheets on these profiles – Place of Death and Care homes and end of life.

Information and resources for health and social care professionals can be found on the National End of Life Care Intelligence Network’s Palliative and End of Life Care Resources and Publications page. This includes a comprehensive catalogue of condition and setting specific data, intelligence tools, policy and guidance.

Resources supporting this factsheet

Data used to produce this factsheet is available as a spreadsheet

The graphics and tables included in the factsheet are available as a slidedeck

Enquiries

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Supporting information

Underlying and contributory causes of death

The selection of the underlying cause of death is based on International Classification of Diseases (ICD) rules and is made from the condition or conditions reported by the certifier, as recorded on the death certificate. The underlying cause of death is defined by the World Health Organistation as the disease or injury that initiated the sequence of events directly leading to death or the circumstances of the accident or violence that produced the fatal injury. More details can be found in the Office for National Statistics User guide to mortality statistics.

Data sources

Annual mortality extracts, Office for National Statistics (ONS) © Crown copyright 2024, Re-used with permission of ONS. All rights reserved. Further information available from ONS.
Linked HES - ONS Mortality extract, Office for National Statistics © Crown copyright 2024, NHS Digital © Copyright 2024, Re-used with permission of NHS Digital. All rights reserved. Further information available from NHS Digital.
Hospital Episode Statistics (HES), NHS Digital © Copyright 2024, Re-used with permission of NHS Digital. All rights reserved. Further information available from NHS Digital.

Methodology

Note Title Content
1 Cohort definition (all but the Emergency hospital admissions section) The cohort was defined from mortality data. The only exception being the ethnicity which came from a combination of the HES linked mortality data and HES. Hospital activity was extracted for the identified deaths. Deaths are included if
  • the death was registered in 2022
  • the recorded home address is in England.Neonatal deaths are excluded. Deaths were excluded from the HES linked mortality data where the data indicated the existence of hospital activity for the person after the date of death.
2 Cohort definition for Emergency hospital admissions section This section included all admissions for residents of England (LSOA11 starts “E”) with an admission date in the 12 months October 2021 to September 2022 whether or not the individual died. Emergency admissions were identitified as ADMIMETH starts “2”.
3 HES linked mortality data The HES Linked mortality was deduplicated using the encrypted NHS Number. The HES Linked mortality data only includes people linked to hospital activity recorded in HES. Deaths with no recorded cause of death were excluded. The difference between the reference ONS deaths and the deduplicated HES Linked mortality data was assumed to be people with no hospital activity.
4 Hospital Episode Statistics Regular day and night attendances and maternity events were excluded. Hospital admissions (“spells”) were counted after grouping the recorded episodes. The episodes within a spell shared common values of person identifier (TOKEN_PERSON_ID), admission date, provider code (PROCODE3), and provider spell number (PROVSPNOPS). Spells with a discharge date more than 1 day after date of death were excluded. The length of a spell in days is the difference between the discharge date and the admission date. Any spells that started and finished on the same day contribute zero days to calculations of time in hospital.
5 Time spent in hospital in the final 6 and 3 months of life This analysis took as a model the end of life care measure Quality Outcome Measure 10: The percentage of last 6 months of life spent at home or in a community setting published in Scotland. For this part of the analysis only, in common with the Scottish measure, deaths from falls and external causes (V00-V99, W20-W99, X00-X99, Y00-Y84) were excluded. Only ordinary admissions were included; regular day and night attendances and maternity events were excluded. When a spell started earlier than 6 (or 3) months before death and finished during the 6 months before death, only the days within the final 6 (or 3) months contributed to this analysis. 3 months was coded as 90 days, 6 months as 182 days.
6 Emergency hospital admissions in the final 3 months of life Identified in the HES data as ADMIMETH starting “2”. 3 months was coded as 90 days.
7 Cause of death Categories were determined from the recorded ICD10 codes for underyling cause of death and up to 15 contributory causes of death.

Broad
  • Cancer C00 – C99
  • Cardiovascular disease I00 – I99
  • Dementia F00, F01, F03, G30, G318, G310
  • Respiratory disease J00 – J99

Narrow
  • Bowel cancer: C18 to C20  
  • Breast cancer: C50 
  • Lung cancer: C33, C34 
  • Prostate cancer: C61 
  • Coronary heart disease: I20 to I25 
  • Heart failure: I50 
  • Stroke: I60 to I69 
  • Pneumonia: J12 to J18 
  • Chronic Obstructive Pulmonary Disease: J40 to J44 
8 Place of death Place of death is recorded in the mortality data. For further information on the methods used for all place of death indicators as classified by ONS death certificate data, described in National End of Life Care Intelligence Network publication: Classification of Place of Death: A technical bulletin.
9 Ethnicity Ethnicity is not recorded in mortality records. The ethnic group reported was derived from patient data recorded in HES, associated with a death record through the Linked HES_ONS mortality data. The methodology is described in the Method for assigning ethnic group in the COVID-19 Health Inequalities Monitoring for England (CHIME) tool. In this analysis a pseudonymised data view was used and no linkage was undertaken using patient identifiable data. Deaths imputed to be missing from the Linked HES_ONS mortality data were assigned “unknown” ethnicity.
10 Socio-economic deprivation The category for each person was determined by the Index of Multiple Deprivation (IMD) rank for the local area (Local Super Output Area LSOA) that includes the person’s postcode. LSOA are grouped into 5 quintiles of equal numbers of LSOAs, where quintile 1 includes areas with the highest IMD score, and quintile 5 the lowest. Further details on IMD are available from the Government website.

Version history

Version Date Summary of changes
1 1 August 2023
  • First publication focussed on 2021
2 18 August 2023
  • Correction of broken URL to the factsheet data spreadsheet
  • Addition of a link to the Major Conditions interim report
3 6 February 2024
  • Refreshed with focus on 2022
  • Refine Time in hospital analysis to include “Ordinary admissions” only (CLASSPAT=1)
  • Correction Emergency admission in last year of life analysis; people under 1 year of age had been misclassified as 85 years or older