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”.

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.

The time period presented includes the 2nd wave of the COVID-19 pandemic and the findings should be considered in this context.

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 2021

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, there are over 2.5 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 2021

Number of deaths
Deaths with the condition as Cancer Cardiovascular Dementia Respiratory Any of the four conditions
Underlying cause of death 135,645 125,445 59,300 51,003 371,393
Only a contributory cause of death 22,114 138,579 36,085 133,890 115,605
Underlying or contributory cause of death (total) 157,759 264,024 95,385 184,893 486,998
Percentage of all deaths
Deaths with the condition as Cancer Cardiovascular Dementia Respiratory Any of the four conditions
Underlying cause of death 25% 23% 11% 9% 68%
Only a contributory cause of death 4% 25% 7% 24% 21%
Underlying or contributory cause of death (total) 29% 48% 17% 34% 89%


Figure 1: Number of people who died of or with 4 major conditions, England 2021


The deaths in each major condition group vary by demographic characteristics. For example Table 2 and Figure 2 show

  • people who died of cancer are on average the youngest, 44% of people who died of cancer were under 75 years compared to 33% of all deaths

  • among people who died of dementia, 65% were female and 35% male compared to 49% female and 51% male for all deaths. They are also the most elderly with 68% aged 85 years or older compared 39% of all deaths

  • the 4 major conditions are the underlying or contributory cause of death for the overwhelming majority of deaths (at least 83%) 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 2021

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 2021

Age
Under 75 75 to 85 85 or older
Distribution of all deaths by age group
Number of deaths (any cause) 178,855 156,846 211,947
Percentage of all deaths 33% 29% 39%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 114,229 113,030 144,134
Percentage of all deaths in this age group 64% 72% 68%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 153,438 147,579 185,981
Percentage of all deaths in this age group 86% 94% 88%
Sex
Female Male
Distribution of all deaths by sex
Number of deaths (any cause) 269,424 278,224
Percentage of all deaths 49% 51%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 184,581 186,812
Percentage of all deaths in this sex 69% 67%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 237,455 249,543
Percentage of all deaths in this sex 88% 90%
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) 19,219 10,143 2,261 487,804 1,833 26,388
Percentage of all deaths 4% 2% 0% 89% 0% 5%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 10,509 5,921 1,320 334,770 1,071 17,802
Percentage of all deaths in this ethnic group 55% 58% 58% 69% 58% 67%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 17,246 9,000 1,873 434,793 1,553 22,533
Percentage of all deaths in this ethnic group 90% 89% 83% 89% 85% 85%
Socio-economic deprivation
1 Most deprived 2 3 4 5 Least deprived
Distribution of all deaths by deprivation quintile
Number of deaths (any cause) 114,231 109,878 112,128 109,657 101,754
Percentage of all deaths 21% 20% 20% 20% 19%


People who died of one of the 4 major conditions (underlying cause of death)
Number of deaths 74,582 73,161 76,625 75,876 71,149
Percentage of all deaths in this deprivation quintile 65% 67% 68% 69% 70%

People who died of or with one of the 4 major conditions (underlying or contributory cause of death)
Number of deaths 100,827 97,676 99,919 97,645 90,931
Percentage of all deaths in this deprivation quintile 88% 89% 89% 89% 89%


Time spent in hospital

Among the people who died in 2021

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 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 2021

This graphic includes data for 395,438 people who were seen in hospital as an inpatient at any time during their final 6 months. It excludes 152,210 people who were never an inpatient during their last 6 months of life. Among those seen in hospital, nearly 25,300 were only seen in admissions with no overnight stay (zero days) many of which will be day case admissions.


Table 3: Time spent in hospital in the months before death for people who died of 4 major conditions, England 2021

During 6 months before death
Measure Cancer Cardiovascular Dementia Respiratory All deaths
People with at least 1 hospital admission 116,559 80,887 31,711 40,336 395,438
People admitted as a percentage of all deaths 86% 64% 53% 79% 72%
Total days in hospital (millions) 2.1 1.5 0.6 0.8 7.7
Range of time in hospital for people with at least 1 admission
Median 13 11 14 13 13
Range for middle 50% (interquartile range) 5 to 25 3 to 26 6 to 28 5 to 27 5 to 27
During 3 months before death
Measure Cancer Cardiovascular Dementia Respiratory All deaths
People with at least 1 hospital admission 106,189 73,868 27,159 38,028 364,759
People admitted as a percentage of all deaths 78% 59% 46% 75% 67%
Total days in hospital (millions) 1.6 1.1 0.5 0.6 6.0
Range of time in hospital for people with at least 1 admission
Median 11 10 13 11 12
Range for middle 50% (interquartile range) 5 to 21 3 to 22 5 to 24 4 to 22 4 to 23

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 2021

Table 4 shows that;

Table 4: Emergency admissions and time spent in hospital following emergency admission by age, England 2021

Number of admissions
Under 75 years 75 to 84 years 85 years or older All ages
Number of admissions (millions) 4.1 1.0 1.0 6.1
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% 33% 15%
Days in hospital
Under 75 years 75 to 84 years 85 years or older All ages
Total days in hospital (millions) 15.6 7.5 7.2 30.5
Days in hospital involving people in the last year of life (millions) 2.9 3.0 3.4 9.3
Percentage of all days in hospital that involve people in the last year of life 19% 40% 48% 31%


Emergency hospital admissions in the final 3 months of life

During the final three months of life for people who died in 2021

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 2021


Table 5: Emergency hospital admissions during the final 3 months of life for people who died of 4 major conditions, England 2021

Cancer Cardiovascular Dementia Respiratory All deaths
Number of emergency hospital admissions 159,129 98,664 35,961 56,705 526,052
Proportion of people with at least 1 emergency hospital admission 71% 55% 44% 72% 64%
Proportion of people with 3 or more emergency hospital admissions 11% 5% 3% 9% 7%


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 2021

Number of deaths
Place of death Cancer Cardiovascular Dementia Respiratory All deaths
Care home 16,433 18,879 37,451 6,435 110,545
Home 56,455 44,674 10,069 12,806 157,312
Hospice 18,979 1,360 381 699 23,882
Hospital 40,566 56,384 10,787 30,431 241,219
Other places 3,212 4,148 612 632 14,690
Percentage of deaths
Place of death Cancer Cardiovascular Dementia Respiratory All deaths
Care home 12.1% 15.0% 63.2% 12.6% 20.2%
Home 41.6% 35.6% 17.0% 25.1% 28.7%
Hospice 14.0% 1.1% 0.6% 1.4% 4.4%
Hospital 29.9% 44.9% 18.2% 59.7% 44.0%
Other places 2.4% 3.3% 1.0% 1.2% 2.7%


Figure 5: Place of death for people who died of 4 major conditions, England 2021

By major condition

Cancer