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
respiratory disease includes chronic conditions such as chronic
obstructive pulmonary disease (COPD) and acute conditions for example
pneumonia. It does not include COVID-19
cardiovascular disease includes chronic conditions such as heart
failure and acute conditions for example myocardial infarction (“heart
attack”). It does not include diabetes or renal failure
dementia includes both dementia and Alzheimer’s disease
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
the overwhelming majority (88.9%, 486,998 ) of people who died in
2021, died of or with one of the 4 major conditions
nearly three quarters (72%, 395,438) of all people who died in
2021, spent time in hospital during the 6 months before they died,
staying for a total of 7.7 million days in hospital
nearly three quarters (73%, 269,493) of people who died in 2021
of one of the 4 major conditions, spent time in hospital during the 6
months before they died, staying for a total of 5.1 million days in
hospital
almost half (48%) of the inpatient care provided by hospitals
(measured in terms of days in hospital) for people aged 85 year or older
is for people in their last year of life
almost two thirds (63.5%) of all people who died had a least one
emergency admission in their last 3 months of life, 7.1% having three or
more emergency admissions in their last 3 months of life
among the major conditions, the likelihood of having an emergency
admission in the 3 months prior to their death is greater for people who
died of cancer (71%) or respiratory disease (72%) than for people who
died of cardiovascular disease (55%) or dementia (44%)
the condition(s) people are living with in their final weeks can
affect where they are cared for and where they ultimately die; comparing
the 4 major conditions with each other
- people who died of cancer were the most likely to die at home (41.6%
compared to 28.7% of all deaths) or in a hospice (14.0% compared to
4.4%)
- people who died of dementia were the most likely to die in a care
home (63.2% compared to 20.2%)
- people who died of respiratory disease were most likely to die in
hospital (59.7% compared to 44.0%)
Characteristics of those who died
In 2021
547,648 people died (excluding neonatal deaths)
two thirds of people (67.8%, 371,393 people) died of one the 4
major conditions
the overwhelming majority (88.9%, 486,998) of people died of or
with at least one of the 4 major conditions
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
a total of 395,438 people were seen in hospital as an inpatient
during the 6 months before they died (72% of all deaths), staying a
total of 7.7 million days in hospital
within the last 6 months of life, the majority of the time in
hospital is during the final 3 months (6.0 million days in the last 3
months out of 7.7 million days in the last 6 months). Table 3 shows this
is similar for each of the major conditions
nearly 25,300 of the people seen in hospital as an inpatient
during their final 6 months were admitted as a day case only. A day case
is admitted and discharged on the same day, and is reported here with a
length of stay of zero days
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
although the median days in hospital is 13 days, the most common
time in hospital is zero days followed by 1 day
half of the 395,438 (197,719) people who were seen in hospital as
an inpatient during their final 6 months stayed in hospital between 5
and 27 days in total. Table 3 shows that this range is similar for each
of the major conditions
caring for people near the end of their life is a significant
proportion of the care provided by hospitals. On average people spend 8%
of their last six months of life in hospital, and 85,932 people (16% of
all people who died) spent 30 days or more in hospital during their last
6 months
Table 3 shows that being seen in hospital as an inpatient during
their last 6 months of life was more likely for people who died of
cancer or respiratory disease, compared to people who died of
cardiovascular disease or dementia
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
there were 6.1 million emergency hospital admissions, 15% of
which involved people in their last year of life
a total of 30.5 million days in hospital followed an emergency
admission, of these 31% involved people in their last year of
life
Table 4 shows that;
of all admissions, the percentage that involve people in the last
year of life is highest among the oldest age group (85 years and older
33%) and lowest in the youngest age group (under 75 years 8%)
of all days in hospital, the percentage that involve people in
the last year of life is highest among the oldest age group (85 years an
older 48% respectively), and lowest in the youngest age group (under 75
years 19%)
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
a large majority of hospital admissions were emergency
admissions, 79% of a total of approximately 667,000 hospital
admissions
nearly two thirds of people (63.5%) had a least one emergency
admission
7.1% of people had three or more emergency admissions
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
hospital is the most common place of death (44.0% of all
deaths)
nearly half of people die in the community, either at home
(28.7%) or in a care home (20.2%)
relatively few people die in a hospice (4.4%) or other places
(2.7%) (for example public places or someone else’s home)
people who died of cancer were the most likely to die at home
(41.6% compared to 28.7% of all deaths) or in a hospice (14.0% compared
to 4.4%)
people who died of dementia were the most likely to die in a care
home (63.2% compared to 20.2%)
people who died of respiratory disease were most likely to die in
hospital (59.7% compared to 44.0%)
a large majority (79%) of the 23,882 people who died in hospice,
died of cancer
Place of death varies by specific underlying cause of death within
the major condition groups, Figure 5 shows for example,
within cardiovascular disease, 60.8% of people who died of stroke
occur in hospital, compared to 38.4% of people who died of coronary
heart disease. 46.5% of deaths from coronary heart disease occur at home
compared to 14.8% of people who died of stroke
within respiratory disease, 54.7% of deaths from COPD occur in
hospital, compared to 72.6% of deaths from pneumonia
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
