A deathly silence: why has the number of people found decomposed in England and Wales been rising?

OBJECTIVES: The number of deaths occurring in private homes in England and Wales had been rising for years, increasingly rapidly from 2020. Media stories and research linked decomposing bodies found in private homes with pandemic-related social isolation. We aim to explore whether these incidents are one-offs or part of a wider trend. DESIGN: Descriptive analysis of publicly available Office for National Statistics (ONS) data. SETTING: England and Wales. PARTICIPANTS: All residents of England and Wales, 1979 to 2020. MAIN OUTCOME MEASURES: Using data from the Office for National Statistics, we calculate European Age Standardised Rates for deaths coded as R98 ('unattended death') and R99 ('other ill-defined and unknown causes of mortality') in the 10th version of the International Classification of Diseases (ICD-10), and the corresponding codes in ICD-9, by sex and age group from 1979 (when ICD-9 began) to 2020. These are proxy markers for deaths where decomposition precludes attribution of a specific cause at postmortem. RESULTS: While mortality from all other causes decreased from 1979 to 2020, the opposite was seen for deaths from R98 and R99 (or 'undefined deaths'), with men more affected than women. There was a sharp rise in these deaths in both sexes but in men particularly in the 1990s and 2000s, coinciding with a time when overall mortality was rapidly improving. CONCLUSIONS: The increase in people found dead from unknown causes suggests wider societal breakdowns of both formal and informal social support networks. They are concerning and warrant urgent further investigation. We call on national and international authorities to consider measures that would make it possible to identify these deaths more easily in routine data.

What can lifespan variation reveal that life expectancy hides? Comparison of five high-income countries.

OBJECTIVES: In most countries, life expectancy at birth (e0) has improved for many decades. Recently, however, progress has stalled in the UK and Canada, and reversed in the USA. Lifespan variation, a complementary measure of mortality, increased a few years before the reversal in the USA. To assess whether this measure offers additional meaningful insights, we examine what happened in four other high-income countries with differing life expectancy trends. DESIGN: We calculated life disparity (a specific measure of lifespan variation) in five countries -- USA, UK, France, Japan and Canada -- using sex- and age specific mortality rates from the Human Mortality Database from 1975 to 2017 for ages 0--100 years. We then examined trends in age-specific mortality to identify the age groups contributing to these changes. SETTING: USA, UK, France, Japan and Canada. PARTICIPANTS: aggregate population data of the above nations. MAIN OUTCOME MEASURES: Life expectancy at birth, life disparity and age-specific mortality. RESULTS: The stalls and falls in life expectancy, for both males and females, seen in the UK, USA and Canada coincided with rising life disparity. These changes may be driven by worsening mortality in middle-age (such as at age 40). France and Japan, in contrast, continue on previous trajectories. CONCLUSIONS: Life disparity is an additional summary measure of population health providing information beyond that signalled by life expectancy at birth alone.

Trends in infant mortality and stillbirth rates in Scotland by socio-economic position, 2000-2018: a longitudinal ecological study.

BACKGROUND: As Scotland strives to become a country where children flourish in their early years, it is faced with the challenge of socio-economic health inequalities, which are at risk of widening amidst austerity policies. The aim of this study was to explore trends in infant mortality rates (IMR) and stillbirth rates by socio-economic position (SEP) in Scotland, between 2000 and 2018, inclusive. METHODS: Data for live births, infant deaths, and stillbirths between 2000 and 2018 were obtained from National Records of Scotland. Annual IMR and stillbirth rates were calculated and visualised for all of Scotland and when stratified by SEP. Negative binomial regression models were used to estimate the association between SEP and infant mortality and stillbirth events, and to assess for break points in trends over time. The slope (SII) and relative (RII) index of inequality compared absolute and relative socio-economic inequalities in IMR and stillbirth rates before and after 2010. RESULTS: IMR fell from 5.7 to 3.2 deaths per 1000 live births between 2000 and 2018, with no change in trend identified. Stillbirth rates were relatively static between 2000 and 2008 but experienced accelerated reduction from 2009 onwards. When stratified by SEP, inequalities in IMR and stillbirth rates persisted throughout the study and were greatest amongst the sub-group of post-neonates. Although comparison of the SII and RII in IMR and stillbirths before and after 2010 suggested that inequalities remained stable, descriptive trends in mortality rates displayed a 3-year rise in the most deprived quintiles from 2016 onwards. CONCLUSION: Whilst Scotland has experienced downward trends in IMR and stillbirth rates between 2000 and 2018, the persistence of socio-economic inequalities and suggestion that mortality rates amongst the most deprived groups may be worsening warrants further action to improve maternal health and strengthen support for families with young children.

Deaths from 'diseases of despair' in Britain: comparing suicide, alcohol-related and drug-related mortality for birth cohorts in Scotland, England and Wales, and selected cities.

BACKGROUND: The contribution of increasing numbers of deaths from suicide, alcohol-related and drug-related causes to changes in overall mortality rates has been highlighted in various countries. In Scotland, particular vulnerable cohorts have been shown to be most at risk; however, it is unclear to what extent this applies elsewhere in Britain. The aim here was to compare mortality rates for different birth cohorts between Scotland and England and Wales (E&W), including key cities. METHODS: Mortality and population data (1981-2017) for Scotland, E&W and 10 cities were obtained from national statistical agencies. Ten-year birth cohorts and cohort-specific mortality rates (by age of death, sex, cause) were derived and compared between countries and cities. RESULTS: Similarities were observed between countries and cities in terms of peak ages of death, and the cohorts with the highest death rates. However, cohort-specific rates were notably higher in Scotland, particularly for alcohol-related and drug-related deaths. Across countries and cities, those born in 1965-1974 and 1975-1984 had the highest drug-related mortality rates (peak age at death: 30-34 years); the 1965-1974 birth cohort also had the highest male suicide rate (peak age: 40-44 years). For alcohol-related causes, the highest rates were among earlier cohorts (1935-1944, 1945-1954, 1955-1964)-peak age 60-64 years. CONCLUSIONS: The overall similarities suggest common underlying influences across Britain; however, their effects have been greatest in Scotland, confirming greater vulnerability among that population. In addressing the socioeconomic drivers of deaths from these causes, the cohorts identified here as being at greatest risk require particular attention.

Changing mortality trends in countries and cities of the UK: a population-based trend analysis.

OBJECTIVES: Previously improving life expectancy and all-cause mortality in the UK has stalled since the early 2010s. National analyses have demonstrated changes in mortality rates for most age groups and causes of death, and with deprived populations most affected. The aims here were to establish whether similar changes have occurred across different parts of the UK (countries, cities), and to examine cause-specific trends in more detail. DESIGN: Population-based trend analysis. PARTICIPANTS/SETTING: Whole populations of countries and selected cities of the UK. PRIMARY AND SECONDARY OUTCOME MEASURES: European age-standardised mortality rates (calculated by cause of death, country, city, year (1981-2017), age group, sex and-for all countries and Scottish cities-deprivation quintiles); changes in rates between 5-year periods; summary measures of both relative (relative index of inequality) and absolute (slope index of inequality) inequalities. RESULTS: Changes in mortality from around 2011/2013 were observed throughout the UK for all adult age groups. For example, all-age female rates decreased by approximately 4%-6% during the 1980s and 1990s, approximately 7%-9% during the 2000s, but by <1% between 2011/2013 and 2015/2017. Equivalent figures for men were 4%-7%, 8%-12% and 1%-3%, respectively. This later period saw increased mortality among the most deprived populations, something observed in all countries and cities analysed, and for most causes of death: absolute and relative inequalities therefore increased. Although similar trends were seen across all parts of the UK, particular issues apply in Scotland, for example, higher and increasing drug-related mortality (with the highest rates observed in Dundee and Glasgow). CONCLUSIONS: The study presents further evidence of changing mortality in the UK. The timing, geography and socioeconomic gradients associated with the changes appear to support suggestions that they may result, at least in part, from UK Government 'austerity' measures which have disproportionately affected the poorest.

How have changes in death by cause and age group contributed to the recent stalling of life expectancy gains in Scotland? Comparative decomposition analysis of mortality data, 2000-2002 to 2015-2017.

OBJECTIVE: Annual gains in life expectancy in Scotland were slower in recent years than in the previous two decades. This analysis investigates how deaths in different age groups and from different causes have contributed to annual average change in life expectancy across two time periods: 2000-2002 to 2012-2014 and 2012-2014 to 2015-2017. SETTING: Scotland. METHODS: Life expectancy at birth was calculated from death and population counts, disaggregated by 5 year age group and by underlying cause of death. Arriaga's method of life expectancy decomposition was applied to produce estimates of the contribution of different age groups and underlying causes to changes in life expectancy at birth for the two periods. RESULTS: Annualised gains in life expectancy between 2012-2014 and 2015-2017 were markedly smaller than in the earlier period. Almost all age groups saw worsening mortality trends, which deteriorated for most cause of death groups between 2012-2014 and 2015-2017. In particular, the previously observed substantial life expectancy gains due to reductions in mortality from circulatory causes, which most benefited those aged 55-84 years, more than halved. Mortality rates for those aged 30-54 years and 90+ years worsened, due in large part to increases in drug-related deaths, and dementia and Alzheimer's disease, respectively. CONCLUSION: Future research should seek to explain the changes in mortality trends for all age groups and causes. More investigation is required to establish to what extent shortcomings in the social security system and public services may be contributing to the adverse trends and preventing mitigation of the impact of other contributing factors, such as influenza outbreaks.

Can changes in spending on health and social care explain the recent mortality trends in Scotland? A protocol for an observational study.

INTRODUCTION: There have been steady reductions in mortality rates in the majority of high-income countries, including Scotland, since 1945. However, reductions in mortality rates have slowed down since 2012-2014 in these nations; and have reversed in some cases. Deaths among those aged 55+ explain a large amount of these changing mortality trends in Scotland. Increased pressures on health and social care services have been suggested as one factor explaining these changes. This paper outlines a protocol for the approach to testing the extent to which health and social care pressures can explain recent mortality trends in Scotland. Although a slower rate of mortality improvements have affected people of all ages, certain ages have been more negatively affected than the others. The current analyses will be run by age-band to test if the service pressure-mortality link varies across age-group. METHODS AND ANALYSIS: This will be an observational ecological study based on the Scottish population. The exposures of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in real terms per capita spending on social and healthcare services between 2011 and 2017. The outcome of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in age-standardised mortality rate between 2012 and 2018 for men and women separately. The units of analysis will be the 32 local authorities and the 14 territorial health boards. The analyses will be run for both all age-groups combined and for the following age bands: <1, 1-15, 16-44, 45-64, 65-74, 75-84 and 85+.A series of descriptive analyses will summarise the distribution of health and social care expenditure and mortality trends between 2011 and 2018. Linear regression analysis will be used to investigate the direct association between health care spending and mortality rates. ETHICS AND DISSEMINATION: The data used in this study will be publicly available and aggregated and will not be individually identifiable; therefore, ethical committee approval is not needed. This work will not result in the creation of a new data set. On completion, the study will be stored within the National Health Service research governance system. All of the results will be published once they have been shared with partner agencies.

How bad are life expectancy trends across the UK, and what would it take to get back to previous trends?

BACKGROUND: Within the UK, there has been debate on whether life expectancy is increasing or decreasing in particular single or 3-year periods, but there has been less thinking whether overall trends have changed. This paper considers the extent to which the trends in life expectancy for the UK and its nations have changed before and after 2011. METHODS: We used the Office for National Statistics period life expectancy data for the UK and its nations. We used Lee's approach to project life expectancy based on repeated sampling of year-to-year change in the baseline periods (1990-2011 and 1980-2011) and applied that to 2012 onwards. FINDINGS: Improvements in period life expectancy were substantially and consistently lower between 2012 and 2018 than predicted from the trends from 1980 and, especially, from 1990. By 2018, life expectancy was lower than projected for females and males, respectively, by 1.22 and 1.52 years (England), 1.44 and 0.95 years (Northern Ireland), 1.30 and 1.44 years (Scotland), 1.53 and 1.63 years (Wales) and 1.24 and 1.49 years (UK overall), based on the 1990-2011 baseline period. Using a longer baseline period, which includes the slower rates of improvement during the 1980s, slightly reduces the gap between the current life expectancies and the projected medians. INTERPRETATION: Future academic and policy focus should be on the deviation of the life expectancy trends from the baseline projection rather than on year-to-year variation. Concerted policy focus to return life expectancy to the projected trends is now urgently required.

Trends in disease incidence and survival and their effect on mortality in Scotland: nationwide cohort study of linked hospital admission and death records 2001-2016.

OBJECTIVES: Identify causes and future trends underpinning Scottish mortality improvements and quantify the relative contributions of disease incidence and survival. DESIGN: Population-based study. SETTING: Linked secondary care and mortality records across Scotland. PARTICIPANTS: 1 967 130 individuals born between 1905 and 1965 and resident in Scotland from 2001 to 2016. MAIN OUTCOME MEASURES: Hospital admission rates and survival within 5 years postadmission for 28 diseases, stratified by sex and socioeconomic status. RESULTS: 'Influenza and pneumonia', 'Symptoms and signs involving circulatory and respiratory systems' and 'Malignant neoplasm of respiratory and intrathoracic organs' were the hospital diagnosis groupings associated with most excess deaths, being both common and linked to high postadmission mortality. Using disease trends, we modelled a mean mortality HR of 0.737 (95% CI 0.730 to 0.745) from one decade of birth to the next, equivalent to a life extension of ~3 years per decade. This improvement was 61% (30%-93%) accounted for by improved disease survival after hospitalisation (principally cancer) with the remainder accounted for by lowered hospitalisation incidence (principally heart disease and cancer). In contrast, deteriorations in infectious disease incidence and survival increased mortality by 9% (~3.3 months per decade). Disease-driven mortality improvements were slightly greater for men than women (due to greater falls in disease incidence), and generally similar across socioeconomic deciles. We project mortality improvements will continue over the next decade but slow by 21% because much progress in disease survival has already been achieved. CONCLUSION: Morbidity improvements broadly explain observed mortality improvements, with progress on prevention and treatment of heart disease and cancer contributing the most. The male-female health gaps are closing, but those between socioeconomic groups are not. Slowing improvements in morbidity may explain recent stalling in improvements of UK period life expectancies. However, these could be offset if we accelerate improvements in the diseases accounting for most deaths and counteract recent deteriorations in infectious disease.

Analysis of age-sex and deprivation stratified trends in assault deaths in Scotland (1974-2015) to identify age, period or cohort effects.

OBJECTIVES: Mortality rates in Scotland are higher, and health inequalities are greater, than in the rest of Western and Central Europe. There was a marked divergence during the 1980s and 1990s in the Scottish rates partly due to rises in alcohol-related and drug-related deaths, suicide and deaths by assault. This study examines whether age, period or cohort effects account for the trends in death by assault in Scotland and any sex or deprivation inequalities in these. DESIGN: We calculated crude and age-standardised mortality rates for deaths by assault for Scottish men and women from 1974 to 2015 for the population overall and for populations stratified by Carstairs area of deprivation. We examined age-sex stratified trends to identify obvious age-period-cohort effects. SETTING: This study was conducted in Scotland. PARTICIPANTS: Men and women whose registered death by the International Classification of Diseases was due to assault from 1974 to 2015 (n=3936) were included in this study. RESULTS: Whereas age-standardised mortality rates from this cause fell gradually for women since 1974, for men they increased in the early 1990s and remained higher until around 2006, before falling. Death by assault was substantially more common among men aged around 15-50 years and in the most deprived areas. There was little change in the age groups most impacted over time, which made cohort effects unlikely. A period effect for the 15 years until 2006, with a consistent age-sex-area deprivation patterning, was evident. CONCLUSIONS: Mortality due to assault in Scotland is unequally felt, with young men living in the most deprived areas suffering the highest rates. There is a 15-year period effect up until 2006, impacting on young men as an age-period interaction, with no obvious cohort effects. Exploration of the demographics of criminological data may identify age, period or cohort effects among perpetrators of assault.

Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study.

INTRODUCTION: Mortality rates in many high-income countries have changed from their long-term trends since around 2011. This paper sets out a protocol for testing the extent to which economic austerity can explain the variance in recent mortality trends across high-income countries. METHODS AND ANALYSIS: This is an ecological natural experiment study, which will use regression adjustment to account for differences in exposure, outcomes and confounding. All high-income countries with available data will be included in the sample. The timing of any changes in the trends for four measures of austerity (the Alesina-Ardagna Fiscal Index, real per capita government expenditure, public social spending and the cyclically adjusted primary balance) will be identified and the cumulative difference in exposure to these measures thereafter will be calculated. These will be regressed against the difference in the mean annual change in life expectancy, mortality rates and lifespan variation compared with the previous trends, with an initial lag of 2 years after the identified change point in the exposure measure. The role of underemployment and individual incomes as outcomes in their own right and as mediating any relationship between austerity and mortality will also be considered. Sensitivity analyses varying the lag period to 0 and 5 years, and adjusting for recession, will be undertaken. ETHICS AND DISSEMINATION: All of the data used for this study are publicly available, aggregated datasets with no individuals identifiable. There is, therefore, no requirement for ethical committee approval for the study. The study will be lodged within the National Health Service research governance system. All results of the study will be published following sharing with partner agencies. No new datasets will be created as part of this work for deposition or curation.

COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study.

Background: COVID-19 is responsible for increasing deaths globally. As most people dying with COVID-19 are older with underlying long-term conditions (LTCs), some speculate that YLL are low. We aim to estimate YLL attributable to COVID-19, before and after adjustment for number/type of LTCs, using the limited data available early in the pandemic. Methods: We first estimated YLL from COVID-19 using WHO life tables, based on published age/sex data from COVID-19 deaths in Italy. We then used aggregate data on number/type of LTCs in a Bayesian model to estimate likely combinations of LTCs among people dying with COVID-19. We used routine UK healthcare data from Scotland and Wales to estimate life expectancy based on age/sex/these combinations of LTCs using Gompertz models from which we then estimate YLL. Results: Using the standard WHO life tables, YLL per COVID-19 death was 14 for men and 12 for women. After adjustment for number and type of LTCs, the mean YLL was slightly lower, but remained high (11.6 and 9.4 years for men and women, respectively). The number and type of LTCs led to wide variability in the estimated YLL at a given age (e.g. at ≥80 years, YLL was >10 years for people with 0 LTCs, and <3 years for people with ≥6). Conclusions: Deaths from COVID-19 represent a substantial burden in terms of per-person YLL, more than a decade, even after adjusting for the typical number and type of LTCs found in people dying of COVID-19. The extent of multimorbidity heavily influences the estimated YLL at a given age. More comprehensive and standardised collection of data (including LTC type, severity, and potential confounders such as socioeconomic-deprivation and care-home status) is needed to optimise YLL estimates for specific populations, and to understand the global burden of COVID-19, and guide policy-making and interventions.

Do age, period or cohort effects explain circulatory disease mortality trends, Scotland 1974-2015?

OBJECTIVE: We aimed to explore whether age, period or cohort effects explain the trends and inequalities in ischaemic heart disease (IHD) and cerebrovascular disease (CeVD) mortality in Scotland. METHODS: We analysed IHD and CeVD deaths for 1974-2015 by sex, age and area deprivation, visually explored the data using heatmaps and dotplots and built regression models. RESULTS: CeVD mortality improved steadily over time while IHD mortality improved more rapidly from the late 1980s. Age effects were evident; both outcomes showed an exponential relationship with age for all except males for IHD in the 1980s and 1990s. The mortality profiles by age became older, although improvement was slower for those aged <50 years for IHD, especially for males, and faster for CeVD in females aged <65 years. Rates were higher, and inequalities greater, among males, especially for IHD. For IHD, increased risk for males over females reduced with age (incidence rate ratio for 41-50 year old males=4.28 (95% CI 4.12 to 4.44) and 1.17 (95% CI 1.16 to 1.18) for 71-80 year olds). Inequalities in IHD mortality by area deprivation persisted over time, increasing from around 10% to around 25% higher risk in the most deprived areas between 1974 and 1986 before declining in absolute terms from around 2000. Inequalities for CeVD increased after the late 1980s. CONCLUSIONS: IHD and CeVD mortality in Scotland exhibit age but not recent distinct period or cohort effects. The improvements in mortality rates have been more sustained for CeVD and inequalities greater for IHD.

Recent adverse mortality trends in Scotland: comparison with other high-income countries.

OBJECTIVE: Gains in life expectancy have faltered in several high-income countries in recent years. Scotland has consistently had a lower life expectancy than many other high-income countries over the past 70 years. We aim to compare life expectancy trends in Scotland to those seen internationally and to assess the timing and importance of any recent changes in mortality trends for Scotland. SETTING: Austria, Croatia, Czech Republic, Denmark, England and Wales, Estonia, France, Germany, Hungary, Iceland, Israel, Japan, Korea, Latvia, Lithuania, Netherlands, Northern Ireland, Poland, Scotland, Slovakia, Spain, Sweden, Switzerland and USA. METHODS: We used life expectancy data from the Human Mortality Database (HMD) to calculate the mean annual life expectancy change for 24 high-income countries over 5-year periods from 1992 to 2016. Linear regression was used to assess the association between life expectancy in 2011 and mean life expectancy change over the subsequent 5 years. One-break and two-break segmented regression models were used to test the timing of mortality rate changes in Scotland between 1990 and 2018. RESULTS: Mean improvements in life expectancy in 2012-2016 were smallest among women (<2 weeks/year) in Northern Ireland, Iceland, England and Wales, and the USA and among men (<5 weeks/year) in Iceland, USA, England and Wales, and Scotland. Japan, Korea and countries of Eastern Europe had substantial gains in life expectancy over the same period. The best estimate of when mortality rates changed to a slower rate of improvement in Scotland was the year to 2012 quarter 4 for men and the year to 2014 quarter 2 for women. CONCLUSIONS: Life expectancy improvement has stalled across many, but not all, high-income countries. The recent change in the mortality trend in Scotland occurred within the period 2012-2014. Further research is required to understand these trends, but governments must also take timely action on plausible contributors.

Socioeconomic inequality in recent adverse all-cause mortality trends in Scotland.

BACKGROUND: Gains in life expectancies have stalled in Scotland, as in several other countries, since around 2012. The relationship between stalling mortality improvements and socioeconomic inequalities in health is unclear. METHODS: We calculate the difference, as percentage change, in all-cause, all-age, age-standardised mortality rates (ASMR) between 2006 and 2011 (period 1) and between 2012 and 2017 (period 2), for Scotland overall, by sex, and by Scottish Index of Multiple Deprivation (SIMD) quintile. Linear regression is used to summarise the relationship between SIMD quintile and mortality rate change in each period. RESULTS: Between 2006 and 2011, the overall ASMR fell by 10.6% (138/100 000), by 10.1% in women, and 11.8% in men, but between 2012 and 2017 the overall ASMR fell by only 2.6% (30/100 000), by 3.5% in women, and by 2.0% in men. Within the most deprived quintile, the overall ASMR fell by 8.6% (143/100 000) from 2006 to 2011 (7.2% in women; 9.8% in men), but rose by 1.5% (21/100 000) from 2012 to 2017 (0.7% in women; 2.1% in men).The socioeconomic gradient in ASMR improvement more than quadrupled, from 0.4% per quintile in period 1, to 1.7% per quintile in period 2. CONCLUSION: From 2012 to 2017, socioeconomic gradients in mortality improvement in Scotland were markedly steeper than over the preceding 6 years. As a result, there has not only been a slowdown in overall reductions in mortality, but a widening of socioeconomic mortality inequalities.

Rethinking one of criminology's 'brute facts': The age-crime curve and the crime drop in Scotland.

Examining annual variation in the age-crime curve as a way to better understand the recent crime drop, this paper explores how the age distribution of convicted offending changed for men and women in Scotland between 1989 and 2011. This analysis employs shaded contour plots as a method of visualizing annual change in the age-crime curve. Similar to recent findings from the USA, we observed falling rates of convicted offending for young people, primarily owing to lower rates of convicted offending for young men. In contrast to the US literature we also find increases in the rate of convicted offending for those in their mid-twenties to mid-forties, which are relatively greater for women than men. Analysis of annual change shows different phases in the progression of these trends, with falls in prevalence during the 1990s reflecting lower rates of convictions for acquisitive crime, but falls between 2007 and 2011 being spread across multiple crime types. Explanations of the crime drop in Scotland and elsewhere must be able to account for different patterns of change across age, sex, crime type and time.

Reconsidering the Relationship between Air Pollution and Deprivation.

This paper critically examines the relationship between air pollution and deprivation. We argue that focusing on a particular economic or social model of urban development might lead one to erroneously expect all cities to converge towards a particular universal norm. A naive market sorting model, for example, would predict that poor households will eventually be sorted into high pollution areas, leading to a positive relationship between air pollution and deprivation. If, however, one considers a wider set of theoretical perspectives, the anticipated relationship between air pollution and deprivation becomes more complex and idiosyncratic. Specifically, we argue the relationship between pollution and deprivation can only be made sense of by considering processes of risk perception, path dependency, gentrification and urbanization. Rather than expecting all areas to eventually converge to some universal norm, we should expect the differences in the relationship between air pollution and deprivation across localities to persist. Mindful of these insights, we propose an approach to modeling which does not impose a geographically fixed relationship. Results for Scotland reveal substantial variations in the observed relationships over space and time, supporting our argument.

Drug-related deaths in Scotland 1979-2013: evidence of a vulnerable cohort of young men living in deprived areas.

BACKGROUND: Even after accounting for deprivation, mortality rates are higher in Scotland relative to the rest of Western Europe. Higher mortality from alcohol- and drug-related deaths (DRDs), violence and suicide (particularly in young adults) contribute to this 'excess' mortality. Age-period and cohort effects help explain the trends in alcohol-related deaths and suicide, respectively. This study investigated whether age, period or cohort effects might explain recent trends in DRDs in Scotland and relate to exposure to the changing political context from the 1980s. METHODS: We analysed data on DRDs from 1979 to 2013 by sex and deprivation using shaded contour plots and intrinsic estimator regression modelling to identify and quantify relative age, period and cohort effects. RESULTS: The peak age for DRDs fell around 1990, especially for males as rates increased for those aged 18 to 45 years. There was evidence of a cohort effect, especially among males living in the most deprived areas; those born between 1960 and 1980 had an increased risk of DRD, highest for those born 1970 to 1975. The cohort effect started around a decade earlier in the most deprived areas compared to the rest of the population. CONCLUSION: Age-standardised rates for DRDs among young adults rose during the 1990s in Scotland due to an increased risk of DRD for the cohort born between 1960 and 1980, especially for males living in the most deprived areas. This cohort effect is consistent with the hypothesis that exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact.

The Geography of a rapid rise in elderly mortality in England and Wales, 2014-15.

Since at least the early 1900s almost all affluent nations in the world have continually experienced improvements in human longevity. Using ONS mid-year population and deaths estimates for Local Authorities for England and Wales, we show that these improvements have recently reversed. We estimate that in England and Wales there were 39,074 more deaths in the year to July 2015 as compared to the year to July 2014 (32,208 of these were of individuals aged 80+). We demonstrate that these increases occurred almost everywhere geographically; in poor and affluent areas, in rural and urban areas. The implications of our findings are profound given what has come before them, combined with the current political climate of austerity.