Key points

  • Coronavirus (COVID-19) has had a major indirect impact on NHS services in England, from primary care to hospital treatment, resulting in disrupted care for tens of thousands of patients.
  • While general practice has remained open throughout the pandemic, many appointments have been switched to remote methods, such as via telephone, to keep patients and staff safe. The overall number of appointments dropped sharply from April 2020 compared with the previous year, but has since recovered. In October, there were 2 million fewer overall appointments than in October 2019, but there were still 7 million fewer face-to-face appointments than in the same month in 2019.
  • There were large falls in the numbers of people attending A&E at the beginning of the pandemic, with visits to major emergency departments down by 48% in April 2020 compared with the same month in 2019. This was caused by a combination of reductions in injuries during lockdown, but also public reluctance to use emergency services when infection rates were high. The volume of A&E attendances rose steadily until September, but have since fallen, as COVID-19 infections began to rise again, suggesting that high infection rates are still a deterrent.
  • There have been major disruptions to planned hospital treatment. Between January and September 2020 there were 4 million fewer referrals to outpatients than in the same period in 2019. There was a 60% fall in the numbers of people referred by their GP for suspected cancer in April 2020 compared with the same month the previous year. Referrals for suspected cancer have since recovered to pre-pandemic levels, but overall there have been 333,665 fewer referrals to date (October) this year compared with 2019.
  • The NHS has launched public information campaigns to encourage people to seek help for non-COVID-19 conditions, and set targets for hospitals to reduce the backlog of non-urgent treatment. Nevertheless, the disruption caused by the pandemic is profound and will take many months, if not years, to be resolved.

Introduction

Health systems around the world have struggled to balance the care of COVID-19 patients with treatment for patients needing care for other reasons. From March 2020 NHS England issued a series of instructions to NHS services that have had long-lasting consequences. This included guidance for NHS hospitals to cancel or postpone non-urgent care, primarily to free up staff and beds for the expected influx of patients seriously ill with COVID-19. Guidance was also issued to a broad range of other services, including general practice, community services and mental health. At the same time, public information campaigns told people where to go (and not go) in case of suspected infection and later the importance of continuing to use services when needed.

This short analysis summarises trends in activity from key NHS services in England, from the beginning of the pandemic to the most recent months for which data are available (up to October and November 2020). This covers the first peak of the pandemic in March, April and May, through to September, October and November, when infection rates began to rise again. The data cover urgent and emergency care, general practice and hospital services.

NHS 111

NHS 111 is a 24/7 telephone and online service that gives urgent health advice but can also dispatch ambulances or recommend that people attend A&E, primary care or other services. In the early stages of the pandemic, the public was directed to use NHS 111 if concerned about possible COVID-19 symptoms instead of accessing NHS services in person. Additional resources were released to NHS 111, including the creation of a specific COVID-19 online service.

As the pandemic took hold in March, there was a large spike in activity, with the number of calls made to NHS 111 more than doubling from 1.44 million in March 2019 to 2.96 million in March 2020. Most of these calls were unanswered with only 1.31 million calls answered in March 2020 (compared with 1.39 million in 2019). The volume of calls returned close to normal levels in the summer, with only 4% more calls offered in July 2020 compared with July 2019. However, from August the number of calls began to increase again, with 1.79 million calls made to NHS 111 in September, before returning to the same as the previous year in November. There is no indication of a surge on the scale of March 2020, which possibly reflects easier access to testing.

Figure 1:

General practice

General practice accounts for the highest volume of patient contacts with the NHS, so preventing infection between patients and staff has meant major changes to the way the service functions. Guidance issued in a letter on 19 March (now no longer available on the NHS England website) instructed local practices to join forces and create separate COVID-19 surgeries for patients who may have COVID-19. All practices were asked to set up telephone or online triage (to avoid infectious people walking into surgeries), and use remote (online and telephone) consultations where possible. Face-to-face appointments were to be used when remote consultation was not clinically appropriate. The letter told GP practices that their income would continue at the same level as before the outbreak, regardless of changes in activity level. Finally, GPs were advised that they could defer some types of routine care, such as medication reviews or health checks for those older than 75, where needed.

Data on GP contacts showed a sharp drop in the volume of overall appointments (Figure 2): in April 2020 there were 7.9 million fewer appointments than in April 2019.

Figure 2:

Figure 2 also shows that appointments have started to return to pre-pandemic levels, with 28 million appointments in October 2020 compared with 30 million in the same month in 2019. The number of appointments that were with a GP were also closer to pre-pandemic levels in October, but there were still over 7 million fewer face-to-face appointments (with any kind of practice staff) compared with October 2019. This is likely to be a reflection of the additional time and workload created by infection control precautions, including PPE for staff, needed for all face-to-face appointments.

NHS Digital has highlighted that this dataset may be an underestimate of overall contacts in general practice due to the changes introduced early in the pandemic. For example, it is not clear how appointments at the COVID-19-specific practices were recorded. Nevertheless, the data suggest a large volume of ‘missing’ GP appointments over the past few months. Our analysis of a smaller but more accurate GP dataset suggested a 30% drop in consultation rates per patient between the end of March and the end of May 2020.

While GP practices remained open throughout the pandemic, there is some evidence that a minority of the public were concerned about possible infection risks by going to their GP and worried about burdening the health system unnecessarily. It is not clear how many patients may have been deterred from using general practice as a result.

The overall drop in appointments and uncertain availability of face-to-face appointments led NHS England in late July to remind all GP practices that they should offer face-to-face appointments as appropriate and restore clinical activity to usual levels where possible. In October, a public information campaign was launched to encourage people to see their GPs, especially for possible symptoms of cancer.

A&E attendance data and ambulance activity

One of the most striking shifts in service use relates to A&E attendances, which fell very sharply from the end of March 2020 after several years of slow increases. In April 2020 there were 48% fewer attendances at major A&E departments compared with 2019. At the end of April, NHS England noted that this fall was ‘likely’ due to changed patient behaviour, a drop in major trauma and road traffic accidents, and changes in clinical behaviour – such as more ‘see and treat’ by paramedics rather than taking people to hospital. Our analysis of more detailed A&E data between mid-March 2020 and mid-May showed steep falls in attendances for injuries, but also for other illnesses, suggesting a combination of factors at play.

The data show a temporary change in ambulance activity which suggests that clinicians avoided sending patients to A&E where possible. In April 2020, the number of ambulance incidents where patients were transported to A&E fell by 29% compared with 2019 and ‘see/hear and treat’ incidents (where patients were treated at the scene and not taken to hospital) increased by 37%. The number of incidents involving transport to A&E started to return close to normal but fell again in November with 4% fewer incidents in August and September and 11% fewer in November, relative to the same months in 2019. The number of see/hear and treat incidents remained slightly higher than 2019 with 9% more in November 2020 compared with November 2019.

As with general practice, concern grew in the spring about people avoiding A&E to the detriment of their health, and information campaigns were launched by NHS England to encourage patients to use the NHS for urgent conditions, such as stroke and heart attacks. Attendance numbers rose over the summer: by August attendances were 11% lower than in 2019, but started to slow again from September as COVID-19 infections began to rise. In November 2020, there were 1,036,350 attendances at major A&E departments, 24% fewer than November 2019.

Figure 3:

Rising attendances pose a major problem for emergency departments while COVID-19 is in circulation. In May 2020, the Royal College of Emergency Medicine warned that emergency departments would not be able to protect patients and staff from infection if pre-pandemic levels of overcrowding returned. This is because emergency departments have changed the way they work, with more staff needing to use more PPE, more space required between patients, and many emergency departments have split services between COVID-19 and non-COVID-19 patients. All of these reduce the speed with which patients can be seen.

Emergency admissions

One of the main predictors of overcrowding in A&E departments is the speed with which patients who need emergency admission can be admitted to a bed within the hospital. Overcrowding was far less of a problem in the early months of the pandemic because beds had been freed up at the start of the pandemic (as patients were discharged where possible) and non-urgent treatment postponed. But the pandemic has also seen a steep fall in both total emergency admissions and emergency admissions via A&E. In April 2020 there were 257,928 emergency admissions via A&E, compared with 405,439 in April 2019 – a 36% drop. Emergency admissions via A&E increased until October but started to fall again with 347,211 in admissions in November, which is 17% lower than 2019. The number of total emergency admissions followed a similar pattern with a 39% reduction in May, a 9% reduction in September, and a 19% reduction in November compared with the same months in 2019.

It is not clear what the impact of reduced emergency admissions has been. Between 20 March and 11 September 2020, the ONS reported over 24,000 excess deaths at home, and nearly 24,500 excess deaths in care homes – deaths in excess of the 5-year average for the same period – for a range of conditions including heart disease, Alzheimer’s and dementia, and cancer. Researchers in Leeds looked more closely at deaths from cardiovascular disease in England and Wales and estimated that there were over 2,000 excess deaths between March and the end of June 2020, from diseases such as stroke, heart attack and heart failure. Of these, there were more deaths at home and in care homes than normal, but no excess deaths in hospital. The research suggests that some of these deaths may have been undiagnosed COVID-19, or potentially the result of people not seeking help for serious conditions not related to COVID-19.

Figure 4:

Planned hospital treatment

NHS England instructed hospitals early in the pandemic to postpone non-urgent, planned treatment to free up beds and staff to care for people with serious COVID-19. Treatment for urgent conditions, such as cancer, was meant to continue and detailed guidance was produced during March and April to help clinicians prioritise treatment; for example, surgical procedures. A fall in activity therefore was to be expected.

The number of outpatient appointments fell by 4.4 million in May 2020, with 6.2 million appointments compared with 10.6 million in May 2019. While activity has increased since May, there were still 2.5 million fewer appointments (a 22% reduction) in October 2020 compared with October 2019.

The number of non-emergency admissions fell by 62% in April 2020 with approximately 540,000 fewer admissions than in April 2019. The number of admissions has increased since April, but by October 2020 were still 22% lower than 2019. Non-emergency admissions refers to all finished admission ‘episodes’ excluding emergency admissions. These are primarily elective admissions but also include other admissions such as admissions to maternity wards or transfers from another hospital. 

Figure 5:

This drop in admissions has created a backlog of people waiting to start treatment. In October 2020, there were 1.5 million people waiting more than 18 weeks for treatment, and 162,000 waiting more than 52 weeks. In October 2019, there were 1,321 patients waiting more than 52 weeks.

This does not include those who might ordinarily have been referred by their GP and are not yet on the waiting list. From January to October 2020, 4 million fewer referrals were made to first consultant-led outpatient appointments, compared with the same months in 2019. The reduction in referrals was greatest in April, when 75% fewer referrals were made, but referrals are still far from normal, with 26% fewer referrals in October 2020 relative to 2019.

Figure 6:

Cancer treatment

The NHS has longstanding waiting time targets that aim to ensure people with suspected cancer can see a specialist, receive diagnostic tests and start any necessary treatment without undue delay. The available data highlight a substantial fall in the number of people urgently referred by GPs (and other sources such as screening), the number starting first treatment (along with longer waiting times for those who did see a specialist or start treatment), and the number starting second and subsequent treatments.

In April 2020, 79,573 patients were seen by a specialist following an urgent GP referral for suspected cancer compared with 199,644 in April 2019, a fall of 60% (Figure 7). This reduction is likely to be the result of a combination of fewer patients going to see their GP, delays in access to diagnostic tests and hospital departments being temporarily closed to new GP referrals.

The data also show that the efforts made by NHS staff to recover from this initial shock have made considerable progress: by September 2020, the number of people being seen by a specialist was higher than in September 2019. But the renewed pressures from increasing cases of COVID-19 have seen numbers fall back slightly since. In October 2020, 8% fewer patients were seen by a specialist compared with October 2019. Overall between January and October 2020, 333,665 fewer patients were seen by a specialist compared to January to October 2019.

For those patients already referred into the system as the pandemic unfolded, their care was also disrupted. In May 2020, 37% fewer patients started treatment for a new cancer compared with May 2019, and 19% fewer patients started second or subsequent treatments. Again, the gap narrowed in September, but has since started to widen, with 10% fewer patients starting treatment for a new cancer and 17% starting a second or subsequent treatment in October 2020 compared with 2019.

There have been big falls in treatment for cancer identified through screening. In July 2020, only 319 patients started a first treatment for cancer identified through screening compared with 1,890 in July 2019, representing an 83% reduction. These patients also had to wait far longer, with 87% of patients waiting more than 2 months from diagnosis to treatment in June. By October 2020, 47% fewer patients started treatment for cancer following screening compared with October 2019.

Data on the impact of these delays will not be clear for some time, as cancer survival is measured in 1- and 5-year intervals. But researchers have modelled the likely impact of 2-week wait delays based on survival data from previous years, and expect that the disruption to cancer services will have shortened survival for a range of tumours, making some patients’ cancers no longer curable.

Figure 7:

Conclusion

NHS services have had to change significantly to meet the challenge of COVID-19. In the early stages of the pandemic, non-COVID-19 hospital care was suspended or slowed down to release capacity and avoid the very real risk of critical care being overwhelmed by patients acutely unwell with the virus. Other services, including primary care, have been transformed in order to protect staff and patients from infection. This has led to a big disruption to the normal flow of patients through the health care system, and has led to tens of thousands of people waiting for hospital treatment, some of whom will have deteriorated. Others, who would normally have been referred by GPs over the period, are also likely to face longer waiting times, and need care in the meantime from general practice, itself stretched by the challenges of delivering care safely.

This analysis has only captured data on a proportion of NHS services. Other services – including dentistry, mental health care, community and social care – have also been affected, though there is less readily available data to understand these effects more fully.

The disruption to non-COVID-19 health services is not unique to the NHS. Countries in Europe and North America have also struggled to keep health services going. The NHS in England has made substantial progress in reopening services and has encouraged people to use services if they need them. However, the recent growth in the rate of COVID-19 cases, together with the expected surge in emergency pressures in winter, means some or all of these gains may be lost.

Much of what happens in the next 6 months will depend on the effectiveness of the measures taken to control the spread of the virus. Even as vaccines are rolled out, this will be the single biggest factor in determining the extent to which the NHS can deliver normal levels of service for the people who need it.

Further reading

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