None of us were quite prepared for the prolonged and devastating impact of the COVID-19 pandemic. And while 41% of excess deaths in England and Wales fell on those over the age of 85, it has become clear over the course of the past 18 months that age is not the only factor that has made people vulnerable to COVID-19. The excess deaths among the UK’s working age population tell a story of a society that lacked social, economic and health resilience. 

In 2020, the UK experienced the second highest rate of excess deaths among people younger than 65 in the whole of Europe, exceeded only by Bulgaria. Excess mortality among working age adults is an indicator of disadvantage and poor underlying health. The UK’s pandemic death toll lays bare the poor health of this population – with our inquiry finding that deaths among people under 65 were almost four times as high for those living in the poorest 10% of local areas than for those from the richest. 

Today, the Health Foundation published the results of our 9-month investigation into how poor health and existing inequalities left parts of the UK vulnerable to the virus and defined the contours of its devastating impact. Finding certain groups more affected than others, the COVID-19 impact inquiry has uncovered the extent of the pandemic’s unequal repercussions.

The inquiry shows that pre-existing inequalities, including disparities between job types, access to sick pay, and isolation payments, as well as the number of people living in a home, put the most vulnerable in the virus’s path, fuelling wide disparities in people’s experiences of the pandemic, risk of infection, and death. Notably, as well as increasing exposure to the virus, low quality jobs were associated with people having poorer health going into the pandemic. The care, leisure and service industries accounted for the greatest proportion of excess deaths both before and after the emergence of COVID-19, suggesting that these workers have a heightened risk of developing a pre-existing health condition. 

In particular, the greatest occupational mortality rates for men were recorded among elementary process plant workers (143.2 deaths per 100,000), food preparation workers (115.7 per 100,000), elementary security workers like security guards (93.4 per 100,000), and personal care workers (91 per 100,000). People working in social care were also more than twice as likely to die from COVID-19 as those working in health care, with 109.9 deaths per 100,000 people compared to 44.9 deaths per 100,000 in health care. Meanwhile, we found working from home really did save lives – for those who were able to do so – with a clear inverse relationship between the rate of homeworking and COVID-19 mortality rates in most areas of the UK. 

Many of these factors had been in play for years before the pandemic began, with the financial crisis acting as a catalyst for the erosion of public services and fraying of the economy. Stalling life expectancy and an increase in conditions such as diabetes, obesity and cancer have contributed to the UK having one of the highest death tolls from COVID-19. Deeper rooted issues – poor health, increased financial insecurity and strained public services – left people at greater risk from COVID-19, making our society more vulnerable.

The buried mental health crisis

The pandemic has given further fuel to the mental health crisis evident before the events of 2020. Early this year, data from the Office for National Statistics suggested that the number of adults experiencing depression more than doubled compared to the year before. Yet diagnoses of self-harm, depression and anxiety, and prescriptions for antidepressants have all fallen rapidly, with referrals to mental health services falling by over 75% in April 2020

Again, this increase in the prevalence of depression was disproportionately felt by those with financial problems, lower educational attainment, lower incomes, or who were living in a poorer area. Renting a home put people at higher risk of poorer mental health (31%) than homeowners (13%) and adults living in the poorest areas of England were 1.5 times more likely to have depressive symptoms than those in the wealthiest. Almost half of those who were unemployed experienced poor mental health (43%) and women were also twice as likely to report a decline in their mental health.

The evidence suggests that access to mental health care also declined during the pandemic. Waiting times for these services were already acute, and although the full demand for mental health support cannot be measured, the pandemic has likely exacerbated it. Waiting lists are already long but there is likely to be a ‘hidden waiting list’ of those who are yet to present to already busy primary care services. 

Preventive treatment for society’s deep-rooted disease

The pandemic threw into sharp focus what happens when people don’t have access to the conditions they need to stay healthy and prosper. It’s time to reassess what ‘health protection’ really means. It is not enough to just protect the UK from the virus; our government needs to build the conditions – through good quality jobs, housing, education and communities – that protect people’s health from the gradual erosion brought about by stress and anxiety, poor diets and a lack of opportunity. 

Reversing years of entrenched health inequalities will not be easy. In fact, growing health care backlogs, education gaps, and increased financial instability during the pandemic will only worsen health outcomes in the long run, placing further pressures on the NHS. It’s now crucial that we build our resilience to future shocks by tackling these issues at the source. The government’s ambition to level up is right and timely but, as a nation, we cannot purely focus on economic opportunity. Ensuring our recovery improves health – as well as the economy – will help to secure a more equitable, strengthened society in the future.

The unwavering dedication of the NHS has kept the UK afloat throughout the worst of the COVID-19 crisis. NHS leaders have gained respect from the British public, becoming a powerful voice for good. Those working in the NHS have first-hand experience of the unequal impact of the virus and are well placed to call for a fairer recovery.  

As a nation, we are dependent on the NHS, and the pandemic has proven to us that our health care is best in class when things go wrong. However, our health system cannot survive on its own; we also need a first-class education, housing and employment system to support people to live healthy lives, because we cannot afford to have a second-rate society. 

Jo Bibby (@JoBibbyTHF) is director of health at the Health Foundation.

This article was originally published by the BMJ on 6 July 2021.

Further reading

Research report

Unequal pandemic, fairer recovery

July 2021
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A comprehensive review of the factors that affected the UK’s devastating COVID-19 death toll.

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COVID-19 impact inquiry

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