The coronavirus (COVID-19) pandemic has delivered a profound shock to the UK. The measures to control the spread of the virus have reached deep into our lives, affecting people’s income, job security and social contacts – factors that are essential to healthy lives.
The public health workforce and local government have reshaped their work in an effort to contain the infection and protect the most vulnerable. Yet this is against a backdrop of successive years of real-terms budget reductions. The NHS has been radically mobilised to respond to the acute needs of people infected with the virus, at the same time as delivering scaled-back non-COVID-19 health care. Social care, weakened by years of declining real-terms public funding and rising demand, has been reeling from the impact of the virus, with many users and staff unprotected, fatally vulnerable and poorly accounted for in the official data until now.
Day to day, most eyes are drawn to the sharp end of the crisis: the rising toll of COVID-19 confirmed deaths and hospitalisations. But each week brings a steady release of more routine national sources of data, with a time lag of one month or more. These sources are not perfect – there are data blind spots in community services or social care in the home – but nevertheless they can start to illuminate the contours of the infection as it took hold from March onwards.
Over the next few weeks the Health Foundation will be publishing a series of charts and brief commentaries, attempting to describe the different dimensions of the impact of COVID-19 as they unfold, from the health and care system through to people’s daily lives. There are at least five dimensions of impact, with as yet unknown depth and distribution.
Direct impact of COVID-19
The first dimension is the direct impact of the virus itself, in terms of death and serious illness. The early evidence from China (and subsequently Italy), suggested that the virus was more likely to kill those who were older, had underlying conditions (especially hypertension, diabetes and ischaemic heart disease), and were male. The pattern in England, Wales and Northern Ireland is the same for patients with COVID-19 needing intensive care.
Underlying conditions are not evenly distributed across the population and are more common in deprived communities. It will be vital, therefore, to begin to analyse data on the spatial patterning of COVID-19 deaths, both in and out of hospital, to see the extent of COVID-19’s unequal impact on older people (in care homes) and those living in deprived communities. There may be differences, by age or by region, in help-seeking for COVID-19 symptoms, in access to NHS 111 for example. There are other facets of differences too: in the US, where poverty magnifies the inequalities experienced by non-white communities, COVID-19 appears to taking a harsh toll. The early evidence from intensive care suggests a similar pattern of disproportionate impact on black and minority ethnic communities in the UK.
Impact on acute care
The second dimension of concern is the indirect impact on people with acute conditions not related to COVID-19. During March, NHS trusts rapidly re-designed their services on a large scale to release capacity for treating patients with COVID-19. This included discharging thousands to free up beds, postponing planned treatment, shifting appointments online where possible and redeploying staff, a process covered widely in the media. NHS England published more than 50 sets of guidance to hospital specialists for the treatment of non-COVID-19 patients during the pandemic.
By early April, concerns were raised about significant drops in A&E use, and admissions for urgent conditions via hospital emergency departments. These included admissions for stroke (a pattern also seen in Europe) and heart attacks. The British Heart Foundation reported a 38% drop in emergency heart surgery in London in the second half of March, and that cardiologists surveyed believe that patients are staying away because of worries about contracting the virus or adding to pressures on the NHS.
We will be tracking some of the big shifts in care and their impact. For example, we will report the data on attendances at emergency departments to see if this drop was temporary or sustained, whether it affected some age groups more than others. Small scale evidence from paediatricians in Italy suggests that parents delayed seeking urgent help for ill children, with some tragic results. There are other urgent conditions, such as cancer, where the picture may be less clear for some time. NHS England guidance is unequivocal: ‘essential and urgent’ cancer treatment must continue. But Cancer Research UK has warned of severe disruption to cancer surgery and chemotherapy in some areas, and researchers are predicting additional deaths as a result. There will be similar questions to answer about maternity care, crisis mental health services, and access to emergency care for those who are considered frail.
Non-acute care including general practice
A third dimension of disruption will affect people with chronic conditions, or people needing less urgent care which may have been interrupted. General practice does much of the work of managing patients with chronic conditions. From mid-March, the way general practice works has profoundly changed: according to the guidance, all practices should have moved to remote triage, where patients are assessed by phone or online before they can access a GP or other health professional. To free up capacity, GP practices were given the option to defer some routine activities, including health checks for the people aged 75 and older and routine medication reviews. Other activities, such as child immunisations, should have continued. At the same time, the public were given instructions to access NHS 111 rather than their GP if they had COVID-19 symptoms.
Understanding how this has affected access to general practice will be critical. A key factor will be the ease with which general practices have been able to move to online working (the Royal College of General Practitioners reports that many practices are struggling with basic IT hardware and software), and whether an appropriate level of patient contacts has been maintained. Patients have been urged not to avoid seeking help for serious non-COVID-19 symptoms, but there are real worries that early detection of cancers will reduce, either because patients have not come forward, or GPs are unable to refer to hospitals for tests. Data on urgent GP referrals for suspected cancer will give some insight into the scale of this in May. General practice will also have to manage the patients whose planned surgery, such as joint replacements, has been postponed. NHS hospitals were instructed on 17 March to postpone all non-urgent elective operations for 3 months. Data on hospital activity will also shed some light on the scale of the reduction in ‘normal activity’.
For other long-term conditions, there is very limited evidence about access to services. For example, a survey of 2000 children and young people with mental health problems (in late March), found that three quarters of young people still had access to some sort of mental health support. But a quarter reported that services had been cancelled, or moved to the telephone or online (which created barriers for patients living at home).
The lockdown and social distancing
The fourth dimension will be the medium and long-term impact on health of the government interventions to restrict movement to curb the transmission of COVID-19. The impact directly caused by the lockdown could be profound, for example resulting in: bankruptcies, unemployment, more domestic abuse, neglect and hardship.
Early estimates show an unprecedented economic shock, with the Office for Budget Responsibility forecasting a 35% reduction in GDP in the second quarter of 2020. Research from the 2009 financial crisis has found the downturn was associated with poorer health outcomes. Initial research on the impact of the lockdown on economic activity has already found higher job and earnings losses for lower earners, younger workers and women. Surveys suggest food insecurity has also increased, driven by income loss and disruptions in the food supply. While the government has intervened to mitigate the shock, there are still gaps in provision likely to cause hardship, as well as slow uptake of small business loans. Prolonged spells of financial hardship and unemployment can affect health directly, potentially through increased allostatic load as one mechanism, as well as affecting future economic prospects.
There are also the social consequences of a prolonged lockdown and period of social distancing: surveys show increases in anxiety and charities highlight a rise in people seeking help for domestic abuse. Overcrowding in English households had been rising in the years prior to the crisis, a more pronounced problem when so many are confined to the home as well as being a potential means of transmission of COVID-19. School closures may have negative and unequal consequences for pupils’ development. Besides these problems, there will also be the question of any future fiscal retrenchment and the consequences it will have for health and health inequalities.
NHS and social care capacity and resilience
The fifth dimension is the longer term impact on service capacity and resilience. The NHS entered the pandemic with a relatively low level of beds and staff per capita, and much of the policy response to the pandemic has hinged on slowing infections to allow time for the NHS to increase critical care capacity in hospitals. Regions within England did not start at the same place, with London having more critical care beds per capita than elsewhere. As a whole, the NHS mobilised a large number of additional critical care beds and equipment. However, it will be important to track hospital admissions data over time, to understand what impact this has had on capacity within hospitals across all regions, for both COVID-19 and non-COVID-19 activity.
A second component of system resilience will be the impact on the workforce. Before the pandemic, the NHS and social care system both had significant staffing shortages. Stress levels for NHS staff were at 5-year highs, and only a third of staff felt there were sufficient staffing levels. Social care has a very high level of staff turnover (almost 1 in 3 leave their job every year) and a quarter of staff are on zero hours contracts. This will be an extremely challenging time for staff, and their safety and wellbeing must be a priority.
The cumulative impact of COVID-19 on the NHS, social care and wider society will take many months to quantify and understand. It will require a multi-pronged research effort by many institutions to explore the relationships between disrupted and changed services and the impact on people’s health and wellbeing. There may be positives. Public awareness of the need to strengthen social care may increase, creating impetus for reform. Large scale volunteering may endure. Some paused health care activity may be found to have not contributed much to outcomes, while the huge shift to remote consultations may prove to be both durable and effective for many patients.
Even though the pandemic has many months to go, pressure is increasing to start planning for ‘after COVID’. The virus will have taken an uneven toll on an already unequal society. For services to meet people’s needs in the future, the stronger the evidence base, the better equipped they will be. The series of charts is intended to make a small contribution, and begin to make sense of the landscape left in COVID-19’s wake.