Changes in the wider determinants of health


Relationships between friends, families and communities changed with stay at home restrictions in place. Many people reported feeling closer to family and their local community, but less connected to friends and other relatives. Loneliness increased over the pandemic. Those living alone, those with poorer underlying health or in rented accommodation were more likely to report higher levels of loneliness.

The closure of schools and reduced access to early years settings led to lost learning and development. Children from more disadvantaged backgrounds experienced higher levels of learning loss than their peers. A lack of social participation affected young people’s mental health and wellbeing.

The UK government launched unprecedented support to mitigate impacts on income and employment, including the Coronavirus Job Retention Scheme and the £20 uplift to Universal Credit. Despite these measures, people in shutdown sectors, those from deprived backgrounds, young people and the self-employed remained among those worst affected by the economic shock.

Challenges in housing security and homelessness were initially met with positive government measures. This included the introduction of mortgage holidays, the halting of evictions and schemes to house homeless people. Yet many families still struggled with housing payments, with an extra 450,000 families in rental arrears by January 2021 and 400,000 at risk of eviction in May 2021.

The greatest influences on health are the factors that shape the conditions in which we are born, grow, live, work and age. Quality of work, housing, education, communities and family all impact on people’s health. The pandemic and the measures taken in response have had direct effects on these wider determinants of health.

Despite concerted and unprecedented measures to protect lives and livelihoods, there are short and long-term implications for the health of the population due to the effect of restrictions on families, communities, the economy, education and housing.

Friends, family and community

Positive relationships and feelings of connectedness contribute to good health and wellbeing. This was inevitably affected by the pandemic, with the scale of the response leading to radical changes in our day-to-day lives. Restrictions during the first wave limited people’s social contact with others outside of their own households and 51% felt less connected to friends and colleagues. In contrast, 47% reported feeling more connected to family and 45% more connected to neighbours.

“47% of people reported feeling more connected to family and 45% more connected to neighbours [during the first wave].”

Loneliness increased in Great Britain between spring 2020 and February 2021. Data from the ONS show that working-age adults living alone were more likely to report loneliness. Those in ‘bad’ or ‘very bad’ health, those in rented accommodation, or who were either single, divorced or separated also reported higher levels of loneliness.

During the first wave, many local communities came together to support each other. By May 2020, there were 2,000 new local support groups on the Mutual Aid website and more than 5,000 neighbourhood-based Mutual Aid groups established to provide support for residents of local communities., More than 750,000 NHS volunteers signed up to help support vulnerable people.

This increase in community spirit was not experienced universally. People with lower levels of education and members of certain ethnic minority communities experienced a greater decline in perceptions of neighbourhood cohesion than their less disadvantaged counterparts. For some vulnerable groups, including people living in poverty or with pre-existing mental and physical health conditions, social support was persistently lower – by about 10–15% – than for those from wealthier backgrounds, or without physical or mental health conditions.

For the majority, feelings of neighbourhood cohesion were mirrored at the beginning of the pandemic by an increased sense of national unity. However, this does not seem to have been sustained. In April 2020, 57% of people thought that Britain would be more united than before once recovered from the pandemic, but by June 2020 this figure had fallen to 28%.

Unpaid carers

Greater responsibility for unpaid care has previously been linked to poorer mental health and greater risk of some physical health conditions., , ,

The number of people caring for older, disabled or seriously ill relatives and friends almost doubled during the pandemic from 17% of the population in 2018–20 to 32% in January 2021. By October 2020, unpaid carers were reporting increases in caring activity but reduced access to support. Many reported lower wellbeing, financial difficulties such as greater reliance on foodbanks, and lack of respite opportunities., , , ,

Carers are more likely to have poor health with over 60% of people providing over 20 hours of care a week having two or more long-term conditions. During the pandemic, over 20% have been waiting for NHS treatment.

Early years

Early years services have profound and lifelong effects on many aspects of health and wellbeing because they support social and emotional development and contribute to school readiness. Early years settings are particularly important for more disadvantaged children, helping to prevent gaps opening up in development levels at this early stage.

Before the pandemic, 68% of parents with children aged 2–4 years reported accessing formal early education or childcare. During the first lockdown this dropped to just 7% and by June 2020 the figure was still below 20%.

During the second wave, families were accessing early years settings more often but not at pre-pandemic levels. In February 2021, early years providers in England and Wales reported that attendance was still 28% lower than in the previous year. In England almost half reported lower take up of government-funded childcare entitlements.

Ofsted found that over half of early years providers felt that children’s personal, social and emotional development had fallen behind during the first lockdown. Almost half (45%) of parents reported a negative impact on their child’s social and emotional development, and 20% felt their child’s language and physical development was negatively affected.


Government restrictions and lockdowns led to school closures, with most children and young people spending almost 60% less time in school by Easter 2021, with corresponding impacts on participation in learning and increased learning loss.,

There was some recovery in the autumn term when schools reopened and increased online provision in January 2021. But by the end of the 2020/21 spring term, primary school children had lost between 2 and 2.3 months of reading progress and between 3.1 and 3.6 months of progress in maths. Secondary school pupils also experienced similar levels of learning loss for reading, amounting to 1.6 and 2 months respectively for years 8 and 9.

The disruption of the pandemic has been greater for some children than others. School-aged children who are eligible for free school meals, have lower-educated parents or are in single-parent families spent less time on home learning than peers. In secondary education, schools with high rates of eligibility for free school meals had higher levels of learning loss than schools with lower rates (2.2 months versus 1.5 months) by autumn 2020.

Box 3: Digital exclusion

The pandemic transformed many day-to-day activities by accelerating people’s reliance on technology. Social distancing policies meant people having to use the internet to access vital services, such as financial, housing, health and social services. Internet access has been necessary to maintain connections with friends and family, to learn and work remotely, and to pursue exercise, faith, cultural and social activities.

This inadvertent and rapid shift in infrastructure widened inequalities for people digitally excluded: those lacking access, skills or confidence to use the internet. Before the pandemic, around 10% of the population had not used the internet in the previous 3 months or more. A considerable proportion of the UK population – 9 million people – is unable to use the internet independently.

Around 53% of the ‘offline population’ may lack the disposable income to afford an average monthly broadband bill of £30–35. The Good Things Foundation reports that certain groups – disabled people, older people, people on low incomes and those living in rural areas – are disproportionately likely to experience digital exclusion. These groups are also likely to have faced worse socioeconomic outcomes, showing how digital exclusion widens existing inequalities.

For example, digital exclusion has affected education and employment. Around one in five children did not have access to a suitable device for home learning during the pandemic, and 3% of school children were unable to do any schoolwork due to digital exclusion.

At the same time, many people with limited digital skills have embraced the internet during the pandemic. The proportion of homes without internet reduced from 11% in March 2020 to 6% in March 2021, while 75% of 50–70 year olds reported making video calls more often. There has also been a threefold increase in the number of 70 year olds registering for an online bank account.

In July 29% of teachers in the ‘most-deprived schools’ (as measured by the highest quintile of children on free school meals) reported that their children were 5 months or more behind, compared with only 5% of teachers in the least. Children from ethnic minority communities were also particularly disadvantaged by school closures. These are explored further in Section 5. The OECD estimates that learning loss equivalent to one-third of a school year can subsequently reduce earned income in later life by 3%. At an aggregate level the current cohort of years 1–12 losing just one-third of a year in effective learning has been estimated to reduce a country’s GDP by an average of 1.5% over the remainder of the 21st century. The negative consequences for individual and societal standard of living would be expected in turn to have negative consequences for health, particularly for those from more disadvantaged backgrounds. This risks widening future health inequalities.

Income and employment

Pandemic restrictions have had a profound effect on the economy, with the reduction in GDP in 2020 the greatest since current records began in the 1950s. Shutting down large parts of the economy has also reduced paid employment and as a result household incomes.,

The huge scale of financial support provided by government has helped to mitigate much of the impact of the pandemic on household finances, as have reduced outgoings for many families. This has left average income levels in 2020 similar to those in 2019. The Coronavirus Job Retention Scheme also has helped to prevent a large rise in unemployment and protected incomes by replacing a proportion of lost earnings. However, there is significant variation in how incomes and employment have been affected.

The duration of the economic shock has meant that by January 2021, 10% of the working population had been unemployed or on full furlough for 6 months or longer. The loss of status and routine that can arise from loss of employment, and reduction in income or disruption such as needing to move home, can increase stress and anxiety and cause depression. A sustained period without work can also cause a scarring effect on future employment chances and earning potential with longer term consequences on health. Increased debts to cover short-term income losses can also create future financial strain.

Box 4: Key government economic support through the pandemic

Job retention: From 1 March 2020 to 30 June 2021, the UK government paid 80% of employee wages, up to a cap of £2,500 a month, for businesses unable to operate fully due to COVID-19. From 1 July 2021 to 30 September 2021, this contribution is being reduced, with the scheme due to end in October 2021.

Self-employment income support: The government offered grants for self-employed people whose businesses were adversely affected. Eligibility required certain criteria: being a sole trader or a partner in a partnership, having been self-employed in the 2019/20 tax year, intending to continue trading in the 2020/21 tax year and being adversely affected by COVID-19.

Business loans: The government offered a range of loans to help businesses recover. The Bounce Back Loan Scheme enabled small and medium-sized businesses to borrow up to 25% of their turnover. And the COVID-19 Corporate Financing Facility involved the Bank of England buying short-term debt from eligible large businesses.

Universal Credit uplift: The government increased the standard allowance of Universal Credit by £20 a week in March 2020 for 1 year, with an equivalent increase to tax credits. In March 2021 it was announced the scheme would be extended until the end of September 2021.


In January 2021 an estimated 25% of the working age population were no longer working, on furlough or reduced earnings (of greater than 10%) compared with February 2020. Some groups were more affected than others including young and old people, those on low pay or in insecure work and the self-employed.

The biggest factor affecting someone’s likelihood of changes to their work status during the pandemic was the sector in which they worked. For example, 72% of people working in hospitality in February 2020 were out of work, furloughed or had a pay reduction of at least 10% or more in January 2021. About 19% of workers in this sector were no longer working compared with 7% across the general working population. Those who work in the sector are more likely to be younger and in low paid or insecure work.

“The biggest factor affecting someone’s likelihood of changes to their work status during the pandemic was the sector in which they worked.”

The share of self-employed people reporting they had stopped working has increased during the pandemic. Compared with February 2020, 9% were no longer working in May 2020, 11% in September 2020 and 14% in January 2021. For this group, earnings were also particularly affected – with 27% reporting they had lost more than 25% of earnings in January 2021 compared with February 2020. Poor targeting of the Self-Employed Income Support Scheme meant that 3 in 10 self-employed workers were not able to receive financial support despite their income decreasing.

As well as younger people (discussed further in Section 5), older people have experienced the most significant changes in employment during the pandemic. In January 2021, 15% of people aged 60–65 were no longer working compared with 7% of all working age people., Among those aged 50–65 working in February 2020, those self-employed (13%), in insecure work (18%), with the lowest weekly pay (14%) and those working in the hospitality sector (10%) were most likely to stop working in January 2021 (compared with 8% across all working people aged 50–65).

Household income

Despite the significant increase in support available, some families experienced large reductions in income – incomes fell by 40% on average for people making claims to Universal Credit. Across the income distribution reductions in family incomes were similar, with 25% of adults from the poorest fifth experiencing a reduction in income, compared with 23% in the wealthiest fifth by September 2020. This is partly because lower income families gained from the Universal Credit uplift, receive a smaller share of income from work overall, and because lower paid workers may live in families with various levels of income.

Taking account of changes in spending and income, 28% of adults saw their family finances deteriorate by September 2020, with poorer families experiencing a bigger hit to their overall finances. One-third of adults from the poorest fifth of families had their income fall further than their spend, compared with a quarter of those from the wealthiest fifth.

Many families have had to rely on savings or increase their debt to get by. However, the experience differed greatly among different sections of the community. The poorest fifth of households were twice as likely as the richest fifth to see their debts rise rather than fall during the crisis. Similarly, 50% of people with savings below £1,000 had to use their savings during the pandemic, compared with less than 20% of those with savings above £20,000.


During the first wave, within parent couples, more mothers than fathers reduced their working hours (21% versus 11% of fathers), quit or lost their job (16% versus 11% of fathers) and were furloughed (34% versus 30% of fathers). The risk of this differential effect is that mothers have had a larger reduction in earnings and employment to recover. If it is also harder to restore their economic position, there could be a prolonged widening in employment and pay outcomes between fathers and mothers.

Already likely to have lower income before the pandemic, almost half of single mothers reported struggling to make ends meet, compared with a third of mothers in couple households. In April 2020, 62% of single mothers reported struggling with going shopping for essentials due to childcare responsibilities, compared with half of mothers in a couple.

During the same month, one-third of mothers on a low income reported having nobody outside their household to help support them during the pandemic. This was higher than the average for all mothers and higher than the average for low-income fathers (29.4% and 25.6% respectively).

Disabled people, young people and ethnic minority communities were also particularly disadvantaged by the economic effects. The outcomes for these groups are explored further in Section 5.

Housing security and homelessness

Good-quality housing can contribute positively to people’s mental and physical health with recent research showing that in addition to quality and condition, the affordability and security of housing are key for ensuring health. Financial pressure can cause increased stress and anxiety and also increase the likelihood of overcrowding.

Due to the financial instability arising from the pandemic, the devolved governments introduced policies to protect families facing rental arrears and mortgage payments. From 26 March 2020 the Coronavirus Act 2020 protected tenants in England by requiring landlords to give extended notice of their intention to evict. Similar legislation was brought in to protect tenants in Wales, Scotland and Northern Ireland.

For homeowners struggling to pay their mortgages, the government announced the availability of a mortgage holiday in March 2020 (extended until the end of July 2021). Despite these schemes, 6% of mortgagors in the English Housing Survey reported being in arrears in July 2020, compared with 1% before the pandemic. Similarly, 7% of private renters were in arrears compared with 3% in arrears pre-pandemic. There was no significant change in arrears for social renters. By January 2021, the Resolution Foundation estimated that the pandemic had led to an extra 450,000 families falling behind on their housing costs. The Joseph Rowntree Foundation estimated that 400,000 renters were at risk of eviction in May 2021.

Rough sleeping

In March 2020 the UK government introduced its scheme ‘Everyone In’ to provide emergency accommodation for people experiencing homelessness. The intervention allowed homeless people to access essential services and enabled self-isolation, which helped to reduce COVID-19 infections and deaths among homeless populations compared with other countries internationally.

The National Audit Office found that by end of November 2020, 23,273 people had been moved into settled accommodation and 9,866 remained in emergency accommodation. However, local authorities and charities reported an ongoing increase in rough sleeping throughout the period.

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