Executive summary

As the success of the COVID-19 vaccination programme sets the UK on a course towards recovery, it is essential to learn the lessons of the past 18 months. What started as a health crisis rapidly developed into an economic emergency, with government taking unprecedented action to protect people’s lives and livelihoods. The pandemic has shown that health and wealth are inextricably connected. A sustainable recovery needs to create a stronger, more resilient economy and will require purposeful commitment to ‘level up’ health and reduce the stark inequalities exposed by the pandemic.

Although COVID-19 has challenged governments around the world, the UK was notable in entering the pandemic with life expectancy stalling for the first time in a century and falling for some. Following the 2008 financial crisis, public services had been eroded and the underlying economy and social fabric frayed.

Over the first year the UK experienced some of the worst outcomes internationally, with 119,000 excess deaths by 13 March 2021. Measures to suppress the virus have led to the UK experiencing a huge economic shock – including a 9.9% drop in GDP in 2020 compared with a 4.8% drop across all OECD countries.

Behind these overall figures lie the unequal burdens carried by different population groups and regions. During the first wave of the pandemic, 40% of all UK deaths were among care home residents. 6 out of 10 people who died with COVID-19 between January and November 2020 were disabled. And people from ethnic minority communities had significantly higher risk of mortality – 3.7 times greater for black African men than their white counterparts during the first wave and Bangladeshi men more than five times more likely to die during the second wave.

The Health Foundation’s COVID-19 impact inquiry has drawn on a broad range of available evidence to consider two main questions:

  1. How were people’s experiences of the pandemic influenced by their pre-existing health and health inequalities?
  2. What is the likely impact of actions taken in response to the pandemic on the nation’s health and health inequalities – now and in the future?

It is beyond our intended scope to propose specific policy recommendations. But the findings from this inquiry can direct policymakers at national and local level to some core issues that need attention as they take the recovery forward.

COVID-19 mortality and the actions taken to reduce it

Government restrictions have suppressed the spread of the virus and saved lives. National and tiered lockdowns, PPE provision, self-isolation measures, and the vaccine programme have moved us towards recovery.

Despite these actions, the UK had the fourth highest excess deaths of OECD countries in 2020. Excess deaths for people younger than 65 were the second highest in Europe after Bulgaria. The UK’s experience was worse during the second wave (326,352 COVID-19-related hospitalisations and 96,763 COVID-19 deaths in this wave alone).

Several factors have influenced variations in the impact of COVID-19 across different countries. The single biggest factor was the timing of pandemic restrictions as these influenced levels of exposure to the virus. Population density and high levels of regional and international travel accelerated spread in the UK ahead of restrictions.

Poor underlying health also accounted for differences in excess mortality among countries – particularly in the outcomes for people younger than 65. Countries with the greatest improvement in healthy life expectancy over the previous decade experienced lower excess mortality during the pandemic. Conversely, countries with the highest levels of disability-adjusted life years lost to diabetes, cardiovascular disease, cancer and chronic respiratory disease had higher mortality rates.

Certain socioeconomic factors were also associated with an increased risk of transmission. In England, COVID-19 mortality rates were more than twice as high for people from the most deprived 10% of local areas compared with people from the least deprived, and almost four times as high for people younger than 65. Pre-existing differences in health were associated with worse outcomes from COVID-19, with those aged 50–69 in the most deprived areas twice as likely as those in the least deprived areas to have at least two long-term health conditions.

The type of work someone does and their access to financial support also shaped their risk of, and outcomes from, COVID-19. People working in elementary, caring, leisure and other service occupations had higher mortality rates, and these were higher still for men. This partly reflects poorer existing health, but also because these roles are often in sectors typified by having remained open during lockdowns or having fewer restrictive measures. For lower income workers, the inadequate level of support for sick pay was a key factor in not self-isolating.

Immediate risks to health

The immediate risks to people’s health go beyond the direct harm caused by the virus. Reprioritisation of health care services to manage COVID-19-related demand has led to increased unmet need for care. Health Foundation analysis shows that 6 million ‘missing patients’ did not seek treatment in 2020, which could mean many living with poor health for longer. In cases of acute need, such as cancer care, where treatments have been delayed, reductions in survival rates are likely.

Long COVID will limit people’s ability to return to daily life. By May 2021, an estimated 1 million people self-reported being affected by long COVID (equivalent to 1 in 5 people who tested positive for COVID-19). Women and those from more deprived backgrounds appear to be at particular risk, disrupting employment and reducing quality of life.

“In England, COVID-19 mortality rates were almost four times as high for those younger than 65 from the most deprived 10% of local areas.”

Pandemic restrictions have also affected people’s mental health through reduced social interaction, changing work conditions and loss of work and income. Although the easing of restrictions tended to improve mental health, by September 2020 there had been a sustained deterioration in mental health for a fifth of the population. Women, younger people and those facing financial hardship have fared the worst.

Access to social care services has declined despite increasing need. This will have longer term effects on the health and wellbeing of those needing care and exacerbate the growing pre-pandemic responsibilities of unpaid carers.

Reported incidents of domestic abuse increased during the first wave of the pandemic. With children out of school, child safeguarding referrals reduced. One study found a 37% decrease in referrals for child protection medical examinations between February and June 2020 than in the same period in 2019 – suggesting some children were left exposed to harm.

The vaccination programme has been crucial in reducing the spread of the virus and preventing deaths and hospitalisations with over 70 million doses of the vaccine given by 12 June 2021. Despite this there are emerging differences in access to and uptake of the vaccine. In the least deprived fifth of areas 95% of people aged 50 and older have received one dose, compared with 88% in the poorest. 67% of black Caribbean people and 78% of Pakistani people older than 50 have received one dose compared with 94% of white people. These threaten to exacerbate existing health inequalities as well as the continued risk posed by existing and emerging variants.

Future risks to health

With large parts of the economy shut down and people required to stay at home, the government implemented unprecedented economic measures to provide support for individuals, families and businesses (such as the Coronavirus Job Retention Scheme) and increased existing financial support (such as the £20 weekly Universal Credit uplift). Despite the scale of action, 28% of adults saw their family finances deteriorate by September 2020. Many families had to rely on savings or debt to get by with more than half (54%) of those in the poorest fifth seeing their debts rise compared with 31% of the wealthiest fifth.

Although there were early signs of labour market recovery in spring 2021, an extra 2.8 million people were out of work in May 2021 than before the pandemic, and the end of the furlough scheme in autumn is likely to mean unemployment rises. Assuming the £20 a week uplift to Universal Credit ends in September 2021, around 6 million families will experience a drop in income.

Experiencing financial strain or periods of unemployment – resulting in lack of status, structure and income – are associated with poorer physical and mental health. As temporary support measures end, the pandemic risks further eroding people’s health through a decline in living conditions and an increase in poverty.

The loss of education during the pandemic also risks widening the gap in future health outcomes. The cohort of children and young people who have missed periods of education could lag behind pre-pandemic cohorts. The loss of education has also not fallen evenly, with children from more disadvantaged backgrounds having experienced a greater deterioration in their educational outcomes.

But the risks to health identified in this report are far from inevitable and can be addressed through a fair recovery.

Ensuring a healthy recovery

The government’s ‘levelling up’ agenda – and its associated funding for local government – creates an opportunity to ensure this recovery is managed better than that following the 2008 financial crisis and creates a more resilient and fairer society.

With poor health estimated to cost the UK economy £100bn a year in reduced productivity, the much-needed economic recovery will also require a recovery in the nation’s health.

Immediate action is needed to address the harm caused by the pandemic – tackling the health care backlog, protecting family finances and ‘catching up’ on education. There need to be greater protections for low-paid workers as well as schemes and targeted support for people whose mental health has deteriorated to get back into work.

Over the longer term, resilience can be built through investment to create good-quality jobs in areas with historically low employment, as well as those hardest hit by the pandemic. Businesses can design better quality jobs and individuals can continue to help strengthen local communities. Weaknesses in the welfare state need to be addressed to provide an adequate safety net that supports people through income and health shocks. Public services will require investment and to be redesigned to put prevention first.

The nation’s health has frayed over the past decade and this has contributed to the UK experiencing some of the poorest global outcomes from the COVID-19 pandemic. Ensuring a recovery that improves health – as well as the economy – will require a cross-government health inequalities strategy with clear targets for improvement and a regular, independent assessment of the nation’s health laid before parliament.

* Excess deaths measure additional deaths over a time period compared with the number of deaths usually expected. We measure the deaths caused by the pandemic in excess deaths instead of registered COVID-19 deaths due to discrepancies in the way COVID-19 deaths are recorded.

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