Today, the Scientific Advisory Group for Emergencies (SAGE) released a further paper estimating the impact of the coronavirus (COVID-19) on England's mortality and morbidity. This was a collaboration between the Office for National Statistics (ONS) and the Department of Health and Social Care (DHSC), with input from the Health Foundation, the Institute and Faculty of Actuaries, the Institute of Fiscal Studies, and academics. It was discussed by SAGE on 9 September 2021.
This series of papers presents estimates of how COVID-19 has affected England both directly and indirectly, investigating four categories of harm. The previous report in this series was discussed by SAGE on 19 November and 17 December 2020, and released on 29 January 2021. We released a statement to coincide with SAGE's release of the previous version of this paper, outlining the significance and structure of this work.
The latest update continues to present the direct and indirect impacts of COVID-19 on mortality and morbidity, for the same categories as previously shown, but with a specific focus on how COVID-19 has affected different groups in the population. This latest release estimates COVID-19's impacts on people depending on region of residence, age, sex, and ethnicity. The indirect impacts of COVID-19 on wider healthcare have been expanded to consider changes in underlying health needs, health-seeking behaviour, and consideration of mental health specifically.
The ONS' primary contribution to the latest paper is estimating how COVID-19 has directly affected mortality for different groups. The paper presents estimates of deaths because of COVID-19 which the ONS has previously published on this website, including data on weekly deaths by age and sex; age-standardised mortality rates by region and deprivation quintile; and hazard ratios of deaths involving COVID-19 by ethnic group and disability status. Additional analysis estimates how deaths for some of these breakdowns represent different amounts of life lost, using Quality-Adjusted Life Years (QALYs).
The main points of the paper for SAGE are summarised below, and the short and detailed papers can be found in SAGE's September meeting papers.
Main points from "Direct and Indirect health impacts of COVID-19 in England"
The latest estimates of COVID-19's impacts on healthcare as a whole suggest there has been a fall in underlying short-term need related to non-COVID infections, accidents, and air pollution. Conversely there has been an increase in underlying need from alcohol and substance abuse and domestic violence. Health-seeking behaviour has altered during the pandemic: primary care consultations fell significantly compared with their 2016 to 2019 average after the start of the pandemic and only fully recovered by May 2021. This fall cannot be directly attributed to changes to underlying need, changes in health-seeking behaviour or adaptations put in place in the health system to respond to COVID-19. Diagnosis of a range of chronic conditions fell significantly, though management of existing long-term conditions appears less negatively affected. There has been a fall in referrals to secondary care for routine appointments mirroring the fall in numbers of GP consultations. Routine referrals to January 2021 generally remained below the four-year average. Hospital activity declined sharply in the first wave, recovering steadily in most specialties but patient wait times have continued to increase. The adverse economic shock and impacts on education are likely to lead to poorer health in the population and future health care need.
People in the most deprived socio-economic groups have experienced greater adverse health impacts in almost all categories of harm for which deprivation levels could be considered. From March 2020 to April 2021, the mortality rate in the most deprived quintile after controlling for age and population size was almost double that of the least deprived quintile (264.6 deaths per 100,000 people and 140.4, respectively). Recent estimates for long COVID (August 2021) also show that self-reported symptoms are 50% higher in people in the most deprived quintile, compared with the least deprived (1.89% of people experiencing long COVID compared with 1.24%).
The reduction in GP consultations per patient in does not significantly differ by socio-economic status between 2019 and 2020 once age has been taken into account, but as there is greater health need in lower socio-economic groups, this will have had greater impact in absolute terms. Similarly, reductions in admissions for elective care and outpatient appointments between February 2020 and February 2021 were similar across socio-economic groups. However, patients on long surgical lists who are in lower socio-economic categories have also reported worse outcomes in quality of life.
Regionally, the pandemic shock and its impacts on the healthcare system varied significantly. Greater London experienced greatest direct health impacts of COVID-19. it had the highest rate of deaths to April 2021 once population size and age were taken into account; it also had the greatest QALY losses from death and morbidity. It experienced relatively lower reductions in elective and outpatient activity than other regions, though London’s reduction in emergency activity was greater than most regions (28.4% reduction compared with median of 24.9%). The West Midlands, East Midlands and Yorkshire and the Humber suffered less from direct COVID-19 impacts, but experienced greater impacts through reduced non-COVID-19 activity in the NHS with elective care down more than 38% between February 2020 and February 2021 compared with the previous 12 months.
Different age groups have experienced diverse impacts as a result of the pandemic. The majority of direct mortality impacts are seen in older age groups, with 99% of deaths recorded in people over the age of 45 years. However, the age group with the greatest percentage reporting symptoms 5 weeks post infection is the 35 to 49-year-old group (25.6% of infected individuals report symptoms at 5 weeks post infection) and the 25 to 34-year-old group have the greatest percentage reporting symptoms 12 weeks post infection (18.2%).
Young people, particularly under 11 years, saw the largest fall in consultation rates and were most likely to have reduced GP appointments relative to older age groups. In April 2020, there was a drop in mental illness referrals from the February levels of around half in 0 to 18-year-olds compared with around a third in adults (19 years and over), but these have recovered and have been above pre-pandemic levels since September 2020.
Impacts for males and females differed depending on the type of health impact; more QALYs were lost for males than females overall through deaths because of COVID-19 to April 2021. Females are more likely to suffer symptoms for an extended period of time compared with males. Reductions in hospital activity in the period February 2020 to February 2021 have been roughly similar.
During the first wave of the pandemic people from all ethnic minority groups (except for women in the Chinese or White Other ethnic groups) had higher rates of death involving COVID-19 compared with the White British ethnic group. The rate of death was highest for the Black African ethnic group, followed by the Bangladeshi, Black Caribbean and Pakistani ethnic groups. In the second wave of the pandemic, the differences in COVID-19 mortality increased for people of Bangladeshi and Pakistani ethnic backgrounds when compared with the White British ethnic group; the Bangladeshi group had the highest rates, 5.0 and 4.1 times greater than for White British males and females respectively. The greatest percentage fall in hospital activity in the year to February 2021 compared with the year to February 2020 is seen for the White British ethnic group, along with all other white ethnic groups, followed by the Asian and Asian British ethnic group. For emergency care, the Other ethnic group and those from the Asian ethnic group saw the most significant fall in absolute volumes. Similarly, for outpatient care, the Other ethnic group and the White British ethnic group saw the largest decreases.