Understanding the impacts of COVID-19 on the provision of NHS health care and patient outcomes

Lead Research Organisation: Imperial College London
Department Name: Imperial College Business School

Abstract

We will provide a detailed description of the extent to which non-COVID-19 NHS activity has been affected by COVID-19, who is most affected, and how patient outcomes have changed.

COVID-19 has led to enormous changes in the provision of NHS care. All non-urgent operations have been cancelled and a third of hospital beds converted for use by COVID-19 patients. A&E attendances dropped by 50% in the past month. This will have major impacts on care received by non-COVID-19 patients and their outcomes during and after the outbreak. However, who is affected and how this is likely to impact future health outcomes is currently unknown.

We will quantify the reduction in NHS care, and examine its distribution by age, sex, ethnicity, deprivation and geography. We will analyse the latest information from Understanding Society and the English Longitudinal Study of Ageing to document disruptions to primary, hospital and community care across England, Scotland and Wales. This will complement analysis of real-time patient records from a large London hospital trust that builds a rich picture of disruptions to hospital care and changes in patient outcomes. This will provide detailed, timely and important evidence of the impacts of the pandemic on care provided to other patients.

The research team has already engaged with key policymakers - including HM Treasury and DHSC - providing evidence on the impacts of COVID-19, and the related economic downturn, on patient health. This research will provide new empirical evidence to help allocate NHS resources to minimise risks to patient health.
 
Description The research funded through this grant has developed an understanding of what happened to non-COVID healthcare in England during the pandemic. Specifically, the research sets out in detail how the overall level of activity in NHS hospitals has changed since the pandemic began, and who has been most affected. Given the very large disruptions to hospital activity, and the subsequent backlog in planned care that has emerged, quantifying these changes and understanding how they related to existing patterns of healthcare use and inequalities is an essential input into post-pandemic NHS planning.
Specific new knowledge generated included:
• Between March 2020 and February 2021, there were 3.5 million (34.9%) fewer elective admissions and 1.6 million (24%) fewer emergency admissions to NHS hospitals than in the previous 12 months. The research showed that not only had activity fallen due to hospital decisions to cancel planned activity, but emergency activity had also fallen in part due to patient decisions not to seek care.
• Changes in activity varied substantially across regions. Falls in planned care were typically larger in the North and the Midlands than they were in London and the South of England (e.g. elective activity fell by 38.5% in the East Midlands compared to a 29.9% fall in the South West). In contrast, emergency admissions fell by substantially more in London than elsewhere in the country. Highlighting these regional differences is important in identifying where the greatest backlogs in planned care are likely to occur.
• The greatest falls in activity (as a % of pre-pandemic levels) were in children. Between March 2020 and February 2021, emergency admissions among the under 18s fell by 40% (compared to the second most affected age group, 18-34 year olds, who saw a 24% fall). This may in part reflect a larger reduction in needs among this group during lockdown periods (e.g. due to decreased infections of other diseases spread at school, or fewer everyday accidents) but also raises concerns over worse outcomes for children who did not receive appropriate care at the time as a result of the pandemic (and is also consistent with international evidence on paediatric hospital activity).
• Falls in activity between March and December 2020 varied by the ethnicity of the local population, even after taking into account the different characteristics of different population groups. Areas with the largest share of non-white populations experienced a 36.7% larger reduction in non-primary-COVID-19 emergency admissions compared with those with the smallest, even after controlling for other time-varying care needs in each area. These areas had typically greater use (and needs) for emergency care prior to the pandemic, and suggests there was a significant risk that health inequalities could be exacerbated if this more vulnerable patient group did not access required care.

The funding also allowed researchers to develop expertise in modelling elective backlogs and future NHS waiting list scenarios. This has allowed the researchers to feed into the important policy debate around how to reduce these lists (e.g. advising the No.10 data team modelling waiting list scenarios).
Exploitation Route The project has generated key new knowledge on the extent of disruption to NHS activity during the first year of the pandemic, and the groups most affected. While these disruptions to care had been speculated upon within the media and by politicians, our analysis was the first to use administrative data to quantify the changes in hospital admissions across England.

Our findings could be used in several ways by others. First, policymakers and practitioners may use findings to identify groups of patients who are at risk from missed care during the pandemic. This can be used by these decision-makers to prioritise patients as the NHS increases activity.

Second, the media may use the findings to inform the public about how use of the NHS changed during the pandemic. This will feed into public discussion of waiting times as the pandemic ends, and help to explain why waiting times have increased (and why they may continue to increase over the coming months as 'missing' patients return).

Finally, our work is a first step in understanding the wider consequences of the pandemic for health outcomes, and other researchers may build on this to explore the consequences of missed care for patients.
Sectors Healthcare
URL https://www.gov.uk/government/publications/dhsc-direct-and-indirect-health-impacts-of-covid-19-in-england-long-paper-9-september-2021
 
Description Significant contributions to DHSC/ONS (2021), 'Direct and Indirect health impacts of COVID-19 in England', https://www.gov.uk/government/publications/dhsc-direct-and-indirect-health-impacts-of-covid-19-in-england-long-paper-9-september-2021 A summary of the ESRC funded research on this is here: https://ifs.org.uk/publications/15625) The research was used as a springboard to study waiting times and the performance of the NHS as we emerged from the pandemic. This has generated considerable impact - including direct discussions with the No 10 data analysis team and Steve Barclay - and we have been shortlisted for a science communications award (the Harding Prize - https://hardingprize.online/).
First Year Of Impact 2021
Sector Healthcare
Impact Types Societal,Policy & public services
 
Description Cited in government publication
Geographic Reach National 
Policy Influence Type Citation in other policy documents
URL https://www.gov.uk/government/publications/dhsc-direct-and-indirect-health-impacts-of-covid-19-in-en...
 
Description IFS podcast 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact IFS podcast

Paul Johnson, George Stoye, 'What does COVID mean for the NHS?', IFS podcast, 1 June 2021
Year(s) Of Engagement Activity 2021
 
Description Interview for national news 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact A podcast from the IFS featuring Carol Propper aimed at those in healthcare policy making and the general public and academia

C Propper (2020) 'COVID-19 and disruptions to the health and social care of older people in England', online event.
https://ifs.org.uk/publications/15180
Year(s) Of Engagement Activity 2020
URL https://ifs.org.uk/publications/15180
 
Description Interview for national news 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Interviews on national radio
George Stoye, BBC Radio 4, Today Programme, Live interview with Nick Robinson, 13 May 2021;
George Stoye, BBC London, Breakfast, Live interview with Vanessa Feltz, 13 May 2021;
George Stoye, BBC Merseyside, Breakfast, Live interview with Paul Salt, 13 May 2021;
George Stoye, BBC Merseyside, News Bulletin Pre-Rec, 12 May 2021 (played 13 May 2021);
George Stoye, BBC News Channel, Live interview with Rebecca Jones, 12 August 2021;
Year(s) Of Engagement Activity 2021