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Shock to the system: COVID-19’s long-term impact on the NHS

The coronavirus (COVID-19) pandemic is a major shock to the NHS and social care systems and has resulted in a substantial rise in mortality. Over recent weeks the Health Foundation has begun publishing a series of charts and commentaries, describing the different dimensions of the impact of COVID-19 as they unfold. One of the key issues we have been exploring is how COVID-19 has impacted on NHS care and services for people with other health needs. Some important trends are beginning to emerge.

Use of emergency care services has changed in some predictable and some less predictable ways
A&E visits this April were less than half the number at the same time last year. Falls in visits to A&E in March and April 2020 were very similar across regions, although reductions were slightly larger in London than other regions. This is consistent with people with less severe conditions being directed to other NHS services or choosing to avoid seeking medical care. The lockdown is also having an impact beyond COVID-19 and Public Health England surveillance reports suggest the prevalence of certain infectious diseases has fallen.

Alongside fewer A&E visits, emergency admissions from A&E have also fallen, but not by as much. This is likely to reflect both a change in the types of patients arriving at A&E and efforts to reduce the risk of non-COVID patients being infected and protect capacity.

In March, there were larger percentage falls in admissions in London (30%) relative to the rest of the country (18-22%). In April, London again saw the largest fall in admissions (45%). Another five regions had falls of between 34% and 40%, with the North West an outlier, seeing a reduction of just 28%.

Although A&E visits more than halved in March and April, there were relatively small changes in the number of calls to ambulance services. However, there have been substantial changes in how ambulance crews treat patients. The number of patients transported to A&E by ambulance in April 2020 was 29% lower than in April 2019.

This is a reduction of 4,000 patients per day or 120,000 across the whole month. There has been a corresponding increase in the number of people who are treated at the scene or by telephone without needing to be transported to hospital.

COVID-19 is having a significant impact on care for people with long-term conditions
Before this crisis, around 85% of the 'burden of disease' in the UK was from long-term conditions rather than infectious disease. Although the government has put measures in place to protect and support vulnerable people, there are growing concerns about the impact of the COVID-19 outbreak on the health care needs of those with longer-term health conditions. Restricted access to care may have arisen if patients choose not to use services, through fears they might contract or transmit COVID-19 or concerns about breaking the lockdown measures, or if they are unable to get an appointment with the relevant health service.

To examine the impact of COVID-19 on access to and use of health care services for people with pre-existing health conditions, the Health Foundation supported an online YouGov survey of members of the public, designed by the Resolution Foundation. 6,005 people in the UK responded to the survey between 6 and 11 May.

The survey found that access to health services for people with pre-existing conditions was 20% lower during the COVID-19 peak period. Some of the largest falls in the use of health services are for mental health and cancer.

Those patients with pre-existing conditions, who reported that they have not accessed care, were also asked the reason. While many patients (47%) reported that they did not need access to health care, 10% said that they were unable to get an appointment and 22% cited concerns over contracting/transmitting the virus or worries about breaking the lockdown.

The survey data is mirrored in data from NHS Digital, which show a substantial fall in GP appointments towards the end of March and during April. Face to face appointments have reduced, and only partially been replaced by telephone or other methods. These data may not count other kinds of appointments taking place, such as in hubs, or telephone triage, but they may also reflect a drop in the number of patients contacting their GP.

Patients may be using NHS 111 instead, or avoiding contact with their GP because of worries over infection or overloading NHS services. The next few weeks will bring data for April, which might shed more light on what’s happened within general practice during COVID-19.

Restarting routine care will be challenging and waiting times are likely to be a feature of the NHS for many years to come
In January 2020, even before large numbers of COVID-19 hospitalisations, a total of 4.4 million patients were on the waiting list for routine hospital treatment – around 730,000 of whom (1 in 6) had waited more than 18 weeks.

New analysis by the Health Foundation finds that even before the coronavirus (COVID-19) pandemic, to meet the 18-week standard for newly referred patients and clear the backlog of patients who will have already waited longer than 18 weeks, the NHS would have needed to treat an additional 500,000 patients a year for the next 4 years.

The pandemic is likely to increase waiting lists further so the challenge will undoubtedly be even greater.

The NHS has begun a cautious programme to resume some routine services. But caring for patients with enhanced infection control arrangements will reduce the volume of patients that can be treated relative to normal. Without a radical intervention to increase capacity, it is unrealistic to expect the 18-week standard to be achieved by 2024 with current infrastructure and staffing levels.

Even before the impact of COVID-19 is factored in, meeting the 18-week standard would require hospitals to increase the number of patients they admit by an amount equivalent to 12% of all the patients admitted for planned care in 2017/18. This would be an unprecedented increase in activity.

Over the coming years there will need to be long-term changes to how routine care is delivered, considerable effort at the front line and potentially an important role for the independent sector if the NHS is to return to a position of meeting the 18-week standard. But even with huge efforts the reality is that longer waiting times for planned care are likely to be a feature of the NHS in England for several years at least.

What next
Over the coming weeks we will continue to extend our analysis; exploring regional variations in the impact of COVID-19 and how the pandemic is affecting the capacity and resilience of the health and care system. You can keep in touch with all the analysis on the COVID-19 charts section of our website.


Anita Charlesworth (@AnitaCTHF) is the Director of Research and Economics.

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