The impact of the pandemic on population health and health inequalities

The fifth and final BMA report with a focus on the impact COVID-19 has had on population health and health inequalities.

Location: UK
Audience: All doctors Patients and public
Updated: Thursday 28 July 2022
COVID virus illustration

About this report

This report looks at the impact of the pandemic on population health and health inequalities in the UK. It discusses how the pandemic has affected the nation’s physical and mental health, as well as social determinants of health such as education and employment.

Throughout, this report pays particular attention to inequalities and how these pandemic effects were distributed. Finally, it looks at the positive lessons that can be learned from the vaccine rollout and efforts to tackle homelessness.

Pre-pandemic population health and health inequalities in the UK

Good population health, distributed equitably across a society, is a buffer against health crises like the COVID-19 pandemic. Unfortunately, in this respect, the UK entered the pandemic on the back foot, due to various factors – most notably underfunding of public health, wider cuts to public services, and an absence of cross-government accountability for health.

Better levels of population health and fewer health inequalities leading into the pandemic would have certainly reduced its devastating impact.

The UK needs to really invest in heathy lives, addressing all the problems which cause illness. Prevention please, not sticking plasters.
GP locum, Northern Ireland

 

Key recommendations

  • UK governments must develop a cross-government strategy to improve population health and reduce health inequalities.
  • All UK governments should adequately fund public health infrastructure and services across the UK. This includes reversing any cuts made in recent years.

Questions for the inquiries

  • How did the poor state of population health and high level of health inequalities affect the UK’s ability to mitigate the impact of the COVID-19 pandemic?

 

The impact of the pandemic on the nation’s health

The pandemic has affected the population’s physical and mental health, and hampered access to care

Over half of the UK population has had COVID-19 since the start of the pandemic, and millions have developed long COVID, suffering long-term effects after infection. Sadly, over 200,000 people in the UK have lost their lives to COVID-19, and other factors, such as delayed cancer diagnoses, have resulted in additional deaths.

The restrictions designed to mitigate viral spread have also influenced our mental health and wellbeing: in March 2022, one in three UK adults reported that their mental health had deteriorated because of the pandemic.

In addition, accessing care has at times been more difficult. When COVID-19 care was prioritised in hospitals across the UK, delivery of non-COVID healthcare became more difficult. Whilst this was necessary to protect under-resourced healthcare systems, it resulted in growing unmet need, and medical professionals are understandably worried about this situation.

 

 

Key recommendations

  • There must be improved treatment and support for those with long COVID.
  • Both physical and mental health services across the UK must be adequately resourced and staffed to respond to the impact of COVID-19.

Key questions for the inquiries

  • Why was there such a high number of excess deaths in the UK and what could have been done to minimise excess deaths?
  • To what extent was the likely mental health impact considered in governments’ responses to the pandemic?

The pandemic has exacerbated health inequalities

The impact of the pandemic on people’s physical and mental health has not been equal across society. Some groups were more deeply affected – especially those who already had worse health outcomes before COVID-19.

The physical and mental health impact on some groups has been much worse

Infection and mortality rates have been much higher, for example, among older people, people from certain ethnic backgrounds, and disabled people – with the risk of death during the first wave three times as high for disabled people and Black African men compared to non-disabled people and White men, respectively. In large part, this has been due to pre-existing health inequalities, and compounded by modifiable factors like lack of targeted support. In addition, public health messaging was not always culturally competent and inclusive.

Communication must ensure to be conducted [sic] in ways that will reach all various groups in our society.
Junior doctor, Wales

One newly defined group that has been at particular risk are those identified as Clinically Extremely Vulnerable (CEV) to severe disease from COVID-19. Though efforts were made to rapidly identify and shield these people, the flawed identification process, often relying on poor-quality linked data, left some unidentified for too long or confused.

The mental health impact of the pandemic was also more keenly felt among certain groups, such as young people, disabled people, and people living in more deprived areas. Reduced social interaction, concerns about access to healthcare and medication, and financial stress are among the contributing factors. For older people and people advised to shield, isolation and loneliness have been common.

Many disabled or clinically vulnerable people were also distressed by damaging narratives that illness or death for them is inevitable, and concerns that they would be deprioritised for life-saving treatment should resource shortages occur.

Society and the health service need to consider those with “underlying conditions” as people whose lives are of value. […] It’s unacceptable to consider some lives as easier to accept as losses than others.
Junior doctor, England

Had health inequalities been better addressed before March 2020, and had these groups been better supported during the pandemic, the physical and mental impact of COVID-19 may not have been so devastating for them.

Reduced access to care has exacerbated the inverse care law

Underlying many health inequalities is the inverse care law – groups who are more in need of healthcare are less likely to receive it – and this trend has been exacerbated by COVID-19, as reduced access to care has disproportionally affected certain at-risk groups. For example, the move to a digital-first approach, mandated across UK health services, may have led to the digital exclusion of some groups, such as older people or those with certain disabilities.

Access to primary healthcare was so difficult for the elderly in terms of phones and IT access, those who had hearing/visual impairment, or those who didn't have English as their 1st language.
Retired doctor not currently working, England

In addition, those without an official immigration status were often fearful of the consequences of seeking COVID care, even when entitled to it – with reports of people dying at home as a result.

Though changes in the way care is delivered during a pandemic are inevitable, more care must be taken that access to care remains equitable.

 

 

Key recommendations

  • Ensure the UK is better prepared to manage a future pandemic in a way that considers the impact on inequalities, e.g., through investing further in high-quality linked data, building trust across society, and improving systems for inclusive and accessible up-to-date public health communications.
  • Ensure that those who are particularly vulnerable to COVID-19 are supported and protected as COVID-19 becomes endemic.
  • Efforts to recover from the impact of the pandemic should explicitly consider groups disproportionally affected by reduced access to care.

Key questions for the inquiries

  • Why were excess deaths inequitable across different groups?
  • When decisions to introduce or relax restrictions were made, to what extent was the impact of those decisions on health inequalities considered?

The pandemic affected people’s health behaviours

Beyond the direct impact of the virus on people’s physical and mental health, the pandemic also influenced the population’s health behaviours – but these effects have been very mixed.

Lockdowns caused changes in physical activity levels

Evidence suggests that lockdowns caused a decline in physical activity, as sport and leisure centres closed, social distancing was enforced, and many people ceased commuting.

But whilst some groups had the time, space and resource to undertake physical activity at home or in nearby green spaces, other groups – often those who already experienced barriers to activity before the pandemic, such as those with a disability or those living in areas without green spaces – found it harder to be active.

The pandemic has changed the way we eat

Studies suggest that, as pubs and restaurants closed their doors, home cooking became more popular and people in the UK improved their diets. Yet diet improvements were more common in certain groups of people: there is a strong correlation between healthier eating habits and increased free time, full-time employment, and higher income.

Alcohol consumption, risky drinking behaviour and alcohol-related deaths increased in the UK

Around one in five UK adults reported drinking more than usual in the first national lockdown, but these levels soon dropped. However, some groups were still drinking more than usual by July 2021, such as those drinking at increasing or higher risk levels, furloughed workers, those that were made redundant, and those struggling with their mental health.

There has also been a stark increase in high-risk drinking behaviour – high-volume consumption that causes mental or physical damage – and, sadly, alcohol-specific deaths during the pandemic.

Some groups smoked more, or more heavily

An estimated 1 million people in Great Britain stopped smoking during the first few months of the pandemic, and it seems that this persisted.

However, while more people overall quit smoking, there was an increase in smoking among young adults and heavier smokers.

 

 

Key recommendations

  • The UK Government must support healthy habits in the long term, by improving access to green spaces, implementing its July 2020 obesity strategy in full, regulating alcohol sales, and increasing efforts to prevent and reduce smoking.

Key questions for the inquiries

  • What evidence is there of barriers to engaging in healthy behaviours during the COVID-19 pandemic, and what might this mean for efforts to improve population health and reduce health inequalities?

 

The pandemic's effect on social determinants of health

Beyond its immediate impact on the physical and mental health of the population, the pandemic has also affected many wider determinants of health, including education and employment.

The health and development of children was affected by school closures, with some children impacted more than others

Pre-school children’s health and development was affected by restrictions

Lockdowns have had a significant impact on early development in young children, causing a sharp rise in developmental issues. For example, fewer opportunities to interact with people outside of their household had a detrimental impact on their psycho-social and language development.

Unfortunately, the public services which could have ameliorated the negative impact of the pandemic on young children had been cut and, in some cases, dismantled ahead of the pandemic.

Disruptions to education across the UK will likely have significant consequences for children and young people’s health

The disruption seen to schooling and further education in the UK, while necessary initially to reduce the spread of the virus, represents a significant risk to the health of children and young people, the full extent of which remains to be seen.

Most children missed out on in-person schooling for substantial periods, which led to a huge reduction in the time they spent on schoolwork every day. In total, UK pupils lost over 60 days of schooling on average.

My biggest concern was the dreadful impact on children’s education. I think there needs to be a very serious review of how to minimise risks to children from impact on their education.
Medical academic (consultant), England

As with most of the harm caused by the pandemic, the disruption of education did not impact on all groups equally, with children from deprived backgrounds being at higher risk of poorer educational and health outcomes.

The pandemic affected employment and financial security for many people, and this has not been equal

Secure employment and financial security are both key determinants of health, and a failure to secure these for the population puts people’s health at risk.

People’s experience during the pandemic has been deeply influenced by their employment. Furloughed workers, those who are self-employed or on zero-hour contracts, and those working in heavily affected sectors like hospitality have often faced huge financial losses and employment insecurity. Some groups, such as women, young people, and certain ethnic minorities, were disproportionally affected in this respect.

Support packages offered by the UK Government were crucial and provided a lifeline for many. Yet they often did not go far enough, or last long enough, to protect those most at risk of financial insecurity. Moreover, questions remain about the decisions to remove such lifelines when COVID-19 continues to circulate in the community.

The long-term impact of COVID-19 on poverty and financial insecurity is likely to be significant. Coupling this with the worsening cost-of-living crisis, projections for population health are poor.

 

 

Key recommendations

  • To reduce health inequalities, the UK Government must take action to ameliorate the financial impact of COVID-19 and the cost-of-living crisis.
  • Future pandemic preparedness must consider the critical importance of household financial security.

Key questions for the inquiries

  • What measures should be taken to ensure schools and nurseries are able to remain open during a future pandemic?
  • What economic support measures should be taken in a future pandemic to ensure the spread of a contagious virus can be contained effectively?

 

Some cautious positive developments

Positive lessons can be learned from the vaccination rollout in the UK

The speedy development and NHS-led rollout of COVID-19 vaccines was the biggest success story of the pandemic. But while the overall vaccine uptake has been momentous, there are significant disparities, particularly along lines of deprivation and ethnicity. Indeed, rates of vaccination were lowest for some of the most at-risk groups, such as some ethnic minorities.

More remains to be done to build trust across all of society and reduce barriers to vaccine uptake amongst these groups. These should build on the significant efforts made by health services, local government, and community leaders to address the historic mistrust of health services amongst ethnic minority groups let down by institutional racism.

Homelessness in the UK was finally addressed during the pandemic, but these measures must now be sustained

Efforts by UK and devolved governments to protect the homeless and those at risk of homelessness during the pandemic were relatively radical, swift and effective: measures were implemented to move people into suitable accommodation with urgency, and eviction bans were introduced.

Regrettably, however, these efforts have not been sustained and progress made during the early stages of the pandemic is at risk of being lost.

Key recommendations

  • Efforts must be made to learn positive lessons from the pandemic, to improve population health and reduce health inequalities now and better prepare for a future pandemic.
  • The positive engagement with communities that was achieved during the vaccine rollout must be sustained, and the institutional racism within the NHS tackled to reduce levels of mistrust and hesitancy amongst ethnic minority communities when engaging with health services.

Key questions for the inquiries

  • What can be learned from the vaccine rollout to better facilitate future public health campaigns?
  • What lessons can be learned about the sustainability and durability of homelessness support initiatives across the UK during the pandemic?