Update: How is the Covid-19 crisis affecting the NHS?

The pandemic has put the NHS under immense pressure: a surge in Covid-19-related care was initially accompanied by a reduction in demand and supply of other services. Waiting lists have now reached record levels; and demand for private healthcare may grow.

Covid-19 has presented substantial challenges to the UK’s National Health Service (NHS). Since the start of the pandemic, over half a million people have received hospital treatment for Covid-19 and in mid-January 2021, over 4,000 new Covid-19 patients were being admitted to hospital each day.

The surge in Covid-19-related treatment has also affected care for other illnesses. This had already begun to show in May 2020 when the original version of this article was published. In this update, we examine in more detail how the numbers of admissions and waiting times have changed over the course of the pandemic, and how the situation is expected to develop.

As predicted, Covid-19 has affected both the demand for care – particularly through fewer accident and emergency (A&E) visits, even after the end of lockdowns – and the supply of care – where many elective (planned) admissions were postponed to maintain capacity for Covid-19 patients.

Between March and December 2020, there were 2.9 million (34.4%) fewer elective in-patient admissions, 1.2 million (21.4%) fewer non-Covid-19 emergency in-patient admissions and 17.1 million (21.8%) fewer out-patient appointments compared with the same period in 2019 (Institute for Fiscal Studies (IFS), 2021).

Figure 1: Weekly appointments in 2019 and 2020

Source: Institute for Fiscal Studies (IFS), 2021

Note: Data are for outpatients only

The decrease in admissions has been more significant among particular disadvantaged groups. People living in the most deprived local areas, defined as the bottom decile of the Index of Multiple Deprivation, had 23% fewer emergency admissions in March to December 2020, compared with a 20% reduction for those in the least deprived areas. This decrease is much larger in absolute terms, as more deprived areas had higher emergency admissions per person before the pandemic.

There are also substantial differences by ethnicity. The largest percentage decreases in emergency in-patient admissions were among Asian, black and mixed-ethnicity individuals – for example, the decrease for Asian individuals was 32%, compared with 21% for white patients (IFS, 2021). These unequal disruptions to treatment are likely to exacerbate existing health inequalities and add to growing evidence that the pandemic has affected some ethnic groups more severely than others (Marmot et al, 2020).

How large is the backlog?

The effects of Covid-19 on the NHS will be long lasting, as exemplified by current waiting list figures. In May 2021, 5.3 million people were waiting to start treatment, with over 336,000 of those waiting for more than a year. The corresponding figures for January 2020 were 4.3 million and fewer than 1,700 respectively. Given the reduction in elective admissions and out-patient appointments, it is perhaps surprising that waiting lists are not even longer.

In fact, the effect of reduced NHS capacity was minimised by a drop in entries to waiting lists through referral from a GP or hospital consultant. Between March 2020 and May 2021, 7.4 million fewer people joined the list than would have been expected if pre-pandemic trends had continued.

Future waiting times will depend on NHS capacity post-Covid-19, how many of these people join waiting lists and when they join (Stoye et al, 2021). In any event, the number of people on waiting lists is expected to rise still further.

For the NHS and the government to deal with the backlog effectively, much more investment in healthcare will be needed. Currently, the NHS is investing an additional £1 billion to carry out extra operations and treatments, and another £160 million to trial new techniques that can increase, for example, the number of scans.

Crucially though, plans for additional funding must take account of the need for sufficient numbers of staff to provide these services. Even before the Covid-19 crisis in December 2019, there were 39,000 nursing NHS vacancies – an 11% vacancy rate. Pre-pandemic trends in staffing and hospital admissions also suggest that staffing numbers have not kept pace with increases in hospital activity.

While the net impact of Covid-19 on NHS staffing levels remains unclear, anecdotal evidence suggests that many healthcare workers are leaving the NHS or the healthcare sector altogether, after a difficult year. Brexit has also led to sharp declines in the number of trained nurses from the European Union coming to the UK, although some of this has been offset by an increase in non-European nurses joining the NHS. Overall, these additional staffing challenges make having a workforce strategy that rewards, trains and retains staff more important than ever.

Worsening diet and exercise habits throughout the pandemic may also increase future demand for healthcare. Total calories consumed by people in the UK were 15% above normal levels by May 2020 and remained higher than normal for the rest of the year (IFS, 2021).

Public Health England estimates that more than 40% of adults in England gained weight during the pandemic, with the average gain being half a stone (around 3kg). Should these lifestyle changes persist, the NHS may come under further pressure due to the resulting increases in health conditions associated with excess weight.

High waiting lists have historically led to increased demand for private healthcare (Besley et al, 1999). It seems likely that the pandemic will result in similar increases for two reasons. First, waiting lists are particularly long for elective surgeries that are commonly performed in the private sector, such as hip and knee operations. Second, the pandemic has enabled many higher-income individuals to save more, making private provision – whether through direct pay or insurance – a more viable option.

This may mitigate short-term pressures on the NHS. But if demand for private healthcare increases such that it starts to draw capacity away from the NHS, this may increase the already high NHS staffing shortages and end up leading to worse outcomes for those seeking free care at the point of use.