Written evidence submitted by The Health Foundation (CLL0089)

About the Health Foundation

The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Our aim is a healthier population, supported by high quality health care that can be equitably accessed. We learn what works to make people’s lives healthier and improve the health care system. From giving grants to those working at the front line to carrying out research and policy analysis, we shine a light on how to make successful change happen.

Executive summary

This submission provides an overview of relevant analysis and commentary published by the Health Foundation, during the first six months of the COVID-19 pandemic. We hope this evidence is helpful to the Committees’ joint inquiry to identify lessons to be learned from the response to the coronavirus pandemic so far.

With the pandemic still ongoing, and as the UK experiences a ‘second wave’, it is too early to make a definitive assessment of the government’s handling of the pandemic. Nevertheless, we can draw out some emerging lessons from the early evidence and indications featured in our submission.

Firstly, the pandemic has exposed and exacerbated major inequalities in our society. COVID-19 and the knock-on effects of lockdown and social distancing measures have affected everyone in some way, but some groups have felt the effects more harshly than others. For instance, people of black ethnicity are four times as likely to die from COVID-19 compared to people of white ethnicity[1]. The virus has demonstrated the need for greater government action, including through a national cross-departmental health inequalities strategy. You can read our evidence on this in the ‘equity impact’ section of our submission.

Secondly, the pandemic and policies to control the virus will have long-term impacts on health and health services. For instance, the delaying and cancelling of elective care during peak periods in the pandemic will have consequences for the size of the NHS backlog, meaning patients will have unmet care needs and face longer waiting times for consultant led care. The mental health consequences of the pandemic are a considerable concern too. On average over the next 3 years we estimate that there could be 11% more mental health referrals a year, costing between £1.1 and 1.4bn extra each year[2]. Similarly, the impact of the pandemic on young people’s employment, education, and health outcomes is likely to be felt for several years to come. One in three 18 – 24 year olds have been furloughed or lost their job – twice the rate amongst working-age adults[3]. As we gradually move from crisis management to recovery in 2021, government will need to reflect the medium and long-term impacts of the pandemic in its response.

Thirdly, the pandemic has further highlighted the fragility and neglect of our social care system. Government action to support social care during the first wave of the pandemic was too slow and inadequate. Protecting and strengthening social care was given far lower priority by national policymakers than protecting the NHS. However, the response was also constrained by longstanding policy failures. We entered the pandemic with a system that was underfunded, understaffed, undervalued and at risk of collapse. Any response to COVID-19 – however fast or comprehensive – would have needed to contend with this legacy of political neglect. Making the system fairer, more sustainable, and reforming the funding system should be a key priority for government. Better data in social care would also help to develop our understanding of the challenges faced by the sector.

Finally, public polling tells us that the public’s perception of the government’s handling of the virus has changed during the course of the pandemic. In July, the public were more critical of the government’s handling of the outbreak compared to May. Polling results from July also showed that the clarity of the government’s official guidance varied, across the range of measures in place at the time.

We will continue to learn lessons as our understanding of the impacts of the virus develops. We hope the information in this submission is useful to the Committees’ inquiry.

Excess mortality: comparing COVID-19’s impact in the UK to other European countries in the first wave[4]

The number of deaths from coronavirus (COVID-19) has often been used to compare countries but is an unreliable metric for making meaningful comparisons. The way COVID-19 deaths are counted varies across countries and may change over time. A better measure is excess deaths (or excess mortality) – the number of deaths in a given period over and above the number expected (such as the number in an average week). Comparing excess deaths across countries, regions and localities can provide valuable learning about differences in impact, and what has contributed to them.

This chart overleaf shows the weekly excess deaths (as a proportion of usual deaths) for selected European countries, during the first wave of the pandemic. Spain had the highest peak, with deaths in the peak week being 155% more than usual. The UK also had a high peak (109%) and experienced a slow descent. Until the first week of April, France and the UK seemed on the same trajectory, but this was actually the peak week in France and their curve flattened quickly thereafter. Meanwhile, the UK’s deaths kept on growing. Germany is notable for the flatness of its wave. Over the 11 weeks of the first wave, the UK had 52% more deaths than usual, trailing Spain (56%), but ahead of Italy (35%), France (20%) and Germany (4%).

Comparing excess deaths per capita, tells a similar story about how the UK has fared compared to other countries. Over the 11-week period, the UK experienced 965 more deaths per million of the population than usual, compared to 1,023 for Spain. The rate in France was less than half that of the UK. In Germany it was less than a tenth.

Overall, this analysis suggests that the UK has been one of the worst affected countries against other European comparators.

The Health Foundation’s COVID-19 Policy Tracker

The policy responses to COVID-19 have been complex and rapidly evolving – with different countries pursuing varying approaches to managing the pandemic. Documenting these policies can help us understand and assess government responses to COVID-19 over time.

The Health Foundation’s COVID-19 policy tracker documents national government and health and social care system responses to COVID-19 in England, and how they change over time[5]. The interactive timeline - shown in the image overleaf – illustrates the key policies and events since 31 December 2019. The full tracker includes data on what changes have been introduced, when, why, and by whom – as well as how these changes have been communicated by policymakers. Within the tracker, policy changes are tracked across five areas – from health and care system changes to wider social and economic policy. New and updated versions of the tracker are uploaded fortnightly.

The impact on the social care sector

Overall, central government support for social care during the pandemic came too late. Some initial policies targeted the social care sector in March, but the government's COVID-19: adult social care action plan[6] was not published until 15 April – almost a month after countrywide social distancing measures had been introduced. Another month passed before government introduced a dedicated fund to support infection control in care homes.

In July 2020 we published Adult social care and COVID-19: Assessing the impact on social care users and staff in England so far[7] – our analysis of the scale of the impact of COVID-19 on social care in England during the first phase of the pandemic. The key findings from our report were:

•                                                                                                                                                                                                             The coronavirus (COVID-19) pandemic has had a profound impact on people receiving and providing social care in England. Between March and June 2020, there were more than 30,500 deaths among care home residents than we would normally expect, and a further 4,500 excess deaths among people receiving care in their own homes (domiciliary care).
•                                                                                                                                                                                                             There was a greater proportional increase in deaths among domiciliary care users than in care homes (225% compared to 208%).
•                                                                                                                                                                                                             Social care workers are among the occupational groups at highest risk of COVID-19 mortality, with care home workers and home carers accounting for the highest proportion of COVID-19 deaths within this group.
•                                                                                                                                                                                                             During March and April, there was a substantial reduction in hospital admissions among care home residents. Elective admissions reduced to 58% of the 5-year historical average and emergency admissions to 85% of the 5-year historical average. By reducing admissions, care home and NHS teams may have reduced the risk of transmission, but there may have also been an increase in unmet health needs.
•                                                                                                                                                                                                             During March and April, discharges from hospitals to residential care homes were 75% of the historical average, while discharges from hospitals to nursing homes increased to 120% of the historical average. These difficult decisions to discharge patients were made in an urgent and uncertain context but may have played a role in transferring risk to a poorly supported social care system.

In July 2020, we also published Adult social care and COVID-19: Assessing the policy response in England so far[8] - our analysis of the national government policy response during the first phase of the pandemic. Our key findings were:

•                                                                                                                                                                                                             Government policies to support social care faced major and widespread problems. There were significant issues with access to testing and PPE, leading to a lack of protection for some people using and providing adult social care. Local authorities reported that additional government funding has not been enough to cover COVID-19 costs. The fragmentation of the social care system has made it difficult to coordinate support.
•                                                                                                                                                                                                             Protecting and strengthening social care services appears to have been given far lower priority by national policymakers than protecting the NHS. Policy action on social care has been focused primarily on care homes and risks leaving out other vulnerable groups and services.
•                                                                                                                                                                                                             The social care system that entered the pandemic was underfunded, understaffed, undervalued and at risk of collapse. Any response to COVID-19 – however fast or comprehensive – would have needed to contend with this legacy of political neglect.
•                                                                                                                                                                                                             We recommended that the Government should learn from the first phase of the COVID-19 response to prepare for potential future waves of the virus. Short-term recommendations for action included greater involvement of social care in planning and decision making, improved access to regular testing and PPE, and a commitment to cover the costs of local government’s COVID-19 response.
•                                                                                                                                                                                                             More fundamental reform of the social care system is needed to address the longstanding policy failures exacerbated by COVID-19.

On 17 September, the Department of Health and Social Care published a COVID-19 winter plan for adult social care[9], which described a mix of new and existing policies to help social care services cope with COVID-19 over winter. Government funding to prevent and control infections in social care was extended to March 2021. The extra £546m funding was allocated to help restrict staff movement between care settings and pay staff who are self-isolating. The plan also committed to free PPE being provided to all social care providers over winter.

Yet the winter plan did have notable gaps, including on testing and on measures to support the rest of the social care workforce—and the millions of unpaid carers. The plan was a further example of a short-term fix for a sector that needs long-term reform.

Further to our own analysis, the Health Foundation commissioned The Institute for Employment Studies in June 2020 to carry out research and produce a report[10] on how government COVID-19 policy may have impacted the adult social care workforce. This includes policy areas such as Test and Trace, the Action Plan for Adult Social Care, Statutory Sick Pay and the Care Home Support Package. The key findings of the report were:

• The adult social care workforce is diverse and fragmented, working in a complex sector with multiple models of ownership and ‘employment’, making it more challenging to develop and implement policies for the sector as a whole.  
• Policies and government guidance introduced during the pandemic have been rushed and, as a result, are fragmented and lack clarity.  
• The biggest concerns for adult social care workers are getting COVID-19, passing on the virus to family and friends and being able to survive on Statutory Sick Pay.  
• More research needs to be carried out into the ongoing impact of COVID-19 on the adult social care workforce including in communication and implementation of future policies.

Impact on NHS services

Elective care

The pandemic’s full impact on access to elective care in England is still emerging. In November we published analysis[11] using routine data on 18-week waiting times for consultant-led elective care, to look at what we know so far:

• Before the pandemic, meeting the 18-week standard would have required the NHS to treat an additional 500,000 patients a year for the next 4 years – an unprecedented increase in activity, which looked unrealistic before COVID-19 and now looks even harder.
• The number of people waiting for consultant-led elective care was 4.2 million in August 2020, around 196,000 less than at the end of 2019 (4.4 million). But this is only the case because the 32% reduction in the number of elective care pathways completed was exceeded by the 34% reduction in the number of new pathways being started. From January to August 2020, 8.9 million new pathways were started – 4.7 million fewer than the 13.6 million started in the same months in 2019.
• From January to August 2020, the specialties with the greatest reductions in new pathways were oral surgery, trauma and orthopaedics, and ophthalmology (42%, 42% and 40% lower respectively than in the same period in 2019).
• The impact of COVID-19, and the response to it, have been felt across the UK but more acutely in some parts of the country. Similarly, while the pandemic has already had a stark effect on the waiting list at national level, there are signs that access to elective care has been better in some parts of England than others. This includes regions with lower rates of the virus after the initial peak, which may have also faced fewer difficulties in restarting routine hospitals services.
• With returning to the ‘old normal’ unlikely to be enough, more radical options are now under consideration. This includes giving full consideration to the role the independent sector can play, while acknowledging the sector is unlikely to be a suitable option for all patients in all regions of England.
• Every day that activity lags behind demand, the backlog will continue to grow. The impact of postponing elective care on millions of people, and the new measures needed to address it, should all be considered when making decisions about future NHS funding.
• Based on our analysis we believe that meeting the 18-week standard by 2023/24 is not achievable – even if the Treasury was prepared to provide all the funding required. It would require an annual average 11% increase in the number of elective procedures being performed each year by the NHS, needing some 4,000 extra consultants and 17,000 extra nurses a year. We estimate that it is more realistic to achieve the waiting time standard and eliminate the backlog of long wait over a 6-year period, ending in 2026/27. To achieve this, NHS England would require an additional £900m on top of current spending plans[12].

Urgent & Emergency care

COVID-19 has led to radical changes in the way people have used NHS and social care services, and emergency care is no exception.

Analysis from the Health Foundation published in June this year found that at the start of the outbreak, the numbers of people attending major A&E departments fell sharply to 52% below normal[13]. By mid-May, A&E visits had increased but were still 36% lower than expected for this time of year. Visits for ‘any type of injury’ fell to a low of 65% below normal, far lower than the 44% seen for visits related to ‘illness’. Furthermore, figures from October show that attendance at major A&Es are still 19% lower than the same month in 2019.

In September, we published analysis examining how children and young people’s use of A&E had been impacted by lockdown and social distancing[14]. We found:

•                                                                                                                                                                                                             Visits to A&E for children and young people (defined as people younger than 20 years of age in this analysis) have seen a 62% reduction. This is far greater than the 45% reduction seen for the whole population.
•                                                                                                                                                                                                             A&E visits for illness by children and young people during the pandemic were 62% lower than the same period in 2019 – twice the reduction seen for adults.
•                                                                                                                                                                                                             The severe social distancing induced by the closure of schools, colleges and nurseries is a likely explanation for the dramatic reductions in illness visits to A&E for children and young people as with less contact they are exposed to less infectious disease.
•                                                                                                                                                                                                             As schools and colleges resume, we should expect to see changes in the prevalence of infections among children and young people, and a subsequent increase in visits to A&E.
•                                                                                                                                                                                                             A&E visits for injuries by those aged 5–19 (school and college age) during the pandemic were 67% lower than the same period in 2019. For all other age groups this was 42%.
•                                                                                                                                                                                                             The reduction in injury visits may be because children and young people are having fewer minor injuries; it may also indicate the threshold for making the decision to attend A&E has risen, both for parents and guardians, and for other services such as NHS 111.

Primary care

The impact of COVID-19 on face-to-face GP consultations since the start of the pandemic has been widely reported. This has raised questions about the care of non-COVID patients, people with long-term health conditions, and the potential for delayed diagnoses.

During the first wave of the pandemic, care provision in GP practices dramatically changed due to COVID-19, with remote consultation rapidly introduced to protect patients and staff from the risks of infection. Our analysis from July suggests that GP practices familiar with conducting appointments remotely were able to adapt quickly to the demands of COVID-19 and undertake more care remotely without significantly impacting the total number of consultations delivered[15]. As the pandemic has progressed, these practices demonstrated resilience by responding flexibly to variations in demand for care throughout April to June. These results point to the benefits of using digital technology in general practice and suggest the NHS should continue to invest in digital-first primary care. Doing so in the short term may make primary care more resilient to future waves of the virus. However, research is required to answer questions about the impact of remote consultation on the quality of care, patient experience and access, and workload.

In September 2020 we published analysis using patient-level primary care data up to the end of June 2020, to explore how different activities and patient pathways were affected around the peak of COVID-19 in England[16]. We also looked at how these effects varied by age, sex and for patients with pre-existing illness.

•                                                                                                                                                                                                             Primary care consultations per person fell from an average of 4.1 before mid-March in 2020 to 3 consultations per person per year (around a 30% reduction) the week after the introduction of lockdown at the end of March. Rates were still at that level at the end of June.

•                                                                                                                                                                                                             The reduction in consultations mask a more fundamental shift in how consultations are taking place. The number of face-to-face consultations has fallen by 2.3 per person per year, which was partially – but not completely – offset by the increase in remote consultations of 1 per person per year.
•                                                                                                                                                                                                             After lockdown 50–60% of consultations in these data were conducted remotely, allowing vulnerable patients the chance to keep in touch with their GPs without the need to visit a practice and risk contraction or spreading of the disease. This is consistent with messaging at the time from NHS England that patients should be seen remotely first then face-to-face if necessary.
•                                                                                                                                                                                                             It is not clear exactly what is driving this reduction. We don't know whether patients were worried about accessing services, making use of NHS 111 services or whether access was restricted because of capacity.
•                                                                                                                                                                                                             Over the same period there was a fall in the number of referrals, medical tests, new prescriptions and immunisations.
•                                                                                                                                                                                                             GPs were advised to hold off on routine referrals to free up capacity for hospitals to deal with the large number of expected severe cases of COVID-19. Routine referrals were 74% lower between the weeks commencing 15 March–21 June when compared with the same weeks in 2019. Routine referrals had not recovered towards the end of June, remaining at a 50% reduction in rates.
•                                                                                                                                                                                                             The reduction in referrals overall occurred before lockdown had started. The drop in referrals was not solely driven by a fall in consultations, as the rates of referrals made per consultation also fell.
•                                                                                                                                                                                                             2-week wait referrals are used by GPs to urgently refer patients who have symptoms which may indicate cancer. Advice to GPs and secondary care was to maintain the normal cancer service throughout lockdown. However, from the middle of March to the end of June there were 43% fewer 2-week wait referrals than in the same weeks in 2019. There appears to be a quicker recovery for 2-week wait referrals than other types. Throughout June they had recovered to a fall of between 10–30%.
•                                                                                                                                                                                                             Repeat prescriptions spiked the week before lockdown was introduced as patients and GPs attempted to maintain continuity of access to medicine for pre-existing conditions. New prescriptions reduced after lockdown at the same rate as consultations.
•                                                                                                                                                                                                             Health testing that occurs in primary care (such as blood tests) fell by 80%. Childhood immunisations appear to have held their pre-lockdown levels, in line with advice to GPs to protect them. While adult immunisations fell, their normal rate throughout early summer is typically very low. It is worth noting that social distancing and reduced travel may have reduced the risk (and demand) of vaccine preventable diseases.

Further to this analysis, in August this year we looked at how COVID-19 could affect the numbers of GPs available to see patients in England during the pandemic[17]. In England, many GP practices shifted to a ‘telephone first’ approach to providing patient care during the early phase of the pandemic. Yet some patients need face-to-face consultations for specific health problems. We applied risk scoring to calculate the number of GPs practising in England who are likely to be at high or very high risk of death from COVID-19:

•                                                                                                                                                                                                             We estimated that of the 45,858 GPs in our sample, 7.9% were at high or very high risk. This is likely to be a conservative estimate.

•                                                                                                                                                                                                             GPs at very high risk of death from COVID-19 are more likely to be working in areas of high socioeconomic deprivation.
•                                                                                                                                                                                                             Almost one in ten GP practices (9.4% or 639 out of 6,771) are run by a single GP. These practices serve 2,497,159 patients and are particularly vulnerable to COVID-19 related disruption should the single-handed GP fall ill or die of COVID-19.
•                                                                                                                                                                                                             Almost one in three of these single-handed GP practices (32.7%, or 209 out of 639) are run by a GP we estimate to be at high or very high risk from COVID-19. If these GPs were to not see patients face-to-face, 710,043 patients would be left without face-to-face GP appointments. Single-handed GP practices in areas of high socioeconomic deprivation are more likely to be run by a GP at higher risk of COVID-19.

Our analysis suggested there are a relatively large number of GPs at high risk of mortality from COVID-19, and there is geographical and socioeconomic variation in the distribution of affected GPs.

Government communications and public health messaging

Public perceptions of health and social care in light of COVID-19

During the pandemic, the Health Foundation commissioned Ipsos MORI to carry out a representative survey of the general public in Great Britain to gather their views on a range of health and care issues in light of COVID-19[18]. The polling was carried out in two rounds; the first round of polling was carried out between 1 and 10 May 2020, and this was followed by a second round between 17 and 29 July 2020.

Below we provide a summary of results from July’s polling, and how they compared to May’s results.

• The results highlighted a significant change in the public’s perceptions towards the Government’s handling of COVID-19 and the measures it has taken to tackle the outbreak so far. In July, the public were more critical of the Government’s handling of the Coronavirus outbreak. A majority (56%) believed that the Government has not handled it well, significantly more than in May (39%).
• In July, half of the public thought that the Government measures to address the pandemic did not go far enough (50%), while a minority believed the measures were about right (40%). Only 33% of people from a black and minority ethnic background thought the measures were about right – compared to 40% overall – which is perhaps unsurprising given that black and minority ethnic groups are among the worst affected by the virus.
• The July survey showed that the clarity of the Government’s current official guidance varied. Nearly four in five thought the guidance on wearing face masks on public transport was clear (78%), but less than half (44%) thought official advice on who and how many people you can meet was clear (54% think it was unclear).
• The survey also showed that overall public confidence in using NHS services had started to return in July, with around three-quarters (77%) of people reporting they would be comfortable using a hospital – a significant increase from 52% in May.
• However, concerns about using hospitals was greater among some of the groups worst affected by Covid-19, with more than one in four (28%) people from black and minority ethnic backgrounds and more than a third (34%) of people with a disability saying they would feel uncomfortable about using their local hospital, compared with just over one in five overall (22%).

Testing and contact tracing

The difficulties associated with implementing an entirely new national programme of testing and contact tracing should not be underestimated. It is no small achievement that a system only launched in May is now delivering millions of tests every week and reaching hundreds of thousands of cases and close contacts. However, NHS Test and Trace (NHSTT) is not yet the world-beating contact tracing programme that was promised and significant scope for improvement remains. As case rates remain high and until an effective vaccination programme has been implemented, a well-functioning test and trace system is crucial for keeping schools and businesses open, and to effectively target support and resources to those most in need.

‘NHS Test & Trace: the journey so far’

In September we published a long-read outlining how the NHSTT programme works and analysed the key stages in the development of testing and contact tracing in England. We also highlighted some of the ongoing challenges faced by the programme and offered suggestions about how these challenges might be addressed[19].

We identified four key challenges that the programme faced in September:

•                                                                                                                                                                                                             Transmission - COVID-19 is difficult to control because of how readily the virus can be transmitted. Isolating infectious cases and their recent contacts quickly is crucial to break the transmission chain. This challenge is complicated further by uncertainty around transmission by individuals who do not develop symptoms.
•                                                                                                                                                                                                             Public engagement with the system - For NHSTT to work effectively and people to follow guidance on isolation, there must be widespread awareness, trust, and use of the system[20].
•                                                                                                                                                                                                             Isolation - Individuals were initially informed that they have a duty to request a test if they develop symptoms consistent with COVID-19 infection and told to adhere to isolation guidance. However, it can be difficult to isolate for the required length of time for a range of financial, practical and emotional reasons, and there have been challenges in accessing a test.
•                                                                                                                                                                                                             Existing infrastructure - The test and trace infrastructure in England at the start of the pandemic was soon overwhelmed by the sheer number of COVID-19 cases and their contacts. Laboratories in Public Health England were not designed for mass testing and the difficulties of rapidly increasing test availability shaped the government’s decision to stop testing potential community cases in early March. 

We outlined a series of recommendations in September for how NHS Test & Trace could increase its reach, many of which still apply. The recommendations from September included:

•                                                                                                                                                                                                             Contact tracing - NHSTT needs to contact more of the cases that are identified, and subsequently reach more contacts. Contact tracing systems led by local authorities will likely go some way to achieve this, alongside the contact tracing app.
•                                                                                                                                                                                                             Funding for local authorities – we said the government needed to make sure that already stretched local government public health departments were adequately resourced to fully implement a contact tracing service. On 12 October, the Prime Minister announced £1 billion of additional support for local authorities, of which £900m was provided to resource ongoing work to support communities during the pandemic.
•                                                                                                                                                                                                             Support to self-isolate - once cases and contacts are identified, compliance with isolation guidance can be improved[21] by helping people to access essentials, providing social support and ensuring adequate financial protection. The £500 available to people on low incomes from 28 September will offer some protection against financial hardship. However, the concurrent introduction of fines for breaching isolation rules may dissuade people from getting tested in the first place, or from disclosing contacts to NHSTT. 

NHS Test & Trace Performance Tracker[22]

In the Health Foundation’s NHS Test & Trace Performance Tracker, we monitor and reflect on the performance of NHS Test and Trace. We analyse the latest statistics on the number of positive cases reached and the number of contacts who were asked to isolate each week since the launch of NHSTT on 28 May 2020. The tracker is updated on a fortnightly basis. See the Sankey diagram below from the most recent update to the tracker.

NHS COVID-19 App

During the development and initial launch of the NHS COVID-19 app, we repeatedly called for greater transparency about the development of the app, and for the government to publish evidence from pilots of the app to demonstrate it was ready for mass roll-out[23]. We have argued that publishing the evidence to demonstrate the app works is a key part of building public confidence and trust in the app, and therefore an enabler of overall success.

Our analysis highlighted a particular concern about how the app would impact, and potentially exacerbate, existing health inequalities. Piloting the app in Newham, one of the most ethnically diverse areas of the country, with a high population density and significant areas of deprivation, offered the opportunity to understand how it worked among different populations. However, without the publication of any findings from the pilot study, we do not know whether these major concerns were addressed before the app was launched in September.

A particular concern was the potential negative impact of a ‘digital divide’, with those without access to the app not receiving the same level of benefit in terms of up-to-date information about their risk of infection from contact with others. Results from our commissioned survey of the public in July 2020 (mentioned already above), highlight two areas in which this could manifest[24]:

•                                                                                                                                                                                                                          Awareness of the app. People from a black and minority ethnic background, women, those in the youngest and oldest age groups, routine and skilled manual workers, and the unemployed, were all less likely to be aware of the plans for an app.
•                                                                                                                                                                                                                          Intent to download and use the app. Younger people (18–24) were more likely to say they would download the app, use the app or self-isolate based on its advice, while the oldest age groups (65+) were the least likely to do so.

At the time of writing this submission, two months after the NHS COVID-19 app was launched across England and Wales, there remains an absence of evidence about how well the app is working in practice, or what contribution it is having in combatting the spread of the virus.

Equity impacts

The COVID-19 pandemic and the wider governmental and societal response have further exposed inequalities in our society. COVID-19 and the knock-on effects of lockdown and social distancing measures have affected us all, but they have impacted some groups more than others. In this section, we summarise and link to some of our emerging evidence on the unequal impact of the pandemic.

In addition to the information below, a Health Foundation blog series[25] rounds up the emerging evidence on the unequal impact of the pandemic and the wider governmental and societal response in the UK.

Living in poverty was bad for your health long before COVID-19

As we learned the fatality rate for COVID-19 was far higher among people from more socioeconomically deprived areas, there was rightly a sense of outrage. Mitigating the impact of COVID-19 on deprived communities should be a key concern for government and health care leaders. But the unequal impact should not have come as a surprise.

Not everyone has the same opportunity to live a healthy life, and one key driver for these health inequalities are the inequalities in society itself. This is not new, but COVID-19 has thrown it into sharper focus. Analysis we published in July 2020[26] explored the nature of the economic shocks experienced in recent years, including those stemming from COVID-19, and the consequences these might have on people’s health.

• Income is associated with health: people in the bottom 40% of the income distribution are almost twice as likely to report poor health than those in the top 20%. Poverty in particular is associated with worse health outcomes. This is especially the case for persistent poverty.
• Income and health can both affect each other – lower income is associated with more ‘stressors’ which can harm health and allow fewer opportunities for good health. Poor health can limit the opportunity for good and stable employment and so affect income.
• The UK entered the coronavirus (COVID-19) pandemic and related economic shock from a starting position of stagnant income growth and low levels of financial resilience. 65% of families in the bottom income quintile had either no savings or savings below £1,500.
• The pattern of employment loss and furloughing by income suggests that the future economic consequences of COVID-19 may be borne by those on lower incomes. This in turn risks an additional long-run burden on health.
• Providing support to bolster people’s incomes for as long as necessary should remain a priority. But there are gaps in the government’s current package of support that risk undermining public health, including the need for more reassurance for renters, retraining support for people who have lost their jobs, and more comprehensive statutory sick pay.

Emerging findings on the impact of COVID-19 on black and minority ethnic people

In analysis published in May 2020[27], we found that the risk of COVID-19 related death is more than four times as high for people of black ethnicity, than for those of white ethnicity after adjusting for age.

Ethnic inequalities in health in the UK have been extensively documented before COVID-19. A wide variety of explanations for these have been examined, ranging from upstream social and economic inequalities to downstream biological factors. Experts in the field point to racism as a ‘fundamental cause’[28], affecting health in multiple ways. A strong evidence base has demonstrated that racial discrimination affects people’s life chances through, for example, restricting access to education and employment opportunities. Black and minority ethnic groups tend to have poorer socioeconomic circumstances which lead to poorer health outcomes. In addition, the stress associated with being discriminated against based on race/ethnicity directly affects mental and physical health through physiological pathways[29].

Public Health England’s report from June 2020, disparities in the risk and outcomes of COVID-19[30], highlighted that the burden of this pandemic has not being shouldered equally. PHE’s findings add to the growing body of evidence showing that older people, those living in more deprived areas, people from black and minority ethnic groups, and those working in certain occupations are at a significantly higher risk of dying from COVID-19.

The impact on young people: ‘Generation COVID-19’

As policymakers look towards a recovery from the COVID-19 pandemic, young people’s long-term health needs to be at the heart of their decision making. In August, we published a long read on young people’s future health[31], drawing on insights from the Health Foundation’s young people’s advisory group, and original analysis of YouGov and Understanding Society survey data conducted by the Health Foundation. We found:

• Emerging evidence on the economic and social impact of the coronavirus (COVID-19) pandemic shows that young people aged 12–24 years are one of the worst-affected groups, particularly in terms of the labour market and mental health outcomes.
• Our analysis found an increased reason for concern across a range of measures. These include young people’s self-reported emotional state, where following the lockdown there is a doubling of the proportion of young people not able to concentrate and a tripling of those not able to enjoy day-to-day activities. Our analysis also shows that one in ten lacked private space in their home to work or study.
• Our analysis also shows that the effect is not equal for all young people. Young people in the north of England, and young people from poorer households have been more likely to lose work. Young people from a minority ethnic background are more than twice as likely to be no longer working since lockdown than their peers, with 12.8% reporting to have lost their jobs.
• As the government looks to ‘build back better’, creating a national cross-government strategy on health inequalities becomes more important than ever and it is vital that young people are placed at the heart of this plan.

Securing the foundations for young people’s healthy futures will require focused and comprehensive action across the range of factors that influence long term health. In August, we recommended that decision makers should prioritise action in the following areas:

•                                                                                                                                                                                                             There needs to be fundamental changes to housing policy to enable all young people to exercise choice and control over their housing situation. This includes providing realistic help with rental housing costs for the young people who need it through the benefits system such as removing the 5-week wait for Universal Credit, maintaining the local housing allowance to a level that enables people to afford housing within the cheapest 30% in the local area, and abolishing the shared accommodation rate. Housing security and quality needs to improve through abolishing ‘no fault’ evictions across the UK and developing a single set of minimum standards for landlords.
•                                                                                                                                                                                                             Preventing short-term losses in income will be critical if risks to future health are to be minimised. The government has already introduced policies that incentivise job creation, such as the Kickstart scheme, announced on the 8 July 2020, by the Chancellor. It is hoped that these measures will create short-term job opportunities and minimise the scarring effect of unemployment for young people. The measures have been widely welcomed as a first step, However, to bring lasting benefits to young people these need to look beyond employment as the primary success measure and monitor the availability of high-quality work. Training offers will be needed to help young people find and stay in high-quality work. Without action, the potential loss of job opportunities for young people could drive widening health inequalities.
•                                                                                                                                                                                                             The pandemic has fractured young people’s opportunities to build vital personal connections within their local communities, from schools and colleges to community and faith-based organisations. These communities offered young people the opportunity to connect with people who might offer support, as well as helping young people develop their emotional and social skills. One potential area for action is to boost funding to youth services, which have taken a significant hit during the pandemic with an estimated one in five youth centres not expected to reopen after lockdown.
•                                                                                                                                                                                                             The impact of the disruption to young people’s education during the pandemic could be severe without remedial action to support attainment and personal development. As young people return to schools and colleges there needs to be more actively monitoring young people’s wellbeing in educational settings.

The links between inequalities - intersectionality

Intersectionality theory[32] is a framework to consider how disadvantage on multiple social dimensions combines to affect outcomes. In May we examined data on socioeconomic deprivation, gender and COVID-19 mortality, to show how acting on only one aspect of possible inequality can prevent us observing and tackling the intersection with others. We found that women living in the most deprived areas of England are 133% more likely to die from COVID-19 than those in the least deprived areas, with the gap for men being smaller.

This analysis illustrates one combination of how social factors may be linked to increase risk of COVID-19. An intersectional approach to inequalities encourages deeper thought about how other combinations could accentuate risk and requires us to consider whether a universal public health approach alone will ensure those high-risk groups are protected from the impact of the virus.

There is a real danger that COVID-19 will increase inequalities. The government response to this crisis must be designed to mitigate this by taking account of the ways in which some people bear the brunt of multiple impacts.

COVID-19 Impact Inquiry[33]

The Health Foundation has recently opened a call for evidence[34] to its COVID-19 impact inquiry. The inquiry – due to report in the summer of 2021 – aims to provide a comprehensive analysis of the factors that will need to be addressed to put the UK back on the road to recovery and ensure that everyone can enjoy the same opportunities for good health and wellbeing. The Health Foundation is inviting individuals and organisations to submit evidence which will help to build greater understanding of how experiences of the pandemic have been influenced by people’s existing health and social inequalities.

The COVID-19 impact inquiry is being carried out by an in-house secretariat at the Health Foundation, guided and informed by an expert advisory panel, chaired by Dame Clare Moriarty.

The importance of health and care data in the fight against COVID-19

Data relating to the COVID-19 pandemic has become a constant feature of our lives since the pandemic emerged, with our days being punctuated by regular updates on the numbers of cases, deaths and hospitalisations. Data has told a horrifying story about the toll that the pandemic is taking. It’s also playing a critical role in the response to the virus, informing national and international policy, the search for new treatments and vaccines, and the rapid innovation that is happening across the NHS. Data can never solve a problem like COVID-19, but it can help in the fight to protect the most vulnerable.

We launched our data analytics for better health strategy[35] in January, with the ambitious aim to ensure that analytics and data-driven technology benefit everyone in the UK. We knew data was critical for the UK to overcome problems like health inequalities, accelerating service improvements, strengthening social care, and now also COVID-19.

The COVID-19 pandemic has exacerbated and amplified many of the longstanding issues within social care, one of which is a problematic lack of data. There are key gaps in the information that is collected, particularly outside the care home system. From the patient and public involvement work we have carried out as part of our research, it is clear that the available data contains large gaps in capturing the needs of those receiving care, particularly in areas such as mental health or the impact of unmet social care needs on wellbeing.

There are particular challenges in how data are collected, shared and used in social care. For example, some care providers may be reluctant to share data for fear of the consequences on their finances, and the data collected may not focus enough on how care can empower users to live independent lives. Most datasets collect information about care from provider organisations, which omit care provided by individuals (paid or unpaid). Addressing these problems will require a new data strategy for social care with the primary objective of improving the quality of care. Such a strategy needs to come with investment so that the data collected can be used to improve care, for example by establishing better data infrastructure to enable real-time analysis, building skills in analysis, and fully incorporating the lived experience of users into the interpretation and use of the analysis.

Better person-level data on staffing, social care capacity, testing and health care and social care provision are needed to better prepare for subsequent waves of COVID-19, and would also bring long-term benefits. During the pandemic, we have seen how valuable health data have been in enabling new treatments and supporting innovation, such as via the RECOVERY trial. With further investment, similar innovations are possible within social care.