Scotland’s Wellbeing: The Impact of COVID-19 - Chapter 2: Health

2. Health

Overview

On Health:

COVID-19 has had a profound negative effect on physical and mental health through both direct and indirect means
The depth, severity, and longevity of some of these impacts are less certain and strongly interrelated with impacts and mitigating measures on other outcomes such as the labour market and economy
Uncertainties over the eventual trajectory of the pandemic persist, but it is likely the patterns seen to date, including the poorer health outcomes experienced by some groups, will continue for some time to come

Related outcomes

A deterioration in health may affect the ability to maintain employment, which in turn will affect public finances, household income, levels of poverty, and children’s wellbeing and educational participation
Poorer mental health may increase isolation from friends, family and neighbours leading to feeling less connected to a local community, which in turn may lead to poorer mental health
Discrimination may occur for those at highest risk of COVID-19 due to curtailment of labour market and other activity
At-risk individuals are less able to use public transport which in turn will also affect their employment and participation in cultural activities and tourism – with consequent economic implications

More evidence

As the COVID-19 pandemic continues to progress, data on impact changes regularly. The sources below are regularly updated.

Direct Impacts of COVID-19

The direct impacts of the virus are in terms of deaths and serious illness. Particular groups, such as older people, those with underlying health conditions, people from some ethnic minorities,[i] those who are obese or people living in deprived areas, have a higher risk of dying from the disease.

Deaths in Scotland

People dying from COVID-19 peaked in April – where 662 people died in the week ending 26 April.^[ii] As at 13 December, there have been a total of 6,092 deaths registered in Scotland where the novel coronavirus (COVID-19) was mentioned on the death certificate.^[iii] About half (46%) of COVID-19 registered deaths related to deaths in care homes and about half (47%) were in hospitals. [iv]

Age: The oldest age groups have been most affected, with more than three quarters (77%) of deaths among those aged 75 and over. The average age at death for those who died with COVID-19 was 79 for males and 84 for females[v]
Sex: Males were 1.4 times as likely to die than females[vi], although recent evidence suggests higher infection rates amongst women than men[vii]
Location: People in large urban areas were more than four times as likely to die than those in remote rural areas¹

Deprivation: People in the most deprived areas were over twice as likely to die as those in the least deprived areas¹
Other health conditions: Most people (92%) who died between March and August 2020 had an existing underlying health condition. The most common pre-existing conditions were: dementia and Alzheimer’s disease (31% of those who died); ischaemic heart disease (13%); and chronic lower respiratory diseases (11%)[viii]

Disability: Evidence from England and Wales[ix] found that the death rate for those disabled and “limited a lot” in their daily activities was 2.4 times higher for females and 2.0 times higher for males[x]
Ethnicity: There is evidence that some minority ethnic groups are at higher risk of dying from COVID-19 than the rest of the population – and that the risk may not be the same for all ethnic groups. In Scotland, an analysis showed deaths amongst people in the South Asian ethnic group were almost twice as likely to involve COVID-19 as deaths in the White ethnic group[xi] during the period March to June 2020[xii]

Many of the factors above are interrelated. For example: those in the lowest paid jobs have been the least likely to work from home during the pandemic and consequently most at risk of infection. Those with disabilities and underlying health conditions are more likely to be living in poverty. Some areas in Scotland have a higher proportion of older people living in them and, given the importance of age in terms of vulnerability to the virus, this may affect area risk. It has been estimated that, for England and Wales, over half of the increased risk of death for Black people was accounted for by geographic and socio-economic factors. [xiii]

Other factors affecting diagnosis, illness and death

Most of the information above is from recorded deaths and does not provide information about relevant circumstances of the people who died: for example, whether they had been voluntarily shielding. However, evidence about other risk factors is building. Obesity is associated with greater risks of hospitalisation for COVID-19, increases the likelihood of being admitted to intensive care, and there is a potentially a higher risk of COVID-19 related death with increasing Body Mass Index.[xiv]

Data about the impact on people with learning difficulties in Scotland is not readily available. However, in England, adults with learning disabilities were over represented among the numbers of people dying in the first wave – especially in younger age groups. [xv]

Those receiving social care support, including care home residents, may be more at risk due to factors such as age, underlying conditions, nature of care provided and living conditions (e.g. large numbers of residents and staff in a care home).

Long term direct impacts of COVID-19

Evidence is emerging of long term impacts for individuals who have had COVID-19.[xvi] Where people were hospitalised, the effects of severe COVID-19 often continue after the individual leaves hospital. Approximately one third are estimated to develop serious mental health consequences, including depression, anxiety, Post Traumatic Stress Disorder, and cognitive problems. [xvii]

There is also growing evidence of people reporting persistent symptoms of COVID-19, regardless of how ill they were initially or whether they were hospitalised. The term “long COVID” is commonly used to describe signs and symptoms that continue or develop after acute COVID-19 infection and are not explained by an alternative diagnosis. It includes both “ongoing symptomatic COVID-19” (from 4 to 12 weeks) and “post-COVID-19 syndrome” (12 weeks or more).[xviii] This points to poorer health outcomes for some people – and may not be confined to the same groups that are at highest risk of death. [xix]

Indirect impacts of COVID-19

Excess deaths

One way of measuring the impact of COVID-19 on the number of people dying is excess deaths, which includes both direct deaths and also those from other causes that might be related to factors like delayed access to care.

National Records of Scotland (NRS) data shows Scotland experienced excess mortality in Spring 2020. After peaking in April, the number of excess deaths has reduced. For the most recent week (ending 13 December) excess deaths were 3% above the normal level.[xx] Over the year to September 2020, NRS reported that there were 4,306 more deaths registered than would have been the case if numbers were similar to the average over the last five year years. Most of these excess deaths (91%) had COVID-19 recorded as the underlying cause of death.^[xxi]

Health service attendance

There were changes to some health services early in 2020 to ensure maximum NHS capacity was available to treat people with COVID-19. Primary care and Accident and Emergency (A&E) services remained available, however secondary care was paused in some areas. Changes in the use of services can result from several factors: reduced availability or accessibility; reduced demand (e.g. people not attending when they otherwise would have); and real changes in demand (e.g. fewer road traffic accidents or sports injuries).

Accident and Emergency: There was initially a large drop in attendances at A&E – to 60% of normal pre-COVID-19 levels in the week ending 29 March. As of week ending 22 November, A&E attendances are about 75% of normal levels – which has fallen slightly since August and September[xxii]

Planned admissions: The number of planned hospital admissions dropped to 27% of normal pre COVID-19 levels in April, and now stand at 76% for the week ending 22 November.[xxiii] Over the year from September 2019 to September 2020, planned hospital admissions fell by over a third (38%)[xxiv]
Cancer treatments: the 31-day waiting times standard from the date of decision to treat to start of first cancer treatment applies to all eligible patients, regardless of the route of referral. There were 4,970 eligible referrals within the 31-day standard who received their first cancer treatment in the period July to September 2020, a decrease of 1.7% from the previous quarter and a decrease of 23.9% on the same period in 2019. The reduction in first treatment is likely to be a combination of patients not seeking out help so as to be referred during lockdown, pausing of the three cancer screening programmes from March – September and because of delays in patients having diagnostic tests and/or starting treatment due to infection control, clinical guidance and hospital capacity due to treating Covid-19 patients^[xxv]

Mental health: Between April and June 2020 there was a decline in both referrals and patients to Child and Adolescent Mental Health Services. There was a decrease in children and young people starting treatment compared with both the period before the pandemic (14.1% decrease) and the same time last year (11.6% decrease), alongside an apparently greater impact on referrals[xxvi]. However, in the period July – September 2020 there was an increase in children and young people starting treatment – by 13.6% since the previous quarter and a 3.3% increase in those starting treatment in the same quarter the previous year.[xxvii] For adults, in the period July to September 2020, there was a 15% decrease in people starting psychological therapies compared to the same period last year and a decrease (39.6%) compared with January – March 2020 [xxviii]

It will take time to address this backlog. Waiting times are likely to increase for many people and these delays in care may mean poorer outcomes in the future. The consequences of the postponement of screening and other preventative service will take time to emerge. This has led some commentators to suggest that past progress made in some areas – for example cancer survival rates – may be at least partially lost.^[xxix]

Healthcare seeking behaviour

The reduction in health service attendance during the pandemic is also likely to be driven by a reduction in people seeking out care or deciding not to present for treatment in some instances. Delays in seeking health care, or not seeking it at all, are likely to lead to poorer health outcomes as treatable conditions are picked up later or not at all. Reductions in A&E attendance and delays in attending GPs were observed earlier in the year and since the end of October between 25-30% of people agreed that they would avoid contacting a GP practice at the moment even if they had an immediate medical concern.[xxx]

Living through the pandemic

“The stopping of non-essential services means we stopped a lot of prevention work and my long-term condition was physically a mess by the time I could re-access a services. That could have been prevented. Some of us got sicker.” [xxxi]

Voices from Scotland on COVID-19’s impact

Impacts of measures to address COVID-19

Measures to reduce the transmission of the virus have had and will continue to have significant impacts on health and other outcomes.

The economic consequences of measures imposed are likely to have negative long term impacts on health. It has been estimated that a 1% fall in employment leads to a 2% increase in the prevalence of chronic illness.[xxxii] A relationship between unemployment and poorer health outcomes,[xxxiii] including mental ill-health[xxxiv] [xxxv] is well established, as is the link between low income and poorer health outcomes.

Isolation and loneliness, mental health

Isolation and loneliness have established impacts on health outcomes[xxxvi] and loneliness increased dramatically during lockdown with 40% reporting feeling lonely in the previous week compared to 21% pre COVID.[xxxvii]

Living through the pandemic

“Everything changed and stopped abruptly. Left with little to zero support. Had to leave my job to provide 24 hour care for my daughter. Abandoned and exhausted. Isolated.” [xxxviii]
[Parent of a child with a complex disability]

“For me the worst part was the isolation. I live alone and not being able to see anyone was awful” ⁵

Voices from Scotland on COVID-19’s impact

Young people and women^[xxxix] in particular found the restrictions on socialising and meeting with friends and family difficult. Other groups, such as those who were shielding, also found lockdown had negatively impacted on their life – even when they thought they were coping well.^[xl] Even as restrictions eased, over the period July to September just under half of respondents reported loneliness.^[xli]

The findings of many studies in the UK^[xlii] suggest that mental health has been negatively impacted by the pandemic, across the population as a whole and for some groups in particular.

Whilst the highest levels of anxiety and depression were early on in lockdown and improvements have been seen since then, levels in Great Britain were and are still higher than pre-pandemic.[xliii]

In a representative survey of adults in Scotland over the period 27 April - 3 May 2020:[xliv]

over a third (36%) of adults reported high level of psychological distress
a quarter of adults reported levels of depressive symptoms and almost one in five (19%) anxiety symptoms of a level that indicated possible need for treatment
10% reported suicidal thoughts in the week prior to data collection
some groups in the survey reported higher than average prevalence of mental health problems than the survey average: young adults (18-29 years); women; individuals with pre-existing mental health conditions; individuals from a lower socio-economic group; and potentially Black, Asian and minority ethnic respondents, though the small numbers surveyed in this group means this finding is more uncertain.

Whilst there is no directly comparable pre-COVID data, levels of distress are higher than reported in surveys such as the 2019 Scottish Health Survey.

For groups who were generally at higher risk of mental ill health – such as younger people and women – these risks persisted through lockdown and following it. Across the UK (as of early October 2020) depression and anxiety are still highest in young adults, people living alone, people with lower household income, people living with children, and people living in urban areas.[xlv]

Commentators have suggested that mental ill health as a result of the pandemic – including concern over the virus, the measures implemented to deal with it and the worsening economic situation – will continue to be a long term health issue.[xlvi]

Living through the pandemic

Many respondents in Social Renewal Advisory Board Listening Events reported negative impacts on their mental health and wellbeing.

“I struggled with mental health and had nowhere to escape”

“I have mental health problems and lockdown made it much worse”

“I often feel lonely and distressed now”

“There was no socialising in the community due to the lockdown which again was a strain on people’s lives in different ways. It caused depression in some people I know or made their anxiety much worse” [xlvii]

Voices from Scotland on COVID-19’s impact

Health related behaviours

The evidence on health related behaviours (e.g. diet, physical activity, alcohol, smoking) is mixed, describing both potentially positive and negative impacts on health. It will be some time before the longer term impact on population health is clear.

There are suggested increases in cooking meals from scratch, eating together as a family and a reduction in eating takeaway foods. However, there were also indications of increases in snacking on unhealthy foods and generally eating more out of boredom.[xlviii] [xlix]

Population level data during lockdown suggests there has been a change to the way people drink. While some drank less as a result of lockdown and felt the benefits, others reported engaging in more harmful drinking behaviour.^[l][li]

In Scotland in late April - early May the SCOVID Mental Health tracker survey of adults found that:^[lii]

33% said that there had been no change in their drinking, 17% reported drinking less than usual and 15% of respondents felt they had drunk more than usual
Among smokers in the survey, smoking more than usual was more common than smoking less, particularly amongst younger age groups. Over a third (38%) of respondents aged 18-29 and just under a third (32%) of 30-59 year olds and 13% of those aged 60 and over reported smoking more than usual in the past week. This was also true amongst those who had a pre-existing mental health condition where over half reported smoking more than usual
Respondents reported that their physical activity increased during the COVID-19 lockdown with men reporting significantly more vigorous physical activity than women. Those without a pre-existing mental health condition reported more vigorous activity than those with a pre-existing mental health condition

A survey of adults in England introduced in April[liii] suggested that whilst some appeared to report doing more physical activity than previously, especially during the initial lockdown, a sizeable proportion reported doing less. Certain groups were particularly negatively impacted: older people, those on low incomes, people living alone, people self-isolating due to age or a health condition and people in urban areas. Even where there were increases, such patterns do not appear to have been sustained.

COVID-19 has also had impacts on drug use at the population level and for those most in need of support. Specialist referrals for drug treatment, needle exchange and opium substitution therapy all dropped at lockdown and had not fully recovered by early July.[liv] Drug-related A&E admissions spiked post lockdown. [lv]

The changing nature of heath care contact

For those who have used health care during the pandemic or as services resume, the nature of the encounter in many instances has been different due to infection control measures (e.g. changed appointment systems and procedures) and the increased use of digital technology as consultations have increasingly moved to remote consultations using telephone and video.

In February 2020 there were around 300 “Near Me” video consultations per week in Scotland, while by June this figure had reached 17,000 per week, and this high level of use has been maintained.^[lvi] An evaluation of Near Me prior to the pandemic^[lvii] showed benefits reported by patients including reduced travel, greater convenience and time savings. Video consulting was particularly suitable for managing stable long term conditions.

Disadvantages found by the evaluation and also a public engagement exercise conducted during the pandemic included: low digital literacy, limited access to technology and lack of private space at home. Video consultations were less appropriate for people with ill-defined conditions. Both the evaluation and the engagement exercise highlighted that people can experience both benefits and disadvantages of video consultations, and that these need to be weighed against each other when deciding on the most appropriate type of appointment for people.

Increased use of video consulting could improve access to services for those with barriers related to travel. However, it could also decrease access for people experiencing digital barriers, and others who may find this type of interaction difficult. This raises the potential of exacerbating or creating inequality among people seeking and accessing health care.

Living through the pandemic

“I can’t have face to face contact with the mental health nurse I work with so we can only have short phone conversations, which don’t provide as much support and my mental health including anxiety and paranoia has deteriorated.[lviii]”

Voices from Scotland on COVID-19’s impact

Impacts on those providing care

Overall the risk of being hospitalised was low for healthcare workers. However, those who had a patient facing role were more likely to be hospitalised than those who did not.^[lix]The social care workforce has relatively high levels of exposure and higher rates of deaths associated with COVID-19 compared to most other settings. [lx] As well as the nature of the work undertaken, which often requires close proximity in confined spaces, demographic and socio-economic characteristics of the workforce may also contribute to a higher risk. [lxi]

Concerns have also been voiced about the medium and longer term impact on health and social care workers who provided care during the pandemic.^[lxii] It is expected that there will be an increase in mental ill health amongst the health and social care workforce,^[lxiii] as this has been found in previous pandemics.^[lxiv] Women and people from minority ethnic groups make up a large proportion of these workforces.

Much of the care given to people is provided by unpaid carers. The pandemic has had a profound impact on the care they are providing and their lives. There are reports that the amount of care being provided has increased[lxv] and the nature of care has changed in some instances. ONS reported that during early lockdown (April) one-third (32%) of adults who reported giving help or support, were helping someone who they did not help before the pandemic. [lxvi] Financial worries are also reported. [lxvii]

[i] https://publichealthscotland.scot/news/2020/august/updated-analysis-of-covid-19-outcomes-by-ethnic-group/,

[ii] https://data.gov.scot/coronavirus-covid-19/detail.html#cases

[iii] https://www.nrscotland.gov.uk/covid19stats

[iv] https://www.gov.scot/publications/coronavirus-covid-19-additional-data-about-adult-care-homes-in-scotland/

[v] https://www.nrscotland.gov.uk/files//statistics/rgar/2019/rgar-2019.pdf

[vi] After adjusting for age.

[vii] https://public.tableau.com/profile/phs.covid.19#!/vizhome/COVID-

[viii] https://www.nrscotland.gov.uk/statistics-and-data/statistics/stats-at-a-glance/registrar-generals-annual-review/2019

[ix] Coronavirus (COVID-19) related deaths by disability status, England and Wales - Office for National Statistics (ons.gov.uk)

[x] After adjusting for age and other characteristics.

[xi] After adjusting for age and other characteristics.

[xii] https://www.nrscotland.gov.uk/files/statistics/covid19/ethnicity-deceased-covid-19-june20.pdf