COVID-19 Wider Impacts

Introduction

The COVID-19 pandemic has led to a range of direct and indirect health consequences (2.8Mb). The direct impacts of COVID-19 through infection with the virus are described in detail by National Records of Scotland, Public Health Scotland and the Scottish Government. Work has also been completed to consider the reasons behind the variation in direct COVID-19 mortality across Scotland during the early part of the pandemic. We have also published information on the burden of disease of COVID-19, including this publication looking at the impact of the pandemic on health inequalities. This page focuses instead on the indirect health consequences of COVID-19, particularly through the unintended consequences of the pandemic control measures.

The potential for a range of indirect impacts on health and health inequalities as a result of the measures introduced to control the pandemic were described as part of a rapid Health Impact Assessment (HIA) published in the British Medical Journal (BMJ) and by the Scottish Health and Inequality Impact Assessment Network (SHIIAN) (1.3Mb). The indirect impacts were theorised to occur through a variety of pathways, including:

  • Changes to employment and income.
  • Access to education for children and adults.
  • Social isolation, family violence and abuse.
  • Changes in the accessibility and use of food, alcohol, drugs and gambling.
  • Changes in physical activity and transport patterns.
  • Changes in the availability and use of healthcare services.

ScotPHO have produced maps to illustrate a COVID-19 community vulnerability measure. These have been created to identify the small areas in Scotland with the populations at highest risk of the direct and wider harms. The community vulnerability measure combines clinical, social and demographic risks to help indicate where resources require to be focused. The maps show that the areas of highest risk are likely to the be the more deprived areas across Scotland, particularly in Glasgow and the west of Scotland, as well as in rural areas in Highland, Fife, the Western Isles and Dumfries and Galloway.

The Scottish Government are monitoring the indirect impacts of COVID-19 through COVID-19 - A Framework for Decision Making. This describes the potential harms arising through: the direct impact of COVID-19; the impact on health and care services; wider social harms; and the economy. Data on measures of each of these are updated regularly. More detailed data on changes in the use of NHS services in Scotland (including by sex, deprivation and age) is provided in the COVID-19 wider impacts dashboard, which can also be accessed via Public Health Scotland's COVID-19 data and guidance web pages.

Excess deaths

Over the course of the pandemic the crude number of deaths has been substantially higher than in previous years, peaking at about double the expected number of deaths in April 2020. Much of this excess is due to direct COVID-19 deaths, but about a third of the excess was certified as being due to other causes. See the National Records of Scotland website for information on deaths involving coronavirus (COVID-19) in Scotland.

The direct COVID-19 deaths, and non-COVID-19 excess deaths, were more common with increasing deprivation, exacerbating the wide socioeconomic health inequalities already afflicting Scotland and also generating inequalities by ethnicity. It is worth noting that although the crude number of deaths caused directly by COVID-19 is very large, the contribution to lost life expectancy is more modest, with background socioeconomic inequalities making a much larger impact on lost life expectancy in the long-run. There are a number of considerations on how best to measure the direct health loss due to COVID-19, which are discussed further in a commentary in the International Journal of Public Health.

Health and social care

Changes in the use of health and social care services during the pandemic could be due to one of four factors.

  • A real change in the need for those services (e.g. fewer road traffic injuries because of less people commuting to work).
  • Reduced availability of services (e.g. services were limited to prevent the spread of COVID-19 within health or social care settings).
  • Reduced demand for services (e.g. people felt like their needs could wait because they wanted to protect services for those with COVID-19 or because they were afraid of catching COVID-19).
  • Needs related to COVID-19 directly or to the interaction between COVID-19 and other health conditions.

Untangling which of these factors are responsible for changes in health and social care use during the pandemic is difficult and a number of research projects are underway to help understand this in more detail. The routine data monitoring of the impacts on healthcare service use, which are included in Public Health Scotland's Wider Impacts dashboard, show:

  • Declines in admissions to hospital (both as emergencies and planned), across age groups and deprivation groups.
  • A marked decline in the number of people attending Emergency Departments (dropping to around 50% of the historical trends during April before slowly returning to close to the expected number by August 2020).
  • Marked drops in out of hours consultations with GPs, which remained around a third lower than in previous years by August 2020.
  • An initial decline, then recovery, in the number of incidents attended by the Scottish Ambulance Service.
  • Lower than expected numbers of interventions for ischaemic heart disease at national referral centres in Edinburgh and in Clydebank (although these trends are quite unstable).
  • An increase in timely uptake of routine immunisations offered to pre-school children.
  • A fall in the coverage of Health Visitor child health reviews offered to pre-school children, with some evidence of recovery.
  • A small increase in the levels of breastfeeding.
  • A fall in the proportion of children identified as having developmental delay during child health reviews. Along with the reduction in coverage of reviews, across Scotland during the period March to July 2020 this has resulted in around 800 fewer children than expected being identified as having a developmental delay at 27-30 months.
  • No significant increase in stillbirth or infant death rates.
  • A fall in contacts for mental health problems during the period of 'lockdown' as well as a fall in rates of prescribing for mental health problems.

Social impacts

Of the available measures, there has been increased uptake of Scottish Welfare Fund crisis grants, reduced police recorded crime and high levels of reported loneliness. A series of surveys are underway to understand the wider impacts of the pandemic (see our COVID-19 Impact Surveys page for further details). This includes Public Health Scotland's COVID-19 Early Years Resilience and Impact Survey (CEYRIS) of the parents of young children (2-7 years old) in Scotland. It is expected that much more data will become available in due course as these surveys and the routine national surveys report.

Economic impacts

The economy, and the consequences this has for employment, income, public services and the environment, are important determinants of population health and health inequalities. Between March and August 2020, there has been a very substantial drop in economic activity and a doubling of the number of people claiming out of work benefits. This is likely to result in very marked negative impacts on population health in the future as the negative consequences of unemployment on health are well known, even though the impacts of recession more generally are more mixed. If further austerity measures are introduced as a means of reducing government deficits, this could further compound the negative impacts on population health that have been seen over the last 10 years.