The lockdown was implemented largely to ‘save lives and protect the NHS’ amid fears of capacity being overwhelmed. What are likely to be the effects of the crisis on the supply of NHS healthcare, and on demand for healthcare, now and in the future?
The UK’s National Health Service (NHS) is at the forefront of policies related to Covid-19. The lockdown was implemented largely to ‘save lives and protect the NHS’, amid growing fears that the coronavirus might overwhelm the country’s available healthcare capacity. Here, we discuss the effects of the Covid-19 crisis on the supply of healthcare provided by the NHS, and the potential impact on demand for healthcare both in the short run and the longer term.
How will the supply of healthcare be affected?
A key impact of Covid-19 on the NHS is through the impact on staffing. Prior to the crisis, the NHS was already constrained in terms of staff numbers, since between 2010 and 2016, the number of doctors and nurses had grown more slowly than the number of hospital admissions and appointments (Lee et al, 2020). If staff are off work due to illness or self-isolation, there will be fewer people to work on both Covid and non-Covid patients. Research on nursing strikes in the United States shows that staff shortages may have knock-on effects on quality of care and thus patient outcomes (for example, Gruber and Kleiner, 2012).
In addition, the government has decided to accelerate graduation of some nurses and invited workers back from retirement, and some staff have been retrained to enable them to move to fields that are experiencing more shortages. While this will increase capacity, research shows that changes in nursing teams when, for example, a new member joins or an experienced member leaves leads to a fall in productivity of the team and thus worse patient outcomes (Bartel et al, 2014).
Staffing shortages are also likely to continue after the peak of Covid-19-related hospitalisations and absences has passed. This is due to a number of reasons – for example, some nurses will return to retirement, fewer nurses may decide to migrate to the UK due to both Covid-19 and Brexit, and the attractiveness of the job is likely to be significantly reduced due to concerns for safety. This is particularly true for the care home sector, where the high number of deaths has been widely covered in media. Shortages of doctors will also be increasingly likely due to similar reasons.
The impact of staff shortages is already being felt unequally between different areas, and the current crisis combined with a recession may increase these geographical inequalities. One study finds that the quality of workers and care is higher in areas where wages in other jobs are lower relative to NHS wages (Propper and Van Reenen, 2010).
Thus, it is likely that the effects of staffing shortages will depend on the overall job market situation in different areas. In some areas, there may even be more people looking to move to the healthcare sector if other jobs are not available. A US study finds that the effect of improved staffing levels in nursing homes reduces mortality of elderly people during recessions (Stevens et al, 2015).
These regional differences in the relative attractiveness of NHS wages may also increase the long-run staff costs for the NHS. In some areas where NHS wages are low compared with other wages, the government may need to ease regulation and increase wages to attract staff.
While in theory the government could also lower wages in areas without shortages to balance costs, it is unlikely that they would be willing to do this. These public sector jobs are an important part of the local economy in many of these areas. It would also be politically unpopular to lower NHS wages after the pressure that NHS workers have been under due to Covid-19. Thus, it is likely that the overall staffing costs for the NHS will increase.
The way in which healthcare is provided is also likely to change as a result of the crisis. We are seeing this already as GP appointments are now mostly happening remotely. It will be important for healthcare providers to assess the quality of remote consultations compared to in-person interactions, in terms of number of prescriptions, referrals and patients’ health outcomes. Given that the drive for digital services is relatively new, there is limited evidence at this stage and existing evaluations only cover those institutions that first adopted these technologies (Ipsos Mori, 2019).
How is demand for healthcare changing – now and in the future?
The current crisis has led to a dramatic reorganisation of hospital facilities and increases in intensive care capacity for the NHS to be able to deal with a higher number of Covid-19 patients. This has largely been done by postponing all non-urgent procedures.
Thus, after the crisis, the NHS will have to deal with a backlog of postponed procedures. The short-term effects of cancelling treatments now, such as some cancer treatments, will also mean that once services resume, some of these people will be more ill than normal, increasing their demand for healthcare going forward.
People have also changed their behaviour during the current crisis and there has been a significant drop in A&E admissions. This may be because people are either healthier (for example, due to fewer accidents and less pollution), not going in for more minor injuries and illnesses that can be treated by non-urgent appointments, or deciding against seeking necessary treatment. A key issue for the current and future health of these individuals will depend on whether they are not seeing a doctor even if they should. This may worsen outcomes for patients.
Both of these factors, the postponed procedures and reduction in people seeking treatment when they need it, are likely to increase waiting times for patients once they resume using NHS services. Studies show that increased waiting times may increase mortality (Gruber et al, 2018). In addition, higher waiting times in the past have increased demand for private care (Besley et al, 1999), although it is clear that this will not be available for all due to the costs associated with private healthcare.
A key question for researchers and healthcare workers is to find out who is not receiving the treatment they need and prioritise treatment for those groups that may be most affected. From existing statistics on the use of A&E and elective procedures, we can see which groups will be most affected, as they will be those groups who in normal conditions use them the most. One study shows that this means that older and less affluent people are most affected (Propper et al, 2020).
Thus, reduced access to the services that the NHS provides has the potential to exacerbate existing health inequalities between groups based on their income, ethnic background, age and location. Trying to reduce these inequalities may require more investment, in particular in preventative and mental healthcare services, which, in the short run, will add more cost pressures on the NHS.
Health behaviours in lockdown
Another channel through which demand for healthcare may change due to Covid-19 is different health behaviours in lockdown. For example, lockdown may change health behaviours through a changed diet or changes in levels of exercise. Diets with more home-cooked meals are generally healthier and thus we may expect diets to improve – although it is not clear how the additional stress of the pandemic may affect overall diet.
It is also likely that on average people are moving less, although some may have more time to exercise. As these examples show, the average health effects driven by changes in diet and exercise can only be determined once we understand how people use their time in lockdown.
It is also likely that the prevalence of mental health conditions will increase due to the Covid-19 crisis, increasing demand for mental health services in the NHS. Recessions are known to have a negative impact on mental health, but the lockdown may also have an adverse effect on mental health. For example, one study finds that social isolation and loneliness have a negative effect on individual’s health (Shankar et al, 2011).
Related question: What are the effects of recessions on health?
But this lockdown is different from situations to which the studies of social isolation usually apply. First, people are currently isolating with their household, so while they are isolated from the rest of society, not everyone is by themselves. Second, people with internet or even phone access can still connect with others. Thus, it is difficult to generalise the results to other groups directly.
All of these health effects are likely to be exacerbated by the recession that we are experiencing as a result of the lockdown – see "What are the effects of recessions on health?" and "What are the likely effects of lockdown and the recession on children’s health?" for more information.
How reliable are the data?
The data used in the studies here are mainly from administrative data on hospital records and deaths, which are generally reliable sources of data.
Where can I find out more?
The wider impacts of the coronavirus pandemic on the NHS: Carol Propper, George Stoye and Ben Zaranko discuss the impact that the coronavirus pandemic will have in particular on the supply of healthcare by the NHS.
We need a better head start for the next pandemic: Mehdi Shiva discusses how increased investment in public health would help countries tackle infectious disease before they become a pandemic.
Dramatic drop in A&E numbers reflects people putting off urgent care because of Covid-19: The Nuffield Trust comments on the dangers of people putting off seeking care.
Who are UK experts on this question?
- Carol Propper, Professor of Economics at Imperial College Business School in the Department of Economics and Public Policy
- George Stoye, Associate Director at the Institute for Fiscal Studies
- Anita Charlesworth, Director of Research and Economics at the Health Foundation
- Andrew Street, Professor of Health Economics at the Department of Health Policy, London School of Economics
- John Appleby, Director of Research and Chief Economist at Nuffield Trust