Impacts of COVID-19 across the lifecourse

Impact

• Reduction of Healthy Child Programme developmental reviews resulting in failure to identify, health and wellbeing issues and safeguarding concerns.
• Reduced vaccination rates leading to reduced herd immunity and increase in outbreaks of communicable diseases.
• Adverse childhood experiences – increased likelihood of abuse and violence.
• Increase in behavioural problems, physical and mental health issues leading to reduction in educational attainment, employment and increase in missing children and crime.
• Dental services unavailable and supervised tooth brushing programmes suspended leading to tooth decay and disruption to school due to extractions and tooth pain in the long term.
• Economic hardship due to parental unemployment leading to food poverty, poor nutrition, anxiety and depression.
• Inequalities in time spent outdoors, physical activity, screen time – vitamin D deficiency, poor sleep, poor mental health, weight gain.
• Increased strain on young carers with no respite.
• Loss of Health, Relationships and Sex Education learning due to school closures.
• Lack of access to sexual health services leading to increase in sexually transmitted diseases and unplanned pregnancies.
• Increase in smoking and substance misuse
• Increase in parental unemployment and greater need for financial support
• Low mood and high anxiety: increased demand for mental health services (CAMHS), A&E admissions for self-harm. Possible increase in suicides. Particularly high for young adults and children shielding.
• Increased need for Bereavement support.

Evidence

• Average forecasts for this year predict unemployment to rise from 4 per cent to 6.4 per cent, falling back to 5.3 per cent in 2021/22 
• It has been estimated that 1.1 million more people could face poverty at the end of 2020 as a result of the pandemic; bringing the total number of children living in poverty in the UK to 4.5 million, an increase of almost 5 per cent. Unemployment is predicted to reach just under 10 per cent in the final quarter of this year 
• 2.3 million children and young people (CYP) in England living at risk due to a vulnerable family background (PHE data). CAMHS referrals - 12 first two weeks of April, usually 1-2.
• Do not have evidence yet to show whether children are spending less time being active and are more sedentary due to school closures and lockdown but we do know that time spent in places associated with PA was down by 31 per cent in the week to April 5 2020 and that children are generally less active on unstructured or non-school days.
• BASHH survey - 54 per cent of sexual health clinics closed /staffing less than 50 per cent. Expansion of virtual services instituting phone triage to restrict in-person attendance to emergencies; retrenching services to operate only in the largest ‘hub’ clinics; and posting out far more STI and HIV home-testing kits plus prescriptions to be filled at high street pharmacies has preserved 50 per cent of previous capacity.

Service impact and response

• Increased virtual capacity and introduced prioritisation of face to face contacts.
• 0-19 services worked with social services and education partners to prioritise the most vulnerable, especially those not attending settings.
• Increase support for parents and publicise Change4Life, social distancing activities.
• Increase comms on safe outdoor activity, Vitamin D supplements/ campaign.
• Dental health campaigns and resumption of supervised teeth brushing in early years settings.

Objectives for additional funding and resource

• Boost availability of online advice, guidance and support or other community capacity in lieu of face-to-face service contacts.
• Prepare for later year pressures, which require immediate effect, including any “catch up” arrangements in future where previously scheduled service contacts, school-based support or other targeted support to help children’s physical health, social or emotional development has been missed.
• Support other measures that may be needed to compensate for less frequent contact with families by safeguarding partners, help families with higher needs or increased numbers of vulnerable children including young carers.
• Increase targeted support and outreach for the most disadvantaged. There is a strong correlation between the most disadvantaged and children who are still not attending early years settings, increasing the potential for hidden harms and development delays.
• Additional school nurse capacity to provide emotional wellbeing and infection control guidance to schools.

Impact

• Suspension of in person sexual health services leading to increase in STIs and unplanned pregnancies.
• Individuals resorting to harmful methods of coping: alcohol consumption, smoking, substance misuse and gambling.
• Substance misuse – changes to services for those already in treatment/recovery – likely impact equals fewer recoveries and increased BBV infections.
• NHS Health Checks paused likely to increase late diagnoses and poor health outcomes and widening of inequalities. The longer term impact of increased negative health behaviours and pauses in services - could mean a greater prevalence of preventable disease such as cardiovascular, diabetes and liver disease with resultant premature mortality. The unequal economic impact of COVID-19 is likely to exacerbate the existing inequalities in this health burden.
• Increase in domestic abuse.
• Immediate impact of economic impact on mental health - anxiety and inability to cope with stress reported by the ONS (ONS, 2020).
• Worsening existing mental health and post-traumatic stress disorder (PTSD) amongst carers and healthcare workers who have faced the trauma and taxing work schedules of COVID-19.
• Likely to be an increase in demand for grief and bereavement services in the medium term and a greater burden of poor mental health in the long-term (depression, anxiety) - increased demand for mental health services and potentially suicide-related deaths.
• Closure of day centres, libraries and other support services will have increased social isolation and impact on vulnerable adults and carers.
• Increased burden on carers with reduced respite services.
• Economic hardship – poor nutrition, increase in stress, anxiety and depression.
• Impact of Everyone In Programme increased numbers of people with no fixed abode accessing drug and alcohol and mental health services.

Evidence

• Economic hardship - Around one in four report a loss of income
• Sport England weekly survey during the initial eight weeks of lockdown: approximately a third of adults were reporting less physical activity than previous. Lower socioeconomic groups, older people, BAME groups and women: all less likely to be active. Fewer of those with long term conditions were doing the recommended 150 minutes of activity a week. People from a black background were least likely to have been active for at least 30 minutes on five or more days.
• 4.2 million people on universal credit within a couple of weeks (a 40 per cent increase in one month). Clear socioeconomic gradient in loss of income and jobs - greatest economic uncertainty faced by our most disadvantaged groups (Marshall, 2020). In the longer term there is potential to see an increase in poverty and housing insecurity and homelessness.
• NHS Health Checks stopped during pandemic. Estimated that the NHS Health Check programme is preventing approx 300 premature deaths (before 80 years) and results in an additional 1,000 people at age 80 years being free of cardiovascular diseases, dementia and lung cancer each year in England. The absolute effect on health was greatest for those living in the most deprived areas. (Mytton OT, Jackson C, Steinacher A, Goodman A, Langenberg C, Griffin S, et al. (2018) The current and potential health benefits of the National Health Service Health Check cardiovascular disease prevention programme in England: A microsimulation study. PLoS Med 15(3): e1002517.
• Research by the Institute for Social and Economic Research at the University of Essex confirms that the earnings of households across the UK have fallen, with lowest earners suffering disproportionately. BAME and single parents worst hit. 24 per cent of jobs at risk.
• The ONS Shielding Behavioural Survey found that in the overall sample, 61 per cent reported no difference in their mental health and well-being (31). However, among individuals aged under 50 years and aged between 50–59 years, almost half report worsening mental health (46 per cent and 45 per cent respectively) compared with 26 per cent and 23 per cent of those aged 70–74 years and aged over 75 years respectively.
• Calls to the UK National Domestic Abuse Helpline have risen compared to the average, to an average weekly increase of 66 per cent (22). Further, figures presented in the Home Affair Select Committee report indicate that at least 14 women and two children were killed in suspected domestic abuse incidents in the first three weeks of lockdown (22). This is the largest number of killings in a three-week period for 11 years and more than double the average rate
• The Trussell Trust (73) reported an 89 per cent increase in need for emergency food parcels during April, compared to the same month last year, including a 107 per cent rise in parcels given to children. Food banks in the Independent Food Aid Network (IFAN) reported a 175 per cent increase in need for the same period.
• During lockdown, the Royal College of Psychiatrists reported that 43 per cent of psychiatrists have seen increases in urgent and emergency cases, but also that a similar proportion (45 per cent) have seen falls in routine appointments (81). There are concerns that this will result in a surge of exacerbated and untreated mental illness after the pandemic. A survey by the charity Mind (82), found that almost a quarter of people who tried to access mental health services within a two week period of April 2020 had been unable to access help.
• A joint survey by YouGov and the campaign group Action on Smoking and Health (ASH), found that more than 300,000 adults may have quit smoking during the pandemic (91). A further 550,000 have tried to quit, while 2.4 million have cut down.
• Writing for the Centre for Mental Health, Duncan et al. (109) suggest that based on experiences from previous epidemics and the aftermath of the 2008 banking crisis, around half a million more people in the UK may experience a mental health difficulty over the next Health & Equity in Recovery Plans Working Group 29 year as a result of the pandemic.

Service impact and response

• Increased referrals into drug and alcohol services
• Increased demand for smoking cessation services
• Increased demand for healthy lifestyle services
• Increased need for public mental health messaging
• Increased need for tailored bereavement support services
• Pressure on NHS Health Checks to ensure catch up and increase outreach and targeted communications to increase uptake Objectives for additional funding/resource
• Expansion of virtual support where appropriate
• Increase capacity in drug and alcohol treatment and recovery pathways
• Increase targeted support to ensure most vulnerable groups can access appropriate services
• Increase public health messaging and community and voluntary sector to increase resilience of local networks, for example, befriending, community groups.

Impacts

• Missed vaccinations (PPV, shingles, flu) leading to outbreaks and loss of herd immunity.
• Food poverty – poor nutrition and negative impact on physical and mental wellbeing.
• Increased social isolation and loneliness. Lack of contact with friends and family. Loss of routine. Suspension of community social groups and classes. Loss of face to face befriending services leading to poor mental health. Many services moved to digital support which can make this age group further disadvantaged as may not be digitally connected/literate.
• Disrupted access to support services – home help, physio.
• Dementia Diagnosis – Lack of cognitive stimulation, physical activity and social connection leading to increased risk of dementia. Less likely to present to GP with memory concerns through fear of contracting COVID. Disruption in Memory Clinic services. Suspended community services, for example, Memory Cafés, carers support groups
• Limited Physical Activity resulting from lockdown, particularly for extended period for the vulnerable or shielded likely to be in this age bracket. Loss of confidence to walk outside leading to further reduction in physical activity and social connection. Not being able to take exercise with friend/neighbour for safety/confidence. Suspended services including Walking Groups, Leisure Centres. Leading to Circulatory problems/obesity/ other complications/falls. 
• Lack of vitamin D, compromising immune system and increasing frailty.
• Injuries due to falls. Risk increased through lack of physical activity impacting on muscle strength. Suspended services including Steady Steps / Seated Yoga/West Berkshire Therapy Centre.
• Negative impact on health and wellbeing of elderly unpaid carers, especially where one partner has dementia. Risk of abuse to both parties. Lack of respite available due to suspended community services, care home capacity due to COVID: Mitigation: Berkshire Carers Hub providing virtual support groups.
• Fuel poverty – Increased risk as autumn/winter approach.
• Increased morbidity and mortality - fear of contracting COVID preventing access to primary care services. Likely to have multiple long-term conditions which they may not manage/self report problems with during COVID (ie/ 50 per cent drop in presentations at A&E with heart attack symptoms.
• Increased vulnerability to scams and abuse. People are at home and more likely to require additional help which may not always be being offered by reputable people. People not visible through usual community routes where signs of abuse may be noted.
• Unemployment and loss of income – possible loss of homes.

Evidence

• 2.2 million people are shielding currently in England.
• 8,769,122 million people are over the age of 70 in the UK.
• The Centre for Ageing Better warns that without action, the impact of lockdown risks creating a ‘lost generation’ of pensioners in poor health and financially insecure.
• During the first month of lockdown, the equivalent of 7.4 million people (14.3 per cent of the entire UK population) said their wellbeing was affected through feeling lonely (termed “lockdown loneliness”2 in the ONS analysis) Impact on Services and Response
• Services such as befriending moved to telephone support.
• Increased demand for mental health and loneliness support services.
• Public health teams supported community volunteer group response through Community Support Hub/ASC/social prescribers phoning shielded and vulnerable residents.

Objectives for increased funding/resource

• Increase public health messaging on keeping physically and mentally in later life.
• Expand social prescribing and community/voluntary sector programmes to increase outreach work and BAME appropriate pathways to health and wellbeing groups.
• Scale up winter pressures planning to ensure those vulnerable to food and fuel poverty receive support in advance.