Pandemic Pressures and Public Health Care: Evidence from England

Person in scrubs within a hospital setting

Non-Technical Summary

New evidence of the long- and short-term impacts of the pandemic on non-Covid-related healthcare.

Delays to cancer referrals and treatment times have led to an estimated 32,000 missing cancer patients that should have already started receiving treatment. Meanwhile, pandemic pressures have adversely affected the quality of care received by non-Covid patients resulting in at least 4,000 additional deaths that could otherwise have been avoided in England.

During the height of the Covid-19 pandemic, healthcare professionals and policymakers were faced with tough choices to delay or cancel some hospital services including cancer treatments. The huge influx of Covid-19 patients during the worst waves of the pandemic also affected the quality of treatment for non-Covid-related emergency care.

New research by Professor Thiemo Fetzer (University of Warwick and CAGE Research Centre) and Dr Christopher Rauh (University of Cambridge) measures the short- and long-term impacts of these challenges on non-Covid-related healthcare services in England.

In the short term, the Covid crisis led to significantly poorer access to and quality of healthcare:

● Patients seeking non-Covid-19 emergency care, for example for heart attacks, saw a notably higher risk of death.

● The increase in non-Covid-19 mortality risk was significantly larger among NHS providers that were particularly under pressure from increases in Covid-19 admissions.

● From March 2020 to February 2021 alone, there were an estimated 4,000 excess deaths among patients admitted to hospital for non-Covid reasons in England.

● These deaths could have been avoided had the patients received the quality of care that the NHS provides in normal times.

● For every 30 deaths directly caused by Covid-19, there is at least one non-Covid death that could have been avoided had the NHS been able to operate as it had been before the pandemic.

The pandemic also limited access to specialist care, delayed diagnostic services and made access to cancer care more difficult. These impacts are having long-term effects:

● The percentage of patients receiving specialist referrals within the NHS’s target of 18 weeks dropped from 83% before the pandemic to 75% during the pandemic, falling to as low as 66% in recent months.

● A&E waiting times have notably increased, with the share of patients receiving treatment within 4 hours declining to as low as 65% in recent months.

● Cancer detection and treatment has been affected by long delays. The share of patients receiving treatment following an urgent referral within the set NHS target of 62 days has dropped from 78% before the pandemic to 71% in 2020. This has fallen as low as 67% in recent months.

● More than 53,000 people have had their cancer treatment delayed past the NHS set goal and currently there are more than 32,000 cancer patients missing from the treatment list.

● The number of cancer cases receiving urgent first treatment dropped by around 2000 per month during the pandemic.

● These backlogs and delays are worse across providers that continue to be more severely affected by Covid-19 pressures and are likely to result in an increase in cancer-associated mortality.

The evidence is drawn from NHS data on A&E waiting times, referrals and mortality rates. The researchers also analyse evidence of NHS staff sickness and absence, vaccination rates and the number of Covid cases in the local community.

They find that one of the mechanisms driving the effects on the speed and quality of patient care are staff absences during the pandemic. Healthcare providers which have since seen a strong vaccination take-up by staff have experienced subsequent improvements on waiting and referral times.

The research provides one of the first empirical studies documenting the impact of Covid-19 pressures on non-pandemic NHS care. Professor Thiemo Fetzer says, “Modelling studies have muted the effect of the pandemic on non-Covid-related healthcare, however, this has, to date, not been empirically quantified. We are able to provide a sound empirical estimate of a lower bound of excess deaths among patients seeking medical help for non Covid-19 reasons. Our estimates show that for every 30 Covid-19 deaths there is at least one death among non-Covid-19 patients receiving worse care.”

Dr. Christopher Rauh says, “Our work highlights the importance of both staff absence rates and the vaccination of critical healthcare staff. The risks Covid-19 poses for healthcare services go significantly beyond individual infection and spread. We find that infections have led to higher staff absence rates which have a negative effect on the accessibility and quality of healthcare services. This along with increased pressures due to high numbers of admissions has led to the avoidable loss of lives both in the short as well as the long run, for example, due to worse cancer care. These risks could be pre-empted by promoting vaccinations or increasing staffing levels.”

Pandemic Pressures and Public Health Care: Evidence from England, joint with Christopher Rauh, CAGE Working Paper 607.

🔓 Open access


This paper documents that the COVID-19 pandemic induced pressures on the health care system have significant adverse knock-on effects on the accessibility and quality of non-COVID-19 care. We observe persistently worsened performance and longer waiting times in A&E; drastically limited access to specialist care; notably delayed or inaccessible diagnostic services; acutely undermined access to and quality of cancer care. We find that providers under COVID-19 pressures experience notably more excess deaths among non-COVID related hospital episodes such as, for example, for treatment of heart attacks. We estimate there to be at least one such non-COVID-19 related excess death among patients being admitted to hospital for non-COVID-19 reasons for every 30 COVID-19 deaths that is caused by the disruption to the quality of care due to COVID-19. In total, this amounts to 4,003 non COVID-19 excess deaths from March 2020 to February 2021. Further, there are at least 32,189 missing cancer patients that should counterfactually have started receiving treatment which suggests continued increased numbers of excess deaths in the future due to delayed access to care in the past.

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