About this report

This report examines the impact of the COVID-19 pandemic on healthcare delivery across the UK. It looks at how well prepared the UK’s health services were going into the pandemic and considers how these underlying conditions impacted care delivery during the first, second, third and fourth waves.

The state of health and care systems going into the pandemic

Health and care systems across the UK were operating in environments of scarcity long before COVID-19 and were poorly prepared to weather the storm of the pandemic. Critical underlying issues were brutally exposed with too few staff, too few beds, and buildings that were unsuitable for effective infection control. 

Sustained underinvestment in healthcare

Growth in health spending has not been consistent over the lifetime of the NHS – and in the decade before the pandemic, spending increases were significantly below the long-term average. This put the UK’s total health spend well below that of comparable nations. While some additional funding was made available during the pandemic, sustained underinvestment left the UK’s health services unable to sufficiently grow the workforce, tackle rising waiting lists, or modernise infrastructure and estates in the years preceding the pandemic.

Acute staffing shortages 

The decade preceding the pandemic saw chronic staff shortages across the NHS. With insufficient investment in all parts of the doctor training pipeline and a doctor-to-population ratio well under the average of comparator nations, the stress of working in a starved NHS had caused a spiralling recruitment and retention crisis. By June 2019, a record number of posts stood vacant across the NHS.

Working overtime to plug staffing gaps had become the norm, resulting in dangerous levels of exhaustion and burnout even before COVID-19. This exacerbated retention issues and resulted in a chronic reliance on expensive agency or locum staff.

Year-round capacity constraints and growing waiting lists 

Health services across the UK entered the pandemic with a significant backlog of care. Waiting times for diagnostics and elective care were increasing, while access to emergency care was worsening. Across the health services, targets were being missed with growing frequency.

After years of declining bed stock, hospitals entered the pandemic with very low numbers of beds, including critical care beds. High occupancy rates in the years prior to COVID-19 reduced hospitals’ flexibility, affecting their ability to cope with any increases in demand, such as those experienced during a pandemic.

In England, this also meant there was an increasing use of the private hospital sector, even before the pandemic.

Estates have been unfit for care delivery for many years

Capital funding over the past decade has failed to keep pace with maintenance requirements, so that many hospital buildings and GP practices across the UK – as well as the equipment inside them – are unfit for purpose, as well as wholly unsuitable for proper ventilation or social distancing requirements. The poor state of the NHS estate reduced the ability of the health services to deliver safe and timely care over the past decade, and proved woefully inadequate for a pandemic.

First wave (Feb 2020 - Sept 2020)

The first wave of COVID-19 tested health services across the UK immensely and further exposed the consequences of sustained under-resourcing prior to the pandemic.

Extraordinary efforts were needed to staff health services

Existing chronic workforce shortages were exacerbated by rising staff absences due to infection and self-isolation, and a sharp reduction in international recruitment.

This shortage of staff necessitated redeploying staff to high-need services to help maintain a base level of service provision across critical and emergency care.

Other measures included asking retired and non-practicing doctors to return, enabling medical students to join the health services early and establishing volunteer programmes for the public.

Key areas of service delivery in secondary care were disrupted

A lack of system capacity meant all but the most urgent of non-COVID care had to be cancelled, including many cancer treatments. This created a mounting backlog which exacerbated pressures in later waves and likely had a significant impact on patients’ mental and physical health.

In an attempt to free up capacity, hospitals were encouraged to discharge patients into care homes or their own homes. At the time testing for COVID-19 was not widely available and, even where tests were available, many people were discharged without being tested - a mistake that likely led to the deaths of many. 

To further increase capacity, new temporary field hospitals were set up and block-booking agreements were made with private sector hospitals. However, both of these systems were under-utilised, mostly due to the fundamental lack of staff to run them.

The model of care delivery within primary care changed considerably

To mitigate infection risk, general practice shifted to remote consulting where feasible, which further exposed the limitations of IT infrastructure within the UK health services. However, contrary to UK media rhetoric, in-person consultations continued to take place where necessary.

The lack of capacity in secondary care meant GPs also saw increased demand as a result of cancellations elsewhere. They were also responsible for many patients whose health issues had been exacerbated by lockdowns, and who had nowhere else to go for care.

Second wave (Sept 2020 - Apr 2021)

Health services were pushed to new limits

UK health services attempted to deliver COVID and non-COVID care concurrently, which was an immensely challenging task given the context of rapidly rising COVID-19 case numbers, the emergence of the Alpha variant, the usual winter pressures and the impact of ongoing IPC measures on capacity.

Record numbers of patients were admitted to hospitals, the number of ambulances held outside hospitals or diverted elsewhere was rapidly worsening, and A&E waits skyrocketed. Increasing staff absences further reduced capacity, which impacted on patient care and pushed services into dangerously unsafe levels of staffing.

Services were again forced to prioritise

UK health services made considerable progress in restoring non-COVID activity after the first wave, but despite best efforts of staff, service suspensions became necessary again in order to cope.

Like in the first wave, waiting lists drastically increased. There was also growing awareness of the ‘hidden backlog’ of unmet need - patients who required care but had either not yet presented or who had referrals cancelled due to reprioritisation or lack of capacity.

General practice played a pivotal role in leading the vaccination programme

The vaccination rollout is widely regarded as an unprecedented success. Vaccinations were delivered remarkably quickly in comparison to other nations, and the UK government hit its ambitious target of offering the vaccine to all adults by July 2021.

General practice, in particular, did an exceptional job at spearheading the programme. This achievement is all the more remarkable considering the vaccination rollout was delivered in addition to standard workload, not instead of it, and at a time when demand was continuously rising.

Third and fourth waves (May 2021 to present)

While cases of COVID-19 remained high throughout summer 2021, the exponential growth of the Omicron variant pushed the delivery of the vaccination programme to new heights through the swift delivery of third dose and booster vaccinations.

GP premises were used to deliver vaccination boosters as quickly as possible, resulting in an ever-increasing number of virtual appointments to meet demand while much of the existing GP estate was used for the delivery of the vaccination programme. Amid (false) media and UK Government narratives about GPs not being open for business, primary care staff faced increasing levels of abuse from patients and, in some cases, sadly violence.

There is an increasing emphasis on the recovery of elective care, yet the goals governments across the UK have set will be extremely difficult for health services to meet without a costed, national, comprehensive workforce strategy, which focuses on staff retention as well as training and recruitment.

Key recommendations

Click to expand recommendations beneath each heading.

Questions for the inquiries

• How could health services have been adequately staffed entering the pandemic? What impact could this have had on healthcare delivery during the pandemic? How should the system enact workforce planning going forward?
• How did low bed numbers impact on healthcare delivery during the pandemic? How can they be sustainably expanded, distinguishing between ward beds and critical care beds, in addition to beds in care homes?
• How did the poor quality of the health service estate impact staff and patients during the pandemic? How can this be improved in the future? What additional lessons can be learned about the use of field hospitals during the pandemic?
• How did inadequate funding, and historical underfunding, impact healthcare delivery during the pandemic?
• What lessons can be learned from the deployment of staff across the service during the pandemic, including the use of returners, early deployment of medical students, and the use of the private sector?
  • Where returner programmes were not well utilised, what lessons can be learnt about what went wrong?
  • How can redeployment in future crises be better managed?
  • What can be learnt from the success of the public volunteers programmes? Is there scope to retain and continue to use volunteers?
• Were proper operational and staffing planning undertaken prior to investing in NHS Field Hospitals?
• What did the government spend on private sector contracts to retain exclusive use of private hospitals? What calculations were done on staff availability to match additional physical capacity?
• What was the evidence base for discharging patients early without testing to free up capacity - including to care homes? How was this decision taken and what impact did it have on care home residents?
• What were some of the positive changes brought about because of COVID-19, and how might some of them be maintained?