At each government briefing we are told the daily death toll from COVID-19 across the hospitals of the UK. However in the background people are still dying from non-COVID-19 causes. This is not, in itself, a surprise because around 500,000 people die each year in the UK. (1) (2) The concern is that the latest data released from the Office of National Statistics (ONS) showed that the UK's non-COVID-19 deaths have risen sharply.
For the week ending April 3rd there were 16,000 deaths, 6000 more than the average for that week of the year. Of those deaths just under 3,500 were from COVID-19 so the pandemic alone is not responsible for all of the increase.
For the week ending April 10th there were 18,000 deaths, 8000 more than the average, and of those 8000 one third were attributable to COVID-19.
ONS official Nick Stripe said the extra deaths were "hugely significant" and "not normal."(3) It is possible that some of these extra deaths are actually non-recorded COVID-19 cases (eg: the death was attributed to "pneumonia" because without testing it cannot be known precisely which pathogen caused it.) This may be particularly true of the deaths in care homes where the patients have not gone into hospital.
However there are factors associated with both the pandemic and the lockdown that will impact on the health of the nation, both now and in the future.
Many articles in the media are conjecture because we are still lacking in raw data but there are concerns within the medical profession that some people with serious conditions are avoiding going into hospital for fear of contracting COVID-19. The cessation of routine medical work, which includes operations and cancer treatments, will impact future healthcare.
With solid data not yet available with which to make precise pronouncements I have instead reviewed some of the statements made by some leading UK charities and the Medical Royal Colleges.
Royal College of General Practitioners
A 5 year study on early cancer referrals by GPs published in the British Journal of General Practice this week showed that GPs were achieving significant success in referring people with suspected cancer to hospital early. This fast track referral system allows earlier diagnosis and treatment of the disease. and a better survival outcome.
Lead researcher, Dr Thomas Round, said that up to 10,000 possible UK cancer deaths are avoidable each year but expressed his concerns about the pandemic and lockdown saying, "Clearly the current COVID-19 situation is putting a significant strain on health services, including for potentially serious conditions, such as suspected cancer referrals and cancer treatment once diagnosed. Whilst the assessments may be different, and NHS capacity is stretched, we are still trying to facilitate urgent two week wait referrals in collaboration with our hospital colleagues." (3)
Cancer Research UK
Cancer Research UK has said that fast track referrals have fallen by as much as 50% in some parts of the country and that in the past month approximately 15,000 newly diagnosed patients should have started treatment but haven't. It is also concerned that the NHS will not be able to cope with the large backlog of cancer care needed when services reopen.
Sarah Woolnough, Cancer Research UK's executive director of policy and information, said: "The pandemic has left cancer diagnosis and treatment in a precarious position, and one of the ways that the NHS is adapting to ensure patients are receiving vital testing and care is through 'COVID-19 free' centres or hospitals. But this won't be possible without the appropriate testing of all staff and patients.
"Already, Cancer Research UK has helped to increase testing capacity through the Francis Crick Institute. We want to continue to contribute towards the national effort to beat COVID-19, so that cancer patients can receive the care that they need during this difficult time. Although some patients are being tested for COVID-19, testing in some areas is reserved for those who are seriously ill."
Professor Charles Swanton, Cancer Research UK's chief clinician, said "We can create a safe environment for both staff and cancer patients now that testing efforts are escalating quickly. Staff in hospitals around the country are working extremely hard and with more testing of staff and patients - with and without symptoms - we will have hospitals and centres relatively free from COVID-19 where patients can be treated safely, and post-operative complications can be minimised."
Cancer Research UK will also be impacted by a reduction in funding as so many of its fundraising actitivities have been cancelled. It anticipates losing up to 25% of its income this financial year.(4) (5)
Multiple Sclerosis Society
The Multiple Sclerosis (MS) Society has surveyed over 1000 people with MS in the UK and found that one third reported that their mental health was suffering and that one fifth were not able to access essential items including medications. Of those who need help with activities such as washing and dressing from outside care agencies, 18% reported that this had been reduced or cancelled altogether. (6)
Royal College of Surgeons
Meanwhile the president of the Royal College of Surgeons, Professor Derek Alderson, has warned that the UK will need a five-year plan to tackle the waiting lists that have developed during the virus crisis. The waiting list in England was 4.4 million before the outbreak. He said: "Where clinicians know a condition will inexorably deteriorate over a matter of weeks and possibly where severe harm or even death might rear its head, those are really hard conversations. The problem is giving them factual information of the two sides of the coin; risk of the condition getting worse without surgery versus the risk of operating and then getting COVID-19. We do not have high quality information with which to advise patients, that is really difficult and it's likely to persist for a while yet." He went on to say "We need a really good, well worked out strategy with the government to cover a number of years — five years probably — that addresses this issue. We have twice the number of people waiting than ten years ago already - that is unacceptable and we have to get out of it." (7)
Diabetes UK
The charity Diabetes UK has warned parents of children and teenagers not to assume all symptoms are because of COVID-19 amid alarm at an increase in diabetic emergencies. The norm is for about 25% of new diagnoses of insulin dependent diabetes in children and young adults to be made after a medical emergency called diabetic ketoacidosis (DKA) which can cause intense thirst, nausea, vomiting and confusion. However a higher than expected number of new cases are currently presenting in this way to Accident and Emergency departments with DKA. Dan Howarth, from the charity, said: "We know that parents currently have a million things on their mind, and they're doing everything they can to keep themselves and their families safe during the coronavirus outbreak. But diabetic ketoacidosis can be a life-threatening complication of diabetes. If a child or young person does not receive immediate treatment for DKA, it can lead to coma, or even death. It is vital that parents are aware of the early signs of type 1 diabetes and seek help if they need it. The NHS is open, and the health service is still there for you."(8)
British Heart Foundation and the NHS Cardiology Teams
Patients with heart attacks may be going untreated according to the BHF and experts in the field. After a myocardial infarction (also known as an MI or heart attack) many patients have treatment to unblock the blood vessels that supply oxygen to the heart. There are six heart centres in London that carry out these procedures and they have reported a 38% drop in the number of procedures they carried out during the last two weeks of March. Meanwhile the number of people presenting to Accident and Emergency departments with the symptoms of a heart attack halved during March. The Academy of the Medical Royal Colleges and The BHF are concerned that these figures show that people are reluctant to visit hospital for fear of catching COVID-19. Cardiologist Dr Ramzi Khamis, from Imperial NHS Trust, London, said: "We have seen about half as many patients as we usually do coming into our heart attack centre at Imperial, some with significant delays. We are now becoming quite anxious about the ones we are not seeing as well as the delays. We want to stress that we have the staff, equipment and resources to treat heart attacks. With swift diagnosis and treatment, most people with heart attacks will recover and go on to live a healthy life. However, delays in treatment puts lives at risk, and will result in more pressure on the NHS, not less." Dr Layla McCay, from the NHS Confederation, said: "These figures suggest more people are adhering to the stay-at-home guidance, and only attending A&E if they have no other option. This is positive, and should help to ease at least some of the unprecedented pressure the service is currently under. However, we would stress that the NHS has not closed its doors to non-Covid-19 patients, and if people need urgent care, they should not feel they cannot attend hospital. At its core, the service hasn't changed: it's there to help those in need." (9) (10) (11)
Mental Health
The psychological aspects of the pandemic combined with the lockdown restrictions are likely to lead to an increase in mental health problems and suicides according to many experts. The data is not robust enough yet to give detailed insight because suicide cases are always referred to the coroner and the subsequent inquest can take many months. As Tom Dening, professor of dementia research at the University of Nottingham, says: "There doesn't seem to be any data that so far suggests there is a wave of suicides. It is however quite possible that we will see an increase in suicides and self-harm over time, the longer the lockdown goes on."
Dr Dean Burnett, honorary research associate at Cardiff Psychology School, said "Most anxiety is caused by perhaps imagined threats and concerns, or potential dangers which may be, whereas now in the news they are telling us every day that there's a genuine risk, just by leaving your house."
He added that there was concern that as things become completely over-whelming for some "things like suicide occur". (12) (13)
In Conclusion
It is clear that both now and into the future this pandemic will affect the nation's health and continue to stretch the NHS well beyond the outbreak. However, anybody with serious symptoms now should still access healthcare as usual either via their GP or local Accident and Emergency department. Normal emergency services are still running and all our hospitals are open and staffed. Not only will this ensure they get the care they need immediately but it will actually help, and not hinder, the NHS when normality is restored and GPs and hospitals nationwide start to work through the back log created by the pandemic.
13) https://www.eveningexpress.co.uk/news/coronavirus-is-lockdown-leading-to-deaths-from-other-causes/
