Chamber and committees

Excess deaths in Scotland since the start of the pandemic

Letter from the Convener to the Cabinet Secretary for Health and Social Care, Scottish Government, 28 April 2022

Dear Humza,

EXCESS DEATHS IN SCOTLAND SINCE THE START OF THE PANDEMIC

As you are aware, the Committee undertook a short piece of work into excess deaths in Scotland since the start of the pandemic. The purpose of the inquiry was to examine the extent to which excess deaths were caused by COVID-19 as opposed to other causes, such as the indirect health impacts of the pandemic.

The Committee examined the pressures facing the NHS, some of the health impacts being experienced by individuals, and considered the level of demand facing services. It also looked at trends in excess deaths over the period of the pandemic and in particular at points in time where those deaths do not seem to be entirely explained by the number of deaths directly attributable to COVID-19.

Following evidence, the Committee agreed to write to the Scottish Government to highlight issues raised during discussion and to write in similar terms to the Health, Social Care and Sport Committee. I look forward to your response to this letter, which will be shared with the Health, Social Care and Sport Committee.

The overriding message from this inquiry was that it is still too early to be definitive about the exact impact that the pandemic has had in terms of excess deaths in Scotland, given the short-term fluctuations in deaths and the complexity in disentangling those caused by COVID from those where COVID may have been contributary or coincidental. This inquiry found that figures from the National Records of Scotland, from the week beginning 24 January 2022, show that based on death certification there have been 11,817 excess deaths overall in 2020-22, of which 11,218 were either caused by Covid or where Covid was a contributory factor[1]. However, is acknowledged that it will take more time to gauge the pandemic’s full impact on mortality.

A summary of the data provided by the Scottish Government to this inquiry is set out in Figures 1-3 of the attached appendix (SPICe analysis). The analysis of this data highlights the complexity of calculating and explaining excess mortality, which is explored in more detail below.

The Committee has made a number of observations and recommendations in this letter. It hopes that these will assist in the development of the understanding of this issue more fully over the next few years and may help mitigate the impact the pandemic has had, and is having, on excess deaths in Scotland as it goes through recovery.

Data Collection

Context

At the outset of the Committee’s inquiry, deaths were 11% above the average for that time of year^[2]. Not all of the excess could seemingly be attributed to COVID-19, which led to the Committee agreeing to take a more in-depth look. Since that time, excess deaths have decreased and, at the date of the this letter, are below average for the time of year.

To provide context, according to an article published in March 2022 in the Lancet^[3], on worldwide excess deaths from Jan 1, 2020, to Dec 31, 2021, the figures for the UK are around the global average at 126 deaths per 100,000.

In his submission, Dr Francisco Perez-Reche indicated that from May 2021 to Dec 2021, excess deaths from non-COVID conditions were statistically significant. This was confirmed by Public Health Scotland who told the Committee in the period January-March 2021 there was a substantial excess in all-causes of deaths, but this was almost entirely due to COVID-19 deaths. However, from July 2021 onwards the pattern changed, with almost all causes of death being in excess. Although COVID-19 deaths continued to represent the largest single cause of excess deaths (and respiratory deaths remained similar to the long-term average), ‘other’ causes of death, circulatory deaths, dementia/Alzheimer’s deaths and cancer deaths all were higher than expected.

It is expected that NRS will produce more data on what these  ‘other’ causes of death include later this year and the Committee would welcome further data on this as it is key to understanding this in more detail in order to mitigate excess deaths in the future.

Causes of excess deaths

Previous analysis by Public Health Scotland found that while most excess deaths were caused by COVID-19, 18% of excess deaths had other causes, and that these were not distributed equally across society. They found that for some causes of death existing inequalities were widened, such as for Alzheimer's, dementia, and deaths from 'external and ill-defined causes'. It is thought that some of these non-COVID excess deaths could be explained by undiagnosed COVID-19 infection.

However, Public Health Scotland said some of them would have been caused by reduced use of health services by those who need them and unintended consequences of the restrictions.

Looking forward, the Committee was informed that longer term excess deaths are likely to be caused by indirect harms from the virus. For example, initially, at the outset of the pandemic, unemployment  which is associated with increases in mortality, rose considerably. Increased educational inequalities are likely to increase inequalities in life expectancy.

Witnesses^[4] said that not enough data on primary care was collected, particularly on those patients who attend repeat consultations, which could help to understand better the causes of excess deaths. In addition, the Committee heard^[5] it was not possible to ascertain the actual relationship between waiting lists and excess deaths as this data is not currently held.

Acuity data

Written submissions called for Public Health Scotland to monitor clinical indicators of patient acuity on a routine basis in order to gauge the impact of the pandemic on indirect health harms.

Dr Perez-Reche told the Committee about his research, which has looked at indicators of changing acuity in patients, including the time lag between hospital admission and death at various points of the pandemic, and the deaths to admissions ratio. In his written submission, he states his team found evidence that non-COVID-19 patients are now presenting in a more acute condition. He called for more data on the time taken for someone to get admitted to hospital or be diagnosed, and their subsequent death and data on the proportion of people admitted to hospital who subsequently die.

The Royal College of Physicians of Edinburgh also provided the Committee with research by Lyall & Lone (2022), which showed a significant reduction in non-COVID-19 acute medical admissions during the early weeks of lockdown. Those patients who were admitted were ‘of a higher clinical acuity with a higher incidence of early inpatient mortality’.

The Scottish Intensive Care Society highlighted that patients presented later with critical illness as a result of delays to surgical intervention resulting from the reduction in theatre activity as staff were redeployed to cover the pandemic.

The Committee heard of the impact of delays in patients being admitted to emergency departments. The Royal College of Emergency Medicine estimated that, in 2021, delays in admissions equated to more than 500 excess deaths in Scotland.

Monitoring and surveillance

A number of submissions called for better surveillance, analysis and research to give a better insight into the indirect health impacts of the pandemic.

Some of the submissions responding to the Committee’s call for evidence criticised the lack of monitoring of other conditions.  For example, Professor Claudia Estcourt, Glasgow Caledonian University said there has been no national data on sexually transmitted infection and blood borne virus (including HIV) diagnoses since the end of 2019. She highlighted that evidence (Natsal Covid studies, Lancet Public Health 2022) suggested that people from some of the groups at greatest risk of infection continued to seek new partners even during lock downs and that that transmission continued with no surveillance and reduced screenings.

The availability of accurate and regular data was also seen as crucial in order to adequately plan services in the future. Chest Heart & Stroke Scotland called for further work to be done on indirect impacts from the pandemic on the patient journey and the way in which care will need to be delivered.

Responses to the call for evidence highlighted anecdotal reports that there has been an increase in sudden deaths from cardiac events and late presentation of diseases such as cancer. Macmillan Cancer Support said that whilst there is anecdotal evidence of people presenting later at hospital with a reduction in stage 1 diagnosis numbers, there is not enough data on this to be sure of the full extent of the issue.

In addition, the Committee was told of barriers regarding IT systems and that primary care systems are not connected to secondary care systems, which impacts on emergency medicine practitioners’ ability to treat patients appropriately.

In advance of your oral evidence session, you helpfully provided information on excess deaths including key data and trends. SPICe produced an analysis of this information, which is attached at the annexe to this letter. 

Having reviewed the available data, the Committee considers that the evidence base that informs decisions about tackling excess mortality could be strengthened. The Committee considers that this needs to be addressed in order to understand the impact on excess deaths more fully, and recommends that the Scottish Government explores the practicality of collecting data on the following measures—

• Weekly deaths and excess deaths due to ischaemic heart disease and whether these deaths occur in hospital or in the community as well as whether that pattern of place of death has altered.
  
  
• Weekly deaths and excess deaths due to cerebrovascular disease and whether these deaths occur in hospital or in the community as well as whether that pattern of place of death has altered.
  
  
• Weekly deaths and excess deaths due to respiratory disease and whether these deaths occur in hospital or in the community as well as whether that pattern of place of death has altered.
  
  
• The number of people who are dying each month whilst on waiting list to be seen for outpatient assessment.
  
  
• The number of people who are dying each month whilst waiting for inpatient treatment.
  
  
• Changes in cancer stage at presentation.
  
  
• Changes in cancer stage at instigation of therapy.
  
  
• Changes in cancer outcome in terms of survival at standard outcome time points.
  
  
• Percentage of cancer diagnosis first being made in A/E or as part of an emergency admission (as opposed to being made following GP referral for investigation)

The Committee is aware that this inquiry has raised a number of complex issues in relation to data collection, monitoring and surveillance. It is accepted that some of the suggestions above will involve a time lag e.g. cancer survival. In addition, witnesses told the Committee that it will take a considerable period of time to fully understand the impact of the pandemic on excess deaths in Scotland.

The Committee was advised that this is in part because some of those who were most vulnerable (e.g. because of advanced old age, dementia or other comorbidity) will have died from COVID. These individuals would have been at increased risk from routine seasonal increased mortality from e.g. influenza in winter 2020/21 and subsequent winters. This may explain why at the start of 2022 and for a short period during the winter of 20/21 there were weeks when we had less deaths than a normal year despite the presence of covid deaths.

Given such complexities, the Committee requests that the Scottish Government, sets out how it plans to improve and enhance its data collection, as highlighted in its inquiry, in order to gauge the pandemic’s full impact on mortality in the coming years.

The Committee is aware of the Scottish Government’s Digital health and care strategy  aimed at making the best use of digital technologies in the design and delivery of health and services. The Committee requests that the Scottish Government keeps the Committee updated on its delivery of this strategy.

Impacts on excess deaths

The Committee considered the interrelationship between the ‘four harms’ of COVID-19 as monitored by the Scottish Government and the potential impact on excess deaths i.e.—

• A&E attendances
• Excess deaths
• Emergency and planned admissions
• People avoiding contacting GPs
•  

In considering the interrelationship between these harms and the impact on excess deaths, the committee heard evidence in relation to four main themes, delayed treatment and backlog, access and use of services, screening programmes and health inequalities as set out below.

Delayed treatment and backlog

Delays in treatment were suggested as a factor in sudden deaths and a contributor to the excess deaths figure. This was most commonly raised in relation to GP services but also in relation to other parts of the patient journey, including—

• ambulance services,
• diagnostics,
• planned operations,
• planned treatments.

The Committee heard that delayed discharges, where a patient clinically ready for discharge cannot leave hospital because the other necessary care, support or accommodation for them is not readily accessible, has had an impact on the treatment of non-COVID-19 conditions in hospitals and therefore potentially could be a contributary factor in excess deaths.

The Committee notes that the most recent statistics show that in February 2022, there were 47,713 days spent in hospital by people whose discharge was delayed which is an increase of 57% compared with the number of delayed days in February 2021 (30,450).

The Committee acknowledges that the pandemic has led to a considerable backlog of people waiting for NHS diagnosis and treatment. The Committee is also aware that the Scottish Government published its NHS Recovery Plan in August 2021 which outlines its 5-year plan aiming to address the backlog of care and meet ongoing healthcare needs.

During evidence, the Royal College of Physicians of Edinburgh and the Royal College of General Practitioners Scotland suggested the treatment backlog could be mitigated by focusing on capacity in the social care sector. It was argued this would reduce delayed discharges and improve patient flow and capacity in the acute sector.

Given the impact the pandemic has had on non-COVID patients waiting for treatments, it was suggested by the Royal College of Physicians of Edinburgh that separating elective care and emergency care could help improve the situation with waiting lists for elective treatment. In addition, they highlighted that delayed discharges in hospitals was also an issue in hospitals’ ability to work efficiently.

Access to and use of services

A significant number of responses to the Committee’s call for evidence highlighted reduced access to services and healthcare personnel as potential contributing factors to people presenting later in an illness thus potentially contributing to the excess deaths figure.

Reduced use of healthcare services was partly attributed to the following factors—

• a fear of catching COVID
• a perception that surgeries are not open
• not wanting to overburden the NHS.

The Committee is aware that the most recent Scottish Government data shows that 21% of people say they would avoid contacting their GP for immediate non-COVID health concerns.

The Health and Social Care Alliance Scotland (“The Alliance”) commented on the perception that non COVID-19 patients should not seek appointments with their GP and that people found it difficult to get GP appointments if they did not have COVID-19. Rob Gowans, representing the Alliance, highlighted their research which showed that around a third of people felt that their expectations were not met when they called the GP surgery citing uncomfortableness with the triage system and concern about the effectiveness of telephone appointments.

In evidence, you acknowledged the impact the pandemic has had on the use of services with patients presenting later therefore ultimately having an impact on the number of excess deaths in Scotland. You acknowledged that more has to be done to increase the number of face-to-face GP appointments, although there is a need to consider a hybrid model for primary care services which will include telephone consultations, video consultations and increasing face-to-face consultations. 

Screening programmes

Concern was raised regarding the impact of the pandemic on cancer screening services. For example, Age Scotland and About Dementia said the pause on self-referral breast screening for women over 70, and the resultant impact on waiting times for treatment courses to start, may have contributed to excess deaths. Macmillan Cancer Support expressed concern that there is still a six-month delay to the bowel-screening programme and the impact that will have on cancer diagnoses and prognosis. 

Some submissions also highlighted an increasing trend for people dying at home and for people presenting to end-of-life care services in a much more advanced stage of disease than normal. This was felt to have had an impact on how services are delivered as patient care needed to be more intensive from the outset.

The Committee is aware that the Scottish Government’s NHS Recovery Plan states that all of the national screening programmes have now restarted, however it is not clear how the delays and backlogs of the national screenings programmes will be addressed. 

You told the Committee that, although all adult screening programmes have resumed, there is a backlog and that you are prioritising higher-risk participants in a bid to address capacity issues. You also confirmed although self-referral to breast screening services had been paused for the over-70s, you hope to resume this in the coming weeks.

You confirmed that there is most concern about the cancer pathway and explained that there are some 5,000 so-called missing cancer patients from 2020. You highlighted that during the first nine months of the pandemic, 2,681 patients were diagnosed with breast cancer, 1,958 patients were diagnosed with colorectal cancer and 3,287 patients were diagnosed with lung cancer which was 19 per cent, 25 per cent and 9 per cent lower than would have been expected in that period if COVID had not happened.

During evidence, it was suggested that it is safe to assume  that  these figures do not represent a true drop in cases but rather that these are delayed presentation cases that will be diagnosed at a later stage of disease development as services once again come up to speed (see Figure 7 in the SPICe Appendix). The Committee therefore urges the Scottish Government to make every reasonable effort to encourage those with symptoms to now come forward. The NHS should also take steps to prioritise cases for investigation based on objective science-based assessment of risk.

Health inequalities

The Health and Social Care Alliance Scotland said that excess deaths in the most deprived areas were twice as great than in the least deprived areas and argued for better data and, in particular, data that is disaggregated by age, sex, race and other aspects in order to understand the impacts fully.

Macmillan Cancer Support also said that people living in a deprived area are more likely to get cancer, to be diagnosed later and to die. Public Health Scotland informed the Committee that COVID mortality was 2.5 times higher in more deprived populations.

Chest Heart & Stroke Scotland agreed the impacts of the pandemic had been more marked in areas of deprivation and called for a more joined up approach to tackling health inequalities.

Although the Committee heard that the impact of the pandemic on people from lower socioeconomic backgrounds with poorer health had been greater, it was not clear from the data available what the exact impact on excess deaths in areas of deprivation was.

You spoke of the recent publication of Primary Care Health Inequalities Short-Life Working Group report which looked at how primary care and communities could be strengthened and supported to more effectively mitigate health inequalities. The report made number of recommendations, including five foundational recommendations which should be prioritised, namely—

• Strengthen national leadership for health inequalities.
• Implement a national programme of multi-disciplinary postgraduate training fellowships in health inequalities.
• Create an Inclusion Enhanced Service that invests in the management of patients who experience multiple and intersecting socio-economic inequalities.
• Develop a strategy to invest in wellbeing communities through local, place-based action to reduce inequalities.
• Commission an investigation into how barriers to healthcare can themselves inadvertently contribute to excess deaths and premature disability related to socio-economic inequalities.

The Committee believes that more can and should be done to address the reluctance of individuals contacting NHS services in relation to non-COVID conditions. The Committee recommends that the Scottish Government considers how best to promote and encourage use of NHS services for non-COVID conditions as we move through the COVID-19 recovery period. 

The Committee recognises some of the benefits that hybrid working brings. However, there needs to be a clearer understanding, for both professionals and the public, on when alternative consultation methods are appropriate. The Committee believes the Scottish Government should develop a policy on how NHS services should be delivered in the future, explaining what role hybrid working will play in primary care to support NHS recovery.

The Committee also recommends that the Scottish Government, in reinstating all national screening programmes, takes steps to address the backlog resulting from the pausing of these programmes. The Committee also requests that the Health, Social Care and Sport Committee is kept updated on the progress in addressing the backlog. In addition, the Committee recommends that the Scottish Government undertakes further research to understand more fully the effect on excess deaths that reduced access to services and the pausing of screening programmes has resulted in.

The Committee understands that the impact of the pandemic was greater on those from deprived areas and that this could have an impact on excess deaths in those areas. The Committee believes that health inequalities is a priority issue and must be addressed as part of Scotland’s recovery. The Committee requests that the Scottish Government sets out its response to the recommendations made by the Primary Care Health Inequalities Short-Life Working Group. In addition, the Committee requests further information on what data would need to be collected in order to measure the differential impact of the pandemic on excess deaths in deprived areas so that the underlying causes may be effectively addressed.

Workforce planning and strategic focus

The majority of respondents in the call for evidence did not think there was enough of a strategic focus on non-COVID conditions. The most common suggestion for improving the NHS recovery was an increase in staffing and bed numbers but many noted the long-term nature of such an approach and that there is no short-term or simple solution to this issue. 

The Committee heard of the impact on the capacity and wellbeing of the NHS workforce since the start of the pandemic. Although workforce pressures existed before the pandemic, witnesses said the problems had been exacerbated. It was suggested that, given it takes 10 years to train a General Practitioner, the Scottish Government should consider international recruitment exercises as a potential short-term option to help increase capacity, although the Royal College of Physicians of Edinburgh pointed out there may be potential ethical issues with such exercises.

The Royal College of Emergency Medicine highlighted that workforce capacity presented a challenge when considering separating elective care and emergency care. They argued that any future strategy for elective care should involve emergency care given the direct impact on elective treatment waiting lists.

This point was echoed by Royal College of General Practitioners Scotland who highlighted the Audit Scotland report, NHS in Scotland 2021, which said that NHS and social care workforce planning has never been more important and recommended that the Scottish Government must prioritise addressing workforce availability challenges.

The Scottish Intensive Care Society and the Royal College of Emergency Medicine noted a large volume of experienced staff leaving the profession, reducing their hours or seeking early retirement. The importance of support for the mental health and wellbeing of staff was highlighted as being crucial, particularly in relation to staff retention. The issue of pension tax charges prompting staff to seek early retirement was also highlighted. When asked about what progress had been made by the Scottish Government with the UK Government on addressing this issue, you said none had been made as yet but that you will continue to pursue this issue.

The Committee is aware of the Scottish Government’s NHS Recovery plan and notes the recent publication of the Scottish Government’s Health and social care: national workforce strategy which will be subject to yearly reviews.

The Committee requests that future reviews of this strategy should take account of the evidence heard by this committee during its inquiry.

This inquiry has been a useful starting point in examining excess deaths in Scotland since the start of the pandemic. The Committee hopes to discuss its findings and your response with the Health, Social Care and Sport Committee in the coming months.

The Committee is very aware that this inquiry considered the statistics on excess deaths, however, as you too acknowledged, these are not abstract numbers. The Committee appreciates that each one of these statistics represent the end of life for real people, and that should always be borne in mind.

The Committee would be grateful to receive your response to this letter by 27 May 2022.

Yours sincerely,

Siobhian Brown MSP
Convener
COVID-19 Recovery Committee