Hampshire COVID-19 Health Impact Assessment Executive Summary

October 2021

Introduction

On the 11 March 2020 the World Health Organisation declared COVID-19 a pandemic. Over a year on, this report aims to look at the impact COVID-19 has had on the residents of Hampshire.

SARS-CoV-2 is a newly emergent virus causing COVID-19 disease, and even now there is still much more to understand. The impacts of COVID-19 will be felt for many years, and some may still not yet be realised. Therefore, this report provides a retrospective view of what the pandemic has meant to our local populations, reviewing national guidance and policy to date and what the potential impacts have been and will be on our populations.

COVID-19 has exposed, exacerbated, and created health and social care needs and new inequalities. People across the UK, and indeed the world, have been harmed by the virus in very different ways. Both the first and second waves of the pandemic have brought challenges. We need to understand how the effects have disproportionally affected different population groups (age, gender, ethnicity, occupations, co-morbidities, deprivation) and how we minimise the negative impacts and maximise the positive benefits.

At the time of writing this report the country is still in response mode of the pandemic and so evidence pertaining to the impact of COVID-19 continues to grow. Each wave has been very different in terms of interventions, national policies such as testing and dominant variant, and these different factors should be considered when reviewing the data and trends.

Over the last 18 months our population movements, how we interact and work, have all been restricted and impacted on due to the public health non-pharmaceutical interventions (NPIs). These NPIs were used, in the absence of a medical intervention such as vaccination, to suppress and slow down the spread of COVID-19. The direct health and clinical impacts of these policies are evident. Across Hampshire, high levels of population compliance of measures such as social distancing and "Stay at home" rules resulted in suppressed infection rates and will have undoubtedly resulted in fewer people being hospitalised and dying. However, the social and mental wellbeing impacts could be less positive.

The Build Back Fairer: COVID-19 Marmot Review found that England has had higher mortality from COVID-19 and a greater number of excess deaths in the first half of 2020 than other European countries. It states that:

this is not just a factor of population age structure, or of high rates of employment in particular sectors, nor is it solely to do with the management of the pandemic, although that is important. It relates to conditions prior to the pandemic.

Therefore, when examining the impact of the pandemic for Hampshire it is important to understand our population health baseline prior to the pandemic.

Hampshire's population is older and ageing faster which has implications for current and future health and social care needs. There is increasing ethnic diversity with distinct areas of greater diversity in districts such as Basingstoke & Deane and Rushmoor. The ethnic minority population has a younger structure than the white population, potentially presenting different health and social care needs. Overall, Hampshire is considered a fairly affluent county but marked inequalities exist within the area.

The Health Index data, developed by the Office for National Statistics (ONS), suggests Hampshire's population has better overall health compared to England, but this has worsened between 2015 and 2018. Exploring subdomains in the Health Index suggest physical health, mental health and musculoskeletal conditions are all worse in Hampshire than England and have deteriorated further. These areas will have been significantly impacted upon further due to COVID-19.

Across Hampshire life expectancy improvements have slowed, particularly in females and in the more deprived areas. While life expectancy is one important measure of health, how long a person can expect to live in good health is an even more significant measure of quality of life. Healthy life expectancy in Hampshire has decreased for both males and females but this decrease is greatest in females.

The patterns and trends observed are similar to the national picture and suggests that before the pandemic, improvements in our population's health had stagnated and, in some areas, deteriorated.

The following sections of the report summarise the impact of COVID-19 on the Hampshire population and is structured into three sections based on the ONS Health Index domains:

Healthy people: Looks at the impact of the pandemic on different groups, such as age, gender and ethnicity
Healthy lives: Considers how different lifestyle behaviours related to health have been impacted by the pandemic
Healthy places: Investigates how COVID-19 has impacted populations differently depending on the area they live

Healthy people

Nationally, diagnosis rates increased with age, and rising rates in the over 60 years population was a strong predictor for higher hospital admission rates (Source: Disparities in the risk and outcomes of COVID-19). Local data is comparable to national findings. Demographic factors such as age and gender correlated with higher rates of hospitalisation and death due to COVID-19, as older people and males in Hampshire were disproportionately affected by these severe COVID-19 outcomes.

Higher numbers of cases were reported in females when compared to males. This may be linked to occupation (for example, a higher proportion of females work in caring occupations with regular testing). Exploring emerging local primary care data suggests that the burden of Long COVID (long-term effects that continue beyond the initial illness) may disproportionately fall on the female working age population when compared to other age groups and males.

Care homes were disproportionately affected by the COVID-19 outbreak as residents and those working in care homes were more vulnerable to the virus. People living in care homes are often frailer and more likely to have underlying conditions than the population in general. Employees of care homes work in an environment where social distancing and infection control may potentially be even more challenging than in hospitals.

Data from the ONS and analysis by Public Health England (PHE), now the UK Health Security Agency (UKHSA), found that deaths in care homes accounted for 27% of deaths from COVID-19 up to the 8 May 2020. In Hampshire, deaths in care homes comprised 44% of all deaths where COVID-19 was mentioned on the death certificate in Wave 1, between the 21 March and the 12 June 2020. By Wave 2, between 24 October 2020 and the 19 March 2021, the proportion of deaths in Hampshire care homes had fallen to just under a third of all COVID-19 deaths. Deaths in Hampshire care homes were at their highest during the week ending the 22 January 2021. It should be noted that these figures will not include all deaths of care home residents who died elsewhere (Source: Disparities in the risk and outcomes of COVID-19).

The impact of COVID-19 on care home residents was not equally distributed across Hampshire. Rushmoor and Test Valley experienced the highest rates of care home mortality in Wave 1, significantly higher than both the national and Hampshire average, and the districts of Hart and New Forest, the lowest rates. In contrast, Hart was disproportionately affected in Wave 2 of the pandemic, with the highest mortality rate of 204.5 deaths per 1,000 care home beds. Rates in Winchester were significantly lower than the national and county average.

Some of this variation may be due to how the virus spread geographically, how quickly and effectively care homes were able to reduce transmission routes from hospitals and the community, implement infection prevention and control (IPC) measures, as well as the availability of personal protective equipment (PPE). In addition, care homes use of agency staff who may work across a number of settings may have impacted the trends observed. More deprived areas, such as Rushmoor, are likely to have experienced greater impact as a result of factors relating to care home staff. These employees are likely to live locally and experience poorer health, greater vulnerability to COVID-19 infection and more overcrowded living conditions associated with deprivation.

In addition to age and gender, people from ethnic minority groups were more likely to be diagnosed with COVID-19 and were disproportionately affected by severe health outcomes. Nationally, people from Black ethnic groups were most likely to be diagnosed with COVID-19 and also had the highest admission rates. It is not possible to look at ethnic minority group data robustly at a local level and in detail, however, analysis has shown that across Hampshire a higher proportion of people in ethnic minority groups tested positive when compared to the white population group. There was also a greater proportion of admissions of people from non-white minority ethnic groups than expected, when compared with their overall population.

The whole population has been impacted by policy; however, particular groups have been impacted in different ways and experienced varying levels of hardship over the course of the pandemic. The variations in the impact effect of COVID-19 on our population can be largely summarised by the broad stages of life.

Older people

Older people were more vulnerable to serious illness and deaths from COVID-19 and more likely to shield. The impact of restrictions on non-essential services has resulted in decreased social connectiveness. Older people are also less likely to use online communications to supplement their interactions, as they are one of the population groups who are less likely to have home internet access (Source: Digital divide narrowed by the pandemic, but around 1.5m homes remain offline). Lack of mental stimulation and socialising during the pandemic has also caused concerns for new and emerging cognitive decline. Age UK reported that one in five older people said that since the start of lockdown, they are finding it harder to remember things (Source: The impact of COVID-19 to date on older people’s mental and physical health).

Anxiety and depression among older people have increased during the pandemic, which can result in self-neglect and loss of confidence (Source: The impact of COVID-19 to date on older people’s mental and physical health). Older people with pre-existing mental health conditions have seen an increase in the severity of their symptoms, while others are struggling for the first time (Source: The impact of COVID-19 to date on older people’s mental and physical health). National Institute for Health and Care Excellence (NICE) guidelines were issued concerning rising self-harm in the over 60s due to mental health issues during the pandemic, including loneliness, bereavement and access to services (Source: Self-harm and suicide in adults Final report of the Patient Safety Group). There is also growing concern of cognitive decline due to lack of mental stimulation and socialising.

Carers and Social Care

Nationally, there has been an increase in unpaid carers during the pandemic as people provide informal help for family members (Source: Unseen and undervalued: The value of unpaid care provided to date during the COVID-19 pandemic). The impact of social distancing restrictions has also compounded social isolation and reduced mobility, so people may require social care services earlier than they may otherwise have done. COVID-19 will also have impacted younger people, especially those with learning disabilities, who receive support services. Many services, such as day centres, were closed during social distancing restrictions which may have resulted in increased social isolation. Children with disabilities, and their families, access to medical services has also been impacted. Sixty percent of families reported delays in appointments, which can be compounded when disabled children experience multiple diagnoses, and therefore a higher number of appointments. Carers and families of these children have reported a decline in mental health and increased isolation (Source: No End in Sight. The Impact of the Pandemic on Disabled Children, their Parents and Siblings).

Working age population

Over the pandemic some people have experienced financial strain, longer working hours, poorer work life balance or increased fear of potential exposure to COVID-19. One in five adults have experienced some form of depression, double that observed before the pandemic (Source: Coronavirus and depression in adults, Great Britain: January to March 2021). Younger adults and women were more likely to experience some form of depression with over 4 in 10 (43%) women aged 16 to 29 years experiencing symptoms of depression (compared to 26% of men the same age). Studies examining the links between wellbeing, employment and low income are emerging, but earlier findings suggest low income or loss of income is associated with increasing levels of loneliness during lockdown and higher levels of anxiety and mental distress. Women in lower socio-economic jobs were more likely to be furloughed than any other positions (including key worker roles) and men in general (Source: COVID-19: mental health and wellbeing surveillance report).

Children

Evidence shows that the number of children living in relative poverty has been steadily increasing prior to COVID (Source: Public Health Outcomes Framework - Data - PHE), and the economic impact of COVID has disproportionately impacted low-income families, potentially further driving and widening the inequalities for these children.

Young people

Although at low clinical risk of severe health outcomes from contracting COVID-19, adolescence is a key period for social cognitive development (Source: Is Adolescence a Sensitive Period for Sociocultural Processing?), and in July 2020, 92% of young people reported missing being face-to-face with people. The main pressures reported by children and young people during the pandemic were; increased feelings of loneliness and isolation, concerns about school, college or university work, trouble sleeping, anxiety about catching and spreading COVID-19 and a breakdown in routine (Source: What children are saying to Childline about coronavirus). Many young people also expressed fears about the future. Online bullying (Source: Online Harms White Paper: Full government response to the consultation) and an increase in online gambling (Source: Gambling by young adults in the UK during COVID-19 lockdown) have also been reported in young adults.

Healthy lives

Our lifestyles, behaviours and existing health conditions affect our population’s health, and in turn they have been impacted by the pandemic. Comorbidities were predictors of worse health outcomes from COVID-19 and were especially evident for those with a history of non-communicable diseases such as obesity, diabetes, heart disease, hypertension and those living in more deprived areas (Source: Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England).

Analysis across Hampshire and the Isle of Wight found that the most prevalent risk factors for testing positive for COVID-19 were excess weight and frailty.

Mortality rates were also found to be affected by co-morbidities. Public Health England’s analysis of national data found that among deaths with COVID-19 on the death certificate, a higher percentage mentioned diabetes, hypertensive diseases, chronic kidney disease, chronic obstructive pulmonary disease and dementia than all cause death certificates (Source: Disparities in the risk and outcomes of COVID-19).

Local analysis found similar patterns to national analysis with the exception of all cardiovascular diseases where rates were actually slightly lower among COVID-19 deaths. All other comorbidities mentioned had higher rates among deaths where COVID-19 was also mentioned on the death certificate, significantly so for diabetes and dementia.

National data has reported a link between occupation and severe outcomes from contracting COVID-19. Men working as security guards, taxi drivers and chauffeurs, bus and coach drivers, chefs, sales and retail assistants, lower skilled workers in construction and processing plants, and men and women working in health and social care had significantly high rates of death from COVID-19 (Source: Disparities in the risk and outcomes of COVID-19). Additionally, men from ethnic minority groups are much more likely to work in high-risk occupations. They are overrepresented in eight out of the ten highest death rate occupations; this is particularly true for taxi and cab drivers (Source: COVID-19, Health Inequalities and Recovery). Long COVID is also more prevalent amongst those working in the health and social care sector, and those with long term health conditions such as obesity (Source: Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021).

Local analysis found that, in 2020, deaths in people aged 20 to 64 were 1.22 times higher when compared to the average of the previous five-year period. For two occupational groups, the relative increase in deaths was far higher than the average of 1.22. These two groups were caring, leisure and other service occupations and elementary occupations, with relative increases of 1.75 and 1.70 respectively. This represents an extra 19 deaths in both of these occupational groups over the course of Wave 1 (eleven weeks). These types of occupation suggest employees with increased socio economic vulnerabilities and working conditions such as unable to work from home, working in multiple settings (such as carers) and being lower paid.

National evidence of the indirect impacts of COVID-19 and how our lifestyles, behaviours and existing health conditions may have impacted our population’s health through the pandemic are summarised below.

Physical activity levels

Physical activity levels have been impacted by the pandemic, for those aged 16 and over physical activity declined during the early stages of the pandemic. Children saw a decrease in overall activity levels (Source: Children's activity levels down but many embrace new opportunities). Sporting activities saw a large decrease, whilst walking, cycling and at home fitness activities saw a large increase. Positive attitudes towards sport and physical activity had decreased, with boys seeing the largest drop in activity levels and girls seeing an increase. Those living in less affluent areas had consistently lower levels of activity. Other studies have reported a decline in children’s physical fitness and increase in weight (Source: Impact of Lockdown Report, Schools Active Movement). Additionally, 2 million children will have missed out on swimming lessons over the past year (Source: Impact of Coronavirus on School Swimming and Water Safety report).

During social distancing restrictions many people experienced reduced levels of activity (Source: Research into how the coronavirus crisis has affected people's activity levels and attitudes towards exercise - Sport England), however, for those with long term conditions who were shielding, this impact would have been even greater. A reduction in exercise can result in deconditioning which leads to an increased risk of reduced bone mass and muscle strength, increased dependence and confusion. The term ‘Deconditioning syndrome’ is used to describe this effect and includes the physical, functional and psychological decline that can be experienced from reduced mobility (Source: Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis). A survey conducted by Age UK asked older people how their health has changed since the start of the pandemic. One in three said they have less energy. One in four older people were unable to walk as far as before, and one in five feel they were less steady on their feet.

In Hampshire over the course of the pandemic approximately 53,000 people were shielding. Spending months with reduced activity is suggested to have an impact on the four aspects of physical fitness (strength, stamina, suppleness and skill) and also on cognitive function and emotional wellbeing. This will increase dependency and reduce life expectancy (Source: Covid-19 will be followed by a deconditioning pandemic).

The long-term impact locally of the risk of deconditioning due to inactivity and evidence pertaining to behaviours such as smoking rates, alcohol consumption and diet are mixed and will need to be analysed over longer time periods.

Diet

Diet has been impacted by the pandemic with hospitality closed more people were cooking from home, however, the quality of food has varied across different groups. Children from disadvantaged background were most likely to eat more junk food and less likely to be eating more fruit and vegetables (Source: The National Food Strategy: Part One – July 2020) and children who were entitled to free school meals may also have experienced food insecurity. Low mood, lack of support for meal preparation, deteriorating physical health, and increased pain has impacted on some older people’s appetite and diet (Source: The impact of COVID-19 to date on older people’s mental and physical health). Older people also reported finding it more difficult to prepare food than before lockdown.

Alcohol

Alcohol purchases (as measured by total volume of duty-paid alcohol) decreased by 1.2% over the year of the pandemic (2020/21) compared to the previous year (Source: Monitoring alcohol consumption and harm during the COVID-19 pandemic). However, there were large peaks in alcohol purchasing over the two periods of social restrictions with increases of alcoholic drinks and tobacco products (Source: Retail sales, Great Britain: February 2021).

Obesity

Obesity is an area in which information is still emerging in the wake of the COVID-19 pandemic. Given recent trends in diet and physical activity it is likely that current levels of obesity may have been adversely impacted for adults and children, and inequalities may have increased (Source: Bakaloudi DR, Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Chourdakis M. Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis [published online ahead of print, 2021 Apr 20]. Clin Nutr. 2021;S0261-5614(21)00207-7. doi:10.1016/j.clnu.2021.04.015).

Smoking

Smoking rates have declined over the course of the pandemic, with an estimated million people stopping smoking since the beginning of the pandemic (Source: A million people have stopped smoking since the COVID pandemic hit Britain). However, contrary to this there is a concern that some of those who stopped smoking may have taken up smoking again due to the stress experienced during the pandemic and that existing smokers may be smoking more frequently (Source: UK Smoking Cessation and E-cigarettes Market Report 2021).

Work-life balance

Work-life balance. During the pandemic many people’s working arrangements changed with nearly half (46.6%) of people in employment doing some work from home from April 2020 (Source: Coronavirus and homeworking in the UK: April 2020). Of these, around one third (30.3%) worked a greater number of hours than usual. Working long hours has been shown to be a risk to health, with people working 55 hours or more per week having an increased risk of heart disease or stroke (Source: Long working hours increasing deaths from heart disease and stroke: WHO, ILO). Reported benefits of working from home include; reduced time spent travelling to work, reduced sickness absence rates, helping fathers to be more present and have greater involvement in childcare (Source: Lockdown Fathers the untold story - Fatherhood Institute ). Many workers have reported that they would like to continue some home working once social distancing restrictions end (Source: Most workers want to work from home after COVID-19).

Healthy places

The Marmot Review highlighted how place matters and is a driver of health and social care outcomes. A person’s socio-economic situation, including place of residence, are important factors to consider when exploring local data and trends.

Analysis of local COVID-19 wave one and wave two data consistently shows that the two districts of Basingstoke and Deane and Rushmoor had significantly higher COVID-19 cases, admissions and death rates compared to other districts. These districts have greater proportions of vulnerabilities which may make them more at risk of COVID-19. They have densely populated areas, more areas that are ‘most deprived,’ especially older people's deprivation, high levels of people working in front line roles such as health care and the service industry and greater ethnic diversity, with a larger population of people from an Asian background who are more likely to be living in multigenerational homes or overcrowded housing.

There are further smaller areas in Hampshire which data suggest are more vulnerable to COVID-19, however, these are masked at a district level. Local vulnerability indices have been constructed to help further understand the impact of COVID-19 on these smaller areas and are summarised later in this report.

A review of the evidence and how place-based factors have been indirectly impacted on by COVID-19 is summarised below.

Education

Education has been significantly impacted on due to school closures. Time spent learning declined during lockdown for secondary school pupils, from 6.6 hours per day before the pandemic to 4.5 hours during the pandemic (Source: Family time use and home learning during the COVID-19 lockdown). This varied by area, for example, those schools in higher areas of deprivation had greater months of learning lost when compared to schools in lower deprivation areas (Source: Understanding progress in the 2020/21 academic year Interim findings). There are many reasons why those children from deprived backgrounds had reduced participation in learning. For example, reduced access to digital resources and support required for distance learning may have been a barrier (Source: National Foundation for Educational Research: The challenges facing schools and pupils in September 2020). Home schooling may also have been especially challenging in households with overcrowding, where parents have lower educational attainment or reduced language skills (Source: Young Mind submission to Education Committee’s inquiry into coronavirus and the impact on education and children’s services). Concerns were also raised for vulnerable children who in lockdown became a ‘hidden population’ due to reduced contact and social interaction with educational and health professionals.

Access to green space

The social distancing restrictions and stay at home measures impacted people very differently depending on where they lived and their type of accommodation. Data from UKHSA indicate that access to a private garden space varies by social class and by ethnicity (Source: Wider Impacts of COVID-19 on Health (WICH) monitoring tool). Those people living in smaller, more crowded homes with less access to private garden space would have experienced greater stress during social distancing restrictions than those with a garden and additional living space.

Air quality

Air quality has been positively impacted on. During the lockdown period in late March and April 2020 motor vehicle travel was 63% lower than during the same months in 2019. Overall, in 2020 motor vehicle travel reduced by 21.3% compared with 2019. The largest decrease was shown for buses and coaches, followed by cars, whilst the use of pedal cycles increased by almost 50% (Source: Road Traffic Estimates: Great Britain 2020).

Crime

Crime data present a mixed picture depending on the type of crime. Police data indicates that crime has been impacted by the pandemic and associated policies (Source: Crime in England and Wales: year ending December 2020). Robbery and theft dropped dramatically during 2020, however, there are reports of young people being at increased risk from county lines as criminal groups find new online ways and social media platforms to coerce young people into drug running (Source: Between the lines). Domestic abuse has also seen an increase during the pandemic, the national domestic abuse helpline reported a 66% rise in calls and a 950% increase for visits to the website compared with pre-COVID-19 (Source: Refuge reports further increase in demand for its National Domestic Abuse Helpline services during lockdown). With the increase in domestic abuse the number of children in care increasing is a concern.

Economy and employment

Economic and employment policy has been introduced throughout the pandemic designed to mitigate the negative impact of the public health interventions on businesses and employees. Around 80% of hospitality and food businesses ceased trading during the lockdown period (Source: Furloughing of workers across UK businesses: 23 March 2020 to 5 April 2020). Consequently, those working in food service, accommodation, arts and entertainment were the workforce most affected. National data suggest that the young working age population had the highest rates of furlough, the most likely age to be furloughed during the first half of the pandemic was 17 years old (Source: Coronavirus Job Retention Scheme statistics: July 2020). This age group was also less likely to be able to work from home due to their roles. Occupations requiring higher qualifications and more experience were more likely to provide homeworking opportunities than elementary and manual occupations (Source: Coronavirus and homeworking in the UK: April 2020).

Employment rate across the population decreased by 1.4% from the start of lockdown. People aged 16 to 24 years and those aged 65 years and over were the main drivers for the annual decrease in the number of people in employment, whilst people aged 50 years and over were most affected by redundancy. In these times of economic uncertainty, there was a sharp and large increase in the number of people who claimed for universal credit during 2020 (Source: Coronavirus: Universal Credit during the crisis).

The unemployment rate for people from a minority ethnic background increased by a larger proportion than those from a white background from October to December 2020 (Source: Labour market overview, UK: December 2020). This inequality maybe in part driven by the types of occupation and industry sector ethnic communities work in. The service and hospitality industries were most affected, national reports suggest that around a third of taxi drivers and chauffeurs are Bangladeshi or Pakistani men (Source: Disparities in the risk and outcomes of COVID-19) and almost one third (29%) Asian / Asian British workers are employed in the service sector (Source: 2011 Census).

Social deprivation is a risk factor for poorer outcomes, evident in higher mortality and hospital admission rates for those living in the most deprived areas (Source: Disparities in the risk and outcomes of COVID-19). People in these areas are also more likely to be employed in insecure work without financial reserves. The economic impact on this population could be severe, potentially widening existing inequalities with families losing the benefits of free school meals and having to meet increasing home costs.

Food poverty is a growing issue across England, including in our Hampshire districts and neighbouring unitary regions. The COVID-19 pandemic has exacerbated existing, already growing health inequalities. Adverse effects on employment, loss of social and support networks and sudden closure of schools all contributed to increased hunger, and as a result we saw a further rise in both formal and informal food aid initiatives being established across the country (Source: Food Foundation (2021) Impact of Covid). The districts of Havant, Gosport, Rushmoor, as well as the Isle of Wight, all had a large proportion of LSOAs within the three deciles with the highest risk of food insecurity. 51% of LSOAs in Havant, 49% in Gosport, and 43% in Rushmoor were in the three highest risk deciles (Source: Hampshire Healthy Places JSNA 2021).

Vulnerability indices

It has been identified that certain communities and individuals within Hampshire are more vulnerable to harm from the indirect impacts of COVID-19. Different factors have contributed to this vulnerability and are strongly linked to the wider determinants of health.

To help understand how the indirect impacts have affected our communities, a Mental Wellbeing Index and Business Vulnerability Index have been developed. These compile datasets from a range of sources identified through statistics and literature published throughout the first and second wave of COVID-19 in 2020. Using Hampshire population, business and economic data, the data included in the indices aim to cover a wide range of characteristics which were identified as creating inequalities between people’s or businesses’ experiences of COVID-19 in the pandemic.

The indices are not intended to be used as a standalone tool but within the context of local knowledge and other available data.

Mental wellbeing vulnerability index

The population groups who were affected most by the NPIs during the early stages of COVID-19 may not have experienced any mental health challenges before COVID-19. They may not live in areas typically associated with poor mental health (such as areas with high levels of socio-economic deprivation (Sources: Mental health and wellbeing: JSNA toolkit. Mental health: environmental factors, Neighbourhood deprivation and health: does it affect us all equally?, Poverty and mental health)). Regardless, there is evidence that aspects of the restrictions could have taken a toll on their mental health.

It is also important to recognise the general low feeling amongst the population due to the changes to daily life which were experienced during the first lockdown, as well as the subsequent periods in lockdown, or tight restrictions. This may create difficulty when trying to identify groups who have experienced vulnerable mental health for the first time during COVID-19, as they may not be able to distinguish their mental health challenges from this general low mood which was widely reported during the first lockdown. It is vital that those with mental health challenges are able to recognise their symptoms, so that they can be made aware of the services which are available to them and how to access them. Without proper support, these populations are at risk of their mental health worsening beyond COVID-19 if they are unable to return to life as normal.

These populations need to be supported appropriately, alongside those with long-term, ongoing mental health conditions who are also at increased risk of worsening mental health as a result of restrictions in place during COVID-19. These populations have also seen a change to the mental health support they have been able to receive during COVID-19, which will present them with challenges managing their conditions.

The Mental Wellbeing Vulnerability Index suggests that in most of Hampshire’s districts, urban populations are more likely to experience vulnerable mental health as a result of the COVID-19 restrictions than rural populations. This urban-rural divide is particularly evident for Basingstoke town centre, Andover town centre, Eastleigh town centre and Winchester city centre, all of which are particularly prominent vulnerable areas compared to the surrounding parts of the districts. In Hart, East Hampshire and New Forest more complex patterns of vulnerability exist. There are both urban and rural populations which are more vulnerable to mental ill health related to COVID-19 restrictions.

The more densely populated districts in the south of the county (Eastleigh, Fareham, Gosport and Havant) have pockets of both more and less vulnerable populations spread throughout.

Business vulnerability index

The Institute for Fiscal Studies reported on the varying impact of COVID-19 and COVID-related policy on parts of England (Source: The geography of the COVID-19 crisis in England). This found that there was no one measure of vulnerability, however some areas that are more vulnerable are more likely to be vulnerable due to health, economic and social factors. Rural and coastal areas are seen as vulnerable for both health and jobs with areas of northern England more vulnerable along health and family dimensions.

The Business Vulnerability Index was created to assess the variations in how vulnerable businesses are to the impacts of the COVID-19 pandemic restrictions across Hampshire. This tool provides an assessment of the relative impacts during the COVID-19 pandemic across the area. The Index is constructed from a range of indicators. These aim to capture the employee and business aspects of the impacts which arose from the COVID-19 pandemic restrictions.

The sector, size, and location of a business alongside the mobility of customers were found to determine the vulnerability of a business, with the impacts of the COVID-19 pandemic disproportionately affecting physical in-store and small businesses, with online and larger firms being more likely to survive (Source: COVID-19 and the retail sector: impact and policy responses).

The impacts of the COVID-19 pandemic on employment were lower in Hampshire compared to England and the Southeast. The proportion of working aged adults claiming out of work benefits only increased to 4.3% in March 2021 in Hampshire, compared to 6.6% and 5.4% in England and the Southeast, respectively. Despite being lower than England average, the COVID-19 pandemic had a major impact on employment within Hampshire, with the number of adults claiming out of work benefits tripling from 12,380 in February 2020 to 35,545 in March 2021. There was a large variation in the proportion of working aged adults claiming out of work benefits within Hampshire. Havant had the largest proportion, 6.3%, and the only district above the Southeast average. While Hart, Fareham and Winchester had the lowest proportions.

In general, businesses across Hampshire appear to be slightly less vulnerable to the impacts of the November 2020 and early 2021 lockdown restrictions, with fewer self-employed businesses using the support scheme, fewer employees being furloughed and fewer people being unemployed. However, businesses in the travel, tourism and food activities sectors were more responsive to changes in restrictions and were still significantly impacted by the November 2020 and early 2021 lockdown restrictions (Source: Coronavirus and the impact on the UK travel and tourism industry).

At a district level, Hart and Havant were identified to be most likely to be vulnerable to the impacts of the COVID-19 pandemic restrictions, with businesses in Test Valley and Winchester being the least likely to be vulnerable.

New Forest experienced a major increase in the uptake of furlough in November 2020, with the number of claims doubling to 10,000 from October 2020. A large portion of this increase is expected to have occurred due to New Forest having around 8,000 jobs in the accommodation and food service activities sector, which was the hardest hit sector by the November restrictions (Source: Monthly gross domestic product: time series). Despite having the second highest rate of businesses operating in the identified vulnerable industries, businesses in New Forest are likely to rebound gradually, as areas of New Forest are likely to be popular destinations for holiday trips as restrictions ease.

Self-employed businesses in Havant were particularly vulnerable, with Havant having the highest uptake rate of the Self-Employment Income Support Scheme (SEISS). The younger aged working population (aged 16-44) in Havant were particularly impacted by the pandemic restrictions, with the claimant count rate rising by 4.5% between February 2020 and March 2021, which was higher than the Hampshire average of 3.4%.

Key areas of focus

The burden of illness and death due to coronavirus as well as the indirect impacts of COVID-19 have not been shouldered equally, disproportionately affecting different population groups (Source: Inequalities and deaths involving COVID-19). It is very clear that the importance of health inequalities has been brought to everyone's attention, existing health and social care vulnerabilities exacerbated and vulnerabilities are evident in population groups not traditionally considered. The Living Safely with COVID report stated that "health outcomes are driven by a wide range of factors. If we are truly going to 'build back fairer' we need a comprehensive recovery strategy that incorporates preventative action at every level."

Areas of focus are presented which emulate the sentiment of The Health Foundation COVID-19 impact inquiry report and look to focus our work on those main drivers of inequalities which have been contributors to the direct and indirect impacts of COVID-19 on our population.

Key areas of focus 1

Many of the underlying health risk factors for COVID-19 are the result of poor conditions associated with the social determinants of health, some of which determined by a healthy place. The rate of improvement of the health of the Hampshire population has slowed and is unequal with the proportion of time spent in good health decreasing.

Provide Public Health leadership to the population health management programme – provide evidence and support to enable focus on modifiable behaviours and the wider determinants of health alongside clinical data.
Focus on lifestyle interventions at person and place level importantly smoking, obesity and physical activity. Public Health should explore conducting a lifestyle survey to provide greater insight and understanding into lifestyle behaviours within local communities, working with relevant stakeholders.
Whilst the present report examines some of the impacts of the pandemic on mental and physical wellbeing, there are longer-term impacts that remain unknown. Public health will continue to monitor trends in the general population for instance the mental wellbeing of our young, working age and older populations, obesity and alcohol consumption.
Capitalise on good joint working between councils, the voluntary sector and the NHS to focus on tackling the wider determinants of health, focussing on health inequalities

Key areas of focus 2

Older people, ethnic minority groups & those living in deprived areas were disproportionately affected by the severe outcomes of COVID-19.

Commissioned services should ensure disadvantaged population groups have equity of access. Recommendations from the Hampshire and Isle of Wight (HIOW) Ethnic Minority and COVID-19 Needs Assessment need to be addressed as a system.
Providers of commissioned services should be outcomes focused. Health equity impacts should be conducted to look at the impacts and health outcomes of the service provision across different population groups. This requires good data collection to identify population groups and measure outcomes which should form part of the key performance indictor data collection.
Providers of commissioned services should analyse their service activity data to help understand what impact COVID has had on accessing services and subsequent delays in treatments or service provision. Has this disproportionately impacted certain populations?
Work with the HIOW Covid-19 Vaccination Programme to maximise uptake of the primary and booster dose in populations most affected by the severe outcomes of COVID-19.

Key area of focus 3

Women of working age have been disproportionately affected by Long COVID

Public health departments have a significant role in continuing to monitor long term outcomes for those populations recovering from COVID.
Reform workplace occupational health policy to recognise and anticipate Long Covid as a debilitating condition and plan support for employees physically and mentally.
Primary Care Network health and wellbeing coaches could provide a supportive role providing practical lifestyle advise.

Key areas of focus 4

Children and young people have experienced disrupted education and have been significantly impacted by economic policies. The pandemic has affected their education, health and wellbeing. Evidence has shown that these impacts are greater for those living in deprived areas driving concerns that health inequalities will have widened for an already vulnerable population.

Public Health needs to work with partners to better understand what the impacts of the pandemic have been on our children and young people especially those children already identified as vulnerable. Disseminate findings and recommendations from the Hampshire and Isle of Wight 0-25 Mental Health Needs Assessment and Impact of COVID-19 Review.
Share Health Impact Assessment report with Hampshire County Council and other public sector partners (for example, digital and remote learning experiences and the lessons learnt).
Work with the business sector to encourage more opportunities for young people such as apprenticeships and work experience to provide economic and educational certainty.

Key area of focus 5

Build on and consolidate relationships established during the pandemic to work more creatively and capitalise on the positives COVID has created.

Public Health should capitalise on the general increase in community groups and mutual support in the wake of the pandemic. Continue to utilise and strengthen initiatives like the community researchers and insight work that has been conducted.
Public Health should drive changes in information governance, data dissemination and data sharing to improve data completeness and enable better local analysis of local inequalities.
The Health Foundation report refers to groups who currently lie ‘below the data line’ such as some ethnicity minority communities. People belonging to inclusion health groups have extremely poor health outcomes, often much worse than the general population, lower average age of death, and it contributes considerably to increasing health inequalities (Source: Inclusion health: applying All Our Health). This includes homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery. The Public Health Joint Strategic Needs Assessment needs to better understand these Inclusion Health Groups at a local level; who they are, where they live, and what are their challenges?

Key area of focus 6

Focus on staff health and wellbeing – we need to recognise and support those who have worked in the pandemic response who may be suffering stress, feeling burnt out or experiencing trauma.

Reform workplace occupational health policy to recognise the impact and potential trauma the pandemic has caused for those working in the pandemic response.

Key area of focus 7

Identify and build on the positive impacts of COVID-19 for example:

COVID-19 lockdown events have led to declines in air pollution and put a big focus on air quality.
Maintain the gains made in the environment, sustain the momentum in home fitness activities in the post COVID-19 era.
Greater community support and resilience.
Greater awareness of infection prevention, control and vaccination.