Covid-19: How has the pandemic differed across the four UK nations?BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1482 (Published 22 June 2022) Cite this as: BMJ 2022;377:o1482
We examined trends over the first two years of the pandemic in terms of the proportion of the population with covid-19 (from the Office for National Statistics’ infection survey), people in hospital with covid per head of population, and the number of deaths registered with covid-19 mentioned on the death certificate per head of population (see box 1 for sources).
Data notes and sources
Information about cases during the first wave is incomplete, because only limited testing was available, and surveillance studies such as the ONS covid-19 infection survey had not started. Case rates from the ONS infection survey are the most robust measure of infections across the four nations, as it is based on random surveys and is not affected by variation in testing programmes or by access to tests, which had an impact on daily reported cases. Source: Office for National Statistics covid-19 infection survey.1
Number of people in hospital with covid-19 has been used, rather than admissions, because the definition for admissions in Wales includes suspected cases and is therefore less comparable. Sources: UK covid dashboard, ONS mid-year population estimates 2020.
Covid-19 death registrations are those in which it is mentioned anywhere on the death certificate, including in combination with other health conditions. Sources: UK covid dashboard, ONS mid-year population estimates 2020.
In broad terms, the shape of the pandemic in each UK country has been similar. Big shifts seem to have been driven by the course of the virus, such as the arrival of the alpha variant and the exceptionally transmissible omicron variant, and the introduction of vaccines and treatments, which have reduced the risk of severe disease and increased survival even when this occurs.
The extent to which high case rates translate into hospital admissions and deaths also depends on demographic and social factors. Case rates have varied over time between occupational, age, ethnic, and socioeconomic groups.2 These factors vary across the UK. For example, Northern Ireland has a younger population and Wales an older population than England and Scotland. England’s rates of cases, hospital admissions, and deaths have been higher in ethnic minority groups, reflected in the greater impact of covid-19 in London, the North West, and the Midlands relative to other parts of England.
Although the overall course of the pandemic has been similar across the UK, there have been instances when the countries’ trajectory has diverged.
In the first wave Northern Ireland had far fewer deaths and hospital admissions. Lockdown restrictions were similar across the UK at this time. One possible explanation for the divergence is that lockdown began at a slightly earlier stage in the pandemic in Northern Ireland, reducing the size of the peak there.
In the second wave Scotland had relatively fewer cases, hospital admissions, and deaths than England and Wales. Scotland also had the most consistent set of restrictions in place between September and December 2020, which may have helped to delay the spread of the alpha variant (which was dominant in England by the beginning of December but not in Scotland until January 2021).34 Northern Ireland had a slightly later peak in cases in this wave, which may have contributed to lower mortality, as a result of the vaccination programme reducing severe disease. Northern Ireland’s younger population may also have been a factor in its lower cumulative mortality.
From the middle of 2021 to February 2022 Northern Ireland had consistently higher rates of hospital admission for covid-19 than elsewhere in the UK, although case rates and mortality have been broadly similar. This suggests that hospital care for patients with covid-19 may have been organised differently in Northern Ireland, resulting in a higher admission rate. Another possibility is that hospital acquired covid-19, which has been a significant concern,5 may be a particular problem in hospitals in Northern Ireland.
In February and March 2022 Scotland had the highest case rates and a rapid increase in hospital admissions, despite retaining restrictions longest in response to omicron.
Impact of policy differences
It is hard to pick out the direct effects on outcomes of the differences in restrictions and guidance in place in each country.
Although legal requirements may have differed, each country has shared the same evidence base and scientific advice. For example, the Scientific Advisory Group for Emergencies and the Joint Committee on Vaccination and Immunisation provide advice to all UK countries.67 Many aspects of the response have also been UK-wide, including the vaccine programme, approach to foreign travel, and most aspects of economic support.8
Furthermore, although health is a devolved function, close collaboration between the four chief medical officers, combined with consistent scientific evidence, resulted in similar public health messaging across the UK.9 So, although England did not introduce new restrictions in December 2021, warnings from the chief medical officer, Chris Whitty, affected people’s behaviour nonetheless.
From the current evidence it is difficult to say whether one UK country’s policies worked much better or much worse than the others over the first two years of the pandemic. For example, while tighter restrictions in the second wave in Scotland coincided with reduced circulation and severe disease, the reverse has been the case in more recent months, despite recent stronger guidance applied there. This could reflect the scale and enforcement needed for interventions to make a difference—or the tendency for behaviour to be consistent across the UK, even without legal requirements.
There is no room for complacency in the UK’s response to covid-19.
Further variants have the potential to reduce the protection from vaccines and previous infection. And evidence is increasing of the disease’s long term effects on health.10 The milder disease seen in recent months is still leading to persistent health problems.11
The pandemic is still very much ongoing. Understanding the reasons for inequalities between different population groups in their experience during the pandemic remains an urgent challenge, so we can reduce inequalities in the future. Alongside inequalities between ethnic groups and according to levels of deprivation, international data indicate that the UK has unusually high excess mortality in younger age groups.12
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Commissioning and peer review: Commissioned; not externally peer reviewed.