The elective care backlog and ethnicity

In England there is a huge backlog in routine hospital care, with more than 7 million patients waiting to begin hospital treatment as of August 2022.

It is now well documented that Covid-19 and associated lockdowns resulted in a huge drop in the numbers of hospital operations, tests and consultations taking place. This had a disproportionate impact on people in more deprived areas – and these groups already had higher levels of health care need than those in less deprived areas. Once Covid arrived, differences began to arise in how many of these operations, tests and consultations were ‘lost’  among different ethnic and social groups during the first two years of the pandemic.

This research looks at variation in treatment rates for routine hospital care, both before and during the Covid-19 pandemic. It considers changes in elective activity overall and specifically in relation to seven groups of common hospital procedures across five main ethnic groups (White, Mixed, Asian, Black and Other). Our focus is on ethnic variations, but we also consider variations by deprivation and region because the proportion of ethnic minority groups is higher in more deprived areas, in cities and in some regions.

Key findings

Our analysis of hospital data from March 2019 to February 2022 reveals that:

• Before the pandemic, the White group had higher rates of elective procedures overall than the Black, Mixed and Asian groups, with the White group having almost a fifth more procedures than the Asian group per head of population. Cardiac and cataract procedure rates were highest in the Asian group and dental procedure rates were highest in the Black group.
• Procedure rates during the first year of the pandemic fell in all groups, with the NHS carrying out around 2.7 million fewer operations and tests in that year compared with the year before.
• However, the falls in activity were not uniform across the different ethnic groups, with the Asian group experiencing the largest overall fall in the first year of the pandemic compared with the other groups (a fall of 49% for all procedures compared with 44% for the White and Black groups). This means that if the proportional fall in activity was the same for the Asian group as it was for the White group, we would have expected to see just over 17,000 more procedures for the Asian group.
• Although the gap narrowed in the second year of the pandemic, there was still a larger deficit of care among the Asian group, with the fall remaining 2% larger for the Asian group than for the White group – an estimated deficit of 6,640 procedures.
• Apart from the Asian group, consistent differences were not found across procedures for other ethnic minority groups. The Black group did have larger rate falls than the White group for cardiac and cataract procedures (the fall was 19% larger for cataract procedures) but otherwise saw similar changes to the White group, including for all procedures taken together.
• The most deprived groups in the population experienced larger rate falls overall and for most specific procedure groups. For hip and knee replacements, there was a 13% larger fall in the most deprived group compared with the national change, and a 7% lower fall in the least deprived group.
• There was no relationship between the fall in elective hospital activity and the local impact of Covid-19 by region (as measured by reported Covid-19 cases and Covid-19 admissions).

The quality of data available for analysis limited our findings. We renew our appeal for national and local organisations to act on the poor quality of ethnicity data and call on national policy-makers and local leaders for:

• Urgent action to address health care inequalities between socioeconomic and ethnic groups, including the large and unexplained falls in planned activity that occurred during the first year of the pandemic
• National and local monitoring of changes to patient pathways (such as more tests being carried out before a patient sees a specialist) that are introduced to manage the elective backlog, to ensure disadvantaged groups are not further disadvantaged
• Addressing the large and sustained deficit in cardiac care for the Asian group and action to understand the reasons for lower demand for elective care among the Asian population
• Further work to understand ethnic variation in elective pathways for specific procedure groups, including action by national clinical audits, which will require improved ethnicity data collection and analysis.

These actions are needed to ensure that learning from the first two years of the pandemic is taken on board, as we move into the next phase of the pandemic.