Intended for healthcare professionals


UK’s record on pandemic deaths

BMJ 2020; 370 doi: (Published 04 September 2020) Cite this as: BMJ 2020;370:m3348

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  1. Veena S Raleigh, senior fellow
  1. King’s Fund, London, UK
  1. v.raleigh{at}

Recent changes in definition can’t disguise the UK’s poor international ranking

The grim daily count of covid-19 deaths in the UK is nearing single digits.1 Although what’s around the corner is unpredictable, it’s timely to take stock after the recent tsunami of deaths.

Evidence of the UK’s higher overall death toll during the first wave of the pandemic relative to comparable countries is unequivocal. England had the highest excess all-cause mortality rate among 23 European countries in the first five months of 2020 compared with 2015-19, followed by Spain and Scotland, with mortality being spread throughout the country in contrast to the more localised patterns in Europe.2 England also had the second (after Spain) highest peak of excess all-cause mortality and the slowest fall to normal levels—so the longest period of excess deaths. The contrasts with Norway, Finland, Denmark, Austria, and some eastern European countries, where no excess mortality was observed throughout 2020, are even sharper.

Recent changes to the definition of a covid-19 death in England (from all deaths after a positive test to deaths within 28 days) have reduced the UK’s official covid-19 death toll by 16%.13 But the change doesn’t alter the UK’s poor ranking among European peers. Excess mortality rates based on death certification data2 are more reliable for national and international comparisons than the covid-19 “surveillance” data used for tracking the pandemic’s trajectory.4 Comparisons of excess mortality circumvent differences in how covid-19 deaths are counted and also include deaths from the wider effects of the pandemic.

So where are we now and how did we get here? The overall death rate for England from 1 January to 31 July 2020 was the highest since 2009 (less consistently true also of Wales).5 The year got off to a good start, with a mild influenza season and almost 5000 fewer deaths in England and Wales up to early March 2020 than the 2015-19 average.167 But in the ensuing five months, there were over 58 000 more deaths than the 2015-19 average, of which almost 52 000 (89%) were related to covid-19.1 Almost half (44%) of all excess deaths occurred in care homes.

Total deaths returned to near normal levels some weeks ago, as they did in other European countries, after which they fell below normal. In the eight weeks to 7 August there were about 1700 (2%) fewer all cause deaths in England and Wales than the 2015-19 average (fig 1).1 This welcome respite has a darker side, however, as it suggests many of the earlier deaths had been premature, for which ONS analyses provide further corroboration.7 It’s unclear whether the increase in deaths in the fortnight to 21 August to above average levels is related to a heatwave or signals a longer term trend. 1

Fig 1
Fig 1

Weekly deaths in England and Wales: week ending 13 March to week ending 21 August 20201

Hidden covid-19 deaths

Early indications suggest that many of the excess deaths not related to covid-19 since March were not the result of reduced care for serious non-covid conditions. For example, the sharp surge in total and non-covid deaths followed by a return to near normal levels mirrors the trajectory of covid-19 deaths,1 whereas the effect of reduced healthcare would have been more persistent. Furthermore, excess non-covid deaths occurred predominantly among frail older adults, many in care homes, and included a sharp rise in deaths from dementia and ill defined conditions, suggesting that many such deaths were related to undiagnosed covid-19.678

Comparisons with 2015-19 also suggest a substantial and continuing “displacement” of non-covid deaths from hospitals to private homes and, earlier in the pandemic, to care homes.17 Fewer admissions to and earlier discharge from hospitals focusing on covid-19 could have contributed to a greater proportion of deaths occurring in other settings with lower rates of testing.6

Wider effects of the pandemic

Even so, lives have undoubtedly been lost as substantially fewer people received healthcare for life threatening conditions during this period. 7910Such deaths could mount over time as the NHS struggles to cope with the backlog of deferred care alongside winter pressures and a possible resurgence of covid-19. Although other countries also face these challenges, the UK is less well equipped to deal with them, with overstretched health and social care services that historically have been under-resourced and understaffed compared with other high performing health systems.1112

Among the many brutal realities of the pandemic has been a clear amplification of existing socioeconomic and ethnic inequalities, both in the UK 13141516 and beyond.17 Some commentators argue that disadvantaged communities are experiencing a syndemic, as the prevalence and severity of covid-19 are made worse by widespread inequalities in non-communicable disease and the socioeconomic determinants of health.17 The economic consequences of the pandemic are likely to exacerbate health inequalities further.

Overall, the UK’s record on mortality thus far compares badly with other European countries. The lessons of the first wave of covid-19 must be learnt and should inform policy decisions for tackling any resurgence. While controlling the pandemic is clearly a priority, it’s also imperative to take the long view as many of the risk factors for dying from covid-19—such as cardiovascular disease, diabetes, obesity, and deprivation—are also leading contributors to the lack lustre mortality improvements and widening inequalities prevailing in the UK before the pandemic.


  • Competing interests: I have read and understood the BMJ policy on declaration of interests and have no interests to declare.




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