Later life and the pandemic: Evidence to the UK Covid-19 Public Inquiry
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On Monday, 23 February, Professor James Nazroo presented evidence to the UK Covid-19 Public Inquiry as part of Module 10, which examined the impact of the pandemic on society.
His testimony drew on his expert report submitted in December 2025 and relied extensively on evidence from the English Longitudinal Study of Ageing, alongside national statistics and linked administrative data.
ELSA’s long-running data collection, including additional surveys conducted during the pandemic, provided detailed insight into how health, economic, and social inequalities shaped older people’s experiences.
A steep age gradient, but not age alone
Unsurprisingly, older age was strongly associated with risk of death from Covid-19 [1][2]. Community infection studies showed that while infection rates outside hospitals and care homes tended to decline with age, the likelihood of dying once infected rose sharply among those aged 65 and over [2].
Frailty, which becomes more common with age, is linked to increased risk of adverse outcomes including mortality [3] and it is also socially patterned. Poorer older people were more likely to experience frailty at younger ages, meaning vulnerability was closely tied to lifetime disadvantage [4].
Deprivation and unequal risk
National analyses conducted during the pandemic showed a clear deprivation gradient in mortality. People living in the most deprived areas faced more than double the risk of Covid-19 death compared with those in the least deprived areas [1][5]. Post-pandemic analysis confirmed that age standardised mortality rates remained substantially higher in the most deprived areas [6].
Given that more than 90% of Covid-19 deaths occurred among those aged 60 and over, this meant that poorer and more disadvantaged older people bore a disproportionate share of mortality risk [1][5].
Care homes and early policy decisions
Care home residents were identified as particularly vulnerable due to high levels of multimorbidity and frailty [7]. The Inquiry heard evidence that, in the early stages of the pandemic, thousands of patients were discharged from hospitals to care homes without routine testing [8][9][10]. Subsequent reviews documented high levels of Covid-19 related mortality in care homes during 2020 and 2021 [10][11].
The report argued that these outcomes reflected not only the clinical vulnerability of residents, but policy decisions that prioritised hospital capacity over protection of social care settings.
Intensive care and clinical judgement
Pre-pandemic data showed that people aged 80 and over accounted for a growing proportion of ICU admissions [12]. During the peak of the first wave, their representation in critical care fell sharply [13][14].
National guidance recommended use of the Clinical Frailty Scale in triage decisions [15][16]. While frailty is a meaningful clinical measure, the report noted concerns about how age and frailty thresholds were applied in emergency settings [16]. Evidence from international studies showed that many patients assessed as frail survived to hospital discharge [17].
Research also indicated that Do Not Attempt Cardiopulmonary Resuscitation decisions were more frequently recorded for older patients with Covid-19 [18][19].
Disrupted healthcare and behaviour change
ELSA data demonstrated substantial disruption to healthcare during lockdown. Many people aged 50 and over reported being unable to access GP services or experiencing cancelled hospital appointments, with disruption greatest among those with multiple chronic conditions [20]. Evidence from multiple UK longitudinal studies showed that older age groups and those in routine or manual occupations were more likely to report healthcare disruption [21].
Changes in daily life were also marked. Around 40% of older respondents reported spending more time sitting, roughly one third reported reduced physical activity and nearly one in five reported eating more [22].
Isolation and mental health
ELSA data showed a sharp drop in volunteering during the pandemic, particularly among those aged 70 and over [23]. While overall increases in loneliness were modest, depressive symptoms rose substantially among people aged 50 and over during 2020 [24].
The evidence suggested that worry about infection, disruption to healthcare, and reduced social contact all contributed to deteriorating mental health during the pandemic.
Lessons for the future
A central theme of the evidence was ageism. Professor Nazroo argued that older people were too often treated as a single, uniformly frail group, obscuring differences in health, wealth, and circumstances. Policies based on crude age thresholds risked reinforcing existing inequalities [16][25].
The report concluded that future pandemic preparedness must address social and economic disadvantage across the life course, strengthen social care, and avoid assumptions that equate older age with dependency.
Professor James Nazroo was a long-standing Co-Principal Investigator of ELSA
References
Bhaskaran, K., Bacon, S., Evans, S.J.W. et al. (2021) ‘Factors associated with COVID-19 death using UK primary care data linked to national death registrations’, BMJ, 372, n834.
Ward, H., Atchison, C., Whitaker, M. et al. (2021) ‘SARS-CoV-2 antibody prevalence in England following the first peak of the pandemic’, Nature Communications, 12, 905.
Rockwood, K., Mitnitski, A., Song, X. et al. (2006) ‘Long-term risks of death and institutionalization of elderly people in relation to deficit accumulation’, Journal of the American Geriatrics Society, 54(6), pp. 975–979.
Nazroo, J. (2025) Expert Report for the UK Covid-19 Public Inquiry, Module 10: Inequality, Later Life and Ageism.
Office for National Statistics (2020a) Deaths involving COVID-19 by local area and socioeconomic deprivation.
UK Health Security Agency (2023) COVID-19 confirmed deaths in England (to 31 December 2022).
Matthews, F.E., Bennett, H., Wittenberg, R. et al. (2016) ‘Who lives where and does it matter?’, PLoS One, 11, e0161705.
BBC (2020) ‘Coronavirus: 1,000 discharged to care homes without virus test’.
Civil Service World (2020) ‘25,000 people discharged from hospitals to care homes without tests’.
National Audit Office (2020) Readying the NHS and adult social care in England for COVID-19.
Care Inspectorate (2021) COVID-19 related deaths in care homes, 2020/21.
Creagh-Brown, B. and Green, S. (2014) ‘Increasing age of patients admitted to intensive care’, Critical Care, 18(Suppl 1), P56.
Calvert, J. and Arbuthnot, G. (2021) Failures of State. London: HarperCollins.
Public Health England (2020a) COVID-19: review of disparities in risks and outcomes.
Dalhousie University (2020) Clinical Frailty Scale.
Tomkow, L., Pascall-Jones, P. and Carter, D. (2022) ‘Frailty goes viral’, Critical Public Health, 33(1), pp. 116–123.
Lewis, E. et al. (2021) Study of ICU outcomes among patients with frailty.
Connellan, D. et al. (2021) ‘Documentation of DNACPR orders amid the COVID-19 pandemic’, Age and Ageing, 50(4), pp. 1048–1051.
Tomkow, L. et al. (2023) ‘Experiences of DNACPR discussions during COVID-19’, Age and Ageing, 52(6), afad087.
Zaninotto, P. et al. (2021) Multimorbidity, access to services and diagnosis of new health conditions during the COVID-19 pandemic. ELSA Rapid Report.
Maddock, J. et al. (2022) ‘Inequalities in healthcare disruptions during the COVID-19 pandemic’, BMJ Open, 12, e064981.
Zhu, Y., Di Gessa, G. and Nazroo, J. (2023) ‘Changes in health behaviours during the COVID-19 pandemic among older adults in England’, Journal of Epidemiology and Community Health.
Chatzi, G., Di Gessa, G. and Nazroo, J. (2020) Changes in volunteering during the COVID-19 pandemic. ELSA Rapid Report.
Zaninotto, P. et al. (2022) ‘Changes in depression and anxiety among people aged 50 and over’, The Lancet Healthy Longevity, 3(3), pp. e162–e171.
World Health Organization (2021) Global report on ageism. Geneva: WHO.
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