Effects on mortality of shielding clinically extremely vulnerable patients in Liverpool, UK, during the COVID-19 pandemic.

OBJECTIVE: This study evaluates the impact of England's COVID-19 shielding programme on mortality in the City of Liverpool in North West England. STUDY DESIGN: Shielded and non-shielded people are compared using data from linked routine health records on all people registered with a general practitioner in Liverpool from April 2020 to June 2021. METHODS: A discrete time hazard model and interactions between the shielding status and the periods of higher risk of transmission are used to explore the effects of shielding across the major phases of the COVID-19 pandemic. RESULTS: Shielding was associated with a 34% reduction in the risk of dying (HR = 0.66, 95% CI: 0.58 to 0.76) compared with a propensity-matched non-shielded group. Shielding appeared to reduce mortality during the first and third waves, but not during the second wave, where shielding was not mandated by the government. The effects were similar for males and females, but more protective for those living in the least deprived areas of Liverpool. CONCLUSIONS: It is likely that the shielding programme in Liverpool saved lives, although this seems to have been a little less effective in more deprived areas. A comprehensive programme for identifying vulnerable groups and providing them with advice and support is likely to be important for future respiratory virus pandemics. Additional support may be necessary for socio-economically disadvantaged groups to avoid increased inequalities.

Excess mortality in Glasgow: further evidence of 'political effects' on population health.

OBJECTIVES: The aim of the study was to update previous analyses of 'excess mortality' in Glasgow (Scotland) relative to the similar postindustrial cities of Liverpool and Manchester (England). The excess is defined as mortality after adjustment for socio-economic deprivation; thus, we sought to compare changes over time in both the deprivation profiles of the cities and the levels of deprivation-adjusted mortality in Glasgow relative to the other cities. This is important not only because the original analyses are now increasingly out of date but also because since publication, important (prepandemic) changes to mortality trends have been observed across all parts of the United Kingdom. STUDY DESIGN AND METHODS: Replicating as far as possible the methods of the original study, we developed a three-city deprivation index based on the creation of spatial units in Glasgow that were of similar size to those in Liverpool and Manchester (average population sizes of approximately 1600, 1500 and 1700 respectively) and an area-based measure of 'employment deprivation'. Mortality and matching population data by age, sex and small area were obtained from national agencies for two periods: 2003-2007 (the period covered by the original study) and 2014-2018. The rates of employment deprivation for each city's small areas were calculated for both periods. Indirectly standardised mortality ratios (SMRs) were calculated for Glasgow relative to Liverpool and Manchester, standardised by age and three-city deprivation decile. For context, city-level trends in age-standardised mortality rates by year, sex and city were also calculated. RESULTS: There was evidence of a stalling of improvement in mortality rates in all three cities from the early 2010s. After adjustment for area deprivation, all-cause mortality in Glasgow in 2014-2018 was c.12% higher than in Liverpool and Manchester for all ages (SMR 112.4, 95% CI 111.1-113.6) and c.17% higher for deaths under 65 years (SMR 117.1, 95% CI 114.5-119.7). The excess was higher for males (17% compared with 9% for deaths at all ages; 25% compared with 5% for 0-64 years) and for particular causes of death such as suicide and drug-related and alcohol-related causes. The results were broadly similar to those previously described for 2003-2007, although the excess for premature mortality was notably lower. In part, this was explained by changes in levels of employment deprivation, which had decreased to a greater degree in the English cities: this was particularly true of Manchester (a reduction of -43%, compared with -38% in Liverpool and -31% in Glasgow) where the overall population size had also increased to a much greater extent than in the other cities. CONCLUSIONS: High levels of excess mortality persist in Glasgow. With the political causes recently established - the excess is a 'political effect', not a 'Glasgow effect' - political solutions are required. Thus, previously published recommendations aimed at addressing poverty, inequality and vulnerability in the city are still highly relevant. However, given the evidence of more recent, UK-wide, political effects on mortality - widening mortality inequalities resulting from UK Government 'austerity' measures - additional policies at UK Government level to protect, and restore, the income of the poorest in society are also urgently needed.