Beyond the lockdowns: Lessons learned from Leicester's COVID story

In the 2018 Leicester Health and Wellbeing survey, around 1 in 10 residents reported that they felt lonely or isolated often or all of the time.[i] A 2016 study by Age UK reported that there are around half a million older adults in the UK who can go 5 or 6 days a week without seeing or speaking to anyone[ii], and the number of people over 50 who are experiencing loneliness is set to increase to 2 million by 2024/25, an increase of 49% in the last 10 years.[iii]

Being isolated and lonely is not just bad for your mental health but can affect physical health as well. Loneliness increases the risk of coronary heart disease, stroke, high blood pressure, memory problems and dementia,[iv] and one study estimated that the negative health effects are equivalent to smoking 15 cigarettes per day.[v]

Social isolation and loneliness is not evenly spread throughout the population. Health inequalities mean that there are those who are more at risk from others. The Leicester Health and Wellbeing Survey found that those with long term health conditions, those that lived alone, and social housing tenants were more likely to feel isolated. There was considerable variation across the city too in the amount of loneliness that people reported:

Against this backdrop of increasing isolation and loneliness, in 2020, the COVID pandemic arrived and brought with it large changes in the ways in which it was possible for us to see, interact and relate to each other.

It was clear from early on that this was going to have serious implications for those who were already feeling isolated and lonely, and those who had previously not felt that way but were now alone at home much more and at risk of feeling isolated. The public health team therefore moved quickly to put a programme in place to help bring people back together, albeit virtually or in a socially distanced or outside setting. One member of the team described their work with the voluntary sector:

“Once COVID restrictions were announced I worked with a VCS organisation to organise provision for people who were already isolated and lonely. These included people using Leicester Ageing Together services and people frequenting lunch clubs (previously run by Adult Social Care but passed to community providers).

The VCS organisation ran ‘Distant Socialising’ a telephone line and webpage for residents to access for information about what virtual activities are available and how to join them. (i.e. someone could say “I used to attend knit and natter at the Brite centre – what else can I do” and they could be directed to a virtual community group offering the same).

The same scheme was also funded to help social activity organisers organise online activities, materials for distribution (i.e. wool for knitting, sewing materials) so people can participate in online activity.

We also launched ‘Distant Companions’ a telephone based befriending line where volunteers are matched with callers to receive regular telephone calls for conversation.

The Distant Socialising work continues, and the VCS organisations maintain a database which is used by community groups and members.”

Bringing people together

Out of this work during the pandemic, came ‘bringing people together’, an umbrella initiative that includes several programmes that aim to reduce isolation and loneliness and improve wellbeing within communities.

In the post pandemic times, with increasing concerns about people’s mental health and wellbeing in the cost of living crisis, this programme has continued to grow and change to help meet the needs of vulnerable people in the city. The programmes include:

Lets get together
Over the past year the ‘let’s get together’ programme has developed. It's a pro-active, successful collaboration between public health, neighbourhood services, museums, active travel and adult learning. The aim of the programme is to improve the social connectivity of community members. Several projects sit within the let’s get together programme, including:

Chatty tables – all libraries and community centres have a dedicated table with activities that people can do whilst talking to others. Volunteers will be sought, via a newly appointed volunteer co-ordinator to ‘man’ the tables and refresh the items on them.

Transforming outside space – we are working with one of our commissioned services making the outside space useable and appealing by planting flowers or vegetables outside of neighbourhood centres and some libraries. The volunteer co-ordinator will help develop volunteer teams to continue this activity in the longer term.

Lets get active
We are working with the Live Well team and offering instructor led low intensity physical exercise in six community centres across the city.

Sociable strolls – we are working with the active travel team to run ‘summer strolls’, ‘autumn ambles’ and ‘winter walks’, these are themed walks that start and finish at a museum. They involve bespoke introductions to the museum, a theme (such as King Richard III) and refreshments at the museum. Museums also set up a chatty table and include the object of the month to generate conversation. Volunteers are trained to continue to lead the walks.

Health walks - we are working with Live Well who deliver a series of health walks for community buildings in the city. The walks are health focused and participants can tailor walks to their abilities choosing from three duration options, they can chat over free refreshments.

Let's get resourceful
In response to the cost-of-living crisis we established a series of three tutor led, practical workshops (keeping warm in the home, sew to save and shop, cook and eat well) and delivered these in 18 locations across the city. These were well-received, and we will be operating a streamlined, more targeted version of let’s get resourceful in 2023.

Social gardens transformation project

Through a joint initiative with Leicester City Council housing department and our food growing activity provider, we are planning a project to improve the usability of a communal garden, shared by 30 bungalows, in the city.

We will make the shared space into a useable accessible area for residents to meet and chat, and hopefully provide them with a place to socialise outdoors. Not only will this bring them the benefit of outside green space, but it will help those who still feel uncertain about sharing public spaces after the pandemic to have an outside space to socialise where they can feel safer.

What did we learn and how did this change things?

The pandemic has changed the way that people choose to socialise. Post pandemic there remains a significant decline in footfall and social groups booking rooms in our community buildings. In contrast there has been increased interest in outdoor activity such as walking and growing food or flowers. The reasons for this are varied but include

• lack of confidence after not socialising for so long
• concerns about COVID or other illnesses, particularly for people who were older or unwell,
• some people found new activities to do, or developed a preference for meeting online or in different locations.

This insight inspired the development of the let’s get together programme activities, and there are plans to further develop the outdoor and food-growing elements into the future.

In March 2020, the Prime Minister gave the order to ‘stay at home, save lives’ and all across the country people took him at his word and stayed indoors. For older people particularly, although it protected them from catching COVID-19, this was to have significant impacts on their physical and mental health. Staying in their homes for a long period of time instead of undertaking usual activities, for many older people led to significant deconditioning, loss of mobility, muscle weakness and joint pain. For many, it also meant a loss of confidence and greater anxiety around going out.

An Age UK survey in the summer of 2020 found that one in three people who responded to the survey felt they had less energy, one in four were unable to walk as far as before and one in five felt less steady on their feet.[vi]

The population of Leicester is younger than average, with only 12% of the population over the age of 65. In Leicester, residents experienced longer periods of lockdown than almost any other area, and given that these survey results were at an early point in the pandemic, it is not unreasonable to assume that these effects have become magnified over time. Although the level of lockdown was eased after a while and people were allowed more freedom of movement, for many older people with long-term conditions, the advice remained to shield and a fear of catching COVID kept them at home in their houses.

Physical health effects

For many older people, staying at home for long periods without the opportunity to exercise and get out and about as normal led to a significant deterioration in their strength and mobility. For many, every day activities such as climbing up and down stairs and going out to the shops became much more difficult. For some, this led to weight gain or an increase in joint pain or stiffness. It also led to people feeling less confident on their feet than before, all of which can increase a person’s falls risk.

Steady Steps is an evidence-based, 24 week programme designed to improve postural stability, balance and confidence. In Leicester, anyone over the age of 65 who is at risk of falling, or who has fallen fewer than three times in the past 12 months. It is delivered at various community locations across Leicester by qualified healthy lifestyle advisors who are part of our Live Well team.

For obvious reasons, it was not possible to deliver this face to face during lockdown. However, recognising that the participants were likely to be at increased risk of falls during this time, the team worked on inventive solutions to the problem. Classes were provided virtually for those that were able to join in, however many found this challenging. For others, the team tried to call them every week and check in, plus share with them some tips and exercises to be done at home. An exercise at home booklet is provided alongside the sessions. As soon as it was judged to be sufficiently safe to do so, the face-to-face sessions were reinstated.

Quite apart from the effects of lockdown on older people, the risk from COVID-19 itself was greater than for many in society- older age was one of the biggest risk factors for severe illness and death from COVID.

Mental wellbeing

The COVID-19 pandemic took its toll on older people’s mental health. Those who had pre-existing mental health conditions often found their symptoms worsening during the lockdowns, and many found themselves struggling for the first time. Anxiety was a big concern. In the Age UK survey, 31% of people over 70 reported feeling ‘unsafe’ or ‘very unsafe’ when they went outside of their house during the pandemic. Although for many people life has now gone back to ‘normal’ with few or no restrictions on activity, for many older people, the legacy of this time has lingered and left them feeling afraid and vulnerable to be out in crowds. The specific impact of social isolation is discussed in a separate section.

Older people living with dementia were significantly impacted by the sudden changes in routine and access during the pandemic. One family member of a lady in her 80s in a care home told Age UK

“She is in a care home and has dementia and gets so upset when we can’t go near her. We just can’t get her to understand why”

For those with dementia living in care homes, there was the grief of losing other residents who were close friends and the confusion surrounding what had happened to them. In addition, the difficulty in recognising the faces of others when obscured by masks could be disorientating and upsetting for those with cognitive impairment.

For many without a previous diagnosis of dementia, the period of relative isolation and lack of socialisation during the lockdowns led to people feeling more forgetful or confused. Many loved ones reported feeling their loved ones were losing their memories and becoming more disorientated in time and place.[vi]

Health inequalities

The COVID-19 pandemic exacerbated existing health inequalities, and this was no different among older people, with older people from poorer backgrounds being more affected both physically and mentally. Of particular importance to Leicester was the fact that older people from ethnic minority backgrounds were particularly at risk of poor outcomes. This was thought to be due to a number of factors including the factors that older people from BAME backgrounds were more likely than their white counterparts to have family members working in key worker roles, where the risk of contact with COVID-19 was higher[vii]. Older people from non-white backgrounds were also more likely to live with their families in multi-generational households, increasing the risk of transmission of COVID-19.

Older people in residential homes

In the UK, around 430,000 people live in care homes (residential or nursing) which equates to about 0.6% of the overall population, or 3.9% of the over 65s.[viii] It is estimated that around 70% of care home residents have dementia or serious memory problems. In Leicester, there are just over 2000 of our residents who live in a care home, either for older people or for working-aged adults. When the pandemic hit in 2020, staff, residents and their loved ones were to experience a period of intense change and difficulty as everyone worked to try and protect some of our most vulnerable members of society.

Overnight, the whole way that care homes worked had to change in order to minimise the risk of transmission of COVID. Like all settings where a number of people live together in close quarters, infection control measures are incredibly important. Consequently, nursing homes already had strict infection control policies, but these had to completely change in response to the threat of COVID. In addition, the risk of people being discharged from other acute care settings into the homes had to be managed, and early in the pandemic when widespread testing was not yet readily available, this made this even more difficult. Unfortunately, in the early days of the pandemic, COVID-19 spread rapidly through some care homes and some of their residents became ill and died of severe COVID.

Reasons why care homes were particularly affected by coronavirus include[ix]:

• Vulnerable residents. Many people living in care homes are in their 80s or 90s and are often living with long term conditions including dementia, frailty and other underlying conditions. This makes them particularly vulnerable to severe COVID-19 and at risk of death
• Features of the virus. The COVID-19 virus is spread by small droplets caused by coughing, sneezing and speaking. These can also settle on surfaces in shared living spaces, of which care homes have many
• The care home environment itself. Care homes are not like hospitals, they are where people live and therefore staff and residents are used to socialising and doing activities together. In addition, staff have to provide close personal care to many residents over a day which means that even when measures are taken to prevent disease transmission, it can still be difficult to prevent spread
• Asymptomatic infection. Older people with COVID-19 were more likely to present with different symptoms to the classic case of sore throat and cold type symptoms, or even no symptoms at all at first which meant that it was possible for staff to miss.

 

Care homes and the pandemic: the early days

As alluded to above, the events at the beginning of the pandemic accelerated rapidly and the rate of change was great. This caused significant challenges for those working in care settings including:

• Difficulty accessing tests for staff, residents and visitors, and initially, people being discharged from hospitals into care homes without a test
• Difficulty sourcing sufficient and appropriate PPE as having to ‘compete’ with health services
• Significant stress for staff related to worry for themselves and their loved ones, who may have been at home shielding. Sadness and worry for residents who might become seriously ill, and hard work wearing hot and uncomfortable PPE helping to cover colleagues absences when they were sick.

Confusion over clarity on guidance due to rapidly changing nature of guidance and inability to access the PHE helplines in a timely fashion due to increased demand.

What did we do to help?

• The Leicester City COVID-19 was formed and had a social care and education sub-cell specifically to look at events in care homes and help to provide guidance and solve problems. This fed back into the main IMT and initially met very often (multiple times per week, decreasing to weekly). The council’s social care department worked hard to try and support their care colleagues across the city wherever they could with accessing equipment, staffing and support
• The public health team set up a COVID-19 advice line for care homes that was via an email inbox. This was then staffed by various members of the public health team who would call back and provide advice and guidance on outbreak management, testing, PPE, isolation and any other questions the staff might have.
• Infection prevention and control advice was provided by a specialist nurse who was also able to go out and visit care settings and give advice and guidance to homes who requested it.
• Provided support with COVID-19 vaccination advice and administration once the programme was up and running. Frontline social care staff and those in the older age groups were among the first cohorts to be invited for their jabs. Getting everyone vaccinated in a short window was logistically challenging as it was a new programme and the services who were delivering it were already stretched with winter pressures. In addition, as with all stages of the vaccination programme, some people were hesitant to accept their vaccinations, and given the vulnerable nature of the care home population, we worked hard to help people make the choice to have their vaccinations by engaging and discussing. There was also some excellent work done on the reasons and barriers to people accessing vaccination- see the vaccination section for details.

Where are we now?

Happily, the current situation is much different from the early days of the pandemic. Circulating rates of COVID are much lower and widespread vaccination has meant that the proportion of people with COVID who get seriously ill or die is much lower, even those who are vulnerable. This has meant that many of the restrictions facing care homes have now been lifted and people can once again visit their loved ones face to face. However, the risk from COVID has not disappeared and it is important also to remember the risk associated with seasonal flu. It remains important that people living in care homes, and those that work in them, take up the offer of COVID boosters and flu vaccinations when advised. Rules on COVID testing in care homes have also recently changed so that in the event of an outbreak, the whole home does not necessarily need to be tested at the same time. However, it is important that there are plans in place to be able to increase testing again or implement stricter infection control measures again should it be needed.