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

On 31 December 2019, the World Health Organisation (WHO) was informed of a cluster of cases of viral pneumonia of unknown cause in Hubei Province in China. It was quickly established that the cause was a virus from the coronavirus family. At first, the implications of this ‘novel coronavirus’ were uncertain, but it eventually became apparent that the soon-to-be-named SARS-CoV-2 virus would change the world and the lives of everyone in it. The disease caused by the virus, COVID-19, was declared a global pandemic by the WHO in March 2020 when rapid spread and severe cases threated populations across the globe.

Here in the UK, on the 23 March 2020, the then-Prime Minister Boris Johnson made the unprecedented move of advising the UK public to stay at home. All ‘non-essential services’ such as libraries, shops, playgrounds, restaurants and cafes were closed, people were only allowed out for exercise once each day, and people were only allowed to mix with those from their own households.

Though some of these restrictions began to be lifted in May 2020, in Leicester, the situation was becoming a concern. At the beginning of June, local public health teams began to flag that they were seeing rapidly increasing numbers of COVID infections, over and above what was being seen elsewhere in the country. An incident management team was rapidly stood up by public health system partners, and on 29 June 2020, Leicester City and some of the adjacent areas of Leicestershire County, were put into a local lockdown by the Secretary of State for Health. They were the first areas in the country to face restrictions of this kind. Over the next year Leicester saw more cases and a slower recovery than the rest of the UK. Consequently, the Leicester experience of the COVID pandemic and its associated restrictions was unique- the people of Leicester spent more time under local restrictions than anywhere else in the country.

This impacted the city in multiple, complex ways. However, the people of Leicester showed remarkable resilience in the face of this adversity. Below shows a timeline of events both nationally and locally as they unfolded.

This graph shows the overall Leicester rates (orange) and how they compared to England (green) over the course of the whole pandemic. The initial Leicester peak in June 2020 now looks small in comparison to later waves of infection:

This is a zoomed-in section of the same curve, with key events added to the timeline. The scale on the second half of the graph had to be increased in order to show the peak of the omicron wave in winter 2021/22:

The map below shows the percentage of different parts of the city that tested positive between March 2020 and March 2022. Over that time almost a third of the population tested positive. The city is broken down into MSOAs (Middle Super Output Areas). The areas in the city centre had the lowest percentage of their populations test positive for COVID-19. Those areas which have the worst health outcomes generally also tended to have the highest number of positive tests. This is of real concern, because those who are the most vulnerable within our community also appear to have been testing positive more frequently.

As the UK’s most diverse city, Leicester’s communities are arguably the most “different” from each other on the surface level, culturally at least. For those who have spent their life growing up in the city however, such as myself, it rarely feels that way, and it is always surprising to learn how much of our concerns, problems, and ambitions are shared regardless of cultural background. Many communities are based on shared interests, or the area they come from.

Fresh in recent memory is how Leicester had a hard time during the COVID-19 pandemic, with some of our communities amongst the hardest hit, and it is this that lead to the formation of the Community Wellbeing Champions programme. Initially a COVID- focused project, though also attempting to address the wider health inequalities that contribute to it, it aimed to discover the barriers to vaccination in communities, and attempt to address these. It has since developed into a broader health and wellbeing-based project, working with communities and using the valuable expertise of the Voluntary Sector organisations who work alongside them on a daily basis, working to identify the main concerns, issues, and barriers to good health in our communities.

The Community Wellbeing Champions programme, which I am a facilitator on, aims to empower a network of organisations and volunteers that will help to form a closer link between services and communities so that health information, guidance, and support reaches those that need it most, while helping to ensure that providers of health and wellbeing services are aware of the views and needs of our diverse communities. The programme works closely with organisations and individuals across the city to help identify and overcome barriers that can result in some communities experiencing poorer health and wellbeing than others. We have created a network of individuals and organisations who work with communities, many from the Voluntary (VCSE) and Faith sectors, whose expertise we utilise to keep on top of the main issues and concerns relating to health and wellbeing inside Leicester’s communities, and who share their ideas via events, meetings, and a number of channels such as e-forms and emails.

While we have recruited over 150 members to our mailing list to date, we aim to continue establishing meaningful, lasting relationships between the council, Voluntary Sector and Faith organisations, and the people of Leicester, for the benefit of the city as a whole.

Who we work with and what we do

At the heart of the Community Wellbeing Champions’ project is forming a relationship with those who already know the individual communities of Leicester best and are already doing amazing work to empower these communities and address the issues they face on a day-to-day basis. Considering this, it only makes sense to make Voluntary Sector organisations a key part of the CWC Network, as well as faith organisations. Groups who are already known and trusted by their communities, who provide visible help on the ground level.

Conferences

This relationship was formalised at an event at the King Power Stadium on the 7^th of June 2022, with key members of Voluntary groups across Leicester, covering as many of the different location, lifestyle, ability, demographic, and cultural groups that live in the city as possible. The event also had many of the Public Health Staff present, and had speeches from Councillor Vi Dempster, Deputy City Mayor for Health, and Ivan Browne, Director of Public Health.  The event featured workshops on the main concerns in the communities of those on their table, as well as what can be done to address these issues. In total, there were over 100 attendees present.

Alongside the more serious workshops and speeches, there was also a quiz on health inequalities in Leicester, with many statistics that surprised those in attendance. There was also the opportunity, in partnership with Live Well (Leicester City Council Public Health’s health and wellbeing service), to partake in a guided walk around the King Power Stadium, towards the Kun Vichai memorial garden.

A second conference was held in September focusing on access to healthcare, the most common issue outlined in our prior engagement work by some distance.  This event was held at Highfields centre, and featured speakers from those in the Public Health team tasked with leading the response to the Fuel Poverty and Cost of Living Crisis, as well as impassioned guest speeches from VCSE organisations on increasing vaccine confidence in their communities. This event led to many new valuable contacts with community groups and organisations.

How we work

A forum meeting has been set up every 2 weeks to give both Voluntary Sector organisations and Leicester City Council departments a chance to present regarding their work, and current health and wellbeing hot topics. Another recent development is the creation of a Cost-of-Living drop-in surgery, where VCSE groups can join a meeting designed to allow the sharing of concerns facing their particular communities.

Alongside partnering with external organisations, we also work with our fellow Public Health teams to work together on various pieces of work, engagement, and projects.

"How are you, Leicester?" and moving forward

The “How Are You, Leicester?” consultation was designed to open discussion on Health and Wellbeing amongst Leicester’s residents, and to check in and see where the city is at after a tough couple of years. It consists of a short survey, asking individuals to rank their current physical and mental health, as well as their pre-pandemic physical and mental health, followed by tick boxes of the main factors impacting both physical and mental health, as well as open-ended questions designed to create a more detailed discussion of the main issues affecting communities, as well as the changes people would like to see to address these. The survey was taken directly to the public in the form of in person focus groups, such as our stalls at the Haymarket, at the St Matthews Big Local Jubilee street party, and the Association of Muslim Police Officers’ engagement event, as well as via social media accounts with links to target demographics, such as facilitating the link to the online form being posted on B-Inspired's social media accounts, with Braunstone (the community the organisation supports), being an area we found to be underrepresented in previous engagement attempts.

The survey data found that Respondents’ perceptions of their current mental and physical health & wellbeing were good pre and post pandemic, but lower after the pandemic, varying more for mental health & wellbeing, with a significant increase in those reporting poor mental health. Sub-analysis shows a steeper decline in mental health reported by “more deprived” and “White” ethnicity groups, and a steeper decline in physical health reported by “other than White” groups. The main factors affecting mental and physical health & wellbeing reported by respondents overall were environment, finances and access to healthcare. Similarly, the open-ended data when coded into themes found the most prominent health and wellbeing concerns within communities being access to healthcare, access to services, and environment.

While not being a particularly scientific survey, the consultation serves as a very useful conversation starter between communities and the council, serving as the official “launch” of the CWC project, as well as checking in on the city’s wellbeing after being hard-hit by COVID. The consultation also helps identify target groups we struggled to engage with, for example the traveller community which we didn’t hear from in our engagement. The findings of the survey also echo the findings of other, later CWC engagement work, with access to healthcare also being the most prevalent theme in the June Conference workshop identifying the main issues found in the community’s attendees worked with. It also serves as a background to help other Public Health teams identify main barriers and health and wellbeing issues in communities.

The future of the network

The CWC network intends to continue expanding, increasing trust, cooperation, and conversation between the council, VCSE organisations, and communities themselves, as well as helping people reach the services they need over what is likely to be a difficult winter for many. The forum meetings discussing wider health and wellbeing issues which take place once a month, and the drop-ins regarding the cost-of-living crisis, held once every 2 weeks, will continue into 2023. Both of these will strengthen the relationship between us and the organisations that make up our network, as well as increasing our knowledge of the issues and concerns present amongst the communities, they work in. Alongside VCSE organisations, we also wish to strengthen our relationship with other Public Health departments, with conversations with many teams about future partnership working taking place.

We are particularly looking to engage more with organisations working in the western part of the City since at the moment this part is under represented in terms of who has signed up to be part of the network. This is particularly important in lesser affluent areas of Western Leicester, as those with a higher likelihood of significant health and wellbeing concerns are not being heard by us presently.

We also are in the process of arranging our next engagement events, as well as maintaining a presence at external events via stalls, presentations, flyers etc. If you are a member of a community or voluntary sector organisation who is not yet part of our network and would like to be so, please email us on wellbeingchampions@leicester.gov.uk.

The first laboratory-confirmed positive test for COVID-19 in Leicester was on March 11 2020. This was to be the first of many thousands to come in the months ahead. In June 2020, Leicester became the first local authority area to become subject to a local lockdown when rapidly rising case numbers were noted. At the time, COVID testing infrastructure was relatively in its infancy. There was no rapid testing available, all testing was via laboratory PCR testing, initially making use of hospital labs (‘pillar 1’) but then escalating and requiring a national network of laboratories (‘pillar 2’) operated by a private provider and run under the umbrella of ‘NHS test and trace’.

The early days

When a local lockdown was declared in Leicester, we suddenly found ourselves the subject of intense national scrutiny, as well as becoming an area of enhanced testing. This meant that the city had to go rapidly from very small numbers of testing to widespread testing of large parts of the community, which was a huge logistical challenge.

Whilst the focus from the national response team was on the rapid upscaling of numbers of testing in the city, it soon became apparent to the public health team that a testing strategy was still required, in order to ensure the testing was used most where it was most needed. Not for the last time in the pandemic did Leicester find itself having to boldly go where no local authority had gone before; and the Leicester city testing strategy was born.

Scaling up of testing in the city commenced on the 29 June 2020; putting the focus initially on areas of the city identified as having particularly high rates of COVID(at the time this was a rate greater than 440 cases per 100,000 population) and high positivity rates (the percentage of the people in that area estimated to be COVID positive at that time). The availability of the data at this level (we used an area size known as a Lower Super Output Area of LSOA, similar in size to a postcode area) meant that we could apply a so-called hyperlocal approach to testing. We used a range of approaches to increase testing uptake in these areas. Volunteers covered the areas going door to door and encouraging whole households to test by either delivering PCR kits to be done there and then, or by signposting people to nearby mobile testing units, MTUs. Of note was the fact that this strategy aimed to test both symptomatic and asymptomatic people (‘universal testing’) in order to try and suppress infection and interrupt asymptomatic transmission of COVID. This was different from the wider national testing strategy at the time, which was only to test people with symptoms.

In addition to this community testing strategy, there was a programme of testing at workplaces and factories within the lockdown area. This was based on two separate programmes; reactive testing based on clusters or outbreaks identified through the health protection team at PHE (as the UKHSA was then) and also a universal testing offer for all workplaces within the area if they chose to take it up. This was enacted in partnership with the business engagement cell of the IMT and with support from regulatory services, who carried out visits to premises to assess COVID-19 security and offer whole-workplace testing.

Although the priority areas and numbers of tests varied throughout the lockdown period, the basic principles of the Leicester city testing strategy remained the same, and based on the idea that testing resource should always be targeted where it was most needed. The principles were:

• Testing should always be easily accessible for people, particularly within the priority groups and geographical areas through a combination of local testing centres, regional testing centres and online ordered home test kits. (This became a challenge at many points in the following months when test shortages became an issue)
• Regular consideration of the data at a local level to ensure identification and monitoring of areas of focus

• Rapid change of testing approach when required in response to changing circumstances and disease rates
• Communication and community engagement in areas of increased transmission to promote social distancing messaging and advise on testing
• Active engagement with key stakeholders including community groups and community leaders across Leicester and Leicestershire to help deliver the strategy successfully. 

City reach and the next phase

An important element of the Leicester response to COVID-19 was our ‘city reach’ team- a 200 strong team of volunteers and staff who worked tirelessly throughout the pandemic.

Initially they went door to door and handed out PCR test kits, but over time their role evolved and they found themselves doing everything from helping people access testing appointments, delivering PCR test kits to people who had positive lateral flow tests through our test sites, working in communities talking about COVID-prevention measures and health messaging, and staffing our lateral flow test sites. They even helped make possible large-scale testing in schools in response to outbreaks.

Alongside highly localised detailed data from the public health analyst team, this allowed highly focused response to even at a street level to be made with the city reach team utilised where required. Over the course of the pandemic, the team visited every area in the city at least once, and this ability to respond rapidly to data at a very local level was one of the things that made the Leicester COVID-19 response uniquely effective.

One of the many highlights of the team’s fantastic work was their nomination for a Lord Lieutenants platinum jubilee award.

Lesia Smaditch, who prior to the pandemic worked within the music industry, joined the council’s city reach team as a leader for one of the city’s reach centres reflected on her experiences:

“It was lovely to work within a team where everyone shared the same vision and narrative on how to tackle high case numbers of COVID-19 in Leicester. Some staff were newly recruited to their roles like me, while others were redeployed from other areas of the council. Nevertheless, everyone really pulled together, and put all the challenges we faced in our stride. It was collectively very rewarding to see how things were required at pace, and then delivered very quickly.

I felt honoured that despite being a new addition to the team, my previous experiences within the community running a local business and choir were valued, and I was encouraged to take a leadership role within City Reach. My experiences of working in this team encouraged me to continue to work in Public Health and enjoy my new roles working in both Leicester City Council and Vista where I am working on a variety of different areas within public health.”

Towards the end of 2020, the arrival of rapid testing for COVID in the form of lateral flow device testing (LFTs) changed the landscape of COVID testing again. Instead of needing to send a swab off to a lab and await the result, this allowed the swab to be processed on the spot, yielding a result within 20 minutes.

In December 2020, Leicester became one of the first local authorities in the East Midlands to set up a comprehensive network of community lateral flow testing sites, using community buildings across the city. A lot of work was done in a very short time to identify suitable council-owned buildings and get them converted into test sites, whilst making sure that we had as good a geographical spread as possible through the city, taking into account that many Leicester residents do not have access to a car or vehicle.

The staff working at these test sites did an incredible job of keeping them running and constantly adapting to changing circumstances which ranged from test kit shortages to high demand, to needing to navigate ‘surge’ testing in response to variants of concern being identified in the city. Memorably, Leicester City made it to the FA cup final in 2021 and this became one of the government’s first pilot large sporting events to take place after the COVID restrictions. As part of the process, staff at our test sites extended their opening hours and managed to test around 1500 people in the 48 hours before the match.

The testing site staff in Leicester also went the extra mile for our residents in that, when initially, a positive lateral flow result required a confirmatory PCR test, they would visit residents’ homes and hand deliver their PCR tests following a positive lateral flow test if they were unable to get one themselves without leaving isolation.

Targeted community testing and the future

Widespread availability of home test kits to order online began in April 2021, and immediately prior to that, a workplace testing offer was set up on the online government portal too. As well as on site testing, our community lateral flow test sites were also given stocks of home test kits to hand out, which proved incredibly popular.

During periods of high transmission at that time, the government was advising everyone to test twice weekly, which increased the demand substantially. Meanwhile, the stocks we were being allocated to distribute via our test sites and teams were being carefully targeted to particularly vulnerable or at-risk groups. The team set up an online portal where local organisations could go and request lateral flow tests, whereupon the city reach team members would arrange a delivery to the site in question. This allowed a prompt and flexible response to need for tests across the city and, to the best of our ability and as supply allowed, ensured that the people who most needed tests could always get them. This approach was really appreciated by the community organisations who used it, as it was efficient and responsive and another example of the testing site teams going above and beyond for their communities.

Universal access to free COVID testing largely came to an end in March 2022 after what felt like a whirlwind two years of logistical challenge and constant change. Though testing still persists through the hospitals (the ‘pillar one’ network), the nationwide network of community testing sites and NHS Test and Trace operated PCR testing sites were stood down and the buildings returned to their communities. It is hard to imagine now the scale of the testing operation that was in action just 18 months ago. It is of course impossible to predict whether in the future, another large wave of COVID infection might require a rapid stand-up of a testing response again, or even if another infectious disease might one day need the same, but many of the lessons learned in the course of the COVID testing programme will stand the city in good stead. Not least of which, the strength of asset that it has in its communities, and their ability to respond to challenge. Many of the city reach volunteers were drawn from the communities that they worked in, and others from across the council. They consistently met and exceeded expectations when they were given new challenges, and became a vital part of the city’s COVID response.

As with many other aspects of pandemic response, Leicester became one of the first areas in the country to pioneer a local contact-tracing approach in addition to the national ‘NHS Test and Trace’ structure in order to try and manage the increasing case numbers more effectively. But what is ‘contact tracing’?

The WHO definition from 2021 is as follows:

‘Contact tracing is the process of identifying, assessing, and managing people who have been exposed to someone who has been infected with the COVID-19 virus.’

The purpose of contact tracing is to try and stop the spread between people and slow or stop the spread of an infection, in this case, COVID 19.

There are several things that are important to this process:

• Being able to identify someone has an infection soon after they have been infected
• Knowing who they have been in contact with during the infectious period – this can be before they have symptoms
• Public support and agreement that it is important to isolate people with infections or who may be becoming infected

Up until June 2020 the national contact tracing system was in place and it was becoming slower in contacting local people as cases increased. This was at the same time as Leicester was experiencing its first local lockdown.

Below is the timeline of events as they unfolded, and Leicester developed its own contact tracing response.

What the team achieved with contact tracing in Leicester was incredible, but why was a local approach so successful?

• Local authorities are embedded in their communities and aware of the geography, needs, enablers and barriers for people to do things that may have an effect on their day to day lives and families.
• Local people working for the LA can speak to local people with direct experience and help them to access support and identify their contacts in an understandable and approachable way.
• Leicester is a very diverse city with a great number of community languages spoken. The team at the local authority has people who are able to discuss contact tracing and its importance with people in their preferred language.

How did it work?

• Leicester was unique as it instigated a ground team from day one. This team knocked on peoples’ doors when they were not contactable by phone. This was important in a diverse area and also meant that if people were ill, support could be provided.
• The team did support calls with all positive cases after three days:
  • They identified people who needed food delivery or access to support fund including food boxes.
• Spreadsheets of different types of contact exposure were kept and sent to different cells in local authority for support where specific settings were involved:
  • School team - rang schools to ensure they were aware of cases for bubbles to isolate appropriately
  • Care Home team - worked with the infection prevention and control team and adult social care to visit care homes and support them with isolation and infection control
  • Workplaces - close work with Public Health England, regulatory and business services to reinforce COVID prevention measures in factories and warehouses
  • University team - provided advice and support to the two universities regarding who should isolate and how to support students.
• International work - identified high numbers of cases prior to India being placed on the Government ‘red list’ for travel, and proactively put in place visits to houses to deliver test kits to family contacts. We also kept a database of international travellers to allow testing of contacts and additional support.
• This helped identify cases linked to international travel that would not otherwise have been identified.

What did the team achieve?

• The team trained a local non-public health team to become very skilled in contact tracing which is a specialised and difficult skill. People from diverse backgrounds within the council stepped up and uncomplainingly learnt a whole new skill set- and excelled at it.
• They prioritised staff welfare and maintaining capacity necessary to maintain quality performance and development.
• The team outstripped the expectations of the national team and proved the value and skills that were here in the local authority.

What were the issues, and how did we solve them?

• At times, the system felt disjointed with multiple organisations- Public Health England, NHS Test and Trace, NHS England, Local Authority, Department of Health and Social Care –with unclear and overlapping roles.
• The team developed a good relationship with the national team, and ensured collaborative working with local expert health protection team, as well as using the untapped health protection skills in local authority public health teams.
• National test and trace IT system and not hearing the local voice
  • Appeared to be a top-down approach to implementation e.g. international travellers returning, but data never fully available locally
  • Capacity planning difficult. For example: on the 31 December, 189 cases were received when we had planned for 40, and on September 9 there were 340 cases in one day.
  • Poor understanding of local pictures: there was a need for data early in the day for teams to contact people. There was less than 24 hour notice of script or data changes that were implemented by the national team
  • Multiple IT organisations and players with their own performance targets not necessarily focused on local issues which were unique to individual areas
  • Testing system involved multiple providers with delays in getting results out therefore infectious period may have elapsed.
  • Complex and difficult cases by their nature were always ending up with the local authority, and late in isolation period, which makes performance appear poor compared to national system

In the end, we developed a good relationship with the national tracing team based upon their trust that we could deliver, and honesty when we had issues. This collaborative approach led to the development of innovative Leicester pilots that were then nationally implemented.

Personal reflections from the team

Liz Rodrigo commented:

‘One day in June 2020 my life changed, I had a call from Ivan Browne the Director of Leicester public health ‘Liz I have a little job for you. Could you set up some local contact tracing and work with someone in customer services’.

It was at least four months of daily calls, texts and emails before I met the ‘man in customer services’ now known as ‘captain COVID’, Edd Quick, in person.

COVID was a time when you felt you had to solve the problems and work fast, we were working for our local community and families trying to stop the spread, especially to the vulnerable. There were many frustrations but also a time of achievement when you could work hard and solve a problem.

Edd’s person skills in building and motivating a team were and are extraordinary. He set up an amazing team that delivered and then delivered more. They had entered a world of contact tracing and used their skills in a new way. This work was grindingly difficult as numbers rose. But many were motivated by wanting to protect their loved ones.

Lockdown fatigue and the media were not always helpful in motivating the public to isolate and staff were often subject to abuse and resistance. Despite this their motivation remained right up to the moment that the funding was withdrawn.

It is difficult once you have experienced something that has an immediate impact on people’s lives to go back to doing things less immediate and challenging. I think that this is the thing that is most difficult about post COVID work. We have seen the potential that staff and teams have to deliver the extraordinary and lead the country and should celebrate the amazing skill of staff in local authorities.

What I have learned from working to implement this is that it is important to embrace change and strive for the best even when that seems unachievable in the time allocated. Working together and trusting others to work with you to use complimentary skills.

Edd Quick reflected:

‘There were a lot of challenges involved in local track and trace.

To begin with, the service needed to be stood up very quickly. Leicester was the only city in the country to remain in lockdown while restrictions elsewhere were being eased. We were also building processes from scratch – it wasn’t something we had a local template for. We were able to combine our operational experience with public health expertise to conjure up and then develop something that turned out to be quite special and successful.

We were able to show great results with very high success rates in tracking down positive cases, and we were able to provide a more complete support offer than our national counterparts.

Our success allowed us to develop the programme to handle cases at an earlier juncture, increasing our effectiveness in making sure positive cases and their contacts were isolating.

As case numbers grew, so did our team. Initially we had been staffed by furloughed colleagues, but this progressed to employing people directly into the role.

We worked weekends and bank holidays, Christmas day and New Year’s Day. The team were incredibly dedicated and contact tracing did not stop.

We were involved in newspaper articles, radio interviews, local and national televised news, and an episode of panorama looking into the national contact tracing set up. There was a lot of media and political attention around the programme. Although contact tracing was only a small element of the broader work being done by the local authority in the city to combat the pandemic, there was a lot of focus on it.’

On December 8 2020, Margaret Keenan became the first person in the world to receive the Pfizer COVID-19 vaccine, kicking off the NHS’s biggest ever vaccination campaign, and changing the course of the COVID-19 pandemic. Although there is already an extensive vaccination schedule through the course of people’s lives in the UK; from infant vaccines to school aged immunisations, travel vaccines and seasonal flu vaccines; this was an entirely new vaccine to a new disease that needed to be given to nearly all of the population in as short a time as possible- a massive logistical challenge. Just short of six months later, by May 2021, it was estimated that around 900,000 doses of COVID vaccine had been delivered to residents of Leicester, Leicestershire and Rutland. To date (May 2023) around 238,238 residents of Leicester City have had at least two doses of COVID vaccine since the start of the programme.

Though the work of rolling out the vaccination campaign fell to the NHS, it soon became clear that in order to make the programme work for everyone, a partnership approach was needed with partners in the City Council, including public health, and the communities themselves. The first six months to a year of the COVID vaccination campaign brought a steep learning curve for all involved and many complications that had to be solved as they occurred. However, it also brought with it some great achievements, and built relationships that are still thriving today.

At around the mid-point of 2021, six months after the start of the vaccination campaign, it became apparent that there were significant disparities in rates of uptake of COVID vaccination, both between the city and the county and Rutland, and also within the city from area to area. It was at this point that the programme moved to a more local focus, with groups set up specifically to target inequalities. Initially, these differences in vaccine uptake were less apparent due to the cohort nature of first doses being offered; the vaccine was first offered to older adults and those in residential care, plus frontline health and social care workers, and uptake was proportionately higher amongst those over 75 than subsequent younger age groups. This initially high uptake by the older aged groups masked some of the variation that would emerge as younger people were offered the jab.

One of the team at Leicestershire Partnership Trust who were coordinating the vaccination programmes locally spoke of the many challenges they faced while setting up the programme- from difficulties finding sites at short notice, to working out how to safely manage moving large numbers of people through a vaccination site at a time when Leicester was still under lockdown restrictions. The challenges continued with it taking time to set up an electronic booking system for the hubs- initially the appointments systems had to be managed and executed by hand and often paper-based, and a lack of a computer system for recording vaccinations across all sites, not just primary care settings. Data capture was limited at first, with ethnicity recording not always done, and eligibility criteria not always being clear. However, there were innovations too- the drive-thru site at Glenfield was one of the first in the country to be set up, if not the first, and was modelled on the premise that it might be a more attractive option for the younger groups who were starting to lag behind in the uptake figures. However, it turned out to be more successful than that, with people coming from both city and county, and across multiple age groups. People reported feeling more comfortable coming and staying in their own cars rather than having to enter a vaccination centre full of people, and it also worked well for some with younger children or those with a needle phobia who felt more comfortable in their own environment. Leicester also were one of the earliest areas to really make the most of mobile vaccination units, however, in the early days of the programme these were quite large and unwieldy and needed a large footprint to set up. This has now changed and our mobile units are much smaller! Another early innovation by the Leicester team was the recognition of the importance of transmission of COVID-19 in multi-generational households, and therefore the team successfully lobbied for the ability to vaccinate those living in a house with people in the vulnerable cohorts as well as the eligible people themselves.

The programme was not without controversy, even in the early days. Some of the decisions on who to include and who to not in the early eligibility groups were questioned by the public, such as the fact that teachers and police/fire services were not initially included, just front-line health and social care workers. And it was sometimes challenging to know who was and wasn’t eligible at one time as supply of vaccine and availability of appointments had to be managed. In addition, a growing anti-vax movement became more vocal and began to demonstrate outside vaccination sites.

Other challenges were a direct result of the speed of mobilisation of the programme and the response to changing evidence and epidemiology. For example, the government Joint Committee on Vaccination and Immunisation (JCVI) changed the recommendation early on to increase the recommended interval between the first and second vaccines, in order to allow a greater proportion of the population to have some protection in a shorter time. In the event, this turned out to be very successful, vastly increasing the proportion of the population who had at least one jab, and also finding the vaccines to be just as effective if not more so with the increased interval. However, it did mean that a large amount of rapid reorganisation had to occur with all the pre-existing appointments for the older age groups needing re-making. When increased supply became available or COVID transmission rates required it, the eligible cohort would often be widened by the government at very short notice, which meant those running the vaccine programme had to scramble to adjust their services almost overnight. For example, in a briefing on the 12 December 2021 in the middle of the omicron variant surge in cases, then Prime Minister Boris Johnson announced that all eligible UK adults over 18 would be offered a booster dose by the end of the month, moving an already difficult target up by a whole month. This felt like a near impossible task to those on the ground, but the NHS team delivering the vaccines in partnership with the public health team and Leicester City Council successfully stood up a programme of surge vaccination.

As mentioned above and in other places in this report, COVID-19 vaccination was one of the places where the need for a local focus became very evident. Initially a lot of the organisation and recommendations for the vaccine programme came straight from NHSE and the Department of Health as national directives with little room for customisation at a local level. However, in order to tackle the differences in uptake and improve people’s confidence in the vaccine, what was needed was local knowledge and intelligence, and a flexibility of planning. The public health team had undertaken some detailed community engagement regarding vaccination and were able to share this with NHS colleagues. In addition, our public health analyst teams developed new dashboards and ways of visualising the data to help inform the programme. This meant we were able to make recommendations at small geography areas, such as where specifically to site a mobile vaccination unit. We recognise that our communities themselves are a vital asset in working to help improve vaccination uptake and as a result, the community champions programme was born- see the specific section for more details. In addition, we were flooded with offers of help and support from community groups and representatives, faith groups and leaders and organisations who facilitated vaccination sessions or information distribution. Members of the NHS and public health teams did many engagement sessions with schools, universities, workplaces, members of the public which were all recorded and available on YouTube, where we attempted to address some of the myths surrounding vaccination and answer people’s questions. These were generally well attended.

The programme in schools was facilitated by our School Aged Immunisation service (SAIS) who also had to find a way to suddenly expand their usual programme of immunisation to include COVID-19 at a time when there were restrictions on social distancing and movement in schools. Not only did they achieve this, they also became important partners in helping to increase uptake, improve people’s confidence and a source of vital information on what was and wasn’t working in the school programme. They also often went above and beyond, attending parents’ evenings to discuss the vaccinations and help with the consent process.

Vaccine hesitancy and behaviour change

As mentioned in other parts of this report, the public health team did a lot of detailed work to try and help understand people’s reasons for vaccine hesitancy and to use a behaviour change approach to improve uptake. Vaccine hesitancy refers to a delay in acceptance or a refusal of a vaccine despite its availability and is often complex and context specific. Vaccine hesitant individuals are found in all communities and often their reasons for being so are complex and individual to them. Together with NHS colleagues, we worked on a model of tackling the three ‘c’s of convenience, confidence and complacency.

Convenience- We worked to make sure that there were available places to get vaccinated within each area of the city, and also that these were accessible if you didn’t have a car. We also worked together with communities to understand what about some sites made them more or less successful as vaccination centres. We now have mobile vaccination vans that can come to events.

Confidence- Engagement work was undertaken to understand people’s reasons for not feeling confident in the vaccine and we did lots of work individually and through groups to address this. The section on the Community Wellbeing Champions and vaccine confidence programme has more detail.

Complacency- This was about ensuring that people adequately understood the need to get vaccinated, even if they themselves did not feel at risk, and tied in with the confidence work above. Here it was all about the messaging, and making sure that it was understandable and delivered by the right people.

Learning points

The story of the COVID-19 vaccination programme could fill a whole Annual Report by itself, and it is still ongoing, but looking back at this point shows a few key facts and learning points.

1. The COVID-19 vaccination programme made a difference. Although the vaccination does not completely prevent COVID transmission, it is likely to reduce it and also is known to reduce the likelihood of someone becoming severely ill or dying. The figures show this quite starkly when looking at the number of cases and deaths in the early days of the pandemic compared with later times when the numbers of community cases were incredibly high, but thankfully the same numbers of deaths were not being seen. The graphs below show the highest peak of cases of COVID-19 in January 2022, but the death rate was much higher during the earlier waves in May 2020 and January 2021, before everyone had the chance to take up the full vaccination course.

Subsequent studies have also shown the benefits of COVID-19 vaccination for pregnant women and their infants, with decreased rates of premature delivery and stillbirth in groups who were vaccinated.

2. The vaccination programme brought to light some of the wider issues in the community with vaccine confidence and confidence in healthcare services. A detailed programme of engagement during July 2020 brought to light key issues that were of concern to our communities. They spoke to us of the impact that the COVID-19 pandemic had had on their communities; with isolation, loneliness and a sense of inequity all coming to light. They also spoke of the importance of community-led action, and using members of the communities themselves to help spread messages. People also gave insight into the reasons for feeling hesitant around the vaccine, and this has enabled us to try and design a programme which minimises these factors.

3. Partnerships are important and must be maintained. We now have regular meetings regarding not just COVID vaccinations, but other vaccinations with our colleagues in the NHS where we exchange data and information and work collaboratively on increasing uptake. We also work with or communities, facilitated by members of our community champions network, to try and address the barriers people still face when looking to get vaccinated.

4. A locally-led approach is needed when organisation vaccination programmes and probably by extension screening programmes as well. All people and communities are different and a ‘one size fits all’ approach does not work. We have taken this to heart moving forwards and look forward to the work we will do in partnership with our communities to improve uptake of these programmes.