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

The first 1001 days of a child’s life, from conception to age two, underpins the lifelong emotional and physical wellbeing of a child all the way into adulthood.

For the 4,300 babies born during Leicester’s extended lockdown period (April 2020-March 2021), these critical early days were far from normal. The COVID-19 pandemic had impacts on planning for birth, on parenting experience and on access to both formal and informal support for new parents and families.

Although severe illness and death from COVID-19 was, thankfully, rare in children, the wider impacts on their education, mental and physical wellbeing and life circumstances were profound.[1] Although these impacts are recognised, and the system did what it could to mitigate against them, the longer-term implications are still not fully known. In ‘Build Back Fairer; The COVID-19 Marmot Review’, the report states

‘…early childhood development has been harmed by lockdown and given what we already know about inequalities in early childhood development it seems certain that the development of more deprived children will have been harmed the most.’

With this in mind, the years ahead must be dedicated to ensuring that we work to protect and improve the health and development of our youngest citizens in the wake of the COVID-19 pandemic.

Leicester is a young and vibrant city with a greater proportion of young people than other cities of comparable size, but it also has its challenges to face, and this was true even before the pandemic. In addition, the size of the population in the City aged 0-19 years is forecast to increase at a faster rate than England and other cities.

The Joint Strategic Needs Assessment (JSNA) for Children and Young people, which looks at the health and wellbeing of young people across Leicester, was updated by Leicester City Council in 2021. In some parts of the city, 50% or more of children are living in poverty, and in a 2016 Health and Wellbeing Survey, around 24% of Leicester children said they were worried about having enough money, and 19% were worried about having enough to eat.

A map of the city showing children living in poverty (after housing costs are accounted for) shows a high proportion of children living in areas of deprivation to the East of the City Centre:

It is also true that children and their families living in areas of greater deprivation are more likely to have worse health outcomes, even before the effect of the COVID 19 pandemic exacerbated this difference. Those children born in our most deprived areas have a significantly lower life expectancy than those born in the least deprived- up to seven years more in boys and six in girls.[2]

Leicester children also had higher rates of dental decay than the England average, and the percentage of five year olds achieving a good level of development was significantly worse than the national average. Other impacts can be seen in the PHOF child indicators.

Prior to the pandemic, Leicester City Council already had several programmes of work aimed at improving the health and wellbeing of Leicester’s children, and these were predictably disrupted by the lockdown. The coronavirus pandemic may have held implications on maternal and childhood experiences as services and the ways of working with communities changed, but as with the long-term health effects, these are yet to be fully understood. Some of the specific programmes and the impact of the COVID-19 pandemic are described in more detail below:

The healthy start scheme

Healthy Start is a government run scheme which aims to give families the best start in life. Women from 10 weeks pregnant and children up to the age of four are eligible for Healthy Start if they are in receipt of certain income-related benefits. In the first year of the pandemic, the average uptake for Healthy Start reduced by 8% from 67% in 2019 to 59% in 2020; then increased to an average of 63% in 2021[3]. The changes in uptake were probably due to a variety of factors and changes to the Healthy Start scheme during the pandemic.

Firstly, the voucher value increased in April 2020, which possibly increased the incentive to apply to the scheme. Secondly, also in April in 2020, the need for a health professionals’ signature on the application form was waived. This increased the ease of applying as health professionals’ capacity was limited and their face-to-face visits reduced. Despite the changes, Healthy Start uptake perhaps saw a reduction in the percentage of eligible people accessing the scheme, as more families became eligible due to the pandemic, but were unaware of the scheme.

Then 2021 brought changes to the design of the Healthy Start website and branding to better associate with the NHS, along with the paper application form and vouchers being swapped for an online form and a pre-paid card, respectively.  This helped beneficiaries to associate with a brand they trust and further increased the ease and user-friendliness of the scheme.

With about 4% of households experiencing hunger and about 12% of households experiencing food insecurity in 2020/2021[4], the importance of schemes such as Healthy Start came to fruition. The impact of lower uptake rates meant an estimated 1685 families in Leicester were missing out on a total of at least £7162 a week. Working to promote Healthy Start during the pandemic showed some difficulties along the way.  Some actions taken by the Public Health team to increase uptake included: social media advertising, radio adverts and mass email and newsletter communications. Going forward, it will be worthwhile to also promote this scheme in-person to be able to reach the correct target groups; as the scheme itself can tricky to navigate and talking to people openly can improve their understanding of how Healthy Start works.

Supervised toothbrushing

Oral health affects people physically and psychologically; and influences how they thrive, look, speak, eat and socialise; as well as contributing to feelings of social wellbeing. Leicester has improved from being the worst in the country with 45% of five years olds experiencing dental decay (2014/2015) to 38.6% (2019)[5]. One factor that has shown effective in improving oral health of children is the supervised toothbrushing programme in the foundation years. Brushing with a fluoride toothpaste at least twice a day removes bacteria and plaque build-up which prevents cavities and gum disease.

Prior to the COVID-19 pandemic, 84 early years settings and 24 schools were participating in the programme. At the onset of the pandemic, as education and childcare settings were limited, the supervised toothbrushing programme was paused in Leicester. This meant all early years settings and reception school aged children could not participate in tooth brushing at their education setting. By the end of 2021, 39 early years settings and two schools had restarted supervised toothbrushing which is a 54% and 92% drop, respectively, from before the COVID-19 outbreak. The full impact of the pandemic is not entirely understood, but it seems that the suspension of the supervised toothbrushing programme coupled with reduced dental access could well have impacted children’s oral health.

With the supervised toothbrushing programme suspended during the most part of the outbreak, alternate methods were used to promote oral health such as using social media channels, newsletters and online sessions for National Smile Month and Mouth Cancer Action Month. The uptake of online materials was good. Towards the end of 2020, the suspension of supervised toothbrushing was lifted nationally; it was decided the programme resume virtually in Leicester with the aim to combine this with some face-to-face visits in the future.

The pandemic has made us more aware of the importance of infection control and the measures detailed in our supervised toothbrushing protocols will be tighter in a post COVID world. It has also made us aware that oral health promotion can work effectively virtually using online platforms; and so from now on, some services will be delivered digitally, whilst events can be attended in-person.

For many children, the single biggest change that the pandemic brought was not attending school. Schools provide an important physical space for children to have time away from home, and for many children, financial insecurity during lockdown and having all family members at home and in close proximity all the time made life challenging.[6] It is also known that children from less affluent backgrounds were disproportionately affected by the change including:

• Less access to online learning or other learning resources
• More lost learning time
• Inequalities in exam grading by teaching assessed grading systems

Children with special educational needs and their families were also disproportionately disadvantaged by school closures[6].

On the 23 March 2020, the then Prime Minister, Boris Johnson, announced the first national lockdown including the closure of all schools, except for the children of key workers, causing a period of unprecedented change and upheaval for children and young people, and their parents, everywhere. From the beginning of June 2020 however, a phased reintroduction of school opening began, and for children, young people, teachers and parents it looked as though things were returning to something more like normal; albeit with masks and social distancing in classrooms.

In Leicester however, things were about to change. A school in Leicester became one of the first to be closed again after a number of cases of COVID were identified, and soon it became clear that cases were on the rise in the city. On 2 July, Leicester schools closed once again.

With rising case numbers and rapidly changing guidance, this was a difficult time for schools, nurseries, colleges, universities and other education settings. Teachers and school staff were working hard to keep themselves and their students safe but knowing what to do and when was incredibly challenging. It was recognised fairly early on that a response to this need at a national, or even regional level was not going to be adequate- regional teams at PHE were overwhelmed with enquiries and a national helpline set up by the department for education (DfE) was soon swamped with calls.

The solution in Leicester was for the public health team to set up a localised response to the problem- an email helpline for local schools and other education settings to submit queries to, and where the team manning the inbox would respond promptly with a call back or email with advice. The team also maintained a database of schools and case numbers, allowing them to monitor which schools might be needing more support, and every day, the team went through the lists, contacting schools with high case numbers to check in and see if they required any support. This was a time-intensive process and many of the members of the team managing the schools helpdesk had minimal previous experience of infection control work.

One of the public health team members reflected on her time spent leading the public health schools’ helpdesk:

“Prior to March 2020 I had no Health Protection [the area of public health practice that deals with communicable disease control] experience at all, and I knew nothing about that field of work. However, it was important to me to do something that contributed to keeping people in Leicester safe and I am optimistic and enthusiastic person who likes to say “yes” so I found myself, way beyond my comfort zone, leading the Public Health COVID-19 support for schools, colleges and nurseries. What I learnt was:

• Leading is not about knowing everything (or even pretending to know everything); I knew from the start I couldn’t be in front of the team or the teachers and pretend to know everything, because I didn’t know much at all.  Rather than trying to bluff it out with bravado, I was just honest about what I knew, what I needed to check, and what we needed to learn together. I learnt that being honest about your weaknesses, while making you vulnerable, can also make you a credible and respected leader.
• Support, kindness and respect is vital; we were all scared – personally and professionally.  When people are feeling like that it’s important to take time to ask how people are, to listen and to reflect. Throughout the Public Health team, under Ivan’s leadership, we had a culture of support and trust – it was a safe place to take on new responsibilities and to learn new skills, we were supported, not judged and this enabled the team to grow in confidence and the thrive.
• Preparation is key; I did so much preparation! I read and re-read guidance, I wrote and re-wrote emails – I asked colleagues to check my understanding. I had to present data and field questions from Head Teachers every week – I prepared carefully for that, I needed to know my stuff, present it simply and answer credibly.
• Strong relationships, and good work, leaves a legacy.  Our team did good work, and I’m so proud of them, and our strong working relationships continue into ‘the day job’, and I continue to work closely and collaboratively with education colleagues.

The pandemic was a hard and frightening time, and I’m proud of the work the team did supporting schools, their staff, children and families to stay as safe as possible.”

The relationships built between the public health team and Leicester schools during this time were strong and enduring and are one of the positives to come out of the pandemic. The schools appreciated having a trusted, accessible and local source of support and advice, and in return the team appreciated the incredible amount of work schools and teachers did to keep their pupils safe. The strong relationship between the public health team and the local schools was one of the things that made it possible to do whole school testing during outbreak situations. Due to the identification of a new variant of concern (VOC) in the population, Leicester became one of the first areas to need to do testing of a whole school with PCR tests and subsequent sequencing of the results. There was no established process for this in place, and so the testing team worked together with the staff at the school, the City Reach team and regional and national PHE (as it was at the time) staff to set up a way to consent and test a whole primary school in one day, plus arrange for the tests to be couriered to a national lab for sequencing and establish a process for results to be chased. Such was the success of this, that head teachers from other areas asked to be put in touch with the team at the school and in public health to talk about processes and get advice. Once again, Leicester had been a trailblazer in COVID response.

The relationship that we built with our local schools is still in evidence in the fact that the email helpdesk remains open to them. Although COVID queries are relatively uncommon now, the remit has expanded to include any infection control or public health related queries that schools might have, and we are able to assist them in managing outbreaks. A recent example was providing advice about Scarlet Fever to teachers during the recent period of increased cases.

Looked after children

The pandemic brought difficulties and challenges for everyone, but for children in care and young people leaving care, it likely will have made worse the difficulties and loneliness that some of them already face[7].

Every year, the government run a survey to get the views of children and their parents across a range of social care providers. In 2021, this coincided with the third national lockdown and they received more responses than ever. In general, though the children’s responses about their experiences of care during the pandemic were positive- with staff working hard to make them feel safe and arrange activities that were allowed- they voiced feeling anxious and worried about the situation, and also spoke about the difficulties with keeping in touch with families and loved ones. Many were unable to see loved ones face to face for long periods which they found difficult.

Leicester has a higher than the England average rate of children in care (LAC), with the rate being 70 per 10,000 children[8]. We already know that children in care and care leavers are more likely to experience isolation and loneliness and the pandemic made that worse. Recognising this, the City’s Young People’s Council and Care Experienced Consultants created ‘Quaranteens’ a social media campaign aimed at supporting young people through lockdown. 

Looking to the future

Although many of the difficulties and restrictions associated with the early days of the pandemic are passed, and much of life is now back to near ‘normal’, it is clear that the long-term impacts of the past few years have not yet made themselves fully known.

For many children, the loss of learning time, school experience and other support systems may have had a lasting impact on their development and children and young people are still reporting problems with their mental health. Public health has always had a role in supporting the health and wellbeing of Leicester’s youngest citizens, and now this is more important than ever.

We know that those families living in more deprived areas have been disproportionately affected by the pandemic and tackling these inequalities remains the focus, but it will also be important to keep gathering information in order to monitor the longer term impacts of the pandemic on children and young people, so that we can specifically design services and interventions to meet the needs of our population.