The Public Health Response to COVID-19 in the UK: A View from the Frontline

Abstract

The author charts the experience of working on the frontline public health response during the pandemic. The UK’s initial public health response to the pandemic comprised a delayed lockdown, shortages of personal protective equipment (PPE), insufficient testing capacity, and ambivalence about mask wearing. The pandemic’s first wave ravaged the health and care sectors. Subsequently, with experience and tight testing regimes, management of COVID-19 in the care sector was improved enormously. Hospitals reduced their workload to a bare minimum initially, followed by designing separate pathways to facilitate elective work, underpinned by testing and infection control. In addition to the elderly and frail, those on the fringes of society—for example, homeless, refugees, asylum seekers, and prison populations experienced high rates of infection and mortality. Nation-wide restrictions on movement were propped by an economic support program. The new school year in 2020 began amid rising cases, as people struggled to interpret confusing policies. Workplaces did not emerge from remote working till mid-2021 and remain a hub of infection transmission. The tussle between maintaining economic activity and education versus preventing the spread of cases continues, while the focus of the public health response moves to high vaccination coverage, rapid testing, and responding robustly to emerging variants of concern.

Introduction

The UK’s public health response infrastructure consists of public health teams based in local authorities (LAs) and Health Protection Teams that are part of a national body called UK Health Security Agency (UKHSA, previously known as Public Health England – PHE).

The local authority (LA) public health (PH) teams work on health improvement activities and on tackling health inequalities through a range of programs. They also commission sexual health services and have an oversight of immunization and health protection issues. The local health protection teams (HPTs) respond to communicable diseases, chemical and radiological hazards, and any threats to the health of the population of UK. They work closely with the local authority public health teams.

I am a senior medical consultant. I work in a health protection team that covers North and East London. There are two other health protection teams in London—for North West London and South London, respectively. For the coronavirus aspect of health protection work, all three health protection teams have merged into one team which is called the London Coronavirus Response Cell (LCRC). The LCRC recruited additional administrative and operational staff, and subsequently, staff from Test & Trace who covered London also became part of this team.

I have been working as one of 3 or 4 clinical leads at the London Coronavirus Response Cell, at least one day a week since early February 2020. I have tried to capture the experience of providing the frontline public health response in London, amidst rapidly changing scenarios and deficient policy making. In this chapter, I describe the pandemic’s impact in different settings, then cover the key aspects of control e.g., the role of Test & Trace, vaccination, and non-pharmaceutical interventions undertaken at borough level by the public health teams.

To date, the UK has had over 14 million people testing positive and over 150,000 deaths (Figs. 1 and 2).

Fig. 1

Source Gov.UK coronavirus (COVID-19) in the UK

Cases of COVID-19 in the UK from April 2020 to January 2022.

Fig. 2

Source Gov.UK coronavirus (COVID-19) in the UK

Deaths due to COVID-19 in the UK from April 2020 to January 2022.

Broadly speaking, the UK’s COVID-19 planning and response fell short both in tackling the spread of infections and in protecting its most vulnerable population groups.

The initial public health response was based on a flu pandemic planning model. Unfortunately, this model was not entirely applicable to SARS-CoV-2. More importantly, public health policy failed to implement the known lessons from the SARS, MERS, and the Ebola epidemics [1]. Thus, it always felt like we were catching up rather than managing the spread of cases proactively.

Each nation within the UK—Scotland, Wales, Northern Ireland, and England—developed its own COVID-19 control measures based on advice from specialists who their political leaders accepted. Overall, control measures like the use of face masks, movement control, and social mixing rules in the other three nations were usually stricter than those imposed in England throughout the pandemic period.

The pandemic affected people living in areas of social and economic deprivation and those from ethnic minority backgrounds most adversely [2]. Health inequalities in England have been widening since 2011 and life expectancy growth had stalled [3]. During the pandemic the stark differences in mortality and number of cases by deprivation indices (the higher the levels of deprivation, the higher the case and death rates) further widened the health divide [4].

Care Homes

The care sector in the UK was easily the worst affected by the pandemic as it holds the most vulnerable population—the elderly, frail, or highly dependent—all at high risk of COVID-19 complications [5].

As the cases began to rise in late February 2020, the situation was fueled by a series of unfortunate events.

Although the UK first developed a reliable polymerase chain reaction (PCR) test for COVID-19, it had not up-scaled the availability of the test to cope with the rising demand. As cases rose, a decision was taken to take away testing capability from the community and prioritize patients who were hospitalized [6]. This was a very poorly thought-out decision, as it meant that there was no way to case-find reliably, or to pick up the third of cases that were asymptomatic, or even to identify and rapidly isolate cases. This impacted the pandemic and really hampered safe working in care homes, which rely entirely on their workforce for all aspects of service delivery and serve those who are likely to have poorer outcomes.

Through March and April 2020, the ongoing plea from care home managers was to have on-site testing available. As their staff watched cases rise and their residents die before them, they became terrified of coming to work. Sadly, the mortality rates in staff increased multi-fold. Most staff who work in care homes belong to black and minority ethnic (BAME) populations who did not have higher case rates than average but had the highest mortality rates of all. We now know that there are both genetic and environmental (e.g., houses with multiple occupancy, multi-generational families, and deprivation) explanations for the higher mortality seen in these groups [7].

HPTs and LA public health teams hurriedly set up webinars for refresher training sessions for care home staff on PPE use, cleaning, donning and doffing of PPE, and appropriate IPC practices. These training sessions were well attended, but the main questions at the end of them were, “How can we get testing for our residents, and where can we get PPE”?

In the absence of adequate testing provisions and lack of PPE, managing and containing outbreaks was an uphill task. Given that ‘confirmation of diagnosis’ is step 1 in outbreak investigation, the frustration from this—both among care home frontline staff and the public health specialists giving advice on outbreak management—was beyond extreme. For two or three weeks, all existing testing capacity was diverted to those in acute care. Hence patients and staff in care homes could not get tested at all [6].

Two weeks into the first lockdown in 2020, possibly driven by research imperatives, provision of testing for care homes began slowly. Initially this was for a few care homes that were part of a study. It was then expanded and was provided from Pillar 1 (PHE laboratories). Soon, testing provision was expanded and was available directly through the Department of Health and Social Care (DHSC) [6].

Figure 3 shows the seven-day rolling rate of infections across age groups in London (with darker shades indicating higher rates). In the first wave, those over 80 were worst affected. Around the January–February 2021 wave, all age groups had high rates. Then in July 2021, it was mainly the younger age groups that had more mixing. In October to December 2021, it was younger age groups of 10–19-year-olds. Driven through transmission in school-age children, younger students starting university and the 40–49-year-olds (possibly parents of school aged children and those who stepped out to work) showed the highest number of cases. As we progressed into January 2022, older age groups—over 60—began to appear amongst those affected.

Fig. 3

Source London coronavirus response cell, weekly epidemiological summary

Seven-day rolling rate of COVID-19 by age group in London.

As the country was not prepared for the first wave of the pandemic, the stocks of personal protective equipment (PPE) rapidly ran out. Clearly, hospitals had to be prioritized. But this was at the cost of inadequate provision for care homes. For a few weeks in the beginning, provision of PPE for care homes was limited and there were similar constraints in hospitals and other healthcare settings [8]. That period was probably the worst few days of work at the frontline. PPE had to be hastily procured and several gaps were identified in the procurement process subsequently [9, 10].

Then PPE provision steadily improved but in the absence of proper infection prevention and control (IPC) training, even with PPE provision there were many cases and deaths. Efforts were made at the local level to provide IPC training to care home staff. But this was patchy and variable. A few webinars were organized to train care home staff from PHE and from the LA. This seemed like a drop in the ocean while a fire raged on, till finally clear guidance for working safely in care homes was published in April 2020 [11].

The LCRC gave outbreak management advice to care homes that contacted us. Each care home received a detailed risk assessment, a systematic discussion on the infection prevention and control measures adopted by them, and then testing was arranged for them or advised where there were local arrangements for tests. The process took about 90 min. There were 40–50 new outbreaks reported to the LCRC from care homes every day and staff worked 11-h shifts (from 9 am to 8 pm daily, including weekends) from February to December 2020.

COVID-19 underscored the neglect of social care. This sector did not receive the same priority as the national health system (NHS) in the initial response to the pandemic and over 15,000 care home residents died as a result [12]. The challenges facing social care have a long history and reflect the failure of politicians of all parties to agree on how care should be sustainably funded. Reforms have been proposed but have not been acted on [13].

Another contributory factor for this sorry situation was inadequate beds in hospitals which led to patients being discharged early to care homes. These patients were not tested and deemed ‘well’. Many of these patients had acquired COVID-19 in the hospital and would take it back to their care settings and spread it there [1]. Cases spread rapidly among the frail, non-immune residents and there were an enormous number of fatalities. This showed the ‘longstanding failure’ to give social care sufficient priority and the same attention as the NHS [1].

By May 2020, the Directors of Public Health were being encouraged to take a more proactive role in the management of COVID-19 outbreaks in the community. They published multi-faceted outbreak management plans that were scrutinized by peers to ensure their robustness and potential for implementation [14].

By June 2020, the national Test & Trace service was set up. There was also an expansion of testing for care from the Department of Health and Social Care (DHSC) to order via Pillar 2 testing routes that went to a network of private laboratories [6].

Care home outbreak management was strengthened once the guidance for their testing regimes was published (15). Most care homes had tight management regimes with daily lateral flow tests (LFTs), weekly PCR testing for staff, and monthly PCR testing for residents [11]. In an outbreak, there would be whole home testing on day 0 and on days 4 to 7 [15, 16]. As disease dynamics and asymptomatic carriage were understood, the role of appropriate PPE became clearly vital for prevention.

By November–December 2020, there was sufficient understanding of the work to be done and the IPC teams in the community had also begun providing a lot of support to care homes for their outbreaks, alongside LA public health teams. By this time, testing drills, PPE, and IPC practices were well known and so were well implemented and it seemed that there was some control on the spread of cases. However, the pandemic effort suffered another blow with the emergence of variants of the virus.

First the Kent or Alpha variant led to a very large increase in cases as the vaccine roll-out was just beginning when it emerged in November 2020. It began to spread quickly by mid-December, around the same time as infections surged [17]. But the real setback was from the Delta variant which was so highly infectious and against which the standard PPE measures were not effective [18]. Well controlled care homes saw their work fly out of the window in the face of the Delta variant. There were a large number of cases and deaths due to this variant in January and February 2021 [18].

In March 2021, lateral flow testing (LFT) was introduced into care homes—for their staff to do daily in case of an outbreak, but otherwise twice weekly [19]. This was another robust control measure, even though the occasional non-concurrence of the LFT with a PCR result was a cause for confusion. Thankfully these instances were few and far between.

As the pandemic rolled on, a degree of control evolved in care homes that was enhanced with the vaccination roll-out that had begun from end November 2020 and is now being supplemented with a 3rd (booster) dose. Control of spread in care homes has now been effectively achieved with high vaccination coverage of residents, mandatory vaccination for care workers, regular testing regimes, IPC, PPE use, and visitor restrictions to main caregivers with on-site LFTs [20]. Care homes have occasional outbreaks where a few staff and one or two residents are picked up on routine screening. We hope that outbreaks of the past with large numbers of cases and deaths will not recur.

From December 2021 to January 2022, Omicron variant cases began appearing in care homes. The reason for this was some laxity in controls in care homes, with the opening of care homes to visitors, allowing residents to leave the care home setting, and some partially vaccinated care workers. Even though there were strict rules around visiting and vaccinations, the highly infectious nature of the Omicron variant contributed to a surge in care homes. It was observed that most cases among residents and staff were asymptomatic and were picked up due to the ongoing regimes of regular asymptomatic testing. Fortunately, the surge in cases was not accompanied by a surge in hospital admissions due to the high rates of vaccination among care home residents and staff, with the latter being mandatory from November 2021.

Hospitals and Healthcare Settings

The lack of preparedness for the pandemic hit hospitals very badly. The management of COVID-19 cases was initially led by the NHS111 response and emergency department services. All cases were asked to call 111 and were triaged by the helpline operators. Some hospitals had a mobile unit that went out to assess and swab patients, while others had testing units set up in their parking or outside accident and emergency (A&E), to avoid cases entering the Emergency Department.

As the pressure on health services mounted from rapidly increasing COVID-19 cases, general practices collaborated by designating some surgeries for the assessment of patients with COVID-19. As the cases began to rise in March 2020 and hospitals began getting filled with patients, it was impossible to control patient flows. There was inadequate Intensive Treatment Unit (ITU) space and a shortage of ventilators. Figure 4 shows the number of cases who received care in UK hospitals throughout the pandemic period.

Fig. 4

Source Gov.UK coronavirus (COVID-19) in the UK

Impact of COVID-19 on healthcare in the UK from April 2020 to January 2022.

Due to inadequate testing provision, it was not known which COVID-19 patients were positive and which were not. The situation was even worse in relation to doctors and healthcare workers. Although the guidance initially said that contacts of a case need to isolate for 14 days, it soon became clear that if this was applied to hospitals, there would be a dire shortage of healthcare workers and running hospitals would be untenable. Hence, any healthcare workers who were not symptomatic were asked to continue working.

Hospitals had reduced their workload to a bare minimum initially. Nearly all the elective work was stopped. Only cancer care, emergency care, and maternity care continued during the first wave. Private hospitals secured large amounts of funding to help the NHS during the pandemic, but treated very few patients with COVID-19 and delivered fewer NHS-funded operations than usual [21].

There was a dire shortage of PPE and many clinical areas of hospitals had no PPE availability [8, 22]. In the beginning of the pandemic, there was insufficient evidence regarding the type of masks appropriate for a particular setting or procedure and there were inadequate supplies as well [9, 10]. Inadequate pandemic plans and equipment stockpile left frontline workers risking their own and their families’ lives to provide treatment and care [9, 10]. There were many cases among healthcare workers, particularly in the initial few months of the pandemic.

As evidence emerged on the proportion of asymptomatic carriage and the possibility of the virus having airborne transmission, PPE usage could be honed based on the type of clinical work being done [11]. Only at the end May 2020 did guidance for PPE use mandate the use of masks in both clinical and non-clinical areas. Initially, it had been available only for clinical areas [23].

In the summer of 2020, with the wider availability of testing, there was a bid to facilitate elective work and get patient waiting lists moving again [24]. There had been a considerable backlog over the months and separate pathways (green = low risk, amber = medium risk, and red = high risk) for patient flows evolved to facilitate elective work, underpinned by robust testing, pre-and post-procedure isolation rules, and effective infection prevention and control measures [24].

Among healthcare providers, certain groups were most affected. Mental health hospitals were among these. There were both patient and staff factors for this. The patients moved between the community and the hospitals but found it difficult to adhere to testing, use of PPE, and particularly isolation measures. This led to several prolonged outbreaks.

Staff factors that contributed to protracted outbreaks in these and other settings were a chronic shortage of staff, inadequate infection control expertise, lack of time to train staff in infection prevention and control (IPC), and an overall lack of understanding of IPC issues in relation to COVID-19. Mental health settings do not see very physically unwell patients. Hence, they had not previously focused on IPC or the prevention of outbreaks. Years of funding cuts had reduced IPC expertise in these settings to a bare minimum.

Once testing provision expanded, rules were put in place for testing of staff. All staff in healthcare settings were expected to do twice weekly LFTs and weekly PCR tests to work safely. The frequency of testing increased during outbreaks and exposure situations (where an infected patient or healthcare worker had exposed others) to daily LFTs and at least twice a week PCRs, and there was some flexibility in testing regimes with more frequent testing being done as needed.

Yet, humans are social animals, and there were a lot of incidents of staff exposures from each other in handovers, huddles, meetings, and training sessions in the early days of the pandemic. Occupational health teams in hospitals had not been trained in contact tracing, especially early on, and they struggled with identifying workplace contacts to test and isolate them quickly.

As cases began to decline, the NHS moved to the operationalization of elective work, with infection prevention and control risk assessments and extensive testing to address the backlog of 5.5 million referrals, alongside high vaccination coverage of healthcare staff, which too was made mandatory.

There was hope that the backlog of elective work would start being addressed. When the Omicron variant first emerged its potential impact on hospitalization was unclear. From mid-December 2021 hospital admissions began rising, but the demand for mechanical ventilation, which is a proxy indicator for severe illness, did not go up concurrently (Fig. 5). There were several weeks of crisis in the NHS due to lack of staff, due to very high rates of sickness absence amongst staff alongside high rates of hospital admissions for COVID-19 and other reasons. There were further constraints as patients found to have the infection and their contacts had to be isolated for a full 14 days, and bays and wards with cases had to be closed, thus adding further pressure on an already stretched system.

Fig. 5

Source Gov.UK coronavirus (COVID-19) in the UK

Impact of COVID-19 on healthcare—Patients in mechanical ventilation beds from April 2020 to January 2022.

Unforeseen Health Consequences

There were unforeseen health consequences of the pandemic too, few of which need to be highlighted.

An unfortunate consequence of the pandemic was its enormous impact on mental health. The mental health effects of the pandemic were not the same for everyone. Those whose mental health was impacted by the pandemic included unemployed people, those with existing long-term physical or mental health conditions, women, people from minority ethnic communities, LGBTQ people, and older people who are isolated or digitally excluded [25].

Young people were disproportionately affected by the pandemic. They faced challenges attaining education and future opportunities, work and unemployment, emotional wellbeing, housing, and relationships—with implications for the whole generation’s future health and wellbeing [26].

Another impact of the pandemic was on immunization coverage. With prolonged periods of face-to-face care suspended, immunization clinics were disrupted. Messaging about staying at home possibly overwhelmed the message that the routine immunization program was to continue [27].

Long COVID is an increasingly widespread, multi-system condition which can be highly debilitating. Anyone of any age, including children, can experience long COVID, regardless of the severity of their initial illness [28]. The term ‘Long COVID’ includes both ongoing symptomatic COVID-19 (5–12 weeks after onset) and the post-COVID-19 syndrome (12 weeks or more) [28]. It is associated with a wide range of different symptoms that affect physical, psychological, and cognitive health. A recent systematic review revealed that an estimated 80% of patients infected with SARS-CoV-2 developed one or more long-term symptoms. The five most common symptoms identified were fatigue (58%), headache (44%), attention disorder (27%), hair loss (25%), and dyspnoea (24%) [29]. It can also influence the quality of life and ability to work or attend education [28]. £100 million of government funding have been allocated for managing Long COVID in hospitals, primary care facilities, and NHS England has published a plan to ensure that a systematic approach is implemented [28].

Schools

Keeping schools open and continuation of lessons was always a priority. There is robust evidence that extended time without face-to-face teaching is detrimental for cognitive, social, emotional, and academic development, learning, and long-term prospects [30]. The government policy objective for children and young people during the COVID-19 pandemic was to maximize school attendance and minimize disruption of lessons [31].

Earlier in the pandemic, before the first lockdown, the schools’ guidance involved basic contact tracing around a case. There was hardly any community testing available. Following a case linked with a school, all school contacts were identified and asked to isolate for 14 days. In December 2020, the isolation period was shortened to 10 days [31].

It is important to note here that in all table-top exercises where pandemic flu plans were tested, significant consideration was given to schools and their closure. It had always been acknowledged that the shutting of schools would impact not only the economy, but also key workers’ ability to work, and so it was considered a last resort step.

However, schools were suddenly closed on 18th March before the first lockdown. And this closure was then kept in place for the rest of the academic year in 2020. To address the key worker issue, children of key workers were allocated school places at a local authority school. This was a pragmatic step that helped NHS and other key workers stay at work.

While key workers’ children could be kept in school, most other families did not have this access and worked on a remote learning program. For homes where parents were not literate or IT savvy and homes where access to technology and computers was limited, remote learning for children was not straightforward at all.

Over the last several decades, the lives of families with children have been accustomed to run along the school year. Parents drop children to school, then go to work. Children where both parents work often attend breakfast clubs and after-school clubs. Furthermore, some families depend on the meals provided for their children at school. None of these were now available and the children were at home all day with parents struggling to balance their study needs alongside their own workday which too was now at home. For families with limited resources or space or both, this was very hard to implement.

By the summer of 2020, with lockdown taking effect, the number of cases began falling and the number of deaths also dropped. Through the summer there was a drop in cases, and then the government started its ‘eat out to help out’ scheme in August 2020 [32]. It encouraged people to eat out and they were given discounts for doing this. This was very popular, especially with young people and families fighting ennui, but all this social mixing led to a surge in cases.

The Test & Trace Program had been put in place on May 28, 2020. But the number of contacts from some of these social events and the snow-balling effect of cases was often beyond any control offered by the contact tracing and isolation done by Test & Trace.

When the schools reopened in September 2020, there were very tight operational plans with ‘bubbles’ to prevent inter-mixing of pupils, on-site cleaning, limited movements between pupil groups, cancellation of school fixtures, one-way systems at school drop off and pick up points, and strict isolation rules for cases and contacts [33]. Certain lessons like drama and singing were suspended. Mask wearing in common areas, seating plans in class rooms, and social distancing were in place, alongside schools being responsible for intense contact tracing [33]. The schools followed the guidance well and had a robust process for contact tracing and isolation which helped prevent the spread of cases.

The implementation of social distancing and bubbles in boarding schools where pupils share bathrooms, common rooms, and dining halls was really difficult. A key constraint was the actual numbers of bathrooms and toilets available and the difficulty of isolating young people who were already living away from their families and homes.

Often the bubble sizes were a whole class rather than a sub-group of it, or a whole year group, and that was difficult because it entailed large numbers of pupils being isolated for a single case. Due to there being larger bubbles, often a much wider cohort needed to isolate than was strictly necessary.

The imperative was for schools to carry on with their plans till the Christmas holidays. As Christmas 2020 approached, the number of cases were on the rise, and school staff were exhausted from the endless contact tracing and isolation protocols that they had to implement. Often irate parents threatened legal action if their ward was found to be the contact of a case on more than one occasion or was asked to isolate soon after s/he had just finished one isolation period.

Remote learning was hard as explained earlier and even the ‘blended learning’ approach of a bit of onsite teaching and some remote teaching was getting exhausting. From the Coronavirus Response Cell, we had a checklist that we would go through to do a risk assessment with the school to ensure that all control measures were in place. This took about 30 min to complete and covered minute details like the size of bubbles, class sizes, number of cases and contacts as well as cleaning regimes and ventilation provision.

As Christmas 2020 approached and cases were on a relentless rise, some schools that had rising numbers of cases closed a few days earlier than scheduled. There was some polarity on this issue that led to a war of words between politicians and the teachers’ unions. The London mayor called for schools to close early [34].

Schools did not then re-open after Christmas. They remained shut for over eight weeks of the new year. On March 8, 2021, schools re-opened, with remote learning in place, and all restrictions as previously, but with larger bubbles and twice weekly lateral flow tests (LFTs) for secondary school pupils. The systems of controls remained in place. Each time there was a case, contact tracing and the isolation involved a smaller, clearly defined group of pupils based on social groups and seating plans, rather than the whole class [33]. This was far more practicable and evidence-based than the previous approach of taking out the whole bubble.

Then the new variants emerged. First the Alpha variant that had led to the inexplicable surge in cases in November and December, then the Delta variant which defied nearly all measures of infection prevention and led to relentlessly rising cases. There were other variants too that emerged.

Schools that had cases of the variant were offered ‘surge’ or enhanced testing at or near their school site through mobile testing units (MTUs). Boroughs had to do enhanced testing when there were cases of variants in a certain geographic area. This was an intensive, door-to-door activity, publicizing, on-site testing with mobile testing units, testing of sewage, and it went on for two weeks each time.

With enormous grit, head teachers managed to run schools till the summer holidays started. There were plans for summer school to make up for the loss of learning but there did not seem to be much appetite for this.

For the first time since the Second World War, examinations for General Certificate of Secondary Education (GCSE) and A level students were cancelled in 2020. The same step was taken the following year [35]. Examinations for GCSE and A levels were cancelled for two consecutive years and two cohorts of pupils going to university in the UK (in 2020 and 2021, respectively) did not take school-leaving examinations at all.

Another summer went by in 2021 with no travel permitted and many restrictions on activities. It was now 18 months since restrictions had been in place and most children had got no exposure to normal respiratory bugs. Hence, severe winter pressures were predicted in end-2021 with a surge of admissions due to respiratory infections.

The Department for Education’s (DfE’s) imperative was to keep pupils in school for their attainment and wellbeing, while the public health objective was to keep schools and communities safe [36]. While it is possible to have a shared agenda on this, education policy-makers decided that there would be no social distancing, no bubbles, no extra cleaning, and no mask wearing when schools re-opened in September 2021. Moreover, contact tracing would be by T&T and would no longer be the school’s responsibility. There were extensive discussions about the need for normalcy versus the need for stopping the spread of cases.

The LCRC schools resource pack was revised innumerable times—made first for September 2020, then for spring 2021, and then for Autumn 2021, based on guidance updates. The need to keep kids in education was the overriding priority. We struggled to keep the number of cases in control as the new school year began in 2021 amid rising cases and no controls. Vaccination coverage was expanded to include 12–15-year-old too, and self-isolation rules were lifted for fully vaccinated people and for those under the age of 18 years.

A contingency framework was part of the guidance for operational management of schools—with a step-wise increase in control measures when there was a rising tide of cases [33]. These ranged from steps like extra cleaning, checking ventilation, and communicating with parents (green measures) to creating bubbles and wearing masks and stopping of assemblies and fixtures (amber measures). And finally, to actual exclusion of a very small group of pupils as a last resort and daily on-site testing (red measures) [33].

By the third week of October 2021 the number of cases in young people aged 10–19 was at a historic high, and remained so till mid-December [37]. Healthcare professionals questioned whether the current rates of COVID-19 infection in school children were acceptable when we have emerging evidence of the virus's lingering health effects [38]. The laxity of approach to controls in the school setting was criticized as a form of ‘childism’ and was deemed unfair [38].

Due to the surge in cases in December 2022 due to the Omicron variant, there were concerns that children could take the infection to their homes. Secondary schools will now return after the Christmas 2021 break with provision for onsite testing and twice a week lateral flow testing for staff and students. Pupils in secondary schools will wear face coverings during lessons from January 2022. Staff in all schools will also wear face coverings in communal areas as previously, and there will be emphasis on increased ventilation and good hygiene [39].

Workplaces

Workplaces—particularly factories and smaller offices, were a hot hub of transmission due to lack of ventilation, space, and understanding. Several initial cases of COVID-19 could be traced back to conferences attended by employees at a large multi-national sports company and another was related to transport companies.

Businesses have a legal duty to manage risks to those affected by their business. The way to do this was to carry out a health and safety risk assessment, including the risk of COVID-19, and to take reasonable steps to mitigate the risks identified. Businesses were expected to use the published guidance to consider the risk within their premises and decide which mitigations were appropriate to adopt [40].

There was a lot of guidance, yet we found that workplaces lacked basic understanding of the steps entailed in a risk assessment, on how to identify contacts, and what information to give to cases and contacts where there was a case or an outbreak. There was an ongoing tussle between their need for business continuity and the necessity of following rules to stop the spread of cases.

The gov.uk website guidance was difficult to trawl through as well so the LCRC created a workplace resource pack that contained a framework for workplace risk assessments and suggested mitigations. It also had resources for communications with both cases and contacts. This was very well received. It ensured that quality advice was given consistently to all businesses that had outbreaks.

In the long term, it was expected that businesses will need to take fewer precautions to manage the risk of COVID-19 and high vaccination rates will mitigate the spread and severity of cases [41]. However, with the emergence of the Omicron variant in end-November 2022, England moved to Plan B. Those who could work at home were asked to do so. Mask wearing when indoors was re-instated and checks for COVID vaccination status were instituted in certain settings e.g. theatres, sports fixtures, and health and care settings [41].

Prisons

Prisons reflected the number and pattern of cases occurring in the community. They were severely affected during the first wave of the pandemic in March 2020. Prison outbreaks that occurred from end-March had large numbers of cases and high mortality—both in residents and in staff. The outbreaks were difficult to contain due to a lack of testing capacity and PPE, and a lack of understanding of infection control principles, compounded by an inadequate infrastructure (in 100+ year old prisons) for contact tracing and isolation.

The lessons from the first wave were learnt and clear pathways and processes were defined for the management of cases of COVID-19 in prisons after the first wave. Yet, it was apparent that COVID-19 exacerbated existing health and social inequalities that usually affect people who are in contact with the criminal justice system.

There was Royal College of General Practitioners (RCGP) guidance which was aimed at ensuring equivalence of healthcare provided in this setting [42]. PHE (now UKHSA) guidance for management of outbreaks, yet outbreak control measures, when necessary, were far tougher to implement in this setting [43].

The main challenges faced were the mobility of detainees and staff and the inability to isolate prisoners effectively due to lack of space and shortage of staff. The ageing buildings were less amenable to adaptation and the already stretched staff were further deployed to unfamiliar areas of work (such as testing large numbers of prisoners quickly) in an outbreak. Despite deployment of a rapid testing team when there was a case or cluster detected and, repetition of the outbreak scenarios in these settings, it was difficult to embed key controls and processes.

There were also issues of delayed reporting and a considerable struggle in obtaining data on cases and their movements. When an area needed to be ‘locked down’ within the prison following two or more cases, it was difficult to implement this fully due to non-adherence to lockdown rules by prisoners and a chronic lack of sufficient staff to implement controls. Other ongoing issues were non-adherence to social distancing and vaccination for both staff and prisoners. There was always a struggle between regime continuation for the prisoners versus further isolation and imposing restrictions on this group of people whose freedom had already been taken away.

Asylum Seekers

Asylum seekers are among the most vulnerable groups in the UK with no money and huge uncertainty about their future [44]. There are language barriers and underlying physical and mental health concerns in this particularly vulnerable group [44, 45]. Their numbers fluctuate weekly and seasonally as larger numbers of asylum seekers crossed the English Channel during good weather [45].

Initial accommodation or contingency hotels are specifically identified for housing destitute asylum seekers in the first phase of the asylum process [45]. The accommodation provider for London is a private company that is commissioned by the Home Office [45].

Accommodation can be in single or multiple occupancy rooms (either family rooms or less usually single person dormitory style sharing rooms) depending on the setting; some may have communal kitchens, bathrooms, and living areas. Some have en-suite bathrooms and food delivered to the rooms. The accommodations are intended to be short-term (usually around 21 days), rapid turnover settings. However due to the pandemic and shortage of onward accommodation, service users can stay on at these accommodations for many months.

A specialist team was commissioned to provide COVID-19 testing in asylum seeker accommodations and a separate contingency hotel was identified for those who tested positive to be moved to. Asylum seeker cases and outbreaks were a challenge due to lack of expertise in staff on the frontline and the complication of explaining isolation and movement restrictions (that often rapidly change as well) to affected cases and contacts with language and cultural barriers alongside existing constraints in the movement options and type of accommodation available for this group.

Testing

Rapid and reliable testing underpins the management of any infectious disease outbreak. Public Health England (now UKHSA) worked with key international partners to design and deliver the first UK COVID-19 diagnostic test, rolling it out faster than any other novel test in recent history [6].

There were challenges as the UK started from a lower base because it did not have a major diagnostics manufacturing industry to call on. With cases rising worldwide, there was also huge concurrent international demand for crucial testing materials like kits, swabs, and chemical reagents [46].

Given this finite capacity it was felt that priorities needed to be defined. Therefore, nearly all the testing capacity was concentrated in hospitals so that seriously ill patients could be diagnosed quickly. Community testing ceased on March 12, 2020 [46]. Any tests used had to be quality assured. This process was arduous and time-consuming in the early stages of the pandemic.

Aiming for testing provision to be universal, a phased approach was adopted—starting with hospitalized patients who needed the test, expanding to NHS workers and their families, then other critical key workers, and then expanding to the wider community over time. A five-pillar testing strategy evolved [6]. Figure 6 gives an overview of the testing provisions in the UK.

Fig. 6

Source Gov.UK coronavirus (COVID-19) in the UK

Testing in UK from May 2020 to January 2022.

Figure 7 describes the breakdown of testing provision by each of the pillars. The first pillar was boosting swab testing—testing to find out if you have the virus—by PHE and NHS laboratories for patients and frontline workers in the NHS [6]. The second pillar was the creation of brand-new swab testing capacity delivered by commercial partners to build a network of new laboratories and testing sites across the country [6]. The third pillar was antibody tests designed to detect if people have had the virus and are now immune [6]. This was found to be less useful in the longer term. The fourth pillar was surveillance, using a high accuracy antibody test operated by Public Health England at their Porton Down science campus. These tests were aimed at strengthening scientific understanding on measures that need to be implemented to tackle the pandemic [6]. Later, it came to light that the 3.5 million antibody tests that had been invested in were not particularly useful. The fifth pillar was to build a large diagnostics industry in a short space of time [6].

Fig. 7

Source Gov.UK coronavirus (COVID-19) in the UK

Testing provision by pillar from April 2020 to January 2022.

There were many criticisms of the testing program [46, 47]. It was poorly coordinated due to the central controls. Up-scaling was delayed. The ceasing of community testing gave mixed messages to the public [46]. During the initial two months of the pandemic, testing capacity was very limited and this was gradually expanded [48].

The NHS testing capacity through its Test & Trace network now includes more than 1,000 sites, including 90 drive-through sites, 514 walk-through sites, 7 lighthouse laboratories, home testing and satellite kits, and a large number of mobile units [49].

Local Authority Public Health Response

Directors of Public Health (DsPH) and their teams are a fundamental part of a wider public health system in the UK. Public Health (PH) teams are based in local authorities. They also play a significant role at regional level, as a part of the local resilience and health protection functions. They are supported in these roles by national bodies (particularly Public Health England – now UKHSA) and they work with key partners including the NHS and the voluntary sector. They are considered appropriately placed to effectively protect and improve the health of their local populations [14]. However, the public health system particularly, and local government overall, had been under persistent financial pressure for several years prior to the pandemic. And trends in population health and inequalities were unfavorable [3].

Local PH teams were well aware that a pandemic could arise and what their response would entail, but there had not been any precedent for the scale at which cases and fatalities rose from COVID-19. This happened due to three main factors: the novelty of the virus, the absence of a vaccine, and insufficient knowledge of appropriate medical management of cases in the early stages [14].

These factors were compounded by the absence of reliable testing, as community testing provision was taken away to prioritize hospitalized cases in the initial stages [6]. Furthermore, the organization of the NHS in England was not fit for the purpose. The separation of commissioner and provider roles, the fragmentation of provision between NHS hospitals, and the legacy of over 30 years of market-oriented reforms made it difficult to plan for the needs of whole populations [16].

Critical factors that explain differences in the worldwide experience of COVID-19 are about how the response was managed—such as adequate testing provision, appropriate timing of lockdown measures, and effective contact tracing [50]. Additionally in the UK, due to the quality of the housing stock and houses of multiple occupation, working conditions, and social and economic factors with pre-existing inequalities, financially disadvantaged groups were far more vulnerable to the pandemic [3, 51].

The local authority PH teams provided support for outbreak management in care homes, schools, prisons, homeless hostels, and asylum seekers accommodation etc. based on their patch. In addition, they provided financial support for those who needed to isolate and supported local testing sites, and targeted testing initiatives when needed. The PH team devised and delivered local communications to promote preventive messages and employed a range of approaches for community engagement. All of this was underpinned by close collaborative working at a local level to ensure that strong COVID-19 controls were in place [14].

When the national COVID-19 vaccination program began, it relied heavily on the local PH teams and their community networks [14]. Quite early on it was clear that not everyone was enthusiastic about getting vaccinated. Several community groups were unsure about the vaccine’s usefulness and some people found it complicated to access vaccinations [52]. Directors of Public Health did a lot of work with local champions and community representatives alongside formal organizations such as the NHS, to familiarize themselves with the concerns raised and the barriers people faced to obtaining vaccines. They worked hard to address the barriers and formulated appropriate messages to promote high vaccine uptake [14].

Test & Trace

The Test & Trace system began on May 28, 2020. It identified contacts of a confirmed case and advised them to be isolated. Any situation where there was a case in a defined setting e.g. in a care home, work place, homeless hostel or school etc., was escalated for follow-up by the LCRC, as these would need more expert public health advice. The LCRC had many new ‘Tier-1 Test & Trace staff’ who only did COVID-19 contact tracing in these settings.

The system was not deemed fit for the purpose from the get-go [53]. It was felt that rather than a centralized system, there should be local Test & Trace teams led by the local authority- based public health teams who should be given additional resources to operate an area-specific Test and Trace system.

As per a critical report from the House of Commons Public Accounts Committee, the “NHS Test & Trace was one of the most expensive health programs delivered during the pandemic with an allocation of an eye watering £37 billion over two years, although it underspent by £8.7 billion in its first year. It focused on delivering programs but its outcomes were muddled and a number of its professed aims were overstated or not achieved” [54].

The report from the Commons Public Accounts Committee said that after the service was set up, there were still two national lockdowns and significant case numbers [54]. Hence, its input was questionable. Although named NHS Test & Trace, the system was largely run by two private companies—Serco and Sitele [55]. It was widely criticized for its use of expensive consultancy companies, its poor performance in reaching people who tested positive and their contacts in a timely fashion, and for its centralized rather than localized approach [55].

In 2020–21, NHS paid £3.1 billion to secure the laboratory capacity to process PCR tests and £911 m for contact tracing, mainly in call centers. However, it only used a minority of the laboratory and contact tracing call center capacity it paid for. Even at times when the demand for testing was high, few people were getting test results back within 24 h [55].

The T&T system is now part of the UKHSA. It was asked to detail how it will reduce its dependency on consultants and to explain the role of the local government in the future operating mode [54]. Local authorities played a vital and crucial role in public health, including in the response to COVID-19. NHST&T was earlier criticized for not engaging properly with important stakeholders, including local bodies [54]. NHST&T has made progress in its relationship with local authorities and the UKHSA has committed to co-designing its new operating model with local stakeholders [54].

Variants

The emergence of variants was a nasty surprise. First the Alpha variant that had led to the inexplicable surge in cases in November and December 2020. And then the Delta variant which defied nearly all measures of infection prevention and led to many cases. There were other variants too that emerged that were graded as Variants Of Concern (VOC) or Variant Under Investigation (VUI) [56].

Each variant case was followed up with a detailed questionnaire to ascertain both how it may have been acquired and how it may have spread further, through taking a history that entailed activities from 14 days before and after the onset of symptoms or the case’s test date if asymptomatic. This was a time consuming and resource-intensive task. There was a stage when the cluster sizes were 50 to 90 cases and the HPT had to follow-up on all the linked cases and contacts.

Boroughs that had a cluster of variant cases in a geographic area had to do the enhanced testing in and around a defined perimeter of those cases. This was a rigorous door-to-door activity, publicizing, on-site testing with mobile testing units, including testing of sewage. Each surge testing initiative ran for at least two weeks.

Then the Omicron variant emerged which was identified by scientists in South Africa. On November 26, 2021, WHO designated the variant B.1.1.529 a Variant of Concern and was named Omicron [57]. The latest variant technical briefing suggests that Omicron continues to grow rapidly in all regions of England as measured by confirmed cases and S gene target failure (SGTF). Initial information suggested that Omicron cases had lower hospitalization and mortality than the Delta variant [58].

However, HPTs followed up the first few hundred cases and their contacts with detailed questionnaires that covered the fortnight before and after the onset of the case, to build a picture of its spread and transmissibility. All household contacts of confirmed cases were initially asked to isolate and have a PCR test done. Initially, even fully vaccinated household contacts of confirmed Omicron cases were asked to remain in isolation which was predicted to have a wider impact on essential services [59].

Studies of contacts showed that Omicron transmitted far more effectively than Delta. The UK Health Security Agency (UKHSA) had estimated that if Omicron continues to grow at the present rate, the variant will become the dominant strain by mid-December [58]. Omicron is the dominant strain in the UK now.

Further studies confirmed the lower risk of hospitalization from Omicron relative to the Delta variant. There was also a substantial reduction in risk of hospitalization in Omicron cases for those who had received three doses of the vaccine compared to those who were unvaccinated [60].

Vaccination

The UK was one of the first countries in the world to roll out a vaccination program—on December 8, 2020, when the first doses of the Pfizer vaccine began to be given. In the UK, the Joint Committee on Vaccinations and Immunizations (JCVI) advises UK health departments on immunization [61].

The vaccination roll-out was the most successful component of the COVID-19 response in the UK. A specially appointed vaccines minister led the delivery of the vaccination program, thus demonstrating that political will is a key factor in successful public health initiatives. The vaccine delivery infrastructure entailed a range of sites from pop-up clinics in pharmacies to large stadiums and mobile vaccination buses. There was enormous investment in freezers for the storage of the vaccines and rapid training sessions were organized for having fully trained staff to deliver one of the larges vaccination campaigns in history.

At the time of writing, over 133 million doses of the vaccine have been given with a coverage of 90.3% of the eligible population for the first dose, 82.8% for the second dose, and 61.3% for the third (booster) dose (Fig. 8) [62].

Fig. 8

Source Gov.UK coronavirus (COVID-19) in the UK

Vaccination in UK.

The vaccination program is increasingly the main component of UK’s COVID-19 control strategy, particularly as emphasis shifts from non-pharmaceutical interventions (NPIs – e.g., physical distancing measures, ensuring adequate ventilation in closed spaces, the maintenance of hand and respiratory hygiene measures, the appropriate use of face masks, and staying home when ill) which are deemed by many as restrictive and infringements on individual freedoms.

The program began with two doses of the vaccine given three weeks apart, and very early on the JCVI recommended increasing the interval between the two doses to 12 weeks. Although this approach was heavily criticized at the time, it turned out to be a wise decision that enabled larger number of people to get initial protection quickly.

The target groups for vaccination are reviewed all the time and are expanding. From October 2021 onwards, 12–15-year-olds were also given a single dose of the vaccine. Currently, everyone over 18 years of age is recommended to have a third (booster) dose of the vaccine. Estimates of the efficacy of the vaccine against the Omicron variant are still emerging. Early evidence suggests that the booster dose is likely to prevent a significant proportion (about 80%) of serious illness [63].

Epilogue

By end-November 2021, more than 160,000 people died in England with COVID-19 being stated on their death certificate [64]. The way a COVID-related death is defined in England is different from the definitions used in other parts of the world. Hence data may not be entirely comparable.

When I look back at what it felt like to be in the pandemic, some things come to mind immediately. A lack of basic civic sense and humanity showed up in behaviors that surfaced very early on. Fights over loo rolls, shelves emptied of hand gel and soap, and food-hoarding beyond belief. This continued till supermarkets began imposing restrictions on the number of key items that people could buy.

Following an impassioned plea on social media of an NHS worker who couldn’t get any fresh vegetables or fruit at the local supermarket after a long day at work, supermarkets created special times when NHS and frontline workers could shop [65]. They put in place one-way systems, limited on-site access, and a huge range of home delivery slots. Those who were on the list of ‘shielded’ (clinically extremely vulnerable) patients were prioritized for deliveries.

The pandemic has had an unequal impact on society in terms of mortality, loss of income, mental health, and other issues [14]. In many places, the pandemic worsened challenges and inequalities that people had already been experiencing [3]. The substantial ‘backlog’ in health and care services will entail major investment and work for the next 3–5 years at least [14].

Another serious consequence was rising unemployment and ensuing or intensified financial insecurity. The social impact of the pandemic was also seen in the large increase in people claiming Universal Credit since the beginning of the pandemic and a markedly higher dependence on foodbanks [66].

The disruption to children and young people’s education for extended periods during 2020 and 2021 will inescapably impact on their future learning and employment prospects [14]. There was also a rise in reported cases of domestic abuse during lockdowns, sometimes resulting in children being taken into care [67]. There is a cohort of babies born in late 2019 who have barely been out of their houses and have not had any human interaction outside their families for nearly 18 months of their lives—till July 2021. It would be interesting to chart their development.

Every Thursday at 6 PM for many months, people stood outside their houses and clapped for healthcare workers. This was poignant and appropriate at the time. And then it was heart-breaking when ministers did not approve higher salaries for frontline healthcare workers and other key workers. Those who work in the health and care sectors despite their fears and the enormous difficulties, felt undermined and unappreciated.

In a global infectious disease crisis, some change is inevitable. Many countries used emergency legislation to extend the power and responsibilities of specialist public health organizations and boosted resource allocation to existing structures to upscale their ability to respond (68). England did not adopt this approach. Instead, it abolished its national public health body (Public Health England) in August 2020 [68].

England’s approach also included choosing commercial sector companies to design, manage, and provide critical public health functions during the pandemic [8, 53]. Despite repeated requests, there were refusals to provide adequate resources to the Directors of Public Health and their teams based in local government across England [68].

Finally, key ministers and government advisors set poor examples of behavior. It began with the Chief Adviser to the Prime Minister, who broke lockdown rules when he travelled out of London with his family in April 2020 [69]. The next year in June 2021, the Health Secretary resigned after it was shown that he had breached COVID-19 social distancing restrictions with an aide in his Whitehall office [70, 71]. And in December 2021, news leaked of Christmas parties held at the Prime Minister’s office in December 2020 when there were strict restrictions on social mixing [72]. The mismatch between ministers’ words and behavior was probably one of the most difficult aspects for people living through the pandemic.