England's Covid-19 frontlines: the race to prevent local lockdowns

At the end of last week, the race was on. Blackburn with Darwen council was identified as an area of “concern” by Public Health England.

With the number of infections rising,an emergency meeting of the Local Resilience Forum, which brings together NHS, councils across Lancashire, emergency services and other agencies, was called last Thursday to devise a plan.

After the meeting, Blackburn’s public health director, Profe Dominic Harrison, told the Guardian he was determined to stop the outbreak without resorting to a Leicester-style lockdown. “A lockdown of the whole borough would be entirely inappropriate and wouldn’t be a solution to the problem we’ve got,” he said.

Harrison explained that analysis of data from May showed 65% of all confirmed cases in the borough were among those identified as black, Asian and minority ethnic (BAME). The area has a large Indian and Pakistani population. By mapping cases to postcodes, his team realised that many involved two adults, several children, and often an older person, all living as a group.

“What we are seeing there is household transmission in multigenerational households in BAME communities. And in lower income areas, areas of smaller terraced housing.”

Harrison believes the virus is spreading through daily trips to cramped shops and through large family gatherings. He is working with imams and community leaders to make videos and deliver leaflets to homes.

While government guidance allows two families to gather under one roof, the area has asked its residents to be more cautious, with no more than two people from a second family joining a gathering. Army swabbing units are being sent to the borough, one of which will tour the busiest shopping streets. But Harrison is in a difficult situation. More testing will mean more positive cases.

“It’s quite likely the government is going to say: ‘You aren’t doing a good job in your area, we are going to have to intervene.’ So we are briefing them.”

Harrison has asked the Department of Health and Social Care what the trigger might be. By Tuesday he had yet to receive a reply.

Across the UK, while reported infections are trending down, local outbreaks are emerging. With pubs, restaurants, gyms, pools and hairdressers open, the risk of transmission has increased. There are patterns – those most at risk are living in poverty, in crowded housing, and in areas with traditionally poor health and large minority ethnic communities.

Until a vaccine is found, the work done by councils will be critical to preventing local lockdowns of the kind imposed on Leicester.

Last week, the Guardian travelled to Liverpool and Lancashire, two areas where infection hotspots are emerging, to watch health directors and their teams at work. The pressure on this frontline is intense; there are concerns about a lack of money, and a lack of data that makes people feel they could be flying blind at a time when they need to be extra vigilant.

It is Friday evening and Matt Ashton is preparing for another busy weekend. After spotting a spike in coronavirus infections to the south of Liverpool, the city’s health chief has asked for the army to send in a mobile testing unit.

Like his father before him, Ashton is director of public health for the city in which he was raised. He moved over from nearby Sefton on 1 April – mid-pandemic. Before Covid-19, most people had no idea what he did for a living, but perceptions have changed. “Suddenly we’re important again,” he says.

Liverpool’s weekly tally of residents testing positive has been ticking up, from about 20 in mid-June to more than 50 last week. For six consecutive days, it was on a red list of councils where new cases are exceeding government forecasts. The latest data showed a dip, thankfully, but nobody is being complacent.

Ashton’s office was on high alert after the “super Saturday” pub reopening. “We called it ‘steady Saturday’,” he says. “We tried to rebrand it.”

In the run-up to the weekend, he had persuaded Liverpool football club manager Jürgen Klopp to let him open a pre-match press conference. The man from the council urged fans to watch the Aston Villa game from home. Everyone was keen to avoid a repeat of the celebrations that had seen the streets filled with raucous crowds celebrating the club’s Premier League title.

Liverpool is England’s fourth largest city and its public health director’s budget has fallen by a quarter in real terms since 2013, when a reorganisation led to the role being transferred from a national agency into local councils.

There have been two tranches of extra cash from the chancellor during the pandemic, but Ashton’s team has still been asked to find a further £2m in savings out of an annual spend of £45m.

Over the last month, the council has been managing an average of nine outbreaks at any one time – outbreaks are defined as two or more cases in a single setting, and Liverpool has had them in hospitals, prisons, and now schools. Classes at three separate schools have been asked to quarantine. Entire families cannot leave their homes for two weeks, and food is being brought to them.

On top of the outbreaks the team is keeping an eye on incidents – these can be just one case, but in a complex setting such as a care home. An estimated 80% of the city’s homes for the elderly have experienced some level of infection and 135 residents with the disease have died. In Liverpool, people are more likely to succumb to the virus than the national average, because underlying health is worse.

In preparation for the second wave, Ashton’s team are busy mapping high risk workplaces – large warehouses, factories and food processing plants. So far there have been no work-related outbreaks reported, but this may be because the data needed to spot them just has not been available. Public Health England (PHE), the national agency responsible for disease control, only began sending out postcode level details on new positive cases at the end of June.

Councils are still clamouring for better information. They want new cases by household, not just by postcode. And they need it daily – ideally in real time. At present, the postcode data arrives once a week, so the information is often seven days old. Details on workplace and ethnicity are often missing.

“If we have full access to data, we are not just waiting for outbreaks to occur, we are anticipating when and where outbreaks will occur,” says Ashton.

From the beginning, there has been a reluctance to share information from the centre. PHE originally refused to release forecasts. This left councils struggling to plan for morgue capacity, extra hospital beds, and discharges into care homes.

Ashton turned to the University of Liverpool for help. A team there is now preparing a health information dashboard. It is part of a wider project to create a civic data cooperative.

“We are trying to drag content back so it’s a public asset,” says Paul Brant, Liverpool’s cabinet member for health. “We don’t want it all given over to Google for their own personal gain. The benefits should flow back to the public and it shouldn’t be used against them.”

The new postcode data has already allowed Ashton to spot a spike in cases among young people in the suburb of Woolton, where there have been reports of parties in the woods and large gatherings on street corners. On Saturday, army “swabbers” were sent in so that residents could get checked without having to book an appointment.

“The fact we’ve got a mobile testing van popping up might make people realise how serious this is and help alter behaviour,” he says. Plans are already under way to contract private companies instead of soldiers to man the mobile units.

For Sakthi Karunanithi, more local control cannot come too soon. Lancashire county council’s public health director wants to offer testing to people living on the margins, to drug users, homeless shelters, domestic abuse refuges and probation hostels.

He is battling on two fronts – residual levels of the disease in some areas, and lockdown fatigue causing new flare-ups. “The message is getting lost. We need to rethink about how we reach people – without unduly affecting what is already a scarred economy.”

With a population of 1.2 million, the county is England’s poorest, demographically. Local jobs are heavily dependent on the aerospace industry, which has gone into free-fall since the world’s airlines were grounded. Engine maker Rolls Royce has already announced redundancies in the area.

On Thursday, the Lancashire team gather for a zoom call. It is a blizzard of statistics. In the last 24 hours, they have been notified about a record five new complex cases. In Pendle, there is a problem at an engineering company where six staff are ill. An outbreak at another engineering firm and one at a call centre are now under control. Overall, the team are dealing with 22 incidents and outbreaks at hospitals, schools, care homes and workplaces.

Each new complex case requires a file. A team is assembled, with a public health consultant from the council, staff from PHE, environmental health, and the workplace manager. In a care home, a case can only be closed 28 days after the last positive test.

According to protocols, councils should be notified of complex cases by PHE, but more often than not the information comes first through local networks. Lancashire has a team which rings every care home manager daily – there are 425 in the county.

Karunanithi worries about gaps in the contact tracing system too. The national helpline, billed as “world-beating” by the prime minister, has a team of 25,000 call handlers, but it is missing cases. The engineering firm in Pendle appears not to have been contacted by contact tracers or by PHE, for example. Lancashire is doubling its infection prevention team so that it can fill the gaps.

For its part, PHE says it is keeping pace. It has added 380 staff to its health protection and field services teams since the start of the outbreak, with 870 people now working in those areas.

“We are committed to transparency and are continuing to make increasing amounts of data available to local authorities,” says PHE’s medical director, Yvonne Doyle. “Every local outbreak we are aware of has been investigated.”

In theory, the national helpline has enough staff for 400 call handlers to be focused just on Lancashire, but the county has no means of contacting them. “We would love to know who they are so we can get in touch,” says Karunanithi, “What we really need is much more joined up working between the levels.”