Better Health For All

In April 2010, one of us wrote a short retrospective of the  H1N1/09 (“Swine Flu”) Pandemic, for  the newly relaunched “Public Health Today”, under the guest editorship of another of us,  entitled, “Modellers not public health doctors had lead in flu planning”.  Its sentiments were echoed in the report on the Swine Flu Pandemic for the UK Cabinet Office by Dame Deirdre Hine, former CMO Wales, that judged that the UK government placed too much reliance on “modelling evidence”.  That Cabinet Office Report went on to recommend that, “The Government Office for Science, working with lead government departments, should enable key ministers and senior officials to understand the strengths and limitations of likely available scientific advice as part of their general induction. This training should then be reinforced at the outbreak of any emergency”.  In doing so the report acknowledges that the mathematical and academic nature of mathematical modelling can be attractive to hard pressed politicians and officials who aspire to “follow the science” but warns against regarding mathematical modellers as, “court astrologers”. Public Health Today, a few short years later, was no more and with it, was forgotten, in the management of the COVID-19 pandemic, this particular lesson.

Indeed “court astrologers” have been ubiquitous in the COVID 19 pandemic from the moment in March 2020 when Imperial College London’s implausible predictions, the most recent example of a long history of the same, led directly to almost simultaneous lockdowns in the UK, France and the USA.

Meanwhile on 24th March 2020, in a letter to the Western Mail, “the national newspaper of Wales”, entitled, “Will social distancing actually work”, one of us wrote,

“This new virus will keep circulating until either we’ve all had it or vaccines or effective treatments become available, both solutions possibly years away. Distancing just makes the virus get round slower, and the pandemic last longer. Distancing also means less wealth and resilience to fight it.”

Previously, on 28th February, another of us had written in a BMJ editorial,

“Given the lessons from 2009—which taught us that containment for a globally disseminated disease was futile….once the disease is recognised as a global pandemic nations, commerce, and healthcare can move into a much more rational phase with resources targeted at those most at need. We should plan on the assumption that most of the population may contract the virus….”

Why have risk based approaches, or “focussed protection” as some have styled them, not been followed; neither in Wales nor elsewhere?  A part of the explanation has been the dominance of mathematical modelling in the scientific advisory machinery.  Welsh ministers, like many politicians and journalists, internalised the widely popularised idea of the effective reproductive rate (R_t)  as a sort of epidemic volume control responding in small increments/declines to their “cautious” changes, a framework that entirely ignores the determinant role of social networks in epidemic patterns. Welsh Government’s Technical Advisory Committee (TAC) is chaired by the Chief Scientific Advisor, not the Chief Medical Officer and despite a number of members, experienced in all aspects of infection, it has been suggested, privately, that it is the mathematical modellers that have dominated the agenda. Certainly the TAC’s outputs, available online, are consistent with this explanation, for example, a paper showing that the Welsh Government’s two week October firebreak was “successful”. In this paper, arcane mathematics is used to claim success, whilst, from a simple eyeballing of the observed COVID incidence, it would be difficult to conclude other than that any effect was marginal at best.

Whilst such global approaches to pandemic management were used, loss of a focus on risk meant that preventable infections remained unprevented, evidenced by the high proportions of deaths in which the infection was acquired in hospital or care settings and the proportion of care home cases, linked to hospital discharges.  Field data to orientate such approaches was available, early on in the pandemic from the “OpenSAFELY”, “ISARIC” and RCGP Research and Surveillance Centre projects, not to mention timely papers from China.  Public Health Wales, subsequently, made important contributions to this work with their studies of hospital discharges and of the community screening project in Merthyr Tydfil. Empirical data from field investigations might similarly be used to establish what works in protecting the vulnerable as well as to evaluate whether some of the Welsh Government’s more singular decisions (closing selected supermarket aisles, pubs prohibited from selling alcohol, vaccine passports for night clubs) were/are of any benefit.

Finally, the Wellbeing of Future Generations Act, some of Wales most forward thinking legislation singularly failed to translate into any sort of systematic evaluation of the downsides of global “lockdown” approaches; downsides most likely to impact on just those future generations whose interests the Act seeks to protect.

What scope was there for an independent stance in Wales, given the high level of economic and social interaction with England?  It has been done. Wales refused to endorse claims from DH in England that BSE could not transmit to humans, chose to wait before embarking on smallpox vaccination of health care workers, due to the high levels of side effects documented in the US, before the Iraq war and during the 2009 Swine Flu pandemic, Wales chose to use usual healthcare providers, bypassed in England by the costly, centralised and often ineffective “Flu Line” (National Pandemic Flu Service).  The scope for leadership is, nevertheless, limited but should that mean that letters to Welsh ministers, from us, suggesting how more focussed approches might look, in practice, simply remained unanswered?

So this is distinctly not the view from Wales but it is a view and a view from four of us who spent much of our senior careers in the epidemiology and control of communicable diseases.  So whatever form Wales’ Public Inquiry takes, we’d like to see our views, particularly in regard to the need to use real world surveillance and investigation, including of the downsides of interventions, taken into account and this time, practical lessons learned and remembered.

Roland Salmon
formerly, Director, Communicable Disease Surveillance Centre, Public Health Wales

Meirion Evans
formerly, Consultant Epidemiologist, Public Health Wales

Stephen Palmer
Emeritus Professor of Public Health, Cardiff University

John Watkins
Professor and Consultant Epidemiologist, Cardiff University

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The COVID-19 vaccine programme has been the largest vaccine campaign in NHS history. The approach in London has and continues to be a true partnership endeavour, bringing together and harnessing the assets of all system partners and our communities in order to achieve high and equitable vaccine uptake across the city. Delivery has been multifaceted, bringing together activities at the hyperlocal, borough, Integrated Care Systems (ICS) and regional levels.

The regional Public Health function has worked to support, enable and contribute to system delivery of the vaccine programme in London by adopting a four-pillar approach focusing on:

• data and evidence
• tackling hesitancy and increasing confidence
• addressing practical barriers to vaccination
• evaluation, monitoring and system leadership

The data and evidence

Timely, high quality data and intelligence on vaccine uptake has been fundamental to London’s effort. Working closely with key London partners, we have developed a range of analysis and reports examining uptake by various groups and demographic factors. This has helped us to track progress in London and guide ongoing system efforts to increase uptake and tackle inequalities. Using presentations and analysis in creative ways has helped to demonstrate progress with delivery and highlight gaps and inequalities creating a shared understanding across partners.

Tackling hesitancy and increasing confidence

Lower self-reported vaccine confidence or likelihood of accepting the vaccine amongst London’s Black, Asian and minority ethnic communities has been mirrored by COVID-19 vaccine programme data showing lower uptake in many minority ethnic communities, and in areas of greater deprivation. Given the stark and persistent inequalities experienced by these communities in terms of risk of COVID infection and poorer outcomes, equitable vaccine uptake across the city has been a critical priority of the programme.

Engaging and working with Londoners has been central to understanding the questions, concerns and barriers experienced by London’s diverse communities. At a regional level, this has included a series of round tables with community groups including a pan-London Community Champion Coordinator programme and resources developed to reach specific communities and populations. A regional ‘bureau of speakers’ was developed to include medical and Public Health experts from a range of communities and backgrounds to support local events. From this grew the Public Health Ambassadors programme where colleagues from across PHE London used their lived experience and networks within their communities to co-design resources  and activities.

Many communities have concerns and fears that reach well beyond vaccine safety and efficacy. Historic and recent medical malpractice was a big feature as well as long standing issues of mistrust, discrimination and fear of state-run services and systemic racism. Listening to and acknowledging these fears and concerns linked to deep-seated and structural issues has been a vital first step towards rebuilding relationships and trust.

Addressing the barriers to vaccine uptake

Vaccine hesitancy is not the only factor behind inequalities in vaccine uptake, practical access issues are also key, The NHS, working with London borough colleagues and wider partners, have sought to adapt programme delivery over time in order to overcome these barriers and maximise convenience.

The use of local community venues, vaccination buses and other hyperlocal locations in non-traditional and more familiar settings are examples of this approach. Outreach models were developedto take vaccination to people who may otherwise not access them through other sites if they were housebound, homeless or asylum seekers for example. Hyperlocal vaccination options, alongside targeted outreach, such as door knocking or street engagement teams, has been effective at reaching people with barriers to access. Local booking systems were developed to overcome some of the challenges associated with the national booking system, and many sites offered walk-in clinics. Local call centres were also established to proactively follow up unvaccinated Londoners and provide support with booking.

Evaluating what we did

A pan-London evaluation of the COVID-19 vaccine programme was undertaken to learn lessons and share innovative practice in real time to inform programme delivery.

The evaluation report was recently published and is itself an example of strong collaboration and partnership across many partners. The report is divided into four distinct areas of focus – barriers, demand, access and legacy–and makes a number of recommendations in order to build on the learnings gathered throughout the programme and to drive continued improvement,  not only for the COVID-19 vaccine programme, for wider vaccines and for broader health systems more generally.

What we learnt

A vital thread across the system has been the importance of partnership working. Whilst the NHS led on the vaccine programme the strength of different partners was brought together through various elements whether it was the deep understanding of localities from Directors of Public Health and local authority partners to best practice engagement from the mayoral team. Much of this was facilitated by meeting to highlight issues and share good practice but also embedded through the agile learning of evaluating our work regularly. This enabled system partners to all constantly learn and grow together towards increasingly innovative methods and approaches.  

Another essential element has been the importance of working alongside communities to understand their aspirations, needs and concerns. This takes time, energy and resource but is vital to understand and address inequalities and is crucial to build confidence in vaccines and health systems. As we start to reflect on the last 18 months, it is essential that we take this as a legacy of learning from this pandemic – aiming to embed and sustain this approach going forwards. This is key not just for a focus on COVID-19 and vaccination but should be used for all health and prevention services more widely.

Written by

Dr Cyril Eshareturi
Senior Project Manager: PHE London COVID-19 response

Dr Leonora Weil
Public Health Consultant: PHE London COVID-19 response

Julie Billet
Director of Operations: PHE London Operations

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