COVID-19 testing and vaccination in a deprived local authority: Blackpool – GOV.UK

Executive summary

This case study describes the experiences of those working in Blackpool Council and its public health team in supporting testing and vaccination among vulnerable groups, as well as some of the local responses implemented to overcome challenges. It also includes the perspectives of the programme director of a third-sector organisation and 3 Blackpool community champions. The case study has been compiled from a series of in-depth interviews. While there may be themes common to other local authorities, findings may not be generalisable: each local area has its own blend of challenges.

The following themes emerged from our in-depth interviews.

According to interviewees, the high rates of transience and temporary accommodation have constituted important barriers to the effective rollout of the testing and vaccination programmes. They have made it difficult to locate residents in temporary housing, efficiently run the local test and trace system, and create a sense of community cohesion.

Houses of multiple occupation (HMOs) have been described as particularly problematic due to the high number of unregistered HMOs and the severe level of deprivation commonly found among occupants.

Widespread apathy and disengagement among disadvantaged groups, and more particularly within those living in HMOs, was a prominent theme in the interviews. Members of the public health team and Community Champions reported that many Blackpool residents were withdrawn from society and completely disengaged from public health initiatives.

Interviewees reported that a lack of awareness or understanding as one of the barriers to increasing uptake of asymptomatic testing in the community. Some residents were reportedly unclear about the purpose of taking regular lateral flow tests (LFTs), and/or where to collect LFTs.

Blackpool public health team reported having worked closely with local employers to promote asymptomatic testing among employees. According to interview participants, they had found the workplace to be an effective setting to engage migrant workers and younger or disengaged groups. However, the local authority had faced some reluctance from large private organisations concerned about identifying positive cases and losing part of their workforce as a result.

The close collaboration between the public health team and Voluntary Community and Faith Sector (VCFS) organisations was described as having been an essential feature of the response in Blackpool to the pandemic. All interviewees emphasised the key role played by the voluntary community and faith sector in delivering the national testing and vaccination schemes. They reported that the 211,690 grant received in January 2021, as part of the Community Champions Programme, had contributed to supporting vulnerable groups with a variety of needs related to testing and self-isolation.

Interviewees emphasised the importance of a localised approach to supporting testing and vaccination in Blackpool. A localised approach involves using local assets including VCFS, police, fire and rescue teams and other organisations in the community; offering pragmatic support to HMO tenants through the local network; and operating a local test and trace system that complements the national scheme.

According to interview data, the local authoritys efforts towards creating tailored communication was driven by 2 principles: simplifying messaging and emphasising the role of local government as a support provider. It was reported that this tailored approach led to many residents being more receptive towards information on coronavirus (COVID-19) testing.

Blackpool is a large town and seaside resort in Lancashire. It has a high level of deprivation, an older population and a high level of transience. These characteristics have created a singular set of challenges in managing the COVID-19 pandemic. In this study, we explore the experiences of the Blackpool public health team, a third-sector organisation and Community Champions to develop and promote COVID-19 testing and vaccination. We also describe some of the local initiatives implemented to address some of the reported challenges.

This report sets the research context including Blackpools socio-demographic profile, COVID-19 positivity and death rates, as well as test and vaccine uptake numbers. It describes the barriers to testing and vaccination reported by Blackpool public health team and the Programme Director of a large third-sector organisation. The report then outlines the local responses put in place to address these barriers. Finally, we conclude this paper with some future considerations.

This study draws on semi-structured interviews, which were conducted in May and June 2021, with 8 stakeholders who were:

Each interview was conducted remotely, was audio-recorded and lasted between 50 and 60 minutes. Thematic analysis was applied to all interviews in order to identify prominent themes and findings were submitted to interview participants to maintain quality and minimise interviewer bias. In addition to qualitative data, quantitative evidence from NHS Test and Trace data management systems was used to determine levels of testing in Blackpool and describe the local context.

This study was conducted in line with government social research guidance (1) and research participants provided informed consent before data collection. This report was reviewed and approved by the research participants.

The report was completed in July 2021.

The focus of the qualitative element of this report is community testing, and as such, it does not address testing or vaccination in institutional settings such as care homes and hospitals neither of staff nor residents or patients.

While much can be learned from a case study, the generalisability of findings from one locality is limited (2). This research draws on a small sample of participants who shared their personal experiences of developing and managing testing and vaccination services within their local authority.

This study focuses on barriers to testing and vaccination, as reported by interviewees. It also presents the experiences of Community Champions, who have been supporting vulnerable residents during the pandemic, but does not involve any direct reporting from disadvantaged groups in Blackpool. With these limitations in mind, the purpose of the case study is not to generalise the results to the wider population. Instead, it provides a description of some the challenges faced by local authorities, charity organisations and volunteers during the COVID-19 pandemic.

Finally, another limitation of this study is the lack of data on hidden groups such as occupants of unregistered HMOs or temporary migrant workers. As a result, these groups are not included in some calculations, such as positivity rates.

We would draw your attention to a postscript to this case study, provided in May 2023 by the Director of Public Health for Blackpool. This can be found in the Annex to this report.

Blackpool is a unitary authority in the county of Lancashire, in North West England. It has a population of 140,000 and an area of 35 square kilometres. Table 1 gives the age breakdown of Blackpools population. As in other coastal authorities, older people (those aged over 65 years) account for a greater proportion of Blackpools population than is observed at national level. People aged 17 years and under represent 21% of the population (3).

Source: Lancashire.gov.uk

Table 2 gives the ethnicity of Blackpools population. The majority of Blackpool residents are of White ethnicity, with minority ethnic groups estimated to make up just 3% of the population, compared with 15% for all of England and Wales (4).

Source: 2011 Census.

The total does not equal 100% due to rounding.

Population turnover in Blackpool is high. Transience the movement of people with a high degree of residential mobility, which frequently accompanies a chaotic lifestyle has been recognised in Blackpool for a long time (5). Population statistics (6) show that some areas in Blackpool have extremely high levels of population inflow and outflow. For example, Blackpool South Shore has a population inflow rate of 193 per 1,000 population. The 2011 census revealed that, using commonly accepted criteria, 11% of the population in Blackpool could be classified as transient. Further evidence from housing and benefits data suggests that within the first 6 months of settlement, 55% of Blackpools transient residents are likely to move again (4). The section on barriers that the high level of transience and the socio-economic circumstances of transient residents pose for test and trace services.

Transience in Blackpool is closely related with a high rate of temporary accommodation and HMOs. The market for poor quality private rented sector properties is fuelled by former hotel accommodation reaching the end of its life, when it is then converted with or without permission to privately rented small flats and bedsits. There are approximately 3,000 known HMOs in the authority (7).

As a major tourist destination, Blackpool has a lower than average rate of employee jobs in the manufacturing sector and a much greater reliance on service sector employment. It is well-represented in the employment sector of arts, entertainment, recreation and other services (3). As a result, Blackpool has a high proportion of seasonal workers employed in the tourism and hospitality industries. The number of Eastern Europeans, mostly Polish immigrants, working in the resort and surrounding area has grown in recent years (8).

The 2019 Indices of Multiple Deprivation revealed that Blackpool was ranked the most deprived area out of 317 districts and unitary authorities in England (9). Forty-two percent of its lower layer super output areas (LSOAs) were among the 10% most deprived in the country, and 8 of these were also in the top 10 (3). The unitary authority also has a high rate of child poverty with 35% of children in Blackpool living in poverty (nearly half in wards with the worst rates of deprivation), compared with 21% of all children in England.

Unemployment (those actively seeking employment but currently not in a job) is around 8% in Blackpool. This is higher than England (6%) and the North West (6%). The Blackpool working-age population claiming employment and support allowance or incapacity benefit is 13%, compared to 8% for the North West region, and 6% for England (10). Blackpool also has more residents with no qualifications (31%) than the national average (22%) (4)

The high level of poverty in Blackpool is reflected in the public health of this authority. According to the Office for Health Improvement and Disparities annual Local Authority Health Profiles (11), residents in Blackpool have a lower life expectancy than the national average. In the poorest parts, life expectancy is 12.3 years lower than the average for men and 10.1 years lower for women.

Behavioural risk factors for Blackpool (2018 Local Authority Health Profile) include high rates of alcohol-related harm hospital admissions. In Blackpool alone, the hospital admission rate for alcohol-related conditions is 1,015 per 100,000 per year, compared with 663 for England (3). In addition, estimated levels of excess weight in adults (aged 18 and over), smoking prevalence in adults (aged 18 and over) and physically active adults (aged 19 and over) are worse than the England average. In 2019, the suicide rate in Blackpool was well above the country average, with 14 per 100,000 compared to 10 per 100,000 for England (12).

As of 28 June 2021, Blackpool achieved good vaccination uptake, with 95,534 people having received one dose and 77,279 people having received 2 doses. Figure 1 below shows the percentage of people, by age group, who have received at least one dose of vaccination in Blackpool and in Lancashire and South Cumbria. The figure is a column chart, the X-axis representing 13 different age ranges and the Y-axis representing the percentage range from 0 to 100. The green columns represent data derived from people living in Lancashire and South Cumbria and the blue columns represent data derived from people living in Blackpool. Vaccine uptake in both areas is about 55% in the 18 to 24 age range and steadily increases to mid to high 90% in the 55 to 59 age range and remains high for all later age groups.

Source: NHS England

As table 3 illustrates, the proportion of people who had taken a polymerase chain reaction (PCR) test in Blackpool from April 2020 until 26 May 2021 was slightly lower than the test uptake for the North West region (42% versus 47% of the population).

Source: NHS Test and Trace Data Management System

Source: NHS Test and Trace Data Management System

Although the uptake in PCR testing in both regions was much reduced between 1 January to 26 May 2021 (Table 4), the number of tests administered per capita was higher in Blackpool (Table 5). This indicates a higher rate of multiple testing of some Blackpool residents.

Source: NHS Test and Trace Data Management System

Similar to PCR uptake, lateral flow test (LFT) rates show that, while the number of individuals tested is at the same level in Blackpool and North West (Table 6), the number of tests administered is higher in Blackpool (Table 7). This, again, indicates a higher rate of repeated testing in Blackpool.

Source: NHS Test and Trace Data Management System

Source: NHS Test and Trace Data Management System

Note: the provision for asymptomatic testing of staff at Blackpool Teaching Hospitals NHS Trust was via a technology called Loop Mediated Isothermal Amplification (LAMP) which would not have been included in either LFT or PCR testing numbers via NHS Test and Trace Data Management System. At the time of the study, the Universal Testing Offer was in place and NHS staff using LFTs may have been accessing testing via this route. The implications of this are that when comparing testing rates between geographies there may have been an impact on the calculation of testing rates (both proportion of individuals participating in testing and number of tests per person). Given the intensity of testing in care homes, and the relatively low number of care homes in the Blackpool local authority area, this may also explain why slightly lower rates of testing were observed via the NHS Test and Trace testing programme.

Blackpool has a substantial transient population, with approximately 8,000 people moving into and out of the area over the course of 2015 (13). These include people moving from other parts of the country to access low-cost housing, seasonal workers, especially from Eastern Europe, and an estimated 500 Gypsy families, according to Blackpool public health officials.

The high rate of transience results in high levels of movement between properties within Blackpool, especially in the private rented sector. The local authority has a large proportion of poor quality privately rented housing, often converted from former guest houses. These have led to intense concentrations of deprivation, and an environment that contributes to lack of opportunity and poor health. Participant B described the severity of the housing situation as follows:

We have the largest tourist economy in the country. Huge stock of ex-holiday homes, ex-bed and breakfasts, converted into very poor accommodations. Its really shocking. It was never built to house people all year round. We have this problem. Bigger here than anywhere else in the country.

Interviewees reported that the high level of low-quality temporary accommodation has been one of the main challenges of rolling out testing and vaccination programmes in Blackpool. They explained that a high level of transience not only makes it extremely difficult to create a sense of community cohesion, but also hinders their ability to locate residents in temporary housing and run the local test and trace system as efficiently as they could.

Interviewees reported that problems associated with inadequate and poor-quality HMOs were identified before the pandemic but that they have since been exacerbated.

Regarding HMOs, that was recognised way before COVID. Weve looked at the uptake in these areas, we know the uptake falls by age, we know its lower for males. Its not a feeling. We know theres a problem in HMOs.

(Participant B)

According to interviewees, one of the main challenges of reaching residents living in HMOs has been the high proportion of unlicensed HMOs and unregistered HMO residents. As 2 interviewees said:

We have a lot of people not registered and living in HMOs. We cant know what our rates are if we dont know the actual numbers. Landlords have been using terms such as students accommodations, but theyre not.

(Participant C)

Theres a lot of sofa surfing and things like that. Informal arrangements. About demographics, we actually dont know since many people arent registered with GP practices. Were suspecting its more than in other places.

(Participant B)

Interviewees description of a sizeable hidden population in Blackpool indicates that the number of positive cases in the authority may be higher than the official figures. Another reported obstacle of engaging HMO occupants was that many are vulnerable individuals living in precarious conditions.

Its not a student population in HMOs. Theyre older than that. People who have been around, theyve got drug problems, drifted around, ended up in Blackpool because its cheap accommodation here, just go to the pub and live on the social security.

(Participant C)

Members of the local public health team concurred that the greatest constraint to rolling out COVID-19 vaccination in HMOs has been the imposition of an age limit. They believed that promoting the vaccine among HMO tenants, while only a proportion of occupants may be in the relevant age bracket, would be ineffective.

The biggest barrier is the vaccine age limit. Were going to get in there once we get in there, we need to be able to offer it to everybody. The message go get the vaccine if youre the right age is too complicated for our population. Its either get the vaccine or dont get the vaccine.

(Participant C)

Theres no point going to an HMO where 6 people live and say Three of you, you can get it, and the rest of you cant have it.

(Participant B)

A prominent theme in interview data was reported apathy and disengagement around COVID-19 testing and vaccination commonly found within some disadvantaged groups, and more specifically among HMO occupants. Interviewees described some Blackpool residents as showing low levels of either health literacy or engagement. One of the interviewees described the phenomenon as follows:

Weve done segmentation work before. We know we have a really large population that are just not engaged with their own health and well-being in general. If they fell ill, they wouldnt do anything about it.

(Participant B)

Furthermore, members of the public health team highlighted that the town includes a large number of residents who are withdrawn from society and, as a result, disengaged from public health initiatives.

The fatalistic and disengaged are a large chunk of people who come to Blackpool and live in HMOs, arent really interested in the wider world. It doesnt matter what the message is, they arent interested.

(Participant C)

One of the barriers to asymptomatic testing described in the interviews is a lack of awareness, as well as some level of confusion, about regular symptomatic testing. Some residents are reportedly unclear about the purpose of taking regular LFTs and/or where to collect LFTs.

The comms to get tested twice a week hasnt really reached anyone anywhere. Theres a large part of the community that seems unaware that they can get tests from the chemist, et ceteraThere seems to be a void in the comms.

(Participant B)

Members of the public health team said that they had detailed data on polymerase chain reaction (PCR) uptake, but were not well sighted on asymptomatic home testing.

For some things we have a huge amount of details. Because we do our own contact tracing. Weve got good information on the symptomatic PCR testing going on. In terms of positive and negative tests. The bit were unsure is the LFT routine, we dont have as much detail there.

(Participant B)

Interviewees described 2 reasons for lack of traceability of LFTs being a barrier to promoting regular asymptomatic testing. First, the local authority is unable to identify the final recipients of collected LFTs unless self-tests are associated with a given official structure such as a school, a workplace or medical setting.

Whether it goes to all the right places and engaging all the right peopleWe dont have that level of detail. Especially with the testing at home. When its attached to a certain setting: school, NHS centre, et cetera, we do have this data. Otherwise, we dont know

(Participant A)

Secondly, although the Blackpool public health team was able keep track of the number of LFTs collected from the various available outlets, they reported a gap in the data where residents do not register their results online.

We know how many packs theyre taking from us but other than that we dont know the results.

(Participant C)

Interviewees expected that many Blackpool residents would not register negative LFT results due to the perceived complexity of the online registration process, which they described as too difficult and very long-winded. On the other hand, they believed that positive LFTs do get reported and are followed by a confirmatory PCR test.

Interviewees described large private organisations reluctance to support testing in the workplace as a missed opportunity (Participant A). While local employers had reportedly embraced the local authoritys campaign for regular testing of asymptomatic employees, national companies in Blackpool had not engaged. According to interviewees, large companies disengagement was due to trade unions opposition to workplace testing schemes, as well as employers concerns about identifying positive asymptomatic cases and losing part of their workforce as a result.

In the workplace, we have an issue with the largest national employers. We cant get it in supermarkets, we couldnt get it in [organisation name redacted] where we have 3,500 people in Blackpool. Because of the trade unions and this not being part of their policy.

(Participant C)

In response to COVID-19, Blackpool public health team reported having established close collaboration with the voluntary community and faith sector (VCFS) which were already providing services to the community pre-pandemic. One aspect of the cooperation between the local authority and VCFS consisted of fortnightly briefings during which the council, Blackpool public health and third-sector organisations discussed the latest official guidance, local priorities and barriers or concerns experienced by the community. Interviewees spoke positively about the collaboration:

The councils approach was key. They very quickly created the infrastructure to bring together the third sector. Council pulled together the infrastructure of the third sector and did it on a geographical basis, so it is accessible equally. The relationship between third sector and local authority is much better than before the pandemic. Having access to the [director of public health] on a regular basis has made a great difference.

(Participant E)

There has traditionally been a third sector-local authority split. Because local authorities used to provide funding. In working together, weve proven that we could achieve so much more.

(Participant D)

In January 2021, Blackpool Council received a 211,690 grant from central Government through the Community Champions Programme. This funding has contributed to supporting the work of volunteers who have offered vulnerable groups assistance with a variety of needs related to testing and self-isolation. Interviewees reported that Community Champions funding was split among 9 organisations in key areas and has made a significant difference (Participant E). Community Champions funds were used to provide VCFS organisations with physical resources, including food parcels, to support vulnerable residents.

Community Champions activities have also been supported by the creation of the Corona Kindness Hub whose goal has been to provide a single point of contact for residents in need of assistance during the pandemic. The hub is staffed with over 100 approved volunteers who have intimate knowledge of their community and how to engage it. In order to minimise negative socio-economic impacts of self-isolation, the Corona Kindness Hub has helped disadvantaged Blackpool residents by providing a wide breadth of support, including help to obtain food, health care and medication; with welfare, mental health and loneliness; help for someone they care for; with utilities and bills, and around debt or benefits (including claiming Statutory Sick Pay).

According to interview data, another important role of VCFS and Community Champions has been to disseminate public health messages and tackle any misinformation from the early stage of the pandemic.

Misinformation isnt really an issue because it was addressed by third sector organisations very early on. Digital comms have been useful to address that.

(Participant E)

Members of the public health team described VCFS as an invaluable asset to support vulnerable groups with testing, self-isolation and vaccination. They also explained that close collaboration with VCFS is aligned with the local authoritys effort to adopt a localised approach drawing on community resources.

A prominent theme that emerged from interviews was the importance of a localised or geographical (Participant E) approach to supporting testing and vaccination in Blackpool.

We have close neighbourhoods in Blackpool. It is not diverse in terms of its population. People identify with the estate or the area they live in. We look at the geographical split and trusted organisations within those geographies.

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COVID-19 testing and vaccination in a deprived local authority: Blackpool - GOV.UK