Public health annual report 2021: rising to the challenges of COVID-19

Turquoise graphic with Local Gov Association and Association for directors of public health
This year's annual report looks back at what public health has helped to achieve and what could have been done better during the pandemic. It also looks to the future - the new UK Health Security Agency (UKHSA) and the publication of the Department of Health and Social Care's (DHSC) white paper, ‘Integration and Innovation: working together to improve health and social care for all’ and the significant organisational changes these could bring.

Foreword

The year 2020 was a year like no other. The COVID-19 virus has taken a terrible toll and continued to resurge despite all-out efforts to control its progress. 

In early 2021 the vaccination programme is well underway and there is hope of a gradual return to normal interaction, but with new variants of the virus posing an ongoing threat.

The grim milestone of 100,000 deaths attributable to COVID-19 has been passed and the total continues to grow, with each death a terrible loss. In the longer term, the experience of the coronavirus pandemic and its impact, particularly on the most vulnerable in society, will long be with us.

Local directors of public health and their teams have been at the centre of measures to tackle the spread and impact of COVID-19. They have worked with partners across local government, the NHS, the voluntary and community sectors, and beyond, to co-produce a magnificent team response.

They have worked quickly, efficiently, and creatively. At times of crisis, people rise to the challenge, and nowhere is this seen more clearly than in the local response to COVID-19.

Public health became a function of local government in 2013. As previous annual reports have shown, over these eight years public health developed its approaches, widened its tasks, and established strong partnerships.

This has contributed to the solid foundation of experience, knowledge, skills and relationships on which the local pandemic response is based.

Throughout the year, many directors of public health and lead members for health, care and wellbeing have regularly appeared in the local and national media. We have been extremely impressed by the calm, clear, informative way they have passed on vital messages to the general public and to national stakeholders.

This year’s Local Government Association (LGA) public health annual report is an important document. It looks back through the events of the last year and focuses on what public health has helped achieve.

It also looks at what could have been done better. COVID-19 was unprecedented challenge for all organisations – national, regional and local – and often there were dilemmas about the best path to take.

Although the rollout of vaccines means that risks posed by COVID-19 will gradually reduce, the virus, in different forms, will be with us for years to come. Continuing to tackle this, and reduce its impact on people facing health inequalities, will be a key task for public health long into the future.

Nor will this be the last major infectious outbreak we face, although we sincerely hope it will be the last global pandemic for many years. We need to understand the lessons from this pandemic and apply them, so we can achieve a seamless response to future challenges.

The annual report also looks to the future. The end of Public Health England (PHE), the new National Institute for Health Protection (NIHP) and the publication of Department of Health and Social Care (DHSC) white paper, ‘Integration and Innovation: working together to improve health and social care for all’  mean we are yet again facing significant organisational change.

The long-standing problems of health inequalities and regional inequality have become ever clearer during 2020, and the pandemic’s repercussions will exacerbate these at a time when resources are limited and unclear.

The one-year spending review of 2020 maintained the public health grant for 2021-22, but this grant has been reduced year-on-year and there are questions over longer-term funding for local government and all public services.

Throughout the pandemic the government has helpfully supported local initiatives with funding – examples ranging from supporting local contact tracing to community champions to promote vaccination. We remain clear that only by proper public health funding, and by harnessing the combined resources of local, system and national organisations, working with individuals and communities, will we see people across the country have longer, healthier, happier lives.

At this crucial time, we must not misstep. We must come together and work at scale wherever this is most effective, but always keep the focus on local places – where people feel a sense of belonging and community, where the direct work of health improvement and health protection take place.

We know that many of you have been working enormously long hours over many months. We would like to express our sincere admiration for public health teams and the wide range of colleagues who embodied the principle “public health is everyone’s business” during 2020.

With grateful thanks to you all.

Councillor Ian Hudspeth,  Chairman, LGA Community Wellbeing Board
Councillor Ian Hudspeth Chairman,
LGA Community Wellbeing Board

 

 

 

 

Dr Jeanelle De Gruchy  President, Association of Directors of Public Health

Dr Jeanelle De Gruchy
President, Association of Directors of Public Health
                   

Kings Fund and The Health Foundation, COVID-19 and the public health system project

“Directors of public health have a critical role in responding to the COVID-19 pandemic.Their knowledge and expertise in population health, training and responsibility in infectious disease control are vital in addressing its immediate impacts on the health of their local populations (as well as the economic impacts of the pandemic and its aftermath).

Their understanding of local places and resources, such as contact tracing, and their broader role in local government situate them at the centre of local decision-making that affects public health.”

Introduction

This year’s LGA public health annual report records the work of public health teams from March 2020 to March 2021 – an unprecedented and hopefully exceptional twelve-months.

The title for this report is ‘Rising to the challenges of COVID-19’ because this has been happening across the country. Local directors of public health (DsPH) and their teams have been at the centre of the local response to the pandemic.

Public health professionals are trained in containing infectious diseases, understanding and interpreting data, recognising risk factors, understanding the scientific evidence base, motivating behavioural change, and helping develop policy interventions. The Directors of Public Health (DPH) effectively works as the chief medical officer for a local area.

Most have already tackled major outbreaks, though nothing with the speed and reach of COVID-19. Some have said that it feels like their whole career was building towards this defining moment. The sense of responsibility for making decisions that could affect thousands of lives was felt deeply.

The report fulfils the important role of witnessing and recording some of the vast range of work that has been done by local authorities with their partners across the various stages of the pandemic.

Measures to tackle COVID-19 have progressed at breakneck speed over many months, with national and local policies and interventions that are complex and ever changing. It is beyond the scope of this report to describe and analyse these measures comprehensively.

Thorough evaluations should take place when the virus is sufficiently under control, so that lessons can be learned for the future. Instead, the report focuses on the key pressures and challenges facing local public health teams, the responses they have made, and some of the dilemmas they have faced.

Through the year, the LGA has published real-time interviews with DsPH from around the country, who reflected on their experiences of working with partners across the local area and on a regional and national basis.

The LGA also produced an extensive range of examples of local good practice on all aspects of tackling the pandemic. The LGA and the Association of Directors of Public Health (ADPH) have published guidance, explainers and position statements on many topics, such as communications, compliance, local contact tracing and rapid testing.

This report draws on these publications, as well as other reports on the impact of the pandemic, and discussions with local and system leaders. From this information, the report describes some of the main themes emerging from work on the pandemic and summarises key priorities which have implications for the future of public health, and the task of building back fairer.

Summary of key themes and priorities

Legacies and learning

The central role of public health in local places

Public health in local authorities has a central role in tackling the virus in local places. It provides the leadership, expertise, partnership-working and access to local resources that are fundamental to effective place-based coordination of health protection interventions.

It also helps local areas to understand and address the economic, social and psychological impacts of the pandemic, and the serious health inequalities that have been highlighted and deepened.

Partners from other organisations who have worked with public health on COVID-19 now have a much clearer understanding and appreciation of their pivotal role, as does the wider society. Local government leaders are clear that the role of DsPH and their teams has been a “gamechanger” and they will have increasing influence across all areas of work in future.

Strengthened partnerships through shared purpose

Working together with a shared purpose has resulted in stronger relationships both within and across organisations in local places. Barriers have been broken down, there is a better understanding of each other’s work, and a feeling of health being everyone’s responsibility.

The primary care network (PCN) structure has proved helpful and shows the potential for PCNs to promote health and wellbeing in their communities. The contribution of communities and individuals coming forward to volunteer, supported by the community and voluntary sector, has been outstanding.

Regional, combined authority and health and care system partnerships have matured through their joint focus on tackling the pandemic, often supported by long-standing DPH collaborations. There is optimism that this will lead to a reinvigorated joint focus on health and care integration, prevention and tackling health inequalities going forward.

Local involvement in national initiatives

Public health teams and councils have played an innovative role in trialling new national initiatives, often building on relationships with academic partners.

However, there is also a strong feeling that the skills, expertise and capacity of local public health was undervalued, particularly in the early months of national planning, and that had their role been better recognised, measures such as contract tracing would have been rolled out more quickly and effectively.

As the pandemic progressed, organisations at all levels got into their stride and showed the value of effective national strategy and local implementation as demonstrated by the vaccine rollout and the swift delivery of surge testing. 

For future outbreaks, a national, regional and local partnership of all key sectors, playing to their strengths and operating as a virtual team, is needed.

Difficult decisions and balancing risks

The pandemic has highlighted innumerable difficult situations, and dilemmas with no easy answers, such as trade-offs between safety from the virus and the psychological impact of isolation.

Many directors of public health have stressed the importance of building people’s trust by being honest about difficult decisions and clear and consistent in their messages. Along with other local leaders, they have modelled a direct and transparent, but sensitive, way of communicating with the public which could be explored as a standard for professional/public dialogue in future complex situations.

Responsive and creative solutions

Public health has used its expertise in communications, behavioural insight and health campaigns to engage with local people to tackle outbreaks and maintain safety. It has used skills in epidemiology, data analysis and soft intelligence to work with partners to map, monitor and model virus transmission so action can be taken.

With council colleagues, it has helped quickly expand services like local contact tracing. It has been flexible and innovative in keeping vital health and wellbeing services running through digital options and has sought ways to tackle the impact of the pandemic on health inequalities.

Priorities for a fairer future

Public health has three overarching goals for the future:

  • tackling the health inequalities that the pandemic has exposed and deepened
  • developing greater understanding of the impact of the pandemic on the general population
  • learning from the pandemic to improve health protection and resilience for continuing threats and future outbreaks.

A national drive to reduce inequalities

Professor Sir Michael Marmot’s report, 'Building Back Fairer’, calls for a national commitment to social justice to reduce health inequalities, and action to make this a reality. It warns of the social and economic consequences of failing to do this.

The government’s levelling up agenda was important before the pandemic and is even more essential for a stable and prosperous future. A comprehensive, ambitious and energetic drive to tackle the social determinants of health at national, regional and system level must be implemented and be properly funded.

Systems prioritise prevention and health inequalities

The joint commitment, energy and resources of combined authorities, health and care systems, and places is needed for there to be any chance of reducing health inequalities. Partners need a relentless focus on prevention, health inequalities and tackling the social determinants of health.

The experience of the pandemic and long-standing DPH collaborations will help identify the activity that is most effective at scale and what works best in places. Places, with their PCNs and communities, are the central building blocks to deliver on prevention.

Understanding the impact of the pandemic on the general population

Most of the reports on the impact of the pandemic on mental and physical wellbeing have focused on how people already facing health inequalities have been affected the most.

However, there are big questions over the longer-term impact on the general population that need to be better understood – for example, will there be longer term impacts on the mental health of young people, on drinking patterns, on obesity. Public health will be working to understand and address such issues in the coming years.

Whole-system health protection

Local government and public health should work with national and system partners to develop a new model for health protection – one which does not just tackle outbreaks or incidents, but responds to the impact on individuals, and harnesses the power of communities.

For future outbreaks, a national, regional and local partnership of all key sectors, playing to their strengths and operating as a virtual team, is needed. The new National Institute for Health Protection should embody this partnership approach, and local government and local public health should have a strong voice in NIHP from the start.

Update and prioritise early years support

The health, wellbeing and prospects of children and young people, particularly in deprived areas, have been damaged in the pandemic. Early years support forms the basis for future healthy lives, but important services with proven effectiveness, like Sure Start, were closed during the years of economic austerity. Redeploying updated models of support, with enhanced digital offers and more focus on community assets, peer support and positive mental health in families, should be a priority.

Employment and poverty

The link between unemployment and low-paid and insecure jobs and health inequalities is fundamental. Poor mental health is a vital issue in employment, potentially leading to people finding it difficult to obtain or maintain employment.

Public health should consider making increasing employment opportunities, and mental health in employment, key priorities, building on links with the business sector locally, in combined authorities, and across health and care systems.

Building on stronger communities and public understanding

The public’s increased understanding of, and personal involvement in, health, and the upswell of community support during the pandemic are important opportunities which public health can capitalise on when the pandemic recedes.

Models previously developed by public health, such as health champions, making every contact count (MECC) and asset-based community development have proved their worth in the pandemic.

Basing their work on community engagement and empowerment, and working with a person-centred approach, areas should consider:

  • developing a comprehensive model of asset-based community development
  • deploying these models first in areas where people are facing high barriers to health and wellbeing, such as black and minority ethnic (BAME) communities
  • developing health and wellbeing champion networks and MECC type initiatives
  • expanding health improvement programmes, making sure these provide single access to both healthy living support and wider help like debt advice.

Aligning climate change and prevention

Measures to tackle climate change and to improve health almost always share compatible aims and have important synergies. Fully aligning the environmental and health prevention and improvement agendas at place, system and combined authority level will bring mutual opportunities and make best use of resources.

Innovation and research

Digital communication is becoming the norm across society and is appreciated by many people who use public health services, particularly as an alternative to travelling long distances. As services shift online, public health teams have evaluated their impact with a view to making sure that people who need personal contact continue to receive this.

The digital offer will continue to develop and improve in the coming years. Public health can be at the forefront of new modes of service delivery. Strong partnerships with academic institutions willing to conduct research with practical benefits will strengthen this.

Sector-led improvement

With the closure of PHE some of its functions need to be reallocated. An enhanced local government sector-led improvement approach would provide a cost-effective and integrated way for local areas to be accountable locally and nationally for their performance in health improvement, tackling inequalities and health protection.

Legacies and learning

Tom Riordan - CBE, Chief Executive, Leeds City Council

The pandemic has placed public health at the centre of public policy and left every household in the country in no doubt about its importance.

The profile of directors of public health has increased to reflect their role as trusted local voices. We need to make sure as COVID gradually recedes and we move into recovery mode that public health remains at the heart of our efforts to reduce inequalities, improve the economy and quality of people’s lives.

Professor Ivan Browne - Director of Public Health, Leicester City Council

The council threw all its resources at [tackling the virus] – it was not just a public health problem. We had the director of finance working on shielding and the head of property services focussing on testing.

This section identifies some of the main themes that have emerged from work on the pandemic.  Some of these reflect the concept of ‘legacy’ – both positive developments that have emerged amidst the stress and uncertainty, which need to be recognised, nurtured and built-on, and challenges which will be ongoing for years to come.

Other themes identify learning about what went well and what could be improved to inform future activity in population health at local, system and national levels.

Public health at the centre of local health protection partnerships

Public health in local government is at the heart local work to tackle the virus. It provides the leadership, expertise, partnership-working and access to local resources that are fundamental to strong place-based coordination of health protection.

In recent years, local public health has tackled many serious outbreaks including HIV, SARS, Swine Flu, Bird Flu, Measles and Hepatitis A – always working with the NHS, local authority environmental health colleagues and other national and local partners.

Local public health is central to resilience coordination and helps tackle the health aspects of major incidents such as flooding – increasingly more frequent in the UK.

DsPH are always alert for the next disease threat and started to gear up when they heard reports of a virus spreading in China. As the intense work to tackle COVID-19 began, directors and their teams were at in the eye of the local storm, fulfilling the role of professional leadership for health protection.

This has been a fast-moving and complicated situation, with demands both national and local, and no blueprint for what was coming next.

Local public health has had to respond quickly, assess what worked, and change direction swiftly when needed. In June, the government formalised local government’s key role in the local response to the pandemic, with areas required to produce local outbreak plans, setting out how they would tackle COVID-19.

These were completed at record speed, within a month, because the actions were already underway and very often in advance of national guidance. The plans set out measures to be taken to meet local needs within key topics including:

Prevent spread by encouraging the public to follow social distancing and hygiene advice, to get tested and self-isolate if needed.

  • Identify and manage local outbreaks in care homes, schools and other high-risk places and communities.
  • Use national and local data flows and surveillance to proactively identify outbreaks.
  • Support vulnerable people to get help to self-isolate and ensure support is available to meet the needs of diverse communities at particular risk from COVID-19, with a focus on health inequalities.

Tackling local health outbreaks requires a multi-agency response, pulling in skills, resources and capacity from across the council, the NHS, the wider public sector, the voluntary and community sector and beyond.

To support this partnership approach, ADPH, the Faculty of Public Health, the LGA, PHE, the Society of Local Authority Chief Executives (Solace) and the UK Chief Environmental Health Officers Group produced guiding principles for developing and delivering local outbreak plans.

In October, when more was known about tackling the virus, ADPH published Protecting our communities guidance on ‘combination prevention’ setting out a menu of evidence-based measures, ranging from infection control to communication and engagement, which could be used in combination and adapted for the needs of local areas.  

Common purpose galvanises local partnerships  

As the public experienced the fear and distress of a little understood and deadly virus and the limitation of their first lockdown, activity in local areas was fast-paced and unrelenting.

People involved in tackling COVID – across local government, the NHS and into the wider community – worked hugely long days under maximum pressure and returned to work early the following day to start again. There was so much to think through, decide, organise, and deliver.

At the same time, despite huge anxiety, many people involved report that this time had positive elements. Everyone was working together on the same goal. People emerged from organisational or functional silos and asked what they could do to help – both in personal contributions and through the resources at their disposal.

There was a strong feeling of camaraderie that went far beyond anything people had previously experienced in the work environment. Staff were redeployed across boundaries and trained in new roles.

Traffic wardens delivered food parcels, library and leisure centre staff supported community hubs, health visitors staffed helplines, voluntary and community organisations delivered leaflets: health truly was everybody’s business.

As organisations moved into the long haul of supporting people through social restrictions and implementing ever-changing measures to slow the virus there have been ongoing challenges. But despite this, an underlying sense of partnership and common purpose has continued in many areas.

Many contributors to this report describe a greater understanding of different partners’ roles, responsibilities and challenges, and a renewed commitment to integrating health and social care and tackling health inequalities together.

The fantastic voluntary and community response  

Public health worked with partners on the first lockdown shielding regime, identifying and providing support for people at particular risk from the virus. Tasks included health advice, staff training, setting up community hubs for essential food and medication, and engaging with the voluntary and community sector to identify community champions.

The spontaneous enthusiasm of individuals was often overwhelming, with friends and neighbours stepping up to help people without family support so that public services were not needed.

Councils used existing relationships with the voluntary and community sector to engage with volunteers and developed new methods of engagement such as using online groups, digital recruitment and social media campaigns.

The voluntary and community sectors have remained fully engaged in efforts to tackle the pandemic, including supporting mass vaccination roll out. The role of community champions and networks has become increasingly important.  Many areas have identified ‘legacy’ groups, organisations and networks of champions who will contribute to COVID recovery and beyond.

Birmingham has 585 COVID champions and commissioned 19 organisations to work with 35 communities of interest from older people with no digital access to Sikh communities and African and Caribbean communities.

The champions have played a vital role in engaging with the public and getting accurate messages across at all aspects of the pandemic from reinforcing preventative measures to encouraging vaccination.

Cheshire West and Chester launched Inspire Cheshire West as an interactive online space for residents to share stories of how neighbourhoods are pulling together under COVID-19.

Council teams also use the site to share ideas and information. In the first two weeks, 116 separate stories and ideas were posted, ranging from small acts of kindness to flourishing community initiatives.

The council is also keen to be transparent with the public so they can understand and manage risks, and has started broadcasting outbreak control management meetings online.

Doncaster’s system data model helped identify additional people who fell into the highly vulnerable group and needed shielding. Of the 9,600 people that were first identified as potentially needing support from the council, only 300 to 400 turned out to need help because family, neighbours, faith organisations and community groups stepped in.

Hackney published guidelines for community volunteers, including safety tips for residents who wanted to set up a private WhatsApp or Facebook group for their community. Working with partners, it also published an interactive map of support services filtered on the basis of residents’ needs such as “feeling anxious”, “feeling lonely” and “food and meals” etc.

In its interim report on COVID and Communities listening project, the Carnegie UK Trust found that work to develop hubs strengthened local partnerships and brought a real recognition of the value of volunteers and grassroots community engagement.

The Trust believes that hubs could have a longer term-role in recovery from the pandemic, connecting people to sources of support and promoting individual and community wellbeing.

Primary care network collaboration

Primary care networks (PCNs) have made an important contribution to the pandemic; particular, the capacity for collaboration within and across PCNs meant that the country was able to quickly set up and extend mass vaccination.

As a relatively new development, PCNs are yet to fully embed in some areas, and their role in integrated delivery across health and social care is generally at an early stage. However, the pandemic response suggests that PCNs can go far beyond a role in health and care delivery to become key contributors to the wellbeing of local communities.

In Calderdale, social prescribers worked with council neighbourhood staff and community leaders, going out into streets, shopping areas and mosques to inform people about the importance of the vaccine.

Local GPs serving vulnerable communities have been highly active in encouraging their patients to take the vaccine. Kirklees Council employs nine social prescribing link workers aligned to the PCNs in the borough.

They are now working in the vaccination centres providing a range of support including carrying out pre-vaccination assessments and monitoring patients afterwards.

Wigan’s pandemic response covering prevention, control, communications, PPE supplies, humanitarian assistance and keeping citizens socially connected is delivered through its network of seven multi-agency neighbourhood service delivery footprints, coterminous with primary care networks.

Collaboration across health and care systems, combined authorities and regions

While most of the direct work to tackle the pandemic happens at place level, the ability to collaborate across regions and health and care systems has been vital. Mature integrated care systems (ICSs) have sound partnerships and are well underway with their work on population health, so were in a good position to respond to the pandemic challenges.

Contributors to this report who are involved in systems, believe that collaboration during the pandemic will have a major positive impact on how they continue to work together on health and care integration, and prevention, including tackling the social determinants of health.

In many regions, directors of public health in neighbouring authorities have collaborated on shared priorities for years. These partnerships have formed an important focus for joint work across systems and regions – pooling expertise, support and resources.

Champs Public Health Collaborative is led by the nine Cheshire and Merseyside DsPH working with other partners. The collaborative approach is seen as critical for a joint response to tackling COVID-19. Measures include:

  • a shared outbreak management framework to inform local outbreak control plans
  • a series of joint public health position statements on a variety of key issues such as schools, asymptomatic testing and use of face coverings
  • a local testing framework to manage testing demand, capacity and workforce development
  • a shared contact tracing hub for complex cases, in partnership with regional PHE, to bolster the local response, staffed by a team of 20 local contact tracers
  • behaviour change campaigns on mental wellbeing and information for young people
  • a new integrated data and intelligence system for population health is being used for COVID-19 www.champspublichealth.com/
  • In the One Gloucestershire ICS, the county council and CCG are coterminous with NHS provider trusts. Strong relationships and integrated services have made a big contribution to a shared COVID response. For example, in the first wave fire fighters were trained to take pillar one testing to care homes and then take completed tests back to labs before the national programme was rolled out www.onegloucestershire.net/

The ADPH London Network has worked with PHE and partner organisations in a pan-London COVID work programme to ensure a coordinated approach to outbreak management, prevention, recovery planning and mitigating the wider impacts of the pandemic, including the disproportionate impact on vulnerable groups and BAME communities. Measures include:

  • ‘once for London’ resources such as PPE guides for local authority settings
  • a mutual aid cell to enable redistribution of staff across the system and the onboarding of volunteers and other specialists
  • daily sit-reps to monitor resilience and provide targeted support if required
  • weekly webinars with DsPH and system partners to share learning, communicate messages and facilitate peer support and light-touch peer review. adph.org.uk/networks/london/covid-19/

Greater Manchester Combined Authority, on behalf of its partners, has begun a comprehensive programme of regular insight studies into the issues and impacts of coronavirus across GM as a whole and within its ten local authorities.

Initial research found that some groups were more negatively affected by the pandemic than others – for instance, young people, particularly aged 16-24, families with young children, BAME residents, LGBTQ+ people, people that have served in the armed forces, carers and disabled people.

The surveys provide a basis for targeted communication and engagement aimed at people working together to stop the virus.

In the North East, collaboration between directors of public health and with the regional PHE team is seen as crucial. Directors have met virtually two or three times a week since the spring.

Groups have been convened across the region to support the work on priority areas such as care homes, universities, children and young people, testing and community engagement. Directors take on lead roles working on behalf of the others and provide peer support.

Since its inception, West Yorkshire and Harrogate ICS has operated according to the principle of subsidiarity, which puts place at the heart of system. Mature working arrangements in the ICS have greatly helped a collaborative response to the pandemic in an area with high levels of health inequalities and subject to long-term COVID restrictions.

For example, the ICS established a population health programme in 2019, and staff and resources from the programme were shifted to the COVID response. A sector leads group has been meeting weekly since March and now has oversight of vaccine roll-out across the system.

West Yorkshire Prepared (local resilience forum) has helped establish test centres across the region, scaling up testing capacity with an expanded offer to a wider group of key workers and their households and bringing testing closer to where people live

An undervalued local public health system

From a local perspective, getting the right balance between national and local measures to tackle the pandemic has been an ongoing challenge.

There is appreciation for the hugely difficult job national government had in responding to the pandemic, and an understanding that some measures are most effective when coordinated and delivered on a national basis. Not least of these is the vital national decision to prioritise the development, purchase and speedy roll-out of vaccinations.

However, throughout the pandemic, local authority leaders have called for greater involvement in decision-making and better dialogue before national announcements about measures with implications for local areas.

Overall, they wanted greater recognition that public health, wider local government, and local partners have the skills, expertise, local knowledge and infrastructure to play a major role in combatting local outbreaks. Directors of public health feel personally responsible for protecting the health of people in their areas and felt huge frustration at not always having the tools to do this well.

Two key areas of concern were restricted access to nationally collected data and initial lack of local involvement in contact tracing. As a result of shared experience and learning between national and local organisations there have been improvements throughout the year, but this took time.

Restricted access to nationally collected data, particularly information about locations of people testing positive at postcode level, meant that local public health did not have full information to monitor, analyse, model and take action on local virus patterns and outbreaks.

ADPH’s Data Explainer provides a detailed analysis of problems local authorities had accessing data up to July 2020. It includes a ‘Data Manifesto’ which asks government and national agencies to adopt the following principles: local data sharing as the default setting, consistent access, high quality and comprehensive, and timely and useable.

NHS Test and Trace performance tracker was set up as a national system, often delivered through contracts with multinational private companies and a national call centre for contact tracing.

From the start there was criticism that this neglected local knowledge and capacity, and this grew when, for many months, the system struggled to contact 80 per cent of people testing positive.  This is minimum effective level, as advised by the UK Scientific Advisory Group for Emergencies (SAGE) meeting.

In contrast, pioneering local test and trace teams set up in local authorities in partnership with regional PHE generally exceeded the 80 per cent minimum.

In August, the national system was redesigned to include local contact tracing, initially in areas with high prevalence, with resources from the national system transferred to local authorities which were tasked with contacting people testing positive who could not be reached within 24 hours, and people in complex settings such as care homes.

The combined effort meant that in December, national test and trace reached 86 per cent of people testing positive (Secretary of State 10 December daily briefing). However, limitations remained, with local teams required to pass on information about close contacts of people testing positive for the national service to trace.

There is a strong view in local government and public health that if local contact tracing had been resourced to take a greater role, this would have led to a more swift and effective system. The ADPH has consistently advocated for a ‘team of teams’ approach with the responsibilities of each part of the system clearly articulated and properly resourced in its Explainer test and trace service.  

In the vanguard of new initiatives

At various stages in the pandemic there have been opportunities for local areas to be involved in national/local partnerships to trial new initiatives. Local government is ideally placed to do this because of its reach across infrastructure and communities, while partnerships between public health and academic institutions provides a good basis to pilot and evaluate new measures.

In November, Liverpool piloted asymptomatic screening tests for anyone living or working in the city, with tests available at a range of fixed and mobile testing sites including leisure centres, community centres and schools.

This was a partnership approach involving the local resilience forum, the army, DHSC, PHE, NHS partners, Liverpool University, and the voluntary and community sector. Around 25 per cent of residents took up lateral flow tests (LFT) and 35 per cent took up either LFT or a polymerise chain reaction (PCR) test.Over the month of the pilot, infections dropped by more than two-thirds.

Learning from the pilot has been used to inform national and local roll-out of asymptomatic testing.For example, the pilot found that sites should be socio-demographic not just geographic, and strong localised communication and engagement is essential because word of mouth is as powerful as social media.

An independent evaluation of the pilot will be published.The first centralised national contact tracing app was piloted in the Isle of Wight and promoted on the island community by the council, eventually being downloaded by around 54,000 islanders.

The pilot showed that the app had significant limitations, and it was abandoned in favour of a model that was compatible with all major smartphone services. However, feedback from the pilot was used to shape a second trial in August, again on the Isle of Wight and also London Borough of Newham, with its ethnically diverse community.Information about the Newham app was available in multiple languages.

The app operated alongside the enhanced local contact tracing and testing system driven by Newham public health team. It was promoted by a COVID-19 health champions network and neighbourhood outreach teams who went to churches, mosques, community centres, local businesses and other settings to offer help and provide demonstrations.

Problems identified in the trial were confusions about QR codes and lack of ability or willingness to engage in tech – some people preferring to provide pen and paper information. Newham advised developers to extend the download age-limit from 18 to 16 to get more young people engaged, involved and able to help older generations.

Learning from early local outbreaks

Over the summer there was a hope that COVID-19 outbreaks could be contained by targeted interventions in specific locations. At that time there were several significant highly localised outbreaks, generally in agricultural, industrial or hospital settings.

Also, as the country was relaxing restrictions, some public health teams were aware that levels in their local authority were not reducing as much as others, in fact they were increasing. This started in the East Midlands but was soon followed by areas in the West Midlands and across the North.

These situations were unchartered territory for public health, and took place at the time that national interventions, such as Test and Trace were just getting off the ground. The areas involved were able to pioneer interventions and articulate learning and key messages, not only across other areas but nationally. For example:

  • Self-isolation was problematic for people on low incomes and insecure employment who needed to work to pay bills – this feedback contributed to the national £500 low-income payment.
  • Workplaces were often COVID-secure, problems lay outside the work environment in car sharing and smoking areas.
In Leicester City, the first signs that the virus had not lost its hold started emerging in early June when the city started to get pillar two data. Because it was just the raw number of cases this was difficult to interpret, and hospital admissions were low. But soon it was apparent the increase was real, and Leicester became the first city in the UK to enter a lockdown.

The city was able to pull in resources quickly. Mobile testing units were deployed, and high-rate neighbourhoods were identified. Much of the early work, from setting up walk-in centres to offering door-to-door testing, was being done for the first time and was a steep learning curve.

The vital importance of neighbourhood-level data was clear, and the city made this point to government and hopefully influenced greater access to information for local areas.

The need to ramp-up capacity to test residents more directly led to the council establishing an outreach operation to distribute and collect testing kits door-to-door in the community.

By the start of September, the CityReach operation had resulted in over 40,000 tests being delivered. The council’s digital transformation team used a package to digitally recruit, manage and coordinate a large group of volunteers – in the first few weeks of lockdown over 500 volunteers had signed up.

Norfolk public health tackled an outbreak in a large local factory with a geographically dispersed workforce and many languages.

The council worked closely with the firm’s HR team: a review of infection prevention procedures set up by the factory was carried out and additional measures adopted, including the installation of more screens between workers and closing a reception area where staff gathered before work.

Financial support for workers self-isolating was needed, and £37,000 of council funding was spent on this. The government’s subsequent announcement of £500 for people on low incomes to self-isolate is seen as very helpful.

In North Somerset, a spike in cases at Weston hospital was the first major hospital outbreak when lockdown restrictions had been relaxed. Weston Super Mare is a popular day trip destination. Because prevalence data was not yet available, it was important to trace the source of the outbreak.

A mobile testing unit was deployed and whole-hospital testing took place. Public health worked with the PHE health protection team which was doing contact tracing, and with NHS Test and Trace which had launched that week.

Combined information showed that the outbreak was mainly within the hospital which changed some protocols and how it cohorted patients.

Balancing risks, difficult judgements

Tackling a pandemic is a rapidly evolving situation in which everyone involved has had to learn, adapt, persist, take risks and innovate, while operating under huge challenges and pressures.

While everyone is focused on the same goal, and there are some clear imperatives, there are also areas on which there are different views about the best way forward so judgements have had to be made.

Sometimes this involves balancing needs and risks to find the least-worst outcome. Throughout the pandemic, there have been tensions between the benefits of keeping people virus free and the negative impacts of individuals and the economy – between individual freedoms, prosperity, and collective safety.

Nowhere has there been a more distressing dilemma than in care homes. After early days of many deaths in care homes, moves to prevent virus transmission by restricting visiting have had a terrible impact on people who live there and their relatives and friends.

Another area of dilemma were mass isolations of university students when there were major outbreaks. With students likely to be asymptomatic transmitters of the virus, mass self-isolation restrictions took place to protect the community. But these were difficult decisions.

There were also differences of view about interventions among academics and public health experts. A prominent example is the use of lateral flow tests (LFTs). In December the government made rapid tests available to DsPH interested in using these in settings or communities that are local priorities.

Rapid testing is also being used in universities, at ports and airports, schools and many other settings. LFTs are non-invasive and have quick results. They contribute to the wider understanding of COVID prevalence and have the potential to break chains of transmission.

The Government’s evaluation is that LFTs are accurate enough for community settings. However, there is a debate in the public health and academic community about the circumstances in which LFTs should be used, how to mitigate any impacts from false positives or false negatives, and whether the significant resources needed to offer tests could be used more effectively.

The LGA produced a briefing on Lateral Flow testing on issues involved in rapid testing, and ADPH with the Faculty of Public Health produced a joint statement on targeted community testing calling for evaluating and learning from pilots.

Raised profile for public health

Awareness and understanding of public health in the general public and in organisational partners and colleagues increased markedly throughout the pandemic.

Local government leaders report that their role in the pandemic has been an irreversible game changer for how DsPH and their teams are viewed in local authorities and across wider partnerships, and their influence will continue into the future.

But for the public, just as social care became equated with care homes, public health is associated with tackling disease. The raised profile is very positive and should be built on going forward, but it will be important to emphasise that public health is a multi-faceted discipline with a large range of functions.

Its basis is in scientific understanding and its methods include epidemiology and understanding the social determinants of health, but it also involves skills like working at the frontline with individuals and communities. This span of functions gives public health its huge potential to make a real difference to people’s lives.

Responsive and creative solutions

Paul Najsarek - Chief Executive, London Borough of Ealing and Solace spokesperson for wellbeing

Public health’s moment has come. The pandemic has shone a light on the pivotal contribution of public health, promoting partnerships and collaboration, focusing on prevention and inequalities, and providing professional skills and guidance so local and system leaders can deploy resources effectively.

Professor Jim McManus - Director of Public Health, Hertfordshire County Council

Keeping vital services running has been one of the most complex parts of the work I and my team have been doing. Resources were diverted to COVID so we had to prioritise which services needed to continue and which could be switched to online.

This requires careful consideration because reducing some services increases risks, such as illness and safeguarding issues. During the pandemic we also increased some services to meet need.

The whole course of the pandemic has been a huge learning experience in which DsPH and their teams and colleagues have had to make quick decisions while being open and flexible to changing circumstances.

Being proactive and innovative has been essential because solutions that worked one week might be redundant the next. Some of the activity taking place has never been tried before, and even familiar processes have never taken place at this pace and scale.

This section highlights some of the key ways in which public health has pushed the boundaries and deployed evidence and experience to try new approaches. There are many other examples of these – see, for instance the LGA’s good practice examples in the resources section.

Local information and engagement

From the start of the pandemic, public health has been at the heart of trying to ensure that local information complements, clarifies and reinforces national messages with a local slant.

Directors have been heavily involved in regular briefings to local MPs, councillors, and senior managers in local government, the NHS and others – setting out the local position and interpreting national information. 

DsPH and lead members for health and wellbeing have often been the face of accurate local COVID information for the public and have been keen to be honest and open to build trust in difficult circumstances. Many have used a questions and answers approach, regularly updating information as the pandemic progressed.

Working with council communications teams, public health used skills in health promotion campaigns and behavioural insights to reach a wide audience and to target information to groups and neighbourhoods at greater risk of infection.

Teams have used local media, social media, blogs, leaflets and foot-leather to communicate directly with communities, including myth-busting inaccurate and potentially harmful theories about the virus and subsequently the vaccine.

Over the summer with a lull in the virus, attention turned to how communities could be engaged in shaping COVID recovery. Participation organisation Involve has published an online handbook on 'How do we involve communities in the Covid-19 response and recovery?' providing practical ideas for engagement and providing examples of areas that have already started the process.

For example, the West Midlands Combined Authority ran a citizens’ panel online, and Bristol City Council has a three phase approach focused on addressing inequalities and engaging the under-represented through focus groups, a survey Your City our Future, and a citizens assembly.

The LGA has produced guidance, templates and case studies in areas such as internal communications, communicating with residents, media and social media – see resources.

Birmingham public health has used a range of platforms to engage with groups and communities, including traditional radio, working with local influencers on social media, live Instagram sessions, bilingual ‘Q&A’s with Sikh KTV channel and online Mirpuri channels.

The health and wellbeing board broadcast a ‘Q&A’ session live and received over 600 questions. Those that could not be answered at the time were responded to in writing by the Chair.

Gloucestershire aimed to make public messaging more positive. The campaign “Do it for us, do it for Gloucestershire” is upbeat, featuring real life stories from residents to make it relatable.

Hackney has a large orthodox Jewish community who do not watch TV or use the internet. The council set up a forum with community elders so they could pass on safety messages to their group.

Leicester City Council stressed the ‘Leicester Together’ theme to emphasise collective effort. In order to provide consistency and build trust, delivery was focused on two clear voices – the DPH and the mayor.In July,

Liverpool identified a rise in confirmed cases in one of its most diverse and deprived wards. It produced key messages which the faith and community sector put on their websites and messaging apps; the community created simple YouTube videos translating the messages into different languages.

It also established walk-up testing and put boots on the ground visiting homes and shops offering advice. It enlisted the local community, such as the ice cream van man to give out leaflets. Within two and a half weeks, case numbers had dropped significantly.

COVID-secure settings – guidance, support and compliance

Public health teams have worked extensively across public sector and private organisations to provide advice, guidance, and hands-on help to make settings COVID secure. Key aims were to reduce overall risk, to target setting presenting greater risk, such as night-time hospitality venues and care homes, and to enable schools, colleges and universities to open.  

Public health also been part of local collaborations to implement COVID compliance and enforcement rules. The overall ethos in local partners is, far as possible in the first instance, to focus on advice and guidance to keep the population on board with restrictions, and to use fines and penalties for repeat or high-risk breaches of COVID rules.

To meet the increased demands, areas have pooled resources and have redeployed staff into other roles, such as parking staff taking on a marshalling role and business support staff providing welfare advice.

The LGA has produced guidance and good practice examples on many aspects of secure settings and compliance – see resources.

Business

Newcastle Council worked with Newcastle University and NE1 business improvement district on the ‘How busy is toon?’ website to assist safe shopping through social distancing. Computer vision cameras track real-time footfall on the main shopping street and information is provided by a traffic light system – green meaning there is sufficient space and red advising people to delay their shopping trip. The site also provides information about car parking spaces.

Walsall public health used established networks and partnerships to work with local businesses like hairdressers and gyms to adopt COVID-secure practices. The council’s business team, which was responsible for managing the grants to local businesses, was part of the local test and trace operational group. They combined allocating grants (about 4,000 were provided) with engaging with local businesses to identify high-risk settings, and around 500 businesses were provided with additional support.

Care homes

Cumbria started whole care home testing before this was introduced nationally. An outbreak control team was established to provide advice and support, including offering testing of all resident through local swabbing teams and testing labs.

Lincolnshire has provided public health support to care homes for several years, and its infection control lead and health protection team, which would normally help with winter illness, was well-placed to help homes through COVID, including setting up a dedicated phone support line.

In the early days of the pandemic, Portsmouth used detailed analysis of national data and local intelligence combined with senior-level meetings to monitor infections in care homes.

The provider infection control team visited each home to provide training and advice on how to prepare for, manage and prevent outbreaks at the time of lock down. The analysis and oversight also meant that Portsmouth was able to decide which homes should be prioritised for whole-home testing.

Portsmouth also sourced its own stockpile of PPE to supplement what was available through the care home supply route and via the local resilience forum.

Schools and universities

In the early months of the pandemic, when information was less available, Hertfordshire set up a dedicated helpline for advice to schools. Advice was given on many topics, such as deep cleaning, and whether children of self-isolating parents could send their children to school.

In Croydon a popular and effective technique in schools is the use of flow charts which take staff and students though how they need to stay safe using a step-by-step process.

Gateshead public health and schools worked hard together over the summer, doing risk assessments to see how they could prevent spread, making sure the flow of the school was right and safety procedures were in place and understood.

Durham public health and Durham University worked through the summer on an outbreak response plan, including mock outbreak control scenarios, induction week planning and community liaison with local residents.

University staff received training in mental health support, halls of residence were split into bubbles and there were plans for food and activities for those isolating and teaching for those who were not isolating. There was an outbreak in the university, but little spread to the community.

Compliance and enforcement

Kirklees worked with the hospitality industry, using webinars to encourage bars and pubs to take the right steps to be COVID-secure and to encourage their customers to be alert. The council also introduced local restrictions, not allowing gatherings of over 30 people, and stopping a fun fair from opening.

Manchester City Council deployed teams of stewards accredited in events crowd management to act as marshals to promote compliance, working alongside neighbourhood managers and police. This involved mobile teams split into areas, deployed 24:7 as needed. The resource is reviewed on a weekly basis. Feedback from the marshals was collated and provided to Manchester City Compliance.

Oxfordshire County Council and the five Oxfordshire districts implemented a system-wide approach to COVID compliance and enforcement including:

  • A new COVID secure team of environmental health officers and COVID compliance support officers working across the county to provide additional capacity for core teams.
  • Mutual-aid arrangements for pooling staff, including officers with experience in infectious disease outbreak control supporting incident control teams.
  • Centralised information gathering with data targeting compliance at areas of highest risk.
  • Delegation of enforcement powers from the county to districts, and a weekly operational forum and leads for different aspects of work.

Local contact tracing

Councils have been setting up local contact tracing services since the early summer, working with regional PHE, and using the expertise that already existed in public health, environmental health, sexual health services and across the council.

Local contact tracing provides many advantages – staff understand the area, a local telephone number which also helps combat contact tracing scams, and a local voice on the end of the phone.

For people who cannot be reached by phone, staff can go out and ring doorbells. Local public health teams have refined how local contact tracing is delivered. Teams are trained to take a supportive and individual approach – linking people to national and local welfare support available to people self-isolating, and also picking up on wider health and wellbeing needs and emotional distress.

Local tracing also provides useful data about the locations of outbreaks. Where there are concerns about the safety of a particular setting, links to colleagues who support safe environments can be made.

Sandwell was one of first areas not facing government intervention to set up its own contact tracing system, going live in July. The core team includes staff from public health, customer services, education and social care, and was expanded to over 25 contact tracers, with 50 in reserve.

It includes Punjabi and Gujarati speakers to communicate with some local communities. The team aims to be friendly and supportive, and the national script has been amended so it provides a more natural conversation.

The team provides access to food and medicines delivery and financial support for those who need this to self-isolate. People reached by national test and trace are also contacted to see if they have welfare needs.

Sandwell has changed its door-to-door tracing to increase contacts. Initially domiciliary care workers spoke with people and encouraged them to accept a phone call, but now the housing support community team collects people’s details and offers welfare support.

Sheffield took time to research, develop and train its local contact tracing service which started in October with a dedicated team of twelve. Data from the service feeds into a dashboard specifically developed by the council to monitor the spread of the virus and to respond to high-risk areas.

The team takes a whole person approach; as well as information about the support available to people who self-isolate, it provides links to food banks, citizens advice, domestic abuse support and other wellbeing services. Some of the work is very sensitive – people being contacted may have loved-ones in hospitals or have suffered a bereavement.

Sheffield added door-to-door contact tracing using community and environmental health teams with access to a team of health advisors the council has recruited.

In September, Solihull set up a ‘backward tracing’ team which investigates where people testing positive caught the virus to provide soft intelligence for how it was spreading across the borough and to spot outbreaks and clusters where interventions from environmental health or others are most likely to add value.

The team was staffed by six public health staff and initially received around 75 cases a day which grew in number. Letters were sent to people testing positive, advising them of their legal obligations to self-isolate and information about support available, including the £500 payment.

These were followed up by a call from the team. One of the first cases identified a link to a hospitality venue and found more than 20 positive cases. The team is now providing local contact tracing to support national test and trace

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Rapid community testing

Rapid community testing for people without COVID symptoms was made more widely available to councils in December, and local public health teams looked to how this could be targeted to make maximum impact in identifying asymptomatic people transmitting virus.

They also sought to reduce the variable accuracy of LFTs done in the community, monitor outcomes, manage expectations about how the approach should best be used and find staff to resource the work.

Areas considered how to deploy the tests to local priority communities, beyond the groups covered by the national testing programme. Rapid community testing was introduced quickly by many areas in December. This is a new type of public health service in the UK, and areas have taken different approaches dependent on the needs of their populations including:

  • permanent testing centres
  • rotating between sites
  • pop-up sites in community hubs
  • drive-through sites
  • mobile testing units
  • drop-in facilities
  • appointment only.

Other areas are focused on at risk groups like homeless people, or on particular settings such as colleges or workplaces.

All areas emphasise the importance of staff who can engage with, advise and reassure people coming for tests. The growing availability of LFTs means that areas are looking to expand their programmes, as one important element of a multi-pronged strategy to reduce community infection.

Luton Council opened three community rapid testing centres in early December, at the main library and two community centres, open on a drop-in basis seven days a week.

The centres proved very popular and by late January 45,000 tests had been carried out with 1,900 positive. Key workers have been encouraged to use the community sites regularly.

The centres use protocols and quality control measures to keep void rates low and ensure tests are as accurate as possible. The council also has a mobile testing team deployed to outbreaks in workplaces and other settings.

It is looking to be more proactive and preventative, such as sending testing kits to employers for regular testing.As well as setting up a rapid testing centre which operates on appointment basis, Hackney and City of London have rolled out LFTs in supported housing projects and homeless sector providers where people may find it hard to use community testing stations.

Nurses and other health staff are deployed to train staff and provide ongoing support.North Somerset set up rapid testing at its main college campus in December, encouraging students and staff to be tested at least once a week.

The experience of setting up and running the site has been used to provide schools with practical information and advice for their own testing regimes. Two further community testing centres have been set up, jointly commissioned with South Gloucestershire.

Wirral made a huge team effort to set up four community testing sites across the borough in December, initially supported by military personnel. Community testing has created employment opportunities for local people, with the council recruiting new staff as well as redeploying or offering additional hours to existing staff – over 150 staff in all.

The service is available to any resident with no booking required and results generally available within an hour. The service was launched through media outlets and proved popular.

In the first ten days nearly 15,000 tests were carried out, of which 83 proved positive. Future plans include working with partners to connect more with groups who may not come forward for testing.

Surge testing

The value of having local testing sites and local teams on the ground able to contact people in specific areas or communities has been demonstrated in surge testing used to identify and contain COVID variants of concern.

Local councils and local NHS with regional PHE are using their capacity and expertise to mass contact and test across post codes where genetic sequencing of test results has revealed individuals testing positive for variants.

Test centres and door-to-door testing are deployed in at risk areas. This initially focused in eight postcodes across the country covering around 80,000 people but has been extended to many regions as other areas identified variants of concern.

Supporting vaccination

Local government has worked with the NHS on practical and logistical tasks to ensure that the vaccination can be given to as many people as quickly as possible. Councils have a wide range of relationships with organisations, such as private landlords and businesses.

Based on the experience of setting up community testing sites, they have identified suitable vaccination sites and helped make these ready for use, including making sure they keep running and are accessible in winter weather – snow and flood.

Council staff have been redeployed to help with car park and queue marshalling, admin support and driving duties and have helped recruit the numerous volunteers working at clinics. A key role for public health has been to encourage vaccination in hesitant groups through designing targeted materials to be distributed through their networks of champions in faith and community groups.

When setting up vaccination sites with the NHS, Kirklees Council’s infection prevention and control team provided advice about reducing infection, and the council also helped with IT connectivity and getting hold of PPE.

In a period of snow 1,400 doses got stranded on the border with Bradford Council which deployed a vehicle to collect and deliver the vaccine to Kirklees. In a period of heavy rain, the council placed spotters round the vaccination centre to monitor water levels, and plans were in place to relocate if necessary.

A system has been set up for GPs to identify people who need help getting to a centre, with help provided by a team of council and voluntary sector drivers.

Gateshead Council has been a big advocate of making every contact count and has a MECC network of more than 40 partners from across all sectors. The network helped public health devise materials to inform communities about the vaccine and has been passing these messages on in their digital or phone contacts.

Some in the network customised material for their groups, such as developing a video for people with learning disabilities. The information has also been distributed across the area’s COVID champions network of community and faith leaders.

Hertfordshire Behavioural Change Unit was set up in August 2019 to embed behavioural science across council workstreams. The work of the unit has been applied throughout the pandemic to support preventative behaviours such as social distancing, positive mental health and resilience and to reduce vaccine hesitancy.

The unit reviewed research on vaccines in past pandemics and undertook local consultation with BAME and gypsy and traveller communities to identify barriers and motivating factors.

The COVID Information Champions project is being used to utilise local networks, train champions and provide targeted information to increase take-up.

Warrington Council is working with a group of pharmacies, run by members of the local Islamic association, that are delivering the vaccine in communities with high numbers of BAME communities, with a view to encouraging greater uptake of vaccine

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Embracing new ways of working

Deploying a limited number of staff where they are most needed and can make greatest impact has been a complex balancing act for public health teams, particularly those in smaller areas with less capacity.

Staff absence when self-isolating through COVID has also been an issue, as it has for all employers. Directors have had to prioritise vital services and identify those that can operate in different ways. They have also had to try and increase services that are more in demand due to the pandemic.

Using online and digital communication has been the cornerstone of making services more flexible. Many areas were already increasing their digital offers in new contracts for services like sexual health and stop smoking.

Some areas not traditionally associated with digital communication, like health visiting and drug and alcohol support groups, have developed online offers, which are being evaluated for effectiveness.

While digital communication will never replace one to one contact or groupwork, it can be highly effective, provides good value for money, and is popular with many participants who find it more convenient, more relaxing being at home, and more environmentally sound.

Stop smoking

Hertfordshire Council combined its move to remote stop smoking consultations with a drive to encourage more people to give up because of the increased risk of complications from COVID-19. 

Hertfordshire’s stop smoking service adopted Quit4Covid branding produced by the Smokefree Action Coalition to reach out to new clients through local services, such as general practice, and through social media. 

The service normally receives 350 referrals a month, but in six weeks received more than 850. The team increased their hours and provided a telephone service which was welcomed by clients who appreciated its convenience.

Remote services are not appropriate for all groups, but they are beneficial for many. Evaluations are taking place and the service is looking to trial video consultations.

Healthy eating

Northamptonshire Council’s adolescent support service ran healthy eating sessions via Zoom as an alternative to their established face to face healthy eating group. The group met to learn about healthy eating, cook basic dishes and talk about how lockdown had impacted on them.

Facilitators had to learn how to operate online, particularly with cooking involved, and some participants were initially anxious, but the sessions became very successful with people enjoying the interaction and saying it reduced feelings of isolation. 

Health visiting When health visiting services had to stop face-to-face contacts for all but the most vulnerable mothers during lockdown, Hampshire Council continued to provide support through online contact.

A digital video service was used to carry out routine appointments, while Zoom was used to support parenting groups and groups for new mothers.

People had access to health visitors, psychologists and nursery nurses to support play activity. An existing text messaging service, Chat Health, provided support for parents of under-fives.

The digital services meant it was harder to pick up on early signs of problems, and workers had to adapt their skills. However, some women reported they felt more comfortable in a virtual setting and some found it easier than travelling to appointments.

Where appropriate, some elements of the digital service will be maintained. Sexual health services Dorset Council was in the middle of re-commissioning sexual health services, with better triaging and a comprehensive digital offer, when the pandemic hit and accelerated the process.

The new service quickly introduced phone and video triaging and online STI and routine oral contraceptive ordering. Vulnerable people were invited to attend the service in person.

The changes were well received, with around 1000 tests and 400 contraceptive prescriptions issued each month, and 95 per cent of users saying they were satisfied. People have particularly appreciated reductions in travelling time in a big county. The service will evaluate the impact of moving online on key groups for future development.

Homelessness 

Stevenage Borough Council’s ‘The No More service’ works takes a holistic approach to help people reduce alcohol consumption, drug use and offending and supports people with complex needs.

It works in partnership with other services including the police, mental health services and housing providers. A support worker is assigned to individuals to develop a support plan and make coordinated referrals.

During the first lockdown the service worked with 48 rough sleepers who had been helped into temporary accommodation. The team had daily conversations with these people to find out more about their lives and support them to make changes.

The team found that the pandemic had a negative impact on existing coping skills, with people feeling more isolated, and some struggling with adapting to temporary accommodation rules.

Domestic violence

In response to the concerning rise in the number of domestic abuse incidents since the first lockdown, partners in Devon and Cornwall issued an online campaign to raise awareness about what counts as abuse, and to assure people that a range of help remained available, including ‘Victim Care’ offering an online live chat service and a telephone helpline.

Clean air and active travel In cities and major towns, with additional government funding, there are many examples of initiatives to reduce emissions and promote active travel options: low traffic neighbourhoods, new cycleways and enhanced walkways, encouraging electric vehicles, cycles and scooters and zero-emission areas.

Not all initiatives have been welcomed in communities and some areas have postponed introducing clean air zones because targets were met through reduced travel, but clean air and active travel will be major priorities going forward.

Building a fairer future

Robin Tuddenham - Chief Executive, Calderdale Council, Co-chair West Yorkshire Prepared

Collaborating on the pandemic has brought West Yorkshire and Harrogate Health and Care Partnership (ICS), West Yorkshire Prepared (local resilience forum) and West Yorkshire Combined Authority closer together. This will help us to tackle both the economic and health impacts of the virus in a joined-up way.

Kate Ardern, Director of Public Health, Wigan

The pandemic has led me to develop my thinking about health protection being a whole-society, whole-place response rather than the epidemiological and biomedical approach public health professionals traditionally take – as important as this is.

Challenges and opportunities

At the time of writing, the country is facing more contagious new variants of COVID-19 alongside accelerated vaccine rollout. Directors of public health and their teams continue to be at the heart of activity to tackle the virus.

Alongside colleagues from the NHS and other frontline sectors, many are physically tired and mentally exhausted, but they always keep one eye on what can be done to rebuild in the future.

Many reports on the disproportionate impact of the pandemic have already been published and many more will emerge as more details of how people’s health has been affected, both by the virus and by measures taken to stop its spread.

The main areas of focus are inequalities linked to geography and poverty, the effect on BAME communities, and issues such as mental health, alcohol, drugs, alcohol consumption, homelessness, domestic violence, food poverty, obesity, children’s development, and physical health.

There is also the huge impact on people who have been at the frontline of tackling the pandemic for so long – NHS workers, care workers and other frontline staff, many of whom are experiencing mental exhaustion, low wellbeing and sometimes mental health problems.

Research is taking place into the effects of people experiencing long COVID symptoms. Less is known about the longer-term impact of living through the pandemic on the general public – their mental wellbeing and resilience, for instance – more information will emerge in time. The pandemic has had a major impact on the health and wellbeing of our society and will be a priority for public health for many years to come.

A timely overview can be found in ‘Build Back Fairer’, Professor Sir Michael Marmot’s report on COVID  which provides a detailed analysis of the terrible impact of the virus on pre-existing health inequalities relating to poverty, deprivation, ethnic background and geographical area, with the North of England hit worst of all.

The COVID-19 Marmot report supplements their ‘Ten Years On’ report of February 2020. It calls for a fundamental shift to social justice and “putting equity of health and wellbeing at the heart of all policy-making, nationally, regionally and nationally” (P196) and makes short, medium and long-term recommendations. With so many councils already using Marmot principles to underpin public health, the recommendations in both reports will form part of the COVID recovery response.

The wider context is a terrible financial situation which will make ‘levelling-up’ even more challenging. A growing deficit and badly affected economy will impact already hard-pressed public health funding. But health inequalities must be tackled.

A recent Institute for Public Policy Research (IPPR) North 'Levelling up health for prosperity' report points out that the poorest parts of England have seen the biggest cuts to council public health budgets and that these regions have particularly hard hit by coronavirus. The IPPR estimates that improving in health of people in the North to same levels as rest of England would add £20bn to the annual economy.

There are also changes to organisational structures. The recent Health and Care White paper sets out a promising base on which to build stronger working relationships between local government and the NHS. Placing ICSs on a statutory footing with a joint health and care partnership in every system provides an opportunity to address the wider determinants of health both across health and care systems and locally.

The new National Institute for Health Protection has taken over PHE health protection functions, and, as it becomes established, effective collaboration is needed with regions, systems and places.

The establishment of NIHP provides an opportunity for local learning during the pandemic to inform future planning and delivery of health protection and resilience functions at a national, regional, system and local level.

The delay to the NIHP becoming fully operational (now October 2021) hopefully means that more time is available to ensure the institute has a ‘whole-team’ and collaborative approach in which local government and local public health have a strong voice from the start.

A full evaluation of the pandemic response is needed, but early suggestions from local public health is that there should be a shift to more emphasis to the impact on individuals and communities affected.

A key example is the issue of people on low incomes with unstable employment finding it difficult to self-isolate for financial reasons, and the government providing £500 funding to support isolation. The role voluntary and community organisations in the pandemic also suggests a greater role for that sector in emergency response.

A question hangs over the future of remaining PHE functions. Local government has many years of experience in operating under the sector-led improvement (SLI) approach. When it joined local government, public health, with its skills in data analysis and evaluation, its regional networks, and its basis in evidence-based practice embraced SLI.

The abolition of PHE provides an excellent opportunity for an enhanced SLI approach in which councils are held locally accountable for improving and protecting citizens’ health, including tackling the social determinants of health. SLI provides collective responsibility and represents significant value for money – operating at a fraction of the cost of alternatives such as national inspection regimes – resources which would be better invested in directly improving health.

The enhanced element of public health SLI would increase the emphasis on robust challenge and accountability, and on shared learning, both locally and nationally.

Priorities for a fairer future

Public health has three overarching goals for the future:

  • tackling the health inequalities that the pandemic has exposed and deepened 
  • developing greater understanding of the impact of the pandemic on the general population
  • learning from the pandemic to improve health protection and resilience for continuing threats and future outbreaks.

The following priorities have been identified through discussions with DsPH and local authority leaders in compiling this, and previous, public health annual reports.

The messages are familiar but are overlaid with a sense of urgency brought about by the experience of the pandemic, and by some of the positive legacies that have emerged.

The measures below are highly important, and all will have a positive impact. But at this pivotal time, directors of public health and local government leaders are clear that only a comprehensive and properly resourced approach to population health will result in fundamental change.

A national drive to reduce inequalities

Professor Sir Michael Marmot’s report, Building Back Fairer, calls for a national commitment to social justice to reduce health inequalities, and action to make this a reality. It warns of the social and economic consequences of failing to do this.

The government’s levelling up agenda was important before the pandemic and is even more essential for a stable and prosperous future. A comprehensive, ambitious and energetic drive to tackle the social determinants of health at national, regional and system level must be take place and be properly funded.

Systems prioritise prevention and health inequalities

The joint commitment, energy and resources of combined authorities, health and care systems, and places is needed for there to be any chance of reducing health inequalities. Partners need a relentless focus on prevention, health inequalities and tackling the social determinants of health.

The experience of the pandemic and long-standing DPH collaborations will help identify the activity that is most effective at scale and what works best in places. Places, with their PCNs and communities, are the central building blocks to deliver on prevention.

The increased understanding of public health in frontline staff can be used to accelerate the rollout of making every contact count models.

Understanding the impact of the pandemic on the general population

Most of the reports on the impact of the pandemic on mental and physical wellbeing have focused on how people already facing health inequalities have been affected the most.

However, there are big questions over the longer-term impact on the general population that need to be better understood – for example, will there be longer term impacts on the mental health of young people, on drinking patterns, on obesity. Public health will be working on these issues in the coming years.

Whole-system health protection

Local government and public health should work with national and system partners to develop a new model for health protection – one which does not just tackle outbreaks or incidents, but responds to the impact on individuals, and harnesses the power of communities.

For future outbreaks, a national, regional and local partnership of all key sectors, playing to their strengths and operating as a virtual team, is needed. The new National Institute for Health Protection should embody this partnership approach, and local government and local public health should have a strong voice in NIHP from the start.

Update and prioritise early years support

The health, wellbeing and prospects of children and young people, particularly in deprived areas, have been damaged in the pandemic. Early years support forms the basis for future healthy lives, but important services with proven effectiveness, like Sure Start, were closed during the years of economic austerity.

Redeploying updated models of support, with enhanced digital offers and more focus on community assets, peer support and positive mental health in families, should be a priority.

Employment and poverty

The link between unemployment and low-paid and insecure jobs and health inequalities is fundamental. Poor mental health is a vital issue in employment, leading to people finding it difficult to obtain or maintain employment.

Public health should consider making increasing employment opportunities, and mental health in employment key priorities, building on links with the business sector locally, in combined authorities, and across health and care systems.

Building on stronger communities and public understanding

The public’s increased understanding of, and personal involvement in, health, and the upswell of community support during the pandemic are important opportunities which public health can capitalise on when the pandemic recedes.

Models previously developed by public health, such as health champions, making every contact count (MECC) and asset-based community development have proved their worth in the pandemic.

Basing their work on community engagement and empowerment, and working with a person-centred approach, areas should consider:

  • developing a comprehensive model of asset-based community development
  • deploying these models first in areas where people are facing high barriers to health and wellbeing, such as black and minority ethnic (BAME) communities
  • developing health and wellbeing champion networks and MECC type initiatives
  • expanding health improvement programmes, making sure these provide single access to both healthy living support and wider help like debt advice.

Aligning climate change and prevention

Measures to tackle climate change and to improve health almost always share compatible aims and have important synergies. Fully aligning the environmental and health prevention and improvement agendas at place, system and combined authority level will bring mutual opportunities and make best use of resources.

Innovation and research

Digital communication is becoming the norm across society and is appreciated by many people who use public health services, particularly as an alternative to travelling long distances.

As services shift online, public health teams have evaluated their impact with a view to making sure that people who need personal contact continue to receive this. The digital offer will continue to develop and improve in the coming years.

Public health can be at the forefront of all new modes of service delivery. Strong partnerships with academic institutions willing to conduct research with practical benefits will strengthen this.

Sector-led improvement

With the closure of PHE some of its functions need to be reallocated. An enhanced local government sector-led improvement approach would provide a cost-effective and integrated way for local areas to be accountable locally and nationally for their performance in health improvement, tackling inequalities and health protection.

References and resources

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ADPH, 2020, Explainer: data

ADPH, 2020, Guiding principles for effective management of COVID-19 at a local level

ADPH, 2020, Statement of principles: contact tracing

ADPH, 2020, Explainer: local outbreak plans

ADPH, 2020, Protecting our communities pulling together to achieve sustainable suppression of SARS-CoV-2 and limit adverse effects

ADPH & FPH, 2020, Joint statement on targeted community testing

Carnegie Trust, 2020, Pooling together: how community hubs have responded to the COVID-19 emergency

DHSC, 2019, Advancing our health: prevention in the 2020s

DHSC, 2020, Community testing: a guide for local delivery

DHSC, 2020, COVID-19 Winter plan

DHSC, 2020, COVID-19 Contain framework: a guide for local decision makers

DHSC, 2020, Guidance for local government

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DHSC, 2021, Integration and Innovation: working together to improve health and social care for all

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Health Foundation, 2020, Test and trace tracker

Health Foundation, 2020, NHS Test and Trace, the journey so far

Health Foundation, 2020, Health equity in England: the Marmot review 10 years on

Health Foundation, 2020, Build back fairer: the COVID-19 Marmot review

HMG, 2020, Health Protection (Coronavirus, Restrictions) (Local Authority Enforcement Powers and Amendment) (England) Regulations

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IPPR, 2020, Levelling up health for prosperity

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Vaccination; community testing; local contact tracing; key practice areas

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LGA, 2020, Test, trace and local outbreak management

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LGA, 2020, Lateral flow testing

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LGA, 2020, Local authority covid-19 compliance and enforcement good practice framework December 2020.

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SAGE, 2020, Thirty-second Zoom meeting on Covid-19, 1 May