Five leaders, five reflections about public health and the Covid-19 pandemic

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Recently we published our report about the experiences of directors of public health (DsPH) in eight different local areas during the Covid-19 pandemic. To take a wider view of England’s emergency response to Covid-19, we also spoke to five other leaders working at either a national or regional level across the Department of Health and Social Care, NHS England and NHS Improvement and Public Health England (just before it was closed and replaced by the UK Health Security Agency and Office for Health Improvement and Disparities).

In the midst of the Covid-19 pandemic, it was a special privilege to hear from individuals who had been closely involved in directing the national response on a range of issues. As well as their engagement with DsPH over the course of the pandemic, the leaders gave their broad assessment of the response to Covid-19 and what role they saw local public health teams playing in its aftermath.

First, in considering the nation’s preparedness for a pandemic, leaders painted a bleak picture of the national landscape before Covid-19 hit. There was a potent mix of health, social and other inequalities that meant the impact of the virus on England was profound and much worse for some. Leaders pointed out how Covid-19 infection and mortality rates reflected the groups known to have worse health outcomes, as well as groups more likely to be living in areas of higher deprivation – where arguably many workers did not have an option to work from home and were more likely to contract the virus. Inequalities were well known before 2020, but it took more than 127,000 deaths in a pandemic to drive home what the implications are (this figure was for the UK from the end of April 2021, when the first of these interviews were conducted).

I think the amount of poverty there is in this country, some communities completely, you know... they couldn't cope with this because they... haven't got the capacity that I do of... working at home, and saving money... They had to get out there and work and catch the disease, and that was often... with some underlying health conditions which are predicted by poverty... you've got a disaster waiting to happen.

The second reflection was about how a decade of funding cuts to local authority services (including public health) had compromised the extent to which health inequalities could be addressed and the people most vulnerable to Covid-19 could be protected. One leader gave an anecdotal example of the impact of cuts to public health funding which meant, in some cases, local authorities were ‘sharing’ the public health workforce due to budget constraints.

So, I had a conversation with one minister about the fact that there was a shared public health consultant, and [they said], ‘why on earth have they done that?’ And [I said], ‘well, because for 12 years [local authorities have] had significant budget cuts. And they [said], ‘well, that doesn’t feel like a sensible decision’. And I said, ‘well, I think pre-pandemic it probably was but now we’re in a pandemic, no, it’s not’. But I think we could say that about lots of decisions that have been taken. They weren’t taken knowing this was coming. 

The third reflection was that despite the critical role of DsPH and their teams in responding to Covid-19, earlier in the pandemic there seemed to be ‘blind spots’ at a national level about the expertise in the sector. One of the national leaders spoke about ‘very poor understanding … [within] government departments of what happens in place, and the role of the director of public health’. Another leader described how, at the outset, there was no direct line of communication between DsPH and the Department of Health and Social Care where Covid-19 policy and guidance were being developed.

The fourth reflection offered by leaders was about the challenges they observed in local systems trying to implement Covid-19 policies and guidance set at the national level. These challenges were particularly evident in initiatives such as setting up the lighthouse laboratories to boost capacity for processing Covid-19 tests, but then test data wasn’t always shared with local public health teams to enable quick contact tracing. Similarly, it was noted that in the early days of the NHS Test and Trace system, local public health teams did not have access to the case-level data that would have helped them carry out contact tracing on the ground. As one leader put it, the relationship between NHS Test and Trace and local authorities (where public health is located) ‘didn’t start from a good place’, however they acknowledged the situation had ‘evolved’ by the time interviews took place in April and May 2021.

The fifth reflection from these leaders was around how the pandemic has changed the profile of local public health teams. As one leader put it, DsPH are increasingly being seen ‘as local champions’ who are there to ‘look at the need of the population and protect them’. Another leader was very clear that the time has come for public health to take on a much more central role in the leadership of local systems and, in their words, ‘there is no going back, ever’ to a time when the voice of public health was side-lined or left out entirely.

…the rebuilding and the renewing and the restarting of our societies and dealing with the health backlog and inequalities agenda will necessitate a strong public health voice and leadership being at the centre of what councils do.

These were reflections shared by leaders in the spirit of learning, not as part of an inquiry. However, these points echo some of the recently published findings of the House of Commons Health and Social Care, Science and Technology Committees which highlight grave consequences to government decisions or actions, including the delayed involvement of public health teams in contact tracing. What leaders told us also demonstrates the consequences of cutting the public health grant which has left the workforce depleted and stretched thinly in delivering vital public health services before and during Covid-19.

Undoubtedly mistakes have been made and the public health system has been woefully overlooked at a critical time. Hopefully the newfound confidence in public health – and the public health community continuing to assert its expertise and voice – is an opportunity to correct this in the months and years to come.

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