The Covid-19 pandemic has put a spotlight on the public health system and the people who work in it like never before. Helen McKenna sits down with Matthew Ashton, Director of Public Health in Liverpool and Tracy Daszkiewicz, Deputy Director of Population Health and Wellbeing at Public Health England, to explore what they’ve learnt from their experiences during the pandemic and, at a time of reform for public health and the wider health and care system, what the future holds for public health.
HM: Helen McKenna
MA: Matt Ashton
TD: Tracy Daszkiewicz
HM: Over the past year and a half or so, the COVID-19 pandemic has put a spotlight on the public health system and the people who work in it like never before. In today’s episode, I’ll be talking to two public health leaders about their experiences of dealing with health protection emergencies, what they’ve learnt from those experiences, and importantly at a time when public health functions in England are being re-organised, what the implications of these changes are for the future. As always, please do subscribe, rate, and review us wherever you get your podcasts. It helps others to find us, and it also helps us to improve the show.
I’m Helen McKenna, senior fellow at The King’s Fund. Today I’m joined by two fantastic guests, Matt Ashton, Director of Public Health in Liverpool and Tracy Daszkiewicz, Deputy Director of Population Health and Wellbeing at Public Health England.
Matthew and Tracy, thank you very much for joining us on this episode.
TD: My pleasure.
HM: So, the last 18 months has clearly been a really busy time for people working in public health. So, first off, can I just ask how both of you are doing and how the last 18 months has been for you. Let’s start with you Tracy.
TD: Thanks Helen. I think for anybody working in public health, it has been an incredibly difficult and busy time. I think, for me, it’s been hugely varied in terms of the work that we can do. A lot of my focus, even in the height of the pandemic, has been more focused in terms of the human aspects and recovery. So, I’m really looking forward to now as we move forward taking that, working alongside directors of public health, local authority to really start and embed that work.
HM: Thanks Tracy. And at the beginning of the pandemic, you were actually a director of public health, but you’re currently in Public Health England. Can you just run us through your, kind of, different roles?
TD: Yes, of course. I was director of public health in Wiltshire prior to June 2020. I delayed leaving a little bit, obviously, because of the pandemic but moved across in June where I took up the role of deputy director for population health and wellbeing, which gave a different lens to the pandemic. Obviously, we have the health protection team that were working on the response, and my side of the business was very much more looking at building a framework around recovery, working with integrated care systems and population health management and how we linked data sets across health and social care. So, it’s a very different dimension to that I started in the pandemic, which was very much hands on COVID work.
HM: And, Matt, how have things been for you for the past 18 months, and also do tell us a little bit about your role as well.
MA: So, I’m the Director of Public Health for Liverpool, so, obviously, I’ve been leading the response to COVID locally along with our fantastic public health team and range of partners. It’s been an incredibly busy period, hasn’t it, for everybody working in public health, and in fact, I think, for everybody it has been so much going on. I think for me particularly, I started in Liverpool April 2020, so right at the start of the pandemic. I had previously been director of public health in Sefton and in Knowsley, so I’m not a new director of public health, but I was new to the city.
So, there is very much lots of learning on my feet and in the environments we’re in and making new connections to people. So, in one sense, incredibly hard, incredibly fast paced, and very difficult, but actually in another way, you know, a great introduction to the city because I managed to speak to lots of people, managed to make lots of connections and managed to hopefully, you know, support a good response to the pandemic locally.
HM: Wow, what a time to move area to the director of public health, that must have been incredible. And, so, Matthew in your director of public health role in Liverpool, what does the role now involve?
MA: Well, it’s a really interesting balance of both response and recovery because we clearly are still in the middle of a pandemic, and we will be for some time to come. We have to make sure that our communities are as safe as we can possibly make them, whilst at the same time helping the local health and wellbeing structures and the local economy to recover to the best of our ability, so it’s really balancing off that response and recovery piece.
HM: And, I guess, just thinking about COVID-19, it’s just a question I’m fascinated by because I’ve got the two of you here, but there was a lot that was unknown about the virus. How much did you as public health professionals understand about the virus in those early days that wasn’t understood by the general public and by lots of other professionals in the system?
MA: So, I think from the virus perspective, clearly it’s a new virus and (inaudible 00.04.45) virus and we’re learning all the time about this virus, and we will continue to learn. And, absolutely, therefore in the early days, you know, there was lots of emerging evidence around it, but in the sense that it was a pandemic, you know, we know what pandemics do. We know the harm pandemics can do, and we understand fundamentally what the right actions are for people to take to minimise or to mitigate the harms from pandemics.
So, the virus bit new, absolutely, but the health protection response is, kind of, I think, well-practiced and well understood. Getting those messages into our communities and into partners isn’t always as easy because we haven’t had a pandemic like this for over 100 years.
TD: Yes, I would absolutely agree with Matt. I think it in any situation like this and we could see it ramping up in the early weeks, but probably wouldn’t have been able to have predicted where it started to escalate to by the end of March, and I think there is that space with pandemics, you plan for the worst and you hope for the best, but you have practiced policies and procedures in place that you then can implement. Obviously, this went bigger than that and we were able then to draw on skills very quickly to meet that escalating need, but also what was fantastic about the early weeks and months of this pandemic was the way it became a whole system response.
So, you were drawing from partners around that collective aim very, very quickly and different people, knowing which part of the system they needed to look at. So, whether it was about a house service response, whether it was around mitigating risks as a public health response, around PPE and that kind of aspect, or whether it was about tackling the vulnerabilities and the community needs, it became a very whole system response that the public health core of that was absolutely about keeping the population as safe as possible. And trying to get compliance around all those responses such as wearing masks, washing hands, then as we moved on ventilation and all those different pieces of advice, and getting a community to buy into that and support that. So, it went beyond the professional and very much into that public space, which has been phenomenal.
HM: Thanks Tracy. And I’m quite interested in your previous experience, Tracy, because I know the pandemic was by no means the first public health emergency you’ve encountered, so you were a director of public health in Wiltshire at the time of the Salisbury novichok poisonings. I’m sure you’ve spoken about this many times, and I think both you and Matthew in your health protection roles have had lots of experience of dealing with local health protection emergencies, but, Tracy, thinking about your experiences in Salisbury, in particular, were their lessons you took from what was a very localised emergency then, that you were then able to apply when it came to dealing with the pandemic in those early days? I know you moved over to Public Health England in June 2020, but in those very early days of the pandemic.
TD: There were certain parts about the 2018 incident, so the Salisbury poisonings, that did then start to come through. So, some of the difficulties we’ve done about closing businesses because of cordons or safety was quite unique, I’ve certainly never had to do anything like that before, and, obviously, those very real and targeted risks.
So, there was definitely similarities, be it they were incredibly different incidents, but I think one thing, and Matt has touched on this in terms of the fact that we were dealing, in this situation we’re dealing with a pandemic, but I think within any emergency situation, one thing that we always said in Wiltshire was we deal with the unusual in the usual way.
I think it is very clear that the greatest thing you can do in the emergency planning in public health space is form your relationships in peace time. Know the way people work so that you haven’t got to negotiate people’s behaviours when you’re in a crisis or in an emergency situation. You know your way around people.
Also, be very clear about the roles that people play in these situations, but be really prepared to be agile, you know, I know that I stepped in and out of the DPH boundary very much so, and I know that people are doing that week in week out at the moment, where people’s roles are expanding into a space that wouldn’t necessarily be fitting their job description, but is absolutely needed, it’s that professional agility was something that the Salisbury poisonings taught me, but it’s something that I’ve drawn on quite heavily during the COVID response and now into recovery.
HM: Thanks Tracy, and I love that phrase, form your relationships in peace time. I think it’s actually useful for anyone in any role. But, Matthew, in your patch you were noted early on in the pandemic for rolling out mass antigen testing to improve Liverpool’s resilience to COVID-19 as part of a national pilot. And I wondered about the balance to be drawn between local innovation, local work, and then national direction, how those two relate really?
MA: Yes, it’s a really good question. You have to get that balance right. Clearly, we have national policy making and direction setting, but it’s essential to get the ownership of your communities that it is seen to be led locally. So, right the way through this pandemic, you know, Liverpool is an incredible place, it’s an amazing place with so many assets, but our communities are brilliant, and we know this. We know there is so much value in our communities if we can use them and utilise them properly.
So, right the way through this we’ve put our communities front and centre, you know, residents at the heart of our COVID response. We’ve tried to be brave, bold, and pro-active to minimise and mitigate that harm to our communities, and we’ve tried to grab the agenda where we can, and I think that’s been seen in some of the things that have played out.
If I give you an example, early on we had an outbreak in Prince’s Park in Liverpool, it’s Toxteth, it’s one of our most deprived parts of the community, one of our most vulnerable, and we had an outbreak which we grabbed on to as quickly as we possibly could. We put testing in place, it was PCR testing only at that point, and we used our community voices, community messages, we used faith leaders, councillors to really push the message out about we needed to protect this community.
And in a situation where we’ve done the modelling afterwards, we managed to close down that outbreak in just under three weeks, which was a significant achievement, I think, especially we modelled how far it could have gone. And in a way, that allowed us to practice for other outbreaks and other events that we’re going to happen during other waves of the pandemic.
And you’ve mentioned one, absolutely the mass testing that we did in Liverpool, which was just such a phenomenal experience, a phenomenal learning experience, and really was partners coming together to test on behalf of the country, you know, what role rapid testing could play in keeping our communities safe. And we took the phone call on the 31st October, and by the 6th November we were live with 6 testing sites, 16 by the following day and 36 a month later. Massive upscaling of resources and a key part of that was, obviously, the engagement with our communities because testing with nobody to test or (inaudible 00.12.04) test makes no difference.
So, community engagement, the reasons why the testing is here, how it will benefit you individually, how it will benefit your communities and the city, and we know from the evaluation that we managed to take 21% of infections out of the city as a result of that mass testing. A phenomenal achievement which I’m so proud of and I’m so proud of the people of Liverpool for responding so positively, you know, we absolutely nailed it and showed that it could have value and make a difference.
HM: That’s such a positive result Matt. And, Tracy, so we’ll talk a bit more about this in a bit, but we’re currently seeing a reorganisation of public health functions alongside a health and care bill currently going through parliament. How do you see the relationships between the local, regional, and national levels changing as a result of the reorganisation and the, kind of, work that Matt was talking about there in terms of the relationships with the community? Do you think that these changes that are currently going through are going to have an impact on some of those, kind of, structures and relationships?
TD: Time will tell, I suppose, but I really, really hope not. I think we will have different ways of working because new structures will teach us that, but I’m really hoping that what we work on, that won’t change. It’s going to be the same people in the system that need to do the same jobs. So, I think regardless of what partner system we are in, and, obviously, the workforce of Public Health England is predominantly going in three different directions into the new security health agency into the new office of health improvement and disparities or over into NHS England.
Whichever direction people go in, the interdependencies of the three pillows of public health remain and we need to be able to work together to make sure we deliver effectively. So, I truly hope that the way we work maybe different, but the fact that we still work towards the same goal and aims will remain in place.
HM: Thanks Tracy. Just coming back to the point you made earlier about, you know, forming your relationships in peace time, which I’m clearly just going to keep going on about because I thought it was such a good point. Matt, you were talking about the relationships that you had already built in the community, and how important they were during those early days of the pandemic in terms of, for example, the antigen testing etc. Obviously, those relationships were already built, but to what extent have some of those relationships been turbo charged or changed as a result of the pandemic? And so therefore is that a silver lining of some of the experiences that you went through?
MA: Yes, the relationships are there, but I think we’ve strengthened them, and we’ve used them for a different purpose, so that’s skills experience and expertise all being developed, you know, over the last 18 months, but we’ve also seen that our community voluntary sector are amazingly skilled and motivated, you know, we just need to work closely with them to help understand where priorities might sit. The response from me from our faith network has been phenomenal and I couldn’t thank them enough for giving me the access into the network and right into the heart of some, kind of, quite deep communities, and that’s the same for, you know, the whole of the CBS sector.
We have our public sector partners. We have our private sector partners, and you would expect and want a good response from them, but with our community partners, you don’t always get that and here we very clearly did. And I think, you know, going back to that recovery point, for me, there is something about how we hold on to those relationships, how we hold on to that exceptional partnership working and use it to, if you like, turbo charge the recovery and make sure we can actually start addressing some of the deep lying inequalities that exist and will have been exacerbated as a result of the pandemic.
HM: I assume that you’ve also strengthened those relationships with the business sector, with schools and others, is that right?
MA: So, I spent most of my weeks speaking to partners right the way across, so speaking to business leaders, speaking to our hospitality industry, and speaking to the hotels and bars, to our communities, to the football clubs and, obviously, you know, to police and fire partners, to the faith network, as I’ve mentioned. We have a very good health protection board at the moment with a wide range of partners who are meeting, you know, every week or every other week just to make sure our strategy is aligned and we’re doing everything we possibly can. So, absolutely that relationship has been deepened and strengthened as a result, and, you know, I’m delighted now when I, you know, meet people because I feel like I’ve got, kind of, strong bonds, strong friendships with people that 18 months ago I wouldn’t necessarily have had in the same way.
HM: Brilliant. Just thinking, I mean I know we’ve touched on it already, but just thinking a bit more about the reorganisation of public health functions that’s currently under way in England. So, as it stands on the 1st October 2021, Public Health England will cease to exist in its shadow form, and then many of its functions will move over to the United Kingdom Health Security Agency and the Office for Health Improvement and Disparities.
So, alongside that, the health and care bill currently going through parliament, I think, is aiming to bring more about joined up working between the NHS, between local government and other partners, which of those changes become law should hopefully lead to an increased focus on population health and work to tackle health inequalities. Tracy, I just wanted to ask you, given all the changes that are currently underway, what would you say are some of the main challenges and opportunities from a public health perspective?
TD: For me, there is, and I think this is partly due to the pandemic, but partly due to any infrastructural change, the system becomes louder than the issues that were there to deal with. And, so, for me, it’s about making sure that we don’t become distracted. There is a real risk, particularly around recovery, that we become very focused on getting services and buildings back to use, and we lose sight of the needs of people within that. Listening to Matt just talk now gave my heart a little skip, in terms of talking about the relationships that have been cemented, his presence in his community and the value that that brings.
And that’s absolutely where I would hope we can maintain our focus; we move on too quickly from the needs of people. And I think as we get caught up in the noise of transition and restructuring we can lose sight of that. We didn’t live in utopia before COVID happened. We had inequalities. We had communities and individuals that were in high need of support and help.
And, for me, it’s that we can continue to focus on those social determinants of health, so where people live, the value and the quality of the homes that they live in. That people are living in good quality homes, have access to good education and employment. Have access to good places to live, whether it’s green spaces or good communities where people feel incredibly connected and safe. That would be how we can maintain good health and wellbeing and help people on the road to recovery from COVID, which is going to be far deeper than just that service of getting them waiting lists cleared and front doors of hospitals all re-opened again, and GPs opened again.
This is about all the people that have missed 18 months of time with their loved ones. People that didn’t get to say goodbye, all of these things will have really deep resonance with people, and they’re going to need the help and support to move on from that, as well as the clinical needs of things like long COVID, and they’re the things that need to be focused on. So, for me, my hope is that we can really focus on what matters and not get distracted by the noise of transition.
HM: Thanks Tracy, that’s really helpful and I like the point you make around the risk of these changes resulting in a distraction, that takes us away from focusing on the needs of individuals and communities. Pre-pandemic, we weren’t living in a utopia, you know, those inequalities were there, and I’m sure both you and Matt, Tracy, in your previous role as a director of public health, and, Matt, in your current one, you were very familiar with the inequalities in your communities, but do you think the pandemic has helped in terms of turbo charging a shared sense of the need to focus more on inequalities given the issue, kind of, coming more to the fore during the pandemic in a, kind of, national narrative sense?
TD: I think it has, but not health inequalities in their broadest sense. There has been greater focus on deprivation, greater focus on the disproportionate impacts on different communities, which is welcome. We’re having conversations about health inequalities in meetings and structures that has never happened before. So, in that way absolutely, but I also think that we need to be mindful of the wider inequalities, so whilst we absolutely need to be mindful of deprivation and we need to be mindful of all communities, you know, we tend to group people together because it’s convenient to do so.
So, we talk about black Asian minority ethnic groups as an example, but within that you have very distinct communities, and what we can’t do is go forward with one size fits all because we’ve conveniently grouped people together for the convenience of quality. So, it’s how we work with individual groups and individual needs to really make that impact, and we can take that out to looking at agenda inequality issues.
We can bring that into learning disability and neurodiversity, so there is a whole range of inequalities we need to be talking about. So, whilst I think the conversation is incredibly welcome, what I welcome is that we start to talk about health inequalities from a fairer society in its broadest sense so that we can really tackle this head on.
HM: And, also, in a more nuance sense I’m hearing Tracy. And Matt what about you?
MA: Yes, I absolutely agree with everything Tracy has said there. I think there are opportunities under the reforms for us to focus more on population health, which is to be welcomed, but we have to work hard to get the detail around prevention within there, and we have to work hard to get under the skin of inequalities in the way that Tracy has described because it isn’t one size fits all. One of the things that we’ve taken advantage of in Cheshire and Merseyside during the course of the pandemic has been our cifer data systems, combined intelligence for public health action, which has really allowed us to bring different data sets together to target and that action.
So, absolutely, our ambition is to do that at a Cheshire and Merseyside level, but at a local level, so that Liverpool place level to make sure, as Tracy says, we’re governed under the skin of the inequalities and actually try and do something about it, you know, everybody needs somewhere to live, someone to love and something to do and we have to find the offer that’s right for people that will allow people to take control of their health and wellbeing, and to allow us to address those deep routed underlying inequalities that have really sadly got worst over the last 18 months.
HM: Matt, one thing we’ve heard in some of our recent conversations with directors of public health is a concern about workforce shortages. So, I just wondered is that something that’s worrying you?
MA: Well, I’m worried about public health capacity overall. I think, you know, the directors of public health up and down the country and their public health teams have worked incredibly hard over the last 18 months, so I think there has been a risk of burnout. I think there is a risk of people perhaps leaving and going elsewhere, so we’re going to have to watch that situation.
And then, of course, we need to keep on growing the public health team and the public health skills and expertise, not just within local authorities, but actually across the system, but, you know, we have to develop people to do that, and we need to have the resources to pay for people. And, so, I’m worried that there is still too much of a gap, and hopefully, you know, under the reforms and under the CSR, they’ll be more money put into prevention, more money put into public health. I think we’ve shown our value over the last year and a half, and I think we need to be able to do more of that.
HM: And presumably having sufficient workforce resilience is going to be important to, you know, how successfully these changes, this reorganisation can be implemented.
TD: Yes, and part of that is about the success being how well we link in with local systems and local directors of public health because we have got to make sure that national policy is translated into a local context and delivers change, and that is a place level. And, so, that is through our directors of public health and through our local authorities, so it’s how that journey happens is really going to make the difference. So, it can’t all be held at a national or even regional level, we’ve got to get in on the ground.
MA: I think just following on from Tracy there, I think that the way that local public health teams have worked with their regional Public Health England colleagues has been a phenomenon, and, you know, it’s been a great working relationship for us in Cheshire and Merseyside, and I’m sure up and down the rest of the country. And Tracy’s right, we can’t afford to lose that relationship, so when our health protection colleagues move over to (inaudible 00.25.32) we need to make sure that the local interface is still absolutely strong with our UK HAS partners.
HM: Thanks Matt. Tracy, the NHS is currently increasing it’s focus on health inequalities and population health, so, for example, by creating system inequality leads in integrated care systems. But the public health sector already has lots of expertise on these issues. So, I just wondered what, from your perspective, can the NHS learn from the work that you and others, other public health experts, including that, have been doing in the past to avoid starting from scratch.
TD: Yes, the conversation in this space is incredibly rich, and there is great leadership from an NHS England point of view around this, you know, the development of the Core20PLUS5 and really thinking about how the inequalities are going to be targeted. And I really welcome that, it’s a real opportunity to bring health inequalities to the fore.
What I will say is, that conversation is very much health service focused, and where the learning comes in terms of the years of experience that existed in public health, health inequalities has run through everything public health has ever done, you know, we’re going back a century and a half since public health started, and health inequalities and tackling health inequalities has been at the core of everything we do.
So, the learning that comes into that conversation is absolutely about the social determinants of health. And like Matt said, this is about everybody having a friend, a job, and a home. It’s absolutely crucial that we build on that, and make sure that that happens, and that isn’t going to happen in the waiting rooms of hospitals. People’s good health happens in the communities and the places where they’re at. By the time people get to a health service, they’re already ill, so we need to focus on people’s homes and communities, and their connectedness to their local place, and that’s where we will see really good health and wellbeing emerge.
HM: And, Matt, Tracy says a friend, a job, and a home, is there anything you want to add?
MA: I absolutely agree, and I think, you know, it’s time for us to get serious around prevention and around addressing inequalities. And if the pandemic doesn’t provide us with the platform to do that, then I’m not sure what will. I think my reflections over the last 18 months are, you know, we’ve dealt with outbreaks all over the place. We’ve had mass testing.
We’ve had the amazing experience around our events as well, the events research programme which really helped us and helped that part of the business economy to open back up safely or as close to safe as possible, has really allowed us to work with public health across a broad range of partners, and I really want to hold on to that. I want to make sure we capture the learning, and we capture the partnership approach and take that into everything else we do.
HM: So, final question for both of you, in the context of the pandemic and the new public health structures being formed, what do you think the director of public health role will look like going forward and what are the key opportunities from your perspective. Let’s start with you Tracy.
TD: So, for me, I hope the director of public health role gains the prominence it should have always had. I think public health is probably the part of local government that sees every part of it, it touches every strand and service that’s delivered, not just in local government, but across the health and social care system, public health touches everything.
And I think recognition of the role of directors of public health in that and the system change leaders, we are going to go through a massive cycle of change now, and what we need is the grip that directors of public health bring, not only in terms of their personable skills and the way they connect with their communities, but the fact that it is evidence based, in the fact that evidence really matters, and drawing on that really helps shape the work that we do. So, I think the director of public health is going to become a central role in terms of local interregional and national policy making.
HM: Thanks Tracy. And, so, it sounds like it’s a, kind of, central co-ordinating glue. And, Matt, does that chime or is there anything you would differ with or add?
MA: It really does. I believe the director of public health role is a strategic leadership role. I think it is the glue that holds the system together. I think the DPH should be seen as equivalence to the director of adults and the director of children and director of communities. And, in fact, we work with all three of those strategic roles. I think, also, directors of public health need to be and are very close to the communities they serve, so they’re the voice of communities often alongside, you know, our political leaders. I think we can make the case between health and the economy very well, so the links between health and wellbeing, inequalities, and productivity gap.
And I also think that we’re good at the learning piece, the reflection piece and the research and development piece, and I think that’s something increasingly we need to bring into in to local governments. That’s certainly something we’re trying to do in Liverpool through the launch of our pandemic institute, to take the learning from the pandemic, not just in this country, but from across the world and to allow us to prepare for pandemics of the future.
HM: Thank you both. So, that’s all we’ve got time for today. Thank you so much to Tracy Daszkiewicz and Matt Ashton for joining me. And I would like to say as well a huge thank you to you both and your colleagues who are directors of public health and others in the public health sector for all the work that you’ve done over the past 18 months and before that, but particularly the past 18 months supporting the rest of us through a really difficult time, so thank you.
MA: Thanks very much.
TD: Thanks Helen.
HM: You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. And you can get in touch with us via Twitter at The King’s Fund account, we would love to hear from you. Thank you also to our podcast team for this episode, Jonathan Homes, Sharon Jones, and Sarah Murphy, and, of course, thanks to you all for listening. We very much hope you can join us next time.
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