After the reforms brought about by the Health and Social Care Act 2012, the public health system in England was moved out of primary care trusts (in health) and into local authorities. Public health teams are responsible for delivering a wide range of services and have a ring-fenced budget to do this. However, public health budgets have been cut significantly since 2015/16 and, as with other health and care sector roles, there are enduring workforce shortages.
Directors of public health (DsPH) have a key role in protecting and improving the health of their communities, including being responsible for infectious disease control. They have played a significant role in England’s response to the Covid-19 pandemic. Their knowledge and expertise (and that of their teams) in population health have been vital in addressing the immediate impacts of Covid-19 on health, as well as understanding and mitigating the economic and social impacts of the pandemic that will affect the health of their populations in its aftermath.
The Health Foundation and The King’s Fund wanted to tell the story of Covid-19 and the local public health system. We set out to understand:
- the experiences of DsPH during the earlier stages of the pandemic (for
- example, their leadership of local structures and committees, the decisions
- they made and the barriers and enablers they came across)
- how local systems responded to Covid-19
- the wider impacts of Covid-19 in local areas (in addition to incidence and
- mortality) and plans for recovery
Our research study consisted of the following components:
- interviewing DsPH from across England up to three times between September 2020 and April 2021
- interviewing other leaders twice in two local areas where we carried out a ‘deep dive’ between December 2020 and March 2021
- interviewing DsPH from Northern Ireland, Scotland and Wales (twice) between October 2020 and March 2021 to understand experiences throughout the UK
- interviewing five leaders who have been involved in the national or regional response to Covid-19
- a focus group discussion with DsPH from England in May 2021
- reviewing documents, such as local outbreak management plans, and other
- strategies produced during the pandemic.
Our study highlighted two key aspects to directors’ involvement in responding to Covid-19. First was their formal role in the local public health system; they helped guide and shape the response within regional and local emergency structures and committees. And second was the striking role that DsPH played more broadly in engaging local communities, facilitating vital social support and acting as a linchpin within the broader response.
DsPH encountered various challenges over the past year. Key examples include workforce shortages within public health teams and not being properly engaged by
central government regarding major elements of the overall response to Covid-19, most notably the national testing strategy and the roll-out of NHS Test and Trace.
Key enablers included the relationships that DsPH built across sectors. The pandemic demonstrated the value of these existing relationships as well as directors’ ability to build new connections, and to bring people together from different parts of the system. Relationships will continue to be important in the aftermath of Covid-19.
Emergency funding to support public health teams to tackle Covid-19 was made available. This helped DsPH to build capacity in their teams. However the short‑term nature of the funding leaves uncertainty about solutions for longstanding challenges in the public health system. Covid-19 has increased the public profile of DsPH. Their skilled leadership of the local response to Covid-19 has also helped to build trust among other stakeholders in health and care and local government. This presents a unique opportunity for DsPH and their teams to develop a central role for population health management within emergent integrated care systems (ICSs) and place-based partnerships.
The Covid-19 pandemic has taken a significant toll on the population of England. The DsPH we spoke to had to prioritise the response to Covid-19, meaning other vital work for population health has been on pause. The economic and social fallout from Covid-19 will be felt for many years.
The pandemic has changed the way in which public health and DsPH are recognised and valued. Given the scale of the challenges that lie ahead, DsPH should be seen as core players in system leadership for health across their populations while maintaining their role in challenging established ways of doing things in the cause of population health.
The following factors will be pivotal in keeping DsPH at the core of system leadership in the future.
- The ongoing relationship between DsPH and local authority chief executives will be important in strengthening the role of directors as system leaders, as well as a critical source of expertise.
- The role of public health in ICSs needs to be fully recognised and embedded. That is, ensuring that ICSs work fully with DsPH and their teams and do not develop in parallel.
- Strong joint working between local communities, community leaders, the voluntary and community sector and DsPH has bolstered the local public health response to Covid-19. This will be as important in recovery as it has been during Covid-19. Local systems, including ICSs, therefore need to support DsPH to strengthen this further and to learn from experiences during Covid-19.
- Finally, DsPH need to be engaged in the design of national population health activity and systems. They have often felt ‘done to’ during the pandemic and left to deal with the consequences of poor communication of decisions, and in some cases poor decisions themselves. As the agencies that replace Public Health England from 1 October 2021 develop their roles, DsPH must be involved in their design, as well as being involved in helping to develop and adapt the forthcoming public health reforms.