'The best thing that ever happened'

Key messages

• Public health is a marathon, not a sprint; it needs patience and energy.
• Allies come in unexpected guises; push on one door another may open – all doors will open eventually.
• You are only as good as your team – not just the people around you but partners and citizens.

Kate Ardern was working as a junior doctor when she had an “epiphany” moment. She helped save a man having a heart attack but realised that even though he recovered he had reduced his overall life expectancy. Kate switched disciplines to public health where she could work on preventing illness and promoting health and wellbeing.

Kate was inspired by Sir Donald Acheson and his great contributions to public health. She has often been involved in national developments, such as developing approaches to Health Impact Assessments, but her heart is in local public health where she feels she can make the biggest difference.

The move to local government

The best thing that ever happened.

Wigan has a tradition of collaboration across the NHS and the council, and the director of public health was a joint appointment for several years before the shift to local government. Kate joined Wigan Council’s senior management team in 2008 and is its longest-serving member.

Kate found working across two “profoundly different cultures” interesting but believes that the shift to local government was the “best thing that ever happened”. Staying in the NHS would have limited the opportunities for public health to influence local political decision-making in areas that impact health, such as planning, education, employment, and economic development. Councillors in Wigan were extremely supportive of public health developments and a Marmot approach was established. The move allowed new people from across the council and more widely to become involved in health and wellbeing established “a coalition of the willing”. A key approach to encouraging people to be involved is “influence not authority”.  

Although the public health grant has been cut nationally, in the NHS the public health budget was the “first budget to be raided” to fund acute care. In local government, there are more opportunities to publicly discuss priorities and consider funding as a whole across the council and the NHS. Public health came to Wigan Council with thirty-five posts and now has around 100, working across many council functions.

Directors of public health increased their influence, their confidence, and their voice in local government, and this developed further with their high-profile role during COVID-19, with other partners and members of the public much more likely to recognise, understand and appreciate the role of the local DPH.

Councillor Keith Cunliffe, Deputy Leader and Portfolio Holder Adult Social Care and Health

"The return of public health to local government, its natural home, in 2013 was a significant moment. Sir Michael Marmot’s report in 2010 had outlined that the wider determinants of health were influenced mainly by socio-economic circumstances. Kate and I both came into the post in 2008 and found that we had a shared vision which was reinforced by the publication of the Marmot Report.

The transfer in 2013 gave us an opportunity to ensure that public health was embedded across all council services and that Health in All Policies was sewn into the culture of the organisation.

The development of the Wigan Deal was a crucial element in accelerating that integration, connecting people to their communities and developing a community-led approach. Our shared vision was the key to providing the professional/political leadership consensus that has resulted in a nationally recognised innovative service improving the health and wellbeing of our citizens."

Changes since the move

It is a privilege to work with Wigan councillors.

Two systematic partnership approaches provide the context to how public health is woven through the work of Wigan Council and Wigan NHS.

The council and the NHS driving prevention

Wigan Council and Wigan NHS take a whole-system approach to health, social care and prevention. Investment is not just about the public health grant, but the total investment and purchasing power of both organisations. Partners have made a huge investment in prevention, including progressive use of section 75 pooled budget arrangements over a range of services. The organisations share a finance director, which helps the system-wide approach to finance. The council, NHS, wider public and voluntary sectors work together in 14 neighbourhoods coterminous with primary care networks.

Successes like winning the FA cup and major ruby trophies have galvanised pride in Wigan and a sense of self-belief.

The Wigan Deal

The Wigan Deal is an asset-based approach in which communities and individuals are key partners. It is led by the council working closely with the NHS, the voluntary and community sector, and other partners. According to the King's Fund, Wigan Deal is “notable for the scale and consistency” in how it has been applied. There are deals for communities, adult social care, business, children and young people, and health and wellness.

Kate believes that the ethos of the Wigan Deal and its emphasis on investing in local people is how public health works best. Rather than professionals imposing ideas about how people can improve their health, through advice and education about lifestyles, Wigan is developing ways of working that are centred around respect for individuals and listening to what is meaningful to them – an approach based on anthropology and ethnography. There is an emphasis on creativity, culture, sense of place, sport, and heritage.

Examples include harnessing the potential of festivals, like Wigan Pride, and sporting activity, which many people in Wigan are passionate about. Communities are invited to put forward their ideas for what will promote health in their areas through a community investment fund. People are encouraged to become involved in the democratic process; this year a five-year-old girl became the youngest person ever to address the council – on the topic of recycling.

The strong joint working and communities in Wigan helped partners pivot quickly into a whole-team response to the pandemic, which was effective, flexible and pragmatic with good results on all measures, including contact tracing and vaccination.

Many public health outcome measures in Wigan kept up through the pandemic and continue to “buck the trend”, performing better than comparable authorities.

• Healthy life expectancy has increased significantly, in contrast to the stagnation seen in the England-wide figures (King’s Fund 2019). Wigan’s female healthy life expectancy has increased by 20 months from 2009 until 2011 compared to England’s decreasing by two months and Wigan’s male healthy life expectancy has increased by 26 months from 2009 until 2011 compared to England’s increasing by four months (Feb 2020 PHE/ONS update).
• Smoking prevalence continues to reduce, including, most importantly, the routine and manual group prevalence, which is now consistently below the England average and lowest in Greater Manchester.
• In the past six years, early deaths attributed to cardiovascular disease have reduced by 29 per cent for males and 25 per cent for females
• In the past six years, early deaths attributed to cancer have reduced by 16 per cent for males and 9 per cent for females. Wigan is now similar to the national rate – previously it had a significantly higher rate.
• Immunisation and vaccine take-up is consistently high and achieves 90-95 per cent across all the childhood programmes and consistently outperforms England. This has been reflected in the high take-up of COVID-19 vaccine (primary course and boosters) in the borough.

Future plans

• Wigan’s health improvement offer will be expanded through co-investment between the council and primary care. Health improvement services have come back in-house and will combine with social prescribing into a new role of ‘care connectors’ based in the 14 neighbourhoods/primary care networks. Care connectors will link people needing support with communities and will help create and develop community assets.
• Health protection and resilience plans will be reviewed and there will be an investment in local systems. Issues covered will range from pandemic protective health through antimicrobial resistance to the climate change action plan.
• Health and wealth are integral to each other, and there will be more focus on asset creation, investment and regeneration across the borough. This will build on previous developments such as apprenticeships at Edge Hill University Medical School and the Arts for Health programme.
• Leisure services have come back in-house and will focus on extending the Be Well movement, maximising the use of green and blue spaces and working closely with the voluntary and community sector.

Devolution to regions and to local government has proved very effective and proves a real opportunity for improving health at scale. The swift response to the pandemic in Greater Manchester shows what could be achieved by local areas cooperating on measures including supply chains, contact tracing, mutual aid and joint guidance for schools and care homes. Kate believes that progress will be challenged if the central government operates a largely top-down, controlling approach instead of providing local systems with the investment and freedom to make decisions based on local knowledge and priorities.

Another important national issue is to shift the focus in the NHS from viewing prevention as a way of protecting the NHS from immediate pressures on services to taking the longer-term view of improving health and reducing inequalities.

Would you choose the same path?

Yes, I would do this again if I went into medicine, but I do have other interests, such as acting and photography, that I would have liked to pursue.

Kate is due to retire as a DPH in 2022 and will continue to advise on public health in various capacities.

Reference

King’s Fund (2019) ‘A citizen-led approach to health and care: Lessons from the Wigan Deal’.