'Districts grabbed the chance to improve health and flew with it. They have vital skills'

An interview with Professor Jim McManus, Director of Public Health, Hertfordshire County Council.


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Key messages

  • Local government provides the most effective mechanism for delivering public health – councils are “public health organisations”.
  • Make sure what you bring to the table adds value.
  • Build a movement, not a department – build a “public health family”.

Jim McManus moved into public health from a career in psychology where he worked in the voluntary sector, commercial sector and in local government. He had become increasingly aware of the problems of preventable illness and health inequalities and developed a long-term interest in building a whole-system approach to public health and in tackling the social determinants of health. He was a consultant in public health in the NHS, then a DPH in Birmingham and then moved to Hertfordshire County Council.

The move to local government

Elected members are a force and a movement in public health.

Jim believes that the move to local government was “absolutely the right thing to do” – consistent with science and the best traditions of public health. The NHS has an important role in public health, but councils are “public health organisations” and have been since their inception, with the potential to improve health through their functions and partnerships. Most countries, including the United States and Germany, lead public health through their local government systems. Jim believes there is a strong scientific rationale for this. Having worked in the NHS in multiple roles including cardiac and stroke service improvement, he believes councils are naturally good at embracing new disciplines like social sciences because they are made up of so many disciplines working together.

Jim found “massive changes” when public health moved into local government. In the NHS the DPH had a lot of positional power, but public health in some parts of the NHS was very focused on reducing pressure on NHS services, such as initiatives to lower blood pressure and help the NHS achieve financial balance. Also in the NHS, the public health budget was very vulnerable to being “grabbed” to address financial pressures in the acute sector. He points out that a former chief medical officer devoted an entire annual report to point out the harm diversion of money from public health within the NHS was doing. While the national public health grant for local government has been cut, there is more opportunity for local discussions on how this can be managed and to consider whole-system funding.

Working in a system with direct democratic accountability can be immensely helpful. Elected members were “the sleeping giants of public health” – keen to get involved but with limited opportunities. When public health moved to the local government they became “a force and a movement”. The relationship with elected members is fundamental to public health and provides a mutually supportive approach. Public health professionals advise and set out the evidence, while councillors provide perspectives from people in their wards and have an overview of the work of the council. Recently, this has proved critical to Hertfordshire’s response to the COVID-19 pandemic. A Members’ Board reviewed progress every fortnight, providing “friendly well-intentioned scrutiny” which involved discussion, reality-checks and testing out thinking.

Joining an organisation with a very different culture and decision-making processes needed new ways of working and understanding, particularly for people with little previous experience in local government. Jim worked with Hertfordshire County Council’s legal team to devise a course in local government law for directors of public health, which was delivered nationally and valued by those who took part. Hertfordshire’s legal team have led and delivered this course nationally for some years now.

The move to local government brought much more freedom to work with a wider range of agencies in a structured way; new partnerships were established, and new people became involved in promoting health and wellbeing.

Councillor Morris Bright, MBE, Executive Member for Public Health and Community Safety

"The transfer of Public Health to the Council has been a huge opportunity for us in Hertfordshire. Our team came over early, in 2012, and in the last ten years have transformed public health services and built relationships across sectors as diverse as business, sport, the voluntary sector and public sector, which have been essential for smooth working during COVID-19.

Partnership is in the DNA of our public health team, which is what we need more than ever coming out of COVID.

I know our county councillors believe we are as a County council, a Public Health Organisation, and that a healthy population means a thriving County.  I continue to be excited about what we will achieve together, especially as we begin the journey of working beyond COVID and its impacts."

Changes since the move

Districts grabbed the chance to improve health and flew with it. They have vital skills.

Public health soon became an established part of the County council. An LGA peer review in 2017 was very helpful – it allowed key stakeholders to examine in depth what the council and public health needed to do to identify and maximise new opportunities, and to work effectively together. It also highlighted the important role of districts, boroughs and other partners. 

Jim wanted to build an inclusive and non-hierarchical “public health family” so that people in the council and beyond felt they were part of a movement to improve health. Some council services, such as environmental health officers – which sit in district and borough councils - are essential for keeping the public safe and healthy, and other roles and settings, like sports, culture, environment and planning bring huge added value to health. They all have a public health role. For example, the Fire Service has a major role in preventing falls and accidents in vulnerable people. District councils were very enthusiastic about their role in promoting health, and each has developed a health hub and is working on local priorities. This “family of equals” approach is crucial to getting things done.

A growing partnership with the University of Hertfordshire has seen a Master’s and a Doctorate in Public Health grow from strength to strength and a series of masterclasses where practitioners and academics together study shared challenges, like domestic abuse. Jim is a Visiting Professor at the University and relishes promoting the huge intellectual capital the University has to apply to public service in Hertfordshire.

The public health approach in Hertfordshire has been to identify and seize opportunities. For example, the discussion about getting more people involved in cycling developed into a successful Year of Cycling, which was followed by years of walking, mental health and volunteering. Public health also promotes an awards scheme that recognises contributions to health and wellbeing – won for three years by the council’s healthy travel team.

Hertfordshire uses a “five engines” approach to developing public health projects and services, which involves capacity and expertise in the following areas:

  • project management
  • commissioning
  • business services
  • technical and public health science
  • analytics.

This approach has been very helpful in Hertfordshire’s response to the pandemic, enabling a project manager to be deployed in every operational cell, from PPE, through contact tracing to mortuary capacity.  It also meant that agencies came together quickly to form the Health Protection Board because they knew each other.

I am awed by the energy of Hertfordshire Sports Partnership and Cultural Services to work on health and wellbeing.

  • Sexual health services have been modernised with new clinics established in central, community settings. For example, next to the FE college in Watford and the Health Hub in Stevenage town centre.
  • Family centres have been jointly commissioned and school nurses and health visitors work with a “single team” approach – for example, staff from all agencies wear the same uniforms.
  • Adult social care preventative programmes have been delivered, for example, helping older adults with mobility issues back to doing daily tasks for themselves and health checks for adults with learning disabilities.
  • Around 96 per cent of children have eye and hearing tests in school.
  • The Drug and Alcohol Board is co-chaired by the DPH and the police to establish a whole-system approach to substance misuse. Hertfordshire has better outcomes on heroin and opiates than comparable areas.
  • The Just Talk mental health campaign provides preventative support for young people with mental health problems. It has won multiple awards and has been adopted in other areas.
  • A behaviour science unit was established to work with council functions, such as encouraging recycling, and with communities with health needs. For instance, promoting vaccine uptake and school attendance in the Gypsy and travelling communities and supporting mentoring programmes for children to be as effective as possible.

Future plans

Hertfordshire public health has three main overarching aims for the next stage of developments:

  • Supporting COVID-19 recovery – a recovery fund is being led by chief executives in district councils. Hertfordshire has already funded a mental health programme in the public and private sectors.
  • Reducing health inequalities – as an initial response, the council has established a £1.5m corporate health inequalities programme which will target groups facing health inequalities and invest further money in a black and ethnic minority communities health inequalities programme.  A workplace health programme has also been started. The public health team has helped co-fund programmes to get people with significant mental health issues into employment through adult learning and skills.
  • Working with the NHS to develop and evaluate preventative approaches that reduce the need for complex care packages in adult social care, such as action on diabetes, and working with health colleagues on improved pathways. Research has shown that social care packages can prevent hospital admissions, so the aim is to develop a proof of concept that prevention will reduce the need for crises support and long-term social care.

Jim believes that integrated care systems provide both challenges and opportunities for improving health and wellbeing and tackling health inequalities. The opportunities are huge but will only be realised if there is a shift in thinking and prioritisation at a national level. The NHS and acute and emergency healthcare dominate national policy thinking, and there is a danger that prevention will be rewritten in a clinical guide.

Would you choose the same path?

Yes absolutely, this role makes the best use of my talents and skills and energises me every day. I wish I had come to public health sooner. Scientifically the role provides unparalleled opportunities to apply disciplines as varied as epidemiology, quality science, biology and psychology to health challenges. In partnership terms, we can make a positive difference in the lives of residents. I would not want to be anywhere else, and I am grateful for the opportunity to be here.