'It was brilliant to be able to work closely with colleagues whose work impacts on the social and economic determinants of health'

Key messages

• The pandemic demonstrates how everyone working for a council can have a role in health and wellbeing and shows the value of localism.
• Reflect on the pandemic and do not bury it. Investigate what impact it has had on the people involved, not just front-line staff. Think about what it means for the sector and where next. Celebrate everything that has been achieved through partnerships working to a shared purpose.

Ruth Tennant moved into public health from a career in public policy – in the EU Parliament, the Audit Commission and the King’s Fund. A turning point came when she realised she loved working in policy but wanted to achieve more “in the real world”. She qualified through the national public health training scheme and worked in the NHS as a consultant. Ruth went into local government as a deputy DPH and has held DPH positions in two councils, moving to Solihull in 2017.

The move to local government

It was brilliant to be able to work closely with colleagues whose work impacts on the social and economic determinants of health.

Ruth believes that the shift to local government made “great sense”, providing an opportunity to make a real impact on the social and economic determinants of health. The change was “eye-opening” because the local government is so culturally different to the NHS. It took some time to nurture relationships, understand how things worked, build skills, and develop the levers to achieve change.

The local democratic element is key to the role of public health – in local government, there is far more freedom to achieve local priorities determined with local politicians based on engagement with communities. The NHS is more centrally driven, with accountability to the Secretary of State rather than locally elected politicians. It was very refreshing that functions like planning, community work, air quality and highways were close at hand. Ruth believes that respect and being clear about the role of public health is vital for developing partnerships – public health can advise from a health and wellbeing perspective, but colleagues are the experts in their fields.

When Ruth became a DPH the cuts to the public health grant had just begun. She started her new job on Monday and on Friday had to start to identify just under £1 million of in-year budget cuts. This made the job more difficult, with most funding already committed to long term contracts.

Changes over the last ten years

A new version of public health involves an army of people in different jobs not reporting to public health but who are essential to improving health and wellbeing.

Solihull has a very mixed economy – large pockets of deprivation but also major economic players such as Birmingham Airport and Jaguar Land Rover. Before the pandemic, Solihull Public Health Directorate took on management responsibility for skills and employment because of their significant interrelationship with health, particularly health inequalities. Corporate leadership gives the potential to support disadvantaged groups, such as young people from deprived areas, people with learning disabilities, and people with mental health problems.

The new responsibilities put public health central to the wider strategic agendas for levelling-up and regeneration and have brought new partnerships with bodies such as the Local Enterprise Partnership, Chamber of Commerce, and West Midlands Combined Authority. The DPH and the Director of Economy and Infrastructure co-chair the Inclusive Growth Board.

Ruth is clear that health and wealth go together and that improving economic circumstances can reduce health inequalities and promote overall prosperity if done in the right way. The next stage is to build a strong narrative and policy framework, bringing together the health and economic agendas. This will form the basis for tangible action with a focus on added value and, so far as possible, quick results. Solihull’s Inequalities Strategy and Economic Strategy have been refreshed to mirror each other. Skills and employment measures were previously funded by the European Social Fund (ESF), and the council has provided core funding of £500,000 to provide continuity, flexibility and scope.

It is essential that health partners are part of this new vision for public health and that this involves a reframing of public health roles and responsibilities. With the expansion of activity to tackle social determinants and connect to the wider economic agenda, Ruth believes that public health needs to focus on getting the “most bang for the buck” which may involve stepping away from some traditional public health approaches.

Birmingham and Solihull ICS is currently developing place-based governance with a strong focus on subsidiarity. Local PCNs are enthusiastic about their role in improving health and wellbeing and tackling health inequalities. New approaches to population health management are being developed, which, over time, should knit together place and neighbourhood data with qualitative information to inform planning and priorities.

The four PCNs are actively involved in Solihull Together, the delivery arm of the HWB, and are interested in a wider approach to primary care delivery. Politicians, senior officers and clinical directors have undertaken a walkaround of deprived local areas. There is active collaboration on regeneration schemes, including a new health centre in a deprived area with co-located services.

Some key achievements include:

• Public health has management responsibility for emergency planning and civil contingencies, taking a lead role across Solihull, Coventry, and Warwickshire. This was very helpful in developing the response to COVID-19. Ruth says that the response from all partners was “phenomenal”. Everyone, from the NHS to council teams to community organisations rolled up their sleeves and worked together with a can-do attitude.
• Data and analytics have improved during the pandemic, building on previous “world-class” developments in this area. The business intelligence team uses a digital dashboard to provide deep-dive, granular data on communities and organisations like schools. The next stage will be to develop this to drive core business and inform ‘build back better’ locality profiles.
• Progress is being made on the skills and employment agenda. A recruitment and training pathways centre has been established in one of the most deprived neighbourhoods, with co-locations of some staff from the DWP. The centre has links with the mental health team and is working on mental health first aid. It is establishing links with local employers on skills needs. A proof-of-concept approach is being taken to track the progress on various elements of the project.

From a wider perspective, having worked in three councils, Ruth believes that the role of DPH is changing, branching out into two different but related directions. The DPH is still a technical professional – in effect the local chief medical officer with an expert and advisory role. But many DsPH are also corporate directors with management responsibility for a wide range of other health-related responsibilities.

Future plans

There is a real energy from clinical directors to work differently on primary care delivery.

• Recovery from the pandemic may take several years. It will initially focus on services in areas that have been particularly affected by the pandemic such as domestic violence, early years, mental health and substance abuse. Horizon scanning is needed to identify other areas of disparities relating to social determinants that are affected by the pandemic.

• A skills and employment policy framework linked to the levelling-up agenda will be developed and initiatives extended.

• Public health has started to work with PCNs and NHS settings to embed health improvement projects, such as initiatives to promote mental health with the Mental Health Trust, and physical activities – with funding from Sports England.  These are small scale at present but will be extended.

There are several challenges to future plans. There is a fatigue in the public sector – people have been “working on caffeine and adrenaline” for two years and rebuilding resilience is really important. Many staff have achieved incredible things in the last few years and as a sector, it is important to look at how these staffs recover but also move into the next phase of their careers using their new skills. There is also a new tier of staff who have been working in temporary roles on COVID-19 from a very broad range of backgrounds who have brought a new depth of experience to local government. Ideally, these staff would be retained within the sector.

COVID-19 has highlighted once again the injustice of health inequalities and there is renewed energy in the NHS to tackle this. However, this needs to be supported by serious and sustained investment in prevention and public health right across the system.

Would you choose the same path?

Yes, absolutely! I didn’t know about public health, and I was lucky to find it!