LGA/ADPH Annual Public Health Conference 2021: Rising to the challenge parts 1 and 2, 23 March 2021

Moderator: Good morning and welcome to the 2021 LGA/ADPH annual public health conference, rising to the challenge. Welcome to all of you at the start of our two days of conference divided into four webinars. So, this morning, we've got a great programme for you, I'm going to be chairing, I'm Janelle de Gruchy, I'm the president of the Association of Directors of Public Health, and I'm also a director of public health in Tameside in Greater Manchester. Really pleased to welcome you, we've got over 1000 people registered for this conference, a lot of people who work in local government or who are councillors, representatives from local government. And we've got people from Public Health England, and a, a, a range of, of people from other, other areas connected to public health or indeed even wider. So, welcome to everyone for joining us this morning. We've got lined up some really excellent speakers joining us over the next couple of days. So, it's now been one year since all our lives really changed beyond measure, both professionally and public-, and publicly socially. During this time, directors of public health and our teams working closely with colleagues in local government, the NHS and all other parts of the public health and wider system have really risen to the challenge that COVID has given us. I think that we've gone above and beyond to protect the health and wellbeing of the communities that we serve. We're not there yet, but we-, as we work towards recovery from COVID, it's, it's not going to be possible until we address the underlying structural inequalities.

 

It's those structural inequalities that are really helping COVID and other viruses to persist, and we owe it to the diverse and disadvantaged communities who've really paid a very high price to create a recovery that addresses our nation's health inequalities. As many of you will know, today also marks the day of national reflection, and because of that, we're going to be finishing our session this morning a couple of minutes early for those of you who want to joint eh national minute's silence at midday. As we remember those who have been lost and lost their lives in the pandemic, let's also take the opportunity to reflect on the incredible work of the public health community in our response to the challenges of the past year. Over the course of the conference, we're going to be exploring and building on some of that experience and reflecting on how we can use the learning to ensure that what comes next is both better and fairer. A reminder that the conference material over the next two days is going to be available on the LGA website in the next couple of days, and there will be recordings of the sessions available early next week. I'm now pleased to introduce to you our first keynote speaker, Professor Chris Whitty. Chris is an epidemiologist with a background in global health, having worked as a doctor in the UK, Africa, and Asia, working both as a doctor and doing research. He holds an MBA and postgraduate degrees in economics and law. We've all come to know Chris for his essential role as chief medical officer, particularly over the last year. What might be less well known is that Chris is also still practising as an NHS consultant physician at University College London Hospitals and we know that he definitely spent last Christmas on shift.

 

He, he's recognised for the style of calm leadership that he's displayed throughout the pandemic and the directors of public health have been fortunate enough to see Chris every week in our conversations with him, and we absolutely have appreciated the way in which he's responded to the pandemic and supported us in our responses locally. So, without further ado, please join me in welcoming Professor Chris Whitty, chief medical officer for England and chief scientific advisor for the Department of Health and Social Care. I will encourage you also to, whilst Chris is speaking and subsequently, please do use the question and answer function because we're, we're going to be-, hopefully, have quite some time for us to engage in questions and answers with Chris. Over to you Chris.

 

Chris Whitty: Thanks very much, Janelle. I mean, building very much on what you've said, I mean, this is-, in a sense, this is an important day to look backwards I think and that of course most of what I'm going to say is going to be looking forwards. But, you know, this is a sad reality, if, if we look at the ONS data that came out today, as of end of last week, 147, 179 of our fellow citizens died of COVID. And even if we look at excess mortality, which is slightly lower, so that's, in a sense, the number in addition to where you would have expected it, they estimate that 111,641 of our fellow citizens died in excess of what you'd have expected over this time, and this is due to this virus. So, no public health teams, no local authorities have had to deal with something like this on this scale for a very long time, certainly, since any of us were working. So, the second point, again, reflecting on what you said, which I wholly agree with, is a massive thanks to people working as directors of public health in wider public health teams, in Public Health England, and in local authorities, because I think that, you know, people have risen remarkably to the challenge, as, as has the whole UK population. It has been actually a remarkable national effort at both a local and a national level. But it has been not just the bits which I think people see very clearly. So, emergency services, obviously, doctors, nurses, healthcare workers in hospitals, care home workers, but also schools, also local authorities who've really stood up a very large amount of the response to this across a whole range of different areas. From dealing with protecting those and supporting those who are shielding through to supporting schools and the DPH network itself.

 

But I do want to just, you know, just take a moment to say how impressively the, the directors of public health and their teams have responded to this, to those who haven't come across them. I think really until this epidemic hit us, many people, even in local authorities, and certainly outside them, didn't realise what a key role directors of public health have and wider public health teams. And I think this has really highlighted so strongly why this is so central to the long term protection of and, and improvement of the health of our, our, our populations. And, you know, I do think that one of the things we need to do as part of our recovery from COVID, we're no-, by no means out of the woods yet, is actually to cement that leadership even more strongly, I think, locally. And also I think importantly make sure that some of the links between the local and the national that have been built up don't disappear because I think there is a real risk of that. In terms of COVID, I, I, I, I could talk at length about where things are going with COVID but I suspect the great majority of you either already know it or if you don't know it's because you're deliberately choosing not to. So, I'm, I'm going to just make an obvious point which is that the path from here on in does look better than the last year, but there are going to be lots of bumps and twists on the road from here on in. There will definitely be another surge at some point, whether it's before winter or in next winter, we don't know, variants are going to cause problems, there will stock-outs of vaccines, and no doubt there will be multiple problems at, at a national level but also at a local level, school outbreaks, prison outbreaks, all the things that people are dealing with on a day to day basis.

 

I'm very happy to deal with any of those on questions, but I suggest we don't dwell on that at this point. The, the-, broadly though there were three broad sets of things I wanted to say as this, kind of, introduction, and then really lead the great majority of the session over to extended answers to questions. The first is just to repeat but then maybe slightly build on what Janelle said about deprivation. The-, this infection has picked out in stark ways, something which everybody on this call knows, which is that ill health follows deprivation, it does for infectious diseases, it does for smoking-related diseases, it does for all cardiovascular diseases, it does for cancer. The same areas are really badly hit every single time, and the same people are very badly hit, sometimes that's geographical, some-, very largely, that's determined by socioeconomic and deprivation indices and sometimes it's defined by for example ethnicity. These existed before COVID but COVID has really thrown a very strong light on them. And what we've had is COVID is most common in these areas, it causes the problem to those once it's there, so it's therefore led to greater infection incidence for a variety of reasons, including the fact people, for example, can't take time off work, people live in large generational households, crowding, a whole bunch of different areas. There's a very, for example, strong example, strong gradient between the most urban, semi-urban and rural areas in terms of incidence of COVID, so some of it's not just purely socioeconomic. It's then tended to lead to higher mortality in these groups, and that's largely because of pre-existing comorbidities that we, we all knew were there, but has made this even more obvious.

 

Smoking-related diseases, for example, obesity, for example. And unfortunately, if you look at vaccine uptake, the people who are the most likely to get COVID and are most likely to die of COVID if they catch COVID are also, in aggregate, not at individual level but in aggregate, actually have lower rates of vaccine uptake at this stage. And we really need to make sure we deal with that because otherwise what's already an entrenched disparity is going to get even worse over time. That's the first, sort of, set of comments, I think-, I think those are, are obvious, but I think they still bear repeating. The second point is that the effects of lockdown, we've known right from beginning the lockdown was going to have really severe effects on many people's health. Absolutely not everybody, for some people, lockdown has either made no difference, or even in some cases, if you actually look at the academic literature and the surveys has even improved life interestingly. But, but for many people, physical or mental wellbeing have been very badly affected by this, ranging from increased levels of domestic abuse, loneliness, particularly in older people who've felt very much isolated in their areas, physical health, people maybe not-, exercising less, more, greater amounts of alcohol consumption. But also, and this will. Be very important in the long run, people not attending things like screening, so the medical things, attending doctors late with things that they would have gone earlier, this may well have a significant effect on cancers being detected later.

 

But in the very long term, for many people, their, their-, who are already on marginal levels of income, marginal levels of deprivation, lockdown, potential for losing jobs, the reduction in income associated with furloughing and so on, all of which the state in multiple ways through local authorities and national government have tried to reduce, but reduce and not eliminate. And there will be many people who were close to deprivation and now will have been shoved further into it by the effects of lockdown and all the things we've had to do. So, there is going to be a very big job of work to do in terms of recovery, and these are going to hit, in particular, people in their early working lives. So, these effects could, if we're not very careful, be lifelong, and that'll be exacerbated by reductions in face to face learning in school and indeed in, in college, further education and universities, which are one of the most powerful engines reducing deprivation over generations. So, there's a-, there's a-, there's going to be a long rain-shadow to COVID, which all of us will be dealing with, and many of these are going to land in the responsibilities of local authorities rather than national government in terms of how we respond to them and how we best recover from them. So, that is really quite a serious set of issues that I think we are going to have to deal with for quite a while. The final set of comments I just wanted to make were really just to reflect on what we could do better, could have done better, and could o better in the future.

 

On the could have done-, could, could have done better and what we could have done better in the pandemic, there will be a lot to learn on that and I, I personally really welcome that, I think-, I think there's a lot we could do better in the future by learning from what we didn't do right this time around. And certainly, there are a lot of things which, you know, if I was rerunning things again, I would do differently, I'm sure that's true actually for everyone on this call, knowing what we know now, we would do it differently, as with almost any situation where you're really doing things from a standing start. But I thought, excuse me, there were two other-, I have just had my-, yesterday had my COVID test, I'm confident it's not that. I, I had two other things that I just wanted to highlight. Place has obviously been really important for COVID, if you look at the maps of COVID, they are very highly geographically focused, but that has tended to move around, and it's tended to move around for a variety of different reasons. At any given point in time, if- the bits of the country that are most affected have been different, but certain areas have come back repeatedly, time and again, to a situation where they were in-, particularly badly affected with COVID, and that is still the case. For example Leicester all the way through had very significant issues, Blackburn with Darwen all the way through has had very significant issues. Other places have, have been really badly affected for particular points in time, and then less so over other times, points in time.

 

And inevitably, the areas that have been badly affected have tended to have things that are in common, and this is my, sort of, my main point on this, is the things that are in common are, are-, do not naturally fit in historical county local authority boundaries. So, many of the problem sets we see from COVID, but this is true for all the other health problems we see, and we're going to have to tackle in the future, they often are geographically localised but dispersed across the country. An example in a slightly different area that I'm looking at at the moment for my annual report for this year is coastal towns for example. The coast-, the problems of coastal towns are more-, very often, more, much more in common with one another than with their nearest inland town in the local authority. So, we need to be thinking about place, not just in terms of, kind of, area of the country, but also problem sets, where place-based issues of health are repeated in multiple parts around the country, what should be our national strategy to that, how should the local and the national public health interventions work? And I think COVID was an example of that, but there are very many others. And the, the final bit of this section I just wanted to comment on was science and research. If you look at COVID, I, I was confident right from the beginning that the only way out of this was going to be science and research, and the reason for that is that has been true for every single major problem we've had in health back over centuries. The way you actually move from where we are now to where we could be is by improving science and research.

 

And I think if we look at public health research in general, it's probably slightly less strong than it could be in the UK in terms of practical responses, some very good academic work, but in terms of things that actually answer practical issues, and much of the research that's done is not done in the places which have got the biggest health problems. You know, there should be far more research going on in Wigan and in Blackpool and in Skegness than there is in North Oxford, but that's not actually what you see. So, we really need to have a much stronger engagement, and local authorities have historically not had anywhere near the kind of interactions with the research and academic areas that has been the norm in the NHS, and I think this is an area we really need to look at. I think COVID has been a very powerful illustration that when you have a series problem, actually, for very many of the issues, you're only going to find one, one way to get out of it, and that's to research your way out of it. And there are many other areas where I think we could do the same, which we currently are not. So, I think that's an area we really all could do a lot better, and I say that as head of the National Institute for Health Research, so that's wearing my other hat. But I go back to my really-, my final-, finally, to my first point, which is really a huge thanks to everybody on this call, and all the people you work with. It has been a depressing but very, very remarkable collective effort by local authorities and people in the widest possible public health community led by directors of public health, and I think people, you know, those who know about it, are immensely grateful, everyone else should be grateful.

 

It has been a terrible year, but it would have been a lot worse if it wasn't for the work of so many people on this call and your colleagues.

 

Moderator: Thanks, Chris for those, that opening points for us, the, the-, it has stimulated a lot of questions, a lot of questions coming in, so we'll, we'll try and group them, and perhaps group them in a way to, to look at the key points that you've made as well. So, if we were to take the point around something around COVID, and the point you've just made, how can we make sure that that expertise and knowledge and experience of the local system is at the heart of developing national policy? So, you mentioned that those connections, those relationships have been really important as we've developed a system approach, how, how can we ensure that that continues, that two-way exchange of expertise and knowledge?

 

Chris Whitty: Well, I think a, a lot of this is that I think that if you look at the, sort of, tripartite relationship between national government, local government and the NHS, there have always been frictions between those three points in the triangle that actually is what supports our health of all of our-, all of our fellow citizens. And by national government, I'm including, for the sake-, for sake of argument, Public Health England, I accept they're not part of government, but they are part of the central national response but with some regional presence. I, I think we need to look at that, you know, there, there is going to be a significant reorganisation of the public health system. I think we need to make sure in doing that that we strengthen rather than make weaker the links between the local and the national on this because there's a tonne of stuff which cannot be done from the centre and can only be done locally. Equally, that's true the other way round, there's a bunch of stuff which actually is much easier done nationally. Or, and I go back to my other point, done as seeing problem sets as local but actually repeated over multiple localities, whether actually there should be a genuine national strategy for whatever the problem, problem is. So, I think-, I think it's really responsibility of everybody on this call, obviously me from the national perspective, but all of you on the call as well, to make sure that in the, the reorganisations that are going to come, and no one-, no one loves a good reorganisation if they've got any kind of sense, but, you know, they, they happen from time to time for perfectly understandable reasons.

 

And when they happen, I think we should take this as an opportunity to strengthen rather than weaken the links, we've got to do that I think because I think this has really shown why that's important.

 

Moderator: Okay, and in terms of there are some things that need to be done nationally as, you know, as opposed to locally, so one of the questions is in terms of recovery, is it-, and inequalities that we've been talking about, is it time for universal basic income or something similar to be part of the COVID, post COVID response? So, what, what are-, what's that national policy response?

 

Chris Whitty: So, one of the few areas that I steer well clear of, well, there are two things I always steer clear of, things I think are far too political, which this isn't, and things which are to do with money, in public, in private I have vies and express them to ministers, but. And the reason for that is I think that's actually properly the role of politicians, local and national, to determine budget, so I don't comment on them. The general principle that-, though that what we need to do is ensure that people who are on the lowest incomes are supported I think is an uncontroversial absolutely central point of public health. And in a sense there's quite a fall off actually, it's not a-, you know, although people imply that this is important at all stages, this really makes its biggest difference for people who are in the most deprived areas, and relatively small changes in, in economic situations can have really quite profound effects, positive or negative, on their health, health prospects and indeed generational life prospects. So, so, I mean, there are lots of mechanisms by which you can address this, universal basic income, it happens to be one of them, but it's, it's not the only one. But the general principle that this is an important area, I don't think is in any sense controversial, it clearly is true.

 

Moderator: Okay, thanks, Chris. And there, there are a set of questions about some of the, the key learning points from the pandemic, for instance, when, when we went into lockdown, for instance, one of the key points last, last September when the second wave started to hit us, could we have gone in, in sooner, could there have been clearer rules, could we have done it differently in terms of students coming back? So, so there are-, there are a number of questions saying, you know, could we have done it better? So, do you-, you said about learning, lots to learn, what's, what's your approach on how we should go about doing that?

 

Chris Whitty: Well I think, I mean, I, I would divide-, in terms of, you know, how-, things you would run differently, if you-, you know, if we had the knowledge and the information systems we have now, let's take the first-, the first lockdown, the second lockdown, different responses on this. On the first lockdown, our fundamental problem was we simply didn't know what we were dealing with, we only realised quite how fast the way it was developing at the point when people started dying in hospitals basically because we-, you know, if we had the kind of testing system we have now, we'd have spotted this way far further out in time and been able to judge it rather more carefully. I think the difference in timing would have been relatively small, but it might have been significant. We didn't actually have any experience in a Western democracy in the last century or having done anything like lockdown to try and achieve these kinds of things, so we didn't actually know how it would work. As it turns out, people responded to it magnificently and it had the effect that we were hoping it would, but that wasn't actually a given at the point we started. There were a bunch of things we didn't-, we, we overestimated what the proportion of transmission was from people who are symptomatic, which was a misunderstanding from SARS, it's an example of where actually, you, you, kind of, look at the examples you've got and actually, you draw the-, draw the-, you know, draw a line through the dots, but that isn't always right. But I think that the decisions in the first wave were largely to do with the lack of information and a lack of knowledge, and the replaying of that would have-, would be different were we to have understood what was going to happen next.

 

I think in the second wave it was slightly more complicated because I think the economic and social effects of lockdown, which I talked about earlier, were always in tension with the COVID effects of, of having a lockdown. And I think anyone who claims that, that those two are not in tension has, has failed to understand even the public health issues, leaving aside the wider societal ones. So, it was always going to be quite a difficult issue on the second one, and that was less about us not understanding where we were on the pandemic, although a surprisingly large number of people in public life, and I'm not meaning the government here, I'm talking more widely, to be clear, don't seem to understand what an exponential curve is. And that-, and this includes people who, who have economics in their title, for example, and which seems a bit surprising, so, you know, don't understand that once something starts, once, once an epidemic starts going, it is simply-, it is either doubling or halving. And if you're doubling, you're going to get from small numbers to scary numbers surprisingly fast. But of course, the, the really big changes tend to be backloaded, so you can see the wave coming out. So, I think there was a combination of an inability of some people to understand how exponential curves work, I'd say this isn't a, a point about government, this is a point about the wider societal response and the difficulty of essentially balancing large numbers of societal.

 

And different people would say-, you know, I think there's-, lots of people would say at the time how would they have balanced it, and then lots of people who say after the events, having seen how things have turned out, how they'd balance them, maybe they're the same, maybe they're different, I think they vary depending on people. We've also always had a really vigorous debate with outriders on either side, there has always been some people who said, 'You shouldn't lockdown at all.' And they said it all the way through, right from before first lockdown, this is the wrong scientific approach, he's a scientist I'm talking about. And people who said, 'We should lockdown early and hard and stay locked down the whole time. We should be aiming for zero deaths.' And where we've ended up is some point between those, which, which is where I think the bulk of scientific and technical opinion is. But to be aware those, those debates have been in the technical press as well, there hasn't been a science view and a political view, there has been a range of scientific view with a midpoint, and there's been a range of political view with a midpoint. And I think how-, you know, I could give a very long answer as to how that's played out, and I think there will be time to do that, I'm just making some-, making the obvious point that actually I think the idea that there was a right answer. The final thing I'd say on this is I, I would divide things that I would do differently into the areas where we had the right science, but we didn't have the data. So, the models as to how the epidemic was going to work were actually pretty accurate, it was just that we didn't realise where we were on the epidemic curve, that was a lack of data rather than the science being right.

 

And ones where the science has, the scientific opinion has changed, either because the data has changed, like, the trajectory of asymptomatic transmission, or because the scientific consensus has changed, like the importance of facemasks, where actually the science hasn't changed itself, to be honest, but where scientists believe the midpoint of the debate is has shifted quite a lot over the course of the epidemic. So, there's a lot of reasons why we've changed, you know, if we were doing-, giving the same advice again, we would have given a different set of advice, and sometimes it's just we know-, we know more, and sometimes it's we just we, we knew the right science but didn't have the data to fill in-, fill in the gaps. I could go on but that's probably enough for now.

 

Moderator: Well, I suppose there, there's a few questions then that flow from that. So, people were-, had flu pandemic plans in place, we had lots of plans in place, were those plans not adequate? Were they not the right plans? So, there's some, some question around that. And then, another question is in terms of our response and that local government, environmental health officers, public health teams, PHE teams, this is bread and butter and used to doing infectious disease control, and outbreak management and so on. But didn't seemingly-, weren't utilised-, used to the-, to the degree to which they felt they should be used and that's frustrating. Although, are there lessons around-, for us around our planning, our plans, what we have in place, the use of, of, of, of, of, of a public health system already in place? What-, so there's a-, there's a-, there's a bit there where people are feeling, 'Well, what isn't that we could have learnt?'

 

Chris Witty: Yeah, so on the-, on, on the-, on, on the should we have used local more at the beginning, I, I think the short answer is yes. But the rather longer answer is when you're trying to stand up a, a capacity from a standing start it, it almost always starts of being done in a centralised way. And in part, that's just because that's-, it's easier to do that if you're trying to do it from the centre, and in part, if I'm-, if I'm honest, it's also because capacity varies across the country. And if we'd done it entirely on a local basis, we would have actually found some areas were in much better shape than others just because of pre-existing skill-sets, pre-existing capacity and a whole bunch of other areas. The advantage of doing it nationally is at least you don't end up with that situation where you often needn't entrench some of the problems you've got because of relative local issues. Now, that wasn't actually the reason it, it was done, it was primarily for the first reason. But it was much easier to do it-, set-, to do stuff at speed because even if we'd utilised all of the local capacity, what we didn't have was the testing capacity and all of the things that needed to go with that. And for a disease which has got an incredibly non-specific syndrome and incredibly common, moving extraordinarily fast, in the absence of testing, your-, you know, the ability to contact trace is, kind of, neither here nor there. You, you're going to have test or you're not going to be able to do this, and it was the standing out testing capacity that was really the rate-limiting stuff at the beginning. Rather than the, the, the, the-, you know, the, the trace bit of Test and Trace, I think you arguably could have done more locally and probably should have done more locally.

 

The test bit, that was always going to have to be done at a central level in the UK environment. Some other countries had had a larger testing industry, were able to do it in a more-, basically by handing it over to the private sector were able to do it in a more dispersed way then the UK was. But we didn’t really have that, that ability, or at least, certainly didn't think we did at that, that point in time.

 

Moderator: Thanks, Chris, and if we can just take one or two questions on vaccination and then there are quite a lot of questions coming in about moving forward and future. But there are still, just on, on vaccination, just perhaps say a little bit, there's questions about, 'Well, how does the JCVI prioritisation work when,' for instance, the question mentions the prison outbreaks and why aren't we, you know, why didn't we get ahead and, and vaccinate prisoners? And then, there's another question around supply and the up and down of supply, and will, will the UK become self-sufficient in developing it's-, enough vaccine, it's own supply? So, that we don't, you know, we don't have to deal with other countries supplying it to us.

 

Chris Witty: Yeah, well, on, on, on prisons, I mean, the, the thing with the vaccine rollout was the reason JCVI took-, the initial set of decisions based on age plus disease multi-mobility and other issues, I think was incontrovertibly right. And that's because the number needed to vaccinate at the top end of the age range is about twenty and the number needed to vaccinate once you get below fifty is about eight thousand. To, to avert one death. This is so predictable in terms of who's going to die that until you've vaccinated all the people who are very high significant risk in mortality and you can predict with 99% certainty, who they will be because 99% of them were in very highly-defined groups. It made complete sense to do that so that's JCVI's list, groups one through nine which is what we're still going through. And I, I actually think most people who make counter-arguments, if they were on (ph 34.37) JCVI, fundamentally would have made the same decision I think they would find it difficult to sustain one. I think the question about what to do once we get below JCVI now nine, is rather more open to discussion and I think different people could come to different views about this. There still remains quite a strong age differential in terms of severe disease. Less, less of mortality, but your probability of getting-, of hospitalisation and getting onto ICU is still very heavily determined by age plus some very, pre-obvious conditions. So, I think the argument-, and the, the main reasons that JCVI went for age were two-fold, one was that, that this at least a very straightforward way of actually defining who's at greatest risk. And the second was actually to do with speed.

 

The, the way that this is most easily-, this disease is going to be most easily be brought under reasonable control, not complete control, for the foreseeable future is to get the maximum number of people vaccinated. So, essentially the first group of vaccinations is to stop people dying and the second group of vaccinations are still in, it's to stop people being hospitalised and (mw 35.43) the disease, plus some deaths. The third group of vaccinations will do that but actually it also, the great majority of the transmission occurs in people under 50 and over 15. So, in that age range. That's by far the bulk and that's what drives the epidemic, so, you know, should you within that go for particular groups or particular geographies? Well, the issue here-, and I-, because I get emailed about this on at least a daily basis by different groups, I'm aware of this, is that there are almost infinite numbers of groups who could make a perfectly judicial case based either on vulnerability, on geography, on as you say with prison outbreaks or, you know, you could say the same about meatpacking, you could say the same about fruit, fruit picking. There's a whole bunch of different things which are clearly associated with either vulnerability disease or vulnerability to mortality, and some of those choices are pretty fine choices. What everybody who makes the choice and I've-, I been-, I've been pretty firm about following JCVI advice rather than trying to deviate from it, but they all made the cases as to why their particular group should get it, very few of them are prepared to make the case as to why another group should therefore not get it.

 

And it's, it's the-, it's the zero-sum nature of this at the moment, because of the number of vaccines you've got which I think is, is really quite important to think through. You know, if, if you say yes to one group, by definition you're saying no to some other group. In terms of the supply, I mean, what I really-, what we-, what we really should all want is a global supply that is sufficient for global need. And in an ideal world, that would mean we didn't worry about borders because there'd be so much supply that it actually doesn't matter one with the other. The reason that we will probably end up with greater supplies partly because that's good for the world, I mean, we clearly have demonstrated in, in sufficient capacity to do this at speed and high quality. So, I would be very much in favour of the UK having greater capacity all the way through the vaccine chain and remembering that it's not just, you know, there's a whole bunch of different steps to that. And, and with the current model, if you look at most of the vaccines we're using, they cross national boundaries multiple times between the first stage of the process and the point it actually gets into someone arm. So, you know, the firm finish is often very different from where the batch is made, are different from where it's tested, and so on in terms of nations. Now, is it a good thing that every country aims to have national self-sufficiency on this? Actually, probably not what we really want is a system where, where globally there is complete sufficiency. But at the moment, it is sensible for the UK given there is global insufficiency to be aiming for maximum internal capacity over the maximum number of platforms, because we are one of the countries that is able to do this.

 

And hopefully, do this for the world as well as just for the UK. I certainly would regret a situation where you only got vaccines from your own country and that's the way it had to work, I don't think that's an efficient or appropriate way to respond. But, you know, I certainly am very strong in favour of the UK having greater capacity.

 

Moderator: Thanks, Chris. So, moving on from learning from Covid, the inequalities element and move-, you know, moving forward. Question about how we can use this time to refocus local government, and place space, public health and wellbeing back to the centre of local government? So, currently a lot of focus on adult and children social care, and indeed on money going to those services, money going into the NHS. So, high-cost, high-demand areas but for-, so the, you know, do we need to refocus local government back to health and wellbeing like they were 80 years ago? Perhaps, reaffirm through legislation and the, the question is, it's (mw 39.49) DPHSomerset says, 'You've been an absolute star throughout all of this, can't wait to shake your hand.' So, I just thought I'd add that into the end of her, she sneak-, snuck that one in on her question. But it is about local government itself, in essence, being there to serve the public health and wellbeing in a broader sense rather than the money focused on high-demand areas whether that's social care or indeed NHS?

 

Chris Witty: Yeah, so the, the difficulty really here, and this has always been the problem, it's true, it's a real problem at national level as well, and anyone in public health recognises this. Is that the urgent crowd, crowds out the important but long-term. And if you're in the central health system, you know, the fact that wait, wait times in A&E go-, are going up, is much like-, is much more likely to hit the news than the fact that actually screening services aren't quite what they could be. Until something really badly goes wrong or, you know, smoking sensation services are, are weak. And now, if you, you-, if actually, if you do, kind of, pound per impact on health, many of these other areas are far more effective, viewed over a long period of time. So, if you were-, if you take them over a twenty-year period, many of these areas are-, have a much bigger impact. But the, the, the nature of most discourse in the public is around the here and now, and that's not particularly surprising. Now, Covid actually almost is the wrong answer on this one, 'cause Covid, in fact, is all about the here and now. It's about trying to get on top of stuff, where we've got an epidemic, we've got to get on top of it both immediately, and also to try and stop it from coming back again. And so, the great majority of our focus has been on issues that are, are about trying to prevent people dying in the next three weeks. And then, preferably in the next three months. As I say, some of the effects of lockdown, for example, are going to have their negative impacts over many years, and in some cases, decades. And it's those kinds of issues that I think often get lost, and so I think what we really have to do is always go back to, 'What is the area under the curve?'

 

And actually, something which has a 10% effect but only for three months will often have a much smaller health impact than something that has a 2% impact but actually is over a lifetime, every year repeating that 2% impact. And, you know, often something like primary education is more important for health in many cases than, you know, something which actually has, you know, a major heart operation or something of that sort. So, I think it's very important that we, we, we prove that with well-done research and then make that point over and over again to those who are making decisions, and basically show them the maths. And say, fundamentally, if you want to improve the lot of our citizens viewed over a lifetime, it's actually not always the thing which is very, very quick that's going to give you the big-, the big impact for the same pound spent. It's actually very often these rather lower key for longer, longer way of issues.

 

Moderator: Yeah, and I guess with the vaccine hesitancy amongst certain groups around trust in the system, trust in the, the public health system, or even the NHS, that does play out even in the immediacy of Covid, doesn't it? I mean, how do we build back that, you know, the, the, the unequal experience of public service and therefore that distrust which is actually, you know, then you can see it whether it's Covid vaccine. But actually, there, there's so much more there, isn't there?

 

Chris Witty: Well, I think-, I think that the, you know, if you look at people's lack-, reduced, reduced enthusiasm to take up vaccines, it's a marker for usually, lack of engagement often for very understandable reasons over multiple other areas of health and indeed wider society. And I think if, if our response to some groups having lower vaccine uptake is, is simply to get them vaccinated, well, I mean, that will help us a bit in the short run but I think that's a huge wasted opportunity. They are absolutely the same groups, this is an opportunity to engage with them, I mean, some ethnic minority groups will be an example of this, this is actually an opportunity to engage with them on wider health issues. And it should be seen as the start of a conversation rather than it's just-, it is the conversation, the vaccines in your arm twice, now that's it, job done. I think that would be an error. And if I can use an anecdote just to illustrate this from my, my previous life, that when we were trying to get people in northern Nigeria to have polio vaccination, and we said to them, 'Why won't you be vaccinated against this?' They were basically saying, 'Well, this is a very rare disease, all we see is twice a year, a government appears in white Land Rovers, tries to vaccinate us. In between worlds (ph 44.32), we have no, you know, no health system, we have no primary school system, why should we trust the government now?' And that's a very fair question so, you know, the reason that people don't trust the system is based on long-standing experience and actually, this is a marker for these are the groups we want to engage with so I think it should be seen very much in that way.

 

Moderator: Great. So, moving onto the science and research element. So, how, how can local government be more involved in public health research, what-, how do we go about doing that? How do we improve it and in those areas, where we already, you know, perhaps are struggling a bit in terms of capacity and capability?

 

Chris Witty: Well, my experience of local government which is far less than most people in-, on this call, is that it is genuinely evidence-based but with a very, very weak capacity to undertake and indeed to analyse quite a lot of data. Which is along the edge of a central government centrally, I think can genuinely help. But, you know, most bluntly, most people who are involved in local government, whether it's on the political or on the-, on the administrative and official side will be living in the same place for the rest of their lives. And that's quite different from it-, they, therefore, have a very strong interest in taking a long-term view about how do we improve the health of our society? Because that's where their children will grow up, it's where they will-, they will end up probably being buried eventually, or cremated or whatever their chosen exit from the world is. So, I think that what we need to do is, you know, harness that and say, 'Well, look, research is actually a long-term thing. It's the-, it's primarily about what is the best way to spend the money we've got.' And all local authorities are about trying to maximise the impact of the very limited resources, very often that are available and we shouldn't expect local authorities either to have the internal capacity, that's what the academic sectors there for. Government doesn't have internal capacity either-, neither central government. Nor to have the resources, that's what the funding agencies are for. So, the funding agencies should put the money on the table and the universities should be incentivised to go and work with local authorities.

 

And then local authorities have to invite them in and say, 'These are our problems, will you help with these and we will give you access. And we will help you to do it administratively, and we will help guide the questions and now get on with it.' And then the academic sector can do that. Now, we've started to make some tentative starts with that, so NIHR for example has put money on the table for research that can only be unlocked if people do it in collaboration with the local authority. So, that's a start. I would though like to get much more to the situation you have in the NHS where it's completely normal that people have joint academic NHS appointments. So, almost my entire career that's what I've had, and that's very normal in the NHS system, it's very rare actually in local authority system. There's no reason why that shouldn't be the case. And, and the final point I make is that I think it is important that when people do this, they don't just assume they have to do it with their local university, or higher, higher, you know, technical college, whatever it might be. You know, you may have the best one on your doorstep for the particular problem you've got, or you may not. And the right thing to do, England and the UK wider, we're a small country, and actually one of the side effects of Covid is actually by Zoom and Teams we can in fact do the great majority of the stuff without even having to travel. I'm used to doing research in different continents, so the idea that it's difficult to do two counties away has always struck me as mad, and if the best researcher is in York or the best researcher is in Truro, well, we should be going to get them and get them to solve the problem.

 

So, you know, for the outcall unit in Newcastle should be helping with problems in Wigan, doesn't have to be Wigan College. Wigan may well be able to help Newcastle with a different set of problems. So, I think what we should be doing is we should be much more adventurous about this. Aiming to go for the best people in the country, challenging the, the, the research funders to put the money in for it so that it is funding neutral to the council, and then saying to universities, 'You've got to do this.' And I think if we do that, we could really be transformational and have more joint appointments. I think it could be-, we could really feel very, very different and feel much more like a joint endeavour rather than academic swooping in and swooping out. And I think, as I say, I think if I-, if I had a single ask of local authorities it would probably be to be imaginative about the possibility of joint appointments where the research side of it is paid for by someone else. But where actually, the fact they're embedded in the system allows then people to understand the questions and then to have access to the information the need.

 

Moderator: Chris, thanks. And I guess it's, it's not just public health, is it? There's a question from Claire Bircham as a qualified social worker, working in Adass, struck by your points about deprivation and the need for local government to raise the bar about research. Some more questions about the involvement on social work research in this and how to strengthen, strengthen practical social work research at a local authority level.

 

Chris Witty: Well, I think social work, work research and the only reason I made it on public health was because this is a joint need-, joint need sponsored by the associate directors of public health. But I completely agree on social care and if we were to look at the-, although, there's a less public health research then I think there should be domestically. If you look at social care research and social work research it's just a fraction of a fraction of a percent of what it should be, given the importance of the problem. I mean, given the huge sums involved and the enormous impact on people's lives, the amount of research that goes on in this area is pathetically small and I think we should all feel, and I feel as a fund-, a funder of researchers including the NIHR, a real sense of, of failure on that actually. And they can't suddenly turn it from being very small to being very vibrant and large, but the key thing is you have got to start somewhere, and I think if anybody on this call knows people who wish to do good social care research, coming from a social work background or indeed any other background, we would be desperate to talk to them. Because this is an area we absolutely have to do, not just a bit better but massively better, there's a huge deficit between where we should be and quite a small amount of, of money would actually go really quite a long way on this. So, I think it's, you know, this is not actually about money resource, I don't-, I don't think that's the limitation in this particular area at all in terms of the research. It's much more about the ideas and getting people to actually engage seriously on this.

 

Moderator: Thanks, Chris. And there's another question from David Acock who's also flagged up about charity and community sector, and how they've stepped up often in really difficult circumstances when, when funding has been a real issue. So, you know, we worked very closely with our, our colleagues in the charity and community sector. So, how can we ensure post-Covid that the, the potential of that sector as well is fully realised and seen as an equal partner in improving public health and tackling health inequalities?

 

Chris Witty: Well, I think both, just to finish off on the last question then on, on (mw 52.00) a very large amount of the best research in the UK is funded by the charity sector. But who've been absolutely hammered by Covid because many of their main funding mechanisms, you know, marathons and charity (mw 52.12) and so on, have absolutely dried up in this-, in this period. So, it's, it's-, they, they are in deep trouble the lot of them, not all, it depends entirely on the funding model but then so is the delivery side. And I completely agree with the, the, the tenor of the question. Now, within the charity sector, it's an incredibly varied sector, charity and voluntary sector more widely, ranging from ones which are incredibly niche and highly technically competent. There are some that are incredibly niche, very good at what they do but actually, research and more technical side are not here. And then, there are very, very large ones which really have the capacity to do a huge number of things, some of which are engaging in really strong technical debate and some which, if I'm honest, are not. And I think that's a shame because the-, you know, if don't engage in a strong debate and probably back it up with some research where there are gaps, then you're, you're condemning yourself to never improve on where you are at the moment. And I think there are some areas where actually, I think we could do better if I'm honest. But, I mean, the charity sector and the voluntary sector in the UK is one of the UK's great glories. And if you look around the world, there are very few other countries and the ones that do are surprising, you know, Bangladesh or some of the countries in Latin America, you wouldn't necessarily need to think of.

 

There are some other countries that have got as strong a third sector, charity sector, voluntary sector influence, but not many actually. So, the UK's very fortunate in this and I think we should make, make full use of it.

 

Moderator: Thanks, Chris. And I can see we, we thought-, it's been fascinating conversation with you, and great questions. So, in the last minute or two, there's a question, 'Is it possible for the sake of wellbeing to provide some positive statistics on recovery rates?' So, I, I guess giving you the opportunity to comment on, you know, finish with some positive thoughts about how we're going to take this forward over the next year?

 

Chris Witty: Well, I think I, I'll, I'll give-, I'll give two positive thoughts. I mean, the first one is that even before we have vaccines and much better drugs and things, the great majority of people with Covid did make a full recovery, and the aim of what we're doing at the moment is to make sure that that ratio is massively improved. And it will be already because the vaccination programme and also the things like dexamethasone and (mw 54.44), and having all these other treatments. So, your probability of surviving Covid are much better now in March 2021 then they were if you caught it in March 2020, much better. Through prevention and treatment overall, and our ability to keep the NHS running with Covid has much improved. So, it's not just the direct effects but the indirect effects on the wider health system. If you look at the number of people in hospital in Covid, on the first wave, it was much smaller than the second wave and yet more non-Covid work happened in the second wave, you know, a great tribute to our colleagues working in the NHS. So, I think and then the final point on that is, you know, science has taken us a very long way in a year, it's quite extraordinary really when you think about where we were, how far we've got on presentation, treatment, understanding, modelling, all these kinds of things. So, I, I feel very positive about the future but very positive doesn't mean we won't have quite a lot of problems between now and when we get to the point we think actually we're now in steady-state with this virus, and we are quite some way from that.

 

So, I want to be very positive about what we have achieved, including massive again thanks to everyone on the call, and very positive about what we've learnt and will continue to learn about this. But without being too pan-glossian about the fact that it's all over now and, you know, this is just done. I'm afraid there's quite a way to go before we get to the point we say, 'Actually, this is just now where it's going to be.'

 

Moderator: Great, Chris. Well, thanks. We’ve-, a lot of questions, thanks very much everyone for your questions, have come in some comments about your leadership Chris and, and thanks very much incredible leadership over the last year. And that it, it has felt, and certainly the conversation this morning, that it's been a, a real team of teams, you know. We mentioned a lot of players within that, that team, environmental health, social care, voluntary, charity sector, academics, it's, it's really been that whole approach together. And led by, by yourself, Chris, so thanks so much for taking the time to come and speak to us. I hope that you've, you've enjoyed the, the interaction with a thousand people even though, though we can't quite see everyone. But it, it's been really good and set us off for, for the next few years in terms of our focus. So, thank you very much.

 

Chris Witty: Yeah, yeah, can I just, I mean, I've-, you know, crisis have many, many downsides. That one of the few upsides is they tend to create links you didn't previously have. I think the links between me and our team, the other DCMOs and the directors of public health are much stronger as a result of this, than they would have been otherwise, which I'm really grateful for. And to your leadership, Jenelle, and I hope we can continue what it is unfortunately made more difficult is getting to know which I was beginning to do, local authority colleagues more widely. So, it's reduced the ability to travel around the country and meet people, and that's certainly, we need-, we need to continue I think. But I just, just thanks so much to everybody for what they're doing, it's just amazing.

 

Moderator: Thanks, Chris. And of, of course, implicit in what I've been saying but I, I know I, I haven't been explicit is Public Health England colleagues who are on the call today, I mean, we absolutely wouldn't-, you know, it's a public health system. So, although we've, we've mentioned local government just I think because of it's LG80PH(ph 58.11) conference, but without our Public Health England colleagues as a public health system, you know, we-, and we absolutely need to maintain that as, as we go forward. And as you said, Chris, strengthen that, us, us.

 

Chris Witty: Yeah, totally agree. And I think-, I think when people write the histories of this, Public Health England will actually be seen as one of the good guys on this, as one of the real heroes in this, they've done a, an absolute terrific job.

 

Moderator: Absolutely. So, that's a, a good note on, on which to end. So, thanks again to, to yourself and colleagues we'll end this part of the morning at this point, and we'll go onto the next sessions which will be on public opinion and public health. So, thanks again, Chris, and you'll have me, I think, chairing the next session as well unfortunately our counsellor Cam, I don't think has been able to make it. So, we'll, we'll, we'll move on then, I think, into the next session. So, we've got again, please do use the Q&A, we'll, we'll take questions as they come. But, we are going to have input from Ben Page, who's chief exec of Ipsos MORI, Professor Linda Bauld, who's prof of Public Health and co-director of Usher Institute in Edinburgh, and Cordelia Hay, who's associate at BritainThinks. So, I'm really looking forward to the next part of the session. I will, delighted to have Ben and Linda and Cordelia with us. So they're going to-, I think that all three of you are using presentations, I think, so if, we'll start with you having your presentation up. You've each got ten minutes, and so that will take us to twenty-five past eleven, and then we're going to have a Q and A. So, please feel free to start putting your Q, questions in as we go through. So, first of all, over to Ben.

 

Ben Page: Thank you very much, Janelle, and I was just going to briefly look at what we've learned because a year ago, we were measuring concern about the pandemic around the world, and about 50 per cent of people in Britain at this point a year ago believed that most of the media coverage about the pandemic was fake news. Well they don't think that now, of course, and so, it's been, you know, we've certainly seen some massive shifts over the last year. I think the first-, I think the main point that I would say is despite social media, despite the Covid research group in the Commons, right-wing Conservative MPs, overall what we've seen throughout the pandemic, is a high level of concern. I mean you can see that the proportion of people who are very concerned, and in polling terms, being very concerned rather than just mildly concerned, is, is something. You can see that it stayed pretty high throughout summer, even as the deaths fell from the first peak, and it's only been recently with the pandemic, with the vaccine rollout, that it's started to fall back.

 

So, I think one of the interesting things, which again, wasn't expected by some of the beavhioural specialists at the beginning of the pandemic, was people's actual willingness to take public health measures seriously, and although there are small demonstrations about it, and although you can go on to YouTube and Facebook, and find people saying, you know, 'It's all fake, a plandemic' et cetera, et cetera, what we've generally seen is pretty high levels of compliance. And in fact, by a margin of between, and at various points, four to one, or three to one during the pandemic, the public believing that the measures the government had put in place were not strict enough, rather than too strict. So I think, you know, the public have pulled together in a way that's incredibly strong. They are-, There is in some ways, you might say, an excess of caution, but given that we are 125, 126 thousand people dead, you can understand, perhaps, where they're coming from.

 

So, that's where-, That's one of the things that we've learned. In terms of the messaging and I think that the early messaging, 'Stay Home, Protect the NHS, Save Lives', was by far the most successful. And later on in the year when we moved to more mixed messaging, to tiers, to some regions in lockdown as opposed to the national lockdown we have now, that was much, that was seen as much more difficult to understand, and of course encouraged people to perhaps be a bit more, a bit less compliant. But overall, people very serious about it.

 

As we-, As Chris has already said, the impacts have tended to follow existing inequalities. This is just a piece of analysis that Andy Haldane at the Bank of England did with some of our data, showing that if you're a knowledge worker, or an administrative worker, able to work remotely and who kept your job, you will actually have tended, particularly if you were better paid, you would have tended to save money. So, people earning over 55 grand increased their savings, but people on the lowest forms of income have been hardest-hit, and I think that's a major challenge.

 

In terms of mental health, women have suffered more than men throughout the pandemic, and it's clear that women took the bulk of work domestically. When you take a household with children in it, women reported spending 47 per cent of their time looking after the home and the house and the family, and men in the same household, only 30 per cent of their time. So, as always, women had it harder. It is worth saying that anxiety among women is generally reported as higher than men in most ONS data before the pandemic. So, although women certainly had more stress and strains in 2020, they generally do, for all sorts of reasons around income insecurity.

 

And of course, physical activity fell, and this is the first time I put race into this. This is the survey we do looking at physical activity around Britain every year, and you can see that particularly, people from Black and Asian backgrounds, less likely to be physically active, and particularly Black and Asian men. So again, the effects as we know are not equal. They have fallen on different ethnic groups more harshly, and the long-term consequences of the pandemic will fall on particular regions of the country, particular neighbourhoods and particular groups, which is, you know, is very, very clear.

 

The other thing I would say is that although vaccine-, We were very worried about vaccine hesitancy, and in the work that we're doing globally with Gavi and with the World Economic Forum, what we've seen in Britain is the proportion of people wanting to have the vaccine go up as the vaccine has been rolled out. So concerns in September, October last year that the programme of vaccinations was going had been rushed, that the medicine, the drugs, the vaccine wasn't fully tested, it'd been produced too quickly. And what we've now seen since the rollout, the successful rollout of the vaccine, is generally rising acceptance across all communities, although as we've already discussed, there are, you know, groups with lower levels of acceptance of the vaccine, which is going to be a real challenge in terms of communication.

 

And that does reflect-, The people who distrust the vaccine are people who also distrust government generally, and they tend to be younger, they tend to be people who make a heavy reliance on social media. You're about three times more likely to believe that this is all a global conspiracy to vaccinate people if you get most of your news from Facebook or YouTube. And so there's a, sort of, intersectionality of youth, of ethnicity, et cetera, in some of the groups that we will be finding harder to reach as the vaccine programme progresses.

 

But overall, if you look at how Britain compares to other countries, we are very, very different in our attitudes, at least to France. We don't have the history that the French do with some vaccination programmes. I think it's also worth saying however, when you look at this data, that people's perceptions and attitudes, as we know very, very well at Ipsos MORI, do not always relate to behaviour. So, the fact that France had only 29 per cent saying they would take the vaccine in September does not mean that ultimately the French won't get vaccinated. If you look at their measles, mumps and rubella vaccinations, I was talking to colleagues at the Gates Foundation, it is not sort of massively, massively lower. Yes, they have some pockets, but-, Certainly the British are positive about the vaccine.

 

We're also positive about public services being able to adapt. Early on in the pandemic, people were most critical of care homes, unjustifiably, because they were being, receiving people, untested from hospitals, to clear out the NHS. So they were most negative, looking across the public sector, at care homes. But overall, we've now got most people, you know, confidence about the NHS after a difficult January, is high, and we saw, and of course some of the nightly broadcasts by the BBC from NHS hospitals were, of course, deliberate, to get people concerned, adequately concerned, about the January wave. But overall, people pretty positive, most negative about civil servants handing out benefits and civil servants generally, more positive, a bit, about local government. But particularly, of course, the NHS.

 

So finally, in terms of what we, where NHS and health spending should go now, of course they're focusing on the waiting times for operations. They're thinking about resourcing. 78 percent of people, including the majority of Conservative voters, say that the one percent pay rise for the NHS was not enough. But unfortunately, with public health, as it well knows, something of a Cinderella service, we've got rather fewer people talking about reducing inequalities in health in society. Just around one in five saying that that should be a priority. And I think that's just a reminder of some of the challenges we have had as a country before the pandemic that we will face afterwards.

 

There is also an interesting age variation in terms of what we should prioritise. So, with the young, who of course vote very differently from the old, focusing on social change and social progress, and older people tending to focus on economic progress. So again, some of those divisions, of course, reflected in our politics. We aren't united, and indeed we have a survey out today with Kings College, that shows that the British are divided even over whether or not we're divided. So, we do face some challenges.

 

But overall I think, in terms of the agenda for people on this call, the difficulty is that it's exposed the existing inequalities we've already had. It’s often made them worse. People like me, living in a nice house, have tended to have a reasonable pandemic, and it's very different in a few neighbourhoods just a few streets away from where I live. It's interesting that the vaccine has saved us and so science has actually worked, and actually, faith in science and in medicine has actually held up throughout the pandemic. Trust in government peaked in April. It then fell back, but overall it's about roughly where it would normally be expected to be. There's been no collapse in faith in science, or indeed, even in government, with the vaccines helping.

 

And I think the main challenges we face now is that, we do, it does to me look like a K-shaped recovery, with some people able to have, bounce back in their spending after, with the money that they've saved, but with a lot of people with diminished savings and health problems. We've got unprotected budgets identified by the Institute for Fiscal Studies, with local government facing real terms cut as we go forward. So it seems to me that we have all the old problems, and some new ones. But the only thing that I would finally say is that, you know, the public is absolutely behind having the money there to do the right thing. And with that, I will shut up. Thank you.

 

Moderator: Thanks very much, Ben. Lots there, raises lots of, raises lots of questions, I guess. So, please encourage those, those of you to put those questions into the Q and A, and we will return to, to hopefully quiz you, Ben, on some of that. But we'll, first, next hand over to Professor Linda Bauld, who's Professor of Public Health, and co-director of the Usher Institute at the Edinburgh, sorry at Edinburgh University. Over to you Linda.

 

Linda Bauld: Thank you very much, Janelle, and thanks to Katrina, who's sharing my slides. I thought it was very important that somebody who followed Professor Whitty was actually saying 'next slide', so that's what I'm going to do. So, I'm going to cover a little bit on the context, which everyone on this call's very familiar with, but I'm also going to focus in on what we know from some of the surveys, different ones from those that Ben has presented from Ipsos MORI, and also other data about compliance, going into a bit more detail. I will make some similar points to Ben. How do these differ between groups? And then, actually, what do we know, in more detail, about trust in government, and also sources of information? And then, for the last couple of minutes, I'm gonna make a few comments about how we could improve communication and both nationally, devolved nations, and also importantly for this meeting, locally. Next slide.

 

So, everyone's familiar now with the timeline of what we've been through in the UK over the last year. The ways that the public has been asked to change their behaviour are really substantial, and they've been long-lasting. The restrictions on movement, as Chris was saying, social interaction, and all the wider harms that the pandemic has caused. I think we're only now beginning to understand the broader impacts, and they will be studied for many years to come. And there's also been important questions asked, I know by yourselves, and by others across the country, regarding whether the public would comply with restrictions, how long that compliance would last, or how comprehensive it would be. And I actually think that there isn't actually much evidence that this concept of behavioural fatigue was something discussed by my behavioural science colleagues, or the social scientists advising government, but probably came from somewhere else. I think we had a lot of faith that the public would be able to change their behaviour, given the resilience that we know that we have, despite the beginner qualities. Next slide.

 

So, again, you're all very familiar with the analysis that's now being done on excess mortality, and it is very positive to hear today from the ONS that in terms of excess deaths, we're now below what, for the first time since early September, what we would expect looking at the five year average. But retrospectively, it's pretty clear that the UK has suffered very badly, and you will have seen this analysis from the ONS that was updated last week, just comparing us with other countries in Europe, and it’s clear now that the first wave, we had the highest levels of excess mortality in Europe, and that England was harder hit than the other devolved nations, but not big differences.

 

And then in the second wave, other countries in Europe seemed to have had a worse experience than we have. But it is worth emphasising that people in the twenty per cent most deprived parts of England, for example, were twice as likely to die from Covid. So we have these differences, both when we compare us to our neighbours, and also within the country. And an interesting point that I think requires more research, is the highest rates of excess mortality in the under-65s, were observed in the UK in both waves, except for Bulgaria in the second wave, and the reasons for this are really not clear, so we're going to need to look at that in more detail. Next slide.

 

So, a few points on compliance, and many of you will be familiar, if not all of you, with the UCL Covid Social Study, which is a fantastic resource, and thanks very much to Daisy and Andrew and colleagues for allowing me to show some of their data. And what you can see here is that the common experience nationally has been of people following guidelines consistently and trying their best to do so, and the reasons why they didn't were not about protest and not wanting to follow the guidance, but more about exposure, and reasons, quite valid reasons why it wasn't always possible. And you can see that the majority compliance, which are doing most of the things that the government has asked, or public health agencies have asked a person to do most of the time, has remained high, and really didn't decline significantly at any point in the pandemic. Complete compliance was more difficult for people in the summer months and has risen again to almost the levels of the spring, as we headed into, unfortunately, the second, really severe period of restrictions that we're just emerging from now. Next slide.

 

There are, however, these differences between groups and there are dozens of charts in the Covid Social Study. These reports are released every couple of weeks, but you can see that is has been much harder for younger adults to adopt complete compliance, probably for very valid reasons, in many cases. The kinds of restrictions that have been imposed on their normal social activities are really very difficult for them to follow, in contrast to, perhaps, older people. And of course, the opportunities they've lost as well. And then in terms of exposure, people who are in essential roles, obviously it's much more difficult for them as well, and you see that women are more likely to comply generally than men. People with children in a household find it harder to follow complete compliance than those without, and actually, people in urban areas are less likely to completely comply, and that's been the case throughout. So, there are really important differences here. Next slide.

 

And then I just thought I'd include a couple, or one slide, from Scotland. Some of the legend (ph 01.16.16) is missing from this, so I'll just go through it. So, there are differences between the devolved nations and they're quite subtle, in relation to a whole variety of measures during the pandemic. But you can see here that the first point is about clarity, so the proportion who think that advice from the Scottish government is clear and helpful, and you can see that's remained pretty high throughout. It's gone down a little bit. And then the dashed line that just starts to emerge from September there, public support, the percentage who support how the restrictions are being handled. The line at the bottom where the legend (ph 01.16.46) has disappeared that starts with 13 per cent, is the proportion who find it hard, who agree that I'm finding it hard to always stick to government guidelines, and you can see that's a minority, but it has risen through time. And then the last dotted line along the top was acceptance, so the proportion who agree that the best thing to do is to follow government advice. So what you see there, is an interesting gap between clarity and support and also the opinion, or the view, that the right thing to do is to follow the advice, even if it isn't always easy to do so. Next slide.

 

And then, interesting differences across the nations, and I'm gonna go on to this briefly when I talk about communication. Confidence in government has been consistently higher in Scotland, for whatever reason, and I think it may be something to do with communication from this government here. And also, to some extent, higher in Wales definitely, than it has been in England. So, those are differences in confidence. And then, I just included because I think it's interesting, the activities that people have missed during the first period of restrictions in the spring, and then looking at the second period that we've just been through now. And you can see in general that people have got used to things. They're less likely to miss things in the second period. But you can see that the impact on interaction, quite understandably, with friends and families, is the biggest loss that people report in terms of personal lives that they've experienced, setting aside issues to do with employment and education. Next slide.

 

The other point, just the final point I wanted to make on compliance, is there are multiple ways of measuring this. You all remember from the Number Ten briefings in the early days, we had all those mobility data we were being shown. But you can see that in terms of the restrictions that we're just emerging from now, average daily contacts between people not in the same household have reduced significantly in Scotland, and that is also the case when you look at the data for England. So, in general, my message is, that we read in the newspaper that, you know, there's lots of non-compliance, that the public have failed at various points, they've requested tests and overwhelmed the system in the September, despite being told for months that they should get a test if they've had symptoms. Students have been blamed for, you know, anti-social behaviour when they were required to go back to university and live in shared accommodation. So, there's been lots of points where I think we’ve not covered ourselves in glory in terms of the finger-pointing, and I don't mean our sector, public health and local government, I just mean the public discourse has been unhelpful. The take-home message is the British public have been through an awful amount and they've tried their absolute best to adjust their behaviour. Next slide.

 

So, I just wanted to spend a couple of minutes, or the last minute or two I have, on communication. Now, this is work that was produced by colleagues in independent SAGE. For the last few months, I've been on one of their sub-groups, the behavioural science group. And this is just-, I'm not gonna go through all the details, but this is available on the independent SAGE website. There's a little bit of humour in here as well. It just looks at some of the different messaging, and I think I would argue, from a behavioural science perspective, that the communication has not been brilliant consistently from government. And you can see that people's understanding, again if you wish to look back, these slides will be available as we heard in the beginning. On the detail here, you can see that understanding of the guidance has lessened through time, as rules have become more complicated and the messaging has been unclear. And we have had unfortunate incidents during the last few months, where high profile figures have not followed guidance. That is not unique to the UK, there's been incidences in New Zealand, Austria, Germany and others where people have had to resign and that undermines trust in government and in the guidance. And that's very clear, in fact, from work again that colleagues at UCL did, looking at what happened with the Dominic Cummings incident.

 

So how can we improve the communication? Just to emphasise this. I think both at local government and national level, just five brief points I'm going to make, because I know I'm running out of time. We should try and be precise and clear in our messaging, make sure that the messages are easy to enact and to adhere to. The messaging should be irony-resistant. I think the phrase 'Stay Alert', there was quite a bit of irony around that. We wish to avoid that. We should also avoid branding or sloganeering, and that should not come at the price of clarity and precision. And messaging should be underpinned by evidence about what is effective. Again, you can find some of that detail in the paper. And then, final point, and you are experts at this, it is about engagement with our local, diverse communities, and making sure that the communication is tailored and is appropriate to them. So, last one or two slides. Next one.

 

And this was just to make the point that trust, in terms of different information sources, has been varied, and as Ben already said, actually trust in science, clinicians, other experts has remained high. Trust in government has declined throughout the period and politicians. Then there's also been high trust in people that we know, and also others in our communities, so that's varied. Next slide.

 

And then just finally, I just wanted to emphasise some of the social impacts, which we don't have time to go into now, but there are multiple data sources on this in the UK, and you can see that life satisfaction has declined, quite understandably, at a general population level throughout the pandemic. We already heard about levels of anxiety and depression. And looking ahead, the public in Great Britain are divided in terms of when they think more normality will return to our lives, with around 30 per cent of adults believing that it will return to normal within six months or less, and this is cut off the text, so 21 per cent now believing it's going to take more than a year. So everyone in the country is looking ahead. And on that point, I think the final slide from me, or one before the last.

 

Just to highlight the excellent report published today by the British Academy, looking at the longer term. So, I think Chris actually said that there will be a long shadow, and we need to think and realise that in local government and public health, obviously, and with all of our colleagues, we'll be working to address this for the foreseeable future. So, it’s a long road ahead, but with many positive things, I think, that we can also emphasise.

 

So, final slide was just to use the local slogan from where I live in Edinburgh, here in Leith. That's about perseverance, which I think, you know, one year on from these restrictions being applied to the population, we have done that, and, you know, I think again, that's something that we can be positive about. Thank you.

 

Moderator: Thanks, Linda, and it's great to see the, I think, the importance of behavioural science, being used as evidence about how we actually can address Covid, the pandemic, and I think that's certainly something that has come much more to the fore over the last, over the year. So, it will be interesting to have your thoughts afterwards. But I encourage people to put a Q and A, for us to come to after Cordelia has spoken. So, Cordelia Hay is an associate at BritainThinks. Over to you Cordelia for a ten-minute presentation, and then, as I say, we'll go to Q and A with the panel.

 

Cordelia Hay: Brilliant, thank you so much, Janelle. So, my presentation very much echoes what we've heard already from Ben and Linda, but tries to look a little bit about the impacts of the pandemic on communities and civic participation, and what opportunities you have from local government to harness some renewed appetite for civic participation, perhaps.

 

The background to this presentation is some work that we conducted with the Local Government Association in late 2020, which was really taking a qualitative, rather than quantitative, approach to understand public opinion and behaviour, and the extent to which this has changed as a result of the pandemic. So, the full report is published on the LGA website, there's lots more detail than I've been able to cram in here. But specifically, we were looking to do two things. Firstly, understand the extent to which public attitudes and behaviours have changed as a result of Covid-19, and then secondly to look at how the public now defines local, and what that means to them in the context of the pandemic, and any changes in their attitudes to civic participation. Where relevant, I've also peppered through some of our own research at BritainThinks that we've conducted over the course of the pandemic. A qualitative, longitudinal study called the 'Coronavirus Diaries'. It was initially going to be a three-week project that we started a year ago today, and here we are still doing it with no end in sight.

 

So, just in terms of some key points that I'm going to bring out over the course of the presentation, that very much echo what we've already heard. Firstly, the public mood is still pretty low, even in the context of the very successful vaccine rollout. There's a real sense of despondency and most people are really focusing on the day-to-day, rather than daring to hope too much and seeing their plans dashed again. That sense of, kind of, moving goalposts which we saw over the course of last year has really limited people's ability to look too far ahead into the future.

 

The pandemic has impacted everyone, but the changed experience has been far from universal, and we think this is a really important point to keep bringing out. And some people actually really struggle to see much that's different about their lives beyond government-mandated behaviours. In their own words, people in communities just want to 'get back to normal', that's a phrase that we hear again and again in our research. That will mean different things to different people, but what's really important there is that what people are not saying spontaneously, is 'Let's build back better.' So that 'build back better' narrative that's becoming increasingly common in policy circles, isn't necessarily intuitive. It isn’t what the public are saying they want. But, it is met with some support when it's introduced, particularly when it's rooted in fairness, and I'll come on to this in a moment.

 

The things that people want to change most about their communities are typically long-lasting. They're typically things that out-date the pandemic. But, taking action on them and civic participation on them in general often feels out of reach for a few key reasons. Once civic participation is brought to life though, with examples with case studies, there is significant interest in hearing more, and in particular about opportunities to get involved digitally in the current context, along with offline alternatives.

 

So, just to bring a bit of the data, qualitative and quantitative data to life on this. So, these word clouds show how the moods of our Coronavirus Diarists have changed over time, so we're just under a year ago here on the far left, to our most recent wave in February of this year. And what you can see is a real evolution in the public mood, from anxiety back in April last year, through to relief last summer when there was, sort of, a respite, or even an end, some people thought, in sight. And then a real growing sense of frustration, tiredness. A small, small hope there in the final word cloud, but a real reluctance for people to allow their hopes to get up too much.

 

And we find that many are focusing on the day-to-day, and really waiting for burdens to be relieved, rather than hoping for the end. A sense in April last year, 'this is going to be over in a few weeks.' A sense at the end of last year that 2021 was a huge threshold and where life would get back to normal. And then in February, a real sense of actually that was very much not going to be the case, and people talked a lot about just treading water 'til it's over. This comment here from a parent with school-aged children, who was feeling particularly stressed at the time, saying, 'I can't see an end to it. It feels like it's lasted so long. I've just got to go with it. If you think too much about the future, then you're only going to be disappointed.'

 

The pandemic has impacted everyone, but as we've already heard, the changes experienced have been far from universal. So some people report experiencing major changes to the way they live, work and travel. Anyone who works in an office job will have seen very major impacts to the way that they work. Anyone with school-aged children will have had huge disruption over the past year. But others actually describe experiencing relatively little change to their lives as a result of the pandemic, and that's really important to stress. If you're someone, and presumably many of us are, if we're online at a conference who work in offices, its really easy to be that everyone is going through the same thing, but actually for people who work in more manual jobs or on the front line who've been going out to work, actually their life may not have changed so much, and really the key thing that might have changed in their life is about reduced social contact with family and friends.

 

Reflecting this variety in impact, while some behavioural changes that people describe have been wide-reaching, others really vary across the population, so actually really the only universal changes seem to be the ones that are government mandated and specifically related to the pandemic, restrictions on social contact which has been challenging for pretty much everyone but particularly those living alone and hygiene and mask wearing again a, sort of, added mental load for people at an already stressful time. But some of the other behaviour changes that people have reported in their lives are very uneven. So, some people talk about increased time, some people have reduced their car usage and gone and reduced their use of public transport but some people haven't and have been going out to work throughout the whole time of this pandemic.

 

When looking to the future people consistently speak to a desire to get back to normal and they speak actually, very conveniently, to the key things on Linda's chart that people are missing, around socialising in person, resuming leisure activities and travel, but actually a sense that there are rules to abide by and a sense that those-, those rules aren't going to change immediately and in the future. When we get people to do a guided fantasy exercise to imagine, you know, what getting back to normal feels like, actually the key thing they often talk about is not having to worry about the rules and what they can and can't do.

 

When prompted there is appetite to 'build back better'. So I think it's really important to stress, because this phrase is coming up a lot in, sort of, policy circles, it isn't a phrase that's coming from the general public themselves, but when you prompt and you probe on this phrase of 'build back better' there is some appetite for that, and there is particular appetite in building back more fairly across key areas of British society. And people point to all sorts of things here, but particularly the points on the left. They point to more fairness for keyworkers, particularly NHS workers, but actually for many this pandemic has really helped them realise the diversity of keyworkers that are out there, and some of those essential workers that aren't necessarily employed by the public sector, a real renewed focus on mental health, social equality and geographic equality, education, unemployment and climate change.

 

When people are asked about priorities for their communities they tend to focus on more long-standing issues including, but not limited to, local infrastructure, particularly roads. I'm afraid that even in a pandemic people love talking about potholes. I think the apocalypse would need to happen for people to not like talking about potholes. When they talk about issues in their local area anti-social behaviour is often a very very common theme, run-down town centres, something often exacerbated by the pandemic and a lack of community spirit. And these factors often far predate the pandemic. Often there's a sense that these are long-standing issues in my community that haven't been addressed for too long. Though some feel lockdown may have worsened some of these factors, for example, when they think about their town centres, or drawn attention to these issues, potentially if they're spending more time in their local areas.

 

However, most people feel they have relatively limited scope to make changes to their local area and to address these issues. Most aren't sure what civic participation is, both by that phrase and in general, or how to create change in their local area themselves. And most feel they haven't really participated in any change locally beyond small individual actions that people aren’t quite sure whether they merit being called civic participation or not, for example, choosing to shop locally which is something that lots of people describe doing in the pandemic. The minority who have taken more active steps to engage in their local area and to effect change are often those, either with something to react against, some-, reacting against some planning permission happening in their local area or a development they don’t feel happy with, a personal interest in a specific issue or often more ties to their community, particularly those with children.

 

And the public really point to two key barriers to civic participation, which they saw both in general and still as being true in the context of the pandemic. The first is a lack of information about how to participate and who to engage with, often underpinned by the assumption that change cannot be enacted alone and that there is something going on that they need to get involved with. And the second factor was an assumed need for regular commitment, many feel that they need real time to participate in things that are going on in their local area and to effect change, and that feels like quite a big ask for people in a very uncertain climate. We heard particularly those from lower socio-economic grades describing real concern about their job feeling incredibly precarious and feeling they should be placing all of their attention on that in the current environment, rather than thinking about civic participation.

 

In addition we heard some other barriers, including physical barriers to participation as a result of illness or disability, but also negative previous experiences of aiming to enact change in the local area and people being very burnt by previous experiences where they felt that they haven't had much impact.

 

In the context of low knowledge then, and our research with the LGA, we shared a presentation with participants, introducing some pretty high level information on civic participation, you can see a couple of excerpts on the right. It covered several key areas about the role of councils, councillors and consultations and used some case studies to highlight how these can work in practice, so the Low Traffic Neighbourhood initiatives in Hackney, the Saving Darlington Library project and the Friends of Alexandra Park in Manchester. And, on balance, we've found that this information goes a long way to bring to life what civic participation looks like and options for getting involved. It raised awareness of ways of participating and made achieving change feel like more of a possibility for this audience. People particularly took out opportunities for community groups to work with local authorities to maintain and improve services wasn't necessarily something that many knew that the general public could get involved with. The option to contact their local councillor to discuss issues in their community and take action, and consultation processes that seek to hear from many individuals in the community in a way that doesn't necessarily seem time-consuming, again something that many weren't aware of. And across those examples it was really the case studies that helped to bring the process of change to life.

 

So looking ahead many call for more information and simple, accessible opportunities to be involved, in particular the communities that we heard from said that several key areas stood out as priorities for consultation on participation, issues relating to housing and affordable housing, changes to road layouts and pedestrianisation which was quite front of mind for some people in the context of the pandemic and those things happening, closures that might impact local businesses and closures to other services, for example hospitals and libraries. For many, participating online is viewed as a simple and easy way to participate in change, provided that offline alternatives are provided for those without access. So there is a desire for websites or other online tools where individuals can find out about ongoing consultations and issues in their area. Some also highlight the existence of platforms such as Nextdoor which they find helpful for these purposes and wonder if local authorities could be doing more to harness.

 

So, to wrap up, we wonder if there are four key opportunities to consider. The first is, what opportunities are there for highlighting the impact of individual actions on communities to demonstrate that participation doesn't need to be large-scale or group-based and to reflect the ways that people feel they are already taking action, particularly in the context of the pandemic, where some of that group-based action is actually incredibly difficult or inadvisable from a public health perspective and people do feel that they are taking small actions to try and help their local area? For example, shopping local is something that feels really tangible to people as a way they could be making a difference to their local economy.

 

Secondly, what opportunities are there to demonstrate the full range of ways in which people can get involved including both digital and non-digital methods to show that civic participation doesn't need to be arduous or time-consuming and may be happening on some of the platforms on which communities are already engaging, like Nextdoor?

 

Thirdly, what opportunities are there to bring to life what civic participation can look like by using councillors to disseminate the message? I kid you not, some people were very surprised to find out that councillors actually live in their local area, they assumed that they were like politicians that live far away and aren't actually based in their community or-, and don’t necessarily live round the corner. And what opportunities are there to use case studies and real-life examples from communities to bring those to life?

 

Finally what opportunities are there to create appetite for civic participation and for change through this frame of 'build back better' which I feel is going to be with us for some time? I am really noticing that, for the public, it's about fairness, the part of that, sort of, narrative that’s particularly compelling. A really key watch out here for local government is going to be ensuring that this isn't positioned as counter to the public's own priority of getting back to normal, but rather as complementary. Is there almost something in there about a better normal than we had before? So, I will stop sharing my screen now.

 

Moderator: That's fascinating Cordelia. Thanks so much, because it really moves us on and forward doesn't it, and I wonder whether getting back to normal is about you as an individual whereas 'building back better' is somehow about groups or-, its a different thing, you're comparing individuals with groups but that's another question for the panel. So, if I invite Linda and Ben back on, and we've got questions and I encourage them to come through, but one of them is something about how we frame our messages which might, Cordelia, be about how it relates to you as an individual as-, as opposed to society or the group, and whether slogans resonate in that way, whether that's different, how we frame between hope and it's not over yet and does it matter, does it actually affect our behaviour, whether it's framed as a hope thing and just keep going and obey the rules, as opposed to it's not over, please obey the rules. Does that framing make a difference? So, should we start there? I don't know, Ben do you want to start with that, and then we'll go Ben, Linda, then Cordelia.

 

Ben Page: Sure. I mean I think people are-, people are now cautious and given the risks of a third wave which Chris identified even because the vaccine isn't 100% efficient, I think you don’t want to tell everybody it's all fine, I think you want to use the caution that people have. I think in terms of the last mile of vaccination we've talked about the framing of vaccination and I think making it your-, making it a, sort of, public duty is a really important thing to do, that it's not just for yourself, that you're actually doing it for your neighbourhood. And one thing that I did think about that, and there is some very interesting questions that there has always been vaccine hesitancy which, of course, is true but I think as we get-, as we are trying to get to 100% quite quickly, or, you know, as high as we can, I think there will be-, this is where particularly for local government, and I've seen this work in other contexts, even in much less important things in some ways, like recycling, people want to know what their-, how their bit of the council, their ward, their neighbourhood, their street, is doing and so, if you can start to show that virtually everybody on this street has now had it, it's now time for you to do it, that's-, that type of messaging has been proven to be pretty effective, and on the work done on getting people to pay your council-, to pay their tax bills and tax arrears on time, telling people not just that most people have now paid up, but actually most people in your town had paid up, that turned out in very large scale tests to be most effective. So I think that, as we-, as we start to focus on particular communities and particularly neighbourhoods it's going to be that, and that's where, of course, local government will come into its own, working with the NHS.

 

Moderator: Thanks Ben. Linda?

 

Linda Bauld: I agree with all of that. I think the-, I guess I would make a couple of points there. If we focus on vaccine uptake as the key example, I think the first one is data. So, we do need, as you have locally, pretty good data to identify where there are gaps in your communities. So, where is there an uptake issue and where is there not? Because clearly there has not been an uptake issue in some of the older groups that we have seen so far but it is going to become more challenging and we do definitely have gaps. So that's the first thing, because then you can tailor your messaging. I think Ben's right, channelling a message of social solidarity, and it's well established in public health communications if it's perceived as a social norm, it's-, this is a behaviour that most people engage in, or alternatively a behaviour that most people avoid, then that's something that people do-, you know, is believable and salient for people. The other thing is, we probably need a mixture between gain-framed and loss-framed messaging. So if we have groups who are hesitant for very good reasons, and there is an excellent report from the British Council, actually, on vaccine hesitancy in case that's of interest to people, which goes through a lot of this literature. So gain-framed is essentially saying, what are you going to gain by the vaccination and loss-framed is, what will you lose if you're not vaccinated? And those will be different types of gains and losses for different groups, for young people, for people in particular ethnic minority communities, for others. So it's thinking about what-, what are the right messages for the different groups in-, in your society, and they-, there is not a simple way to communicate this, there is not a single message that works for everyone. Thanks.

 

Moderator: Thanks, and Cordelia?

 

Cordelia Hay: I think that, to, sort of, the way that you initially asked the question Jeanelle, there is not perhaps necessarily-, it's not necessarily mutually exclusive to, sort of, be pragmatic and optimistic. I think that the public, as I have tried to get across, have grown very tired of, sort of, moving goalposts and this has led them to, sort of, take any signs that things might be over, or things might be looking more hopeful, with some scepticism, but to shamelessly steal something that someone has said in the Q and A, someone who is really cutting through and does seem to be striking this balance is Professor Van-Tam, who actually has been using very, sort of, simple believable analogies to help bring to life where we're at in the pandemic and help, sort of, ground this in a combination of, sort of, pragmatism and optimism. It's very much about not wasting all of the great progress that we've made and the very difficult sacrifices that people have had to make, and that's something that, kind of, really plays to that. His, sort of, football match analogies, I don’t know enough about football to repeat them unfortunately, but his football match analogies have really, sort of, helped to ground it in, I guess, something that people can understand and believe in and relate to.

 

Moderator: That's interesting isn't it, because he-, so you're right, but I suppose it resonates with people who understand and believe and are excited about football, so there are questions-, there are some great questions coming in, aren't there, but there is something about how do you communicate to different groups who might have different interests, different life experiences, with something like that and, you know, the questions do go into that, and I suppose, so there's both how do you communicate to different groups who-, who-, who have different life experiences using the football analogy? And I suppose what's the balance then between national communication that has to be quite, you know, all encompassing or just, you know, not very nuanced with local communication? So how important is it that we do communicate locally, I mean what's the balance there and, you know, how much energy and effort should we put into our local communications with our communities or does it all get ground out anyway by national communication?

 

Ben Page: Well you're more-, you know local government-, everybody on the call knows that local government is far more trusted than national government and local councillors are far more trusted than politicians so, although that's not perhaps saying much given how bad ratings of trust in national politicians are. So I think there is a huge task for local authorities to now actually, as we start to do the last mile on the vaccine, to really start ramping up the messaging, finding people who are connected in the community, working with churches, and going on to-, so, you know, getting-, we need-, I would love to see a social media meme come of out local government either on YouTube or Facebook about, you know, the people having the vaccine. So it will-, get all your local personalities and celebrities, get them jabbed, film them doing it, all of that will matter, I think, in the last-, in the last mile.

 

Linda Bauld: Yes, and just to add, I mean, local radio is a very power-, powerful tool. You know, different types of local media, I think, can be used, and again, building on what we know from broader public health campaigns, having that tailored local messaging I think-, I think, is very valuable. Yes, so I would-, I would agree with that. I also think that, you know, just to again give credit to some of the Directors of Public Health, who have been very active in local and national media, they are really seen as credible communicators in this pandemic. We've had a couple of just, you know, to just focus on Scotland, we've had a couple of outstanding examples up here who are regularly used by, for example, BBC Scotland and, I think, are listened to far more than some-, certainly than the politicians. So I think it is about identifying who. The other thing I would say, and this is maybe something Cordelia would want to come back to is, there are people who have better communication skills than others. It's just an innate thing, some people have that skill, like some people are better at reading a map and all kinds of different things. We're all different as human beings. I think Professor Van-Tam just is a really good communicator. So finding those people, again, locally, that have that ability and, you know, choosing them, I think, you know, they don’t need to be celebrities, but they can be, is a good technique. Thanks.

 

Moderator: Cordelia.

 

Cordelia Hay: It's been said already but I think local communication is going to be very important to make this feel relatable. There's a bit of a risk that, at the national level, it feels disconnected from what people are experiencing. And, of course, we all talked about how experiences of the pandemic have been unequal, and geographic inequality has been such a huge driver as well, of very, very, very unequal experiences of the pandemic. And, you know, you can really feel the anger and the frustration when you're hearing from communities where, actually, there has been very little respite from restrictions over the past year, you know communities in Leicester and parts of the North West, and actually reflecting that, kind of, local experience is incredibly important rather than that blanket national message. So, I absolutely agree.

 

Moderator: Yes. That's certainly my experience in Tameside where we've now, unfortunately, entered the top ten, but we've certainly been restricted in Greater Manchester for very much longer and you can-, you can really feel that. The social media element is interesting isn't it, because it does enable you to have that local sensitivity with-, with-, with local voices, if we include WhatsApp groups and all sorts, you know, there, not just Twitter. So there is something-, there is a question in there about BAME groups, the way that particularly, I think, is being well used. There's an interesting question here about brand perception and how we're thinking about perceptions of Pfizer, where some people didn't want Pfizer they wanted the British AZ, and then when things were a bit dodgy with AZ perhaps, they didn't want AZ, unclear about origins of Moderna? There was a question earlier to Chris Whitty, wasn't there, about should we have our own supply of vaccine? Does that make a difference? And then if I can just add in another question as well. On some of the slogans, so the branding or the slogans and the 'build back better' might that be picked up by populist voices? Cordelia, perhaps if we start-, if we start with you, I mean how does that, sort of, populism around a brand, the British brand or the 'build back better' link with the civic participation points you were making?

 

Cordelia Hay: Yeah, I think the key thing about the 'build back better', sort of, message is that it feels like, you know, there's a lot of people jostling for that territory at the moment. You know, a lot of people in, sort of, policy circles, are talking about it and when you speak to real people, you know, there is certainly some receptiveness to the phrase, but it's not necessarily something people-, ordinary people are going around and saying to each other, 'Oh I wish we'd build back better'. You know, for them, it’s very much about getting back to normal. And actually I think if local authorities really want to show that they understand their communities and their priorities, actually reflecting a bit of that language back to them is going to be very important. As I've, sort of, tried to say at the end of the presentation, not going too hard on, you know, let's have a green revolution, you know, there is some appetite for green recovery but actually, if you make it too much about change, then you will not be seen to be listening to what people really want and that really is that sense of normality back in their lives, though of course that will look different for different people. So, with any of those sorts of brands and slogans, and we've got very obsessed with three word slogans lately haven't we, the best thing is to make sure it's really rooted in something that people feel themselves. And actually the more authentic it can be, the more likely it is going to be to-, to resonate and engender the change, or get across the message that you're trying to achieve.

 

Moderator: Linda. Oh, you’re on mute.

 

Linda Bauld: Yes, I'm sorry, I was just on mute. I don’t have much to say on the slogans except, again from a public health messaging perspective looking at the literature on this, it is easier to have simple phrases that people can recognise and understand and repeat. That certainly is the case rather than something that is more complex. Just on the vaccines question on the branding, I think there is a genuine issue around choice and also-, and so, I’ve had a lot of questions about 'Why do I-, why am I not going to know which vaccine I receive?' And, you know, the response to that has been, well we are trying to provide access to everyone, these are safe and effective vaccines, it doesn't matter which one you get. That's the appropriate public health response. However you then get questions about, 'Well I want to be able to read, you know, the patient information leaflet for the vaccine that I am receiving, in advance, and want to know more about it', which might be a more viable question. And then the final point is just the vaccine nationalism. Obviously I think, you know, anecdotal reports of people wanting the Oxford one because it's made in the UK, and then alternatively the very clear evidence from some of the polling this week that Europeans don’t want the Oxford AstraZeneca vaccine at the moment for a variety of other reasons. That's quite dangerous and I think it’s very important that we try and move away from some view of one brand being better than another while recognising, I think, the valid questions about where do I obtain information about, you know, what I have just received or am about to receive. Yes.

 

Moderator: Linda, can I follow that up, before going to Ben then, what does the general public think about making the vaccine mandatory then?

 

Linda Bauld: Is that a question for me?

 

Moderator: Well yes, unless Ben, you’ve actually asked the public? And do you know the answer?

 

Ben Page: Yes, from memory it's about six in ten support mandatory vaccine, it's about six in-, yes, yes.

 

Moderator: They do? And is that stratified?

 

Ben Page: Yes. But, of course, you get the same pattern that you get on vaccines. So younger working class people and people from ethnic diverse-, ethnically diverse backgrounds, who are obviously more resistant to the vaccine. I mean it was interesting seeing some of the comments in the questions where one authority is using local imams and celebrities, but of course they're getting backlash from inside the community and I think one-, one thing that we-, I was just reflecting on the lessons of this year and one is that, which we saw in Brexit, we saw in the-, in the crash, is that rational people telling people facts is not on its own persuasive. And we've just seen that again. And even when people say things that are factually completely-, or believe things that are insane, I mean, I’ve been dealing with people on social media who believe that Ipsos MORI stands for They Die and I am somehow involved-, we are obviously doing large scale testing, and somehow we're part of a conspiracy to extract everybody's DNA and then pass control of them to Bill Gates or something. And I-, I mean, what I would say, so I've been engaging with some of these people and I think, what's clear, and I think this is important, is that a lot of the evidence on this now is that you can't just tell people 'That's just not true', you almost have to listen-, ask them why they think that, and I think that, which of course takes time, because if you just tell people, 'You're nuts', which is my first reaction when I'm told that I'm part of a conspiracy to kill millions of people, it just doesn't work. So I think there's some real-, some real nuance there, but I think ultimately we have to engage people and we're only going to get the last mile if we are out there, you know, with-, resources are tight, time is tight, but it will-, that’s what it’s going to be, and that of course is exactly the roots of the public health community. But that-, this is going to test us in a way that we haven't been tested for a long time.

 

Moderator: Thanks Ben. So I’ll turn to Linda and then Cordelia for the last word because we are just wrapping up and we wanted to finish early so that people can mark the time of a year of Covid and those who have lost their lives. But with, you know, so we have that really difficult memory, there's this huge milestone, but what-, you know, how do we-, how do we go forward in terms of feeling part of something that-, that's building pragmatic hope as it were? Linda, and then Cordelia.

 

Linda Bauld: So I think that the data shows from the past year that there is this resilience but also that we do have a sense of solidarity, not across all groups, but the collective effort, the collective behavioural effort, I think, is something that we should continue to emphasise, and also emphasise the positive, as in what has been achieved. And that's multiple, it's not just the vaccines and treatments etc, there's multiple things as well, so focusing on the positives. The other thing I would comment on and it's in the-, its another question in the box, for-, particularly for public health and local government, is really having that narrative about the autumn and the winter and winter preparedness. So I think, we haven't heard much about this, I know you're thinking about it but I don’t think the public is thinking about it. So I think having the positive while alongside saying, 'But this is what is likely to happen, and we're going to have to continue planning for outbreaks and, you know, a surge on demand for the NHS etc in the coming months'.

 

Moderator: Thanks. And, Cordelia?

 

Cordelia Hay: I mean this anniversary of lockdown does potentially present a bit of opportunity to remind people of some of the things that they, sort of, found as unexpected silver linings of the initial lockdown. You know we saw that in the first lockdown, actually a lot of people found unexpected positives and that's really tailed off, as lockdowns have continued and gone on. So, is there an opportunity, actually, to help bring back to life some of those initial silver linings that people found and felt quite positive about? I think the other point there is just really understanding people, and understanding communities and breaking them down. I think that was an excellent comment about, it's quite dangerous to talk about BAME people in general and actually there needs to be a lot more work breaking down people from different ethnic minority backgrounds to better understand some of the barriers to uptake of vaccine and other behaviours and messages cutting through. It’s not large sample sizes but we've certainly done some work which surfaces some quite key differences between the Black and Asian communities and more work in that area, I think, is really really important to understand the communities and therefore the messages that they need to hear.

 

Moderator: And what Ben was saying in terms of why people think what they're thinking, and it's that real understanding about people, communities, that we can help them support them to, kind of, move on in a positive way. Brilliant. Well, thanks so much for your input, panel. I really appreciate it. Thanks everyone. I look forward to having you in this afternoon's webinar which starts at 2:00pm and we'll end there to enable us, if you choose, to have the minute's silence. Thanks very much. Bye now.

Moderator: Good afternoon and welcome to afternoon-, well, the afternoon of the first day of our two-day LGA/ADPH conference, Annual Public Health Conference 2021, Rising to the Challenge. So, this is our second webinar of the four for-, that cover the two days, and we really are delighted to have 1000 registered attendees across the whole conference. We've had a great session this morning, there was some lively Q&A on the conference itself as well as good, lively tweeting, so please do feel free to use the hashtag 'LGAPublicHealth21' and you can also get a flavour, if you weren't able to get to the first webinar, you'll have a flavour of the conversation then. But, what we had was our Chief Medical Officer, Professor Chris Whitty, opening the conference with us, or for us, with an inspiring address and Q&A session, a lot of interaction with all the delegates, the attendees, reflecting on the learning over the past year, reflecting on the huge impact of health inequalities in this country, but also looking forward to 2021 and our ambitions as we move forward. We-, the second part of the morning, we had a panel discussion on public opinion and public health, where we explored how people and communities have engaged with public health messages through COVID and what the learning has been over the past year. So, this afternoon, what we're going to do is look at the challenge around health inequalities and recovery, and we've got an excellent panel of speakers who are all working to ensure that health inequalities are the centre of the recovery efforts. We're going to have the opportunity to explore where community-led approaches are having an impact in reducing health inequalities, and discuss the immediate and long-term priorities that can help us mitigate the impact of COVID-19 in our local communities.

 

I really encourage you to submit questions through the Q&A function. So what we'll do is we'll have each speaker, I'll introduce them at the start of their talk, if you-, feel free to use the Q&A function, which is live, as they're talking. After the fifth speaker, we'll then have the panel together and respond to questions that have come in during their talk. So, I'm delighted to be joined on the panel, to explore the theme of health inequalities and recovery, by five esteemed guests, and we'll kick off first with Professor Kevin Fenton, who is Regional Director in London, Public Health England. Kevin, over to you.

 

M: Thank you Jeanelle and good afternoon everyone. Jeanelle, I hope you can see my slides?

 

Moderator: Yes.

 

M: May I begin by just saying thank you so much for the invitation to speak this afternoon, to the conference. This is truly an important time for us, and I'd like to begin by thanking everyone, and just acknowledging the tremendous work and partnership that we've done together over the past year, to get through what has been an unprecedented and very challenging time. I think all of us have been affected by this pandemic in so many ways, but I am confident that we will emerge from this stronger, far more integrated, far more collaborative, than we could ever have imagined. So, today I've been asked to reflect on our journey with health equity and the COVID response, and the lessons that we have acquired over the past year, and I've also been asked to reflect on our own journey in, in London, and what we're doing and learning differently in response to the pandemic, leaving a foundation for addressing health inequalities in our system. So I'll begin by just quickly reflecting on where we began, nearly a year ago, when we were asked by the Chief Medical Officer and then the Secretary of State for Health, to do a rapid investigation into the risks and outcomes, disparities in risks and outcomes, for COVID. We did a mixed-methodology work at that time, looking both at the epidemiological data for routine health and surveillance data available, as well as a stakeholder engagement exercise, review of the literature involving more than 4,000 people over a six-week period. Now many of you will remember the key findings from the report, we were able to, for the first time and systematically, really describe the differential patterns of disease by age, geography, the impact of deprivation, and of course the variations across ethnic groups.

 

And in the key recommendations which arose from this work, we really highlighted what I, I think have become three of the most emblematic, emblematic phrases to really characterise this pandemic's impact on communities. The first was that the inequalities were-, they existed before the pandemic, but the pandemic has certainly worsened these, and exacerbated these inequalities, and made them far more apparent. Second, the report really underscored the importance of the social, the structural, the cultural, and the behavioural factors which are driving and underpinning transmission within communities across the country, in addition to a number of the clinical risk factors which were identified at that time. And finally, the report captured the hearts and voices of our communities across the country, both dealing with the trauma of going through the first wave of the pandemic, but looking forward and asking that community, as our core part of the actions, the recommendations, and the changes which are made moving forward. Now, the reports had seven key recommendations which were based upon the review, the data, and the stakeholder engagement. These covered a wide range of topics but were largely geared towards actions that could be implemented in the short and medium-term, to help to mitigate the impact of a second wave, but also to ensure we were building the foundation for changing the way we engage communities, and tackle inequalities, as part of the pandemic. So we covered both data, research, culturally competent interventions and actions that all partners, system partners, should be putting in place to address the issue.

 

Now over the year we have continued to see the impact of the pandemic on a variety of communities across our country, and here I am simply highlighting some of the changes and challenges that we observed across ethnic groups over the past year. Throughout the course of the pandemic we've seen a disproportionate burden on our communities, minority communities, with those of South Asian backgrounds, especially Pakistani and Bangladeshi communities, being-, bearing a disproportionate burden, in addition to our Black British, African and Caribbean communities. And as the epidemic has evolved, affecting different geographical areas of the country, we've seen these repeated patterns of risk continuing to play out. But there are other domains of inequalities that we have observed and we've also, for the past year, learnt more about some of the structural drivers of the-, of the pandemic, and here I'm highlighting just a few, because I know in your own jurisdictions, and in your own work, you now have a clear understanding of the factors driving enduring transmission and risk. So for example, we now appreciate and understand the importance of household size and composition, and the fact that the largest households are three times more likely to COVID than the smallest households in the country, and they're also seven point five times more likely to die from it. We've also seen the differential impact of patterns of multi-generational housing, as well as patterns of overcrowding in households, and how that has an impact on influencing COVID risk.

 

We also have a better understanding now of occupation, and how occupations can increase probability of coming into contact with people who are infected, but also by virtue of simply being in contact with more members of the public, how that can increase your risk of acquisition and transmission of the infection. And we also understand that Black, Asian and minority ethnic communities occupy higher proportions of some of the most highest-risk occupations within our country, and that lesson from what we've learned meant that as we meant-, went into wave two and beyond, we've been doing far more work with our workplaces and occupations. We also now understand that interesting and challenging intersection between ethnicity, deprivation and risk of acquiring and transmitting infection. With increasing deprivation, as highlighted on the left-hand side of the chart, we know that we see an increasing proportion of minority communities being affected, and here you can see particularly the Pakistani's communities being disproportionately affected. But we also understand that with each level of deprivation, on the right-hand side of this graph, with increasing proportions of occupation, in this case in South Asian communities, we do see increasing risk of increased disease incidence. Finally, we know that these inequalities have tracked throughout the pandemic over the past year. We initially described it for increases and differentials in testing and diagnoses, but as we rolled out our contact tracing programme, and as we've rolled out self-isolation programmes, and most recently with our vaccination programmes, we have continued to see variations across groups, either by ethnicity, age or deprivation.

 

And again, an example here of the differentials we're now observing, the vaccine hesitancy across various ethnic groups, and the material impact that this is having on the uptake and coverage of our vaccines across the country. And these differences will have a severe impact on both ongoing transmission within the community, as well as potentially areas for enduring transmission as we emerge from the second wave and prepare for the summer. So very briefly, to reflect a little bit then, including on London, we have had a pretty severe pandemic, experience with the pandemic in the city, of more than 700,000 Londoners being diagnosed with COVID, and unfortunately having lost more than 15,000 of our fellow citizens. We've seen a disproportionate burden of disease across the city, with boroughs especially in the outer ring of the city, having higher mortality rates than those in the centre. Given our experience over the past year, and the work that we have been doing on inequalities, London partners have pulled together to ensure that as we view recovering the city, we are doing so with a lens of equity firmly embedded in everything we do. The Mayor of London, working with our local government partners, have now identified a grand challenge for London, with nine missions for recovery in the city. Those nine missions meant to restore confidence in the city, and minimise the impact of the epidemic on London's communities. They cover things from health and wellbeing, whether mental health as well as healthy food and healthy weight, straight through to sustainability with our Green New Deal, a better deal for young people, digital access for all, and of course, building strong communities and work for all.

 

All of these missions involve partnerships between statutory agencies, the Greater London Authority, and London Councils and our partners, and key Cross Cutting Principles are highlighted here, ensuring that inequalities are placed in everything we do, collaborating with diverse communities, leveraging the impact of digital technology and data, and focussing on sustainability, health and wellbeing, and affordability of our interventions. Now in addition to our grand challenge as a city, and these nine missions, our system partners are working together to ensure that we keep a laser focus on key outcomes. Tackling those social and structural drivers, including inequalities, unemployment and ensuring that our young people can flourish. Finally we are working again as system partners on key aspects of driving forward the results from the-, beyond the data recommendations. Building system capacity to understand inequalities and respond to those inequalities across all system partners, and working collaboratively as a system to address key recommendations from PHE, from the NHS Phase Three letter, as well as recommendations from our ADPH partners in the city. The policy response to inequalities have been strengthened by the launch of a Health in All Policies approach, leveraging the assets in the GLA, but also working closely with our London Councils, and we're now embarking upon the refresh of the London Health Inequalities Strategy. We're using data differently across the city, to both characterise inequalities, leveraging information from system partners, and developing core inequalities data sets for monitoring in the city.

 

We're focussing on our workforce, ensuring that equality, diversity and inclusion is a part of everything we do, but also ensuring that workplace wellbeing is a core part of protecting and supporting our minority staff, those from disadvantaged backgrounds, and looking at the role of our organisations and institutions (ph 14.12). We are changing the way we engage with our communities, in terms of better mutual aid, better engagement, and the work that we're doing now on vaccine hesitancy and engagement, I believe, is setting a new foundation for community participatory programmes, both in public health and policy. And finally, strengthening the way we look at communication and engagement, as part of our work. So Jeanelle, I'm going to pause here, this is a story of a year of change, a year of challenge, but I believe that together we have demonstrated that we can rise to those challenges, and we can have a lasting and enduring impact on the way we both understand inequalities, and the way we respond to them. Thank you.

 

Moderator: Thanks Kevin, that was brilliant, a great-, today, to show the entire year that we've experienced and that you’ve experienced in London, and to see that-, that, kind of, progression through the year. Thanks for that. So we'll go straight on to Dr Jo Bibby, who's Director of Health at the Health Foundation. Jo, over to you.

 

F: Great, thank you Jeanelle. So I'm going to share my screen as well, so hopefully most of the people here are familiar with the work of the Health Foundation, but just a very short, sort of, overview, we fund research, policy and improvement work to improve health and healthcare, and have a number of programmes that are aimed at reducing inequalities and addressing wider determinants of health, some of which directed at councils and public health leaders, particularly our Shaping Places for Healthier Lives programme that we do jointly with the LGA, and our new Economies for Healthier Lives programme. And we also do a range of in-house analysis, a lot of long reads and data on the relationship between health and wider determinants. So that's a bit about us, but reflecting on the theme of the conference, Rising to the Challenge, I was, kind of, thinking about, you know, which challenge to focus on, clearly the community's been through a very challenging year and there's more to come, but one of the questions that I've been considering is, how can we build public support for the action needed to reduce inequalities in health? Because I think this is fundamental to getting the change we want to see, and in doing that, there's three questions I come back to, one is, do people know? Do they know the extent of inequalities in health? Second, do they care? And thirdly, do they buy in to the strategies? So, on the question of 'Do people know?' Now, you know, clearly those of us who live and breathe this, you know, and we're often looking at charts like this one, looking at the difference in life expectancy, healthy life expectancy, you know, it's-, it's all eminently clear to us, the issue of health inequalities in our society.

 

But what I have observed, when I talk to people outside the public health community, and both people who are expert in some field of their own, as well as people who, you know, are potentially more lay-members of the public, is that actually, the extent of the health inequalities that exist often isn't that familiar to people, and particularly the inequality in healthy life expectancy, so I think this is something we need to hold on to, and bear in mind that perhaps people aren't really fully aware of this. Now, on to question of 'Do people care?' There was a fascinating report published last month by Bobby Duffy and colleagues at King's College London, it's part of the Deaton review that the IFS are doing on inequality, and as you see the title, 'Unequal Britain, attitudes to inequalities after COVID-19.' Now it looks at a whole range of inequalities, but the question that really, I was drawn to was the question about which of the-, which three of four of the following areas of inequality do you think are most serious? And the responses that came out was, at the top, the, sort of, area of greatest concern, was the inequality between more and less deprived areas of the UK, then income and wealth, then between racial groups, but the one that we're concerned about, health and-, inequalities in health and life expectancy, actually comes surprisingly low down, for people like us, you know, who are concerned with this, this list, and this really got me thinking, and in some ways you could say, 'Well, you know, we all know that actually deprivation and income and wealth are the big drivers of health and life expectancy inequalities, so does it actually matter?'

 

But if the conversation we want to have with the public is about the need for action on wider determinants of health, and they don't understand those connections, you know, maybe they're not really understanding why we're prioritising the things that we're talking about. Now, this work that was done by King's was based on a-, it was a, sort of, over 2000 poll with YouGov, of a cross-section of the British public, but the Health Foundation, as part of our COVID impact inquiry, we're also doing some deliberative work with the public, and this is actually-, we've been running a series of workshops across the UK, with, you know, cross-sections of people, to really explore inequalities, health inequalities, and the impact of COVID, and I think what this has, sort of, started to show is that there's a bit more of a, kind of, nuanced position in terms of the public understanding of inequalities, and the-, we've been working with Kantar, and they have, kind-, they have four categories, segments of the public, that-, there's a segment they call the 'Activists', that we've been working with, and these are people who see the issue in health inequalities and see the possibility for societal change, so, kind of, absolutely the people we, we-, I'm sure we all fall in to that category. There's another group they call 'Recognisers', they recognise the issue but they really don't know what can be done about it. The third they call 'Disengaged', they see the issue but, you know, often they just think, 'Well, you know, that's life, you know, this is just, kind of, what happens in our society.' And then the fourth group are the 'Sceptics', who have generally lower awareness of health inequalities, and in so much as they do engage, they're, kind of, more likely to look at individual-level solutions.

 

And just to show you how the, sort of-, these segments break down across the population, you know, reasonably even split, obviously slightly more on the 'Sceptics', but I think this starts to, sort of, perhaps explain, you know, those of us who are 'Activists', we are in the minority here, and there's something about, how do we actually start to communicate in a way to the 'Recognisers', to the 'Disengaged', to show that actually this isn't inevitable? That things can be done and that change is possible. So, one of the other things then is, do people buy in to the strategies that are needed to change-, needed for the change we want to see? So again, going back to the 'Unequal Britain' report, people were asked about the factors they associated with people's health and life expectancy, and this list here, you can see at the top, people associate access to good quality health and medical care, then lifestyle choices, social care, I think interesting, how we're brought up as children is fourth. But the kinds of things that we would be talking about in terms of inequalities, you know, the housing, the employment we do, the education people have, are all lower down in people's understanding as to what's contributing to people's health and life expectancy, so I think again, kind of, reinforcing the need for better explanation and communication on this. Now, in the deliberative work that we're doing, one of the things we are able to do is really explore with people their understanding of what's driving people's health, and we, you know, we do give them some information and evidence to reflect on.

 

And I think one of the things that's really struck me, sitting in on these conversations, is that when people are given the evidence around wider determinants of health, actually, you know, people come-, it becomes very intuitive, people really do get it, some-, some of the groups I've been in see education and skills as absolute-, that, sort of, foundational things that, kind of, really drives other aspects of your life, other people see work, employment and income as foundational, but there's a real, sort of, intuitive engagement. However, not quite so positively, is that then at the end when we've said to people, 'What would you like to see the government doing to address health inequalities?' Generally the response is, you know, 'More funding for the NHS.' So I think this really does start to surface, the fact that there is this, kind of, disconnect in the public understanding, between both the awareness of inequalities, but, kind of, what needs to be done to address them. So I think one of the challenges we need to think about for the next year is, how do we increase our understanding of the public's understanding of health inequalities? Because I think without that there's a risk that we're, kind of, like ships in the night, we're not really communicating, we need to find better ways to communicate about health inequalities that start from that understanding. And so some of the work that we're doing at the Health Foundation is, we have our COVID impact inquiry, we'll be writing up the findings from our deliberative work in that, and publishing in the summer, and another piece of work we've had underway for some time is with the FrameWorks Institute, which is an organisation that looks at how you frame complex social problems in a way that the public can engage in. So, these are my reflections on some of the challenges ahead and I look forward to a chance to discuss them, so thank you.

 

Moderator: Thanks very much Jo. Fascinating, I love that, 'Increase our understanding of the public's understanding', that's a great line. Thanks very much, I'm sure we'll come back to that in Q&A. Let's move on then, to Alice Wiseman, who's Director of Public Health in Gateshead. Alice.

 

F: Thank you Jeanelle. So, as Jeanelle said, I'm Alice Wiseman, I'm Director of Public Health for Gateshead, and I'll start with my-, the front cover for my annual report for this year. And I think COVID-19 has highlighted and exacerbated, in-, in my view, our shameful position on the growing gulf between the 'Haves' and the 'Have-nots' across England. This year has been hard for everyone, but I want you to try and imagine what it would be like living in a small property with little or no outdoor space, worried about heating your home, feeding your kids, or providing access to the necessary IT so your children don't fall behind at school. And then add to that the fear of bringing COVID home to your family, to your mum who provides the childcare, or risk losing your job. Imagine being furloughed on 80% of the National Living Wage, with no chance of overtime to top up your income. Imagine being told that your child should isolate as a close contact, but that means you can't go to work and therefore you won't get paid, or worse still, you might find-, lose your job. COVID has exacerbated and shone an even brighter spotlight on the unacceptable inequalities that we have in the UK today, but what have we learnt from this? So this is lessons from our teacher called COVID. Next slide please. I know that we all know this already, but many of the factors that have created and exacerbated inequalities during COVID have not only been driven by physical health independently. Inequalities is driven by that interaction between the wider determinants of health, the psychosocial impact of those experiences, health-harming behaviours that many times are adopted in an attempt to alleviate the psychosocial impact, and culminating in the physiological impact of those interactions together.

 

The-, the things that create the context where inequality thrives, housing, employment and education, are many of the same things which prevented people from being able to protect their families and their communities during COVID. Next slide please. Evidence has identified the potential pathways that link deprivation to higher COVID-19 infection rates, cases, case severity and deaths. Exposure as a result of inequalities in working conditions, lower-paid workers, particularly in the service sector, were much more likely to be key workers, and therefore required to work during lockdown, also much more likely to rely on public transport, and we know that there's a clear social gate-, gradient in the ability to work from home. Transmission, inequalities in housing conditions, are also likely to have contributed to inequalities in COVID-19. Deprived neighbourhoods are more likely to contain houses of multiple occupation, lack outdoor space, as well as experience high population densities, which may have also increased transmission rates, and well as making isolation much more difficult. Vulnerability due to a higher burden of pre-existing health conditions that increase the severity and-, of-, and mortality risk of COVID-19, and we know that these co-morbidities arise of-, as a result of the inequalities in the social determinants of health. Finally, susceptibility due to an immune system weakened by long-term exposure to adverse living and environmental conditions. The social determinants of health also work to make people from more deprived communities more vulnerable to infection from COVID-19, even when they have no underlying health conditions.

 

Next slide please. Thankfully, evidence has shown us that children and young people have the lowest clinical risk from COVID. Nevertheless, they have experienced a year of disruption at-, at arguably the most critical time of life for development. Many children have missed months of education. However, the impact of this has been different, and there have been marked inequalities in learning hours, digital access to resources, and completion of homework. Even before COVID, around 30% of children in the UK were living in poverty. Poverty's an enormous source of stress for families, and we know that when parents are overwhelmed by stress they can struggle to meet the basic emotional, physical needs of their children.

 

F: This in turn can adversely affect the physical, emotional and social development, impacting on a child's brain and immune system, leading to susceptibility in mental health problems and chronic disease in later life. There are significant concerns about the overall mental health and wellbeing of children and young people resulting from the increased family stress, reduced access to early intervention and support services. And decrease in social interaction with others during the pandemic. For them, for some, again, this will have been exacerbated as they have experienced the repeated stress of abuse, neglect, parents struggling with mental health or substance abuse. Problems potentially being stored up for a generation to come. Next slide please. From the perspective of infectious disease there is little point in having a small 'us'. Our secret weapon in the fight against COVID has been our communities up and down the country. We've observed, in a very tangible way, the art and science of promoting health through the organised efforts of society. COVID gave us a collective goal, a greater sense of 'us' for everyone, at least initially. Even if an individual's ultimate goal was to protect the smallest, me and my family, it was understood that we could only do this by working together. Next slide please. Our teacher called COVID. Lesson one from our teacher called COVID. We can improve and protect the public's health if we're able to find and agree on a collective goal that we want to achieve. The shared cooperation was palpable during the first phase. We all remember the doorstep clapping, the thank you rainbows in windows and the local community groups stepping up to help each other.

 

We housed the homeless, we fed the hungry. We protected business and we provided additional income for those who had the least because we all agreed it was the right thing to do. Personally I was blown away by the community action during this phase. United against a common enemy people came together, unaided, independent and unfettered by process and bureaucracy and I think this has resulted in a change in community leadership, as people reconnected and engaged in social action within their own communities. Lesson two from our teacher called COVID. Harness the power of social isolation, of social action rather, in communities. And let's not underestimate the impact of-, on health and wellbeing of being locally connected as an end in itself. On reflection I do wonder why it took a crisis to push us as a society to do the right thing. Was it just because their 'us' affected our 'us'? Or did we suddenly see the needs of others around us in a very different way? There is so much evidence that inequalities are bad for us all, regardless of the opposition and no matter how small your 'us' is. Countries which have the greatest level of inequality are also the countries where crime, and particularly violent crime, is higher. Child wellbeing is lower and community cohesion is minimal. Rather than recognise need and help each other, we fight each other to meet our own needs. We've definitely seen this in the UK. A rise in violent crime parallel to a growth in inequality. Lesson three from our teacher called COVID. If we really believe that inequality is unacceptable, then we must create a narrative that engages people across the whole spectrum of 'us'. We need to get clearer in our mission and the benefit that it will bring for all.

 

Our entire strategy for COVID is built on the actions of citizens all working together in harmony. We needed people to get tested, engage with contact tracing and then isolate to prevent the onward spread. And this sounds really easy, but we can only secure engagement in those actions if we understand the challenges that people face in doing so. In my opinion this is where the bit-, this is the bit of the jigsaw puzzle that was largely neglected at the start. And this is what we must now strengthen. The logistics of scaling up a national testing and tracing system is tangible and exciting, but it falls at the final hurdle if we don't understand how people experience these measures and how they interact with them. Lesson four from our teacher called COVID. Work with communities to hear and understand the things that matter to them. As a director of public health and public health teams, local government across the country, we've experienced how it feels for people to be making well intentioned decisions above our heads and imposing them down with little regard for how they actually land in our place. I'm really sorry if that's hard for anyone to hear, but that is the truth. How many times over the past year have you felt frustrated by the fact that no one seems to understand the nuances that make your place different? No one seems to be hearing why something won't work or, indeed, isn't working like it was intended. Infuriating? Yes. Avoidable? Yes. Disempowering? Absolutely yes. But I'm now asking myself how many times have I actually done that? Imposed a well intentioned initiative or a solution into a community with little regard to the context in that place?

 

For example, healthy eating advice with communities who are struggling to put food on the table at all. So lesson five from our teacher called COVID. Engage communities in the solutions. Enabling people to maximise capability and have control of their lives, as we know that this is part of the solution. Next slide. So finally, if COVID has taught me nothing else, it's certainly taught me what's important in life. It's not fast cars, expensive clothes and luxury goods. They're all nice but on their own they're meaningless. I've missed human contact. I've missed my own friendships. I've missed my colleagues in the office, my friend popping in for a cuppa, meeting my mum for dinner and seeing my baby niece take her first steps. This is what I've missed. So finally, lesson six from our teacher called COVID. As we look back, both now and in the future, we must reflect not only on the things that we have done really well, but critically the things we could have done better if we'd had a more equal world. I don't want to see people in my community struggling. One of Obama's chief of staff famously said 'You never want a serious crisis to go to waste'. It's an opportunity to do things that you think you could not do before. So I want to believe that we now have a real opportunity, based on the shared learning from our teacher called COVID, to really come together in this collective space to tackle inequalities. So I'll just finish by asking again 'How big is your "us"'? Thank you.

 

Moderator: Thanks Alice, that's a brilliant, challenging input from your experience as a director of public health. Very honest. I hope you also are missing the social contact from face to face conference? So maybe next year, maybe next year. There's something about being face to face, isn't there? And just having social connection to people, physical social connection. Thanks Alice. So we'll move on then to the last two speakers. If I can ask Jim McManus, professor Jim McManus, who's also vice president of the Association of Directors of Public Health and a director of public health in Hertfordshire County Council. Jim, over to you.

 

M: Thank you, and can you see my slides okay?

 

Moderator: Yeah, we can see you and your slides.

 

M: Wonderful. Well, sorry that you can see me but there we are. Perfect face for radio. We've heard some very eloquent speakers remind us of the enduring nature of inequalities and the fact that, during this pandemic, they have made matters much worse, and we really need to address them. And Alice has shared with us five lessons, particularly. I want to, kind of, look at what lenses we might have for local leadership in response to this and I want to suggest to you that there are three lenses going forward. And those lenses are tried and tested in public health. And one of the problems with the pandemic is that an awful lot of people have invented science with no science behind it. And everyone's a scientist and an epidemiologist. And if every-, and if there were as many people claiming to be pilots as there were epidemiologists there would-, there would be thousands of people dying in, in flight accidents every hour. I want to suggest to you that those three lenses are systems lenses, syndemic lenses and determinants. And we've got them in our tool box if we want to use them. And actually, I won't dwell on this, but they are part of the kind of leadership tool kit of local public health, and I use here the Health Foundation's leadership model developed by-, with Ashridge. But I'm not going to dwell on that. And that makes me question terms like 'enduring transmission'. My worry with phrases like 'enduring transmission' is that, while it may help us respond and it may be a useful shorthand term for what is a growing phenomenon, it actually masks the response, or risks over simplifying something which is not enduring transmission. It's multiple infection dynamics which are riven and caused by inequalities and determinants.

 

And if we are not careful, terms like 'enduring transmission' can stigmatise the very communities that are worst affected by them. Inequalities are at the root of propagated multiple epidemics of disease. If we know nothing from HIV, we know nothing about that. And good epidemiology should understand and complexify what we're dealing with, not deliver linear thinking where that linear thinking may oversimplify. So more questions here about enduring transmission for you to ponder at your leisure. And the ADPH policy paper, the third of our policy papers on COVID, talks about how we operate safely in an environment where the disease is not immediately vaccine eradicable, where inequalities will persist and long term impacts will persist. And we call for building back fairer. And that means we need to complexify the impacts of COVID in the way I think that Alice and Kevin and Jo have done. The dimensions of public communication. The dimensions of its impact on different communities and the move away from linear thinking. Last week we did a day of self isolation support in Hertfordshire and knocked on 1,000 doors. And 89% of people were at home self isolating. Unsurprisingly, 528 needed offers of support and most of those people were the people who found difficulties in self isolating. There were very few people, fewer than 2%, who wouldn't self isolate or didn't want to. Most people either could or just couldn't and needed help. And those are the dynamics that we need to do some significant work on. And actually looking through the idea of syndemics and systems and determinants lenses is far more valuable for us. So we have these tried and tested tools.

 

I'm not going to talk at great length about determinants, but Dettells in 1990 talked about the layers of determinants, from biological to social, neatly illustrated, I think, by Kevin and by Alice. And I think, once we move on from there, how we look at whether these are tractable needs to be through both the systems lens and the syndemics lens. But why a systems lens? Because we know, actually, that we don't live as isolated, atomised individuals. There are multiple things that impact on our health, from the air we breath to the services we can access. And so we need to take a systems approach. And if the work on obesity has proved anything it has proved that, actually, the one single thing to understand about healthy weight is that there is no one single thing to do about it. There are multiple and many. So we need to become adept at changing and influencing systems. And I'm not going to talk through this but the work of Donella Meadows is a useful reminder here. But it also reminds us about a level of humility that we have to work. You know, that line of team of teams, no one person or system has the answer. It's certainly not the NHS, wonderful organisation though it may be. But we need each other in order to actually address the systems approaches of inequalities going forward. The next lens, I think, is a syndemic lens and, if you haven't read Merrill Singer's books or any papers about it, on syndemics, I'd commend them to you. Because actually we know, if we know anything about HIV or TB or any other epidemic, it doesn't come by itself. It brings with it stigma, poverty, long term mental health problems, economic problems, lack of access to care for other difficulties. And that is exactly what we're seeing.

 

How will we deal with that in a way that doesn't just end up putting more money into NHS services when actually these services isn't the answer? So we need a syndemic lens to look at how we recover and how long it will take us. We will have thousands of people with complicated grief. The answer for that is not anti depressants. It is helping people to work through their grief and resolve and rebuild their lives. Not treatment, recovery and response through a syndemic lens has to be our priority. And if Kevin's presentation did anything in this report, it showed us, eloquently, just how much the impact on black, Asian and minority ethnic populations is syndemic, systemic and actually intimately tied in with inequalities and determinants. And so must the response be. And you could take this for almost anything. Young people's mental health. But we have a lesson here that we're-, that gives us an opportunity to reset how we do health inequalities for the next ten years, if we are going to do it. This graph is one that I have on my desk daily. And it actually reminds me that there are multiple and syndemic impacts. From structural discrimination in getting access to vaccines, for example for gypsies and travellers, right through at the other end to the fact that people's jobs may mean they are far more exposed to COVID than those of us who can work at home, because they have to use public transport, for example. So as we go forward I want to suggest that there are three big phases of work for us, around which we can use these three lenses. And this is the root of our plan in Hertfordshire for our health inequalities and for our public health strategy. The first, that we exit the pandemic phase and manage COVID as part of an ongoing health protection approach.

 

Health protection was always about inequalities. The people who experience the worst environmental inequalities are the people who are the poorest. So we have to exit and be ready for that on an ongoing basis. The second is we have to begin to recover. And that means we need to use analytics and intelligence and the syndemic lens, and every piece of insight we can get, and work with our partners. I can't do my job in Hertfordshire without our district and borough councils, our environmental health officers, social care, the voluntary sector and many other, and indeed business. So it genuinely has to be a systems approach. And that applies to build back fairer. We can't do that unless we understand the determinants, our population, and actually embed these responses. And it is not about, I would argue, funding the NHS. The NHS is one part of this. And that means we need a dramatic reset of the language around population health. It is right to focus on inequalities with NHS systems but it is surely also absolutely salient for us to do our part outside NHS systems, to work together. And so, locally, we've actually been working with businesses. We've done quite a considerable amount of work on supporting businesses, especially in psychological wellbeing with our growth hub and with our behaviour change unit. We've actually been looking at how we look at the quality of place to promote better and fairer access to means of transport. And identifying priorities for employment going forward are going to be crucial, as well as educational outcomes. I won't dwell on this but our prevention strategy, which we passed just before COVID hit, actually talks about how we pursue opportunities to really transform the way we work into giving people better healthy lives.

 

Now that's ambitious, but I do think it is right to be ambitious. The next two years that I want to focus on is how we use these lenses to go forward to do that. So in conclusion, for me, I've had a rallying call today from Chris Whitty, a rallying call from Alice, a stark reminder from Kevin of the impact and the reason why we're in this business and a real knotty, thorny set of problems elucidated by Jo in relation to where we go next and how we work with people to understand the complexity. The only way I can think of of getting through that is to use these lenses. Determinants, syndemics and systems. That also means that we need the leadership of local government as never before. And the leadership of the local members, which is why I think it is very fitting that we have an elected member summing up this session. So I'll stop there, if I may.

 

Moderator: Thanks Jim, that's great. And you've done a brilliant sum up and intro to our elected member Councillor Paulette Hamilton, vice chair LGA community wellbeing board and cabinet member for health and social care in Birmingham City Council. So if we can move on to Paulette who's our last speaker who, as Jim has said, will provide that real local member's perspective and then we'll go to the panel. So over to you Councillor Hamilton.

 

F: Good afternoon everybody. I was delighted to be invited here this afternoon to speak. I am not one of the eminent speakers on the panel, but I know my community. I was born in the community that I'm now a councillor. I grew up in that community. I did everything that local people do in that community so, when COVID hit, I wasn't surprised at the reaction of the community that I serve. But let me just go through and do things in order. The crisis that happened last year really marked our streets and communities across Birmingham but also across the country. Families lost loved ones, our businesses were suffering, we were losing jobs in the city. We were a very young city so we really saw the financial implications of COVID really quickly. The growing health inequalities and the poorer communities was incredible because many people in our community last year didn't actually believe that they had health inequalities. The mental health issues within the community was stark from early on. As a city Birmingham is ranked 7th in the most-, in the most deprived community of the country. We speak over 90 languages. In a ward, such as the ward I represent in Holyhead, we're 84% ethnic minority, so it is a super diverse ward. And also, 46% of our citizens are actually under the age of 30. We have a city of 1.2 million people. And we also have, believe it or not, lots of parks and green spaces, but many people don't actually use them. And last year was testimony that people just weren't aware of what they could use. We, as a local authority, last year we supported our hospitals and care homes. Also, as many authorities did, we did the usual. We delivered the food parcels.

 

We made sure the safe and well checks were done. We also had the saga of PPE and we had to ensure that we did what we needed to do in that area to sort that out. But the big issue came in April that I want to concentrate this afternoon. We had-, within our community around the 11th April last year there was, those of you that understand, something called the '(mw 52.33) call'. The community just exploded. But it was fear. It's a fear that I have never ever seen before. It was palpable. You could feel it. You could taste it. You had people in the community refusing to go into hospitals. You had people in the community actually being driven to the hospital and refusing to go through the doors of the hospital. It was terrible. So we decided to call an extraordinary health and wellbeing board. Now we couldn't just call the board. And remember, I'm talking about this as the person that led on the political front, but we needed all the other partners on board. The public health director and his team were phenomenal and we also had so much support from the NHS. So we had to promote this. What we found was that-, that's why I hate the term 'hard-to-reach communities' because, if you find ways to access your community, they will tell you what the problem is. And so, in one week, we were able to call a health and wellbeing board meeting. What we said to our community-, communities, what we asked them was-, the question was 'What are your fears? What are the issues? What do you not understand about COVID?' We were overwhelmed. We had over 600 questions from over 200 people. Now the public health director at the time made a promise that every single question would be answered and that is exactly what we did.

 

We answered all the questions. We grouped the questions, the way Jeanelle has said she'll do today. We answered all the questions. Some we couldn't do at the meeting but we made sure that everybody had an answer to their question. I'm not saying that it was the be all and end all, but the community felt they were being heard. And, from that, what it really highlighted was the links that we could then see between inequality that-, between the issues with race, class, gender, disability and age. We really started to see early on what was going on on the ground. The inequalities were absolutely exacerbated by the fact that education had stopped suddenly. We had lots of people living in high rise flats. The health inequalities that were out there. The fact that many of our low paid workers, if they didn't lose their job, they knew nothing about being at home furloughing or being working from home. Because that didn't exist. We had large numbers of our children and adults, they had no IT support. They were not actually-, they didn't have the structures in place to be able to access what they needed to access to continue learning or working.

 

But what we saw most of all was the issues around death. When people started to pass away, in the African Caribbean community and many of the Asian communities, they have rituals. And these rituals were not then being carried out. So many of our local communities were starting-, from early on we started to see the issues developing around anxiety, mental health type issues, because they weren't able to grieve in the way that they needed to grieve. But as a city we knew we needed to respond. We did lots of letters to the government. I've got to know Kevin really at this point because of the report he was doing. The public health director and the leader worked really hard, and the whole council. But what was really interesting at that time was the work we did to actually take on board community champions. These were local people talking to local people about the issues and, to date, we now have 782 of them. We also did some work-, we started some work with Lewisham because we found, as a city, some of the issues around the BAME community, African Caribbean community, they had five times more chances of dying at child birth than any other group. So the issues were horrendous. Then we had the issue of vaccine hesitancy. We know this was an NHS issue, but it became a local issue. I keep saying 'We know our communities'. Local government absolutely knows their community. So what we had to do at this point was join with the NHS and started doing a series of webinars. We went out there and did radio interviews. We did talks. Anything we could do. One to ones to encourage people to become confident in taking the vaccine. We then-, as a community, we saw the impact of social distancing.

 

I'm not going to go on because time is short, but the impact of social distancing, the impact of our young people not being in school and the fact that 65% of our young people started-, they were worried about their mental health. And 16% of our young people having-, have been entirely isolated since the start of the lockdown when we did the survey.

 

F: We had a large number of mental health challenges but, for the speed of time, fear and promoting resilience and encouragement has to be key if we are going to sort this-, that out. Now, going forward, as a city, what we needed to look at and what we are looking at is post-COVID recovery. We must be a greener city for all which is across the country. But it must also be fairer and more inclusive because in part-, if you live in parts of Birmingham, you can leave the city centre and go less than three miles away and your life expectancy is between five to eight years shorter than other parts of the city, just because of where you live and you grow up. And we need to implement innovation approaches to return our services so that they can recognise and respond as to identified route cause of deprivation, poverty and inequality. We have to mean this. We can't-, words are cheap. And, you know, I've loved what Alice has said, because less-, the lessons from COVID, if they not learnt now and if we do not go forward with those lessons, this is going to happen again. A pandemic will happen again. And if we are not in a position to actually deal with it the next time round, we cannot then be excused. And my last point is inclusion has to be key to everything we do. I am tired of hearing that-, that we have hard to reach communities. No, they're not hard to reach. I'm a black woman. I'm not hard to reach. You have to make an effort to reach me. Otherwise, I am not always aware of how to access things that people have put out there.

 

So, we have to learn to change the way we engage with our communities. And that actually includes some of our working class communities that for three or four generations they've not worked. They've absolutely and utterly stepped out of the race. I'm going to end by saying COVID has been a sad time for me. But it's also been an opportunity. It's an opportunity to see change. And I'll stop there. Thank you.

 

Moderator: Thanks Councillor Hamilton. And that was a rallying call to wrap up all the input from the the speakers. So, thank you very much for that So, if I can invite the panellists back, so that we can have some conversation based on the-, lots of questions that have come in So, I'm going to start with a question really that-, that draws together a little bit of a theme about-, we talk about COVID fatigue, but I'm picking up amongst the questions a bit amongst us as the public health community but of health inequalities fatigue. So, that desire to see things change more quickly, more visible You know, why-, why-, why are we not seeing changes? and potentially also in terms of health inequalities around race So, if-, if we can have your reflections on that? Shall we start, Kevin, with yourself?

 

M: Thanks Jeanelle (ph 01.02.36) and can I just say, thanks everybody. Thanks for an amazing panel. I think we need to challenge that assumption and that narrative, er, you know, Jeanelle, because what I've seen and I hope what I've shown in the work that we're doing with London, is that we have grasped this opportunity to make the change that we have been calling for for so long. And I've been in public health practice now for 25 years, and I have never seen a moment in time where every partner, every community, every member of our cities-, our city, is actually focused on these inequalities, the unfairness, and a commitment to be-, to do things differently. So, that's the first thing. Just in terms of let's no be in a (inaudible 01.03.26) of defeatism now. Second, let's acknowledge the gains that we have made, even in the course of the pandemic in the last year. There's a question in the chat about, well, what has been achieved? You know, we now have better data than we did at the beginning of the pandemic. We now have campaigns which have people that look like me. Focused on people like me, in different languages engaging with communities. And we are investing in and ensuring that all of our programmes are far more culturally competent than they have been. And that is happening in the NHS. It is, has always happened in local government, and it's going on now. So, I want to challenge that assumption because I think we need to get our mind in the frame that we have to build on the gains, because the work that's coming up ahead is going to be even more challenging. And we need to do that mobilisation. And it starts with us.

 

Moderator: Thanks Kevin. Good challenge back. would anyone else like to pick-, pick it up and perhaps even reflect on the question about so if not health inequality fatigue as we just then talking to ourselves? Are we, er, in a particularly bubble, er, around our partnerships? So, I think, perhaps, Jo, if we pass it on-, on to yourself? Are-, are we talk-, just talking to ourselves? That's what your report seemed to suggest.

 

F: S o, it's the-,

 

Moderator: (talking over each other 01.04.49) Not your report, but the report-, sorry, that you were talking to. Yes.

 

F: Yes. I think-, I suppose listening to the presentations, I mean, you know, that polling data is the polling data, it's attitudes that have been collected by the public, and we need to reflect on them. I think what I've really been struck by in listening to the presentations is this real opportunity around local leadership. You know, and maybe there is something about the fact that where this becomes real for people is in their communities and the role that colleagues round this, you know, table have been talking about in terms of that local leadership. That seems to me the real opportunity here. and perhaps that's where, if you can start to get that shift in understanding about what can be done, you know, maybe that eventually does start to change some of the more, sort of, national dialogue. But, I think there are huge opportunities, because of the way local leaders have responded, and it's about building on those.

 

Moderator: Councillor Hamilton, would you agree with that? Huge opportunities for local leaders and leadership here?

 

F: Absolutely. For myself, over the last year, the data-, well, there's two things. One, I believe public health has absolutely earned their place in, in, in local government. And if anybody tries to challenge that, that is my first-, going to be my first issue. Secondly, I do believe that local leadership is the way-, well, it has always been the way forward. We know our communities, and with the expertise of public health, and with the knowledge of people like myself, as local councillors, it can't be beaten. And also, working with the NHS, primary care, the voluntary sector. It cannot just be one place or another. It has to be joined up, but I know that over the last year, I've never seen things shift where data would be an issue, where things around protection data, protection or whatever. All that seemed the leave the room during the pandemic, and I'm just hoping-, and I agree with Kevin, that we build on some of this excellent work that's been done around the country, to ensure that our citizens start to see the value of it. Because they can't-, they can't go on like this. The level of fear, the level of distrust. They feel that people don't care. They need to start to feel that we're listening to them. And I'll stop there.

 

Moderator: Thanks. So, Alice and Jim, Councillor Hamilton. Resounding support for directors of public health and leadership. What-, what-, where-, where do you want to come in on some of those questions that-, that have been put to us?

 

M: Alice, after you.

 

F: Okay. so, I'm just reflect-, I mean, that was great from Councillor Hamilton, because actually that's how I feel in my local place in Gateshead as well, that, you know, if people had asked a year ago what your job was. How many times-, how much time do you spend explaining to them what public health was, whereas I feel like we're-, a year later we don't need to do that And I think the CMO talked about that this morning as well. He talked about the fact that his-, he's improved all of his relationships across government, so we really have an opportunity to you know, think about actually how we do use this moment to influence in the right way. I'm-, I have to say that I've recognised people feeling impatient and frustrated, because I'm the most impatient person in the entire world. my mum would definitely agree with that. But I think think that we can't do these jobs unless we do tackle inequalities. And we can't just tackle inequalities from the perspective of the lifestyle issues that everybody, kind of, related back to us. We have to start having these conversations and that's why public health is in local government. So, you know, as much as I recognise other people's frustrations, I equally think there's something we must do. And then, picking up on Councillor Hamilton's point there at the end, it's actually-, I think the community leadership has developed and changed over the last twelve months and I think it's about how we, as local directors of public health, or public health teams across the country, actually make-, form better relationships with our communities, so that we can hand over the power to those communities to define what it is that's needed for them.

 

And to actually give people in those communities a voice, 'cause the reason things haven't changed, is because the people who are most disadvantaged are less likely to vote. What we need to do is make sure that people feel that they are engaged-, well, we don't need-, we don't need to make sure that people are engaged, because that's not-, but we need to enable a context where people feel engaged and feel that they have a voice, and feel that they have a place, so that then they start to vote. And then we start to see a shift and change in the way that people are listening to them. So, there is a whole piece of work that we need to do, and some of it is about handing over power, and some of it is just about, you know, tenacity or stubbornness, whichever you'd like to look at it as.

 

Moderator: Great. Thanks Alice. Jim?

 

M: I think we're a time of both the greatest opportunity and the greatest risk for the public health profession in the last fifteen years. The greatest opportunity is we've come out of COVID making it very clear that national government can't (audio cuts out 01.10.15) without us-, can't deliver. And also, our NHS partners, hugely valuable though they are, can't deliver. We all need each other. None of us are perfect I think the other thing is we've demonstrated that inaugural government we have delivered more in six year than we did in the NHS in the previous twenty, in many respects. NHS needs public health, but local government health is a different animal. So the great risk-, the great opportunity here is to realise that change making takes decades, unless there is an immovable force that makes it happen in weeks, i.e. the pandemic. So, we're in this for the long hall. The greatest opportunity for us is to article health inequalities and how we work together with local communities and local agents to do that. So, put the NHS, and central government, and all the other agencies alongside us as (inaudible 01.11.12) partners The great risk is that if we just go back to a language that sounds rather academic and distance, and we do (inaudible 01.11.22) each others that the-, that the frameworks institute working with Jo has given us. That's a leadership challenge. And it's a leadership challenge that you can only rise to with local elected members. It also requires a great deal of humility. So, our NHS colleagues need to understand and discern their priorities. Directors of public health need to understand and discern ours. Elected members (inaudible 01.11.52), because we've all got a role to play, but it's culture, behaviour and long t erm thinking. Not the short time policy objectives or spending reviews that will get us out of this.

 

Moderator: Thanks, er, Jim. So, you've taken us on to another area that's come through in the questions, which is around how we work together with our partners. and I know S-, er, er, Kevin you talked quite a bit about system partners. Now, clearly the NHS is a-, a major system partner. We've got, er, NHS reorganisation happening at the same time. So, there-, the two questions if you can reflect on. I'll take them together. How-, how can we make the next four years about healthier, fairer places, and not about whether the NHS has enough money? And then second one I suppose there's that challenge back which Chris Whitty picked up about that the urgent crowds-, crowds out the important, but long term. And my-, I suppose, my challenge is-, is both in local government and NHS. Often the urgent gets funded and, er, the long term prevention er, and public health work struggles in terms of, er, funding. Both in-, in both organisations let's say. So, those two challenges. So, you know, it is-, it isn't about the money, but it is about the money What-, how do we provide leadership within that? those shifting movements over the next year. Kevin shall-, let's start with you.

 

M: Er, thanks Jeanelle. So, on first reflection about system partners, let me be absolutely clear here, that if the pandemic has taught us anything, it's that I view the public, (inaudible 01.13.43) communities, community organisations, businesses, head teachers, as system partners. I would like us not to habitually go back to the NHS as-, and I know (inaudible 01.13.54). Don't worry. To be absolutely clear here, to Alice's point about the lessons of the pandemic have taught us and how we therefore change those behaviours moving forward. So, that more expansive view of who system partners are, valuing those relationships, investing in those relationships. Creating governance that are meaningful to sustain those relationships I think will be key. And with the governance, as we're doing here in London with the grand challenge and emissions, co-creating, co-producing with those system partners the strategies that are required to get our city moving again as we emerge from lockdown. Third, I cannot stress this enough. Data. Data. What gets measured, is what gets done. What we understand, we're able to improve and you cannot emerge from that with a (inaudible 01.14.47) of data that will(inaudible 01.14.49) to give us that. So, again, I think that's very important on the systems partnership. And then finally, to your question on the urgent and important versus the strategic and sustainable. I think that is a challenge that we're going to continue to have.

 

We cannot build back fairer, thinking of a six week or three month timeline, because inequality (inaudible 01.15.14) have been ingrained within societies for decades. So, I think taking that long term, er, strategic planning priority, working across systems partners, but understanding what are our short term milestones that that we need to be working towards. So, whether it is free school meals for every kid in the school, every child in the city. No brainer, that we should be focused on and accelerating on in the short term to create the momentum, the engagement and the will to go for the medium and long term. That's, I think, one of the ways in which we balance that short and medium term.

 

Moderator: Thanks Kevin. Who-, who would like to-, who in the panel would like to pick up next? Let me-, let me go to Councillor Hamilton, yes So, can we-, can we, in local government, balance that short term long term, and how do we work with our NHS partners, communities, er, and others? How-, how do we make the money go round?

 

F: Me, as a local councillor, and I'll just say it straight. There's no other game in town. The money, there just isn't enough of is, so we have to learn to work in a more smarter way. So, when you're working with the system, you need to look-, I believe if you're going to make change, you need to look at the-, at people in the place where they live. Because, I've said before, I was born in Birmingham, I've grown up in Birmingham, I went to university in Birmingham, I've had my children in uni-, in Birmingham. And I will become an old aged pensioner in Birmingham. I don't know if I'll be a pleasant one, but I will do. But I expect the people to come to me in the place where I am, and we work together to make the changes in what I need to grow old gracefully. And I'm saying that sparingly. But, for me, the system is key. You have got to understand the data, you've got to understand the population you're dealing with, you've got-, you're going to have to understand the changes you need to make, you're going to have to understand who needs to lead on it. And sometimes the problem we've had in the past, the NHS, or local government, or whoever, wants to lead on everything, when they perhaps are not the right people. So, it's how are we going to work with our local universities. I've heard Kevin talk about teachers, and others. But going forward, thinking out of the box, because change is possible and public health is key to this, but part of it is relinquishing some of their power, allowing others to take hold of that power. The NHS are saying wait, local government are saying wait, and putting the person first. And I'll stop there.

 

Moderator: Thanks Councillor Hamilton, and you rarely-, I don't know whether you, er, heard Professor Whitty this morning, but he was-, he was strong on people who live in a community, grow up in a community, are there the whole time and are totally invested in a community. And the connection he was making was also to research and so there's data for the immediate, but it's that research data for the longer term. And he was making that-, that call for local government to get involve in making sure that we do capture and research in our local communities and really harness, you know what you've been talking about in terms of your commitment to a place, and-, and-, through a lifetime. So, let-, let me, er, go to Jo. Would you like to come in and then I'll-, I'll finish it again with Jim and then Alice.

 

F: Yes, great. I think one thing I was just reflecting on from, sort of, earlier discussion, about the health inequalities fatigue. There's something about the language that we use, and health inequality is a, sort of, abstract cont-, concept. You know, as an in-, it's a population effect, it's not an individual affect, and so, you know, when we're talking about health inequalities, that doesn't necessarily mean something to the individuals we're communicating with. So, I think that language thing is really important. But on the, kind of, incentives to think more long term, which has to be absolutely at the heart of getting the change we want, and one of the things we've been talking about at the health foundation, is the ONS health index, which was published as a beta form before Christmas. There was a consultation exercise, which is now closed, but it's gonna be revised and launched later in the year. And the health index came out of Sally Davies's CMO report in 2018 when she was, sort of, advocating for the need to have an alternative measure to GDP. Something where we can look at the, sort of, health stock of the country. Now, I know all the reasons why the health index isn't perfect, but I think one of the things that's interesting in it, is that it does include measures that are both showing, sort of, immediate health effects, so, you know, health status of individuals, but it also has in measures that reflect some of the sort of, er, things we need to build into society that have more long term effects.

 

So, you know, more green-, access to green space, or taking children out of poverty. I think there's something really interesting about the fact that the index does start to incentivise potentially, and kind of measure some of the action that, if you take it now it may not deliver benefit for several years to come, in a sense, you can demonstrate through the index that you're making that investment. So, I think there is something that we should engage in around that, and think about. And then final thing. I think there's something about the fact of, you know-, if we could perhaps be better at tracking what is the government investment in the strategies that we know keep people well, and kind of show what that looks like relative to the investments that government makes that actually is about, not just poor health, but, sort of, wider societal consequences of poor health, whether it's mental health or other factors. And, I think, you know, if we could better track that, sort of, what is the investment being made nationally and that, kind of, preventative action, it would give us something a bit more tangible. Because I think, you know, we-, intuitively, we know that should at least stay the same if not go up, year on year, and if it isn't it gives something more direct to point at.

 

Moderator: Thank Jo, that's really helpful and in that theme about data and understanding and knowing exactly what's going on and how-, how we are making that impact. So, er, Alice, if I can come to you. And then Jim.

 

F: Yes. Thank you Jeanelle. Yes, so I mean, I'm reflecting on all of the things that the previous speakers have said, and actually, you know, agreed with everything that's been said. But what I'm thinking in terms of adding to that is, it's not-, it's not just about the data in terms of the numbers, it's about the qualitative data that we get when, you know, so it's-, and I think lots of people on the panel have already spoken about the importance of relationships and how we build relationships with our communities, and, you know, so there is something about commission to go out and build relationships with real people in real spaces. I think, probably over-, over a number of years, we've got really caught up in commissioning a service, and the tangible things that you can see, whether you've written a service spec and you've commissioned something for however many thousands of pounds, and actually, sometimes it's just the conversations that you have at the local level that make a-, you know, all the difference. So, for me, there is something about actually going back to basics and enabling-, giving permission to people to get out into their spaces and to understand exactly how it is, and what communities themselves think the solutions are. And actually, many of the solutions that the communities that I've been involved with come up with are not expensive. They're not big things. You know, we worked with a community in Gateshead around childhood obesity and they talked about safer street to be able to walk their kids to school.

 

You know, looking at parking round the school. You know, the-, there's kind of basic stuff that we would never have thought about if we'd flown into that area and thought we could land a well intentioned service. So, I-, I love-, I love the research plug that Chris made this morning, and I would just make the plug slightly bigger that it needs to not just the, kind of- the research that we're used to in terms of the gold standard RCTs, that let's really start to embrace qualitative research and the understanding that that gives us around people that we all are here to serve.

 

Moderator: Great, thanks Alice. And challenging the methodology of that research, isn't it. and that-, you know, even contributing to how we can do research in a meaningful way in our communities. Yes. Jim?

 

M: I'd agree with everything that's been said. I think at the end of the day, this remains a cultural issue. You know, the most important thing we can do, to make our really precious NHS sustainable for the future is for every single agencies and actor to realise that we all have a rule, and for every single agency and actor to respect that rule. Because, you could say the same about housing, er, which is equally crucial for health and is fact is foundational for health. And the same about education. So-, and I've pasted in the chat my link to the team of teams book. Awful cover, great book I think the second thing is where that fits into the research agenda is an opportunity for us really to recover models of research that sit well with health inequalities because they start from a position of respecting and understanding the individual in the community, so not doing the research to people, doing research with people, and working with people. And there's one little blue book, which I've forgotten the name of, but it was published by the health foundation where they used a multiple set of disciplines to look at childhood obesity. So they had a sociologist, a lawyer, a psychologist, and various others look at it. And I think it-, what that says to me, is that actually we've spent too long with public health research trying to be biomedical research, and actually we need to be much more research about and with people for change. And it's an ethical disposition, and it's an ethical commitment that follows from that culture.

 

We have the opportunity to do this reset, but only if we all put our minds and efforts to it, and seize the money from the funders. It's great that local government has been recognised for research, that's really good. But we have a lot of work to do to build the infrastructure to make it capable to do that. And let's do as we want it to be, not-, let's not take biomedical research, because that needs to do what it does, we need to do what we do.

 

Moderator: Thanks Jim So, if I could draw us close-, to a close there panel. I think er, we've had a fantastic input in terms of your presentations, but equally just the conversation, the Q&As, it's just really impressive. So much coming-, so much thought, energy knowledge and- and thinking about what's needed over this next year. It's really really inspiring I know that Paul Ogden has also, er, put on the the chat if you can see it? The public health annual report 2021 rising to the challenge of COVID, which looks at what we have helped to achieve and what could be done better during COVID-19. So, I do commend that report to you. So, it-, I think it-, it builds on a lot of what we've been talking about here and gives us real local examples of work that's been done I do hope you found it helpful. The presentations will be available on the LGA's events page within two days. I think I heard this morning's session is already potentially up, or will be later today. So, a very, er, impressive turnaround by the LGA team. Er, there'll be a short survey that we are going to send to you. Please do, er, complete it. Er, you'll appreciate this is an unusual way of doing a conference, so, er, we do-, would value your feedback. I think that would be really helpful in terms of the way in which we do conferences And, er, finally if you, er, commend tomorrows speakers and programme too, we really hope that you can join us.

 

The details are on the LGA website and your booking for today allows you access for tomorrow as well. Er, so it's been, er, fantastic to spend the afternoon with you. Thanks again to our speakers. And, er, thank you all and, please, er, stay safe. Bye for now.