LGA/ADPH Annual Public Health Conference 2021: Rising to the challenge parts 3 and 4, 24 March 2021

Moderator: Good morning, everybody, I think we're now ready to start. I'm counsellor Ian Hudspeth, chairman of the Local Government Association Community Wellbeing Board and leader of Oxfordshire County Council. I'm pleased to welcome you to the second day of Local Government Association and Association of Directors of Public Health-, Public Health conference. Yesterday was a very sobering day for all of us, as we reflected on the impact of the pandemic on our communities a year on from the first lockdown. I'd like to add my personal thanks to all those who've worked tirelessly to protect us and keep us safe over the last twelve months, from care home staff to Public Health and community nurses, to the directors of Public Health leading their local responses. It has been a privilege to see how the local system pulls together in a time of crisis.

 

However, we must stay vigilant of the threats posed by new variants, as well as now focusing on improving the health and quality of life for our communities, especially in relation to health inequalities. Key to doing so will be strengthening the relationship and communication channels between national and local governments. I am therefore very pleased to welcome this morning, secretary of state for health and social care, the Right Honourable Matt Hancock. Good morning. It's one of those where I'm waiting. Secretary of State, are you there? Ah,m good morning, yes.

 

M: Good morning, how are you?

 

Moderator: Very good indeed. Welcome, and we'll just go straight over to you, to give your presentation, and thank you for taking the time out this morning to speak to us all. We really appreciate it.

 

M: Well, thanks very much indeed, Ian, and thank you for your-, for your work, and thank you very much for all of the engagement that I-, I've had with the LGA all the way through this crisis, it's been-, it's been an enormous effort and it's been an enormous effort by you and I'm very, very grateful. Today, I want to talk about Public Health because there's never been a more important time for Public Health. If you think about it, never in this country's history has a year taught the public more about the importance of, of Public Health, and never before have those of us who work in Public Health learned more than over the past year. I'm so proud of what Public Health teams have done across the UK, you've never worked harder. And some say that after this pandemic we must learn the lessons for the future, and of course, we must. But why wait until after the pandemic? The truth is that we've been learning throughout, from the first moment that PHE colleagues last January developed a test for Covid-19 before it was even called Covid-19, from the moment we brought in colleagues with private sector experience alongside academic, clinical, government experience at local and national level, to build a testing infrastructure and then to build a vaccination programme, both on a scale never seen before.

 

And we've also learned a huge amount about the vital importance of the health family all working together as one big team, breaking down silos, working as a system. Today, I want to talk about the future of our Public Health system and our reforms to build on this work and make changes from what we've learned over the past year. At the heart of our Public Health reforms is the insight that it is critical in good times and in bad times to have an institution whose sole job is to protect the nation from external threats to our health. We must do that at that same at the constant work for health improvement, and for health improvement to be as effective as possible it must be embedded in the heart of government across government local and national, and not at arm's length. There are two functions of our Public Health system, health security and health promotion. Health security is about protecting the country from external threats to health, like Covid. Health promotion is about marshalling the collective power of our society to promote good health of the population on the basis that prevention is better than cure.

 

These two concepts, health security and health promotion, are of course linked on many levels. For instance, obesity is a major factor in how ill you get if you get Covid. But while health security and health promotion are deeply intertwined, they are emphatically not the same thing. We need to get better at both. They each need focus, they need dedicated homes at a national level, and strong connections to the local. And in both, we must harness the dramatic innovations of the last decade and the last year, in data, in genomics, in population health, in science, in research, and so much else. Now, in the coming days we'll set out our approach to health promotion. Today, I want to set our approach to health security. We've made huge strides in how we do this in the last year. At the start of the crisis, we didn't have a significant diagnostics capability in this country, so we built one. We did have a world-leading capability in genomics, and we've built on it further. The analytical capability of the joint bias security centre, which builds on the expertise of Public Health England, has developed, in my view, into the best analytical resource I've worked in a decade as a minister.

 

And of course, the vaccines programme has been a template of how governments can get things done, harnessing science, enterprise, and the NHS to develop, manufacture, and deploy at huge scale and speed. So, in all of this and the reforms that I'm setting out today, we build on strong foundations. I'm so proud of what the team have achieved together over the past year, across PHE, NHS Test and Trace, the JBC, local and national government, directors of Public Health. We will now build on these foundations a dedicated, mission-driven national institution for health security, that brings together all these capabilities in our ability to respond to with total focus on the prevention and response to pandemics, communicable diseases, and external threats to health. On 1st April, so next week, we will formally establish the new UK Health Security Agency, UKSA, as it'll be known, will be this country's permanent standing capacity to plan, prevent, and respond to external threats to health. UKSA will bring together our capabilities in this area, from the scientific excellence embodied by the likes of Dr Susan Hopkins and her amazing colleagues in clinical Public Health, to the extraordinary capability that NHS Test and Trace has built, which Dido Harding has led so effectively over the last nine months, and the JBC, with that analytical brilliance.

 

I want everybody at UKSA at all levels to wake up every day with a zeal to plan for the next pandemic. That sort of focus is vital. It's vital when the crisis is live, like now, but in a way that's the easy bit. The hard bit is keeping that focus in the good times, too, when there's no pandemic on the horizon. As part of this planning, UKSA will work with partners around the world and lead the UK's global contribution to health security research. Next, UKSA will be tasked to prevent external threats to health, deploying the full might of our analytic and genomic capability on infectious diseases, holding responsibility for our health security capabilities at Porton Down and Collingdale and elsewhere, preparing for and preventing external threats to health like bioterrorism. In all, helping to cast a protective shield over the nation's health. Third, UKSA will respond to the threats we face with speed and scale, and these are critical. As we saw at the start of last year, when a new pathogen mutates, it can spread dangerously fast. Even after years without a new major Public Health threat, UKSA must be ready, not just to do the science but then to respond at unbelievable pace. This is what NHS Test and Trace has done, and this is what we've learned from the vaccine programme, too.

 

The challenge, and it is a genuinely difficult thing to pull off, is for the institution to stand in readiness and be able to scale up quickly. So, it must plan, it must prevent, and it must respond. UKSA must be ready. Now, in a previous life I worked at the Bank of England, and in financial stability work it's said that the next crisis comes when the last person who was around in the previous crisis retires. That's why we have the Bank of England looking out for the nation's financial stability, to scan the horizon for threats to financial stability and take action to plan, prevent, and respond in bad times and in good. That's what our new institution will do for health security. UKSA will be empowered to hire the very best team possible from around the world. Its chief executive will be Dr Jenny Harries, who has performed brilliantly during this crisis. Dr Harries has led the Public Health response to the Novichok poisonings, she played a critical part in the UK's Ebola response, and last year as deputy chief medical officer she's delivered the shielding programme which is both incredibly sensitive and has been superbly delivered. Dr Harries' distinguished career as both a Public Health physician and crucially as a Public Health leader make her impeccably qualified for this role.

 

I'm also delighted than Ian Peters has accepted the position as UKSA's chair. Under Ian's leadership as chairman of (mw 11.13), that NHS trust has built an impressive track record in the life sciences, with a combination of private sector, academic, and government capability that is so important in delivering excellence at scale. Ian bring his extensive experience of leadership in the public and private sector to this crucial task. I'm looking forward very much to working with them both, and I want to say a word about how UKSA will operate and what is culture will be, because UKSA's task is to be vigilant, yes, and to engage in scientific excellence, but it must also be open, dynamic, and confident, and reach out to work with partners wherever it finds them. This isn't just an agency, its job is to provide professional leadership in the field here and around the world. General Stanley McChrystal once said, 'Anybody who has ever played or watched sports knows that instinctive, cooperative adaptability is essential to high-performing teams,' and that is what UKSA will be all about. UKSA will be an essential partner for us all, leading on health security for the whole of the United Kingdom, collaborating with devolved administrations and the Public Health agencies for Scotland, Wales, and Northern Ireland, and crucially working in partnership with directors of Public Health and our partners in local government.

 

These deep connections to the local level are vital, because if the last year has taught us anything it's that a local problem has never been more likely to become a global problem, and a global problem has never been more likely to become a local problem. UKSA forms part of the new health landscape that's taking shape around us, where the gravity is shifting and decisions about health are being taken closer to the people they affect. That is reflected in all the reforms that we're undertaking across the department. The health and care white paper, which is essentially about integrating the NHS and social care, our mental health white paper, these Public Health reforms, and our forthcoming new data strategy, all of these are about making sure that decisions are taken as close to the people who they affect. Because in all of these, collaborative engagement with local government is absolutely critical. Through the pandemic, you've shown how you can break down traditional barriers and achieve remarkable things, like for instance, the Everybody In campaign, where you've worked hand in hand with the NHS to support 37,000 vulnerable people and rough sleepers, or the innovative new ways that local resilience (mw 13.50) has brought the NHS and other blue light partners together to coordinate responses to local outbreaks. You've been at the forefront of our national effort, you've been tested but never beaten, locked but never down, and any change in how we do Public Health must be done alongside and with the people who know their citizens best, who work at the local level.

 

Take our proposals for the Health and Care bill, for example. A central change will be the introduction of statutory integrated care systems, or ICSs. The idea builds on what's already happening in many parts of the country, where ICSs have shown the way forward, demonstrating how we can integrate those responsibilities which look up to the NHS and those responsibilities that look up to local government. And if further inspiration were needed, few things have demonstrated the power of what we can achieve when we work together as a system than our vaccine rollout, where we've broken down all sorts of silos to vaccinate over half the population in just over 100 days. That is the spirit that our new ICSs will work in, getting local authorities and the NHS working together, taking decisions together, and delivering services together. Crucially, ICSs will not only cater to the health and care needs of their populations, but support people to stay healthy in the first place. This prevention agenda is critical, with directors of Public Health playing an ever-greater role as champions of health in their communities, on everything from action on smoking and alcohol misuse to tackling obesity and much more besides. And this is how we put the power of the NHS budget behind the prevention agenda, by empowering the ICS locally to support the integration of NHS and local authority responsibilities to promote good health and give them the space to work together to deliver on that promise.

 

I'm incredibly grateful for what you've done to help develop this new model of integrated health and social care and Public Health at the local level. I specifically want to thank James Jameson and you, Ian, for being such important sounding boards as we develop the proposals, which have meant that everywhere in England decisions about people's health and care can be taken as locally as possible. Over this last year in local government you've moved mountains. I'm in awe of the way you've protected and supported the people who you serve, the residents. It inspires me that a better future for Public Health in this country is possible, with local government at its heart, building on the best of the last year, driven by a clear mission, with everyone in the health family working together as one, rising to the challenges that are thrown at us, and planning for the future with confidence. That is a formula for success and a formula for a happier and healthier country in the years to come. Thank you very much.

 

Moderator: Thank you very much, Secretary of State, and thank you for those kind words. I think it's so important we hear the breaking down on silos and actually everybody working together and that is so important. Local government has been, as you say, at the forefront of it, and-, but it's actually seeing those breakdown of silos, and more importantly what we've got to make sure is we don't lose that as we move forward and actually retain that balance. And of course, health inequalities is a massive agenda for us and at the local level we're ready to help and work with everybody to see where we can remove those inequalities, which actually we've seen the effect they have on people during the pandemic. Well, I've got a few questions for you, if you don't mind. It's-, the first one is, the response and recovery, recovery from any health protection incident is carried out first and foremost at the local level, as you say. How will the proposals genuinely ensure local first (ph 17.53) as promoted in the narrative document, will that be different this time? Do you want me to just do one question at a time, or three in a group?

 

M: Well, I think this is such an important question, why don't we-, why don't we address it head on? The new UK Health Security Agency must work with an integration with the directors of Public Health at a local level. That is the only way for this to work effectively. Now, in responding to an incident, when it's done well, that is exactly what happens. You have the national agency with the, the clout, sometimes the specialist expertise, some of the facilities especially for the very high-end response, but you need the local understanding and information. I, I can't think of anybody better than Dr Harries to, to lead and make sure that we get the culture of the new UKSA from the start. A, a really good example to this was the response to Novichok, where the local authority and local director of Public Health played a critical role alongside the national agency. Now, we've also seen that in the pandemic. It's obviously been, been, you know, the biggest thing that has happened to anybody in Public Health in their career, but where the response has worked best has been when the local and the national has been pulling together.

 

Moderator: Thank you. Next question. It was the Conservatives that introduced the first national Public Health strategy in 1992, the health of the nation, a major achievement, it's now time for a new positive strategy to tackle key issues such as mental health, obesity, lack of exercise, and inequality. Well, I think that's what you're, you're doing, which is good news.

 

M: Yeah, trying to. So, the-, look, the-,

 

Moderator: We'll work with you.

 

M: What I've set out today is the health security aspects. Now, of course, Public Health is about health security and health promotion, and in the coming days we will set out the strategy on the health promotion side. Both are vitally important, and actually, we can improve the way that both are doing. One of the views I've come to, learning from the experience of being health secretary during this pandemic, is that it is critical that there's an agency whose sole job is pandemic preparedness, because then even when there's no pandemic on the horizon, they spend their time worrying about when the next pandemic hits. And a separate but vital task is ensuring that we are constantly working to improve outcomes to, to improve the prevention of ill health, and on the health improvement, health promotion agenda. But there, having that in an arm's length body, actually detracts from its power at a national level, because instead of being in a department where you can influence all the other departments who have a say on, on things that matter here, you know, that-, the quality of our housing stock, the way that schools operate, the, the, the role of business. All these things are run out of other departments, and having a-, having this as a departmental rather than an arm's length responsibility will, I think, strengthen that, and critically, getting those responsibilities right at a local level.

 

Moderator: It's so important, and I'm so pleased you mentioned about housing as well, 'cause I think that's absolutely critical, to make sure that everybody has the opportunity to have a good, quality house or home. A concern from directors of Public Health may be that we have a top-down approach rather than a bottom-up approach for, for people on places, and rather than looking at people on places that know the communities best, can we have additional-, a national inequalities strategy that focuses on a properly resourced and empowered local Public Health teams and systems?

 

M: Well, look, I, I think this is incredibly important, and my, my goal here is to ensure that the whole NHS budget in the local area, alongside the budgets that the local authority in that place chooses to put into place, that whole budget is brought to bear on this agenda. And the way to do that is through the new statutory integrated care systems, holding the NHS budget locally, of course doing-, to pay for people's episodes in hospital, for instance, when that's what's necessary. But ultimately, I think all of us know in our hearts that, that money could be better spent if more of it was focused on keeping people healthy in the first place. There are enormously good value for money interventions that will prevent NHS activity, but need to be funded, and, and the NHS-, bringing the NHS budget to bear on this prevention agenda, not as a top slice or, you know, finding a, a pot for this agenda, which has been the approach until now, but rather, saying the whole NHS budget, say, in Oxfordshire, you know, Oxfordshire is part of the, the, the, you know, the, the ICS, with Buckinghamshire, and, and Berkshire, that budget, bringing that budget to bear on the priorities agreed between you, Ian, as the leader of the council, and the NHS locally, asking the question, 'How do we keep our population as healthy as possible?' And of course that means making sure that the John Radcliffe is properly funded to do its work, but it also means spending the resources that it takes to keep people healthy so they don't have to end up in the John Radcliffe.

 

Moderator: Exactly. I think that's the key to it, to understand how we can do that and work in that collaboration work, and I can honestly say that throughout this pandemic, working with (mw 24.10) has been really a dream, and those barriers have been stripped away and we've just on to delivering that care. So, I thought you were gonna make an announcement there for Oxfordshire, I was well looking forward to that. Anyway, we do have a question on it. To match the growth in overall NHS funding as part of the long-term plan which we all welcome, will the government commit to increasing the Public Health grant in future years? And I think this is one of the key bugbears for all Public Health, that I'm always saying that, you know, since it's taken over we've had a reduction of £700 million, and I think all of us in the local governments and Public Health are saying, 'What else could we have done if we had, had that in our baseline budgets?'

 

M: Well, that-, you know, the question, you tempt me-, the question for budgets is for the-, for the spending review, but there's a broader point, which is we all know that high-quality Public Health, especially on the health improvement side, on health promotion, is not just about the direct budget spent on it. It is also about the decisions taken in all sorts of other areas of, of policy. You know, we talked about housing, both at a national level, that this department influencing MHCLG, so that its policies are set with improvement of health and wellbeing in mind, and then critically at a local level, for planning authorities to take into account, building houses in such a way that they promote good health. That's one example, but there are legion. Air pollution is not something is done out of the Public Health grant, but it is vital to public, Public Health. But the, the other point that I've been-, I was trying to make in the speech is that there are-, there are two sides to Public Health, essentially infectious diseases and the support of people to stay healthy in the first place. And the policy response to each, although there is an overlap, of course there is, the policy response needs to be different, because otherwise the danger is that when there isn't a pandemic on the horizon, naturally the focus goes onto their health promotion, health improvement side, because that's, you know, we need focus there all the time. That's an ongoing challenge, always. And we mustn't lose the focus on pandemic preparedness, and that is why we're establishing UKSA as a new national institution, so there is always somebody who worries in the middle of the night about the next pandemic, both when-, both when we're in the middle of one and when one may come in the years ahead, and that person will be Jenny Harries.

 

Moderator: It's so good to hear that, because being prepared, as you say, is so vital to make sure that we have everything, and also still having that local connection will be really important as well. Are you able to say-, there's always these rumours about Public Health returning back to the NHS, are you able to give any answer to that question or is it gonna remain firmly with local government? Because we really do appreciate working with local-, Public Health in local governments, and actually it's that cross-departmental work that's so important, having a director of Public Health talking about housing, talking about the inequalities, and that's so good and that's such a useful mechanism for both Public Health and local government.

 

M: Yes, clearly it's-, look, it's the integration and the working together that's critical, and we've discussed this many times. You know, the, the, the need for those services that are rightly accountable to local voters and local taxpayers and those services which are rightly accountable to national democratic institutions, taxpayers and, and voters, making sure there's the integration even though the formal accountabilities go in different directions. That is-, that is critical.

 

Moderator: Excellent, thank you very much. Obviously, local resilience forums have been in place and they've been crucial during the recent pandemic, and obviously with the partnership across a wide range of local partners, what will the relationship between local resilience forums and UKSA be?

 

M: Well, the, the crux of this will be the director of Public Health, because the directors of Public Health have done an amazing job in this crisis, and I'm-, I, I want to ensure that there is-, that there is an, a, a, an easy and successful integration between the national and the local, lots of people were asking this question in the chat. Ultimately, through the professional accountability of, of directors of Public Health. So, directors of Public Health are rightly part, part of the leadership of the council, but also need to ensure that they dock in with UKSA and ultimately on the clinical side, that professional leadership will look to-, look to Jenny Harries and the medical director of UKSA as well as looking to the council, to make sure that there is the join-up. So, getting that right is, is absolutely critical.

 

Moderator: Excellent, thank you. Have we got time for one last question, I think? Have we got-, yep. Ah, yes, it's actually picking up on that. Will the new agency have a regional footprint? And of course, this-, if there is a regional footprint, which regional footprint will it be, because will it be a local government or a health footprint or even a police footprint?

 

M: Well, in my view there's only one set of regions in England. They're, they're the regions, and, you know, I think co-(mw 30.18) will help us all a lot both in terms of integrated care systems and in-, at a regional level as well. You know, it, it's a challenge when the regional boundaries have been drawn slightly differently for different-, for different services, I think that's a-, that would be a useful bit of tidying up. But the-, but yes, making sure that there is-, that there is that proper integration between the local system and the national level is important, but ultimately it's that, you know, in the-, in the health service it's at system level that we need to look to leadership in the future. A co-terminus wherever possible with local authority boundaries. Sometimes, that means that the system in health is a bit bigger than an (mw 31.11) local authority, but that's because that's what works. So, for instance, Manchester has nine local authorities but one health system, and I wouldn't want to-, I wouldn't want to change that. So, that-, there's detail work there to make sure those, those boundaries are got exactly right. The statutory ICSs will come into force in April next year, that is our-, that is our goal. So, we've got a year or so to make sure that all of that works at a local level, you know, but I'm also cognizant of the fact that especially over the last year and in particular over the vaccination programme, such strong local relationships have been built up, probably better than any time I've been in government, and that is something that we need to cherish and, and build on. Because it’s not just about the dry, you know, government architecture. It's about the relationships, that's-, you know, it's when-, it's when the relationships are good that, that we can really deliver for the-, to-, for the citizens who we serve.

 

Moderator: Absolutely. And I think the one thing-, we talk about boundaries, but of course we know only too well that actually pandemics don't respect boundaries, so we can't just-, we've gotta be very careful to make sure that we don't, sort of, get into our own silo and we do have that cross-working as well. What about, obviously, if it's a UK agency, what does it mean about Public Health in Wales, Scotland, and Northern Ireland? Are they going to be reorganised or is that down to the devolved government?

 

M: No, so there's no-, there's no proposed changes there. I, I mean, Public Health England was, in a way, misnamed, because it has both UK and England responsibilities, in the same that the same way that the UK government has both England and UK responsibilities, and so it-, this is more appropriate. We had-, we had as a working title, we were gonna call this agency the NIHP, the problem with that was that the, the, the word 'national' actually made things more rather than less confused, and, and, and so we've, you know, we've, we've taken soundings and updated the, the name for its formal institution from the 1st of April. And this-, and, and the, the collaborative working with Public Health Wales, Public Health Scotland, and Public Health institutions are absolutely critical to getting this right. There is no proposed change of responsibilities there, but the name makes it clear that just like the UK government, some of its responsibilities are UK-wide, some of its responsibilities are for England. Of course, you know, ultimately if we step back, we live on an archipelago. Communicable diseases do not respect administrative boundaries. We should take advantage of the fact as much as we can that we are an island in helping to protect against communicable diseases, we have to look out for the health security of the entire United Kingdom and take responsibility for that, but at the same time health is rightly and properly devolved and so working very closely between the UK government, the governments in the three devolved administrations, is an incredibly important part of getting this right in the same way as working from the UK government for England with local authorities and getting those relationships right. All of that is very, very important to pull this off.

 

Moderator: Thank you. Have you got time for one more question?

 

M: One more question, go for it, Ian.

 

Moderator: Okay. It's core targets. Are they going to have very narrow health inequalities, and-, rather than, sort of, the local ones and, I would quote Oxfordshire as having that sort of issue, and what are we going to have the funding-, is it going to be across government inter-department strategy, or is it solely going to be on the health?

 

M: Well, that is-, no, the answer to that question is for another day. Ultimately, we have very significant health inequalities across the country, and we also have health inequalities within geography. You know, Oxfordshire has one of the best healthy life expectancy outcomes, but that's at an Oxfordshire level. Within Oxfordshire, there are also geographic variations. My view is that, you know, levelling up health outcomes is, is the most important levelling up of all.

 

Moderator: Fantastic, that's so good to hear, 'cause we're so aware of that in Oxfordshire, that I know the perception is from outside, but actually there's some areas that we really-, and we've gotta target those and it's that targeting to make sure that we raise-, level up everybody. It's really important. Well, thank you very much, Secretary of State, for your time this morning. We really appreciate it, and particularly the announcement, that's really good news to hear, and local governments and the directors of Public Health will be looking forward to working to actually make sure we have a healthier population, so that Jenny Harries, perhaps she's worrying about something that needn't happen because we'll be taking care of the Public Health ourselves. Thank you very much indeed.

 

M: Thanks very much

 

Moderator: Thank you. Thank you everybody. Now, that brings us to the end of that particular session, and now I'm equally delighted to announce that we've now got Baroness Dido Harding, who's going to give a presentation and then also take some questions as well. And-, so, it does have to leave by 11:00, I know, and thank you very much, Baroness, for coming along today, we really appreciate it and it's so good of you to find time. So, we'll go straight over to you. Thank you.

 

F: Thanks very much, Ian. And, and thank you for, for having me. I thought, following as I am from the Secretary of State's announcement about the future for health protection, I thought I'd use this, this time, if that's okay, to reflect a bit on what we've learnt in the last year and encourage everyone in the chat and in the Q&A to, to share their thoughts as well. If, if we could move on to the, the next slide, I sort of want to reflect first of all on where we were this time last year and how much we've all done together. So, this time last year as, as a country, you know, there was so much that we didn't know about Covid and also so much that we didn't have at our disposal. As a country, we were able to do 2000 tests a day for Covid this time last year. Since then, together, we've conducted over 100 million Covid tests. We've found over 4.2 million people with the disease. And, and this week and last week now we're doing up to 1.5 million tests a day, through a combination of public sector, private sector, including the, the NHS, Public Health England, the military, academia, local governments running test sites, private and public sector providers running test sites. Extraordinary work from our local directors of Public Health, our regional health protection times in PHE, and all of the additional sources that have come in to test and trace.

 

So, we've built testing on a scale that was really, frankly, unimaginable this time last year. If we move onto the next slide, 'cause I will try and canter through these quite quickly. We've built a local to national network of both sites and laboratories. Laboratory capacity for 750,000 tests a day, and as you can see this is a, a four nations-, a four nations laboratory network that, that covers both academia, Glasgow, the University of Glasgow, who developed one of those early labs, the third sector in Milton Keynes, NHS laboratories now in Newcastle, in Plymouth, and in (mw 39.29), private sector laboratories through (mw 39.31) in Northern Ireland and, and in Newport, for example. And over 2600 testing sites, through a combination of local authority-run community testing sites, regional testing sites or local testing sites, walk-in, drive-through, you name it, together we have built it, to make it possible for anybody who needs to get a test, whether they have symptoms or not anywhere across the country. If we move on to the next slide. And I thought these, these two photos sort of symbolise some of the things that we've done together in, in keeping the country moving.

 

This is a photograph of the stacked queues of lorries on Christmas Day just outside Dover at the airport, and then on Boxing Day, on the base-, back of an extraordinary mobilisation across Test and Trace, the military, local leadership, the, the LRF, they did extraordinary work in Kent, as we set up the ability to conduct 25,000 tests in the space of 48 hours at about 48 hours' notice, which was an extraordinary effort that we all did together. If we move on to the next slide. The, the, the key message I would want to land in here is this has all been able locally driven partnership. The outbreak management work that we've done together, one of the things that has helped me personally hugely has been having local authority leadership in my team from day one. So, first (audio cuts out 41.04) from Leeds, who joined me in the first week in May, and now Carolyn Wilkins from Oldham. Both have been in the NHS Test and Trace leadership team throughout and have been instrumental in helping us shape our approach to be one of local and national partnership. We now have 313 out of 314 local contact tracing partnerships up and running across the country, we've just published last week the updated contain framework, which like its first incarnation last summer is fundamentally based on subsidiarity, the principle that it is so important to do everything that we possibly can at a local level and only escalate where absolutely necessary. And together, we are continuing to innovate.

 

So, the, the, the map on the country shows you a number of different pilots that are currently ongoing across the country with different local authorities. We've got 26 areas in our local-O pilot-, our local-0, sorry. Looking to start local contact tracing instantly that we get the index case testing positive and working in parallel for digital as well as, as national teams. We've got Southampton, Sandwell, and Staffordshire working together on a pilot of how we find better ways of reaching out to uncontactable cases, people who aren't responding to any of our efforts, to, to work out what we need to do to give them the confidence or the trust to, to communicate with us. Manchester and Newcastle both have got phenomenally impressive local contact tracing hubs serving a number of local authorities, and we have a number of, of trials now kicking off looking at how we can better support people in isolation. We also have phenomenal work that's happening on rapid response teams, to be able to deploy really urgently if we identify variants of concern, which probably takes us on, to the next slide, if we could.

 

We're adapting as the virus does, and, you know, I've got some, some photographs here from some phenomenal work that we've done together with the team in Broxbourne, our EN-10, where in eight days the team succeeded in, in testing 10,000 people as we surged testing to suppress a, a variant of concern. And that was a, a really proper team effort led, as you can see, by, by Jim, the extremely well-known Jim McManus, the extremely well-known director of Public Health in Hertfordshire, but included the fire and rescue service, the police, trading standards, volunteers, actually neighbouring local authorities as well, first through using a community hub, then a letter drop, a letter from Jim himself, and then our police and fire service colleagues going door to door to, to reach everyone. A really phenomenal team effort that I know isn't unique to Broxbourne, is being replicated in other parts of the country as we speak. If we move onto the next slide.

 

We've also built a genuinely integrated digital local to national citizen journey. Obviously, the, the, the app plays an important part in that, the second-most downloaded app in the country last year after-, only after Zoom and slightly ahead of TikTok, 21 million people downloaded the app and with the work we've done with Oxford University and the Turing, Turing Institute, we've been able to demonstrate that over 600,000 cases have been prevented by people using the app. And for every 1% increase in app users, we see a reduction of 2.3% in the number of cases. So, a, a really useful tool, and a tool that we couldn't have launched without the support and partnership with local authorities, with, with, with both Newham and the Isle of Wight being fantastic partners in helping us learn how best to engage local communities and launch the app, and then embed it. Together, we're continually improving the citizen journey, the citizen experience, and also improving the data and the analytics that we are using together. And and there's no doubt, to my mind, that, that one of the things we've learnt is how incredibly powerful it is when we're able to combine the public sector and private sector leadership with academia and third-sector partners at a local and a national level to innovate. That's when you get the, the magic really happening, when we get all those stakeholders together working on a single purpose as we've been able to do together over the course of the last twelve months. If we move onto the next slide.

 

And this is an example of some of the innovation that we've been doing together. The development and rollout of wastewater analysis, which I, I think is going to be something that is going to stand us in tremendously good stead for the very long term, as a non-intrusive way of being able to really identify at very detailed levels where infectious diseases may be starting to emerge. And, and this has absolutely been the product of a partnership, a partnership with academia, with the business sector, with the public sector, local and national. If we move onto the next slide. And, and clearly it's been hugely important to make sure that our local authorities have been-, have been effectively funded. Over the course of the last year, £1.6 billion of funding has come from Test and Trace to local authorities to the contain outbreak management fund,and from April a further £400 million will be available through that fund. Allocations will be based on the Covid-19 relate needs formula. Use of this formula maps well against areas enduring transmission and, you know, additional funding will be going direct, so local districts can access new funding quickly. And, and I think I'm very mindful wanting to create enough time for questions. If we quickly go to the next slide.

 

I wanted to dwell on this a little bit, because I think Covid really has highlighted and exacerbated the existing inequalities, both health inequalities and overall inequalities in our country. And I saw from the Secretary of State's speech there were a number of questions about this, and, and I think it's so important as we come out of lockdown that together we are working on how we do really reach in to all communities in-, across the country, to really tackle these huge inequalities that have been exposed by Covid. And, and on the slide I've got two examples, some fantastic work that's been done in Wolverhampton, led by the Guru Nanak Sikh gurdwara, which is a multi-faith community testing site, where leaders from the faith groups in Wolverhampton have got together to run a community testing site, which proved extremely effective at encouraging people from the ethnic minority communities in Wolverhampton to come forward and get tested and, and identified a number of people who weren't aware that they had the disease but were, sort of, unfortunately as a result at risk of infecting their friends, families, and colleagues. So, a hugely effective initiative which I know is being replicated by faith communities across the country, you know, very much led and sparked by local authorities.

 

And the, the, the Zoom picture on the right is a round table actually I did last week with a number of different community groups. I very much recognise that this is not only about ethnic minorities. There are a number of excluded groups across the country where it's really important that together we build a health protection and a health security system that really, genuinely meets everyone's needs. And, you know, I think we've seen that laid bare in the last year, and the work that we're doing together on this now I think will prove an extremely helpful springboard for Jennie Harries and Ian Peters as they take this board into the UK health security agency. Which takes me to my final slide, if we could move on. Just some thoughts on the joint legacy, that together we lead. Obviously, yesterday at midday, as we all stepped back and, and reflected the over 111,000 excess deaths in a year, which is a sad and, and, sort of, humbling thought and, you know, obviously all of our hearts I know will go out to every friend and family who, who lost a loved one in the course of the last year. But we have learnt a lot together and it is hugely important, I think, in their memory that we take forward what we've learnt together into the future health protection system. And I offer up, sort of, four key things.

 

The first is that we have built the ability to respond in real scale, and, you know, the first priority for, for UKSA as it sets up will be still the fight against Covid. And we have now together built this scalability to test, trace, and support people in isolation, and the ability to adapt that scale response locally and nationally as we come out of lockdown, and it's hugely important that we all work together on that. The second legacy I think we lead-, leave is a deep belief in partnership working, that the only way that we can really embed the health protection and health security system that the nation deserves is by working in partnership. It isn't an either or between local and national, between human and digital, it's, it's a proper partnership for, for all of us. The third piece is how strong the, the UK can be in science-led innovation, that the, the triple helix, the, the overlap, when we get the overlap between the UK's extraordinary, sort of, academic strength in science and, and health, our life sciences commercial sector, and our brilliant NHS and Public Health system all put together and ultimately enabled by local and national governments. That science-led innovation has enabled us to, to be at the forefront of the-, of vaccination development and rollout. It's enabled us to develop a testing infrastructure that was unimaginable a year ago, it's enabled us to develop new technologies that were unimaginable a year ago, and it's also enabling us to learn how to reach into every community across the country through that scale response, partnership working, and science-led innovation, that need to include everyone.

 

As I said on the previous slide, building this scale system, it now needs to really focus and make sure that we're able to reach into every community across the country. And I do think now we have many of the tools-, many of the tools that we didn't have together this time last year, now, to help us to get back to normal. And that partnership working will ensure that we continue to develop those tools going forward through the next year and beyond, and I'm delighted to be, sort of, handing over to Ian and to Jenny and, and making sure that together that they are able to build the foundations of a UK health security system that we can all be proud of. Now, I'm very happy to take questions on anything, Ian, and I hope I've left a bit of time for them.

 

Moderator: Yes, you certainly have, and that's really good news, and it was, you know, those figures on your first slide, and I think there was a question, so the slides will be available, I think they'll be put on the websites later, so they will be available. Those figures on the slides really highlighted just what an incredible scaling up has gone on, so congratulations. And that, that picture of the Kent depot with on Christmas day, just phenomenal, absolutely. Anyway, enough of me wittering on. One of the key challenges is supporting people in self-isolation regarding the finances, and this is where we have real issues. How can we address these solutions in a-, in a major way, and how can we really get in-, this ability to-, so people can come forward, I suppose, the point really is, and they're not gonna be financially penalised.

 

F: So, a, a couple of things on that, Ian. The Prime Minister in the, the roadmap out of lockdown, a, a substantial increase in the funding for local authorities' discretionary financial support pots. So, a really important role for, for everyone on this call to play, to make sure that you're tailoring those to meet your local community needs. I think there's a, a combined responsibility for all of us and particularly for some of my team to make sure that we're communicating better right at the beginning of the journey, to-, I think a lot of times the, the groups I've been talking to recently across the country are unaware of what is available, both financial and non-financial support. So, they don't even start the journey. They don't come forward for testing at all because they're scared that there isn't anything. So, I think there is a lot that we can do to, to make it clearer and simpler for everyone in the country that there is financial support available for people who really need it, and there's also that there's non-financial support as well to help you collect prescriptions or get food delivered or help with urgent caring responsibilities you have. But I also think we need to work together on piloting more innovative ways, and I'm really delighted that we are starting now to kick off a number of pilots with a number of, of local authorities I'm sure are on this call, to look at ways that we can target support for people in, you know, multi-generational households where self-isolation physically just is impossible, and finding a solution that really genuinely works, for example.

 

Also, for households where maybe there are, you know, eight or ten people who are all working, all of whom fearful that they might lose their job, which means that no one comes forward and that actually self-isolation for one person in the household doesn't practically work for everyone else. So, there are a number of different pilots where I think we can target resources to, to make a really big difference.

 

Moderator: Absolutely fantastic. The next one, how are you ensuring lived experienced versus choice-, voice is part of the thinking to really ensure delivery meets the needs of the marginalised communities, and then really can reduce health inequalities? And I think this is a theme we've been addressing, 'cause we're-, everybody's passionate about it and, you know-, but that's a really key, so, how do we-, the needs of those marginalised communities.

 

F: Well, I think this is the sort of question for all of us in leaders-, as leaders in this space, isn't it? You know, however hard we are all each trying, I'm sure we can all try harder, and I feel that myself every day. So, what we're doing within, within NHS Test and Trace right now is we're looking to embed local leaders in all of our design work, so genuinely believing in that principle of co-design. So, we have a number of directors of Public Health working in all of our developments to make sure that we're hearing their voices really clearly. We're, we're making sure that we hear citizen voices regularly in our-, in our reviews. So, you know, one of the things that we, we have is this scale system where we're in touch with a lot of people all of the time, so making sure that the people designing and developing improved systems are actually listening directly to what people are saying on the-, when they call and the feedback they're giving us, and then reaching out.

 

So, in the last week or so, and I, I believe this very, you know, personally, you have to reach out at, at a senior level and then your teams will follow. So, I've, I've done a couple of really eye-opening listening groups in the last two weeks with leaders of third sector organisations, but one devoted to faith leaders and one devoted to different organisations, so, sort of, refugees, taxi drivers, who we know have been very badly affected, for example. A number of different groups like that, both Crisis and Shelter were involved in it as well. And, and hearing directly there just isn't a substitute, in my book, for hearing directly from, from people who were affected, and I, I just don't think we can try hard enough on that. I think we've got to keep doing it as we build up the services. What, what we've got that we didn't have a year ago is this scale system, and I think, as I said, I think the prize is learning how to now target it and adapt it, which is gonna require us to really live that principle of subsidiarity, and to, to give more and more freedom and ability to, sort of, control the assets to, to all of you.

 

Moderator: Yes, and of course the thing is there were marginalised communities, we talk about Zoom and everything, but of course that does mean we've gotta have good broadband and more importantly, the hardware for people to actually be using it, otherwise how do we contact those? So, it's a really important question. What-, some of-, what are the key learning points of the national Test and Trace system? Where do you-, oh, this is a-, where did we get it right and wrong? Crikey, that's-, we could be here all day on that one. (mw 58.48) where you got it right, but how are we going to support local teams for the responsibility that now local (mw 58.54) plays?

 

F: If I answer that last question first. I, I think-, so, so the local-0, moving more and more, as, as, as the number of positive cases goes down, god willing, I definitely see a, a world where we're shifting proportionately more and more of the contract tracing to being led and owned locally, and we maintain the, sort of, national surge capacity if, you know, god forbid, we need it. And, and your questioner rightly points to it's important that we manage that transition together carefully, because this is the-, forgive my commercial language, I spent ten years as a food retailer, and this is the most short life of short life products. It's really important that we reach people quickly, and, and, and because the disease spreads exponentially, when things change and you get an outbreak, you suddenly see a surge very, very quickly. So, it's really important that we've got the local to national and the, sort of, self help routes in place, so that if a local team does see a sudden surge they're not overwhelmed and they don't suddenly fail to reach people fast enough. So, that's why I see this as it isn't-, I think it's a false choice to think is this local or is this national. This works by being an integrated system of partnership, and so part of the reason for piloting the local-0 approach is to make sure that we've got those escalation and de-escalation pathways right, so that we're not just suddenly handing the problem over and saying, 'Over to you.'

 

Moderator: Thank you. Sometimes it feels like that in local government, I must admit. But there we are, I'm not gonna down that route. But, but also the digital divide, I mean, the-, obviously, the success of the NHS Covid app, with 21 million, that's fantastic, downloads, but of course, people who don't have that, how do you think we can improve that inequality and not, sort of, almost have a different group of society not aware of they're coming in contact with people.

 

F: Well, I think that's exactly right and why this is a combination of multiple different solutions. You know, one of the things, I think, this time last year there were a lot of people in the, sort of, tech sector globally who thought that an app would just solve the Covid problem. You know, so you think, well, we've certainly learnt that's not true, that an app can help, but this is a human disease and unsurprisingly human contact and people knocking on doors, community leaders, you know, talking one to one with people who were scared is, is hugely important. And so, you know, an app is a huge-, a very useful tool, but it's not a substitute for human relationships. We've got to have both, is the way that I think, and, and maybe if that's one of the things we've learnt in the last twelve months, that in the end this is digitally enabled for a lot of people, but it's ultimately a human disease. And I think the way you reach in to not all, I mean, some of our communities who are not engaging are very highly digitally literate, but others are not, and so, you know, I spent eight years running a broadband business as, as many on this call will know, and, and, and I care passionately about closing that digital divide, but I also know that the world's a human one and the, the role of our local health protection teams and our local DPHs and, and all of the different support services that only local authorities can really bring to bear are in the central component if we're going to make this a service that works for everyone.

 

Moderator: Thank you, that's really reassuring, and thank you so much for your time. We've slightly overrun, so I do apologise for wherever you're supposed to be next, but thank you so much indeed, appreciate all the work and good luck for the future. Thank you very much.

 

F: Thanks, all.

 

Moderator: Bye. Okay. So, we now move onto the panel. We were going to have first of all, but obviously the baroness had to leave, so we're now going to first of all go to Joanne Roney OBE, chief executive of Manchester City Council. Over to you, Joanne. Thank you.

 

F: Thank you. Good morning everybody. Let, let me just start by saying a huge thank you to all of you. You-, I'm, I'm in awe of all of the Public Health teams up and down the country and the role that you've played, so let me just start by saying, on behalf of Solace and all chief executives, thank you, thank you all so, so much. As, as we've already reflected on this morning, Covid's clearly been the greatest challenge of our profession in local government, whichever role you were in, and Public Health provided the glue between the national response and the community response, and the Public Health teams have been at the, the very heart of our resilience forums, emergency response, but you're also still very much at the heart of the recovery. I think it would be fair to say that our response nationally and locally, whilst not perfect, has actually had quite a lot of positives. And, and so I want to just focus on, really, maybe the standouts for me about what we've learnt and what we need to build on for the future. I think I'll start by agreeing with the Secretary of State when he said we, we mustn't wait until-, I agreed with a lot of what he said, actually, but we mustn't wait for some independent review before we start to implement the lessons that we've learnt now. I completely concur with that. And the, the, the legacy of Covid that is loud and has been repeated by every speaker so far is that the stark reality of inequality has been demonstrated and shown and therefore there is a focus and a renewed energy, I think, to start to tackle this. And I think that legacy for all of us is about the coming together, the partnerships that have been created at a local level, not necessarily the structures, we just got on and did stuff, didn't we? Reflect in Manchester, we trebled the rate of our hospital discharges within a week just by people getting in a room together, something we struggled with for twelve months because of structures and systems. And yet, we just stepped up and did it.

 

Now, we have to hold onto that, stepping up and just doing it. I guess we did that because we had a national framework. We also had packages of financial support which enabled us to do things like commission the voluntary and community sector at pace, quickly, to get things in place to link into our communities and provide the much needed boots on the ground. So, I think we did some great stuff there. I also think the profile of public health and the importance of you, as public health system leaders at a local level, was catapulted to the forefront of every event and every communication that was done. And, my reflection on that is that you were the trusted voices by our workforce, by business, by communities, by the faith leaders, it was you, when you fronted media, when you did many, many digital engagement sessions. I hope colleague chief executives were alongside you and supported you by bringing that wider system into play be it schools, housing, business, employers, health colleagues. But, your currency, your credibility, was absolutely phenomenal and we must hold on to that, as system leaders. We worked at speed, on a place based response and we, effectively, did create a single system, be that in a locality when responding to outbreaks or be that at, through our reliance forums. I, also, want to acknowledge the role that regional colleagues played. They acted as a very important (ph 01.07.16) interface with their data, their modelling, their wider epidemiology analysis.

 

Moderator: Oh, you've flicked on to mute, you must've knocked your mute button as you turned the page there.

 

F: Sorry, sorry, I think I flicked mute, (toeo 01.07.36).

 

Moderator: You had just said epidemiology, which I was impressed with.

 

F: Sorry about that. So, I was just saying that we must hold on to the systems which included the role that the regional teams played, I think, as well as what we did at a local community and place-based level. A couple of standouts for me, if I can just talk about Manchester, I think, and the learnings that we had there, and there's loads to go through. I thought the role that digital played was very important and I agreed with what Dido was saying there, that, whilst an app won't sort it, a digital technical response alongside the public health teams is something that we should hold on to. I was reflecting on Operation Eagle, we did about 10,000 tests in Manchester, in two parts of Manchester, where we knew, through local intelligence, the variety of languages that were spoken. Through Operation Eagle testing, we actually discovered, if I can just take the example of our Ghanaian community, who were very reluctant to engage and were very vaccine-hesitant, by talking to them we discovered it was because they were worried about what questions would be asked of them, they were expecting there to be questions around immigration status. We are the people who connect into those communities, at that basic level, to build that trust. I think the dashboard and the data, the way that was all made public, was so important. It was used by local media, it was used in every source, we had that single version of truth and that single narrative, and we must hold on to that. We outperform Track and Trace because we know people, our local voices, our local accents, our ability to engage with the people that we were talking to, meant that all of us outperformed the tracing and the contact part of Track and Trace.

 

And, of course, we immediately responded with the speed of PPE distribution just because we knew how to get the right kit to the right place quickly. I'll come back to that point about your consistent, loud voice and your trusted voice, and how we take that forward, in terms of the challenge that we now have for equality and inequality. For me, this was your greatest strength and one that we must hold onto. And I'm just going to quote Martin Luther King, who said, 'All labour that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.' That's what you did, that's what you did. So, let's move forward, let's think about moving forward. What would I want to see? I want to see a system that is not silo-based and actually is built around people and place, and you have to be at the heart of that. I do want a joined-up framework that reflects the local role with the national role and, unashamedly, I think public health needs to stay in local government and be very much at the heart of all that we stand for in local government. I think the regional dimension is important, people live, work and play, not-, in broader footprints than just locality areas, so we must get that right in the new arrangements. I, also, think public health outcomes should not be a postcode lottery any more than health outcomes and medical treatments should be a postcode lottery. So, what are we going to do moving forward then? The relentless focus on inequality. To do that, you need stable, long-term financial settlement, and we need to continue to push for that. You need prevention to be recognised as a crucial part of NHS Recovery, and that that work on prevention and early intervention is as much as returning NHS functions back to business as usual.

 

And our learning around our communities, and the behaviours, and what effects the greatest change for population health has to be at the heart of any system reconfiguration. I hope the engagement with government continues in the way that we've had to date, not necessarily through an emergency situation but, certainly, ongoing engagement. And I want the wellbeing focus of our places to continue, that's, potentially, the mental health of young people which I think is a legacy that will affect all of us and is as much a part of our economic recoveries as it is our health recoveries. I want to focus on workforce in public health, where is the talent coming from for the next generation and how do we help you become sustainable and resilient? Ultimately, I want us to focus on the benefits of the world-class international connectivity that we've got. You're talking to a Chief Executive of Manchester who's twinned with Wuhan, we got an awful lot of support and assistance and learning from Wuhan, and we must continue that global reach. As much as, my final point, really, about a relentless, unashamed, loud voice on tackling inequalities. And as chief executives, we'll be right alongside you. I will leave you with a final quote, 'Healthcare is vital to all of us some of the time, but public health is vital to all of us all of the time.' I know you all know, we need everybody to know that. Thank you.

 

Moderator: Thank you very much indeed. That's a really good way to end that and you did start off by saying you agreed with the Secretary of State, it is permissible to agree with the Secretary of State, we don't always have to.

 

F: I was trying to be a-political for a second, but I do, actually, agree with him.

 

Moderator: No, it's just the way you said it, I thought, 'Oh, that's it, you know.' But, we can agree, not all the time, I don't want it to be all the time.

 

F: Not all the time but on this time.

 

Moderator: Thank you so much and you'll be coming back as a, on the panel later on. Thank you so much indeed. Now, we move on to Professor Maggie Rae, President of the Faculty of Public Health. Maggie, over to you.

 

F: Thank you so much, Ian. I'm just going to share some slides, if I may. Thank you.

 

Moderator: Yes, they're coming up so if you just go to the slideshow there.

 

F: Thank you. That's lovely, have you got them now?

 

Moderator: Yep, we can see them, thank you.

 

F: Excellent. Thank you so much, Ian, and great, great input from Joanne. It's a delight to be with you today so thank you very much for inviting me. I'm not going to apologise for starting with an effective public health system starts with local because I was very impressed with the Secretary of State and Baroness Harding's inputs. But, I have to say, my lifelong experience of public health is that every pandemic we have there's too much central control and a determination to control things from the centre. And I am delighted to hear those words today and many congratulations to Jenny Harris and Ian Peters and the new agency. But I still feel that, unless we have a strong voice, we will not start with local. This pandemic didn't start with local. In fact, I think it's fair to say we were bypassed, the local systems were bypassed, unfortunately. And I'm glad people have learnt, along the way, but, actually, I'm absolutely convinced, if they had gone to local first, we would've told them all these things that we know already from our experience. So, I think it's been fantastic that COVID has emphasised the importance of the public health team being part of local government. I remember when the decision was made and I, personally, went round, with lots of public health leaders and chief executives, talking about public health returning to local government, from where we came in the first place. So, but what we need for a country the size of England is really and effective local, regional and national public health system. And I think that's coming across strongly in the conference.

 

And we shouldn't even be thinking about further changes and any moves of the local public health teams, out of local government, that should be closed down. But, I think we do have to speak up for the wonderful teams in Public Health England and the excellent work they have done in this pandemic. And we have to remember that it's not very helpful for your organisation to be disestablished in the middle of a pandemic, last August, but I think we'd all recognise the fantastic professionalism and the way, the resilience, that they have shown in protecting the country's health. So, a very big thank you to them. But, it's local leadership and ownership that must be involved and prioritised at all points. And we almost have to pull the national in that direction. And it's wonderful now that we have that but I still believe we have to work hard not to lose it. The knowledge of local based public health teams and local government is, actually, what needs to be utilised and I think I could say more about that but I think Joanne described it absolutely beautifully. And, we need this place based public health system led by directors of public health, not just for pandemics and high days and holidays. We actually need it if we're really going to tackle health inequalities. And many of you will know that I have the great privilege of leading on the health inequalities agenda, in the early 2000s, when we did actually manage to narrow the gap. And I can assure you we did that by concentrating more, not on national strategy, but on local delivery and enabling all the local authorities, communities, public health, all the efforts of society were required to make that happen. And I'm feeling quite optimistic and excited that we could do that again. And that's what we need to concentrate on.

 

So, in terms of local leadership with the public health system, there's so many people we should be thanking for their fantastic work, in the last year, far too many that we could possibly mention today. But, I did want to single out the directors of public health, it's right and proper their recognition as come to the fore. And I can remember in the early days of the pandemic that the Department of Health didn't even their email addresses. So, as I say, we've had to push and tug, tug and push, to get in there. But, we have had great leadership from Jeanelle, Jim and the whole team at ADPH. But, I think the magic comes together in public health when you have your local leaders and your local councillors taking a role in public health. After all, I think local government is a public health organisation, first and foremost. So, thank you Ian for everything that you've done, I know people don't see all the extra work you've done but thank you very much for it. And to James, too. James has sat alongside me at the advisory board where we've really lobbied with Jeanelle, and others, for getting the local bits right. And I think it was good that Baroness Harding did acknowledge the difference that Tom Reardon made when he came into the system, I think that's when we did see changes. So, all of those local authorities, chief executives and the work through Solace has really helped ensure that local authorities are recognised for what they can do. But, of course, it's not just that particular, those particular professions, we've got so many people, the environmental health officers, we've got our school nurses and health visitors, dental public health, the list is a long, long list.

 

But, the important thing, for me, is we all rallied, didn't we, we all rallied to make this an effective response. Sometimes in spite of central command to ensure that our local communities and our places were protected. And perhaps it's those people who didn't have public health, or even health, in their title that we should probably thank most because it's our day job, it's not their job, their day job, but yet they did rally round to help us all deliver this in the voluntary sector. So, I, I have said my thanks to Public Health England but, last but not least, I wanted to recognise the public health speciality registrars, a small group, public health is part of the medical training where a multidisciplinary speciality, it's a very, very small number of individuals. But, if any of you have worked with public health registrars through this pandemic, I'm sure you would agree with me that they've been absolutely awesome. They've stood up, they've set up Test and Trace centres, they've really demonstrated the excellent skills and training that they've taken part in. And there's nothing like learning on the job, there's nothing like a pandemic to help your, help improve your, public health skills. So, this has led me to guiding principles and I thought we should be looking forward now. And Ian, I hope you don't mind but I've invented another principle this morning having listened to the Secretary of State. So, I think the most important principle is that we must listen to our local leaders and public health specialists. We must hardwire this cooperation, this cooperation has resulted because of a crisis and I think we know we're pretty good in a crisis in England, aren't we, but, in actual fact, how do we build that when we're not in a crisis? And the ICS, and the involvement with the ICS systems will be crucial to this. And we must tackle the challenges proposed by the separation of the Health Protection function.

 

We've had these separations before and I know we could pick up sexual health, TB, we could, probably, look at any communicable disease and realise it has a poverty element to it, it has a health inequalities element to it, or the very sheer nature of the engagement to stop the infections, we need to engage with communities. So, I think that is a risk for us in England, it's not a risk in the rest of the UK because they haven't made that change. But, I think we will have to work very hard to make sure that we can ensure that things are joined up, particularly at the regional and the local level. And at the end of all this, I'm really hoping we know who is responsible. Now, I think the Secretary of State said this morning that the new agency, the UK Health Security Agency, will be responsible for pandemics, for horizon scanning for pandemics and response to pandemics, I think I heard him say that. But, of course, the devil's in the detail, and what role we're all playing. In 2012, when the changes were made, we were told that local directors of public health and their teams were going to assure health protection and assure screening (mw 01.23.15). And I think we'd all agree that local government, and directors of public health and their teams, have done an awful lot more than sitting back and assuring, they've got stuck in and responded. So, I, I don't think it's quite right yet and I think we have some work to do. The other principle I wanted to add, having listened to the Secretary of State today, is that we should have a percentage of the ICS budget allocated for prevention.

 

But that, that doesn't mean to say we shouldn't be putting in bids to, business cases bids, to the spending round because I think, Ian, I was incredibly pleased when you spoke up and described the amount of money that's been taken out of public health. And yes, just you think what we could've done with that if we'd had that money. So, I will continue to fight with LGA and other colleagues, ADPH, to make the case for that money coming back in. But, if we even got a tiny, not even 1%, of the NHS budget, think what a difference we could make to health inequalities. And so, just my last slide, I think, for me, you'll see I'm making a reference back to Michael Marmot, and I think that's because, for me, public health is all about health inequalities, that's really what public health is all about. And I think we've seen the local authorities play a key role in this pandemic. We're not going to get the vaccination rates uptake correct, in the right communities, without local government and the local teams. We must ensure that that's not just for this pandemic because there's an awful lot of other immunisation and screening programmes that are free, free in our country, but are not taken up. We know that the solution to that is local. And we must hold government to account and try and get this promise of a percentage of the NHS spend on prevention. I think that's really important. And to join with you in asking for, basically, our money back, the money that was taken out.

 

We could do with more than that, but even getting the money that was taken out back would help. And last but not least, to ensure that we have enough of the specialist workforce going forward. We're not a big speciality and we're not the only people, public health is a team sport, it's not something that public health specialists can do on their own. I think we're humble enough to recognise that. But, we really need the public health specialists, I think we've proven our worth, and to make sure that we have the registrars into the future. And those registrars want to work in local government but then they, also, want to work in the new agency, or they may want to work in academia. It's very important that these silos, the potential silos for the future, don't become boundaries and barriers. And I'm sure, like Jenny Harries, we will have people that want to work across the system. And it's important to acknowledge that Jenny has been the Director of Public Health twice. So, I think it is good for us to move through the system and get different experiences. So, thank you, Ian, that was, I'll hand back to you now, that's what I wanted to present today. Thank you.

 

Moderator: Thank you so much. And thank you for those kind words, really appreciate them. I think it's interesting that you mentioned about local and national, and it's, actually, local and national, it's complimenting each other rather than competing against each other. And that's the key to it. It's not all one way or the other 'cause both have their specialities and it's that complimentary. But, thank you very much and thank for all you've done. Okay, if we now move on to Doctor Justin Varney, Director of Public Health at Birmingham City Council, over to you.

 

M: Thank you, Ian, and good day colleagues. And it's always, when you come at last, everyone steals your thunder. And there are so many things that others have said that I think have resonated with my experience, as a Director of Public Health, and, also, in the questions and the comments that people are saying about some of those tensions that we've experienced. No one agency can tackle health inequalities. And the, the issues of infectious disease are entwined with the issues of non-infectious disease. And we've seen, through the COVID pandemic, this has come back again and again, whether it's been the impact of obesity on COVID mortality or the increased case rates in workers who are unable to work from home during the waves of the pandemic, health improvement and health protection are intertwined and interconnected. And it is essential, as we move into the next phase of our public health system, that that strong connection remains and is part of the discourse and the development. The future public health system has to be based on trust and mutual respect between national, regional and local partners. And I do give credit to Dido for the way that she has brought local government and directors of public health in the table, and I know a lot of that is down to lobbying from ADPH and the work of the LGA. But, it has been, actually, really good to see that mutual respect and that partnership in the delivery of many aspects of the pandemic. It's not perfect by any sense of the imagination, and many colleagues will be instantly going, 'Yes, but it didn't happen here.'

 

No, it didn't but it can. And we now know that that kind of relationship can be developed. But, throughout this, there has to be primacy at place, where citizens and systems interplay with the local public health ecologies. And these can too easily be disrupted by national intervention that doesn't understand actually how fragile some of these local ecosystems are. We must have a national intelligence function that really gives us insight and granularity. And through the pandemic, we, I think, have really reflected on how limited, actually, public health intelligence has become. And although we've talked about opportunities such as population healthcare management, they're still in the distance rather in the real-time now. And that left us a little bit short in wave one when it came to drilling down into the insights we needed to understand inequalities of this pandemic. But, the insights are not just about health protection. They are also about health improvement. And actually, where we benefit one we also benefit the other. The pandemic has truly demonstrated how essential the connection in understanding between the art and the science of public health is. And you cannot achieve improvements in the populations' health by simply doing the art or simply doing the science. We have to be masters of both and we have to be able to weave them together to improve the health of the citizens that we serve. Transparency across this systems goes hand-in-hand with accountability. And that will require honest conversations and they won't always be easy. And I think, over the last year, we've seen a real change in the relationship between national, regional, and local partners, where it has become a much better, honest conversation about decision making of deployment of resources and responding to the needs of local systems.

 

And there must be parity of leadership between those new agencies and local authority public health. As directors of public health, we are charged with protecting improving the health of our population and that's a task that we take very seriously every day. But, it's one that has to be respected by the system and seen in parity with others when it comes to those leadership decisions and discussions. I would be remiss if I didn't talk about the need for sustainable funding and the commitment of security of public health in local government. We can't do the jobs that we need to do if we're forever watching our backs for a new land grab or a handbrake policy shift. It undermines confidence, not just in terms of our teams and our workforces but, also, in terms of delivering strategies that will truly achieve change. Too often, we've seen good strategies or initiatives reinvented, re-badged and taken to the point of breaking, with little commitment to evaluation or evidence building. And it was great, yesterday, to hear the CMO talk about important evaluation is and he wants to see that strengthen for public health, particularly in local government, because it is a key part of us being able to demonstrate the impact as well as the activity. Investment in local government public health leadership is key to all of this. And the recognition that we've demonstrated through COVID that place based approaches are best placed to respond to local inequalities, needs to play out as we move forward and new structures are formed, where directors of public health should sit at board and executive levels of the new emerging structures such as the ICSs, so that we can provide that system leadership within the NHS as well as in local authority. That doesn't mean taking us out of local government.

 

But, it does mean giving us parity and leadership within those executive structures so that we're able to influence from within the tent as well as outside the tent. But, the relationship with the NHS is not the only relationship that's important when it comes to tackling inequalities. We all know that, at a grass roots level in communities, working with education, businesses, the voluntary and community sector, the faith sector, these are all strongest at place level. And the pandemic's demonstrated how essential it is that we have a public health system that has strong engagement. And that that is resourced and supported so that when we need at the times of most crisis it can deliver. And we don't have to build it back from scratch, that many of us have had to spend so much time over the last year rebuilding those connections that had been lost through repeated rounds of cutting and slicing of the public health capacity and the public health family. It would be remiss of me if I didn't give a shout out to Environmental Public Health and our environmental health officers that have stood by us through the pandemic, some of us within the structures of public health within local government, many of them without. But, actually, their resource and their capacity with local government has not been protected in the way that public health has at least had some protection. And it's important, as we move through a new system and are looking to the future, that that is integrated into protecting the public health system moving forward. Place needs to be recognised beyond geography and this doesn't mean, however, that we ignore communities of identity and interest.

 

And it's demonstrated, over the last year, actually, how limited our understanding is of these communities. We only have to look at the conversations we've had about ethnic inequalities to show how poorly served we had been and had done, in terms of addressing these inequalities prior to COVID. Too often, we'd use the euphemistic phrase of BAME to bundle together individual communities of identity and culture under 4 letters, that completely failed to understand or recognise the nuance of the differences between people from the Caribbean and people from Eastern Europe. We cannot continue that. And we have a long way to go when it comes to understanding these inequalities and developing a truly culturally competent response. And this requires a partnership between national and local, in where national agencies support us much more strongly in understanding the evidence base and the knowledge of what works, and investing in it. Finally, I would say that the essence of this, that Maggie eluded to at the end, is that we must have fluid movement between national, regional and local systems. The pandemic has demonstrated the value of having DPHs at the heart of Whitehall policy settings. And the taskforce teams have demonstrated the value of central officials coming to the frontline. I remember from own experience at PHE how colleagues at DWP were surprised that I wanted to spend time in a job centre plus when trying to inform the creation of the health and work policy and strategy. And how unusual it is, actually, to see that interplay and that coming out from the offices into communities to truly understand. But, that's something we need to keep going and move forward in the new system. And part of that is about supporting fluid careers, not just at registrar level but for consultants and directors in public health to be able to move across boundaries, without financial detriment or career stagnation.

 

And to support this there must be parity of terms and conditions across the system so we truly deliver a public health system. The pandemic has demonstrated what a public health system can achieve. So, now it's important to all of us that we truly deliver a system that starts at place, is supported by regional and national partners, in a landscape of respect, partnership and honest conversations. We have the opportunity, at the moment, to shape a better future for public health. And we talk in our communities about building back better, and building a different approach that removes some of the structural inequalities that we had before COVID pandemic. It is resonant on all of us to stand up to that for our own system and our own professional groups, and create a public health system that truly is an ecology of change and truly delivers the aspirations that I, and many others, have seen report after report reiterate the need to reduce inequalities in this country and truly deliver sustainable change so that everyone can achieve their potential in life. And since quotes are the flavour of the day, I'll close today with a quote from Coretta Scott King who said, 'The greatness of a community is most accurately measured by the compassionate actions of its members.' Over the last year, I have seen more compassion and partnership in the public health system than at any time in my entire career, either as a doctor in clinical medicine or when I came into public health. Let's use this and build on it to a better future for all of us. Thank you.

 

Moderator: Thank you very much indeed. And particularly picking up on that parity of esteem as so important in those conditions so that we're, it's not just about the overall funding, it's about the culture there. If, could I ask everybody to return to the panel format, that would be brilliant. We've got some questions which are good to see. First one, COVID-19 exposed and inflamed decades old inequalities, what can we learn from this and what do we want to see from the new system? I think we've touched on this already, a little bit, but is there is anything anybody would like to just come in there, in particular what, there we are Justin's straight in.

 

M: So, I would say that one of the big things I think we can learn from is that we need to get the data right, we need the transparency and the visibility. And we talk about inequalities and we refer to data that is usually several years old, and, actually, I think the key space that we need to move forward in is how to we get real time data that we can cut, and explore, and examine, by different demographic groups, you know. We have had decades in which there have been requirements for the NHS to record demographic data properly and it still hasn't been achieved. So, I think there is a call to action for all of us to look at the data that we're collecting in local government, in local NHS, and really say, 'Will we be blind, again, to inequalities if this happens? Or, are we going to move this moment forward by truly opening our eyes to what the data is telling us?' And then, we can build from that to a better future.

 

Moderator: Thank you. Maggie or Joanne, do you want to?

 

F: Yeah, I, I'll come in and, perhaps, then Maggie afterwards. Okay.

 

Moderator: Yeah, sure.

 

F: So, I agree on the data point. I think there's, also, something about being more explicit by what we mean by work local and working in local places with local people. And for me, one of the things that public health have been brilliant about is the behavioural insights, what the deployment of, you know, boots on the ground, knocking on doors, all of those, practices around surge testing, all that rich data that we got about our communities and what drives the anxiety, not just about COVID but about wider health concerns and access to health system. So, I think behavioural insights as well as data, and a real narrative about what working locally looks like, what do we mean by it, let's not just say it and all nod about it, let's articulate what a local public health system has its core components. And that's about tackling inequality.

 

Moderator: Thank you. And Maggie?

 

F: Yes, I think it's trying to ensure that we're never in this place again. For those of you that follow pandemics, when we had SARS, it nearly brought down the whole of the Canadian system because the Canadian system had taken all its money out of public health, taken all its money out of pandemic planning, and, I mean, when we transferred public health into local government, I could never have believed that we would have a cut to public health because we'd always protected the public health budget. So, I think that's a really important lesson, building on what, I agree whole heartedly with Justin and Joanne, but, actually, we cannot get into this mess again because it leaves us in such a bad place to start something off. Now that we've arrived, that we're working together, things are more integrated, let's build on that. But, it has to involve getting the fair share of the resources for the local, we haven't got that yet.

 

Moderator: It is and I think equally from local government point of view, making those really difficult decisions about where to put the money and we all know that situation where everybody says, 'Well, why don't you do this? And you wouldn't have to spend that.' But, of course, we need the funding in the first place and it's a very brave decision to take, I can assure you, we've got to make. Anyway, we won't go there. But, I've got a couple of questions now I'll take together, a denova (ph 01.42.49) test and trace system was needed in England, could we learn from more successful countries who have had test and trace systems ready to scale up? And then, what has been the key learning from this pandemic and we'll need to apply to the next one? I don't know whether you partly answered that a little bit already but does anybody want to come in there?

 

M: Shall I kick off? I, I, in terms of I think the Test and Trace system, we've got to remember the testing bit was the bit that held us back and, as Dido mentioned, we just didn't have the testing capacity but I think that is changing and building. So, I think we would be in a different position. The tracing capacity, we've always had, you know, we've done outbreak tracing multiple times before, not necessarily at this scale but we knew how to do it. So, I think we were, actually, in a reasonable position but the testing bit was the, the, the gap for us. I think, in terms of the, the learning space and what we could take forward, I mean, I talked a bit about this before but I do think that engagement with communities, and particularly with ethnicity, and the conversation about ethnicity has completely changed in the last year from where we've ever been before as public health. I would love to see this extended to other protected characteristics and for us to have the same level of passion and engagement about disability and the inequalities there. And I think it's quite interesting how little reaction there has been to the inequalities of deaths and the impact of COVID on disabled people compared to the, the narrative and the discourse around the impact on ethnicity. So, I think we should build on that and continue to get much more granular in our conversations and our approaches to inequalities.

 

Moderator: Okay. Maggie, did you want to come in there, or?

 

F: Yes, thank you. Just, just building on that, I mean, I, I think we need to really, really to look at the test and trace. I'd be very worried if we continued with the test and trace. The fact it doesn't include test trace, the word isolate isn't in the test and trace, and the bit that was most successful was the regional to local teams, they did so much better performance-wise than anything else. And I think the, what is up to now, 37 billion, 50 billion, it's just eye-watering sums of money. And I think we could do it more effectively. If you look to Germany, they built on their public health local system, they didn't bypass it. I think it needs to be looked at and I was really heartened to see that Baroness Harding had shown the slide about wastewater monitoring because, actually, I think testing's really about who has got time to go and get the test, some of the time. And it isn't the most effective surveillance method when you get to the point where we're not dealing with massive amounts of outbreaks. So, I think that's where I'm hoping we'll get some of the local money from. Ian?

 

Moderator: Thank you. There's a problem, everybody always gives me a quick nudge and everything, but there we are. Joanne, did you want to say anything?

 

F: Just really quickly. And I think it's thinking looking forwards. I, I think the app is here to stay and the, kind of, every young person has got a mobile phone, well everybody's got a mobile phone, haven't they, and so I would like to see us working on getting apps that are really connected better into our local public health systems. And I'm thinking, particularly around, hospitality sector and as we open up our economy and venues, and where the app's going to feature in, in kind of, the future. And I'd like to see more attention and more discussion around how we develop the app to support local economies and local public health strategies. I, also think we should learn globally, I think there is a lot to learn, Maggie mentioned Germany, I think Israel, we've got a lot we could learn from Israel in terms of technology and the link to public health. So, and my final point would be, I think I said it when I was speaking really, for me, levelling up needs to be as much about public health as it needs to be about infrastructure investment. And I still think we need to make the case that it's not all just about revenue support for public health, there is some major capital investments required, and it may well be in the technology side.

 

Moderator: Absolutely. And you know, that's some well-made points there. Alright, what will business as usual look like when we, when all the national systems stand down? Looking into the future, there we are, that's, I think, it'll probably look a lot different to what it was before the pandemic, I certainly think that. But, does anybody have, I mean, hopefully, we'll, when the national systems stand down, we'll have the core infrastructure ourselves to, actually, have that ability to scale up and, actually, address those problems and points that we've so often made. And particularly, and you picked up on it Joanne, as we move into the next phase and coming out, and the hospitality industry, how are we going to actually engage with that, does anybody, is there anything else? Yeah, Maggie.

 

F: Yes, thank you. I mean, I, in all the pandemics and major incidents including Novichok that I've been involved in, it's been the local government group that has led recovery. And I think that's right. You know, and I hope now we will see and recognise that local government and local public health have an incredible role in really trying to, you know, we've got the interest of government in levelling up, we don't always have that, we have it now, and we have to maximise that. And I think that really allows us to get back to some of the root causes of why we are where we are in the first place. And I think to try and get national investments, I think Joanne is absolutely right, to get excited about a digital world, this is where health is going, we heard that from the Secretary of State. And I think it would be wonderful to see some of those investments put in some of the more deprived area of the countries, I think that would be fantastic. But, I think local government, and I commend the strategy, Ian, that you and Paul Ogden, I was determined to get Paul Ogden's name into the conversation today-

 

Moderator: Well done.

 

F: -but to ensure that, you know, you've laid out a good strategy for us and I think we need to build on that and make it happen.

 

Moderator: Okay, thank you. Yeah, okay. Next question, clarity and responsibility to ensuring meaningful overview and scrutiny, something that's based on national guidance for the role of health overview and scrutiny committee is well being broad (ph 01.50.10), but where does the function of overview and scrutiny have a role in shaping this new world of ICS and health security? I mean, that's always a big challenge in local governments, where does it, where does it, anybody?

 

F: Shall I? Well, I think-

 

Moderator: Yeah.

 

F: It falls on the Chief Executive, as always, to explain the value of scrutiny and I'm happy to do so. I mean, I think scrutiny is an incredibly important element of the creation of ICSs. And that isn't just about overview of strategy, and performance, and development. For me, scrutiny plays a crucial role in bringing voices to the shaping of plans and future strategies moving forward. And I was just reflecting that because Manchester's part of Greater Manchester and we've had a devolved health system in operation for a number of years, and I have to say it's colleagues, I think are at the conference, and I, you know, take my hat off to the work we've done at a Greater Manchester level, and the pooling of public health resources, and the deployment, and the expertise, and the talent at Greater Manchester has been a real strength, I think, in terms of our response. And I think the, the health and scrutiny at a Greater Manchester level has, also, played a part. So, it isn't just your local places, it's how you come together on wider footprints, I think. And it's to keep that narrative around population health, outcomes and addressing inequalities. That has got to be core, consistent, and that is business as usual as much as returning NHS hospital trust operations back. We have to keep this as business as usual. And the role of elected members cannot be underestimated in that voice and that bringing things to the fore, and keeping the focus on it. So, all power to (mw 01.52.11). All power to scrutiny in the elected members, Ian.

 

Moderator: And I do, even as a leader, like scrutiny. But, actually, I think one of the key things is we need to be working with scrutiny before the decision's made rather than after the decision. And if we get that right, it gets much better involvement to ensure we get the right outcome for the local system. But, don't tell anybody, my councillor might not believe what I just said. Justin, did you want to add something?

 

M: Yeah, I think it's a really important point about health and wellbeing boards in the relationship, not just for scrutiny but also health and wellbeing boards with the ICS and the emerging structures. Health and wellbeing boards really being the partnership space that we have between the local authority elected members, the NHS, academia, the business sector, the community voluntary sector, blue light services, and it would be madness to try and reinvent that and create yet another partnership group. So, I think there is a real opportunity to use the health and wellbeing boards to strengthen, to use the ICS emerging health inequalities strategies, to sit alongside the health and wellbeing boards strategies, and to be really clear about who is leading what, and strengthen that Secretary of State call that the NHS puts its shoulder to the wheel of inequalities in a really meaningful way, particularly in the areas where they can lead it best, addressing variations in clinical practice. We know that the impact of inequality in diabetic care has played out in the pandemic. So, number one, can the ICSs close those gaps in variation rather than perhaps trying to express their views on housing provision, which is not necessarily within their remit? So, finding ways of working together to address inequalities, I think, will be really, really key. And I think the role of elected members has really come to the fore through the pandemic. Certainly in my own area, we could not have achieved the community engagement without elected members, both with ethnic communities, and communities of place, and communities of business, they have been pivotal. And they've worked across party boundaries when we've needed them to, particularly in terms of surge testing and specific incidents. And I hope that that will continue and that we will see more elected members playing greater roles, not just when it's within their portfolio but, actually, recognising that public health as a system requires all portfolios in councils to play a role and all members to play a role, in terms of moving forward the health of the populations they serve.

 

Moderator: Thank you very much indeed. So much public health is linked to sedentary (ph 01.54.58) lifestyle, and no more so than at the moment 'cause I know the number of steps today will go way, way down, but how loudly should public, those in public health, be calling out policies and budgets that reinforce car dependency instead of championing investments in walking and cycling? 'Cause I think, I'll just quickly say something, that one of the difficulties that we have in local government is the fact that we, there's all these projects that we can bid for for the big shiny infrastructure and people say, 'Well, why can't you use those funds elsewhere?' But, of course, if we don't bid for it, on what the criteria says, we don't get it. So, I think we've got to work with national government to be, actually, assisting us to have more flexibility and local determination of what we can do with those funds. But, that's a big trust for them, I know. Justin, you wanted to come in on that one.

 

M: Yes, I, I, I would, kind of, reframe that slightly differently. You know, we know that every movement matters, and more and more evidence has been building over the last couple of years that the more you move every day the better your health is. And then, actually, how you move, the majority of us do it through utility based activities, where we go to the shops, it's where we drive our kids to school or we walk them to school, it's how we get to work, rather than through recreation. Recreation is important but the majority of that day to day physical activity is through utility. And as we come through the pandemic, and many business review and say, 'Well, actually, we don't need everyone in the office every day.', those daily commutes, which do generate a lot of physical activity, are going to disappear. And I think there's an onus on all of us to talk about that and have those conversations. And reframe physical activity, and revisit what our messages and our approaches are because a lot of this has always been based on how can we get from A to B most efficiently and effectively. Whereas, actually, if we're not going from A to B anymore because we're working remotely, we need to find a different reason to walk out the front door and go and get physically active. And I think that's going to be more of the challenge moving forward. I don't know a director of public health who isn't talking about physical activity and isn't involved in their transport and planning infrastructure thinking in the capital plans for their areas. You know, it is part of what we do as delivering a healthier system for our population. But, it is a moment to reflect because the nature of the way that we live our lives, particularly our working lives, has radically changed and I don't think it's going to go back to normal. And that means we need to revisit our approach to making activity part of our daily lives when we don't physically have to go anywhere.

 

Moderator: Thank you. Maggie or Joanne, do you want to say anything, to add in? Very quickly, actually, I might say.

 

F: Well, I think just keep it simple, you know. I think it's easy for some of us to do activity, I think what we really need to get to the bottom of is what's the barriers to people and how do we help them, however way, whatever way, we help them because, and you could apply that to any issue of public health intervention, couldn't you, 'cause, you know, the great sadness, to me, is we continue to get these widening gaps 'cause it's much easier, every health intervention's much easier for people with money, time and motivation to do. I think it's about how you turn that around and get to the people who really need it. Thank you.

 

Moderator: Thank you. (toeo 01.58.40)

 

F: A quick comment, a quick comment from me. So, I'm ashamed to admit I made, I did 7 steps yesterday, and that's just the reality of this working from home for a number of people. So, I completely agree with what Justin said. And I, also, agree with Maggie that it's about barriers. But, at the same time as I did 7 steps, I was in a meeting about parks and they were telling me how busy parks are, and how we're going to manage parks as lockdown eases and more and more people are going outside. So, you know, we have to acknowledge that we've got, I think, more people doing outside activity because it's safer and that's going to be a continuation of key messaging, but, at the same time, we've got some doing less activity. So, I think this is a whole place based conversation and I'm very keen that we engage employers, as well, in terms of building into future ways of-

 

Moderator: Oh, we've just, just lost you there right at the end. But, not to worry, I think we got the point there. I'd just like to say a big thank you to Joanne, Maggie and Justin for their contributions, and the Secretary of State and Baroness Dido Harding, as well. Can I just finish with something that was posted by, he got a shout out, Jim McManus, today, it's not a question, more of a comment, thank you for a truly barnstorming call to action, teamwork and resilience, from Joanne Rooney and Maggie Rae, reminded me why I do this job, thanks to these two awesome leaders for reconnecting me so strongly with emotional heart of what we do and what we are. So, thank you very much, I think, very (mw 02.00.31) turned out. Thank you everybody.

M: Good afternoon and welcome back to this fourth and final session of the LGA ADPH Annual Public Health Conference 2021. And this session is rising to the challenge. First of all I'll just have to remind everybody that these sessions are being recorded so those that are unable to attend will be able to view later. If you do want to ask a question please ask it through the Q&A function and we'll pick it up when we come to the Q&A session. And all slides are available from the conference-, all, all conference slides will be available on the LGA website in the next one to two days, and, and the recordings will be available early next week. So, we hope you enjoy this final session, Rising To The Challenge, and I think that that's certainly something that in the last year during the pandemic. So, I'll now hand over to my co-chair, Jeanelle De Grucy, to introduce the rest of the session. Thank you very much. You're on mute, Jeanelle.

 

F: Thanks, yeah, and I was saying it's great to be co-chairing this with you and, there you go, very helpful to make sure that I un-muted. So, this is a session on the politics of a pandemic, and I'm delighted to be joined by our speaker for today to talk on the topic. It's Professor Devi Sridhar, who is Chair of Global Public Health at Edinburgh University and pandemic advisor to the Scottish Government. It's a final session for us at this really brilliant conference, but what it's going to do is explore, we've been looking really at the, at, at, at quite a UK focus, but this is exploring how the pandemic has played out at a global level, and look to the future of collaboration and international politics in responding to future threats and improving population health. So, with that we'll hand over to Devi.

 

M: Great, and thank you all for joining, I know you've had a long and busy conference and the last session can be a hard slot, but I'll try to keep it fast-moving and interesting. So, I run a research team at the University of Edinburgh that's focused infectious disease management, and it's been largely in low- and middle-income countries, so team members posted in Haiti working in cholera, in Senegal working on malaria, in India working on water-born diseases, and so actually this is the first time in my career where I've really focused on a high-income topic in a big way, and in this case, you know, focused in, on Britain and on Scotland. And in early April the Scottish government set up its own advisory group to work alongside SAGE but to tailor the advice and complement the advice with what would be relevant for Scottish ministers, and so I've served on that group for the past year, as well as a group on children and schooling issues around education. So, my talk is really, I only have 20 minutes or so, is, kind of, three things. How did we get here globally? Where are we now? And what do we know and not know, and where is this going, at least in my view? And I'm really keen to take your questions and have time for that to make sure that I'm not telling you things you already know. You guys are all expert in this area, but actually trying to share novel information and hopefully insights based on the work our team has been doing on COVID-19.

 

So, to come to the first slide. We can see that how the pandemic has played out. Can we shift to the next slide, please? There we go. Okay, has increased, and every day, kind of, new records being set in terms of the number of cases. These plateaued about two weeks ago but then they continue to accelerate, which means we're probably in about chapter two to three of the pandemic story. It emerged in China, as we know, and then spread rapidly across the world and has affected different regions in different ways. We come to the next slide. This is about daily confirmed cases, which tells you about where the burden was hitting at different points in time. Again, this is confirmed cases, which means it's dependent on testing capacity. One of the things that Donald Trump said that was correct was that if you test more, you find more, you test less, you find less. And so there are some, kind of, grumbles about these figures, could they be accurate for different regions in the world. But they provide, I think, a broad contour. So, we know at the start there was China that was hit, this is the dark red, and they brought their epidemic under control in about two to three months. They've had flair ups, but generally China has been unaffected by (inaudible 04.54) they have gone quite harsh. In Asia, and this is the small peach was East Asia, Taiwan, Singapore, Hong Kong, Vietnam, Thailand, they struggled at first but they brought it under control. But then we saw it seep into other Asian countries like India, Pakistan, Bangladesh, you know, the really populous countries, and then cases take off.

 

Europe we know was hit very early on, starting in Italy but moving through Spain, France, Britain. But, again, in the summer you can see the broader numbers really, really low, thinking about last summer, and that was across Europe, the idea of almost is the pandemic over. But instead of being able to manage to keep them low in some East Asian countries, it kind of took off again as we saw this winter into a second wave, and potentially now we are looking ahead to will there be, and large will there be, a third wave. North America, the United States and Canada and Mexico, and then South America. Here, again, Brazil, we're seeing images out of there that they have been hit pretty badly, and the two, kind of, places to look that haven't been as well covered globally are Africa. We always expected that African countries, because of their weak capacity, both in public health infrastructure as well as in health systems, would suffer quite badly. But actually we haven't seen the case numbers that we'd expected. Part of that has to do actually with, of course, testing, but we haven't seen the healthcare that one would expect either in most countries, and so that's quite an interesting story of what has happened in that part of the world. And then Oceania, this is New Zealand, Pacific Islands, Fiji, as well as Australia, who have managed to keep the numbers pretty low as well through this. Also, you know, because of their isolation from the rest of the world, as well as their, kind of, following of China and the East Asian model in terms of what kind of strategy they pursued.

 

So, you can a bit about, kind of, how it has evolved, and right now the main challenges being in Europe, North America, South America, and then Asia being, now India again being hit with a new variant and increasing numbers. So, how did this all start? If we go to the next slide, this all, kind of-, most countries knew about this early on 'cause of intelligence, but really on 5th January officially when WHO notified the world. They were informed of cases of a pneumonia. No one knew the cause at the time. We didn't know if it was human-to-human transmission. We didn't understand what the link was to this Wuhan seafood market. It was closed on 5th January, and so there was this idea of how bad is this really? You have to remember this started with 44 patients with pneumonia, and this is all that was sent out to countries across the world, though of course they had their intelligence agencies trying to get more information, and scientists in China were trying to share more information about the SARS-like disease. And so at this point you might wonder, well why weren't alarm bells ringing. Well, if we come to the next slide. WHO has a difficult challenge because, actually, it manages so many thousands of disease alerts, currently screening approximately 3,000 signals a month. That's various countries saying they have some kind of disease outbreak, some kind of difficult situation.

 

They follow up on 300 and they investigate 30. And so it's almost like how do you pick out when you're sitting in Geneva and regional hubs which are the viruses that have the pandemic potential and which are the ones that actually will be managed and, you know, handled? And you can think over the past few years we've had Lassa fever in Nigeria, we've had cholera in Haiti, we've had plague in Madagascar, we've had Nipah virus in India. And so I think the turning point was really in mid-January when we saw human-to-human transmission as well as Wuhan going into lockdown, that actually this was going to be unlike other, kind of, outbreak events that were actually quite common happening across the world but are generally managed locally or nationally and don't become globalised events. So, if we come to the next slide. We are seeing more and more of these, kind of, we call spillover events. Most of our viruses do come from animals. There are zoonotic, kind of, spillover events, when animals and humans come closely together, and this is largely from rodents and bats and livestock, as well as primates. And so if you think of AIDS, if you think of, you know, other, other diseases that have emerged, it's, it's largely actually from our interactions with animals. And so we have, because of deforestation, because of practices in terms of how we keep and hold animals in factory-like conditions, seen more and more of these spillover events. And there's a real question in the scientific community of do we try to stop viruses circulating among animals, especially livestock animals, or do we actually just try to stop spillover events when they actually have a chance to jump into humans, and where do we put our emphasis as we try to prevent the next pandemic.

 

If we come to the next slide. Then all it takes is someone to get on a plane, as we've seen clearly, and, and, again, this modelling was done in 2013, and it spreads across the world, and we have seen how rapidly it reached every corner of the world within, you know, weeks, and, and, and months, and possibly even before that, where testing infrastructures were in place. And this is also why you might have seen hubs were hit harder. Hubs like London and New York, but also what was astonishing is how much we couldn't predict. I don't think anyone saw skiing resorts in Europe as being one of the reservoirs of infection that, kind of, spread across Europe. Iran was hit very hard early on. And so there are some surprises in that we can plan through, kind of, airline transportation networks and passenger traffic how bugs travel, but not perfectly. Another thing to say is, you know, we often talk about travel bans, but just putting in a ban to China wasn't really going to help you because a lot of the seeding we now know in Britain, from sequencing work, was from Europe, and so we would had to have cut ourselves off from Europe at that point, and that's a very hard decision to make. And so really it comes down to do you cut yourself off fully from all countries of the world once we are in a, kind of, a globalised situation, just targeting specific countries doesn't really help you, given the way passenger traffic moves across the world. And we're seeing this now with the P1 variant, the Brazil variant, rising in France. We can have Brazil on our red list but we do not have France, and how does that actually mean in terms of importation of cases if we're just looking at some places and not others.

 

We come to the next slide. What do we know and we not know a year in? So, from that point, a year back, when all we knew was this cluster of infection, we didn't know much about this virus, we've actually come an amazingly long way. Science has really put us into a pretty strong position in terms of what we know about the virus. So, then come to the next slide. This is just a few things to pull out but I'm happy in the questions to look at others. So, immunity. There was the idea of did most people already have immunity to this, or crossed immunity? How many people had been exposed? We didn't have for weeks an antibody test to actually detect that people had antibodies against the virus. And so I think what we now know is we do have good (mw 11.24) prevalence studies, we know the ONS does this as well, to look at how many people have been exposed to the virus. We also know antibodies fade, which means it does not give you a reliable indicator of the extent of people who have had this virus over the course of the pandemic. There are probably people who have had it who are testing negative on antibody tests. But we also know that the T-cells probably play an important role here. We've seen that with SARS. And so it could be that if we can develop some kind of T-cell test, which seems much more difficult to do, we could get a better idea of how many people can, actually have been exposed to this virus over the past year. We still don't how long immunity lasts.

 

We are seeing, you know, a whole range of people who seem to have immunity longer than six months, to others who don't seem to have built up any immunity. We know re-infections occurs, albeit very, very rarely. And then we, again, we don't know how many people have actually, in the course of the past year, been exposed to this, either had it or not had it that we can, kind of, guess at numbers. Health issues. This was first seen as a pneumonia, respiratory disease. We know it's a multi-system disease. It affects all parts of the body, whether it's kidney, heart, brain, blood vessels. We know about long-haulers, or long COVID, or what we might call as kind of post-COVID syndromes, that it seems to affect certain people for quite a long time, so the morbidity is concerning. It's not like you just, you know, you live or you die. You could live with actually longer-term health issues like breathlessness, fatigue, re-occurring fevers, lung damage. And we know that children, while largely unaffected, can face in some instances a multi-system inflammatory disorder several weeks later. And, again, if your prevalence is low it's not really an issue, but even in the States over 1,000 children have been hospitalised with pretty serious health conditions because so many children have been exposed to the virus, which is, again, pointing to, kind of, the importance of keeping prevalence in mind in terms of your, your denominator.

 

So, what we don't know is how long recovery could take. Will these people get better really soon in a few months? Is there a treatment they could take? And the exact percentage of people who develop long-term health issues, that prevalence of, actually, for the number of people who are infected how many actually are ill three or four months later? And some early studies coming through, but I don't think there's an agreed definition of what actually long COVID is across the world, or an agreed, kind of, prevalence number. A vaccine. We have several confirmed candidates. We know we have Astra Zeneca and Pfizer, Johnson & Johnson, Moderna, also Sinovac, we have Russia's Sputnik, you know, India has Novovax. Amazing that so many different ways of approaching a vaccine have all worked. Many haven't worked but we're having quite a strong position of having different kinds working. But we still don't know whether one will provide protection from re-infection with variants, which variants, how much will that effectiveness be, how long do vaccines provide protection for, and do the stop transmission, which is what we ultimately need them to do.

 

For treatments, we have now had great clinical trials in Britain. We have approved treatments. What we really need to get out of our lockdown cycles is a treatment to keep people out of hospital and the burden off health services, because we know this is what constantly happens with this virus, the hospitals become full and we're forced into lockdowns to make sure everyone can get care. So, if we can find some kind of treatment people could take in the first week when they test positive, that would mean they don't descend into a more severe state. This would also be transformational, 'cause then it would become treatable, manageable outside of hospitals, and we still don't have that, and that's, again, could come in the future. And children are really puzzling because usually coronaviruses like children, but actually for this instance it seems like they are different to adults. Younger children seem less likely to transmit, they seem less likely to, you know, have clusters, than older children. Both can carry the virus, we know that from virology, but they seem to transmit to different extents. And there are all kinds of hypotheses of why children are less affected, why do we see fewer outbreaks in younger kids. So, there was a great graph from Public Health England you probably have all seen where you saw, like, nurseries were tiny, primaries a bit more, secondaries larger and universities, and you can see that age gradient.

 

And so what is the role of schools in community transmissions? When we do our modelling, what is the impact on R exactly? There is a lot of uncertainty, and does our new variant, called the Kent variant, or B117, changes the picture? Does it mean suddenly children transmit in a different way? Does we have to reassess how we see schools as new variants emerge, and how do we move the evidence as new variants emerge, as well as not overreacting and, kind of, completely throwing out everything we've learned. So, if we go to the next slide. Choices for countries. Okay. So, a year back all, kind of, governments were probably getting the same scientific advice of there were three ways to go. It was, in a sense, a very difficult puzzle to solve but the options were clear. The first were you just do the elimination, and this was what you call the New Zealand, the island model. Many islands of small populations went for this, but also Taiwan and China as well. And basically the idea is you lock down hard, you clear the virus with your testing and tracing, and then you bubble yourself off from the world through strict border measures, and you try to keep stopping imported cases. Because the virus is circulating in the world at increasing numbers, you will continually see cases, and we've seen that in Vietnam, we've seen that in China, in New Zealand and Australia, but you just keep locking down for three days, clear the virus. Australia, testing thousands and thousands of people cleared the virus.

 

So, again, the idea of just try to stop it. That has been really, I would say, kind of, more islands and East Asia and Pacific. Then you had control models, and this is what I would say the, kind of, the German or South Korea model, probably Britain is in here as well. Where you have some kind of voluntary, more light lockdown. You have a strong test, trace, isolate system to actually try to chase down cases. You'd need to have strict rules over super-spreading events, that means mass gatherings, you know, where many people mix and can become infected, and light border checks. But the control model, as I'll show you in a minute, already showed at the start recurring lockdown, release cycles, because you had to stay within healthcare capacity, and test and trace becomes overwhelmed when cases numbers become too high. So, in a way this was the lockdown, release, kind of, pattern that we've been through, which is that you're just trying to keep a handle on it, and, and keep a lid on the situation so it doesn't actually collapse. And then you had what we call the herd immunity, some have seen it as the Swedish model, the build up of natural immunity. The slow running through in the hope that there will be a mutation that makes it less severe, there will be a treatment that emerges, you try to keep you death disability to a minimum, you ensure your health services don't collapse, and you try to keep confidence in the economy.

 

Because one of the things was, of course, you take this route to try to save your economic performance and keep the economy open and society open. The interesting thing about Sweden is they have pivoted from when actually in The Lancet, one of their advisers published that they wanted, they saw every country having to see this as uncontrollable, is was gonna be your health service's capacity that determined your final death rate, to actually then, when I presented this to Swedish officials they actually said, 'No. We're in control. We're similar to Germany.' They see themselves actually as a control model. So, in the herd immunity, build up of natural immunity, there is probably no country really in that, choosing that right now. You have uncontrolled transmission right now in Brazil. You had uncontrolled transmission in the States at a point last year, in different, different states like Florida and Texas, but actually it was not like a deliberate choice. It was actually just you don't really have-, you just try to keep things open without having a, a strategy. So, we come to the next slide. This is what control looked like, and this is what most countries have chosen, which is that we know without protective measures the cases deluge your healthcare system, people die because they can't get care.

 

And this is something that I don't think enough of the British public picked up on, which is they kept saying, 'Why are we having cancer treatments delayed?' 'Why are we choosing COVID patients over other patients?' And the point being that if health services are full, no patients can get care and your excess mortality jumps up. And so in a way we're not choosing COVID patients over other patients, we're trying to keep COVID out of hospitals so hospitals can run for everything else. And unfortunately, if we had-, this was the situation if we didn't have a vaccine we probably would be in recurring lockdown cycles. I don't see another way through this unless you really go through, go towards your full elimination, which is very difficult in an interconnected world. So, if we come to the next one. Again, this economic, health issue, and this is one that every, you know, country has grappled with, which is should we save our economy that, you know, affects of millions of people, it affects the young, it's jobs, and also jobs also affects, as we all know working in public health, affect people's lives, or do we go for, you know, deaths? But actually, what you've seen is, and I think this is now accepted, that actually economy and health go together.

 

The countries that managed to suppress their outbreaks early on without harsh lockdown measures and keep their numbers low, have actually run their domestic economies much more effectively than those who actually let the wave get quite big and had to put in harsh measures. And so we can see here, for example, Sweden versus its Scandinavian neighbours, that actually it didn't save its economy. Its economy was very similar to the hits that some of its neighbours took because people changed their behaviour. And in a way this is the same thing. Just because Britain kept its airports open through much of this it did not save aviation. Passenger traffic still came down 98%, not because we had restrictions at our airports, but because people changed their behaviour, businesses and others, on flying, and so in a way the virus kills your economy if it's left to circulate, not just restrictions themselves, though of course restrictions have harms. So, if we come to the next slide. When will this end? So, I could go on this-, on this for hours. I'll just put up two articles that I've written in case you wanted to, kind of, look through in more details, but I wrote the first one, The Coronavirus Could End In One Of These Four Ways, last, I did it a year ago. And at that point you could really see very few routes, as I said, out of this.

 

So, either you would see all countries at some point saying, 'We can't live with this. It's too severe. We're going to follow and work collectively towards elimination.' Or, you were gonna see at the other side countries just giving up and saying, 'Actually, lockdowns are too harmful. We're gonna have to live with this and we're gonna take the deaths and hope our health system doesn't collapse,' or many countries looking like Brazil, of just, kind of, you know, letting it go, we have to, kind of, keep our economies open. And then probably in the middle you had countries that were just buying time, almost like a control, you know, a, a, an, an airplane circling in the sky. It can't land, doesn't have the information to land. So, either you could do that through lockdowns, so repeated lockdown cycles, you're just buying time, buying time, hoping for some kind of Hail Mary solution to this, some scientific breakthrough. Or, you could buy time through a really robust test, trace, isolate system like they have in East Asia, which is that you have a really robust mass testing infrastructure, but also people isolate. And that's one of the problems in Europe, looking comparatively, is that we haven't offered people the support to isolate. The practical support, the financial support, 'cause there's no point testing people if they're still positive and show up to work the next day or still send their kids into school because they have no alternative options. And so those were, kind of, the four ways you could see at the time of where is this gonna go without knowing if there would be a vaccine.

 

Luckily, we've gotten our vaccine. We've had, kind of, the breakthrough we needed, and so actually right now, I think the way it will end is through equal vaccine access, but also, for a certain point, travel restrictions, because of the variant issue, that we don't want to have a variant imported that could undermine that vaccine access while vaccines are rolled out to the world. And so in a way it's thinking globally about how do we get vaccines to all parts of the world and help countries suppress so that we don't have uncontrolled transmission and new variants arising in other, other places, as we're seeing with New York and South Africa and Brazil, as well as in, in, in South of England. So, if we come to the, the next slide, and this is my last one and then we can take some questions, is that I think there is huge, and everyone has kind of recognised this, you know, inequalities, vaccine nationalism. We're seeing it blatantly today between the EU and Britain, but across, globally, we've seen Canada acquire, you know, nine times as many doses for its population as it needs. Britain as well has done quite a lot, you know, having to choose, when we didn't have full results, which of these were you actually gonna invest in. We're seeing a lot of countries left behind, in specifically, you know, low-income countries, you know, I think it's 90 recently, who have no access to any vaccines.

 

And I think, kind of, the two things that-, you're, you're seeing basically three parts of the world right now in terms of their vaccine strategies. You have rich countries that have a huge problem and need to vaccinate, because of their economies, as quickly as possible. So, Britain, we know that we're probably going to vaccinate about 80-90%, in the model of Israel, to be able to lift restrictions and keep R under one, which is what Israel seems to be doing successfully. We know from Chile that if we only vaccinate 30-40% of people over 50, our ICUs are gonna fill up with people in their 30s and 40s, 'cause that is what's happening in Chile, and so you still have a major crisis on your hand in terms of hospitals. And so you, kind of, really have to vaccinate into those younger groups, and this is what high-income countries are realising, which is why they're trying to get the vaccine and get them out as quickly as possible, and Britain has done remarkable job of this. Then we have countries in East Asia, like Taiwan, South Korea, even, you know, Australia and New Zealand, who have practically eliminated the virus and are just waiting it out. They're not gonna fight for these vaccines because they know they have the time to wait, and in a way we're the guinea pigs, while they wait for all the issues to be ironed out, and they're just gonna sit it out. And that's why you saw Australia very relaxed when Italy took its Astra Zeneca doses.

 

They said, 'They need it more than us. We're fine with it.' You see South Korea saying, 'We're gonna wait 'til end of 2021. We're gonna take our time.' Countries know they have to vaccinate but they don't feel that intense pressure. And then you have low-income countries where it's starting to rip through and actually governments need to, kind of, get those vaccines out because, but they just don't have access to it. And so there's a Covax facility that WHO have set up, rich countries can donate doses and money to it. Rich countries have donated money but they will not give doses, and Dr Tedros from WHO has said money is not the problem. Money doesn't count for anything if we can't buy the doses. And so right now it's a supply issue across the world, a manufacturing issue of how do we get enough, which is what we're seeing. And this is where I think it's interesting if you have manufacturing capacity because Canada, while it signed the most agreements has not actually received enough supply because it's dependent on other countries who have decided not to share and export their vaccines. The United States is steaming ahead right now. I mean, they're doing almost 4 million a day. They'll be done by 4th July, a large American holiday, and that's because they can manufacture enough Moderna and Johnson & Johnson and Pfizer and get them out.

 

And India right now is also interesting to watch because as you can see here it wasn't one of the ones that signed lots of doses, but the Serum Institute in India produces. It's the largest producer of vaccines in the world, and it was supposed to be exporting a lot of those vaccines to Britain and Finland and other countries, but they're actually being told by the Indian government to redirect them to Indian nationals. And so per million people, India is doing quite well in terms of its rollout of vaccinations, because of the manufacturing capacity that it has. So, it shows just half of it is actually signing the agreements and, kind of, getting the pre-arrangements. Another half of the battle has been actually having the physical doses at hand and countries having control over that manufacturing capacity. So, we are going to see lots more I think of what we're seeing today, of vaccine nationalism, of countries fighting each other for these right now. But in the end, as we know, the way through this is we need to be thinking collectively because as long as the pandemic is circulating somewhere else, the virus is circulating, we know it can always come back in a different form and in a way that, kind of, undermines all the progress that we've made. So, I will stop there. Thank you.

 

M: Thank you, indeed. That's so insightful, and lots to talk about there. Jeanelle, are you going to be the-, ask the first question?

 

F: Yeah, I will, and there are some great questions coming in, but I guess going back to, Devi, you were saying how did we get here. If we're really looking at prevention, do we need to be actively promoting a plant-based diet? In, in, in other words is, is there something about the reduction in biodiversity, or climate change, that's actually driving more transfer between animals and humans in terms of the virus, and should we be doing more prevention wise in terms of that, at the very-, at the very start if you-, if you are looking longer term in, in terms of our security on, on protecting health?

 

M: Yeah, great question. I think, actually, there are two ways to see it. The first is we know increasingly there is demand for cheap meat, and it's actually not just in Britain. It's China, it's Brazil, it's India. And, of course, you can understand it. I mean, these are people who have lived in poverty for decades and finally they can afford to have meat, and so, of course, at this point why would you be able to say to them don't have chicken or eggs or fish, which were considered luxury goods when you were a child, when suddenly you can earn enough as, as, to be able to buy them. And that's what we've seen with the growth. They want to have that consumption that we've had and, kind of, expected in the West. And so you are starting to see, we have-, we do have an issue with factory farming, which is large farms where animals are kept in pretty unhygienic conditions, and here my worry is not just about viruses jumping. It's also about antimicrobial resistance, AMR, which for me is, actually, we know Dame Sally Davies has talked a lot about this, is probably more of a realistic threat in the next year or two than these others. Because animals are being fed antibiotics as growth promoters, and, to prevent infection, and then they are developing infections that are resistant to our last resort antibiotics, like colistin.

 

And then all that has to happen is someone gets infected, and it has happened already, and it gets into our hospitals, and all of a sudden things like C-sections and cancer treatments and, I mean, even, like, regular things like urinary tract infections. It's not regular but you know what I mean? Like, things that we have circulating, become untreatable, and we forget how many people used to die before the days of penicillin. So, I think there, there has been a need to not just focus on what's happening in Britain, but what's happening across the world in terms of how we're keeping animals and our use of antibiotics. And on a second point, yes, I mean, I think there was nothing more clear than the situation of mink in Denmark that some of you might have heard of, which is SARS COVID-2 jumping into the mink population, circulating, mutating to a new form, and then coming back and infecting people in Denmark. And the Danish government moved very early on to cordon off the whole area, don't let anyone in and out, shut everything, sequenced. They were lucky to have great sequencing facility to find any cases, and they killed, I think it was, like, 20 million mink, off the back of that. I didn't even know there were that many mink in Denmark and that that was such an issue.

 

So, I think it's, you know, for me, we focus a lot of, kind of, plant-based diets, but I think there it's just generally about how we manage animals and keep them, and making sure that we don't have animals in situations where you don't need to be worried about, you know, bioweapon factories if you know that you have animals that basically can create viruses that are probably even more dangerous on their own accord. And I think the other thing about diets, and this is less about plant-based but generally about diet, is it has revealed how important underlying health is to overall. 'Cause we know COVID-19, kind of, preys on health inequalities. It goes after those who have existing health issues or those who are overweight, or, or are obese, and through no, no fault or no, no choice of their own. So, how do we actually create an environment where we think more about our inequalities and about creating healthy populations, because for the next pandemic we wanna be in better shape, and I think this has really revealed how unhealthy segments of the population currently and how perhaps we haven't been addressing it as openly as we should be.

 

M: Okay. Thank you very much indeed, and that actually, sort of, leads into this next question because, you know, the question is do we have enough time to implement the learnings from the first wave of the pandemic in the UK before restrictions start to lift? Is a third wave in the UK inevitable and unavoidable? And I suppose that's really interesting there because we've heard a lot about the inequalities, and you've mentioned it yourself there, but how much of a short-term issue can we reduce those inequalities to make, to, sort of, create that prevention, and do we have enough time?

 

M: Yes, I think there are different timeframes, right. There's a timeframe of the next few weeks. Are we gonna see-, I think we're all probably concerned about that. Are we gonna see cases increasing in the next few weeks like what we're seeing across Europe? There's the worry about next winter and are we gonna see flu coming back to bite us all, because already they're seeing in Australia children having an increase in respiratory infections and coming back with a vengeance, 'cause we haven't had them circulating. And then of course there is the next pandemic, of whether it's Avian influenza being seen in humans in Russia on a poultry farm, of how do we actually think. So, I think there are different timeframes. I do worry when I hear people say a third wave is inevitable, 'cause for me, it sounds like what I was hearing in China last January, which is cynical fatalism. So, when this first emerged in China a lot of the modellers, in, including in East Asia, were saying 80% of Chinese population is gonna get this. It's uncontrollable and a fast-moving respiratory infection is unstoppable. And all of a sudden you saw within, I think, a 75-day, you know, period in Wuhan, a quite draconian lockdown, but they stopped it. And it was not just lockdown. It was testing, it was contact tracing, and things that you can do with a very powerful state infrastructure. I'm not saying we should repeat China, I think we should observe it and see what they've done from a distance.

 

I think there are many things the Chinese government-, we're not here to talk about the Chinese government but we can go into that with a different question. We don't want to, to repeat or emulate. At the same time, then you saw Taiwan turning, saying, 'We can manage this,' and you saw South Korea handle its first wave through mass testing. And then you can see that New Zealand and Australia saw this. They were watching, 'cause they were following the flu model until mid-February, and this is the moment when Bruce Aylward came back, the WHO mission leader, to China, and said, 'This is what we've learned about the virus,' and he went through it. And the three things that struck me listening to him were, first, that this was gonna overwhelm any healthcare service in the world, because of the clinical need, what they were talking about, in terms of ventilation, beds, oxygen, the profile of how many people were affected. The second thing was how it transmitted, that there seemed to be already a hint of aerosol transmission, that there was, kind of, it was-, it was not just fomites, it was actually spreading in a different way. And the third thing is that it was-, it was controllable, through mass testing, through tracing and through restrictions, and that actually you could get through this quickly and lift restrictions fast, but you would have to probably bubble yourself off.

 

And all of a sudden you saw Australia and New Zealand pivot and actually go that way. And I think, in a way, now we look towards a third wave, is it inevitable? A part of me says, well, it's not like it's an earthquake or a comet hitting us. It's about our behaviour. We create the third wave, all of us, our communities. So, we need to figure out what, how do we make, from a policy point of view, people's choices easier in terms of not being in environments where they're at risk of becoming infected? How do we communicate clearly that outdoors are safer than indoors and get better compliance with masks, and tell people all the things they can do safely, 'cause there are a lot of things you can still do safely, not what they can't do, 'cause people are fed up and tired of restrictions. What, how do we reopen the economy, keep R under one, slowly, using vaccines and using mass testing and wastewater testing and lateral flow testing, all the things we didn't have a year ago, while also making sure that we don't kick off, as Chile has done, a rise, increases in younger ages groups which fill your hospitals and put you back into a harsh lockdown? So, I think the way (inaudible 34.16) is that we can shape the future and we need to anticipate what are the risks and then take the actions to prevent them happening, which is what public health is all about.

 

So, sorry, it was a long answer but it's, kind of, how I try to think about it, and I think if next winter we're still-, if, if we find ourselves back in lockdown and with hospitals full I think all of us have to look in the mirror and say, 'What should we have been saying a year ago to make sure we aren't in this position?' Because it's not inevitable, it's the choices we each make, and government makes each day about how we manage this virus.

 

F: So, that's really interesting, isn't it, 'cause there, there are lots of choices you have to make in, in a really rapidly-changing, complex environment, and that's both nationally and, and I guess locally as well. So, you, you've talked I think about decisive action needing to be taken and, and, and other, other measures. But, so, and you showed some slides, one where it showed the UK didn't do very well, both in the economy and in deaths. So, when international comparisons are made, by that account it looks like the UK isn't performing that well, but is it or isn't it? And if it's not doing well, well, I'm gonna add my own question, why, why have we done so badly?

 

M: I mean, I think we heard the Prime Minister yesterday say very clearly we didn't-, we hadn't done very well, and I think we heard the Chief Medical Officer, Chris Whitty, say, well, many other countries also didn't do well. And so I think we can, kind of, accept that we haven't done great. And I think at a point we have to hold up our hands and just accept that's true. I think part of it has to do with the cynical fatalism that we saw last February and March, and I might be being harsh here but, like, if you read the SAGE minutes at the time, this was being treated like flu. And we didn't really move into action until about mid-March. We had already seen Italy collapse in late February. If you look at other parts of the world, they were running really fast. Taiwan already, 'cause of its intelligence, end of December, they had already implemented, you know, restrictions from China and they had already started, kind of, asking people to wear masks and advised them about this. South Korea, you know, travel restrictions 2nd January. They met with 22 diagnostic manufacturers by the third week of January and asked them, 'We need to get our testing-,' they knew testing was the key to getting through this. And so I think-, Senegal as well, in January, was already reaching out to UK, actually, manufacturers asking for testing 'cause they didn't have the lab capacity to do PCRs, they wanted rapid tests, like, you know, kind of, the tests we have now.

 

And so I think, in a way, why haven't we done well? One, we were following a flu model for quite a long time, of just accepting with it. And it's tricky 'cause this virus falls between stools, right? So, if it was like SARS or MERS, if it killed a third of people like MERS, or, like, ebola, 50 plus, 50% or more people, we wouldn't have decided to live with it. It'd be unacceptable. If it killed children or if it killed young people we would have made that same decision, right? We couldn't have said, you know, given the death rates of over 80s and over 70s, if that was happening in 20 and 30 year-olds, there's no way a government would have said that's an acceptable loss, right? So, the way this virus is, but at the same time it's not as innocuous flu. I'm not saying flu is innocuous. We know seasonal flu is a big issue. But I mean, you know, every year across the world it's not-, you know, flu kills a lot of people but we have a vaccine against it, we have-, we have now, you know, the States has treatments against it. So, in a way, like, we were, kind of, stuck, right? It's not so severe we have to go, go harsh, and it's not so innocuous we can live with it. So, we kind of ended up with a here nor there strategy, which is, 'We've just gotta suppress.' And, of course, the longer you suppress-, I mean, the thing that Sweden and New Zealand had in common in their advisers, having talked to both of their advisers, is they didn't see a vaccine on the horizon.

 

And if you didn't see a vaccine on the horizon you knew that lockdowns were two years, in and out cycles, were unsustainable socially, economically, and so on. And so New Zealand chose, 'We're gonna go. We're remote enough, we're isolated enough, we can do it,' right? Sweden said, 'We wanna stay open. We've gotta live with it. We're not gonna destroy all of our values and our society for this.' I'm sympathetic to both sides. They just didn't think there would be a vaccine. And so Britain, yeah, are testing we were really slow on, but now, again, we're getting up there. Our testing works really good. We were slow at the start on our border measures. We still haven't got there in my view, but it's very hard. We're very integrated globally. We're a hub. We were slow on putting in lockdowns, which no one wants to do, but when you know, when the part of you thinks, 'We need a lockdown,' that's probably when you need a lockdown. When that's niggling you of, actually the numbers are getting uncontrolled. And the places that-, we know test and trace works well until it gets higher up, and then it breaks down. And the other thing is that, and this is just-, not a political point, but it seemed like test and trace in England was very centralised and kept to private contractors and they did not trust the NHS, and they did not trust what we have in Scotland is public health boards. And public health boards are responsible and it's a local thing, so local action, local consultants, local public health expertise.

 

So, people who know that. And it just seemed like the investment wasn't made locally, it was made centrally, and we know that you can't do contact tracing centrally. They didn't have that local, public health infrastructure to build off of, and I think they need to build it up rapidly, super fast because that's actually a lesson. You need to have that local intelligence and local input. So, yeah, I think we should look at some point at this and how we got here, but I think it's clearly the result of different decisions. And now with the vaccines, we've seen the NHS, what it can deliver. We've seen ourselves steaming ahead, but I am worried now with the whole fights with the EU we might derail the vaccination programme in the process, if they decide to stop exporting to us and then India decides to divert to somewhere else, then all of a sudden the whole agreements break down, right? That's why we have agreements, so that people know what's predictable. But now we're seeing that, kind of, predictable nature, because it has been set up as a competition between countries, of course every country is looking for itself and to its people, and that's my worry, that that might derail us currently. Are we gonna be able to reach those mid-July goals if all this fighting starts occurring over doses and blocking exports, when actually we are reliant on other parts of the world. We should just accept it and we should cooperate with them 'cause we all want the same thing, which is to vaccinate everyone as fast as possible.

 

M: Thank you very much, that's interesting. It's interesting you say about the local public health and that, because I think that we'd say in local government that we actually do have those resources. I mean, I think that obviously scaling up would have been a massive challenge and I think that we've got to make sure that the system locally compliments nationally or nationally it compliments locally. But one of the key functions of local government and public health is the, sort of, the boots on the ground and actually knowing where possible outbreaks may be and, you know, being able to identify it and also pulling together. And it's, you know, environmental health and Trading Standards into that, sort of, family that-, who already do this sort of methodology and could actually have been brought in at an earlier stage, but-, so I think, you know, it's not necessarily a political thing you're saying. It was something that local government we're, sort of, saying, 'Yes, we're here, we want to help and give us the resource so we can scale up.' 'Cause actually, I think one of the issues perhaps we were concerned about, is that when there was everybody being taken to the national system, what would it do to our local system? So, it was there I'd say and, you know, we were-, we did have our hands up and say, you know, 'Yes, please.' So, it was there I could say. But anyway, I've got a couple of questions actually roll into it, sort of, how might the pandemic play out from June and beyond? And, I think that's always a question that was, sort of, in our minds. But it then rolls into, as lockdown measures are eased, what are your views on the immediate risk and how do we keep the public on side? Because I think that's-, and those two questions seem to, sort of, roll into it because we all want to know when's it going to-, when are we going to be back to normal? But we're not going to be back to the old normal.

 

M: Yeah, high questions. So the first, June and beyond. I guess is a-, so I guess also back to your previous point on local governments. Yeah, I mean it is astonishing to me that how many billions have gone into Test and Trace and if it had gone to local governments, what could have been the sustainable infrastructure? Because we really should have been thinking about sustainability, which is how do we build structures that are not just for COVID but are for the next thing? And unfortunately-, I mean, I don't know much about it with our current systems. I do wonder how much of that £37 billion-, because a lot of it has been spent on consultants, like McKinsey and BCG and all these ones, daily rates. It's just burned money in my view. It's not sustainable because the infrastructure isn't there. You don't have the, you know, the local side. I guess, it's supporting what you're saying. That I actually think we should have given the money locally to build more sustainably. On June and beyond, I-,

 

M: I think, could I just go-, to be fair to the government there, I think the £37 billion is over the two-year period so it hasn't all been spent yet. So, there is an opportunity for it to come back to us.

 

M: Well, I will keep hoping that happens. I will, I will support you in that and to your view. June and beyond, I think there's a best case and a worst case, right? So, best case is we've vaccinated all adults, you know, largely probably in richer countries by mid-July. I don't think that's so unrealistic if everyone can cooperate. You know, we start trying to help poorer countries getting their vaccines rolled out, we get mass testing in place, we get our sequencing in place and actually we can lift a lot of the restrictions and keep an eye out for variants, right? So I think, like, there is a path ahead, we have tools we didn't have before. I think we'll see this become a classic global health issue. I mean, some of you might have heard me refer to this as a measles issue and it's not because SARS-COVID-2 is like measles as a virus. It's not about that, it's about how we deal with measles which is that we vaccinate a large percent of the population to prevent flare-ups. Flare-ups still occur now. We've lost our elimination status because we haven't vaccinated enough people, but we don't just let measles spread. We actually go after it, right? And, we isolate people and we test for it and we identify it and then we deal with it. And, I think that is hopefully where we're reaching in rich countries, but I also see it as measles because measles still kills thousands of kids in poor countries. It's endemic and we try to have Gavi Alliance and other alliances to get vaccines out there for childhood vaccinations, which we've done a remarkable job. There's been a child survival revolution until COVID-19 hit. And so, I think that's where I see, kind of-, it's sad to say best case, but I think that's where we going. Which is that we deal with our problem then we can be globally engaged and start helping those low income countries on rolling out their programmes and dealing with this like we helped them deal with other issues, infectious diseases. Worst case, we end up with some really nasty variant, which no one wants to hear about but we have to keep it on the table. Which is we know P1 already can re-infect people. There could be others circulating where vaccines have less effectiveness or vaccines start to wear off. And so, I think I'm really optimistic in terms of where we can go globally, except for that uncertainty around variants, 'cause this virus is so-, as we know over the last year, it's so wily. It's like as soon as you think you've got a handle on it, it somehow moves in some way and it mutates. Look at B117. I mean, I would have loved to see something more transmissible but less severe. That would have been wonderful, can you imagine? It would have been like the common cold.

 

We could say, 'We have another coronavirus, let it become the dominant strain across the world. Our gift to you,' right? We could have exported global Britain, right? They could have our B117. Unfortunately we've exported something that's more severe and fills up your hospitals even faster, as we're seeing with Europe. So, this pathogen does not evolve in ways that are conducive to our well-being. It works against us, as we have learned. So, we might hope for that, but so far I'm very nervous around the variants having seen what's happening in Brazil and now there's a P2 variant I know out in Chile. New York I know is having an issue with re-infections, and now I come to like immediate risk of the public. I think the immediate risk is that we move to early to lift and we end up in a third wave in over-40s. We already know-, I mean from data and I'm sure all of you have seen that data as well, that over-64 hospitalisations are coming down. Now our hospital beds are being filled with under-64s. This is not just a virus that kills people over-70 and it will kill people in their forties and fifties if they cannot get hospital care, right? I think that's the message people don't get. They're surviving because they're getting really good quality of care and we also know, health service staff are really mentally exhausted and traumatised from the past six-months, which means how much can you push them and the system to fill our hospitals and our beds, before the quality of care goes or people just can't show up to work anymore. So for me, that's the immediate risk of moving too fast, too early, before we've really rolled out our vaccines. And, I think in terms of the messaging, we are seeing fatigue set in. The thing I think we need to, kind of, reinforce is first, optimism of-, people feel it's endless and it's hopeless. When people feel it's endless and it's hopeless, they say, 'Why should I comply? Anyway is the situation, nothing.' And, that's why I always try to emphasise the progress we've made, to say, 'This is why we're in a better situation.' We have lateral flow testing in school. We have better isolation packages, hopefully soon, I hope. We have border measures, we have mass PCR testings. We can have-, testing capacity is no longer a big issue, we can turn around results. We have waste water testing, which I think is really exciting. So, we can understand prevalence in different parts of the country. You know, we have-, we now finally have face masks, so we know we can open certain sectors. We have dexamethasone and treatments, so you'd much rather be in hospital today than you would be a year back 'cause you'll get better treatment, 'cause they know how to save your life better and treat and recover better.

 

So, I think-, and the next thing on the horizon and I've seen this out of Edinburgh, is they actually are now doing genetic sequencing work on humans, like, our sequencing to understand through genomics. Who is most at risk of ending up in ICU by comparing those who end up in ICU versus those who test positive in the community and then end up being at home. And, they are finding markers of actually why some people get severely ill. That's amazing, right? If we can understand from this Russian roulette we currently have, of why one 80-year-old is asymptomatic and a 50-year-old ends up dying of it. I mean, it's random right now. We have an age gradient, but at a certain point it is-, there's a randomness and we can start to understand that scientifically. So, I think one is just messaging optimism and hope and scientific progress, because the time has mattered. Australia and New Zealand bought time, which meant they didn't suffer the loss of life and they're just now going to vaccinate their population and hopefully escape this, without the loss of life that we've seen, right? And, so I think that's the message. Time bought lives. Science bought lives over time. And, I think the other thing is telling people all the things they can do. There's so much you can still do outside and I hope at a certain point, that we can have a bigger differentiation between outdoor activities and outdoor hospitality and outdoor tents for learning and universities and indoor. We know that indoors is risky. Also ventilation, keep your window open, have a draught. We knew this actually from last February. There was a study of two buses in China. One had all the windows closed and AC, the other one had the windows open. There was one person infectious on each bus. One person infected everyone on the bus, one person infected no one on the bus. I mean, there are certain things we've learned and so, I think we can't tell people just, 'Don't do stuff.' We have to say to them, 'This is what you can do. This is how you can change little things in your life. ' But, I think the biggest problem here is actually-, I mean, we heard about this yesterday. It's the deprivation element. That those who are most at risk are least able to change their behaviour. They don't have time to take off work to get tested. They don't have time to apply for the £500 grant and then be rejected, because they can't show up for work. So, it's the deprivation element which is-, we can tell people all we want but if they can't implement it, what's the point? Which of course, we know in public health always there. We can tell people everyday, 'Get your two hours of exercise.' But, if people are working all day, they're not going to do it, and I think that's where public health and policy comes in.

 

Which is how do we create those policies that we protect those people most at risk and least able to make those choices. And, you've seen it, I mean, COVID you can map across the UK according to deprivation I think. I mean, even in Edinburgh, the neighbourhoods where the rates are the lowest are the wealthiest and the rates of the highest are the most deprived. Why? We know it. Occupational risk, housing risk, education, you know, wealth. Wealth is the best shielding mechanism against this virus and so, I think that's the challenge right now in terms of the immediate risk. Is that we can message all we want, but in end people's choices are very much determined by their circumstances and right now, for a lot of people getting infected, their circumstances aren't very good to be able to avoid getting the virus because of their employment or their housing or their specific situation.

 

F: Yes, it's really important isn't it? That focus on why the determinants that affect our behaviours and our choices, apply not just to COVID but of course to many other health issues. I wanted to turn a number of questions, Devi, about vaccination and with your experience and knowledge about global. So, I've been vaccinated in the UK but my parents who are in their eighties in South Africa haven't been vaccinated, which is one of those-, you know, just so unfair isn't it, kind of things? And so, the question's coming in about, you know, WHO readiness tools have shown us that African nations are missing many resources, let alone supplies and I guess, vaccines is one of those. And, then another question which takes it a bit-, brings it a little bit closer around. So, there's issues around supply isn't it but then there are also issues around vaccine confidence? And, it's interesting interplay between supply and who has it and who's producing it and the vaccine confidence, really interesting interplay. So, the question is, vaccine confidence is greater here than elsewhere on continental Europe, what are the implications for us and them? So, something about all that interplay about-, because vaccine and vaccination is going to be one of our ways out of this isn't it? But it's just-, we've just got so much more to do and learn on that front over the next year. So, your thoughts on that?

 

M: I think the positive message is uptake, at least in Britain. And, the States as well has been higher than any of us I think anticipated. I mean, I was looking at some of the numbers yesterday, over 90% in a lot of groups and so yes, there are pockets of resistance but actually the vast majority of people are choosing to get the vaccine and excited to get the vaccine. If anything, demand is outstripping supply right now and that's I think, true in all parts of the world. Even I know, like, in New Zealand because many of the people want to get off their island are asking, 'When are we going to be vaccinated?' Because they feel that and I know they're probably not the front of the queue of vaccines but they've acquired as you saw with the deals, enough of Pfizer. I think the way I might try to message this, is that would you rather have COVID or would you rather have the vaccine? And, I think when you lay it out this clearly to people and then talk through, what are the risks of getting COVID and what are the potential health implications and for young people, long COVID is no joke. I mean, it's random. You could be asymptomatic or you could actually suffer from months of breathlessness and fatigue and not be able to go back to work, right? It's a gamble. I see it as really like Russian roulette with your health at this point, because we don't understand generally. And, it's weighted by age and your health state but again you have really young and fit and healthy people getting really ill, like, triathletes and stuff. We've seen athletes in the States having cardiac issues. So, that's the way I try to explain it to people and then I talk through the vaccines. What is the data on safety and effectiveness? So, even like blood clots, I know that came up with the Astra Zeneca vaccine. At a population level, and this is why they decided, you'd much rather still have the vaccine than risk getting COVID because the risks of COVID you get blood clots at a higher level, right? So, I think it's that comparison. Of course if you tell people, 'Do you want a vaccine versus nothing?' They'll say, 'Well, I liked my life before. Why do I need the vaccine? I don't need it.' So for me, it's saying to them, 'If you want to get back in,' and I think this is where a lot of young people don't fully understand it. Because unfortunately, like, we talked a lot about this as being, like, an elderly disease or those who will have pre-existing issues. But actually it is a serious virus at all ages, I mean, you don't want to get it and even in children. Again it's generally children are fine but you don't want to be exposing children to this if they don't have to be, if they can be protected.

 

Which is why I've been saying, I'm glad to hear the plans to vaccinate children. Also, 'cause of the risk of mutations if we let an uncontrolled epidemic in young people happen. So, I think that's the way I, kind of, try to talk to people about it, which is like, 'This is what happens if you get COVID. These are the risks, these are the chances.' Give examples of, kind of, people who have had it and then I also say, 'Well this is the risk of the vaccines. It's been trialled in this many thousand people. These are the processes it's gone through. It's been approved in this many different countries.' You know, this is the best evidence I think. I mean, France was amazing with Astra Zeneca. First they said, 'Don't use it in over-65s.' Then they said, 'Don't use it at all,' and now they say, 'Don't use it in under-55s.' Of course it's confusing to people, right? Like, where I think, you know, my point when I was talking to a French advisor is like, 'We've been the guinea pigs in Scotland.' I mean, we've given it to all the over-65s. How many adverse reactions have we had? Look at our hospitalisation data. Look at what's happening with our death data. That's the evidence you need to look at and then I think it's going to combine-, you know, telling people, just laying it out that clearly sometimes helps. And, that we haven't seen really serious adverse effects beyond, kind of, some of the background-, we call it background, usual impacts of health issues in a population.

 

F: Sorry, Devi, the global element around supply and how are we going to vaccinate our population fully but also make sure we vaccinate the rest of the world? 'Cause isn't-, you know, how are we going to stop those mutations or-, 'cause it's not just country by country is it?

 

M: WHO says that it's unethical for a 25 or a 30-year-old who is healthy to have a vaccine before a 55-year-old asthmatic health worker working on a COVID ward in Malawi. I think we can all accept that logic, right? Like, who's more at risk? At the same time, rich countries know that the only way to lift restrictions and avoid this third wave is to vaccinate enough people. They need to vaccinate their way through this, unless they've eliminated the virus but that's a minority of countries. Israel are already showing the path for that and it's astonishing. If you look at their R, it's come down and they've eased a lot of restrictions 'cause they've vaccinated down to their, you know, sixteen and seventeen-year-olds. So, is any politician going to stand up to their public after a year of restrictions, unemployment rising, GDP losses, schools being shut, people being-, not seeing their families and say, 'I'm sorry you're not going to get a vaccine 'cause we're giving one to Malawi or to South Africa.' They're not going to. I mean it's-, that's why I guess, I'm happy WHO is leading that charge but my view is maybe-, is that I understand right now the political pressures in Europe and in Britain and I think the best thing we can do now is vaccinate, as the States is doing. This is what Joe Biden has said, the president there has said that, 'We're going to vaccinate Americans, we're going to vaccinate everyone living here and then we will help the world. But we have to deal with our domestic problem too.' And I think there's some logic to that and that actually you have to get your own house in order before you can help others. And, I think, you know, the big difference to the West Africa Ebola crisis was that this was really a West Africa centred problem and the US and the UK and France could really come in and bring in their resources and help and support those countries. In this crisis, because we've been so consumed internally, it's been very difficult to cooperate and work across countries because we have such a big fire in our own back yard. So, how can you go and solve other people's fires when your own house is on fire? So, I'm sympathetic to both sides. As I say, I don't think there's an easy answer but I think politically it's pretty difficult. I think Norway has a great-, I think it's the only country I've seen which are, 'We are going to give doses abroad while we do our population.' And, amazingly their public agree with it, but Norway's numbers are really low compared to ours and they haven't dealt with the kind of waves we've seen here.

 

M: And, so a really interesting point because of course the other issue is if we get to the second doses and then of course, when do we need the booster doses to back-up? So, at the moment as far as I'm aware, we don't know how. Is this an annual, is it bi-annual, tri-annual, you know, how often is it? We can have the, sort of, ambition as a country that once we're-, you know, and Joe Biden can say, 'Once America's all vaccinated, we'll give all to the third of Malawi.' But of course what happens if just as the whole of America is vaccinated, you've got to go back to the start again and revaccinate? So, it throws up a real ethical question there that-, and you're absolutely right that without the-, you know, if you are fighting fires in your own back yard you can't, but-, so there does have to be that global issue doesn't it? It's-, that wasn't a question, that was just picking up on your answer.

 

M: Yes. I know I'm with you completely. I'm always focused on, kind of, low and middle-income countries. The first time I've actually worked on, like, a British topic in this detail, kind of, local topic and it's hard, I agree with you. I'm very worried about the variants that we're seeing like-, what is happening in Brazil, every country needs to be paying attention to right now. Because the re-infections one also gets me. Which is that you can have someone-, or they've found people who have two different strains at the same time. Which just shows that, like, this virus is quite-, it's not like you get it once and that's it and you're done, right? It's like-, and this is one of the things and I remember last January, February, I guess we all had that moment of, 'Shall we just get it?' Right? Like, should you time when you get it when health-, that was bad for you, right? That was one of the discussions and a part of me was like, 'Well, there's no point if you're going to get it again in six months,' right? Like, if you're going to avoid getting it, avoid getting it for as long as possible until there's a vaccine.

 

M: Yes. There's another issue you picked up on about the buses and air. Someone's asked about we have technologies available as-, for air purification that could kill COVID and future-proof our society against future outbreaks. Should we not focus more on complimentary prevention solutions relating to air quality in indoors, but I suppose that could also link on to say, 'Well, why don't we improve the public health so that we can improve everybody's chances if they do catch it of surviving as well?'

 

M: Yeah, so I think ventilation has been one of things that all countries-, I mean (mw 01.00.24) here have been slow to catch up on, which is that actually the virus can transmit. I mean, I found, like, last summer the discussions on one metre and two metre so frustrating because we know if you are in a crowded bar, someone can be six metres away and probably still infect you if there's no air circulation, right? Where you can also be outdoor in a park with someone who is a metre away from you and you're very unlikely to be infected by them. So, it's all context specific. So, I think that's right about ventilation systems that we do need to think about. I mean, the one thing and I think that everyone's going to be thinking about having a window in their-, and then I think we've revealed actually how many schools don't have windows that open, right? Like, you would think that you would say to schools, 'Open your windows,' and you realise windows don't open actually at all. I think also-, we saw this also in 1918 flu pandemic, of actually getting people outside, like fresh air and like pushing-, I think people have gotten outside because they've got no choice, but to like push people into green spaces and parks and I don't mind people going to beaches. I'd rather them on a beach than at a house party. You know, I'd rather them be-, you know, even when I see large gatherings. A part of me is like, 'Imagine that was in a house.' Like, I'm happy it's outside in a way. That's what we see, so that's what we shame, but for me it's actually that could be taking place indoors, at least it's taking place outdoors. So, I think that's one that we need to work on, especially now I think with schools while we're in this bumpy phase. And, on the health of the population we should anyway be fixing and working on that, right? So, I think this has just been like a reminder of the-, someone called it the 'Coming back of the tide,' right? Like, it was always there, it's just now been laid bare of actually the vast health differences and how much they're related to wealth as well.

 

F: There's a question here about going back to vaccination and as we go down into the younger age groups. I mean, you talked earlier about how the uptake in older age groups has been fantastic. But actually as we go down, I think concerns that we'll see more and more inequality or variation in uptake. So, your thoughts on that I guess and if you've got knowledge of other countries that maybe are managing to vaccinate younger age groups. But the question really is also, is there specific research on this or-, and, or is this seen elsewhere in epidemiology?

 

M: So, I guess, kind of, the two models at least most common I think with vaccinations, have been the childhood vaccinations that we all get and protect us for quite a long time with various boosters, as well as the flu vaccination programme which is for specific at-risk groups. I don't think I can think of a, as rapid, whole population vaccination programme like we have currently being done in a high income context and it is a challenge. I think the country to watch is Israel, because they think are one of the only countries that I can think of. There is a town in Brazil that was taken as an experiment. I think they vaccinated everyone in that town, so everyone's watching that as a science experiment of like, they actually just chose a random town, vaccinated everyone in it and they're going to see what happens. But I think the key to releasing restrictions seems to be vaccinating the age group sixteen to 30. And, then actually it does seem-, I mean, Pfizer specifically seems to dampen transmission. I don't know about Astra Zeneca, I haven't seen their results. And, I think the messaging to younger people is if you-, if we want to give each back some normality, we all need to be vaccinated and it's not just personal protection, it's societal protection. And, I don't think anyone wants to be under restrictions anymore, so in a way like, we all have to play our part and get vaccinated so that we can open up. Israel has done something that has been really controversial which is these green passes. That if you want to go to a bar or to a pub or to a concert, you must have a pass that you've been vaccinated. This-, and they even I think set up vaccination stations nearby, I was thinking people have talked about vaccination stations outside football stadiums. You know, like if people want to go to the big football games, it's like concerts, people say, 'Is that-,' you know, it riles people. They don't like that, right? They don't like being forced, like, if you want to be a part of society, you have to be vaccinated. So, I think obviously it's controversial. In the States there's an offer from Krispy Kreme that if you show your vaccination card, you get a free doughnut everyday for the rest of the year, like, every day. It's been brilliant marketing from their point. It seems to have helped reach many groups who were not thinking there was any benefit to vaccination. We can talk about the public health impacts of that but we are seeing various countries trying different things. Luckily in Britain so far, people just seem to do it. I mean, I think the one thing I say about-, you know, we always talk about all the shaming of people who have parties or people who break rules, but actually the vast majority of people have been incredibly community minded.

 

A lot of people have sacrificed seeing their family, their friends, their normal life, their jobs, their hospitality businesses, their concerts, their arts. All the things that they love about their life for the greater good and so, I think we shouldn't underestimate that spirit that we have seen over the past year. I don't think any of us could have-, if we were right now asked a year ago, where we'd be now. I don't think any of us would see the terms of compliance we've seen in terms of people looking out for each other. So, I think that we are on track now and hopefully we can continue that spirit of like, we want to get to normality. We want to hug people and be in bars and we want to be in restaurants and we are humans and we are social. We don't want to be living with distancing and masks for the rest of our lives and I don't think we will be. I mean, 1918 also had masks and distancing and get out, I mean a lot of the advice was the same. They didn't have the saviour that we have of science and great communication across the world, but it's not like we wore masks for the last 50 years, right? Or whatever, 100 years. So, I think, like my-, I'm quite optimistic we'll get there. We need to tell people how do we get there and how do we get there and what are the steps we need to take and how can each of us play our part to get there.

 

M: I was just about to get on the plane to go and get my free doughnuts everyday, I must admit. It's, sort of, 'I don't know what it would do to my public-,' as you say, the public health. But I was right there for that one, and it's interesting that actually, you know, are there different ways to attract to those people that we are struggling to get to and, you know, that is one of the things. But, it does raise the question and it's one of the questions that's on here, what about compulsory vaccination? Because, I suppose that's almost going down the Chinese-, full totalitarianism lockdown but, you know, is there an argument that we should have compulsory vaccination just to protect everybody?

 

M: You know, I think-, well, it's very much all dependent on the country context and we don't have compulsory vaccination, I don't think for anything in Britain. I mean in the States, if you want to go to school you need to have your childhood jabs, like, you need to show the school you've had them from a paediatrician. I know Australia and Germany now have fines if you don't have your MMR vaccine 'cause they had so many measles, you know, outbreaks across Europe. So, we've generally created a system of fines and benefits. We haven't done this like, 'You have to do it.' And even then, I don't know if that's the right way with this. I think it could put off a lot of people. I think what's going to happen whether we like it or not, is that we are going to see internationally, vaccine passports. It's already happening, in that you can do more things if you are vaccinated and you can do fewer things if you're not vaccinated, and so I think what we are going to see is basically huge incentives to become vaccinated. It's still a challenge though, because I was seeing today that even if we vaccinate all adults in the UK, it's only about 75% of people. And, if we do need to reach that, kind of, 80-90% threshold, we need to be vaccinating into children and this seems to get parents quite-, some parents quite enraged. So, I think that's going to be for me, actually the bigger battle than adults. I think most adults are happy enough and I think most twenty-year-olds if you say to them, you know, 'This-, we need to lift restrictions,' and we have-, all of us have been vaccinated in the past, it's not like vaccines are like this thing out of Sci-Fi. I mean, we have vaccines against so many things and we travel to different countries when you're gap year, you get vaccines based on where you're going and you go to the travel clinic and you have the list and you say, 'Vaccinate me against those four things,' and you don't think much about it. And, I think with COVID, the number of people who have been vaccinated with this. I mean, it's clear that I think it's safe and it's effective, so why wouldn't you take it? I mean, I think the people who are really brave, I think were the people at the start who were part of the trials. Those were the people who really had the courage, because we had seen trials in animals but we hadn't done them in humans. So, those people I think are real heroes, because they went into uncertainty over what this could mean, although obviously with safeguards. Where I think now it's been trialled, thousands of people, it's been give to millions of people across the world. So, I think that's what we have to keep messaging, is actually all the benefits and that the costs are very minimal.

 

F: So, we're coming into the last five minutes or so, Devi. So, you'll be-, I mean you've-, it's been a marathon Q and A session hasn't it? So, I think-, I don't know, Ian? Should I ask the last question and-, or if you ask the last one, but I guess one of the questions relates to the role of local government and you've-, it would be interesting just to get your sense of the-, you have talked about the importance of local. But that mix between what national government does and then what local government does. So, the question is what would be your single message to local government or local authorities in terms of COVID?

 

M: Well I think to-, you know, that's where I think we need to see the locus of action. I think one of the astonishing things across the world is that countries-, it's not always true, but the countries with smaller populations seem to have done better, 'cause they seem to have a better handle on what was happening. So, what can you do in a larger place? You can break it down into local councils, different parts and actually say, 'How do we manage this?' They understand the background of the people who live in their community, you understand the occupations, you understand the ethnic breakdown. You understand what might work and so I think, you know, for me, everything has to come down to local action in an outbreak. We already have known this. I mean, if you look at, kind of, the outbreak response for cholera in Haiti, it's actually like people going out to communities, the human-to-human contact. I shouldn't say that with COVID but do you know what I mean? It's, like-, it's communities and I think when we try to decentralise it too much with-, sorry, centralise it too much to a state level, to a London level, it can make some parts of the country feel completely excluded. So, I know there was tension over, 'Are we all moving according to London's timetable?' Which actually benefited us in Scotland because we went into lockdown earlier in our epidemic curve several points because we were behind. And, how actually do we make people feel like the government that they have, represents them and their interests and there are very diverse interests right now across the country depending on where you live and what you have. So, obviously you need to have leadership and stewardship, but I think coming down to, kind of-, this is all about communities and it's about caring communities. And compliance is less about the police and it's more about how people go out of their way to help each other because they think it's the right thing to do and where is that messaging coming from? And, we've seen this with the vaccines. I think someone-, I was just looking at the comments, put it in that some of the most effective vaccine outreach has been through local community leaders. It's not been because someone says it on TV. It's actually through the local leadership that you see on a daily basis in your community and the people who you know represent you and your interests.

 

M: Thank you. Jeanelle, that was the question I was going to ask as well, so thank you. But ultimately that's my particular interest in local government. Really well answered, that's really good. I mean, thank you. That's just been so brilliant and everybody's putting some really positive comments, Devi. That's really good that you've gone through, sort of, quite an interrogation there, from two people bouncing around. Perhaps you should have been asking the questions and bouncing it the other way, because it felt as if it was a bit ganging up on you, but it's really interesting, and everybody has really appreciated. Thank you. Right, so Jeanelle, do you want to, sort of, sum up and-,

 

F: Yeah, well echo your thanks Ian. Thanks very much too, Devi, for coming and being on the firing line, the end of a firing of the questions. Thanks also to all the attendees to the conference for putting those questions forward to us. Really helpful, thank you very much and I certainly, you know, learnt a lot about what we know, but also what we don't know and I'm sure we can just imagine after this year, how much more we're going to know about COVID. And, some of those questions that we've asked today will develop and emerge as we go through. But, it now comes to the time where we are bringing the annual public health conference, LGA/ADPH Annual Public Health Conference 2021 to a close. So, I'm just going to give some closing remarks if I may. So, first of all, thanks to all the speakers. They've been absolutely brilliant over the last few days. Some really thought provoking, inspiring, hugely heartfelt contributions. Thanks to our LGA and ADPH teams and colleagues who've put so much effort into delivering this conference virtually. In brackets, please do fill in the survey so that we know what you like, what did work, perhaps what didn't work as well, close brackets. And, then thanks to everyone who's attended and contributed, as I say, those questions, not just questions but comments as well and I do hope that we'll have the opportunity to meet in person again next year. So, what will the Public Health Conference 2022 look like? Hopefully will be in person. So, I think what I've taken from the last two days and certainly going on comments on Twitter and other comments I've had from folks, is that we can really be confident about our leadership as a public health community, proud of what we've done. We've heard yesterday, today, how public health has as a community, as a system, has raised it's profile. And, it's risen to the challenge, this huge challenge over the last year of protecting our communities, strengthening our relationships and ensuring that local experience and knowledge we have, is championed in Whitehall. And, the session we've just had reaffirms the huge importance of that. You know, COVID has shown the value of local public health and demonstrated the challenges but also the potential of a team of teams approach. With not just public health for DPH, the public health teams, but also the councils, Public Health England teams, the NHS, other public services, voluntary sector, charity sector. All working collaboratively on everything, from Test and Trace through to making sure that vaccination roll out is equitable. The profile of the Director of Public Health as a system leader within that team of teams has increased, in our communities and nationally.

 

And, we want that to strengthen and to continue. Our connections with the Office of the Chief Medical Officer and with Chris himself, have particularly reflected an increase in recognition of the Director of Public Health role. Throughout the pandemic we have fostered these close collaborative relationships, particularly I want to say with our local councillors and with our other local government officers. You know, it's been really important that it's been a local government family. The DPA and just public health teams have operated within the local government family and it's been fantastic hearing today, you know, about how important we are all and strong we are together. But we've also developed a really quite close relationship with various parts of national government, which I think is quite new for us over the last while. Putting local public health knowledge and skills at the centre of the newly announced today-, but the new UK Health Security Agency-, I can't quite bring myself to say the acronym yet, is critical to it's success and we therefore warmly welcome Dr Jenny Harries, who, you know, we all know quite well. She's got a wealth of public health experience and expertise and of course was a Director of Public Health. So, we welcome her to the role of chief executive and we look forward to building a strong and collaborative relationship with her, well ongoing, our strong relationship with Jenny, but also with the chair of the UK HSA, Ian Peters. I want to take a moment to express our gratitude to our Public Health England colleagues, many of whom I think, who are still-, you know, have attended the conference. Our thanks and gratitude to you. You've been working tirelessly alongside us in the fight against COVID-19 and you've been absolutely brilliant. But now, we need to rise even higher to the challenge of this year, 2021. We need to embed the lessons from COVID and put local at the heart of this new public health system that we're going to develop, and we need to make the case for the funding that is crucial to tackling the unacceptable levels of inequality and to create healthy places for all. Thanks very much and over to you, Ian.

 

M: Thank you very much indeed and first of all, I'd like to thank you for being, like, my co-chair this afternoon. It's been a great session. But also all the panellists and delegates over the last two days, there's been some really good contributions. I think it's strange to think that, you know, it was just over a year ago we were, sort of, actually thinking of almost packing our bags and getting ready to go to Brighton and then suddenly, you know, it was cancelled. You know, nobody could have imagined that we'd still be in this situation now and-, but, you know, I hope that next year that we will be in a physical location, Brighton or somewhere else. There's lots of places. I'm not going to get specific on that, but, you know, 2020 has been a year like no other and COVID has taken such a terrible toll on the communities and, you know, throughout this conference we've heard that local councils have actually been at the centre of the action to tackle the spread and protect that wider health and well-being. But of course, it's not just councils, there's the communities around there and I know certainly in my local area, that community spirit has really built up which is so, so important and we must keep that going. But Directors of Public Health and their teams have worked across all local government, with the NHS, voluntary community sectors and it's just been a massive team response which has been really good to see. And, at the time of crisis, people do rise to the challenge and we've seen this right across the country. And of course, public health in local authorities will continue to have a central role in tacking the virus in local places. It's providing that local leadership, expertise, partnership working and access to local, sort of, resources that are fundamental to effective place-based coordination of health protection interventions. At the same time, it helps local areas to understand and address the economic, social and psychological impacts of the pandemic and the serious health inequalities that have been highlighted and deepened. As we heard in Tuesday's session on public health and public opinion, awareness and understanding of public health in the general public and in the organisational partners has increased markedly through the pandemic. We've got to maintain that. Local government leaders report that their role in the pandemic has been an irreversible game changer to how Directors of Public Health and their teams are viewed in the local authorities, and across wider partnerships, their influence will continue.

 

The race profile is very positive and we should be built on as we move forward and it'll be important to emphasise that public health is multi-faceted discipline with a large range of functions, and it's not just about health protection, it's right across the local government. As local leaders of place, we now know that the span of public health from epidemiology to understanding social determinants and working face-to-face with the public to support behavioural change, has a huge potential to improve people's lives. We should invest and champion in it and we'll continue to do so at local government. This year's Public Health Annual Report from the LGA is an important document and you'll find it on our website and on the addend page of the conference. It looks back at the events of the last year and focuses on the public health-, on what public health has helped to achieve. It also has looked at what could have been done better and that's always important, to learn. COVID was an unprecedented challenge for all organisations, national, regional and local and often where the dilemmas were about the best path to take. Although the roll out of vaccines means that the risks posed by COVID-19 will gradually reduce, the virus in it's different forms will be with us for years to come. Continuing to tackle this and reduce it's impact on people facing health inequalities, will be a key task for public health long into the future. Nor will this be the last major infectious outbreak. Although we hope sincerely it will be the last global pandemic for many years, we need to understand the lessons from this pandemic and apply them. so we can achieve a seamless response to future challenges. As we look back over the pandemic, at the same time we need to look to the future. The end of Public Health England and the new National Institute for Health Protection and the Health and Care White Paper, mean we're again facing significant organisational change. The long-standing problem of health inequalities and regional inequality have become even more clearer during 2020 and the pandemic's repercussions will exasperate there, at this time when resources are limited and unclear. At this crucial time we must not misstep. We must come together and work at scale, whatever is the most effective, but always focus on local places where people feel a self, sense of belonging and community and where direct work of health improvement and health protection takes place. Thank you very much everybody for attending. I hope everybody's enjoyed it as much as we all have. The presentations should be on the website by now. The recordings will be within a couple of days. There is the feedback form if we-, if you could fill it in because it is so useful for when we're preparing for the next one. But I think it's-, and actually we've managed to sign-off early, this could be quite amazing. Public health again, it's that bit of we've got five minutes now to go and do that exercise. So, all I can say is thank you very much everybody for attending, I hope you've really enjoyed it and I hope to see you in person wherever that may be, next year. In the meantime, take care. Thank you, bye.