An interview with Professor Trudi Grant, Director of Public Health, Somerset County Council.
Key messages
- Shoot for the stars, looking up and out, not down and inwards – maintain the broadest view rather than focusing on small details, which can risk missing opportunities.
- The job of public health teams is to inspire and support others in order to get health and wellbeing on all agendas – engage with people, learn their priorities, and speak their language.
- Understand the important role of politicians, when we are all aligned, we can move heaven and earth.
Trudi Grant was working as a sport and exercise scientist when she saw her “dream job” – promoting physical activity. As she learned more about public health, she became increasingly aware of the negative impact of health inequalities. Trudi found that public health matched her values – working to address injustice and unfairness and to achieve the same chances for everyone. She was supported by inspirational public health directors to make it her career.
The move to local government
The move to local government and the increased focus on tackling the social determinants affecting health inequalities was a dream – a gift.
Prior to the move, Trudi had been a consultant in the NHS and had asked for her post to operate jointly with the council. Working this way reinforced how much potential there was in local government and how hard it was to influence social determinants from the NHS. It also meant she had a head start in understanding how local government worked, but the shift was still a big cultural change. The public health team did a lot of groundwork to increase understanding of their new public health responsibilities with council staff and councillors.
In early 2014, not long after the move to the council, significant flooding in large parts of the county meant the system was operating within a major incident for an extended period of time. Public health was an important part of the flood response and helped lead the two-year recovery afterwards. The crisis fast-tracked the embedding of public health within the council, giving a real-life example of the skills and expertise the council had inherited. Reflecting back on it now, Trudi views it as a helpful learning experience for the response to COVID-19.
Trudi sits in the senior leadership team reporting directly to the chief executive; they both hold the strong belief that this is the right level for public health accountability in local government.
Councillor Clare Paul, Cabinet Member for Public Health and Education, and Chair of Somerset Health and Wellbeing Board
"Regaining responsibility for public health in 2013 was a real turning point for Somerset County Council. The new responsibilities and the transfer of the Somerset public health team have challenged and truly transformed the business plan for the council, now focussing far more on taking preventative activity and addressing health inequalities.
The council has changed its approach to align the whole organisation and the business plan to the County Health and Wellbeing Strategy ‘Improving Lives’.
The vision is far more forward-looking, recognising that many of the important influences on people’s lives and their health and wellbeing are complex and deep-rooted and require a focus over the medium to longer term.
It is very inspiring working with Trudi and the public health team in Somerset."
Changes since the move
Working with elected members has been brilliant. They are strong advocates for health and wellbeing in their communities and are eyes and action on the ground.
Moving to local government brought huge opportunities for new partnerships. The public health team did a lot of work on health in all policies, creating a collaborative approach in which a range of public service and community partners engaged in improving health and wellbeing. To do this, Trudi found it helpful to understand partners’ priorities, world views and language. For example, initially, it was difficult to engage all council functions with the health and wellbeing strategy, but this changed when the strategy shifted to a broader approach – ‘Improving Lives in Somerset’.
Trudi believes that a key role for public health is getting health and wellbeing onto the agenda of partners. Similarly, the public health grant has always been small – the way forward is to use this well but focus on influencing expenditure across the system to improve health and wellbeing and tackle inequalities.
Moving to local government provided the opportunity to recommission services to be more responsive to people’s health and wellbeing needs and with a greater focus on health inequalities. Somerset recommissioned all its public health services over a two-year programme. Good commissioning practice in local government, assisted this process and has driven enhanced performance and added greater social value to the contracts.
The team has taken on a range of additional responsibilities which fit naturally within the skillset and value-base of public health. These include community safety and domestic abuse; resettlement of refugees; volunteering service; and lead responsibility for equalities.
Some key achievements include:
- In Somerset, the NHS and the Council work very closely together (Somerset ICS is coterminous) and public health has had a lead role in plans to “flip the system” from a very demand-driven system towards prevention and tackling health inequalities. Progress has not always been as swift as Trudi would like, but money is being invested in prevention, and things are moving in the right direction. The current national focus on prevention and health inequalities in the NHS is helping progress this agenda, and the experience of COVID-19 has made this more real for everyone.
- Public health in Somerset had been trying to integrate sexual health services for seven years in the NHS without success. In the council, services have now been integrated, the success achieved by strong commissioning. The services are now based in community settings to improve access and delivered with an enhanced digital offer.
- Somerset has brought public health nurses into the public health team. This may be a unique model because in other areas nurses are often part of children’s services. The thinking is that public health nurses are the primary public health workforce. As part of Somerset’s public health department, they work in a social and environmental model of health, encompassing the range of health needs from developmental issues through mental health, healthy living, and environmental factors like housing.
- As well as challenges, the shared purpose formed in the pandemic brought opportunities, such as tackling homelessness across the council. A local homelessness reduction board was established under the health and wellbeing board and a small amount of funding “blossomed into” a permanent team working largely to support homeless people to access primary and secondary care and other support.
Patrick Flaherty, MFPH, Chief Executive Officer
"Since joining the council, the public health team have significantly influenced all service areas, from adult and children’s services, through to libraries, highways, waste services and finance.
Health in all policies is truly becoming a reality in Somerset. Huge strides forward have been made in the past ten years with much more to come, but the foundations have been well and truly laid.
Somerset is in the process of embarking on local government reorganisation, working towards a new unitary authority in April 2023. An integral part of the business case for this has been the benefits to the public’s health, an argument successfully made by the public health team using their expertise in evidence-based practice and outstanding knowledge of data and intelligence. The exciting future for local government in Somerset will see public health become even more central to the new organisation and the new integrated care system."
Future plans
Prevention is everyone’s business. The development of Somerset ICS provides an opportunity to inspire the health system to recognise that it can improve health and tackle inequalities as part of its everyday work.
- Somerset is preparing to become a unitary council in 2023, merging four district councils with the County Council. Work is taking place to re-envision public health and shape how health and wellbeing can best be led, organised and delivered across the new structure and alongside Somerset ICS. Ensuring that health protection functions are robust will be a priority as well as a far greater emphasis placed on tackling inequalities.
- Some communities, towns and villages are becoming active in promoting health and wellbeing; for instance, Frome is funding a health and wellbeing coordinator through its precept. An integral part of the new unitary council will be the development of local community networks, supporting and promoting community action and more local decision-making. This approach, alongside the developing PCNs, will provide joined-up with place-based integration, bringing opportunities for community action on health and wellbeing.
- PCNs also provide a mechanism for improving population health data and information, and further developing population health management techniques. The public health team is currently working with PCNs on reducing hypertension as a population health management demonstration project. The vision is to inspire and develop a distributed leadership model of population health improvement, embedding methodologies like population health management and making every contact count (MECC) right across the system workforce.
- Health needs are changing with the pandemic. Some, like various health inequalities, are already identified, others are not yet known; some will be short-term, others will require long-term support. Public health needs to be alert to changing needs and should be central to assessing them, ensuring they are well understood throughout the local system and are used to drive local policy, service development and decisions.
The increased profile of public health during the pandemic provides a window of opportunity to promote work on health and wellbeing across multiple partnerships. To make real progress the NHS needs to place a far greater emphasis on funding and embedding preventative action throughout its activity but with a real focus initially on reducing the healthcare inequalities.
Attracting the workforce to Somerset is a significant challenge for some sectors and medical disciplines, but it has invested significantly in developing the public health team over the past few years and this has stood up in good stead for the management of the pandemic. This progress has recently been reinforced still further through collaboration with the University of the West of England, and the development of a new public health apprenticeship programme, aiming to make a career path into public health even more accessible and attractive.
Would you choose the same path?
100%! 110%! I can’t think of a better job. It’s the best job in the world…and even more of a pleasure in Somerset as I serve the people in my home county!
