An interview with Dr Louise Smith, Director of Public Health, Norfolk County Council.
Key messages
- COVID-19 has been a harsh lesson in the importance of public health – health affects everything we do and should never be taken for granted; greater national funding and more investment in public health systems are needed.
- The pandemic has worsened disparities and health inequalities; we need to pursue a levelling-up agenda and target people who will most benefit from public health support.
- Recruiting skilled staff was difficult, even before the pandemic – training to develop and expand the public health workforce is needed. On a positive note, remote working has increased flexibility in recruiting trained specialists.
Louise Smith started her career in medicine, working in obstetrics, gynaecology, and paediatrics. She was interested in medical politics and was aware of the impact of poverty and deprivation on the health of patients she treated – cases like a teenage girl who had had a miscarriage in a hospital without any friend or family support. It was a logical move into public health to try and achieve system-level change. Louise spent some time as a senior medical advisor on women and children’s health in Scotland before becoming an NHS public health consultant in England and a deputy DPH in local government. She became DPH in Norfolk in late 2015.
The move to local government
We were able to prioritise health visitors – they were no longer ‘number 60’ on the long list of priorities for community services.
Louise found that working in a local democratic system has a clearer scheme of delegation and authority compared to the NHS. Democratic decision-making through the portfolio system sets the local direction, and if public health operates within this and within budget there is far more scope and freedom to tackle priorities, alongside an expectation that it will get on with the job. This brought “massive benefits” such as being able to work with services that needed more attention, like sexual health, improving commissioning, and developing innovation.
Councillors have a direct link to citizens and people who use services and advocate on their behalf. The relationship with the portfolio holder has been very helpful in bringing the voices of communities into public health. The move to local government also significantly widened the set of partners and led to a far greater influence on the broad system issues that affect people’s lives.
An initial challenge in the move was how to establish health and wellbeing as a priority within a wider set of priorities – particularly in the early days when councils were learning more about the role of public health, and public health was learning about councils. Whilst NHS colleagues value health as a priority, views in local government are sometimes more nuanced – balancing wider outcomes such as the economy, and individual choice as well as health outcomes. This means that public health has to set out a clear evidence base for its proposals.
Councillor Bill Borrett, Portfolio Holder for Public Health
If there is one lesson we have learned from the pandemic, it is that prevention is more critical than ever. The leadership shown by our public health team during this difficult time will help us to continue to drive our prevention agenda in Norfolk, supporting our district councils to improve the health and wellbeing of our communities.
Councillor Andrew Proctor, Executive Leader
We have shared so much during the pandemic; new partnerships have been forged with a simple shared message about what we can do better together to protect ourselves and others – a message and approach that we will take forward as we support our communities into the future.
Changes since the move
The opportunity to tackle the broader health threats facing the county to prioritise prevention has been very exciting.
Louise became DPH in Norfolk at the time of the 30 per cent reduction to the public health grant. This involved an early requirement to reduce activity, which made partnerships and networking initially more difficult. The voluntary and community sector faced many reductions, which was very hard, given that they provided support valued by local people.
Some major reforms, such as service recommissioning, were already in place and operational, which allowed public health to look at some of the wider health issues in the county, including the social determinants of health. Norfolk is a large, disparate county with rural and coastal inequalities but also high-end skilled tech and green jobs, a tourist industry, and high levels of retirement that contribute to an ageing demographic.
Men’s mental health and suicide is a priority, and a range of interventions was put in place. Other areas of focus were a national beacon project to reduce domestic abuse and improvements to accessing services through digital technology, most recently as a national pilot delivering drug and alcohol treatment orders.
Public health is embedded in the county’s environmental and community services, and an early focus was resilience, emergency planning, targeting inequalities and promoting wellbeing with district councils.
Work on the pandemic has brought some positives – deeper partnerships, shared understanding and better data on schools, business and communities. New partnerships have emerged, and new staff have joined the public health team. All this provides a legacy for the future.
Although no planning could have fully prepared areas for the enormity of the pandemic, the partnerships with communications teams, resilience and emergency planning, and with community services such as libraries and customer services “helped enormously” with Norfolk’s effective response to COVID-19. Public health helped guide and land the local response and aimed to communicate with the public with straightforward and clear messages. The response has been effective, with some of the best performance in testing and contact tracing in the country.
Media relations have been enhanced over the past 18 months and more with Louise becoming a trusted commentating and informative voice in Norfolk.
It was possible to maintain crucial services in the pandemic, often due to previous investment in digital services. For instance, there has been a large increase in health visitor contacts and online access to sexual health services. Although less face-to-face activity has been possible, satisfaction with the service continues to be strong.
Future plans
- Dealing with the continuing threat of the pandemic and COVID-19 recovery continue to be the highest priority. Strong partnerships and improved data infrastructure will be built on and linked with population health management approaches across healthcare.
- A proactive approach to further strengthening resilience, emergency response and infection control in vulnerable settings such as care homes is in place.
- As part of recovery, less urgent services will now be re-prioritised – for instance, a large catch-up in NHS health checks is planned, bringing in new service providers to bolster primary care capacity. Services will also be reviewed and evolved to target people most likely to be facing health inequalities.
- The development of place-based working in Norfolk and Waveney ICS is another opportunity. Integrated health and wellbeing partnerships will align with council districts. The district councils in Norfolk are already involved in health and wellbeing initiatives (for example, community champions in Yarmouth, young people’s mental health and wellbeing in Norwich and environmental health in Breckland). They are keen to do more to develop prevention and tackle the social determinants.
- Louise coordinates the east of England network of directors of public health, which includes nine public health councils. The network has provided considerable peer support during the pandemic and is looking to build on the sector-led improvement approach with a specific programme to build shared learning from Coronavirus’ response and tackle priority issues such as suicide prevention.
- Tackling drug and alcohol harm is a priority in Norfolk. The county received investment in drug and alcohol services from the Home Office for a three-year pilot of the targeted use of treatment orders for people headed for custody.
Both the council and the NHS in Norfolk have seen a lot of organisational and personnel change in recent years. Stability is needed so that both can fully get on with the job of developing prevention, health improvement and integration.
Organisations are facing huge demand pressures, often made worse by COVID-19. There is pressure on mental health services and huge demographic pressure from older people and people with long term conditions. The NHS in Norfolk is very keen to move beyond a treatment service to one which prioritises prevention, but this ambition is challenged by overwhelming pressures on services.
Recruitment of skilled staff is a challenge in Norfolk due to its geography. The move to video conferencing has helped to some extent, enabling public health to successfully recruit experienced staff more widely. But developing a trained public health workforce should be a national priority.
Would you choose the same path?
Yes – there are so many opportunities to make a difference in this role. The work is constantly changing, there is a lot of energy from colleagues and partners, and this keeps the work fresh. But the pandemic has been relentless, and care and support for everyone is needed going forward.
