Tom Riordan - CBE, Chief Executive, Leeds City Council
The pandemic has placed public health at the centre of public policy and left every household in the country in no doubt about its importance.
The profile of directors of public health has increased to reflect their role as trusted local voices. We need to make sure as COVID gradually recedes and we move into recovery mode that public health remains at the heart of our efforts to reduce inequalities, improve the economy and quality of people’s lives.
Professor Ivan Browne - Director of Public Health, Leicester City Council
The council threw all its resources at [tackling the virus] – it was not just a public health problem. We had the director of finance working on shielding and the head of property services focussing on testing.
This section identifies some of the main themes that have emerged from work on the pandemic. Some of these reflect the concept of ‘legacy’ – both positive developments that have emerged amidst the stress and uncertainty, which need to be recognised, nurtured and built-on, and challenges which will be ongoing for years to come.
Other themes identify learning about what went well and what could be improved to inform future activity in population health at local, system and national levels.
Public health at the centre of local health protection partnerships
Public health in local government is at the heart local work to tackle the virus. It provides the leadership, expertise, partnership-working and access to local resources that are fundamental to strong place-based coordination of health protection.
In recent years, local public health has tackled many serious outbreaks including HIV, SARS, Swine Flu, Bird Flu, Measles and Hepatitis A – always working with the NHS, local authority environmental health colleagues and other national and local partners.
Local public health is central to resilience coordination and helps tackle the health aspects of major incidents such as flooding – increasingly more frequent in the UK.
DsPH are always alert for the next disease threat and started to gear up when they heard reports of a virus spreading in China. As the intense work to tackle COVID-19 began, directors and their teams were at in the eye of the local storm, fulfilling the role of professional leadership for health protection.
This has been a fast-moving and complicated situation, with demands both national and local, and no blueprint for what was coming next.
Local public health has had to respond quickly, assess what worked, and change direction swiftly when needed. In June, the government formalised local government’s key role in the local response to the pandemic, with areas required to produce local outbreak plans, setting out how they would tackle COVID-19.
These were completed at record speed, within a month, because the actions were already underway and very often in advance of national guidance. The plans set out measures to be taken to meet local needs within key topics including:
Prevent spread by encouraging the public to follow social distancing and hygiene advice, to get tested and self-isolate if needed.
- Identify and manage local outbreaks in care homes, schools and other high-risk places and communities.
- Use national and local data flows and surveillance to proactively identify outbreaks.
- Support vulnerable people to get help to self-isolate and ensure support is available to meet the needs of diverse communities at particular risk from COVID-19, with a focus on health inequalities.
Tackling local health outbreaks requires a multi-agency response, pulling in skills, resources and capacity from across the council, the NHS, the wider public sector, the voluntary and community sector and beyond.
To support this partnership approach, ADPH, the Faculty of Public Health, the LGA, PHE, the Society of Local Authority Chief Executives (Solace) and the UK Chief Environmental Health Officers Group produced guiding principles for developing and delivering local outbreak plans.
In October, when more was known about tackling the virus, ADPH published Protecting our communities guidance on ‘combination prevention’ setting out a menu of evidence-based measures, ranging from infection control to communication and engagement, which could be used in combination and adapted for the needs of local areas.
Common purpose galvanises local partnerships
As the public experienced the fear and distress of a little understood and deadly virus and the limitation of their first lockdown, activity in local areas was fast-paced and unrelenting.
People involved in tackling COVID – across local government, the NHS and into the wider community – worked hugely long days under maximum pressure and returned to work early the following day to start again. There was so much to think through, decide, organise, and deliver.
At the same time, despite huge anxiety, many people involved report that this time had positive elements. Everyone was working together on the same goal. People emerged from organisational or functional silos and asked what they could do to help – both in personal contributions and through the resources at their disposal.
There was a strong feeling of camaraderie that went far beyond anything people had previously experienced in the work environment. Staff were redeployed across boundaries and trained in new roles.
Traffic wardens delivered food parcels, library and leisure centre staff supported community hubs, health visitors staffed helplines, voluntary and community organisations delivered leaflets: health truly was everybody’s business.
As organisations moved into the long haul of supporting people through social restrictions and implementing ever-changing measures to slow the virus there have been ongoing challenges. But despite this, an underlying sense of partnership and common purpose has continued in many areas.
Many contributors to this report describe a greater understanding of different partners’ roles, responsibilities and challenges, and a renewed commitment to integrating health and social care and tackling health inequalities together.
The fantastic voluntary and community response
Public health worked with partners on the first lockdown shielding regime, identifying and providing support for people at particular risk from the virus. Tasks included health advice, staff training, setting up community hubs for essential food and medication, and engaging with the voluntary and community sector to identify community champions.
The spontaneous enthusiasm of individuals was often overwhelming, with friends and neighbours stepping up to help people without family support so that public services were not needed.
Councils used existing relationships with the voluntary and community sector to engage with volunteers and developed new methods of engagement such as using online groups, digital recruitment and social media campaigns.
The voluntary and community sectors have remained fully engaged in efforts to tackle the pandemic, including supporting mass vaccination roll out. The role of community champions and networks has become increasingly important. Many areas have identified ‘legacy’ groups, organisations and networks of champions who will contribute to COVID recovery and beyond.
Birmingham has 585 COVID champions and commissioned 19 organisations to work with 35 communities of interest from older people with no digital access to Sikh communities and African and Caribbean communities.
The champions have played a vital role in engaging with the public and getting accurate messages across at all aspects of the pandemic from reinforcing preventative measures to encouraging vaccination.
Cheshire West and Chester launched Inspire Cheshire West as an interactive online space for residents to share stories of how neighbourhoods are pulling together under COVID-19.
Council teams also use the site to share ideas and information. In the first two weeks, 116 separate stories and ideas were posted, ranging from small acts of kindness to flourishing community initiatives.
The council is also keen to be transparent with the public so they can understand and manage risks, and has started broadcasting outbreak control management meetings online.
Doncaster’s system data model helped identify additional people who fell into the highly vulnerable group and needed shielding. Of the 9,600 people that were first identified as potentially needing support from the council, only 300 to 400 turned out to need help because family, neighbours, faith organisations and community groups stepped in.
Hackney published guidelines for community volunteers, including safety tips for residents who wanted to set up a private WhatsApp or Facebook group for their community. Working with partners, it also published an interactive map of support services filtered on the basis of residents’ needs such as “feeling anxious”, “feeling lonely” and “food and meals” etc.
In its interim report on COVID and Communities listening project, the Carnegie UK Trust found that work to develop hubs strengthened local partnerships and brought a real recognition of the value of volunteers and grassroots community engagement.
The Trust believes that hubs could have a longer term-role in recovery from the pandemic, connecting people to sources of support and promoting individual and community wellbeing.
Primary care network collaboration
Primary care networks (PCNs) have made an important contribution to the pandemic; particular, the capacity for collaboration within and across PCNs meant that the country was able to quickly set up and extend mass vaccination.
As a relatively new development, PCNs are yet to fully embed in some areas, and their role in integrated delivery across health and social care is generally at an early stage. However, the pandemic response suggests that PCNs can go far beyond a role in health and care delivery to become key contributors to the wellbeing of local communities.
In Calderdale, social prescribers worked with council neighbourhood staff and community leaders, going out into streets, shopping areas and mosques to inform people about the importance of the vaccine.
Local GPs serving vulnerable communities have been highly active in encouraging their patients to take the vaccine. Kirklees Council employs nine social prescribing link workers aligned to the PCNs in the borough.
They are now working in the vaccination centres providing a range of support including carrying out pre-vaccination assessments and monitoring patients afterwards.
Wigan’s pandemic response covering prevention, control, communications, PPE supplies, humanitarian assistance and keeping citizens socially connected is delivered through its network of seven multi-agency neighbourhood service delivery footprints, coterminous with primary care networks.
Collaboration across health and care systems, combined authorities and regions
While most of the direct work to tackle the pandemic happens at place level, the ability to collaborate across regions and health and care systems has been vital. Mature integrated care systems (ICSs) have sound partnerships and are well underway with their work on population health, so were in a good position to respond to the pandemic challenges.
Contributors to this report who are involved in systems, believe that collaboration during the pandemic will have a major positive impact on how they continue to work together on health and care integration, and prevention, including tackling the social determinants of health.
In many regions, directors of public health in neighbouring authorities have collaborated on shared priorities for years. These partnerships have formed an important focus for joint work across systems and regions – pooling expertise, support and resources.
Champs Public Health Collaborative is led by the nine Cheshire and Merseyside DsPH working with other partners. The collaborative approach is seen as critical for a joint response to tackling COVID-19. Measures include:
- a shared outbreak management framework to inform local outbreak control plans
- a series of joint public health position statements on a variety of key issues such as schools, asymptomatic testing and use of face coverings
- a local testing framework to manage testing demand, capacity and workforce development
- a shared contact tracing hub for complex cases, in partnership with regional PHE, to bolster the local response, staffed by a team of 20 local contact tracers
- behaviour change campaigns on mental wellbeing and information for young people
- a new integrated data and intelligence system for population health is being used for COVID-19 www.champspublichealth.com/
- In the One Gloucestershire ICS, the county council and CCG are coterminous with NHS provider trusts. Strong relationships and integrated services have made a big contribution to a shared COVID response. For example, in the first wave fire fighters were trained to take pillar one testing to care homes and then take completed tests back to labs before the national programme was rolled out www.onegloucestershire.net/
The ADPH London Network has worked with PHE and partner organisations in a pan-London COVID work programme to ensure a coordinated approach to outbreak management, prevention, recovery planning and mitigating the wider impacts of the pandemic, including the disproportionate impact on vulnerable groups and BAME communities. Measures include:
- ‘once for London’ resources such as PPE guides for local authority settings
- a mutual aid cell to enable redistribution of staff across the system and the onboarding of volunteers and other specialists
- daily sit-reps to monitor resilience and provide targeted support if required
- weekly webinars with DsPH and system partners to share learning, communicate messages and facilitate peer support and light-touch peer review. adph.org.uk/networks/london/covid-19/
Greater Manchester Combined Authority, on behalf of its partners, has begun a comprehensive programme of regular insight studies into the issues and impacts of coronavirus across GM as a whole and within its ten local authorities.
Initial research found that some groups were more negatively affected by the pandemic than others – for instance, young people, particularly aged 16-24, families with young children, BAME residents, LGBTQ+ people, people that have served in the armed forces, carers and disabled people.
The surveys provide a basis for targeted communication and engagement aimed at people working together to stop the virus.
In the North East, collaboration between directors of public health and with the regional PHE team is seen as crucial. Directors have met virtually two or three times a week since the spring.
Groups have been convened across the region to support the work on priority areas such as care homes, universities, children and young people, testing and community engagement. Directors take on lead roles working on behalf of the others and provide peer support.
Since its inception, West Yorkshire and Harrogate ICS has operated according to the principle of subsidiarity, which puts place at the heart of system. Mature working arrangements in the ICS have greatly helped a collaborative response to the pandemic in an area with high levels of health inequalities and subject to long-term COVID restrictions.
For example, the ICS established a population health programme in 2019, and staff and resources from the programme were shifted to the COVID response. A sector leads group has been meeting weekly since March and now has oversight of vaccine roll-out across the system.
West Yorkshire Prepared (local resilience forum) has helped establish test centres across the region, scaling up testing capacity with an expanded offer to a wider group of key workers and their households and bringing testing closer to where people live
An undervalued local public health system
From a local perspective, getting the right balance between national and local measures to tackle the pandemic has been an ongoing challenge.
There is appreciation for the hugely difficult job national government had in responding to the pandemic, and an understanding that some measures are most effective when coordinated and delivered on a national basis. Not least of these is the vital national decision to prioritise the development, purchase and speedy roll-out of vaccinations.
However, throughout the pandemic, local authority leaders have called for greater involvement in decision-making and better dialogue before national announcements about measures with implications for local areas.
Overall, they wanted greater recognition that public health, wider local government, and local partners have the skills, expertise, local knowledge and infrastructure to play a major role in combatting local outbreaks. Directors of public health feel personally responsible for protecting the health of people in their areas and felt huge frustration at not always having the tools to do this well.
Two key areas of concern were restricted access to nationally collected data and initial lack of local involvement in contact tracing. As a result of shared experience and learning between national and local organisations there have been improvements throughout the year, but this took time.
Restricted access to nationally collected data, particularly information about locations of people testing positive at postcode level, meant that local public health did not have full information to monitor, analyse, model and take action on local virus patterns and outbreaks.
ADPH’s Data Explainer provides a detailed analysis of problems local authorities had accessing data up to July 2020. It includes a ‘Data Manifesto’ which asks government and national agencies to adopt the following principles: local data sharing as the default setting, consistent access, high quality and comprehensive, and timely and useable.
NHS Test and Trace performance tracker was set up as a national system, often delivered through contracts with multinational private companies and a national call centre for contact tracing.
From the start there was criticism that this neglected local knowledge and capacity, and this grew when, for many months, the system struggled to contact 80 per cent of people testing positive. This is minimum effective level, as advised by the UK Scientific Advisory Group for Emergencies (SAGE) meeting.
In contrast, pioneering local test and trace teams set up in local authorities in partnership with regional PHE generally exceeded the 80 per cent minimum.
In August, the national system was redesigned to include local contact tracing, initially in areas with high prevalence, with resources from the national system transferred to local authorities which were tasked with contacting people testing positive who could not be reached within 24 hours, and people in complex settings such as care homes.
The combined effort meant that in December, national test and trace reached 86 per cent of people testing positive (Secretary of State 10 December daily briefing). However, limitations remained, with local teams required to pass on information about close contacts of people testing positive for the national service to trace.
There is a strong view in local government and public health that if local contact tracing had been resourced to take a greater role, this would have led to a more swift and effective system. The ADPH has consistently advocated for a ‘team of teams’ approach with the responsibilities of each part of the system clearly articulated and properly resourced in its Explainer test and trace service.
In the vanguard of new initiatives
At various stages in the pandemic there have been opportunities for local areas to be involved in national/local partnerships to trial new initiatives. Local government is ideally placed to do this because of its reach across infrastructure and communities, while partnerships between public health and academic institutions provides a good basis to pilot and evaluate new measures.
In November, Liverpool piloted asymptomatic screening tests for anyone living or working in the city, with tests available at a range of fixed and mobile testing sites including leisure centres, community centres and schools.
This was a partnership approach involving the local resilience forum, the army, DHSC, PHE, NHS partners, Liverpool University, and the voluntary and community sector. Around 25 per cent of residents took up lateral flow tests (LFT) and 35 per cent took up either LFT or a polymerise chain reaction (PCR) test.Over the month of the pilot, infections dropped by more than two-thirds.
Learning from the pilot has been used to inform national and local roll-out of asymptomatic testing. For example, the pilot found that sites should be socio-demographic not just geographic, and strong localised communication and engagement is essential because word of mouth is as powerful as social media.
An independent evaluation of the pilot will be published. The first centralised national contact tracing app was piloted in the Isle of Wight and promoted on the island community by the council, eventually being downloaded by around 54,000 islanders.
The pilot showed that the app had significant limitations, and it was abandoned in favour of a model that was compatible with all major smartphone services. However, feedback from the pilot was used to shape a second trial in August, again on the Isle of Wight and also London Borough of Newham, with its ethnically diverse community.Information about the Newham app was available in multiple languages.
The app operated alongside the enhanced local contact tracing and testing system driven by Newham public health team. It was promoted by a COVID-19 health champions network and neighbourhood outreach teams who went to churches, mosques, community centres, local businesses and other settings to offer help and provide demonstrations.
Problems identified in the trial were confusions about QR codes and lack of ability or willingness to engage in tech – some people preferring to provide pen and paper information. Newham advised developers to extend the download age-limit from 18 to 16 to get more young people engaged, involved and able to help older generations.
Learning from early local outbreaks
Over the summer there was a hope that COVID-19 outbreaks could be contained by targeted interventions in specific locations. At that time there were several significant highly localised outbreaks, generally in agricultural, industrial or hospital settings.
Also, as the country was relaxing restrictions, some public health teams were aware that levels in their local authority were not reducing as much as others, in fact they were increasing. This started in the East Midlands but was soon followed by areas in the West Midlands and across the North.
These situations were unchartered territory for public health, and took place at the time that national interventions, such as Test and Trace were just getting off the ground. The areas involved were able to pioneer interventions and articulate learning and key messages, not only across other areas but nationally. For example:
- Self-isolation was problematic for people on low incomes and insecure employment who needed to work to pay bills – this feedback contributed to the national £500 low-income payment.
- Workplaces were often COVID-secure, problems lay outside the work environment in car sharing and smoking areas.
In Leicester City, the first signs that the virus had not lost its hold started emerging in early June when the city started to get pillar two data. Because it was just the raw number of cases this was difficult to interpret, and hospital admissions were low. But soon it was apparent the increase was real, and Leicester became the first city in the UK to enter a lockdown.
The city was able to pull in resources quickly. Mobile testing units were deployed, and high-rate neighbourhoods were identified. Much of the early work, from setting up walk-in centres to offering door-to-door testing, was being done for the first time and was a steep learning curve.
The vital importance of neighbourhood-level data was clear, and the city made this point to government and hopefully influenced greater access to information for local areas.
The need to ramp-up capacity to test residents more directly led to the council establishing an outreach operation to distribute and collect testing kits door-to-door in the community.
By the start of September, the CityReach operation had resulted in over 40,000 tests being delivered. The council’s digital transformation team used a package to digitally recruit, manage and coordinate a large group of volunteers – in the first few weeks of lockdown over 500 volunteers had signed up.
Norfolk public health tackled an outbreak in a large local factory with a geographically dispersed workforce and many languages.
The council worked closely with the firm’s HR team: a review of infection prevention procedures set up by the factory was carried out and additional measures adopted, including the installation of more screens between workers and closing a reception area where staff gathered before work.
Financial support for workers self-isolating was needed, and £37,000 of council funding was spent on this. The government’s subsequent announcement of £500 for people on low incomes to self-isolate is seen as very helpful.
In North Somerset, a spike in cases at Weston hospital was the first major hospital outbreak when lockdown restrictions had been relaxed. Weston Super Mare is a popular day trip destination. Because prevalence data was not yet available, it was important to trace the source of the outbreak.
A mobile testing unit was deployed and whole-hospital testing took place. Public health worked with the PHE health protection team which was doing contact tracing, and with NHS Test and Trace which had launched that week.
Combined information showed that the outbreak was mainly within the hospital which changed some protocols and how it cohorted patients.
Balancing risks, difficult judgements
Tackling a pandemic is a rapidly evolving situation in which everyone involved has had to learn, adapt, persist, take risks and innovate, while operating under huge challenges and pressures.
While everyone is focused on the same goal, and there are some clear imperatives, there are also areas on which there are different views about the best way forward so judgements have had to be made.
Sometimes this involves balancing needs and risks to find the least-worst outcome. Throughout the pandemic, there have been tensions between the benefits of keeping people virus free and the negative impacts of individuals and the economy – between individual freedoms, prosperity, and collective safety.
Nowhere has there been a more distressing dilemma than in care homes. After early days of many deaths in care homes, moves to prevent virus transmission by restricting visiting have had a terrible impact on people who live there and their relatives and friends.
Another area of dilemma were mass isolations of university students when there were major outbreaks. With students likely to be asymptomatic transmitters of the virus, mass self-isolation restrictions took place to protect the community. But these were difficult decisions.
There were also differences of view about interventions among academics and public health experts. A prominent example is the use of lateral flow tests (LFTs). In December the government made rapid tests available to DsPH interested in using these in settings or communities that are local priorities.
Rapid testing is also being used in universities, at ports and airports, schools and many other settings. LFTs are non-invasive and have quick results. They contribute to the wider understanding of COVID prevalence and have the potential to break chains of transmission.
The Government’s evaluation is that LFTs are accurate enough for community settings. However, there is a debate in the public health and academic community about the circumstances in which LFTs should be used, how to mitigate any impacts from false positives or false negatives, and whether the significant resources needed to offer tests could be used more effectively.
The LGA produced a briefing on Lateral Flow testing on issues involved in rapid testing, and ADPH with the Faculty of Public Health produced a joint statement on targeted community testing calling for evaluating and learning from pilots.
Raised profile for public health
Awareness and understanding of public health in the general public and in organisational partners and colleagues increased markedly throughout the pandemic.
Local government leaders report that their role in the pandemic has been an irreversible game changer for how DsPH and their teams are viewed in local authorities and across wider partnerships, and their influence will continue into the future.
But for the public, just as social care became equated with care homes, public health is associated with tackling disease. The raised profile is very positive and should be built on going forward, but it will be important to emphasise that public health is a multi-faceted discipline with a large range of functions.
Its basis is in scientific understanding and its methods include epidemiology and understanding the social determinants of health, but it also involves skills like working at the frontline with individuals and communities. This span of functions gives public health its huge potential to make a real difference to people’s lives.