The Association of Directors of Public Health (ADPH) has argued for the continuation of the Contain Outbreak Management Fund.
You can approach this from any number of angles.
The one I’m approaching it from is that both SAGE(The Scientific Advisory Group on Emergencies) and the World Health Organization have made clear that in order for the Government to meet its objectives in the Living with COVID plan there needs to be an ongoing baseline infrastructure and there also needs to be surge capacity. That’s either for another surge in infections or indeed another variant, if this virus does what it has been doing for the last two years. ADPH recently in its Living Safely and Fairly with Covid briefing (an update of our Living Safely with Covid Guidance from 2021) made these same points.
And the signs are that we are by no means out of COVID yet. The ONS infection survey for 4 March suggested 1.93m people in England had COVID, around 1 in 30 people. While less severe for many, that’s only because we’ve managed to get levels of immunity from vaccine up to the point where we are protecting against serious disease in most people.
And there are other signs that plain sailing out of COVID this is not. Hospital admissions are going up again in Scotland and in some other parts of the world, there is an increase in reports of this being associated with pneumonitis - inflammation of the lungs which can be very serious - and the number of people developing long COVID symptoms needing clinical treatment is also on the rise. While we’re at it, let’s address the ‘are people going into hospital with COVID or because of COVID’ issue. If a hospital bed needs to be occupied by someone with COVID, it’s more work and more demand on our NHS than if they haven’t. Did the tree that wrecked your roof come down with the storm or because of the storm? For practical service demand questions, that’s essentially irrelevant. You have no roof.
There are continuing jobs for local authorities to do beyond the pandemic phase, and as we transition into what comes next. Supporting and advising businesses, continuing to support people who remain more vulnerable, managing outbreaks in high risk or high consequence settings (eg care homes) and addressing inequalities continue to be areas for us, before we even address the need to help the next booster get into the arms of those most needing the protection it will afford against severe disease.
It is quite clear that the local authority component of the response to COVID was arguably as important as that of national government and therefore the UK Health Security Agency (UKHSA), the Department of Health and Social Care and the Department for Levelling Up, Housing and Communities all identified that it is a risk to our biosecurity if we don’t have some contingency. That means funding, or cutting other work. Within local government (and in PHE) there has never been sufficient capacity for surge, or even a boots on ground operational health protection response. That lack of capacity was clear early in in the pandemic, thus local government subverted many other functions to enable place based operational response. This level of local authority response wasn’t possible without affecting other essential services, for example housing repairs, customer services, leisure provision (which had consequence including lengthening backlogs), and is not sustainable in the medium term without resourcing.
The second point is that in those areas that have spent most Contain Outbreak Management Fund (COMF) money are the areas that had highest transmission rates – termed enduring transmission - greatest inequalities and greatest enduring transmission. Those are also the areas that are most likely to be worst affected if we get another surge or another variant. those areas with highest levels of transmission throughout the pandemic. These areas, according to the Institute for Fiscal Studies, also experienced the most severe cuts in core funding during the years of austerity and thus have the lowest funding base from which to mount any necessary surge capacity. That lower funding base means it is conceivable that the recovery in those more socioeconomically deprived communities will be slower and harder.
There is a third point, which is that while it is almost random chance where a new variant comes from, it is entirely possible that another ‘home-grown’ British variant may emerge. If that happens then those areas of enduring transmission may be the areas where such a variant will arise. It’s also the areas where a new variant even if not ‘home-grown’ may hit hardest. Local DsPH are most likely to spot the unusual epidemiology and infection patterns of a new variant emerging, as we have seen before. It’s quite clear there is a memory and a corporate capability in most local authorities that will be lost if we don’t have some continuing COMF.
ADPH conducted a survey of what local DsPH and councils have been doing recently and found that local authority staff including environmental health officers have been absolutely crucial during this crisis, along with contact tracers and infection control nurses to deal with particular workplace settings, because there are some workplaces that COVID rips through. A range of other staff will also be lost if funding is not continued.
UKSHA and DHSC and DLUHC are absolutely right to point out that we need additional funding, and ADPH are fully behind them, and indeed we’ve made our own calls for it. This level of common cause between local and national has to be heartening. There are two major reasons we all recognise we need this money. First is the risk that we lose the capabilities we have for the next variant or surge, and the second is our own ongoing biosecurity. We need some transition money to be able to embed the learning and the memory from COVID into what happens when the next zoonotic infection or novel pathogen arises. The scientific consensus globally is that we’re looking at another ten years at best after COVID before another novel infection of the same level of public health severity arises.
The £100m called for by local government secretary Michael Gove and health secretary Sajid Javid is a good start. Obviously there are some local authorities that have COMF money carried over. So how more COMF is distributed would need to be very carefully considered. We need to come to a consensus on what a minimum level of capability looks like. We’re not there yet.
As part of any future strategy, we need to recognize that environmental health and regulatory services have fared badly during the last ten years. This group of functions have been critical during the pandemic, have a significant backlog of other work now (food premises inspections, which come with some public health risk) and focused attention must be given to their long term sustainability.
There’s a big levelling up component to this. One of the core planks of any sensible strategy on COVID - and it’s in the Government’s plan - is getting the highest level of protection from severe disease through the highest levels of population immunity possible. And that means vaccination. There is clearly a geographical and a social gradient on vaccine access and uptake and most local authority Health Protection Boards spent some of their COMF on helping vaccine uptake in populations most likely to bear the worst burden of disease and death. So if we want to keep the progress we’ve made we need to keep that equality drive in vaccination going, especially when the next booster comes for the people who are most clinically vulnerable. Otherwise we may start to see the mortality picture worsen in the poorest areas of the country, at the very time we don’t want that to happen.
Jim McManus is president of the Association of Directors of Public Health, executive director of public health at Hertfordshire CC and honorary visiting professor at the University of Hertfordshire