Inequality matters

By Ann McGauran | 25 March 2021

Matt Hancock’s ‘Big Bang’ unveiling of the name of the new agency to lead on pandemic preparedness could have hijacked local government’s public health conference this week.

Delegates at the Local Government Association (LGA)/Association of Directors of Public Health (ADPH) Annual Public Health Conference 2021 listened attentively to the secretary of state for health and care as he outlined how the UK Health Security Agency (UKHSA) would protect the country from infectious diseases and other hazards.

But the announcement did not overshadow a series of passionate, thoughtful, and forensic presentations, which prompted discussions on the most pressing issues confronting local public health leaders and their communities across the UK.

 In reality, the role and responsibilities of the new agency had already been well prefaced. The fact that it would bring together elements of Public Health England (PHE) with the Joint Biosecurity Centre (JBC) and NHS Test and Trace (NHST&T) has been known for some time. The organisation will be formally set up from the beginning of April.

Mr Hancock said that while it was crucial to have an institution whose ‘sole job is to protect the nation from external threats to our health, we must do that at the same time as the constant work for health improvement’.

He argued that health security and health promotion ‘are of course linked on many levels – for example obesity is a major factor in how ill you get when you get COVID’. He told delegates:  ‘We need to get better at both’.

In his view, both sets of activities need focus, including dedicated attention at the national level and strong connections to the local. Both had to harness the ‘dramatic innovations of the last decade and the last year, in data, in science, in research and so much else’.

He promised the Government would set out its plans for the future of health promotion ‘in the coming days’. For health improvement to be optimally effective, he stressed ‘it must be embedded in the heart of government – across government, local and national – and not at arms’ length’.

He was careful to say that ‘deep connections to the local level are vital’, and that UKHSA would work ‘in partnership with directors of public health and our partners in local government’. And he praised local government and national resilience forums for being at the forefront of the national pandemic effort.

Mr Hancock underlined a future role for Integrated Care Systems (ICSs)  - which the recent health and care white paper confirmed would be moved onto a statutory footing. He said: ‘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.’

He added: ‘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.’

Mr Hancock said 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’.

A year on from the first lockdown, the conference provided a forum for delegates to both take stock, and to raise their concerns, in the context of COVID, about the cumulative impact of years of cuts to public health funding. They also looked at the role of public opinion in public health - and, crucially, focused on the challenge ahead for health inequalities and recovery.

A blistering Public Accounts Committee (PAC) report earlier this month on NHST&T concluded the programme made no difference to reducing infection levels and said there was no clear evidence to judge its overall effectiveness, despite a budget of £37bn over two years. The report also questioned why the programme failed to draw on local expertise at the start.

But the outgoing NHST&T chair Baroness Dido Harding put forward a spirited defence at the conference, describing an approach she said had been based around ‘locally-driven outbreak management’. She highlighted a ‘local to national network of sites and labs’, with over 2,600 Test and Trace and community testing sites.

She added: ‘The key message I would want to land is that this has all been about locally-driven partnership - the outbreak management work that we’ve done together.’

Baroness Harding said she had been ‘hugely helped by having local authority leadership in my team from day one’, praising the work done by chief executive of Leeds City Council Tom Riordan, ‘who joined me in the first week in May, and now Carolyn Wilkins from Oldham (MBC)’. Both ‘have been in the NHST&T leadership team throughout, and have been instrumental in shaping our approach to be one of local and national partnership’.

Rapid response surge testing teams were doing ‘phenomenal work’, and 26 areas were running Local-O (zero COVID) pilots, ‘looking to start local contact tracing instantly we get the index case testing positive’. On funding, she said local authorities had received £1.6bn in 2020/21, with a further £400m available from April via the Contain Outbreak Management Fund. Allocations will be based on the COVID-19 Relative Needs Formula, which she said would ‘map well against areas with enduring transmission’.

But president of the Faculty of Public Health Professor Maggie Rae challenged Baroness Harding’s view that tackling the pandemic had started with the involvement of local public health. ‘This pandemic didn’t start with local. In fact, I think it’s fair to say the local systems were bypassed unfortunately.’

The LGA has called for public health funding to reach at least £3.9bn by 2024/25 to match the growth in overall NHS funding. Prof Rae called for a percentage of  the ICS budget to be allocated for prevention – ‘though that doesn’t mean to say we shouldn’t be putting in business case bids to the spending round’.

Chair of the LGA’s Community Wellbeing Board Cllr Ian Hudspeth said responding to and recovering from an outbreak of this scale should start at the local level, working closely with national agencies.

He added: ‘The UKHSA needs to be able to operate nationally as a global player to major health threats. This needs to be aligned with councils’ ability to react swiftly on the ground, using their local knowledge, expertise and skills.

‘It is vitally important that we clearly define the role and accountability of each, as well as devolve more leadership, control and resources to councils.’

Health inequalities between the most and least deprived have been exacerbated by the pandemic, he stressed – ‘so any future model for health protection needs to be intrinsically linked with health improvement, if we are to realise real improvements for our residents.’

The need to prioritise tackling inequalities within any future model for health protection was returned to frequently by many of the event speakers, including chief executive of Manchester City Council and president of Solace UK Joanne Roney.

She concluded: ‘There needs to be a relentless focus on inequality. To do that you need a stable long-term financial settlement, and we need to push for that.

‘You need prevention to be recognised as a crucial part of NHS recovery, and our learning around our communities and what effects the greatest change for population health has to be at the heart of any system configuration.’

The Local Government Association's Public health annual report 2021: rising to the challenges of COVID-19, is available here

Hancock launches 'dedicated, mission driven institution' to halt future pandemics

Whitty defends decision to centralise initial pandemic response

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