Bruce Laurence, ex-DPH Bath and North East Somerset
I was a director of public health in Bath and North East Somerset for the first 14 months of the covid pandemic. I was also consultant in charge of health protection in Derbyshire during the 2009 swine flu pandemic. Previously I worked for many years in international medical relief with involvement in a range of outbreaks including cholera, dysentery, kala azar, lassa fever, TB and malaria. These reflections are mainly specific to the covid-19 pandemic as it is recent, and my involvement was UK-based. Some of this will also be relevant to other situations although, of course the nature of each disease, its transmission, its effects, and the context in which an outbreak occurs will greatly alter the details of prevention and management.
To make this article reasonably short and easy to follow, I will frame the article as a set of key points.
The English health protection system is very complex.
DPHs had many roles in the covid pandemic, but a central one was as a leader of the local system. The “system” that governs health protection in England is extremely complex. At the start of the pandemic PHE provided direct HP expertise in terms of epidemic monitoring, outbreak control policy development and operational expertise for outbreak management. The NHS, itself a super-complex network of organisations, obviously provided medical care to people who become ill (and later led on the vaccination campaign). Councils control adult social care and have a vital role in understanding in detail and communicating with their local communities. Educational establishments for all ages were major local players. The government decided early on to set up the national track and trace system as a new and stand-alone organisation which had major long-term consequences. In certain situations, the army played a role too.
Just in case this level of complexity wasn’t already too difficult to master, the government also decided half-way through the first year of the pandemic to abolish PHE, its main expert outbreak control resource, divide it into two, and put the health protection part in with “track and trace” as a new organisation. I would say that this was a thoroughly bad move, made for the wrong reasons, and announced in a way that was both destructive and disrespectful of an important organization and workforce.
The DPH as local system leader.
With this complexity no one could be said to be fully in charge of the whole, but at a local level the DPH was a figure who could bring all players together (to some extent), assess and provide an overview of the local situation and system performance, hold the main players to account (morally, if not with great official authority), and deploy their own limited resources to support local outbreak control. They did this through use and presentation of data and information, giving advice and practical support to settings like care homes and schools, making plans for the protection of vulnerable communities, support to management of excess deaths, and increasingly as the pandemic went on, with direct practical support to local track and trace efforts as the limitations of the central T&T system became apparent. The DsPH also functioned as chief advisers to their councils on both health and social aspects of the outbreak, and as one of their most important roles provided tailored communication to local, and often very diverse communities. In addition, DsPH co-ordinated their efforts at both regional and national levels and were the eyes and ears on the ground of the national effort, although not always much listened to.
Every DPH chaired some sort of local covid health protection committee and produced a Local Outbreak Management Plan. The management of covid was a gigantic team effort and while we and our teams were thinly spread across the local scene, I would assert that the DPH probably has the widest single view of the impacts of the pandemic, and of the system set up to prevent and mitigate those impacts. In such a complex picture partnership is all important. This has formal and “human” elements. A major part of leadership is to engage with hard-pressed partners on a human level. Looking round the country it was striking that systems can only work as well as the interpersonal relationships between members allows. Personally, I used a lot of humour in my management of the network, which along with clarity of purpose and good administrative back-up, hopefully supported collaborative enthusiasm, a high-energy working environment, and a welcome diffusion of tension. I was also very obsessive about being honest in my presentation of data, in my assessment of future trajectories, or in giving opinions on the effectiveness of control measures when evidence was limited. I was careful never to over-state a case to win temporary influence, as that would quickly have undermined my local credibility. Every DPH has a different personal style and set of colleagues and counterparts, but all would agree that they had to use as much interpersonal skill as technical expertise in managing this pandemic. For all DsPH, Councillors are one of the most important stakeholder groups and many of us would say that this pandemic led to a higher level of joint-working and for many a higher level of challenge than ever before as the prominence of public health as an important issue, DsPH and their teams rose so high.
Information.
In any outbreak gathering and use of information is obviously key. Of course, when we are faced with an outbreak of an entirely new disease this takes on a new dimension as you can’t take effective control measures until you know something about the virus and the disease that it causes. I would say that for practical purposes, one might differentiate two kinds of information. One is the general understanding of how the illness spreads, the impact of possible preventive measures, the immediate and longer-term health effects and how these might be managed. This kind of knowledge is ultimately based on local experience and data in health services and communities but aggregated and processed at national and international level and informed through the work of an array of scientific experts, in many different scientific and technological disciplines.
The second main type of information is what could be described as the detailed local picture. This includes the number of cases and their distribution in the population by such categories as age, sex, and ethnicity, impacts on the health and wellbeing (including mortality) of distinct groups and on health and care services, education, and the local economy. This can also extend to relevant comparisons with other areas, projections forward of the possible course of the outbreak, and data on the extent of vaccination and the success, or otherwise, of with other control measures in the community, including the test and trace service. Obviously both categories of information are of interest to DsPH but it could be said that they are very particularly the specialists in local picture and that this is a major source of their system leadership, and they are expected to both understand and present this to all local stakeholders in ways that support the outbreak control effort.
A key point to make on information is that in a new situation like covid, so much is not known at the start and yet decisions must be taken long before a full understanding has emerged. Many of the controversies around this pandemic, particularly early on, occurred when scientists, policy makers and politicians were trying to make such decisions eg. about use of face masks or the extent of lockdown procedures. Only retrospect (may be years hence) will show which decisions were the best in terms of outcomes. But faced with such situations, all one can do is to get the best existing evidence, use knowledge gained from previous outbreaks judiciously, and find some balance between being decisive enough to develop workable plans, while being flexible enough to amend views and plans as understanding develops. Unfortunately, the covid pandemic showed how some people in positions of power too easily became attached to clear, fixed and simplistic views that played well to certain political constituencies but inhibited an effective response. The UK certainly has a mixed record during this pandemic and some significant mistakes have been made (one of the worst being the discharge of many undiagnosed cases from hospitals to care homes at the very start of the outbreak seeding many devastating outbreaks among some of the most vulnerable people). But perhaps one of the more positive points is the relatively good cooperation between scientific experts, notably the Chief Medical Officer, and senior politicians, at least for the first year, even though there was certainly a lot of intense discussion and negotiation behind the scenes.
A final point about information, but that really applies to everything about the outbreak, is the importance of learning and applying lessons based on decisions made and their impact on national health and wellbeing in the widest sense. Some of this needs to be an almost continuous process so that the system and policies can be improved and refined in real time, while at certain points during the course more formal evaluations may be undertaken. Unfortunately, experience suggests that many factors can hamper lesson learning (and implementation of those lessons) including the sheer pressure of work, the lack of resources to evaluate effectively alongside operational work, the common reluctance of people throughout the system to being criticized, even implicitly, (and politicians, perhaps most of all), and the fact that when an emergency is over everyone involved wants to more on, recover and make up lost ground, and there is always the next challenge or crisis to deal with so the past is easily forgotten. And finally, to implement lessons learned almost certainly requires spending more money on people or equipment, that then impacts on other equally pressing needs in an always resource-constrained national system. My experience suggests that lessons are most easily learned at local level where there are very short feedback loops, and people can see the results of their actions and are therefore willing to change direction. But the freedom of action at this level is very constrained by national rules and policies. However, I should counter this by also pointing out the value of having clear rules and policies coming from the centre. Flexibility and discretion can easily become confusion and conflict when people want, not surprisingly, to interpret rules to suit their social and commercial interests, and some of the examples that I will give at the end of this article reflect such situations.
Levels of planning and operation.
In any significant emergency, planning happens at different levels. A common way to express this concept is to identify strategic, tactical, and operational levels. In the UK public sector these used to be called Gold, Silver, and Bronze. I always found this a poor notation because it implied that one was more important than another whereas all must work well and work well together (and in my opinion, while Gold typically is where those with most system authority sit, the most expertise is often to be found among the tactical and operational folk).
How did this work during covid? Put very simply, the strategic level of planning was where the big decisions about the general direction of national policy, the nature of the covid specific services like Test and Trace, the large-scale allocation of resources and the basic rules by which different areas of society (care homes, schools, businesses, and individuals) were to respond to the crisis. Practically speaking, the players here were national politicians, senior national health advisers such as the CMO and the SAGE committee, and national level leaders in the NHS and other sectors.
The tactical level of planning covers a wide set of people and situations but could be seen as sitting with local leaders, often working in regional or sub regional networks working within the parameters of rules and resources from the strategic level and using and interpreting and using them to create workable systems across the country. Networks such as Local Resilience Fora were prominent in this effort as well as specially developed regional networks often involving DsPH, regional health protection specialists, reps from health and care services, test and trace services, police and others. The DsPH probably worked mostly at this level. Individually and collectively we did have some influence on the national strategic discussions that set policy (although maybe not that much), and all of us provided oversight of, and often got stuck in to the details of local operational issues personally or through our teams, but I would take the view that the tactical level was probably where we made our main contributions.
The operational level is where front line work is managed, in health and care and humanitarian aid services, educational establishments and many more. This work also includes the intensive communications effort to inform the public, and all local organisations and businesses of the outbreak and their role in controlling it. At this level members of my team worked with local managers of all these sectors providing detailed support with information, training and sometimes the provision of direct resources. As the test and trace service set up nationally faltered, all DsPH set up local extensions of these services, and getting the local and national to work well together was certainly one of the challenges that we faced.
Some examples.
Some of the more interesting and challenging parts of the DPH role during the pandemic arose when local discretion about covid rules led to conflict between different groups in the community.
Each year Bath hosts one of the largest national Half Marathons. The previous year this had been called off due to snow for the first time, so the organisers and the runners were keen to get it back again. It was scheduled for March 15th. This was a most tricky time in the course of the pandemic because Bath area had had zero known cases until March 11 and in the UK generally there had only been a handful, and most sporting and cultural events around the country were continuing. Furthermore, asymptomatic transmission was strongly suspected, but not entirely proven. Also, the event is essentially an outdoor one. But on the other side of the argument, the pandemic had clearly started, some people getting to the event would be coming by trains and buses, and people would meet in cafes and bars afterwards. Had it been planned for just a few weeks earlier, no one would have thought twice about it, and if it had been a few weeks later it would have been unthinkable. As it was, it was a judgement call.
The Council did not have the official authority to stop the event, which was within government rules and privately run, but it does have a strong influence. There was some local opposition to the event but not a great deal. In the end, after advice from myself, the emergency planning team and others, the Council agreed not to oppose it going ahead, but asked that a number of conditions be applied to course and event management that minimized risk during the event, (but could not eliminate it). As Bath and North East Somerset had very few cases for many weeks afterwards, and remained one of the lowest areas during the first wave of the pandemic, this event probably had minimal impact, (and some health and wellbeing benefit as with any large public participation sporting event). But it could have worked out differently, and there was a nearby example of the Cheltenham Races where a slightly different type of event at the same time may have been one of the early super-spreader events.
Similar sorts of calculations were made over local events like the Bath Christmas Market and the University of Bath graduation events in 2021, and over closure of children’s playgrounds or care homes with cases when there was local discretion. In all these situations, the DPH is one of the influential voices and their role is to steer a reasoned discussion that assesses the risks of viral spread and its consequences against the very significant mental and physical but also social and economic consequences of lockdown in its different forms. These are almost never decisions that can be reduced to simple calculations that give clear answers, but are complex ones that require comparing different categories of benefit and harm, against a background both of scientific uncertainty and strong public and political views on both sides of any debate. And of course, social cohesion and the legitimacy of decisions depends to a great extent on the process of coming to those decisions.
One important role of DsPH and their teams was to engage with and support particularly vulnerable or hard-hit communities. Bath and NE Somerset does not have large ethnic minority groups which a lot of my colleagues spent a lot of time and effort supporting but as an example of such a group we do have a “boater” community of folk who live a semi-mobile life on the local canal in quite tough circumstances, They are something like a water-born Gypsy and traveller community. They do not easily use local services and over the years we had made some efforts to bring preventive health care to where they lived on the Canal. So, when we wanted to provide vaccination to this community, we used a method of doing them on a boat that we hired as we had piloted with the previous flu vaccination campaign. This is just one very small-scale example of a large set of efforts across the country.
Crises can sometimes facilitate positive change.
A final reflection I will give is that some opportunities came out of the extremity of need during the pandemic. One local example is how community and voluntary organisations managed to work together in ways that we had been trying to achieve for years but had not managed to. Within weeks of the pandemic taking off our local community health services (under Virgin Care) and the local third sector group coordinating service had set up a virtual, and later physical “one stop shop” that residents could access through a single phone number, and which could triage and refer people in the community with a wide range of covid related needs from mental health support, to food packages to increased social care needs. The same system also created large volunteer network that assisted with basic humanatarian support work. Members of the public health team were involved in this effort in different ways. Similar stories arose in other parts of the council and health services of people being freed up from bureaucracy’s usually heavy hand to work in more flexible ways, sometimes making much greater use of IT and remote contacts. So as well as all the many and very significant negative impacts of this pandemic, there are some positive things to build on.
Finally… a word about public health and politics.
It is obvious that the way this pandemic played out owed much to political views and influences in the UK and internationally. I have always maintained that there is no such thing as a politics-free public health because health is impacted by the whole range of societal choices about use and distribution of collective resources and the rules under which all public and private systems are managed. These choices involve people’s values, beliefs and preferences and individual choices writ large become political positions.
I bring this up because one of all DsPH main roles locally was to interface with local politicians in Councils and to a generally much lesser extent with local MPs. Councillors looked to DsPH to interpret detailed information and present it honestly and comprehensibly, to give advice on local system management, to take sensible approaches to difficult decisions and to produce local outbreak management plans that would reassure constituents. This required some interpersonal skill on all sides, because local politicians were put in the unfamiliar position (also seen at national level) of having to give up their usual sense of “running the show” and allowing DsPH (who had not necessarily appeared high on Councillors’ radars before the pandemic and so were not all that well known) to become high profile and influential figures taking important decisions (within national parameters), and speaking directly to communities and media channels; and all at a time when residents and businesses were under much pressure, some of which was relayed very vocally to political representatives. And as you could see nationally, there was something of a symbiosis in this. If the DPH was seen to be locally credible, authoritative but also a listener and a good collaborator, it provided some defense to Councillors in the face of community concerns, to be able to show that they were taking good scientifically based advice, and achieving the best outcomes for residents in difficult circumstances. And from the DPH perspective, if Councillors felt that they were well served by their DPH, they would back up the public health decisions even in the face of public criticism. And I would like to end therefore by saying that in my Council, I had excellent support from the council leader and the cabinet member for health throughout and that in some ways the pandemic was something of a highpoint in the way that local politicians, senior council officers, the local NHS and a vast range of community and voluntary organizations, and, for the very most part, members of the public, came together in the face of a major threat.