Jim McManus is Executive Director of Public Health for Hertfordshire and President of the Association of Directors of Public Health.
Hertfordshire County Council recently approved its new Public Health Strategy (2022-2027), produced by multiple stakeholders including elected members. One of its main aims is to continue reducing the health inequalities existing in the county, which have been brought into sharp relief and worsened by the COVID-19 pandemic.
Our strategy recognises that Public Health has a major role to play in fulfilling the council’s corporate strategic priority – for our residents to lead healthy and fulfilling lives. We want to ensure we continue to develop and deliver a range of preventative services promoting health and wellbeing for all residents, particularly targeting people most in need. The strategy sets out the role of Public Health in getting there, and means citizens and partners know what they can expect of us.
This is important, because while the county’s health statistics are mostly favourable compared to national figures, there are persistent health inequalities, especially, but not only, in areas of deprivation. To take one example, we have historically significant and large Gypsy, Roma and Traveller populations across 55 sites. The work they are co-leading with us on suicide prevention, education and training and vaccination uptake will reduce inequalities.
The COVID-19 pandemic led to many more people experiencing inequalities through changed economic, employment or health circumstances. Several new health challenges have also arisen in Hertfordshire, including long Covid, an increase in mental health needs, more widespread harm from drugs and alcohol and increased numbers of overweight and obese adults and children.
The new strategy outlines our vision and priorities and highlights how, informed by best practice and evidence, we will work with colleagues, partners and communities to reduce health inequalities and support healthy lives for all.
A great example of how we are already doing this, is our Shape Up Together programme. Originally launched as Shape Up in 2015 to address inequalities in mens’ access to healthy living support – it was funded by Public Health, the Premier League and Hertfordshire’s district and borough councils, and run by Watford Football Club’s Community Sports and Education Trust. Delivered free, the programme aimed to improve the lives of men with a BMI of above 30 through bespoke programmes. Since its launch, over 1,000 people have collectively lost seven and half tonnes of weight and that’s just one outcome.
Although Shape Up continues to run, last year we identified a need to develop a programme aimed at some of our Black, Asian and Eastern European populations, people with a physical and/or learning disability and people with severe mental health issues. As a result, Shape Up Together was born. Although still in its early days, Shape Up Together (which is open to both women and men) is set to be as successful as its predecessor.
In May, we invited community and voluntary organisations to apply for grants of up to £10,000 each, funded by Public Health, to develop innovative community projects which responded to local needs and focused on promoting mental health wellbeing through physical activity.
With a specific remit to tackle inequalities by building resilience for residents with low to moderate mental health problems, the programme has awarded just over £100,000 to 15 local organisations. Successful projects included some very creative ideas, from dancing and Nordic walking to horticultural gardening and wild play. We are working on strong pathways between these projects and Money Advice services to reduce financial inequalities too.
Equitable digital inclusion is a corporate priority for us, but lack of availability of online access must not disproportionately exclude lower-income areas. We are using Togetherall, an evidence-based, clinically-moderated, online 24/7 peer-to-peer mental health community, for residents aged 16+ who are feeling low or depressed. It can help prevent mental health unwellness with support and courses, plus the additional benefit of professionals monitoring for signs of distress. This is just one tool in our kit of mental health support, ensuring those disadvantaged by limited access to other services have an option, but at the same time we’re working to make digital access itself more equal.
With the full support of our Executive Member, Morris Bright MBE, who was persuaded that part of our work was identifying what our role was in a world where COVID-19 has worsened health inequalities, we hope the strategy will set us on the road to tackling these inequalities and placing Public Health firmly at the centre of a forward-thinking council whose aim is to help our residents lead healthy, happy, and fulfilling lives. You can read the strategy here.
The Commonwealth Games took place in Birmingham 28th July to 8th August in (for once) balmy, sunny weather harking back to the days of the 2012 London Olympics. Here is an account of the final months of a five-year journey that UKHSA was a key part of, through three registrars who worked on the project:
Steve Barlow, ST3
Steve Barlow – Pictured on ‘Black Sabbath Bridge’ in Birmingham, along with Games mascot Perry, and Cassie Gregory, Principal Health Protection Nurse from the West Midlands Health Protection team
When I joined the Registrar training scheme in 2019, I never imagined that there would be a global pandemic. However, this provided me with a unique opportunity to observe mobilisation of a combined local authority (LA), UKHSA (then PHE) and wider healthcare response to an unprecedented public health type incident. Interestingly, this also helped in building relationships which then played out on another global platform: the Commonwealth Games (CWG).
As part of the CWG team, given my previous knowledge and experience, my main workstream was liaising with LAs and Integrated Care Boards (ICBs). As with all CWG work, it required degrees of overlap to ensure that the health protection response was as cohesive and comprehensive as possible. This involved a series of meetings to define and document the whole system preparedness should any health protection issue arise from CWG. Whilst some may consider this business as usual, we needed to streamline the system, to make the response more timely by calling on local relationships built during the pandemic.
Through leadership, advice and influencing, I worked on assessing any opportunities, good practices, and gaps in each area’s health protection response, looking at role and responsibilities, trying to clarify and agree these, and then share this information wider to develop more robust systems. I documented the current situation with a baseline survey and through our discussions, helped to produce formal plans for each local authority area. With support from the team, I then held a workshop for all the LAs in which over 80 individuals attended, to put plans into practise through a series of scenarios.
During Games time we were co-located in the Games Operational Centre (GOC) which was fascinating. Here we worked with a number of commercial partners as well as a few familiar faces. From the beginning, we became established (with our branded UKHSA branded, teal-coloured tops!) and, I believe, added value as we were able to assess and control situations in real-time. As part of the legacy work, I am evaluating the local partnerships workstream and looking longer term to make the health protection planning, commissioning, and response more cohesive in the wider health and social care system.
Clare Brehmer, ST4
Clare Brehmer – Wishing her children goodnight on the phone, with Games mascot Perry in the background, whilst working an evening shift in the Games Operations Centre
As the last member to join the core CWG team (fresh from maternity leave!) I was keen to “hit the ground running”. From the start the team were incredible to work with as there was nothing but positive vibes – all of us had chosen to work on the Games and were excited to showcase our work in the West Midlands.
My main workstream was to help develop operational plans for the laboratory testing during the Games period. One quirk of the Games was that there were pop-up polyclinics at five accommodation sites across the region, with a 24/7 motorbike service to courier samples to our UKHSA public health lab at Heartlands site. These services were set-up by the medical arm of the Organising Committee for the Games and provided routine medical services for all athletes and officials residing at these locations.
At UKHSA, we provided bespoke packs of consumables to each site, to be used in the event of an outbreak. We also developed a pathway for surveillance and reporting of any results related to the Games, and a round-the-clock rota for specialist laboratory technical and microbiological advice. This brought together staff from the public health lab, the local hospital lab, the CPHIs (Consultants in Public Health Infection) and health protection team, in a collaborative effort to streamline the testing and reporting processes for the Games period.
Our UKHSA public health lab also started providing Monkeypox testing for all Midlands samples a few weeks before the start of the Games; a useful addition to cut turnaround times should any potential cases arise.
The workload ramped up quickly, with extended hours starting a week before the actual start date of the Games, to allow for an enhanced public health response as athletes and officials entered the country. This meant we were all well-versed in the “Battle Rhythm” by the start of the Games. I was involved in the early preparations in the Games Operations Centre (GOC), meeting partners and introducing UKHSA to many people for the first time. Event planning is not something we often get involved in as registrars, and it was exciting to collaborate with others in health and safety, venues management and security to ensure all plans were in place. Several people even approached us to ask about careers in public health. During the Games I have to say, it was very quiet! We had heard similar reports from colleagues involved in London 2012 Olympics, but I didn’t want to jinx it. In reality, we had a steady workload of low-risk incidents and cases which rumbled along for the duration of the Games. This meant there was plenty of time for learning as a registrar and even acting-up as the public health adviser to the Games. As expected, there was a certain amount of politics involved and people management, at times with conflicting views. However, we continued to work effectively with our partners while providing sound public health advice and this undoubtedly contributed to ensuring a safe and successful Games.
David Collyer, ST3
David Collyer – With family enjoying the athletics competition at the Alexander Stadium pictured with England 100m sprinter, Imani-Lara Lansiquot
I joined the Commonwealth Games project team in February of this year, and early highlights (and opportunities to meet other team members in person rather than just on Teams!) were visits to the Lee Valley velodrome, and to the prospective athlete villages. Regular meetings of our core project team meant that we all had a chance to discuss our individual workstreams, get help and support, and maintain a good overview of all the work that was taking place.
One of my areas of work was participating in a planning group for ‘Health Protection Operations’ during the Games, which included leading workgroups for 2 areas in particular – plans for how we would work with the ‘polyclinics’ in the athlete villages and plans for how we would make use of the Medical Encounter System (a bespoke computer system being developed for the Games to capture medical data).
My prior experience of health protection work was limited, so this was a very steep learning curve, but planning a health protection response ‘from the ground up’ was an interesting way to get to grips with how the different elements all fit together. I also updated the Birmingham Airport Health Protection Plan (one of the main ports of entry for the Games) which included an appendix to cover the Commonwealth Games, particularly the COVID testing requirements for arrivals/departures. This required working with numerous stakeholders including the Organising Committee (OC) for the Games, the airport, the local authority, and other UKHSA teams including the Port Health lead, and the International Travel Contact Tracing team.
However, the most challenging and time-consuming area of work for me was around COVID and our recommendations for testing during the Games. The plans evolved considerably as the Games approached, and it was fascinating to see how decisions made by external stakeholders were influenced as much by politics as by epidemiology! As part of this work, I was able to attend a weekly meeting with the Chief Medical Officers for various UK elite sports, which had been convened early in the pandemic to facilitate a return to competition. This was a brilliant forum for discussing our COVID plans for the Games, as well as an amazing opportunity to hear the collective wisdom of an eminent group of sports medics.
Ultimately there were no big outbreaks during this Games, but I felt reassured that we had all the structures and processes in place to detect an outbreak and respond should it occur. Despite this lack of ‘action’ it was also fascinating just to be in the Games Operational Centre, watching as an event of this huge scale unfolded.
The Commonwealth Games Project Team was great to work with. Although the work was challenging at times, and definitely pushed me outside my comfort zone, I always felt well supported. I learnt so much during the 6 months and will never forget the buzz in Birmingham as the event we had spent so long planning for, finally came to town! I would recommend getting involved with a similar mass-gathering event, to any registrar offered the opportunity.
Caryn Cox, Lead UKHSA Health Protection Consultant for the Commonwealth Games
‘Having public health registrars embedded in the UKHSA West Midlands Commonwealth Games programme team and leading on key workstreams in the planning and preparation phase for the Games was fantastic. Each brought differing skills and knowledge to enhance the core programme team.
Clare, Steve, and David also each voluntarily stepped up in the operational phase of the Games competition time – working both the 6am early morning shifts and midnight finishing evening shifts and across multiple weekends.
They also undertook a rota slot where they were the Public Health Advisory lead in the Games Operational Centre, sat along with multi-agency colleagues. I hope they were each able to gain the development and learning opportunities they were seeking, as well as enjoying the experience and joy of being part of the largest Commonwealth Games ever held – held by all to be a great success.
As we capture the lessons learned from this Games to transfer to future events as well as internally in the UKHSA, we have already noted and recorded that registrars should, where possible and relevant to their training, be an integral part in planning, preparation and response, as opportunities such as these do not come along very often.
Our thanks to the triumphant trio, Clare, Steve and David, as well as Dr Alex Cockburn, an ST5 West Midlands registrar who worked on the Games prior to Feb 2022 and laid excellent foundations for other registrars to follow. We now hand over the baton to the State of Victoria, Australia for the 2026 Commonwealth Games’.
I qualified in 1965 and having sampled hospital clinical medicine in London and Cambridge for 3 years I decided that it was not for me – I neither enjoyed it nor found it particularly challenging (interestingly at University I was told that reading medicine was a waste of talent and that I should do something really scientific!). With a wife and three children by this time I looked for a job that allowed more time with the family and which paid more than a junior hospital doctor’s salary. It never occurred to me to become a GP which would have satisfied these two criteria and instead embarked on a public health career as a Medical Officer at the Birmingham Regional Hospital Board. This post which introduced me to health needs analysis and the planning of hospital services for a population of 5 million was not particularly interesting but it allowed me to embark on the formal training pathway to become a qualified public health practitioner. Although the London School of Hygiene and Tropical Medicine was then offering a brand new 2 year masters training programme, encouraged by my Scottish boss I applied instead for the Diploma in Social Medicine Course in Edinburgh which I obtained in 1971.
Then I very rapidly climbed the new career ladder in Community Medicine as it was then called and following posts in Wolverhampton, Stoke on Trent and Wakefield I was appointed Regional Medical Officer at the North East Thames Regional Health Authority. Not only was a regional post as high as I could go in the profession, the region I was appointed to was in a class of its own among the 14 regions in England – It was in a very real sense the dream job.
After 7 years in this job I got itchy feet and fortunately another NHS reorganisation saved the day by introducing general management. So, having had a long term interest in management and been sent to the US by the NHS for management training, I applied for and obtained one of the new District General Manager posts in Frenchay, Bristol where I stayed for three years. Falling out with my Chairman who was an import from industry who knew absolutely nothing about the NHS and healthcare – such wrong-headed appointments were all the rage with the Government of that time – I moved back to community medicine and obtained a post as DPH for the Norwich Health Authority which I held for 5 years before moving to Wales, initially as a Senior Lecturer in Applied Epidemiology and then as a locum consultant in public health with the Dyfed Powys, Swansea and Mid Glamorgan health boards and ending my career as the Public Health Director for Ceredigion and Powys Health Boards.
While working in Wales I joined the Labour party, became Chairman of the Socialist Health Association and for a period was a City Councillor in Bristol for a deprived ward in the south of the City.
The only time I felt that I was practicing real public health i.e. public wellbeing, as distinct from applied epidemiology, was when I was a Deputy Medical Officer of Health in Wolverhampton and later a Bristol City Councillor. In both posts I had a real sense that I was working in an organisation that could control at least some of the main levers of public health – or more correctly public wellbeing – for the benefit of the local population.
The main influences on my career were Gerry Morris, Bob Logan and later Julian Tudor Hart. In it’s origins the Faculty was a relatively inaccessible organisation, and as such I was very supportive of the Public Health Alliance and its successor the Public Health Association.
A mistake made by the Faculty at its inception in my view was to limit membership to doctors only, and whilst the Faculty now has a much more open membership, as a young community physician this prevented me from engaging with or supporting the Faculty at that time.
My own experience was essentially positive, probably helped by working as a GP and as an academic in other countries, and away from the PH service work so I came back with new experiences and perspectives.
I qualified first in Dentistry in 1965 determined to continue with Medicine and a career as an oral surgeon or in dental medicine. An oral surgery job in Scotland was interesting but not for a lifetime and returning to Medicine I became fascinated by Social Medicine. The teaching was uninspired, but I got to know Jock Anderson, the Head of Department and he helped me to think things through (everyone else thought I was mad)!
I qualified in 1969 and there were house jobs at Guy’s and Guildford but a desire to go to Africa where Jock advised I could get maximum experience across the spectrum. Wife, 3-month son, we sailed for Cape Town and on to Zambia…. On my return 3 years later he supported my application for the 2-year MSc at LSHTM. The MSC.in Social Medicine was designed for the new Public health role of the 1974 changes, and a different background and content from the DPH. It was two years, a whole year for a research project and enlightened teaching in Sociology, Economics, Epidemiology, Statistics, Management – but best by far the other people on the course, with a good deal of clinical experience but a genuine interest in a community and preventive approach with an understanding of information and to make for efficient and effective services within a cost envelope.
I was appointed to Tower Hamlets as DCP in 1976 and was there until 1981. I was single handed and also managed Infectious Disease/ hazards like asbestos. There were major health issues with homeless alcoholics with TB and Bengali immigrants in sweat shops, in squalid accommodation and with TB, Typhoid, Diphtheria…19th century stuff. Nobody quite knew what a DCP did, so I followed my instincts in a deprived part of London with a famous teaching hospital. I also worked quite a lot in the old MoH model with the LA, attending meetings, medical housing, school health…and the Winter of Discontent plus major industrial action by the Health Unions. Frank Murphy was at Area, you came to Region, Spence Galbraith had set up CDC Colindale – there was HIPE, HAA (neither very useful and full of errors) and RAWP
I persuaded the HA to let me do a year as a P/T trainee GP as the next re-organisation was coming. I had done a lot of locums by then as we had a young family, I was offered a partnership in Bedfordshire where we had done several locums and the practice agreed I spend 2 days a week in PHM my salary going into the practice earnings and I did 2 days a week in Luton working mainly in planning and supporting /deputising for the DCP (the unfortunate David Josephs who became a good friend and took his own life).
After 8 years as a partner we wanted to get away from the London orbit and after a few attempts got the DPH job in North Devon in 1989. We have lived here since. Again (as in TH) I was singlehanded and had time and space to do my own thing. (There were excellent secretaries, a registrar and information expert to help). Again I worked across the interface with the LA and in the MoH mode, this worked well and with excellent GP’s and Consultants, a new Hospital and no serious deprivation it worked well. I got much involved with the health problems of sheep dip in farmers. And the Cinderella services as we worked through Purchaser/Provider, contracts, and a new Trust.
When North Devon joined with Exeter, I did not get the DPH job and after several tries in Britain I went again to Zambia as an academic teaching Social Medicine and an MPH course for 3 years. There was quite a bit of clinical medicine too – I visited a mission hospital alternate weekends where there was no doctor. There was the chance for research too – I have always tried to publish stuff and with moderate success ever since Zambia in the 1970’s.
Returning to Britain in 1998 I could not get a job in PHM – too old, too experienced, a loose cannon… several long locums and the best a long appointment looking at rare diseases which cost a lot and have to be planned and organised at regional or national level. This was fascinating and with computers and enlightened statisticians it was possible to build costed models of care reflecting need, demand, and practice.
However when I had struggled to get work I had applied for an academic job in Papua New Guinea – they tardily got in touch and after some heart searching went again alone (dangerous for wives) to teach mainly PHM as an MPH but also a whole range of stuff to undergraduates – from biochemistry to forensic psychiatry…
On return, and I had my NHS pension by then, I did 5 years as a GP with the British Army and became involved with various national bodies e.g. NICE. Information Standards. The best things in PH to my mind – The CDC at Colindale, The Cochrane Foundation and NICE
I liked being in the NHS rather than the LA and being able to talk “doctor to doctor” with clinicians. I was working before the purchaser provided split and in North Devon acted as a personnel manager for the Consultants. I liked being between Medicine and Management and trying to explain one to another. On the whole I was lucky with Chairmen and Chief Executives who let me get on with things, more or less unfettered. It is now much more difficult, tight job descriptions not much room to pursue possible problems.
I think there were lessons to be learned for the Faculty in their response to Nuclear weapons and opportunities to challenge Government. The BMA Board of Science produced good science, Brian Jarman measured deprivation and health.
Other doctors in PHM, generally good experiences, (a few rogues, idlers, and villains but so it is everywhere) and excellent registrars, I helped to train. The newer younger GP’s and Consultants seem more open and easier now we need care ourselves!
I have been very fortunate; I am glad not to be working in the NHS now but also miss the struggles and occasional triumphs!
The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.
Better Health For All 