The greatest public health emergency of our time has been unfolding for at least three months. Yet England’s local public health directors have found themselves struggling to get a hearing, let alone a key role, in the fight against the deadly disease.
“It is remarkable,” says a rueful Jeanelle de Gruchy, the president of the Association of Directors of Public Health (ADPH), their representative body. “I think it reflects a historic lack of understanding of the importance of public health. As a society we tend still to think that a healthy population is created by the NHS – and it’s not.”
Does this lack of understanding extend to the highest reaches of government? “Without a doubt,” she responds, while adding that she exempts the chief medical officer, Chris Whitty, who she says has sought to involve the ADPH from the start of the Covid-19 crisis.
Directors of public health are senior doctors and other professionals, with further specialist qualifications, employed by the 150 bigger local councils to advise on health protection and health improvement and to lead on commissioning of services such as sexual health, drug and alcohol treatment, school nursing and health visiting. Their role is statutory and separate from that of Public Health England (PHE), the government agency that has faced criticism over its handling of the crisis.
Over the past fortnight, the directors have belatedly been drawn closer into national Covid-19 planning: on 7 May, the care minister Helen Whately issued a letter admitting that the testing programme for the disease in care homes needed to be “more joined up” and giving directors lead responsibility to coordinate and prioritise. Last Friday, the health secretary, Matt Hancock, pointedly spoke at the daily Covid-19 media briefing of “local public health officials playing such a critical role”.
The directors are now hoping to be influential also in the rollout of community tracking and tracing of Covid-19 carriers: the appointment last week of Tom Riordan, the chief executive of Leeds council, to lead on tracing strategy is being seen as a key pointer.
De Gruchy is reluctant to dwell on what might have been. “We are now being recognised as having an important role. I hope that will continue,” she says. “We need to do much better than handing down decisions to councils with a ‘made in Westminster’ label. That is what has been happening.
“We are not saying it’s one or the other, national or local. We are saying the scale of this is so large it needs to be multi-agency, a team of teams. Our position is that we want to be as constructive as possible, but as challenging as necessary.”
She says her members will use their leadership role to ensure that testing is prioritised according to local needs and that people get clear advice on contact tracing. In a statement of principles on tracing, published on Monday, the ADPH identified 11 key issues including greater responsiveness, local flexibility and effective data-sharing among relevant agencies, expressing “disappointment at the limited extent that government has involved local government in all aspects of the test, track and trace programme”.
De Gruchy is herself director of public health in Tameside, part of the Greater Manchester devolution partnership, and she operates de facto across both local government and the NHS. She says this has made it immeasurably easier to organise integrated responses to the Covid-19 crisis, especially on tracking and tracing, distribution of personal protective equipment, domestic abuse under lockdown and humanitarian measures. Some of her staff have been seconded to food banks.
Elsewhere, however, argument persists over the wisdom of the transfer of public health duties from the NHS in England to local government in 2013. And the crisis has raked over the coals. Would the overall response have been better, some ask, if the function had remained in the health service alongside hospital and community services?
De Gruchy insists not. “We absolutely need to be in local government,” she says. “We feel strongly that given the range of influences on health and wellbeing – and remember that healthcare contributes to only 10% to 20% of all our health – we are in exactly the right place to bring about change.
“But more than that, the NHS is fundamentally just not set up to focus resources on [illness] prevention. Yes it’s one of the best healthcare systems in the world, but its main focus is still on acute hospital care. And that’s where the money goes.”
She concedes that the cause of public health in local government in England was not helped by cuts totalling £850m in its earmarked government grant between 2014-15 and 2019-20. Research has suggested that the burden of resulting service reductions fell heaviest on deprived inner-city communities. In mid-March this year, just as Covid-19 was taking hold, ministers made an exceptionally late announcement of a real-terms increase of £145m in grant for 2020-21.
While welcoming the boost, De Gruchy reckons the system still needs £850m to get back to where it was in 2014, after allowing for population change. And she fears the impact of the present crisis on local government finances. “There needs to be proper recognition of the importance of ‘local’ to really get us out of this crisis – and if you recognise local, you have to fund local.”
Brought up in South Africa, where she qualified as a hospital doctor, De Gruchy moved in the late 1990s to the UK where she found her public health vocation and further trained for the role. She thinks the experience of growing up under apartheid primarily shaped her strong belief in social justice, but she also credits her family background – she comes, she says, from “a family of theologians” – and her experience as a gay woman. Covid permitting, she plans to marry her partner next January in a ceremony in South Africa.
She thinks the crisis has laid bare the deep inequalities in the UK. “It’s held up a mirror to society,” she says. “It’s people from particular deprived communities who are dying, it’s people from BME communities, it’s older people in care homes which have been calling for improved funding for a long time.
“We don’t want to go back to normal after this. There are some things about normal I really liked, like seeing my friends and family, going out for a meal once in a while and, yes, going to the hairdresser. But the normal I don’t want to go back to is hidden inequalities, hidden poverty, hidden discrimination against groups of people. I want us to use this crisis moment to ensure that what comes next is better.”
Curriculum vitae
Age: 55
Lives: Manchester
Family: Engaged (and hoping wedding goes ahead)
Education: Westerford high school, Cape Town, South Africa; University of Cape Town (BA English & history, MBChB medicine); Loughborough University (MA sociology & social policy); Nottingham University (MPH public health)
Career: 2018-present: director of public health, Tameside council; 2010-18: director of public health, Haringey council/NHS, north London; 2005-10: deputy director of public health, Nottingham NHS; 2000-05: public health training including 12 months at the Department for International Development; 1995-2000: range of clinical roles in UK and South Africa, including co-author of health and human rights study for South African Truth and Reconciliation Commission
Interests: Swimming, running, cycling, brunch
