Associate feature: working together for public health

Public Health Scotland (PHS) came into existence at the most precarious moment of the biggest public health crisis the country had seen in 100 years.

Launched on April 1, and headed by former council chief executive Angela Leitch, the new national agency tasked with protecting and improving health and wellbeing immediately had to pivot to focus on the unfolding emergency.

Then and since, according to some of those at the heart of Scotland’s public health effort, the value of having such a national agency has been clear to see.

Look at its role in helping handle the recent Aberdeen COVID outbreak, says Susan Webb, director of public health for NHS Grampian and NHS Shetland. With cases rising fast following a late-July weekend when the virus spread in pubs and other venues, the national body helped local partners access the “surge capacity” they needed to reach the contacts of infected people fast.

“We actually ‘phoned a friend’,” explains Webb, describing how Grampian turned to Public Health Scotland for support and to health boards across Scotland to get their contact tracers to help out. “Contact tracers in other boards were trained and knew how to use the case management system, but at the time didn’t have any local contacts to follow up so were able to divert their capacity to Aberdeen.

“At the peak of it, particularly during weekends and evenings, colleagues from Public Health Scotland and local boards across the country worked as a public health system.”

There is already a strong tradition of mutual aid amongst health boards, but what was different this time was the new shared information system. It meant staff could work from anywhere but still be part of a single approach. “Mobilising that surge capacity was made easier by having one data recording system, which meant that boundaries didn’t matter. In addition, being able to download data and to link it to local information systems and knowledge, meant that we were able to identify clusters that might be happening,” she says. “That allowed us either to enhance our risk mitigation actions or identify new ones that we might need to put in place.”

The team was striving to get in touch with the majority of contacts of cases within 24 hours and “due to sheer determination and hard work managed to do so”, adds Webb. “That’s what allowed us to break the chain of transmission within our community.”

PHS has been at the heart of tackling COVID, from providing data to health boards and guidance about protecting key workers for different sectors, to preparing for the Test and Protect scheme and getting the National Contact Tracing Centre up and running.

As in Grampian, contact tracing is done by local boards who have expertise on the ground, but the establishment of a National Contact Tracing Centre, with its national case management system, has meant extra help and expertise can be brought in when required.

Meanwhile, other PHS teams have been working with health boards’ directors of planning to think about future service provision as normal NHS services are brought back on stream, services like cancer treatment, surgery and treatment for cardiovascular disease. “Our team has been working with them to model how they can manage that whilst still being ready in the event of a resurgence of COVID, and managing capacity for any increase, particularly over the winter,” explains Leitch.

The variety of these activities reflects PHS’s broad remit of complementary functions and the fact that it brought together the work of three legacy agencies, Information Services Division, Health Protection Scotland and NHS Health Scotland.

The new body has a collaborative leadership role in the country’s effort to deliver Scotland’s six public health priorities, developed by the Scottish Government and COSLA after extensive stakeholder engagement. These create a vision of Scotland in which everyone lives in healthy, safe communities; flourishes in the early years of life; has good mental wellbeing; is at lower risk of harm from alcohol, tobacco and other drugs; is part of a sustainable, inclusive economy; has a good diet and healthy weight, and takes regular exercise.

by Gemma Fraser

Society & Welfare

New coronavirus cases in every mainland health board in Scotland

But leadership is only one part of the story. Leitch is keen to stress that collaborating with others – be they health boards, councils, voluntary organisations, Police Scotland or others – is at the heart of the new body’s work.

The importance of collaboration applies internally too: before the agency launched, Leitch talked to staff to find out from them what they regarded as the strengths of the three legacy organisations and also what they saw as the opportunities the new body would bring for working more closely. During the pandemic, she says, staff have been making those connections themselves, enthusiastically, all across the organisation, and pays tribute to them “for working flat out, collectively, in a very agile way”.

Scotland faces significant health and wellbeing challenges, with wide health inequalities that have worsened over the last ten years. PHS was established in recognition of the need to do things differently to address these challenges: indeed, its stated intention is to build on the best part of the legacy organisations but also to “do things differently and do different things”.
Leitch explains: “Simply keeping things going that we’ve previously done, won’t have the impact that we want.

“I do genuinely believe that that wider collaborative effort is something that the new body can bring, working as an equal partner with a range of stakeholders from across the country, being dually accountable to COSLA and the Scottish Government, focusing our efforts on those that are most disadvantaged as well as making sure that we’ve got the right skills and can track what’s working and what’s not working.”

She sees a real opportunity to work with local authorities and through them, give additional support to community planning partners (local public sector bodies in each council area that come together to plan services) to identify strategies that will make a difference to public health locally.  A live example of this is the way in which PHS worked with local authorities and local public health teams to ensure the necessary public health measures were in place to allow pupils and teachers to return to school.  This includes advice, guidance and ongoing surveillance.

Webb agrees: “What is really clear is that decisions taken by national and local government impact on health. We have strong local partnerships and the pandemic has demonstrated the power of national and local partnerships working together.”

Leitch stresses the agency is working “extremely closely” with local directors of public health and colleagues in local government. The three PHS directors will have regional leadership responsibilities as well as functional responsibilities. “We know that our communities in Scotland are all different and we know that we’ll need to work in conjunction with people in local communities if the work that we want to take forward is to have meaning and impact,” she says.

The organisation’s strategic plan goes to the PHS board this month. Then, once approved, it will be time to deliver on it, though other organisations will also be critical to that, she notes once again: “We know that we can’t do it on our own.”

The first phase of the strategic plan will deal with the continuing work on coronavirus, but mental health and poverty – both having worsened as a result of the crisis – are also key priorities.

The eruption of a pandemic has meant that the work of the new organisation has been in the spotlight, and although its counterpart south of the border Public Health England will be replaced by a new agency, the direction of travel of public health reform in Scotland sees staff with expertise in infectious diseases working for the same body as those focused on the social determinants of health such as income and poverty, place, employment and education. Right now, the pandemic is foremost in the public consciousness but the move to reform public health in Scotland was driven by the urgent need to tackle those stubborn health inequalities, so will PHS ultimately be judged on whether it shifts the needle on that?

“We need to reduce the gap,” says Leitch. “As a single body, we will lead that and provide as much information, data and intelligence as we possibly can so that others can work towards closing the gap too.” But again, PHS will be working closely with others: “I’m acutely aware having come from local authorities that the work that is done in local communities is led from community planning partners, whether that’s councils, third sector, health boards, or different agencies involved in economic activity.”

She adds: “I came into this thinking it was a fantastic opportunity to lead an organisation that has a dual sponsorship – the Scottish Government support us as well as COSLA. I still maintain that working with those two sponsors we have an opportunity really to address some of the long-lasting issues that pervade a lot of our communities.

“The opportunity to work in partnership has never been stronger and we’ve started the way we mean to go on.”