“Local authorities have seen their resource base cut by half over the past decade or so,” says Greg Fell. As director of public health (DPH) at Sheffield City Council, Fell has the advantage of ring-fenced grant funding – but this too has fallen by nearly 30%. “That’s had an impact,” he comments. “We’ve cut health visiting, school nursing, drug and alcohol services, sexual health services. That’s the reality of the cuts that have been made, and there’s no point trying to dress it up in fancy language.”

And while Fell’s core budget is protected, his work to improve public health is hampered by the still deeper cuts in other council services. “The vast majority of public health [work] is done by people who don’t have the words ‘public’ or ‘health’ in their job title,” he notes, citing the housing and transport teams in particular. Across the local authority’s responsibilities, “our ability to do some of the stuff that we [did] historically – it’s just not there any more.” 

Now Fell and his team face a vast new set of public health challenges: lockdown measures have led to “long-term social and economic consequences that will be with us for a generation,” he says. The city’s GPs are seeing a big rise in mental health problems, while the UK looks set for a period of negative economic growth. “Recessions have health consequences. All the previous recessions have told us this,” he points out. “This one, I’m sure, will be no different.”

A preventive model

To address these looming threats, Fell believes, we’ll have to adopt a very different approach to service delivery across public health, NHS and care services. A recent report by the LSE’s Lancet Commission on the future of the NHS, he notes, emphasises that “the nature of disease burden has fundamentally shifted over the last 30 years. The delivery of services to support, enable, cure and prevent has not kept up with that.” To reduce the pressure on NHS services, Fell says we should be investing in preventive services, primary care and social care: he cites work by the University of York’s Centre for Health Economics, which found that investing in public health work produces three to four more ‘quality-adjusted life years’ than equivalent spending on NHS services. 

A “shift to a preventive-oriented model”, Fell argues, is required to slow the rise in demand for NHS services. But “I’ve been in this space for about a quarter of a century; for a quarter of a century we’ve done exactly the opposite” – cutting funding for preventive work, while NHS budgets increase. “The reality is that we’re getting less public health.” 

“Now, that’s not to pit prevention against cure; public health against the NHS. What the NHS does is really important to society,” he continues. “I don’t think that my gran should have to wait three years for a hip replacement.” But when elective treatment waiting lists are competing for funds against the “long-term, more nebulous, harder-to-define” results of public health interventions, funders find that cutting preventive work “doesn’t yield as many terrible headlines” – even when protecting it would ultimately reduce sickness and disability rates, leaving more space in NHS services for granny’s hip replacement. “We get what we pay for,” comments Fell. “Meanwhile, we’ll do as good a job as we can with the resources we’ve got.”

Off the naughty step

If Sheffield’s record during the pandemic is anything to go by, they’ll spend those slender resources well. In March 2020, the city hosted the UK’s first contact-tracing service: a community operation, led by retired medical and public health professionals. By April, Sheffield Teaching Hospitals NHS Foundation Trust had built a Covid test lab and launched an extensive testing programme – covering not only NHS and social care staff, but also care home residents and the immediate families of health and care professionals. 

“That was a good thing to do, but it also had adverse consequences,” recalls Fell. “If you look, you find; and we were looking really hard. So we found more [cases] than other places in Yorkshire. As a result, Sheffield became [seen] as ‘a hotspot of infection’, which probably wasn’t epidemiologically correct.” Soon afterwards, the importance of regular testing in care homes would be widely recognised; but at the time, Sheffield spent a period “on the naughty step”. 

In October, Sheffield became one of the first councils to launch its own contact-tracing service – taking over the task of reaching positive cases from the national operation. Local authorities had long been asking for the role, Fell recalls, “but it took a while for government to agree that a locally-oriented model, working with NHS Test and Trace, was the optimal model.”

When Sheffield began contact-tracing, NHS Test and Trace was reaching 67% of cases within 24 hours, and about 13% after that deadline. In contrast, “our completions are northwards of 90%, and have been just about since its inception,” says Fell. “We can demonstrate depth of coverage in communities that a national model just can’t get to.” At the time of our interview, the council’s team were reaching 95% of cases within 24 hours. 

How has the city got those results? “We know the communities, we know the community leaders – and sometimes we’ll call in favours from them,” he replies. “And people tell us fairly consistently that both local accents and local phone numbers really matter.” Staff can also arrange for food and medicine deliveries, or visits by community support workers: “Again, that matters – and those people will tell their friends, so word of mouth will spread,” Fell comments. 

Fell is careful not to criticise NHS Test and Trace, but he highlights a weakness in the financial support available for those asked to self-isolate: the £500 payment simply isn’t sufficient to cover up to ten days of lost income for low-paid workers, who often lack savings. Many people react to calls from contact-tracers by saying: “‘Yeah, I get it, but the lived reality is that I can’t afford to’,” Fell comments. An effective policy would ensure that “people aren’t out of pocket” for doing the right thing, he says, “and the answers in that space are in the Treasury, in the main.”

He has two further worries about contact-tracing. The Contain Outbreak Management Fund, which pays for Sheffield’s operation, expires at the end of March. And the staff manning the phones have been “filleted from all sorts of other bits of the council… At some point, they’ll need to go back to running leisure centres, or fixing homes, or all the other stuff that was put on hold during lockdown. And that’s a very real problem; I don’t know how to solve that one.”

A trusted local voice

Greg Fell: “Nobody knew who the hell I was before the pandemic; now I appear to be some form of local celebrity. I wish that wasn’t the case!”

Alongside Sheffield’s testing and contact-tracing operations, the city’s public communications – including Fell’s weekly video updates – have also attracted attention. From the moment the pandemic arrived, he recalls, national guidance “kept changing, and it was all a bit confusing”. The council has responded by trying to “tell people honestly what we do know and what we don’t know”, while providing “local interpretations of the guidance” and explaining “the core principles that underlie it”.

The city also identified a need for “a credible message communicator and message deliverer – which, sadly for me, happens to be the director of public health! It transpired that the integrity of the message deliverer was really, really important,” he says. “Nobody knew who the hell I was before the pandemic; now I appear to be some form of local celebrity. I wish that wasn’t the case!” In his view, the presence of a “trusted voice that delivers a fairly consistent message with honesty and integrity” has been crucial to bolstering public understanding and compliance. 

Asked whether central government’s communications have reached that standard, he skirts the question: “I’m trying to be diplomatic today!” But of the public sector’s wider response to the pandemic, he says, “one of my lessons… is that local really, really matters.” Most challenges are best addressed by concerted, co-operative action across both national and local levels: “Single, monolithic national response has done amazing things, but it hasn’t done some things optimally,” he comments. “We can do some things better locally, and finding the sweet spot has been a key learning for us.”

Fell is, though, a big fan of some national interventions. “This has been Public Health England’s finest hour,” he comments. “They really know what they’re doing, and my team would have fallen over without their support, effort and expertise. I think they’ve done an amazing job in every respect.” But the decision to dismantle Public Health England (PHE) has been made, he accepts: “What matters now is making the emerging new public health system as functional as it can be.” 

How to realise that goal? Forging a coherent, unified organisation is one major challenge, he replies; another is maintaining staff morale during the transition to a new model. Chief medical officer Chris Whitty will need a great support team, he adds, while the new body’s regional operations will require careful attention. And it’s important that PHE’s health intelligence work is maintained: “The Public Health Outcomes Framework is ‘national treasure’ space for every DPH in the country,” he says. “That won’t be maintained by itself; it needs skilled people and a huge amount of effort.”

Fell “was initially fairly critical” of the decision to abolish PHE, he recalls – but “what’s done is done; no point me crying about it.” And “actually, I think there are lots and lots of opportunities.” Nowadays, he’s “reasonably positive about the future – but the positive future will only happen if we make it happen.”

Who’s accountable?

Asked about the forthcoming NHS reforms, he sounds a little jaded. “I think it will be my 17th reorganisation of the NHS,” he says, urging a focus on goals before structures in the development of Integrated Care Systems. “We’ll spend some time working on form; we neglect function at our peril!”

That, he believes, means moving resources and accountabilities so that organisations’ goals can better address the public’s needs and the government’s wider policy objectives. “When I ask the question: ‘Who’s accountable for the 25-year gap in healthy life expectancy in Sheffield?’, everyone stares at the floor and looks for interesting patterns in the carpet,” he says. “I carry that responsibility, but I don’t have control over the levers to enable positive shifts to happen; they’re controlled in other spaces.” 

Existing accountabilities in health care, Fell suggests, drive behaviours that can leave these big challenges unaddressed. “People will say: ‘I’m accountable for cancer waiting lists’, for example. Brilliant; but who’s accountable for cancer mortality? Nobody puts their hand up at that point, so that’s the fundamental challenge that we’ve got to get sorted out.”

“I don’t hold out much hope that we’ll sort it anytime soon, because we’ve been trying to sort it for about the last 60 years – but it remains the fundamental challenge,” he concludes. “Everyone always wants more public health, until the point of investing in it – and therein lies the problem. If we want more preventive-oriented stuff, it needs to be funded from somewhere.”