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May 31, 2020
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ADPH Presidential Blog: A time for steady leadership, careful preparation and measured steps

COVID-19 has already taken a huge social and economic toll on our nation – and the reality is that it will continue to do so for some time.

We are at a critical moment. We need to weigh up the balance of risks between easing restrictions, to enable more pupils to return to school, more businesses to open and more social connections to happen, with the risk of causing a resurgence of infections.

Directors of Public Health are increasingly concerned that the Government is misjudging this balancing act and lifting too many restrictions, too quickly.  

This is a new disease; evidence is still emerging and there is much uncertainty. However, based on what is currently known, several leading scientists and public health experts have spoken out about a string of recent national policy announcements affecting England which project a degree of confidence that many – including ADPH members – do not think is supported by the science.

Over the weekend we have seen signs that the public is no longer keeping as strictly to social distancing as it was – along with this, we are concerned that the resolve on personal hygiene measures, and the need to immediately self-isolate, if symptomatic, is waning. A relentless effort to regain and rebuild public confidence and trust following recent events is essential.

At a local level, Directors of Public Health (DsPH) consider that honest and open dialogue with their communities is integral to effectively containing COVID-19 and managing outbreaks. That focus must be echoed at the very top of Government.

The Government has set five tests, each of which must be regularly reviewed as restrictions are adjusted and eased. Here is our current assessment:

Firstly, the pressure on the NHS – and those that tirelessly and expertly work within it – has been significant but it has been able to cope with those who unfortunately need hospital treatment for the effects of COVID-19. The number of people in hospitals with COVID-19 is falling, and beds are available for those that require them.

Secondly, there must be a sustained and consistent fall in the daily death rate. While the first peak in deaths has passed, the downward trend is slow – particularly in care settings. Deaths are a measure of what happened roughly two weeks before – the effect of easing measures now will only become evident in two weeks.

The critical debate is about the third test - ensuring the rate of transmission of the infection continues decreasing to manageable levels (taken to mean R being well below 1). The rapid and multiple ways in which measures are being eased is likely to make it difficult to judge the cumulative impact on R. As we saw in March, R can go above 1 in a very short space of time - and once it does it can take many months to bring it back down. The room for manoeuvre is tight.

The fourth aspect, ensuring supply of tests and PPE is able meet future demand, remains an enormous challenge. PPE manufacturing and supply chains are stronger, but shortages are still being reported and it is not clear that supply can meet new demand as different parts of society, public services and the economy open. While testing capacity has undoubtedly increased, we are not yet confident that the current testing regime is sufficiently effective in getting the priority tests done and the results to where they are needed to enable swift action.

Finally, the fifth test. A second peak cannot be ruled out – whether it will overwhelm the NHS is an important question to ask. But perhaps the even bigger one is, do we really want the same number of deaths again? The scale to date represents an unimaginable tragedy and we must do everything possible to limit further loss of life.

The ADPH has argued that an effective contact tracing system is vital to keep R consistently below one. We set out a ‘Statement of Principles’ to outline what needs to be in place to make this work. A huge effort is underway to establish such a system. We would pay tribute to valued colleagues at Public Health England, who have built on the contact tracing work they conducted at the start of the pandemic - and Dido Harding and Tom Riordan who have shown great energy and leadership in recent days. We also welcome the new Joint Biosecurity Centre to support action based on intelligence and there are welcome signs that local knowledge, insight and capabilities are more widely understood and recognised by the Government.

As ever, the ADPH will continue to be as constructive as possible and as challenging as necessary.

But, let’s be clear, the NHS ‘Test and Trace’ programme is currently far from being the robust operation that is now urgently required as a safeguard to easing restrictions. Directors of Public Health are working at extraordinary pace to develop Local Outbreak Plans. The ADPH will shortly be publishing a briefing paper setting out the guiding principles needed to shape – and implement - them. It is important to recognise that these plans will largely build on the health protection duties that DsPH already have. The work that has been going on throughout this pandemic, including managing outbreaks in settings such as schools and care homes and support for vulnerable people, continues day in and day out.

DsPH have proved themselves capable and ready to take on this leadership role and will develop and deliver local plans with the support and collaboration of local government colleagues and PHE regional teams, as well as the NHS, third sector and business.

Now is the time for steady leadership, careful preparation and measured steps.

The ADPH is calling for full implementation of all Phase 2 measures to be delayed until further consideration of the ongoing trends in infection rates and the R level gives more confidence about what the impact of these will be. There also must be a renewed drive to promote the importance of handwashing, social distancing and self-isolating if symptomatic, positive for COVID, or a contact of someone who is. And, additional assurance is required that the NHS Test and Trace System will be able to cope with the scale of the task.

The risk of a spike in cases and deaths – and of the social and economic impact if we have to return to stricter lockdown measures - cannot be overstated; this needs to be understood not only by the public but also by the Government.

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