Explainer: Living Safely and Fairly with COVID-19

February 15, 2022 in ADPH Updates, Covid-19, Health Protection by Campbell Findlay

Download PDF version here

Download Appendix 1- Events Guidance here

Introduction 

In February 2021, The Association of Directors of Public Health (ADPH) published Living Safely with Covid: Moving toward a Strategy for Sustainable Exit from the Pandemic. Directors of Public Health (DsPH) wanted to help shape a longer-term approach to managing the virus which would enable education, society, and the economy to operate more normally. 

This explainer aims, at least in part, to update our thinking on the key elements that are inherent to ‘Living Safely and Fairly with COVID-19’ and the role of DsPH and their teams. Our intention is for the document to support local and national planning and implementation.

In parallel, ADPH is revising a paper setting out our asks for the new health protection system as the UK Health Security Agency continues to establish itself and its relationships with key partners, such as local government, whilst building on the lessons of the last two years. 

Summary

COVID-19 is not over and achieving elimination is unviable in the short-term. The virus is yet to become endemic, and it is difficult to predict when this state may be attained. Significant levels of cases, hospitalisations and deaths continue to disrupt and devastate individuals, public services and the economy. There remains a degree of unpredictability about the course ahead. Over time we can expect further waves of transmission because of waning immunity and the emergence of new variants. Disadvantaged areas are likely to be more at risk from surges and outbreaks, and at risk of prolonged disruption of education and economy. The severity of these episodes will vary depending on a range of factors including behaviour, policy and seasonality. 

Directors of Public Health – in common with our communities – want to avoid strict measures and lockdowns. Vaccinations and advances in treatment and care, as well as public health advice and information, could enable us to manage the virus with a much-reduced response. 

However, a much-reduced response does not mean no response. Living Safely and Fairly with COVID-19 will have to mean charting a sensible path between the extremes of lockdowns and letting the virus rip – oscillating harms businesses and disrupts public services more than a course of action to keep infection rates more stable. The Government should ensure that plans can be scaled up if required and that all partners are sufficiently engaged and resourced.

As we make this transition, we need to keep at the fore the underlying poor health exposed and exacerbated by the pandemic. Nothing short of a fundamental shift in attention and resources towards improving public health and reducing inequalities will do.

Strategy 

The Government is currently developing a plan for managing COVID-19 in the medium term. The role public health teams can play will be limited not by knowledge, expertise and commitment, but by resources. At the time of writing, considerable uncertainty around the Contain Outbreak Management Fund means capacity is being reduced in local government. This process risks losing experienced staff and leaving weaker capability at a local level to the detriment of local communities and the health protection system.

From managing contact tracing to promoting vaccination uptake and supporting those most vulnerable in their communities, the local public health system has coped remarkably well. Councils have built up teams over the past two years and whilst some scaling-down is inevitable as  

the omicron wave passes and national funding falls away, retaining crucial skills and capacity should be a priority. 

ADPH supports five cornerstones to make Living Safely and Fairly with COVID-19 work. These are captured in the graphic below.

The key elements of the strategy are as follows:

Risk 

Central to deliberations over the strategic approach to ongoing COVID-19 response is determining what we are prepared to tolerate in terms of harms and interventions to mitigate harm. The appropriate risk threshold should reflect peak weekly deaths, hospitalisations, and community prevalence of viral respiratory illnesses during high-severity years. It remains sensible to limit transmission where prevention measures are simple and cost-effective. 

Communication

Regular communication to and with the public, at a national and local level, still matters. There are behaviours and norms that are valuable to promote if we are serious about using the pandemic as a turning point to drive improvements in public health, such as regular hand washing and opening windows, although the approach must be one of engagement not enforcement as mandated restrictions and extensive guidance falls away. Whilst personality responsibility in and of itself is an insufficient public health strategy, risk management on an individual level is becoming a more important feature of the response. 

Prevention measures may be more or less critical depending on the level of transmission at any given time. Leaders, whether in politics, public service, sport, business or cultural and religious life, have a responsibility to model good behaviour and foster an environment of trust and collective spirit. 

We need to be open and honest about those population groups who are more vulnerable to COVID-19 going forward, what it means for them and how they will be supported. 

Communication between key national and local agencies will also need to be strong, with clear channels available for policy development and improving practice. 

Vaccination 

The vaccination programme will of course be nationally driven. However, at the very least ongoing efforts to increase vaccination uptake, particular amongst diverse and disadvantaged communities, within the existing programme should continue at local level where councils are best placed to run schemes like Covid Champions (this is dependent on sufficient funding being provided to local authorities). This should include the ongoing support for the community resilience structures, which can be built further to support this and many other aspects of the public health agenda over the long term. Collaborative working between the NHS and councils at a local level is critical.

Moving towards vaccination of 5–11-year-olds would also be welcome, although the exact timing should be carefully considered. In the medium to long term, it is entirely possible that COVID-19 vaccination could become part of the routine annual programme, potentially as a joint jab along with the flu vaccine.

Testing 

The overall volume of testing and available laboratory capacity has risen substantially, and this represents an impressive logistical achievement. Access has gradually widened and increased to meet the scale of cases. 

Lateral Flow Tests (LFTs) continue to offer a reasonable safety net at the present time and seem to be very widely tolerated by the public – but on the scale that they are currently being used they are extremely expensive, and a programme of the current size is not sustainable indefinitely. However, they will clearly have a part to play in ongoing case identification and be of particular use for vulnerable groups and those living or working in high-risk settings. 

In addition, until the pandemic is largely over everywhere there will be an ongoing need for surveillance for new variants that could cause significant new waves – and this requires PCR testing, not just LFTs. The introduction of charges for LFTs is likely to have a detrimental impact on take up, especially amongst disadvantaged communities.

UKHSA needs to develop a clear and targeting testing plan which focuses on the most vulnerable individuals and settings, surveillance and maintaining the operational of critical national infrastructure. Sufficient capability (e.g. supply chains, laboratories) – which can be scaled up at pace – must be maintained in the event of new variants and surges. The ONS COVID-19 Infection Survey should be retained.

Tracing 

While the local contact tracing system has been one of the most important tools we’ve had to control transmission for more than 18 months, and we have done it extremely well (and flexed it appropriately to respond to changing circumstances), in the next phase universal contact tracing is likely to have limited value on an everyday basis. Where contact tracing may still be required is in response to outbreaks, particularly in more vulnerable settings, and in response to new Variants of Concern.

Unless additional resources is available capacity to do any contract tracing at a local authority level will be extremely limited and in many areas non-existent. However, we have learnt that contact tracing at a local level is more effective. Any scaling up of this activity in the future should reflect this. 

Isolation 

Once the legal requirement to isolate is removed, it will still be the case that this is sensible public health advice. Regardless, employers can help by creating a culture in which coming to work when ill, whether with COVID-19 or the flu, is discouraged and considered not in the interests of the individual concerned, their colleagues or customers. In the event of individuals needing to isolate, financial support should be available so that inequalities are not exacerbated. In must be recognised that many employees are not able to work from home due to the nature of their job and sector e.g. food processing, warehousing, retail/hospitality, call centre work. These are the types of businesses where we have seen the most significant outbreaks and as we learn to respond to any future variants of concern in the medium to long term. The arrangements for testing, tracing and isolation therefore need to be carefully considered.

Settings 

While contact tracing and isolation may largely end, that does not imply the end of support to key settings such as workplaces, schools and care homes. Ongoing infection prevention and control response will continue to be appropriate for these settings, though the thresholds for intervention are likely to be higher. 

In care settings COVID-19 may be managed in a similar way to flu, with additional measures including greater levels of mask-wearing and potentially the provision of prophylactic antivirals could be stepped up in response to an outbreak. 

Education settings should be encouraged to follow the guidance for the general population, with isolated cases not receiving a public health response, but with support available to help manage outbreak situations where there is evidence of in-setting transmission – including potentially a short-term return to mask wearing at least in secondary settings. Minimising disruption to education should remain a key priority at a local and national level to safeguard the wellbeing and life chances of children and young people. 

Other workplaces should continue to be able to expect an outbreak response including advice and support to access testing should this be required. Capacity in public and environmental health teams will continue to be needed to meet this demand, though this is likely to be at lower levels than at present.

The pandemic has highlighted the case for strengthened indoor air quality standards in respect of both domestic and commercial settings. 

Appendix 1 contains guidance to Directors of Public Health for the management of events which present specific challenges.

Resources 

There has been an increasing recognition of the role and value of local authorities and public health teams in terms of guiding changes in people’s behaviour through skilled and bespoke messaging, providing advice to public and private sector organisations to reduce the risk of transmission, promoting and enabling testing and supporting self-isolation. Local intelligence on potential routes and sources of transmission has also helped with the early identification and management of outbreaks. Any ongoing local response will depend on continued provision of person level data on testing and cases. 

The Contain Outbreak Management Fund should be extended for a further year to ensure whatever local response is agreed, can be carried out effectively. Public Health Grant allocations for 2022/23 include two non-prescribed categories relating to COVID-19 (25 – test, track and trace and outbreak planning and 26 – other public Health spend relating to COVID-19). ADPH is clear that this represents an unfunded medium-term burden on the grant which could lead to cuts in other public health services if local authorities continue to bear significant responsibilities for elements of government’s approach to managing COVID-19. 

A properly funded public health system, at all levels, would support the mission of reducing health inequalities and improving health outcomes for all whether in relation to COVID-19 or health and wellbeing more broadly.   

Future health protection system 

Public health in local government is at the heart of local work to tackle the virus. It provides the leadership, expertise, partnership-working, and access to local resources that are fundamental to strong place-based coordination of health protection. As the UK Health Security Agency (UKHSA) continues to take shape, it is critical that the local-national relationship is central to policy and planning – not just for the next phase of COVID-19, but to meet the health security threats of tomorrow.

The public health system reforms provide an opportunity to reflect on the lessons learned and take an enhanced ‘local first’ approach in which LAs are held locally accountable for improving and protecting citizens’ health. To enable this, there needs to be seamless national to local and local to national partnership which recognises subsidiarity, enables data flows across organisational boundaries, understands the need for mutual aid and easily accessible surge capacity, and acknowledges the benefits of tailored health protection services that are appropriate for local demographics and needs.

A separate paper will describe ADPH’s key asks for the new health protection system. 

Conclusion

COVID-19 is one of many challenges for Directors of Public Health, and the wider public health community, to meet over the coming months and years.

The pandemic has shown that if we fail to protect public health, the economy suffers. If we are bold enough to deliver improvements to public health it will have a positive impact on the economic success of our places and regions. The government’s levelling up agenda should build on existing work undertaken by local authorities across the country. There is no shortage of energy and knowledge available, not least in local public health teams. However, there is a shortage of funding – the government has reduced public health spending year on year by almost a quarter since 2015.

One central challenge for government’s policy and action is taking coordinated action. New investment in weight management and obesity services, for example, is welcome but they must be backed up by policies and funding to address the causes of poor health, from poverty to poor housing to limited access to green space to inadequate educational, skills and employment opportunities. 

After spending two years focussed on the pandemic, Directors of Public Health are ambitious about the opportunities to create healthier places and people. 

If you have any questions about this briefing, please contact policy@adph.org.uk. It may be subject to review and revision as national policy and guidance evolves. 

Appendix 1: Events Guidance for Directors of Public Health 

Plan B measures have now been lifted, with people no longer advised to work from home and face coverings not legally required. People are still advised to wear face coverings in crowded and encloses spaces. The legal requirement for the Covid pass has also been removed; although venues and events can still choose to use the pass on a voluntary basis. 

Updated government guidance is at: Events and attractions – Working safely during coronavirus (COVID-19) – Guidance – GOV.UK (www.gov.uk)

The recent decline in community case rates and people requiring hospitalisation is encouraging, and it is of course thanks to the support of businesses, the events and hospitality industry, and the general public who have taken up vaccination and followed Plan B measures that we have got to this point.

However, the COVID-19 virus is still here. It hasn’t gone away, and we need to remain proactive in reducing further spread, both now and in the future, to minimise harm and disruption in our communities.

This guidance has been developed with a view to supporting Directors of Public Health to produce and implement local advice for anyone organising or hosting an event or gathering. 

  • Request that people continue to take a rapid (LFT) covid test on the same day as the event, and ask people not to attend if the test result is positive.  *Note, to detect infectious people, the LFT should be done as close as possible to the time of the event.
  • Remind people that testing is in addition to vaccination, as even if people are vaccinated they can still be infectious and spread the virus to other people
  • Advise that anyone who has been in contact with a case of Covid in the last week should not attend the event (even if they have a negative test).
  •  Ensure staff are testing regularly and have a negative LFT on the day of the event.  As employers, consider carefully how you will monitor this
  • Strongly encourage the wearing of face coverings by staff and customers when appropriate to do so, especially when people are moving around inside a venue or event.  Consider how you can make this as easy as possible for people to do, including through the supply of face-coverings for people who need them, and through active monitoring and encouragement.
  • Make sure the event is well-ventilated – to reduce the amount of virus in the air. Avoid congestion and facilitate social distancing during the design stage of any event
  • Do not admit customers (or staff) who have symptoms of Covid- even if mild.
  • Get vaccinated. Encourage any unvaccinated staff and the public to take up the offer of vaccination without further delay. It is never too late to have your first vaccine. There are lots of resources available to promote and provide true information about vaccination at: https://campaignresources.phe.gov.uk/resources/campaigns

In addition to the above, it is recommended that event organisers establish links with their local public health team/Director of Public Health (DPH), and liaise with them on any specific issues relating to Covid19, and also any general issues relating to Alcohol, Drugs, Gambling, Sexual Health, etc, where there may be value in work being carried out jointly. This could be done through the local Safety Advisory Group (SAG), Joint Advisory Group (JAG), or direct with the local director of public health.

List of Directors of Public Health can be found at the following link:-

https://www.gov.uk/government/publications/directors-of-public-health-in-england–2