175th anniversary videos: Being a DPH

Why did you go into Public Health?

I have been interested in the social, political, economic, and environmental determinants of health and wellbeing since my undergraduate years. After qualifying, I worked as a GP in Tower Hamlets (TH) – one of the most disadvantaged and diverse communities in the UK. During this time, as a GP, I saw a community that was a mix of an ageing post-industrial, working-class, dockland population and increasing numbers of relatively poor migrant families with English as a second language – all with very high health needs.

Despite having a large teaching hospital in the district, our primary care services were weak with many GPs nearing retirement and still working from lock up shopfront premises. I helped establish the Tower Hamlets Health Inquiry (1987), Chaired by Dr Brian Jarman, and the report highlighted the inner-city population’s health needs. The Health Authority responded positively to the recommendations and agreed, among other things, to jointly invest in a new purpose-built multidisciplinary health centre. As part of that new primary care team, I saw first-hand what a difference it made, not just to delivery of health services, but in terms of promoting good health too.

Then, after the ‘Public Health in England’ Acheson Report in 1990 opened the possibility of training in Public Health for clinicians like me, I jumped at the chance.

While working as a DPH, what was your biggest challenge?

One of my motivating ambitions as a DPH was to identify and reduce health inequalities in the communities I served. One of the challenges in delivering such change was the need for long term strategic investment and interagency commitment, not just locally, but nationally too. This type of political and corporate commitment requires winning hearts and minds over the long term because inequalities are seen over the entire life-course – from early years to ageing well.

Sadly, my career coincided with a lot of organisational change in the NHS which meant that delivery of a consistent strategy was immensely challenging. However, in all the geographical areas I had responsibility for, I made sure that health inequalities across the different populations were clearly mapped and reported and made numerous recommendations to partners on policies to address them.

What was your greatest legacy as a DPH?

After 10 years as a DPH in three NHS organisations, I became CMO for Wales. As with the DPH role, the position carried responsibilities for the health and wellbeing for the community and I drew on all my previous experience as a DPH to shape my time as CMO. I proposed, and then led, the development of Public Health Wales, ensuring that DsPH were responsible for areas that were coterminous with Local Authority and NHS footprints and had access to specialist PH capacity.

During this time, along with the other UK CMOs, I worked closely with national public health agencies and other organisations such as the ADPH, LGA, CIEH and partners like ASH to achieve the Smoke Free enclosed places legislation in 2007. This was as huge step forward on Tobacco Control and paved the way for much of the legislation now in place that has helped save countless lives.

How did the DPH role change throughout your career?

As ADPH President in the early 2000s, I sat on the Faculty of Public Health (FPH) Board. There was an explicit commitment to the three domains of public health practice – health improvement, health protection and healthcare – as well as to the central importance of knowledge and information. The multi-professional contribution to public health led to the decision to admit non-medics onto public health specialist training schemes. This ‘opening up’ of the profession was a positive change and a recognition that public health should be a multidisciplinary workforce.

I was also part of the movement to promote, via the ADPH, LGA and FPH, joint appointments of DsPH between the NHS and local government. These successful joint appointments then led to DsPH in England being solely based in Local Government in 2012.

What advice would you give to new/potential DsPH?

Leadership roles in political and corporate organisations can be a challenge, especially when there are competing demands on scarce resources. I have always tried to champion the needs of the more disadvantaged communities using evidence and data. I would also strongly advise to always keep channels of communication between different departments, agencies and organisations open so that true partnership and collaboration can take place – it is only through this joined up approach that we can bring about change.

Finally, I would say that when in the early stages of your career, it’s good to really think about what your core values are and keep referring to them – your moral compass – to keep you on track!

Why did you go into public health?

I kind of fell into public health by accident, but also because it strongly resonates with my values and – if it’s not too arrogant to say – my skills.  For me it’s a vocation not a profession. When your aptitudes and gifts resonate with your motivations and values, a particular role, and a need in society you can make a contribution to, that’s a pretty good sign it’s a vocation.

I hadn’t heard of public health until, as an undergraduate volunteer I worked with people who had real health problems including HIV and addictions. I also experienced close friends becoming ill with HIV and, in those days, dying all too painfully. Apart from doing my bit as a friend and volunteer I felt there was a strong social element to this, public health also strongly fed the science nerd in me.

I got hooked on epidemiology and went into a role which would probably be called wider public health because at that time specialist public health was reserved for medics. When the specialist field eventually opened to non-medics, I grasped it enthusiastically.  The great thing about multidisciplinary public health is that it allowed public health to do what it is great at – embrace and include other disciplines. We should remember the Germans saw epidemiology as a social not a biomedical science. Public Health needs a multiplicity of disciplines to thrive in the 21st century, simply because we have to deal with the complexity of life.

Public health is about sustainable and equitable human flourishing and development in all its aspects, and using multiple domains of knowledge from biology to leadership psychology to improve peoples’ health. These values, for me, are strongly informed by my faith, and one of the things I sometimes say about public health is that at its best it embodies the very best of Catholic Social Thought, and at its best Catholic Social Thought is the soul of Public Health practice.

The Dignity of the Human Person, Subsidiarity, Common Good, the preferential option for the poorest and the right to participation in all aspects of economic and social life are principles I see strong in both disciplines.  Sandro Galea talks about love in action and public health having much in common.  Most people I see in public health are in it out of both love and scientific curiosity. That’s truly wonderful.

What has been your biggest challenge?

As a non-medic I have seen my fair share of behaviour from people who felt non medics had no place in senior public health leadership. Thankfully, that is largely, but not entirely, a thing of the past and is great for our profession. I have also had to overcome both homophobic and anti-faith behaviour – a source of resilience now but a huge challenge at the time.

Today, I think the biggest challenge is getting policymakers and politicians to really hold in their minds three important things: firstly, the fallacy that just giving the NHS more money is the best way to a healthy population; healthcare is vital but it is not the only producer of health, by a long way. Housing, jobs, education, the physical environment and positive psychosocial environments are also crucial.  Secondly, the belief that we cannot think long term beyond four years so most policies are short-term. It is possible, it’s mindset and how we plan.  Other countries excel at this. The third thing is to control the incessant impulse to tinker with structures and governance. When a structure or system doesn’t deliver what you want, restructuring is rarely the answer.

How has the increased attention because of COVID-19 affected your work?

Well, the obvious one is that everyone now considers themselves an epidemiologist or a virologist.  Directors of public health became very prominent during the pandemic. Most people know who we are now, but only a fraction know what we do beyond Covid-19.

However, this gives us the opportunity to remind people a DPH is for life not just for Covid – to emphasise what DsPH and public health as a profession can do as we come out of the pandemic.  This 175th year is a golden opportunity to seize that opportunity.  We also have an opportunity to revisit the debate about science. One of the reasons Covid-19 was a multiple trauma was the shattered assumption that science is a certainty, and medicine will always save us. We found that not to be true. This gives us the chance to shift to a different way of discussing the role of different disciplines in policymaking and put more of an emphasis on prevention. That said, the pandemic also highlighted to us that no one is safe from emergent infections – or indeed health risks – until we are all safe. Human health in any one community or country is intimately linked to health in others, and to the health of our planet which is something that is now, more than ever, at the forefront of my mind.

What would you like your greatest legacy to be?

There are multiple things I would like to achieve and if I make a list I won’t stop! As most people know, one of my drivers has been to ensure social and behavioural sciences are really used with esteem and purpose in public health. That will be an enduring concern for me.

Perhaps the one exercising my mind most right now is the workforce challenge. We are in a workforce crisis and we’ve been in one for some years – it feels like we’re missing good people who could get into all levels of public health practice if we got the pathways right for them.  We need to revisit this urgently, and it’s wonderful that the Faculty of Public Health is using its convening role to think about workforce.  We need to find consistent, better, understandable and accessible routes to attract people wanting to use their best skills and talents to public health.  Every person we turn away because there isn’t a route for them is a missed opportunity – for them and for the profession.  We need to lay seriously to heart the fragmentation of routes into public health.  I think the answer is to take the best of the medical royal college training model and combine it with the best models other professions use. There is a long British tradition of Chartering professionals in many fields from actuaries to psychologists and environmental health specialists which has international standing and it is time we really shifted our gears on this. I’d like to help make a start to that.

What advice would you give to others thinking of going into public health?

Firstly, discern very carefully if this is for you – if your talents and skills, values and motivations coincide with the values of public health and you are prepared for a long haul and hard work, then that’s a very good sign this may be for you.  Next, find a DPH or Consultant or Specialist who can give you good honest advice about the available routes into public health for you. Our greatest weakness in public health is we still don’t have a coherent set of career pathways for everyone and many of us who didn’t go through the training scheme found we had to cobble things together with help.  Thirdly, , if you are from a profession or discipline other than medicine, value that profession and love it, because you will be bringing something extra to the table, adding to what we already have in public health, and perhaps bringing something we don’t have.

Finally, be determined. There may not be a route into specialist public health that is easy for you. But persevere.  And if there really isn’t a role right now, what can you do that uses your values and takes the best of public health into another discipline or profession? You don’t have to have a public health label to be a public health professional.

Why did you go into public health?

I started off my career as a medical doctor and through my work with the Red Cross, Medecins Sans Frontieres and the World Health Organisation I saw first-hand that health wasn’t just about medical treatment. 

While it is of course important to have access to medical care – and my work as a GP is testament to that – the wider determinants of health such as education, wealth, environment and geography have a far wider impact on our wellbeing. 

What do you think your biggest challenge will be?

In order to truly advocate for a population and to be able to bring about positive change, it is absolutely vital to understand that population, its make up, its systems, its leadership and its environment.

As an experienced PH consultant in London boroughs north of the river Thames, I spent a long time establishing close working relationships with partners in the NHS, local councils and voluntary sector organisations to give me that understanding which then meant I was able to create and tailor public health programmes and measures to make a difference to people’s lives. 

I have now started my first DPH role in Bexley, a very different area of London, south of the river. In Hackney, there were long standing health inequalities, cases of very cramped living conditions and a largely younger population who struggled to stay due to rising house prices. In Bexley, which is a long term family area with established communities and good schools, we are seeing widening health inequalities with increasing numbers of families using food banks. 

Understanding the different needs and priorities, different hospitals and health care systems and different political environment is a huge challenge and one that will be absolutely critical to my success. Only through understanding the community I serve and getting to know how all the different stakeholders work here, can I implement successful public health measures that accurately respond to the needs of the community. This will involve forging links with partners and creating those relationships by listening and responding to what they have to say to make sure that what we do in public health, is right – and done in the right way – for the needs of our population.

What would you like your greatest legacy to be?

Ultimately, I would like to improve the population’s health. In real terms, that means that babies are born healthier and have a better start in life with access to all the preventative services required to be able to lead longer, healthier and more fulfilling lives. I want to reduce health inequalities in the area, so that everyone has access to good work in a society where being healthy is the default and prevention is truly embedded in policy. 

In order for that to happen, I want to create a really strong public health team which grows talent and provides opportunities to progress through supporting ongoing training and qualifications and to establish really strong relationships and partnerships with stakeholders.  

What advice would you give to others thinking of going into public health?

Public health is an incredibly wide-ranging field! No two days are the same and anyone interested should be prepared for the challenge – and reward – that that brings. Reducing health inequalities and improving people’s lives is such a long-term commitment, it can feel that nothing is changing but it is important to remember that all the incremental steps involved are every bit as important as the outcome. Those steps involve working collaboratively with everyone involved – from business leaders to leaders of the Council and from teachers to health care workers. If you are solution focussed and like working together with people to make a difference then public health is definitely the area for you! 

How do you see the role developing throughout your career?

While the role of a DPH has changed considerably in terms of scope, the underlying principles have remained – and will always remain – the same, namely health promotion, health protection and prevention of ill health. How these look and play out will undoubtedly change with emerging threats to our way of life. For example, climate change is, relative to our 175 year history, a new issue but one that will dominate my work going forward. Covid-19 has also changed our landscape – the likelihood is that we will see more pandemics and diseases we are less familiar with as a result of travel and indeed climate change. 

I see positive developments too though, increased partnership working and a greater join-up between departments is something I am really excited about leading and something that will have huge benefits for our communities. 

Ultimately, I would like to see the role develop to be even more integrated, to be used as a source of expertise and knowledge by all agencies to help prevent ill health so that a healthy, sustainable society becomes the norm.