Responding to the COVID-19 pandemic as a Director of Public Health Q&A with Dr Muna Abdel Aziz

What have been the main challenges of dealing with COVID-19 as Salford’s Director of Public Health?

In Salford our outbreaks in care homes started really early on in the pandemic. Sadly, we had a large number of deaths in those homes. At the peak of transmission in early April, Salford was the top local authority outside of London for the number of deaths. As one of the first areas hit in March, we were dealing with COVID-19 at a time when there was no testing or contact tracing in place out in the community. So we were fighting an invisible virus. That was a big challenge for us in Salford in those early weeks. It has meant however that we’re recovering from the outbreaks sooner than our neighbouring areas, and we could be more confident about easing the restrictions; for example when opening up schools. 

At first everyone saw COVID-19 as an indiscriminate virus. We thought we’d all be equally affected, because we're all equally non-immune. Now it's clear some people are at much higher risk. Whether it’s age, social disadvantage, or ethnicity, some communities are feeling the impact of coronavirus more than others. And that’s really exposed existing disparities and exacerbated the sense of historical health inequality. People are angry about these inequalities now – the vulnerabilities of care homes, of BAME individuals, and about the economic impact of poverty. 

In a more positive sense, COVID-19 has forced local services to respond together as a whole system. We've come together very quickly, in ways we wouldn't have thought possible. This gives us a stronger platform to be able to tackle some of those broader issues that have always been difficult: child poverty, mental health and wellbeing, social isolation, climate change, racial inequality. All these issues have become more visible due to the pandemic, and we’ve started to build more of a system response – we really shouldn't lose that. It would be easy to slip back into the way things were. We have an important opportunity to really reframe how we look at these issues and how we work together to make change happen. 

We are calling this the Spirit of Salford and this really shone through in the work by Salford health and wellbeing partners, including the voluntary sector. We set up a central helpline for vulnerable people to call if they need any kind of support, from food deliveries for people needing to self-isolate, to mental health and wellbeing support, advice around household poverty or problems with income or accessing welfare support.

How is the test and trace system working in your area? 

Test and trace is a real building block for us being able to keep the virus visible and to stop forward transmission. Basically, the sooner we find a case who tests positive, the sooner we can trace their contacts and ask them all to stay at home. Straight away, this protects others from being exposed to the virus. The NHS Test and Trace system is being rolled out now and we have shared arrangements across Greater Manchester to work together; for example to trace contacts who may live, work and travel from different local authority areas.

Our local response in Salford has been in place for many weeks. We set up our local testing from mid-April as a partnership across the NHS, the council and with the voluntary sector. The ability to test locally has been really valuable because we can move as soon as we know of a suspected case – someone who is unwell in a school, a care home, or a keyworker’s household – and we can get the result very quickly. 

We start contact tracing and public health advice even before we have the results. If the test comes back positive for COVID-19, we've already advised everyone on how to act, done that household's contact tracing and worked out the workplace implications. Then we can look at their wider social contacts and that’s where the Greater Manchester and national service will help as they kick in following a positive test.

What can we learn from the way the public health system has responded? 

All the Directors of Public Health have been networking and sharing good practice through the Association of the Directors of Public Health (ADPH). We have responded better together as the Greater Manchester ADPH group to get consistency of approach across our care homes, schools and other settings. 

Being issued with national guidance without prior warning, and partial data without having the full picture, has undermined our ability to be able to react and respond quickly enough locally. We've been forced to take a more precautionary approach just because everything’s so uncertain. 

With national testing, for example, the tests were taking so long to order. And the results go back to the individual, not necessarily to the setting that requested it (school or workplace). So even though the public health team can direct some of the national testing, we can’t always get hold of the results. Until we’re in a position where we've got named, personal level information on people who are testing positive and their contacts, and without a complete picture on the data side we're always working to catch up. Even the negative results are important so we can step down our isolation and advice to contacts.

On the positive side, I should mention personal protective equipment (PPE) and the risk assessments for frontline workers, because those are areas where we've been quite proactive in Salford and done things well at a local level. 

Greater Manchester arranged additional supplies for PPE, which meant our local areas were better prepared in managing stock. Public health managed this on behalf of the city, so we could top up our CQC registered and NHS settings if they were running low. We've also been able to offer PPE stock to the voluntary sector, social workers on home visits, schools, funeral directors and others where most needed. That has meant that frontline staff and volunteers were and continue to be protected. 

As evidence emerged around risk factors like high blood pressure, smoking, or being from a black, Asian and minority ethnic background making you at higher risk, we introduced individual risk assessments for frontline workers – not just at the setting or service level but also for those with different job roles, health conditions and lifestyles. We agreed our approach across Salford to ensure we took a consistent approach in a culturally sensitive way, as managers and staff consider the personal risks for staff in the front line, and how they can reduce that risk. 

People have been so focused on the PPE, but actually you can reduce people’s personal vulnerability to the virus by supporting them to stop smoking, for example, or by finding out if they have high blood pressure which needs managing. This protects people from the severe impacts of COVID-19, and gives them the opportunity to talk about their risk, their protection and any worries they may have. It also boosts their emotional wellbeing and shows them that we care. 

We've offered the risk assessments to all our frontline NHS, council workers and volunteers. We’re now rolling out health checks to care homes and home care staff. It's a thank you from the city to these frontline workers. 

What do you think will be the main challenges in the recovery phase? 

We’re all working with this dilemma about needing to open up workplaces and businesses for the economy, but also knowing that will promote more social interactions and risk kickstarting a second wave. How much can we dampen that down? Nobody has the answer. We're just going to have to work and live through this. 

On a macro level, the national economy has just taken the double knock of coronavirus and Brexit. In the immediate term, recovery will be about access to jobs and making workplaces safe so that things can get back up and running. In the longer term, it’s back to tackling those bigger issues like child poverty, mental health, climate change, economic inclusion and Black Lives Matter.

We’ve had more than 10,000 people contact the Spirit of Salford helpline. I think we've done remarkably well in our joined up local response, and hopefully that will continue to help with the recovery. But you can't ignore the macro impact. You can only live within that. 

In our area, I'm looking at this as three overlapping circles. We've got our response to COVID-19, which is about health protection, infection control and other issues like seasonal flu. We've got recovery from COVID-19 which is about business and building a fairer economy, and all the other sectors including health care. And then we've got our Locality Plan, which is our usual five-year population health plan and the prevention priorities within that. Salford has great assets and at the same time great challenges as the 18th most deprived local authority area in England (out of 317).

I’m clear that for Salford, the recovery phase needs to consider the important things that our Locality Plan has always highlighted were issues for us: child poverty for starting well; mental health, wellbeing, and suicide prevention for living well; social isolation for ageing well; and for communities it's climate change and racial equality. We can't just say we'll look at this later once we have recovered from COVID-19. We're in this for the next 12 to 18 months. And who knows what next…? 
 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.