In this blog, Ruth Tennant, Director of Public Health at Solihull Council and ADPH Board Member, unpacks the vital but often invisible systems that protect our health every day.
Health protection is the collective effort to protect populations from infectious diseases, environmental hazards (chemical, radiological), and emergency situations. In simple terms, it’s our invisible safety net.
Like many public health endeavours, getting this right relies on a complex range of players. First, we need to see the issue: John Snow became famous for identifying the link between the water dispensed by the Broad Street Pump and cholera. Good detective work and on-going surveillance is the bedrock of health protection, helping us see emerging issues or spot where things are going off track.
Next, we need to put in place the safety net.
- Legislation often takes the heavy lifting: many of the public protections that have improved health at a population level have come through this route. In 1952 the ‘Great Smog’ in London – linked to pollution from solid fuels - was linked to 4,075 additional deaths. Following this, the 1956 Clean Air Act gave councils the power to control emissions of smoke, grit, dust and fumes from industrial premises and furnaces, and set up smoke control zones. Making the case for change can take years (and thousands of preventable deaths): in the 1920s a US doctor identified a link between lead in petrol and health harms: it took until 2021 for a global ban on leaded petrol to come into force.
- Regulation, standard-setting and guidance are key tools to keep things on track. Food safety laws and regulation protect the public against food poisoning and exposure to harmful allergens. Infection prevention and control standards, guidance and training protect care homes residents and people in hospital from cross-infection. These need to be consistently applied with the right checks and balances in place.
- Protective programmes: we have a range of programmes which protect the public against harms to health. Immunisation and vaccination are the most high profile, providing protection against avoidable disease and associated complications at different ages and stages of life. Other programmes such as latent TB screening in certain high-risk communities provide more focused protection.
But when the invisible safety net isn’t working, we also need to spot the signs early and intervene quickly. A notifiable disease (these are around 40 diseases with public health impacts) must be reported rapidly to the UK Health Security Agency (UKHSA) by registered medical practitioners. Diseases are classified as ‘urgent’ or ‘routine’ depending on the disease and associated level of risk. Importantly diseases should be notified on suspicion so that the right steps can be taken to identify and protect anyone who has been in contact with the case and for the disease detectives to get to work identifying any patterns which might help control spread as quickly as possible.
Large-scale incidents or outbreaks such as the recent Meningitis B outbreak in Kent require the rapid mobilisation of effective incident command structures, fast deployment of additional resource and strong public communication. Advanced planning can help organisations and individuals know how to respond and what resource to mobilise, from where, help systems step up rapidly – and deal with uncertainties more effectively.
While some health protection threats become visible very quicky, other risks may emerge more slowly. For example, falling coverage of vaccination or screening programmes emerge over time and the impacts of this (reduced protection) may not be visible for several years. Again, surveillance is a key tool to spot these trends and identify the right, credible, deliverable solution to turn things round.
How to do this well
There is no one single organisation or agency that is responsible for the full span of health protection: getting it right relies on a shared vision of the risks, challenges and solutions at national, regional and local level, effective system-working and clarity around who is responsible for what.
The Association of Directors of Public Health and the UK Health Security Agency have co-produced a guide to good health protection systems. This does not set out step-by-step who does what but provides a basic set of principles to be reviewed at local level:
- strong systems leadership
- a clear understanding of legislative powers
- evidence-based planning and delivery: the right ‘safety net’, delivered in the right way that consider the right policy levers (including regulation, legislation, programmes and services, guidelines, communications)
- a good health protection workforce, recognising that this spans a wide range of staff in different organisations which may include specialists in health protection, environmental health, infection prevention and control.
- good governance which may include local oversight mechanisms such as local Health Protection Boards
- mechanisms to measure progress including surveillance systems and good reporting.
- a life-course approach to health protection that recognises that different risks (and associated protections) apply at different stages of life.
What does this mean for local councils?
Local councils have a critical role to play around health protection. Directors of Public Health have a statutory responsibility to be assured that adequate arrangements are in place locally to protect the health of the public in their area. This requires close joint working with different parts of the NHS and other partners such as the UKHSA as well as the care sector, emergency planning and regional players. Front-line teams such as environmental health officers deliver front-line prevention as well as intervention and support when things go wrong. Social care teams – as commissioners or providers will have a role around quality in their services.
Health protection issues and impacts do not play out equally across all our communities. The COVID-19 pandemic showed clearly how some groups can be hit hardest. Work by the UKHSA noted that people from more deprived areas are disproportionately impacted by radiation, chemical, climate and environmental hazards through their exposure, direct impacts on their health, and the exacerbation of existing health conditions and that emergency hospital admissions from infectious diseases are nearly twice as high in the communities in the 20 per cent most deprived areas. Local areas should therefore consider the health inequalities impacts of health protection and how these can be assessed and addressed.
Local councils can also play a key role around governance and local oversight: many areas have Health Protection Board (which may report to local Health and Well-being Boards) whose job is to provide a local systems overview of health protection, reviewing local data, identifying any local issues and working with partners to address these.
Celebrate success, avoid complacency
Finally, a word on success. Whilst complacency is the enemy of health protection, it’s important to recognise the silent successes. In the first year after the introduction of smokefree legislation in England, there was a 2.4% reduction in the number of hospital admissions for heart attacks. (1,200 fewer admissions). The introduction of vaccination against the HPV virus has led a substantially reduced incidence of cervical cancer right across the deprivation gradient (an inequalities success story). Health protection is an area where we have – and can – continue to make important gains.
But to do so, we need to see the invisible safety net and remain alert to the next challenge. Factors such as climate change, challenges to global health cooperation and structural change can all throw us curve balls.
Let’s make sure our nets are strong.