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Public health: Facing down another wave

While the historic agreement to provide consultant status to specialists in public health medicine was a welcome
development, the specialty is facing further exhaustion and burnout amid the latest surge in Covid-19. David Lynch reports

Speaking on 16 November, Dr Tony Holohan, Chief Medical Officer at the Department of Health, said the level of Covid-19 in the population was “unsustainable”. In a live TV address on the same day, Taoiseach Micheál Martin told the nation that “this is the fourth surge of infections that we have experienced as a country”. This was not news to many working in the Irish health system, particularly public health doctors who have been highlighting the increasing Covid numbers in recent weeks.

Specialists in public health medicine have lived and worked through an extraordinary two years at the centre of the national response to the pandemic.

During this time they have also agreed an historic new deal on consultant status (see panel). But as we head deeper into winter and Covid cases continue to rise, public health doctors are reporting something that many healthcare workers are feeling. They are worn out.

Asked about the most pressing challenge facing public health doctors and the service, Specialist in Public Health Medicine Dr Regina Kiernan summarised it in one word – “exhaustion”. “The work that public health doctors are currently doing is not sustainable,” Dr Kiernan told the Medical Independent (MI).

“We are working long hours; for example, I have worked 120 hours over the past seven days with 66 of those being active working, and the other time on an out-of-hours telephone support service. I will not get two days off in lieu of working a weekend and will work 12 days straight without a break. This cannot continue.

“We need to take stock of what we are doing, why we are doing it and what we are achieving, and how we can best focus our energies and resources. We cannot continue to respond to the pandemic in the same manner as we did at the start.”

Irishman Dr Niall Conroy, a Consultant in Public Health Medicine working in Queensland, Australia, also warned that the energy of public health teams was depleting internationally. “Most countries are hitting theirfourth wave,” he
told MI. “And it’s hard to describe how exhausting that is for public health units.”

“But there are not many people skilled in outbreak management, so that’s a lot of pressure to put on a very small workforce over a long period of time. It’s not sustainable and people are falling over. I’m not sure how long a high-energy response like this can go on for.”

Dr Conroy said there were “quite a few challenges” facing public health globally as we enter the next phase of the pandemic. “Not least the reality that almost every country has been, and continues to be, hit hard by Covid. It’s not over by a long shot.”

Lessons

Regarding the current surge in Covid-19 cases, Dr Anne Dee, IMO Public Health Committee Chair, told
MI that the pandemic “has taught us a lesson that has been repeatedly learned and forgotten throughout
the past century or more in many jurisdictions”. She said that this lesson is “the need to adequately resource and support the public health medicine function of a nation”.

“In Ireland, lack of sufficient staffing and IT capacity is still a difficulty in managing the pandemic and the swift implementation of an electronic case and outbreak management system for the country is an urgent priority.”

With many challenging weeks ahead, what can be learned from the public health response over the last two years? “Population-level measures are the most effective for achieving public health objectives generally and in Covid-19 this was also the case, with lockdown being most effective,” said Dr Dee. “At a regional level, contact tracing based in local departments of public health was very effective at identifying and controlling clusters and outbreaks among connected situations and households.”

Dr Dee added this was especially the case “among vulnerable groups in congregated settings who needed intensive input to manage the situation and where local knowledge and networks were able to contribute to the overall protection efforts”.

Dr Kiernan thinks one of the stark lessons of the crisis has been “that we weren’t properly resourced or structured going into this pandemic”. She said while there are multidisciplinary teams, they are “not at the required numbers”. These numbers were very low at the start of the pandemic and have increased, but not to the level necessary.

“Compared to other countries with similar public health units, Ireland did not have sufficient numbers of public health doctors; doctors who are recruited as specialists in public health medicine are employed on contracts that don’t facilitate them working as consultants which we have been trained to be.”

The multi-disciplinary team members required to support consultants include infection prevention and control
nurses, surveillance staff, environmental health officers based in public health, epidemiologists, and others. Dr Kiernan
said this situation has led to “exhaustion and burnout”.

Irish-based doctors have observed that their working lives compared unfavourably to some other developed countries. “We could see from Irish doctors based in Australia and, in particular, in New Zealand the staffing and other resources that were available to their public health units at the start of the pandemic and how they were able to promptly respond to the pandemic,” she said.

Reform

Regarding what the Government and health management can do to help, Dr Kiernan highlighted the need to speed up the “implementing [of] the reform and restructure of public health in Ireland”, which she said was currently being rolled out at a “snail’s pace”.

She added that the Government should “escalate the implementation of a consultant-led service with full multidisciplinary teams. Thirty of the promised 34 consultant posts from the initial trance of recruitment have now been advertised, but no date set for any interviews or when the next phase of consultant posts will be advertised” (see panel). She said this slow pace is leading to growing “demotivation and lack of morale amongst public health doctors”.

From his viewpoint on the other side of the globe, Dr Conroy believes many of the lessons of the last two years will be beneficial for the “next pandemic”. “For example, it’s now clear that we need some kind of centralised model of vaccine distribution. The global inequity in vaccine access will be remembered for generations as one of the low points of this century.”

Dr Conroy said nations also need to develop “pandemic plans that are not based on one type of virus”. He pointed out that many countries have historically concentrated their planning around a pandemic strain of influenza. Future plans need to be based around “multiple types of pathogen”.

“We also need a research infrastructure in place, so that next time around we can get answers to the type of questions that we’re still asking now, two years into the current pandemic. We also need properly resourced public health units. That type of expertise is difficult to surge rapidly, so the staffing needs to be in place before the next one arrives.”

Regarding the response to the current evolving crisis, Dr Conroy said “governments are struggling to deliver coherent
messaging” and “while you can reduce case numbers, once the virus is circulating it’s very hard to control numbers effectively”.

“Yet there is still confusion in the messaging around what we can and can’t do when the incidence is very high.”Dr Conroy added that “very few politicians” are willing to have that conversation with the public. “Instead, there’s all of this fighting in political circles and in the media, where the tone is very much ‘you’re not doing enough’ and‘all of this is preventable’.

In reality, when cases surge, your efforts need to be on protecting the medically and socially vulnerable, like people in prisons, nursing homes, and at-risk communities. I think that the conversation in most countries hasn’t honed in on that fact yet. There’s also a huge challenges around public health workforce sustainability globally.”

The continuing journey to consultant status

For public health doctors, the agreement signed in May between the HSE, the Department of Health and the IMO was historic. The HSE agreed to establish 84 consultant in public health medicine posts on a phased basis between June 2021 to December 2023.

Phase one will finish at the end of June next year, “with priority focus on health protection and regional consultants” with 34 priority posts earmarked to be inplace by that deadline.

There are a further 30 posts meant to be in place by the end of June 2023 and another 20 by the end of December 2023. A HSE spokesperson told the Medical Independent (MI) that it believed “significant progress” had been made. In figures provided to this newspaper, the HSE said that campaigns for 30 of the 34 phase one posts have progressed to recruitment, with the remaining four progressing through the approval process for campaign launch by the end of the year.

Campaigns for 12 of 34 posts have closed to applicants and are progressing through the candidate selection process and the campaign for the next 18 posts “is currently live” on publicjobs.ie.“A public health consultant recruitment working group was mobilised in May 2021 to progress necessary processes, documentation and approvals…,” said the spokesperson. “While this process introduces a lead time to recruitment, it ensures that the significant investment made by the HSE in all consultant posts is optimised for the health system.”

With the IMO and IHCA currently locked in negotiations with the HSE and the Department of Health over the details of the new Sláintecare consultant contract, an Executive spokesperson said that “all consultants in public health medicine appointed prior to the introduction of the Sláintecare contract will be appointed to the common consultant contract, amended to include specific provisions relating to consultants in public health medicine(Section 10A). Appointments will be on the basis of a public only contract.”

“The new Sláintecare consultant contract 2021 will be applicable to all new and replacement consultant contracts issued after the implementation date,” said the spokesperson. They added that the HSE has yet to receive confirmation of the implementation date for the new Sláintecare consultant contract.

Last month, the Minister for Health Stephen Donnelly told the IHCA annual conference that he wanted the new contract agreed by the end of this year. If this timetable is followed, it would seem likely that most public health consultants would be employed on the new Sláintecarecontract if and when it is agreed.

One of these new consultant posts is a particularly high-profile position, that of the national director of public health in Ireland. According to minutes of the HSE safety and quality committee meeting in September, HSE Chief Operations Officer Ms Anne O’Connor, updated the committee on the search for this new national director.

“The campaign for the national director of public health has been progressed at pace and is currently progressing through the candidate interview and selection process, with appointment dependent timelines on the outcome of this process,” a HSE spokesperson told MI. The spokesperson added that the post will be filled by a public health physician“with significant senior management and leadership experience”

The national director will report to the HSE’s Chief Clinical Officer and will be a “system leader with responsibility for protecting and improving the health of the Irish population”. According to minutes of the same September meeting, Ms O’Connor also provided the safety and quality committee with an update on the “public health reformplan, which will strengthen public health”

“The HSE’s public health service is embarking on a programme of strategic structural reform to implement a new,consultant-delivered service delivery model aligned to international best practice and to address the recommendations of the Crowe Horwath Report,” a HSE spokesperson told MI in regards this reform plan update from Ms O’Connor.

“The enhanced service delivery model introduces a strong public health function strategically aligned within
the HSE and to healthcare delivery structures. One key aspect of reform is the restructuring of departments of
public health from eight regions to align with six public health areas.”

The spokesperson added that the new plan is a ‘hub and spoke’ model, where the hub will coordinate and set standards and policies, provide leadership, and “centralise critical expertise”.

On the specific role of public health consultants in the new plan, the spokesperson said: “Under the new model, consultants in public health medicine will lead appropriately resourced multidisciplinary teams including, for example: Surveillance scientists/epidemiologists, senior medical officers, research and information staff, administrative staff, and, crucially, robust operations and management support.”

The spokesperson added the new structure will mean consultants in the six public health areas will “play a key strategic and leadership role in protecting the population from threats to health, while also promoting health and wellbeing within the health area”

An official public health risk

In a front page story in February 2021, the Medical Independent reported that there was a risk to the ongoing effective management of the pandemic because of “inadequate and sustained resourcing of public health teams”, according to the HSE’s own corporate risk register (CRR), which was approved by the Executive last December.

That story garnered significant online comment and reaction from public health doctors and other healthcare workers.
Nine months on and warnings continue to be made in the updated risk register.

The most recent register, which was approved by the HSE’s executive management team on 7 September 2021, still highlights risks within the public health service. Public health capacity is noted as one of the 18 ‘red’ risks out of a total of 28 risks on the new CRR. “There is a risk to the ongoing effective management of the Covid-19 response as a result of inadequate and sustained resourcing of public health teams, contact tracing capacity and infection prevention [IPC] control teams including IPC nursing in community services,” reads the recent CRR.

There is another public health ‘red’ risk noted under the heading “integrated testing and contact tracing”. “There is a risk the test and trace service will be unable to respond in a sufficiently robust and agile way across the end-to-end service pathway to the evolving capacity demands of the Covid-19 pandemic,” the most recent CRR notes.

This risk may result “in a failure to efficiently and effectively control the spread of the virus within the population”.“The rapidly increasing prevalence in Ireland of the Delta variant poses a very substantial risk to the current test and trace service pathways.”

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