David Boulger is Head of Population Health Transformation in Greater Manchester, leading an ambitious programme of activity to improve health as part of the unique devolved arrangements that exist in this city-region. 

David has over 20 years of experience working across Public Services in Greater Manchester including Local Government, Youth Justice, Social Care, Police and Health. In this post he reflects on the challenges to population health in the wake of Covid-19 and what can be done to recover.

Over the past month, the world has changed and our way of life has been fundamentally and profoundly altered, most likely forever.

We are all going through our own personal and professional journeys within this, and working out what it means for our future and the future of our society. We all have our own perspectives and this article represents my current reflections and thoughts. I’m sharing them openly as the starter for a conversation that I hope others will join in with, challenge, and contribute to in order that together we can work out where we are going next.

There is little doubt that Covid-19 has had a devastating impact at a societal and personal level.  All of our best endeavours so far have been directed towards mitigating the potential harm that could be caused by the virus, protecting our health and care services from being overwhelmed and, ultimately, saving people’s lives.

As a passionate advocate of prevention and population health, there have been times when I have been forced to remind myself of why our work is so important when all of the focus has been on matters such as critical care, hospital capacity and crisis / outbreak management.  After all, no one has really explored the role of a long term Population Health approach in the midst of a Public Health emergency of this magnitude?  This has generated lots of helpful and fascinating discussions with colleagues and friends, and some who are both.

The key to unlocking this conundrum becomes more apparent when we ask ourselves some fundamental questions.  What comes next?  What does ‘recovery’ actually mean? What is our new ‘normal’? 

Articulating some aspirational answers to these questions helps us to maintain hope and optimism, enables us to consider a compelling vision for a better future, and empowers us to plan and to take action now.

To explore this it feels helpful to draw on a concept that has become a familiar part of our lives over recent weeks – flattening the curve – the term initially used to describe the efforts to ensure that Covid-19 demand remained within the capacity limitations of the health and care system

UK coronavirus 'to last until spring 2021 with 8,000,000 ...

I believe that this concept also holds real value as we move beyond the initial crisis, through whatever may emerge in the months to come, and towards long-term recovery – a recovery that I will contend must be rooted in people, prevention and population health.

A helpful diagram was recently shared on twitter by @JesseOSheaMD and @VectorSting setting out the projected waves of health and care impact that we could potentially expect to see over the coming months as a direct consequence of Covid-19. 

This model makes real sense and has gained attention as health and care systems across the world look to explore what happens next and how they plan for it.  Whilst it is a helpful starting point, there are limitations to this model when we reflect on the likely future impact, both direct and indirect, of Covid-19 across an entire population and beyond health and care provision:

  • The model does not adequately articulate what actually happened in terms of demand during the initial crisis in the UK (as a consequence of the actions taken), or the likelihood of repeated and potentially localised Covid-19 peaks until such a time as a vaccine becomes widely available or herd immunity is reached;
  • The model potentially underestimates the impact on the harm associated with the exacerbation of chronic long term conditions and the disruption to testing, screening and immunisation, that are not Covid-19 related but where treatment has been impacted or where diagnosis has not taken place.
  • The model does not highlight that the direct impact of Covid-19 has not been uniform, that it has further exacerbated existing inequalities within our society, and that the long term impact will not be felt equally.  
  • Finally, and I would argue most importantly, the model operates in the context of health and care services rather than at a system or population level and, as such, visually underplays the likely potential scale of future poorer health outcomes associated with the societal impacts of the Covid-19 pandemic or the time over which they would be felt.

In many ways, I would contend that if we do nothing the waves are more appropriately articulated as follows:

A return to business as usual, without proactively addressing the fundamental issues that will emerge within waves 3 and 4 of this crisis will condemn millions of people to poorer health and shorter lives than they would have experienced prior to the Covid-19 pandemic. 

It will cause a level of longer-term harm that is of an order of magnitude which is far greater than that caused directly by Covid-19. 

Put bluntly, waves 3 and 4 could generate a tsunami of ill health that will be relentless and overwhelming beyond anything that Covid-19 directly threw at us, and will permanently exceed our capacity to run health and care services at their normal pre-Covid levels. 

This impact will be unequal and will adversely harm the most vulnerable in our society, potentially for generations.

This may seem like a bleak outlook, but it is from this that the big opportunity actually emerges.  The scale and protracted nature of waves 3 and 4 can be influenced and will be determined by the approach we take to mobilising our recovery as a system and as a society. 

We can flatten these curves if we reimagine our future world and shape our approach to recovery accordingly.

Underpinning this is one key and unavoidable truth – we cannot and must not plan to return to ‘business as usual’ – we need to aspire to a new normality. 

In our new normality, we must ensure that we harness the many positive attributes of the national response to this crisis and build upon them – the people powered approach that has protected our most vulnerable citizens through a new sense of caring, civic duty and the mobilisation of an army of volunteers; the rapid mobilisation of integrated service delivery at a neighbourhood level; the recognition that our society is built upon the hard work and sacrifices of some of our lowest paid and least valued employees; the cleaner air and flourishing natural environment; and the realisation that a system in which all of our ‘eggs’ are placed in the healthcare ‘basket’ has limitations that are exposed at a time of national crisis.

So what could recovery look like and what might flatten the curve in relation to waves 3 and 4?

My emerging blueprint proposes that our recovery must:

  • Be People Powered – We must harness the overwhelming sense of care, compassion and civic duty that emerged during this crisis and build upon it.  Our people and communities, supported by a vibrant voluntary, community, faith and social enterprise sector were at the heart of our crisis response and must be at the heart of our recovery.  We must retain and add to our army of volunteers who have made us so proud during the pandemic and grow their battalions even further.
  • Tackle the Causes of the Causes – We won’t be able to do everything and so we must prioritise tackling the post Covid-19 issues that will have the greatest impact on the future health of the population – early years, employment, housing, the places we live and the economy.  This will involve challenging discussions about the way in which we want to shape our future economy and an aspiration for it to be more equitable and inclusive.  It will involve a radically different approach to how we ensure that we support people to gain and maintain rewarding roles with good employers, and how we ensure greater financial and societal recognition for those who have kept society afloat during this crisis – this should involve shining a spotlight on those employers who behaved with integrity during this crisis, and modelling their values across our society.  It will involve a reinvestment in children and young people to support them to move out of this crisis and build a future that isn’t permanently adversely impacted by this experience, especially in relation to early years, primary school education and skills / qualifications which have been disrupted by the pandemic.  It will involve ongoing concerted efforts to ensure that everybody has a home, and that their home is conducive to good health.  It will involve shaping our places as environments that are green, sustainable and deliberately designed to be good for our health.
  • Be Inclusive – The impact of Covid-19 has not been equally distributed with those already disadvantage being the most affected by the virus and the least able to protect themselves from it – we must not hide from this, however uncomfortable it may make us feel.  Our lowest paid and least valued employees have been at the forefront of the struggle through the Covid-19 pandemic as they cared for vulnerable people, stacked shelves, served customers, drove buses, cleaned hospitals and emptied bins.  This has placed them at the greatest risk of infection while many of us were privileged to work from, and be confined to, our homes.  Our response should recognise this and we should aspire to rebuild and reshape our economy (and our society) to be more equal and fair. This will include having a difficult, but meaningful and informed, dialogue about welfare reform, universal basic income, the living wage and community wealth-building.  It will require us dusting off our thinking about proportionate universalism and restating it as our overarching future philosophy.
  • Take a Whole System Approach – We cannot treat our way out of waves 3 and 4.  If we wait for the illness and death to emerge through waves 3 and 4 we will have failed.  There is a need for acceptance that addressing waves 3 and 4 requires a whole system approach to population health, and a shift in resources and emphasis towards preventing ill health.  Without action, the likelihood is that the system will simply be overwhelmed for years to come by an unprecedented level of ill health demand, and the economic recovery that is required will be a pipe dream undermined by chronic ill health and inequalities. .
  • Use this Teachable Moment – This has been a teachable moment for many of us, culminating in a heightened sense of our own health and mortality.  We should not be afraid to speak about this uncomfortable truth. It will be essential that we build upon this and strengthen our messages and continue the system and culture change work that is required around healthy behaviours in relation to physical activity, diet, alcohol, tobacco and drugs.  This will lessen the prevalence of future morbidity and reduce the impact of ill health when it does occur.  We should also ensure that we continue to embrace the difficult but inevitable conversations about death and dying and encourage people to talk about this issue without the taboos that currently exist in our society.
  • Lead to Greater Integration and Devolution – Our recovery will require system working, integration, and  innovation at a level that is unprecedented, even in our most well developed towns, cities and city-regions.  A top down recovery will not work.  Our recovery will be nuanced and will differ across different places.  To enable this there needs to be a continued push away from centralisation and towards the devolution of powers, responsibilities and resources.  Without it, the level of required innovation and creativity will be inhibited and the ability to meet the needs of specific populations will be constrained, further exacerbating inequalities and injustice. 

By recognising this challenge now, and beginning the conversation early enough, we stand a real chance of flattening the wave 3 and 4 curve and preventing a worst case scenario in which our long term future and prosperity is blighted by poor health and wide-ranging inequalities.

We can flatten these curves.

We won’t eradicate these post Covid-19 challenges – we need to accept they are there – but we could minimise the harm and we might reduce the unequal impact if we act now and we act decisively. 

If we are brave and bold enough we might even create a system and a society that is more progressive than the one we had before and which will achieve better health and social incomes in the long term than we would have achieved if the Covid-19 pandemic had never happened. 

That system needs to be anchored in a people-powered, preventive and population health led recovery.

This is where my reflections take me today. These aspirations might seem like a wish list, but it feels like we could all do with a few wishes coming true at this point in time.

In a fast changing world my thinking will continue to evolve. We have an opportunity to think and learn together if we take time to lift our heads up and imagine a different future. Let’s work it out together. Please join in the conversation.

You can view this post and more insights from David on his blog: Reflections on Health and follow him on twitter @daveboulger

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Reflecting on the challenges to population health in the wake of Covid-19 and what can be done to recover.

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