Joint supplementary memorandum by The
Faculty of Public Health Medicine and The Association of Directors
of Public Health (PH 52C)
Response to those questions that were unanswered
when giving oral evidence on Thursday 23 November 2000 to the
Health Select Committee.
Would a split between the public health medical
function and the broader public health function make public health
The Faculty believes that this would be against
current developments and against the spirit of the Government's
White Paper Our Healthier Nation. Much of the work that
the Faculty is currently engaged in is concerned with the bringing
together of the many strands of public health to ensure that a
multi-skilled, multi-disciplinary approach is available to those
who require public health expertise. Whilst more work is required
the Faculty is actively collaborating with a number of other organisations
to improve the breadth of public health skills that can be available.
The Faculty believes that there is an important role for public
health in developing primary care settings. It will be essential
to develop strong public health teams of a sufficient critical
mass to support Primary Care Trusts/Groups. Splitting public health
medicine from public health would not be wise, it would decrease
the influence of the director of public health on the various
systems that we need to influence in order to improve health.
Whilst superficially it could be argued that work could become
more manageable, very quickly it would be necessary to invent
mechanisms to re-integrate between directors of public health
medicine, directors of public health, directors of health protection
etc. This would probably be more time-consuming than current arrangements.
There is no place for the isolated public health professional,
as they need to rely on a range of skills within a team. New collaborative
arrangements that are currently being piloted in some parts of
the country are already showing promising results.
In your opinion, does the director of public health
have to be medically qualified or is it sufficient for expertise
to be available (to put it colloquially, do doctors have to be
"on top" or "on tap")
The Faculty believes that the post of director
of public health should be clearly defined and reflect the responsibilities
and seniority of this important post. If that is achieved, then
those with appropriate skills should be appointed to such posts.
It is likely, for the foreseeable future, that many such people
will be qualified doctors, but that should not preclude others
who have sufficient knowledge and skills in public health.
The Faculty strongly believes that there will
always be certain functions within public health teams that require
the skills of a doctor, and these should remain and be valued.
The position of the Association of Directors
of Public Health is that it is not essential that directors of
public health are medically qualified. However, there are many
advantages to the current system because it means that one individual
has responsibility for public health medicine, and the many aspects
of public health are thus integrated. That individual has undergone
a lengthy training which is at least as long in terms of generic
public health skills as it is in terms of medical skills. It would
be wrong, therefore, to think of directors of public health exercising
an excessively medical model simply because at one point in their
training and career they were taught to be, and practised as,
If the director of public health were not to
be medically qualified then you would need to have a medical director
of health authorities as a separate position. You would also need
to have an individual who provided the clinical communicable disease
control service. These three posts would have different training
requirements. The non-medical DPH would need to be trained in
public health but not medicine. The medical director would need
to be trained in medicine and also in clinical epidemiology with
training and experience in health economics, health promotion
and medical statistics being an advantage. The communicable disease
control consultant would need to be medically qualified and trained
in the public health and epidemiological aspects of communicable
disease control. Currently, all of these roles are centred on
and co-ordinated by DsPH who are trained in medicine and public
health. While it is certainly possible to desegregate them, there
is a danger that one could end up spending much of the time in
a new arrangement having to re-integrate and co-ordinate the efforts
of three individuals, rather than it all being centred on one
individual as a leader of a multi-disciplinary team.
In addition, there is a danger that non medical
DsPH may have less influence over clinical colleagues who can
be most useful advocates for change in altering attention to health
related behaviours and circumstances.
What skills does a modern director of public health
need? Are these different from their predecessors in the past?
If so, in what ways?
Key skills needed by a director of public health
Directors of public health need to lead upwards,
sideways and downwards.
We are most often not in a position of executive
power and therefore need influencing skills to ensure that the
wider vision of improving the health of the population prevails.
Directors of public health need professional leadership combined
with management skills to run effective and productive departments.
They need to develop and motivate their staff, ensuring such approaches
as continuing professional development, audit and business planning.
The wider vision is critical. Directors of public
health come in to work with a missionary drive to improve the
health of their local population. This vision is central to everything
they do. This vision and perspective does not appear to be prevalent
in other health and local authority staff. Translating this vision
into key strategies such as the Health Improvement Programme is
clearly an essential skill.
Epidemiological skills are critical to assess
the health needs of the population using survey methods, research
methods and statistical analysis. These approaches answer the
Who is more likely to suffer from
a certain health problem?
Where will a health problem be commonly
When is it most likely to occur?
What is its likely cause?
A detailed understanding of research methods
is also needed to interpret research findings on the effectiveness
and cost-effectiveness of health care and other interventions
to improve health.
Medical knowledge and skills are useful, particularly
when working with medical colleagues, to understand: the underlying
pathology and natural history of diseases, how doctors think and
approach the care of their patients and to challenge medical colleagues.
An understanding of pathology and the natural history of disease
are also important when advising local authorities.
Change management is central to the role of
the director of public health. They need the skills to make this
happen and the robustness of character to understand that change
agents can't always be popular. These skills must be applied equally
adeptly in many different organisations and working with many
different professions and disciplines.
Public health medicine is both a science and
an art. Directors of public health combine many skills in one
person. This is important so that directors of public health can
use many different skills and approaches effectively, appropriately
and simultaneously as and when a situation requires.
The skills are largely the same but applied
within different organisational structures. Differences include
an increasing need for computing skills, time management and setting
priorities (the workload for DsPH has increased considerably during
the last five years) and managing more through influence rather
than through executive power.
Does the Association consider there to be a tension
between the core business of public health and much of the management
workload of DsPH? Is there a risk of the urgent always driving
out the important?
Yes, this is a problem perceived by many directors
of public health. In a recent ADsPH survey of directors of public
health in England, Scotland, Wales and Northern Ireland, 37 per
cent highlighted this as a key problem. They expressed difficulty
in linking the aims and objectives of the health improvement programme
with the service and financial framework. There was particular
difficulty in securing funding for health gain initiatives. However,
it is important to point out that this is not necessarily a conflict
between health services and the wider determinants of health.
Directors of public health have an important and central role
in health authorities and it is critical to the achievement of
health improvement that appropriate and effective health services
are developed and delivered to meet local health needs.
Health authority chief executives tend to perceive
that the government's priorities for health are not all equal.
In health authorities we perceive the Department of Health considers
waiting lists and times, critical care, winter pressures and service
continuity and on occasions introducing new expensive drugs as
being the only serious business. Health authority chief executives
are hired and fired on these issues, along with achieving financial
balance. Urgent crises frequently drive out the important initiatives
which will deliver health gain in the medium to long term. At
the Health Select Committee, Dr Donnelly and Dr Geller suggested
ways to combat these problems and these are repeated briefly here:
Persuade the government that population
health improvement is as important as hospital waiting times.
Ring fence funding for prevention
and other health improvement initiatives through modernisation
funds or other means.
Insist that directors of public health
attend regional reviews.
Insist that key public health issues
appear on the agenda of regional reviews with equal prominence
to health service continuity of service issues.
Appraise, hire and fire health authority
and local authority chief executives based on health improvement
and health outcome measures and targets.
Increase the profile of Our Healthier
Nation, and other similar health strategies in other home
NB Directors of public health are aware and
very supportive of many of the recent initiatives for health improvement
particularly the national service frameworks, dedicated money
for smoking cessation and teenage pregnancy and including hospital
control infection as a priority in the national priorities guidance.
Are directors of public health appropriately trained
for their job? Are there skills deficits? If so how might these
As with any senior post in a modern organisation,
the skills required to perform at an optimum level continually
change. It is therefore essential that continuing professional
development (CPD) plays an important role in ensuring that directors
of public health are kept up to date with current thinking on
public health. To meet these challenges the Faculty has developed
a flexible, accessible system that is subject to rigorous audit.
The directors of public health undergo a very
lengthy training involving five or six years at medical school
followed by a minimum of three years and often very much more
clinical work. That is then followed by five years in training
as a specialist registrar in public health medicine and, finally,
by a period as a consultant in public health which averages five
years but often again is much longer. Thus by the time somebody
is appointed as a director of public health, they are probably
at least 20 years out of school and 15 years post-graduation,
they have the wealth of training and experience which is required
for the demanding post which they have to fill.
However, the Association of DsPH believes that
there is room to further improve this training particularly in
terms of preparing people for the transition between consultant
in public health medicine and director of public health.
The director of public health role is an executive
one requiring considerable management and strategic skills which
individuals may or may not have had the opportunity to practise
at consultant level. The model which is probably best suited towards
developing and maintaining these additional required skills is
that of an executive education approach rather akin to that used
by business schools in North America. In this model individuals
who hold, or aspire to hold, such senior positions are taken away
from their work place for short (but very concentrated) periods
of additional training. In order to ground such training in reality,
the case study approach used by many schools of public administration
or business administration is advocated. Unfortunately, many university
departments of public health within the United Kingdom are involved
in aetiological epidemiology or in running major intervention
trials and understandably they has the research assessment exercise
at the forefront of their minds. The ADsPH would therefore argue
that few university departments actually research or teach what
we would term public health practice. If such a university were
to start research and teaching in this area, they may become natural
leaders in the field of executive education for existing aspiring
directors of public health.
Is there a general skills deficit in public health,
and if so who, apart from health professionals, should we be training?
Public health requires professionals with a
wide range of skills and from a diverse background. Those working
in local government, the health sector and the non statutory sector
all have a vital and important contribution to make towards improving
the public's health. Many of these professionals have not been
seen, and do not see themselves as public health professionals,
but are beginning to undertake more and more public health type
tasks in their daily routine. Some of these people have embarked
upon Masters in Public Health courses, and this is to be encouraged
and developed. Public health has always sought to contribute in
a range of settings and teams should be made up of professionals
from diverse backgrounds.
The Faculty regularly reviews and updates its
education and training programmes to ensure that they remain relevant
to current public health issues. There is a need to develop specialist
training for those who choose to focus on health economics, communicable
disease, public health dentistry, and some of the other specialities
within public health. A programme of enhanced training could be
developed to cover these areas.
Two years ago the Faculty introduced a Diploma
and Part I examination in public health, which is open to all.
This has proved popular, and there is currently debate on proposals
to allow all Faculty examinations to be open to doctors and those
not medically qualified.
There is concern over the increasingly high
turnover of director of public health posts. This obviously leads
to a lack of continuity at a local level, but also a loss of skills
at a national level, as skilled directors leave the specialty.
The ability to fill these posts can be used as an indicator to
show that there is sufficient capacity of trained skilled individuals