Evidence submitted by the Faculty of Public
Health of the Royal College of Physicians of the UK (WP 81)
The Faculty of Public Health is an authoritative
public health body which aims to advance the health of the population
through three key areas of work: health improvement; service improvement
and health protection. In addition to maintaining professional
and educational standards, the Faculty advocates on key public
health issues and provides practical information and guidance
for public health professionals.
We are pleased to be asked to submit evidence
to the Health Select Committee's Inquiry into Workforce Planning.
We will focus our response on the public health workforce, as
this is the area that is currently of grave concern. The Faculty
has undertaken workforce surveys for a number of years and a copy
of the most recent survey is attached to this submission. Key
findings from the recent survey are highlighted below:
— The 2005 survey of the specialist
public health workforce identified 1,107 individuals working at
consultant level in public health in their primary post, 224 (17%)
less than in 2003. About 20% of this fall is in service pubic
health posts.
— The problem is particularly acute
in England, with only 36% of Primary Care Trusts England believing
that they have sufficient capacity and capability to deliver public
health effectively. This is compared to Northern Ireland , Scotland
and Wales where 70%, 60%, 56% respectively of those surveyed agreed
their team was adequate to deliver the public health agenda.
— Academic public health has shown
a decline of 53.3% reduction in numbers. This fall is consistent
with data from the Council of Heads of Medicals Schools (CHMS).
— The restructuring of Primary Care
Trusts and Strategic Health Authorities following Commissioning
a Patient-Led NHS (CPLNHS) could result in 100-150 more senior
positions being lost.
— There is a 40% reduction in planned
recruitment for public health training for 2006, compared with
2005. Sources within the Deaneries reveal that four of the 13
regions plan to cancel their public health training completely
for this year.
Figures collected by the NHS Health and Social
Care Information Centre on public health consultants and dentists
show variable numbers for earlier years with a decline in 2004-05.
Information from the Council of Heads of Medical Schools also
demonstrates in the number of clinical public health academics
in medical schools over the same period.
This picture is of particular concern given
the NHS restructuring subsequent to CPLNHS in UK, which threatens
to lead to loss of senior public health consultants in the NHS
given the reduction in the number of strategic health authorities
and primary care trusts. Despite the assurances given to the Select
Committee that there would be no loss of public health posts,
there is serious concern that the human resources approach is
not set up in such a way to deliver this. In addition, recruitment
is currently under threat to specialist public health training
programmes as postgraduate deaneries also deal with anticipated
cuts to their budgets next year.
Given the strong support for public health demonstrated
by the Government in the Wanless Report and Choosing Health, it
is extremely worrying that the current re-organisation actually
threatens the public health workforce still further.
How should effects of the following be taken into
account?
Recent policy announcements including CPLNHS
Technological change
An aging population
The increasing use of private providers
The potential adverse effect on the public health
workforce, both consultants and their teams, of CPLNHS has already
been highlighted. Explicit assurances are needed that current
levels of the public health workforce will be protected. The 2005
FPH survey found that only 36% of PCTs would describe their public
health team as of adequate capacity- the creation of larger PCTs
with the pooling of resources has the potential to improve this
position but only if the total levels of staffing are protected.
As highlighted in the Wanless Report, the impact
of technological change, and an aging population, together with
a number of behavioural and life style factors mean that investment
in public health services must be made if the health services
are not to be overwhelmed.
The increasing use of private providers threatens
to fragment care, and the multiplicity of providers may affect
both access and quality. More vulnerable populations may find
it difficult to negotiate more complex systems. Thus the public
health role of considering at a population level, access, equity
and quality of care across care pathways will become ever more
important.
How will the ability to meet demands be affected
by?
Financial constraints
EWTD
Increasing international competition for staff
Early retirement
As already alluded to, the financial constraints
on SHAs and PCTS in the restructuring are likely to jeopardise
an already thinly stretched public health function unless specific
action is taken to protect these resources. Loss of senior experienced
individuals to early retirement or redundancy is a real likelihood.
Early retirement generally for public health
professionals is a real issue, and very much higher than in the
clinical specialities. This must be taken into account when workforce
planning is undertaken to avoid the overestimation of future workforce
numbers. A further issue is that many public health professionals
are highly experienced and many have also completed GP training
prior to public health. We are already seeing a number leaving
public health to return to general practice. The establishment
of the Health Protection Agency has also created a further large
and important employer of public health professionals that provides
a significant alternative to the NHS.
At the same time, pressure on training budgets
within postgraduate deaneries may lead to public health training
budgets and recruitment being cut for 2006-07. As public health
training budgets are not embedded in acute service delivery in
trusts in the same way that junior hospital doctors are they can
prove more vulnerable to cuts.
To what extent can and should the demand be met,
for both clinical and managerial staff by:
Changing the roles and improving the skills of
existing staff
Better retention
The recruitment of new staff in England
International recruitment
The Faculty of Public health has pioneered the
development of multidisciplinary public health. Senior public
health posts are open to those from a variety of backgrounds,
not just medicine, and the UK Voluntary Register has established
a specialist register for those working in public health from
backgrounds other than medicine. However, it is clear that there
remains a need for individuals in public health from both clinical
(including specifically medicine) and other backgrounds if a comprehensive
service is to be delivered across the three domains of public
health: health protection, health improvement and service improvement.
It is essential that Directors of Public Health
are well supported by appropriately resourced teams, which include
other consultants, health promotion specialists, information and
intelligence analysts and adequate administrative support. The
Faculty workforce survey found a strong correlation between the
number of consultants per million population and the self reported
capacity of the team. This suggests that there has not been a
compensatory shift from senior to more junior posts, and that
quite simply where there are not enough consultants there are
not enough junior posts either. Whilst it is essential to ensure
a wide skill mix within teams this does not negate the need for
senior posts to provide leadership and direction.
How should planning be undertaken?
To what extent should it be centralised or decentralised?
How is flexibility to be ensured?
What examples of good practice can be found in
England and elsewhere?
The planning of the public health workforce
is essential, and it needs to take into account a number of factors:
— The diversity of key employers for
a comprehensive public health service; the NHS, the Health Protection
Agency, central and local government—the FPH target of 2.5
service consultants per 100,000 population takes the variety of
service locations into account.
— The additional need for public health
academics in universities.
— Actual data on attrition and early
retirement.
— The numbers of senior public health
consultants and dentists and Directors of Public Health AND.
— The size of the wider public health
workforce.
The work undertaken by the National Workforce
Review Team has in general been of high quality, timely and useful
for planning, and we would support its continuation. It is particularly
important for areas such as public health where there is a need
for long-term vision and planning to ensure that there is a robust
workforce in place. Given the flexibility and adaptability of
the public health workforce (in contrast to some of the clinical
specialities) we are concerned that "under-production"
is a very much more serious issue than "overproduction"
of public health specialists.
FPH has worked with the WRT to try to ensure
that an appropriate target is set, and importantly that realistic
assumptions about retention and early retirement are included
in the model. In contrast to other clinical specialities it must
be recognised that public health professionals work in areas other
than the NHS in order to deliver a comprehensive public health
system, and this must be recognised in the planning.
There is also a need to ensure that the NHS
staff census captures not only the senior public health staff
working at consultant and director of public health level, but
also the wider public health workforce of health promotion, public
health intelligence analysts and so forth who form an integral
part of the delivery system.
It is essential that robust links are made between
the WRT and the newly established Health and Social Care Information
Centre. The HSCIC may need to consider what approach it should
take to identifying the consultant public health workforce within
the Health Protection Agency.
Overall we support the national approach to
planning but would wish to see it refined further.
Faculty of Public Health
8 May 2006
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