Public Health - Health Committee Contents


3 The public health workforce

Regulation of public health professionals

253.  Both the General Medical Council and the General Dental Council record public health as a specialism on their respective registers, meaning that consultants in public health with medical or dental qualifications are effectively subject to statutory regulation. This applies to "about 75% or 80% of current senior public health professionals".[435] However, public health specialists without such qualifications, who hold posts including those of consultant and DPH, are not subject to statutory regulation. In order to allow non-medically / non-dentally qualified public health specialists to demonstrate appropriately high standards of practice, a voluntary UK Public Health Register (UKPHR) was established in 2003. The voluntary register is recognised under the current NHS rule requiring DsPH and public health consultants to be appropriately registered.[436]

254.  In the light of concerns about the effectiveness of the current arrangements for professional regulation, a review of those arrangements by Dr Gabriel Scally was commissioned in early 2010 by the then CMO. In his report, published in November 2010, Dr Scally stressed that the purpose of professional regulation is the avoidance of "morbidity or mortality resulting from poor professional practice".[437] His overall conclusion was that:

The current pattern of regulation, a mixture of statutory and voluntary, and the growing number of routes to specialty registration are unsatisfactory. The time is right to bring quality and clarity to the approach to specialist regulation.

Having considered the options for change, he found that:

There was strong support for a system of statutory regulation and a desire to avoid the requirement for multiple registration with different regulators. Contributors stated a strong desire for a system that was both equitable and as simple as possible.[438]

Accordingly, Dr Scally recommended:

that the Health Professions Council [HPC] should regulate public health specialists as an additional profession, and that there is no substantial change in the roles of the General Medical Council [GMC], the General Dental Council and the Nursing and Midwifery Council in respect of public health.[439]

Dr Scally told us that his preferred solution had been for the GMC to take on the registration of all public health specialists. However, this was not feasible, given the major issues with which the GMC was currently grappling.[440] The arrangement he had recommended was analogous to that adopted in respect of the pathology profession, whose medical members registered with the GMC and non-medical members with the HPC.[441]

255.  While the conclusions of the Scally Review were widely welcomed, the Government was sceptical. In Healthy Lives, Healthy People it called for views on the report, but made clear that: "As the Government believes that statutory regulation should be a last resort, its preferred approach is to ensure effective and independently-assured voluntary regulation for any unregulated public health specialists."[442]

256.  Professor Alan Maryon-Davis referred in evidence to the role of public health specialists in dealing with outbreaks of deadly diseases, such as E. coli or pandemic flu as well as other emergency responses. In such cases, poor practice could "have a direct effect on the health, life and limb of the general public".[443] He argued that the changing balance of the profession (with a preponderance of non-medics coming into the specialty) reinforced the case for compulsory registration. The NHS Future Forum also recommended "that registration by an appropriate national body should be compulsory for non-medically qualified public health staff."[444]

257.  In Healthy Lives, Healthy People: Update and way forward, the Government recognises "the strong support in the public health profession for a compulsory statutory regulation system for all public health consultants." It does not, though, concede the case for such regulation, but rather says it:

would welcome further evidence from the profession on significant risks to the public which would necessitate a statutory regime and which cannot be addressed through other means. This evidence will be considered carefully over the summer with the profession, employers and other interested parties and final proposals will be put forward in the in the autumn.[445]

In evidence to us, the DH indicated that it might consider the option of "chartered" status for non-medical public health professionals,[446] an option which the RSPH has put forward as a "middle way" between statutory and voluntary regulation.[447]

CONCLUSION AND RECOMMENDATION

258.  There is widespread support for the recommendation in Dr Gabriel Scally's report that non-medically qualified public health specialists should be subject to statutory regulation. In view of the rising proportion of public health specialists that do not have a medical or dental background, the Committee recommends that the Government review its opposition to this proposal.

The future of the public health workforce

259.  In Healthy Lives, Healthy People the Government set out its "vision for the public health workforce":

We envisage that the public health workforce will be known for its:

  • expertise - public health staff, whatever their discipline and wherever they work, will be well-trained and expert in their field, committed to developing and maintaining that expertise and using an evidence-based approach to practice;
  • professionalism - they will demonstrate the highest standards of professional conduct in their work;
  • commitment to the population's health and wellbeing - in everything they do, they will focus on improving and protecting the health and wellbeing of their populations, taking account of equality and rights, whether it be a DPH in a local authority, an infection control nurse in an acute trust or a microbiologist within Public Health England; and
  • flexibility - they will work effectively and in partnership across organisational boundaries.[448]

It was also promised that a detailed Public Health Workforce Strategy would be developed "by autumn 2011, working with representative organisations." This would "support a smooth and effective transition, informed by the views of people on the frontline of public health delivery."[449]

260.  Uncertainty has however inevitably been created by the transition to new structures. Professor Lindsey Davies, President of the FPH, told us that "In terms of morale at the moment, it is very low indeed. People are exhausted […] Morale […] is not great."[450] We heard from one DPH of "an uncertain and demoralised workforce" that was "being asked to take on an ever more complex and demanding task of change management that could be a major distraction" from its actual job.[451] Professor Newton was somewhat less gloomy, telling us that "We are seeing a mixed picture in terms of morale."[452] Ms Marsland, of the DH, admitted that "It has been a difficult period for colleagues", but also told us "I think morale is improving."[453] The CMO was more upbeat, telling us that, when she attended the recent FPH conference: "I expected low morale. Actually, people were really up for it",[454] a view that somewhat contradicts that of the Faculty's President.

261.  The process of transfer of functions to new bodies inevitably creates uncertainty. The Department says in Healthy Lives, Healthy People: Update and way forward that:

Work will continue over the summer 2011 on the development of the Public Health England "People Transition Policy" that will set out the principles applying to the HR and employment processes supporting the transfer of staff into Public Health England.[455]

In addition, the DH is:

responding to the concerns raised by developing a high level HR "concordat" in partnership with the NHS and Local Government Employers on the effective transition of public health staff between the NHS and local authorities.[456]

The DH has stated that these will be covered in the System Reform Update on workforce issues, which will "address concerns relating to terms and conditions".[457] Where current postholders are transferred to a new employer TUPE rules will apply.[458] There are, though, no such obligations where roles or posts are transferred but actual postholders are not. Healthy Lives, Healthy People: Update and way forward makes clear that the forthcoming Workforce Strategy "will not make specific proposals for the terms and conditions of service of constituent workforces, which are matters for individual employers and employer groups".[459]

The DH told us its approach to developing the Workforce Strategy was:

consultative, through a workforce strategy group chaired by a Regional Director of Public Health [Yvonne Doyle, the DPH in the DH South East Region]. The group, whose membership is flexible, will engage more widely with others as its work proceeds. The strategy will be published for wider formal consultation later in [2011] […][460]

According to Healthy Lives, Healthy People: Update and way forward, the Strategy (focused on the specialist workforce, but also "inclusive") will:

  • scope the current situation of public health workforces;
  • consider the role and purpose of the public health workforce in the context of the White Paper […];
  • examine how best to transform the workforce to meet the challenges and opportunities of the future, but also offer career pathways to those with different entry points;
  • set out how to deliver a high quality, sustainable, specialist workforce with the flexibility to move across employment sectors;
  • look at the training and education opportunities to support wider public health workforces (such as health visitors, school nurses, many allied health professionals and others) and the relationship between Public Health England and Health Education England;
  • consider how best to build on and use workforce data effectively, not least for planning the future.[461]

262.  Some witnesses expressed the fear that the public health workforce could become fragmented in the new system, and that this may undermine the cohesion of the profession and disrupt established pathways for education and training.

263.  We heard that the move of public health away from the NHS could make it a less attractive career choice for clinicians.[462] We heard this "may well be an important factor that particularly influences career choices among recently qualified doctors, the vast majority of whom are employed in the NHS".[463] Some see a risk that Specialty Registrars in public health might no longer have adequate access to the full breadth of experience and settings needed to fully develop their specialist public health competencies.[464]

264.  There are particular concerns that local authorities will not have sufficient appreciation of the qualifications and experience required by the public health workforce. It is feared that councils have too little understanding of how medical and public health training works (particularly the role of the postgraduate deaneries).

265.  Unite the Union told us of concerns that local authorities could disperse public health staff across their organisation, potentially leaving those staff without sufficient professional support, coaching, management and mentoring. It has also been argued that local authorities will be unable properly to support staff in achieving revalidation and undertaking Continuing Professional Development.[465] Councillor Rogers of the LGG, though, rejected this:

There are something like 480 [types of] professionals that currently work in local government. They are all valued and they are all subject to professional competencies, training, ongoing professional development and all that sort of thing. I don't see it as any different in the longer term […] to those.[466]

266.  Little thought appears to have been given to the future of the academic public health workforce, which plays an important role, particularly in the PHOs, where public health research and practice come together.[467] The BMA told us: "We are particularly concerned about the place of academics in public health under the new arrangements." The latest report by the Medical Schools Council on Medical Clinical Academic Staffing Levels in Medical Schools had reported a steady decline in staffing levels in public health, amounting to a 21.7% drop since 2000, including "a massive 76.9% drop in lecturers since 2000 from 57 to just 13 in 2010".[468]

CONCLUSIONS AND RECOMMENDATIONS

267.  THE UNCERTAINTY CAUSED BY THE TRANSITION TO THE NEW PUBLIC HEALTH SYSTEM IS INEVITABLY HAVING AN UNSETTLING EFFECT ON THE WORKFORCE, WHICH IS UNDERMINING MORALE AND CAUSING PEOPLE WITH VALUABLE SKILLS TO LEAVE THE PROFESSION. THE STRUCTURES WILL RELY FOR THEIR EFFECTIVENESS ON THE AVAILABILITY OF MOTIVATED AND COMMITTED PROFESSIONAL STAFF; IT IS THEREFORE IMPORTANT THAT UNCERTAINTIES AROUND STAFFING ISSUES ARE RESOLVED AS QUICKLY AS POSSIBLE.

268.  It is also important that the public health specialty is fully integrated into its forthcoming proposals for healthcare workforce planning, education and training.

269.  Finally, we attach importance to the future role in the workforce of public health academics, particularly in their role in the Public Health Observatories. The importance of academia as a career option within public health should not be ignored.


435   Q 378 [Dr Scally] Back

436   Q 69 [Dr Fiona Sim] Back

437   Department of Health, Review of the Regulation of Public Health Professionals, November 2010, p 4 Back

438   Ibid., p 1 Back

439   Ibid., pp 40-1 Back

440   Q 381; cf. Department of Health, Review of the Regulation of Public Health Professionals, November 2010, p 33 Back

441   Qq 362, 381 Back

442   Department of Health, Healthy Lives, Healthy People, November 2010, para 4.96 Back

443   Qq 367-8 Back

444   NHS Future Forum, Clinical advice and leadership, June 2011, para 3.20 Back

445   Department of Health, Healthy Lives, Healthy People: Update and way forward, July 2011, para 2.59 Back

446   Q 515 Back

447   Q 69 [Dr Sim]; cf. Ev 146 Back

448   Department of Health, Healthy Lives, Healthy People, November 2010, para 4.89 Back

449   Ibid., para 4.90 Back

450   Q 68 Back

451   PH 12 [Dr Bruce Laurence] Back

452   Q 308 Back

453   Loc. cit. Back

454   Q 318 Back

455   Department of Health, Healthy Lives, Healthy People: Update and way forward, July 2011, para 2.58 Back

456   Ibid., para 2.57 Back

457   Department of Health, Healthy Lives, Healthy People: Update and way forward, July 2011, p 6 (para 7) Back

458   For transfers of employment outside the public sector, the relevant provisions are under the Transfer of Undertakings (Protection of Employment) Regulations 2006 (SI 2006 / 246); for transfers within the public sector, the Cabinet Office Statement of Practice on "Staff Transfers in the Public Sector" (2000) applies. Back

459   Department of Health, Healthy Lives, Healthy People: Update and way forward, July 2011, para 2.57 Back

460   Ev 110; cf. Department of Health, Healthy Lives, Healthy People: Update and way forward, July 2011, para 3.5 Back

461   Ibid., para 2.56 Back

462   PH 27, PH 58, PH 131, PH 180, PH 190, PH 191 Back

463   PH 87A [UK Public Health Register] Back

464   PH 129, PH 180 Back

465   PH 100 Back

466   Q 139 Back

467   Ev 118; Q 101 Back

468   Ev 158 Back


 
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© Parliamentary copyright 2011
Prepared 2 November 2011