HC 1048-III Health CommitteeWritten evidence from Dr Mark Lim (PH 129)


1. This is a personal contribution from a Public Health Specialty Registrar solely on the issue of Public Health Workforce, in particular those in Public Health Specialist Training.

2. Doctors undertaking Public Health Specialist Training have previously worked in Senior House Officer, House Officer or Foundation Year posts for between two and five years after qualification. They then apply and enter Public Health Specialist Training which takes five years. For example, the contributor entered medical school in 1998 and is due to complete Public Health Specialist Training in 2012.

3. The contributor believes that there are opportunities to improve the current outlook for those completing Public Health Specialist Training during the transition.

4. The contributor believes that Public Health Specialist Training is totally viable in a system where health improvement and health protection takes place in Local Authorities. The health system must, however, ensure that certain mandatory elements of training and experience (healthcare public health and health intelligence) are still accessible, to meet requirements for Specialist Registration with the General Medical Council.

5. The contributor has summarised the rationale for Public Health Specialist Training, as there has been little specific reference to this in other publications.

Main Section

1. About the contribution:

(i)Although the contributor is co-chair of the British Medical Association Public Health Medicine Registrars’ Subcommittee, this is a personal contribution on the subject of Public Health Specialist Training within the context of the Public Health Workforce.

(ii)The contribution also follows up the concerns around training voiced by Professor Lindsey Davies at the first session of this inquiry.

2. The most pressing issues are:

(i)The number of Specialist Registrars completing training is rapidly outstripping the availability of substantive consultant jobs; the ratio will be approximately 4:1, if the situation remains similar to the financial year just gone.

(ii)During the financial year ending 2010–2011, 23 Specialty Registrars were appointed to substantive consultant posts, 22 were appointed to short term posts as locums, 10 did not get appointments or did not complete training and a further 12 were in their “grace period” (a short term contract extension). Those not receiving substantive consultant posts in 2010–2011 will, during 2011–2012, be in competition with a further 52 completing training during that year.

(iii)There are at least four types of organisation that might claim or disclaim responsibility for this situation. The Deaneries currently employ Specialist Registrars through host organisations and are primarily responsible for ensuring they are trained well; the Department of Health leads work on transition work in relation to health improvement and health protection which affects employment prospects radically, and of course they were responsible for Modernising Medical Careers in the first instance; Primary Care Trust clusters currently employ the majority of Consultants in Public Health; Strategic Health Authorities tend to have workforce directorates that engage in regional public health workforce planning to varying extents.

(iv)Specialist Registrars currently within training have a specific set of skills and experiences that they must acquire during their training, else fail to meet General Medical Council requirements for Specialist Registration. Currently, the majority of these are obtained in within the commissioning and health improvement functions of Primary Care Trusts, local Health Protection Units, Public Health Observatories and Universities. The future health system must ensure that equivalent opportunities exist during the transition and in successor organisations; in particular it is not yet clear where Specialist Registrars in Public Health will be able to acquire ‘healthcare public health’ skills and health intelligence skills. These skills have been described in detail by submissions to the previous inquiry into Commissioning.

3. How I would like the Health System to Respond

(i)An explicit recognition that for those doctors who are about to complete Public Health Specialist Training, the winding down and abolition of the entire class of major employing organisations poses a problem that is unique to the specialty and not faced by doctors in hospitals.

(ii)That whilst Deaneries are in the process of being replaced by Provider Skills Networks and Health Education England, one organisation should have clear and ultimate responsibility for exploring the issues in relation to those completing Public Health Specialist Training during the transition. If the new Public Health system is unable to accommodate all those it has trained at taxpayer expense, I would like that conclusion to have been drawn after a big, open and comprehensive effort to avoid this scenario.

(iii)If and when a system of Provider Skills Networks overseen by Health Education England is established, it has to be crystal clear who is ultimately responsible for workforce planning. I would suggest that within the Government’s proposed structure, this should be Health Education England.

(iv)At present, Deaneries ensure that elements such as healthcare public health and health intelligences remain available as experiences during the transition. If and when Deaneries are abolished, I would like to be clear who would be responsible for maintaining this availability.

4. Benefits of Public Health Specialist Training

(i)As with any medical specialty, any industry or the armed forces, the key is to recruit people with the correct skills, background knowledge, experience and commitment. It is vitally important that the public health workforce continues to recruit doctors. Medical entrants to public health will have had a grounding in human biology and clinical experience that gives them knowledge, perspective and passion for public health.

(ii)Every doctor will have spent a substantial proportion of their career working in a multidisciplinary team. Through their clinical experience they will recognise, facilitate and support the key and massive contributions of non-medical colleagues.

(iii)There is however a difference between “knowing that something should done” and “knowing how something should be done”. The following three sections give examples in health improvement, health protection, and healthcare.

(iv)Excessive alcohol consumption, and the harm done to our society as a result, is a complex problem. As well as being recognisable champions for the community’s health, doctors have the potential to use their experience of the way in which patients with alcohol abuse problems present themselves to improve the way in which society (a) supports these people to reduce their drinking and (b) establishes appropriate referral and treatment pathways. Specialist training will unlock this potential, by instructing the doctor on a wide range of relevant skills that will allow him or her to utilise this knowledge and experience. In this instance, he or she would learn how to (a) quantify the harm done by alcohol (b) construct effective programmes aimed at preventing alcohol misuse (c) calculate the capacity or other specifications required of alcohol misuse services at every level (d) evaluate existing services for effectiveness and value for money. Training will also provide the doctor with other more generic skills that are necessary to make these efforts successful, notably the ability to lead local teams, establish a strategy, work with partners and communicate effectively through the media.

(v)For a disease which is infectious and can be prevented by a vaccine, a doctor will know the biology of the virus or bacteria, how affected patients appear and what the treatment is. Public Health Specialist Training will enable a doctor to ascertain how infectious a disease is, how it should be monitored within a population (such as a school or a town) and what measures need to be taken at a population or individual level to prevent its spread.

(vi)For a complicated intervention or service, such as bone marrow transplantation, a doctor will have a knowledge of the diseases that would require such a service. Public Health Specialist Training will give the doctor the necessary skills to (a) calculate the likely need for such services (b) estimate future need for such services based on technological, population and policy changes (c) assess, in terms of overall effectiveness and value for money, the different options for providing that service (d) formulate evidence-based indicators, such as outcome measures that will make the provider accountable to the commissioning community or organisation.

June 2011

Prepared 28th November 2011