HC 1048-III Health CommitteeWritten evidence from the Training Programme Directors of the Faculty of Public Health (PH 191)



Public Health has always been the prerogative of many different professionals, and the Faculty of Public Health (FPH) formally recognised this and opened its doors to non-medical colleagues to be able to attain full membership through the training programme and examination route. Training in PH is multi-disciplinary, with people entering the programme from a variety of clinical and non-clinical backgrounds over the last ten years. Between 2003 and 2008, approximately 25–30% of the intake was from candidates with backgrounds other than medicine.

Current Situation

Over the last five years, PH has moved towards a system of national recruitment. There is now a single recruitment process which covers England and Wales (and is likely to include Scotland and Northern Ireland soon) and which ranks candidates through a complex and well-validated process and then makes offers in that ranking order. As a result, we are appointing the best candidates to the speciality, regardless of background or geographical location.

This integrated process facilitates monitoring the data for applications and appointments. Figure 1 shows the number and proportion of applications to PH entering through the medical route. This has dropped from 67% to 29% over four years.

Figure 1


There has been a decline in the numbers of applicants to PH over the last four years, and the proportion of medical to non-medical applicants dropped again last year. For the first time, three Deaneries recruited only non-medical trainees in the cohort to start training in August 2011. What is clear is that, if this trend continues, there will be virtually no medical recruitment to PH within five years.

The Issues

Recruitment into PH Medicine can occur at any stage, but Modernising Medical Careers put pressure on young doctors to choose their career path at the end of the second year of Foundation Training. This is much earlier than was the case in previous generations, when many doctors came to PH after time spent in another speciality, when they realised that they could achieve more at a population level than at an individual one.

Why might PH appear to be an unattractive career choice? There are long-standing issues around the profile of PH within the medical curriculum and in the Foundation Programme that are being addressed, but the present changes are also likely to have an impact. The possible reasons for this are:

1. Uncertainty

(a)It is very unclear at present what the PH structures will be in the future. More damaging, it is very uncertain where they will be placed. The spectre of fragmentation remains, and young doctors may be unwilling to take the risk of there being no medical PH in the future.

(b)There is a perception that Health Services PH is undervalued and unwanted. Despite some acknowledgment recently of the existence of health services PH, it is still not well understood at the centre and this is reflected in the constant use of the word ‘advice’ in relation to commissioning, rather than the integration of PH into the commissioning function. This branch of PH has always been medically dominated, and is often more attractive to medical graduates than the health improvement role.

2. The NHS

(a)Trite as it may sound, most young doctors want their careers to be in the NHS. Contrary to the impression received by the Future’s Forum, the concept of moving to the LA does not find favour with the majority of PH personnel.

(b)Still less do they wish to leave the NHS before their training is complete, thus closing down many options. We have, so far, been unable to secure assurances that PH training will remain part of postgraduate medical education, and there is nothing about LAs in the workforce paper.

(c)The perception that there might be a much-increased role for private medicine militates against PH.

3. Loss of senior PH staff

(a)We are seeing increasing numbers of medical PH Consultants retraining in clinical medicine or leaving medicine altogether.

(b)We are also seeing our most senior PH Medical consultants taking Voluntary Redundancy or early retirement. Most senior staff are medical, since non-medical colleagues are still climbing the ladder, so this is having a disproportionate effect on the relative numbers of medical and non-medical PH personnel.

(c)This will also have an effect on our ability to train the next generation of PH professionals, and to provide population medicine training to other medical specialities.

4. Terms and Conditions

(a)It would be naive to assume that Terms and Conditions do not play a part, although it is probably a small part of the decision-making process for young doctors.

In Conclusion

Medical recruitment to PH has declined. The concern is that this trend is accelerating. If the current trend continues, and if nothing is done to encourage young doctors to believe that they have a future in the NHS in PH, we shall effectively eradicate medical recruitment over the next five years. It is also likely to discourage the best of our non-medical colleagues from entering PH, as they will no longer perceive it to be a genuine career path. This matters for a number of reasons:

A clinical background, especially where an individual has completed some specialty training and practice, is one of a range of important backgrounds that add to a Public Health Specialists offer. Because doctors and other clinicians make such a powerful contribution to leadership and delivery of health care, it is essential to have a significant cohort of public health specialists who are from medical and other clinical backgrounds.

The health protection function of PH requires doctors within its ranks; there are limited possibilities for non-medical PH personnel in health protection.

The health services PH function, although not exclusively medical, benefits from having a considerable proportion of doctors. The understanding of the natural history of disease and the nature of clinical care will be needed by the Clinical Commissioning Groups.

It will fundamentally change the relationship of PH to other Royal Colleges and specialities.

The disproportionate number of doctors leaving the speciality, dictated by the age and seniority profile, means that the shift from a medical speciality to a non-medical one is happening extremely fast. Action to correct this needs to be taken as a matter of urgency.

August 2011

Prepared 28th November 2011