Health CommitteeWritten evidence from the UK Faculty of Public Health (ETWP 112)

Introduction

1. Public health is a multidisciplinary specialty in the UK. Training is overseen by two Regulators; the General Medical Council (GMC) and the UK Public Health Register (UKPHR). The role of the GMC is to maintain a register of qualified doctors, promote standards and accreditation for education and training including posts, programmes and curricula. The UKPHR is responsible for regulating and keeping a register of accredited PH specialists from disciplines other than medicine. It is essential that there is a robust statutory regulatory system that oversees the public health workforce and protects the public.

Summary

Public Health (PH) is a shortage specialty. Recent evidence shows that there has been a significant reduction in the advertisement, and by extrapolation, recruitment to Public Health consultant posts in England since the publication of the government’s reform plans.

Presently there is a high quality, well-structured multi-disciplinary PH training programme with relevant curriculum developed by the Faculty of Public Health and approved and reviewed by the General Medical Council (in line with other medical specialities) and the UK Public Health Register.

The delivery, quality assurance and quality management of public health specialty training should remain firmly within postgraduate deaneries to ensure continuation of high standards in PH training.

The proposed transfer of public health teams from the NHS to LAs presents new challenges. These include the rapidly expanding employment market for public health specialists by other public and private providers and commissioners of health and social care, appropriately accredited training locations and robust appointment processes and revalidation.

About the UK Faculty of Public Health

2. The UK Faculty of Public Health (FPH) is the standard setting body for public health in the UK, maintaining professional and educational standards for specialists in public health and quality-assuring professional standards. FPH provides advice to employers and other bodies on statutory and good practice processes for senior public health appointments. In addition, FPH advocates on key public health issues and provides practical information and guidance for public health professionals, aiming to advance the health of the population through three key areas of work: health promotion, health protection and healthcare improvement.

3. The GMC, UKPHR and FPH are UK organisations, and thus the roles, responsibilities and standards are applicable across the four countries of the UK. It is important to note that proposals affecting education and training systems in England will have an impact across the whole of the UK.

4. In its initial response to the Government’s consultation document “Developing the Healthcare Workforce”, FPH underlined the following overarching principles:

The public health workforce should remain fully integrated with the healthcare professions.

Specialist public health workforce planning should be undertaken alongside other clinical specialities.

There must be expert public health input into Health Education England.

Public Health England should have a key role in workforce planning.

Local authorities, GP Consortia, higher education institutions and if appropriate the private sector must be included as part of the environments that provide accredited and relevant training in PH.

The current functions of postgraduate deaneries must be preserved during the transition.

The importance of Health Protection and Academia functions and skills for PH specialists must be underlined and training in these areas must be delivered in appropriate placements.

Specialty Training

5. In order to be registered as a specialist in PH on the GMC register and as a specialist for those from disciplines other than medicine on the UKPHR, a structured training programme is available in common with training in other medical specialities. The curriculum and assessment methods are developed by the FPH and submitted to the GMC. The GMC has a statutory role to approve, review and monitor the curricula to ensure it reflects the changing nature of the knowledge and skills required.

6. Public health specialists must achieve competence across nine key areas as outlined below, identified within the public health curriculum.

(1)Surveillance and assessment of the population’s heath and wellbeing.

(2)Assessing the evidence of effectiveness of health and healthcare interventions, programmes and services.

(3)Policy and strategy development and implementation.

(4)Strategic leadership and collaborative working for health.

(5)Health Improvement.

(6)Health Protection.

(7)Health and Social Service Quality.

(8)Public Health Intelligence.

(9)Academic Public Health.

These are the requirements included in the curriculum for PH training and acquiring competence in these areas is mandatory prior to inclusion in the GMC or UKPHR specialist register for PH.

7. There are various organisations that will have responsibilities for the delivery and planning of education and training in the UK. These include Health Education England (HEE), Public Health England (HEE), Local Education and Training Boards (LETBs), Deaneries and training locations in service PH, health protection and academia. It is important to note that rules, regulations and standards for public health training are applicable to the whole UK. Mechanisms for UK wide engagement and interaction of these organisations into education and training structures should be made clear. It is important that the roles and responsibilities of all of these organisations are clearly articulated and developed in collaboration with FPH and other stakeholders to ensure roles and functions are complementary to each other.

Training and Deaneries

8. PH specialty training is structured in three phases ((1) knows how/Academic; (2) Basic shows/application; (3) advanced shows/consolidation) lasting five years. Training includes acquiring learning outcomes as outlined in the curriculum and assessment through a range of methods including FPH exams (in common with other Royal Colleges) and work based assessments.

9. The progression of specialty registrars in training is monitored and approved by an Annual Review of Competence Progression (ARCP) panel, convened by the local Deanery. This panel assesses a Registrar’s satisfactory progress in training and reports to FPH. On completion of training a recommendation is made from the FPH to the Regulators for inclusion onto the appropriate specialist Register.

10. The delivery, quality assurance and quality management of public health specialty training should remain firmly within postgraduate deaneries. As public health (in common with other clinical specialities) is a structured training programme for inclusion to the specialist register, the planning and commissioning of public health training must be undertaken alongside the other medical specialties and healthcare professions and be subject to the same quality standards of delivery. FPH welcomes Health Education England (HEE) as the overarching body to inform workforce planning and monitor standards for training in medical specialties. It is important that there is clarity in the relationship between HEE, LETBs and deaneries to ensure that training is delivered to a high standard.

11. It is important that Deaneries and their functions such as recruitment, human resource management, remediation, training, coaching, formal review of progression and formal reporting to the Regulators are maintained locally to ensure that Registrars are provided with the appropriate infrastructure to enable them to undertake training. Whilst there may be a desire to create economies of scale for these services, it is important that there are responsive functions such as HR, coaching and remediation that are maintained within local deaneries.

12. Deaneries have a responsibility to deliver training in line with nationally approved standards of the Regulators and the relevant colleges/faculties. Whilst working to national standards deaneries must be allowed local autonomy and flexibility to encourage and enable innovation.

Training in the New PH Structures Based in Local Authority

13. Previously training for the service components of PH was obtained mainly in PCTs. Registrars usually spent a year in PCTs getting experience of basic skills at the start leading on to developing more advanced skills related to dealing with complex PH projects. With the imminent move of some of these functions from the PCT to the Local Authority (LA) it is important to ensure that LAs are set up as appropriate training locations (in line with the requirements of the regulators) to deliver the range of opportunities to enable registrars to gain the appropriate experience and skills. This will require appropriate educational supervisory and training capacity and quality control within LAs.

14. It is therefore important that LAs are encouraged to engage with local deaneries and LETBs to ensure high quality training is delivered by public health professionals. Widespread opting out by LAs of their training function would present a risk for future public health training, with lack of experience of new consultants to work and operate in an important and essential area of PH delivery as envisaged by the government reforms.

15. To ensure public health education and training continues to be delivered to a high standard, it must be adequately resourced which would involve protected and ring-fenced funding for training.

Advancing Continuing Professional Development

16. FPH, employers and individuals have an important role in supporting and providing continuing professional development (CPD) for doctors and specialist from disciplines other than medicine beyond formal training. The proposed transfer of public health teams from the NHS to LAs and the rapidly expanding employment market for public health specialists by other providers and commissioners of health and social care, including those in the private sector, presents new challenges, particularly with regard to the appointments process. The current statutory appointment system—the Appointments Advisory Committee (AAC)—provides a robust system of monitoring applications for specialist public health posts. Through this system, candidates’ qualifications, training and experience are scrutinised by experts in the field of public health, (FPH Assessors), to ensure that only appropriately qualified and trained people are appointed.

17. Currently, the system covers appointments in the NHS. The move to LAs would mean this safeguard may be lost. Extending the AAC process to cover appointments to LAs is essential to maintain the existing level of public protection in the public sector. This would not however cover appointments to organisations in the third or private sectors, many of which now provide publicly-funded services and support public sector commissioning.

18. The AAC process assesses and assures standards at appointment. However, it does not confer timeless assurance, immunity from personal or professional misconduct or protection for the employee, employer or public in the case of fitness to practice issues. For example, if a local authority dismissed someone because they were considered unfit to practice, that information would not necessarily be available to future employers. Similarly, it is possible that a public health specialist removed from a specialist register for professional misconduct could successfully obtain a public health specialist post within a local authority, where there is no requirement for them to be statutorily registered. It is crucial that all public health specialists, whether medically qualified or not, are regulated by an appropriate body.

19. The AAC process is also unable to ensure that professional standards are being maintained. For this purpose, CPD and revalidation are essential. Revalidation will ensure that the CPD and practice of public health specialists will be closely scrutinised and high standards maintained. Currently, it is suggested that this will only be a statutory requirement if they are on the specialist registers of the GMC or GDC, and hence it is essential that revalidation is mandated by law for all public health specialists, including those registered with the UKPHR, who are presently developing a parallel process of revalidation.

Public Health Workforce

20. Whilst workforce planning is notoriously difficult, it is unlikely that in the medium term the need for consultants required in public health will decrease especially, given the prominence that the government has given to the importance of public health in its plans. The recent NHS Future Forum concluded that “the need for a strengthened public health system at local and national level is clear”. The forum recommended that this should be supported by “an independent, expert public health advice at every level of the system”.

21. Ensuring that we have a public health workforce which is robust, cohesive and continues to attract the very highest calibre of applicant, it is vital that the wider lack of clarity with regards to public health specialists’ terms and conditions of employment, is addressed and does not lead to a loss of morale, and vital expertise and knowledge from the service, not least with regard to those public health specialists directly involved in the provision of education and training.

22. As the FPH’s Summary of Professional Standards activity 2008–11 demonstrates, public health is a shortage speciality. Statistics from the previous three years of AACs reveals an unambiguous downward trend. In 2008, 208 AACs were held, by comparison with 169 in 2009, 79 in 2010 and so far this year 31. Of the 31 AACs held this year, 12 have so far been filled.

23. Recent data analysis confirms the anecdotal concern that there has been a significant reduction in the advertisement, and by extrapolation, recruitment to public health consultant posts in England around the time of the publication of the government’s reform plans. Public health consultant posts are disproportionately affected by this reduction compared to hospital consultant posts. This contradicts the Government’s commitment to the maintenance of a “well-trained, highly motivated Public Health workforce”.

24. Fowler et al (Fowler et al, “Changes in recruitment to public health consultant posts and hospital consultant posts in England: potential impact on the sustainability of the public health system”, Journal of Public Health, Volume 33, Number 4, December 2011) found a highly significant reduction in the mean number of advertisements for public health consultant posts from 27.9 posts per month in the period October 2008 to November 2009 to 6.3 posts per month between December 2009 and May 2010. The ratio of public health: hospital consultant posts fell sharply from 3.3 to 0.9 public health consultant posts per 100 hospital consultant posts. The 2007 Faculty of Public Health workforce census suggested that 20% of the public health specialist workforce were planning to leave the profession during the 2007–11 period, over half of whom were 55 years of age or over at the time of the survey. In previous substantial reorganisations of public health, around 20% of the workforce has taken early retirement. Workforce data suggest that, even with current recruitment to specialist training programmes, there is likely to be a shortage of qualified individuals over the next few years. In addition, at present ~15% of DPH posts are vacant.

25. From October 2008 to November 2009 inclusive, there were 3.3 PH posts advertised for every 100 hospital posts and from December 2009 to April 2011 there were 0.9 PH posts for every 100 hospital posts. The difference in this ratio was a reduction of 2.4 advertised Public Health posts per 100 hospital number of advertised public health consultant posts (England).

26. More significantly, it demonstrates that advertisement, and by extrapolation, recruitment of public health consultant posts have been disproportionately affected by this reduction in recruitment compared with hospital consultant posts. This drop in advertisement, and by inference recruitment, potentially poses a considerable threat to the integrity of local public health departments and the ability of PCTs, LAs and emerging clinical commissioning groups to tackle the needs of health improvement, reduce health inequalities and successfully manage the transition of public health over the next two years.

Possible Impact of the Proposed Move of the PH Function to a Non-NHS Body

27. The move of public health away from the NHS could potentially make it a less attractive career choice, particularly for clinicians. In turn, the provision of public health specialists within an education and training context may—and indeed is, given the figures above—be negatively impacted. It is vital that the highest quality applicants are attracted to these posts. The Government’s proposed workforce strategy, will not make specific proposals on terms and conditions. This will be left to individual employers. There is a real risk that the public health workforce could become fragmented in the new system, with public health specialists being employed in a number of different settings, including Public Health England, LAs, some retained in the NHS and others will move to the voluntary or private sectors. This would undermine the cohesion of the profession, and disrupt education and training.

December 2011

Prepared 22nd May 2012