Health CommitteeWritten evidence from the Cheshire & Merseyside Public Health Network and the North West School of Public Health (ETWP 94)

1.0 Background

Current activities to support the NHS reforms in the North West, and the Health Select Committee interest

The Health Select Committee has issued an invitation to submit written evidence for its inquiry into Education, training and workforce planning. Alongside the passage of the H&SC Bill through parliament, national and North West Health Care systems are being prepared for the expected directions and vision contained in the bill. This is as true for the workforce planning, training and education systems for health and social care professionals, as for the commissioning architecture of the NHS. For example, the clustering of SHAs, and formation of local provider skills networks across the region is well under way.

Three skills networks (Cumbria & Lancashire, Greater Manchester and Cheshire & Merseyside) have been declared. The North West networks are called Network Leadership Groups, and each one includes Director of Public Health membership.

2.0 This response

There follows evidence to the Health Select Committee from the Cheshire and Merseyside Public health Network (ChaMPs) and the North West School of Public Health.

ChaMPs is a well established, respected local public health network owned by the NHS and Local Government. It includes current Directors of Public Health, academics, and the wider community of public health professionals, including those working in local government.

The North West School of Public Health is the training team and structure responsible for ensuring the supply of future public health experts and leaders in the North West. The School has 50 people in training and a large community of public health experts who are also educators.

2.1 The Role of the Secretary of State for Health in the New System

The Secretary of State for Health, as an integral part of their responsibility to deliver a fit for purpose health and health care system, must have responsibility to ensure that training and education delivers a highly expert health care professional work force. This includes a dedicated public health specialist and practitioner work force. It also requires a wider work force that understands basic health principles: for example, the importance of evidence and evaluation; the effectiveness of screening and immunisations; the need to promote healthy environments and lifestyles.

2.2 he proposed role, structure, governance and status of Health Education England (including how it will take on the roles of Medical Education England and the Professional Advisory Boards), and its relationship to professional regulators and to the other parts of the new NHS system architecture

We fully support the proposed role of Health Education England (HEE) and see Public Health England (PHE) as one of the key partners in advocating for specialist and practitioner training within HEE.

Public Health England will be a principal employer of public health professionals at specialist and practitioner level in the future system. With this in mind, PHE should have a specific remit for public health professions in other organisations such as local authorities, Health Education Institutions, NHS foundation trusts and elsewhere. PHE may in effect be the “guardian” of public health standards in training and education. Advantages to this approach include a fit for purpose public health workforce with education and training plans that are coordinated and meet the needs of the communities in which they serve. They will also be responsible for providing an organised and modelled approach to continuing professional development to secure consistency and a high quality workforce.

There needs to be National leadership for the public health workforce—this will assist local authorities to meet their statutory responsibilities around public health delivery and protect them from the risks associated with an inadequately trained workforce.

Knowledge and skills for building for health improvement need to be accessed by many professional groups. This needs to be driven forward within the planning and development of the workforce at local level.

2.3 The implications of a more diverse provider market within the NHS

There is a need for national leadership to continue to set standards for public health practice. Public Health England must be a major player in this.

Local skills networks/Local Education and Training Boards have responsibility also to set standards those local providers can then be held to account for delivering.

2.4 How professional regulators, healthcare providers and commissioners, universities and other education providers, and researchers will all participate in the formulation and development of curricula

Regulation will protect employers and the public in the new system, where multiple providers and smaller independent public organisations such as local government will need assurance that the people they employ are safe, and can be trusted. The experience of GP out of hour’s providers employing doctors in the UK illustrates the risk involved.

All Health Care and Social Care Professional groups and regulators have a responsibility to articulate and develop public health content in their respective under graduate/post graduate curricula.

Professional registration for medically qualified public health staff’s should continue to be via the GMC and for non medically qualified the UKPHR working as part of the Health professional Council.

Education providers including universities must be fully integrated into workforce planning and curriculum needs for health care professionals, so that they can deliver what is needed.

The workforce for those services commissioned and delivered by Local Authorities will need to include public health skills and competencies to deliver on the prevention agenda and to tackle health inequalities. Their education and training is best integrated within locality-based Skills Networks as part of the wider health care education system.

As a multidisciplinary profession, the registration mechanism needs to be robust. There is a single standard setting body (the Faculty) which has half its active members form backgrounds other than medicine. If there cannot be in the same vein a single registering body for all public health specialists, then there must be as much equivalence as possible in registration with different bodies. This is the case now with the GMC and UKPHR, There is a risk not only to non-medics, but also to Drs that the standing of the registration will suffer if half of trainees on the training scheme do not have a robust body to register with.

In Cheshire & Merseyside the four universities that train under graduate nurses collaborated to add healthy lifestyle training into the core curricula as part of a pilot project that is currently the subject of a longitudinal evaluation. This is a good example of a large scale approach to public health workforce development of the future clinical workforce that could be extended and built upon with support from PHE and the professional regulatory bodies.

2.5 The future of postgraduate deaneries

Post graduate medical specialty education, including public health specialist training, needs a strong infrastructure and a resourced team at sub regional level to ensure equality, satisfy regulators, and deliver tomorrows senior doctors and public health specialists.

Post graduate medical specialty education teams should also carry responsibility for ensuring public health skills and knowledge is in every specialty curriculum and every specialty practice.

2.6 The implications of a more diverse provider market within the NHS

Local skills networks must have local authority input in order to ensure that local commissioning decisions reflect local health priorities and need.

Local authorities are community champions and are also significant employers of social care staff—health literacy needs of social care and wider workforce can be addressed through local skills networks with support from local authorities.

Similarly, CCG’s and NHS commissioning boards need public health skills and awareness with public health commissioners having an active role in health commissioning decisions through these bodies.

Local skills networks will secure standard setting which will become increasingly important in the environment of “Any Willing Provider.”

2.7 The role of the Centre for Workforce Intelligence, and how future healthcare workforce needs are being forecast

The only national body that collates and published comprehensive workforce data on the medical specialties, including public health, is the Centre for Work Force Intelligence (CfWI). Unfortunately the statistics published by CfWI regarding public health posts has been very seriously flawed. For example, CfWI reports have claimed scores of “public health associate specialists” in Acute Trusts across the North West. These posts do not exist.

It is accepted that ESR has not easily (or accurately) identified the PH practitioner and wider workforce partly because of the variety of job titles used to describe public health roles and partly because of the complexity, and subjectivity of estimating the proportion of time given to public health functions, where this is a secondary or tertiary role.

2.8 How funding will be protected and distributed in the new system

As the tariff is reviewed the need for public health education and training needs to be acknowledged and protected so as not to lose public health capacity to acute, apparently urgent, educational needs in acute health care in acute trusts.

Need to ensure that local Skills Networks work with HEI’s to ensure the sustainability of specialist subject areas where numbers are very small eg virologists.

2.9 Plans for the transition to the new system, up to April 2013

There is a high risk of loss of public health experts to the system, and loss of public health expert posts that are essential to the establishment of a strong new public health system. Over the past two years the number of advertised consultant posts has dropped to less than a third of previous levels. The result is that trained, expert individuals are unable to secure appropriate posts on completion of training. This is a waste of the £250,000 investment of public money in their training; it means that the right expert professionals are not in place to work in the new public health tams, and it means that recruitment to specialist training in the future will become less attractive.

The new structures do not include senior public health leadership at regional, sub regional or supra regional level. The loss of equivalent posts to that of regional director of public health is a serious threat to the public health.

Experts and professional leaders have to maintain their skills in order to effectively serve the public and their host organisations. In the workforce planning and guidance so far released, there is absolutely no commitment to continuing professional development for public health teams transferred to local authorities. Our understanding is that the NHS culture, which supports CPD as an essential part of a professional’s duties, may not currently be replicated in most local authorities.

There are positive opportunities and attractions linked to transfer of public health functions to Local Government. However, the financial climate within the NHS (that is, the pressure to rapidly reduce running costs prior to April 2013) is resulting in significant threats to public health capacity and capability in some local areas. This has a direct effect on training, CPD and the ability of public health teams to meet the wider training and education needs.

2.10 The impact of people retiring from, or otherwise leaving, healthcare professions

We have already relayed the serious and continuing reduction in numbers of senior professional posts in public health across the NHS. We have described the reduction to less than one third of advertised consultant vacancies. This is in stark contrast to official guidance and statements from the centre. For example, Sir David Nicholson wrote to NHS chief executives in February 2011:

“During the transition year 2011–12 the NHS must continue to lead on improvements to public health, ensuring that public health services are in the strongest possible position when responsibilities are devolved to local authorities. As we deliver the very significant cost savings required of us, it is important that our plans reflect the need to retain staff with scarce specialist public health skills.”1

And later in 2011, the East Midlands Regional Director of Public Health wrote similarly to NHS organisations instructing that no screening infrastructure.

2.11 How the public health workforce will be affected by the proposals

There are three recognised groupings of staff in the public health workforce:

Specialists—eg DsPH, consultants, specialists;

Public health practitioners eg remainder of the public health workforce—whose main job role is public health (either of these two roles could sit in health protection, health improvement or health care quality domains of public health);

and the wider workforce which includes clinical staff, voluntary workers, social care staff and anyone who has the potential to provide “public health input” in their daily work/role.

We have described the very serious reduction in the specialist/consultant public health establishment that has accompanied the first period of transition in the NHS. However, we are aware of similar threats to the practitioner and wider workforce, sometimes related to staffing reviews seeking efficiency and cost gains that are short term (for example, reducing community awareness work that reduces the burden of late presentation of disease). Sometimes the cull in management posts has similar effects: for example, when key programme management posts are lost to screening programmes then a very short term saving can quickly lead to a reversal of the positive benefit/harm balance that is essential in screening.

Public Health England needs to have a specified role that is recognised fully by Health Education England the local provider skills networks to champion public health workforce development for public health professionals, clinical and non clinical workforce and the wider workforce.

2.12 The roles of Skills for Health and Skills for Care

CASE STUDY

The development of an initiative initially developed by C&M tPCT “The core Skills Framework” could provide a structured and systematic approach to raising awareness of the three domains of public health and the individuals own public health role across a wide range of organisations and settings including the NHS, LA and the voluntary sector. There are significant organisational benefits to this approach not least the realisation of financial savings associated with a “one stop” approach to statutory and mandatory training. The approach is currently being developed for use across the NHS in the North West and Skills for Health are taking this forward nationally. It would seem timely and useful to ensure a public health element is included in the Core Skills framework.

2.13 The future of Health Innovation and Education Clusters

We are unsure of what the Health Innovation and Education clusters are achieving for public health education and training. We have not seen evidence of them having a community, prevention or public health impact at this juncture.

December 2011

1 Sir David Nicholson 17/02/2011 Equity and Excellence: liberating the NHS—managing the transition. Gateway 15594 1553

Prepared 22nd May 2012