“It is essential that the general public is in the driving seat for all aspects of their own health and wellbeing……..This approach emphasises what people can do rather than what they cannot”
- irrelevant questions – how often should we renew a workforce strategy – should it be every 3 years or every 5?” (p10)
- unchallenged assumptions – “at a time of change it is essential to focus on sustaining the specialist workforce” (p12) – why? Or – “Public health specialist and practitioners should be subject to quality assured enumeration” (p12) – why?
The reason for the above approach is clear – while the public health profession continues to aspire to a role of national significance – it still assumes that the most important audience are the current inhabitants of the Public Health Village – primarily members of the Faculty.
What is most concerning though is that the consultation document seems to have been written in isolation – failing to recognise the demographic, socioeconomic, practice and policy challenges that contemporary public health faces at the moment.
Reading this document it is not possible to get a feeling for how big the challenge facing the public health workforce is or indeed the scale of ambition to transform it. The executive summary states that “the current changes to the public health system will have a significant impact on the public health workforce and will lead to a new system of delivery that will need new skills and new ways of working” (page 6). This is not really explained – but the impression that is created is that the challenges are organisational ones – transfer to local government, creation of Public Health England etc. There is an absence of context and analysis about what is currently working or not.
The economic and policy context
Helpfully on page 9 TaWSPH draws attention to the Local Government Workforce Strategy which is called “Delivering through People”. This provides a strategic analysis of the context and challenges that will face public health as it moves over to local government. Here are three key quotes from the foreword.
- ‘The most critical issue currently is addressing the workforce dimension of major service and organisational transformation. With partners, councils are reconfiguring local public services to ensure that they achieve priority local outcomes with significantly less resources.”
- “If we ever had the ‘burning platform’ required to make major cutural changes, we have it now.
- “We need to tackle the difficult issues that get in the way of setting up new organisational structures, such as professional rigidity ..”
In the section on context (p6) the document sets out some of the key challenges:
- Councils face an unprecedented period of declining resources and growing demand
- This is driving customer focused service transformation and innovation
- Well established professional disciplines and practices will need to be reviewed and updated
So the local government environment is one where services are being cut, salaries have to be justified and existing roles questioned – any workforce strategy must acknowledge this context – TaWSPH fails on this count.
The practice challenge
In addition to the economic and policy context described so clearly in ‘Delivering through people” Public health also needs to look very critically at its current delivery model. There are strong arguments that it is currently not fit for purpose – particularly with regard to its impact on key issues such as health inequality, obesity, mental health and the social determinants.
In Nigel Crisps (ex Chief Executive of the NHS) book – “Turning the World Upside Down – the search for global health in the 21st Century” which Simon Duffy at the Centre for Welfare Reform brought to my attention Crisp elegantly sums up the challenge:
“The core features of western scientific medicine are:
- greater professional competence
- scientific discovery
- commercial innovation
- massive spending
Crisp states that all these core features )which have some similarity with the public health vision described on page 9 of TaWSPH) need to be turned upside down as part of a paradigm shift:
- greater professional competence is achieved through patients and communities empowering and working with professionals
- Scientific discovery is made relevant by our understanding of society and how to apply it
- Commercial innovation is effective only as part of wider goals
- measures of input spending are replaced by measures of social and economic value achieved”
Three challenges that the workforce strategy needs to address.
Impact – It has to keep a focus on reducing health inequalities at a time of huge challenge. The starting point must be a robust assessment of what has worked well and what has not. This document reads too much as though the purpose is the defence of the public health specialist.
Citizens in control of their health – there needs to be a fundamental rebalancing – focussing on public healths contribution to co-producing solutions with communities. This is not an add-on – which is how it feels in this document. We need to re-balance our approach to put community leadership at the heart of this work. There are plenty of examples already – such as Well London, Altogether Better and the Health Empowerment Leverage Project (HELP).
Public Health Leadership – the workforce strategy needs to recognise that leadership for public health now rests with local government. So the leaders of the public health system are Cabinet Leads for Health and Wellbeing and Local Authority Chief Executives. Their role needs to be formally acknowledged in the broad groupings of public health that are used (p14 of TaWSPH)
What do you think?