BMA survey of public health workforce – transition and division?
The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.
The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.
Loss of Independence and Loss of Medical Professionals.
“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”
“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”
John Ashton President of the Faculty of Public Health
John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair
“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”
Lets have a look at these two questions in turn.
Q – “I have the professional independence I need to speak out on public health issues”
- Agree – 49.90%
- Neutral – 23.7%
- Disagree – 26.4%
Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.
But it is equally possible to say:
“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”
Indeed if we were to put aside those who were neutral we could even claim that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.
Q – Medics – have you considered leaving the profession in the past two years?
- Yes – frequently and or seriously – 25.7%
- Yes – it has crossed my mind – 34.7%
- No – 36.3%
So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.
Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.
In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)
I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.
More Survey Problems
Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.
So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.
My favourite question has to be:
Q “In my local authority, the public health grant is not seen as a resource to be raided”
This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.
For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ. In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:
“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”
In the same article Duncan Selbie Chief Executive of Public Health England notes that:
“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”
What is the real issue?
I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:
“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.
What the survey tells us
This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.
It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.
There do seem to be as many concerns about Public Health England as there are about working with Local Government.
Some thoughts
- This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
- Public Health is still bedding into the new structures.
- Its not just about local government – if anything there are more fundamental concerns about Public Health England
- Trainees are generally positive about their future.
- Non Medics are positive about the future
- The independence of Directors of Public Health (whatever that means) is not under threat
- It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.
Conclusion
It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.
What do you think?
First of all we should ask how the health for the public could be achieved?Secondly what a public health specialist should do?
First; it seems to me that the health of the public will be achieved when their basic- needs and rights have been met.
Secondly; a public health specialist hand in hand with the specialist from the other development sectors, should organize and empower the people, and work with the people and not for the people, in collaboration with the other sectors to meet the basic-needs/ rights of the public. Mohammad Ali Barzegar, MD.,MPH.n
Completely agree Mark! However I can understand nervousness of FPH in relation to fragmentation of profession when one of its strengths is its multi-disciplinary nature. For PH in LAs this is particularly true for statutory duty to provide PH advice to CCGs – and medics are in a strong position (though not exclusively so) to do this effectively. If their T&Cs in LAs are no longer consistent with other specialities we will lose them and I think that would be to the detriment of public health and the health of the public.
Thanks Rob – I don’t think I commented specifically on the point you raise – although I think it relates to the Duncan Selbie quote above.
I fully support employees making trade union arguments to defend their interests but that is not the same as saying that the health of the public is dependent on the Terms and Conditions of a specific group of employees.
I think the logic of my point though is that if public health medics do not join PH in LAs (because of the T&Cs or for other reasons) then we lose the extra influence they have to advise and support CCG commissioning (and let’s face it that’s where the money is!). Whether they do have this additional influence (i.e. over and above that of a non-medical PH specialist) is obviously an arguable point, but I can see how having that common culture/language/status with CCG Board members could support this view. The impact of not having this influence is that CCGs continue to commission evidence free and cost ineffective services that do not reduce health inequalities.
Thanks Rob – while it is tempting to agree with you….I don’t! For these reasons:
First – the job of public health is to influence across sectors – NHS, Local Govt, VCS, Education, Private Sector etc – thats what we are meant to be good at. The requirement is not for PH specialists from across those sectors to be in PH but for PH as a specialism to be able to influence those players.
Second, I think increasingly we want to see the sectoral specialists – housing officers, social workers, teachers, advice workers understanding their PH contribution – this would include none PH clinicians playing in.
Third, a number of CCGs are employing their own PH specialists – great in my view – I am also aware of some who sit in health trusts too. Some are part of the local PH team others are not – I don’t see that as problematic.
Fourth, You have just come through a tough training programme to qualify as a non medical public health specialist – you are as qualified as a medical specialist (even if the BMA survey shows that most PH medics don’t agree with that!) – but probably cheaper – that feels good too.
I think the report highlights the wide variety of opinion across different groups in PH. Some local authorities are making the most of their new found opportunities and others have been less visionary – pretty well what one would expect of course. It is is nigh on impossible to deduce a collective view a little over one year in. As for PHE, some things have gone well, not least bringing around 120 organisations together with little time to plan, but there is much to be done. The Health Select Committee made some very helpful observations and these are being taken seriously by PHE. There are undoubted risks associated with the new arrangements, not least in relation to fragmentation, confused commissioning, and sorting out where some of the responsibility boundaries lie. I am also concerned that we retain active engagement with the healthcare system, as well as reach out effectively to other sectors able to address social and economic determinants. We will have failed if the new arrangements do not ensure that the ‘whole is greater than the some of the parts’. We need to keep ‘taking the temperature’.
Thanks Richard – very helpful. Of course this is not just about the re-organisation following the H&SC Act. The PH profession is going through a process of renewal and change. Apparently for the first time there are now more non medical DsPH than medical ones. I suspect that this is in part due to the creation of the voluntary register etc but also is probably due to more medical PH professionals gravitating to PHE following re-organisation. This in itself has the potential to create an ‘interesting’ variation in perspectives – between PHE and local authority teams if not managed well. I agree with your point about the NHS. I do think that CCGs and NHS provider organisations need to consider investing in PH teams to ensure that their services are informed by PH expertise. I do not know how common it is for CCGs to invest in PH – I know that Sheffield CCG does do this – but am not sure how widespread it is. Maybe this is something for the Faculty to discuss with NHS Clinical Commissioners and the NHS Confederation?