The focus on practitioners and the wider workforce
The focus on practitioners and the wider workforce
Abstract and Keywords
This chapter widens the history from consideration of specialists to outline key changes from 2005 for public health practitioners from all backgrounds, as well as the attention given to others in the workforce who could benefit the public's health and ways, such as via specific networks, their development needs could be met. As part of this response to continuing public health challenges as outlined in the 2005 Choosing Health White Paper, the mid-2000s saw the development of national agreement on the core competencies for anyone working in public health as well as those skills needed for specific areas of practice, leading to development of a competency framework applicable to the whole public health workforce. The UKPHR from 2008 opened for registration of public health practitioners in addition to specialists.
Keywords: Public health practitioner, Wider public health workforce, Teaching Public Health Networks, Skills for Health, Public Health Skills and Competency Framework, Core and defined areas of public health practice, Health trainers, Choosing Health, Registration of public health practitioners, MECC
The focus of the early 2000s was on developing the specialist role in public health for those from backgrounds other than medicine and ensuring that this was embedded in appointments and training and development processes, providing equivalence with public health doctors. From 2004, attention shifted to development of the rest of the public health workforce –practitioners delivering public health programmes on the ground (eg health promotion and health visiting staff) and the front-line so-called ‘wider workforce’, who could have an impact on the population's health through their roles (eg teachers, social care and health service staff) (Donaldson, 2001).
This chapter outlines:
• the context for addressing the development and competency needs of practitioners and the wider workforce;
• the start of voluntary regulation for the senior public health non-medical workforce working in defined areas of practice and the unregulated practitioner workforce; and
• the development of, and the prominence given to, the role of those in the wider public health workforce.
Rise of interest in developing and recognising specific public health practitioner disciplines and functions
Practitioners have been a much more complex group to both understand and support strategically, being diverse in function and in employing organisations, and being numerically much greater than specialists.Whereas some practitioners would remain, along with public health specialists, in Primary Care Trusts (PCTs) following the 2002 health service reforms (DH, 2002a), many were located in provider health organisations, local authorities, primary care and the voluntary and independent sectors.
(p.112) The spur for the public health skills and knowledge development of practitioners and the wider workforce was, as with specialists, in response to government policy, this time the White Paper Choosing health: making healthier choices easier (DH, 2004b).There had been earlier recognition, in the Treasury reports of 2002 and 2004 (Wanless, 2002, 2004), that addressing only the development needs of specialists would not deliver the wholesale changes to population health which would ensure that the health service could be affordable in the future: the so-called ‘fully engaged scenario’ whereby the whole population took more responsibility for health and prevention and adopted healthier lifestyles. The 2004 White Paper was in response to this challenge and addressed the development of practitioners and the wider workforce.
There was fertile ground for these messages to fall upon, and a growing identity among different occupational groups of their allegiance to a public health workforce ‘family’. As early as 1994/95, the survey conducted by Somervaille and Griffiths (1995) had identified over 1,000 people working in public health across the UK who were not within the public health medicine framework. Their follow-up survey in 1998 (Somervaille and Griffiths, 1998) began to group people more closely according to whether they were working on the service side, in health protection, health intelligence or health promotion, or whether they were working in academic public health.
The importance of the contribution of the public health workforce beyond public health consultants was subsequently confirmed in the Chief Medical Officer's (CMO's) project to strengthen the public health function in England (Donaldson, 2001). This categorised the workforce into three groups, comprising specialists and consultants at the strategic level, practitioners at the operational level, and the wider workforce, who can influence the health of the public through their roles, for example, as teachers and social workers, but who would not call themselves part of the public health workforce.
The public health skills audit (Burke et al, 2001), undertaken as part of the implementation of the 1999 White Paper Saving lives: our healthier nation (DH, 1999a), specifically included a number of key occupational groups as part of the public health workforce: nurses (health visitors and school nurses), health promotion specialists, environmental health officers, epidemiologists and public health information officers.
In developing the very detailed National Occupational Standards for Public Health (Skills for Health, 2004), Healthwork UK213 worked (p.113) with those in the field from diverse backgrounds to understand what competency was required to deliver a range of public health functions. One former Director of Public Health (DPH)214 recalls being asked to undertake a public health skills audit for this project, whereby everyone in the health authority public health department had to maintain a diary logging their public health activities, including those working in health promotion, pharmacy, oral health, health intelligence and community development. The importance of having occupational standards for public health practice should not be underestimated. It provided the first competency framework for the practitioner public health workforce, spanning the 10 key areas of public health,215 and was pitched at graduate level. It showed practitioners what competency was required across the 10 key areas of public health, and informed the content of relevant university and further education college courses.
However, the only formal recognition of practitioner status remained through the Chartered Institute of Environmental Health (CIEH) for environmental health officers and through the Nursing Midwifery Council (NMC) for public health nurses. Public health nutrition staff were voluntarily regulated by the Public Health Nutrition Society. All other public health practitioners, including health promotion and health intelligence staff, were unregulated, with no clear career or qualification routes, although many would have master's degrees relevant to public health.
The rise of the concept of specialists in defined areas of practice216 and its impact on practitioners
Specialist practice, as defined by the Faculty of Public Health (FPH) and adopted by the UK Public Health Register (UKPHR), required competency across all the agreed 10 areas of public health practice. Most practitioners, however, worked in specific areas of practice, such as health intelligence, health protection, health improvement, research (academic public health) or health services. Debates began in the 2000s about whether and how competency in specific areas of practice should be recognised and developed. Further work was undertaken to capture and define specific workforce groups, some of whose members wished to ally themselves to public health.
(p.114) Following the opening in 2003 of the UKPHR for registration of ‘generalist’ specialists, that is, those competent across all 10 key areas of public health at an equivalent level with public health doctors, the clamour started for recognition at a senior level equivalent to consultant status of those with expertise in specific areas of public health practice. According to Jones and Earle (2009), early critics of the UKPHR 2003 competency-based framework were concerned that all public health specialists were expected to be competent across all 10 key areas of public health. They argued that if a truly multidisciplinary approach were to be adopted, the competencies should be measured across a whole multidisciplinary public health team and not based purely on individuals.
From a very early stage, the UKPHR was interested in the concept of recognition at consultant level for specialists in specific (defined) areas of practice (McEwen, 2004). Griffiths and Sugarman's (2004) Scoping study, commissioned by the UKPHR and followed by the Public Health Resource Unit's (PHRU's) work to establish a competency framework for retrospective portfolio assessment of defined specialists, identified and confirmed a wide range of disciplines wishing to formally ally themselves with public health at specialist level. These included health psychology, health economics, public health management and public health nutrition, and went beyond groups already identified (health promotion, health intelligence, public health nursing, health protection and environmental health).
This work led to a need to redefine the 10 key areas of public health. In developing a framework for assessment that would meet competency needs for a very wide range of specific public health disciplines (up to 20), the PHRU quickly discovered that having health promotion and health protection within the same key area would not work. A national workshop in March 2006,217 at which all the main national public health organisations, as well as the Department of Health (DH), were present, recognised that there were competencies common to all public health professionals, whatever field of public health they worked in, and competencies relating to specific areas of practice. This was an important advance in enabling a wide range of practitioners, as well as those in the ‘wider workforce’, to identify themselves more clearly with the public health function. These revised competencies were subsequently used by the UKPHR within its assessment framework (p.115) for defined specialists, and also informed the revised curriculum for the FPH higher specialist training scheme.218
The core and defined areas of public health practice (2006)219
Core areas (applying to anyone working in a public health field at whatever level):
• surveillance and assessment;
• assessing the evidence;
• policy and strategy; and
• leadership and collaborative working.
Defined areas (applying to those working in specific areas of practice at whatever level):
• health improvement;
• health protection;
• public health intelligence;
• academic public health; and
• health and social care quality.
Practitioner expectations for development and progression were still frustrated. The identification and opening up of specialist career channels to those from backgrounds from medicine had served to raise expectations of, and aspirations for, opportunities for their own progression among practitioners. The ‘window’ for retrospective assessment by the UKPHR by portfolio for ‘generalist’ specialists ended (apart from exceptional cases) in 2006, effectively closing that route to most senior practitioners. The requirements for defined specialist registration from 2006 were challenging, requiring ‘super-specialist’ knowledge and skills in defined areas of practice. In the event, by 2013, relatively few practitioners have achieved this level of registration compared with generalist specialists220 and it is unknown how many are preparing portfolios. The standard/default route for (p.116) formal development and recognition at specialist level (as a generalist specialist, ie, competent across all core and defined areas of practice) has remained the higher specialist training scheme, to which entry is highly competitive and restricted to around 70 new trainees in any one year.
The PCT and Strategic Health Authority (SHA) mergers, resulting from the 2006 health service reforms (DH, 2005), served to create, within larger public health teams, more assistant and deputy DsPH posts from backgrounds other than medicine, many of whom could not formerly have progressed to this level of seniority. There was a thirst among this group below specialist and consultant level for development, recognition and a proper career structure beyond the handful of practitioners who, from 2003, could reach specialist-level practice.There were still no formal development routes for recognition of the much larger practitioner workforce and, other than the scarce places on deaneries' specialist training schemes, little opportunity for career progression from practitioner to specialist despite obvious interest in the field.
Focus on specific initiatives for the development of practitioners following the 2004 White Paper
The situation changed for the better in 2005 following the publication of the White Paper Choosing health in 2004 (DH, 2004b), when the DH was able to use the opportunity for developing a population approach to healthy lifestyle behaviours, outlined in the White Paper, to peg and fund a number of different initiatives for the development of the whole of the public health workforce –the ‘golden years’, according to a former public health workforce lead.221 From 2005, the DH funded a suite of major developments, which had a subsequent impact on different groups in the practitioner workforce. These developments included support for the health promotion workforce, developing a new health trainer workforce, developing a competency framework that would apply to different career levels in the workforce and supporting public health career and leadership development, the latter building on the programmes already taking place in London and the West Midlands. These years were also marked by continuing agreement across national public health organisations and a willingness to work together on shared development. (p.117)
The first public health practitioner group to receive attention following the 2004 White Paper were health promotion specialists. The report
Shaping the future of public health: promoting health in the NHS (Griffiths and Dark, 2005), the result of a two-year project, was issued by the DH in July 2005. This followed earlier scoping work in 2003 by Griffiths, in preparation for setting up the UKPHR, when she had found a demoralised health promotion workforce for whom the ‘glory days’ of the mid-1980s' programme Health for All by the Year 2000222 (WHO, 1981) were long gone. Many dedicated health authority health promotion teams had been broken up in 2002 as a result of the health service reforms to create smaller PCTs, and a number of staff had moved into provider trusts. Griffiths and Dark's survey, which fed into the 2005 report, identified a specialised health promotion workforce in England and Wales of around 2,000 whole time equivalents contributing to health improvement. The report compared this numerically with the FPH's membership workforce report for 2004 of 600 NHS consultants and specialists (including DsPH) and 350–400 specialist registrar trainees (only a small number of whom would be working at any one time on health improvement programmes). On the basis of the 2005 report, the DH funded an annual conference for health promotion specialists to be able to meet to debate issues and to share good practice.
A new look at public health competencies
The next stage was to develop, across the newly specified core and defined areas of public health practice, public health competencies that addressed the needs of different practitioner levels in the workforce. In 2006, commissioned by the DH and working with the PHRU, Skills for Health commenced work on a competency framework that spanned the four core and five defined areas of practice competencies across nine ‘career’ levels, from direct entry to the workforce, to senior strategic roles, such as DPH. It also looked, for the first time, at competency requirements across the ‘wider’ workforce. This was different from their National Occupational Standards for Public Health (Skills for Health, 2004), which were much more detailed, related to the former 10 key areas of public health and based around a single point of graduate-level practice.
(p.118) The resulting ‘UK public health skills and career framework’ (UKPHSCF) (Skills for Health, 2008) was published by Skills for Health in April 2008. This provided, for the first time, a comprehensive framework for practitioners (and, indeed, those in the wider workforce) to self-assess their level of competency against what was required at the level in the workforce within which they were operating. They had a much clearer idea of personal development needs, as well as what would be required at other levels of advancement. The framework was extensively used across the four UK countries by those within, or leading, public health teams to aid recruitment and development and by those running public health courses to ensure that they were pitched at the right level and covered the required content (Carlson, 2008; Wright et al, 2008). A major weakness of the framework, however, was its failure to be formally taken up by the DH (and thereby employing organisations) as a way of recognising competency across the whole public health workforce. Because of this, it was not fully embedded within career structures and linked to required training and development for, particularly, specific roles or grades of the public health practitioner workforce.
The Choosing health White Paper (DH, 2004b) was also used to announce the launch of a new programme, funded by the DH, to establish health trainers across the country. This new cadre of frontline public health workforce, trained in behaviour change, was to have a vital role in working with individuals to help them adopt healthier lifestyles: ‘They will work with individuals to agree personalised health plans and overcome barriers to changes’ (Bimpe et al, 2006). Funding was allocated initially to the most deprived 20% of geographical areas, which were designated to be spearheads for the initiative (Green, 2007). Health trainers were recruited from local communities to work with individuals in a variety of locations, including the NHS, prisons, post offices, the army, schools and libraries. Formal basic training and qualifications were provided. A qualitative review of health trainer programmes in two PCTs between 2007 and 2009 revealed satisfaction with the role and achievements of those health trainers and their managers interviewed, but some concern about where they fitted into overall service provision (Ball and Nasr, 2011). Following cuts to the DH public health development programme, 2011 was the last year of national funding, though many PCTs continued to commission this workforce at the local level.
Information on the breadth of public health careers and how to attain them
A further project funded by the DH public health workforce development team following the Choosing health White Paper (DH, 2004b) was the development of a UK public health careers website. This was in response to concerns about capacity following the 2006 health service reforms (DH, 2005) and the lack of an obvious source to find out about the range of public health careers and how to attain them. The website was developed by the PHRU working with East Midlands Healthcare Workforce Deanery, and was launched in April 2010.223
Initiatives that did not make progress
Other initiatives, such as the accurate defining and counting of the public health practitioner workforce, did not come to fruition. A (p.120) national workshop in September 2008, hosted by the DH, to look at the feasibility of extending the current health service Electronic Staff Records to include a refined data collection, which would be more sensitive to the needs of public health and recognise the richness of disciplines comprising the practitioner workforce, did not lead to further work. The 2013 Public health workforce strategy picked up this issue (DH et al, 2013).
An unpublished review of academic public health carried out by Solutions for Public Health (SPH) for the DH in 2010 (Dunkley and Wright, 2010) reported on the long-standing issues of uncertainty of employment for non-medical public health researchers on a series of short-term contracts and lack of equality of opportunity and pay compared with the medical academic workforce.224 Again, this issue, along with overall concern about the state of academic public health, medical and non-medical, was picked up in the 2013 Public health workforce strategy (DH et al, 2013) which promised further work led by Public Health England (PHE).
The Faculty of Public Health: a specialist professional body only or inclusive of practitioners? A strategic approach to practitioner recognition and development
The FPH had a long-standing interest in working with different public health professional organisations over developing a common approach to competency, not only for those organisations representing or regulating the workforce at specialist level (eg General Dental Council [GDC], College of Paediatrics and Child Health, and Faculty of Occupational Medicine), but also for those representing practitioner groups such as public health pharmacy and public health nursing.
From 2005, the FPH had a number of different strands of work under way relating to the development of the public health practitioner workforce. It set up its own practitioner development project in 2005, part funded by the DH, in the wake of the UKPHR-led work to prepare for registration of specialists in defined areas of practice and the forthcoming Skills for Health UK public health competency framework. Its newsletter for members in June 2006 (Ph.com, 2006), for example, had specific articles recognising the range of those working in public (p.121) health practitioner roles, including information and intelligence, public health nursing, health promotion, environmental health, and pharmacy. The FPH had already created a category of associate membership (for a small sum, anyone could subscribe and receive regular news updates) and wanted to consider whether it should set up formal practitioner membership at some stage and what this would entail if it did.
A working group was established to undertake further scoping work. Part of its remit was to consult with the national public health organisations and informal groups representing different contributions to public health (including environmental health, public health intelligence, health protection, nursing, health promotion, health psychologists, health services, public health academics and public health nutrition) over how practitioner competency could be formally recognised and the potential role of the FPH in this process as a possible standard-setting body for the whole of public health practice.225 At the time, the FPH was the standard-setting body for specialists only. As stated earlier in this chapter, the only groups that had formal recognition and registration at practitioner level in public health were environmental health and public health nursing on a statutory basis and public health nutrition through voluntary regulation. There was a lack of clarity over whether practitioners needed to be regulated for public protection and whether registration and regulation would enhance personal and career development.
Another strand of work considered changes to the higher specialist training scheme. A formal Practitioner Committee was established at the FPH in October 2007, with a brief to consider whether prospective higher specialist training routes leading to registration at specialist level were needed for practitioners in the five defined areas of public health practice (health improvement, health intelligence, health and social care quality, health protection, and academic public health). Discussions were already under way across the national public health organisations over a strategic approach to the development of the whole practitioner workforce and these ran alongside the setting up of registration for defined specialists. There was also concern, in the interests of both public protection and career progression, to have recognition of practitioners at appropriate career points. Following agreement across national public health organisations in March 2006 to move to recognition of four core and five defined areas of public health practice, the FPH was also considering at this time whether its (p.122) Part A examination should be offered in sections in diploma form to meet the needs of specific areas of practice.
In the event, the FPH moved away from consideration of practitioners to retain its role as a membership body and standard-setter for specialists only. Following a change of personnel within the DH, funding to support the FPH's practitioner development work ceased from 2008.The revision of the FPH's core curriculum did not include higher specialist training routes for defined areas of practice and the requirement for all trainees to demonstrate competency in all four core and five defined areas of practice was retained in order to qualify for the mandatory Certificate of Completion of Training (CCT). This subsequently left the UKPHR in some difficulties –as well as practitioners themselves –as its retrospective portfolio assessment route for defined specialists had been introduced in 2006 with the aspiration that, in future, there would be a prospective training route for defined specialists with equivalence to that for generalists.
The UK Public Health Register opens up its register to practitioners
The UKPHR started to work on the possibility of developing a regulatory framework for public health practitioners in 2006, following the Choosing health White Paper (DH, 2004b), and, with DH funding support, launched a major consultation exercise with the practitioner workforce from 2007. It used the UKPHSCF (Skills for Health, 2008) competencies as the basis for developing a draft set of standards for public health practitioners at graduate level in the workforce. A formal consultation took place in November 2008 on its proposals for retrospective recognition via portfolio assessment for practitioners (Somervaille, 2008). Standards were finalised and a process for retrospective recognition developed, which, because of the potentially large numbers seeking recognition, and to make it financially viable, was established as a devolved scheme using UKPHR-trained local assessors and verifiers of practitioner competency, with quality assurance of local schemes provided by the UKPHR.
According to the UK Public Health Careers website,226 initially, both practitioner and advanced practitioner registration and regulation ‘levels’ were identified by the UKPHR as being needed to provide a proper career structure for public health practitioners. However, the Council (p.123) for Healthcare Regulatory Excellence (CHRE), now the Professional Standards Authority for Health and Social Care (PSA)227 advised that much of what is called ‘advanced practice’ represented an individual's career progression and should be recognised through professional accreditation rather than through regulation. The UKPHR decided, therefore, to progress with only a single (graduate) level of formal practitioner registration and regulation at that point.
DH funding support to the UKPHR for its practitioner work ceased from 2010. A further blow for the UKPHR was the conclusion of the DH-commissioned regulatory review on public health that the case for practitioner regulation was not proven (DH, 2010c).The UKPHR board decided, however, that there was sufficient demand to launch voluntary practitioner registration as a pilot programme from May 2011 and invited locally funded schemes to participate. Registration was only permitted for practitioners taking part in UKPHR-approved pilot schemes and the UKPHR instituted tight quality assurance. Early adopters were Wales and South Central England, where local development work in preparation for the opening of the register started in 2010.They were followed from 2011/12 by the South East Coast, West Midlands, Bristol and Glasgow and the Highlands in Scotland. A scheme for 12 practitioners in the South West and one across the 10 boroughs in North Central, North East Inner and Greater London started in 2013.
At September 2013, there were 95 practitioners registered with the UKPHR, with many more preparing for registration (from an estimated potential pool across the UK of 40,000). Since 2013, the UKPHR has been working on a programme to require Continuing Professional Development (CPD) for registered practitioners and intends, in time, to develop revalidation requirements.228
Some practitioners working not far below consultant level had been attracted to aim for defined specialist registration as the only formal route to progression open to them apart from the higher specialist training scheme. As one commentator from the UKPHR stated: ‘some people had thrown themselves into defined specialist registration because there is nothing else’.229 Similarly, a number of the early practitioner registrants with the UKPHR were working at levels well (p.124) above the minimum (graduate) level required for registration, anxious to have some form of formal recognition.230
As yet, there is no employer requirement for practitioner regulation, apart from those who have to be statutorily regulated (eg environmental health officers and public health nurses). Practitioner regulation was not directly covered in the Public health workforce strategy (DH et al, 2013). The UKPHR chair, however, stated at a celebration of the first 10 years of the register on 4 September 2013 that, on the basis of the pilot schemes, it was aiming to launch a national programme for practitioner registration during 2014. It was in active discussion with Public Health England (PHE) over this, as a major employer (alongside local government) of the public health practitioner workforce since April 2013.
Recognising the value of the wider public health workforce
While the potential importance of the wider public health workforce had been recognised in The report of the Chief Medical Officer's project to strengthen the public health function in England (Donaldson, 2001) and by Derek Wanless (2002, 2004) in his ‘fully engaged scenario’, in reality, little had happened since then to turn that potential into practice. The problem then, as now, was not only identifying this more nebulous workforce, but also getting their engagement and changing practice on a large scale.
A project conducted in London in 2002 had attempted to map the wider workforce and ascertained that the total public health workforce in London, the majority of whom would comprise the wider workforce, potentially numbered up to a quarter of a million people from an enormously diverse range of occupations, who met the inclusion criteria for having the potential for improving the health of the community or population for which they worked (Sim et al, 2002). In keeping with the earlier CMO's project to strengthen the public health function (Donaldson, 2001), this mapping exercise recommended subdividing the wider workforce, for example: chief (p.125) executives in local government and in the NHS who had a strategic role (who were described as ‘key influencers’ for health); experts and scientists from a range of disciplines, for example, toxicologists and traffic engineers (‘technical experts’); clinicians and the hands-on workforce, such as social workers, who were working with users; and commissioners, business managers, service providers and audit/quality assurance staff, who use contracts, governance and audits to deliver and measure quality and outcomes.
Initiatives from 2006
The Head of Public Health Workforce Development at the DH in 2006 commented:231 ‘Choosing health was the best opportunity to deliver change for the public health workforce and [it is] always important to build on whatever opportunities [are] offered.’ She had been able to lead writing of the workforce chapter of Choosing health (DH, 2004b) and she could then peg initiatives to it. Slogans such as ‘public health is everybody's business’ gave credibility and legitimacy, and, with these, funding for specific initiatives. One of these initiatives was the Healthy Universities network, established in 2006 and continued with modest support from the higher education sector, with universities able to market themselves as healthy organisations.
A second initiative was the establishment of Teaching Public Health Networks (TPHNs).232 In December 2005, the DH hosted a conference to launch these new networks, whose function would be to extend knowledge and skills to large numbers of people who would become identified members of the wider public health workforce. The broad objective was to boost teaching capacity in a range of educational institutions to ensure that public health skills would be disseminated among a diverse workforce. The TPHNs were established with agreed key deliverables, including an increase in teaching capacity and increases in the numbers of participants in a range of relevant courses provided by colleges of further education and institutions of higher education. The intention here was to build capacity on a large scale through participation in existing mainstream educational courses.
The FPH newsletter (Ph.com) in June 2006 was devoted to the concept of the inclusive public health workforce, although no one really had an understanding of how this was to be achieved. The TPHNs would set (p.126) out to introduce pilot initiatives for the training and development of the wider workforce with a view to further roll-out if successful.
The DH invited expressions of interest in setting up TPHNs following the consultation meeting in December 2005. The outcome of this exercise was a skewed distribution of interest around the country, so the DH revisited its invitation and made an expectation that there would be one TPHN in each of the NHS regions to ensure a more equitable distribution of both infrastructure and outputs. After a further round of proposals to the DH, nine TPHNs were approved, covering the whole of England. Funding was distributed pragmatically, using a combination of an evaluation of the content of the proposals and the population base. The TPHNs were established during late 2006 through 2007 (Sim, 2007).
Each TPHN was invited to take a lead interest in a particular topic or part of the workforce, or both. The model adopted was similar to that of the Public Health Observatories, although the TPHNs lacked the stability of the Observatories, which enjoyed substantial personal support and patronage from the CMO, and a stable level of funding. Nevertheless, useful work was undertaken. In London, for example, at the first meeting of the TPHN Steering Group, there was consensus that the priority should be on building capacity in the third (voluntary) sector –thus, this became a lead area for London's TPHN, and, subsequently, as a result of the award of additional grant funding, a second lead area was added, that of childhood obesity. The London TPHN work with the third sector led to a feasibility study for creating a Health Passport for Health and Wellbeing, a concept that was revived by the DH in 2013 for the public health workforce in its strategy for the public health workforce (DH, 2013). The South West TPHN led on building capacity in relation to the built environment, and the South Coast led on incorporating public health into teacher training. The outputs of the TPHNs, many of which were innovative and original, were shared through its informal Association of Teaching Public Health Networks (ATPHN) and captured on the association's website (no longer active).
An early task of the TPHNs was to map existing educational provision for the wider public health workforce, but this became an enormous task, with hundreds of courses in further and higher education having at least some content that was relevant to public health, though few used the conventional terminology of public health. Nevertheless, networks were able to review some course content, and the importance of the UKPHSCF, published in 2008 by Skills for Health, to wider workforce development should not be underestimated. It provided, for the first (p.127) time, the concept of core competencies needed by anyone working in any field at any level in public health and was used extensively by TPHNs for course mapping and informing new course development.
In 2007, the potential role of the wider public health workforce was considered in an international context by Sim et al (2007) in the Bulletin of the World Health Organisation. They described different ways for building capacity in public health, recognising the great size of the wider workforce and that many may be in third sector organisations, as well as in a variety of independent sector organisations. They highlighted the roles played by the leisure sector, for example, in addition to those working in health and social care, education, and housing and planning departments. The authors called for ways that are more open and inclusive of people from a wide range of educational and occupational backgrounds not previously the target of public health training.
The wider workforce in the reformed National Health Service and public health systems
The Marmot (2010) review on health inequalities, Fair society, healthy lives, issued in February 2010, highlighted the social gradient of health, whereby the lower one's social and economic status, the poorer one's health. He called for action across all the social determinants of health, including education, employment, income, home and community, and provided new impetus for looking at the contributions to the delivery of health outcomes across many workforces.233
Following the English health system reforms in 2013,234 responsibility for development of the wider public health workforce rests across Health Education England (HEE) and its constituent Local Education and Training Boards (LETBs), PHE, and individual local authorities.235 It is in the interests of hospital trusts, sitting on these new LETBs, to invest in promoting public health awareness in their own workforces not only to enhance their own staff's health, but to provide information for their one-to-one contacts with patients. Local authorities may choose to develop the wider workforce. There is no mandatory requirement to do so, although one aim in moving NHS public health teams into upper-tier local authorities is to help them focus more holistically on their public health outcomes. Health and Wellbeing Boards –the newly (p.128) appointed statutory bodies set up as local authority committees and normally chaired by a local councillor –with local strategic oversight of health in its widest sense, may well play a part in future. Senior officers from PHE have indicated their recognition of the importance of the wider workforce and commitment to its development.
Meanwhile, initiatives that began prior to the reforms were embedded to varying extents across the country. The NHS Future Forum set out clearly the role of the NHS in the promotion of health in it summary report (Field, 2012, p 8):
Firstly, we must support the NHS to use every contact with patients and the public to help them maintain and improve their physical and mental health and wellbeing, including those already living with a condition. Each day, GPs [General Practitioners] and practice nurses see over 800,000 people and dentists see over 250,000 NHS patients. There are 31,000 NHS sight tests, while approximately 1.6 million people visit a pharmacy. Secondly, we must help the NHS workforce to improve their own health and act as role models for their patients and communities. And finally, we must embed the prevention of poor health and promotion of healthy living into the NHS's day-to-day business.
‘Making every contact count’ (MECC), whereby each encounter by a health care professional with a patient or service user would include a health promotion element, was subsequently adopted by a number of SHAs and a number of products were produced (including a tool kit in the East Midlands SHA236 and a lifestyle, behaviour change competency framework in the Northern and Yorkshire SHA237), but implementation was not national and has not been monitored. Unless individual Clinical Commissioning Groups adopt it and/or choose to performance manage providers in this area of delivery, it may be impossible to evaluate the extent of its impact. What we do know from evaluation of projects that have been undertaken is that the methodology is sound, and that MECC has considerable potential for changing staff attitudes in relation to promoting health-enhancing behaviour among members of the general public coming into contact (p.129) unclear how the responsibilities of PHE and HEE will converge, but it is conceivable and, indeed necessary, that both of these new national agencies will collaborate to take the development of the wider public health workforce seriously. with services (Nelson et al, 2013). The current distribution and reach of MECC remains unknown.
In the reformed health structures, HEE is responsible for development and training of the NHS workforce, which includes many members of the wider public health workforce. At the time of writing, it is unclear how the responsibilities of PHE and HEE will converge, but it is conceivable and, indeed necessary, that both of these new national agencies will collaborate to take the development of the wider public health workforce seriously.
What was achieved
• A focus on competency and development for the practitioner workforce.
• New skills and approaches in changing lifestyle behaviour.
• Some underpinning foundations for practitioner development in a common framework of competency for the whole of the public health workforce and bringing together information on the breadth of public health careers into one place.
Key learning points
• Importance of DH policy backing and funding to pump-prime initiatives.
• Importance of public health organisations working together to progress development.
• Importance of recognition of public health practice at different levels, which is independent of employing organisation.
• A recognised competency framework is the foundation for bringing together a disparate workforce and also providing a common language for accepted and acceptable practice.
(213) Later to become Skills for Health, the sector skills council dealing with the health service.
(214) Personal communication, 2013.
(215) See Chapter Four.
(216) For the full history of registration of specialists in defined areas of practice, see Chapter Five on regulation.
(217) Personal archive of the authors.
(218) The UKPHR has continued to retain the 10 key areas for its ‘generalist’ specialist retrospective portfolio assessment framework.
(219) Adopted by the FPH in its post-August 2007 curriculum, and forming the basis for development of the UK public health competency framework (see Skills for Health, 2008).
(220) At September 2013, 51 registered as defined specialists compared with 312 via the generalist specialist route (personal communication with UKPHR chief executive officer [CEO], October 2013).
(221) Personal communication, 2013.
(222) The Health for All by the Year 2000 initiative, launched in 1981 by the World Health Organization (WHO), had as its programming goal to promote health and human dignity and enhance the quality of life
(224) ‘Academic public health in England’, SPH, August 2010; personal archive of the authors.
(225) Paper to FPH board, February 2007; personal archive of the authors.
(227) April 2014: UK Public Health Register's voluntary register of public health specialists and practitioners was accredited by the Professional Standards Authority for Health and Social Care [PSA] under the PSA's Accredited Voluntary Registers (AVR) scheme. Details can be accessed at: www.publichealthregister.org.uk/node/218
(228) Personal communication with UKPHR CEO, October 2013.
(229) Personal communication, 2013.
(230) An interesting corollary has been the progression of dental public health, where the decision of the GDC was only to register and regulate qualified dentists at specialist level although the GDC does register dental practitioners (hygienists, dental nurses and therapists). This is possibly because dental public health is a very small specialty, and following recognition of competency with the Faculty of Public Health (FPH) at specialist level, a number of dental public health consultants had moved into generalist public health roles.
(231) Personal communication, 2013.
(232) The TPHNs were called ‘teaching’ to distinguish them from ‘research’, which was the CMO's prerogative.
(233) One response to the Marmot review was the Coalition government's pledge in February 2011 to increase the number of health visitors to 4,200 by 2015 (DH, 2011, p 4) to provide renewed focus on ensuring all families have a positive start.
(234) For details on the reformed structures, see Chapter Eight.
(235) For details on the reformed structures, see Chapter Eight.
(236) See: http://www.midlandsandeast.nhs.uk/OurAmbitions/Everycontactcounts.aspx (accessed September 2013).
(237) See: http://chain.ulcc.ac.uk/chain/documents/competenceframeworkintro.pdf (accessed April 2014)