Select Committee on Health Appendices to the Minutes of Evidence


Joint supplementary memorandum by The Faculty of Public Health Medicine and The Association of Directors of Public Health (PH 52C)

Response to those questions that were unanswered when giving oral evidence on Thursday 23 November 2000 to the Health Select Committee.

Would a split between the public health medical function and the broader public health function make public health more manageable?

  The Faculty believes that this would be against current developments and against the spirit of the Government's White Paper Our Healthier Nation. Much of the work that the Faculty is currently engaged in is concerned with the bringing together of the many strands of public health to ensure that a multi-skilled, multi-disciplinary approach is available to those who require public health expertise. Whilst more work is required the Faculty is actively collaborating with a number of other organisations to improve the breadth of public health skills that can be available. The Faculty believes that there is an important role for public health in developing primary care settings. It will be essential to develop strong public health teams of a sufficient critical mass to support Primary Care Trusts/Groups. Splitting public health medicine from public health would not be wise, it would decrease the influence of the director of public health on the various systems that we need to influence in order to improve health. Whilst superficially it could be argued that work could become more manageable, very quickly it would be necessary to invent mechanisms to re-integrate between directors of public health medicine, directors of public health, directors of health protection etc. This would probably be more time-consuming than current arrangements. There is no place for the isolated public health professional, as they need to rely on a range of skills within a team. New collaborative arrangements that are currently being piloted in some parts of the country are already showing promising results.

In your opinion, does the director of public health have to be medically qualified or is it sufficient for expertise to be available (to put it colloquially, do doctors have to be "on top" or "on tap")

  The Faculty believes that the post of director of public health should be clearly defined and reflect the responsibilities and seniority of this important post. If that is achieved, then those with appropriate skills should be appointed to such posts. It is likely, for the foreseeable future, that many such people will be qualified doctors, but that should not preclude others who have sufficient knowledge and skills in public health.

  The Faculty strongly believes that there will always be certain functions within public health teams that require the skills of a doctor, and these should remain and be valued.

  The position of the Association of Directors of Public Health is that it is not essential that directors of public health are medically qualified. However, there are many advantages to the current system because it means that one individual has responsibility for public health medicine, and the many aspects of public health are thus integrated. That individual has undergone a lengthy training which is at least as long in terms of generic public health skills as it is in terms of medical skills. It would be wrong, therefore, to think of directors of public health exercising an excessively medical model simply because at one point in their training and career they were taught to be, and practised as, medical practitioners.

  If the director of public health were not to be medically qualified then you would need to have a medical director of health authorities as a separate position. You would also need to have an individual who provided the clinical communicable disease control service. These three posts would have different training requirements. The non-medical DPH would need to be trained in public health but not medicine. The medical director would need to be trained in medicine and also in clinical epidemiology with training and experience in health economics, health promotion and medical statistics being an advantage. The communicable disease control consultant would need to be medically qualified and trained in the public health and epidemiological aspects of communicable disease control. Currently, all of these roles are centred on and co-ordinated by DsPH who are trained in medicine and public health. While it is certainly possible to desegregate them, there is a danger that one could end up spending much of the time in a new arrangement having to re-integrate and co-ordinate the efforts of three individuals, rather than it all being centred on one individual as a leader of a multi-disciplinary team.

  In addition, there is a danger that non medical DsPH may have less influence over clinical colleagues who can be most useful advocates for change in altering attention to health related behaviours and circumstances.

What skills does a modern director of public health need? Are these different from their predecessors in the past? If so, in what ways?

  Key skills needed by a director of public health are:

    —  leadership;

    —  strategic vision;

    —  epidemiology;

    —  medicine; and

    —  change management.


  Directors of public health need to lead upwards, sideways and downwards.

  We are most often not in a position of executive power and therefore need influencing skills to ensure that the wider vision of improving the health of the population prevails. Directors of public health need professional leadership combined with management skills to run effective and productive departments. They need to develop and motivate their staff, ensuring such approaches as continuing professional development, audit and business planning.


  The wider vision is critical. Directors of public health come in to work with a missionary drive to improve the health of their local population. This vision is central to everything they do. This vision and perspective does not appear to be prevalent in other health and local authority staff. Translating this vision into key strategies such as the Health Improvement Programme is clearly an essential skill.


  Epidemiological skills are critical to assess the health needs of the population using survey methods, research methods and statistical analysis. These approaches answer the questions:

    —  Who is more likely to suffer from a certain health problem?

    —  Where will a health problem be commonly found?

    —  When is it most likely to occur?

    —  What is its likely cause?

  A detailed understanding of research methods is also needed to interpret research findings on the effectiveness and cost-effectiveness of health care and other interventions to improve health.


  Medical knowledge and skills are useful, particularly when working with medical colleagues, to understand: the underlying pathology and natural history of diseases, how doctors think and approach the care of their patients and to challenge medical colleagues. An understanding of pathology and the natural history of disease are also important when advising local authorities.


  Change management is central to the role of the director of public health. They need the skills to make this happen and the robustness of character to understand that change agents can't always be popular. These skills must be applied equally adeptly in many different organisations and working with many different professions and disciplines.


  Public health medicine is both a science and an art. Directors of public health combine many skills in one person. This is important so that directors of public health can use many different skills and approaches effectively, appropriately and simultaneously as and when a situation requires.


  The skills are largely the same but applied within different organisational structures. Differences include an increasing need for computing skills, time management and setting priorities (the workload for DsPH has increased considerably during the last five years) and managing more through influence rather than through executive power.

Does the Association consider there to be a tension between the core business of public health and much of the management workload of DsPH? Is there a risk of the urgent always driving out the important?

  Yes, this is a problem perceived by many directors of public health. In a recent ADsPH survey of directors of public health in England, Scotland, Wales and Northern Ireland, 37 per cent highlighted this as a key problem. They expressed difficulty in linking the aims and objectives of the health improvement programme with the service and financial framework. There was particular difficulty in securing funding for health gain initiatives. However, it is important to point out that this is not necessarily a conflict between health services and the wider determinants of health. Directors of public health have an important and central role in health authorities and it is critical to the achievement of health improvement that appropriate and effective health services are developed and delivered to meet local health needs.

  Health authority chief executives tend to perceive that the government's priorities for health are not all equal. In health authorities we perceive the Department of Health considers waiting lists and times, critical care, winter pressures and service continuity and on occasions introducing new expensive drugs as being the only serious business. Health authority chief executives are hired and fired on these issues, along with achieving financial balance. Urgent crises frequently drive out the important initiatives which will deliver health gain in the medium to long term. At the Health Select Committee, Dr Donnelly and Dr Geller suggested ways to combat these problems and these are repeated briefly here:

    —  Persuade the government that population health improvement is as important as hospital waiting times.

    —  Ring fence funding for prevention and other health improvement initiatives through modernisation funds or other means.

    —  Insist that directors of public health attend regional reviews.

    —  Insist that key public health issues appear on the agenda of regional reviews with equal prominence to health service continuity of service issues.

    —  Appraise, hire and fire health authority and local authority chief executives based on health improvement and health outcome measures and targets.

    —  Increase the profile of Our Healthier Nation, and other similar health strategies in other home countries.

  NB Directors of public health are aware and very supportive of many of the recent initiatives for health improvement particularly the national service frameworks, dedicated money for smoking cessation and teenage pregnancy and including hospital control infection as a priority in the national priorities guidance.

Are directors of public health appropriately trained for their job? Are there skills deficits? If so how might these be filled?

  As with any senior post in a modern organisation, the skills required to perform at an optimum level continually change. It is therefore essential that continuing professional development (CPD) plays an important role in ensuring that directors of public health are kept up to date with current thinking on public health. To meet these challenges the Faculty has developed a flexible, accessible system that is subject to rigorous audit.

  The directors of public health undergo a very lengthy training involving five or six years at medical school followed by a minimum of three years and often very much more clinical work. That is then followed by five years in training as a specialist registrar in public health medicine and, finally, by a period as a consultant in public health which averages five years but often again is much longer. Thus by the time somebody is appointed as a director of public health, they are probably at least 20 years out of school and 15 years post-graduation, they have the wealth of training and experience which is required for the demanding post which they have to fill.

  However, the Association of DsPH believes that there is room to further improve this training particularly in terms of preparing people for the transition between consultant in public health medicine and director of public health.

  The director of public health role is an executive one requiring considerable management and strategic skills which individuals may or may not have had the opportunity to practise at consultant level. The model which is probably best suited towards developing and maintaining these additional required skills is that of an executive education approach rather akin to that used by business schools in North America. In this model individuals who hold, or aspire to hold, such senior positions are taken away from their work place for short (but very concentrated) periods of additional training. In order to ground such training in reality, the case study approach used by many schools of public administration or business administration is advocated. Unfortunately, many university departments of public health within the United Kingdom are involved in aetiological epidemiology or in running major intervention trials and understandably they has the research assessment exercise at the forefront of their minds. The ADsPH would therefore argue that few university departments actually research or teach what we would term public health practice. If such a university were to start research and teaching in this area, they may become natural leaders in the field of executive education for existing aspiring directors of public health.

Is there a general skills deficit in public health, and if so who, apart from health professionals, should we be training?

  Public health requires professionals with a wide range of skills and from a diverse background. Those working in local government, the health sector and the non statutory sector all have a vital and important contribution to make towards improving the public's health. Many of these professionals have not been seen, and do not see themselves as public health professionals, but are beginning to undertake more and more public health type tasks in their daily routine. Some of these people have embarked upon Masters in Public Health courses, and this is to be encouraged and developed. Public health has always sought to contribute in a range of settings and teams should be made up of professionals from diverse backgrounds.

  The Faculty regularly reviews and updates its education and training programmes to ensure that they remain relevant to current public health issues. There is a need to develop specialist training for those who choose to focus on health economics, communicable disease, public health dentistry, and some of the other specialities within public health. A programme of enhanced training could be developed to cover these areas.

  Two years ago the Faculty introduced a Diploma and Part I examination in public health, which is open to all. This has proved popular, and there is currently debate on proposals to allow all Faculty examinations to be open to doctors and those not medically qualified.

  There is concern over the increasingly high turnover of director of public health posts. This obviously leads to a lack of continuity at a local level, but also a loss of skills at a national level, as skilled directors leave the specialty. The ability to fill these posts can be used as an indicator to show that there is sufficient capacity of trained skilled individuals available.

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