Who contributes to the public health function?

Transcription

1 Journal of Public Health Medicine Vol. 9, No. 4, pp Printed in Great Britain Who contributes to the public health function? Diane C. Smith and Lindsey Davies Abstract Background This paper describes the current nature and distribution of staff making an active contribution to the public health function in Health Authorities in England, so as to assess the extent to which the public health function is truly multidisciplinary and to begin to consider the National Health Service public health capability. Methods A pre-piloted questionnaire was administered by Regional Directors of Public Health (RDsPH) to their respective District Directors of Public Health (DDsPH) in all Health Authorities in England over the period June 995-April 996. The questionnaire asked for details of all staff in Health Authorities contributing to the public health function as defined by the DDsPH. This provided distributions of: Public Health Physicians; Consultants in Dental Public Health (CsDPH); Trainees in Public Health Medicine (PHM); Epidemiologists; Research Officers; s; Medical Advisers; s; Directors of Health Promotion; (job titles specific to public health) in Health Authorities in England. Results Staff contributing to the public health function were distributed as follows: Public Health Physicians (3 percent); Research or Information Officers and Epidemiologists (6 per cent); Trainees in Public Health Medicine (6 per cent); s (8 per cent); s (6 per cent); Medical Advisers (5 per cent); Directors of Health Promotion (4 per cent); Consultants in Dental Public Health (3 per cent); (job titles specific to public health) ( per cent). Conclusion The public health function is multidisciplinary, but the skill mix within Health Authorities is variable. The contribution of all disciplines to Health Authority public health functions needs recognition, not least in the provision of training, accreditation schemes and continuing professional development for all staff so as to secure an effective public health function at local levels to deliver the health agenda. Keywords: public health function; Health Authorities; multidisciplinary workforce Introduction Health Authorities were established in 974 with the primary role of managing health services. In 99 they became purchasers rather than managers of care, with a remit to secure services appropriate to the health needs of their population. The evolution of Health Authorities into organizations which accept and address a wider public health role has continued, encouraged by the Government's commitment to the Health of the nation strategy, published in This culminated in 996 in the explicit recognition that the purpose of the 'new' Health Authorities, formed from the fusion of Health Authority and Family Health Service Authority functions, 4 is to improve the health of their population. This they are expected to achieve partly by purchasing services and partly by influencing other organizations and individuals, within and outside the National Health Service (NHS), to act to improve health. In effect, the Health Authority has evolved from a manager of services into, increasingly, a public health organization with a remit above all to improve health. In parallel with this functional change, there has been a developing awareness that the traditional, purely medical, Health Authority Public Health Department may no longer be able to fulfil all the Health Authority's needs, and failure to capitalize on multidisciplinary and multi-professional teamwork could represent a missed opportunity. 5 Training and career structures for people working in this field who are not public health physicians (including, for example, primary care medical advisers) are very limited, but there is currently no sound evidence which quantifies the need and can act as a basis for planning. As a result, many staff feel undervalued and teamwork is inhibited. 6 In 994, the Department of Health published Public health in England: the roles and responsibilities of the Department of Health and the NHS, 7 setting out the framework for public health roles and responsibilities in the NHS. Regional Directors of Public Health (RDsPH) agreed, in 995, to audit NHS public health in their regions against the principles set out in the report, which included an expectation of multidisciplinary working. The new Government's increasing emphasis on the public health function as a means for delivering better health demands that the roles and responsibilities of the multidisciplinary public health workforce are addressed, to ensure that the public health function is delivered effectively. In this paper, we report on results from a survey relating to workforce and discuss the implications for the future development of multidisciplinary public health in the NHS. NHS Executive Trent, Fulwood House, Old Fulwood Road, Sheffield S 3TH. Diane C. Smith, Senior Public Health Manager Lindsey Davies, Regional Director of Public Health Address correspondence to Dr D. C. Smith. Oxford University Press 997

2 45 JOURNAL OF PUBLIC HEALTH MEDICINE Table Specified job titles listed on the Staff section of the questionnaire designed to survey the Public Health function within Health Authorities is England Job title Director of Public Health Consultant in Communicable Disease Control Consultant in Public Health Medicine Senior Registrar in Public Health Medicine Registrar in Public Health Medicine Honorary Appointment Epidemiologist Research/Information Officer Health Promotion Director Health Promotion Officer Medical Adviser (Primary Care) Medical Adviser () Audit Staff Administration and Clerical Staff Materials and methods To survey the current structure of staff in health authorities contributing actively to the public health function and the extent to which those functions are being carried out, a questionnaire was designed based on the public health functions as identified in Public health in England. 7 The questionnaire was divided into two sections: a workforce section posing specific questions concerning all members of staff, throughout the Health Authority, who contributed actively to the execution of public health functions; and a functional section, which asked about the Authority's ability to perform its public health functions. For each of the job titles shown in Table, the workforce section asked for: numbers of staff posts, whole time equivalents (WTEs), vacant posts, vacant WTEs; staff grade; staff qualifications; and managerial accountability. The questionnaire was piloted on DDsPH in the Trent region administered by interview by the Regional Director of Public Health during July-August 995. After the pilot, the questionnaire was revised appropriately and sent to the remaining seven Regional Directors of Public Health (RDsPH) in England for comment and suggestions. After incorporation of suggested amendments by RDsPH, the questionnaire was then returned to RDsPH in August 995. RDsPH were asked to interview DDsPH from each of the Health Authorities in their region, complete the questionnaire proforma and return. In practice, for some regions, interviews were not possible and arrangements were made for DDsPH to self-complete the questionnaires. After reminders, a per cent response rate was achieved. All rate calculations were based on the revised Office of Population Censuses and Surveys (OPCS) mid-year population estimates for 994, 8 adjusted where necessary to take account of boundary changes. For the 4.6 per cent of responses in which no WTE data were provided, WTEs were assumed to be equal to the numbers of posts. Results Directors of Public Health cited a wide range of staff as contributing actively to the public health function (Table ). As varying organizational and contractual arrangements could have invalidated inter-authority comparisons, we excluded health promotion officers (with the exception of the Director of Health Promotion), clinical audit staff, and clerical and Table Distribution of number of WTEs of staff contributing to the Public Health function within Health Authorities in England ( )* Job title Mean Mode Maximum Total Director of Public Health Consultant in Communicable Disease Control Consultant in Public Health Medicine Senior Registrar in Public Health Medicine Registrar in Public Health Medicine Epidemiologist Research/Information Officer Medical Adviser (Primary Care) Medical Adviser () Director of Health Promotion Total Excludes Health Promotion Officers, Honorary Appointments, Clinical Audit and Administration and Clerical staff.

3 WHO CONTRIBUTES TO THE PUBLIC HEALTH FUNCTION? 4S3 secretarial staff from our analyses. With these exclusions, we identified a total of 47. WTE public health staff. The mean number per Health Authority was 4.3, with a range of 5.-36, mode.5; 76 per cent of Authorities had.5 or more. Job titles varied from district to district; for example, an Epidemiologist in one district could be doing the same job as a Research Officer in another. For this reason, analysis of Research or Information Officers and Epidemiologists and the two categories of Medical Advisers were pooled before further analysis. Figure shows the distributions of the various Total Staff per million of resident population Public Health Physicians per million of resident population Research Officers/Epidemiologists per million of resident population Trainees in Public Health Medicine per million of resident population 4 6 Other Professions per million of resident population s per million of resident population s per million of resident population Medical Advisors per million of resident population Health Promotion Directors per million of resident population Consultants in Dental Public Health per million of resident population Figure Distribution of disciplines contributing to the public health function in English Health Authorities, (/-axis shows the number of Health Authorities).

4 454 JOURNAL OF PUBLIC HEALTH MEDICINE Table 3 Numbers (percentage) and rates of staff, identified by DDsPH, contributing to the public health function in Health Authorities in England, Staff category in English Health Authorities Rates of staff in Health Authorities per million of resident population Job title Number % Mean Range Public Health Physician Research or Information Officer, Epidemiologist Trainee in Public Health Medicine Medical Adviser Director of Health Promotion disciplines contributing to the public health function, and Table 3 shows numbers and mean rates for those disciplines. Public Health Physicians accounted for 3.4 per cent of staff contributing to the public health function in Health Authorities, with Trainees in Public Health Medicine bringing the total of Public Health Physicians up to 47.9 per cent. The second largest category of staff was that of the pooled job titles of Epidemiologists and Research or Information Officers (6 per cent). Table 4 demonstrates the wide variations in staffing between regions, from 8.3 WTE/million in North West and in Trent to 4. WTE/million in West Midlands. The numbers of Health Authority-based NHS Public Health Physicians in WTEs per million population served were calculated by combining data for District Directors of Public Health (DDsPH), Consultants in Communicable Disease Control (CsCDC) and Consultants in Public Health Medicine (CsPHM) (Table 5). Data on honorary posts were of poor quality and these were, therefore, omitted from the analysis. We identified a total of 46. Public Health Physicians in post and 4. WTE vacancies. These figures are similar to those described in the Faculty of Public Health Medicine's manpower survey. 9 The number of WTEs per Health Authority ranged from two to nine with a mean of 4.6. The modal value for CsCDC was one, and for CsPHM, two. WTEs of Public Health Physicians correlated significantly with the population served (r =.7, p<.), although this disguised large variations in the population served by individual specialists. For example, the population covered by one WTE CCDC ranged from 5 to 88. Only five authorities exceeded the Acheson report's recommendation of 5.8 Public Health Physicians per million population, including four of the smallest districts in the country. The overall rate for England was 9.5 Public Health Physicians per million population, considerably less than the Acheson recommendation. However, this analysis does not include Public Health Physicians in academic centres. To assess the extent to which relatively low numbers of Public Health Physicians were redressed by a higher investment in other staff groups, we analysed correlation using Spearman's correlation coefficient. No statistically significant negative correlations were found. An element of association was Table 4 Staff contributing to the Public Health function in Health Authorities in England per million population averaged by region, England Anglia & Oxford North Thames North West Northern & Yorkshire South & West South Thames Trent West Midlands Total staff Public Health Physician Research/Information Officer/Epidemiologist Trainee in Public Health Medicine Medical Adviser Director of Health Promotion

5 WHO CONTRIBUTES TO THE PUBLIC HEALTH FUNCTION? 455 Table 5 Whole time equivalent posts of Public Health (PH) physicians by number and rate per million population for English regions showing range of District Health Authority rates within regions Region Number of PH physicians (WTE) Regional rate of PH physicians per million population Range of district rates of PH physicians per million population Anglia & Oxford North Thames North West Northern & Yorkshire South & West South Thames Trent West Midlands Total demonstrated, however, for Public Health Physicians and Research or Information Officers and Epidemiologists (/? =.), for Public Health Physicians and Trainees in Public Health Medicine (p =.), and for Public Health Physicians and Health Promotion Directors (p =.). The only category of staff found consistently in every Health Authority was the Public Health Physician. All other groups, including Medical Advisers, were absent in one authority or more. Qualifications of non-medical staff were from various disciplines, including the biological, social and environmental sciences, as well as professional qualifications in nursing, dentistry, health promotion and pharmacy. Many were graduates (8 per cent of those reported) with Masters degrees (4 per cent of those reported) and Ph.D.s ( per cent of those reported). In particular, 9 per cent of Epidemiologists, for whom qualifications were reported, held Ph.D.s. There was a wide variation in the grading of non-medical staff, from A&C grades to senior manager pay. Medical Advisers were mostly cited as general practitioners and there were many examples of transition of line management from Directors of Primary Care to Directors of Public Health. Public Health Physicians, Trainees in Public Health Medicine and Epidemiologists were the only disciplines reporting exclusively to the Director of Public Health. Discussion and conclusion Inter-district variation The lack of any consistent patterns in skill mix and numbers of staff involved is surprising, given that the essential public health functions are the same for all authorities and that we allowed for variations in served population by using rates in our analysis. Some of the variance could be explained by our exclusion of honorary contract-holders from the analysis. These are, however, generally held in districts which host undergraduate or postgraduate medical schools. As most of these authorities have relatively high levels of contributing NHS staff, the inclusion of honorary staff is likely to emphasize rather than reduce the differences demonstrated. The high staff:population ratios found in very small districts are less surprising, as all districts are required to appoint as a minimum a Director of Public Health (DPH) and a Consultant in Communicable Disease Control (CCDC), resulting in a rate of ten WTE per million population (assuming both are full-time and a typical small population to be ) for doctors alone. Variation could also be explained by the limitation of the analysis to staff holding contracts with the authority, excluding contributions purchased from other organizations, such as management consultants or Institutes of Public Health. This, too, is likely to have resulted in an underestimation of interauthority variance, as our data on funding for external contracts showed that funds were used for this purpose in a small minority of authorities, most of which had high staff: population ratios. Given, then, that the variation is real, why is it so wide? One explanation might be that there are real differences between districts in the detail of their public health tasks. The work can be particularly demanding, for example, in districts with complex health issues to address or with relatively large numbers of local authorities, trusts or general practices. Equally, it may be that some districts are using their staff more efficiently than others, or that some chief executives and DDsPH are unaware or nervous of the potential for multidisciplinary development. Another real possibility is that variations in investment are a reflection of the extent to which Health Authorities take seriously their public health responsibilities. Management Implications The involvement of a wide range of disciplines in public health activities suggests that programmes for education, training and professional development may need to be reviewed and reorientated. Our results show that, although most staff are formally qualified in at least one relevant discipline, relatively few have formal public health qualifications. The wide range of

6 456 JOURNAL OF PUBLIC HEALTH MEDICINE job titles and grades for staff with similar qualifications who seem to be doing essentially similar jobs is also a cause for some concern. The findings support those of Somervaille and Griffiths, 6 who, in a recent survey of non-doctors in public health, identified a widespread demand for appropriate training and career opportunities. As an increasing number of doctors working primarily in other medical disciplines, encouraged inter alia by Health of the nation, seek to address wider public health issues, it is important that they, too, have access to training relevant in content and duration to their needs. Conclusion In every English Health Authority, disciplines other than Public Health Medicine are contributing actively to the authority's public health activities. The disciplines and staff numbers involved vary widely. Further work is required to elucidate the causation and full implications of this. In particular, consideration of Health Authorities' ability to carry out their public health function, as posed in the second half of our questionnaire, but not reported here, may shed some light on the optimum skill mix required for Health Authorities. The remarkably low numbers of contributing staff in some authorities, however, suggest that these districts may be unable to address their public health responsibilities adequately. This may, over time, put the health of their population at risk. Regional Offices of the NHS Executive must ensure through active performance management that Health Authorities invest appropriately in the development of their public health function. Acknowledgements We thank Regional and District Directors of Public Health for their advice and contributions to the survey, Mr Andrew Nicholson and Mrs Janet Buckle for technical and clerical support, and Dr Mike Bedford and Dr Elizabeth Clough for commenting on the manuscript. References National Health Service Reorganisation Act 973. London: HMSO, 973. National Health Service and Community Care Act 99. London: HMSO, Department of Health. The health of the nation. A strategy for health in England. London: HMSO, Health Authorities Act 995. London: HMSO, Scally G. Public health medicine in a new era. Social Sci Med 996; 4(5): Somervaille L, Griffiths R. The training and career development needs of public health professionals. Report of postal survey and discussion workshops. University of Birmingham, NHS Executive. Public health in England: the roles and responsibilities of the Department of Health and the NHS. NHS Executive, Office of Population Censuses and Surveys. Registrar General's Population Estimates for Mid-994. London: OPCS, Moore AT. Faculty of Public Health Medicine: annual manpower report for 995. London: FPHM, 995. Committee of Inquiry into the future development of the public health function. Public health in England (Acheson report). London: HMSO, 988. Department of Health. Public health: responsibilities of the NHS and the roles of others: advice of the committee set up to undertake a review ofhc(88)64. Circular HSG(93)56 (Abrams report). London: DoH, 993. Accepted on 9 July 997