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A significant part of the work of all healthcare professionals is concerned with improving the health of the population. For some, public health tasks form the bulk of their day-to-day work, while for others, involvement varies according to job descriptions and work plans. In principle, swelling the ranks of those who see themselves as part of the public health workforce is an important part of the drive to improve the public health. The development of Health Boards as public health organisations also provides an important opportunity for chairmen, general managers and other Board members to contribute by ensuring that the Board’s public health function is strong and fit for purpose.
Public health medicine and dental public health
Public health medicine is the branch of medical practice that is concerned with improving the health of the population rather than treating the diseases of an individual. Dental public health is similarly orientated to the health needs of populations rather than individuals, its practitioners having their initial training in dentistry. CsPHM work with others to monitor health status, prevent disease, screen for early disease, control communicable disease, foster policies that promote health, and plan and evaluate the provision of health care. CsDPH have a similar role focusing on topics such as dental and oral health, food and nutrition, monitoring health status, promoting health improvement programmes such as screening for early disease, health education and fluoridation and planning and evaluating relevant health care services. In addition they have the role of chief dental advisors to Health Boards.
After basic medical training, would-be public health medicine specialists must obtain clinical experience in postgraduate training programmes. Most entrants have significantly more clinical experience than the minimum requirement; many are accredited in another specialty by the time they enter public health medicine, or are accredited general practitioners. Other entrants have significant research or management experience. Specialist training in public health medicine usually takes five years, during which practitioners are called Specialist Registrars. The extent of competition for training posts means that recruits to the specialty are generally of a high calibre. On completion of specialist training and having passed the Membership examination of the Faculty of Public Health Medicine of the Royal Colleges of Physicians of the UK (or acquired an equivalent qualification), they become accredited specialists with the General Medical Council.
Dental public health specialists have usually obtained clinical experience (in junior hospital posts, general dental practice and community dental practice) and obtained a Fellowship in Dental Surgery of one of the UK Royal Colleges before being accepted as trainees. On completion of the equivalent of four years of specialist training and after passing the intercollegiate examination, they become accredited specialists with the General Dental Council.
Consultants in public health medicine and dental public health have to be able to take an objective, often broad-based, view informed by experience of and insight into health services and clinical medicine/dentistry. They must be politically aware and possess a number of generic and transferable skills. Their distinctive role derives from their broad training and acquisition of skills that include networking, communication and the ability to influence others.
The Review believes that there is an expanding role for public health medicine and dentistry but is concerned that:
The actual and proportional amount of consultant time and manpower devoted to particular tasks varies inexplicably between Health Boards;
In some regions, key public health priorities appear to have very little manpower devoted to them;
A number of consultants report inappropriately large remits and workloads;
There is great potential for unnecessary duplication of consultant work particularly between Health Boards;
While one of the specific strengths that CsPHM bring to their role is the breadth of their knowledge and expertise, some of the tasks being undertaken by consultants could be readily and more appropriately undertaken by others. These tasks include a range of administrative tasks, contact tracing, data/information gathering and analysis.
It seems likely that CsPHM and CsDPH will remain a relatively scarce resource (see below). In order to make optimal use of their expertise, they should operate as members of a multi-professional team, undertaking only those functions and roles that require their unique blend of expertise and skill. We believe that explicit job plans are necessary to ensure appropriate deployment of CsPHM and delineate individual responsibility for public health tasks.
Each of Scotland’s 15 Health Boards has a Director of Public Health (DPH) who leads and organises the delivery of the public health function. The DPH is medically qualified, accredited as a specialist in public health medicine, and appointed by a NHS Advisory Appointments Committee constituted by regulation.
Towards a Healthier Scotland emphasises the pivotal role of DsPH if Boards are to fulfil their role as public health organisations. In concert with colleagues in public health medicine, Directors:
act as a focal point when identifying needs, and planning and monitoring health improvement;
influence the development of healthy public policy with partner agencies and the strategic shaping of services (using among other things the DPH Annual Report);
use their role as DMOs to strengthen links and ensure that health improvement is a key element in local authority plans;
encourage the pursuit of quality in healthcare services;
strengthen initiatives within communities to improve the health of those with special needs.
In their response to the Review, Directors of Public Health emphasised their clear corporate responsibility within Boards, providing public health leadership, and contributing to agenda setting, prioritisation and organisational development. The DPH and his/her staff are responsible for providing focused and objective public health and medical advice to the Board, and act as DMOs for local authorities in the area. The Review heard that the DMO role is under-utilised in many areas of Scotland and that there is significant variation in the extent to which the DPH and CsPHM are involved in the work of local government.
The Designated Medical Officer function and local authorities
Any medical practitioner is eligible to be "designated" in writing by Health Boards within the terms of the NHS (Scotland) Act 1978 Section 14 to exercise "such functions on behalf of local authorities as may be assigned to him by or under any enactment and such other functions as local authorities may, with the agreement of the Health Board, assign to him…". The effect of the National Health Service (Designated Medical Officers) (Scotland) Regulations 1974 was that CAMOs (now DsPH) would normally be designated ex officio and serve as the DMO in respect of the full range of (often unspecified) functions where local authority responsibilities impact on the public health. Except in cases of urgency, local authorities must be given the opportunity to comment before any others are authorised to act as designated medical officers. Consultants specialising in CD&EH are usually designated for responsibilities relating to these hazards. Section 14(4) allows for the DMO to appoint deputies when, for practical reasons he or she cannot fulfil all the duties. In practice therefore, all CsPHM who participate in on-call rotas must be so designated. In managing outbreaks of communicable disease, the DMO has dual accountability to both the local authority and the Health Board for discharge of the range of statutory duties.
Clarification of the DMO role in relation to CD&EH is being considered by a sub-group of the Public Health Legislation Group, due to report separately (para 80). It is clear that the DMO function in respect of other areas of public health is also poorly defined. For example, the arrangements for advice on housing strategy and policy are unclear, being potentially covered either by a DMO or by Housing Medical Advisers providing (policy and operational) input under the terms of the circular NHS 1982(GEN)2.
A number of respondents expressed the view that the DMO role could be better utilised to increase the involvement of public health doctors in the work of local government. Accordingly, we recommend that work is brought forward to describe the range of roles for accredited public health doctors acting as DMOs. Furthermore, we recommend that a description of the DMO role is included in the job descriptions of CsPHM. Local authority representation on Advisory Appointments Committees for CsPHM and DPH posts would help to ensure that appropriate expertise was recruited and would strengthen the Board-local authority partnership. Consultation on the current Review of Public Health Legislation will help to clarify the role of the DMO and the statutory powers associated with the post.
Consultants in public health medicine and dentistry
Public health doctors and dentists are located in 28 organisations across Scotland, including the 15 Health Boards. A manpower survey was undertaken during the Review to identify staff in NHS and academic departments of public health, and in other locations where public health doctors and dentists work (including SCIEH, HEBS, ISD and the Scottish Executive Department of Health). CSO research units were excluded from the exercise.
While it is relatively easy to determine the numbers of whole time equivalent (wte) CsPHM and trainees in public health medicine and dentistry, it is much more difficult to define the number of other staff who contribute to the public health endeavour. These include clinical staff working in departments of public health, health economists, health promotion specialists, and secretarial, administrative, information and research staff. What is clear is the great variation in the structure of public health departments of Health Boards, and the extent to which various professionals are included in descriptions of the public health workforce. For example, some Boards count all health promotion specialists among their public health staff, whereas others count only those who contribute at senior level to strategic development.
The Tables below set out the number of wte consultants in public health medicine, (including DsPH and other accredited public health doctors) and dental public health. For convenience, all trainees in public health medicine are identified as Specialist Registrars for this exercise. Other staff are not included because of the difficulty of ensuring like-with-like comparison across Scotland.
Following the Shields Report, Health Board expenditure on headquarters "management" was limited to £10 per head of population in order to maximise expenditure on direct patient care. The cost of employing public health professionals was not excluded from this figure although an exception was made for health promotion specialists. While the Review recognises that expenditure on public health has to be managed, it takes the view that capping Health Board expenditure on public health in this way will compromise the development of a strong public health function. We have real anxieties that continuing this cap in Scotland (it was removed in England and Wales in 1998) will jeopardise the drive to improved public health and weaken Boards as public health organisations. The appropriate number of consultants in public health medicine and dentistry (and other public health professionals) should be determined by need, as it is for clinical specialties. We are particularly concerned by critical mass issues and the problems faced by smaller Health Boards where economy of scale is denied.
Whole time equivalent Consultant and Specialist Registrar (SpR) Posts in Public Health Medicine and Dentistry in Scotland in Service Departments, Scottish Executive Health Department and Agencies13
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Location |
WTE CsPHM ( per million in mainland Boards) |
WTE SpRs in Public Health Medicine (note e) |
WTE CsDPH (SpRs) |
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Argyll & Clyde |
6.5 (14.4) |
0.7 |
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Ayr & Arran |
5.0 (13.3) |
0 |
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Borders |
3.0 (27.3) |
0.2 |
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Dumfries/Galloway |
3.0 (20.1) |
0.3 |
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Fife |
4.5 (12.9) |
0.4 |
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Forth Valley |
5.0 (18.2) |
0.3 |
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Grampian |
6.1 (11.5) |
0.4 |
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Greater Glasgow |
9.1 (10.0) |
1 |
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Highland |
4.2 (19.7) |
1 |
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Lanarkshire |
8.0 (14.2) |
1 |
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Lothian |
8.3 (11.1) |
0.4 |
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Tayside |
5.4 (17.2) |
0.6 |
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Orkney |
1.0 |
0 |
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Shetland |
1.0 |
0 |
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Western Isles |
0.65 |
0 |
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CSA |
11.2 |
0 |
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HEBS |
2.0 |
0 |
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Scottish Executive HD |
8.5 |
0 |
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TOTAL NHS |
92.45 (18.4) |
32.3 |
6.3 (2) |
13 Notes:
a) CPHM column includes DsPH and PHM accredited chief officers
b) Vacant posts have been included
c) Scottish Executive data only includes CPHM staffing in the Health Department
d) SpRs funded by Scottish Council for Postgraduate Medical and Dental Education with exception of one part-salary in CSA.
e) Doctors in training are "supernumerary" (ie not counted as part of the public health establishment). For this reason, SpRs have not been assigned to organisations in this Table.
Whole time equivalent Consultant and Specialist Registrar Posts in Academic Departments of Public Health Medicine in Scotland14
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Academic PHM Department |
Funding |
Cons PHM
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Specialist Registrar PHM |
Cons Dental PH |
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Aberdeen University |
HB |
0.5 |
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SHEFC |
1.5 |
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SPGMDE |
1.0 |
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Glasgow University |
HB |
0.2 |
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SHEFC |
4.0 |
1.6 |
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SE |
1.0 |
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SPGMDE |
1.0 |
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Edinburgh University |
HB/SE |
2.0 |
1.0 |
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SHEFC |
3.0 |
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Dundee University |
HB |
1.0 |
||
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SHEFC |
1.0 |
2.0 |
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SHEFC/HB |
1.0 |
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TOTAL ACADEMIC |
15.2 |
3.0 |
3.6 |
Public health medicine manpower
The 1988 Acheson Report recommended that each district (equivalent to a Health Board in Scotland) should have access to the advice of at least two consultants in public health medicine (including the DPH) and should nominate a district control of infection officer (DCIO - in Scottish terms a CPHM with responsibility for CD&EH). It was recognised that a full-time DCIO would not be dedicated exclusively to each district. The Inquiry recommended that there should be 15.8 consultants in public health medicine per million population by 1998.
In extrapolating this standard to Scotland it must be remembered that in 1988 the average English health district had a population of 250,000, slightly less than the average population of Scottish Health Boards. The Acheson assessment also took no account of the need for public health professionals to work actively with local authorities, a need emphasised repeatedly in this Review. The Acheson Report also predated the development of Primary Care Trusts and LHCCs with its implications for wider work on health improvement.
The Table discussed earlier shows that every mainland Health Board currently has access to more than two CsPHM including the DPH. However, none of the Island Health Boards, with their populations of less than 30,000, achieves this level of access. About one-third of the total workforce is located in central or academic units. CPHM input also varies significantly when expressed relative to population size but Scotland has sustained an overall ratio above the 15.8 CsPHM per million suggested by the Acheson Inquiry despite falling numbers of wtes. Even when consultants employed in national agencies or Government are removed, the rate falls to 14.4, just below the Acheson figure. The data suggest that economy of scale may operate in that larger Boards generally have smaller numbers of CsPHM relative to the size of their population than smaller Boards.
A survey undertaken by the Scottish CsPHM CD&EH group in 1998 sought to determine the time individuals spend on the CD&EH role as opposed to other public health tasks. It showed that all mainland Health Boards had met the Acheson recommendation in that they had a designated CPHM for communicable disease control. However, the total time available for this function varies greatly between Boards, regardless of whether the whole time equivalents are expressed alone or standardised by population. It is clear that consultants with a designated CD&EH function frequently undertake significant additional tasks. The consultants concerned and their DsPH confirm that there are relatively few economies of scale to be made in respect of the CD&EH function in Health Boards serving larger populations. One might therefore have expected large Boards to dedicate correspondingly more manpower to the CD&EH function; this does not always seem to be the case.
The Review did not undertake a detailed study of the deployment of public health consultants, but recognises that this will be important to inform the development of the public health function at regional level. We are not complacent about the sustainability of the public health function given current manpower and deployment, and have particular anxiety about the situation faced by smaller Boards. We see considerable room for improved networking and multi-professional working across existing organisational and regional boundaries. However, we are conscious of the increasing demands arising from, for example, the need for sustained work to develop health partnerships and respond appropriately to CD&EH issues. All of this underlines the need for Health Boards to review their public health manpower needs. We predict that this exercise is likely to lead to a modest increase in the public health workforce but it may well identify opportunities for more effective and efficient ways of working. This work should be co-ordinated at national level by the Scottish Executive Health Department and its Public Health Policy Unit working with the Faculty of Public Health Medicine, and the Scottish Committee for Public Health Medicine and Community Health.
The Review regards it as imperative that Health Boards maintain a robust CD&EH function. Evidence collected by the Review indicated that to be able to respond effectively to public health emergencies, each mainland Board should have at least:
1 WTE Consultant in Public Health Medicine dedicated to CD&EH;
1 WTE Public Health Infection Control Nurse/Advisor;
1 WTE Secretary/administrative assistant for the CD&EH function;
Appropriate support from information and public relations services.
In reviewing requirements for the CD&EH function, Boards should also take into account the need for community-based infection control nursing input (with particular reference to nursing and residential homes). It is suggested that Boards with a population of over 350,000 require at least two CsPHM to develop and discharge the CD&EH function. Our residual anxieties about the quality and sustainability of on-call rotas for CD&EH emergencies are addressed further elsewhere (paras 320-330).
Consultants in Dental Public Health (CsDPH) have a range of responsibilities within the Health Board, serving as the main advisers on dental services within the area in addition to their main role in dental public health. Many consultants have national responsibilities and some provide advice to more than one Health Board.
The number of CsDPH covering the work of Scotland’s mainland Boards has fallen from 12 wte to 6.3 wte over the last ten years. The predecessors of the CsDPH (the Chief Administrative Dental Officers or CADOs) had administrative and management responsibilities for the community dental service as well as public health remits. Such jobs and titles persist in the three Island Health Boards. Mainland-based CsDPH are distributed unevenly; three Boards employ a full-time consultant while the rest share consultants across two or three Boards. One Health Board has no consultant input but retains advice from senior dental professionals in the local NHS Trust.
The CsDPH are organised in association with the Chief Dental Officer, his deputy (post currently vacant) and academic colleagues in a collaborative dental public health network. The network has facilitated sub-specialisation among CsDPH in areas such as epidemiology and primary care, and has significantly influenced dental public health strategy and practice across Scotland. In particular, epidemiological monitoring has underlined Scotland’s unacceptably poor oral health; informed oral health promotion, disease prevention and educational initiatives; and helped to ensure equitable service quality and distribution. This has allowed the best use of a scarce resource, with apportionment of responsibilities on a national as well as a local basis to the mutual benefit of practice in both settings. The Review sees continued development of the network as important for Scotland’s dental public health.
In the course of its work the Review met all consultants in dental public health and some non-consultant advisers. We see CsDPH as having a great deal to offer the wider public health function in that dental status is also influenced profoundly by life circumstances and lifestyle factors such as diet, smoking and alcohol. As well as their dental role, CsDPH have generic skills which can be applied to a range of public health tasks and clinical effectiveness work.
A number of CsDPH appear to be involved in areas outside their immediate remit but there is no evidence of unnecessary duplication of tasks. On the other hand, it is clear there are gaps in the availability of professional advice, both functionally and geographically. We are concerned that there are too few CsDPH to cover national and regional functions and maintain effective links with the dental profession. We are also concerned about the variable input to Health Boards and the sustainability of some posts that are shared between Boards.
The Review recommends that each mainland Health Board should have ready access to specialist CDPH advice with a suggested minimum commitment of 5 sessions per week, the overall provision equating to two consultants for a population of 1 million. The Island Health Boards should continue to receive dental public health advice from their Chief Administrative Dental Officer. The Scottish Executive will continue to need input from CsDPH to support the Chief Dental Officer and provide advice to the Public Health Policy Unit and associated agencies such as HEBS and the CSA.
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