Communicable disease and environmental health matters are closely allied major elements of health protection. Consultation on this continually changing area highlighted the need to use a wider range of analytical techniques in the epidemiological investigation of outbreaks and incidents; development of risk management, including health impact assessment; further evaluation of interventions; and continuous improvement of arrangements to manage emergencies. In the longer term, closer technological and organisational ties should mean greater integration of health (embracing both communicable and non communicable disease) with food and environmental safety. A potential benefit of networks is that given CsPHM could develop particular expertise in areas such as bloodborne viruses, food, or meningococcal disease, and promote commonality of working methods across Health Boards. SCIEH and its involvement in the proposed Public Health Institute (paras 349-357) could facilitate such integration and development.
The Review was concerned to learn of the lack of suitably experienced applicants for vacant CD&EH consultant posts. This threatens the integrity of the Scottish response to CD&EH issues, and it is inappropriate for consultant colleagues with other public health remits to carry responsibility for this specialist activity. Those who wish to pursue this specialist training should be encouraged to do so, for example, through structured attachments to SCIEH and/or CDSC. The Review sees a need for the CMO to work with the DPH Group and the CD&EH network to address the shortfall of recruits as a matter of urgency.
A strong CD&EH function needs adequate resourcing and appropriate management commitment. The manpower requirements have been discussed earlier (paras 137-138). CsPHM need to build strong teams with fellow professionals and have good networks with other public health colleagues, clinicians and those working in microbiological disciplines. Adequate cross-cover arrangements are crucial and a Northern CD&EH network might provide a valuable model for networking and the involvement of suitably trained colleagues who are not CD&EH specialists (eg primary care practitioners).
Public health CD&EH networks are already in place at national and regional level, while local networks support surveillance, control of infection and the counter attack on antibiotic-resistant organisms. These networks will benefit from the links emerging from EU and UK commitments, and closer working between the Communicable Disease Surveillance Centre (CDSC) in Colindale, London and SCIEH.
Each network within Scotland needs strong ties with local authority professionals and management in order to strengthen the role of the DMO. Local liaison committees between CD&EH specialists, EHOs and others would help to strengthen overall links between Health Boards and local authorities. At national level, the proposed Public Health Institute could further support and strengthen an integrated CD&EH function. The Public Health Legislation Group (para 80) is examining the DMO role in relation to CD&EH, and review of public health legislation will provide further opportunities to strengthen CD&EH links.
Out-of-hours arrangements to cover the CD&EH function remain a matter of concern, and there are particular anxieties about within-hours cover for single-handed CD&EH consultants. Within Health Boards the creation of a communicable disease team which includes a suitably trained public health nurse may relieve some of the in-hours pressures, as will the further development of managed networks. In larger Boards the employment of more than one consultant with CD&EH responsibilities will both cover absences and broaden the skills base. Among the wider consultant body, there appears to be general recognition that all colleagues must maintain the competence and skills needed to deal effectively with out-of-hours emergencies. This will require appropriate training opportunities, written policy development and communications aids.
Each Health Board, in association with its local authority partners, should maintain clear written procedures for the escalation of response to public health incidents. For smaller Health Boards, such incidents can swamp all management resources available to the organisation at an early stage; even the largest Health Boards can experience extreme pressures if incidents are of sufficient size. The development of written mutual support protocols across Health Boards, which include arrangements for the early involvement of SCIEH (advice and logistical/operational support) in responding to public health incidents, is commended by the Review.
Investment in training and professional development for specialists and non-specialists alike is crucial to success in delivering the communicable disease function across Scotland. We see a continuing central role for SCIEH in providing training, operational support, expert advice and encouraging general development of the CD&EH function (eg risk assessment, risk communication, epidemiological investigation of outbreaks and incidents, effectiveness of interventions, integration of health with food and environmental surveillance). Health Boards also need to accord continuing high priority to their CD&EH function within the mainstream of public health. SCIEH also has an explicit strategic role in surveillance of disease across Scotland and internationally, and in developing links between health, food and environmental issues.
The Review has heard that although SCIEH has a portfolio of communicable disease-related research, the research investment by University Departments in this area has waned. The proposed Public Health Institute could help to integrate interests, allay concerns of clinical, laboratory and public health specialists in the field, and foster the epidemiological research needed to investigate links between health and the environment. We recognise that ISD and SCIEH already have capabilities and interest in these areas and see the need for further research and surveillance as additional drivers for closer working between these two organisations within the Common Services Agency.
The Review received proposals to create a Centre for Disease Control in Scotland and several issues considered in this section support the concept as a development that could be part of a national Public Health Institute. Several of the essential elements of such a Centre are already in existence and we see incremental progress to functional integration as highly desirable. As well as favouring a coherent national approach, such developments would enhance the position of Scotland in relation to other parts of the UK and the European Union.
Training and the continuing professional development (CPD) of the workforce underpins the quality of the public health function. The Review considers it essential that training must emphasise the core skills and attributes needed for public health practice, provide expertise in the use of epidemiological methods and promote a standard and rigorous approach to public health problem solving. It should be multi-professional where possible, fostering working relationships and encouraging workforce flexibility. Specifically in relation to doctors and dentists, it should produce individuals able to function as consultants, meeting the regulations laid down by professional registration and accrediting bodies.
The Review heard the competing arguments for public health consultants as generalists or specialists. While it accepts the need for increasing specialisation in some areas, it favours having a skilled workforce that remains able to respond in a structured way to the changing circumstances of the public health. Only when the generic skill base is secure, can we proceed to the further development of specialisation. This has particular importance in respect of CD&EH; although the specialty has specific training needs, core skills need to be maintained by all CsPHM who are expected to participate in out-of-hours rotas and respond to public health emergencies.
Training courses to support the public health function should be tailored to the needs of the trainee or specialist, but should be so structured that they take full advantage of the strengths of the available teachers. Every public health professional has a responsibility to fulfil their own training and CPD needs in appropriate ways, promote peer support, and provide a suitable environment for trainees. Implicit in these considerations is the need for all organisations employing public health specialists to recognise the need for training, and meet regulations laid down by the General Medical and Dental Councils and professional organisations, particularly the Faculty of Public Health Medicine. The section that follows highlights specific areas of training.
The Master’s degree in public health There were variable accounts of the quality of Master’s courses in public health. Among the explanations offered for the variability was uncertainty regarding policy on funding. The Review understands that the employing authority, normally the host Health Board of the trainee, now bears the additional cost of academic secondment. In the comments received by the Review, positive aspects of training included the range of students on the course and the variety of available modules. Some remarked on the patchy nature of management training, and there was a more general call for higher levels of epidemiological skill and expertise. Modular courses based on a number of sites in England received favourable comment; this approach offers a way of conserving teaching resources while maximising the quality and depth of teaching. Service and academics interest should jointly review the practice of early secondment of trainees from various disciplines (including medicine and dentistry) for a full-time academic Master’s course. The Review sees great merit in developing an integrated modular course to which all University Departments and specialist units in Scotland would contribute.
Training co-ordination The Review received written evidence regarding the post of Faculty Adviser and Training Co-ordinator from the then incumbent, Dr Maria Dlugolecka. The post places a burden on the host Health Board and we advocate that this responsibility and cost should be borne by all Boards. The commitment of Boards to training might be enhanced if such a collective approach was adopted. The current system, in which the areas occupied by the four Postgraduate Deans’ constitute separate training locations for relatively few trainees, was also questioned by a number of contributors. A single all-Scotland organisation would offer consistency of approach, flexibility in training pathways, and better co-ordination than the current system or a two Deanery model. We strongly recommend that there should be one Scottish Public Health Training Scheme supervised by the Faculty Adviser and Training Co-ordinator with appropriate assistance from Health Boards, Universities and regions.
Mobility within training Trainees recognise the need to work and train in several settings, preferring to begin by learning the core business of public health while within their host Health Board. Travel to other areas can be constrained by distance and domestic considerations. Nevertheless all parties accept the need to travel to gain exposure to a variety of professional settings and organisations, and this is a strong commendation of the Review.
Flexibility of training programmes The work of all public health trainees should be integral and relevant to the work of the department to which the trainee is attached. Trainees are there primarily to be trained and not to provide indispensable support for the core activity of the department. The correct balance between acquiring necessary skills and being seen to contribute is easier to achieve if there is active supervision and management of training. Training should be tailored and include attachments to national units (e.g. SCIEH, HEBS, ISD, Public Health Policy Unit), NHS Trusts and/or local authorities. For some trainees, venues might also include voluntary and commercial organisations, and UK and international health organisations. Trainees in dental public health and public health medicine should be linked where appropriate.
Academic public health The Review heard a number of concerns about hurdles for those pursuing academic interests or an academic career. The training framework does not lend itself well to this career pathway, as service attachments and residual responsibilities following attachment often take precedence over academic equivalents. Career progression had stalled for the few who had persisted and there are clearly concerns about a relative lack of career academic posts in the discipline. While some of these problems are experienced by all trainees, the Review is concerned by the overall need to strengthen the academic base and integrate its contributions effectively into the broader movement to improve public health. We strongly commend the recent SCPMDE initiative to encourage lecturer appointments in clinical university departments including public health.
Training for specific groups Training and CPD for aspiring and substantive Directors of Public Health should span the career paths of those involved, and their training and development programmes should be tailored to reflect their needs. The need for continuing investment in training for communicable disease control among specialists and generalists has already been emphasised. The Review appreciates that some recruits and the vast majority of clinicians, carry out valuable public health work in non-public health career locations. As indicated earlier, much could be gained by providing skills training in appropriate settings for non-specialists, including clinicians with a public health interest (eg primary care workers and academic staff in a range of disciplines).
Enhanced management skills While the DPH has a distinct management role, management skills should be a generic attribute of all specialists who interact outside their own professional group. Training programmes should reflect this need.
Enhancing research and development capability Elsewhere in this Review we have highlighted the value of service networks; such networks would also enhance the development of epidemiological expertise and provide opportunities for research training and development. Networks could also create new alliances around the R&D arms of Health Boards, academic centres and national agencies.
Career development Common core elements of career development should in the long-term align more closely across the disciplines. This does not imply homogenisation of specialist public health professionals; indeed it will be crucial to recognise the unique contributions of each professional group in order to maximise effectiveness. In the medium-term, the Review welcomes the movement towards accreditation of public health specialists who are not doctors and dentists.
Skills audit A wide range of organisations have skills and resources that can be deployed in the pursuit of better public health and in training. An electronic public health database that maintains a register of interests and skills, publications and other outputs would strengthen Scotland’s public health function and could form part of the work of the proposed Public Health Institute (para 349-357).
Leadership and co-ordination of the public health function in Scotland
The Review welcomes the commitment of the new Scottish Executive to public health as reflected in its endorsement of the White Paper Towards a Healthier Scotlandand its decision to identify ‘Promoting Public Health’ as a key cross-cutting initiative driven at cabinet level by the Minister of Health.
A recurring difficulty for those conducting this Review has been identifying a national forum in which to engage all public health doctors and dentists, let alone other public health professionals or the public. The Review acknowledges the contributions of the Faculty of Public Health Medicine, the Scottish Forum for Public Health Medicine, the Office of Public Health in Scotland (OPHIS), and the Scottish Committee for Public Health Medicine and Community Health in attempts to co-ordinate and drive the public health function in Scotland. The nature of these organisations and their contribution is described in Appendix 2. In their written evidence, many respondents stressed the need for a defined national point of focus for the public health function. We also consider that a new national focus would be extremely valuable and the remainder of this Report is devoted to considering issues of leadership and the nature and implications of any new national public health initiative.
Role of the Chief Medical Officer
The Chief Medical Officer (CMO) is appointed as the chief medical adviser to the First Minister and the Scottish Executive with a remit to monitor the state of health of the people of Scotland and the outcome of health care. He is also charged with assessing determinants of health and ill health and advising on the measures needed to improve health and health care. He serves as the main point of contact between the government and the medical profession in Scotland. The CMO has the right of direct access to the First Minister and other Ministers. He devotes some 50% of his time to NHS affairs and sits as a Director on the NHS Management Executive Board. With regard to public health, he is supported by a Deputy CMO and other accredited public health medicine specialists, and by the Public Health Policy Unit (PHPU) of the Scottish Executive Department of Health. The Health Education Board for Scotland reports to the PHPU. SCIEH and ISD are part of the Common Services Agency and their medical staff look to the CMO for professional leadership, linkage and support.
The CMO holds regular meetings with Directors of Public Health and periodic meetings with SCIEH, ISD, HEBS, the Scottish Affairs Committee of the Faculty of Public Health Medicine, OPHIS, the Scottish Committee for Public Health Medicine and Community Health, heads of academic departments, and consultants in CD&EH. A benefit of the present Review has been the opportunity to engage further with professionals working in public health throughout Scotland.
The fact that the CMO serves as an arm of Government when it comes to framing and executing public health policy does not compromise his ability to serve as an adviser who can form and express an independent view. Despite strong working relationships with those working in public health and exercise of a leadership role, he has no direct management responsibilities for the affairs of Health Boards or various public health agencies. He is ideally placed to transmit the views of public health medicine to Government without being well placed to direct operational activities and the organisation of the constituency. If a Public Health Institute were to be created in Scotland (see below), the CMO would welcome the presence of a coherent public health focus outwith the Scottish Executive Department of Health.
A national body for public health in Scotland
One response to the Review was to suggest the creation of a public health body outside the Scottish Office that could offer public health advice and comment at national level, co-ordinate public health activity and ensure greater collaboration between the various agencies and professions which can influence health.
Another suggestion was that a national body could provide a public health resource for Government, Health Boards, NHS Trusts and other relevant agencies. This resource would support, but not replace, local organisations of public health practitioners and might use the clinical network model described in the Acute Services Review. It would allow greater development of specialist skills than could be sustained or justified at a more local level, and its availability could help to redress some of the present shortfalls in skill provision in some Health Boards, particularly those serving smaller populations. At the same time, a national resource might avoid duplication of effort and over-provision of skills for a population of just over 5 million people, promote economies of scale, and facilitate the development of national public health strategies in priority areas such as coronary heart disease, cancer and mental health.
If a national resource is to be developed, the Review appreciates that most public health doctors and dentists are employed by Health Boards and care will be needed if public health practitioners are not to be detached from local communities with loss of essential local knowledge and networks. However, it considers that an appropriate balance is attainable, with certain functions being developed by a national body while the main strategic public health function remains within multidisciplinary public health departments in Health Boards. It also strongly supports the development of public health networks at local, regional and national level to ensure equitable provision of public health functions, help to maintain a skilled and motivated workforce, and provide a strong base for service development, surveillance, audit and research activities.
A virtual public health institute
Another option suggested was a ‘virtual’ national body or Institute, drawing together and promoting synergy between existing organisations/programmes such as SNAP and agencies such as SCIEH, HEBS and ISD with major public health functions. A virtual institute could also drive the national research agenda, promote effective evidence-based public health initiatives and programmes, and serve as an authoritative source of advice to Government and others. The Review is not totally unsympathetic to this concept but sees problems in creating a virtual institute which lacked leadership, authority, profile and dedicated resource, and which might drift down the same road to extinction taken by the Scottish Forum for Public Health Medicine (Appendix 2).
Another virtual institute model that was proposed would retain the present structure of NHS and academic public health in Scotland but would be driven by a Management Committee of Directors of Public Health, heads of academic departments and CSO funded public health units. Representation from non-medical and non-dental public health specialists would ensure a multidisciplinary culture. All public health practitioners in Scotland would provide a common pool of expertise that could be drawn upon to service local, regional and national needs. The Institute would maintain an up-to-date database of expertise of all public health practitioners in Scotland and would act as a clearing-house for information and calls for assistance. Protocols and guidelines would be needed to underpin such arrangements, while electronic communication would minimise the need for bureaucracy. We can see some virtue in these proposals but are again concerned by the similarities between this model, OPHIS and the Forum for Public Health Medicine, and have doubts about the sustainability of a virtual Institute and its ability to thrive.
A Standing Commission for Public Health
A fifth suggestion was a Standing Commission (akin to the Scottish Law Commission or the Accounts Commission for Scotland) reporting to a parliamentary select committee (i.e. the newly constituted Health and Community Care Committee of the Scottish Parliament). The Commission would monitor and audit the public health work of other public health agencies (e.g. by performance management of Health Boards), commission work from environmental health departments, and inspect and report on aspects of the work of Local Authorities and national bodies with specific public health functions.
The case for an independent Commission was examined in a Nuffield Trust Workshop held at Christ Church, Oxford in 1998. Background concerns were expressed at the lack of linkage between health authorities and local authorities, and the absence of a national body that could consider public health concerns before they reached Ministerial level. It was suggested that influences and activities that have an impact or a bearing on public health could be co-ordinated through a matrix organisation, perhaps in the form of a Board of Health. There was support for the idea of Commissioners for the Health of the People who would be responsible for promoting activity aimed at safeguarding and improving public health but independent of spending departments. While they would remain ‘outside’ the structure looking in, it was recognised that history suggests that the only effective way of getting things done in the UK system is from the ‘inside’.
The Review sees merit in some strands of the argument for a Public Health Commission but is strongly against imposing another layer of bureaucracy with its resource and expertise implications, and replacing, duplicating or complicating existing performance management mechanisms. We agree with Holland and Stewart19 that an independent National Commission of Public Health is unlikely to be acceptable in that its need both to investigate and act might stifle local initiative. We also share their concern that a Commission might not be given a sufficiently wide remit by Government and can see potential for overlap between its work and that of a parliamentary select committee. We appreciate that the New Zealand experiment with a Public Health Commission separate from the Ministry of Health foundered on the difficulties of reconciling independence with the exigencies of Government.
Role of the Public Health Policy Unit
A sixth option suggested was a strengthened and expanded Public Health Policy Unit (PHPU) under the leadership of the CMO, offsetting any perceived lack of impartiality or transparency by agreement that all transactions between Government and PHPU would be in the public domain. This was intended to avoid the need for a new public health body that might find itself in competition or conflict with PHPU. While the Review is firmly wedded to the concept of a strong PHPU located within the Scottish Executive Health Department and chaired by the CMO, it cannot see how this unit could function (or being seen to function) as independent of Government. It also sees no possibility of expanding the role of PHPU to make it directly responsible for the operational aspects of the public health function.
A national Public Health Institute in Scotland
A workshop on structural options for organising public health in Scotland was hosted by OPHIS in Stirling Royal Infirmary on 11 June 1999 under the chairmanship of Professor Phil Hanlon. The main conclusions of the workshop were as follows:
There should be a Public Health Institute for Scotland with responsibilities which would include leadership, co-ordination of public health work above local level, work to assist policy development, fostering innovation, facilitating communication and improving public and press understanding of public health issues;
While the Institute should have close relationships with PHPU, it should function at ‘arms length’ from Government;
HEBS, SCIEH and the relevant parts of ISD should form part of the Institute;
The Institute should have a small core (or hub) to manage and co-ordinate activities;
Public health professional workforces should become increasingly multi-disciplinary;
The professionals concerned should maintain their current employment arrangements (e.g. with Health Boards and academic departments) but models that include secondments and joint appointments (e.g. with local authorities and Trusts) should be explored;
Each centre of local public health expertise, such as Health Boards and University Departments, should provide an agreed and negotiated human resource for national activities and work among groups of Health Boards. In this way public health networks would be created;
The Head of the Institute and Directors of Public Health would take responsibility for managing resources and delivering outcomes, all of which would be set out in clear management plans;
The Head of the Institute with heads of academic departments and research units would develop and pursue a national research and development strategy for public health.
The Review is greatly attracted to the broad thrust of the OPHIS proposals and welcomes the consensus nature of the workshop and its conclusions. We share the vision of an Institute that would serve as a centre of excellence, a source of authoritative advice to the Scottish Executive, a focus for multidisciplinary working and as a real force that could help to implement policy that would improve the health of the people of Scotland. The major role of the Institute would be supportive, with important input to the co-ordination of public health research and epidemiology, and in making the public health evidence-base more accessible to users, including Health Boards, the public and the media. It could be instrumental in supporting work already underway in Scotland to develop medical and community genetics with their important implications for public health. It would also have a significant training and development role. The scope of potential involvement of such a National Institute is included in the box below.
Potential roles for a Public Health Institute for Scotland
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The Review can see a strong case for the participation of SCIEH and relevant parts of ISD in the work of the Institute but is sensitive to the need for further debate about the nature of these exact relationships. The relationship between the Institute and HEBS will also need further discussion. The work of SNAP should be integral to the Institute.
HEBS is a Special Health Board with executive functions and important operational and supportive roles, as well as a strategic and policy-generating role. It is difficult and undesirable to incorporate all the HEBS roles into the Institute. However, the Review felt that it would be attractive to create an integrated intellectual focus for health improvement and this element of the HEBS role should relate clearly to the Institute. The Review also anticipates that the Institute could provide support to the evaluation of interventions intended to improve health.
While co-location with SCIEH and part of ISD would enhance the profile and identity of the Institute, the Review recognises that this could prove expensive and has implications for the overall function of ISD and the Common Services Agency. With continued improvement in electronic information flow and communication, it would be feasible to have functional integration of the various components of the Institute without the need for co-location.
The Review sees great merit in the Institute having an identifiable core and a full-time Director if it is to have long-term durability and success. It appreciates the need for the Institute to have strong working relationships with Government (and in particular with PHPU) but sees value in retaining some distance between the two. While the Institute would be called upon to assist Government it could also serve as an external source of advice and comment on public health issues. We envisage that the Institute would make a major contribution to policy implementation as well as policy development and would be a powerful agent for the dissemination of good practice. We see the Institute supporting and assisting Directors of Public Health rather than weakening their relationship with local populations and Health Boards. If the Institute was seen to have appropriate independence and rigour, it could be called upon in exceptional circumstances to help resolve an area of conflict between a Health Board and its Director of Public Health.
The working relationship between the Institute and the CMO requires careful consideration. It would be logical to have the CMO serve as the point of contact between the Institute and the Public Health Policy Unit, Scottish Executive Department of Health and Government. In that financial resource would be needed to support the core function of the Institute, the CMO could also provide lines of accountability and performance management. In turn, he would support and facilitate the Institute’s development and enhance its identity and profile. Representation on the Clinical Effectiveness Strategy Group chaired by the CMO would ensure that the activities of the Institute were co-ordinated with those of other relevant Scottish bodies (eg Clinical Resource and Audit Group, the Scottish Health Technology Assessment Centre, the Clinical Standards Board and the Chief Scientist Office). The relationship with the Chief Scientist would require particularly careful consideration if the Institute is to develop national research and development strategy and capacity in concert with university departments and research units.
Finally, the Review can see that a Public Health Institute could facilitate the development of high quality national training and CPD programmes for all public health professionals. Furthermore, it could provide a platform on which to develop specialist skills and expertise in areas such as epidemiology and health impact assessment.
The Review appreciates that full discussion with all interested parties will be needed to agree on the need for a National Institute, define its purpose, remit and relationships, and consider its resource implications. We do not underestimate the complexity of these considerations and the degree of difficulty involved. Nevertheless, we are convinced that Scotland needs to develop such a centre of excellence and that it would add immense value in the drive to understand and improve Scotland’s health.
This Review sets out a challenging agenda to create a robust Public Health Function of the type which Scotland needs to make radical improvements in its health record. It builds on momentum begun by the consultation process and which should continue through implementation work with all concerned. The Review will be worthwhile only through co-ordinated efforts to see through its recommendations.