Journal of Public Health Advance Access originally published online on May 26, 2007
Journal of Public Health 2007 29(2):103-106; doi:10.1093/pubmed/fdm034
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Faculty of Public Health Leadership interview
Aruna Stannard, Medical Student
St George's Hospital Medical School, University of London, Cranmer Terrace, London SW17 0RE, UK
Address correspondence to Aruna Stannard, E-mail: m0100654{at}sgul.ac.uk
Alan Maryon Davis, new President of the Faculty of Public Health, Director of Public Health for Southwark, honorary professor, healthy lifestyles guru and a familiar figure through his long history of writing and broadcasting on health matters, arrives on a pushbike to talk fitness, fatness and why he's not going to be a presidential pushover...
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What would you consider to be the greatest challenges facing public health in the UK at the moment? |
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TOP
What would you consider...
So what would you...A huge issue is our ageing population with chronic diseases such as hypertension, type 2 diabetes, heart disease and other conditions many of which are linked to an unhealthy diet, inactivity and obesity. Alongside this, we have increasing problems with alcohol and sexual ill health, particularly among younger people. And, jumping to health protection, there's the issue of the ‘bugs biting back’—MRSA, SARS, bird flu...and tuberculosis hasn't gone away. But I think the most overriding challenge for public health professionals is the problems of inequalities in health and inequities in access to health services. The divides in society are still there, some are increasing, and we in the public health movement have a big part to play in helping to tackle them.
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So what would you say are your immediate priorities as Faculty President? |
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With such a huge agenda, one of the immediate priorities is trying to hold the public health community together. There is a likelihood that the different domains will split in different directions so we might find, for instance, that health improvement specialists link more closely with the local authorities, health protection people go in another direction, and the health service development and quality people become very NHS-focused. This specialization can bring great benefits, but the core public health approach and values remain and we need to hold the specialty together to maintain strength in unity.
Another priority is to address the ‘voice’ of public health. It's been very much weakened over the last few years. Constant reorganization of the NHS hasn't helped and the multiplicity of independent public health bodies dilutes the voice. I think one of the reasons the government and NHS have been able to run rings around us is that we have been divided and marginalized. The crucial thing to do is make these bodies work more effectively together and pack much more collective punch.
And third, the UK is now four countries, moving further apart. We've got to try to bridge the gaps and work more closely with our colleagues across the nation. Beyond the UK, another priority is to develop the role of UK public health on the global stage, from climate change to international development and cooperation. I think we've got a lot to share in terms of knowledge and experience. That's not much to do!
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With the NHS in financial difficulties is national policy regarding public health merely rhetoric or do you see real investment? |
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Ask the government and they'll say they're investing very heavily. It's not always labelled as ‘public health’. They will say the money was devolved to local areas and local areas choose what to do with it. When you ask about ‘ring-fencing’ [the money] so that you can protect it, the government says ‘it's not our policy, we like to devolve decisions to the local people, rhubarb rhubarb’. It's pretty clear that money ‘allocated’ to health improvement is an ‘easy target’ for financial directors to snaffle to prop up their bottom line, and that's what happens. The Faculty's got to fight hard to protect the allocations and make sure money is invested. It's a very false economy to try to whip money away from prevention.
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The 2005 Workforce Survey revealed that only 36% of Primary Care Trusts in England believed they had sufficient capacity and capability to deliver public health effectively. How would you address this? |
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You can't do public health on the cheap. We will be working with regulators and performance organizations such as the Healthcare Commission to try to ensure that chief execs won't get their brownie points unless they have a properly resourced, fit for purpose public health workforce.
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You've spoken about the voice of public health being somewhat weakened of late. There are concerns this may relate to the emergence of non-medical Directors of Public Health. What are your thoughts? |
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I'm very much of the opinion that public health is a multidisciplinary business and I can see no convincing argument why directors of public health have to be medical. Public health training is pretty comprehensive and covers all the skills needed. It doesn't matter if your background is medicine, nursing, environmental health, health promotion, epidemiology, catering or whatever; provided you've gone through the training or have had equivalent experience, have satisfied the competencies and are an effective leader you should be able to be a good DPH. What you must have however is enough medical public health expertise to call upon as and when it's required.
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In light of changes to medical training there have been concerns about recruitment of medics to the specialty being radically reduced. What advice would you give to medical students and junior doctors? |
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There's a huge job to be done in public health and I'm optimistic that there will continue to be a substantial role for medics in our specialty. There are areas where it's definitely useful to have a medical background, for instance when you're negotiating with trusts around commissioning or service development and eyeballing the clinicians. But training budgets have been hacked right back and we've got to restore them.
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Some feel that revalidation processes aren't entirely relevant to the public health profession. How would you identify a failing public health professional? |
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We now have formal appraisals for non-medics as well as medics and so we have a mechanism for identifying public health professionals who need support and personal development to help them provide a quality service. It still needs honing and refining, but we've got a process to build on.
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The papers continuously predict grim things for the future health of the nation. What are your predictions and do you think it's a future that can be changed? |
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Let's celebrate the good news about smoking first. The new smoke-free legislation across the nation is a fantastic achievement, and in my view probably the biggest leap forward in public health since the birth of the NHS. I think great swathes of the British public will finally give up smoking, so that's terrific. On the obesity front we have got a big problem. At the moment things are going in the wrong direction but the food industry is responding slowly and there is a growing market in healthy foods. Jamie Oliver gave the healthy school food movement terrific prominence. We have restrictions on junk food advertising on television. And we're getting there in terms of simple ‘traffic light’ nutritional labelling. There's also a burgeoning interest in everyday physical activity for health. One of the biggest challenges on the lifestyle front is alcohol; we're still back in the dark ages in terms of alcohol misuse, especially about what should be done at local level. I'm hoping the Faculty could work with the Royal College of Physicians and Alcohol Alliance on this. It ties in a lot with crime, community safety and mental health.
Then there's sex, drugs and rock ‘n’ roll. You can encapsulate it under ‘youth health’ which is always a challenging area because young people like to take risks and we don't want to be health fascists. It's a question of how do you change hearts and minds, and the ideas of what's cool.
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Having discussed the importance of lifestyle choices on health, I am sure readers will be interested to know whether yours measure up to your own expectations? |
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Well they're a bit of a curate's egg—good in parts. I cycle everywhere, chop two pieces of fruit on my homemade muesli for breakfast, have wholemeal sandwiches for lunch and more fruit, and then, in the evening, I'm afraid I do ever so slightly pig out! I have an occasional glass of wine, Guinness on a Saturday lunchtime, and a whisky and milk nightcap most nights. I've just written a book for Age Concern on how to have a healthy middle age, so I've got to stay in reasonable shape at least until that's been launched. I try to balance my work and life; although my dear wife may not always agree! All in all as long as I don't get knocked off the bike, I'm not doing too badly but could certainly do better. Come to think of it, the same goes for public health.
OURNEW VICE PRESIDENT
Steve George is an academic at the University of Southampton who has undertaken work for the Faculty of Public Health for nearly 11 years, including a 3-year spell as Academic Registrar. Promising to do his ‘very best to fight the corner for Public Health’, he takes up his new role as Vice President of the Faculty in June.
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What would you consider to be the greatest challenges facing the Faculty at the moment? |
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I think the greatest challenges are around the implementation of change. Change is welcome and needed, but we are in a position whereby the Faculty membership has diminished in the 10 successive years from 1997, despite the fact that we opened our doors to non-medical graduates in 2000. That's diminished our capacity to deliver change.
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What do you consider to be the reasons for the diminishing membership? |
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With successive reorganizations, people of a certain age get offered early retirement, so we've lost wave after wave of the most senior people. It's meant that our membership has been increasingly strained. Splitting the English health authorities into Primary Care Trusts at the last reorganization strained it even more. Suddenly people who were used to working in a multidisciplinary team found themselves stranded in a ‘one man and his dog’ type approach to providing public health. Thankfully that's changing, but of course it's changing via another reorganization. There used to be an understanding that the sort of national level work that Colleges and Faculties need could perhaps count for a day of your contract but since the new consultant contract that is not the case. In several instances people have said ‘I'm sorry, I can't do a national level job as well as my day job’. Somebody somewhere will have to tackle that if they want the Colleges to continue to provide what they have.
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So when you start in June what are your immediate priorities? |
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We have to look very carefully at the maintenance of standards. In particular, how we can maintain standards without imposing a hugely burdensome regime. We're going to have to think very carefully about how you might, for instance, run a revalidation process. Is it realistic to expect people who are working far more hours than they should be to spend day upon day undertaking appraisal of colleagues? People used to joke that by the time you'd done your appraisal and your Continuing Professional Development (CPD) there wasn't actually any time to do your job. There is an element of reality in that statement.
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You've mentioned the importance of the multidisciplinary team in public health. How do you think the Faculty can ensure that standards are maintained across the whole board? |
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I think it's very simple: put everybody through the same system. If everybody undertakes the same training, assessment and exams and gets the same qualifications at the end, then the standards will remain the same.
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Do you feel that if the training processes are standardized, no matter what background you go into it from, everyone should come out with the appropriate skills? |
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Certainly the appropriate core of skills. I don't think the Faculty should be taking a multicoloured universe and turning it into breeze blocks. I think people should bring their own backgrounds and particular skills with them. Our new curriculum has nine areas, four of them are core skill areas and five of them represent places in which you might apply those. There's a great difference between me working in a university and someone working in the Health Protection Agency but we still use the same four core skill areas.
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Turning to the topic of revalidation, how would you identify a bad public health professional? |
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One has to start by asking the question ‘is there such a thing as a bad public health professional?’ Everything we do in public health is such a long-term process; people are doing things and expecting results 10 years down the line. It is possible to get de-motivated and people who are de-motivated don't function as well. I think picking them up and turning them back into properly functioning people is the major thing that needs to happen, rather than identification of doctors who are going to leave instruments inside patients or deliberately bump them off. I don't think those are major risks in public health.
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How would you demonstrate a lack of leadership? |
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I don't know. I'll have to ask somebody! To be serious, one can recognize the syndrome. People turn up at the office, empty the in-tray and go home. That's not the way public health should work. People who are effective in public health go out there and get things done. The usual reason that they don't is that they're demoralized and de-motivated I think it's fair to say there are a lot of people in public health who feel like that at the moment.
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How could revalidation be organized? |
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There's talk of a 5-yearly basic test of knowledge and skills. It could be formative. You could do it online and have three attempts before it flashed a red light at you and said ‘You really ought to bone up on sensitivity and specificity’ or whatever. We have started to pilot a 360 degree appraisal process which allows a range of people to give their views of you. Those two things could cover the first four areas of our nine-area curriculum. We're looking at local appraisal and targeted CPD for the other five. That's how I see it at the moment but I'm open to suggestions.
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With public health operating as a multidisciplinary system at a local level, how do you identify what part of the system's going wrong? For example, if you had a huge problem with teenage pregnancies, is it the GPs, the PCTs, the teachers, the parents? |
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That's a very complex question and I'm not sure revalidation is the appropriate tool for solving that problem. If your teenage pregnancy rate is high, everyone needs to get stuck in and sort it out. It's a question of concerted team action not individual blame. Having said that, there are some instances where it's possible to spot where a problem's come from.
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What is the future of CPD? |
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We've got a new director of CPD. We'll be having discussions about the future of CPD, particularly how it fits in with appraisal and how we can make that a ‘closed loop’. We need to make sure CPD activities are a targeted response to appraisal findings. One suggestion is to submit one year's learning plan and see how well it marries up with the next year's CPD return.
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Some feel there's a ‘disconnection’ between the academic side of public health and the service side. Do you agree and do you think it's a problem? |
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Speaking as an academic, there can be a disconnection. It's been exaggerated in the last few years by the shortage of people. People simply haven't got time to go to the joint meetings we used to have 20 years ago. The work done in academia is probably very different to the majority of what's done in Primary Care Trusts but I think that our guiding principles are the same. We could do with improving understanding between the two communities. Academics hate the notion that they sit around in leather armchairs reading big books with lots of time to think about things, when in reality it's all about delivery: securing your grants or you're out on your ear. On the other side PCTs dislike the view that all they do is the ‘quick and dirty work’. We need to improve understanding of what you have to do to survive in both environments.
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And finally, what would you say has been the highlight of your career so far? |
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Being elected Vice President of course! Before that, being invited to give a lecture at the American Public Health Association conference last year. Or maybe being interviewed by Sue McGregor on the Today Programme, or by John Waite on ‘You and Yours’!
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