Written evidence submitted by the UK Faculty of Public Health (RTR00018)
Workforce: recruitment, training and retention in health and social care
The UK Faculty of Public Health (FPH) is a joint faculty of the three Royal Colleges of Physicians of the United Kingdom (London, Edinburgh and Glasgow). We are a membership organisation for approximately 4,000 public health professionals across the UK and around the world and our role is to improve the health and wellbeing of local communities and national populations. We do this by supporting the training and development of the public health workforce and improving public health policy and practice in partnership with local and national governments in the UK and globally. Given the Faculty’s remit, our submission focuses primarily on the public health workforce rather than the broader health and social care workforce.
Brief summary of evidence in this paper
Workforce pressures are the greatest challenge facing health and social care today. Attracting and retaining high-calibre and appropriately trained professionals is crucial to ensuring a sustainable health and care system across the four nations.
In public health, there is a clear need to build public health capacity and resilience in the UK, which has been made particularly apparent throughout the global COVID-19 pandemic. However, increased capacity and resilience is not only a requirement to control COVID-19 and future pandemics, but also in reducing health inequalities ‘by levelling up’, combating the major current and emerging population health threats especially from obesity, inactivity, poor air quality and the climate emergency, and ensuring the continued provision of proven public health services including screening and immunisation. The Faculty of Public Health have previously mapped the functions required for a robust public health system.
In terms of increasing the capacity of the public health specialist workforce, the Faculty has previously set out the case for 30 public health specialists per million of the population working in all parts of the health and social care system across the UK. This expansion cannot take place unless there is an increase in the number of public health specialist on the training scheme and an increase in the number of public health practitioners moving onto the specialist register via a portfolio application.
We need to ensure there is adequate capability and resilience in the system to respond to current and future public health issues. COVID-19 has exposed significant gaps in the multidisciplinary workforce needed to deal with all public health issues and upskilling of public health practitioners is needed, alongside the development of data science and health intelligence staff and the embedding of basic public health skills across the whole health and care workforce, maximising the use of e-Learning and other digital tools
With this increase in recruitment there naturally needs to be an appropriate level of resource and funding provided to the public health system; the Faculty calls for a percentage of NHS ICS spend to be dedicated to public health prevention.
Steps to recruiting extra staff
Public health, uniquely amongst the medical specialties in the UK, provides multi-disciplinary entrance to specialty training and is therefore able to access a wide talent pool, with approximately 50 per cent of entrants to specialty training coming from a background other than medicine.
The recent increase in medical school places is of course welcome, but there is a significant ‘lag time’ between entry into medical school and the completion of specialty training, regardless of the specialty. The increase in undergraduates must also be matched by equivalent expansions to the number of foundation programme and specialty training places, to ensure there is a smooth flow through the training pipeline. This is crucial if we are to stem attrition and make sure that additional medical student numbers are translated into an expanded medical workforce.
Public health is not currently a designated ‘workforce shortage specialty’ – there is a shortage of public health consultants, but an excess number of people wanting to take on these roles and join the training scheme. The bottleneck appears in the number of training places, which are very limited (typically 75-80 per year) and extremely competitive. With better directed funding, there could and should be an urgent expansion of the training scheme. Faculty analysis of workforce needs has demonstrated the need for 30 consultants per million of the population, and this figure would be achievable in 10 years with a modest increase to c100 trainees per year.
Aside from the specialty training programme, alternative routes remain theoretically more accessible, but fewer and fewer applicants are gaining access to the public health specialist registers (GMC, GDC, UKPHR) through the portfolio routes. The GMC’s certificate of equivalence for specialty registration (CESR) is very rarely used by medically qualified registrants for public health and the United Kingdom Public Health Register (UKPHR, the regulatory body for public health specialists not from a medical or dental background) has closed the defined specialist route which previously produced 15 people a year, approximately 20 per cent of specialist registrants in a typical year. The new UKPHR Specialist Registration by Portfolio route has had very limited uptake, despite the potential demand being there. While the training programme will and should always be the default route, modest additional funding (£10,000 per nation/region per year) to support the transition of a limited number of public health practitioners onto the UKPHR register by the portfolio route would provide more readily available added capacity at least in the interim period before any increase in the training pipeline matures.
Balance between domestic and international recruitment
The UK is not self-sufficient in producing health and care staff to meet patient demand. Overseas-trained doctors and other staff form a significant part of our health and care workforce and will remain crucial to the delivery of care in the years to come. Even with greater investment in UK education and training and incentivisation of domestic recruitment, there is a substantial ‘lag time’ in medicine needed to train healthcare professionals. Further, staff from countries beyond the UK bring a wealth of skills, experiences and attributes that enrich professional life and clinical practice and which enable the workforce to better serve the needs of diverse patient communities.
While public health is not currently a workforce shortage specialty, we note the importance and value of schemes such as the Medical Training Initiative (MTI) and the benefits it brings to both the UK NHS and the doctors’ home countries when they return. An expanded MTI scheme would bring even greater benefits to both the UK and overseas health services. Staff recruited from overseas must be properly inducted and supported once working in the UK
However, a reliance on overseas importing of medical expertise is not a sustainable solution for either the UK or the provider countries. Additional resources must be provided to boost the domestic supply of suitably trained health and care staff. Further increases in the numbers of medical school places at universities across the UK would be welcome, and this should include broadening the pool of future doctors to include those from widening access backgrounds and those on graduate-entry programmes.
Initial and ongoing staff training
Long-term workforce projections
At present, there is not an effective system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term patient need. As outlined below, there is a pressing demand for current and future projections of workforce supply and population health needs. This work should be undertaken at a national level and should draw on current expertise and sources of data from organisations such as the medical royal colleges and faculties, trade unions and the statutory education boards (HEE etc) in the four nations of the UK.
Curricula and skill-mix
The curricula for doctors, nurses and allied health professionals are already updated to reflect the changing needs of the healthcare system. Regular reviews of curricula are important to ensure staff have the right mix of skills to support the communities they serve. It is important that curricula remain agile and flexible so they can adapt to an evolving healthcare environment while continuing to ensure patient safety. Given the shifting focus of health and social care from episodic care to long term support, it will be important for wider medical curricula to embrace public health principles and knowledge that are fundamental to the development of population health.
The revised and updated public health specialty training curriculum is in the process of being approved by the two public health regulators (GMC and UKPHR).
Cap on medical student places
The Faculty of Public Health has previously supported the call from the Academy of Medical Royal Colleges for a substantial expansion in medical school places to ensure a modest oversupply of doctors. Staff involved in training the future workforce must be given sufficient time and support to manage the additional work created by this expansion. As noted above, increases in medical student numbers must also lead to more resourcing for corresponding increases in the number of foundation programme places and specialty training posts.
Factors driving staff attrition
The principal factor driving people to leave the NHS, social care and wider health workforce is the challenging workload caused by increasing staff shortages, workload pressure and under-resourcing of services. These conditions were present before the COVID-19 pandemic and the pressures have intensified in the last two years. This has been prolonged and acutely felt in public health, which had faced several years of real-term budget cuts since the transfer of public health to local authorities in 2013. It remains to be seen how the recent restructuring of the public health system affects attrition and retention.
The total number of individuals registered as specialists (working at consultant level) in public health (GMC, UKPHR and GDC) is around 1,780. The COVID-19 pandemic has brought some specialists back into the workforce on a temporary basis. There needs to be better understanding of what would encourage more registered and potentially re-registered trained public health professionals back into the workforce, in order to meet the shortfall in capacity until any additional higher specialist training places mature.
Senior careers are in public health tend to be relatively short, as it is often a ‘late-entry’ specialty with trainees starting their training in their early to mid-30s and completing training in their late 30s. Therefore, there is an average career length of little over 20 years (~40 to ~60). Increasing retention at 60 could therefore have a significant impact on numbers.
Public health staff are also often employed in ‘administrative structures’ such as health authorities, boards and ALBs, rather than trusts and GP practices. They are therefore subject to regular re-organisations which tends to lead to attrition of senior staff (as has happened recently with the dissolution of PHE) and this pushes down the typical retirement age. While it is unrealistic to expect governments not to re-organise public sector structures, there needs to be a focus each time on retaining key clinical staff such as public health consultants and practitioners.
The Faculty’s own analysis has shown that the public health workforce is robust and resilient but this cannot be taken for granted. Employers have a critical role in improving the day-to-day experiences of staff to make sure they feel valued and respected in the workplace. The culture also comes from the top, however, and the government and national organisations have important parts to play in creating a culture in which all staff feel their hard work is recognised and appreciated.
The COVID-19 pandemic has also exposed a huge gap in workforce intelligence which hampered redeployment and must be urgently corrected. We need to be able to optimise what resources we have and plan future needs so the right staff can be recruited and trained. We must attract and keep the best people in public health careers. We must also know the capacity and capability of the whole system to be able to rapidly deploy people in exceptional circumstances such as a pandemic.
There are a number of measures which can help to increase the resilience of the public health workforce:
Looking at the wider public health workforce, there needs to be much better recognition of the role of public health practitioners as an essential cohort of public health professionals operating below the level of consultants/specialists. This workforce is fundamental to the delivery of public health in the UK and is a skilled workforce. Better and more formal ‘professionalisation’ of this workforce, including training and accreditation, would support retention efforts.
The Academy of Medical Royal Colleges has also previously highlighted a number of measures that might support short term workforce solutions.
Issues with recruitment to specific roles and geographical locations
The issue of workforce shortages and the gap between supply and demand is particularly acute in some specialties, such as psychiatry, geriatric medicine, general practice and social care is well recognised. There are also workforce shortages in many geographic regions of the greatest need and staff distribution is a crucial component of workforce planning. Health inequalities are most acutely felt in remote and rural, coastal and inner-city areas which experience the highest levels of deprivation and many of these can struggle to attract and retain doctors. In recent years there have been welcome efforts to tackle these problems, from HEE’s work on the geographic distribution of training posts to local initiatives to recruit and retain staff in remote and rural locations. More work is needed to incentivise living and working in under-resourced areas, however. These may be unpopular with staff due to a variety of reasons beyond health and care employment, but which are pertinent to experiences of family and personal life (for example, housing, education, public transport, amenities).
The People Plan and recruitment, training, and retention
The Faculty of Public Health has welcomed previous versions of the NHS People Plan (and similar initiatives in the devolved nations). It provides a helpful framework for tackling many workforce issues and presents an admirable vision for treating and valuing healthcare staff.
Since the publication of the last People Plan in July 2020 there have been some developments in discussions about workforce planning, including HEE’s Long-Term Strategic Framework 15 review, and debates during the reading of the Health and Care Bill about the Health Secretary’s potential role in and responsibility for workforce projections. The merger of NHS England and HEE presents an opportunity to unify discussions about workforce, service and financial planning but there is also a risk that HEE’s ability to provide an independent voice on workforce issues may be lost.
Across health and social care, there is widespread support among stakeholders for the Health and Care Bill to be amended to strengthen workforce planning arrangements in the longer term. The proposed amendment would require the Health Secretary to publish independent assessments of current and future workforce numbers every two years. This would increase transparency and accountability on whether we are training enough staff to meet future demand. Workforce planning must not focus solely on current vacancies and staff numbers but should consider a range of factors encompassing - but not limited to – the increasing demand for flexible training and working; changing patient needs (for example, health inequalities and an ageing population); and new models of care and ways of working (including increased use of technology and the multi-professional team).
Contractual and employment models
While contractual models and employment conditions fall outside the remit of the Faculty, we recognise that workplace cultures and practices are important to attracting, training and retaining staff. Improved opportunities for flexible training and working are paramount. Workplans and contracts must also provide sufficient time to allow for education and training, supervision, research, CPD and other professional duties – as well as clinical responsibilities – to enable public health specialists to have meaningful, rewarding and varied workloads.
One factor that does need to be addressed in public health is the disparity in pay, primarily between public health specialists working in local government (on LG pay grades) and those working for the NHS, DHSC or national public health bodies (usually on NHS AfC pay scales). This is a longstanding concern and has led to significant inequities between similarly qualified and experienced specialists working across the public health family.
Additionally, there should be formal recognition and protection of the title ‘consultant’ within all institutions with responsibility for delivering statutory public health responsibilities, to mirror the protection and status afforded to colleagues working in similar levels and grades within the NHS.
Integrated Care Systems (ICSs)
The Faculty supports the direction of travel towards greater integration across care systems. We welcome the development of ICSs and greater integration both within the NHS and between the NHS and local government, which present vital opportunities to drive improvements in public health outcomes and health inequalities. We expect public health experts to play a significant role in these partnerships, specifically including local authority directors of public health and their teams who can support, inform and guide approaches to population health management and improvement. Public health leaders are able to identify and address local population health needs, but the ICBs must be given the appropriate levers to make high-level policy changes.