Written evidence submitted by ADPH (RTR0136)

The Association of Directors of Public Health (ADPH) is the membership body for Directors of Public Health (DsPH) in the UK. It represents the professional views of all DsPH as the local leaders for the nation’s health. 

The Association has a heritage dating back over 160 years and is a collaborative organisation, working in partnership with others to strengthen the voice for public health. It seeks to improve and protect the health of the population through collating and presenting the views of DsPH; advising on public health policy and legislation at a local, regional, national and international level; facilitating a support network for DsPH; and providing opportunities for DsPH to develop professional practice.

Key Recommendations

• Strengthen the specialist pipeline, by increasing training numbers and supporting portfolio applications
• Provide sufficient resource for DsPH to employ public health analysts locally
• Ensure there is sufficient health protection expertise in every local authority
• Improve workforce intelligence to support workforce planning and mobility
• Remove the barriers to workforce mobility, enabling portability of continuity of service and alignment of terms and conditions
• Encourage secondments (national and regional to local and local to national and regional) as part of PH workforce development 

Introduction

The Covid-19 pandemic has shone a spotlight on Public Health and the role of local public health teams led by the work of Public Health Specialists. The Public Health Specialist workforce is numerically small, compared with other parts of the healthcare workforce such as nurses, but it is critical. It not only provides key leaders such as DsPH but also the technical skills and knowledge in all domains of public health.

There is currently a crisis in public health capacity at a senior level, with a critical shortage of public health specialists which needs to be dealt with urgently. Without sustainable investment in the public health workforce, we will continue to be vulnerable to future pandemics and other health threats, will be unable to reduce inequalities effectively, and unable to prevent the burden of chronic ill health overwhelming the NHS.

The ADPH welcomes the opportunity to provide written evidence to Health and Social Care Committee. The submission below sets out ADPH’s views and recommendations for strengthening the public health workforce and addressing issues around recruitment, retention and training.

Retention & Recruitment Issues

• The public health system pre-covid was expanding but was constrained by the lack of trained specialists, as evidenced by 80 (18%) vacant and unfilled posts in Local Authorities (LAs). There has subsequently been an increase in posts to support the Covid-19 response. However, vacancy rates have continued to increase due to the limited number of specialists. The difficulties with recruitment are also increasing pressure on the existing workforce, which is already experiencing burnout and high levels of sickness and absences.
• In addition, there is likely to be an increase in specialists leaving public health as a result of demography, system reform and Covid-19 exacerbating the shortfall. ADPH Membership statistics show that between September 2020 and September 2021, 36 out of 143 (25%) DsPH left their role (ie to retire or to take up another role in/outside the Council).
• While the issues around capacity persist, the demand for public health specialists continues to grow. There is now an increasing demand for public health specialists in UKHSA and the NHS, in particular, within the Integrated Care Systems (ICS).

Key Recommendations

1. Strengthen the specialist pipeline, by increasing training numbers and supporting portfolio applications

• To strengthen the specialist pipeline and meet the increasing demand for public health specialists, there must be an increase in the annual intake to the Public Health Specialty training programme. ADPH is supporting calls for at least 30 additional specialist training posts per year.
• There should also be consideration for how to strengthen the leadership pipeline (ie by developing system leadership skills at all levels) and retain the expertise in the system (ie by ensuring those who returned can stay on the register and enabling recent retirees to take on appropriate roles to strengthen the system).

2. Provide sufficient resource for DsPH to employ public health analysts locally

• The system needs to foster the development of a strong and sustainable analyst workforce, in terms of both capacity and skills. Investment is urgently needed to enable DsPH to employ public health analysts and address the cuts which have stripped LA public health analytical capacity.
• A specific set of skills is needed, which differs from the other analytic functions within LAs (ie business analytics, performance analytics). Experienced and appropriately trained public health analysts with a grounding in epidemiology and wider public health are vital to ensure the availability of wider local intelligence to inform decision making.  

3. Ensure there is sufficient health protection expertise in every local authority

• Public health in local government is at the heart of local work to tackle the virus. It provides the leadership, expertise, partnership-working, and access to local resources that are fundamental to strong place-based coordination of health protection. It is critical therefore to ensure there is sufficient health protection expertise in every LA.
• This, however, should be separate to the role of the Consultant in Communicable Disease Control (CCDC). This expertise should be provided by public health professionals within the LA PH team who focus specifically on health protection issues (alongside their wider PH responsibilities), work closely with the CCDC, and are involved in all discussions locally around health protection.
• This capacity, although linked, is separate to the surge capacity required to manage outbreaks emergencies. Surge capacity must build on local systems and should not be seen as a substitute for sustainable, long-term investment in local public health teams.  
• With health protection function being separated from other public health functions, there is a risk of fragmentation of the workforce, loss of broader skills and the development of silos with narrow career tracks.

4. Improve workforce intelligence to support workforce planning and mobility

• There must be a more systematic approach to the development of core and specialised skills and surveillance of what future skills will be needed.
• The complexity of multiple employers and roles has made workforce planning difficult, and Covid-19 has emphasised the need for this issue to be resolved to ensure resilience and flexibility of the public health system. A viable national dataset on the public health workforce (including occupational definitions) must be developed and implemented to enable proper workforce planning.
• An effective data-driven system should be able to:

• predict future capacity and capability requirements, identify and address gaps, and anticipate and avert bottlenecks
• optimise existing resource to ensure the right staff are in the right place at the right time
• plan future need so that the right staff can be recruited and trained
• ensure we understand career pathways, bottlenecks and opportunities, to attract and keep the best people in public health careers
• knowing the capacity and capability of the whole system in order to be able to rapidly deploy people in exceptional circumstances such as a pandemic.

5. Remove the barriers to workforce mobility, enabling portability of continuity of service and alignment of terms and conditions

• Enabling and supporting public health professionals to take up posts in different sectors is critical to growing and maintaining a cadre of appropriately qualified and experienced people.
• It is essential that during a public health career that staff can move between employers. This is to give breadth of experience, particularly in leadership roles; to ensure staff can be moved between employers if functions are moved between sectors and to give resilience to the system and to give resilience to the system if there is need for rapid redeployment of staff in an emergency.
• The core issues that need to be addressed include the lack of a statutory basis for protecting continuity of service across sectors, particularly in respect of redundancy; differences in pay scales and grade requirements between sectors; and differences in organisational culture between sectors.
• To overcome existing legacy issues around mobility requires both a system-wide culture that movement between roles and sectors is positive and expected, and the removal of bureaucratic barriers to changing employer. The most important of these is the recognition of continuity of service. The convergence of all terms and conditions, while important, is a much longer-term endeavour.
• There is also a need to ensure we have common approaches across professions, such as a digital Public Health Skills and Knowledge Framework (PHSKF) to facilitate mobility.

6. Ensure Public Health Specialty training programmes placements continue to be provided across the whole system

• There is a risk, with the restructuring of the public health system, that the workforce becomes fragmented. While the restructure has led to the establishment of organisations focused on specific domains (eg health protection, health improvement), public health specialists will need to continue to operate across all domains.
• As a result of this risk, there is a particular need to ensure that public health speciality training programme placements continue to be provided across the whole system, including the NHS, ICSs, UKHSA and OHID.

7. Encourage secondments (national and regional to local and local to national and regional) as part of PH workforce development 

• Secondments (ie national and regional to local; local to national and regional) should be encouraged and be part of workforce development. This will help to mobilise expertise across the system and support the retention of staff within the system.

Association of Directors of Public Health

Jan 2022