Mind the gap: developing the PH workforce in the North East and Yorkshire and Humber regions: a scoping stakeholder study

OBJECTIVES: The aim of this study was to identify key issues around public health workforce development in the North of England, considering the gap between need and current capacity and the training requirements to deliver the public health and health improvement agenda. METHODS: Interviews were carried out with over 50 professionals in a variety of stakeholder organizations, seeking their views on priorities for workforce development and perceived opportunities and threats to the development of a good public health workforce. RESULTS: There was general recognition of a gap between current public health resources and what is needed to meet the public health agenda. Priorities included both increasing capacity at the specialist end of public health and raising general public health awareness at all levels of public organizations. Major barriers identified to meeting these needs included organizational difficulties, professional barriers and shortages of appropriate training and resources. Opportunities were seen to be presented by the increased amount of joint working and by national and local raising of awareness of public health issues. CONCLUSIONS: Across the health sector, local authorities, training organizations and voluntary sectors, similar issues and expectations were mentioned at both specialist and practitioner levels. However, it has not been possible in North East England to translate this finding into practical programmes in the absence of nationally identified resources to address the issue.     

Developing public health nursing: barriers perceived by community nurses

OBJECTIVES: To understand the key issues for field nursing in developing their public health role within five primary care trusts (PCTs) in Merseyside, in the North West of England. DESIGN: Qualitative study. METHODS: Fourteen school nurses and 30 health visitors participated in 11 focus groups consisting of others from their profession working within the same PCT, and 24 practitioners responded to a questionnaire. RESULTS: The findings suggest that there are a number of shared obstacles that need to be overcome before the public health approach can be fully developed within community nursing. These include: the need for facilitation to deal with organisational change, lack of clarity around the public health role, inadequate administrative support, general practitioner attachment problems, poor interprofessional partnerships, competing priorities and resistance to change. CONCLUSIONS: The development of public health nursing in England envisaged in current government policy will not occur in full unless the kind of issues identified in this study are adequately addressed. This will require participative, interprofessional approaches to redesigning services by all relevant public health practitioners.     

Intelligent policy making? Key actors' perspectives on the development and implementation of an early years' initiative in Scotland's public health arena

Increased political enthusiasm for evidence-based policy and action has re-ignited interest in the use of evidence within political and practitioner networks. Theories of evidence-based policy making and practice are being re-considered in an attempt to better understand the processes through which knowledge translation occurs. Understanding how policy develops, and practice results, has the potential to facilitate effective evidence use. Further knowledge of the factors which shape healthcare delivery and their influence in different contexts is needed.This paper explores the processes involved in the development of a complex intervention in Scotland's National Health Service (NHS). It uses a national oral health programme for children (Childsmile) as a case study, drawing upon key actors' perceptions of the influence of different drivers (research evidence, practitioner knowledge and values, policy, and political and local context) to programme development. Framework analysis is used to analyse stakeholder accounts from in-depth interviews. Documentary review is also undertaken.Findings suggest that Childsmile can be described as an ‘evidence-informed’ intervention, blending available research evidence with knowledge from practitioner experience and continual learning through evaluation, to plan delivery. The importance of context was underscored, in terms of the need to align with prevailing political ideology and in the facilitative strength of networks within the relatively small public health community in Scotland. Respondents' perceptions support several existing theoretical models of translation, however no single theory offered a comprehensive framework covering all aspects of the complex processes reported. Childsmile's use of best available evidence and on-going contribution to knowledge suggest that the programme is an example of intelligent policy making with international relevance.     

Specialist public health capacity in England: working in the new primary care organizations

OBJECTIVES: To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service. STUDY DESIGN: Questionnaire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England. RESULTS: Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably "developing quality and risk management" and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized. CONCLUSIONS: Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams.     

Developing a speciality: regearing the specialist public health workforce

OBJECTIVES: To identify issues surrounding the future training needs of the specialist public health workforce following the most recent restructuring of the National Health Service (NHS) in England. METHODS: All directors of public health (DsPH) based in strategic health authorities and nine senior staff working in public health at the regional level were invited to participate in a semi-structured telephone interview. RESULTS: Twenty-six people were interviewed. Many interviewees expressed concern that because consultants and specialists in public health will be working in much smaller teams than hitherto, they will have to generalize their skills to cover a much wider range of functions (including board-level duties). This may result in a loss of specialist expertise. Successful public health practice in the new structures will require new ways of interorganizational working that will add an administrative burden to specialists in public health. Also, the creation of a board-level post in each primary care trust (PCT) has resulted in more time spent on corporate responsibilities and less on public health for DsPH, who are often the only fully trained specialist in public health in their PCT. Furthermore, interviewees expressed their anxiety about the lack of diversity in the posts available to specialists in public health and particularly to those newly completing their specialist training. Generally, interviewees felt that traditional public health roles and responsibilities were being eclipsed by corporate and managerial ones. Professional development activities were being carried out, but in a rather ad-hoc fashion. Interviewees were hopeful that public health networks would lead professional development initiatives once they were more established. CONCLUSIONS: It is important that excellence in public health is maintained through a set of accreditable standards, whilst corporate skills, essential to successful public health practice in the new UK NHS, are developed among specialists in public health.     

What sort of networks are public health networks?

BACKGROUND: Re-organization of the English National Health Service (NHS) has fragmented the public health workforce, relocating teams from about 100 health authorities into over 300 primary care trusts (PCTs). The UK Government announced the setting up of public health networks (PHNs) as a solution to the problems created by fragmentation. METHODS: Fifty-seven semi-structured telephone interviews were held with key players in PHNs in all strategic health authority areas in England in early 2003. RESULTS: PHNs appeared to be primarily networks of public health professionals rather than of organizations. Informants were unsure about PCTs' commitment to public health. Predominantly, members were those NHS personnel with a clear and explicit public health role. Most PHNs intended to include others later (e.g. health visitors, environmental health officers), although a few thought that inclusivity was essential from the start. Continuing professional development for public health personnel dominated the work being undertaken, with some collaborative work across PCTs. PHNs were seen as a compulsory reconfiguration of existing networks, and informants doubted that they were appropriate for the many levels of networking that public health work requires. CONCLUSION: The formation of PHNs does not appear to have been either necessary or sufficient. However, the public health community has a well-established tradition of networking, and therefore has the skills to use PHNs advantageously.     

Engaging Local Public Health System Partnerships to Educate the Future Public Health Workforce

The Institute of Medicine concluded that keeping the public healthy required a well-educated public health workforce, thus leading to its recommendation that “all undergraduates should have access to education in public health” [2]. In response to this call, the authors examined the current practice, feasibility, and value in strengthening (or building) a functional collaborative model between academic institutions and practitioners from local health departments to educate tomorrow’s public health workforce. Local and regional health departments in New England were surveyed to: (1) establish a baseline of existing working relationships between them and nearby academic institutions; (2) examine the barriers that inhibit the development of collaborations with academic partners; (3) assess how they jointly promote public health workforce development; and (4) analyze which essential public health services their partnership addresses. Despite the lack of financial resources often cited for the absence of academic-local health department collaborations, some New England states reported that their academic institution and local public health department partnerships were valued and productive. The authors discuss how effective academic-community collaborations have the potential to facilitate a broad-based appreciation of public health among students via a wide array of public health curricula and applied experiential learning opportunities in public health settings. The authors propose a model for how to combine basic public health lessons with practical experience and leadership offered by local health departments, in order to foster a real understanding of public health, its importance, practice, and relevance in today’s society from a public health workforce perspective.     

Understanding the Organization of Public Health Delivery Systems: An Empirical Typology

Context: Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.
Methods: This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.
Findings: Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.
Conclusions: Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.     

The development and application of a public health skills assessment tool for use in primary care organisations

The public health skills assessment instrument described in this paper was developed to provide a key group of UK primary care practitioners (health visitors) with a personal development planning tool and researchers with a robust assessment tool for use in evaluations of innovative local public health programmes. Pilot testing with over 120 practitioners has provided evidence of its reliability and validity as a research instrument as well as yielding useful insights for public health educators, practitioners and policy-makers. Factor analysis confirms 10 core competency domains for health visitors which are remarkably consistent with those recently identified for UK public health specialists, interpreted here as grounds for optimism in the greater co-ordination between strategic and front-line approaches to public health work in primary care. However, results also confirm earlier findings indicating low levels of skill amongst health visitors in tackling health inequalities through interventions such as community development, raising questions about their capability to work effectively in new roles proposed by the Department of Health.     

Public health leadership in primary care practice in England: Everybody's business?

This article analyses the concept of leadership in relation to the UK Government's current approach to ‘modernizing’ the NHS in England. Focusing on public health in primary care, the authors consider current developments in the public health workforce, in particular attempts to differentiate between public health ‘specialists’ and ‘practitioners’ by different levels of leadership function. It looks at leadership in policy, theory and practice, and draws attention to a number of key challenges along the leadership path. The concept of ‘leadership skills’ as a taught competence is questioned, and Shelton and Darling's (2001 Shelton, CK and Darling, JR. 2001. The quantum skills model in management: a new paradigm to enhance effective leadership. Leadership and Organisation Development Journal, 22(6): 264–273.  [Google Scholar]) ‘quantum skills’ model of leadership is provided to suggest new ways in which public health leadership in a primary care context might be approached. Whilst this article focuses on public health and primary care in England, the complexity of primary care settings and public health delivery in other international contexts extends its relevance to non-UK settings.