- Dr Veena C Rodrigues
- Clinical Senior Lecturer and Head of Year 3 MBBS
- Norwich Medical School
I have only recently made the transition from ‘lurker’ to ‘active user’ on Twitter. Recently, I found myself following a talk by Dr Jeremy Farrar, Director of the Wellcome Trust via live-tweets from a London meeting for clinician scientists in training (Nurturing the next generation of medical researchers). Dr Farrar cited three challenges to UK science:
(1) bringing young people into science and finding ways to keep them there;
(2) addressing the divide between the clinical and research communities and encouraging them to work together; and
(3) tackling the damaging separation of PH from clinical service delivery.
As a clinical academic in public health medicine (PHM), the last two points resonated strongly with me. I have held joint academic-service roles in PHM right through specialty training and into my Consultant role. Core to such a role was the need to bridge the gap between academia and the service setting, not only to work efficiently and flexibly across the two, but also to ensure that the skill set developed and enhanced in one role was utilised clearly to benefit the other.
In my case, my clinical academic skills of research methodology, critical appraisal and evidence-based medicine were ideally suited to needs assessments, priority-setting, service specification and clinical policy development, clinical engagement with provider Trusts, evaluation of cost-effectiveness of services at my Primary Care Trust (NHS) employment.
Similarly, my local service provision experiences enabled me to pull out of my tool box examples and anecdotes to liven up any teaching/ training sessions in my educator role. You must remember we are talking about integrating PHM into undergraduate medical education, which is a daunting challenge: ask any UK medical school public health educator! I also had first-hand knowledge and experience of the service setting to inform the writing of research proposals to apply for grant funding, etc.
It is easy to assume that clinicians and scientists would work together naturally but at a time when healthcare provider organisations face increasing scrutiny in terms of meeting targets for service provision, service priorities often trump teaching and research. Addressing this widening divide in the face of conflicting organisational priorities is likely to be challenging but crucial for nurturing the next generation of medical researchers.
The NHS reorganisation following the Health and Social Care Act 2012 resulted in public health departments being moved out of the NHS and into local authorities (LAs). While the advantage of joint working between public health and local authorities to improve and protect the health of the population cannot be underestimated, the benefit of this conscious coupling to local clinical service delivery is much harder to visualise.
Relationships that had been built after years of committed and painstaking nurturing of the clinician/provider-commissioner relationships through clinical dialogue facilitated or led by PH specialists were suddenly stripped away resulting in another layer of bureaucracy (albeit with a ‘core offer’) diluting the relationships between the two organisations (1).
The public health emphasis on health needs assessment, priority setting, fairness, equity, appropriate and effective commissioning in the face of budget restraints. Monitoring and evaluation of services is likely to vary in breadth and depth across the country. It is dependent on whether local authorities have kept local structures in place and the level of commitment of the local authorities to health/ clinical service delivery. A postcode lottery?
A recent publication confirmed that local authorities across England are diverting ring-fenced public health funds and scaling back staffing to plug funding shortfalls caused by government budget cuts (2). It has also been reported that despite a mandatory requirement for Health and Wellbeing Boards to provide public health advice to local clinical commissioning groups (CCGs), sufficient public health input into NHS services to is lacking. This is at a time when CCGs are struggling to balance quality improvement and financial equilibrium (3).
Following the NHS reorganisation in 2013, public health clinical academics and researchers who had honorary clinical contracts with local NHS organisations (PCTs) lost their clinical (NHS) links when the hosting of these contracts moved to PH England, a new non-NHS organisation, still struggling to establish its mark (4). This resulted in the formal separation of a link between academic and service public health that had facilitated joint working, making it nearly impossible to influence the work of local CCGs without getting embroiled in convoluted management links and processes.
So, you might well ask: where does this leave healthcare public health? It is difficult to predict the future but if the government is listening, please could you strengthen the requirement for local authorities to have an appropriately skilled public health workforce to provide adequate input into local NHS services? Supporting the work of CCGs towards effective and cost effective local health services commissioning is after all a key part of the standards for delivery of public health within local authorities! (5)
And pretty please, could you also restore public health academic-service links especially for clinical academics? I am fast running out of new examples to give my medical students to emphasize the clinical relevance of the public health curriculum.
- Department of Health. Guidance on the healthcare public health advice (core offer).
- Iacobucci G. Raiding the public health budget. BMJ 2014; 348: g2274.
- Furber A. Public Health: what has worked, what hasn’t, and what’s next? The Guardian, 5th April 2014.
- UK Parliamentary Health Committee. Public Health England: Eight report of session 2013-14. London: The Stationery Office Ltd, 2014.
- FPH. Standards for Public Health, 2013.