The BMA is committed to supporting and promoting public health as a medical specialty with multidisciplinary specialists, maintaining a dedicated route of entry for medically qualified professionals.
The specialist public health workforce leads and delivers a range of work to protect and improve the health of populations at local, regional, national and global level and to tackle inequalities in health, including those driven by poverty, racism and discrimination. (1-2)
Alongside health improvement and health protection, the third key domain of public health is healthcare public health. This involves using public health skills and knowledge to ensure that healthcare services are safe, patient-focused, generate good health outcomes and make the most effective use of the available resources. (3)
All public health specialists complete a period of formal, accredited specialty training in public health following the same curriculum and leading to specialty registration with the General Medical Council, the General Dental Council or the UK Public Health Register. (4)
This combination of a rigorous specialty training programme, professional regulation and the requirement to undertake ongoing continuous professional development is the necessary requirement for ensuring that the provision of specialist public health advice is safe, effective and held to account. Despite their importance, the UK has a large shortfall of these specialist roles. (5)
Following the establishment of integrated care systems in England and their statutory duty to improve outcomes in population health and health inequalities, there has been an emergence of new non-specialist, senior roles within ICBs (integrated care boards), such as ‘directors of population health’ or ‘health inequality leads’. The King’s Fund report Public health and population health: leading together explores these roles and their interactions with existing specialist public health roles. (6)
Ultimately, despite not clearly setting out how population health differs from public health, and with concerns raised about ensuring the competence and accountability of those providing advice on the health of the public, the report sets out the potential of a growing population health/health inequalities workforce, undertaking healthcare public health, without accredited public health specialists. While the recent model ICB blueprint rightly outlines a range of functions that should be led by public health consultants, the cuts to ICB budgets alongside the abolition of NHS England risk further undermining public health expertise within the NHS.
The COVID-19 pandemic and the infected blood inquiry report (7) made clear the benefits of having public health specialists embedded in local populations who can bring epidemiology expertise, system leadership, healthcare system knowledge and multi-agency working experience.
The use of non-specialists in new population health roles not only raises questions on their competence to undertake specialist public health activities but also risks the fragmentation of public health knowledge and experience within the system. Titles such as ‘director of population health’ are unhelpful and potentially misleading, unless exclusively reserved for public health specialists, who have traditionally been associated with this activity. If organisations continue to use these titles, then there should be explicit and equivalent public health specialist roles created alongside them, such as ‘chief public health officer’ or ‘director of public health’.
We acknowledge that improving the public’s health requires a breadth of professions and is not something public health specialists can do alone. However, it is also important that specialist roles are undertaken only by appropriately experienced and properly accredited individuals, who have the necessary competencies and experience to safely and effectively undertake the role.
‘Population health’ and ‘health inequalities’ emerging as domains in parallel to public health risks, at best, confusion and the duplication of efforts, at worst, less effective decision-making leading to poorer care and outcomes for the public. Ultimately, we need more public health specialists, including more medically qualified specialists.
The new UK Government has set out a bold vision for health including ambitious plans to halve the gap in healthy life expectancy between the richest and poorest regions, ending the transmission of HIV by 2030, and transforming the NHS into a service that focuses on preventing sickness and not just treating it. As Lord Darzi highlighted in his investigation, 'there is extraordinary power in getting public health right. We can reduce premature mortality, reduce social disparities, and reduce the absolute time in ill health'. But achieving these plans requires just that: getting public health right.
Individuals rightly expect that their NHS clinical care is led by appropriately experienced and registered medical specialists fully trained in their specialty of practice. The population as a whole deserves the same right to public health advice and practice led by properly registered public health specialists equipped with the knowledge and skills necessary to work across all three domains of practice.
Given all of this and our existing policies, it is the position of the BMA public health medicine committee and public health medicine registrars subcommittee that:
1) The number of public health specialists should be sustainably increased to 30 whole-time equivalent specialists per million population in the UK by increasing the specialty training intake to 120-150 individuals per year (inclusive of GP/public health dual training posts), with an even mix of professional backgrounds. There should be consultant post expansion aligned with this
2) The current concept of population health represents only a subset of the knowledge, skills and techniques that comprise specialist public health practice; and poorly defined ‘Population health’ roles without specialist training cannot ensure safe, effective and accountable practice.
3) Senior leadership for and advice on the health of populations and health inequalities must always be delivered or overseen by appropriately experienced public health specialists registered with either the GMC, GDC or UKPHR. This should include having a registered public health specialist on each integrated care board in England as per existing BMA policy (8).
4) There needs to be a recommitment to healthcare public health in specialty training across the UK, including the use of mandatory training placements in the NHS/HSCNI, with a particular need for placements and supervisors in all English integrated care boards, as this is currently not the case (9).
Footnotes
1) Faculty of Public Health ‘What is Public Health?’
2) Royal Society of Public Health ‘Rethinking the public health workforce’
3) Faculty of Public Health ‘Key areas of work in public health’
4) Public health specialists may also register through submission of a portfolio of work in lieu of specialty training
5) Faculty of Public Health ‘The public health workforce’
6) The King’s Fund ‘A vision for population health: towards a healthier future’
7) https://www.infectedbloodinquiry.org.uk
8) BMA policy book
9) Approved GMC training locations as listed on 14th October 2024.