Douglas Noble and Felix Greaves: stealth attack on public health

Last month we drew attention to three critical pieces of data that painted a picture of the piece by piece dismantling of the public health specialist workforce. Consultant appointment processes have dropped considerably in the last three years, registrars at end of training are failing to get substantive full time consultant posts, and academic public health seems to be declining. 

What’s really behind this is not clear, but findings in an important paper in this month’s Journal of Public Health continue to show this is a real stealth attack on the public health specialist workforce, and not just disparate pieces of unconnected information. Harrell and colleagues present a scholarly piece of research directly comparing recruitment in public health to that of hospital consultants. 

In their introduction they recall that the current public health specialist workforce was already expecting an exodus, 15% of director of public health posts were vacant, and that in past reorganisations early retirement occured in 1 in 5 practitioners. 

This existing gap in the public health workforce should have been a major priority to address, especially given the extraordinary policy objectives for public health in the Conservative Green Paper: “A Healthier Nation” in January 2010. 

In fact, this Green Paper is so long forgotten it’s worth remembering one of its most memorable quotes:

“Our decentralised approach to NHS reform will completely redefine the role of the Department of Health. We will enshrine this change: it will be renamed the Department of Public Health and its role will be focused much more strongly on the prevention of disease, rather than just its cure.” 

Crumbs.  Talk about visionary. What on earth happened? 

With this cauldron of lack of capacity in public health prior to the general election in May 2010, and the ambitions of the incoming government, Harrell et al.’s research is all the more relevant.  Given this policy agenda, one would expect to find a significant increase in the public health workforce to address a deficit, and, if anything, evidence of an extra recruitment drive. The exact opposite has occurred. 

Over three years Harrell and colleagues scrutinised the archives of BMJ Careers. Hospital and public health consultant posts both showed a decrease in advertisements, but this trend was more pronounced in public health. The comparison was stark. 3.3 public health jobs were advertised for every 100 hospital jobs for consultant level positions between October 2008 and November 2009. From December 2009 to April 2011 this figure fell to 0.9 (p<0.005). 

One wonders if the significance of these data has been realised in the corridors of power. Anecdotally, in some places, public health consultant positions are not being recruited and as staff leave, posts are not backfilled. Clinical Commissioning Groups may rely on private sector consultants to provide public health support. 

If the government is serious about public health, it needs to be serious about having the right people to deliver it. What comes next is anyone’s guess. 

Douglas Noble is a public health doctor and university lecturer in the East London.  You can follow him on twitter @douglasnobleMD

Felix Greaves is a public health registrar and research fellow at Imperial College London.  You can follow him on twitter @felixgreaves