The public health workforce: overdue for attention

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There were times in the early stages of the Covid-19 pandemic when the decision-makers in Whitehall (including in the Department of Health and Social Care) gave the impression that they did not know what or who their directors of public health (DsPH) were, or how to use them. The 134 DsPH, based in local authorities across the country, were left battling Covid-19 while essential information failed to reach them from the centre.

How different now. On Covid-19, more information and control was shared; more money was provided, primarily through the Covid Outbreak Management Fund; and a number gained in profile in the national media. Many more gained local profile, proving their worth across a range of local stakeholders.

But success brings its own challenges, and the asks on the public health community in general and on DsPH in particular are growing. There is the public health 'backlog' to deal with as many local public health services were put on hold during covid. The lockdowns and economic damage have also changed the health of the population and exacerbated inequalities. This needs understanding and analysis.

Meanwhile the government is pushing ahead with legislation that will try to cement closer working between all the parts of the NHS, local government and other stakeholders in the health and care sector (such as the voluntary, community and social enterprise).

The goal here is not only to provide better integrated services to patients and users but to create the coalition that can really focus on improving population health and reducing inequalities.

The goal here is not only to provide better integrated services to patients and users but to create the coalition that can really focus on improving population health and reducing inequalities. Much of this second agenda will naturally look to the DsPH and their teams to provide the expertise and understanding that is a necessary (but not sufficient) condition for change.

If this wasn't enough, Public Health England has been abolished and the two successor organisations are still taking shape, creating uncertainty within the public health community itself, but also opportunities to design a better relationship.

From this perspective the future role for DsPH looks promising. Yet - just as with the health workforce - Covid-19 has made enormous demands on the DsPH and their (usually small) teams and many are exhausted. As findings from our joint research with The Health Foundation on the role and experiences of DsPHs during the pandemic has found, while there is potential for them to play a central role in the emerging structures, there is also a risk of competition for these scarce resources. This may be exacerbated as Covid-19 funding dries up, some of which has gone towards funding larger temporary teams.

This is not a challenge limited to the DsPH. Other key elements of the public health workforce are also in short supply: more than half of local authorities report unfilled vacancies in their environmental health teams lasting six months or more and a third report statutory responsibilities being at risk due to resource issues. There are other resources to call on as a small number of acute trusts also employ public health consultants. Beyond these formal public health staff sits a much larger workforce that also does (or could) engage in providing public health advice and supporting efforts to tackle health inequalities, including allied health professionals, pharmacists and professions outside of health care like the fire service.

We, like many other organisations, have been calling for a funded workforce plan for health and care that tackles both the short-term staff shortages we already see, as well as the ones that are storing up for the future. But the need for such a plan is just as great for the public health workforce to confront the existing shortages and then deliver on the real opportunities the future could hold for public health staff if only we had enough of them. Public Health England got part of the way in its 'Fit for the Future' but this fell short of quantifying the sheer lack of capacity and setting out a strategy to fill it, even if it contained much else that was useful.

Any real plan must confront the shortages and how to fill them and must do so against a backdrop of a lack of national data.

Any real plan must confront the shortages and how to fill them and must do so against a backdrop of a lack of national data. It will need to take a system approach when thinking about demand and supply for three reasons. First, formal public health roles exist in both local government and in the NHS and a coherent and attractive career path is needed across both. Second, the wider workforce that could engage with public health goes beyond even the health and care sector itself. And third, given the core role the DsPH will play in the future it will also need to think about how it supports and resources them to influence up, out and around, the emerging reformed system.

This is a lot to take on, but the opportunities offered by a new focus on population health and the new system working enshrined in the Health and Care Bill are the prize that makes it so important.


Tim Wilson

public health/mental health,
Comment date
01 September 2021

Equity a moral issue it's about social justice, human rights, fairness, having the prerequisites of health for all. Inequities are the causes of the causes they cause inequalities in health.
According to the Kings Fund 1981 the social political economic and broad environmental (SEPE) determinants of health are the causation of 80 -90% of health or ill health, this is still the case in 2021 – health services only account for 10 % of health – this should have profound resource allocation and research implications. Need to adopt an upstream public and social health approach, promote health and a quality of life? Need to adopt a social model of health, stop individualising and medicalising political social ideological and equity issues?
An up stream approach is undertaken by environmental health practitioners , who should be called public and environmental health practitioners - why are they so invisible so underused? - why has public health been deliberately run down (resource and people wise in the last 40 neo-liberal years?) - yes health is about politics economics and ideologies - the situation needs to urgently change and must e.g. climate change - choose public health people not by inappropriate psychometric tests but on the basis of practical public health knowledge and human principles, ethical beliefs about equity, advocates of equity, social change for health for all - also need shoe leather public health, not people with their head in the clouds who just know theory, basically need a public health revolution.

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