- Email: [email protected]
Fringe benefits? The impact of the Multidisciplinary Public Health Forum in the UK outside of England
ARTICLE IN PRESS Public Health (2007) 121, 438–442
www.elsevierhealth.com/journals/pubh
Minisymposium
Fringe benefits? The impact of the Multidisciplinary Public Health Forum in the UK outside of England Phil Mackie Lothian NHS Board, Faculty of Public Health, Edinburgh, Scotland UK Available online 25 April 2007
KEYWORDS History of Multidisciplinary Public Health; Scotland
Summary The impact of the UK Multidisciplinary Public Health Forum in developing the public health workforce has been the subject of some discussion. However, much of the work to date has focused on the impact of the Forum in the English context. This paper uses the same techniques used to examine the impact of the Forum in England to describe the situation in Scotland. The key themes that emerge are that the impact of the Multidisciplinary Public Health Forum in Scotland was marginal and that a multi-professional approach was the more likely route of development. The adoption of regulatory policy by the UK Government in Westminster had the effect of producing a multidisciplinary approach in Scotland. The relationship of these findings to the experiences of Wales and Northern Ireland is discussed. & 2007 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Introduction The impact of the UK Multidisciplinary Public Health Forum (MPHF) in reviving and refocusing the trans-disciplinary approach in public health has been the subject of some discussion. Both the Wellcome Foundation funded Witness Seminar1 and the papers published elsewhere in the journal have shown2–9 that ‘‘the Forum,’’ exercised far greater influence than might have seemed possible for what was a ‘‘network of networks’’.1 However, the impact of the MPHF outside of the English public health fraternity has not been systematically explored within the context of the
public health systems in Scotland, Wales and Northern Ireland. From the outset there was national representation from the so-called ‘‘Celtic Nations’’ on the National Co-ordinating Group (NCG) of the MPHF and the records show that considerable time and effort was spent in encouraging development in Scotland, Northern Ireland and Wales.1 Yet the way in which that encouragement translated into influence or prompted specific actions within the local public health systems was obscure. This paper reports on a qualitative study undertaken to explore this key issue in relation to the development of public health in Scotland.
Tel.: +44 207291 8359; fax: +44 207291 8383.
E-mail addresses: [email protected], [email protected] (P. Mackie). 0033-3506/$ - see front matter & 2007 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2007.03.012
ARTICLE IN PRESS Fringe benefits?
Methods This study was undertaken using semi-structured interview questions based on those used by Somervaille et al.2 These were: 1. How was the Forum viewed in Scotland? Did its way of working translate into the public health culture of the local public health function? 2. What were the ‘tipping points’ and milestones which in Scotland made it impossible to go back? How involved/influential was the MPHF in this? 3. What can we learn from the last 10 years that will help us tackle challenges to public health capacity and capability in the future? and 4. What is still to be achieved in Scotland? Study participants were identified by the author as not having been a member of the NCG and had been clearly influential in progressing the multidisciplinary developments in Scotland after the establishment of the Tripartite Agreement.2 This created a sample of three individuals who had been involved either in relation to establishing public health policy or in public health training. Interviews were carried out by telephone or face-to-face, whichever was the more appropriate for the responder.
439 There was a core of medically led interest in multidisciplinary public health but this was not formally linked to the types of aims and objectives of the MPHF. Certainly, there were very strong views advanced that the last thing that public health in Scotland needed was more regulation! The networking elements of the MPHF did not seem to translate into the Scottish context. This was considered to be a consequence of the availability of different networks that already existed and brought together disparate public health professionals. Notable amongst this was the Office for Public Health in Scotland (OPHIS). This umbrella organisation—which was created by the Faculty of Public Health Medicine, the academic departments of Public Health, the Royal Environmental Health Institute for Scotland and the Scottish Office Health Department—provided a focus for the national Scottish Needs Assessment Programme (SNAP) which provided a much broader purpose for public health networking. It is indicative of the relative importance of this body that when the MPHF became recognised in Scotland, it was invited to provide a representative for OPHIS. Subsequently OPHIS became the Scottish Forum for Public Health (SFPH). However, this was a move taken to avoid confusion with the short-lived (and much lamented) Public Health Institute for Scotland (PHIS).
The MPHF and Scotland How was the Forum viewed in Scotland? Did its way of working translate into the public health culture of the local public health function? The general view of responders was that whilst the existence of the MPHF function was acknowledged, there was little evidence that early involvement from the MPHF was either influential or effective. Generally this was felt to be a consequence of a very different public health culture in Scotland that had developed a more multi-professional public health function. As a consequence it was not uncommon to find public health departments that brought together medical, dental, pharmaceutical and health promotion specialists into a single local function. The pattern of national specialist public health organisations also created a multi-professional culture. For example, the Information and Statistics Division of the NHS Scotland Central Support Agency brought together consultants in public health medicine with epidemiologists and health informatics specialists into a multi-professional organisation.
What were the ‘tipping points’ and milestones which in Scotland made it impossible to go back? How involved/ influential was the MPHF in this? The consensus amongst respondents was that the MPHF was not directly involved in the ‘‘tipping points’’ in Scotland. Indeed, in many respects the influence was exercised more as a consequence of the arrangements for devolution. The phrase ‘‘parallel track’’ was used by more than one responder. The appointment of a Scottish professor of public health to be the President of the UK Faculty of Public Health Medicine was one clear ‘‘tipping point’’. Whilst there are the obvious issues of ensuring that a UK-wide approach is supported in Scotland, this appointment also provided a means of directly influencing the work of the Chief Medical Officer’s Review of the Public Health Function in Scotland (The Carter Review).10 At a very late stage in the progress of the review, a submission was made by the NCG of the MPHF to support the need for multidisciplinary public health development in Scotland. It is considered that this intervention facilitated the inclusion in the final
ARTICLE IN PRESS 440 review of a specific chapter which covered this area. However, it is notable that the NCG submission was—of necessity—made by the Chair of the NCG who was working in England. It is also important to note that the review chapter does emphasise multi-professional public health.10 Attention was drawn to the role played by public health policy in Scotland. It was felt important that policies such as Towards a Healthier Scotland11, Health Improvement in Scotland: The Challenge12, and the Local Government (Scotland) Act (2003)13 are all highly supportive of a multidisciplinary public health function, supported by a multidisciplinary public health workforce. However it is notable that only one area of policy—that of public health nursing—makes any direct reference to new workforce groups and then at public health practitioner level.14 The key tipping point was a consequence of the solution to the ‘‘Midlothian Question’’. Given the way in which devolution had occurred in Scotland, the formal adoption of policy in England regarding the need to develop and—most importantly—to regulate specialists in general public health from backgrounds other than medicine, meant that the Scottish Executive Health Department started to work with colleagues in the UK Government to develop mechanisms that could regulate such professionals. In reality, such a change is likely to have occurred anyway as during the same period work was underway to create a National Training Scheme for Public Health Specialists. This scheme was from the outset blind to the base discipline of the specialist in training. However, it remains untested in that Scotland has yet to unpick a number of workforce issues that will allow nonmedical recruitment to the specialist training scheme in Scotland.
What can we learn from the last 10 years that will help us tackle challenges to public health capacity and capability in the future? Perhaps the most important lesson is that we now need to harness the same degree of energy and enthusiasm to developing ways of intervening to improve the public’s health. As one responder noted: ‘You know, my greatest fear is that we will have gone through all this and the net gain will be to those employed to do public health and not the public whose health needs to be improved!’ It this regard, three themes seem to have emerged from the interviews.
P. Mackie Firstly, the view was advanced that there is a need to cope with complexity and not avoid it. Actually making the multi-disciplinary, multi-professional workforce a reality has meant that people have had to embrace complex situations and find ways of working within them. As such, we need to use this type of learning and apply it in the area of creating strategic frameworks for health that can encompass the problem of linking policy to action in a way that can address inequalities that are structural yet flexible. Secondly, we need to move beyond consideration of competence as the key factor in creating effective public health systems and start considering how—at an individual, corporate and systemwide level—we start to be capable and performing to agreed standards for public health practice. Only then will the benefits of developing the public health workforce be realised. Finally, more than one responder commented on the need to develop sufficient resilience to allow change to be accommodated without major problem.
What is still to be achieved in Scotland? With regard to the aims and objectives of the MPHF2 there is much still to be achieved in Scotland. Perhaps most notable of these are those which relate to ensuring that the development of the wider public health workforce is carried forward. In many respects, given the multi-professional roles adopted in Scotland, this is more likely to be an area for rapid progress than in some of the other UK countries. For example, there is a very proactive approach to the development of defined public health specialists and Scotland has been central to the UK work on developing public health practitioner roles. Ensuring that the approach goes beyond the NHS and into the wider public health workforce remains an issue. Improving the health of Scottish people requires that we can deliver a capable and high performing public health workforce that goes beyond traditional public health professionals. To establish this, we urgently need to understand what truly constitutes the modern public health function in Scotland and establish mechanisms that can support and sustain its operation.
Scotland, Wales and Northern Ireland It almost goes without saying, but it is important to realise, that for much of the decade that the MPHF
ARTICLE IN PRESS Fringe benefits? was effecting significant change in England the situation in Scotland was somewhat different. The relative stability that existed ‘‘north of the Border’’ and the different response to the implementation of the purchaser/provider split15 meant that public health departments had been relatively stable and had been developing along more multi-professional lines. A similar situation seems to have occurred in Northern Ireland where the way in which Health and Social Service Boards were constituted during that period meant that the director of public health presided over departments retained largely medical functions. In Scotland, the main tipping points actually seem to have been the workforce requirements placed on local public health systems following the implementation of policy and the adoption of regulatory policies which were binding across the UK. The same is also true for Wales where both national health policy16 and the Chief Medical Officer17 signalled toplevel support for the development of a multidisciplinary public health workforce and the need for regulation. In Northern Ireland, the Chief Medical Officer’s Review of the Public Health Function in Ireland18 had a similar effect. However, given the emphasis that was placed on the practitioner and wider public health workforce in the public health review, it is likely that this will be more obvious in the practitioner developments now being progressed across the UK. So, taken in the round, it is probably appropriate to recognise the impact of the MPHF only indirectly on these changes. The main learning from Scotland—as indeed in all the ‘‘Celtic Nations’’—is that there is a tension between the requirement for a UK-wide response to the quality assurance of the public health workforce and the need to re-interpret approaches and trends that simply cannot be applied in ‘‘small’’ populations. Scotland, Wales and Northern Ireland all have populations which are small enough to make it unlikely that a solution which can be applied in an English region of 8 or 9 millions of people will be sustainable. The key challenge of devolution in any system is to allow that system to develop its own ways of achieving progress. In Wales, for example, the development of the National Public Health Service of Wales is a local response to providing sufficient public heath expertise at local, regional and national levels. In supporting this approach, the Welsh Assembly Government and the NHS in Wales have recognised that consolidating the public health function into a single unit provides a robust, sustainable solution to meeting population health needs. Operationally, it has also meant that in relation to the training of future public health specialists, Wales does not find
441 itself in the type of paradoxical situation in Scotland, where policy (and funding) exists to support trainees from backgrounds other than medicine, but progress is slow due to the lack of agreed terms and conditions of service.
Conclusion However it is viewed, the major theme to emerge from this analysis is that in Scotland the MPHF had a fairly limited impact. What impact it did have was indirect in that—because of the devolution settlement—the need to establish UK wide regulatory structures meant that the MPHF’s influence on the policies of the UK Government’s Department of Health carried across into Scotland.
Statement of Competing Interests The author is Joint Editor in Chief of Public Health. He is also a former Chair of the National Coordinating Group of the UK Multidisciplinary Public Health Forum.
References 1. Evans D, Knight T. There was no plan! The origins and development of multidisciplinary public health in the UK. Bristol, University of the West of England, 2006. Available at: /http://www.hsc.uwe.ac.uk/hsc/index.asp?pageid=843S 2. Somervaille L, Knight T, Cornish Y. A short history of the Multidisciplinary Public Health Forum. Public Health, this issue, doi:10.1016/j.puhe.2007.02.003. 3. Berridge V. Multidisciplinary public health. Public Health, this issue, doi:10.1016/j.puhe.2007.02.004. 4. Griffiths S, Crown J, McEwen J. The role of the faculty of Public Health (Medicine) in developing a multidisciplinary publich health profession in the UK. Public Health, this issue, doi:10.1016/j.puhe.2007.02.021. 5. Orme J, de Viggiani N, Naidoo J, Knight T. Missed opportunities? Location health promotion within multidisciplinary public health. Public Health, this issue, doi:10.1016/ j.puhe.2007.02.005. 6. Evans D, Adams L. Through the glass ceiling—And back again: the experiences of two of the first mon-medical directors of public health in England. Public Health, this issue, doi:10.1016/j.puhe.2007.02.006. 7. Pilkington P, Dowling S, Barnes GJ, Lindfield T, Pritchard A. Trainees’ experiences of multidisciplinary public health training schemes in England. Public Health, this issue, doi:10.1016/j.puhe.2007.02.007. 8. Sim FM, Griffiths J. Origin and development of the UK Voluntary Register for Public Health Specialists. Public Health, this issue, doi:10.1016/j.puhe.2007.02.022. 9. Rayner G. Multidisciplinary public health: leading from the front? Public Health, this issue, doi:10.1016/j.puhe. 2007.02.008. 10. Scottish Office. The Review of the Public Health Function in Scotland. Edinburgh: The Stationary Office; 1999.
ARTICLE IN PRESS 442 11. Scottish Office. Towards a healthier Scotland—a white paper on health. Edinburgh: The Stationary Office; 1999. 12. Scottish Executive Health Department. Health improvement in Scotland: the challenge. Edinburgh: Scottish Executive; 200? 13. Scottish Parliament. Local Government (Scotland) Act (2003). Edinburgh: Scottish Parliament; 2003. 14. Scottish Executive Health Department. Nursing for health: a review of the contribution of nurses, midwives and health visitors to improving the public’s health in Scotland. Edinburgh: Scottish Executive; 2001. 15. Laing AW, Galbraith A. Developing a market orientation in the Health Service: a survey of Acute NHS Trusts in Scotland. J Manage Med 1996;10:24–35.
P. Mackie 16. National Assembly for Wales. Improving health in Wales: a plan for the NHS and its partners. Cardiff: National Assembly for Wales; 2001. 17. National Assembly for Wales. Health in Wales: Chief Medical officer’s report 2001/2002. Cardiff: National Assembly for Wales; 2002. 18. Department of Health, Social Services and Public Safety. Public health function review in Northern Ireland: the policy context. A Report Commissioned by the Chief Medical Officer. Belfast: Department of Health, Social Services and Public Safety; 2004.
www.elsevierhealth.com/journals/pubh
Minisymposium
Fringe benefits? The impact of the Multidisciplinary Public Health Forum in the UK outside of England Phil Mackie Lothian NHS Board, Faculty of Public Health, Edinburgh, Scotland UK Available online 25 April 2007
KEYWORDS History of Multidisciplinary Public Health; Scotland
Summary The impact of the UK Multidisciplinary Public Health Forum in developing the public health workforce has been the subject of some discussion. However, much of the work to date has focused on the impact of the Forum in the English context. This paper uses the same techniques used to examine the impact of the Forum in England to describe the situation in Scotland. The key themes that emerge are that the impact of the Multidisciplinary Public Health Forum in Scotland was marginal and that a multi-professional approach was the more likely route of development. The adoption of regulatory policy by the UK Government in Westminster had the effect of producing a multidisciplinary approach in Scotland. The relationship of these findings to the experiences of Wales and Northern Ireland is discussed. & 2007 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Introduction The impact of the UK Multidisciplinary Public Health Forum (MPHF) in reviving and refocusing the trans-disciplinary approach in public health has been the subject of some discussion. Both the Wellcome Foundation funded Witness Seminar1 and the papers published elsewhere in the journal have shown2–9 that ‘‘the Forum,’’ exercised far greater influence than might have seemed possible for what was a ‘‘network of networks’’.1 However, the impact of the MPHF outside of the English public health fraternity has not been systematically explored within the context of the
public health systems in Scotland, Wales and Northern Ireland. From the outset there was national representation from the so-called ‘‘Celtic Nations’’ on the National Co-ordinating Group (NCG) of the MPHF and the records show that considerable time and effort was spent in encouraging development in Scotland, Northern Ireland and Wales.1 Yet the way in which that encouragement translated into influence or prompted specific actions within the local public health systems was obscure. This paper reports on a qualitative study undertaken to explore this key issue in relation to the development of public health in Scotland.
Tel.: +44 207291 8359; fax: +44 207291 8383.
E-mail addresses: [email protected], [email protected] (P. Mackie). 0033-3506/$ - see front matter & 2007 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2007.03.012
ARTICLE IN PRESS Fringe benefits?
Methods This study was undertaken using semi-structured interview questions based on those used by Somervaille et al.2 These were: 1. How was the Forum viewed in Scotland? Did its way of working translate into the public health culture of the local public health function? 2. What were the ‘tipping points’ and milestones which in Scotland made it impossible to go back? How involved/influential was the MPHF in this? 3. What can we learn from the last 10 years that will help us tackle challenges to public health capacity and capability in the future? and 4. What is still to be achieved in Scotland? Study participants were identified by the author as not having been a member of the NCG and had been clearly influential in progressing the multidisciplinary developments in Scotland after the establishment of the Tripartite Agreement.2 This created a sample of three individuals who had been involved either in relation to establishing public health policy or in public health training. Interviews were carried out by telephone or face-to-face, whichever was the more appropriate for the responder.
439 There was a core of medically led interest in multidisciplinary public health but this was not formally linked to the types of aims and objectives of the MPHF. Certainly, there were very strong views advanced that the last thing that public health in Scotland needed was more regulation! The networking elements of the MPHF did not seem to translate into the Scottish context. This was considered to be a consequence of the availability of different networks that already existed and brought together disparate public health professionals. Notable amongst this was the Office for Public Health in Scotland (OPHIS). This umbrella organisation—which was created by the Faculty of Public Health Medicine, the academic departments of Public Health, the Royal Environmental Health Institute for Scotland and the Scottish Office Health Department—provided a focus for the national Scottish Needs Assessment Programme (SNAP) which provided a much broader purpose for public health networking. It is indicative of the relative importance of this body that when the MPHF became recognised in Scotland, it was invited to provide a representative for OPHIS. Subsequently OPHIS became the Scottish Forum for Public Health (SFPH). However, this was a move taken to avoid confusion with the short-lived (and much lamented) Public Health Institute for Scotland (PHIS).
The MPHF and Scotland How was the Forum viewed in Scotland? Did its way of working translate into the public health culture of the local public health function? The general view of responders was that whilst the existence of the MPHF function was acknowledged, there was little evidence that early involvement from the MPHF was either influential or effective. Generally this was felt to be a consequence of a very different public health culture in Scotland that had developed a more multi-professional public health function. As a consequence it was not uncommon to find public health departments that brought together medical, dental, pharmaceutical and health promotion specialists into a single local function. The pattern of national specialist public health organisations also created a multi-professional culture. For example, the Information and Statistics Division of the NHS Scotland Central Support Agency brought together consultants in public health medicine with epidemiologists and health informatics specialists into a multi-professional organisation.
What were the ‘tipping points’ and milestones which in Scotland made it impossible to go back? How involved/ influential was the MPHF in this? The consensus amongst respondents was that the MPHF was not directly involved in the ‘‘tipping points’’ in Scotland. Indeed, in many respects the influence was exercised more as a consequence of the arrangements for devolution. The phrase ‘‘parallel track’’ was used by more than one responder. The appointment of a Scottish professor of public health to be the President of the UK Faculty of Public Health Medicine was one clear ‘‘tipping point’’. Whilst there are the obvious issues of ensuring that a UK-wide approach is supported in Scotland, this appointment also provided a means of directly influencing the work of the Chief Medical Officer’s Review of the Public Health Function in Scotland (The Carter Review).10 At a very late stage in the progress of the review, a submission was made by the NCG of the MPHF to support the need for multidisciplinary public health development in Scotland. It is considered that this intervention facilitated the inclusion in the final
ARTICLE IN PRESS 440 review of a specific chapter which covered this area. However, it is notable that the NCG submission was—of necessity—made by the Chair of the NCG who was working in England. It is also important to note that the review chapter does emphasise multi-professional public health.10 Attention was drawn to the role played by public health policy in Scotland. It was felt important that policies such as Towards a Healthier Scotland11, Health Improvement in Scotland: The Challenge12, and the Local Government (Scotland) Act (2003)13 are all highly supportive of a multidisciplinary public health function, supported by a multidisciplinary public health workforce. However it is notable that only one area of policy—that of public health nursing—makes any direct reference to new workforce groups and then at public health practitioner level.14 The key tipping point was a consequence of the solution to the ‘‘Midlothian Question’’. Given the way in which devolution had occurred in Scotland, the formal adoption of policy in England regarding the need to develop and—most importantly—to regulate specialists in general public health from backgrounds other than medicine, meant that the Scottish Executive Health Department started to work with colleagues in the UK Government to develop mechanisms that could regulate such professionals. In reality, such a change is likely to have occurred anyway as during the same period work was underway to create a National Training Scheme for Public Health Specialists. This scheme was from the outset blind to the base discipline of the specialist in training. However, it remains untested in that Scotland has yet to unpick a number of workforce issues that will allow nonmedical recruitment to the specialist training scheme in Scotland.
What can we learn from the last 10 years that will help us tackle challenges to public health capacity and capability in the future? Perhaps the most important lesson is that we now need to harness the same degree of energy and enthusiasm to developing ways of intervening to improve the public’s health. As one responder noted: ‘You know, my greatest fear is that we will have gone through all this and the net gain will be to those employed to do public health and not the public whose health needs to be improved!’ It this regard, three themes seem to have emerged from the interviews.
P. Mackie Firstly, the view was advanced that there is a need to cope with complexity and not avoid it. Actually making the multi-disciplinary, multi-professional workforce a reality has meant that people have had to embrace complex situations and find ways of working within them. As such, we need to use this type of learning and apply it in the area of creating strategic frameworks for health that can encompass the problem of linking policy to action in a way that can address inequalities that are structural yet flexible. Secondly, we need to move beyond consideration of competence as the key factor in creating effective public health systems and start considering how—at an individual, corporate and systemwide level—we start to be capable and performing to agreed standards for public health practice. Only then will the benefits of developing the public health workforce be realised. Finally, more than one responder commented on the need to develop sufficient resilience to allow change to be accommodated without major problem.
What is still to be achieved in Scotland? With regard to the aims and objectives of the MPHF2 there is much still to be achieved in Scotland. Perhaps most notable of these are those which relate to ensuring that the development of the wider public health workforce is carried forward. In many respects, given the multi-professional roles adopted in Scotland, this is more likely to be an area for rapid progress than in some of the other UK countries. For example, there is a very proactive approach to the development of defined public health specialists and Scotland has been central to the UK work on developing public health practitioner roles. Ensuring that the approach goes beyond the NHS and into the wider public health workforce remains an issue. Improving the health of Scottish people requires that we can deliver a capable and high performing public health workforce that goes beyond traditional public health professionals. To establish this, we urgently need to understand what truly constitutes the modern public health function in Scotland and establish mechanisms that can support and sustain its operation.
Scotland, Wales and Northern Ireland It almost goes without saying, but it is important to realise, that for much of the decade that the MPHF
ARTICLE IN PRESS Fringe benefits? was effecting significant change in England the situation in Scotland was somewhat different. The relative stability that existed ‘‘north of the Border’’ and the different response to the implementation of the purchaser/provider split15 meant that public health departments had been relatively stable and had been developing along more multi-professional lines. A similar situation seems to have occurred in Northern Ireland where the way in which Health and Social Service Boards were constituted during that period meant that the director of public health presided over departments retained largely medical functions. In Scotland, the main tipping points actually seem to have been the workforce requirements placed on local public health systems following the implementation of policy and the adoption of regulatory policies which were binding across the UK. The same is also true for Wales where both national health policy16 and the Chief Medical Officer17 signalled toplevel support for the development of a multidisciplinary public health workforce and the need for regulation. In Northern Ireland, the Chief Medical Officer’s Review of the Public Health Function in Ireland18 had a similar effect. However, given the emphasis that was placed on the practitioner and wider public health workforce in the public health review, it is likely that this will be more obvious in the practitioner developments now being progressed across the UK. So, taken in the round, it is probably appropriate to recognise the impact of the MPHF only indirectly on these changes. The main learning from Scotland—as indeed in all the ‘‘Celtic Nations’’—is that there is a tension between the requirement for a UK-wide response to the quality assurance of the public health workforce and the need to re-interpret approaches and trends that simply cannot be applied in ‘‘small’’ populations. Scotland, Wales and Northern Ireland all have populations which are small enough to make it unlikely that a solution which can be applied in an English region of 8 or 9 millions of people will be sustainable. The key challenge of devolution in any system is to allow that system to develop its own ways of achieving progress. In Wales, for example, the development of the National Public Health Service of Wales is a local response to providing sufficient public heath expertise at local, regional and national levels. In supporting this approach, the Welsh Assembly Government and the NHS in Wales have recognised that consolidating the public health function into a single unit provides a robust, sustainable solution to meeting population health needs. Operationally, it has also meant that in relation to the training of future public health specialists, Wales does not find
441 itself in the type of paradoxical situation in Scotland, where policy (and funding) exists to support trainees from backgrounds other than medicine, but progress is slow due to the lack of agreed terms and conditions of service.
Conclusion However it is viewed, the major theme to emerge from this analysis is that in Scotland the MPHF had a fairly limited impact. What impact it did have was indirect in that—because of the devolution settlement—the need to establish UK wide regulatory structures meant that the MPHF’s influence on the policies of the UK Government’s Department of Health carried across into Scotland.
Statement of Competing Interests The author is Joint Editor in Chief of Public Health. He is also a former Chair of the National Coordinating Group of the UK Multidisciplinary Public Health Forum.
References 1. Evans D, Knight T. There was no plan! The origins and development of multidisciplinary public health in the UK. Bristol, University of the West of England, 2006. Available at: /http://www.hsc.uwe.ac.uk/hsc/index.asp?pageid=843S 2. Somervaille L, Knight T, Cornish Y. A short history of the Multidisciplinary Public Health Forum. Public Health, this issue, doi:10.1016/j.puhe.2007.02.003. 3. Berridge V. Multidisciplinary public health. Public Health, this issue, doi:10.1016/j.puhe.2007.02.004. 4. Griffiths S, Crown J, McEwen J. The role of the faculty of Public Health (Medicine) in developing a multidisciplinary publich health profession in the UK. Public Health, this issue, doi:10.1016/j.puhe.2007.02.021. 5. Orme J, de Viggiani N, Naidoo J, Knight T. Missed opportunities? Location health promotion within multidisciplinary public health. Public Health, this issue, doi:10.1016/ j.puhe.2007.02.005. 6. Evans D, Adams L. Through the glass ceiling—And back again: the experiences of two of the first mon-medical directors of public health in England. Public Health, this issue, doi:10.1016/j.puhe.2007.02.006. 7. Pilkington P, Dowling S, Barnes GJ, Lindfield T, Pritchard A. Trainees’ experiences of multidisciplinary public health training schemes in England. Public Health, this issue, doi:10.1016/j.puhe.2007.02.007. 8. Sim FM, Griffiths J. Origin and development of the UK Voluntary Register for Public Health Specialists. Public Health, this issue, doi:10.1016/j.puhe.2007.02.022. 9. Rayner G. Multidisciplinary public health: leading from the front? Public Health, this issue, doi:10.1016/j.puhe. 2007.02.008. 10. Scottish Office. The Review of the Public Health Function in Scotland. Edinburgh: The Stationary Office; 1999.
ARTICLE IN PRESS 442 11. Scottish Office. Towards a healthier Scotland—a white paper on health. Edinburgh: The Stationary Office; 1999. 12. Scottish Executive Health Department. Health improvement in Scotland: the challenge. Edinburgh: Scottish Executive; 200? 13. Scottish Parliament. Local Government (Scotland) Act (2003). Edinburgh: Scottish Parliament; 2003. 14. Scottish Executive Health Department. Nursing for health: a review of the contribution of nurses, midwives and health visitors to improving the public’s health in Scotland. Edinburgh: Scottish Executive; 2001. 15. Laing AW, Galbraith A. Developing a market orientation in the Health Service: a survey of Acute NHS Trusts in Scotland. J Manage Med 1996;10:24–35.
P. Mackie 16. National Assembly for Wales. Improving health in Wales: a plan for the NHS and its partners. Cardiff: National Assembly for Wales; 2001. 17. National Assembly for Wales. Health in Wales: Chief Medical officer’s report 2001/2002. Cardiff: National Assembly for Wales; 2002. 18. Department of Health, Social Services and Public Safety. Public health function review in Northern Ireland: the policy context. A Report Commissioned by the Chief Medical Officer. Belfast: Department of Health, Social Services and Public Safety; 2004.