- Email: [email protected]
The role of the Faculty of Public Health (Medicine) in developing a multidisciplinary public health profession in the UK
ARTICLE IN PRESS Public Health (2007) 121, 420–425
www.elsevierhealth.com/journals/pubh
Minisymposium
The role of the Faculty of Public Health (Medicine) in developing a multidisciplinary public health profession in the UK Sian Griffithsa,, June Crownb, Jim McEwenc,d a
School of Public Health, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Faculty of Public Health, London, UK c University of Glasgow, UK d UK Voluntary Register for Public Health Specialists, UK b
Available online 25 April 2007
KEYWORDS Faculty of public health; Specialist public health; Multidisciplinary profession
Abstract The Faculty of Public Health (FPH) started out its life as the Faculty of Community Medicine. Its initial membership was drawn from the ranks of Medical Officers of Health (MOsH), medical administrators and consultants working in communicable disease. Born under the aegis of the three Royal Colleges of Physicians, it was de facto for members of the medical profession. This was despite the intention of some of the prime movers in its creation that its membership should reflect the multidisciplinary nature of specialist public health. As such, whilst the Faculty’s establishment was indeed a triumph, the triumph was only partial, since many senior public health professionals were precluded from full membership. Over the years this situation has changed, but the road to the Faculty’s current open policy, based on achieving public health excellence rather than holding a professional badge, has not been a smooth one. The fears of many medical members that the specialty would be down graded through opening up its membership posed successive presidents with many, often justifiable, challenges. In this article we, former presidents, reflect on the key events during our successive tenures. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The role of the Faculty of Public Health (FPH) 1 is to ensure that standards for practice in speciaCorresponding author. Tel.: +852 2252 8700;
fax: +852 2145 8517. E-mail address: [email protected] (S. Griffiths).
list public health are met through three key functions of:
education and training; professional support including appointments; and advocacy and policy.
0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2007.02.021
ARTICLE IN PRESS Faculty of Public Health in developing a multidisciplinary public health profession As a professional body the Faculty creates and promotes national standards of practice and supports their development in partnership with other countries and organisations. Other important aspects of its work include forging alliances across all sectors of society with those with an interest in public health (particularly local government), identifying and reducing inequalities and promoting academic research.1 Given this remit, it is clear that specialists from a wide variety of backgrounds are needed to promote the public’s health and over the last thirty years the Faculty has progressed from a medical organisation to one which embraces all specialists. Structures for delivering public health differ between countries as do their associated career patterns. Within the UK there has been a historical legacy of medical public health within the National Health Service (NHS) which has played a key role in all fields of public health practice: health protection, health improvement, health service delivery. The contribution of doctors has been significant but they do not work alone nor do they have the monopoly or primacy in specialist skills. Yet whilst it was recognised that in practice public health specialists may come from a wide variety of backgrounds and disciplines, mutual professional recognition was somewhat slower to develop. This is reflected in the story of the journey of the professional body of medical doctors associated with public health, the Faculty of Community Medicine, to its current status as the Faculty of Public Health (FPH), an organisation responsible for multidisciplinary specialist standards.
Background The Faculty of Community Medicine was established in March 1972 within the three Royal Colleges of Physicians in the UK (Royal College of Physicians of London, Royal College of Physicians of Edinburgh and Royal College of Physicians and Surgeons of Glasgow). With this parentage, it is not surprising that foundation fellowship and membership were restricted to medical practitioners. However it was always the intention of the ‘founding fathers’, who included Professors Jerry Morris, Archie Cochrane and Dr. Wilfred Harding, that it should be a multidisciplinary body, recognising the membership of both service and academic public health departments in those days. The final draft of ‘The Proposal’ drawn up by the working party on the proposed Faculty of Community Medicine,2 states that ‘‘At a later date, and by agreement with the Royal Colleges, consideration would be given to the eligibility of non-medical
421
colleagues practising, teaching, or conducting research on the field of Community Medicine.’’ But what were the obstacles in achieving this goal and why did it take so long to achieve multidisciplinarity? There is no simple answer to this question. Perhaps those original and exciting hopes for multidisciplinary community medicine were overridden by the need to establish the new profession created by the changes introduced in 1974. These changes were the first major restructuring of the NHS since its introduction in 1948. Between 1948 and 1974 public health services were the responsibility of local authorities, led by the Medical Officers of Health (MOsH). They were run as a tripartite service; through local government public health services, general practice and through administered hospitals. As noted by Rivett,3 ‘‘By 1968 MOH had a smoothly running empire, managing community nursing services, social work services, the aftercare of people who were mentally ill or handicapped, the ambulances and the child and school health services.’’ The new structures created a centrally dictated system in which community medicine synthesised some of its previous local authority roles with those of medical administration. Each ‘area’ was required to appoint an Area Medical Officer and designated specialists in community medicine (child health, social services liaison, and information and planning). Each ‘district’ (defined as the hinterland of a general hospital) had a District Community Physician. All of these jobs were only open to doctors and the terms and conditions, negotiated by the British Medical Association (BMA), were equivalent to clinical consultants. In Scotland, the posts, although having slightly different titles such as Chief Administrative Medical Officer, were also filled by doctors in public health. The focus of the work of these new health authorities was on developing and managing clinical services. Environmental health and social work remained the responsibility of local authorities and the wider areas of health promotion developed slowly and often uncomfortably, in the health care dominated structures.4 This arrangement fractured the relationship of specialists with those influencing the broader determinants of health and subsequent reorganisations saw the increasing identification of public health specialists with NHS managerial structures.5,6 Other parts of the profession continued to develop their separate identities within individual structures. Meanwhile whilst the working environment was changing there were differing levels of support for change within the three parent Royal Colleges. There was pressure to retain close links with
ARTICLE IN PRESS 422 clinical consultants, a title only adopted by public health doctors much later. There was particular concern about setting a precedent for mutual recognition for those who were not medically trained within the Colleges, although examples existed in other Colleges. At the same time, academic departments of community medicine were recruiting increasing numbers of statisticians, sociologists and researchers from a range of social and psychological science backgrounds. In spite of the high level of specialist skills of some of these colleagues, all academic departments were headed by doctors, a situation regarded as acceptable and appropriate since the departments were part of medical schools. The professional work environment for public health specialists continued to change with successive structural changes in the NHS. The managerial reforms of the 1980s and the separation of ‘purchasers’ of health services from their ‘providers’ left many public health professionals perceived by clinical and other colleagues as mere administrators, siding with management and often responsible for refusing funding for a new medical service. Service public health relationships with community based public health practitioners such as health visitors, school nurses, community development workers and environmental health officers were weakened. Academic public health colleagues, often focussing on epidemiology, were working in different environments unrelated to the day to day pressures of service practice. However, arguments were made7 that being close to the service funding decisions outweighed the disadvantages of isolation from clinicians, academic colleagues from a wider variety of backgrounds, communities and local authorities. With the preoccupation on structures and continual reorganisation of posts, there was little debate on broadening the membership of the Faculty. Within day to day work situations there was a general trend, not only in the UK, to assume that the problems of infectious diseases were less important and the investment in communicable disease control began to dwindle. This resulted in a lack of a common purpose and unification in the specialty, despite the wishes of many in the public health community who wished to promote a more coherent focus for public health practice which addressed root causes of ill health and was not tied so closely to the vagaries of management structures for delivering health services. Alarm bells eventually began to ring as events like Stanley Royd8 made it apparent that infectious disease control was dropping off the radar screen and capacity of
S. Griffiths et al. public health services was severely weakened. Donald Acheson’s report on public health in England,9 helped to refocus and revitalise the public health community particularly in relation to communicable disease control. His definition of public health: ‘‘The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.’’ acted as a unifying banner and the Faculty was renamed as one of Public Health Medicine (FPHM). Despite the re-embracing of the broader public health function both locally and at an international level, as reflected by the Ottawa Charter10, it was not until the early 1990s that the Faculty annual general meetings and board meetings regularly debated the possibility of opening up the membership to include all public health specialists. The first formal change was the introduction of honorary membership in 1991. The standards for honorary membership were high (publications were assessed and applicants were expected to have at least 10 years experience in a department of community medicine). The purpose of honorary membership was to include those holding senior academic and research posts, many of whom were teaching the junior public health doctors, and election of service based colleagues was extremely rare. Those elected were clearly outstanding, but there was ambiguity about the status conferred. It was not honorary since there was an annual membership fee and it was not membership since the honorary members were not allowed to vote nor to serve as full members of the board. However there was now a powerful synthesis of medical and non-medical voices within the Faculty calling for change. The establishment of the honorary members committee and representation on the board ensured that the pressure was maintained. As ever, timing was difficult with the NHS undergoing yet further restructuring in 1991. ‘Areas’ were abolished and many ‘district’ boundaries changed. Almost all public health doctors were required to re-apply for their jobs, if they were relatively unaffected by the changes, or else compete with their friends and colleagues for posts in the new structures. Many senior people took early retirement. The self confidence of those who remained was often undermined. The standing of the profession within medicine was diminished in some eyes, since it was clear that no clinical consultants would ever have been treated in this way. Unsurprisingly, morale was low. The impact on the move to multidisciplinarity was to create hesitancy amongst some of the more senior doctors and those in training who either had to compete for posts, or who were anxious about their future
ARTICLE IN PRESS Faculty of Public Health in developing a multidisciplinary public health profession employment prospects. In particular there was anxiety about the possibility of competition from well-experienced people without medical degrees, who might be employed to do the same jobs for a much lower salary. Whilst this could be described as medical protectionism it can also be understood in human terms. Those responsible for communicable disease control were particularly concerned, threatening to remove themselves from the Faculty and establish a separate clinically focussed body linked to the Royal College of Physicians of London. On the other side of the argument, there were many honorary members of the Faculty holding senior and influential positions, who argued that they should be fully welcomed and recognised within the profession and that it was time to end the glass ceiling that operated both in the Faculty and in health service employment.11 They contemplated establishing a new body for public health practitioners from all professional backgrounds, in competition with the Faculty. It was at this time that the independent Multidisciplinary Public Health Forum (MPHF) was set up as a temporary organisation with the aim of bringing about change.12 A survey of the views of the Faculty membership was carried out in 1996 and one of us (JC) had the unenviable task of announcing the results, rejection of opening examinations and full membership to non-medical colleagues, to the second national conference of public health professionals, which led to the establishment of the MPHF.12 As a result of this survey, the Faculty board decided that it would be unwise to take a formal motion to the annual general meeting, fearing that defeat would be likely and would prejudice further efforts in the foreseeable future. A vote in 1998 showed some change. The proposal to open membership to non-medical colleagues on an equal basis was rejected, but there was support for opening ‘part one’ of the membership examination.a Successful non-medical candidates could not proceed to ‘part two’, but would be awarded Diplomate status within the Faculty. This encouraged the board to put a formal motion to the annual general meeting in 1998 which, to the relief of the President (JC), was approved without any a Trainees were required to sit the FPH Part I membership exam between one and two years after starting their training programme and the Part II exam six to nine months later. Part I tested knowledge of the skills while the Part II exam demonstrated that trainees could translate their knowledge effectively into practice. Trainees were also subject to ongoing assessment in the workplace. See the Exams section of the Faculty website for further details.
423
significant opposition. It is interesting to note that previously there had been a Diploma in Epidemiology which was open to all, but as this had no real standing and did not give successful candidates any role or continuing relationship with the Faculty, a mere handful of people had taken it and it had not had any impact. Further progress was made in 2000 when a postal ballot supported opening membership. This was confirmed at the annual general meeting in Scarborough and non-medical public health professionals then became eligible to take the examinations and, if successful, to enjoy all the rights of membership. This meant that, when in 2002 yet further reorganisation was introduced to the NHS, public health specialists from all backgrounds could be appointed as directors of public health (DsPH) within the newly established primary care trusts. The category of honorary membership by assessment was now redundant and was discontinued. Subsequently it was agreed that all members should be equally eligible to proceed to the ‘fellowship’ and the criteria for all categories of membership have now been revised and all members, independent of their specialist background, may stand for all posts within Faculty elections. On 24 June 2003 the Faculty changed its name to the Faculty of Public Health (FPH). This change marked official recognition that, whilst doctors have an important contribution to make to improving the public’s health, so too do other skilled specialists in the professional community. What should count to the public is each member’s level of competence and skill to work in public health. The FPH became the specialist professional organisation committed to supporting and maintaining standards of public health practice for all specialists. In doing this, emphasis was placed on the inclusive definition of multidisciplinarity; not doctors and ‘others’, but doctors as one of a key group of professions who can be specialists in public health.
Professional registration As for any professional group, it is important to safeguard the public through both regulation and registration. At the same time as the Faculty was restructuring itself as a multidisciplinary organisation, developments were also taking place in professional registration. In 1997 the ‘Tripartite Agreement’ was drafted and signed by the FPHM, the Royal Institute of Public Health and Hygiene and the MPHF, to take forward the development of multidisciplinary public health.12 After a comprehensive scoping study13 and extensive development
ARTICLE IN PRESS 424 work by the Tripartite Group and by Skills for Health, the UK Voluntary Register for Public Health Specialists (UKVRPHS) was established as an independent body in 2003, formally announced by a ministerial statement at the UK Public Health Association conference in March of that year. The establishment of the voluntary register provides the framework for the regulatory functions of public protection and formal recognition of professional status for public health specialists, mirroring the work of other regulatory bodies such as the General Medical Council for doctors and the Nursing and Midwifery Council for nurses. The standards of practice are based on the ten areas of specialist practice agreed by both the FPH and MPHF as the basis of training. The code of conduct, ‘Good Public Health Practice’, adapted from ‘Good Medical Practice’, underpins the ethical expectations of the public health specialists.14
Specialist training Entry to common pathways of specialist training now exists for a diverse workforce from a wide range of backgrounds, all of whom need to achieve common recognised and validated standards of professional practice. The framework for specialist practice1 has been established through extensive discussions with a variety of professional groups as well as discussion with other countries. The framework is based on the ten key areas of specialist practice which were derived in consultation with a wide variety of specialists and agreed with the four Chief Medical Officers in England, Scotland, Wales and Northern Ireland in June 2002. The 10 key areas of specialist practice: 1. Surveillance and assessment of the population’s health and well-being. 2. Promoting and protecting the population’s health and well-being. 3. Developing quality and risk management within an evaluative culture. 4. Collaborative working for health. 5. Developing health programmes and services and reducing inequalities. 6. Policy and strategy development and implementation. 7. Working with and for communities. 8. Strategic leadership for health. 9. Research and development. 10. Ethically managing self, people and resources.
S. Griffiths et al. These 10 key areas form the basis for all the Faculty’s professional activities and provide a comprehensive framework for generic public health competencies. They form the basis for the creation of the UKVRPHS. In conjunction with the Faculty’s guidance ‘Good Public Health Practice’,14 these ten key areas set the professional framework for training, continuing professional development, appraisal and potentially for revalidation
Conclusions The changes that took more than a quarter of a century are welcome. Public health demands able, well trained professionals from many disciplines if it is to have the impact on population health and well being that we all strive for. However, there is still much to be achieved if the full potential of multidisciplinary public health is to be realised. The progress that has taken place is leading towards a public health workforce with rich and diverse skills, from a wide range of backgrounds, yet with a common core of public health sciences, theory and practice. There have been examples of opposition, prejudice and ignorance yet this has been matched by a clear commitment from many that the direction of change within the Faculty was both appropriate and necessary. Further challenges exist. For example, the introduction of changes in medical training through the creation of the Postgraduate Medical Education Board and the impact of European directives have meant the Faculty has had a key role to play in alignment of specialist standards, not only between those from different professional backgrounds, but those trained in different nations. As successive presidents we reflect not only on the steps made but those still needed. We know the efforts made by many to reach this point, and urge that, despite constant health service reorganisations, the profession continues to develop the true potential of multidisciplinary public health to address the global challenges to improve population health.
References 1. www.FPH.org.uk (accessed February 2007). 2. Working Party, Proposed Faculty of Community Medicine. Proposals under discussion with the Royal Colleages of Physicians in London, Edinburgh, Glasgow, fifth draft, WGH papers, January 1970. Quoted by Warren M. The Origins of the Faculty of Public Health Medicine, London: Faculty of Public Health Medicine; 2000. p. 91.
ARTICLE IN PRESS Faculty of Public Health in developing a multidisciplinary public health profession 3. Rivett G. From cradle to grave: fifty years of the NHS. London: King’s Fund; 1998. 4. Orme J, de Viggiani N, Naidoo J, Knight T. Missed opportunities? Locating health promotion within multidisciplinary public health. Public Health, this issue, doi:10.1016/ j.puhe.2007.02.005. 5. Holland W, Stewart S. Public Health: the vision and the challenge. London: Nuffield Trust; 1998 [Rock Carling Fellowship 1997]. 6. Francis H. Towards community medicine: the British experience. In: Bennett A, editor. Recent advances in community medicine, vol. 1. Edinburgh: Churchill Livingstone; 1978. 7. Griffiths S, Thorpe A, Wright J. Change and Development in specialist Public Health Practice. Oxford: Radcliffe Publishing; 2005. p. 33–7 [chapter 3]. 8. Report of the Committee of Inquiry into an outbreak of food poisoning at Stanley Royd Hospital. London: HMSO; 1986. 9. Secretary of State for Social Services. Public Health in England: the report of the committee of inquiry into the
10. 11.
12.
13.
14.
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future development of the public health function, Cmd 289, The Acheson report. London: HMSO; 1988. World Health Organisation. Ottawa charter for health promotion. Geneva: WHO; 1986. McPherson K, Fox J, Adam S, Cornish Y, Griffiths J, Knight T, et al. , Public health: an organised multidisciplinary effort. In: Scally G, editor. Progress in Public Health. London: FT Healthcare; 1997. 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. Lessof S, Dumelow C, McPherson K. Feasibility study of the case for national standards for specialist practice in public health: a report for the NHS Executive. London: London School of Hygiene and Tropical Medicine; 1999. Faculty of Public Health. Good public health practice, standards for public health practice. London: Faculty of Public Health; 2001.
www.elsevierhealth.com/journals/pubh
Minisymposium
The role of the Faculty of Public Health (Medicine) in developing a multidisciplinary public health profession in the UK Sian Griffithsa,, June Crownb, Jim McEwenc,d a
School of Public Health, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Faculty of Public Health, London, UK c University of Glasgow, UK d UK Voluntary Register for Public Health Specialists, UK b
Available online 25 April 2007
KEYWORDS Faculty of public health; Specialist public health; Multidisciplinary profession
Abstract The Faculty of Public Health (FPH) started out its life as the Faculty of Community Medicine. Its initial membership was drawn from the ranks of Medical Officers of Health (MOsH), medical administrators and consultants working in communicable disease. Born under the aegis of the three Royal Colleges of Physicians, it was de facto for members of the medical profession. This was despite the intention of some of the prime movers in its creation that its membership should reflect the multidisciplinary nature of specialist public health. As such, whilst the Faculty’s establishment was indeed a triumph, the triumph was only partial, since many senior public health professionals were precluded from full membership. Over the years this situation has changed, but the road to the Faculty’s current open policy, based on achieving public health excellence rather than holding a professional badge, has not been a smooth one. The fears of many medical members that the specialty would be down graded through opening up its membership posed successive presidents with many, often justifiable, challenges. In this article we, former presidents, reflect on the key events during our successive tenures. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The role of the Faculty of Public Health (FPH) 1 is to ensure that standards for practice in speciaCorresponding author. Tel.: +852 2252 8700;
fax: +852 2145 8517. E-mail address: [email protected] (S. Griffiths).
list public health are met through three key functions of:
education and training; professional support including appointments; and advocacy and policy.
0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2007.02.021
ARTICLE IN PRESS Faculty of Public Health in developing a multidisciplinary public health profession As a professional body the Faculty creates and promotes national standards of practice and supports their development in partnership with other countries and organisations. Other important aspects of its work include forging alliances across all sectors of society with those with an interest in public health (particularly local government), identifying and reducing inequalities and promoting academic research.1 Given this remit, it is clear that specialists from a wide variety of backgrounds are needed to promote the public’s health and over the last thirty years the Faculty has progressed from a medical organisation to one which embraces all specialists. Structures for delivering public health differ between countries as do their associated career patterns. Within the UK there has been a historical legacy of medical public health within the National Health Service (NHS) which has played a key role in all fields of public health practice: health protection, health improvement, health service delivery. The contribution of doctors has been significant but they do not work alone nor do they have the monopoly or primacy in specialist skills. Yet whilst it was recognised that in practice public health specialists may come from a wide variety of backgrounds and disciplines, mutual professional recognition was somewhat slower to develop. This is reflected in the story of the journey of the professional body of medical doctors associated with public health, the Faculty of Community Medicine, to its current status as the Faculty of Public Health (FPH), an organisation responsible for multidisciplinary specialist standards.
Background The Faculty of Community Medicine was established in March 1972 within the three Royal Colleges of Physicians in the UK (Royal College of Physicians of London, Royal College of Physicians of Edinburgh and Royal College of Physicians and Surgeons of Glasgow). With this parentage, it is not surprising that foundation fellowship and membership were restricted to medical practitioners. However it was always the intention of the ‘founding fathers’, who included Professors Jerry Morris, Archie Cochrane and Dr. Wilfred Harding, that it should be a multidisciplinary body, recognising the membership of both service and academic public health departments in those days. The final draft of ‘The Proposal’ drawn up by the working party on the proposed Faculty of Community Medicine,2 states that ‘‘At a later date, and by agreement with the Royal Colleges, consideration would be given to the eligibility of non-medical
421
colleagues practising, teaching, or conducting research on the field of Community Medicine.’’ But what were the obstacles in achieving this goal and why did it take so long to achieve multidisciplinarity? There is no simple answer to this question. Perhaps those original and exciting hopes for multidisciplinary community medicine were overridden by the need to establish the new profession created by the changes introduced in 1974. These changes were the first major restructuring of the NHS since its introduction in 1948. Between 1948 and 1974 public health services were the responsibility of local authorities, led by the Medical Officers of Health (MOsH). They were run as a tripartite service; through local government public health services, general practice and through administered hospitals. As noted by Rivett,3 ‘‘By 1968 MOH had a smoothly running empire, managing community nursing services, social work services, the aftercare of people who were mentally ill or handicapped, the ambulances and the child and school health services.’’ The new structures created a centrally dictated system in which community medicine synthesised some of its previous local authority roles with those of medical administration. Each ‘area’ was required to appoint an Area Medical Officer and designated specialists in community medicine (child health, social services liaison, and information and planning). Each ‘district’ (defined as the hinterland of a general hospital) had a District Community Physician. All of these jobs were only open to doctors and the terms and conditions, negotiated by the British Medical Association (BMA), were equivalent to clinical consultants. In Scotland, the posts, although having slightly different titles such as Chief Administrative Medical Officer, were also filled by doctors in public health. The focus of the work of these new health authorities was on developing and managing clinical services. Environmental health and social work remained the responsibility of local authorities and the wider areas of health promotion developed slowly and often uncomfortably, in the health care dominated structures.4 This arrangement fractured the relationship of specialists with those influencing the broader determinants of health and subsequent reorganisations saw the increasing identification of public health specialists with NHS managerial structures.5,6 Other parts of the profession continued to develop their separate identities within individual structures. Meanwhile whilst the working environment was changing there were differing levels of support for change within the three parent Royal Colleges. There was pressure to retain close links with
ARTICLE IN PRESS 422 clinical consultants, a title only adopted by public health doctors much later. There was particular concern about setting a precedent for mutual recognition for those who were not medically trained within the Colleges, although examples existed in other Colleges. At the same time, academic departments of community medicine were recruiting increasing numbers of statisticians, sociologists and researchers from a range of social and psychological science backgrounds. In spite of the high level of specialist skills of some of these colleagues, all academic departments were headed by doctors, a situation regarded as acceptable and appropriate since the departments were part of medical schools. The professional work environment for public health specialists continued to change with successive structural changes in the NHS. The managerial reforms of the 1980s and the separation of ‘purchasers’ of health services from their ‘providers’ left many public health professionals perceived by clinical and other colleagues as mere administrators, siding with management and often responsible for refusing funding for a new medical service. Service public health relationships with community based public health practitioners such as health visitors, school nurses, community development workers and environmental health officers were weakened. Academic public health colleagues, often focussing on epidemiology, were working in different environments unrelated to the day to day pressures of service practice. However, arguments were made7 that being close to the service funding decisions outweighed the disadvantages of isolation from clinicians, academic colleagues from a wider variety of backgrounds, communities and local authorities. With the preoccupation on structures and continual reorganisation of posts, there was little debate on broadening the membership of the Faculty. Within day to day work situations there was a general trend, not only in the UK, to assume that the problems of infectious diseases were less important and the investment in communicable disease control began to dwindle. This resulted in a lack of a common purpose and unification in the specialty, despite the wishes of many in the public health community who wished to promote a more coherent focus for public health practice which addressed root causes of ill health and was not tied so closely to the vagaries of management structures for delivering health services. Alarm bells eventually began to ring as events like Stanley Royd8 made it apparent that infectious disease control was dropping off the radar screen and capacity of
S. Griffiths et al. public health services was severely weakened. Donald Acheson’s report on public health in England,9 helped to refocus and revitalise the public health community particularly in relation to communicable disease control. His definition of public health: ‘‘The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.’’ acted as a unifying banner and the Faculty was renamed as one of Public Health Medicine (FPHM). Despite the re-embracing of the broader public health function both locally and at an international level, as reflected by the Ottawa Charter10, it was not until the early 1990s that the Faculty annual general meetings and board meetings regularly debated the possibility of opening up the membership to include all public health specialists. The first formal change was the introduction of honorary membership in 1991. The standards for honorary membership were high (publications were assessed and applicants were expected to have at least 10 years experience in a department of community medicine). The purpose of honorary membership was to include those holding senior academic and research posts, many of whom were teaching the junior public health doctors, and election of service based colleagues was extremely rare. Those elected were clearly outstanding, but there was ambiguity about the status conferred. It was not honorary since there was an annual membership fee and it was not membership since the honorary members were not allowed to vote nor to serve as full members of the board. However there was now a powerful synthesis of medical and non-medical voices within the Faculty calling for change. The establishment of the honorary members committee and representation on the board ensured that the pressure was maintained. As ever, timing was difficult with the NHS undergoing yet further restructuring in 1991. ‘Areas’ were abolished and many ‘district’ boundaries changed. Almost all public health doctors were required to re-apply for their jobs, if they were relatively unaffected by the changes, or else compete with their friends and colleagues for posts in the new structures. Many senior people took early retirement. The self confidence of those who remained was often undermined. The standing of the profession within medicine was diminished in some eyes, since it was clear that no clinical consultants would ever have been treated in this way. Unsurprisingly, morale was low. The impact on the move to multidisciplinarity was to create hesitancy amongst some of the more senior doctors and those in training who either had to compete for posts, or who were anxious about their future
ARTICLE IN PRESS Faculty of Public Health in developing a multidisciplinary public health profession employment prospects. In particular there was anxiety about the possibility of competition from well-experienced people without medical degrees, who might be employed to do the same jobs for a much lower salary. Whilst this could be described as medical protectionism it can also be understood in human terms. Those responsible for communicable disease control were particularly concerned, threatening to remove themselves from the Faculty and establish a separate clinically focussed body linked to the Royal College of Physicians of London. On the other side of the argument, there were many honorary members of the Faculty holding senior and influential positions, who argued that they should be fully welcomed and recognised within the profession and that it was time to end the glass ceiling that operated both in the Faculty and in health service employment.11 They contemplated establishing a new body for public health practitioners from all professional backgrounds, in competition with the Faculty. It was at this time that the independent Multidisciplinary Public Health Forum (MPHF) was set up as a temporary organisation with the aim of bringing about change.12 A survey of the views of the Faculty membership was carried out in 1996 and one of us (JC) had the unenviable task of announcing the results, rejection of opening examinations and full membership to non-medical colleagues, to the second national conference of public health professionals, which led to the establishment of the MPHF.12 As a result of this survey, the Faculty board decided that it would be unwise to take a formal motion to the annual general meeting, fearing that defeat would be likely and would prejudice further efforts in the foreseeable future. A vote in 1998 showed some change. The proposal to open membership to non-medical colleagues on an equal basis was rejected, but there was support for opening ‘part one’ of the membership examination.a Successful non-medical candidates could not proceed to ‘part two’, but would be awarded Diplomate status within the Faculty. This encouraged the board to put a formal motion to the annual general meeting in 1998 which, to the relief of the President (JC), was approved without any a Trainees were required to sit the FPH Part I membership exam between one and two years after starting their training programme and the Part II exam six to nine months later. Part I tested knowledge of the skills while the Part II exam demonstrated that trainees could translate their knowledge effectively into practice. Trainees were also subject to ongoing assessment in the workplace. See the Exams section of the Faculty website for further details.
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significant opposition. It is interesting to note that previously there had been a Diploma in Epidemiology which was open to all, but as this had no real standing and did not give successful candidates any role or continuing relationship with the Faculty, a mere handful of people had taken it and it had not had any impact. Further progress was made in 2000 when a postal ballot supported opening membership. This was confirmed at the annual general meeting in Scarborough and non-medical public health professionals then became eligible to take the examinations and, if successful, to enjoy all the rights of membership. This meant that, when in 2002 yet further reorganisation was introduced to the NHS, public health specialists from all backgrounds could be appointed as directors of public health (DsPH) within the newly established primary care trusts. The category of honorary membership by assessment was now redundant and was discontinued. Subsequently it was agreed that all members should be equally eligible to proceed to the ‘fellowship’ and the criteria for all categories of membership have now been revised and all members, independent of their specialist background, may stand for all posts within Faculty elections. On 24 June 2003 the Faculty changed its name to the Faculty of Public Health (FPH). This change marked official recognition that, whilst doctors have an important contribution to make to improving the public’s health, so too do other skilled specialists in the professional community. What should count to the public is each member’s level of competence and skill to work in public health. The FPH became the specialist professional organisation committed to supporting and maintaining standards of public health practice for all specialists. In doing this, emphasis was placed on the inclusive definition of multidisciplinarity; not doctors and ‘others’, but doctors as one of a key group of professions who can be specialists in public health.
Professional registration As for any professional group, it is important to safeguard the public through both regulation and registration. At the same time as the Faculty was restructuring itself as a multidisciplinary organisation, developments were also taking place in professional registration. In 1997 the ‘Tripartite Agreement’ was drafted and signed by the FPHM, the Royal Institute of Public Health and Hygiene and the MPHF, to take forward the development of multidisciplinary public health.12 After a comprehensive scoping study13 and extensive development
ARTICLE IN PRESS 424 work by the Tripartite Group and by Skills for Health, the UK Voluntary Register for Public Health Specialists (UKVRPHS) was established as an independent body in 2003, formally announced by a ministerial statement at the UK Public Health Association conference in March of that year. The establishment of the voluntary register provides the framework for the regulatory functions of public protection and formal recognition of professional status for public health specialists, mirroring the work of other regulatory bodies such as the General Medical Council for doctors and the Nursing and Midwifery Council for nurses. The standards of practice are based on the ten areas of specialist practice agreed by both the FPH and MPHF as the basis of training. The code of conduct, ‘Good Public Health Practice’, adapted from ‘Good Medical Practice’, underpins the ethical expectations of the public health specialists.14
Specialist training Entry to common pathways of specialist training now exists for a diverse workforce from a wide range of backgrounds, all of whom need to achieve common recognised and validated standards of professional practice. The framework for specialist practice1 has been established through extensive discussions with a variety of professional groups as well as discussion with other countries. The framework is based on the ten key areas of specialist practice which were derived in consultation with a wide variety of specialists and agreed with the four Chief Medical Officers in England, Scotland, Wales and Northern Ireland in June 2002. The 10 key areas of specialist practice: 1. Surveillance and assessment of the population’s health and well-being. 2. Promoting and protecting the population’s health and well-being. 3. Developing quality and risk management within an evaluative culture. 4. Collaborative working for health. 5. Developing health programmes and services and reducing inequalities. 6. Policy and strategy development and implementation. 7. Working with and for communities. 8. Strategic leadership for health. 9. Research and development. 10. Ethically managing self, people and resources.
S. Griffiths et al. These 10 key areas form the basis for all the Faculty’s professional activities and provide a comprehensive framework for generic public health competencies. They form the basis for the creation of the UKVRPHS. In conjunction with the Faculty’s guidance ‘Good Public Health Practice’,14 these ten key areas set the professional framework for training, continuing professional development, appraisal and potentially for revalidation
Conclusions The changes that took more than a quarter of a century are welcome. Public health demands able, well trained professionals from many disciplines if it is to have the impact on population health and well being that we all strive for. However, there is still much to be achieved if the full potential of multidisciplinary public health is to be realised. The progress that has taken place is leading towards a public health workforce with rich and diverse skills, from a wide range of backgrounds, yet with a common core of public health sciences, theory and practice. There have been examples of opposition, prejudice and ignorance yet this has been matched by a clear commitment from many that the direction of change within the Faculty was both appropriate and necessary. Further challenges exist. For example, the introduction of changes in medical training through the creation of the Postgraduate Medical Education Board and the impact of European directives have meant the Faculty has had a key role to play in alignment of specialist standards, not only between those from different professional backgrounds, but those trained in different nations. As successive presidents we reflect not only on the steps made but those still needed. We know the efforts made by many to reach this point, and urge that, despite constant health service reorganisations, the profession continues to develop the true potential of multidisciplinary public health to address the global challenges to improve population health.
References 1. www.FPH.org.uk (accessed February 2007). 2. Working Party, Proposed Faculty of Community Medicine. Proposals under discussion with the Royal Colleages of Physicians in London, Edinburgh, Glasgow, fifth draft, WGH papers, January 1970. Quoted by Warren M. The Origins of the Faculty of Public Health Medicine, London: Faculty of Public Health Medicine; 2000. p. 91.
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