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A new model for public health medicine?

With the Crowe Horwath report on public health doctors finally published, Niamh Cahill examines what its recommendations mean for the future of the specialty and whether they will be accorded the status of ‘consultant’ after years of campaigning

Minister for Health Simon Harris recently declared that the specialty of public health medicine “needs to be substantially reformed and strengthened”.

Minister Harris was speaking as he announced the establishment of an implementation oversight group to put in place “a new model of public health medicine” in Ireland.

His declaration and the establishment of such a group are hugely significant developments for the specialty following years of campaigning by doctors.

Yet what new model will evolve and, crucially, whether consultant status will be awarded to public health specialists in the future, remains to be seen.

The future of the specialty, which is severely hampered by staff shortages, hinges on the introduction of major transformation in public health.

Dogged by a lack of development and reorganisation for decades, the specialty is now entering a critical phase. Is the tide finally turning for public health?  

Urgent action

According to the HSE, almost one-quarter of public health consultants are due to retire in the next five years.

There are currently 99 directors, specialists and specialist registrars in public health medicine in Ireland; 23 of these will have retired by 2023.

Ireland needs to dramatically increase the number of public health personnel in the coming years to meet growing demand.

However, it will not achieve this without drastic action from the Department of Health on a number of fronts, not least the introduction of consultant status for public health specialists.

The Crowe Horwath Report on The Role, Training and Career Structures of Public Health Physicians in Ireland was finally published in December. The delay in publishing the report, which was completed in April 2018, was a source of huge frustration for public health doctors. In November, the IMO balloted members on industrial action due to the delay.

The action, supported by 100 per cent of public health doctor members, sought consultant status for all specialists in public health medicine to eliminate the gross pay inequality.

Three years ago, the IMO calculated that specialist-trained public health doctors earned 58 per cent of other specialist colleagues, but this has now reduced to 44 per cent.

The Crowe Horwath report warned that “large cohorts of the profession are due to retire within the next five-to-10 years, representing a considerable challenge to the public health system”.

It said that “simply replacing retiring public health doctors on a like-with-like basis will mean recruiting 40 new entrants to the workforce over the next five years”.

Anomalous position

Public health in Ireland sits in a somewhat unusual position. Public health specialists undergo the same higher specialist training as their consultant colleagues in other specialties, yet they do not enjoy consultant status. This is unlike other European countries.

Mr Val Moran, IMO Director of Industrial Relations, General Practice, Public and Community Health, believes the status issue may have “evolved organically”.

“There was, I suppose, a thought that public health was not clinical or patient-facing, even though it can be, but largely it’s not, therefore that would not accord them consultant status on that basis,” Mr Moran told the Medical Independent (MI).

Mr Val Moran

“But in most other jurisdictions they have a recognised role of consultants in public health medicine. It’s a largely female-dominated profession as well. I’m not sure if historically that has anything to do with it.”

Dr Mary O’Riordan, Specialist in Public Health Medicine, works in the area of health protection and infectious diseases at the Health Protection Surveillance Centre (HPSC). She is also a member of the IMO public health committee.

According to Dr O’Riordan, public health physicians are a diverse group, which can make it difficult for people to understand and recognise how they are defined.

“That’s why as an identity it can sometimes be quite challenging to distil it down to something for people to grasp what we actually do,” she told MI.

She believes it is interesting that “the most female-dominated specialty in medicine, which is public health, is the one that does not get recognised as equal in terms of consultant status”.

“I also think it’s because of the preventative element. If you prevent something it almost doesn’t seem like a service. But if you take good, robust public health away from a health system it causes so many problems,” Dr O’Riordan said.

Dr Mary O’Riordan

“We’ve been working away with what we can do with the narrow mandate we have and actually doing quite a good job in one sense. We have been trying to hold the fort together, but there comes a time when you want to have the power to gain the resources to ensure you’re doing as good a job as possible. Public health has always suffered in a way from that preventative element, when it’s not there and it’s not seen it’s almost like it’s not going to be resourced.”

Ultimately, public health physicians are “looking for the ability to be able to perform our job to the highest possible standard; to do the job we were trained to do”, she underlined.

Industrial relations discussions

The current review process stems from the Strategic Review of Medical Training and Career Structure Working Group (MacCraith Review).

On foot of this review, the Crowe Horwath report into public health medicine was commissioned.

Given its recommendations and advice on the need for action in developing the specialty, the IMO is increasingly eager to achieve improvements.

“We are anxious that it doesn’t become just another report on the shelf gathering dust and in fairness to the Department [of Health] they are working positively on it,” Mr Moran said.

In a recent update, the IMO informed public health doctors that the “working group must now begin its deliberations on the structural reform of public health and as this progresses, discussion must commence with regard to consultant status”.

“It is recognised that in any structure there would need to be flexibility and posts of differing levels of responsibility and remuneration, but all SPHMs should, in the view of the IMO, be accorded consultant status and contract,” the update stated.

“The IMO will be holding specific sessions with invited speakers on this issue at our AGM in Killarney in April this year and all public health members are encouraged to attend to discuss and give their views. We will be meeting the Department of Health again prior to the AGM and will update members further at that point.”

According to Mr Moran, the IMO is seeking a structure that will enable public health physicians “to take on leadership roles, manage multidisciplinary teams and generally operate at the top of their license using their qualifications and experience”.

“The key point is they undergo higher specialist training the same as any consultant would. They are on the specialist register, yet they are the only group that aren’t recognised as consultants despite undergoing higher specialist training. If you look at other jurisdictions, the NHS in the UK, Canada, New Zealand, they all have a role for consultants in public health medicine. They would operate on the same contract as any other consultant would.”

He believes the next year will be critical for the future of the specialty.  The current process will take at least a year, possibly 18 months. However, the IMO hopes talks will “be fairly far advanced” by the end of 2019. 

“We hope there will be a positive outcome that will see a restructured public health function to operate to the best of its abilities rather than constrict it,” Mr Moran said.

Lack of visibility

Public health medicine suffers from a lack of visibility, not only among clinicians, but also among the public, commentators have suggested. 

Dr O’Riordan believes this represents a “problem” for the specialty, which needs to be addressed by the Department of Health.

“People don’t even know that this exists and that it’s a training programme you can do. I think that’s a major problem. If you’re not seen then how can you even get to the point of [the specialty] being attractive or not attractive.”

Chair of the IMO public health committee, Dr Ina Kelly, works in the area of environment and health as a Specialist in Public Health Medicine.

She is also Chair of the HSE’s public health medicine environment and health group, which provides expertise, leadership, support and advice on environment and health issues in Ireland, including risks from biological, chemical and radiological hazards. The group aims to support the implementation of the medical officer of health function at regional and national level, providing for health protection and health improvement relating to environmental influences on health.

Dr Ina Kelly

In order to increase the visibility of the profession, education, awareness and information dissemination needs to improve, she said. 

Dr Kelly told MI that during healthcare restructuring in the past “there was an underestimation of what public health brought, a misunderstanding by the health services themselves and they didn’t understand that when they restructured and changed things that they were going to lose something”.

“I don’t know that public health itself really informed the planners in a comprehensive enough manner to ensure that the impact of change had been considered properly,” she said.

Scally report

The decision to finally address the challenges faced by the specialty was perhaps given added impetus by the CervicalCheck controversy and the subsequent report by Dr Gabriel Scally.

The implementation oversight group, led by the Department of Health, will include representation from across the HSE, including from the National Cancer Control Programme and the National Screening Programme.

It will also have representation from HIQA, the National Cancer Registry, the Institute of Public Health in Ireland, the RCPI and academia.

Minister Harris has said this “wide representation” reflects Dr Scally’s recommendation, which states that the skills of public health physicians should be more appropriately deployed across all public health programmes so that they contribute at leadership level across the health service.

The Scally report emphasised that there should be greater public health involvement in areas like screening and cancer control, and other aspects of the health system, which do not currently have as much public health involvement as they should.

The recommendation by Dr Scally was a watershed moment for public health physicians who have been fighting for greater recognition for the specialty for years, according to Dr O’Riordan.

“I was delighted [with his comments]. When you’re trying for so long to be heard and when you see someone acknowledge what we’ve been saying for a long time and to really reinforce this… the whole idea that a recognition of strong public health medicine will prevent us going down certain roads we’ve gone down in the past… For him to say that out like that… was very satisfying… It was very reassuring to us that there is some sense of a mindset change and an acknowledgement this is an area that needs to be addressed.”

Staffing

Public health, which needs to dramatically increase recruitment levels, is already suffering from an acute staffing shortage.

“We are very short-staffed so everything we do is not as comprehensive as we would like,” Dr Kelly said.

“There has been almost no public health medical involvement in health service improvement, which is why things like CervicalCheck were left without any operational public health involvement. It’s the same with a lot of services out there. A lot of the screening services don’t have it either even though screening would be considered a public health programme. Bit by bit we’re trying to get back into those programmes. I don’t know what happened, but for a long time it seems to have been forgotten about.”

Because of ongoing staffing problems at the departments of public health nationally, work mainly centres on the investigation and the control of infectious diseases.

Dr Kelly explained that the staff shortages have meant public health planning has been lacking. With the reform process now underway, she hopes public health specialists could begin to get more involved in planning and be more active in advising planners on health impacts.

Mr Moran agrees that employment levels within public health are low and action is needed to make the specialty more attractive.

“According to our figures the levels of staffing are not what they should be. Clearly in order to make the specialty attractive, particularly for the SpRs and to ensure they remain in the jurisdiction once they finish the training scheme, it’s essential they can see a clear career path that would put them on a par with their colleagues on other higher specialist training schemes. It’s essential for the future of the specialty that pathway is seen when coming out of training. If it’s not you lose the brightest and best,” he said.

Consultant status

The Crowe Horwath report recognises the need for consultant status within the profession. Why is this status so important for the progression of the specialty?

According to Dr Kelly, the current structure and situation “is extremely frustrating” because of a “massive anomaly”.

“I’m not employed to do the job I’m doing. I do the job because it needs to be done, but I’m not employed to do it,” she explained.

“The State has to recognise it is under-employing us to a terribly poor extent. We would step up a lot more if we were properly employed to do the job we’re trained to do and want to do.”

“We all want to work to the full extent of our license, but we need to be employed and facilitated to do so.”

She believes consultant status is a necessary part of enabling specialists to work to the full extent of their license.

Dr O’Riordan said, upon qualification, public health doctors seek to “drive change”, but become hampered because they do not have access to a multidisciplinary team, unlike their clinical colleagues.

“You’d never ask a surgeon to anaesthetise a patient as well, but sometimes with public health it seems like we have to be all things at all times, but there isn’t enough people and there isn’t enough of a multidisciplinary team supporting the work that public health has to do,” she said.

“We’re trying to get the multidisciplinary team mindset into public health so that you can have statisticians and health economists and other specialties all feeding in and bringing forward robust evidence and bringing forward interventions to benefit us all.”

Future

Despite the challenges, however, Dr Kelly believes public health is one “of the most intellectually stimulating jobs you could do in medicine”.

Dr O’Riordan concurs, stating “with public health medicine there is something attractive in the fact that you could make a difference to a large group of people”.

“The frustration is that (a) you’re not seen as equal. Nobody wants to feel they do exactly the same training and they come out the other end and they’re seen as ‘lesser than’. Nobody wants that and I think that has been a big barrier to attractiveness.

“[And] (b) surprising and all as this sounds… Ireland does train their public health doctors to a high level. The Crowe Horwath report looked at all of that [to examine] if we had a very good training programme. To come out after all those years and putting all that money into it and then not being able to bring forward all the changes you know are needed, that’s very frustrating. That’s why it’s not attractive in my view.”

Dr O’Riordan is seeking consultant status in order to be seen as a “leader in the area” of public health. She is anxious, like many of her colleagues, that the review process will lead to a positive outcome for the specialty.

“A country that has a strong public health backbone is a country that has a healthy population. There is no question about it, the amount saved if you have strong public health means you don’t have to go down the road of dealing with chronic illness and sickness in that way because you have already done work upstream,” according to Dr O’Riordan.

“I think the country deserves to have strong investment in public health medicine.”

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