Personal Views: Changing titles
Authors: Sam Ramaiah
Journal: BMJ (2006)

Another season of reorganisation hits the NHS, and over the next few months many public health doctors will be anxiously wondering where their future lies—assuming they have one. This is a time when the government wants the public health sector to lead on the implementation of its white paper Choosing Health and to be involved in its much heralded new initiative of “practice based commissioning.” What we need, therefore, is stability not disruption. Why are we in this position, and why haven't we learnt lessons from other recent reorganisations?

Public health doctors are in the front line of any reorganisation in the NHS, and many end up having their job title and content changed as a consequence. How many other types of doctor in the NHS are affected every 3-5 years by organisational disruption such as this? Very few, if any.

Some years ago a colleague was affected by an internal reorganisation, and not being able to retain his post he was told by the chief executive to “change the title.” He was astonished that no procedure existed to support him either to help reposition himself in the restructured organisation or to create career opportunities for him to move on. Neither option was available, so a highly experienced colleague retired. Many experienced and skilled professionals have left the NHS in this way in successive reorganisations at a time when the Department of Health wishes to expand the public health workforce.


Public health doctors are in the front line of any NHS reorganisation


I am sure things have improved since this episode, and greater attention is now given to the human resource aspects of reorganisation, although this may not be much comfort to public health doctors affected by the current disruption. Of course, the effects are not just on individual doctors but also on a range of public health measures.

Primary care trusts were created some three years ago, and many have become effective health organisations by establishing relationships with local authorities, voluntary agencies, and groups of citizens. It takes a long time to build partnerships and agree common agendas. What is likely to happen in the current scenario is that achievements will be delayed, progress slowed, and unnecessary anxiety generated.

How can the NHS avoid this uncertainty? Several ways are worth considering, and some solutions have been implemented elsewhere or applied to a subspecialty within public health. One solution is to create a national public health service whereby public health doctors are employed by a national agency and their services are subcontracted to a local health agency, such as a primary care trust. This avoids the periodic disruption of reorganisation both in terms of doctors' employment and their continuing contribution to health improvement. This suggestion is not a new one: such a system has been successfully implemented in Wales, and the Health Protection Agency in England has similar arrangements. The disadvantage may be a lack of local accountability, but robust contractual obligations can overcome this.

Another solution may be to increase the workforce. A number of major new NHS initiatives have led to greater demands on the already stretched public health function. These stresses are exacerbated by reorganisation. Not only would increasing the public health workforce absorb the many public health doctors affected by organisational change, but it would send a strong message highlighting the importance of public health medicine. Anecdotal reports indicate that public health specialists wish to train only in communicable diseases, as this offers relatively stable employment in the Health Protection Agency. But public health is necessarily multidisciplinary. To remain truly multidisciplinary the specialty needs to attract a sufficient number of graduates into its training programmes. Uncertainty generated by reorganisation is a deterrent.

The Faculty of Public Health continues to have an important role in the survival of the specialty. It has participated in discussions in redefining and reshaping the public health workforce. However, like the royal colleges the faculty's main role is in setting standards and overseeing and maintaining educational requirements, and so its role is limited with regard to issues of reorganisation.

Although my concerns relate mainly to the future of public health doctors, the wider NHS faces a major conundrum. The Wanless report recommended more resources for preventive activities. With the introduction of practice based commissioning and patient choice the danger arises that prevention might become an afterthought. Prevention is everyone's business; for too long public health doctors have been its principal advocates. Preventive strategies depend on the survival of public health doctors as an effective force, and the time has come to ensure that these professionals are allowed to carry on their work in a stable environment, not in an uncertain and often disruptive one.