Intended for healthcare professionals


Plans for public health in England are confused, warn MPs

BMJ 2011; 343 doi: (Published 01 November 2011) Cite this as: BMJ 2011;343:d7099

Re: Plans for public health in England are confused, warn MPs

Public health practice has a long and proud history in England. Not just the heroic activity of a celebrated few- Chadwick, Snow or Jenner- but in the structure and organisation of the whole public health system. Today, this public health system operates across three domains: health protection, health promotion and health services public health (1).

Last week's critical report on the public health reforms by the health select committee demonstrates the reservations that a group of informed, cross party politicians have about the changes (2). We would go further and suggest that the government reforms threaten this system at every level. What started as laudable commitment to public health (3) has finished in a piece by piece erosion of each part of the system.

The health protection function is led by the highly regarded Health Protection Agency (HPA). The HPA faces losing expert capacity and independence (4). The proposal to house it within central government will compromise objective communicable disease control - running the risk of the organisation being subject to the whim of politicians. It also jeopardises the ability to generate independent grants for epidemiological research.

Health promotion functions are transferring wholesale to local authorities, but possibly without the accompaniment of a specialist and statutorily regulated public health workforce. Directors of Public Health will be based in these settings and will require independence, as well as skilled, qualified and regulated staff and control of ring-fenced budgets. All are under threat.

Health services public health faces oblivion - a disastrous situation for a specialty with expertise in commissioning, healthcare intelligence and economics, and design of evidence-based healthcare systems. Many of these specialists help make the tough decisions about rationing and allocative efficiency that keep the NHS ahead of its international peers (5).

Knowledge of the destructive nature of these changes is reinforced by evidence of an attack on employment. This is despite the recent instruction of the Chief Executive of the NHS to protect the public heath workforce (6).

Data on advisory appointments committees (which occur for every post) held by the UK Faculty of Public Health show that while there were approximately 131 and 106 appointment processes in the period January to July of 2008 and 2009 respectively, this figure fell to approximately 72 in the equivalent period in 2010 and 35 in 2011 (7).

In financial year 2010/2011 only a third of public health registrars at end of training secured substantive full time consultant posts (8). The creation of this lost tribe represents an astounding waste of money and loss of skills. Specialist training is broad, but not simple. Highly competitive to enter (with 7 applicants for each place) (9), progression is not a formality - the first stage professional exams had a pass rate of 29 to 56% between 2008 and 2011 (10).

There is no protection to be found in academia either. The number of full time equivalent public health lecturers has fallen by more than 76% from 2000 to 2010 (11).

It's hard to know whether these employment data represent a conscious attack on the profession, by those looking to devour 'low hanging fruit', or are the unintended consequences of a reform so hurried and poorly coordinated that it has allowed one of the fundamental pillars of our health system to be sidelined and fragmented.

Public health specialists work tirelessly, inconspicuously and conscientiously for long term societal goals. They believe in partnership not partisanship. If the country is going to get rid of its public health system, then let's do it by the mechanisms we all believe in - open debate, professional and public consultation, and by the will of parliament - not by stealth.


1) Faculty of Public Health. What is Public Health? London: Faculty of Public Health, 2011. Accessed 12th September 2011.

2) Limb M. Plans for public health in England are confused, warn MPs. BMJ 2011; 343:d7099

3) Conservative Party. A Healthier Nation. Policy Green Paper No. 12. London: Conservative Party, 2010.

4) McKee M, Hurst L, Aldridge R et al: Public health in England: an option for the way forward? Lancet 2011; 378: 536-39.

5) Davis K, Schoen C, Stremikis K, How the Performance of the U.S. Health Care System Compares Internationally. 2010 Update. New York: Commonwealth Fund, 2010.

6) Nicholson D. Liberating the NHS - managing the transition. London: Department of Health, 2011. Accessed September 12th 2011.

7) Unpublished data. Faculty of Public Health. Personal communication, Dr. Jeremy Hawker, September 2011.

8) Unpublished data. The National Public Health Training Programme Directors Group. Personal communication, Drs. Dan Seddon and Brendan Mason, September 2011.

9) Faculty of Public Health. Success Rates. London: Faculty of Public Health, 2011. Accessed September 12th 2011.

10) Faculty of Public Health, Part A result archive. London: Faculty of Public Health, 2011. Accessed September 12th 2011.

11) A Survey of Staffing Levels of Medical Clinical Academics. 2011, Medical Schools Council: London.

Competing interests: FG and DN both work as public health registrars in the NHS.

09 November 2011
Felix C Greaves
Public Health Registrar
Douglas J Noble
London Deanery