Peer Review An evaluation of a Public Health Practitioner registration programme
An evaluation of a public health practitioner registration programme: lessons learned for workforce development Authors Em Rahman School of Public Health, Health Education Wessex, Southern House, Otterbourne, SO21 2RU, UK Email: Em.Rahman@wessex. hee.nhs.uk Jane Wills School of Health & Social Care, London South Bank University, UK
Corresponding author: Em Rahman, as above
Keywords public health regulation; public health practitioner; public health registration; public health workforce development.
Abstract Aim: This article explores the lessons learned for workforce development from an evaluation of a regional programme to support the assessment and registration of public health practitioners to the UK Public Health Register (UKPHR) in England. Methods: A summative and process evaluation of the public health practitioner programme in Wessex was adopted. Data collection was by an online survey of 32 public health practitioners in the Wessex area and semi-structured interviews with 53 practitioners, programme support, employers and system leaders. Results: All survey respondents perceived regulation of the public health workforce as very important or important. Managers and system leaders saw a register of those fit to practise and able to define themselves as a public health practitioner as a necessary assurance of quality for the public. Yet, because registration is voluntary for practitioners, less value was currently placed on this than on completing a master’s qualification. The local programme supports practitioners in the compilation of a retrospective portfolio of evidence that demonstrates fitness to practise; practitioners and managers stated that this does not support current and future learning needs or the needs of those working at a senior level. Conclusion: One of the main purposes of statutory regulation of professionals is to protect the public by an assurance of fitness to practise where there is a potential for harm. The widening role for public health practitioners without any regulation means that there is the risk of inappropriate interventions or erroneous advice. Regulators, policy makers and system leaders need to consider how they can support the development of the public health workforce to gain professional recognition at all levels of public health, including practitioners alongside specialists, and support a professional career framework for the public health system. Introduction Public health reflects many of the tensions in debates about professionalisation.1–3 On the one hand, professionalisation can be seen as acting as a framework for good practice establishing rules and standards for training, practice and registration as well as the implementation of processes to tackle complaints and deal with disciplinary procedures and fitness to practise.4,5 It allows for an agreed title to be protected for individuals who are registered on a statutory register and enables regulators both to set standards for entry to practice and to remove
those who failed to meet those standards. On the other hand, professionalisation came to be seen in the 1970s as a project of self-interest in which market power is achieved through restricting supply of a workforce and enabling those allowed entry to command high salaries.6,7 Gabriel Scally in his review of the public health workforce denies that there is any economic consideration and states that ‘A move to statutory regulation is not intended to improve the standing or financial rewards for members of the profession’.8 In many countries, public health professionals are often physicians and therefore are already
Copyright © Royal Society for Public Health 2014 September 2014 Vol 134 No 5 l Perspectives in Public Health 259 SAGE Publications Downloaded from rsh.sagepub.com at DUQUESNE UNIV on July 9, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914544883
Peer Review An evaluation of a Public Health Practitioner registration programme
regulated.9,10 In these countries, public health workforce development has focused on defining the workforce and establishing the levels of competence to practise.11,12 Finland, Ireland, the United States and the United Kingdom were among the first countries with multiprofessional public health, and in these countries, the sheer breadth of those working in public health has stimulated debates about professional jurisdiction and regulation.13,14 In the United Kingdom, the requirement to be registered as working in public health has considerable variation. The UK Public Health Register (UKPHR) is an independent regulator that provides professional registration15 for specialists/consultants in public health from backgrounds other than medicine successfully completing training and those able to demonstrate competence retrospectively – to take account of those already in practice. Employers are then able to appoint to roles and posts with titles such as ‘public health consultant’ or ‘public health specialist’ those who have a protected title linking back to this registration.16,17 Statutory regulation with the Health and Care Professions Council (HCPC) for all public health specialists was recommended in a review in 2010,8 including public health alongside a wide range of other professional groups. At the same time, the current government is keen to reduce regulation, and the Hampton principles of regulation as expressed in ‘Enabling Excellence’18 are that regulation should be proportionate, accountable, consistent, transparent and targeted. Public health practitioners (PHPs) are those people in the public health workforce who spend much or all of their time in public health practice working at a minimum of level 5 of the Public Health Skills and Career Framework15 (PHSCF; Figure 1). They may work across the full breadth of public health from health improvement and health protection, to health information, community development and nutrition, in a wide range of settings from local government and the National Health Service (NHS) to the voluntary and private sectors.19,20
Figure 1 The nine levels of the Public Health Skills and Career Framework Level
Public Health Skills and Career Framework
1
Has little previous knowledge, skills or experience in public health. May undertake specific public health activities under direction or may acknowledge the value of public health in a wider context.
2
Has gained basic public health knowledge through training and/or development. May undertake a range of defined public health activities under guidance or may use knowledge to influence public health in a wider context.
3
May carry out a range of public health activities or small areas of work under supervision. May assist in training others and could have responsibility for resources used by others. May use public health knowledge to set priorities and make decisions in a wider context.
4
Has responsibility for specific areas of public health work with guidance, which may have a breadth and/or depth of application.
5
Has autonomy in specified public health areas, continually develops own area of work and supports others to understand it. May contribute to a programme of work in multi-agency or multidisciplinary environment.
6
Has autonomy and responsibility in coordinating complex public health work, reflecting wider and deeper expertise in own area of work. Able to develop, facilitate and contribute to programmes of work in multi-agency or multidisciplinary environment.
7
Has autonomy and expertise in a number of areas of public health. Will lead on areas of work within a defined field.
8
Has a high level of expertise in a specific area of public health work or across a substantial breadth of public health service delivery and/or programmes. Is accountable for work across boundaries and agencies. Has leadership responsibility and autonomy to act. Sets strategic direction in own area of work.
9
Sets strategic direction across organizations and/or areas of work. Provides multidisciplinary or multi-sectoral public health leadership that determines priorities. Works at executive level.
The term ‘PHPs’ is used in the United Kingdom to describe a level of practice – not a specific job role or type of job. Although they carry out key public health roles, many PHPs remain unregulated,21 and there is no obligation for those working as PHPs to register as a public health professional. Nurses (public health nurses, including health visitors and school nurses) must be registered with the Nursing and Midwifery Council and may choose to register via the Specialist Community Public Health Nursing (SCPHN) part of the register.22 Other PHPs are self-regulated by a voluntary scheme23 of the UKPHR that opened in 2011. Assessment of competence is done against standards developed
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by the UKPHR24 using the PHSCF15 (Figure 1) using a retrospective portfolio of evidence showing achievement against these standards. Pilot local programmes to support PHPs to register with the UKPHR were started in 2010 in NHS South Central, NHS West Midlands, Public Health Wales and Kent and Medway and later, West of Scotland, Bristol and North London with a locally devolved system of verifiers and assessors. Currently, there are 101 practitioners registered nationally on the UKPHR, 23 of who are from Hampshire, Portsmouth, Southampton, and the Isle of Wight. Each of the local programmes that provide a regulatory pathway for PHPs is varied in its structure although all
Peer Review An evaluation of a Public Health Practitioner registration programme
practitioners will be assessed against the Public Health Practitioner Standards. Table 1 shows how the Wessex PHP programme, for example, differs from other pilot programmes by providing a structured support programme commissioned from the Open University. The support programme consists of a one-to-one assessment with the practitioner in readiness to complete their portfolio for registration, followed by five portfolio development groups (PDGs) in the form of action learning sets. The support programme also includes a series of master classes and learning sequences that provide updates and the filling of any knowledge gaps that are identified as part of the one-to-one assessment for individuals. The Wessex scheme also provides mentoring support for individuals through its local Public Health Workforce Development Leads who are employed and located within local public health teams and existing assessors who have also been trained as mentors. In Wessex, 88 PHPs commenced the pilot support programme over three cohorts 2010–2012 (cohort 1), 2011– 2013 (cohort 2), 2012–2014 (cohort 3), and 23 (26%) have completed it to registration. These high levels of attrition prompted an evaluation to consider the lessons learned in relation to the regulation of the public health workforce.
Methods An independent evaluation team conducted a pluralist, multi-method approach, over a six month period that included the following: • A summative evaluation concerned with the assessment of achievement of the programme’s objectives and outcomes in relation to both support and training, and portfolio development leading to registration; • A process evaluation, concerned with the examination of how and why these effects came about, that is, the reasons behind the outcomes achieved, in terms of the identification of different
facilitating factors and/or barriers, including where relevant examination of issues related to organisational culture. The aim of the evaluation was to have a rounded view of the programme, and invited to take part were other stakeholders and system leaders (n = 12) identified as public health managers (n = 2), Directors of Public Health (n = 5), local authority department managers (n = 2) and those responsible for workforce development (n = 3). Also invited to participate were those providing support to the programme as learning support providers (n = 4), mentors, verifiers or assessors (n = 31; some of them performed dual roles as mentors and assessors) and PHPs themselves (n = 88; PHPs who had started the practitioner programme). The 88 PHPs included those who had successfully completed registration (n = 23) and those who had not done so (n = 65). The evaluation also included a further six practitioners identified by the local workforce development managers, who were invited to participate and who had not taken part in the programme. Data collection was by an online survey of all PHPs in the area. All PHPs were sent an email inviting participation with a link to the online survey and sent a reminder after three weeks. Completion of the survey was taken as informed consent. The structured questionnaire had sections on recruitment and induction for the programme, preparation for registration, experience of the programme, impact on working life, views and actions on registration, the assessment process and support and feedback from the mentor and assessor. Semi-structured face-to-face or telephone interviews (depending on the participant’s preference) further explored motivations to be registered as a PHP, facilitators and barriers to becoming registered, the impact of registration on role and any perceived benefits. Semistructured telephone interviews on the regulation of the public health workforce and the impact of the programme in relation to work capability and
employability were also undertaken with managers, stakeholders such as those involved in workforce development, and public health system leaders, including Directors of Public Health and local authority department heads. The assessors, verifiers, mentors and learning support providers for the programme were also interviewed. All interviews were transcribed and the data were analysed by the evaluation team using a content analysis based on the questions asked.
RESULTS A total of 53 (N = 53) participants took part in the interviews and 32 PHPs completed the online survey (some PHPs may have completed the survey and an interview). This comprises an overall response rate of 63% of those identified to take part in the evaluation, as shown in Table 2. At the time of this evaluation, three cohorts had taken part in the scheme, with 23 out of a possible 88 practitioners registering with the UKPHR (26%). In all, 17 of these PHPs were from cohort 1, the remaining 5 were from cohort 2 and 1 from cohort 3. The programme is for practitioners who are expected to be working at a minimum of level 5 of the Public Health Skills and Career Framework, which is equivalent to an undergraduate degree level, and have at least two years’ public health related experience. Of those whose qualifications are known, many are working at a senior level: 18% have at least a master’s degree and 36.4% are working at level 7 or 8 of the Public Health Skills and Career Framework. A total of 25% of the PHPs worked in health protection, 25% in health improvement, 13% on lifestyles work in the NHS or local authority, 12% in smoking cessation, 12% in health intelligence and the others did not specify.
Views on the regulation and registration of the workforce Those PHPs completing the survey perceived regulation of practitioners as very important or important (100% of those registered, 80% of those not yet registered and 66% of those not on the
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Peer Review An evaluation of a Public Health Practitioner registration programme
Table 1 The Wessex Public Health Practitioner Programme and other local programmes Wessex
Kent, Surrey, Sussex (KSS)
West Midlands
West of Scotland
Wales
Scheme name
Wessex PH Practitioner Registration Programme
Kent, Surrey Sussex Practitioner Registration Support Scheme
West Midlands’ Public Health Practitioner Development Programme
UKPHR West of Scotland PHR Pilot Scheme
Portfolio Development Support Programme
Geographic region
Hampshire, Isle of Wight and Dorset
Kent, Surrey, Sussex West Midlands
Lanarkshire; Ayrshire Wales and Arran; Greater Glasgow and Clyde; and Highlands
Year scheme launched
2009/2010
2009/2010 – Kent and Medway
2011
2012
2009
2011/2012 – Surrey and Sussex Scheme Support Programme Induction day
Yes
Yes
Yes
Yes
Yes
1-2-1 session
Yes
No
On request
On request
With mentor
Focus of 1-2-1 session
To identify – practitioners learning and support needs.
To review an individual’s progress and support to complete.
Basic level support on specific issues identified by practitioner.
Introduction to programme; support and two-way management of expectations; and to promote the benefits of registration.
Mentorship
Yes
Currently in development.
On request
No
Yes
Up to 6
As many as required
–
Up to individual and mentor but recommend a minimum of 5
Mentor programme 4–6 sessions
PDGs/Learning sets
Yes (formal)
Yes (formal)
Yes (formal)
Yes (informal)
Yes (formal)
Number of PDG/ learning set sessions
5 sessions
Up to 8 groups over 24-month period
3 facilitated learning sets (encouraged to meet informally between sets).
–
4 sessions
Master classes
Yes
Yes
Yes
No
No
12–18 months
18 months
12–18 months
12 months
Practitioner 18–24 months completion time (as advised/ recommended)
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Peer Review An evaluation of a Public Health Practitioner registration programme
Table 1 (Continued)
Support programme provider
Wessex
Kent, Surrey, Sussex (KSS)
West Midlands
West of Scotland
Wales
Open University provides Induction Day; 1-2-1; PDGs and master classes.
No one provider.
Public Health Potential provides learning sets.
No official support programme. If learning needs become different in one cohort, then Boards may come together to offer training as appropriate/where available.
Professional and OD Manager coordinate, external consultants provide learning sets.
Scheme coordinator commissions master classes based on Higher Specialty Mentors provided by needs during initial Trainees deliver scheme coordinator. PDG. programme of 15 master classes MBTI assessment 3 different facilitators provided by scheme commissioned to Mentoring and coordinator. run portfolio coaching support development available through groups. Health Education West Midlands’ Mentornet and Coachnet
Programmes of support are established as necessary and taken forwards by practitioners with input from scheme coordinator if required.
Recruitment and Application form, Application form and Application form and Minimum criteria in selection process self-assessment and place. self-assessment self-assessment to PHP programme interviews against standards against standards. Employment in KSS. Application must be made with Minimum two years manager’s support. experience at level 5 of PHSCF or above. Application form to local scheme, where local coordinators discuss and make the final decision.
Advertise on intranet and Internet, bi-lingual guidance and supporting information; application pack including selfassessment.
MBTI: Myers Briggs Type Indicator; OD: Organizational Development; PDG: portfolio development groups; PH: public health; PHP: public health practitioner; PHR: Public Health Register; PHSCF: Public Health Skills and Career Framework; UKPHR: UK Public Health Register.
Table 2 Participation numbers Telephone/face-to-face interviews
Online survey (PHPs only)
Total
PHPs
27
32
59/88
Assessors, mentors and verifiersa
17
N/A
17/31
Other stakeholders and system leaders
7
N/A
7/12
Learning support providers
2
N/A
2/4
PHP: public health practitioners. aSix of the assessors were also involved in the mentor role.
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Peer Review An evaluation of a Public Health Practitioner registration programme
programme). Among the managers and system leaders interviewed, there was also a general consensus that registration was a public demonstration of a level of quality of service offered and provided external assurance that working to a certain standard ensures public health governance. Many also cited the transition of the public health function to local authorities as being at a time when it is vitally important to demonstrate that public health is a ‘profession’ and has certain practice and academic standards: It provides that professional cohort at a time when the local authority is trying to de-professionalise the profession…the whole profession is seen as too expensive because they do not value a public health practitioner in the same way they value a social worker. (Stakeholder) The programme was also seen as an important way of being clear about who the workforce is, within this new context: Without it there’s a danger that the workforce won’t be clear, that we won’t be clear who the workforce is. If the workforce isn’t clear there is a danger we’ll end up with public health work being undertaken by people who don’t actually understand it. (Workforce Development Strategist) PHPs and managers felt that completing the programme would not necessarily make a member of staff more competent or capable than another and nor did it particularly benefit the department. But there was a sense that completion of the programme offered a manager an assurance that a member of staff was able to reflect on his or her practice and that he or she was keen and committed: They would be able to evidence their competence. I don’t know if I would know their capability but I would know their competence because it’s signed off. (Director of Public Health)
Registration, the final outcome of the entire process of the programme, was met with mixed feelings by PHPs in interviews. There was a perceived discrepancy between the effort involved to achieve registration and the resulting output where there appeared few, if any, tangible benefits: For the amount they charge a year I would expect something other than having my name on a register. (Registered Practitioner) Some PHPs commented that a master’s qualification is more universally recognised in comparison to the registration, which currently is only recognised locally. Hearing negative feedback from colleagues that portfolio registration is time-consuming, that registration has no benefits and the feeling that it is not valued nationally has made the programme, as one practitioner stated, ‘a tough one to sell’ (and further explains the low numbers of practitioners who complete registration).
Views on the PHP programme In many of the interviews, registered PHPs and managers viewed the programme as one of professional development offering career opportunities. There was some frustration then that the programme did not ‘tell me anything I didn’t know’ and that it does not support current or future learning needs. While some found the retrospective nature of the portfolio route for registration by which a practitioner demonstrates competence through providing evidence of the achievement of a standard in practice as confidence-boosting, for others it did not provide a career framework: It’s back to front they wouldn’t have hired me to do the job if I didn’t know how to do it and then you hire me and then say prove that you know the information … (Non-Registered Practitioner) All the practitioners commented that the portfolio registration is:
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…a hugely onerous undertaking that is highly complex piece of admin as much as a reflection of personal achievement and outcomes that must be simplified if to be achieved by more staff at band 5 level. (Registered Practitioner – written survey response) Some PHPs saw the programme as sufficient to complete what they saw as an administrative task. Others had expectations of their mentor as a career development advisor while several mentors commented that they had little preparation for the role and felt they had simply been recruited because they worked at a senior level. Some PHPs commented on perceived inconsistency in the assessment of the commentaries that are provided by PHPs to demonstrate achievement of a specific standard. Opinions by PHPs on the various aspects of the programme were mixed. The level of learning of the K311 Promoting Public Health: Skills, Perspectives and Practice module25 was not perceived appropriate for some who expected it to be professional learning: You’re only learning from your own practice your own reflection. (NonRegistered Practitioner) Portfolio development groups (PDGs) are aimed at helping practitioners organise their evidence in preparation for submission to their assessor. Most practitioners found the learning set format frustrating and insufficiently tailored to individual needs and the specific work context of public health: I didn’t have time to take out of work to listen to people talk about their work. (Registered Practitioner) You need to understand the setting of the person, what they’re writing about, what their core area of work is …have a good background in public health yourself. (Programme SupportAssessor) Despite these reservations, 57% of registered practitioners who undertook the survey found that the support to
Peer Review An evaluation of a Public Health Practitioner registration programme
complete the portfolio was the most beneficial aspect of the programme.
Discussion The importance of regulation for the PHP workforce is gathering momentum and new programmes are being rolled out in many areas of England.26 The findings from this evaluation highlight key lessons that need to be considered in relation to ‘the product that is registration’ and in ensuring that a streamlined, relevant and efficient process is in place in order to support future PHPs in their journey to registration.
The product The Public Health Workforce Strategy acknowledges that practitioners ‘have a crucial role to play and deliver some of the most complex components of public health outcomes’.6 Yet, PHPs are only regulated on a voluntary basis although professional regulation is intended to sustain the confidence of both the public and the professions through improving and assuring the professional standards of health professionals. The protection of title that is a consequence of professional regulation was also seen by system leaders in this evaluation as particularly important as public health positions have moved from the NHS into local authority settings both to quality assure the workforce and also to promote it as a ‘profession’. This evaluation showed widespread support for the professional regulation of PHPs, and there are schemes being rolled out across the United Kingdom to support PHP registration. Since 2007, Wessex (then NHS South Central) was at the forefront of innovation exploring the development of PHPs.27 The development and piloting of the PHP scheme gained support from the then Regional Director of Public Health, along with all of the PCT (Primary Care Trust) Directors of Public Health, yet paradoxically the workforce itself does not yet support registration because it is seen as lacking teeth and voluntariness. In the absence of a statutory licence to practise, there is an important role for the employer. Employers can ensure that registration is included in job descriptions
and person specifications, making sure that registration is explored as part of the appraisal and personal development review (PDR) processes. Equally, marketing of the programme needs to be strategised to not only raise the importance of registration but also to help establish an inclusive public health workforce that recognises the contributions of a wide range of practitioners including those within local authorities. The PHP Programme is a programme to support practitioners towards registration. As such, it uses a retrospective assessment of competence. The Public Health Workforce Strategy talks about the need to develop career pathways for the public health workforce,11 and this evaluation has highlighted the potential for a developmental programme where individuals will be developing the skills and knowledge towards registration, similar to the five-year public health specialist training programme.28 The programme also assumes that those applying to become registered are already working at a minimum of level 5 of the Public Health Skills and Career Framework.15 Several individuals in Wessex have become registered as PHPs, although they are working at senior levels. While ‘advanced practitioner’ is a term sometimes used, there is no protection of this title. Advanced Nursing Practice has been widely promoted for many years, but this is seen as an individual’s career progression supported by prescribed competences, education and development and professional accreditation rather than by regulation.29
The process The Wessex PHP Programme process evaluation has highlighted the need for a structured and systematic process to be in place to support individuals’ journey to registration, as shown in Figure 2. The evaluation developed a quality framework based on the findings from the process evaluation, which identifies six domains.
Domain 1 – Quality The Wessex support programme has an administrator and a coordinator, and this
was crucially important in its implementation. The PHP workforce is part of Health Education England (HEE) and Local Education and Training Board (LETB) priorities (HEE mandate), and this cannot be achieved without core funding and resources. An investment in workforce development such as this means there should be annual management plans along with a monitoring process.
Domain 2 – Recruitment and Selection The high levels of attrition in the programme demonstrate a need to make clear the benefits, the time commitment and the process of the programme from the start, ensuring that individuals understand what is expected of them. The Wessex programme has ensured that strict adherence is maintained to the selection criteria in accordance with the UKPHR guidance30 along with a Wessex standardised application process, which includes an interview with the prospective applicant. A structured induction day has been introduced and a clear programme contract now needs to be signed off by the practitioner, his or her employer, support programme lead, mentor and assessor (at the assessment phase of the programme).
Domain 3 – Development/Support Programme Because there are different expectations of the support programme, clear descriptors of the different elements have now been included, and there are performance indicators for the externally commissioned support programme providers. Mentors who are senior public health professionals or registered PHPs are formally assigned to practitioners. They now receive training for the role, both in recognition of its importance but also as a development outcome for them, given the voluntary and time-consuming nature of their contribution. The evaluation identified a large group of ‘drifters’ who did not go on to register. Reports on individual practitioner’s progress are provided to the PHP programme management team in an effort to monitor timely progress to registration.
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Peer Review An evaluation of a Public Health Practitioner registration programme
Domain 4 – Assessment and Verification
Month 16
Month 17
Month 18
Final Submission
All assessors and verifiers are appropriately trained by the UKPHR, and regular and ongoing local training is provided in order to maintain skills and knowledge. As assessors and verifiers may not see many portfolios, it is important that regular and spot moderation takes place to ensure consistency.
Ongoing and regular supervision with Line Manager
Mentoring
Formal Review
Because many practitioners express frustration at a lack of perceived benefits from registration, the programme is linked more closely with appraisal and performance review processes. A local registration awards ceremony celebrates and recognises the professional registration of practitioners. Continuing professional development (CPD) maintains the currency of this registration.
Domain 6 – Evaluations of Learning This domain is focused around closing the loop, ensuring that feedback from all parties involved (practitioners, employers, support programme leads, assessors, mentors and verifiers) is captured to gather learning on how to improve the programme for future cohorts.
Conclusion
*Open University (OU; Support Programme Provider). †Myers Briggs Type Indicator (MBTI) assessment.
Master Class
Por olio Development Groups (PDGs) x 5 OU* 1-21 MBTI†
Apply for Mentor
Formal Review Apply for Assessor
Month 9 Month 8 Month 7 Month 6 Month 5 Month 4 Month 3 Month 2 Month 1 Induc on
The journey to registration as a public health practitioner in Wessex
Figure 2
Month 10
Month 11
Month 12
Month 13
Assessment
Month 14
Month 15
Domain 5 – Registration and Continuing Professional Development
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Workforce development is both a technical and political exercise, that not only builds capacity but also requires the building of trust among the public and stakeholders. This trust assures competent performance but also for the professionals, clear understanding about their own fitness for award, practice and purpose. Public health in England is now working in a radically new system as a result of the Health and Social Care Act which transferred the function to local authorities that work across many of the social determinants of health such as education, housing and planning.31 The recognition of public health as a profession that requires a specific set of technical skills and knowledge in order to improve health outcomes at a population level is even more important as otherwise public health can be seen as a function that any practitioner could do.
Peer Review An evaluation of a Public Health Practitioner registration programme
Statutory regulation for the specialist workforce has been recommended;6,8 however, the public health workforce is not just at this level. The current voluntary nature of the scheme for practitioners was perceived in this evaluation to lack influence and accounts for the high levels of attrition from the support programme. In order to ensure a consistent and quality-assured workforce at practice level, both practitioners and system leaders supported statutory regulation for practitioners. There remains a gap between the practitioner registration for those working at level 5 and the specialist registration for those at level 9. This evaluation showed that a section of the public
health workforce are applying to be level 5 registration practitioners in order to gain that formal recognition of a profession even though they may be working at higher levels. Regulators, policy makers and system leaders need to consider how they can support this section of the workforce to gain professional recognition at the level they are working at (advanced practice).
Acknowledgements We are particularly grateful to Sabrena Jaswal who collected the data for this evaluation and made a major contribution to the project report. We also wish to thank the PHPs; all those who gave their time and expertise to support the Wessex
programme by being mentors, assessors or verifiers; the learning support providers and local managers and system leaders who provided detailed comments in interviews and the survey.
ETHICAL APPROVAL This study was reviewed by the London South Bank University Research Ethics Committee (University Research Ethics Committee (UREC) 1322 number) in 2013 and was identified as service evaluation; therefore, additional research ethics approval was not required.
Funding This evaluation was funded by the School of Public Health, Health Education Wessex.
References 1.
Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. London: University of Chicago Press, 1988. 2. Parsons T. The Social System. London: RKP, 1951. 3. Evashwick CJ, Begun JW, Finnegan JR. Public health as a distinct profession: Has it arrived? Journal of Public Health Management and Practice 2013; 19(5): 412–9. 4. Department of Health. Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century. London: The Stationary Office (TSO), 2008. 5. Zurn P, Dal Poz MR, Stilwell B, Adams O. Imbalance in the health workforce. Human Resources for Health 2004; 2: 13. 6. Larson M. The Rise of Professionalism: A Sociological Analysis. Berkeley, CA: University of California Press, 1977. 7. Johnson T. Professions and Power. London: Macmillan, 1972. 8. Department of Health. Review of the Regulation of Public Health Professionals. London: The Stationary Office (TSO), 2010. 9. Bjegovic-Mikanovic V, Vukovic D, Otok R, Czabanowska K, Laaser U. Education and training of public health professionals in the European Region: Variation and convergence. International Journal of Public Health 2013; 58: 801–10. 10. Beaglehole R, Dal Poz MR. Public health workforce: Challenges and policy issues. Human Resources for Health 2003; 1(1): 4. 11. Czabanowska K. Shaping and authorising a public health profession. PhD Dissertation, School of Public Health, Faculty of Medicine, University of Belgrade, Belgrade, 2014. 12. Frank MW, Weihofen A, Schmucki MD, Nocera S, Paccaud F. Public Health Workforce in Switzerland: A National Census. Swiss School of Public Health, 2013. Available online at: http://www.ssphplus.info/files/v2_public_ health_february_2013b.pdf (Last accessed 14th May 2014). 13. Starr P. Professionalization and public health: Historical legacies, continuing dilemmas. Journal of Public Health Management and Practice 2009; 15(6): 26–30.
14. Evans D. ‘Taking public health out of the ghetto’: The policy and practice of multidisciplinary public health in the UK NHS. Social Science & Medicine 2003; 57: 959–67. 15. General Medical Council (GMC). Memorandum of understanding between the Joint Board of the UK Voluntary Register for Public Health Specialists and the General Medical Council. GMC, 2004. Available online at: http://www. gmc-uk.org/about/partners/joint_board_ukvol. asp (Last accessed 6th May 2014). 16. Department of Health. Healthy Lives, Healthy People: A Public Health Workforce Strategy. London: The Stationary Office (TSO), 2013. 17. Council for Healthcare Regulatory Excellence (CHRE). Protecting the Public from Unregistered Practitioners: Tackling Misuse of Protected Title. London: CHRE, 2010. 18. Department of Health. Enabling Excellence – Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers. London: The Stationary Office (TSO), 2011. 19. Public Health Online Resource for Careers Skills and Training. 2010. Available online at: http://www.phorcast.org.uk/ (2010, Last accessed 13th November 2013). 20. Wright J. PHORCaSTING insights on public health careers. Perspectives in Public Health 2011; 131: 20–1. 21. Somervaille L, Griffiths J, Mitchell L, Clark Z. Developing a regulatory pathway for public health practitioners. Report to UK Public Health Register Board, May 2009. Available online at: http://www.workforce.southcentral. nhs.uk/pdf/WESS_PH_report_may_09_ 20090519.pdf (Last accessed 19th July 2014). 22. Nursing & Midwifery Council. Specialist Community Public Health Nursing. 2004. Available online at: http://www.nmc-uk.org/ Nurses-and-midwives/Regulation-in-practice/ Specialist-community-public-health-nursing/ (Last accessed 15th October 2013). 23. UK Public Health Register (UKPHR). Development of Regulation for Public Health Practitioners: Further Consultation on Assessment Process. Birmingham: UKPHR, 2009.
24. UK Public Health Register (UKPHR). Public health practitioner standards for registration. UKPHR, 2009. Available online at: http://www. publichealthregister.org.uk/sites/default/files/ Practitioner_Standards_0.pdf (Last accessed 15th October 2013). 25. Open University. K311: Promoting public health: Skills, perspectives and practice. 2010. Available online at: http://www.open.ac.uk/ courses/modules/k311 (Last accessed 3rd December 2013). 26. UK Public Health Register (UKPHR). Newsletter, Spring 2014. Available online at: http://ukphr. org/sites/default/files/Spring%202014%20 Newsletter.pdf (Last accessed 25th April 2014). 27. Zolle O, Chapman-Andrews J. Evidence of the need to develop practitioners for a coherent public health workforce. Report for NHS South Central, 2010. Available online at: http://www. workforce.southcentral.nhs.uk/pdf/Evidence_ of_the_need_to_develop_practitioners_for_a_ coherent_public_health_workforce_Oct_2010. pdf (Last accessed 18th July 2014). 28. Faculty of Public Health (FPH). Public health speciality training. 2006. Available online at: http://www.fph.org.uk/specialty_training (Last accessed 25th April 2014). 29. Royal College of Nursing. Advanced Nursing Practitioners. 2012. Available online at: http:// www.rcn.org.uk/__data/assets/pdf_ file/0003/146478/003207.pdf (Last accessed 3rd May 2015). 30. UK Public Health Register (UKPHR). Public Health Practitioners Assessment and Registration: Framework and Guidance for Applicants Assessors Verifiers. 2013. Available online at: http://www.publichealthregister.org.uk/sites/ default/files/7.%20Framework_and_guidance_ for_applicants_assessors_and_verifiers_2014.pdf (Last accessed 2nd October 2013). 31. National Archives. Health and social care bill. 2012. Available online at: http://webarchive. nationalarchives.gov.uk/20130805112926/ http://healthandcare.dh.gov.uk/category/ health-and-social-care-bill/ (Last accessed 9th May 2014).
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An evaluation of a public health practitioner registration programme: lessons learned for workforce development Authors Em Rahman School of Public Health, Health Education Wessex, Southern House, Otterbourne, SO21 2RU, UK Email: Em.Rahman@wessex. hee.nhs.uk Jane Wills School of Health & Social Care, London South Bank University, UK
Corresponding author: Em Rahman, as above
Keywords public health regulation; public health practitioner; public health registration; public health workforce development.
Abstract Aim: This article explores the lessons learned for workforce development from an evaluation of a regional programme to support the assessment and registration of public health practitioners to the UK Public Health Register (UKPHR) in England. Methods: A summative and process evaluation of the public health practitioner programme in Wessex was adopted. Data collection was by an online survey of 32 public health practitioners in the Wessex area and semi-structured interviews with 53 practitioners, programme support, employers and system leaders. Results: All survey respondents perceived regulation of the public health workforce as very important or important. Managers and system leaders saw a register of those fit to practise and able to define themselves as a public health practitioner as a necessary assurance of quality for the public. Yet, because registration is voluntary for practitioners, less value was currently placed on this than on completing a master’s qualification. The local programme supports practitioners in the compilation of a retrospective portfolio of evidence that demonstrates fitness to practise; practitioners and managers stated that this does not support current and future learning needs or the needs of those working at a senior level. Conclusion: One of the main purposes of statutory regulation of professionals is to protect the public by an assurance of fitness to practise where there is a potential for harm. The widening role for public health practitioners without any regulation means that there is the risk of inappropriate interventions or erroneous advice. Regulators, policy makers and system leaders need to consider how they can support the development of the public health workforce to gain professional recognition at all levels of public health, including practitioners alongside specialists, and support a professional career framework for the public health system. Introduction Public health reflects many of the tensions in debates about professionalisation.1–3 On the one hand, professionalisation can be seen as acting as a framework for good practice establishing rules and standards for training, practice and registration as well as the implementation of processes to tackle complaints and deal with disciplinary procedures and fitness to practise.4,5 It allows for an agreed title to be protected for individuals who are registered on a statutory register and enables regulators both to set standards for entry to practice and to remove
those who failed to meet those standards. On the other hand, professionalisation came to be seen in the 1970s as a project of self-interest in which market power is achieved through restricting supply of a workforce and enabling those allowed entry to command high salaries.6,7 Gabriel Scally in his review of the public health workforce denies that there is any economic consideration and states that ‘A move to statutory regulation is not intended to improve the standing or financial rewards for members of the profession’.8 In many countries, public health professionals are often physicians and therefore are already
Copyright © Royal Society for Public Health 2014 September 2014 Vol 134 No 5 l Perspectives in Public Health 259 SAGE Publications Downloaded from rsh.sagepub.com at DUQUESNE UNIV on July 9, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914544883
Peer Review An evaluation of a Public Health Practitioner registration programme
regulated.9,10 In these countries, public health workforce development has focused on defining the workforce and establishing the levels of competence to practise.11,12 Finland, Ireland, the United States and the United Kingdom were among the first countries with multiprofessional public health, and in these countries, the sheer breadth of those working in public health has stimulated debates about professional jurisdiction and regulation.13,14 In the United Kingdom, the requirement to be registered as working in public health has considerable variation. The UK Public Health Register (UKPHR) is an independent regulator that provides professional registration15 for specialists/consultants in public health from backgrounds other than medicine successfully completing training and those able to demonstrate competence retrospectively – to take account of those already in practice. Employers are then able to appoint to roles and posts with titles such as ‘public health consultant’ or ‘public health specialist’ those who have a protected title linking back to this registration.16,17 Statutory regulation with the Health and Care Professions Council (HCPC) for all public health specialists was recommended in a review in 2010,8 including public health alongside a wide range of other professional groups. At the same time, the current government is keen to reduce regulation, and the Hampton principles of regulation as expressed in ‘Enabling Excellence’18 are that regulation should be proportionate, accountable, consistent, transparent and targeted. Public health practitioners (PHPs) are those people in the public health workforce who spend much or all of their time in public health practice working at a minimum of level 5 of the Public Health Skills and Career Framework15 (PHSCF; Figure 1). They may work across the full breadth of public health from health improvement and health protection, to health information, community development and nutrition, in a wide range of settings from local government and the National Health Service (NHS) to the voluntary and private sectors.19,20
Figure 1 The nine levels of the Public Health Skills and Career Framework Level
Public Health Skills and Career Framework
1
Has little previous knowledge, skills or experience in public health. May undertake specific public health activities under direction or may acknowledge the value of public health in a wider context.
2
Has gained basic public health knowledge through training and/or development. May undertake a range of defined public health activities under guidance or may use knowledge to influence public health in a wider context.
3
May carry out a range of public health activities or small areas of work under supervision. May assist in training others and could have responsibility for resources used by others. May use public health knowledge to set priorities and make decisions in a wider context.
4
Has responsibility for specific areas of public health work with guidance, which may have a breadth and/or depth of application.
5
Has autonomy in specified public health areas, continually develops own area of work and supports others to understand it. May contribute to a programme of work in multi-agency or multidisciplinary environment.
6
Has autonomy and responsibility in coordinating complex public health work, reflecting wider and deeper expertise in own area of work. Able to develop, facilitate and contribute to programmes of work in multi-agency or multidisciplinary environment.
7
Has autonomy and expertise in a number of areas of public health. Will lead on areas of work within a defined field.
8
Has a high level of expertise in a specific area of public health work or across a substantial breadth of public health service delivery and/or programmes. Is accountable for work across boundaries and agencies. Has leadership responsibility and autonomy to act. Sets strategic direction in own area of work.
9
Sets strategic direction across organizations and/or areas of work. Provides multidisciplinary or multi-sectoral public health leadership that determines priorities. Works at executive level.
The term ‘PHPs’ is used in the United Kingdom to describe a level of practice – not a specific job role or type of job. Although they carry out key public health roles, many PHPs remain unregulated,21 and there is no obligation for those working as PHPs to register as a public health professional. Nurses (public health nurses, including health visitors and school nurses) must be registered with the Nursing and Midwifery Council and may choose to register via the Specialist Community Public Health Nursing (SCPHN) part of the register.22 Other PHPs are self-regulated by a voluntary scheme23 of the UKPHR that opened in 2011. Assessment of competence is done against standards developed
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by the UKPHR24 using the PHSCF15 (Figure 1) using a retrospective portfolio of evidence showing achievement against these standards. Pilot local programmes to support PHPs to register with the UKPHR were started in 2010 in NHS South Central, NHS West Midlands, Public Health Wales and Kent and Medway and later, West of Scotland, Bristol and North London with a locally devolved system of verifiers and assessors. Currently, there are 101 practitioners registered nationally on the UKPHR, 23 of who are from Hampshire, Portsmouth, Southampton, and the Isle of Wight. Each of the local programmes that provide a regulatory pathway for PHPs is varied in its structure although all
Peer Review An evaluation of a Public Health Practitioner registration programme
practitioners will be assessed against the Public Health Practitioner Standards. Table 1 shows how the Wessex PHP programme, for example, differs from other pilot programmes by providing a structured support programme commissioned from the Open University. The support programme consists of a one-to-one assessment with the practitioner in readiness to complete their portfolio for registration, followed by five portfolio development groups (PDGs) in the form of action learning sets. The support programme also includes a series of master classes and learning sequences that provide updates and the filling of any knowledge gaps that are identified as part of the one-to-one assessment for individuals. The Wessex scheme also provides mentoring support for individuals through its local Public Health Workforce Development Leads who are employed and located within local public health teams and existing assessors who have also been trained as mentors. In Wessex, 88 PHPs commenced the pilot support programme over three cohorts 2010–2012 (cohort 1), 2011– 2013 (cohort 2), 2012–2014 (cohort 3), and 23 (26%) have completed it to registration. These high levels of attrition prompted an evaluation to consider the lessons learned in relation to the regulation of the public health workforce.
Methods An independent evaluation team conducted a pluralist, multi-method approach, over a six month period that included the following: • A summative evaluation concerned with the assessment of achievement of the programme’s objectives and outcomes in relation to both support and training, and portfolio development leading to registration; • A process evaluation, concerned with the examination of how and why these effects came about, that is, the reasons behind the outcomes achieved, in terms of the identification of different
facilitating factors and/or barriers, including where relevant examination of issues related to organisational culture. The aim of the evaluation was to have a rounded view of the programme, and invited to take part were other stakeholders and system leaders (n = 12) identified as public health managers (n = 2), Directors of Public Health (n = 5), local authority department managers (n = 2) and those responsible for workforce development (n = 3). Also invited to participate were those providing support to the programme as learning support providers (n = 4), mentors, verifiers or assessors (n = 31; some of them performed dual roles as mentors and assessors) and PHPs themselves (n = 88; PHPs who had started the practitioner programme). The 88 PHPs included those who had successfully completed registration (n = 23) and those who had not done so (n = 65). The evaluation also included a further six practitioners identified by the local workforce development managers, who were invited to participate and who had not taken part in the programme. Data collection was by an online survey of all PHPs in the area. All PHPs were sent an email inviting participation with a link to the online survey and sent a reminder after three weeks. Completion of the survey was taken as informed consent. The structured questionnaire had sections on recruitment and induction for the programme, preparation for registration, experience of the programme, impact on working life, views and actions on registration, the assessment process and support and feedback from the mentor and assessor. Semi-structured face-to-face or telephone interviews (depending on the participant’s preference) further explored motivations to be registered as a PHP, facilitators and barriers to becoming registered, the impact of registration on role and any perceived benefits. Semistructured telephone interviews on the regulation of the public health workforce and the impact of the programme in relation to work capability and
employability were also undertaken with managers, stakeholders such as those involved in workforce development, and public health system leaders, including Directors of Public Health and local authority department heads. The assessors, verifiers, mentors and learning support providers for the programme were also interviewed. All interviews were transcribed and the data were analysed by the evaluation team using a content analysis based on the questions asked.
RESULTS A total of 53 (N = 53) participants took part in the interviews and 32 PHPs completed the online survey (some PHPs may have completed the survey and an interview). This comprises an overall response rate of 63% of those identified to take part in the evaluation, as shown in Table 2. At the time of this evaluation, three cohorts had taken part in the scheme, with 23 out of a possible 88 practitioners registering with the UKPHR (26%). In all, 17 of these PHPs were from cohort 1, the remaining 5 were from cohort 2 and 1 from cohort 3. The programme is for practitioners who are expected to be working at a minimum of level 5 of the Public Health Skills and Career Framework, which is equivalent to an undergraduate degree level, and have at least two years’ public health related experience. Of those whose qualifications are known, many are working at a senior level: 18% have at least a master’s degree and 36.4% are working at level 7 or 8 of the Public Health Skills and Career Framework. A total of 25% of the PHPs worked in health protection, 25% in health improvement, 13% on lifestyles work in the NHS or local authority, 12% in smoking cessation, 12% in health intelligence and the others did not specify.
Views on the regulation and registration of the workforce Those PHPs completing the survey perceived regulation of practitioners as very important or important (100% of those registered, 80% of those not yet registered and 66% of those not on the
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Table 1 The Wessex Public Health Practitioner Programme and other local programmes Wessex
Kent, Surrey, Sussex (KSS)
West Midlands
West of Scotland
Wales
Scheme name
Wessex PH Practitioner Registration Programme
Kent, Surrey Sussex Practitioner Registration Support Scheme
West Midlands’ Public Health Practitioner Development Programme
UKPHR West of Scotland PHR Pilot Scheme
Portfolio Development Support Programme
Geographic region
Hampshire, Isle of Wight and Dorset
Kent, Surrey, Sussex West Midlands
Lanarkshire; Ayrshire Wales and Arran; Greater Glasgow and Clyde; and Highlands
Year scheme launched
2009/2010
2009/2010 – Kent and Medway
2011
2012
2009
2011/2012 – Surrey and Sussex Scheme Support Programme Induction day
Yes
Yes
Yes
Yes
Yes
1-2-1 session
Yes
No
On request
On request
With mentor
Focus of 1-2-1 session
To identify – practitioners learning and support needs.
To review an individual’s progress and support to complete.
Basic level support on specific issues identified by practitioner.
Introduction to programme; support and two-way management of expectations; and to promote the benefits of registration.
Mentorship
Yes
Currently in development.
On request
No
Yes
Up to 6
As many as required
–
Up to individual and mentor but recommend a minimum of 5
Mentor programme 4–6 sessions
PDGs/Learning sets
Yes (formal)
Yes (formal)
Yes (formal)
Yes (informal)
Yes (formal)
Number of PDG/ learning set sessions
5 sessions
Up to 8 groups over 24-month period
3 facilitated learning sets (encouraged to meet informally between sets).
–
4 sessions
Master classes
Yes
Yes
Yes
No
No
12–18 months
18 months
12–18 months
12 months
Practitioner 18–24 months completion time (as advised/ recommended)
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Table 1 (Continued)
Support programme provider
Wessex
Kent, Surrey, Sussex (KSS)
West Midlands
West of Scotland
Wales
Open University provides Induction Day; 1-2-1; PDGs and master classes.
No one provider.
Public Health Potential provides learning sets.
No official support programme. If learning needs become different in one cohort, then Boards may come together to offer training as appropriate/where available.
Professional and OD Manager coordinate, external consultants provide learning sets.
Scheme coordinator commissions master classes based on Higher Specialty Mentors provided by needs during initial Trainees deliver scheme coordinator. PDG. programme of 15 master classes MBTI assessment 3 different facilitators provided by scheme commissioned to Mentoring and coordinator. run portfolio coaching support development available through groups. Health Education West Midlands’ Mentornet and Coachnet
Programmes of support are established as necessary and taken forwards by practitioners with input from scheme coordinator if required.
Recruitment and Application form, Application form and Application form and Minimum criteria in selection process self-assessment and place. self-assessment self-assessment to PHP programme interviews against standards against standards. Employment in KSS. Application must be made with Minimum two years manager’s support. experience at level 5 of PHSCF or above. Application form to local scheme, where local coordinators discuss and make the final decision.
Advertise on intranet and Internet, bi-lingual guidance and supporting information; application pack including selfassessment.
MBTI: Myers Briggs Type Indicator; OD: Organizational Development; PDG: portfolio development groups; PH: public health; PHP: public health practitioner; PHR: Public Health Register; PHSCF: Public Health Skills and Career Framework; UKPHR: UK Public Health Register.
Table 2 Participation numbers Telephone/face-to-face interviews
Online survey (PHPs only)
Total
PHPs
27
32
59/88
Assessors, mentors and verifiersa
17
N/A
17/31
Other stakeholders and system leaders
7
N/A
7/12
Learning support providers
2
N/A
2/4
PHP: public health practitioners. aSix of the assessors were also involved in the mentor role.
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programme). Among the managers and system leaders interviewed, there was also a general consensus that registration was a public demonstration of a level of quality of service offered and provided external assurance that working to a certain standard ensures public health governance. Many also cited the transition of the public health function to local authorities as being at a time when it is vitally important to demonstrate that public health is a ‘profession’ and has certain practice and academic standards: It provides that professional cohort at a time when the local authority is trying to de-professionalise the profession…the whole profession is seen as too expensive because they do not value a public health practitioner in the same way they value a social worker. (Stakeholder) The programme was also seen as an important way of being clear about who the workforce is, within this new context: Without it there’s a danger that the workforce won’t be clear, that we won’t be clear who the workforce is. If the workforce isn’t clear there is a danger we’ll end up with public health work being undertaken by people who don’t actually understand it. (Workforce Development Strategist) PHPs and managers felt that completing the programme would not necessarily make a member of staff more competent or capable than another and nor did it particularly benefit the department. But there was a sense that completion of the programme offered a manager an assurance that a member of staff was able to reflect on his or her practice and that he or she was keen and committed: They would be able to evidence their competence. I don’t know if I would know their capability but I would know their competence because it’s signed off. (Director of Public Health)
Registration, the final outcome of the entire process of the programme, was met with mixed feelings by PHPs in interviews. There was a perceived discrepancy between the effort involved to achieve registration and the resulting output where there appeared few, if any, tangible benefits: For the amount they charge a year I would expect something other than having my name on a register. (Registered Practitioner) Some PHPs commented that a master’s qualification is more universally recognised in comparison to the registration, which currently is only recognised locally. Hearing negative feedback from colleagues that portfolio registration is time-consuming, that registration has no benefits and the feeling that it is not valued nationally has made the programme, as one practitioner stated, ‘a tough one to sell’ (and further explains the low numbers of practitioners who complete registration).
Views on the PHP programme In many of the interviews, registered PHPs and managers viewed the programme as one of professional development offering career opportunities. There was some frustration then that the programme did not ‘tell me anything I didn’t know’ and that it does not support current or future learning needs. While some found the retrospective nature of the portfolio route for registration by which a practitioner demonstrates competence through providing evidence of the achievement of a standard in practice as confidence-boosting, for others it did not provide a career framework: It’s back to front they wouldn’t have hired me to do the job if I didn’t know how to do it and then you hire me and then say prove that you know the information … (Non-Registered Practitioner) All the practitioners commented that the portfolio registration is:
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…a hugely onerous undertaking that is highly complex piece of admin as much as a reflection of personal achievement and outcomes that must be simplified if to be achieved by more staff at band 5 level. (Registered Practitioner – written survey response) Some PHPs saw the programme as sufficient to complete what they saw as an administrative task. Others had expectations of their mentor as a career development advisor while several mentors commented that they had little preparation for the role and felt they had simply been recruited because they worked at a senior level. Some PHPs commented on perceived inconsistency in the assessment of the commentaries that are provided by PHPs to demonstrate achievement of a specific standard. Opinions by PHPs on the various aspects of the programme were mixed. The level of learning of the K311 Promoting Public Health: Skills, Perspectives and Practice module25 was not perceived appropriate for some who expected it to be professional learning: You’re only learning from your own practice your own reflection. (NonRegistered Practitioner) Portfolio development groups (PDGs) are aimed at helping practitioners organise their evidence in preparation for submission to their assessor. Most practitioners found the learning set format frustrating and insufficiently tailored to individual needs and the specific work context of public health: I didn’t have time to take out of work to listen to people talk about their work. (Registered Practitioner) You need to understand the setting of the person, what they’re writing about, what their core area of work is …have a good background in public health yourself. (Programme SupportAssessor) Despite these reservations, 57% of registered practitioners who undertook the survey found that the support to
Peer Review An evaluation of a Public Health Practitioner registration programme
complete the portfolio was the most beneficial aspect of the programme.
Discussion The importance of regulation for the PHP workforce is gathering momentum and new programmes are being rolled out in many areas of England.26 The findings from this evaluation highlight key lessons that need to be considered in relation to ‘the product that is registration’ and in ensuring that a streamlined, relevant and efficient process is in place in order to support future PHPs in their journey to registration.
The product The Public Health Workforce Strategy acknowledges that practitioners ‘have a crucial role to play and deliver some of the most complex components of public health outcomes’.6 Yet, PHPs are only regulated on a voluntary basis although professional regulation is intended to sustain the confidence of both the public and the professions through improving and assuring the professional standards of health professionals. The protection of title that is a consequence of professional regulation was also seen by system leaders in this evaluation as particularly important as public health positions have moved from the NHS into local authority settings both to quality assure the workforce and also to promote it as a ‘profession’. This evaluation showed widespread support for the professional regulation of PHPs, and there are schemes being rolled out across the United Kingdom to support PHP registration. Since 2007, Wessex (then NHS South Central) was at the forefront of innovation exploring the development of PHPs.27 The development and piloting of the PHP scheme gained support from the then Regional Director of Public Health, along with all of the PCT (Primary Care Trust) Directors of Public Health, yet paradoxically the workforce itself does not yet support registration because it is seen as lacking teeth and voluntariness. In the absence of a statutory licence to practise, there is an important role for the employer. Employers can ensure that registration is included in job descriptions
and person specifications, making sure that registration is explored as part of the appraisal and personal development review (PDR) processes. Equally, marketing of the programme needs to be strategised to not only raise the importance of registration but also to help establish an inclusive public health workforce that recognises the contributions of a wide range of practitioners including those within local authorities. The PHP Programme is a programme to support practitioners towards registration. As such, it uses a retrospective assessment of competence. The Public Health Workforce Strategy talks about the need to develop career pathways for the public health workforce,11 and this evaluation has highlighted the potential for a developmental programme where individuals will be developing the skills and knowledge towards registration, similar to the five-year public health specialist training programme.28 The programme also assumes that those applying to become registered are already working at a minimum of level 5 of the Public Health Skills and Career Framework.15 Several individuals in Wessex have become registered as PHPs, although they are working at senior levels. While ‘advanced practitioner’ is a term sometimes used, there is no protection of this title. Advanced Nursing Practice has been widely promoted for many years, but this is seen as an individual’s career progression supported by prescribed competences, education and development and professional accreditation rather than by regulation.29
The process The Wessex PHP Programme process evaluation has highlighted the need for a structured and systematic process to be in place to support individuals’ journey to registration, as shown in Figure 2. The evaluation developed a quality framework based on the findings from the process evaluation, which identifies six domains.
Domain 1 – Quality The Wessex support programme has an administrator and a coordinator, and this
was crucially important in its implementation. The PHP workforce is part of Health Education England (HEE) and Local Education and Training Board (LETB) priorities (HEE mandate), and this cannot be achieved without core funding and resources. An investment in workforce development such as this means there should be annual management plans along with a monitoring process.
Domain 2 – Recruitment and Selection The high levels of attrition in the programme demonstrate a need to make clear the benefits, the time commitment and the process of the programme from the start, ensuring that individuals understand what is expected of them. The Wessex programme has ensured that strict adherence is maintained to the selection criteria in accordance with the UKPHR guidance30 along with a Wessex standardised application process, which includes an interview with the prospective applicant. A structured induction day has been introduced and a clear programme contract now needs to be signed off by the practitioner, his or her employer, support programme lead, mentor and assessor (at the assessment phase of the programme).
Domain 3 – Development/Support Programme Because there are different expectations of the support programme, clear descriptors of the different elements have now been included, and there are performance indicators for the externally commissioned support programme providers. Mentors who are senior public health professionals or registered PHPs are formally assigned to practitioners. They now receive training for the role, both in recognition of its importance but also as a development outcome for them, given the voluntary and time-consuming nature of their contribution. The evaluation identified a large group of ‘drifters’ who did not go on to register. Reports on individual practitioner’s progress are provided to the PHP programme management team in an effort to monitor timely progress to registration.
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Domain 4 – Assessment and Verification
Month 16
Month 17
Month 18
Final Submission
All assessors and verifiers are appropriately trained by the UKPHR, and regular and ongoing local training is provided in order to maintain skills and knowledge. As assessors and verifiers may not see many portfolios, it is important that regular and spot moderation takes place to ensure consistency.
Ongoing and regular supervision with Line Manager
Mentoring
Formal Review
Because many practitioners express frustration at a lack of perceived benefits from registration, the programme is linked more closely with appraisal and performance review processes. A local registration awards ceremony celebrates and recognises the professional registration of practitioners. Continuing professional development (CPD) maintains the currency of this registration.
Domain 6 – Evaluations of Learning This domain is focused around closing the loop, ensuring that feedback from all parties involved (practitioners, employers, support programme leads, assessors, mentors and verifiers) is captured to gather learning on how to improve the programme for future cohorts.
Conclusion
*Open University (OU; Support Programme Provider). †Myers Briggs Type Indicator (MBTI) assessment.
Master Class
Por olio Development Groups (PDGs) x 5 OU* 1-21 MBTI†
Apply for Mentor
Formal Review Apply for Assessor
Month 9 Month 8 Month 7 Month 6 Month 5 Month 4 Month 3 Month 2 Month 1 Induc on
The journey to registration as a public health practitioner in Wessex
Figure 2
Month 10
Month 11
Month 12
Month 13
Assessment
Month 14
Month 15
Domain 5 – Registration and Continuing Professional Development
266 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at DUQUESNE UNIV on July 9, 2015
Workforce development is both a technical and political exercise, that not only builds capacity but also requires the building of trust among the public and stakeholders. This trust assures competent performance but also for the professionals, clear understanding about their own fitness for award, practice and purpose. Public health in England is now working in a radically new system as a result of the Health and Social Care Act which transferred the function to local authorities that work across many of the social determinants of health such as education, housing and planning.31 The recognition of public health as a profession that requires a specific set of technical skills and knowledge in order to improve health outcomes at a population level is even more important as otherwise public health can be seen as a function that any practitioner could do.
Peer Review An evaluation of a Public Health Practitioner registration programme
Statutory regulation for the specialist workforce has been recommended;6,8 however, the public health workforce is not just at this level. The current voluntary nature of the scheme for practitioners was perceived in this evaluation to lack influence and accounts for the high levels of attrition from the support programme. In order to ensure a consistent and quality-assured workforce at practice level, both practitioners and system leaders supported statutory regulation for practitioners. There remains a gap between the practitioner registration for those working at level 5 and the specialist registration for those at level 9. This evaluation showed that a section of the public
health workforce are applying to be level 5 registration practitioners in order to gain that formal recognition of a profession even though they may be working at higher levels. Regulators, policy makers and system leaders need to consider how they can support this section of the workforce to gain professional recognition at the level they are working at (advanced practice).
Acknowledgements We are particularly grateful to Sabrena Jaswal who collected the data for this evaluation and made a major contribution to the project report. We also wish to thank the PHPs; all those who gave their time and expertise to support the Wessex
programme by being mentors, assessors or verifiers; the learning support providers and local managers and system leaders who provided detailed comments in interviews and the survey.
ETHICAL APPROVAL This study was reviewed by the London South Bank University Research Ethics Committee (University Research Ethics Committee (UREC) 1322 number) in 2013 and was identified as service evaluation; therefore, additional research ethics approval was not required.
Funding This evaluation was funded by the School of Public Health, Health Education Wessex.
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