The case for reforming public health medicine

The subject of our previous editorial was the slow pace of healthcare negotiations, with consultants being the main focus. It was written as talks between the IMO and the Department of Health were due to begin on the consultant recruitment and retention crisis. After the talks, the IMO said it will ballot for industrial action if the Government does not produce concrete proposals within 21 days to reverse this crisis.

While relations between consultants and health management have become increasingly frosty, another group of doctors are hopeful that the progress they have been calling for can be achieved. Like consultants, public health doctors had become increasingly frustrated about how they were being treated by the Government and health management. The level of frustration was such that the group actually voted for industrial action in December 2018. However, the publication of the Crowe Horwath report and the subsequent engagement with the HSE has offered causes for optimism. Talks have now commenced between the IMO and the Department about the implementation of the report, including the recommendation for the group to be given the title of ‘consultant’. The Association of Public Health Registrars of Ireland (APHRI) has written a letter to this newspaper (see below) in response to a Medical Independent editorial in January about the future of public health medicine in Ireland. The letter offers the compelling reason why reform of the specialty is urgently needed and why the recommendations of the Crowe Horwath report need to be implemented.

With consultants and the Government currently at loggerheads, examples of constructive engagement and progress in the medical workforce sphere are sorely needed.

LETTER TO THE EDITOR

Response to: ‘Is hope on the horizon for public health doctors’, Medical Independent, 24 January 2019
In January 2019, an editorial in this paper asked if there was hope on the horizon for public health doctors after the publication of the Crowe Horwath report. This report, along with the Scally report, prompted the Department of Health to prioritise a review with the express aim of reforming public health medicine in Ireland. The specialty was tasked with designing a new model of service delivery where consultants in public health medicine take on greater leadership roles within our health service and across all domains of our practice: Health protection, health improvement, health service improvement, and health intelligence. We are now at the point where proposals for the future of public health medicine in Ireland have been submitted to HSE leadership and the Department of Health implementation group. Specialist registrars in public health have been involved throughout the process. As a group, we are hopeful that the new model will enable us to work at the top of our licence in order to truly impact our population’s health.
The proposals submitted to the HSE and Department of Health outline an exciting vision for public health medicine, one in which public health physicians’ expertise is deployed in a more balanced and strategic manner across the core domains of public health practice. Much of our vision for the future aligns with Sláintecare, the Healthy Ireland strategy and the recommendations of the Scally review. Public health medicine physicians will be instrumental to the development of a powerful prevention strategy to combat the rise of chronic disease in Ireland. We will also contribute to the planning and development of our health services to optimise care for our ageing population, providing more care in the community, rather than in hospitals.
In particular, more needs to be done to address the social, economic, and environmental determinants of health in Ireland. The latest mortality data from the Central Statistics Office describe a difference in life-expectancy of up to five years between those living in affluent versus deprived areas. Our health service is also facing unprecedented challenges with increasing numbers of homeless people and the continuing migrant crisis in Europe. The complexity of medical needs, coupled with health inequalities, experienced by these and other marginalised groups, requires public health expertise at all stages of their care: From tackling the upstream determinants of their health to planning and designing adequate health service delivery. To improve people’s social circumstances, we need to work more closely with local and national Government to build healthy cities and towns and to create schools, universities, and workplaces that enable everyone, not just the wealthy, to live long, healthy lives.
Reducing health inequalities is a core aim of our specialty; however, to date this has not been prioritised. The creation of a health equity unit, which would have responsibility for tackling health inequalities, was proposed to the HSE and the Department of Health by the public health specialist working groups. We hope that the HSE and the Department of Health seize this opportunity to show real commitment to the Healthy Ireland strategic goal to reduce health inequalities. In the 21st Century, where you are born and where you live in Ireland should not determine how long your life is. The reform of public health medicine provides us with a unique opportunity to tackle health inequalities head on.
Dr Laura Heavey
Specialist Registrar in Public Health Medicine on behalf of the Association of Public Health Registrars of Ireland (APHRI)