Two years after the landmark public health agreement, David Lynch assesses the progress made in reforming the specialty and the challenges that lie ahead
Public health doctors were critical to the Covid-19 pandemic response, but also overwhelmed by the lack of resourcing and infrastructure for their specialty.
There was considerable frustration about the failure to implement the recommendations of the Crowe Horwath Report on the Role, Training and Career Structures of Public Health Physicians in Ireland to reform terms and conditions and make public health in Ireland fit-for-purpose.
However, a breakthrough was made, and in May 2021 public health specialists in the IMO voted to approve the terms of an agreement reached with the Department of Health. The agreement allowed for the creation of consultants in public health medicine in addition to wider reform.
It is now two years since the agreement. While the threat posed by Covid-19 has receded and progress has been made in recruitment and structural reform, major challenges still remain.
“We are at an unprecedented time in relation to the implementation of Sláintecare,” Prof Cecily Kelleher, Dean of the Faculty of Public Health Medicine, told attendees at the Faculty’s recent Summer Scientific Meeting in the RCPI in Dublin (see panel).
“And we believe we now have the impetus to really finally achieve the integrated healthcare system that you all look forward to participating in and working for, in the betterment of the public health of this country.”
Speaking at the same event, Dr Paul Kavanagh, who is based in the HSE national health intelligence unit, noted that there was a “huge amount of change happening to health services driven by Sláintecare”. He added that this was “going to deliver a more integrated approach to care based on population health needs”.
“So the question it poses is – how do we [public health professionals] respond to all of that? How can we as public health professionals lead improvement in our health service? How can we exploit health information to try and identify where change is needed and deliver that sort of change?”
Lessons
The implementation of the report of the public health reform expert advisory group (PHREAG) is much anticipated by public health doctors. However, concerns have been raised over delays in its publication.
The PHREAG commenced its work in January 2022. According to the Department, the group was tasked with identifying “learnings from the public health components of the response to the Covid-19 pandemic in Ireland and internationally” with a view towards “strengthening public health including health protection generally and future public health threats and pandemic preparedness specifically… as well as the delivery model for public health”.
Minister of Health Stephen Donnelly received the report last September and “has been giving consideration to its contents”, a Department spokesperson told the Medical Independent (MI). “The Minister plans to bring the report to Government shortly, with a view to publishing it thereafter.”
The Chair of the Irish Society of Specialists in Public Health Medicine (ISSPHM), Dr Douglas Hamilton, stressed the importance of this report and the need for it to be published soon.
Dr Hamilton pointed out to MI the review encompassed “a lot of work undertaken by top international public health experts over a relatively short period of time”.
He added that the content and recommendations needed to be studied and addressed by national policy makers, public health specialists, and others.
“We continue to stress the need to publish the report ASAP to allow transparent consideration of the recommendations of the expert group,” he said. “We would also like to flag that we haven’t yet received any communication from the Minister following our request to publish.”
Dr Hamilton noted that publishing does not mean that all the report’s recommendations have to be implemented. “But they need to be considered in a consultative and transparent fashion. It is a concern that this has not been done yet, nine months after the report was finalised.”
Consultants
The May 2021 agreement included a commitment to establish 84 consultant posts. The recruitment process was to take place in three phases between June 2021 and December 2023. A total of 34 posts were filled by the end of last year. In line with the agreement, a further 30 posts are expected to be recruited by June 2023 (phase two) and an additional 20 by December 2023 (phase three).
A HSE spokesperson told MI that the recruitment for phase two is “well underway”. A total of nine candidates are at the onboarding stage; 12 whole-time-equivalent (WTE) candidates are at interview stage; and six WTE posts are currently being advertised. The final three posts are in line to be reviewed at the next consultant applications advisory committee meeting on 13 June.
The spokesperson noted that following a Department of Public Expenditure and Reform review, the Executive has received sanction to continue with phase three recruitment of a further 20 WTE consultant posts “and work is currently underway on the job specifications”.
The interest in the posts “has remained strong and at the same level in 2023 as compared to 2022”, the spokesperson added.
“This is an enormous undertaking in terms of recruitment of a large number of consultant doctors over a relatively short period of time,” Dr Hamilton said.
“In terms of keeping to the planned rate of recruitment, it is doing very well, but it is a very stressful period for [the specialty] at a continuously very busy and demanding time in public health.”
Writing in MI in April, Chair of the IMO public health committee, Dr Anne Dee, noted that “recruitment for the second phase has met with some delays”. However, on the wider public health reform, Dr Dee wrote that “a lot of work has been done, a lot remains to be done and an enormous amount of change has happened in a short time”.
Research
When the PHREAG report is eventually published and begins to be implemented, it will have a significant impact on those working in public health. But what do public health graduates, current specialists and new consultants think about their future working lives and the health service in Ireland?
In recent years the hospital doctor retention and motivation (HDRM) project has gathered and published considerable data about doctor retention and the working lives of hospital doctors in Ireland, as well as Irish-trained hospital doctors living abroad. Now public health doctors are on the project’s radar.
“Yes, the final phase of the HDRM project is focused on public health doctors,” Dr Niamh Humphries (PhD), Senior Lecturer at the RCSI Graduate School of Healthcare Management, told MI.
“Although the focus of HDRM was hospital doctors, I’m also interested in looking at the working conditions of doctors who work outside of hospital settings. This project will look at public health doctors and I’ll shortly begin a new HRB [Health Research Board]-funded project looking at GP retention.”
Dr Humphries noted that “public health doctors were critical to the pandemic response and also have been at the centre of a recent reforms, so it seemed like a good time to undertake a small piece of research on their wellbeing and working conditions”.
“We hope that the findings will help to inform policy and practice and we hope to have findings to share in late 2023/
early 2024.”
Dr Humphries said the HDRM project would “love to hear” from doctors working in public health, “including trainees and senior medical officers for this phase of the study.” Further information can be found at https://doctorretention.eu/project-invitation/.
IT infrastructure
Concerns over lack of adequate IT infrastructure across the health service have been increasingly raised by public health doctors in recent years.
In its first position paper, published in early 2022, the ISSPHM called on the health authorities to “address longstanding and critical IT infrastructure gaps, including the lack of a case and outbreak management system, an integrated surveillance system, an immunisation reporting system”, as well as the development of a “fit-for-purpose” health information system capable of linking information across all service delivery sites.
Early last month, this newspaper reported that a market soundings process was being undertaken for the procurement of a national outbreak case and incident management IT system.
However, Dr Hamilton said the concerns “very much remain”. He said that while work is being undertaken to identify and procure a fit-for-purpose case and outbreak management system, “we are really no closer now than three years ago.”
Dr Hamilton added that a national immunisation information system would “only realistically [be] in place in a further two years or so”.
“Work on delivering an individual health identifier to enable linking patient information across all service delivery programmes and sites is ongoing, but is still not in place, [meaning] that the services remain inefficient.”
Building the evidence-base
The RCPI Faculty of Public Health Medicine held its hybrid Summer Scientific Meeting on 23-24 May.
“This Summer Scientific Meeting, over two days, complements our Winter Scientific Meeting and the Faculty of Public Health Medicine, as you know, plays a pivotal role in the education and training of public health consultants and doctors in Ireland,” Prof Cecily Kelleher, the Faculty Dean, told attendees.
Prof Kelleher noted that this was a period of significant change in public health in Ireland and “evidence is a crucial part of that and the scientific meeting contributes hugely to that evidence-base”.
‘Health is better than wealth’ was the theme of the conference, which featured guest speakers as well as oral and poster presentations.
Speakers included Dr Triona McNicholas, Specialist Registrar in Public Health Medicine at the HSE national health intelligence unit, who presented research on the impact of demographic change on health service utilisation.
“Unlike most European countries, Ireland’s population is increasing,” said Dr McNicholas, adding that the demand for healthcare is expected to “grow significantly” due to the increasing and ageing population. This is happening against “the background of well publicised… hospital waiting lists, high bed occupancy rates, and long waiting times in [emergency departments]”.
In her conclusion, she said the results of her research showed that “there will be a substantial increase in both hospital and community healthcare [demand] levels in the coming years”.
“These results demonstrate the importance of maximising health wellbeing… and shifting models of care towards community care in
line with Sláintecare reforms, to ensure the capacity is in place for
our health service.”
Ms Caroline Walsh, Public Health Officer at the National Screening Service, presented on the capturing of patient reported experience measures (PREMs) in BowelScreen.
Ms Walsh said that the aim of the PREMs project was to gather real-time patient experience feedback and to use this to identify opportunities for quality improvement across the programme. The project also wanted to test the capability of a paperless text message approach to the survey and the scalability of the approach.
Some 89 per cent of respondents reported that their BowelScreen experience was good or very good. There were “exceptionally high levels
of satisfaction with the programme”, Ms Walsh stated.
“We have identified that the text message approach has proved to be an acceptable means of obtaining feedback from BowelScreen participants. With a response rate of up to 48 per cent, it was considered excellent and considerably higher than paper-based surveys that we conducted.”
As a result of the success of this project, funding has been secured to scale-up the initiative and work had commenced with BreastCheck.
Ms Leah Evans, Nurse Health Protection at HSE Public Health Mid-West, presented research looking at the different health needs of the cohort of Ukrainian refugees who arrived in Ireland during the first six months after the Russian invasion in 2022. This was compared to the cohort who arrived during the subsequent six months.
The second cohort showed an increase in the proportion of males
and adults over 65, as well as
pregnant women. Fewer people in the second cohort had received two Covid-19 vaccinations.
“The level of reported childhood vaccine uptake was similar across the two groups [but] remains low compared to the general population in Ireland,” said Ms Evans.
“Differences in age and sex distribution between cohort one and cohort two will impact on the ongoing utilisation of the health services locally…. Increasing rates of pregnancy may impact on primary care and maternity services…. Low rate of Covid vaccination in cohort two may lead to increased transmission [of Covid] in crowded settings.”
Ms Evans said that the low level of childhood vaccination among the Ukrainian community had led to the roll-out of a childhood catch-up vaccination programme.
“By analysing and predicting these patterns, we in the Mid-West can address the health needs of the beneficiaries of temporary protection and reorient health services to ensure this cohort can continue to shelter successfully.”
Speaking during the first day of the conference, Dr Elise Crayton (PhD), Faculty of Brain Sciences Disability Equity Lead, and Research Fellow at the University College London Centre for Behaviour Change, led a discussion on applying behavioural science frameworks to drive change in public health behaviours.
During the questions and answers session, Dr Crayton was asked how best to ensure public health interventions do not exacerbate health inequality.
“When we are thinking about public health, we do need to be thinking about everyone who is receiving that intervention, especially if it is going to be at scale. So it is really important that we are carving out the time to think about what we are recommending and talking to those that we think are important to make sure we are delivering it and implementing it in a way that is equitable,” she said.
On the need to review and monitor long-term public health interventions, such as promoting sexual health and condom use, Dr Crayton said “we should always be monitoring how an intervention is working”.
“Certainly, when we do it initially and at a large scale, we power a lot of resources into evaluation. There should always be a plan in place just to keep monitoring some sort of data coming in, just to see how it is working. If you notice a drop off… you should then be able to unpick as to why it may have dropped off in working, if you are noticing that trend.
“Then you can think what you can do differently. Is it that this intervention is no longer working because the context has changed? Or is it just the way we are implementing the intervention that needs to be slightly changed or tweaked to sustain that behaviour?”
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