Training in public health medicine

This paper considers the possible relevance to psychiatry trainees of a period of training in public health medicine. The work of public health doctors is to identify ways of improving the health of populations and to promote relevant change. It is of relevance to psychiatrists, who have to consider needs of whole catchment populations rather than Justof patients who seek help, and who have historically experienced difficulty in compering for resources. We discuss tasks that trainees might undertake during a brief public health attachment, the potential benefits of such an attachment and some of the practical considerations.

Most psychiatrists recognise the value of experi ence in other areas of medicine and some psychiatry training schemes have included time in other specialities, such as general practice, neurology or elderly medicine.Up to one year of training in general medicine or its subspecialities is recognised as approved training for MRCPsych part II.We are aware of a handful of individuals who have undertaken periods of training in public health medicine either before or between training posts in psychiatry.However, we do not know of any psychiatry training schemes that have attempted to include public health medi cine.With increasing emphasis on effectiveness and efficiency.Health of the Nation targets and the need to 'sell' services to new primary care based purchasers, combined with unchanging difficulties in identifying adequate resources, more than ever there are opportunities for psychiatrists to use the sort of skills which public health training is designed to foster.

What is public health medicine?
Public health is defined as 'the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society' (Acheson, 1988).It is concerned with health and disease in populations rather than individuals.Public health medicine is a branch of medicine specialising in public health.
Over the last two decades public health medicine has undergone a succession of changes in title, job content and organisation.At present most public health doctors in England work for district health authority purchasers and their responsibilities are defined by recent guidance as 'assessing local health needs; developing and as appropriate implementing, local health and health promotion strategies; leading the health author ity's work in improving the appropriateness and effectiveness of clinical and non-clinical interven tions; and developing and sustaining relationships between the health authority and clinicians (in cluding GPs), local authorities and the local community' (NHS Executive, 1994).
What does this mean in practical terms?All district health authorities in England are re quired to employ a director of public health and a consultant in communicable disease control1.Usually the public health department will contain other doctors (consultants in public health medicine) and other non-medical staff, such as information and health promotion specialists and research staff.The director of public health will almost always be an executive member of the health authority.It is impossible to define a standard pattern in the other work of public health doctors.Some will carry ongoing respon sibilities for specific services or client groups.For others the focus of their work will change as particular projects are completed.Work will always relate to the underlying themes of: 1. Identifying ways in which the population's health may be improved.This may involve discussion with clinicians, ascertaining the views of patients and public, studying the literature, reviewing routine data sources and collecting new data on the population's health and the effectiveness of local services.2. Promoting relevant change.This can involve seeking changes in the volume, style or quality of health services purchased or it can mean seeking to influence the activities of other agencies through information, negotiation or lobbying.
The structures of the Scottish Health Boards and of Northern Ireland's Health Authorities differ in some important respects from the English Health Authorities.In spite of this, the 1.Communicable disease control is not discussed further.Although psychiatrists may be involved in control of infection in a hospital environment, specialist knowledge in this area is of less relevance.

What could a psychiatry trainee achieve during a short placement in a public health department?
This would depend to some extent on the skills and experience of the trainee.Opportunities would fall into three main groups.First, research projects relating to mental health: second, other work directly concerning mental health, for example, an input into population needs assess ment, policy development and contract specifica tion; and third, work on areas other than mental health.The aim would be to develop knowledge and skills relevant to the practice of psychiatry, for example, learning about approaches to promoting health, joint work with community groups and other agencies, achieving change, and obtaining and using information about popula tion health.
For other District Health Authority staff to be free to work in collaboration with the trainee, the trainee's work may need to relate to the agreed priorities of the district.To give an example of the sort of tasks that might be undertaken.Table 2 lists some of the projects carried out in a single public health department over a 12-18 month period.

Enhancement qfjutwe practice of psychiatry
While there are limitations to what can be achieved in a brief placement, experience in public health medicine could potentially foster abilities to identify changes which will benefit the catchment population of a mental health service and help get these changes to happen.This is particularly relevant In a speciality such as psychiatry which has a history of difficulty in competing for scarce resources and which also has to consider the needs of its whole catchment population, not just those who seek help.
Mechanisms for enhancement of future prac tice could include: (1) better understanding of how purchasers think, the mechanisms of con tracting and how the NHS and other agencies work; (2) new knowledge and skills in specific Table 2. Examples of some of the work related to mental health undertaken in one public health department over an 18 month period

Research and related activities
Study of professionals' views on criteria for using the Care Programme Approach Study of numbers of patients meeting criteria for the Care Programme Approach Pilot study of use of a self-help booklet for anxiety management in general practice Commissioning of qualitative study of views of users and carers on priorities for service development Commissioning of study of professional and client views of priorities for changes in services for children with emotional and behavioural problems Brief review of literature relating to mental health promotion Brief review of literature on effectiveness of in-patient management in child psychiatry

Other activities
Participation in multiagency mental health services commissioning group, preparation of advice for this group and assisting in the development of strategy for purchasing of mental health services Participation in joint planning and negotiation with providers re future development of mental health services Discussion of priorities for service development with users' forum and Community Health Councils Assessment of needs for service of mentally disordered offenders Contribution to provider-led audit of suicides Assembly of routine local data relevant to psychiatric services Participation in regional group commissioned to prepare guidance for districts on the promotion of mental health Commissioning a university department of psychiatry to work with a local mental health unit on development of a computerised system for collation of outcome and other data from the Care Programme Approach Bidding for funds for a project to improve detection and management of depression in general practice areas such as those listed in Table 1; and (3) useful contacts among public health practi tioners, health promotion specialists, other pur chasers and within other agencies.

Additional benefits to the individual doctor
In addition, the potential for carrying out research projects will often be an important consideration for trainees.

Benefits to the public health
From the viewpoint of the purchasers, there are clearly limits to what can be achieved through assessing health need and seeking change from a distance.If the providers have similar population health goals, and where mutual understanding is possible, the potential for useful development is much greater.

Form and timing of attachments
Experience in public health could be obtained on a full-time or part-time basis, through involve ment limited to specific tasks or through shared training opportunities.Involvement in specific tasks (e.g. a needs assessment or consultation exercise) could, on a basis negotiated with the training scheme, be appropriate to psychiatrists at all stages of training.There would be some advantages in more extensive experience in public health being later rather than earlier in training.Knowledge, skills and contacts would be more likely to be retained and remain relevant into a consultant appointment.Also, a Health Authority would be likely to find an experienced senior registrar more valuable and employable than someone more junior.One option for senior registrars would be to use one or two 'special interest' sessions to gain experience in public health.

Choosing a placement
Currently government initiatives make mental illness a priority for all purchasers but this will not always be the case.Where mental illness is not a priority the value of a placement with a health authority would be more limited.In this situation there would be less support from other purchaser staff, fewer opportunities to work with other disciplines, and less chance of the trainee's work being relevant and leading to action.Directors of public health would be able to advise on this issue.District health authorities are not the only place where public health is practised.University departments and health service research units may also offer worthwhile training opportunities.Not all public health departments will be equally dynamic or stimulating places to work.Some may be dogged by organisational changes and some lack trainers in public health medicine.
health trainees may be a useful source of information on good placements.

Funding
If a psychiatry trainee has relevant experience and is able to carry out work which a health authority wishes to commission, it would be worth exploring the possibility of the health authority funding the placement.There are incentives for health authorities to pay outside agencies for specific tasks rather than add staff to their own payroll but the relatively high cost of doctors in comparison with other trained re search staff might militate against full payment of a doctor's salary.

The future
District health authorities are now beginning a further period of reorganisation as they merge with Family Health Services Authorities and general practitioners take on increasing respon sibilities for purchasing.The emphasis on pri mary care led purchasing is likely to increase considerably and may well have more impact on mental health services than any of the other recent health service changes.Whatever the future scenario, the need for psychiatrists to understand how services can best serve their populations' health will remain, and the skills to achieve change in complex NHS organisations will always be relevant.

Table 1 .
Knowledge base of public health med icine