Public Health in England – A frontline trainee viewpoint

Dr. Sylvia Garry – Public Health Specialty Registrar

I have been a junior doctor for 10 years. Well, 10 years minus 3 months, but by this point, who’s counting? 

In the midst of my Paediatric training I spent a few years working in the humanitarian sector. MSF, MdM, THET, the Royal Colleges, and a multitude of small NGOs that you most probably will never have heard of. I worked in a dozen healthcare systems and learnt the difference between necessary and unnecessary public health measures. Working in low-resource settings was just brilliant. Tough, difficult and challenging but also interesting. If I could have transported my life and family to where I was, I probably wouldn’t have come back.

By the time I returned to the UK, a few years remained before the final CCT goal. But I had experienced a different reality the previous few years. It’s difficult to watch an entire generation of children starving to death in South Sudan, and then come back and try to comprehend obesity in the UK. It’s near impossible to have weathered measles, whooping cough and meningitis outbreaks across East Africa, to then have coherent conversations with parents in the UK who do not believe in vaccination.

And it was difficult to comprehend the new status quo that had evolved whilst I was gone. Things had changed. Austerity had morphed the clinical training schemes into hectic service-provision. Patient expectations had become unrealistic, the public now increasingly viewed the medical profession with suspicion, and the service had become stretched to breaking point. 

Last year I made the switch from being a Paediatric registrar, to starting Public Health training. I switched because I wanted to work towards preventing problems before they occurred. The impact of inequality on health outcomes is apparent every day in clinical practice for a Paediatrician in London. The health outcomes of children are dependent on where they are born and most importantly, into which families. I had the somewhat idealistic and unrealistic view that inequality can be resolved with a little innovation and elbow grease. 

The training scheme has been a great opportunity to gain insight into the complexity of our healthcare system. The public health system has adapted due to need and opportunity and faced a multitude of re-arrangements. Some of these were strategic, some by chance, and all were political. Whereas the NHS has been somewhat protected from frontline cuts, the same cannot be said for the public sector. 

The premise of the NHS 5 Year Forward View relies on savings that would arise as a result of investment in public health strategies to prevent ill-health and promote wellbeing. Let's be clear: this plan is not being followed. It’s frustrating to understand and discuss the cost-effectiveness of health promotion whilst simultaneously watching governmental cuts take funding away from the very same public health services in the name of austerity and cost-effectiveness. It’s demoralising to consider that political opinion is more important than the evidence base when deciding strategy. 

There are multitudes of people working behind the scenes who genuinely want to improve the ways that things are. It’s encouraging to be surrounded by like-minded people who believe in the importance of a public-held, public-minded and public-focused healthcare system. They are passionate, although weary. 

This healthcare system is still in a stronger position that pretty much any other I have worked in. However, I do look to the end of my training and wonder what the landscape will look like. 

(The 5 year forward view is found here: https://www.england.nhs.uk/ourwork/futurenhs/)

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