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TRANSCRIPT
An evaluation of Public Health placements
for General Practice specialty training
March 2011
Dr Ian Davison
Sandra Cooke
Professor Hywel Thomas
Centre for Research in Medical and Dental Education
(CRMDE)
in partnership with the
West Midlands Workforce Deanery
©2011 University of Birmingham
All rights reserved. No part of this publication may be reproduced or transmitted in any form s or by any means, without permission from the University of Birmingham (contact Ian Davison).
Published in the United Kingdom by The University of Birmingham, Edgbaston, Birmingham, B15 2TT.
I Davison, S Cooke & H Thomas assert their rights under the Copyright, Designs and Patent Act 1988 to be identified as the authors of this work.
ISBN: 9780704428096
Copies (£15:00 including p & p) available from:
Magdalena Skrybant
CRMDE
School of Education
University of Birmingham
Birmingham, B15 2TT
T: 0121 414 4855
Contents
Acknowledgements .................................................................................................... 5
Introduction and Aims ................................................................................................................... 6
Method ............................................................................................................................. 7
Literature review ........................................................................................................ 9
Background ................................................................................................................................... 9
Public Health teaching in the undergraduate curriculum.............................................................. 10
GP views on PH ............................................................................................................................ 11
Previous studies of Public Health Placements for General Practice............................................... 12
Summary ..................................................................................................................................... 13
Survey of GP trainees ............................................................................................... 15
Results ......................................................................................................................................... 15
Summary ..................................................................................................................................... 26
Placement Interviews.............................................................................................. 27
The trainees ................................................................................................................................ 27
Expectations of the trainees ........................................................................................................ 27
Work Activities Undertaken ......................................................................................................... 28
Reported benefits for trainees in undertaking the Public Health placements ............................... 29
Reported benefits for the trainers and the PCTs from the Public Health placements .................... 32
Issues associated with the placements......................................................................................... 33
The ePortfolio and Public Health: a poor fit ................................................................................. 34
Summary ..................................................................................................................................... 35
ST3 Interviews ........................................................................................................... 37
Understandings of Public Health .................................................................................................. 37
Experiences of Public Health in General Practice .......................................................................... 37
Specific Public Health training to date .......................................................................................... 38
How to include Public Health in GP Specialty training .................................................................. 38
Summary ..................................................................................................................................... 40
Conclusion and recommendations .................................................................... 41
Possible changes to Public Health placements ............................................................................. 43
Alternative approaches ................................................................................................................ 43
Appendices .................................................................................................................. 44
Appendix 1: Online Survey ........................................................................................................... 44
Appendix 2: Public Health placements for GP trainees: interview schedule for Trainees .............. 51
Appendix 3: Public Health placements for GP trainees: interview schedule for Trainers ............... 52
Appendix 4 Interview schedule for ST3 trainees ........................................................................... 54
References.................................................................................................................... 55
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Acknowledgements
The authors would like to thank all the General Practice trainees and Public Health trainers for their
involvement in this Evaluation. Their willingness to complete the questionnaire and take part in the
interviews was greatly appreciated.
We also acknowledge the work of members of the West Midlands Strategic Health Authority: Dr
Martin Wilkinson and Dr Rob Cooper for their perceptive comments during the design of the
evaluation and construction of the data collection instruments; Carol Harper for helping to organise
interviews; and Dr Martin Wilkinson for sending out emails regarding the survey.
We are grateful to Magdalena Skrybant for numerous administrative tasks including involvement
with the survey and this final report.
This is an independent report funded by the West Midlands Strategic Health Authority. The views
expressed are not necessarily those of the Strategic Health Authority. All errors and omissions are
the responsibility of the authors.
6
Introduction and Aims
This evaluation was commissioned by the West Midlands Strategic Health Authority (SHA) as Public
Health was seen as an important part of General Practice (GP) training, but prior research indicated
that GP trainees do not often see the benefit of Public Health placements. Therefore, the aim of this
research was to evaluate the GP Public Health placements and make recommendations to the West
Midlands SHA on possible improvements. It was important to conceptualise the issues with these
placements and to explore ways to address them.
The research questions (RQs) were:
RQ1 For trainers and trainees,
a. What are the perceived roles of Public Health within GPs working lives?
b. When and how is it best for GPs to prepare for these roles?
RQ2 How well does the current Public Health programme in GP specialty training prepare
for the roles identified in RQ1?
a. Are the learning experiences suitable?
b. What are the impacts on future practice?
c. Is the assessment structure suitable?
d. What is the overall value of this programme?
RQ3 How have training placements changed the attitude of GP ST3 trainees to working in
General Practice? Due to the small number of Public Health placements, this will look at all
their F1, F2, ST1 and ST2 placements.
RQ4 What are the best ways to conceptualise the issues regarding these Public Health
placements?
RQ5 How could the Public Health programme in GP be improved?
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Method
Four methods were used to address these research questions: a brief literature review; an online
survey of GP trainees; interviews with trainees and trainers on Public Health placements (placement
interviews); and interviews with ST3 trainees (ST3 interviews).
The short literature review was undertaken to help conceptualise the reasons for and against
positive trainee perceptions of these Public Health placements (RQ4). In September 2010, Ovid/
Medline, Embase, HMIC Health Management Information Consortium July 2010, CAB Abstracts
1973 to 2010 Week 34, PsycARTICLES and PsycINFO were searched using the following search terms:
‘Public Health’ title, ‘General Practice’ keyword and ‘train*’ keyword. This generated 76 matches.
Scrutiny of the titles led to selection of 26 references, of which 16 were incorporated into this
literature review; from these a further 8 papers were referenced.
Bristol Online Survey was used to survey the opinions of current GP trainees within the West
Midlands (see Appendix 1). The range of questions was designed to address all the RQs. Dr Martin
Wilkinson, Director of Postgraduate General Practice Education, West Midlands Deanery, sent an
email to GP trainees’ ePortfolios and their course organisers on 2nd December 2010. A reminder
email was sent on 15th December 2010 and a final email on 8th January 2011 indicated that the
survey would close on 16th January 2011.
Data were exported from Bristol Online Survey to Excel and then into SPSS. Little data cleaning was
required. However in question 3, a few respondents gave placement in hours so these were
converted to months assuming 1 hour = 1 month / (4.5 weeks x 5 days x 6 hours) = 0.0074 months.
The placement interviews were designed to address RQ1 (what are the perceived roles of Public
Health within GPs working lives and how it is best to prepare for these roles?) and RQ2 (how well
does the current Public Health programme prepare for these roles?).
After some initial delays, contact was made with the four GP trainees undertaking Public Health
placements in the August – November 2011 rotation within the West Midlands Deanery. Semi-
structured interviews were conducted with the trainees either in their workplace or by telephone, at
their convenience. Interviews lasted approximately fifty minutes, were recorded, summarised and
then analysed to provide evidence addressing the research questions listed above. Issues of
confidentiality were discussed with participants, and permission to record the interviews was
obtained. Interviews took place towards the end of placements, between 18 November and 9
December 2010.
8
Further interviews were undertaken in person or by telephone, with three placement supervisors,
one of whom had discussed the research questions with four other trainer colleagues within her
department. Therefore the views of seven trainers are in some measure represented in the data.
Similar permissions were obtained and interviews lasted approximately fifty minutes each.
In the final phase of the project, telephone interviews were conducted with five ST3 GP trainees in
February 2011; they had completed the survey and indicated a willingness to be interviewed about
their experiences. At this stage, the trainees were all based within GP practices and they were asked
to reflect on the role Public Health played in their practise and how well, with some hindsight, they
felt they had been prepared for this aspect of their work. The specific research question that this
phase sought to answer was RQ1 (what are the perceived roles of Public Health within GPs working
lives and how it is best to prepare for these roles?)
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Literature review
Background
On the Department of Health website, public health is referred to as health protection, health
improvement and health inequalities with a White Paper to create a ‘wellness’ service and
numerous campaigns including obesity, immunization and violence against women and children
(Department of Health 2010). There are other numerous UK bodies concerned with Public Health
(PH). For example, the role of the Health Protection Agency is "to protect the community (or any
part of the community) against infectious diseases and other dangers to health" (Health Protection
Agency 2011). The Royal Society for Public Health, The Institute of Health Promotion and Education,
and the UK Public Health Association are additional organizations with informative websites relating
to PH (The Royal Society for Public Health 2011) (The Institute of Health Promotion and Education
2011) (UK Public Health Association 2011).
The Faculty of Public Health1 uses Sir Donald Acheson definition of public health (PH): "The science
and art of preventing disease, prolonging life and promoting health through organised efforts of
society” (UK Faculty of Public Health 2010). The Faculty's approach to PH is population-based looking
at the underlying determinants of health, emphasising collective responsibility for health with a key
role for the state. It divides PH into three domains: Health Improvement (Education, Housing,
Lifestyles, monitoring diseases etc); Improving services (Service planning, Audit etc) and Health
Protection (Infectious diseases, Environmental health hazards etc).
With these domains and their core values, the Faculty specifies nine key areas: Health Surveillance;
Evidence of Effectiveness; Strategy Development; Leadership; Health Improvement; Health
Protection; Health and Social Service Quality; Public Health Intelligence; and Academic Public Health.
The GP Curriculum defines the learning outcomes and skills required for general practice. Many of
these are related to PH; for example, domain five, Community Orientation, is concerned with the
ability to reconcile the health needs of individual patients and the health needs of the community in
which they live, balancing these with available resources; this includes epidemiology and dealing
with health inequalities (Deighan 2008; 18). Also GPs should use the context of the person, the
family, the community and their culture (Deighan 2008; 20).
Ashton (1990) describes four phases of health care in Europe and North America. The first focuses
on environmental improvement (of air, water and food) from the 1840s to the end of the century.
The second is characterised by personal preventive medical services, such as immunization and 1 The Faculty of Public Health is the standard-setting body for public health in the UK
10
family planning. Third is the therapeutic phase, with a shift from PH and general practice (GP) to
hospital-based medicine. Finally, Ashton argues that we are entering a fourth phase of ‘New Public
Health’, which is a synthesis of environmental and lifestyle change together with appropriate
prevention and treatment interventions. The main health problems include psychological disorders,
cardiovascular disease, diabetes, cancers and accidents which are related to lifestyle and affected by
public policy. It is argued, therefore, that there should be a shift towards PH and GP. General
practitioners are playing an increasingly important role in prevention-orientated activities; however
"there is a general lack of what might be called the epidemiological or population view of primary
health care" (p. 391).
Several authors have described the need for collaboration between General Practice and Public
Health but highlight the difficulties. Quoted by Morris, Bullock et al. (2001), these difficulties are
due to different approaches and mutual suspicion (Cornell 1999). Thus Graffy and Jacobsen (1995)
argue that GPs need to be confident about the principles of and their skills in PH to use it in primary
care. These distinct PH skills are ‘political’ in terms of using power to effect change and ‘people
management’ to work effectively with different professions (Eskin 1991).
Public Health teaching in the undergraduate curriculum
Edwards, White et al. (1999) noted that the undergraduate curriculum gave little attention to public
health medicine. Since then, policy initiatives in the United Kingdom (UK) have underlined the
importance of public health education. Questionnaires returned by 21 (75%) of teaching leads in
academic departments of Public Health in UK medical schools displayed great variability between
schools in teaching methods, curricular content and resources used. Topics included in the majority
of schools were Epidemiology, Disease prevention, Health promotion, Health inequalities, Critical
appraisal skills, Literature searching skills, Statistics, Communicable disease control, Health
economics ⁄ rationing, Medical sociology, NHS organisation, Occupational health, Environmental
health, Global public health, Health policy. In most schools, public health was at least partially
integrated with clinical teaching; there is also a move towards self-directed learning. More than half
the medical schools had difficulty finding teachers for Public Health and staffing levels had
deteriorated in 55% of schools. Many interviewees felt that their contributions were undervalued,
with one commenting: "I don’t think anyone would notice if we stopped teaching Public Health
(Senior lecturer)" (Gillam and Bagade 2006; 434).
In his reflections of the last two decades, Ben-Shlomo (2009) argues there has been a big change in
attitude toward PH teaching. It is now much more acceptable, but students still focus on diagnosis
and treatment. They may see 'Inequalities in health' as important but beyond their realm. As
11
epidemiology is the key to both Public Health and evidence based medicine, he suggests it is best to
focus on this and perhaps address ‘middle ground’ topics like screening. Also, trainees may be more
receptive as postgraduates.
GP views on PH
The 1990 GP contract emphasised population surveillance including checkups, health promotion,
immunisation (Paris, Wakeman et al. 1992). In an editorial, Hannay (1993; 516) wrote: "In 1990
general practitioners were made responsible for health promotion and disease prevention for the
first time". Hannay also suggests that "The barriers between the specialties need to be broken down
by joint appointments so that epidemiology and health promotion are given credibility by clinical
contact" (p. 517).
Analysing 300 (60%) UK GPs responses to a postal survey, Summerton (1995; 320) concluded that
GPs saw the Health and Safety at Work Act 1974 as relevant, but “detailed knowledge about health
protection legislation was consistently poor" and that "some doctors do not believe that risks and
regulations apply to them" (Summerton 1995; 321). His view was that GPs have a positive attitude to
Public Health, but lack knowledge.
Bradley and McKelvey (2005) proposed the creation of general practitioners with special interests to
ensure PH is delivered in primary care. They favourably quote Tudor Hart’s (1988) community
approach and use of the tools of community orientated primary care, developed in South Africa, to
provide leadership to other GPs regarding health improvement and community roles. They describe
the following models of health care. The Biomedical model views the GP’s job as fixing the broken
‘‘machine’’. In the Humanist model, the GP explores illness within the patient’s personal and
psychological context; whereas a ‘Family’ model uses the family context. Anticipatory care is centred
on individual health promotion; in a Public Health model, the doctor seeks to influence the social
and environmental context to promote health. Finally, the Business/consumer model is about
providing a good service, so the practice focuses on patient choice and maximising profits.
In Australia, 840 GPs returned questionnaires (65% response rate) about attitudes to and
involvement in child PH (Waters, Haby et al. 2000). Involvement was greater if the GPs were young,
female, qualified outside Australia, attending further training and if they expressed confidence in
dealing with children. The most common barriers to involvement were time, remuneration and
perceived inappropriateness.
In a book review, O'Donnell (2009) suggested the growing number of professional groups, ever-
changing organisational structures and the ‘small business’ model of general practice all militate
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against GPs adopting PH approaches. In addition, there is the overwhelming pressure of seeing
patients and meeting their needs within individual consultations.
Brenner, Money et al. (1994; 173) indicate it was argued in 1985 (Mant and Anderson) that “quality
in general practice entails recognition of the PH content of primary care; to this end, specific training
in the skills of population medicine were required". However, few principals and trainees in general
practice understood the roles of their colleagues working in Public Health (Voss 1992). Brenner,
Money et al. (1994; 174) believe “that there is a strong case for all general practice training
programmes to introduce some Public Health teaching and practice to their curricula".
Previous studies of Public Health Placements for General Practice
Mason, Udenze et al. (1994) surveyed the doctors who had undertaken the two year Leicestershire
Senior House Office (SHO) training scheme in PH since its inception in 1981. All 21 (84% response)
respondents viewed the scheme positively in terms of subsequent career choice. Five had stayed in
PH, eight had moved into GP, five into clinical medicine, two into occupational health and one
destination was not reported.
Graffy, Foster et al. (1998) described a single joint training post in GP and PH medicine. The post
focused on learning about needs assessment which evaluated local back pain services, critical
appraisal and evaluating services, but the registrar also played a full role in the Department of Public
Health medicine.
Brenner, Money et al. (1994) described the Sligo general practice training programme which
included a PH module within two years of community-based training. The objectives were: to
provide training and concepts in basic PH, and insight into the concepts of primary health care; to
enable research into primary health care; and to improve the liaison between GP and PH. Similarly,
an evaluation of three month part-time PH placements in Buckinghamshire focused on agreed
competencies, an audit project and unanticipated problems or benefits (Plugge, Banerjee et al.
2002). The authors concluded that the registrars generally enjoyed and benefited from their
attachment.
Fraser (2007) explained that with increasing recognition of the environmental and social
determinants of health, it was proposed that “Public Health to be a core component of general
practice” (Royal Australian College of General Practitioners 1997) and PH was included in GP
curriculum in 1998. Rural Australia has particular problems with high mortality and morbidity,
coupled with GP and PH workforce shortage. Therefore this paper described collaboration with six
academic general practice training posts in population health and PH for GP registrars, partly to
13
attract GPs to work in the area. Six (out of seven) GP registrars liked their projects (in obesity,
smoking and cardiovascular issues) and published them.
Morris, Bullock et al. (2001) report on a pilot with eight GP trainees who did PH placements "to
improve their knowledge of Public Health medicine". Their work was focussed on projects such as:
the preparation of information leaflets for GPs and patients about the appropriate use of antibiotics;
a rheumatology needs assessment; and the development of a purchasing policy for Pacecetabine.
Each placement programme needed to cover three specific topics: communicable disease control
(CDC); health needs assessment for populations; and the organisation and responsibilities of Primary
Care Groups (PCGs). Trainees felt their knowledge was initially very weak but had increased in all
three areas. They felt the placements had improved their skills in communication, management,
audit, and health needs assessments, also to build bridges / links with PH. They valued time with PH
Specialist Registrars (SpRs) for social interaction, increased exposure to issues, and the opportunity
to ask questions. All would recommend the placement to others, although they argued the
programme should have been structured to allow them to be more part of the team and they should
have worked with those on the interface with GPs e.g. the primary care and pharmaceutical
advisors.
A more recent study looked at PH placements for GP trainees in the London Deanery (Wills,
Reynolds et al. 2009). They interviewed 19 trainees towards the end of their PH attachment as well
as PH trainers and GP training programme directors. They suggest that the placements can address
relevant areas of the RCGP training curriculum, but this may not be sufficient to influence trainees’
perceptions of their future practice as GPs. Also, they point to a gap between the understanding of
training providers and trainees towards the changing nature of general practice.
Summary
The Faculty of Public Health divides PH into Health Improvement, Improving Services, and Health
Protection; the GP curriculum does not use the same categories but clearly involves many PH areas,
such as health inequalities. Ashton (1990; 391) argues for a shift from therapeutic medicine to PH
and GP, but notes a lack of the “population view of primary health care”.
Despite this common ground, there lack of understanding of PH in GP. One reason for this is that
although PH is included in medical schools, the focus is on diagnosis and treatment; this has been
described as the Biomedical model in contrast to the Public Health model which addresses social and
environmental factors. Additionally, there may be lack of understanding of the changing nature of
GP.
14
Suggested ways forward involve focussing on ‘middle ground’ topics such as epidemiology. Several
studies report positively on PH placements for GP trainees. There is a suggestion that a range of PH
areas need to be covered and some of the focus should be on the interface with GP such as
pharmaceutical advice.
15
Survey of GP trainees
Results
The survey was completed by 296 GP trainees; with about 950 trainees in the West Midlands, this is
a response rate of about 31%. Most answered almost all questions, although a few only completed
Question 1 and their personal information, presumably because they had not done any PH training
and did not see the relevance of the questionnaire. The number who answered individual questions
was usually less than 296, due to these non-responses.
Attitudes to Public Health
Respondents were asked to rate PH areas in terms of a) importance for their future work as a GP,
and b) the learning they “have achieved so far compared with how much you think should be learnt
during GP training”. The rating scales were from 1 = low to 6 = high, so 3.5 is the mid-point.
All the PH areas displayed in Table 1 were above this mid-point for ‘importance’; ‘Health promotion’
(5.4) and ‘Disease prevention / immunisation’ (5.4) were rated highest, whereas ‘Occupational
health’ (4.6) and ‘Environmental health’ (4.4) were lowest. Overall, there were significant
differences between areas (Friedman Test, chi-square (6) = 509, p<0.001).
Table 1 also displays rating for “the learning you have achieved so far compared with how much you
think should be learnt during GP training”. Highest rated for ‘learning’ were ‘Health promotion’ (4.3)
and 'Disease prevention/ immunisation’ (4.0) which were the only ratings above the mid-point.
‘Environmental health’ (2.9) was rated lowest, closely followed by ‘Occupational health’ (3.1) and
‘Health economics / rationing’ (3.1). Overall, there were significant differences between areas
(Friedman Test, chi-square (6) = 492, p<0.001). The ‘learning’ ratings are substantially lower than for
‘importance’ for each Public Health area (all p<0.001, Wilcoxon Signed Ranks Test, minimum z=11.2,
except z=5.5 for ‘Other’); this is shown in the ‘difference’ column in Table 1.
Although 130 responded to ‘other’ for ‘importance’ and 127 for ‘learning’, only 12 described other
areas. These were: commissioning services; health statistics; Local policies coordination between
GPs, other health sectors, how it's implemented; medical concerns; Medicine management,
Statistics, critical reading, evidence based medicine, HPU placement; Minority Groups; Public health
for overseas visitors, disasters, events, etc; PH publicity e.g. wearing helmets - specific campaigns
not just as and when opportunities to promote health; research methods, health informatics; sick
notes (med3 issues); Statistical analysis of papers; and travel medicine.
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Table 1: Rated ‘importance’ and ‘learning’ of Public Health areas
Public Health area
Importance Learning Difference
N Mean Std.
Deviation
N Mean Std.
Deviation
Epidemiology 295 4.53 1.006 291 3.40 1.156 1.13
Disease prevention /
immunisation
294 5.40 .772 290 4.02 1.221
1.38
Health promotion 294 5.42 .826 287 4.30 1.195 1.12
Knowledge of local health
inequalities
295 4.97 .910 288 3.33 1.303
1.64
Health economics /
rationing
293 4.81 .942 289 3.12 1.312
1.69
Occupational health 291 4.60 .982 286 3.07 1.283 1.53
Environmental health 292 4.40 1.062 285 2.94 1.308 1.46
Other 130 3.57 1.599 127 2.84 1.417 0.73
Public Health Placements
Assuming that no-response means that a placement was not undertaken, respondents’ postgraduate
Public Health placements are shown in Table 2. In total, 28 (9%) had some experience of PH, with
four month placements in FY2 (10) and ST1 (8) accounting for the majority of placements.
Table 2: Time spent on postgraduate Public Health placements
Months FY1 FY2 ST1 ST2 Other Other (description)
0.02/ 0.03 1^ 1^ 1^ 1^ ST3
2 1 House officer overseas
3 1 1 1 -
4 10 8 1 1 MSc in Public Health trainee with HPA
6 1
12 1* 1* 1* 1* 1 Worked in public health as epidemiologist prior to undertaking medicine
Total 3 12 10 4 5
^Same respondent. *Same respondent, so probably misunderstood the question
The next question asked about their most recent Public Health placement. Five trainees completed
this although they had not indicated experience of PH placements: these responses were ignored.
Table 3 shows that trainees rated their PH placements highly, with average responses between 4
17
and 5 on the six point scale. Although ‘Were the assessments appropriate?’ had the lowest mean
rating, differences between the questions were not significant (Friedman test, chi-square (4) = 8.5,
p=0.08).
Table 3: Your most recent Public Health placement
1 = ‘No, not at all’ to 6 = ‘Yes, very much’
Mean
Total 1 2 3 4 5 6
Was the placement well
organised?
2 1 2 3 13 5 4.50 26
Did it meet your learning
needs?
1 2 2 5 11 4 4.40 25
Were the assessments
appropriate?
2 2 3 4 10 4 4.20 25
Did your skills in Public Health
develop satisfactorily?
1 2 1 7 10 4 4.40 25
Overall was the placement
beneficial?
1 2 1 6 11 4 4.44 25
When asked: “Can you suggest two improvements to Public Health placements”, 17 of these
trainees made 30 suggestions. Table 4 reproduces the responses in full: 7 comments were for more
clinical/ practical work; 6 were general suggestions to improve learning, such as more structure or
taking courses; 13 comments were asking for specific activities such as areas of PH or attendance at
particular meetings; 2 felt the placement should be shorter but more intense, and the ‘Other’
comments were about location and availability of posts.
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Table 4: suggested improvements to the placements
Areas Full text of the suggestions
Clinical /
Practical work
Mixed with more clinical application
Need more clinical contact as I had none in 4 months
Some clinical exposure.
More clinical contact either with patients/ colleagues
More practical work
More community based, not office based.
Organise projects for trainees to work on as soon as their rotation starts
Learning A more focussed curriculum or agreed learning objectives
More structure to the programme would be beneficial
Incorporate into Public Health degrees like Diplomas Post graduate award or master degree during the replacement
Good supervision/ supervisor overseeing learning
Weekly teaching sessions on Public Health
To be able to sit online courses specifically for Public Health
Specific
activities
More relevant meetings to sit in such as PBC
Involving students/doctors in health promotion campaigns
Being able to compare different populations i.e. inner city London to Cumbria
Should target specific area of needs within GP...
...and the area of interest for the trainee, with overall benefit for the end users taking into account
Importance of health economics/rationing
To be able to visit the HPA and spend a few weeks there
More time in HPA
To spend more time in the different departments in Public Health
To learn more about commissioning
Participation in IMC meetings
placements in different departments of PCT
Longer time in HPU.
Duration It should be shorter and more intensive
Shorter intense duration
Other More awareness of posts availability
The replacement should consider placing and distance from the trainee house
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Attitude towards Public Health placements
Respondents were asked to “Indicate the influence of each factor on your attitude towards choosing
a placement in Public Health as a GP trainee” using a scale ranging from ‘-3 = negative influence’
through ‘0 = no influence’ to ‘3 = positive influence’. Results are shown in Table 5. The questions
have been re-ordered with the most positive responses at the top: ‘Relevance to your future GP
work’ (mean = 1.7) was most positive; then ‘To understand population issues’ and ‘To improve your
ability to treat patients’ (both 1.5); closely followed by ‘Relevance to the GP curriculum’ and
‘Opportunity for audit and research’ which both had a mean of 1.4. Least positive were ‘Opportunity
to undertake WPBAs’ (0.5), then ‘To work with the PCT’ (0.7) and ‘Opportunity for clinical work’
(0.8).
Eight trainees made a comment about this question: five of these indicated that they do not choose
placements; the other three comments were “Different set of environments”, “If I’m being honest, it
sounds boring” and “To learn how to be able to make models for hospital demand”.
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Table 5: Influence on attitudes towards placements
-3 = Negative influence to 0 = No influence to 3 = Positive influence
-3 -2 -1 0 1 2 3 Mean Total
Relevance to your future
GP work
n 1 4 4 25 73 110 71 1.70 288
% 0.3 1.4 1.4 8.7 25.3 38.2 24.7 100
To understand population
issues
n 3 10 33 85 96 60 1.54 287
% 1 3.5 11.5 29.6 33.4 20.9 100
To improve your ability to
treat patients
n 1 4 11 45 81 78 68 1.45 288
% 0.3 1.4 3.8 15.6 28.1 27.1 23.6 100
Relevance to the GP
curriculum
n 3 5 3 39 89 99 50 1.44 288
% 1 1.7 1 13.5 30.9 34.4 17.4 100
Opportunity for audit and
research
n 1 9 8 48 71 87 64 1.42 288
% 0.3 3.1 2.8 16.7 24.7 30.2 22.2 100
To understand lifestyle
issues
n 2 4 10 58 96 74 44 1.22 288
% 0.7 1.4 3.5 20.1 33.3 25.7 15.3 100
Opportunity for self-
directed work
n 6 12 78 82 84 25 1.05 287
% 2.1 4.2 27.2 28.6 29.3 8.7 100
Personal interest n 2 14 19 66 65 77 44 1.04 287
% 0.7 4.9 6.6 23 22.6 26.8 15.3 100
Opportunity to undertake
a Diploma in Public Health
n 9 4 15 91 64 58 47 0.94 288
% 3.1 1.4 5.2 31.6 22.2 20.1 16.3 100
Geographical location of
placements
n 4 10 11 89 67 70 33 0.93 284
% 1.4 3.5 3.9 31.3 23.6 24.6 11.6 100
To work with the PCT n 3 9 12 104 75 53 30 0.81 286
% 1 3.1 4.2 36.4 26.2 18.5 10.5 100
Opportunity for clinical
work
n 12 21 21 68 72 63 29 0.65 286
% 4.2 7.3 7.3 23.8 25.2 22 10.1 100
Opportunity to undertake
WPBAs
n 11 19 25 87 64 62 19 0.52 287
% 3.8 6.6 8.7 30.3 22.3 21.6 6.6 100
Other n 4 1 47 10 9 3 0.32 74
% 5.4 1.4 63.5 13.5 12.2 4.1 100
21
Although 40% of trainees indicated they would recommend PH placements to future GP trainees,
46% were unsure, and 13% indicated ‘No’ (Table 6). A similar percentage (46%) thought PH
placements should be increased, with 44% preferring them to be maintained at the current level
(Table 7). The majority (54%) favoured ST1 and 2 for PH placements, with 22% preferring post-
qualification and 17% during foundation training (Table 8).
Table 6: Would you recommend that future GP trainees undertake a Public Health placement?
Yes No Don't know Total
n 116 38 133 287
Percent 40.4 13.2 46.3 100.0
Table 7: Thinking about GP training, should Public Health placements be:
Discontinued Decreased Maintained at the
current level
Increased Total
n 11 19 125 131 286
Percent 3.8 6.6 43.7 45.8 100.0
Table 8: If GP STs were to experience a single placement in Public Health during their postgraduate training, should this be during: Foundation
training
ST1 or 2 ST3 Post
qualification
Total
n 48 157 21 63 289
Percent 16.6 54.3 7.3 21.8 100.0
Respondents were asked to explain their answer to “Would you recommend that future GP trainees
undertake a Public Health placement?” There were 163 (55%) responses; these were thematically
coded and are displayed in Table 9. Many of these comments displayed nuanced understanding of
the issues, for example:
“The GP curriculum is huge covering every specialty. To say yes GP trainees should undertake Public
Health placements is similar to saying a GP trainee should have a placement in every specialty.
Ultimately specialist placements are helpful but I have found you learn what you need to know doing
the actual job of a GP.”
Of these 163 responses, 42% were coded as positive; many described how PH understanding helps
GP work (14%) such as: “Public health policy is probably the single most important modifier of
22
societal health and not to investigate it as a trainee would create an unbalanced perception of
health needs.”
Where trainees indicated a specific area of PH, the most common responses concerned ‘Population/
community issues’ (11%); responses relating to ‘Understand commissioning/ PCT’ and ‘Disease
prevention/ health promotion’ (4% each) were also cited. Less common was a concern that it was
‘Not or poorly taught earlier’ e.g. “I feel that this area is very overlooked in the GP curriculum and
overlooked in training at medical school and it is very, very important in General Practice.”
Negative comments were primarily concerned that inevitably there would be ‘Less learning in other
areas’ (18%) e.g. “With the 3-year GP programme it is more important to get in core topics such as
obs and gynae, paeds, medicine, ENT etc.”
There were views that they ‘Can study Public Health separately/ be taught in GP’ (4%): “I think it
should be integrated into the GP placement part of GP training.”
There were criticisms that the “Placements were too narrow/ badly taught/ lack clinical focus” (4%);
for example: “... I am not sure if current placements are that relevant and whether a whole
placement is needed.” Also, “The work I was doing in my Public Health placement was related
mostly to what the team was involved with at the present time. Very narrow area of lifestyle
concerning one epidemiological issue.” Also, “... most trainees worry more about their day to day
clinical knowledge not being good enough rather than the larger issues dealt with by Public Health.”
Finally, “My Public Health placement was poorly supervised for the majority of my four months and I
was left to my own devices...”
Most of the other comments were that they ‘Can't say as no Public Health experience’ (17%). There
were also comments that it ‘Depends on individual interest and placement content’ (4%); ‘Shorter
placements would be better’ (3%); ‘Shouldn't be compulsory/ not essential’ (3%) and ‘Yes, if training
extended (to 5 years)’ (3%).
23
Table 9: Explanation for responses given in Table 6
n Percent (%)
Positive Comment Public health helps GP work 23 14.1
Population/ community issues 18 11.0
Not or poorly taught earlier 3 1.8
The reasons given in Table 5 4 2.5
Provides overall picture/ holistic
approach
3 1.8
Other positive 4 2.5
Understand commissioning/ PCT 6 3.7
Disease prevention/ health promotion 7 4.3
Total positive comments 68 42
Negative comment Less learning in other areas 29 17.8
Can study Public Health separately/ be
taught in GP
6 3.7
Placements were too narrow/ badly
taught/ lack clinical focus
7 4.3
Public Health not a core skill/ area 3 1.8
Total negative comments 45 28
Other comments Can't say as no Public Health experience 27 16.6
There is no choice of placements 2 1.2
Depends on individual interest and
placement content
7 4.3
Shorter placements would be better 4 2.5
Shouldn't be compulsory/ not essential 4 2.5
Yes, if training extended (to 5 years) 5 3.1
Other 1 .6
Total other comments 50 31
Overall total 163 100.0
Personal Information
Respondents were asked some questions about themselves. Table 10 indicates that 56% were
female and 44% male. Ages ranged from 25 to 54 years, with a median of 30 years. The most
24
common ethnic groups, shown in Table 11, were White British (36%), Indian (28%) and Pakistani
(14%).
Table 10: Gender of respondents
Frequency Percent (%)
Female 165 56.3
Male 128 43.7
Total 293 100.0
Table 11: Ethnic background
n Percent
White White British 102 36.2
White Irish 1 .4
White Other 16 5.7
Total White 119 42
Mixed Mixed: White and Asian 7 2.5
Mixed Other 4 1.4
Total Mixed 11 4
Asian Asian: Indian or Indian
British
79 28.0
Asian: Pakistani or
Pakistani British
39 13.8
Asian: Bangladeshi or
Bangladeshi British
2 .7
Asian Other 9 3.2
Total Asian 129 46
Black: African or African
British
10 3.5
Chinese 6 2.1
Other 7 2.5
Total 282 100.0
Table 12 shows that similar numbers of respondents were in ST1 (37%) and ST3 (37%), but fewer
were in ST2 (26%). The majority (61%) had undertaken initial medical training in the UK, 5%
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elsewhere in the UK and 34% in non-EU countries (Table 13). Table 14: Years of previous
postgraduate experience was calculated by subtracting respondents’ current Specialty Training year
from their total postgraduate experience. Just over half (53%) had two years’ prior experience i.e.
Foundation training or equivalent; 37% had between three and seven years’ prior experience.
Table 12: Current position
n Percent (%)
ST1 108 36.7
ST2 75 25.5
ST3 109 37.1
ST4 2 .7
Total 294 100.0
Table 13: Where did you undertake your initial medical training (e.g. MBChB, MBBS)?
n Percent (%)
UK 179 60.9
Other EU country 15 5.1
Non-EU country 100 34.0
Total 294 100.0
Table 14: Years of previous postgraduate experience
Years n Percent (%)
<2 3 1.1
2 148 53.2
3 29 10.4
4 21 7.6
5 23 8.3
6 13 4.7
7 16 5.8
8 9 3.2
9 7 2.5
11 to 21 9 3
Total 278 100.0
26
Table 15 shows the career aspiration selected by respondents. The most common aspiration was to
become a ‘GP with Special Interest (58%), followed by being a ‘GP partner’ (35%) and GP trainer
(24%). ‘Public Health’ was indicated as a possible career aspiration by 14 trainees (5%). The ‘Other’
category contained teaching, training, working as a locum GP, out of hours work and working in a
developing country.
Table 15: What are your career aspirations in the first 5 years as a GP? (Select all that apply)
Frequency Percent (%)
GP partner 103 34.8
GP with Special Interest 173 58.4
GP Trainer 71 24
Academic GP 26 8.8
GP Consortium Board 19 6.4
Public Health 14 4.7
NHS Leadership 18 6.1
Other 10 3.4
Total 434 146.6
Summary
In all PH areas, trainees rated the ‘importance’ higher than the ‘learning’ they had achieved (Table
1): this could be regarded as a knowledge gap. Only 28 (9%) had some experience of PH, mainly in
Foundation or GP training. Generally these trainees regarded their PH placements highly. Their
suggestions for improvement included more clinical/ practical work, more structure and specific
activities/ areas of PH.
The most highly rated reasons for PH placements were relevance to future GP work and
understanding of population issues. Just under half of the respondents (46%) thought PH placements
should be increased and 44% thought the current level should be maintained; most thought
placements were best in ST1 or 2.
There was some concern that placements were too narrowly focused, but a great dilemma was that
time in PH inevitably meant lack of experience in a core clinical area. Overall the survey revealed
some antagonism to PH, but many trainees felt it to be an important area and were positive towards
PH placements. A small percentage of trainees (14.5%) had career aspirations towards PH.
27
Placement Interviews
The trainees
Of the four trainees interviewed about their PH placement, three were in their first placement of
Specialty Training and one was in their second year. All four were based within Primary Care Trusts
(PCTs). Two of the trainees had completed a rotation within a GP practice within their Foundation
Training; another had completed a taster week in a GP’s practice prior to commencing Specialty
Training. One trainee had originally trained abroad and had some experience of PH in a developing
country; another had completed a Diploma in Tropical Medicine and Hygiene and volunteered
abroad, again in a developing country, working on PH-related projects. However, all trainees felt that
their prior clinical background had been hospital based, either in surgery or general medicine, and
felt an initial lack of understanding about what PH was or what they would be doing whilst on
placement.
Expectations of the trainees
A common theme amongst trainees was the distant and vague memories they had of studying a
Public Health module as part of their Medical Degree. In contrast to the intensive clinical teaching
they received, PH focussed heavily on epidemiology and trainees found it hard to relate to relate to
this approach. Typical was one trainee’s description:
It was a lot different from anything else that we did, so it was kind of ‘so what’s this then?’ It was hard to fit it in with anything. And then you suddenly get this and it’s like what?! Trainee III
Trainees described their uncertainties about what to expect of their placements once they knew
they were allocated to PH. Trainee II described his initial reaction:
I didn’t know what to expect, I didn’t know what they wanted from me, you know, what was it going to be like? What was I going to do in PH? And then suddenly I’m in a placement where I don’t know what it is, PH. Obviously I’d studied it and I’d done a bit of PH but what do they actually do here? It was quite scary, I mean, would I be out and about? In a car or a vehicle? Standing in town, talking to people? Or I just didn’t know what to expect – it was quite scary. Trainee II
The PCT setting was new to all the trainees who had spent their prior working experience in dealing
with patients face to face. The office environment and lack of clinical immediacy required them to
adapt to a different way of working. As Trainee IV explained, it was not always possible to see the
outcomes of work completed in the same way as a patient might improve within a clinical setting:
It takes time to sort of build up, it’s not like a clinical setting where you get there and the patients are there and you get straight in. It takes time, there’s a learning curve. It takes time for things to get underway. And I think also the timescales within which things happen, with how things happen, you don’t get feedback immediately because you don’t always see immediate results. Trainee IV
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Despite the uncertainty, all trainees recognised this was a particularly apposite time to be
undertaking a PH placement just as NHS changes were beginning to take place with the move to GP
consortia and commissioning of care.
Work Activities Undertaken
Three of the trainees described a high degree of flexibility and autonomy in the work programme
they undertook. In just one case, there was a particularly structured list of tasks awaiting the trainee.
Two trainees held prior meetings with their supervisor to discuss the range of opportunities they
might take part in. As the trainers explained, Public Health placements are subject to topical issues
arising so some flexibility is inherent in their work. The flexibility also allowed trainees, at least in
part, to tailor their work programme to suit both their interests and training needs and all had held
discussions with their supervisors over this. The three trainees with the most flexible programmes
commented that they needed to be pro-active in determining their priorities, unlike in a clinical
setting where the priorities were usually dictated by patient need. Two trainees suggested that
having some knowledge of PH from prior experience helped them in determining their priorities but
trainees without that experience would have found it much harder. Perhaps as a result of this
flexibility, the range of work undertaken by the trainees was very broad and is summarised below.
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Table 16: Work undertaken by placement trainees
Trainee Areas of work
W Audit of cancer screening programme
Preparation of, and review of papers
Data interpretation and analysis
Screening programme work
NICE decision making evidence gathering
Awareness raising session
Patient checks in the community
Preparation of policy guidance
2 possible publications
X Individual funding requests panel
Cancer reform strategy research
Single technology appraisal for NICE
Cancer awareness roadshows
Journal clubs
Y Audit of Cancer Screening programme
Multi-media distribution and evaluation
Evaluation of vaccination take up in particular communities
Analysis of TB cases in the region
Taking part in a Roadshow to present findings from a report
Needs assessments
Teaching
Sitting on a Research Proposal panel
Z Audit of suicide in the region
Prison Health Needs Assessment
Review of Commissioning policies
Review of individual treatment requests
Reported benefits for trainees in undertaking the Public Health placements
The trainees were consistent in their perceived benefits of the placements and all trainees were
positive about their experiences. The strengths included a better understanding of health as a
population issue, the process of commissioning, working in partnerships and the community, health
30
promotion and protection work, as well as a range of skills including literature reviews, critical
analysis, using and interpreting evidence, and presentation skills. These are explained in more detail
below.
Health as a population issue
Prior to undertaking the placements, trainees had very little experience of broader health policy
work, having had training with a clinical focus throughout. They were used to dealing with the
patient in front of them, rather than thinking about the health of the population as a whole,
exemplified in this extract from Trainee I interview:
Looking at them holistically as an individual, but then also looking, in the back of your mind, looking at the whole population you’re serving. Especially now, we’ve stopped for example elective orthopaedic procedures, so as a GP and you’re sat there, I did this with my supervisor, when you have to tell Mrs Bloggs that she can’t have her hip replacement that she waited six months for, because you’ve had to make cuts because you’re over budget or you’ve decided instead to spend the money on other services, it’s a constant struggle in the back of your mind as well. So it’s looking at things two-dimensionally if you like. So the person in front of you, who is your priority, but then also remembering that you’ve got other responsibilities and you’ve got other patients you have to look after too.
In addition, the breadth of work undertaken in Public Health was not previously understood by
trainees, who left their placements with a much greater understanding of what PH was actually
about:
Better appreciation of what PH is, the breadth of its work and what goes on at PCT level, as a GP trainee it’s certainly adjusted my, made me more aware of the need and potential for PH slant to your work and initial outlook. Trainee IV
The need to see policy decisions in the broader context was identified by the three interviewed
trainers as well as the trainees, as this extract from the interview with Trainer A illustrates:
Because I do think if you haven’t had this experience, it just seems a bit of a chaotic mess. How are decisions getting made? Who is making them? It will be changing in the future with consortia and everything. But I think Dr X will have a much better understanding going out into GP about who he can link in with, where decisions are being made, and perhaps an understanding when things come down and appear like a missile landed on his desk, that there’s probably some context behind it.
Experience of commissioning
The placements commenced three months after the 2010 General Election and the announcement
that PCTs were to be disbanded with responsibility for commissioning of services moving to GP
consortia. All trainees recognised that their placements were therefore timely and gave them useful
knowledge of the issues the PCT had faced in commissioning services. The key benefits reported
were a better understanding of the process itself, an introduction to the different roles people
undertook and a better understanding of issues of prioritisation in treatment. Having been used to
the clinical setting where they were expected to decide the best treatment for the patient in front of
31
them, this was the first time trainees were being asked to think about prioritising one need over
another.
I have probably come at the right time really, with all the changes that are coming, with GPs commissioning. People have said to me that would be really useful for you to go to the policy commissioning meetings, you can see how difficult it can be that will be useful for you. And also, we obviously have to read a lot of papers to get evidence. Even that is useful because you’ll probably have to do a lot of research with GPs commissioning so… Trainee III
As a GP trainee I think more of us should be able to come in and do this and to have some awareness of how to commission services how it’s going to be GPs to be able to think about patients and their procedures and costs etc. I’ve learnt a lot about commissioning. Trainee II
And another thing, as a GP trainee, when I got here, I just thought it would be a sort of waste of a resource if I didn’t exploit the fact that I am at the PCT and it’s a good opportunity to find out about what they do. You know, with all the changes coming to GP. The good thing about the PCT is that everybody’s just literally in an office down the corridor, so I contacted the Head of Finance, the Head of Commissioning, the Head of Strategy and Innovation and asked them if they wouldn’t mind if I either sat in on some meetings or did a bit of work for them, or just had a chat with them, just so I learnt a bit about that aspect of everything which will, by the time I qualify will be a big part of GP. And that’s been really good. Trainee I
This broader understanding of commissioning and the work of the PCT was recognised as a key
benefit by the trainers too, as Trainer B described:
I think there’s the knowledge and the breadth of understanding about the health service…understanding how does a primary health organisation work [sic], what’s the relationship with an acute trust, which is all most people have understood at the point at which they come, and what’s the relationship then with GP, so it’s a more holistic view of a health service and understanding the complexities of, and I think understanding the complexities around it in terms of the politics but also the management. Moving from an individual patient perspective to when you’re looking at a whole population or a whole service how is that different? You have to make some very difficult decisions really.
Working in partnerships and the community
For the trainees, coming as they did from a clinical environment, experience of the wider health and
health-related community was limited. The time spent in the PCT with the Public Health department
both made them more aware of, and gave them experience with other professionals involved in the
delivery of frontline care services. For example, Trainee I remarked:
Yes, a big part of it is prevention. I didn’t know there was so much going on in the community. There’s so much that happens in the community, and I was really naive actually. I didn’t know there are community nurses, we have fat-busters, I knew about smoking cessations – the big ones, but there are people out there who really help people that need it most. And sometimes they’re the people who don’t even see their GP until it’s far too late, until they’ve gone on with their heart attack. So it’s those people we need to target. Community nurses do an amazing job, going to the pub at midday….. as a GP you’re central to the community and so if you’ve got strong links, if you even know they exist, you’re off to a flying start.
32
Even the availability of complementary services that a GP would inevitably need to utilise was new
knowledge for some of the trainees. Being involved in public campaigns, such as cancer awareness
raising activities in the high street, brought trainees into contact with a broad section of their
community as well as with fellow professionals. The trainees reported an increased respect for the
more diverse range of health professionals that led them to report viewing health issues in a more
holistic way:
I think it will make me appreciate the challenges of PH and sort of work with and integrate with PH professionals in a more co-ordinated fashion, having a better understanding of their perspective. Because my supervisor expressed some kinds of frustrations about how difficult it was to get GPs engaged with some the work he was doing, even on a basic audit level and trying to get systems to change. It’s made me much more aware of that and I’ll be much more willing to engage with that in the future.’ Trainee IV
Related skills to inform the development of practice
So far, the benefits reported by trainees on placements have related either to new knowledge of
procedures or to developing a broader understanding of PH reaching beyond the confines of a single
patient: doctor relationship. Alongside these important benefits, there were a number of new skills
that they reported they had developed or refined as part of their placement with PCTs. These fell
into two categories: academic or researching skills, and presentational or communication skills.
All trainees had been asked to prepare background research to inform different aspects of
commissioning work, whether this was individual case treatment requests or broader health care
audit reports. Here they gained experience of conducting literature reviews, and taking a critical
approach to reviewing evidence. This included the analysis of statistical information to inform
practice. They reported that this helped them to understand the need to question information and
evidence in their practice as a future GP and to assess sometimes conflicting claims in relation to
treatment practices.
Alongside these academic skills, all trainees reported having been asked to present the findings from
their research to a variety of audiences. These included professional panels, medical trainees and
the general public, in a variety of settings. All participants, both verbally and in writing reported
improved communication skills.
Reported benefits for the trainers and the PCTs from the Public Health
placements
All three trainers interviewed reported benefits to their department in having GP trainees. Although
one trainer remarked that when the trainee was less competent they proved to be a drain on
resources, all trainers had viewed the current rotation positively. There were three key areas where
the PCT benefitted from having the trainees in place: the clinical experience the trainees brought,
33
the additional staffing they provided and the introduction of fresh ideas and enthusiasm on a regular
basis.
The up-to-date clinical experience that trainees brought was of use to the Public Health department
particularly when they had to prepare proposals or strategy documents. For example, Trainer B
described the broader benefits of an enthusiastic trainee who had recent clinical knowledge:
Good from both perspectives. We get a trainee who is experienced, usually quite motivated, variety of skills, usually proactive, they fit in well, their range of skills and attributes fit in well, and we get some good pieces of work out of them. But also we get that outside challenge, the clinical edge and they are up to date. So we get a lot out of it.
These thoughts are echoed in this extract from Trainer A’s interview:
They do add another dimension to the department. They add a clinical dimension. We have our own SPRs, not all are clinical but it is very useful, they are all very clinical, the GPs, and that’s valuable, and it’s very useful to have that in some of the work because some of the work you do need that clinical view.
As well as up to date clinical experience and knowledge, all the trainers described how trainees are
expected to complete actual pieces of work whilst with the PCT. Some trainers had very fixed views
about what trainees should cover on their placement while others were less explicit, but all saw the
relationship with GP trainees as being of overall benefit. Common amongst their descriptions was
the advantage of having an extra pair of hands in the department to help with specific projects.
Alongside being a staffing resource, the injection of new enthusiasm and commitment was valued by
trainers, as was the opportunity to influence the PH awareness of future GPs.
Issues associated with the placements
The four main issues described by participants here were common between trainees and trainers.
They include the timing of the placements, understanding where the placement fits into wider
training, levels of understanding of what Public Health is, and finally the lack of fit between the
ePortfolio and the non-clinical environment of PH in the PCT. These will be addressed in turn below.
Timing: Is four months long enough?
The issue of timing came up in every interview. There is clearly a tension between making the PH
placement long enough to complete meaningful projects and fitting the placement into the broader
GP specialty training. Most trainers felt that four months was ‘about right’ but that longer would
potentially allow the trainees to take responsibility for a bigger project. In one case a trainee was in
ST2 and she was undertaking a six-month placement. However, she was concerned that six months
was too long to be away from the clinical environment and she would have lost vital skills by the
time she returned. She had undertaken some locum work in the meantime, but questioned whether
34
it was not possible to have a mixed placement pattern of four days with the PCT and one day in a
clinical setting:
I suppose the only other thing I would say is that 6 months away from clinical practice is a long time. Four months isn’t so bad, but 6 months is a long time. I think when I go back, I’m going to find it quite difficult. I’ll probably adapt quite quickly, but you soon get out of the habit of seeing patients. I’ve done about two or three paediatric locums just to keep my finger in a bit, but I have noticed that when I’ve been there I have had to think a little bit longer. So I don’t know if they could do maybe four days in PH and then one day maybe in a GPs, or in a hospital maybe just for one day a week, just to keep you in. Trainee III
All trainers commented that the nature of PH work meant that trainees were required to respond to
topical events as and when they arose, such as disease outbreaks, and the four months was
therefore difficult to plan for until the trainee arrived ‘on our doorstep’.
Seeing where the placement fits with other training
There were two aspects with this issue. The first was whether or not trainers felt fully informed
about what trainees they were expecting and how this placement sat with their broader training.
Some trainers reported this was an issue, in part relating to communications with the centre
(Postgraduate Education School) although this had improved considerably more recently:
They come, they do it and they go. I don’t feel that we have a sort of overview or an involvement in the whole thing. They come here, four months, we do it, I do the computer, they go off, somebody else comes. Now I haven’t got a clue really, how the rest of the thing is structured. Trainer B
However, for the trainees, their lack of appreciation of what PH was had created a degree of
apprehension about the placement. This was usually dispelled once their programme of work had
been agreed but the lack of preparedness was an initial issue. This was in part informed by the
perception amongst some trainees of the value of Public Health:
People sort of laugh when I say I’m in Public Health. Public Health? What’s Public Health? They call it Public Holiday. They say how’s ‘Public Holiday’?! Because they know it’s a 9 to 5 and sitting at a desk. You’re not saving lives in a critical, clinical setting. Trainee III
Some people think it’s a ‘walk in the park’ post, that it’s a holiday, but it’s got it’s own stresses and demands. You might not be on call on an evening, but you’ve got deadlines and having to work on reports and so forth. I was pretty busy outside of work trying to do a good job, I easily filled my time. Trainee IV
One respondent suggested it would have been helpful to have had some kind of induction package
prior to starting, both to give a better indication of what to expect on placement and to help
familiarise with the language of PH practice.
The ePortfolio and Public Health: a poor fit
The issue of greatest concern to both trainees and trainers was the poor fit between the
requirements of the ePortfolio and the nature of work in PH. The essentially clinically based
35
assessments required by the ePortfolio could not be undertaken in the PCT setting and this was of
concern as Trainee II describes:
The problem with our portfolio is that we have assessments which are direct observational skills….and they involve patients but here we don’t have patients so that’s one of the big weaknesses… so that I feel I am falling behind with, getting my competencies signed off.
Some attempts were made to match the tasks with the requirements, although both trainee and
trainer admitted this was more fitting around the requirements than a good match:
That’s where I’ve really struggled. I’ve managed to get three case based discussions done which is the minimum in 6 months, but they are quite limited in what is written. I can’t do any DOPS, mini-CEX I can’t do, ….I don’t know if I can get them done in the HPU, but I don’t know. Trainee III
Of perhaps greater concern was the way in which the trainers felt this mis-match did not allow them
to fully record the true value of the trainee’s work, as this trainer described:
Colleagues that have used the ePortfolio, have found it too clinical to reflect work fairly. This prevents a proper reflection of the trainee’s work: eg if they have gained great IT skills, on the ePortfolio it is about primary care systems. So you can’t give credit. All you can do is put it in the comment box. You can’t say they have done clinical work when they haven’t. Trainer D
This trainer went on to argue that the mismatch could be interpreted as a lack of priority being given
to the PH placement:
So if PH rotation is serious then the assessment has to reflect that importance. We get irritated by that – they could be a really good trainee and that is not reflected. Trainer B
Summary
Overall, trainees reported the following benefits:
• A broader understanding of health as a population issue rather than as a clinical problem in
a one-on-one relationship between doctor and patient;
• A greater understanding of the processes involved in commissioning health care, making
priority judgements and the need for rationing of health care against budgetary constraints;
• A better knowledge of the possibilities of partnership working, the availability of health
related services and professionals, and an understanding of the roles different services may
play in a GP’s work.
The main benefits of the placements from the trainers’ perspectives included:
• Trainees with recent clinical experience offering a clinician’s perspective;
• Additional staffing resource that is enthusiastic, committed and willing to undertake a
variety of different projects whilst offering a new perspective on the department’s work.
• The issues identified that could improve the Public Health placements included:
• Developing a greater awareness of what PH is amongst GP trainees more generally;
36
• Providing trainees with some induction materials that would help them to understand what
PH entailed before they commenced their placements;
• Adapting the ePortfolio to allow for the demonstration of non-clinical achievements, or
better guidance on adapting the existing processes to a non-clinical environment.
37
ST3 Interviews
Understandings of Public Health
Trainees were asked to describe the ways in which they understood Public Health based on their
experiences and training to date. They generally saw PH in terms of three key concepts: health as a
population not individual issue, health prevention and health promotion. Trainee 4 summarised
their understanding:
It’s the study of the wider, health of the community that we serve, and I always think of it as something locally, and then on a national level, so it’s the study of prevalence and incidence of disease and how quality of life can be improved for the general population that we serve.
All trainees felt that PH was an important aspect of GP work and could see how experience in PH
would improve their practice. Trainee 1 described how they felt the media coverage of health issues
was changing the expectations and knowledge of patients, altering the interaction between doctor
and patient:
Media has played a huge role trying to educate people to be quite honest. Patients tend to be a lot more open nowadays because when people hear something on the radio or watch it on TV they will come and ask us about it and they are more willing to take, I suppose, take their health into their own hands and try and improve things, try and prevent their illness. They are quite happy to do that rather than wait and come in and see us when they have become unwell.
They later went on to suggest that this interaction was often two-way in that patients might know
more about current treatments than they did and how they then took their lead from patient’s
knowledge.
Experiences of Public Health in General Practice
All the trainees interviewed had experienced some PH related tasks in their final year in specialty
training, the most common of which was conducting audits. Other common areas included diabetes
care, smoking cessation clinics, healthy eating advice and responding to infectious diseases. A
common theme, which recurred in interviews, was the issue of knowing how to signpost people to
help and who and where to go to for advice and guidance:
I had a man with a needle stick injury while he was vaccinating sheep and I thought ‘Oh God, I don’t know!’ And you think who deals with this? What do I do?! You just give standard advice and then the HPA were the first people I went to and said ‘Is there anything else I can do?’ It would be good to have a little bit of insight and know what is available, what services are there and what you can tell patients quite confidently, rather than ‘I’ll get back to you’. (Trainee 1)
The PH placement trainees had described being involved in other tasks such as commissioning of
services, impact assessment and individual treatment requests; these tasks had not been
encountered by the ST3 trainees but they were aware that they might be asked to get involved in
the future.
38
Specific Public Health training to date
None of the trainees interviewed had completed PH placements in their Foundation or Specialty
training to date; although two had studied Public Health related modules in formal Postgraduate
courses. Trainees reported they had not received any formal CPD sessions on PH as part of their
Specialty training and Trainee 2 was typical in saying: ‘I have found that it is not enough’. Trainees
were then asked how they felt their training had prepared them for PH within GP practise, and
unsurprisingly four out of five replied that they did not feel their training had prepared them:
I’m not sure that it has, to be honest. … I haven’t had any contact with PH during my training at all, so I’m not sure that my GP training has prepared me at all. (Trainee 4)
I’m not sure the training did, to be quite honest. (Trainee 1)
Honestly? Not at all. Everything I have done, I have had to learn practically on the job. (Trainee 5)
The trainee who described feeling more prepared had studied a BSc in Public Health at Medical
School and they drew upon that experience to help them:
I think it’s quite difficult to communicate PH to postgraduates without doing PH placements, I don’t think it’s very effectively done. But I do feel that I had some kind of idea because of the extra year I spent doing a BSc in PH at university.
Recognising that trainees felt they had not received formal training in PH, they were then asked how
they coped in their work when they came across issues to do with PH. What they all described was
learning on the job, by doing, and by reacting to situations as and when they arose. Having to deal
with specific requests or issues meant the trainees turned to more senior colleagues in the practice
for advice on who to contact and how to respond. One trainee described the process as ‘you don’t
exactly get it handed to you on a plate’ (Trainee 3). Trainee 1 stated that they also learnt from their
patients but recognised there were significant gaps in their knowledge:
It can be quite scary sometimes. But I suppose it builds up your confidence if you have to find these things out for yourself.
Trainees had all found their own ways of learning on the job but were unable to draw upon specific
training experiences to do so.
How to include Public Health in GP Specialty training
Participants were asked how and when they thought it would have been helpful to receive more
training in PH issues. The breadth of training required for GPs was seen to be a barrier to increasing
the amount of PH specific training offered but nevertheless there was consensus that a placement in
39
PH would be useful if time allowed. The real value of placement experience was in the embedded
nature of the experience:
Yes, because that’s the only way you’re going to meet all the people involved in the community medicine side of things and the interpreting of guidelines into local care pathways. (Trainee 4)
As an alternative or in addition to placements, they suggested that more PH input into VTS sessions
would be welcomed.
Competing priorities
Participants recognised the pressures created by the breadth of the curriculum for GP specialty
training and the need to balance competing demands for knowledge and teaching. For example,
Trainee 4 recognised the potential value in a PH placement but felt that other clinical areas were
equally important:
I never did obstetrics and gynae etc in my training. You’ve only got 3 timeframes where you can do PH, so the only way is to increase the length of GP training, but whether that actually happens… I can’t see how it would be possible to routinely give people PH training over and above other important specialties.
In contrast, Trainee 5 said they would be willing to give up one of their other specialty placements in
favour of one in PH. However, all trainees argued that they would have liked to have a placement,
even if it was short as Trainee 2 described:
I think it might have helped me if I would have had even a small placement in PH, maybe just for a couple of months as well. That would have helped me.
Respondents varied in their views about when the best time might be to have a placement, with
three trainees arguing that this would best be placed in their ST3 year or later in ST2, once they had
experienced what Trainee 1 described as the hospital : primary care interface. One trainee argued
the placement would be better early in ST1 and another argued FT1 was the most appropriate time.
VTS sessions
There was wide support for more input by PH professionals into the VTS sessions all trainees
participated in. None of the trainees could recall any such input to date although Trainee 4 did
describe a session where:
This year we didn’t have anything specific although someone did talk about healthy people, screening, child surveillance, smoking cessation so that is the closest we’ve come to in PH teaching.
Trainees described two key areas they felt they would benefit from more knowledge and could be
gained in such VTS sessions: knowledge about services and who to contact and how to promote
better health awareness amongst their patients. These are summarised by the extracts below:
If there were some teaching sessions, for example, that were specifically about PH in GP training, that would really be useful, just to give us a little bit of an idea of what is available and what we can do to promote the well-being of our patients basically, rather than learning on the job and trying to look
40
things up. It would be good just to have a little bit of an idea, maybe just as part of the VTS teaching sessions. And maybe if someone came and spoke to us about it and just said ‘This is what your role is with regards to promoting better health’ so we have a more structured idea of what our responsibility is basically, what we’re supposed to do, rather than everybody just winging it and thinking ‘Oh, I think I’m doing the right thing. (Trainee 1)
There does not seem to be much communication between PH and GP during the training. I wouldn’t know how to speak to someone from PH. Just maybe them coming to talk to us at a VTS session, or arranging a small group session about the work of PH, the impact it might have on GPs, might be useful to everybody even if people can’t do 6 month blocks. (Trainee 3)
In addition to these suggestions, there was some limited support for an online module to give
trainees an introduction to basic concepts. Trainee 5, for example, argued that the Deanery should
develop such a module and award CPD credits for its completion.
Summary
From the interviews with ST3 trainees, there was clear evidence that there were gaps in knowledge
as a result of not having completed a PH placement in their training. Those gaps included: awareness
of service provision; approaches to health improvement; notification procedures; and the
responsibility GPs carry in relation to PH. Instead, trainees described a process of learning on the job
as they went along, responding to specific cases.
All trainees recognised the value of PH knowledge in relation to their work as a GP.
Pressure on GP training to cover all specialties was seen as a barrier to including a PH placement for
all GP trainees but there was little evidence of anything having been provided to replace the
placement experience. The best time to include such placements was reported by most trainees as
being later in the specialty training, in ST2 or 3.
PH input into VTS sessions would be welcomed but was currently not in evidence. Such input would
help to raise awareness amongst all trainees about the need to understand PH and how to deal with
issues of PH as they encountered them in their practice.
41
Conclusion and recommendations
This evaluation considered four areas of evidence: literature, online survey, placement interviews
and ST3 interviews. All four areas were positive about PH placements for GP trainees but raised
important issues. These will be considered within the framework of the five research questions
(RQ).
RQ1 For trainers and trainees,
a. What are the perceived roles of Public Health within GPs working lives?
b. When and how is it best for GPs to prepare for these roles?
From the survey, all PH areas were regarded as important, particularly ‘Health promotion’ and
‘Disease prevention/ immunisation’. For all these areas, the trainees rated their current learning as
insufficient. For the placement trainees, the key roles that PH can play are greater understanding of:
health as a population issue; commissioning and rationing; and, the way health related services and
professionals support GP work. It was notable that the survey respondents also rated understanding
of population issues as a key reason for PH placements.
PH trainers afforded a different perspective: they valued the GP trainees’ input due to their
enthusiasm, recent clinical experience and being additional staff.
In the survey, 90% of trainees thought PH placements should be maintained at their current level or
increased. Most of them thought these placements were best in ST1 or 2; however, the ST3
interviewees felt the placements were better later in specialty training i.e. ST2 or 3.
RQ2 How well does the current Public Health programme in GP specialty training prepare
for the roles identified in RQ1?
a. Are the learning experiences suitable?
b. What are the impacts on future practice?
c. Is the assessment structure suitable?
d. What is the overall value of this programme?
In both the survey and placement interviews, trainees were positive about PH placements.
Suggestions for improvement included: more practical work; more structure to the placements; and
experience of particular areas of PH. Lack of clinical work was probably the major concern for
trainees. Related to this is the difficulty of undertaking workplace-based assessments, although
some Case-based Discussions did take place.
42
Several respondents to the survey said that PH placements were too narrowly focussed; however,
the placement interviews revealed a great breadth of activity.
RQ3 How have training placements changed the attitude of GP ST3 trainees to working in
General Practice? Due to the small number of Public Health placements, this will look at all
their F1, F2, ST1 and ST2 placements.
This could not be addressed as only one of the 14 ST3 trainees who agreed to be interviewed had
experience of a PH placement. Also only 9% of survey respondents had any experience of PH.
Therefore, this RQ changed to be “What is the attitude of GP ST3 trainees, who have not experience
a PH placement, to PH?”
The five ST3 trainees who were interviewed said there were gaps in their knowledge as a result of
not having undertaken a PH placement. These gaps related to service provision, particularly in terms
of what services GPs might draw upon to support them with their work; health improvement and
how best to influence their patients in healthier habits; notification procedures for example with
communicable diseases or issues of health and safety; and their own responsibilities regarding PH, in
the light of new policies around commissioning of services.
RQ4 What are the best ways to conceptualise the issues regarding these Public Health
placements?
The GP training curriculum and most of the GP trainees value the importance in principle of
addressing social and environmental determinants of health i.e. they regard Public Health as
important. However, as found by Voss (1992), the ST3 interviewees said that without a PH
placement, they had little idea of what happens in PH.
In terms of Bradley and McKelvey’s (2005) almost all of their training uses the Biomedical model of
diagnosis and treatment of individual patients. The Anticipatory, Public Health and
Business/consumer were all evident in interviewee’s comments, but they were much weaker than
the biomedical approach that was dominant in their prior training.
Placement trainees said PH was initially hard to relate to: an office environment; no patient contact;
and, longer timescales to complete tasks. Day-to-day activities, as well as the theoretical approach,
therefore, require considerable adjustment by trainees.
The biggest issue raised was that a PH placement inevitably means lack of experience in a clinical
area that is more clearly relevant to the GP trainees’ principal focus of helping individual patients.
43
One approach to bridging this conceptual divide between GP and PH is to look for areas of overlap
such as audit and screening. Similarly, ST3 trainees find they need to refer patients to areas of PH
e.g. smoking cessation; input by PH specialists in these areas of GP training would be beneficial.
RQ5 How could the Public Health programme in GP be improved?
Potential improvements to PH education for GP trainees are described in terms of changes to Public
Health placements and alternative approaches
Possible changes to Public Health placements
Trainees on the PH placements found it quite difficult initially in terms of what to do and expect.
They suggested there should be better induction materials, so they could more quickly adapt to the
very different approach.
It is important that those on PH placements are not disadvantaged in terms of the workplace-based
assessments that they can undertake. Either, guidance is required to explain how suitable
assessments can be undertaken using the current system, or the ePortfolio needs to be adapted to
include PH activities.
There was a wide range of trainee attitude towards PH from a minority of trainees quite hostile, to
the majority, who were positive. Five trainees stated they had career aspirations in PH. This
suggests that it is important to give trainees some element of choice so that PH is seen as a desirable
placement.
Greater awareness of the way PH can help General Practice would improve the attitude of trainees
towards PH. Some ideas regarding this are considered in the next section.
Alternative approaches
In both the survey and interviews, there were several suggestions for ways to increase their
understanding of PH without undertaking a placement. One step down from a full placement is to
spend a few days per week in PH whilst working in GP i.e. as a dual-setting post. The ST3 trainees
who were interviewed would welcome PH input into VTS sessions. This would give them greater
understanding of PH and enable them to deal more effectively with PH issues when they
encountered them in practice.
As indicated by several survey respondents, if GP specialist training was increased to five years, then
the conflict between developing understanding in core clinical specialties and Public Health would
be greatly reduced.
44
Appendices
Appendix 1: Online Survey
BOS Home | About BOS | Contact Us
What Public Health training should there be in GP HST?
Public Health for GP trainees
Dear Colleague,
This survey asks you as a GP trainee about your attitude towards Public Health, its place in the GP curriculum and the
relevance of Public Health placements for GP trainees.
We would like you to complete this questionnaire, as it will help the GP Directors develop the Deanery's approach to
Public Health training for General Practice. The Centre for Research in Medical and Dental Education (CRMDE) at the
University of Birmingham has been commissioned by the SHA/ Deanery to do this work. Your responses will be
confidential to CRMDE and reported anonymously.
Yours sincerely,
Dr Martin Wilkinson, Director of Postgraduate General Practice
Dr Ian Davison, Centre for Research into Medical and Dental Education
Continue >
Top Copyright | Contact Us
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BOS Home | About BOS | Contact Us
What Public Health training should there be in GP HST?
Question Page
All the survey questions are on this page. We would like you to answer them all, but all questions are voluntary. Please
note that once you select 'Yes' to the last question and click on continue at the bottom of the page, you will not be able to
change any of your answers
Attitudes to Public Health
The GP Curriculum contains Public Health-type attitudes, which are different from the bio-medical approach of
treating the patient who is in front of you. For example, Domain five: Community Orientation is about reconciling the
health needs of individual patients with that of the community; it also includes epidemiology and dealing with health
inequalities.
1. For the following Public Health areas, please rate:
a) the importance of these areas for your future work as a GP, and
b) the learning you have achieved so far compared with how much you think should be learnt during GP training
Importance
(1=low, 6=high)
Learning
(1=low, 6=high)
1 2 3 4 5 6 1 2 3 4 5 6
a. Epidemiology
b. Disease prevention/ immunisation
c. Health promotion
d. Knowledge of local health inequalities
e. Health economics ⁄ rationing
f. Occupational health
g. Environmental health
h. Other
2. Please describe 'other' in question 1, if applicable.
Public Health Placements
Please go to question 7, if you haven't undertaken any public health placements during your postgraduate training
3. Please indicate any time you have spent on postgraduate Public Health placements
Full time equivalent length of placement in months
a. FY1
b. FY2
c. GP ST1
d. GP ST2
e. Other
4. Please describe 'other'in quesiton 3, if applicable
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1 of 4 25/03/2011 13:07
5. Thinking about your most recent Public Health placement
1 = No, not at all, 6 = Yes, very much
1 2 3 4 5 6
a. Was the placement well organised?
b. Did it meet your learning needs?
c. Were the assessments appropriate?
d. Did your skills in Public Health develop
satisfactorily?
e. Overall, was the placement beneficial?
6. Can you suggest two improvements to Public Health placements
a. 1
b. 2
Please answer these questions even if you have not been on a Public Health placement
7. Please indicate the influence of each factor on your attitude towards choosing a placement in Public Health as a
GP trainees
-3 = Negative influence
0 = No influence
3 = Positive influence
-3 -2 -1 0 1 2 3
a. Relevance to the GP curriculum
b. Relevance to your future GP work
c. Opportunity to undertake WPBAs
d. Opportunity for self-directed work
e. Opportunity for clinical work
f. Opportunity for audit and research
g. Personal interest
h. To understand lifestyle issues
i. To understand population issues
j. To improve your ability to treat patients
k. Geographical location of placements
l. To work with the PCT
m. Opportunity to undertake a Diploma in
Public Health
n. Other
8. If other, please describe
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9. Would you recommend that future GP trainees undertake a Public Health placement?
Yes No Don't know
Please explain why.
10. Thinking about GP training, should Public Health placements be:
Discontinued Decreased Maintained at the current level Increased
11. If GP STs were to experience a single placement in Public Health during their postgraduate training, should
this be during:
Foundation training ST1 or 2 ST3 Post qualification
Section 4; Personal information
Please tell us a little about yourself
These data will help us determine if our sample of respondents matches the national profile of GP trainees and also
to identify differences in preferences between groups.
12. Gender
Female Male
13. Age (in years)
14. Ethnic background
If you selected Other, please specify:
15. Current position
ST1 ST2 ST3
Other (please specify):
16. Where did you undertake your initial medical training (e.g. MBChB, MBBS)?
UK other EU country non-EU country
17. How many full time equivalent (FTE) years of postgraduate experience will you have at the end of this training
year (e.g. 5 for standard foundation + GP training, if you are in ST3)?
18. What are your career aspirations in the first 5 years as a GP?
(select all that apply)
Salaried GP GP Partner GP with Special Interest GP Trainer Academic GP GP
Consortium Board Public Health NHS Leadership
Other (please specify):
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3 of 4 25/03/2011 13:07
Finished questions?
19. Please add any further comments that you may wish to make
20. We are planning some 20 minute telephone interviews for deeper consideration of these issues. If you are
willing to be contacted about this, please give your name and contact.
a. Name
b. Phone or email contact
21. When you are happy with your answers, please click on Yes then Continue
Yes
Continue >
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4 of 4 25/03/2011 13:07
BOS Home | About BOS | Contact Us
What Public Health training should there be in GP HST?
Thank you for participating in this Survey
Thank you for completing this questionnaire; your answers will help the Deanery develop Public Health training for future
GP trainees
Individual replies to these surveys are confidential to the survey team at The University of Birmingham and will not be
shared with any third party, such as the West Midlands Postgraduate Deanery.
For questions relating to this survey or the use of BOS at University of Birmingham, please contact: Ian Davison
View and print your responses
Please note that you will only be able to follow this link within 15 minutes of completing the survey. After this time you will
not be able to access your responses.
View and print your responses
Alternatively you can view your responses with a list of all the possible responses for a question:
View and print your responses (including all possible responses)
Top Copyright | Contact Us
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1 of 1 25/03/2011 13:08
51
Appendix 2: Public Health placements for GP trainees: interview schedule
for Trainees
Introduce yourself and explain the project is looking at the place of Public Health placements in GP training, what works well and what could be improved, and what impact it has on the ways in which GP trainees perceive Public Health in their working practices.
Confirm recording and confidentiality issues as well as informed consent.
Please confirm your name, organisation and role.
When does/did your PH placement take place?
Where were you based for the placement?
Did you complete Foundation Training?
Please give me a brief summary of your prior clinical experience?
Did you have any previous experience of working or training in Public Health prior to this
placement?
What was your main reason for undertaking the PH placement?
What are the main aspects of work covered in your placement to date?
What workplace assessments have you undertaken so far?
How useful have you found those assessments (specific breakdown according to response)?
What would you say you have gained as a result of undertaking the PH placement?
How do you think PH will fit into your work as a GP?
What has worked well in your placement?
How might the placement be improved for future trainees?
Would you recommend these posts to other trainees?
Have you any other comments to add to what you have already told me?
Thanks and concluding remarks.
52
Appendix 3: Public Health placements for GP trainees: interview schedule
for Trainers
Introduce yourself and explain the project is looking at the place of Public Health placements in GP training, what works well and what could be improved, and what impact it has on the ways in which GP trainees perceive Public Health in their working practices.
Confirm recording and confidentiality issues as well as informed consent.
Please confirm your name, organisation and role.
The place of Public Health
Could you say briefly what part you think the placements play in a GP’s training?
About the placements
And thinking about those placements, can you explain what the trainees do on their
placements?
Do they get involved in project work at all? If so, can you describe how that might work with
an example?
How are trainees introduced to the placement?
What resources do they have at their disposal (eg desk/computer etc)?
What level of control/choice do trainees have in their training on placement?
Supervising the trainees
What contact do you have with the trainees?
Can you explain what involvement you have with their portfolio?
Do you have other, informal contact with the trainees?
Valuing PH
What do the trainees contribute to the work of Public Health? (Or is it one-way with you
providing training?)
53
What do you think works well with these posts?
Are there things that you think work less well and what do you think might improve things?
In your experience, what motivates trainees and what do you think they get out of
placements?
From the trainer’s point of view
As a trainer, what do you get out of the placements?
What issues for you as a trainer do you think need addressing?
What place do you think these placements should have in GP training?
Thanks and concluding remarks.
54
Appendix 4 Interview schedule for ST3 trainees
Introduce yourself and explain the project is looking at the place of Public Health placements in GP training, what works well and what could be improved, and what impact it has on the ways in which GP trainees perceive Public Health in their working practices.
Confirm recording and confidentiality issues as well as informed consent.
Please confirm your name, organisation and role.
Can you please tell me where you are currently based and how long you have been there?
From your experiences in General Practice to date, what do you think the role of Public Health in GP
is?
So how what do you understand Public Health to be about?
How has your training prepared you for this Public Health aspect of your role?
(Both how in detail and to what extent has it done so)
Has anything else prepared you for this aspect?
If not, how have you coped with the demands placed upon you?
Here is a list of tasks identified by PH placement trainees as being important to their work. Have you
come across any of these so far and how prepared were you for them if you have done so?
Audit; Commissioning, Impact Assessment; Individual Treatment Requests; Strategy development.
How do you think you could have been prepared differently?
When do you think the best time for such training might be?
Is there anything else you think I should know about your experiences/understandings of PH?
Thanks and concluding remarks.
55
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