How to develop and maintain a role in Population Health and Health Inequalities

Basic qualifications:

• Primary Medical Qualification from UK or overseas
• MRCGP or equivalent route to UK general practice (e.g., Certificate of Eligibility for GP Registration)
• Full GMC registration with licence to practise on NHS performers list. 

This framework does not suggest any other mandatory qualifications, although GPwER would be advised to consider the large number of educational opportunities available, some of which are accredited. See Appendix 2.

The RCGP would strongly recommend that commissioners/ employers support any GPwER to acquire the following qualifications, if they do not already have them:

• A Post Graduate Certificate/Diploma in Public Health as a minimum
• A Master’s degree in Public Health (offered by multiple Higher Education institutions, with online and part time options)
• The Faculty of Public Health Diplomate examination (open to anyone with a university degree).

Population health is closely associated with sustainability and planetary health. A GPwER working in population health should encourage the adoption of practices which reinforce good human and planet health. Organisations that employ or commission GPwERs should create the necessary conditions and culture for this to happen.

Climate change impacts more on populations in deprived communities, therefore a GPwER should ensure that interventions and programmes of work address factors that contribute to inequalities in this area.

A helpful framework is the Welsh Government Well Being of Future Generations Act   which is now being considered for adoption across other UK Nations and globally.  

A GPwER should be a champion for health inclusion and health equity as central to the delivery of public health programmes and interventions, and in the setting that they are working in. Organisations that employ or commission GPwERs should create the necessary conditions and culture for this to happen. The GPwER should explore and understand diversity and inclusion, including identifying their own learning needs and seeking advice as appropriate. They should lead with values and authenticity, and advocate for all in system wide decision-making, they should actively seek a wide variety of views, and advocate for others.

However, a GPwER PH and HI is not the same as an Equality, Diversity and Inclusion (EDI) lead and does not require the training and qualifications associated with this role.   

To demonstrate capabilities associated with the extended role, we have taken the five areas of capability described in the RCGP curriculum as a starting point. These are based around the GMC's generic professional capabilities framework.

1. Knowing yourself and relating to others
2. Applying clinical knowledge and skills
3. Managing complex and long-term care
4. Working well in organisations and systems of care
5. Caring for the whole person, wider community, and the environment.

Capabilities are competencies plus capacity. Therefore, the role description should define the core competencies required and ensure adequate capacity to perform the role (for example, time, office space, multidisciplinary team support, mentorship, and access to tools for delivery and for continuing professional development).

Defining the core competencies

This Framework is based on two resources, which set out a full range of competencies for public health, from which the relevant competencies for a specific role can be extracted.

Further details are given in Appendix 1.

We have mapped the recommended competencies from the above sources to the five main areas of GP capabilities and added relevant wording from the GP curriculum. The relevant competencies should, therefore, be separated into each of the areas below. All GPwER role descriptions should include a basic level of these competencies, while some will require more in-depth or extensive skill sets, according to the needs of the role.

Knowing yourself and relating to others

• GP curriculum
  • Treat others fairly and with respect and acting without discrimination or prejudice.
  • Demonstrate the attitudes and behaviours expected of a good doctor.
  • Manage the factors that influence your performance.
  • PHSKF – Professional and Ethical Underpinnings (see Appendix 2)
• Understand and apply the principles underpinning public service.
  • Adhere to professional codes of conduct, occupational codes, employer behaviour frameworks and practice standards.
  • Ensure compliance with statutory legislation and practice requirements, including compliance with mandatory training.
  • Promote ethical practice with an understanding of the ethical dilemmas that might be faced when promoting health and reducing health inequalities.
  • Identify and apply ethical frameworks when dealing with difficult decisions when promoting the public’s health and reducing health inequalities.

Applying clinical knowledge and skill

• PHSKF Area A - Technical
  • Measure, monitor and report population health and wellbeing; health needs; risks; inequalities; and use of services.
  • Promote population and community health and wellbeing, addressing the wider determinants of health and health inequalities.
  • Protect the public from environmental hazards, communicable disease and other health risks, while addressing inequalities in risk exposure and outcomes.
  • Work to, and for, the evidence base, conduct research, and provide informed advice.
  • Audit, evaluate and re-design services and interventions to improve health outcomes and reduce health inequalities.

Managing complex and long-term care

• PHSKF Area A - Technical
  • Promote population and community health and wellbeing, addressing the wider determinants of health and health inequalities.
• PHSKF Area B – Context
  • Work with, and through, policies and strategies to improve health outcomes and reduce health inequalities.

Working in organisations and systems

• PHSKF Area B - Context
  • Work collaboratively across agencies and boundaries to improve health outcomes and reduce health inequalities.
  • Work in a commissioning-based culture to improve health outcomes and reduce health inequalities.
  • Work within political and democratic systems and with a range of organisational cultures to improve health outcomes and reduce health inequalities. 

Caring for people, wider community and the environment

• PHSKF Area C - Delivery
  • Provide leadership to drive improvement in health outcomes and the reduction of health inequalities.
  • Communicate with others to improve health outcomes and reduce health inequalities.
  • Design and manage programmes and projects to improve health and reduce health inequalities.
  • Prioritise and manage resources at a population/ systems level to achieve equitable health outcomes and return on investment.

These areas will also be represented in a diagram format for more visual learners.

Employers and commissioners may find the tools provided by the Public Health Skills and Knowledge Framework (PHSKF) helpful, for example in defining the required competencies to include when writing role descriptions and person specifications.

• GPwER Population Health Venn Diagrams (PDF file, 459 KB)

Leadership skills are particularly critical in this role as by definition it is working across the community with other organisations.

In this section, we describe GPwER leadership capabilities in the extended role, highlighting aspects of leadership that are more relevant and specific to this role, including, for example, the setting in which the leadership takes place.

We refer to the domains of the RCGP Leadership Capabilities Framework, as follows: 

1. Demonstrating personal qualities
   1. Flexes and adapts own leadership style to situations, concepts, people and problems.
   2. Develops a wide teamworking skills set.
   3. Explores and understands diversity and inclusion.
   4. Leads with values and demonstrates duty of candour and authenticity.
   5. Advocates for all in system wide decision-making
2. Working with others
   1. Pulls in expertise from all parts of the system.
   2. Understands how all parts of the system work.
   3. Develops a collective leadership approach.
   4. Challenges, identifies, and develops the next generation of leaders.
   5. Actively seeks alternative views.
   6. Promotes values-based team working.
   7. Respects and develops inclusion and diversity.
   8. Advocates for others
3. Managing services
   1. Addresses performance.
   2. System level leadership.
   3. Brings patient stories into performance management.
   4. Able to state and challenge clearly difficult issues.
   5. System level leadership
4. Improving services
   1. Encourages cross-collaboration.
   2. Develops strategies in collaboration with the right teams.
   3. Knows when the time is right.
5. Setting direction.
   1. Facilitates the introduction of new services, systems and processes.
   2. Identifies good practice and communicates this to a wider audience.
   3. Commits to outcome-based impact measures.
   4. Reports clearly, efficiently, and in a timely manner.

This section explains how a GP can develop the skills, knowledge and experience to undertake the extended role. This includes acquisition of core knowledge and skills relevant to the extended role. A GPwER should have an appropriate balance of practical and theoretical knowledge in relation to their extended role. Refer to the RCGP Guide to GP Clinical Extended Roles for further information.

GPs will certainly need to assess and develop their knowledge and skills carefully to be able to add value to the public health workforce. The Public Health specialist workforce is highly trained. For example, consultants have completed 5 years of training, including a Masters in Public Health, and demonstrated the full range of competencies through formal assessments and examinations. The RCGP would expect a GPwER PH and HI to acknowledge and respect that there are significant additional competencies that they would need to be aware of and to make efforts to acquire.

The UK Government’s Public Health Skills and Knowledge Framework provides a range of tools and resources for organisations and individuals to map skills gaps and develop role descriptions and address learning needs.

For example:

Self-Assessment tool for individuals

The framework covers three areas:

• The five technical areas specific to public health practice
• The areas of context ie: policy and strategy; collaborative working; a commissioning-based culture; and the political and democratic context
• the functions that relate to delivery ie: leadership; communication; programme management; and the prioritisation and allocation of resources

Each function and sub-function can be assessed for a specific role, with the following questions:

• Is this relevant for the role?           Y or N
• What is your level of capability?           0-4
• What is your level of confidence?        0-4
• Is this a development need?                  Y/N

As this provides a menu of functions, it can also be used by potential employers to identify the key skills that are required or desirable when developing a new post for a GPwER. It can also help employers support those already in post in their professional development to better carry out the delivery of the role.

It is very likely that extended roles will require a wider range of competencies, and at a greater depth than most GPs will have achieved before taking on extended roles. There is a significant risk that GPs and employers “don’t know what they don’t know” and that this may result in a mismatch between perceived and actual ability to carry out what the role requires. Therefore, we advise that GPs should engage with a public health specialist supervisor to discuss how to assess and develop their own competencies and how to match competencies with their specific role.

The RCGP's position is that GPs are expert medical generalists and, as such, do not need formal accreditation in enhanced roles for which they have been trained. However, where formal accreditation is desired by a GP, programmes that offer accreditation should be made available. Refer to the RCGP Guide to GP Clinical Extended Roles for further information.

As for all doctors, GPs are required by the GMC to recognise and work within the limits of their competence and should refer to the GMC's Good medical practice for a description of what it means to be a good doctor.

It is worth noting that employers and service commissioners may have specific requirements relating to the provision of a GPwER service.

A GPwER may wish to work towards credentials through local higher education institutions or via distance learning.

The Multi-Professional Framework for Advanced Clinical Practice covers many extended and advanced roles. This is designed for Allied Health professionals, although open to any regulated health professional. Credentials are set out for delivery by higher education institutions. Centre-endorsed credentials are designed to develop multi-professional advanced-level capability and capacity, in their specified areas. This includes one for regulated healthcare professionals wishing to develop advance practise skills in public health: Working at advanced practice level with expertise in public health: capabilities and curriculum framework (PDF file, 1.7 MB).

Some GPwERs may wish to go on and fully develop their specialist public health skills and consider applying for Public Health Specialty Training. Some doctors may wish to apply for Dual Training Scheme at an earlier stage.

The evidence that a GPwER is keeping their requisite knowledge and skills up to date and maintaining their competencies should be reviewed through the GPwER's annual whole scope of practice appraisal. This should form part of the discussion of all external roles, including quality improvement activity such as case analysis and audit. This has replaced any need for periodic re-accreditation. Please refer to the RCGP Guide to GP Clinical Extended Roles (PDF file, 440 KB) for further information.

The RCGP would expect that, for a GP to describe themselves as a GPwER, at least some ‘core’ general practice should be maintained. This is because as a GP they bring important additional skills in practising holistically and dealing with complexity and uncertainty to their GPwER role.

Where there is a need for a GPwER to demonstrate at their annual appraisal that they remain safe, competent and up to date in their core general practice role, they may wish to utilise the Academy of Medical Royal Colleges' factors for consideration template (PDF file, 77 KB).

The RCGP would expect the GPwER to have a named public health clinical supervisor (if not as line manager) who would provide written evidence and feedback for the GP’s annual appraisal. The GPwER would be advised to seek support from their clinical supervisor on identifying their learning needs and resources to maintain competence in the specific role.