The applicability of the UK Public Health Skills and Knowledge Framework to the practitioner workforce: lessons for competency framework development

The applicability of the UK Public Health Skills and Knowledge Framework to the practitioner... Abstract Background Many countries have developed competency frameworks for public health practice. While the number of competencies vary, frameworks cover similar knowledge and skills although they are not explicitly based on competency theory. Methods A total of 15 qualitative group interviews (of up to six people), were conducted with 51 public health practitioners in 8 local authorities to assess the extent to which practitioners utilize competencies defined within the UK Public Health Skills and Knowledge Framework (PHSKF). Framework analysis was applied to the transcribed interviews. Results The overall framework was seen positively although no participants had previously read or utilized the PHSKF. Most could provide evidence, although some PHSKF competencies required creative thinking to fit expectations of practitioners and to reflect variation across the domains of practice which are impacted by job role and level of seniority. Evidence from previous NHS jobs or education may be needed as some competencies were not regularly utilized within their current local authority role. Conclusions Further development of the PHSKF is required to provide guidance on how it should be used for practitioners and other members of the public health workforce. Empirical research can help benchmark knowledge/skills for workforce levels so improving the utility of competency frameworks. education, employment and skills, public health A number of countries have specified competencies for knowledge, skills and attitudes for public health practice.1–5 Frameworks cover similar competencies although in varying number. The UK Public Health Skills and Knowledge Framework (PHSKF)1 has 70 competencies categorized within 13 functions. Some countries specify a minimum level of competency expected of all public health workers,2 while others have different expectations for varying seniority.3,4 An earlier PHSKF6 categorized nine workforce levels, however, a review7 recommended simplification. The various frameworks do not specify detailed methodology for their production other than reference to consultation with various organizations/individuals.2–4 The best described was the updated PHSKF1 which involved a desk-based review of other frameworks, eight consultation workshops, an online survey with 520 responses, and recruiting 100 public health workers to conduct a self-assessment against the previous version6 of the framework. One of the priorities of the UK Faculty of Public Health Workforce Strategy & Standards Document 2018–218 was to define ‘standards for the necessary professional workforce required to enable transformations in health and wellbeing of the population to take place’ including ‘the development of an effective public health practitioner workforce’. The initial objective of this study was to develop a public health practitioner apprentice training curriculum.9 Given that the PHSKF1 has been adopted for the UK, the PHSKF would be a sensible starting point. However, the PHSKF needs benchmarking to the level of the practitioner workforce. Hence, another objective of the study was to assess the extent to which practitioners utilize the competencies defined within the PHSKF. A further objective was to provide guidance on PHSKF competencies not adequately addressed by existing formal (degree course) and informal (on-the-job) training. The final objective was to evaluate the utility of the PHSKF itself. Whilst some of the frameworks have been refreshed, there seems to be no attempt to evaluate the extent to which they have been used and whether they are fit for purpose. In the UK, practitioner is a mid-career post within the public health workforce7 (levels 5 and 6 on the previous PHSKF6) ‘who spend a major part or all of their time in public health practice. They are likely to work in multi-professional teams and include people who work with groups and communities as well as with individuals. Some of this group may be involved in project delivery. At a more senior level, they will be providing management and leadership across different organizations’.10 This definition excludes public health specialists (and those training to be specialists); generic business support roles; healthcare and social care staff working directly with individual patients; laboratory-based scientists/technicians; members of the wider workforce where public health functions make up a minority of their role. The estimated 10 00011 public health practitioners in the UK are mainly employed within local government, some within the NHS and public health agencies and a smaller number in voluntary or private sectors. Methods Email requests to interview public health practitioners were sent to all 14 Directors of Public Health in Yorkshire and the Humber (population 5.7 million people). The email stated that a very broad definition of practitioner was being used. Although Directors of Public Health proposed interviewees, each participant provided written informed consent prior to interview. Interviewees were sent the PHSKF prior to the interviews to familiarize themselves with its content. Fifteen small group interviews (median size 3) involving 51 participants (36 females) (Table 1) were conducted in eight local authorities. Interviews were conducted by the lead author (D.S.) and held at participants’ workplace. While saturation of ideas was achieved prior to completing all 15 interviews, all local authorities that had agreed to participate were visited. Table 1 Number of participants and data items analysed within each group Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 *A data item could be a quotation from a single participant or a short dialogue between participants that captures an idea/argument. Table 1 Number of participants and data items analysed within each group Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 *A data item could be a quotation from a single participant or a short dialogue between participants that captures an idea/argument. Participants were asked to state their job title and role. The interviews also covered appropriateness of the PHSKF as a basis for degree curricula and apprenticeship schemes. PHSKF functions were discussed at random until all had been selected or the time for the interview completed. Randomization was used to ensure an equal chance of a group discussing each PHSKF function. Interviews were recorded and transcribed. A deductive approach was used within a framework analysis.12 A deductive approach was used as the topic guide was developed to explore the skills and knowledge of interviewees in relation to an existing framework, in this case the functions listed in the PHSKF. Deductive approaches test whether a theory/framework is valid, whilst inductive approaches generate new themes and theory emerging from the data. The transcribed text was divided into sections of data relating to separate ideas. These could be part or all of a quotation from a single participant or an exchange between interviewees. Codes were manually applied to these data and combined into themes as appropriate. Interviewees commented on the completed analysis. Quotations supporting the analysis are provided in a Supplementary data annex available on-line. Ethics approval was obtained from University of Leeds Research Ethics Committee (MREC16-037). Results Participants had a wide range of roles and job titles, reflecting the broad definition of practitioner. Given the breadth and inconsistency in categorization of job titles it was not possible to present a coherent analysis for the purposes of this article. More senior participants were asked to comment on the knowledge and skills of practitioners within their team. One group contained two practitioners working in the voluntary sector. None of the interviewees were registered as practitioners with the UK Public Health Register (UKPHR), which is one of the regulatory bodies for practitioners. The value of registration was discussed within interviews. A few had considered it but decided against it as there was no registration scheme covering the region and interviewees did not see the value if registration was voluntary and not an essential/desirable requirement within job descriptions. Two interviewees were registered with the Environmental Health Registration Board. Most participants had not seen the new or previous PHSKF. Those that had, preferred the simpler, new layout. None had attempted to assess their competencies against the framework. There was variation in the number of groups that discussed each function, the length of time discussing the various functions and hence the amount of data relating to each (Table 1). This partly reflects interest of participants discussing functions particularly related to their roles, but also that for others there was unanimity in view and hence less need for discussion. On the whole, participants were able to demonstrate some evidence for all 70 PHSKF competencies. Although some evidence related to previous roles (e.g. prior to reorganization of public health functions in 2013), and hence would be more difficult to evidence in their present job. Some competencies required more ‘creative interpretation’ than others. Some of the more junior practitioners (who typically had less strategic roles, e.g. smoking cessation advisors) had difficulty providing evidence of both breadth and depth. Given that the PHSKF covers all levels of the public health workforce, all groups suggested that for some competencies there needed to be word changes to make them more appropriate for practitioners. For example, ‘manage’ or ‘lead’, could be changed to ‘understand’, ‘develop’, ‘influence’, ‘contribute towards’. There was widespread acceptance of the need for a broad competency base for public health practice, within a prospective training programme (e.g. apprenticeship) for practitioners who hitherto had varying training opportunities and ambiguous career ladder. A1: Measure, monitor and report population health and wellbeing; health needs; risks; inequalities; and use of services On the whole participants were regularly involved in analysing and presenting data. Although this competency was more relevant to public health analysts. Those participants with less senior roles were least confident with the A1 competencies and were given data rather been expected to find/analyse it. The most problematic A1 competency related to predicting future data needs and developing data capture methods. A2: Promote population and community health and wellbeing, addressing the wider determinants of health and health inequalities Participants thought all public health workers would contribute to this function. However, many participants reported using these competencies less than they did previously. Some practitioners had limited contact with the public, but could still see why these competencies were needed. A3: Protect the public from environmental hazards, communicable disease and other health risks, while addressing inequalities in risk exposure and outcomes A3 competencies were perceived as areas of public health that required specialist (and typically clinical) expertise that most practitioners did not have. Although more senior participants recognized that they may need to provide support if there was an emergency incident or infection outbreak. Participants felt more comfortable when it came to competencies managing specific risks related to their role. For example, practitioners working with substance misuse needed to respond to deaths due to contaminated drugs. At the micro level, all practitioners have organizational obligations for fire safety and health and safety training which required staff to analyse/manage risks within their workplace A4: Work to, and for, the evidence base, conduct research and provide informed advice Utilizing evidence and guidance, from a range of sources, was seen as very important for public health practice. There was a tendency to use guidelines and advice from respected organizations rather than searching for and interpreting the evidence themselves. Many participants discussed the challenges of using research techniques with limited time, expertise and resources, although some did commission/collaborate with Universities. An important skill was to be able to present evidence in a suitable format for a range of audiences. A5: Audit, evaluate and re-design services and interventions to improve health outcomes and reduce health inequalities Participants were most concerned about competencies relating to economic analysis. Some participants would rely on other team members to lead on appraising new technologies and interventions. That said it was recognized that such skills were important. B1: Work with, and through, policies and strategies to improve health outcomes and reduce health inequalities Although they had less involvement in developing strategy, many practitioners implemented national or international strategies/initiatives. There was recognition that effective policies and strategies needed good partnership working. B2: Work collaboratively across agencies and boundaries to improve health outcomes and reduce health inequalities There was unanimous agreement that partnership working and collaboration with other agencies was key to the work of a practitioner. Getting ‘buy in’ from partners was a skill. Practitioners needed to be effective communicators as partner agencies had their own remits, targets and agenda. Participants also spoke of the difficulty in engaging with some groups and communities. B3: Work in a competitive contract culture to improve health outcomes and reduce health inequalities For many participants, commissioning was a very important aspect of their role, and more than when they worked in the National Health Service (NHS). There was a shift towards influencing commissioning arrangements within other departments and stakeholders. Thus, an understanding of the commissioning process was very important. B4: Work within political and democratic systems and with a range of organizational cultures to improve health outcomes and reduce health inequalities The need for these competencies was widely recognized as they had now become part of the ‘day job’. Although more junior participants thought they were less likely to get involved at their level. Many participants noted working within local government was different to working in the NHS as it was necessary to have the support of the elected politicians. C1: Provide leadership to drive improvement in health outcomes and the reduction of health inequalities There was agreement on the importance of professional behaviours such as integrity, personal development, managing conflict and adapting to change. ‘Leadership’ and ‘providing vision’ were responsibilities at a more senior level, but participants recognized that they were all leaders in their own way. C2: Communicate with others to improve health outcomes and reduce health inequalities There was widespread recognition of the importance of communication across the range of individuals and organizations. There was also a recognition of the need to coordinate communications to prevent duplication both within own and with other organizations. Some practitioners were using the range of communication skills, including new technologies and social media, better than others. C3: Design and manage programmes and projects to improve health and reduce health inequalities Many groups discussed the use of formal project management tools. Some practitioners had PRINCE2 project management training, but did not find it particularly useful. However, a structured approach to project management was important. C4: Prioritize and manage resources at a population/systems level to achieve equitable health outcomes and return on investment There had been more scope for managing budgets within the NHS. Managing budgets within local authority tended to be done centrally or by more senior staff. Although practitioners still had a role with opportunities for small projects. Whilst the financial management and the workforce development competencies appear separate, one participant recognized that they are inter-related as the workforce was still an important resource. Discussion Main findings of this study Participants had not used the PHSKF and many had not seen the new version. Most participants were content that with sensitive interpretation and top-up training, they could provide some evidence for all competencies. It will be important to assess whether and how the updated PHSKF is being used, otherwise the utility of such frameworks is brought into question. Practitioners applying for registration with the UK Public Health Register13 are assessed against the previous PHSKF, although the proportion of the practitioner workforce who have registered is very small. Group participants were supportive of apprenticeships and a prospective training programme that allowed apprentices to rotate between training opportunities so that they could develop proficiency and document experience for all of the PHSKF competencies. Some participants with less senior roles had more difficulty in providing evidence for all PHSKF functions, and hence there will be a threshold of seniority, below which competency in only defined areas of expertise might be expected. While the PHSKF may be applicable to the core workforce (practitioners, advanced practitioners, specialists, etc.), it might not be applicable for the wider public health workforce. Separate research would be needed to identify the competency required of these parts of the workforce. Competency frameworks already exist, for example, for health promotion practitioners14,15 or epidemiologists in communicable disease surveillance16 (although details of the methodology used to develop these frameworks are also variable and do not appear to be underpinned by competency theory). What is already known on this topic Competency theory has been used to guide development and evaluation of competency frameworks in other clinical professions, e.g. pharmacy.17 Without theory to underpin public health framework development, there is a danger that they will not deliver some or all of the rationale for their development. Sandberg proposed three theoretical approaches to deriving competency frameworks.18 In worker-orientated approaches, existing workers and managers identify knowledge, skills, abilities and personal traits required by workers for effective work performance. For example, numeracy and informatics skills would be required for health needs assessment. The approach has been criticized for producing descriptions of competence that are too general and abstract. Work-orientated approaches focus on personal attributes linked to activities central to the role of the worker. For example A1.5 of the PHSKF (which is in effect a health needs assessment competency) is defined in terms of ability to ‘collate and analyse data to produce intelligence that informs decision making, planning, implementation, performance and evaluation’. The weakness of this approach is that lists of work activities usually do not adequately describe the attributes needed to accomplish tasks effectively. The multi-method-orientated approach combines both the worker- and work-orientated approaches and therefore tends to be more comprehensive. The various public health frameworks all focus on the activities undertaken that are central to the role of the worker, and hence they seem to follow the work-orientated approach, although given that the frameworks were developed by existing workforce, it could be argued that a multi-method approach was used. Norris19 suggested three other way of categorizing competency. The behaviourist construct is based on a description of behaviour (performance) and the situation(s) in which it is to take place in a form that is observable and measurable. Competence is something that a person is or should be able to do. In contrast the cognitive construct only defines competence as what a person knows and is able to do in ideal circumstances as opposed to performance under existing circumstances. The generic construct approach involves identifying the most effective performers in a job; studying what these people actually do that distinguishes them from individuals whose performance is less satisfactory; and identifying the specific skills, abilities and characteristics which are responsible for this difference. A study of patrol officers identified the following generic competences of good practice (which might equally apply to public health practitioners): “competence in ‘assessing the total situation’, ‘self-monitoring one’s own conduct’, ‘empathizing accurately with the concerns of others’ and ‘exercising power and authority in manner consistent with organizational goals and professional ethics’”. We have previously used a generic construct approach within qualitative research20 to identify leadership talents of ‘Public Health Superheroes’ which we mapped against other leadership competency frameworks to assess face validity. Within competency literature there tend to be more concerns relating to the way frameworks are implemented: As tacit understandings of the words have been overtaken by the need to define precisely and operationalize concepts, the practical has become shrouded in theoretical confusion and the apparently simple has become profoundly complicated… Notions of role, effectiveness standards and quality are combined into a model supposedly preserving the essential elements of competence and indicative of evidence of competent performance. Such models can be highly reductive, providing atomized lists of tasks and functions, or they can be highly generalized, offering descriptions of motivational dispositions or cognitive abilities such as problem-solving (p331–4).19 Frameworks such as the PHSKF are developed with an objective to improve the delivery of public health functions. However, if they are not used, then it may be necessary to ensure strengthening of the workforce’s competencies in reflective practice, self-evaluation and self-directed learning. An evaluation of the NHS Knowledge and Skills Framework21 also identified problems with implementation. It will also be important to strengthen the five disciplines of a learning organization identified by Senge.22 Public health practitioners learn together and from each other and perform together for common goals.23 Thus personalized competency models may have limited utility, even though staff appraisal and personal development plans usually have a focus on the individual. In a review of the public health literature, Reid and Dold24 found that although Senge was widely cited and clearly influential, there was limited substantive use and implementation of his key concepts (and those of Burns’ Transformational Leadership25) within public health competency frameworks. Reid and Dold warned that unless public health organizations recognized the need for a common understanding of competencies, how to measure their attainment and act on that understanding, there may uncertainty as to whether certain individuals, public health agencies, or the entire public health workforce were competent.24 What this study adds The research aim was to assess the applicability of the PHSKF to practitioners, and in particular whether it could be used as a curriculum for practitioner apprenticeship training. To this extent, frameworks such as PHSKF are suitable for this purpose. However, given that Public Health is a discipline that advocates the use of evidence, the methodologies used to develop competency frameworks should be more robust and underpinned by competency theory. Although the updated PHSKF abandoned competencies benchmarked to different levels within the public health workforce, this study has demonstrated that it is possible to use a ‘single level’ approach, provided each competency is interpreted for the specific section of the workforce. The practitioner definition used for recruiting interviewees was broad, and practitioner interviewees seemed to be operating at different levels. It may therefore be difficult to develop guidance for PHSKF interpretation suitable for all practitioners. The danger is that trying to tailor guidance to meet individual needs may lead to having a multitude of levels that was the problem with the old version of the PHSKF.6 Many interviewees said that they would use evidence from previous roles prior to reorganization of Public health functions in England in 2013.26 The PHSKF may need to be reviewed to reflect the changing working environment for public health practitioners and the skills and knowledge needed for evolving roles. We contend that the solution to both of these conundrums is to use competency theory to derive the framework using a generic construct of competency that is less dependent on analysis of specific roles which vary between people or over time. Limitations of this study The vast majority of mid-level public health staff do not have ‘practitioner’ in their job title, and the lack of an agreed definition meant that it was left to recipients of the invitation letter to decide who was suitable to be interviewed. Therefore, there will be selection and volunteer bias within the sample. While the sample size is respectable in terms of qualitative research,27 the number of people interviewed and bias means that care must be taken when extrapolating findings. Future research should apply a more explicit definition of practitioner in order to assess the skills and knowledge of specific sections of the public health workforce. It would also have been desirable to analyse the data according to the seniority and public health discipline of interviewees. However, even though participants described their job titles and roles, the significant variation in job titles and the breadth and heterogeneity of roles meant that this was not possible. The use of small focus group format permitted participants to interact with one another to test out understanding with colleagues as to whether elements of their work satisfied competencies. Whilst this is the main advantage of focus groups28 there is a risk of participants not wishing to reveal significant competency gaps in front of colleagues. It is also important to be reflective as to whether interviewees modified their responses to fit with perceived requirements of the interviewer, especially given that the interviewer was a senior local public health academic. While it is not possible to be certain if and how this might have introduced bias, the consistency between groups suggests that this impact was not significant. It was also difficult to assess specific individual’s competencies. Instead there was a tendency to assess the competency of the team. Whilst this is how the Public Health England intended the PHSKF to be used, future research should be conducted at an individual level. The research was also mainly conducted with practitioners working within local authorities. The responses of practitioners from other types of public health organizations may have been different. The research was also only conducted within Yorkshire and the Humber, and it is feasible that practitioners working in local authorities elsewhere may have different experiences. Conclusions Most participants had not seen, let alone used, the PHSKF. Consideration should be given to publicize ways it could help the public health workforce. It may be appropriate to use the PHSKF to develop a curriculum for a public health practitioner apprentice scheme, if the competency levels were benchmarked appropriately. Using the PHSKF for this purpose would also be appropriate as it has been adopted by countries within the UK. Apprentices could prospectively rotate between roles to gain the necessary experience, supported by an academic degree programme. There is also an argument that some, if not all, levels of the public health workforce do not need to be trained in all public health competencies. The PHSKF User Guide suggested that the aim of the framework is ‘to set out the functional areas in which individuals, teams and organizations operate, to deliver on public health outcomes… to provide a set of statement that describe what functions an individual might carry out in the course of their work. The combination of functions will vary from individual to individual, and from role to role’.27 Thus, while it does not benchmark competencies to levels (as in Canada3 or USA4) it also does not claim that the competencies are required for all public health practice at the baseline level (as in New Zealand2). Instead, as the PHSKF User Guide29 suggests, the key is that public health teams assess the group competencies required for delivering their functions and then ensure that individuals have specialist skills to contribute to the collective effort. However, in other research that we have conducted,9 Directors of Public Health saw value in staff having a wider understanding of public health, in addition to the more specialist skills and knowledge required for specific roles. Further work is required to permit individuals and organizations to interpret the breadth and depth of competencies for different levels of the public health workforce, especially for those in more junior roles, those in more specialist public health niches or who for the wider workforce. In particular, research is needed to understand competencies required for working in the voluntary and private sectors and how these can be achieved and maintained. It was outside of the scope of this article to review the curricula of current public health degree courses to assess whether they cover all PHSKF competencies. It is unlikely if many align directly with the PHSKF functions. However, if at some point in the future practitioners are expected to provide evidence against PHSKF functions, universities may wish to review the content and structure of courses. Frameworks will need regular updating to reflect evolving public health functions and organizations. There are trade-offs here between frameworks being in a constant state of review versus being out-of-date and hence not useful tools for some or all of the workforce. Frameworks should routinely provide details of methodology used for their construction, to assess methodological appropriateness and robustness. Having now tested the PHSKF against the self-reported knowledge and skills of practitioners in the field and previously developed our own leadership competency framework9 we believe that competency theory should be used to guide these processes. Supplementary data Supplementary data are available at the Journal of Public Health online. References 1 Public Health England . Public Health Knowledge and Skills Framework . London : Public Health England , 2016 . https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/584408/public_health_skills_and_knowledge_framework.pdf. (2 May 2018, date last accessed). 2 Public Health Association of New Zealand . Generic Competencies for Public Health in Aotearoa-New Zealand . Wellington : public Health Association , 2007 . http://www.publichealthworkforce.org.nz/data/media/documents/Competencies/WEB%20-%20Generic%20Competencies%20for%20Public%20Health%20March%202007.pdf. 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J Public Health (Bangkok) 2017 : 1 – 8 . doi:10.1093/pubmed/fdx081 . 10 The Centre for Workforce Intelligence . Understanding the Public Health Practitioner Workforce: a CfWI Study . London : The Centre for Workforce Intelligence , 2016 . http://webarchive.nationalarchives.gov.uk/20161007105036/http://www.cfwi.org.uk/publications/cfwi-publishes-a-study-on-the-public-health-practitioner-workforce. (2 May 2018, date last accessed). 11 Centre for Workforce Intelligence . Mapping the Core Public Health Workforce . London : The Centre for Workforce Intelligence , 2014 . http://webarchive.nationalarchives.gov.uk/20160809013245/https://www.gov.uk/government/publications/mapping-the-core-public-health-workforce. (2 May 2018, date last accessed). 12 Spencer L , Ritchie J, O'Connor W et al. Analysis in practice. In: Richie J, Lewis J, McNaughton Nicholls C, Ormston R (eds). Qualitative Research Practice: A Guide for Social Science Students & Researchers. London: SAGE, 2013. 13 United Kingdom Public Health Register . https://www.ukphr.org/ (2 May 2018 , date last accessed). 14 International Union for Health Promotion and Education . Core Competencies and Professional Standards for Health Promotion. Saint Denis Cedres, France; IUHPE. 2016 . http://www.iuhpe.org/images/JC-Accreditation/Core_Competencies_Standards_linkE.pdf (2 May 2018, date last accessed). 15 Australian Health Promotion Association . Core Competencies for Health Promotion Practitioners . Queensland, Australia : University of the Sunshine Coast , 2009 . https://www.healthpromotion.org.au/images/docs/core_competencies_for_hp_practitioners.pdf. (2 May 2018, date last accessed). 16 European Centre for Disease Prevention and Control . Core Competencies for EU Public Health Epidemiologists in Communicable Disease Surveillance and Response . Stockholm : European Centre for Disease Prevention and Control , 2009 . https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/training-core-competencies-EU-public-health-epidemiologists.pdf. (2 May 2018, date last accessed). 17 Wright D , Morgan L . An Independent Evaluation of Frameworks for Professional Development in Pharmacy . Norwich : University of East Anglia , 2012 . http://groups.medbiq.org/medbiq/download/attachments/15991574/Independent%20evaluation%20of%20professional%20development%20frameworks%20-%20UK%20Pharmacy.pdf?version=1&modificationDate=1342686331000&api=v2. (2 May 2018, date last accessed). 18 Sandberg J . Understanding human competence at work: an interpretative approach . Acad Manage J 2000 ; 43 ( 1 ): 9 – 25 . 19 Norris N . The trouble with competence . Camb J Educ 1991 ; 21 ( 3 ): 331 – 41 . Google Scholar CrossRef Search ADS 20 Day M , Shickle D , Smith K et al. . Training public health superheroes: five talents for public health leadership . J Public Health (Bangkok) 2014 ; 26 ( 4 ): 552 – 61 . Google Scholar CrossRef Search ADS 21 Brown D , Mercer M , Buchan J et al. . NHS Staff Council. Review of the NHS Knowledge and Skills Framework . London : Institute for Employment Studies , 2010 . http://www.employment-studies.co.uk/system/files/resources/files/nhse_0410.pdf. (2 May 2018, date last accessed). 22 Senge PM . The Fifth Discipline: The Art and Practice of the Learning Organization , 2nd edn . London : Random House , 2006 . 23 Wenger E . Communities of Practice: Learning, Meaning, and Identity . Cambridge : Cambridge University Press , 1998 . Google Scholar CrossRef Search ADS 24 Reid WM , Dold CJ . Leadership training and the problems of competency development . J Public Health Manag Pract 2017 ; 23 ( 1 ): 73 – 80 . Google Scholar CrossRef Search ADS PubMed 25 Burns JM . Transforming Leadership: A New Pursuit of Happiness . New York : Grove Press , 2003 . 26 Local Government Association . Get in on the Act: Health and Social Care Act 2012 . London : Local Government Associations , 2012 . https://www.wirralintelligenceservice.org/media/1352/get-in-on-the-act-health-and-social-care-act-2012.pdf. (2 May 2018, date last accessed). 27 Mason M . Sample size and saturation in PhD studies using qualitative interviews . Forum: Qual Soc Res 2010 ; 11 ( 3 ): 8 . http://www.qualitative-research.net/index.php/fqs/article/view/1428/3027. Article noaccessed 2 May 2018. 28 Finch H , Lewis J , Turley C . Focus groups. In: Ritchie J , Lewis J , McNaughton Nicholls C , Ormston R (eds) . Qualitative Research Practice: A Guide for Social Science Students & Researchers . London : SAGE , 2013 , 211 – 242 . 29 Public Health England . User Guide [version 1] for the Public Health Skills and Knowledge Framework (PHSKF) . London : public health England , 2016 . https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/545011/Public_Health_Skills_and_Knowledge_Framework_2016_User_Guide.pdf. (2 May 2018, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

The applicability of the UK Public Health Skills and Knowledge Framework to the practitioner workforce: lessons for competency framework development

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Abstract

Abstract Background Many countries have developed competency frameworks for public health practice. While the number of competencies vary, frameworks cover similar knowledge and skills although they are not explicitly based on competency theory. Methods A total of 15 qualitative group interviews (of up to six people), were conducted with 51 public health practitioners in 8 local authorities to assess the extent to which practitioners utilize competencies defined within the UK Public Health Skills and Knowledge Framework (PHSKF). Framework analysis was applied to the transcribed interviews. Results The overall framework was seen positively although no participants had previously read or utilized the PHSKF. Most could provide evidence, although some PHSKF competencies required creative thinking to fit expectations of practitioners and to reflect variation across the domains of practice which are impacted by job role and level of seniority. Evidence from previous NHS jobs or education may be needed as some competencies were not regularly utilized within their current local authority role. Conclusions Further development of the PHSKF is required to provide guidance on how it should be used for practitioners and other members of the public health workforce. Empirical research can help benchmark knowledge/skills for workforce levels so improving the utility of competency frameworks. education, employment and skills, public health A number of countries have specified competencies for knowledge, skills and attitudes for public health practice.1–5 Frameworks cover similar competencies although in varying number. The UK Public Health Skills and Knowledge Framework (PHSKF)1 has 70 competencies categorized within 13 functions. Some countries specify a minimum level of competency expected of all public health workers,2 while others have different expectations for varying seniority.3,4 An earlier PHSKF6 categorized nine workforce levels, however, a review7 recommended simplification. The various frameworks do not specify detailed methodology for their production other than reference to consultation with various organizations/individuals.2–4 The best described was the updated PHSKF1 which involved a desk-based review of other frameworks, eight consultation workshops, an online survey with 520 responses, and recruiting 100 public health workers to conduct a self-assessment against the previous version6 of the framework. One of the priorities of the UK Faculty of Public Health Workforce Strategy & Standards Document 2018–218 was to define ‘standards for the necessary professional workforce required to enable transformations in health and wellbeing of the population to take place’ including ‘the development of an effective public health practitioner workforce’. The initial objective of this study was to develop a public health practitioner apprentice training curriculum.9 Given that the PHSKF1 has been adopted for the UK, the PHSKF would be a sensible starting point. However, the PHSKF needs benchmarking to the level of the practitioner workforce. Hence, another objective of the study was to assess the extent to which practitioners utilize the competencies defined within the PHSKF. A further objective was to provide guidance on PHSKF competencies not adequately addressed by existing formal (degree course) and informal (on-the-job) training. The final objective was to evaluate the utility of the PHSKF itself. Whilst some of the frameworks have been refreshed, there seems to be no attempt to evaluate the extent to which they have been used and whether they are fit for purpose. In the UK, practitioner is a mid-career post within the public health workforce7 (levels 5 and 6 on the previous PHSKF6) ‘who spend a major part or all of their time in public health practice. They are likely to work in multi-professional teams and include people who work with groups and communities as well as with individuals. Some of this group may be involved in project delivery. At a more senior level, they will be providing management and leadership across different organizations’.10 This definition excludes public health specialists (and those training to be specialists); generic business support roles; healthcare and social care staff working directly with individual patients; laboratory-based scientists/technicians; members of the wider workforce where public health functions make up a minority of their role. The estimated 10 00011 public health practitioners in the UK are mainly employed within local government, some within the NHS and public health agencies and a smaller number in voluntary or private sectors. Methods Email requests to interview public health practitioners were sent to all 14 Directors of Public Health in Yorkshire and the Humber (population 5.7 million people). The email stated that a very broad definition of practitioner was being used. Although Directors of Public Health proposed interviewees, each participant provided written informed consent prior to interview. Interviewees were sent the PHSKF prior to the interviews to familiarize themselves with its content. Fifteen small group interviews (median size 3) involving 51 participants (36 females) (Table 1) were conducted in eight local authorities. Interviews were conducted by the lead author (D.S.) and held at participants’ workplace. While saturation of ideas was achieved prior to completing all 15 interviews, all local authorities that had agreed to participate were visited. Table 1 Number of participants and data items analysed within each group Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 *A data item could be a quotation from a single participant or a short dialogue between participants that captures an idea/argument. Table 1 Number of participants and data items analysed within each group Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 Group code Number of participants in group Length of interview (minutes) Data items* included in analysis relating to functions of Public Health Knowledge and Skills Framework A1 A2 A3 A4 A5 B1 B2 B3 B4 C1 C2 C3 C4 B1 4 53 5 3 14 – – 12 5 5 – 8 6 14 – D1 3 58 – – – 9 – – 3 – – – 3 – 7 D2 3 48 – – 8 – 12 – – 10 – 8 5 – – D3 4 51 – 4 6 7 – 8 – 5 – – 12 3 – D4 5 52 – – 5 21 – – 2 – 8 – 9 8 – G1 6 57 9 – 6 – 4 7 – – 7 – 12 11 – G2 3 50 7 – – – – – – – 9 – 34 – – G3 6 48 3 5 5 4 2 4 4 5 4 1 2 2 2 H1 2 61 7 1 – 7 5 – 4 3 – – – 4 4 K1 4 46 – – 13 – – – 6 – 8 9 – – – K2 3 37 – 9 – – 10 3 – 10 4 – 8 – – N1 3 54 – 9 22 16 9 5 – 7 – – 14 13 – N2 2 60 – 4 5 5 8 4 – 7 4 3 6 6 4 W1 2 57 1 1 5 2 8 6 3 1 5 4 7 7 11 Y1 1 50 2 1 3 2 4 3 2 2 3 2 2 4 5 Total 51 782 34 37 92 73 62 52 29 55 52 35 120 72 33 *A data item could be a quotation from a single participant or a short dialogue between participants that captures an idea/argument. Participants were asked to state their job title and role. The interviews also covered appropriateness of the PHSKF as a basis for degree curricula and apprenticeship schemes. PHSKF functions were discussed at random until all had been selected or the time for the interview completed. Randomization was used to ensure an equal chance of a group discussing each PHSKF function. Interviews were recorded and transcribed. A deductive approach was used within a framework analysis.12 A deductive approach was used as the topic guide was developed to explore the skills and knowledge of interviewees in relation to an existing framework, in this case the functions listed in the PHSKF. Deductive approaches test whether a theory/framework is valid, whilst inductive approaches generate new themes and theory emerging from the data. The transcribed text was divided into sections of data relating to separate ideas. These could be part or all of a quotation from a single participant or an exchange between interviewees. Codes were manually applied to these data and combined into themes as appropriate. Interviewees commented on the completed analysis. Quotations supporting the analysis are provided in a Supplementary data annex available on-line. Ethics approval was obtained from University of Leeds Research Ethics Committee (MREC16-037). Results Participants had a wide range of roles and job titles, reflecting the broad definition of practitioner. Given the breadth and inconsistency in categorization of job titles it was not possible to present a coherent analysis for the purposes of this article. More senior participants were asked to comment on the knowledge and skills of practitioners within their team. One group contained two practitioners working in the voluntary sector. None of the interviewees were registered as practitioners with the UK Public Health Register (UKPHR), which is one of the regulatory bodies for practitioners. The value of registration was discussed within interviews. A few had considered it but decided against it as there was no registration scheme covering the region and interviewees did not see the value if registration was voluntary and not an essential/desirable requirement within job descriptions. Two interviewees were registered with the Environmental Health Registration Board. Most participants had not seen the new or previous PHSKF. Those that had, preferred the simpler, new layout. None had attempted to assess their competencies against the framework. There was variation in the number of groups that discussed each function, the length of time discussing the various functions and hence the amount of data relating to each (Table 1). This partly reflects interest of participants discussing functions particularly related to their roles, but also that for others there was unanimity in view and hence less need for discussion. On the whole, participants were able to demonstrate some evidence for all 70 PHSKF competencies. Although some evidence related to previous roles (e.g. prior to reorganization of public health functions in 2013), and hence would be more difficult to evidence in their present job. Some competencies required more ‘creative interpretation’ than others. Some of the more junior practitioners (who typically had less strategic roles, e.g. smoking cessation advisors) had difficulty providing evidence of both breadth and depth. Given that the PHSKF covers all levels of the public health workforce, all groups suggested that for some competencies there needed to be word changes to make them more appropriate for practitioners. For example, ‘manage’ or ‘lead’, could be changed to ‘understand’, ‘develop’, ‘influence’, ‘contribute towards’. There was widespread acceptance of the need for a broad competency base for public health practice, within a prospective training programme (e.g. apprenticeship) for practitioners who hitherto had varying training opportunities and ambiguous career ladder. A1: Measure, monitor and report population health and wellbeing; health needs; risks; inequalities; and use of services On the whole participants were regularly involved in analysing and presenting data. Although this competency was more relevant to public health analysts. Those participants with less senior roles were least confident with the A1 competencies and were given data rather been expected to find/analyse it. The most problematic A1 competency related to predicting future data needs and developing data capture methods. A2: Promote population and community health and wellbeing, addressing the wider determinants of health and health inequalities Participants thought all public health workers would contribute to this function. However, many participants reported using these competencies less than they did previously. Some practitioners had limited contact with the public, but could still see why these competencies were needed. A3: Protect the public from environmental hazards, communicable disease and other health risks, while addressing inequalities in risk exposure and outcomes A3 competencies were perceived as areas of public health that required specialist (and typically clinical) expertise that most practitioners did not have. Although more senior participants recognized that they may need to provide support if there was an emergency incident or infection outbreak. Participants felt more comfortable when it came to competencies managing specific risks related to their role. For example, practitioners working with substance misuse needed to respond to deaths due to contaminated drugs. At the micro level, all practitioners have organizational obligations for fire safety and health and safety training which required staff to analyse/manage risks within their workplace A4: Work to, and for, the evidence base, conduct research and provide informed advice Utilizing evidence and guidance, from a range of sources, was seen as very important for public health practice. There was a tendency to use guidelines and advice from respected organizations rather than searching for and interpreting the evidence themselves. Many participants discussed the challenges of using research techniques with limited time, expertise and resources, although some did commission/collaborate with Universities. An important skill was to be able to present evidence in a suitable format for a range of audiences. A5: Audit, evaluate and re-design services and interventions to improve health outcomes and reduce health inequalities Participants were most concerned about competencies relating to economic analysis. Some participants would rely on other team members to lead on appraising new technologies and interventions. That said it was recognized that such skills were important. B1: Work with, and through, policies and strategies to improve health outcomes and reduce health inequalities Although they had less involvement in developing strategy, many practitioners implemented national or international strategies/initiatives. There was recognition that effective policies and strategies needed good partnership working. B2: Work collaboratively across agencies and boundaries to improve health outcomes and reduce health inequalities There was unanimous agreement that partnership working and collaboration with other agencies was key to the work of a practitioner. Getting ‘buy in’ from partners was a skill. Practitioners needed to be effective communicators as partner agencies had their own remits, targets and agenda. Participants also spoke of the difficulty in engaging with some groups and communities. B3: Work in a competitive contract culture to improve health outcomes and reduce health inequalities For many participants, commissioning was a very important aspect of their role, and more than when they worked in the National Health Service (NHS). There was a shift towards influencing commissioning arrangements within other departments and stakeholders. Thus, an understanding of the commissioning process was very important. B4: Work within political and democratic systems and with a range of organizational cultures to improve health outcomes and reduce health inequalities The need for these competencies was widely recognized as they had now become part of the ‘day job’. Although more junior participants thought they were less likely to get involved at their level. Many participants noted working within local government was different to working in the NHS as it was necessary to have the support of the elected politicians. C1: Provide leadership to drive improvement in health outcomes and the reduction of health inequalities There was agreement on the importance of professional behaviours such as integrity, personal development, managing conflict and adapting to change. ‘Leadership’ and ‘providing vision’ were responsibilities at a more senior level, but participants recognized that they were all leaders in their own way. C2: Communicate with others to improve health outcomes and reduce health inequalities There was widespread recognition of the importance of communication across the range of individuals and organizations. There was also a recognition of the need to coordinate communications to prevent duplication both within own and with other organizations. Some practitioners were using the range of communication skills, including new technologies and social media, better than others. C3: Design and manage programmes and projects to improve health and reduce health inequalities Many groups discussed the use of formal project management tools. Some practitioners had PRINCE2 project management training, but did not find it particularly useful. However, a structured approach to project management was important. C4: Prioritize and manage resources at a population/systems level to achieve equitable health outcomes and return on investment There had been more scope for managing budgets within the NHS. Managing budgets within local authority tended to be done centrally or by more senior staff. Although practitioners still had a role with opportunities for small projects. Whilst the financial management and the workforce development competencies appear separate, one participant recognized that they are inter-related as the workforce was still an important resource. Discussion Main findings of this study Participants had not used the PHSKF and many had not seen the new version. Most participants were content that with sensitive interpretation and top-up training, they could provide some evidence for all competencies. It will be important to assess whether and how the updated PHSKF is being used, otherwise the utility of such frameworks is brought into question. Practitioners applying for registration with the UK Public Health Register13 are assessed against the previous PHSKF, although the proportion of the practitioner workforce who have registered is very small. Group participants were supportive of apprenticeships and a prospective training programme that allowed apprentices to rotate between training opportunities so that they could develop proficiency and document experience for all of the PHSKF competencies. Some participants with less senior roles had more difficulty in providing evidence for all PHSKF functions, and hence there will be a threshold of seniority, below which competency in only defined areas of expertise might be expected. While the PHSKF may be applicable to the core workforce (practitioners, advanced practitioners, specialists, etc.), it might not be applicable for the wider public health workforce. Separate research would be needed to identify the competency required of these parts of the workforce. Competency frameworks already exist, for example, for health promotion practitioners14,15 or epidemiologists in communicable disease surveillance16 (although details of the methodology used to develop these frameworks are also variable and do not appear to be underpinned by competency theory). What is already known on this topic Competency theory has been used to guide development and evaluation of competency frameworks in other clinical professions, e.g. pharmacy.17 Without theory to underpin public health framework development, there is a danger that they will not deliver some or all of the rationale for their development. Sandberg proposed three theoretical approaches to deriving competency frameworks.18 In worker-orientated approaches, existing workers and managers identify knowledge, skills, abilities and personal traits required by workers for effective work performance. For example, numeracy and informatics skills would be required for health needs assessment. The approach has been criticized for producing descriptions of competence that are too general and abstract. Work-orientated approaches focus on personal attributes linked to activities central to the role of the worker. For example A1.5 of the PHSKF (which is in effect a health needs assessment competency) is defined in terms of ability to ‘collate and analyse data to produce intelligence that informs decision making, planning, implementation, performance and evaluation’. The weakness of this approach is that lists of work activities usually do not adequately describe the attributes needed to accomplish tasks effectively. The multi-method-orientated approach combines both the worker- and work-orientated approaches and therefore tends to be more comprehensive. The various public health frameworks all focus on the activities undertaken that are central to the role of the worker, and hence they seem to follow the work-orientated approach, although given that the frameworks were developed by existing workforce, it could be argued that a multi-method approach was used. Norris19 suggested three other way of categorizing competency. The behaviourist construct is based on a description of behaviour (performance) and the situation(s) in which it is to take place in a form that is observable and measurable. Competence is something that a person is or should be able to do. In contrast the cognitive construct only defines competence as what a person knows and is able to do in ideal circumstances as opposed to performance under existing circumstances. The generic construct approach involves identifying the most effective performers in a job; studying what these people actually do that distinguishes them from individuals whose performance is less satisfactory; and identifying the specific skills, abilities and characteristics which are responsible for this difference. A study of patrol officers identified the following generic competences of good practice (which might equally apply to public health practitioners): “competence in ‘assessing the total situation’, ‘self-monitoring one’s own conduct’, ‘empathizing accurately with the concerns of others’ and ‘exercising power and authority in manner consistent with organizational goals and professional ethics’”. We have previously used a generic construct approach within qualitative research20 to identify leadership talents of ‘Public Health Superheroes’ which we mapped against other leadership competency frameworks to assess face validity. Within competency literature there tend to be more concerns relating to the way frameworks are implemented: As tacit understandings of the words have been overtaken by the need to define precisely and operationalize concepts, the practical has become shrouded in theoretical confusion and the apparently simple has become profoundly complicated… Notions of role, effectiveness standards and quality are combined into a model supposedly preserving the essential elements of competence and indicative of evidence of competent performance. Such models can be highly reductive, providing atomized lists of tasks and functions, or they can be highly generalized, offering descriptions of motivational dispositions or cognitive abilities such as problem-solving (p331–4).19 Frameworks such as the PHSKF are developed with an objective to improve the delivery of public health functions. However, if they are not used, then it may be necessary to ensure strengthening of the workforce’s competencies in reflective practice, self-evaluation and self-directed learning. An evaluation of the NHS Knowledge and Skills Framework21 also identified problems with implementation. It will also be important to strengthen the five disciplines of a learning organization identified by Senge.22 Public health practitioners learn together and from each other and perform together for common goals.23 Thus personalized competency models may have limited utility, even though staff appraisal and personal development plans usually have a focus on the individual. In a review of the public health literature, Reid and Dold24 found that although Senge was widely cited and clearly influential, there was limited substantive use and implementation of his key concepts (and those of Burns’ Transformational Leadership25) within public health competency frameworks. Reid and Dold warned that unless public health organizations recognized the need for a common understanding of competencies, how to measure their attainment and act on that understanding, there may uncertainty as to whether certain individuals, public health agencies, or the entire public health workforce were competent.24 What this study adds The research aim was to assess the applicability of the PHSKF to practitioners, and in particular whether it could be used as a curriculum for practitioner apprenticeship training. To this extent, frameworks such as PHSKF are suitable for this purpose. However, given that Public Health is a discipline that advocates the use of evidence, the methodologies used to develop competency frameworks should be more robust and underpinned by competency theory. Although the updated PHSKF abandoned competencies benchmarked to different levels within the public health workforce, this study has demonstrated that it is possible to use a ‘single level’ approach, provided each competency is interpreted for the specific section of the workforce. The practitioner definition used for recruiting interviewees was broad, and practitioner interviewees seemed to be operating at different levels. It may therefore be difficult to develop guidance for PHSKF interpretation suitable for all practitioners. The danger is that trying to tailor guidance to meet individual needs may lead to having a multitude of levels that was the problem with the old version of the PHSKF.6 Many interviewees said that they would use evidence from previous roles prior to reorganization of Public health functions in England in 2013.26 The PHSKF may need to be reviewed to reflect the changing working environment for public health practitioners and the skills and knowledge needed for evolving roles. We contend that the solution to both of these conundrums is to use competency theory to derive the framework using a generic construct of competency that is less dependent on analysis of specific roles which vary between people or over time. Limitations of this study The vast majority of mid-level public health staff do not have ‘practitioner’ in their job title, and the lack of an agreed definition meant that it was left to recipients of the invitation letter to decide who was suitable to be interviewed. Therefore, there will be selection and volunteer bias within the sample. While the sample size is respectable in terms of qualitative research,27 the number of people interviewed and bias means that care must be taken when extrapolating findings. Future research should apply a more explicit definition of practitioner in order to assess the skills and knowledge of specific sections of the public health workforce. It would also have been desirable to analyse the data according to the seniority and public health discipline of interviewees. However, even though participants described their job titles and roles, the significant variation in job titles and the breadth and heterogeneity of roles meant that this was not possible. The use of small focus group format permitted participants to interact with one another to test out understanding with colleagues as to whether elements of their work satisfied competencies. Whilst this is the main advantage of focus groups28 there is a risk of participants not wishing to reveal significant competency gaps in front of colleagues. It is also important to be reflective as to whether interviewees modified their responses to fit with perceived requirements of the interviewer, especially given that the interviewer was a senior local public health academic. While it is not possible to be certain if and how this might have introduced bias, the consistency between groups suggests that this impact was not significant. It was also difficult to assess specific individual’s competencies. Instead there was a tendency to assess the competency of the team. Whilst this is how the Public Health England intended the PHSKF to be used, future research should be conducted at an individual level. The research was also mainly conducted with practitioners working within local authorities. The responses of practitioners from other types of public health organizations may have been different. The research was also only conducted within Yorkshire and the Humber, and it is feasible that practitioners working in local authorities elsewhere may have different experiences. Conclusions Most participants had not seen, let alone used, the PHSKF. Consideration should be given to publicize ways it could help the public health workforce. It may be appropriate to use the PHSKF to develop a curriculum for a public health practitioner apprentice scheme, if the competency levels were benchmarked appropriately. Using the PHSKF for this purpose would also be appropriate as it has been adopted by countries within the UK. Apprentices could prospectively rotate between roles to gain the necessary experience, supported by an academic degree programme. There is also an argument that some, if not all, levels of the public health workforce do not need to be trained in all public health competencies. The PHSKF User Guide suggested that the aim of the framework is ‘to set out the functional areas in which individuals, teams and organizations operate, to deliver on public health outcomes… to provide a set of statement that describe what functions an individual might carry out in the course of their work. The combination of functions will vary from individual to individual, and from role to role’.27 Thus, while it does not benchmark competencies to levels (as in Canada3 or USA4) it also does not claim that the competencies are required for all public health practice at the baseline level (as in New Zealand2). Instead, as the PHSKF User Guide29 suggests, the key is that public health teams assess the group competencies required for delivering their functions and then ensure that individuals have specialist skills to contribute to the collective effort. However, in other research that we have conducted,9 Directors of Public Health saw value in staff having a wider understanding of public health, in addition to the more specialist skills and knowledge required for specific roles. Further work is required to permit individuals and organizations to interpret the breadth and depth of competencies for different levels of the public health workforce, especially for those in more junior roles, those in more specialist public health niches or who for the wider workforce. In particular, research is needed to understand competencies required for working in the voluntary and private sectors and how these can be achieved and maintained. It was outside of the scope of this article to review the curricula of current public health degree courses to assess whether they cover all PHSKF competencies. It is unlikely if many align directly with the PHSKF functions. However, if at some point in the future practitioners are expected to provide evidence against PHSKF functions, universities may wish to review the content and structure of courses. Frameworks will need regular updating to reflect evolving public health functions and organizations. There are trade-offs here between frameworks being in a constant state of review versus being out-of-date and hence not useful tools for some or all of the workforce. Frameworks should routinely provide details of methodology used for their construction, to assess methodological appropriateness and robustness. Having now tested the PHSKF against the self-reported knowledge and skills of practitioners in the field and previously developed our own leadership competency framework9 we believe that competency theory should be used to guide these processes. Supplementary data Supplementary data are available at the Journal of Public Health online. References 1 Public Health England . Public Health Knowledge and Skills Framework . London : Public Health England , 2016 . https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/584408/public_health_skills_and_knowledge_framework.pdf. (2 May 2018, date last accessed). 2 Public Health Association of New Zealand . Generic Competencies for Public Health in Aotearoa-New Zealand . Wellington : public Health Association , 2007 . http://www.publichealthworkforce.org.nz/data/media/documents/Competencies/WEB%20-%20Generic%20Competencies%20for%20Public%20Health%20March%202007.pdf. (2 May 2018, date last accessed). 3 Public Health Agency of Canada . Core Competencies for Public Health in Canada. http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/pdfs/cc-manual-eng090407.pdf (2 May 2018 , date last accessed). 4 The Council on Linkages between Academic and Public Health Practice . Core Competencies for Public Health Professionals. 2014 http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf (2 May 2018, date last accessed). 5 Birt C , Foldspang A . European Core Competencies for Public Health Professionals (ECCPHP) . Brussels : Association of Schools of European Region , 2011 . http://www.aspher.org/download/77/eccphp-2011.pdf. (14 September 2017, date last accessed). 6 Public Health Resource Unit, Skills for Health . Public Health Skills and Career Framework. Multidisciplinary/Multi-agency/Multi-professional . 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London: SAGE, 2013. 13 United Kingdom Public Health Register . https://www.ukphr.org/ (2 May 2018 , date last accessed). 14 International Union for Health Promotion and Education . Core Competencies and Professional Standards for Health Promotion. Saint Denis Cedres, France; IUHPE. 2016 . http://www.iuhpe.org/images/JC-Accreditation/Core_Competencies_Standards_linkE.pdf (2 May 2018, date last accessed). 15 Australian Health Promotion Association . Core Competencies for Health Promotion Practitioners . Queensland, Australia : University of the Sunshine Coast , 2009 . https://www.healthpromotion.org.au/images/docs/core_competencies_for_hp_practitioners.pdf. (2 May 2018, date last accessed). 16 European Centre for Disease Prevention and Control . Core Competencies for EU Public Health Epidemiologists in Communicable Disease Surveillance and Response . Stockholm : European Centre for Disease Prevention and Control , 2009 . https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/training-core-competencies-EU-public-health-epidemiologists.pdf. (2 May 2018, date last accessed). 17 Wright D , Morgan L . An Independent Evaluation of Frameworks for Professional Development in Pharmacy . Norwich : University of East Anglia , 2012 . http://groups.medbiq.org/medbiq/download/attachments/15991574/Independent%20evaluation%20of%20professional%20development%20frameworks%20-%20UK%20Pharmacy.pdf?version=1&modificationDate=1342686331000&api=v2. (2 May 2018, date last accessed). 18 Sandberg J . Understanding human competence at work: an interpretative approach . Acad Manage J 2000 ; 43 ( 1 ): 9 – 25 . 19 Norris N . The trouble with competence . Camb J Educ 1991 ; 21 ( 3 ): 331 – 41 . Google Scholar CrossRef Search ADS 20 Day M , Shickle D , Smith K et al. . 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New York : Grove Press , 2003 . 26 Local Government Association . Get in on the Act: Health and Social Care Act 2012 . London : Local Government Associations , 2012 . https://www.wirralintelligenceservice.org/media/1352/get-in-on-the-act-health-and-social-care-act-2012.pdf. (2 May 2018, date last accessed). 27 Mason M . Sample size and saturation in PhD studies using qualitative interviews . Forum: Qual Soc Res 2010 ; 11 ( 3 ): 8 . http://www.qualitative-research.net/index.php/fqs/article/view/1428/3027. Article noaccessed 2 May 2018. 28 Finch H , Lewis J , Turley C . Focus groups. In: Ritchie J , Lewis J , McNaughton Nicholls C , Ormston R (eds) . Qualitative Research Practice: A Guide for Social Science Students & Researchers . London : SAGE , 2013 , 211 – 242 . 29 Public Health England . User Guide [version 1] for the Public Health Skills and Knowledge Framework (PHSKF) . London : public health England , 2016 . https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/545011/Public_Health_Skills_and_Knowledge_Framework_2016_User_Guide.pdf. (2 May 2018, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Public HealthOxford University Press

Published: Jun 5, 2018

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