Public health skills are now more in demand than at any time in the past. Many health professionals have a very real and urgent need to develop the skills for managing health at a population level. This is especially true in primary care where a population perspective has always been important. In addition, clinicians in secondary care are required to demonstrate their population, management, and research skills to fulfil a role where team working and skill mixing are increasingly important. Lastly, we are all under increasing pressure to identify where we can contribute best, and how our skills need developing in order to be able to do that. Public health skills add breadth and enable use of existing specialist skills more efficiently and effectively. There are simply not enough dedicated public health professionals to do all that could be done. Relationships between public health professionals and practising clinicians are often distant or poor. We present here an initiative to take public health skills to clinicians, with the aim of broadening the base of public health skills within the NHS, as well as improving understanding of different roles and working relationships across the wider health service.

The regional training committee of public health medicine in the Anglia deanery offers Fellowships to both general practitioners (GPs) and hospital doctors for 6–12 months within an existing public health medicine training programme to help them develop these very skills. The hope is that the clinicians emerge from the Fellowship programme better equipped to manage health care issues at a population level as well as understanding the techniques, language, culture, challenges, and opportunities associated with the discipline in particular and the changing face of health and health care generally.

With the appointment of the first Minister for Public Health in 1997, the value placed on the contribution made by the practice of public health was affirmed. This has been strengthened in the White PaperSaving Lives: Our Healthier Nation where the emphasis on public health actions and public health skills confirms the need for a critical mass of public health aware professionals within the NHS.1

The practice of public health involves specialists from a wide range of professions (both medical and non-medical). Other practitioners with an understanding of these basic public health sciences are needed to effect the public health and to work together for the improvement of the public's health. The skills that have traditionally been specific to the practice of public health medicine are now recognised by many clinicians as valuable for their practice to enhance their delivery of health care.

The first Anglia Public Health Fellowship (to a paediatrician) was awarded by competitive interview in February 1998. The Fellowship programme was conceived and developed in the preceding 12 months. The idea came originally from the associate dean for hospital training in Anglia who had been running a week long course in management skills for senior registrars (now SpRs) in their final year of training. Feedback and evaluation of this course revealed a desire among many of the participants to understand more of the wider aspects of the health service into which they were about to enter as new consultants in their own specialties.

The Fellowships, fully funded from the Medical and Dental Education Levy (MADEL), are offered through national competition each year. Criteria for application include the current holding of a National Training Number (NTN) in any specialty and signed agreement of the current programme director for a six month time out from clinical training. Applications are encouraged particularly from SpRs in their third and fourth years of training. GP registrars who apply for a Fellowship must have completed their summative assessment before starting their Fellowship. More details, including job descriptions, person specifications, application forms, and contact points are available from the Anglia public health medicine training programme web sites.2 ,3 Successful applicants may defer their appointment for up to 12 months to allow their specialty training programme to recruit a locum for the duration of the Fellowship. Applicants are encouraged to seek accreditation of their training in public health towards their own programme through their Royal College. All who have applied for accreditation of the Fellowship as a part of their own programme have been successful. However, while the recognition of the value of the Fellowship is valuable, several of the Fellows have wished to undertake both the public health training and a full clinical training. This has been seen by them as an enhancement to their future careers rather than as a way of shortening their clinical training. Before taking up the post, successful candidates are expected to have fully worked up a programme including proposals for work relating to their own specialty with a public health focus. Indeed, to be able to establish a provisional work programme is an important criterion of the assessment process at the interview stage.

The skills curriculum includes the following: epidemiology and statistics, determinants of health, planning, routine sources of data, the commissioning cycle, prioritisation and budgeting, evidence based health care, audit and clinical quality, guideline development, management skills, and development of interpersonal skills. Fellows are allocated to a fully accredited training department of Public Health in the Anglia deanery. They become full members of the training scheme with the benefits of service and academic supervision accorded to their public health SpR contemporaries. Fellows are allocated a service supervisor for their service programme and have access to academic support from one of two university departments in the deanery. Study leave relevant to training is also fully funded.

Examples of work undertaken by the first two Fellows in post include:

• An evaluation of neonatal hearing screening

• Study of the epidemiology of childhood diabetes and a service audit of provision for this

• Analysis of deaths in childhood in a health authority area

• Analysis of orthopaedic outpatient waiting times with relation to Charter standards

• Assessment of need for community physiotherapy

• Audit of current maternity services

• Development of a service specification for renal services

• Development of guidelines for oral surgery

• Publication of a business plan for alcohol services.

Fellows are encouraged to work in areas both within and outside their clinical specialty interest. The development of public health skills can be acquired through carefully supervised projects without necessarily covering a familiar clinical area. However, the value of using some relevant clinical expertise is obvious, both in allowing the Fellow to appreciate the wider perspective of population health in their clinical practice and also in maintaining clinical links during the six months.

Evaluation of the first two years of this programme has been positive.4 Fellows have returned to their clinical training with a wider perspective and with skills immediately valued by their clinical colleagues. Stated positive benefits include:

• An understanding of the role and functioning of a health authority

• Ability to use routine data

• Seeing one's own specialty through another's eyes

• Learning the skills to influence

• The power of evidence

• How to deal with obstructive colleagues

• How to manage meetings

• Patience with long timescales for change in health systems

• How to read hidden agendas

• How to prepare a development bid

• How to write a research proposal

• A strategic approach

• Using communication skills with colleagues as well as with patients.

Holders of Fellowships include a rheumatologist (now a lecturer), a paediatrician (now working part time in a health authority), a dermatologist (now within a Cochrane review group), an A&E SpR, a psychiatrist, an SpR in obstetrics and gynaecology, and three GPs (including one from Eire).

Only by attracting, funding, and skilling different professionals in such programmes will we ever be able to add meaningful breadth to the considerable depth of health care professionals. Much emphasis in the White Paper Saving Lives is put on the necessity of working together across boundaries if we are to tackle the underlying causes of many preventable diseases. Initiatives such as this Fellowship programme that encourage us develop such skills and awareness in closely related areas are a small but essential part of this process.