Health Protection Agency East of England East of England Deanery School of Public Health Public Health Specialty Training Programme This document outlines the learning opportunities for specialty registrars in the HPA East of England. Specialty Registrars will achieve health protection competences with the support of HPA and their training location coordinators. The content of health protection training is summarised in the table appended to this document together with appropriate assessment methods. 1. Programme of Health Protection during Public Health Specialist Training The Health Protection Agency (HPA) East of England will provide training, support and opportunities for Specialty Registrars (registrars) to gain the necessary health protection knowledge, skills and experience to become a Consultant in Public Health. Registrars will normally have a relationship with the Health Protection Unit (HPU) for the area they are based over the five years of the training programme. The training journey in health protection will consist of: Two day induction in the HPU as part of an introduction to public health; Support for preparation for Part A examination; Three months full time (minimum) HPU attachment; that is 60 days attendance ; Preparation for safe on call assessment; Participation in on call health protection rota; Provision of on call information pack and opportunity to revise and update this during HPU attachment; CPD activities within HPU for example regional or local teleconferences, seminars at ERTAG meetings; Refresher attachment in year 5 of training programme; Short term attachments working on outbreaks or incidents individually tailored Additionally, some registrars following selection onto specialist training in health protection in phase three of training, after the Part B examination, will undertake HPA attachments covering HPU, the Regional Epidemiology Unit, microbiology at Addenbrooke s Hospital and national centres. 2. Aims and objectives Health protection is an integral part of public health, defined as those public health activities intended to protect individuals, groups and populations from infectious diseases, environmental hazards such as chemical contamination, and from radiation 1. Key elements include:- the investigation and control of communicable diseases; the public health aspects of environmental hazards (including chemical, radiological and nuclear hazards) managing deliberate release incidents health emergency planning 1
During training, registrars should gain an understanding of the aetiology and pathogenesis of infectious and environmentally caused diseases, and their management on an individual and population basis. This may require understanding of principles of: 1. Epidemiology and statistics 2. Information management and surveillance 3. Microbiology, virology and immunology 4. Genetics 5. Therapeutics 6. Non-Infectious Environmental Hazards including chemistry knowledge (as needed for toxicology); 7. Principles of communicable disease control including modification of health behaviour, screening and vaccination 8. Principles of infection control These basic sciences will be taught as part of the Cambridge University M.Phil course with inputs from Health Protection consultants. The practical application of the basic health protection sciences will be through working with the HPU during attachment, on call and as need arises to meet learning outcomes (for example follow up of an outbreak or incident on call). HPUs will also provide teaching and suggest useful resources as required to support Part A study groups in preparation for the examination and during the HPU attachment. Registrars will be expected to gain fundamental skills required for health protection practice and be able to demonstrate competency in the following skills sets: 1. Gathering and synthesising clinical, microbiological and other information 2. Interpretation of microbiological tests in consultation with microbiologist 3. Disease surveillance 4. Strategic work on prevention programmes or provision of services for health protection illness 5. Emergency planning and preparedness 6. Multidisciplinary working and understanding roles of Environmental Health Officers (EHOs), clinical services, Tuberculosis (TB) nurses, Drug teams, Prisons, Local Resilience Fora (LRFs) 7. Audit and evaluation 8. Teaching and research (posters and publications) 3. The health protection curriculum and training portfolio Health protection training will primarily cover Key Area 6 of the Faculty of Public Health curriculum. The curriculum outlines 15 key learning outcomes (LOs) specific to health protection in section 6 of the curriculum, plus an additional thirteen optional specialist learning outcomes (see Appendix 1). Some learning outcomes may have been achieved during early training in the PCT and any which are not covered during the HPU attachment may be completed with specific PCT projects. The HPU will ensure with training location coordinators (TLCs) that all registrars complete the core health protection competences. The educational supervisor and registrar are expected to ensure that the learning across the PCT and HPU is integrated and that any outstanding health protection LOs have been attained, or are being addressed, after the three month attachment. Higher specialist training in health protection will be overseen by an HPA Educational Supervisor. A clinical supervisor will be appointed for HPU attachments to oversee the educational objectives of the attachment and assist the educational supervisor with assessment of competence.
3.1 Managing common health protection problems Registrars will be required to demonstrate a basic understanding of the epidemiology of common infectious diseases, and understand the principles of managing common health protection problems. This should at a minimum include involvement in the management of cases of: - Meningococcal disease - Legionella disease - Hepatitis B - Enteric fever - Food poisoning (for example: E.coli O157 or Shigella flexneri/boydii/dysenteriae; and Salmonella, campylobacter or Shigella sonnei) - Cryptosporidium - Environmental hazard for example chemical incident or water contamination Experience of managing these problems should enable the registrar to gain experience of identifying and assessing problems or hazards, their associated risks and determining appropriate action. Evidence of achieving these is likely to come from a consultant directly witnessing the registrar taking a first call, or from discussion at handover or using the registrar s log book 3. Learning outcomes 6.1-6.5 deal more explicitly with the health effects associated with a hazard that may similarly be encountered as an immediate problem for example a case of an infectious disease, or consideration of a more long-term local health protection issue. Management of incidents or enquiries may also contribute to evidence for LO 6.13, related to providing advice based on local or national guidance and policies. 3.2 Outbreak investigation and management Registrars are expected to participate in and make a significant contribution to the investigation of an incident or outbreak including preparation of a final report which covers key stages of an investigation (LO 6.15) 3. A significant contribution should include the registrar leading on an aspect of the investigation or management (for example, the epidemiological investigation to generate or test a hypothesis) as well as participating in multi-agency discussions on management of the incident 3. This level of involvement may not be available to every Registrar during a three month attachment but they will be welcomed back if an incident arises. TLCs will support registrars returning to HPU to meet learning outcomes at short notice. 3.3 Infection control Registrars should be able demonstrate an understanding of the organisation of infection control services in hospital and the community relevant to routine prevention and be aware of appropriate policies and procedures to reduce risk 2. They should offer effective and appropriate advice when responding to a communicable disease enquiry or outbreak (for example a case of gastrointestinal infection), particularly in a nursery, school, hospital or residential institution (LO 6.12) 2. This can be evidenced by direct observation or feedback based on involvement in infection control and prevention services, or could form part of the discussion around the enquiries that are recorded in the trainee s log book 3.
3.4 Health protection strategy and service provision During the three month HPU placement and in the PCT setting, registrars are expected to have contributed to a Health Protection Agency strategic objective, in one of the following areas: - TB control - Blood borne viruses - Vaccine preventable Illness - Influenza pandemic - Health Care Acquired Infection (HCAI) - HIV and sexually transmitted infections - Chemical, nuclear or radiation hazards This could include attendance at meetings or specific projects. This is also likely to involve advising on and co-ordinating public health action required in the light of existing local and national policies and guidelines (learning outcome 6.13) 2. Registrars will also be expected to have experience or awareness of the commissioning of health protection services and programmes during training in the PCT or regional health department. Training outside the HPU is also likely to include exposure to global environmental issues such as climate change, sustainability and the role of global health agencies 1. Projects involving health promotion aspects of reducing high risk behaviour, assessing and tackling health protection problems in at-risk or hard-to-reach groups are areas covered by specialist LOs (LOs 6.19, 6.20 and 6.22) groups 2. Aspects of data management, including surveillance and health needs assessment incorporate specialist LOs 6.16, 6.24 and 6.28 as well as offering experience in Key Area 1, surveillance and assessment of the population's health and well-being. Strategic or policy-based work may also enable registrars to gain knowledge and skills detailed in learning outcomes in Key Area 2, assessing the evidence of effectiveness of health and healthcare interventions, programmes and services and Key Area 3, policy and strategy development and implementation. 2 3.5 Emergency planning Registrars must demonstrate awareness of the principles of emergency planning and the networks involved in the emergency planning process, including threats from chemical, biological, nuclear and radiological attack (LO 6.15) 2. All registrars are expected to participate in a major incident (or major incident exercise) at the HPU or with the PCT. Registrars who take a major role in the investigation and management of a significant incident, and its evaluation can also fulfil additional LOs 6.17 and 6.18 3. This would include short attachments or specific training in communications skills.
3.6 Partnership working The HPU placement should enable the Registrar to be involved in working with partners including: - Local authorities - Environmental Health officers - TB nurses - Infection Control Teams - Primary Care Teams - Clinical teams (child health; maternal health; GUM service) - Drug treatment and rehabilitation services or prison health services This may also contribute valuable experience related to a number of relevant learning outcomes in Key Area 4, strategic leadership and collaborative working for health 2. 3.7 Academic health protection Registrars are expected to be involved in teaching and audit work in the unit (F2 doctors, medical students, nurses and colleagues). Those with specific interests in research in this area can opt to produce a paper or poster, design a study or perform an audit during their placement, or in association with the HPU. Registrars will have an Academic Supervisor to support them throughout their training and guide them in getting papers published. Registrars can tailor their experience and portfolio in Key Area 9, Academic Public Health, towards health protection issues and LO 6.28 allows specific recognition of testing of hypothesis using epidemiological studies 2. Registrars who have completed their three months attachment and are still on the on call rota are invited to participate in continuing professional development (CPD) activities including HPU grand rounds, teleconferences, teaching and audit as well as attending On call refresher courses for the second on call consultants. Short term attachments prior to consultant interviews for ST5 registrars are welcomed. 4. Standards for Health Protection Practice HPA staff have adopted a set of values and behaviours which dovetail with the ethical management of self and others detailed in the FPH curriculum, which apply throughout training and professional practice. In particular working in the HPU or on call specifically includes adopting clinical values of respecting confidentiality and properly handling patient identifiable information (EMS8) and keeping clear, contemporaneous clinical records (EMS3). As part of professional behaviour it is also expected that registrars will be readily accessible to the public and colleagues when on duty, including arranging suitable cover (EMS11). Registrars should practise safely including assuring professional indemnity and maintaining safe management practice (EMS14). They must recognise and work within the limits of professional competence (EMS1) and are encouraged to consult other colleagues (EMS2) and keep them informed, including referring clinical issues where appropriate (EMS4). Throughout health protection training, registrars should develop and refine effective communication skills with colleagues and patients (EMS5) and be able to describe complex issues clearly to individuals, groups and communities (LO 6.6)
5. Phase threetraining in Health Protection and achievement of OSILOs (optional special interest learning outcomes) Registrars in the East of England have an opportunity to apply for phase three specialist training in health protection over 24 months within East of England and at national centres. The training comprises working in Regional Epidemiology Unit (REU) in Cambridge, a second HPU attachment as a phase three registrar, an attachment in microbiology at Addenbrooke s Hospital and attachments to HPA centres such as Centre for Infections. While this is currently provided on the basis of a series of attachments, it is expected that there will be flexibility to respond to health protection incidents across the region. The opportunity to develop a longer term project and work at a strategic level and in managing change will be facilitated by having a long term relationship with an HPU over the whole period of training. The HPA adviser will organise these learning opportunities over the two year programme. Health protection specialist training is open to registrars who have completed part B and have two years remaining on the training programme. They are appointed by interview and up to two registrars each year can be accommodated. The Faculty of Public Health has developed specific optional special interest learning objectives (OSILOs) for those with a particular interest in health protection (see Appendix 1). Currently the East of England programme offers: Epidemiological and surveillance training in REU Coordination of region-wide programmes in HCAI, hepatitis, TB and STIs, Bench training in microbiology Observation of the role of microbiologist in clinical care and infection control Observation of the role of national centres in surveillance and research Attachments to Centre for Infections and other national services Participation in the strategic role of HPU Opportunities for the acquisition of practical skills in responding to a full range of Health Protection issues Acquisition of a skills base appropriate to a CCDC or Health Protection lead in a PCT. Document Review This document will be approved by Regional Executive Group in August 2010 form adoption by Specialist Training Committee in October 2010 and review by Public Health Service and Public Health Training Programme in April 2012. References 1. Faculty of Public Health. Training in Health Protection. 2003. Available at: http://www.fph.org.uk/training/downloads/how_you_learn/training_in_health_pr otection.pdf. 2. FPH curriculum 3. FPH Guide for Assessors 4. FPH Curriculum Assessment Blueprint
Appendix 1: FPH Curriculum Key Area 6: Learning outcomes in each phase and recommended assessment LO Learning outcome description 2,3 Phase Method of assessment 4 6.1 6.2 6.3 Identify known or potential health effects associated with a particular hazard relevant to health protection which is common in a population Characterise the hazard identified, both quantitatively and qualitatively Assess the degree of risk associated with exposure to a hazard commonly found in a population These are most likely to come from direct discussions of local issues. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. 6.4 Integrate hazard identification, characterisation and assessment into an estimate of the adverse events likely to occur in a population, based on a hazard commonly found in that population For this phase 2 learning outcome, evidence is most likely to come from direct discussion of a local problem. The assessor should seek evidence that: The trainee has clearly defined the hazard The trainee has clearly defined the relevant population Numerical estimates have been made where appropriate Uncertainties surrounding any estimates have been clearly documented and discussed The source of evidence for any estimates is documented 6.5 Be able to complete a risk assessment for a hazard not commonly found in a population, drawing on external expertise as appropriate For this phase 3 learning outcome, the assessor should seek evidence that: The trainee has consulted the appropriate experts or data sources/policies The trainee has clearly identified the hazard and whether it is of public health importance The trainee has identified the potential health effects of the hazard and potential routes of exposure The trainee has clearly defined the relevant population potentially at risk The trainee has identified the control measures that could be used. 6.6 Describe complex issues clearly to individuals, groups and communities Evidence is likely to come from asking members of the relevant audience whether the issue had been clearly described by the trainee. This should also form part of the discussion around the enquiries that are recorded in the trainee s log book. 6.7 Meet the educational requirements for commencing supervised on call. Particular standards to be reached before commencing on call are identified in a separate document 6.8 Meet the educational requirements for undertaking on-call as a generic consultant in public health (operating within limits of own professional competence and with the advice of a medical consultant who specialises in health protection available at all times) A separate document* sets out the criteria for achievement of these. 6.9 Ask appropriate questions to recognise a problem when presented with a health protection challenge 6.10 Interpret the answer received and recognise the need to ask for relevant advice where appropriate 6.11 Identify and confirm the risks and possible exposures Evidence is likely to come for direct witness of the trainee taking a first call, or from a handover or log book with the relevant information complete. 6.12 Describe the organisation of infection control and apply effective and appropriate procedures and policies to reduce risk Registrars should demonstrate an understanding of the infection control services in hospital and community relevant to routine prevention and to outbreak control He/she should offer effective and appropriate advice when responding to a communicable disease enquiry (e.g. a case of gastrointestinal infection), incident 1 2 2 Written report / Case discussion / Part A written exam 2 Written report / Case discussion 3 Written report / Case discussion 2 2 3 Case discussion / OSPHE 2 Case discussion 2 Case discussion
or outbreak. This can be from direct observation/feedback or could form part of the discussion around the enquiries that are recorded in the trainee s log book. 6.13 Advise on and co-ordinate public health action required in the light of existing local and national policies and guidelines The assessor should seek evidence which will most likely come from work in response to on-call enquiries (e.g. meningitis case) or an outbreak/incident. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. 6.14 Describe the general principles of emergency planning and managing a major incident This is most likely to come from direct discussions of local scenarios or participation in an actual emergency or exercise. 6.15 Participate in and make a significant contribution to the investigation of an incident or outbreak including preparation of final report This should be assessed by direct observation during an outbreak or incident and particularly by assessment of the written report. The report should cover key stages of an investigation, e.g.: for an outbreak: establishing that a problem exists confirming the diagnosis immediate control measures case finding collection of data descriptive epidemiology hypothesis generation hypothesis testing further control measures declaring incident over 2 or 3 Case discussion 2 Case discussion / Part A written exam 2 or 3 Written report 6.16 6.17 6.18 6.19 6.20 6.21 6.22 6.23 6.24 6.25 6.26 6.27 6.28 A significant contribution should include the trainee leading on an aspect of the investigation or management, e.g. the epidemiological investigation to generate and/or test a hypothesis; communications; audit etc. participating in the multi-agency discussions on management of incident Additional optional specialist learning outcomes: Integrate different types of data, using complex data sets, or collection of ad hoc data to draw appropriate conclusions for disease control, environmental and chemical hazards control and health improvement Lead or take a major role in the investigation and management of a significant incident, to include an outbreak, non infectious disease incident and a look back Evaluate the management of an outbreak or incident Evaluate a health protection service improvement Apply heath protection principles to services relevant to health protection in particular settings and in high risk groups (eg. prisons, with asylum seekers, in dental health, port health) Undertake a complex health protection health needs assessment Understand and apply the theoretical models of behaviour change, in the context of health protection for the general population and high risk/ hard to reach groups Develop and test/audit a multi agency incident control plan Establish or evaluate and quality assure a specific health protection surveillance system, including reporting and early warning, to meet a specified need for a defined population. Lead or make a substantial contribution to the implementation of a health protection policy or campaign Show appropriate judgement on the basis of potentially incomplete/conflicting clinical information Identify and intervene when a clinical risk to the health of the public is identified Generate hypotheses for health protection problems and test them in appropriate epidemiological studies
Assessment of Key Area 6 WRITTEN REPORT, CBD, PART A 1 6.1 Identify known or potential health effects associated with a particular hazard relevant to health protection which is common in a population. For many trainees this will have been done on an academic course such as a Masters or diploma course. The assessor does however still need evidence that the trainee has achieved this learning outcome: this is most likely to come from direct discussions of local issues. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. WRITTEN REPORT, CBD 2 6.2 Characterise the hazard identified, both quantitatively and qualitatively. For this learning outcome, evidence is most likely to come from direct discussion of a local problem. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. WRITTEN REPORT, CBD 2 6.3 Assess the degree of risk associated with exposure to a hazard commonly found in the population For this learning outcome, evidence is most likely to come from direct discussion of a local problem. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. Assessment Type Phase WRITTEN REPORT, CBD 2 6.4 Integrate hazard identification, characterisation and assessment into an estimate of the adverse events likely to occur in a population, based on a hazard commonly found in that population. For this phase 2 learning outcome, evidence is most likely to come from direct discussion of a local problem. The assessor will seek evidence that: The trainee has clearly defined the hazard The trainee has clearly defined the relevant population Numerical estimates have been made where appropriate Uncertainties surrounding any estimates have been clearly documented and discussed The source of evidence for any estimates is documented
WRITTEN REPORT, CBD 3 6.5 Be able to complete a risk assessment for a hazard not commonly found in a population, drawing on external expertise as appropriate For this learning outcome, the assessor will seek evidence that: If the hazard is known, but uncommon: The trainee has consulted the appropriate experts or data sources/policies The trainee has clearly identified the hazard and whether it is of public health importance The trainee has identified the potential health effects of the hazard and potential routes of exposure The trainee has clearly defined the relevant population potentially at risk The trainee has identified the control measures that could be used. If the hazard is unknown: The trainee has consulted the appropriate experts or data sources/policies The trainee has identified the possible hazards and which are of public health importance The trainee has identified the potential health effects of these hazards and potential routes of exposure The trainee has clearly defined the relevant population potentially at risk The trainee has identified the generic control measures that could be used The trainee has identified what further investigations need to be carried out. NB: the important aspect of this competence is to be able to carry out these aspects of a risk assessment. This could be demonstrated by applying the same principle to a relatively common hazard. Assessment Type Phase DOPS, PART B 2 6.6 Describe complex issues clearly to individuals, groups and communities. For this learning outcome, evidence is likely to come from asking members of the relevant audience whether the issue had been clearly described by the trainee. This should also form part of the discussion around the enquiries that are recorded in the trainee s log book. Assessment Type Phase PART B 2 6.7 Meet educational requirements for commencing supervised on call. A separate document is available from the Faculty which sets out the assessment procedure for this learning outcome.
CBD 3 6.8 Meet the educational requirements for undertaking on-call as a generic consultant in public health (operating within the limits of own professional competence and with the advice of a medical consultant who specialises in health protection available at all times) A separate document* is available from the Faculty which sets out the criteria for achievement of this learning outcome. * Annex B of Health Protection Training for generalists in public health, including Educational Requirements for on-call (FPH, 2006). DOPS, CBD 2 6.9 Ask appropriate questions to recognise a problem when presented with a health protection challenge. For this learning outcome, evidence is likely to come for direct witness of the trainee taking a first call, or from a handover or log book with the relevant information complete. DOPS, CBD 2 6.10 [to be read in conjunction with 6.9] Interpret the answer received and recognise the need to ask for relevant advice when appropriate. For this learning outcome, evidence is likely to come for direct witness of the trainee taking a first call, or from a handover or log book with the relevant information complete. DOPS, CBD 2 6.11 [to be read in conjunction with 6.9 and 6.10] Identify and confirm the risks and possible exposures. For this learning outcome, evidence is likely to come for direct witness of the trainee taking a first call, or from a handover or log book with the relevant information complete. For this learning outcome the assessor will seek evidence that The trainee can demonstrate an understanding of the infection control services in hospital and community relevant to routine prevention and to outbreak control The trainee offers effective and appropriate advice when responding to a communicable disease enquiry (e.g. a case of gastrointestinal infection), incident or outbreak. This can be from direct observation/feedback or could form part of the discussion around the enquiries that are recorded in the trainee s log book.
CBD 2 6.12 Describe the organisation of infection control and apply effective and appropriate procedures and policies to reduce risk. For this learning outcome the assessor will seek evidence that The trainee can demonstrate an understanding of the infection control services in hospital and community relevant to routine prevention and to outbreak control The trainee offers effective and appropriate advice when responding to a communicable disease enquiry (e.g. a case of gastrointestinal infection), incident or outbreak. This can be from direct observation/feedback or could form part of the discussion around the enquiries that are recorded in the trainee s log book. DOPS, CBD 2 or 3 6.13 Advise on and co-ordinate public health action required in the light of existing local and national policies and guidelines. For this learning outcome, the assessor will seek evidence which will most likely come from work in response to on-call enquiries (e.g. meningitis case) or an outbreak/incident. This should form part of the discussion around the enquiries that are recorded in the trainee s log book. CBD 2 6.14 Describe the general principles of emergency planning and managing a major incident. For many trainees this will have been done on an academic course such as a Masters or diploma course. The assessor does however still need evidence that the trainee has achieved this learning outcome: this is most likely to come from direct discussions of local scenarios or participation in an actual emergency or exercise.
DOPS, WRITTEN REPORT 2 or 3 6.15 Participate in and make a significant contribution to the investigation of an incident or outbreak including preparation of the final report. This learning outcome is assessed by direct observation during an outbreak or incident and particularly by assessment of the written report. The report should cover key stages of an investigation, e.g.: for an outbreak: - establishing that a problem exists - confirming the diagnosis - immediate control measures - case finding - collection of data - descriptive epidemiology - hypothesis generation - hypothesis testing - further control measures - declaring incident over A significant contribution should include the trainee leading on an aspect of the investigation or management, e.g. the epidemiological investigation to generate and/or test a hypothesis; communications; audit etc. participating in the multi-agency discussions on management of incident