04 Jan 2008
Institute of Public Health
Submission to the Northern Ireland Executive
Building a Better Future – Draft Programme for Government 2008-2011
The Institute of Public Health in Ireland (IPH)
The Institute of Public Health in Ireland (IPH) aims to improve health on the island of Ireland, by working to combat health inequalities and influence public policies in favour of health. We promote cooperation between Northern Ireland and the Republic of Ireland in public health research, training, information and policy.
IPH welcomes the opportunity to comment on the Draft Programme for Government 2008-2011. We support and welcome the vision of the Programme for Government (PfG) to promote a prosperous, fair and inclusive society and welcome the Executive’s vision of a better future for all.
We think a better future for all should include a commitment to protect health and create opportunities for everyone to achieve the best possible level of health and well being. We believe that improving public health and reducing inequalities in health should be an overarching priority for the Northern Ireland Executive.
The following response outlines the issues IPH see as necessary in the development and delivery of the Programme for Government.
1. Health in all policies
Our health is largely determined by public policy and all policies should be developed and implemented with this in mind.
Health was recently identified in the Eurobarometer survey as the most important issue facing European citizens. We believe this finding should inform the PfG and that good health for all citizens should be an Executive priority in Northern Ireland.
Improvements in the health of the people of Northern Ireland will only come about by ensuring that all policies are developed in ways which protect and improve our health. The PfG acknowledges the social determinants of health such as poverty, housing, transport, education, employment and agriculture. This acknowledgement should be extended to a clear commitment to cross departmental working. The Ministerial Group for Public Health is an excellent model and we urge the Executive to make a clear statement of intent to strengthen its role.
Investing for Health (IfH), the government’s public health strategy is recognised internationally as an example of excellence. We are disappointed that there is little mention of this as since 2002 it has provided a strong foundation for public health initiatives. IPH believes that PfG presents the opportunity to strengthen IfH and recommends that there should be a clear target to implement the public health strategy. The PfG should also ensure that there is support for community development to ensure that communities are involved in planning and implementing the programmes which affect their lives.
IPH has developed a suite of reviews examining the health impacts of employment, transport and the built environment and a forthcoming review will consider education. Responsible government departments which will have major increases in budgets over the next few years (DRD, DE and DEL) should be asked to ensure their policies are health proofed.
Poverty and inequality are key determinants of health and their reduction should be a key goal
Households in Northern Ireland experience higher rates of poverty, unemployment and low-paid employment than other households in the UK. Poverty and inequality are known to be important determinants of health and action to reduce poverty should be a key goal of PfG. We are disappointed that there is little in the PfG to show a determined effort to implement and monitor the Lifetime Opportunities strategy.
In Northern Ireland, children born into poverty are four times more likely to die before the age of twenty than non-poor children. There is wide support to end the appalling level of child poverty in Northern Ireland. IPH calls for a real commitment by the Northern Ireland Executive to end child poverty.
We urge the Executive to include a commitment to eradicate Fuel Poverty from all vulnerable households by 2010. This would be a great success for the Executive and we believe it is achievable. We also urge a connection with the emerging climate change agenda where the impact of energy taxation and other economic instruments on low income households needs to be continuously monitored.
Food poverty stems from the wider effects of social exclusion and is inextricably linked to education, finance, housing, culture, and planning. Limited economic resources and the cost of nutritious adequate food is considered to be the greatest obstacle in seeking and achieving a ‘healthy’ diet and subsequent good health. It needs an integrated, multi-sectoral approach and has a fundamental impact on health and wellbeing. A recent report by the Public Health Alliance for the Island of Ireland recommends that a combination of policies and actions be linked so that the vulnerable have the resources to access good food.
Inequalities in health
High levels of inequality are a matter of social injustice and tackling inequalities in health needs to be a key priority for the PfG
IPH welcomes the statement within PfG to take action to prevent illness
and improve physical and mental health, but regrets the lack of
specific actions to tackle health inequalities.
IPH reports have consistently shown high levels of inequality in both death and disease. Our high levels of inequality are a key cause for concern, a matter of social injustice and a terrible waste of life. High levels of inequality are a serious contributor to our high overall levels of ill health.
The gap in health between the richest and the poorest was outlined in the most recent Chief Medical Officer’s report, and in recent inequalities monitoring reports from DHSSPS. Men living in the most deprived areas of Northern Ireland are living on average 7 years less than those from the most affluent areas and 4 years less than the Northern Ireland average. Life expectancy in women living in deprived areas is over 2 years less than the average for Northern Ireland women.
Figures from the Joseph Rowntree Foundations Monitoring Poverty and Social Exclusion in Northern Ireland 2006 show premature death rates in Northern Ireland are higher than in 8 regions in Great Britain and lower than in 3. There are marked inequalities in infant mortality and premature death rates. Compared to professional and managerial workers the premature death rate for those in manual occupations is 2 ½ times as high and the rate for those who have never worked/long term unemployed is 3 ½ times as high.
Inequalities in health are not inevitable. The magnitude of the difference in health between the rich and the poor varies between countries. We urge the Executive to make a commitment to reduce health inequalities. There is a widespread assumption that efforts to improve health will automatically improve health inequalities. This is not so. Effective policies need to meet two criteria; improvements in health available to all AND a rate of improvement which increases all the way down the social ladder.
The causes of health inequalities are the unfair and systematic distribution of the social determinants of health. The Executive’s commitment to a fair society requires action specifically designed to address this systematic injustice.
3. Public services particularly health services
We welcome the commitment to world class public services. Effective, equitable and accessible public services are a key aspect of good government. We note and welcome the Executive’s key goals but are surprised and dismayed at the lack of reference to inequality and previous commitments to reducing health inequalities appear to have disappeared.
We are very concerned at the long list of public services which will not be delivered unless there is essential additional funding for health and social care. The way in which we treat people who are frail, weak and most vulnerable is an indicator of a civilized society. We believe that much greater investment in health and social care services is really important.
The Wanless Report ‘Securing Good Health for the Whole Population’
(2004) highlighted the important role of disease prevention and public
health interventions and this needs to be prioritised.
Investment in preventive, treatment and rehabilitation health and social care services should be seen as investments for a developed society rather than a drain on the economy as they are often portrayed.
If the draft Budget goes ahead in its current form, there will be a disproportionate impact on disadvantaged communities. This would include up to 45,000 women aged over 65 not benefiting from the extension of breast screening until 2010, Northern Ireland’s inclusion in a UK-wide vaccination programme to prevent cervical cancer for schoolgirls due to begin next year being under threat and only limited bowel cancer screening for those aged 60-69 in 2010 will be possible.
There is a clear need to maintain balance between social and economic development. A healthy population is a prerequisite for economic and social development.
The Executive’s commitment to the economy has been widely welcomed and
while we accept this is a key part of Northern Ireland’s future success
we believe this must go hand in hand with a commitment to social
The structural weaknesses of the economy must not be addressed in isolation.
PfG directs attention to growing a dynamic, innovative economy. Health spending should be seen as an investment in a common future rather than the traditional economic view of it as consumption of scarce resources.
In particular there is a need to focus on health where there is now widespread international recognition that investment in health is a prerequisite for economic development as much as a result of it. Investment in a common future rather than the traditional economic view of spending on health resources is vital to create a healthy workforce for future generations. Attention must be paid to building a qualified workforce and also putting in place the necessary actions to ensure an increase in the number of young people leaving school with qualifications. Key goals need to be set in PfG to improve literacy.
5. Linkages and learning from others
We welcome the commitment to fostering linkages outside Northern Ireland. Both North/South and East/West links offer many opportunities and practical benefits for Northern Ireland. We believe that the joint statement by the First Minister and the Taoiseach that “We have one issue – we want both parts of the island to prosper” was a significant statement and that its interpretation should include an understanding that we will not prosper in Northern Ireland or on the island without a commitment to health and wellbeing. We also urge strengthening international and European relationships in the interests of all citizens.
There is a strong link between sustainable development and public health and this should be recognised and made clearer in all government policies and actions. IPH welcomes the commitment in PfG to sustainable development as a cross-cutting principle, and believes that this is an important and integral part of tackling health inequalities. However sustainable development needs to be understood at all levels of government.
The focus on sustainable development is very welcome but in reality spending on services such as roads rather than public transport makes some of the focus look rather blurred. We are disappointed that there is no mention of an Environmental Protection Agency and we support many other agencies who have called for this.
7. Public service agreements (PSAs)
We welcome the approach of PSAs as a way of identifying the actions, outcomes and targets that the Executive aim to achieve over the next 3 years. Unfortunately we do not feel we have enough information on budgets to be able to indicate whether we support the detail of this approach. In relation to health, social services and public safety we draw attention to particular public health challenges such as the persistently high levels of health inequalities, poor mental health and increasing rates of obesity. We are concerned with the indicators resource allocation and the impact that this will have particularly on children, those with disabilities and older people.
The Executive’s Programme for Government is a crucial opportunity for all parts of government to act together to fulfil the vision of a better future for all. Opportunities to improve health and reduce health inequalities must be part of this vision and inform the actions of all aspects of government. We urge the Executive to see investment in health and health services as an investment in a fair and prosperous society in which all citizens have the opportunity to achieve optimum health and well being. We welcome the Executive’s desire to draw on the energy and expertise of those outside government and will willingly respond to this.