28 Sep 2007
Author:
Institute of Public Health
Background
The Department of Health and Children Statement of Strategy will map out in broad terms the Department’s key areas of strategic action in the coming three years and act as the backdrop against which the Business Plans of each division of the Department will be prepared. The Institute’s recent submission on the Department’s Strategy Statement proposes that tackling inequalities in health form a key area of strategic action across all divisions within the Department in the coming three years. The Institute called for the Department to make additional commitments to tackle health inequalities at their root causes, in addition to developing services to meet the needs of poor and vulnerable members of society.
The submission states that the full implementation of the National Health Information Strategy is now a matter of urgency and also strongly recommends that the Department makes the achievement of the recommendations of the recent A Strategy for Cancer Control in Ireland a priority in the coming years within its enhanced policy evaluation and analysis role. A stronger leadership role to advance the vision set out in the Primary Care Strategy is encouraged. The submission also recommends the development of a new set of high-level long-term targets relating to the reduction of inequalities to provide an overarching policy context against which related policies and the HSE operations could be structured.
Below is the IPH’s full response:
Submission to the Department of Health and Children on Statement of Strategy 2008 to 2010
28th September 2007
The Institute of Public Health in Ireland
Key messages
• Tackling inequalities in health must form a key area of strategic action, not merely in those divisions with a social inclusion and equity focus or those catering for disadvantaged groups, but across all divisions within the Department.
• The Department should make additional commitments to tackle health inequalities at their root causes, in addition to developing services to meet the needs of poor and vulnerable members of society.
• The Department must continue to prioritise the development of its own internal capacity for effective policy formulation and evaluation. This should include national information policy. The success of policy directives should be monitored in terms of reducing health inequalities as well as improving health overall
• The full implementation of the National Health Information Strategy is now a matter of urgency and the development of the proposed Departmental Data Strategy in conjunction with HIQA, the Health Intelligence function of the HSE, and other key stakeholders such as the research community and the general public, is imperative.
• The Department should adopt a stronger leadership role to advance the vision set out in the National Health Information Strategy.
• It is strongly recommended that the Department makes the achievement of the recommendations of the recent A Strategy for Cancer Control in Ireland a priority in the coming years within its enhanced policy evaluation and analysis role.
• The Department should adopt a stronger leadership role to advance the vision set out in the Primary Care Strategy.
• As cardiovascular disease continues to be a major cause of morbidity, disability and premature mortality in Ireland and a major contributor to health inequalities , a comprehensive review of the implementation of the National Cardiovascular Health Strategy -Building Healthier Hearts should be considered in 2009.
• The forthcoming strategy should articulate the Department’s role in respect of the health of ethnic minority groups in Ireland and in particular that of migrant workers and Travellers, in the context of the forthcoming HSE Intercultural Strategy.
• We recommend that the Departments key actions relating to health promotion and social inclusion be further developed in the forthcoming strategy. In particular, we would recommend the continuation of existing plans to further the capacity to carry out Health Impact Assessments over the period 2008 to 2010.
• A new set of short-term and medium term indicators, and longer-term targets, relating to the reduction of inequalities should be developed to provide an overarching policy context for the HSE. They should be directly linked to related policies and HSE services plans at the national and sub-national level.
• An ongoing development of the commitment to North-South co-operation should feature within the forthcoming strategy.
The Institute of Public Health in Ireland
The Institute of Public Health in Ireland (IPH) is an all-island body
which aims to improve health in Ireland, by working to combat health
inequalities and influence public policies in favour of health. The
Institute promotes co-operation in research, training, information and
policy in order to contribute to policies which tackle inequalities in
health.
The Institute has enjoyed good working relations with the Department of Health and Children and welcomes the opportunity to submit its views for inclusion in the Department’s forthcoming Strategy Statement.
Context of the forthcoming Statement of Strategy 2008-2011
It is our understanding that the forthcoming Strategy Statement will
map out in broad terms the Department’s key areas of strategic action in
the coming three years and act as the backdrop against which the
Business Plans of each division of the Department will be prepared.
We propose that tackling inequalities in health must form a key area of strategic action, not merely in those divisions with a social inclusion and equity focus or those catering for disadvantaged groups, but across all divisions within the Department. This would enhance and build upon the commitments made in the current Statement of Strategy 2005-2007 and within the over-riding health strategy Quality and Fairness – A Health Strategy for You.
For the lifetime of the forthcoming Statement of Strategy, goals and targets relating to health inequalities must be made in the context of the National Action Plan for Social Inclusion 2007-2016 and the National Development Plan 2007-2013. In drafting its Statement of Strategy we would urge the Department to carefully consider recent policy developments and emerging issues in the area of poverty and social inclusion in Ireland.
Format of the Institute’s submission to the forthcoming Statement of Strategy 2008-2011
In this submission, the current Statement of Strategy is used as the template for making recommendations for the future.
The high level objectives of the Statement of Strategy 2005-2007 are
1. High Performance
2. Fair Access
3. Better Health for Everyone
4. Supporting Wider Government Programmes and International Health Policy
The introduction of the current statement of strategy states that the Department ‘considers that the nature of health determinants points to a compelling need for greater intersectoral action to address the impact of social, economic and environmental factors on the physical, mental and social well-being of individuals and communities. The health system will need to focus further on addressing health inequalities: otherwise the gap in health between the rich and poor will continue to widen’. The Institute strongly recommends that this ethos be reinforced within the forthcoming strategy and that concrete measures to address health inequalities within the business plans of each division be further developed and expanded.
The current strategy prioritises the development of the Department’s role in policy formulation, policy evaluation and planning at a strategic level with the devolvement of other functions to the HSE and HIQA. This should include national health information policy.
We strongly support the Department’s aspiration to monitor and evaluate the equity, quality and value for money of the health system. In particular, we would encourage the Department to focus on ensuring that all health policy and health services have an appropriate health equity component and that success with achieving equitable health outcomes is monitored and reported on an ongoing basis.
Now that the core period of organisational change has passed, we would
recommend that the Department focus on the development of its own
internal capacity to increase effectiveness in the policy-making arena.
Policy evaluation skills and resources must be prioritised to ensure
that
– existing Department of Health and Children policy recommendations are being implemented in a meaningful way
– stakeholder groups are provided with transparent feedback on progress with policy goals and targets
– the evidence-base to support and reorient the Department’s policy
recommendations is being developed on an on-going basis as part of a
process on continuous quality improvement
– neglected health issues most in need of strategic policy direction are highlighted and addressed
– policy directives are successful in reducing health inequalities as well as improving health overall
In order to achieve this goal, an agreed structure for the evaluation
and monitoring of key policies must be agreed between the Department of
Health and Children, the HSE and HIQA as a matter of urgency. Such a
framework would ideally be inclusive of a number of stakeholders
including patient representatives, community and voluntary sector and
frontline health service personnel.
High Level Objective 1 – High Performance
The Institute considers that the Department of Health and Children
should expedite the process of organisational reform by finalising and
bedding down fruitful working boundaries and working arrangements with
the HSE and HIQA within the first two years of the forthcoming strategy.
It is therefore hoped that the health service can begin to enjoy the
long-term benefits originally envisaged to result from the process of
reform.
The current statement of strategy commits to being inclusive and ensuring the views of all stakeholders are reflected in the planning and delivery of services. In this regard, the Department should oversee the roll-out of the HeBe guidelines for community participation.
Building on the current strategy’s commitments to develop health information systems must receive priority in the future. The full implementation of the National Health Information Strategy is now a matter of urgency and the development of the proposed Departmental Data Strategy in conjunction with HIQA, the Health Intelligence function of the HSE, and other key stakeholders such as the research community and the general public, is imperative. This Data Strategy must be allied with the data strategy developed by the Office for Social Inclusion in respect of monitoring the National Action Plan for Social Inclusion. In this way, information on health and poverty and the interface between these issues will be better integrated.
The Institute is concerned that several important aspects of the
National Health Information Strategy – such as the development, analysis
and reporting of the national health information systems – need greater
co-ordination and direction. The Department should adopt a stronger
leadership role, in collaboration with key stakeholders, to advance the
vision set out in the National Health Information Strategy.
In addition to the priorities set out in Making Knowledge Work for
Health: A Strategy for Health Research, produced by the Health Research
Board, the Department must articulate and advance its own priority
research needs and enlist the support of other agencies. While the
importance of continued investment in clinical, pharmacological and
biomedical type research is recognised, it is also clear that a number
of stubborn health issues relating to health behaviours and health
inequalities may require alternative research approaches. The Department
should support the translational research, and the knowledge brokerage
function provided by the IPH that are needed to ensure that national
policy formulation, development and evaluation is based on the best
available intelligence.
High Level Objective 2 – Responsive and Appropriate Care
The publication of A Strategy for Cancer Control in Ireland has been an
important achievement within the lifespan of the current strategy. It
is strongly recommended that the Department ensures forwarding the
recommendations of this strategy a priority in the coming years within
its enhanced policy evaluation and analysis role.
Similarly, the Department should lead on the advancement of the vision set out in the Primary Care Strategy within the forthcoming strategy. A review of the targets set out in the primary care strategy is scheduled for 2008 and this commitment should be reinforced within the Department’s statement of strategy.
Cardiovascular disease continues to be a major cause of morbidity, disability and premature mortality in Ireland and a major contributor to health inequalities and the poor health of disadvantaged groups. Consideration should be given to a comprehensive review of the implementation of the National Cardiovascular Health Strategy Building Healthier Hearts in 2009, representing ten years since the policy’s initial publication. This review could also consider the impact of emerging issues relating to cardiovascular health such as ethnic diversity, population ageing, rising levels of obesity and diabetes and changes in tobacco consumption.
With regard to the development of acute hospital services, we recommend that the current policy being pursued in respect of the development of private facilities on public hospital sites should be reconsidered. The long-term implications of this policy are currently unclear. The cost-effectiveness in the long-term and the potential to threaten equity of access to services to rich and poor are a cause of concern. Building on the Department’s commitment to develop appraisal frameworks and applicable criteria for proposals to develop private facilities on public hospital sites, such frameworks must explicitly consider the impact of these proposals on health inequalities at national and regional level.
The current statement of strategy commits to extend the national breast cancer screening services to all women aged 50 to 64 by 2007 but this aspiration has not been realised. We would encourage the Department to achieve full national coverage by BreastCheck within the first year of the forthcoming statement of strategy.
In relation to the current statements on strategies on obesity and diabetes, the Department must lead on the advancement of the recommendations of the National Taskforce on Obesity as a matter of priority within the next 3 years. Consideration should be given to commissioning an independent review of the implementation of these recommendations in 2010.
High Level Objective 3 – Fair Access
We would encourage the Department to expand this objective to encompass
fair access to health, in addition to the current strategy commitments
in respect of fair access to healthcare. By this we mean that the
Department could make additional commitments to tackle health
inequalities at their root causes, in addition to developing services to
meet the needs of poor and vulnerable members of society.
Such a commitment would involve
– improved health information and health intelligence on health
inequalities and the health of vulnerable and socially excluded groups,
allied to the needs of each of the Departments divisions
– an ongoing commitment to prioritise health inequality and social
inclusion issues within all future Department of Health and Children
policy and strategy documents
– monitoring the effectiveness of existing policies on access to
healthcare (e.g. GMS eligibility) in terms of their impact on health
inequalities
– monitoring equity of access to health services including health promotion and preventative services.
The forthcoming strategy should also articulate the Department’s role in respect of the health of ethnic minority groups in Ireland and in particular that of migrant workers and Travellers, in the context of the forthcoming HSE Intercultural Strategy. Preliminary findings from the Travellers Health Study should be available during the lifetime of the forthcoming strategy and a plan for the integration of these findings into policy and practice should be included within the strategy.
High Level Objective 4 – Better Health for Everyone
The Institute welcomes the existing commitment to adopt a population
health approach with functional areas of health intelligence, policy
evaluation and planning, health protection, health promotion and social
inclusion.
We recommend that the Departments key actions relating to health promotion and social inclusion be further developed in the forthcoming strategy. In particular, we would welcome the continuation of the plans to develop further the capacity to carry out Health Impact Assessments over the period 2008 to 2011.
In terms of the action to ‘review by end 2007 the extent to which key
NAPS health targets have been achieved’, it is recognised that there are
a number of statistical issues hampering the ability to monitor some of
these targets. Nonetheless, it is important that a further set of
targets/indicators relating to health inequalities are developed in the
context of the better knowledge gained through experience. These targets
should relate to 2007 onwards, the year in which the current targets
expire. These targets would represent high-level long-term goals
relating to the reduction of inequalities and provide a broad policy
context against which related policies and the HSE operations could be
structured. These targets would interlink and build upon existing
Department of Health and Children health inequality targets and
commitments as articulated in
– Quality and Fairness – A Health Strategy for You (2001)
– National Action Plan for Social Inclusion 2007-2016
– A Strategy for Cancer Control in Ireland (2007)
– Breastfeeding in Ireland – A Five-Year Strategic Action Plan (2005)
– Traveller Health – A National Strategy 2002 – 2005
– Report of the National Taskforce on Obesity (2005)
A detailed account of these targets and commitments is provided in the appendix.
In terms of children’s health, the Institute welcomes the formation of the Office of the Minister for Children during the lifespan of the current strategy. We also support the commitment made to further develop health and social services for children and families and would recommend that this remain a strategic priority in the coming years. The Institute has previously recommended that an interdepartmental group including key personnel from the Department of Health and Children and OMC be formed to address the particular issue of child health inequalities (Child Health and Poverty, Institute of Public Health in Ireland, Combat Poverty Agency 2007).
High Level Objective 5 – Supporting Wider Government Programmes and International Health Policy
In terms of this section of the Statement of Strategy, the Institute
considers that ongoing development of the commitment to North-South
co-operation should feature within the forthcoming strategy. In view of
the strong statement on strengthening North South working, the Institute
recommends that strategic and operational co-operation becomes a key
part of the Department’s ethos and that it is considered as an integral
part of each of its objectives rather than as an add on . Effective
cross-border co-operation should be consolidated, strengthened and
developed to ensure mutually supportive health initiatives and health
benefits across the island.
Appendix
| Government Policy | Target and/or commitment in respect of health inequalities in Ireland |
| Quality and Fairness – A Health System for You Health Strategy Dept. of Health & Children 2001 |
The gap in premature mortality between the lowest and the highest
socio-economic groups should be reduced by at least 10% for circulatory
diseases, for cancers, for injuries and poisoning by 2007
The gap in life expectancy between the Travelling community and the
whole population should be reduced by at least 10% by 2007
The life expectancy and health status of Travellers, asylum seekers
and refugees should be monitored so that targets can be set for asylum
seekers and refugees and reviewed and revised for Travellers by 2003.
The gap in low birthweight rates between children from the lowest
and highest socio-economic group should be reduced by 10% from the
current level by 2007.
Initiatives to improve the health and well-being of the homeless
will be advanced by 2003 and of drug misusers will be advanced by 2008.
Initiatives to improve the health of prisoners will be advanced.
Initiatives to eliminate barriers for disadvantaged groups to
achieve healthier lifestyles will be developed and expanded (Full
implementation of National Health Promotion Strategy and introduction of
community initiatives on an ongoing basis) |
| National Action Plan for Social Inclusion 2007-2016 Office for Social Inclusion 2007 |
Develop a new programme of action in respect of Youth Homelessness in 2007 Monitor inequalities in cancer risks, cancer occurrence, cancer services and cancer outcomes, as set out in A Strategy for Cancer Control in Ireland Development of HSE National Equality Strategy Framework & HSE Intercultural Strategy in 2007 & roll-out of ethnic identifier Fuel poverty commitments as articulated in the White Paper. Ongoing investment in roll-out of Primary Care Strategy Delivery of Vision for Change Mental Health Strategy Development of initiatives to encourage healthy eating, promote access to healthy food and physical activity with a particular focus on adults living in areas of disadvantage Review of National Drugs Strategy in 2008 |
|
Breastfeeding in Ireland – A Five-Year Strategic Plan Dept of Health & Children 2005 |
The national breastfeeding initiation rate should increase by at
least 2% per year and by 4% per year for socio-economic groups 5 and 6.
This target applies nationally as well as at individual maternity unit
level.
The national breastfeeding duration rate to increase by at least 2%
per year and by 4% per year for socio-economic groups 5 and 6. This
target to be measured at 3 to 4 months of age, at 6 months of age at one
year and is to apply nationally and at HSE Local Health Office level. |
| A Strategy for Cancer Control in Ireland Dept. of Health & Children 2007 |
The HSE should put in place arrangements to monitor inequalities in
cancer risks, cancer occurrence, cancer services and cancer outcomes.
Subsequently… Targets for the following indicators will be developed in 2007 (i) Stage of presentation of common cancers broken down by geographic area and by deprivation index (SAHRU index category) (ii) Survival rates for common cancers broken down by geographic area and by deprivation index (SAHRU index category) (iii) Uptake of breast cancer screening by women in the appropriate age group covered by the BreastCheck programme – broken down by medical card status (iv) Cigarette smoking prevalence broken down by social class and gender |
| Traveller Health – A National Strategy 2005-2005 Dept of Health & Children 2002 |
122 actions proposed relating to – health service cultural awareness training and skills – health research – planning and provision of health services including women’s health and maternity care – health promotion – structures supporting inclusion of Travellers in decision-making and policy |
| Obesity – The Policy Challenges Report of the National Taskforce on Obesity 2005 |
Review of social assistance payments to take account of the relatively high cost of healthy foods for disadvantaged groups
Access to a healthy diet should be included as an indicator as part
of the National Anti-Poverty and social inclusion process
Improved access to physical acitivity for lower socio-economic and minority groups
Prioritisation of community development programmes supporting
healthy eating and active living for lower socio-economic groups |
|
A Vision for Change Report of the Expert Group on Mental Health Policy Dept of Health & Children 2006 |
Mental health services should take into account of local deprivation patterns in planning and delivering mental health care
Measures to protect the income of individuals with mental health
problems should be put in place. Health care access schemes should also
be reviewed for this group |
|
Building Healthier Hearts Report of the Cardiovascular Health Strategy Group 1999 | Evidence-based, focused, sustained initiatives should be developed to promote cardiovascular health in disadvantaged groups and communities Targeted, focused, sustained programmes should be implemented to promote healthy eating, especially for those on low incomes and in other at risk groups. Innovative solutions are required to increase access to healthy food choices by low income groups. The HPU should establish an evidence-based programme to promote health among disadvantaged groups and communities. |
| Primary Care- A New Direction | 2001 Needs assessment should specifically identify special needs or areas of disadvantage to ensure that primary care teams can be targeted to meet those needs. |
For further information or queries on this submission, please contact Helen at the Dublin office of the Institute of Public Health in Ireland
Ph 01 4786300
E-mail: helen.mcavoy@publichealth.ie
