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Health check on HI

This month Minister Leo Varadkar commented that if he is re-elected, he would like to remain in Hawkins House.

On a recent episode of RTÉ’s The Week in Politics, he cited a number of projects he would like to continue working on, including the Healthy Ireland (HI) Framework.

HI was originally launched in 2013 when Dr James Reilly was in Hawkins House. Dr Reilly was very vocal on promoting its aims until he was moved around the Cabinet table last year.

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Minister Leo Varadkar

Since entering office, Minister Varadkar has been focused on high-profile issues around consultant recruitment, free under-sixes GP care and the ED crisis. However, concerns that he may not be as committed on HI may have been assuaged a little. Recently, he has raised the priority of HI at a number of public forums, including the IMO AGM.

The Department of Health is certainly pushing the HI brand. Currently, on all official letterheads from the Department the HI logo is very prominent. However, whether there is a clear conception in the public’s mind of what HI is remains a very open question.

Dire consequences

The HI policy was launched two years ago, with Minister Reilly speaking of the dire consequences facing the country if the long-term challenges around chronic illnesses were not faced up to.

“If we do not tackle this problem we could very well be the first generation to bury our children,” he memorably said at the launch of Healthy Ireland: A Framework for Improved Health and Wellbeing 2013-2025 in March 2013.

The document was the result of a very extensive period of consultation with medical staff and others and received over 104 submissions from individuals and organisations.

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Minister James Reilly

HI’s ‘whole-of-Government’ approach has been praised and it promised to tackle issues such as obesity. With its 64 actions, it is intended that by 2019, almost 100,000 more children and 160,000 adults will be of a more healthy weight and there will be a million more people active and eating the correct number of fruit and vegetables a day. Obesity, mental health and problems caused by smoking and alcohol are the biggest challenges outlined in the document.

When initially launched, HI found significant support among public health doctors for its vision, and much of this early goodwill seems to remain.

“The whole idea is a good one, and the whole-of-Government approach is to be welcomed,” Prof Joe Barry tells the Medical Independent (MI).

Prof Barry also praises the work of the Healthy Ireland Council: “I think the Council is working well; I have a colleague who is on it and they report good things from it.”

He adds that he remained an “optimist” when it came to Healthy Ireland. “I also think the way it is being promoted and highlighted by the HSE and the Department has been good.”

He also says that the ‘whole-of-Government’ approach to public health did not have to necessarily mean that the policy was “unwieldy,” rather that many different departments had a vital role to play in the implementation of HI.

Prof Barry also welcomes the Healthy Ireland Survey currently underway (see panel above), which he feels will garner some helpful public health statistics.

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Prof Joe Barry

However, Prof Barry, who has held the Chair of Population Health Medicine in Trinity College since 2009, has a number of specific concerns.

“It is disappointing that the National Physical Activity Plan has not been published yet,” he says.

“That would be something practical that we could work with. We are doing a lot of work out in Tallaght with the community regarding physical activity and it would be good to have the plan published to help support that sort of work,” he said.

The Department of Health has told MI that the publication of the action plan this year is a priority for HI.

Prof Barry also mentions that he would like to see other leading politicians mention HI and promote its goals more vigorously in public forums.

“It is important that with a whole-of-Government approach, that this is not just left to the Department of Health,” he explains.

“I would like to see the Taoiseach mention it more often and other ministers, not just the Minister for Health. Maybe they have, but I have just not heard them.”

Last summer was the latest big moment in the organisational evolution of HI, with the launch of the HI Council. The Council’s patron is President Michael D Higgins. It is a 36-member body Chaired by former rugby international Mr Keith Wood. It was established last year to be a “platform to connect and mobilise communities, families and individuals” under the Government’s HI policy initiative.

The establishment of the Council “is the most significant action within Healthy Ireland to leverage engagement with whole-of-society,” says the Department. “The Council provides the platform to connect and mobilise communities, families and individuals into a national movement with one aim: Supporting everyone to enjoy the best possible health and wellbeing.”

As reported in our last issue, a majority of Healthy Ireland Council members expressed significant concerns over the Government’s HI policy’s ability to “effect change” in a survey last October.

A report of the survey has been seen by this newspaper following a Freedom of Information request.

Members were consulted last year on a number of aspects of the HI policy and 22 members “shared concerns over the likelihood of the Healthy Ireland initiative effecting real change,” according to the results of the process.

“Concerns here included: A perceived lack of cross-departmental buy-in; a lack of joined-up thinking across services; a perceived lack of power of the Council; and a lack of clarity over the Council’s role.”

MI can further reveal that according to the report on the consultation process, some members “highlighted what they felt was a lack of clarity over the Council’s role and, for some, it having too wide a brief.”

‘Size matters’, many of the Council members seemed to be saying.

“It was feared that the wide brief might lead to a lack of momentum, or that its relatively large size might ‘lead to paralysis’,” continues the report.

“Finally, lack of funding was cited by some members as a challenge.”

Expenditure

There is no budget for the Healthy Ireland Council. Members are reimbursed for travel and subsistence expenses by the Department of Health. Expenditure on HI by the Department of Health was €89,315 in 2013, €586,470 in 2014 and €18,930 to date in 2015. “Most of the expenditure in 2014 relates to the Healthy Ireland Survey,” the Department states [see panel opposite].

“It should also be noted that the majority of Health and Wellbeing-related expenditure is by the HSE and HSE-funded agencies. “

The Department spokesperson adds that concerns raised last year by Council members were taken on board and fed into a new action plan for 2015.

It is disappointing that the National Physical Activity Plan has not been published yet

“Council members were surveyed, shortly after their first meeting in June 2014, to get their initial views on what they perceived to be the key challenges ahead as they started on the process,” the spokesperson says.

“Based on feedback received, an action plan for 2015 has been agreed by the Council, which takes account of Council’s role, the priorities and challenges identified and the contribution that Council members can make to address these issues.”

The Department insists that the Council has an important role to play in the delivery of the wider framework.

“The role of the Healthy Ireland Council is to connect and mobilise communities, families and individuals into a national movement with a common aim to support everyone to enjoy the best possible health and wellbeing.”

But concerns over funding go far beyond that of the Council. With the general focus of HI in tackling chronic illnesses like obesity, public health doctors feel general cutbacks have made the situation difficult.

Resource concerns

Public health doctors have recently raised concerns that resources and low staffing levels could well prevent the successful implementation of HI. Replying to questions from MI just prior to the recent IMO AGM, Dr Patrick O’Sullivan of the union’s Public Health and Community Health Committee addressed these concerns.

“Regardless of the structures that are in operation, the greatest challenge facing the departments of public health remain our inadequate staffing levels, both in the medical and non-medical grades,” he said.

“As a consequence, we have become increasingly focused on working in health protection, responding to outbreaks and reports of notifiable diseases, and unable to work in the areas of health service improvement and health improvement.

“This depletion of the human resources in the departments is contrary to the thrust of Healthy Ireland.

“At the launch of that health strategy, former Minister Reilly highlighted the need to focus on preventing people from becoming ill and on dealing with more patients in primary care to reduce the pressure on the acute services.

“Since then, the departments of public health and community health have been increasingly depleted of human resources and there has been no evidence of the required increased investment in primary care either.

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Dr Patrick O’Sullivan

“In addition to this inability to deliver a full range of public health services to our patients and communities, public health doctors have become demoralised because of the de-skilling that they have suffered as a result of doing the work previously done by many of our support staff colleagues, who have, like doctors, left and not been replaced.”

A motion calling on the Department of Health “to make the necessary investment in preventative medicine and primary care in line with proposals in the Healthy Ireland Strategy” was passed at the IMO AGM.

However, apart from the concerns with funding, the general “whole-of-Government” approach of HI, and the need to involve all areas of healthcare, including primary healthcare, has been welcomed by many doctors.

Such a wide agenda and its multifaceted nature means that organisation and leadership are especially crucial, as Council members have noted.

To date, the Healthy Ireland Council has met three times in June and October last year and again in March this year.

Healthy Ireland comes under the auspices of the HSE’s Health and Wellbeing Division, Chaired by National Director of Health and Wellbeing, Dr Stephanie O’Keeffe

The Health and Wellbeing Division reports to the Cabinet Committee on Social Policy and Public Sector Reform, which deals with a variety of issues, including the implementation of HI. This Cabinet Committee is where the ‘whole-of-Government’ approach to the framework is co-ordinated. This is certainly a powerful Committee, with the Taoiseach and a number of other ministers, including the Minister for Health.

“The Cabinet Committee on Social Policy and Public Service Reform has met on six occasions since last summer, four meetings in the second half of 2014,” confirms a spokesperson for the Department of the Taoiseach. Three meetings took place so far this year.

“Discussions at the Cabinet Committee are covered by the provisions of Cabinet confidentiality. Therefore, we are not in a position to provide information regarding agenda items discussed by the Cabinet Committee.” However, this paper was told last year by the Department of Health that HI is raised on the agenda of these Committee meetings.

But in the Department’s view, how much progress has been made since the Summer of 2013?

Driving the HI agenda has been identified as a “Ministerial and Departmental priority for 2015,” Hawkins House insists to MI.

“The specific priority deliverables for 2015 include a number of projects being led and managed by the Health and Wellbeing Programme.”

Priorities

These priorities include the publication of the first Healthy Ireland Survey, the publication and implement National Physical Activity Plan, and the plan to develop a national ‘Healthy Workplace’ framework across public and private sector. The final priority listed by the Department in reply to our questions was the publication of the first National Sexual Health Strategy.

But what specific initiatives can the Department of Health point to when looking back on the first two years of HI?

“The initial phase of implementation (2013/14) focused on

establishing the underpinning architecture and accountability structures and mechanisms,” says the Department.

“Building the capacity of the programme and embedding its work in the Department’s overall responsibilities and work, establishing and supporting the HSE capacity around health and wellbeing through the Health and Wellbeing Division, identifying and building key strategic relationships and partnerships across a range of cross-sectoral partners and initiating a number of foundational projects.”

These ‘foundational projects’ include the Healthy Ireland Survey (see sidebar), the Healthy Ireland Outcomes Framework, the National Physical Activity Plan and a range of communications activities, including with the recently-established Healthy Ireland Council.

“The Healthy Ireland Framework emphasises the international evidence that a whole-system approach, involving Government and society, is required to effect sustainable improvements in health and wellbeing,” says the spokesperson.

“To that end, work continues to build working relationships with key areas in other departments across a range of issues relevant to the Healthy Ireland agenda and to identify potential barriers or progress and find solutions, and to exploit opportunities to progress a ‘Health in All Policies’ approach.”

Engaging the public

If much of the public is still not so clear on Healthy Ireland (HI) and its existence, that may change in the coming weeks.

An extensive survey is currently being undertaken by HI, and whatever its results, they are sure to make headlines later this year.

The Healthy Ireland Survey is currently underway and is being conducted by Ipsos MRBI. The fieldwork commenced in November last year and the data collection is still underway.

Over 10,000 households have been randomly selected for the nationwide survey, which is designed to provide vital data on the state of the nation’s health.

The survey is due to report back on key heath indicators among the public on issues such as nutrition, alcohol consumption, smoking, levels of physical activity and wellbeing and sexual health.

“The results will be reported on in early summer,” a Department of Health spokesperson tells MI.

“The data will provide an up-to-date picture of the nation’s health. The results will give us a baseline set of data telling us how healthy or unhealthy Ireland is. We can then use future surveys to assess whether or not our policies are working. “

Thinking outside the health box

The October 2014 report on the consultation process with Healthy Council members is packed full of intriguing insights and ideas.

The report was seen by MI following a Freedom of Information request and is the result of 35 out of a possible 37 Council members replying to a questionnaire.

The Council, which was established last summer for a three-year period, is staffed by some well-known faces both inside and outside of the health system. It is chaired by former Irish rugby international Keith Wood, and other sports stars include Olympic silver medallist and Chief Executive of the Irish Sports Council John Tracey.

From within the health world, people like HSE DG Tony O’Brien and the Director of the Health and Wellbeing Division Dr Stephanie O’Keeffe also sit on the Council.

In their replies to the questionnaire, Council members revealed both concerns and optimism over the impact that HI could have on the future of the country.

As mentioned, some concerns were raised over the ability of the Council to effect real change. However there was also much input from Council members on ideas to make a difference — especially with obesity.

Some 13 Council members prioritised the promotion of physical activity, including investment in recreation facilities. Some respondents recommended targeting particular sections of the population, “such as young people, older people and low-income communities”.

There was also an emphasis from some respondents on the need to address the particular health inequalities faced by Traveller and Roma communities.

There were some very interesting ideas about how to facilitate public sector employees to take part in physical activity; this included “offering them the option of standing desks”.

Other ideas included having a Healthy Ireland walk or run, or to promote a ‘National Fitness Week’.

Eleven members identified challenges relating to changing deeply-ingrained mindsets and habits among the population.

“Here, the Council’s role was seen to be about advocating and promoting Healthy Ireland’s positive health messages, both nationally through the medics, social media, campaigns and other forums, and more locally through their constituent groups and networks,” reads the report.

Two members suggested that role models, such as national celebrities, including ‘celebrity chefs’, could lead campaigns on healthy living.

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