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Unhealthy progress on Healthy Ireland?

Launched in March 2013, Healthy Ireland (HI): A Framework for Improved Health and Wellbeing 2013-2025 is the Government’s flagship public health initiative.

Just over four years in existence, HI will now most likely work in tandem with the recently-published, all-party, 10-year plan for health, the Sláintecare Report.

The new Taoiseach Leo Varadkar has only recently reaffirmed his commitment to HI. His leadership manifesto launched at the beginning of his contest with Minister Simon Coveney stated the “Healthy Ireland programme will be developed into a new State agency responsible for promoting personal and public health and wellbeing with a ring-fenced budget to do so”.

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Taoiseach Leo Varadkar

The Sláintecare Report, produced and agreed by the Oireachtas Committee on the Future of Healthcare, is highly supportive of the aims of HI but does raise significant concerns on its implementation.

The Committee’s report calls for the “urgent” publication of implementation time lines and an “Outcomes Framework” for the Healthy Ireland strategy.

The report says it “supports the key aims of the Healthy Ireland strategy, which is targeting the broader social determinants of health, recognising that investment in population-level interventions that improve health outcomes is not only fair, but also good investment.

“The Committee echoes the cross-departmental approach outlined in Healthy Ireland, which takes population health and wellness into account in all areas of Government,” continues the report.

“However, it notes that Healthy Ireland’s promised implementation plan and Outcomes Framework are yet to be published.”

Concerns

Thus, the report recommends “the urgent publication of specific timelines and measurable goals and Outcomes Framework for Healthy Ireland and the adequate resourcing of the work needed to carry it out”.

The leading political voice behind the report tells the Medical Independent (MI) that this is vital.

“When HI was launched in 2013 it was a good strategy in itself, [but] there was an implementation plan and Outcomes Framework promised,” Future of Healthcare Committee Chairperson Deputy Róisín Shortall (Social Democrats) tells MI.

“They were supposed to be published in 2013 and it never happened. And we are saying we need a very clear implementation plan and it needs to be fully funded and we need an Outcomes Framework to measure the impact of the health promotion.

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Deputy Róisín Shortall

“It’s one thing to have the strategy in place for promotion; it’s another thing to be clear about the timelines for implementing it. Setting the goals and measuring the outcomes from it is the only way it will be taken seriously across all the departments. That obviously needs to be funded and we are recommending a doubling of the funding for the Healthy Ireland programme.”

In response to concerns raised in the Sláintecare Report, a spokesperson for the Department of Health told MI that the Outcomes Framework is “nearing completion” and the first version should be published before the end of this year. The spokesperson added that the Outcomes Framework promises to “monitor and drive the achievement of Healthy Ireland’s targets and performance indicators”.

“The Outcomes Framework provides this structured approach. It is a tool to assess and report (through a set of indicators) on progress being made in the implementation of Healthy Ireland.”

The spokesperson pointed to other plans connected to HI, which have implementation timelines included. 

“The Government is committed to the implementation of the Healthy Ireland Framework and it is currently being implemented through a number of action plans and other initiatives, including A Healthy Weight for Ireland — the National Obesity Policy and Action Plan and Get Ireland Active! The National Physical Activity Plan for Ireland,” the spokesperson told MI.

“Both of these action plans contain a number of actions in relation to the need for assessment and monitoring of the various initiatives and programmes being undertaken to implement the Framework.”

The need for stronger implementation of HI was highlighted in the final report because concerns were raised in a number of submissions to the Committee regarding the lack of strength around the implementation and monitoring mechanisms of HI.

But it is not only the publication of the Outcomes Framework that has been delayed. In recent months, MI has repeatedly enquired as to whether any decision has been made regarding the make-up of the next Healthy Ireland Council.

The term of office of the Council, headed by ex-Irish rugby international Mr Keith Wood, came to an end last month. However, last week the Department told this newspaper that there is still no decision on whether the current Council will remain in place, or whether there will be changes in personnel.

“Matters relating to the Council are under deliberation within the Department at present,” a spokesperson told MI.

Despite these delays, HI and preventive healthcare in general are supported by the Future of Healthcare Committee. The Sláintecare Report references the importance of HI on a number of occasions.

“We did want to put an emphasis on preventative medicine and health promotion generally, given the fact that so much of the health service activity relates to chronic illness; much of that is avoidable with better lifestyle choices being made,” Deputy Shortall tells MI.

“So the whole area of health promotion is very important. We generally supported the approach taken by the Healthy Ireland strategy, particularly its element of involving leadership from the Taoiseach and then all other Departments and having wider responsibility — an all-of-Government initiative, because things like safe walking to school and playgrounds and things like that relate to other departments. Everyone needs to play their part.”

Minister

Uniquely, in terms of recommendations regarding political appointments, the Sláintecare Report also suggests that the “role of Minister of State for Health Promotion should be retained in future Governments” to drive forward HI and the wider public health agenda.

Deputy Shortall says Minister of State for Health Promotion Marcella Corcoran Kennedy had been “doing well in that area”.

“She has been particularly strong on alcohol, in spite of opposition from a number of quarters; she has been very determined to see the passage of the Alcohol Bill.”

At press time, news was awaited on whether Minister Corcoran Kennedy would be kept in situ and on the future of this role, following the change in Taoiseach and Cabinet reshuffle*.

Deputy Shortall says it was the opinion of the Committee that a Ministerial position overseeing health promotion and the wider work of HI is important in all future Governments over the next decade. 

“It is very important in the view of the Committee that there be a Minister with a very clear, focused responsibility on health promotion and [ability to] pursue that agenda relentlessly, so it would not get lost among all the other pressing health issues,” said Deputy Shortall.  

Prof Joe Barry, Professor of Population Health Medicine in Trinity College Dublin, tells MI that he fully agrees with this Sláintecare recommendation regarding the retention of the Minister of State position.

“It’s an essential role, I think. In fact, we advocated at one stage for a Minister for Public Health,” says Prof Barry.

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Prof Joe Barry

Lobbying

However, Prof Barry says the new Taoiseach Leo Varadkar would need to strongly support HI and other public health legislation, as well as stand up to lobbying.

“The National [Physical] Activity Plan has been published; the Public Health Alcohol Bill hopefully will get enacted by the new Government and the new Taoiseach,” Prof Barry tells MI.  “The new Taoiseach, as a former Minister for Health, will have an interest I hope in getting the Public Health Bill enacted; there has been quite a bit of legislation on tobacco. I think one area that needs more concentration is obesity. There is lobbying against healthy food policy,” he says.

The Sláintecare Report is critical of the current progress made with HI and asks for a “possible” Health Impact Assessment to be undertaken to examine the Government-wide approach to population health and HI.

The report suggests strengthening “mechanisms for the full implementation of Healthy Ireland, including leadership from the Taoiseach, Government-wide and health system implementation, taking  population  health  and  wellness  into account  in  all  workings  of  the  government,  possibly  through  Health Impact  Assessment, and the  prompt  development  and  publication of an Outcomes Framework for Healthy Ireland.”

Implementation

Prof Barry agreed that both implementation of HI and political leadership are crucial.

There are many action points in the plan and he indicated that more focus is needed in relation to implementation and the Outcomes Framework.

The cross-Governmental nature of the plan is positive and it is still early in its life-cycle, he points out.

“It has a long-term timeframe. It goes up to 2025, so I don’t think anybody thought this was all going to happen very quickly. I think it is making progress,” says Prof Barry.

“There are high-level goals but there are actions in it. There is a new Healthy Ireland Network, so there are structures that are building up alright; it is just taking time, I would not be too critical of that.”

Echoing the concerns raised in Sláintecare, Prof Barry says HI “just needs to be given a bit more of an implementation focus during the next three years, with tangible changes. They have done three annual surveys, so at least they are tracking the changes.

“The problem for prevention is that it is not as attractive as [funding] hospitals, so it does need a focus from the Government and they need to recommit themselves to prevention and lifestyle changes.”

Survey

The annual surveys that Prof Barry references have so far cost over €1.6 million, according to figures supplied to this newspaper.

The third survey is currently underway.

The Department’s spokesperson told MI that a contract to the value of €1,687,920 was awarded to conduct three waves of the HI survey. Data collection for the third wave is underway and publication is expected later in 2017.

Asked whether the contract for the surveys would be renewed or whether they would continue on an annual basis, the Department was non-committal in its response.

“The position in relation to the further conduct of the Healthy Ireland Survey is currently under deliberation.”

The Department confirmed there would be some different questions in the third survey to provide new information.

“The modular nature of the survey allows questions to be added in or removed, depending on the data requirements of the Department and other key stakeholders,” the Department’s spokesperson told MI.

The spokesperson also outlined the importance of the survey, as it “provides an up-to-date picture of the nation’s health with a robust and credible baseline set of data on a range of health behaviours”.

They added: “The Department is now in a position to report credibly on a range of issues which have a significant impact on health outcomes, as well as being able to provide reliable and current data to fulfil a number of international reporting requirements. These data are now being used to inform current and future policy direction, programme development and implementation.”

In terms of wider spending on HI, earlier this year the Department told this newspaper that it is not possible to identify in totality how much funding is currently spent on improving health and wellbeing across all Government departments and agencies and in wider society.

In July 2016, the Government announced the details of a specific €5 million Healthy Ireland Fund. However, last month Minister Corcoran Kennedy told the Dáil that no decision had yet been taken on how to spend the money.

“Work by my Department on the establishment of the Fund is at an advanced stage, and upon the commencement of the Fund, I will make an announcement that will provide further detail.”

Earlier this year, the Department did inform MI that “in 2016, expenditure on implementing Healthy Ireland from within the budget of the Department of Health amounted to €1,156,406”.

The spokesperson added that it was not “possible to disaggregate expenditure on promoting and improving health and wellbeing generally from overall HSE expenditure”.

*After this article went to press, the announcement of Ministers of State confirmed that Deputy Corcoran Kennedy had lost her role in health promotion, which has now been acquired by Minister Catherine Byrne, in addition to her drugs strategy brief.

Sláintecare — ‘implementation’ is the watchword

David Lynch and Catherine Reilly gauge ongoing reactions to the report of the Oireachtas Committee on the Future of Healthcare

Some years ago, when management consultant Dr Eddie Molloy was asked by the Department of Health to undertake a research piece, he requested prior reports on health reform as background reading material. The following day, a van arrived to his house — filled with crates of them.

So in summer 2016, when the Oireachtas Committee on the Future of Healthcare set about its work, Dr Molloy emphasised to its members that if they did not want their report to be consigned to a crate, they needed to ‘go big’ on implementation.

One year on, Dr Molloy tells the Medical Independent (MI) he is pleased that the recently-published Sláintecare Report includes a number of specific points on implementation.

“That translates into a request that, by July, the Government ring-fence €10 million for a programme office,” notes Dr Molloy, an expert in organisational change who advised the Oireachtas Committee. 

The report also prescribes that the implementation office should be accountable to the Department of An Taoiseach and this is another positive point, according to Dr Molloy. It is essential that those charged with implementing the report can “call in higher powers”, he says. 

“A lot of attention has gone into the programme office and its relationship with the Executive of the HSE — that it will work hand-in-hand with the HSE and Department but can go higher; it can go up to ‘god’.”

An implementation office may be seen by some as another ‘layer’ to health sector reform, but Dr Molloy says it is pivotal.

Dr Molloy says that if the Government decided to rebuild spaghetti junction at the Red Cow, the traffic would still need to be kept moving, simultaneous to planning and executing change, hence the importance of a programme office to manage the transformation.

He underlined that the work of planning and executing change is additional to the major operational work ongoing within the health sector, which clearly must continue in tandem. “There are two jobs: One is to keep the ‘show on the road’; the other is a separate, demanding piece of work to map-out, plan, drive and execute change.”

Dr Molloy is also in full agreement with a key tenet of the report: Shifting more care away from hospitals and into the community. A “big proportion” of hospital attendances and admissions could be addressed in the community, with appropriate infrastructure and resources, he says. 

There will be challenges in respect of implementation. The “dominance” of hospital-based medicine and associated political support will be chief among them, feels Dr Molloy.

Ultimately, he believes this is a report with noteworthy differences to all that has gone before. Crucially, it was written and agreed by politicians from across the political spectrum, rather than generated by an outside entity. 

He says the politicians on the Committee are fully aware that the system is “broken” and that public hospital waiting lists will likely continue their inexorable rise, if substantial reform is not initiated. 

The ‘acid test’ will centre on adequate resourcing and empowering of the implementation process, adds Dr Molloy. This will be crucial in determining if the ‘tectonic plates’ of the health system begin to shift for once and for all. 

Meanwhile, Chairperson of the Committee on the Future of Healthcare, Deputy Róisín Shortall (Social Democrats), says the reaction to the Sláintecare Report has been “quite positive”, despite some concerns raised by GPs and consultants.

“That we get agreement across all political parties about what kind of health service we need is important,” says Deputy Shortall.

“The political debate then should be around the phasing-in of the new health system and the funding of it, rather than the kind of system itself. I think that will be a huge step forward for us as a country if we have that agreement. That agreement has been achieved at a political level in terms of the most appropriate health system we need in the country — a universal, single-tier health system. That is an historic change in the country’s approach to healthcare.”

Co Clare TD Dr Michael Harty (Independent), another member of the Future of Healthcare Committee, tells MI the report requires a “culture change” across the entire health service. 

“There has to be a whole-of-Government view of how the health service goes forward. I think there has to be cultural change in the HSE, in the Department of Health, in hospital systems and structures, in how they are governed and how they have answerability. And also in general practice. It is challenging all those elements of the health service to have a bigger view.”

MI also sought comment from the Department of An Taoiseach and the Department of Health regarding any preparatory work they were doing in respect of the Future of Healthcare report. A response to both queries was issued to MI by the Department of Health.  

“The Minister [Simon Harris] has been clear since the cross-party Committee on the Future of Healthcare commenced the development of a long-term vision for Ireland’s healthcare system that he would not advance major structural reforms until it had reported, out of respect for the process,” stated a Department of Health spokesperson.

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Minister for Health Simon Harris

“The Committee has now completed its work and the report is the culmination of a year-long process of unprecedented cross-party collaboration, dialogue and engagement and is testament of the desire across the political spectrum and across the broader stakeholder community to work collaboratively to address the challenges in the health service.

“It is vital that we now allow time to reflect and deliberate on the findings of the Committee. The Minister looks forward to the forthcoming Dáil debate on the report and will give full consideration to the report’s recommendations after having had the opportunity to hear views from across the Dáil. Following the debate, it is his intention to bring detailed analysis and proposals to Government. The report rightly places a central focus on ensuring that robust implementation structures and an effective implementation plan are put in place quickly and this will be one of the first issues that will be considered.”

The report was due to be debated in the Dáil on 15 June, but business was suspended following the election of the new Taoiseach the previous day. At press time, the debate had been rescheuled to the evening of 22 June.

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