HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health Promotion Agency
22 May 2008
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr John McCallister
Dr Brian Gaffney ) Health Promotion Agency
The Deputy Chairperson (Mrs O’Neill):
In the first of today’s two evidence sessions, representatives from the Health Promotion Agency (HPA) will give evidence on the proposals to reform the health and social care system. Members have hard copies of the HPA’s submission and a briefing paper from the Assembly’s Research and Library Services.
I welcome Brian Gaffney, the chief executive of the Health Promotion Agency. I invite you to make a presentation, after which Committee members will ask questions.
Dr Brian Gaffney (Health Promotion Agency):
Thank you. I am delighted to meet the Committee. My invitation reflects the Committee’s interest in public-health issues, and it affords me the opportunity to convey my organisation’s perspective on the proposed changes to structures, which will have a wider impact on public health in Northern Ireland.
I will provide some background information on public health in general and on health improvement in particular, and I will then talk about changes to the current structures. I will focus on the proposal to establish a regional public health agency (RPHA), because that will have the greatest impact on the Health Promotion Agency. However, if required, I will also comment on the broader structural reorganisation.
Much debate on the health system rightly concerns medical care and treatment — they are the most expensive, demanding and, probably, most important aspects. Public-health issues have increasingly come to the fore over the past two decades. More evidence has been gathered, and that evidence shows that healthier communities are more socially cohesive, economically productive and, interestingly, more involved with local structures, such as local government. That is why we want to improve public health.
The Wanless Report and the Appleby Report, which dealt with economic issues that affect England and Wales and affect Northern Ireland respectively, indicated that we will no longer be able to afford such an extensive healthcare system without public-health improvement and an engaged population. Public health and health improvement should be taken very seriously.
Public health is a complex matter, but, in order to improve discussion, we divide it into three domains. The first domain is health protection, which covers protection against disease, through immunisation and other programmes, and environmental protection’s contribution to health. The second domain is service development, which deals with ways in which public-health specialists have an input into the development of other health and social care services. That input includes providing evidence, and debating how services can be improved and made more cost-effective. The third domain — in which I operate — is health improvement. When people use the term “public health”, they are usually describing health improvement or health promotion.
Since the mid-1980s, health improvement and health promotion have developed beyond the previous individual-based, medical model. That model was thought to be quite straightforward — if people were told what was good for them, they would change their behaviour and, thus, their health would improve. However, that is often not the case with public health, so any model must be more in-depth.
We now appreciate that public health — both physical and mental — is a resource that develops over a person’s lifetime. Public health concerns people’s appreciation of their capacities, knowledge, skills and behaviours, and their interaction with their social and economic environment. Health is more complex than, say, whether a person feels sick, so we must find ways in which to improve it.
The Health Promotion Agency offers programmes for individuals, because we want to develop individuals’ skills and knowledge, and help them to make healthy decisions. However, we must create environments that enable people to make those healthy decisions. That is why the issue is so important for the Committee for Health, Social Services and Public Safety, and, indeed, for other instruments of government. Consideration of environments and of how people interact requires work in many different sectors. Children and young people must be educated to enable them to make healthy decisions. People need to have a healthy workplace that helps them to make healthy decisions on their behaviours, including on smoking and nutrition.
Moreover, safe neighbourhoods are needed. The physical environment must allow people to take physical activity where they feel safe. People must be able to make healthy and affordable choices about food, and so on, and they must be provided with the skills to use those choices. That is particularly relevant to the Committee and the Government, because we realise that the legislative programme has an impact on people’s health.
That is most clearly seen in the example of smoking legislation. For many years, those of us who work in public health lobbied for smoking not to be allowed in public places or workplaces, but Government action is required to legislate on such issues in order to allow us to put programmes in place. The current debate on alcohol misuse depends on legislation that will enable people to make choices about alcohol. Changes may be reflected in licensing laws and sales restrictions.
Public health and health improvement is so complex, and involves so many people, that no one agency or organisation can be responsible. The issues require much collaboration and many partnerships. The Health Promotion Agency has partnerships at community level with various organisations, such as healthy living centres and community development programmes. We have relationships with many community and voluntary groups, such as Action Mental Health, the Ulster Cancer Foundation, the Northern Ireland Chest, Heart and Stroke Association, Age Concern, Barnardo’s and PlayBoard. All those are important partners of ours in developing public health.
The Health Promotion Agency describes its work as being an integrated approach across many areas. Those areas include research, because we need to know what we are talking about, we need to know the evidence for what works and we need to know what is effective. That research should feed into training for professionals, not only health professionals but educational professionals, and even Government professionals who work in the legislative field. We disseminate a great deal of information, to health professionals in particular but also to the public. Some of that is evidenced in many of the programmes with which the Health Promotion Agency is involved.
None of that work goes on by itself. It must be linked to what is happening locally, and it must be linked to other organisations. It must be done through many different health settings, including work with local councils, other agencies and local health structures. I hope that the current proposals will facilitate that work. In our various consultation submissions, we said that current structures do not easily facilitate those partnerships or local working. They do not facilitate a truly cohesive relationship between local work and regional work, and they do not necessarily link that work. Therefore, we are neither making best use of scarce funding nor ensuring that good programmes are sustainable.
Much good work is taking place, particularly at community level. The Health Promotion Agency and other organisations, such as local councils and other health structures, are doing work at a regional level. However, there is, as yet, no joint-planning approach or agreed funding mechanisms across the partnerships and programmes. There are no common objectives, nor is there joint accountability. There is no real, agreed process for evaluation or measurement of outcomes. It is to be hoped the current proposals will tackle and improve those areas.
We consider the current restructuring proposals to offer a major opportunity for change. To do that, much of the work that is done on health improvement regionally and locally must be linked. We hope that, by sharing evidence and by planning programmes together, we will ensure local input as well as regional commitment, and we hope that the two sides can work together. Any proposed new organisations should make public health, particularly health improvement, a priority.
Sometimes, in the public-health system, health improvement plays second fiddle to health protection and service development, which often eat up resources. It is important that the proposed RPHA focus mainly on health improvement and collaborate with local commissioning groups (LCGs) and the proposed regional health and social care board (RHSCB). The Health Promotion Agency is unsure of the RHSCB’s commissioning and providing function, and the proposals do not outline clearly the plans for other sections of the health system. For instance, our relationship with primary care and, especially, general practice must be outlined in the new structures.
We must accept that we do not want longer timescales or the difficulty in measuring health outcomes to deflect the focus from health improvement. Health improvement is essential — we want to improve individuals’ health and produce a vibrant, more productive — socially and economically — community in Northern Ireland. We need structures that will enable us to help the community. If such decisions were determined by the market, there would not be any smoking legislation or restrictions on alcohol sales, and other development programmes would not exist. Government must take the lead and establish structures that will allow public-health workers to work together with other health-system employees and local-government representatives.
Therefore, I look forward to the changes, because there are faults in the current structures. I hope that the debate on the new structures will consider health improvement a top priority.
The Deputy Chairperson:
You mentioned that adopting a partnership approach is crucial to delivering health promotion. Do you think that the review of public administration (RPA) proposals should impose a statutory requirement to compel local councils to become involved? Would such a measure strengthen health promotion? Would that enrich the council’s forthcoming local community-development plans?
The HPA’s work with local government is always conducted on an ad hoc basis; those sectors do not usually work together, and they do not always prioritise public health. In the history of public health, local government has, undoubtedly, played a major role. Through its traditional and regeneration roles, it can enhance public health. Local government also has a long history of community development and of working at a local-community level.
The public-health agendas of the Health Service and local government must come together. There are proposals to introduce community-planning rules and to impose a duty of well-being on local government. Local councils should have a statutory responsibility as well as a responsibility to work closely with any new health-system structures.
I have known Brian Gaffney for a long time — longer than I care to admit — and I am interested in health reform. I am worried that the Health Reform Bill will not be passed by its target date. The intention is that it will come into operation on 1 April 2009. However, its Second Stage is scheduled for the week commencing 23 June 2008, and its Committee Stage is expected to commence at the end of June.
I am familiar with the HPA’s work. I spent this morning in Altnagelvin Area Hospital, where I saw a poster, which probably came from the HPA, that I had never seen before. I do not know whether other Committee members have seen it, but it is anti-drink-driving poster carrying a slogan along the lines of “I’m sure you wished you’d crashed at your mate’s”. Such posters convey a message effectively, as do television adverts.
I wonder just how many people will be involved in the regional public health agency. Will there be too many organisations? Will it be too complicated? I have heard other people ask whether the proposed RPHA should be incorporated in the proposed RHSCB. What are your views on that? Furthermore, if my figures are correct, even with the RPHA and the RHSCB to come into being next year, the Department of Health, Social Services and Public Safety (DHSSPS) will continue to employ around 400 people in the trusts. Why are those staff required?
I have another question on coterminosity. Interestingly, I have changed my tune. Initially, I would have preferred there to be five to seven LCGs, but I now think that, given the proposal to have 11 councils, there should be six LCGs — one for Belfast and one between two for each of the 10 other councils — particularly as they are involved in local councils. That would help secure councillor representation. It is right to base the number of LCGs on the number of councils. For example, a single LCG, coterminous with the trust, would not be adequate for the west. I am sure that Tommy will agree, because it would be a city-dominated LCG. The commissioning body would be in the city, as would the provider. For example, Derry has entirely different needs from the rural populations of Tyrone and Fermanagh. My view is that LCGs should be based on councils.
I agree with Brian that the whole idea of LCGs is that they will involve GPs and other health professionals in the area, as well as local councillors — we health professionals are keen to work with health promoters in future. I am sure that Brian will agree that the health and social boards, with which I have worked for well over 20 years now, have, in many cases, not been in touch with the local communities. I mean no disrespect when I say that. Local communities do not know what they are. They adopt a top-down approach, through which decisions are made. Services are commissioned by people who are not really in touch with local communities at all. The new method of health commissioning, and the other new proposals under the RPA, are supposed to have the reverse character and operate in a bottom-up fashion.
Do you agree with me on that, Brian? A very good relationship could be formed were the new RPHA to work with the LCGs, which should take over most of the commissioning in future, once the process has bedded down for a few years. Indeed, that were the original plan. Those are all my questions and comments.
The Deputy Chairperson:
There are plenty to keep you going.
I will try to cover all the points raised. I cannot really comment on the size of the organisations, because, in a sense, it is still up for debate, because the consultation has only just finished. On whether public-health agencies should be incorporated in the board, I urge that, at least, there should be a separate health improvement agency. One might think that I am bound to say that because I come from a stand-alone agency; however, the proposed RHSCB, which will contain the LCGs, will be a huge commissioning organisation. Its budget will be huge, if not the number of people that it employs. As I said earlier, health improvement in particular sometimes loses out when decisions and choices have to be made about hospital care, and waiting lists tend to dominate in those circumstances. Sometimes, health improvement and public health must have a separate focus. I am not 100% sure what the relationships will be — I think that a decision has yet to be made — nor am I sure whether the RPHA will be commissioned by the board or the Department. Therefore, I do not know what the relevant sizes will be.
However, where important public-health issues, such as alcohol misuse, require discussion, it is important that a focused body raise them. Although it does not seem difficult for an agency such as the Health Promotion Agency to raise issues around smoking, that has not always been the case. In my first ever meeting with Government, an outgoing Conservative Minister with responsibility for health did not allow us to raise the issue of smoking legislation. However, that did not stop us. My chairman at the time, the late Jimmy Hawthorne, who was outspoken on public health, did not hesitate to raise the issue.
Sometimes, an independent voice is required. Issues that are coming to the fore include obesity, which will involve the food industry, and alcohol, which will involve the drinks industry. The revenue that the Government collect in tax means that it is sometimes difficult to tell them what needs to be done. An independent body that is at arm’s length from Government could raise the difficult issues. I am not sure whether that body should incorporate the three domains of public health — health protection, service development and service improvement — because those domains must have strong, close links with services that the proposed RHSCB will develop. Therefore, whatever structures are created, it is important that those links be tight, because the body needs to influence what is commissioned. In some ways, I am glad that I do not have to answer the questions about the structures that should be created and the relationships that there should be. However, a separate, independent and health-improvement-focused public-health body is necessary for a range of reasons.
The Health Promotion Agency is a regional provider of public health and, because of the current structures, it has no formal mandate to work at a local level. Despite that, much of our work is done at a local level. Dr Deeny is correct to say that people who work at the community level often do not know the functions of their local health and social services board. Recently, we had to work with a range of local groups on mental-health issues and, because we were not 100% sure of their agenda and what they do, and vice versa, that has been a fractious relationship at times. However, the results have been positive, so such difficulties can be overcome. In future, we must ensure that whatever is created is accessible to LCGs.
As an aside, we must realise that five or six LCGs will not be local to the communities that they serve; for example, the Belfast Health and Social Care Trust is a huge organisation, with many employees. I am not saying that that trust should be smaller, but, when an organisation covers such a large population, the body that commissions from it will not be able to work with local communities day to day. A way must be found to ensure that those local communities have an input into the process. A series of proposals, such as the community commissioning associations and community development processes, has not solved the problem.
Our new local trusts must have their agenda set clearly by the commissioning process that is implemented. They must interact with local communities, because I cannot see any other way for local communities to feed into the process under the current system. It is difficult to get a grasp on local issues, and local people may sometimes, for genuine reasons, find it difficult to get a grasp on regional issues. Nevertheless, both are important and must be accommodated. There is a clear role for input from those who are involved in primary care, especially GPs, who are the top health professionals at a local level. After all, the organisation with which local people are registered is the local practice, so GPs should reflect that.
Very few local practices are concerned about coterminosity — many of their patients are from locations that are within different local-government or health-trust boundaries, yet those practices manage to work around that. We must consider every body’s boundaries, but, for me, two points stand out. We must ensure local input — be that through a system that the LCGs develop or through the trusts being told that they must obtain that input — and it must be balanced against regional provision of public-health functions. It is sometimes the case that those functions can only be delivered regionally, so they must be developed in that way. The question of how we strike that balance is difficult to answer, but it is not, and should not be, insurmountable. In a sense, it should be the main driver for creating the new structures.
Thank you, Brian, for your presentation. I agree with the point in the Heath Promotion Agency’s response to the consultation on proposals for health and social care reform that the proposed RPHA should have executive powers. It is obvious that the HPA is concerned about which body will have responsibility for health improvement and, if I interpret your response correctly, the HPA believes that that responsibility should remain with the local trust. Given that the trusts have badly managed health improvement, will you explain why the HPA would not want the proposed RPHA to assume responsibility for health improvement?
I do not necessarily feel that the trusts are doing that work badly. In many instances —
Sorry, that is simply my opinion.
Much of the work may be a duplication of, or it may not be linked to, other work. For example, I am working in the system and even I was surprised to find that some of our Investing for Health partnerships, even at a local level, were not really aware of the work that their local healthy-living centre was undertaking. It did not seem to be possible to co-ordinate the two, because they were funded and managed separately, and did not seem to be part of the same system. Therefore, it is not the case that the trusts are doing bad work, but it may be that they do not co-ordinate.
The HPA feels that we still need health-improvement and health-promotion staff based in trusts, because we see no other way in which local links can be established. In any part of Northern Ireland, it is possible to find examples of work going on between local community groups and local health trusts. A regional organisation would not be able to replicate that work.
Even if all health-improvement staff were relocated from trusts and based in a regional agency, at some stage they would have to return to local level and work with the local trust. Therefore, as far as I am concerned, it is a question of whether we can ensure that the work that those people do ties into a common agenda and that it is subject to a common system of accountability and a common planning process.
If the proposed RPHA is to commission health improvement, it must ensure that trusts, through their health-improvement staff, are meeting the regional agenda and that their work complements it. I see no point in reorganising the existing structures to make health-improvement staff work at a regional level, only for them to return to work at trust level subsequently. However, greater co-ordination is needed.
We all agree that we must make huge strides to make the entire population aware of public-health issues.
I am interested in following up on questions about tying in the issue of health to the proposed new council structures. Would councils play a strategic role, using their structures as a delivery mechanism to get across the message?
There are examples of local councils taking the lead role in public-health programmes and in the work of Investing for Health partnerships, and those are good examples of what councils should do at a local level. Regionally, we have engaged with councils on issues such as workplace health, and that has been a fruitful exercise. Therefore, the public-health role of councils could be played at strategic and local implementation levels.
Councils have vast experience of working with their local communities, but some public-health workers may feel that if we encourage that partnership too much, we will hand over public health from the health system to local councils, thereby losing something. However, I regard such a partnership as a strength rather than a weakness. If we can ensure that the councils, whatever their number or size, prioritise local public-health programmes and issues, that will only enhance the process. Councils must work in close partnership with the health system, but they have slightly different perspectives and structures, so they could assume responsibility for many areas. Although we have developed a good training programme with GPs to address fuel poverty, much of the real work on tackling fuel poverty should have local-council input.
Fuel poverty is a health issue. Many people who endure fuel poverty develop ill health, and some of those people die a result of the cold weather. That is only a small example, but it is one that local councils could implement locally, by improving the housing stock and providing grants. Therefore, there is a role for strategic input at both council and local implementation levels.
I agree that councils have a huge role to play, but some are better than others at dealing with such issues. How do we ensure that the programme is delivered evenly across Northern Ireland?
Again, I would look to examples of good work elsewhere. I would not normally hold up England as being somewhere with examples of good public health. However, it has tried not only to have coterminous boundaries with its health and local government structures but to have joint planning. Therefore, local authorities there have a community-planning brief, but they work to that within existing health structures.
Some local authorities appoint a director or head of public health, who is jointly appointed with the local health trust, which, in England, is known as the local primary-care trust. The model is one that we could use, in order to ensure that community planning, for example, were done jointly by the health system and local authorities. That would guarantee accountability, with joint funding and programmes. People would try to ensure that it were evenly spread and that no inequity existed in the work done in Northern Ireland.
You touched on my question. Will the proposal to transfer public-health functions from the boards and trusts to the new RPHA lead to more effective delivery of public-health services for Northern Ireland?
We must examine more closely public-health functions in boards and trusts. Currently, the health boards are involved in commissioning and in providing some public-health and health protection programmes, and they provide some health improvement. The trusts, as the providers, are involved in all three areas. If nothing else, reorganisation should provide some clarity on who commissions and provides the different local and regional services, which may lead to better co-ordination and a more cohesive approach to public health.
Of the three public-health domains that I mentioned earlier, the Health Promotion Agency’s focus is on health improvement. I do not want whatever new system is created to allow the boards’ current public-health functions — service development and health protection — to dominate. That could mean that they take their eye off the ball when it comes to health improvement. However, bringing the functions of the health boards and trusts together in order to match them to local input will be an improvement.
The Deputy Chairperson:
Fewer Committee members than normal are present today, Brian, so that concludes the questions. Thank you for coming; it has been most helpful. The Minister is attending next week’s meeting, and you have given us some questions to put to him.
If Committee members have any further questions, I am happy for them to contact me at the agency, and I will supply information on public-health issues.
The Deputy Chairperson:
When the legislation comes before the Committee next month, we will write to you to request feedback. Thank you.
Thank you very much.