HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Health & Social Care Reform
Institute of Public Health in Ireland )
19 June 2008
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Mrs Claire McGill
Ms Sue Ramsey
Ms Claire Higgins ) Institute of Public Health in Ireland
Dr Jane Wilde )
The Deputy Chairperson (Mrs O’Neill):
Our first evidence session today on the Department of Health, Social Services and Public Safety’s proposals for health and social care reform comes from the Institute of Public Health in Ireland. A copy of the institute’s response to the proposals, its report entitled ‘Towards Healthier Societies’, and a briefing paper from Assembly Research Services can be found in members’ pack.
I welcome Dr Jane Wilde and Ms Claire Higgins. Jane Wilde is the chief executive of the Institute of Public Health in Ireland, and Claire is the public health development officer. I invite you to give a short presentation of approximately 10 minutes. Members will then have the opportunity to ask questions.
Dr Jane Wilde ( Institute of Public Health in Ireland):
First of all, thank you very much indeed for asking us to come and give evidence. We are delighted to be able to come to the Committee, because we think that the proposals are such an important change issue in Northern Ireland. We also think that politicians have a huge role to play in health and social care — particularly in the public-health agenda, which is what we are interested in as an institute of public health.
I will say a few words about us so that the Committee is aware of our perspective. Claire Higgins, who works in the institute with me, leads on our health impact assessment programme. She is particularly interested in looking systematically at how different policies, programmes and projects affect the health of communities, particularly the most vulnerable people in those communities. She worked previously in a local strategy partnership in Antrim and also in the voluntary and community sector.
I am a public-health doctor. I worked in the health system in Northern Ireland, and then I was the founding director of the Health Promotion Agency. Later, I became an executive in establishing the Institute of Public Health, which was set up to promote co-operation between North and South.
We have been asked to say something about the proposals for health and social care reform. There are five main strands to the Minister’s proposals, but I will confine my comments to just three areas: the proposed regional health and social care board; the proposed regional public health agency; and proposals for increased democratisation of the system.
It is important for us to think about whose eyes we are looking through when we examine the proposals. Therefore, I thought that it would be useful to outline the most important issue, which is whether the proposals will make any impact on community health inequalities. That is the whole purpose of the issue. When I talk about health inequalities, I am talking mainly about socio-economic inequalities; in other words, the huge gap between the rich and the poor. Therefore, the first issue is whether the proposals will make a difference.
The second issue is whether the proposals will help to use the mammoth amount of expertise, commitment and experience that exists in Northern Ireland. The third issue is to think about how the Institute of Public Health can contribute, and whether the proposals will allow us to contribute to better health in Northern Ireland.
We welcome the proposals. They provide a way ahead for Northern Ireland. They are radical, but they are sensible and timely, and can be made to work.
With regard to the proposal for a regional health and social care board, the functions of commissioning, financial management and performance management are sensible and rational, and no further functions should be added. There are huge issues with regard to commissioning. We welcome the issue of local commissioning and the role of primary care and others in that. Commissioning should cover the different fields of public health. Therefore, we are talking about how we protect people from infections, and so on, how we help people to improve their health, and how the services that we deliver are directed to, and planned for, the most vulnerable people.
There must be strong links between the board and the proposed regional public health agency, but it is not entirely clear how those links would be taken forward. We have some ideas about how that might happen, but, in the absence of clear proposals, the Committee may have views on the issue.
Our view is that there must be a strong relationship. We would like the proposals for the regional health board to include a requirement that commissioning plans go through the regional public health agency when they are being signed off by the board. Therefore, they should be checked from a public-health perspective.
The proposals have a strong focus on increased democratisation, in particular trying to strengthen the role of local government. Claire has a wealth of experience in that area, and she will say a few words about that.
Ms Claire Higgins ( Institute of Public Health in Ireland):
The institute welcomes calls for closer links with local government and supports that action to strengthen its role in improved public health for communities. There are already good working relationships between local communities and local authorities, and they should be supported and strengthened to help to develop and shape services for improved quality of life.
That could be done by community planning and the power of well-being. That presents an opportunity to create healthier communities and to address health inequalities. It is essential that the regional public health agency is strongly involved in the development of the community planning framework. It is important to ensure that Investing for Health targets for tackling health inequalities are reflected in the planning process, that they complement and build on existing area-based partnerships, such as the Investing for Health teams and the health action zone teams, and that community planning targets should reflect the social determinants of health in all action areas — for example, in transport and education — and not just through health actions.
The institute recommends that community plans are signed off by the regional public health agency. That will ensure that health is adequately addressed in each of the area plans.
Finally, local government is in an excellent position to engage in health impact assessment (HIA), which is a methodology to assess the health impacts of an identified proposal. The institute, with the Department of Health, has led in HIA in Northern Ireland, and the regional public health agency has a key position to support conducting health impact assessments.
The institute has been closely involved in the health impact assessment in the west Tyrone area plan, which is funded by Omagh and Strabane District Councils, and the Western Investing for Health partnership. The assessment will engage with key stakeholders to look at the health impacts of the plan, which will be in place until 2019.
Therefore, HIA presents a way of working that engages local communities, local government and other sectors that need to take into account the impact of their work on health.
The proposed regional public health agency is very dear to our heart. I have been working in public health in Northern Ireland for almost all of my working life. I see this proposed agency as a major opportunity to bring together the different aspects of public health, and to give public health a much stronger voice.
I welcome the proposal to put public health at the centre of these proposals, and I note that the Chairperson of the Committee has welcomed the proposals. I hope that the Committee will feel able to do likewise as this develops.
The functions that are set out are the right functions for the regional public health agency. However, there must be a stronger function relating to research and information. Unless we have good information across a range of issues, it will be very difficult to be sure that we are doing the right thing and in the right way.
The agency must be multi-professional. That means bringing in not just public health doctors like myself, but other members of the health-and-social-care family, as well as economists, behavioural scientists and anthropologists to consider how to shift Northern Ireland’s rather poor health record. I cannot think of any professional group that does not have a role in public health.
The agency must also be multi-sectoral. Public health is not about just the Health Service, as the Committee well knows, but about other areas such as housing, education, agriculture, transport and rurality. This organisation must be outward looking and forward looking. There is here a fantastic opportunity to create in Northern Ireland something that is truly world class.
I have just come from an international event at which Queen’s University, the institute, and the Community Development and Health Network were chosen as one of five centres across the United Kingdom to create a centre of excellence for public health, bringing £5 million into Northern Ireland in order to build capacity. That shows what can be done when we join together: we can beat other people and be not only good but really great.
We are very enthusiastic about the proposals, and we look forward to contributing to making them work. I have not mentioned anything about the institute’s work, but Committee members have copies of our first 10-year report. Rather than talking about the institute’s contribution, I hope that we might come back and say what the institute is doing for public health in Northern Ireland and across the island of Ireland. Thank you very much.
The Deputy Chairperson:
Thank you. The Committee welcomes your enthusiasm for the proposals and the way forward, because we want to make an impact on the community.
How do you visualise the healthy living centres, which you evaluated, fitting into the proposals?
Healthy living centres, and the many other partnerships in Northern Ireland, whether Investing for Health partnerships, community development partnerships, or Healthy Cities partnerships, have a key place with regard to the proposals.
As the term “public health” has become better known, and as action locally has flourished, there is now a range of partnerships. Healthy living centres, for example, have made a big impact locally, as the evaluation states. Partnerships that work should be strengthened, and the proposals not used to leave them behind. We are very keen to see the existing successful partnerships being strengthened, resourced and supported. For too long, partnerships have had to exist with minimal resources. I recently met the Community Development and Health Network; it does not know how much money will be available next year. That is despite that fact that that organisation is a remarkable network that brings community-based organisations together throughout Northern Ireland. We are very keen to see existing successful partnerships being better supported.
The Deputy Chairperson:
With your background in the Health Promotion Agency, you will be aware of its five core aims. Do you think that the proposals will subsume and build on the current role?
That is a good idea. If people work in an organisation, they have a commitment or loyalty to that organisation. They might not want to see organisational shift. However, it is the right way to go because it can strengthen the work that has been done in the Health Promotion Agency by bringing a stronger element of the other aspects of public health — the health protection aspect, for example, which provides protection against infectious diseases. It also has a stronger role in ensuring that the services that are commissioned throughout Northern Ireland have a strong public health function. Including those considerations will be very important in strengthening the role of the work that the agency does.
The Institute of Public Health has had a very strong role in health intelligence — the information side of things; forecasting new conditions; and evaluation, as you mentioned. We can continue to bring that to the new public health agency, but we will do that from a slightly external perspective because of our North/South links.
I thank Jane and Claire for coming to the Committee today. There is no doubt that these changes will be challenging for the Department, the Committee and to folk like you with regard to the delivery of better health provision right across Northern Ireland.
What input did you have into the development of the Minister’s proposals for the restructuring of the Health Service? Community planning and well-being were mentioned. You also talked about the West Tyrone area plan and the work that was done with various stakeholders between Omagh District Council and Strabane District Council. Do you think that the joined-up working between the key policy stakeholders will provide a better, improved service right across Northern Ireland?
You also spoke about the good partnerships that are already in existence and about how those need to be strengthened as they are currently underfunded. Do you see the new proposals strengthening or having a detrimental effect on those good partnerships?
Claire will comment on the community-planning side of things, and then I will cover some of the inter-sectoral issues and answer some of the questions about how we have been involved.
We have been working in partnership with the Community Development Health Network, the Northern Ireland Council for Voluntary Action (NICVA) and the Health Promotion Agency to draw up a briefing paper for what politicians should look to include in community planning. There are 10 action points, and those should be assessed against community plans so that health inequalities can be addressed through community plans. That is a piece of work that we have started, and we will approach political parties in the autumn. Hopefully, that will filter down to communities.
The new proposals should strengthen the partnerships that are in operation. Using the example of community planning, the Investing for Health teams developed a wealth of resources, including baseline health statistics. All of that information needs to be included in community planning. The process should strengthen the partnerships that are in existence.
I will pick up on a couple of other points that were mentioned, such as how we have been involved. Like others, we responded to the consultation. Because we are primarily funded by the two Health Departments, North and South, we also have good relationships with the Chief Medical Officer’s office, for example. We have had an input into the thinking about public health, and we have had a good chance to put our views forward and hope to continue to do so as the process rolls out.
New functions that have been proposed for the regional public health agency include a stronger role in resourcing and help to support local government in public health. It is important that funding goes to the new agency for that function. The proposals are scripted in such a way that all the money goes through the new regional health and social care board, which will be the main funders of the system. However, I think that some money should go directly from the Department of Health to the new regional public health agency to protect the idea of public health and health improvement, because, for understandable reasons, it generally gets a low priority compared to acute services. Therefore, it is important that a strand of money goes directly from the Department of Health to the regional public health agency. I hope that I have answered some of your questions.
Yes, you have covered most of the questions.
I will be happy to follow up any questions that I have not answered.
Thank you for coming before us. The issue is of great interest to me, because I have been working in the Health Service for years. It is potentially a very exciting time if we get it right. Rather than waiting for disease to occur and then trying to prevent it, the focus will be on health promotion and disease prevention, as well as a link up with other areas, such as local government, community groups and leisure centres, walkways, cycleways and even mental health. There should be facilities for people, both young and old, living in rural communities who are isolated and lonely. Such facilities would help to prevent ill health.
How big will the regional public health agency be? You mentioned that the agency should have a say before services are commissioned, but that worries me. Are you saying that it should have a commissioning role, or are you saying that it should have a veto?
I have asked the following question before, but I have never been given a clear answer to it. I know Dr Brian Gaffney well, for example. There is a major role in public-health promotion, but how many people will be employed by the regional public health agency? Should they not be part of the regional health and social care board?
I will be celebrating an anniversary tomorrow — I will be 28 years qualified — and I have worked in the Health Service for more than 25 years. Over the years, I have seen many great ideas get bogged down in bureaucracy. What worries me is that there will be lots of wonderful ideas, but there will be another huge agency that will be separate from the five local commissioning groups. For instance, the Western Health and Social Care Trust has four tiers of management. New bodies always have fancy, great ideas, great strategies and protocols, but it is different on the ground. I do not want my hopes being built up for the future. We cannot afford to build up people’s hopes nor can we afford duplication, with people trampling on one another’s toes.
I do not want to get into competition over how long people have been qualified. In many ways, I have total empathy with the points that you make. The overall point that I would make is that you do not run systems, which is what we are really talking about here, by deciding what organisations you are going to have; you do it by deciding how those organisations link up, what kind of relationships people have and what kind of processes you build up.
With regard to your points about bureaucracy and waste, and so on, when the four boards are scrapped and trusts are more streamlined, the proposals will ultimately reduce the number of organisations, rather than create more. The issues are the relationships between the Department of Health, the board, the agency and the trusts. The practitioners will feed in through those organisations.
As I understand it, commissioning will be done by the board, but it will need public-health advice, and that advice should be provided by the public health agency. There must be a contractual relationship between the expertise of the public-health agency and the needs and requirements of the board. I am not sure how that might best be done; some of the staff of the agency will have to either be seconded, or have joint appointments, or it may all be a matter of grace and favour. That causes a few complexities in regard to how those different organisations are governed, but a lot will depend on the senior leadership in the board and of the public health agency, because if those two organisations do not work in a streamlined and sensible way, any contract that is put in place will be inappropriate.
I actually think there is a need for some tension between the health and care system and the public-health system. Public health is all about the organised efforts of society, but if I go to see a GP or a nurse I want the very best for me. There is a healthy tension between what we do overall in society and what each individual practitioner is going to do. I do not think that everyone is going to agree about every detail of the system, but that is OK.
I have an issue with the number of people that will be employed by the proposed agencies.
To be honest, I am not actually sure how many people are being proposed.
A staff of 200 is mentioned for one of the bodies.
I do remember a figure of 400 staff for the regional health and social care board. I have a vague notion of that, but I would have to check — I cannot remember.
I cannot understand the numbers. For example, there will be 16 staff in each of the local commissioning groups, making a total of 80, and then there will be 400 staff in the regional board; it seems an awful lot, never mind those in the Health Department in Belfast. That is my worry.
It would be very useful if the Committee considered the issue of the actual breakdown of staff in those organisations. I do not have any inside information about that.
Jane, Claire, you are very welcome. I have some of the same concerns as Kieran, even though I do feel that it is a very exciting time. In all the time that I have been on the Health Committee since 1998, this is the first time that I have heard public health being talked up, from the Chief Medical Officer down. There does seem to be more of a focus on that, which is very welcome.
The setting up of those two bodies does seem to be quite complex. In one way, it is good to have a separate public-health body, as long as it actually has a clear role. The arrangements certainly cannot be voluntary; there must be statutory partnerships and links established. The proposals do need to be checked out; in fact every proposal that will involve so many staff should be checked out. We do not want to be overly bureaucratic. That problem has arisen with so much of our legislation, such as equality legislation, and we must ensure that it does not become a box-ticking exercise, but genuinely does make a difference. That is particularly the case with regard to local government — the Minister has said that he plans to have local elected representatives on the proposed new bodies.
We want to ensure that the proposals actually do make a difference this time, particularly regarding health inequalities. They must tackle the challenging lifestyles and make a difference to the people who most need help, for they are the very same people who suffer from the health inequalities. If we do not make a difference on those issues, we are really not making a difference at all.
The Committee must tease out from the Department exactly how the proposals are going to work. We must look at the family tree of each of the proposed organisations to ascertain who is in it, what are they doing, and where they are making links with other organisations. At the end of the day, the whole idea of the review is to make the system better for patients. Early intervention and prevention must be at the heart of that. There is a lot of work to be done, and we in the Committee must work with the Department to tease out the details. Otherwise the proof of the pudding will be in the eating, and it may be too late then. We must ensure that statutory links are established between the relevant organisations. It cannot be the case that there will only be links between the bodies if someone feels like consulting.
It would be terrible to set up an organisation, such as a public health agency, but give it no power or influence. That would be a waste of money.
The patients and people must be kept in mind.
The community must also be kept in mind. I am glad that you raised the issue of health inequalities, because it is at the core of public health. In comparison with other countries, it is socio-economic inequalities that hold back Northern Ireland. As well as the terrible suffering, the loss of life and the impact on individuals, society and the economy, socio-economic inequalities stop us from having better health and being able to be proud of that
That is why it is so important to have the health action zones.
We know the importance of early intervention and see it in primary care all the time. For example, if older people require a physiotherapist or an occupational therapist, they need that service immediately, not in six months’ times. Early intervention in such cases can keep people out of acute beds in a hospital, but it does not happen. We must try to change that.
It is also important that community needs are addressed locally. That way, people can plan and manage their own healthcare organisations and health.
I thank you for the presentation, you are both welcome.
Claire, you mentioned the partnerships and referred to the Western Health Action Zone and Western Investing for Health and the relationship between those bodies and the councils. I declare an interest as a member of Strabane District Council, and it was great that you used my area as an example. I endorse what you said — I am well aware of the good work that is done in that area.
Strabane District Council recently received a presentation from a group of dentists who were very keen to be represented on the commissioning groups. In your submission, you state that you want a range of bodies and professions to be represented. I want to put on record that the council received that presentation and that I am passing on what was said, which concurs with the points that you made.
You said that the role of councillors and elected members on the commissioning groups has not been established and requires clarification. What should the role of elected members be on those commissioning groups?
We would very much like to see elected representatives to be on all these groups, which is what the Minister has proposed. However, we do not know how the membership of the groups will be chosen, so we do not really have a view on that. We hope that the Committee will help us decide.
The commissioning groups will be made up of 16 members — what would be an adequate number of elected members on a commissioning group? I ask that because the number of councillors in council areas varies, and the change in the structure of local government will also have an impact.
The Deputy Chairperson:
What do you think?
I have already declared an interest, so I cannot comment.
I do not know. Although we support the proposal for elected representatives on commissioning groups, it is important that membership also includes people from the local communities. I recognise the local role of councillors, but we do not want the number of elected representatives to be at the expense of local people. However, that does not answer your question.
Geographical spread is important in choosing the number of elected members on commissioning groups.
That is absolutely correct. Geographical spread, how people will be chosen, whether those people will be independent, and how the system will work are all issues that have to be considered. However, that is part of what is needed in public health — more democracy, community participation and political thwack.
Will an elected member sitting on a commissioning group be independent? I ask that question because that individual has been elected to represent a particular geographic area.
This is not the only area where these issues are being debated — they apply to all sectors.
The Deputy Chairperson:
Many of the questions that have been asked will be relevant in the upcoming evidence session with NILGA.
It is important that the health systems either side of the border learn from each other. Indeed, the Committee for Health, Social Services and Public Safety has already met its Southern counterpart. Where does the Institute of Public Health in Ireland fit in, particularly regarding the regional public health agency?
I have not discussed what we do in any detail, and I would love to come back and do that at some stage. There are three areas in which we can help to strengthen public health in Northern Ireland. First, the same public-health issues and challenges are faced throughout the island. I did not elaborate on those because the Committee is already well aware of those. The health systems, North and South, can meet those challenges by sharing resources, where appropriate — for example, media resources, skills and expertise, and so on.
Secondly, things are done differently, North and South. There is, therefore, an opportunity to learn from that and to lever. The smoking ban is a good example of that; its introduction in the South helped us in Northern Ireland realise that it could work here too.
The third issue is about people crossing the border for treatment. The border should not undermine anyone’s health. If people in the North need to access services that are available in the South, the necessary arrangements should be made to make that possible, and vice versa. That would benefit people here and in the South.
The Institute of Public Health in Ireland essentially works in three areas. Research and information is one area. There is a lot that I could say about that, but this is not moment. The second area is capacity building, including training, sharing programmes, and health impact assessment, which Claire Higgins mentioned. The third area of work concerns policy and policy advice. We have a lot to learn from each other, and also from outside Ireland.
The proposals provide an opportunity for the Institute of Public Health to help with the new arrangements in Northern Ireland. The institute has strong academic links. We ensure that the research carried out is appropriate and addresses the relevant matters and that the results are well communicated.
The Deputy Chairperson:
Thank you very much. I appreciate that today’s session has been very much focused on the RPA. Therefore, we will invite you back another day to discuss your specific role in further detail.
The relevant legislation will probably be proposed in the next few weeks, so you can come back to us over the summer with any comments that you wish to make on that.
We will be delighted to follow that up; thank you very much for giving us the opportunity to do so.