NORTHERN IRELAND ASSEMBLY
COMMITTEE FOR HEALTH,
SOCIAL SERVICES
AND PUBLIC SAFETY
Public Health Issues
14 June 2007
Reply from the Minister for Health Social Services and Public Safety to issues raised 14 June 07
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mrs Carmel Hanna
Witnesses:
Dr Margaret Boyle Senior Medical Officer
Dr Michael McBride Chief Medical Officer
The Chairperson of the Committee for Health, Social Services and Public Safety (Mrs I Robinson):
I welcome Dr McBride, who will make a 10-minute presentation on public health issues. After that, Committee members may ask relevant questions. Dr McBride, may I ask the name of the lady sitting at your right-hand side?
Dr Michael McBride (Chief Medical Officer):
This is Dr Margaret Boyle who is a senior medical officer.
The Chairperson:
Welcome, Dr Boyle. I am sorry that the Committee did not know that you would be attending the meeting. Had it been known, a proper nameplate would have been made for you. However, I am sure that you will remember your name.
Dr McBride:
I thank the Chairperson and the Committee for the opportunity to present my first annual report as Chief Medical Officer for Northern Ireland. The role of the Chief Medical Officer is to state the health of the population and to advise Government and Ministers on measures to safeguard it. I hope the Committee received an advance copy of my report, which is embargoed until 20 June 2007. At that time, the report will be launched at a primary school in north Belfast.
The format of this year’s report is different, and there is a rationale for that. This year, the report will be published in magazine format, and approximately 200,000 copies will be distributed through local newspapers, GP surgeries and hospital outpatient departments. By doing so, it is hoped that the contents of the report will be brought to as many people and as many homes as possible.
A number of vital messages must be delivered if preventable ill health in Northern Ireland is to be avoided. We all need to take greater responsibility for our health. Public awareness of the importance of lifestyle changes and the associated health benefits must be raised, which can only be achieved by empowering individuals and communities to have real choice through meaningful engagement and partnership working at all levels.
I have sought, in particular, to highlight obesity. The rates are rising at a dramatic level: they have tripled over the past 20 years. After smoking, poor diet is the most significant contributory factor to poor health in Northern Ireland. It is alarming that 20% of our primary-school children are overweight or obese. Two thirds of men, and over half of women, are either obese or overweight. It is well known that obesity significantly increases the risks of heart disease, diabetes, stroke, cancer and osteoarthritis.
Obesity claims about 450 lives each year. Apart from the human costs associated with obesity, it is estimated that the Department of Health, Social Services and Public Safety could save £200 million over the next 20 years by halting its rise. UK research indicates that communities in greatest need face particular challenges in accessing good quality affordable healthy food. It is a fact that obesity is more common in adults and children in poorer communities.
Last year, the Ministerial Group on Public Health (MGPH) established a cross-departmental task force, which produced the report, ‘Fit Futures: Focus on Food, Activity and Young People’, to encourage healthy living, healthy eating, active lifestyles, and discourage an overemphasis on body image. Following a public consultation exercise, the Fit Futures implementation plan is being reviewed, and the results will be finalised shortly.
There is a lot of work ongoing. Health and social services boards are working through Investing in Health partnerships and there is a wide range of programmes ongoing: healthy breaks in schools; support for active play; dance, and walking programmes. There is active training and guidance for parents in skills such as cooking, particularly for those in the most deprived areas,
Under the children’s and young people’s element of the extended schools programme, £10 million is available each year from 2006 to 2008 for schools to extend that programme to include healthy lifestyles and tackle childhood obesity. As part of the Sport in Our Community programme, Sport Northern Ireland — formerly the Sports Council for Northern Ireland — is making a major investment to encourage more children to develop the basic physical movement skills to facilitate sustained involvement in sport and a healthy and active life.
More recently, there have been major advances in tackling smoking since the introduction of the ban. However, smoking continues to be of significant concern, and now is the time to redouble our efforts to deal with the scourge of tobacco smoking, which is responsible for approximately 2,300 deaths each year and much ill health. Those ill-health effects are not limited to those who smoke; people who inhale second-hand smoke have a 30% increased risk of developing lung and heart diseases.
The introduction of smoke-free legislation, which the public unanimously accepted, was a major step forward, and everyone involved must be congratulated. Not only is it a step forward for non-smokers, but it has significantly encouraged greater numbers of people to indicate their preparedness to give up smoking. However, we cannot be complacent. There are 350,000 smokers in Northern Ireland, and smoking is a significant cause of health inequalities. If someone is poor they are more likely to smoke, and that has a disproportionate impact on their health.
Northern Ireland has the second highest percentage of 13-year-olds in Europe who smoke. Therefore, more must be done to help smokers to stop and to prevent children and young people from starting. A positive step would be to consider raising the age at which tobacco products could be sold to 18.
People are all too aware of the problems with alcohol in society. In the past 10 years, alcohol-related deaths in Northern Ireland have doubled, and binge drinking is now more common. In Northern Ireland, there is an unhealthy attitude towards alcohol consumption. A recent population survey showed that half of men and a third of women admitted to binge drinking on at least one occasion in the preceding week. Binge drinking is more common among young people. Not only do they put themselves at risk due to the short-term effects of alcohol, such as accidents, alcohol poisoning and antisocial behaviour; they are more susceptible to the longer-term effects, such as liver and brain damage, developing cancer, depression, alcoholism and family problems. We estimate that there are 15,000 to 20,000 problem drinkers in Northern Ireland. In real terms, alcohol has never been more affordable in the UK. The case for increased taxation must be re-examined to gauge its effect on addressing the problem of binge drinking.
I have also sought to highlight the issue of sexually transmitted infections. They are increasing at a dramatic rate, with just below 13,000 new diagnoses last year of all sexually transmitted infections, including HIV. That represents a 100% increase over the past ten years. It is important that people have access to information and services to enable them to make informed choices and avoid risky behaviour. We have a five-year sexual health promotion strategy and action plan, which will be published this autumn. It is time for people in Northern Ireland to begin to talk about, and develop, a healthier attitude to sex, and for access to information for young people to be more readily available.
I particularly wish to highlight the issue of suicide. Suicide rates in Northern Ireland and across the world are increasing, and have been doing so for the past 20 to 30 years. In relative terms across Europe, Northern Ireland does not have a high suicide rate, and it is lower than in Scotland. Nonetheless, after cardiovascular disease and cancer, suicide is now the third biggest cause of years of life lost. There were 291 deaths by suicide in 2006 — almost double the average in 2004, and behind each statistic is a real personal and family tragedy.
Committee members will be familiar with our response to the issue — the suicide prevention strategy, which was published on 30 October 2006. In that strategy, over 60 actions are recommended, and there is an annual budget of £3 million. There have been number of successful pilot schemes including a self-harm mentoring scheme in the north-west, a 24/7 telephone helpline and other schemes throughout Belfast. A substantial proportion of the funding is being targeted to help local communities develop initiatives that will support the implementation of the strategy.
We are rolling out a depression-and-suicide-awareness training programme for GPs across Northern Ireland, and almost 170 GPs have been trained. We have launched a major mental-health awareness public information campaign, which has been aired on TV and radio and across the border. A cross-sector suicide strategy implementation body with a significant representation from the families forum for relatives of those bereaved by suicide has been set up. The families forum has been influential in helping to determine much of this strategy development.
Much more must be done, and the wider ‘Promoting Mental Health Strategy and Action Plan 2003–2008’ and the Bamford Review must be taken forward in tandem. Although crisis intervention is important for suicide prevention, we must equally begin to concentrate on the causes in communities that lead young people to take their lives in such a way.
In general, the health and life expectancy of people in Northern Ireland has been improving in recent years. However, not everyone has experienced that improvement. In Northern Ireland, where one is born has always mattered, and it still matters when it comes to how long one lives. There is a definite link between poverty and ill health. Those in our community who live in the most deprived areas have the poorest health and die earliest.
The health experience of those living in the 20% most deprived electoral wards shows that men die four years earlier, and women two years earlier, than the Northern Ireland average. The gap is seven years for men in the most deprived areas, compared to the most well off in our society.
Those living in the most disadvantaged areas suffer significantly higher rates of premature death. They have a 40% greater chance of dying before the age of 75. Suicide rates, as I have mentioned, are higher, as are admission rates to hospital services. Deaths of infants under one year of age are 30% higher. In the Travelling community, the gap is even starker. There are 2,500 people in that community in Northern Ireland. Their life expectancy rate is 20% lower and they die 15 years earlier than the Northern Ireland average. The death rate of their children under 10 years of age is 10 times higher than that for Northern Ireland as a whole.
We have the worst dental health in the UK. Dental health is much worse for children in poorer and more deprived areas, and they have almost twice the level of tooth decay when compared with children from the most affluent areas. We urgently need to revisit a population-based approach to improving the poor dental health of our population, particularly of our children.
It would be a significant improvement if the life expectancy and health of those living in the most deprived electoral wards could be increased to the Northern Ireland average. However, that is undoubtedly a major challenge, and not something that we in the health sector can address alone. Input from all in society is required; everyone needs to take some responsibility for their own health. However, there also needs to be cross-departmental support for initiatives aimed at supporting and improving health and well-being across Northern Ireland.
The Investing for Health strategy is now at its midpoint and will be reviewed next year. The strategy was launched in March 2002. It was developed by all Government Departments through the MGPH and was endorsed by all Ministers of the former Executive. It is still regarded as being at the forefront of public health strategies. The strategy aims to address the broad determinants that impact on health and well-being. It contains a framework for action, and, for the first time, included a wide range of agencies and stakeholders to work in co-operation and collaboration to address health inequalities and improve health and well-being.
Investing for Health partnerships have been established in each of the four Health and Social Services Board areas and have developed health improvement plans with local communities. In line with the strategy, a number of cross-departmental strategies and action plans have been developed. I have mentioned one — the Fit Futures action plan — but there is also the Home Accident Prevention plan. Other areas being worked on include mental-health awareness promotion, childhood obesity, sexual health, tobacco and teenage parenthood.
The strategy has produced results, good work, and partnership working. It is a 10-year strategy and it may be a number of years before its impact will show measurable change in areas such as life expectancy and premature death. However, I suggest that the midpoint review will provide an opportunity for the Executive to take stock and to reaffirm its commitment to working together, and with others, to improve the health and well-being of the whole population of Northern Ireland.
Public health in Northern Ireland is getting better but the health gains have not been equally experienced by all. There is much more work to be done, particularly for those living in the most deprived areas. The adoption of changing lifestyles by many in our society is a major challenge. The trends in obesity must be reversed; the numbers of people who smoke must be reduced, and more must be done to get people to take a more responsible attitude to alcohol consumption and to tackle the increasing numbers of people who are acquiring sexually transmitted infections.
I conclude by saying that the aim of this year’s report is to continue to seek to raise awareness among, and engagement of, the wider public in those important public-health issues. People must be supported in making positive lifestyle changes, which will result in improved health and life expectancy for them and their children. Prevention is still better than cure, and that must be a key pillar of the public health strategy.
Much cannot be tackled by the health sector alone. There needs to be a commitment from Government Departments to address many of the contributing factors. To help support health protection and prevention initiatives, a change in the pattern of spending is needed — moving resources upstream from the acute sector into prevention.
I thank Members for their attention and for the opportunity to speak to the Committee. I am happy to answer questions on any of the aspects that I have covered.
The Chairperson:
Thank you for that very detailed presentation. Before members begin to ask questions, I want to address some issues that are close to my heart — I may need a soapbox. For example, sexually-transmitted infections: in Westminster I have often tried to obtain figures for the rates of sexual activity among young people before and after the morning-after pill was introduced through schools and pharmacies. That was to ascertain whether the number of young people who were sexually active was on the increase because the morning-after pill was available. Given that young people are becoming sexually active at a younger age, is there a knock-on effect with diseases being transmitted more freely? Is the morning-after pill having a positive or detrimental effect on the spread of sexually-transmitted infections?
Dr McBride:
It is a fact that young people are having sexual relationships at an earlier age. The reasons for that are complex and reflect trends in other European countries. I do not know of any evidence-base for a relationship between the availability of post-coital contraception and the lowering of the age of first sexual experiences. It is a complex set of interactions.
However, it is incumbent on us all to ensure that we give information to parents and to those at home and at school so that children can make informed choices and do not feel pressurised by their peers. Young people can then decide for themselves, after discussion with parents or other adults if they wish, whether they want to engage in sexual relationships at any particular time.
Society must have a more mature dialogue about sexual activity. It should assert the positive aspects of a mature and healthy sexual relationship while warning that unprotected sex carries the risk of sexually-transmitted infections, which can have very significant long-term sequelae, particularly for young women.
The Chairperson:
How much emphasis is being placed on educating young people? Children are being spoken to about the issue in school at an increasingly earlier age. Is anything being done to balance the pressure on young people to have sex, with information that abstinence is the better way to look after their bodies? Much of the problem comes from peer pressure and children boasting about what they have done. Is money being spent on educating children not to consider sexual activity and that there is no shame in total abstinence?
Dr McBride:
Many programmes are ongoing in the various board areas. I launched a programme in the Southern Board area several months ago that provides online advice and information for young people about sexually transmitted infections and making informed choices about sexual activity.
In the autumn, the Department will be launching its five-year sexual health strategy, which will look at the issue you have raised. The aim is to improve and promote appropriate decision-making about engaging in sexual activity. It is there to advise and inform.
You are right that information is key, and in the absence of information other factors influence the decisions of young people — peer pressure is a particularly important one. Equally, it is important for parents, and I speak as one, to become more comfortable with discussion about sexual activity in the home.
Culturally, in Northern Ireland, we do not feel comfortable having such conversations, and that is something that needs to be addressed.
The Chairperson:
Finally, I do not wish to monopolise the questions, but these are two specific issues that I have been highlighting for a long time. As you said, the incidences of suicide are spiralling, and it is a very worrying to see so many young people taking the option of death rather than life. The statistics are horrendous. Are you aware that yesterday eight people from the Shankill Road area attempted to kill themselves? You will surely agree that that is horrendous, considering that it is only one small area of the Province.
Do you agree that, although £3 million has been allocated to the suicide prevention strategy — and we can throw money at pilots and at community groups who are trying to pick up the pieces for friends and families who have lost loved ones — it is most important that we address the lack of psychiatric nurses and ask what is being done to encourage nursing staff to go into that area in their profession? The numbers of psychiatrists and psychologists are also well down.
This issue has been flagged up for many years, and yet we still seem to be at a low ebb when it comes to dealing with the horrendous practice of young people taking their own lives. Would you like to comment on the need for more professional and nursing care — as well as child and adolescent beds, which are few and far between — to deal with bullying, anorexia, and all the issues that can trigger children spiralling into a world in which life is not worth living, and in which it is easy to kill oneself?
Dr McBride:
I am happy to comment on those areas. It must be borne in mind that service provision is vitally important, and I do not think any of us would say that the level of mental-health service provision is as we would wish it, hence the significant resources that we are going to commit to taking forward and implementing the recommendations of the Bamford Review.
Medical and nursing workforce planning is not a precise science, and there have been significant lags in the availability of medical and nursing staff in a number of specialities across the UK as a result of the unpredictability of future service demands. We are making, and will continue to make, a significant investment in additional psychiatrists and those working in mental health and nursing, and in some of the other healthcare professionals in that area.
However, as I said at the beginning, that is only one element in dealing with the suicide and the increasing number of deaths from suicide in Northern Ireland. We must begin to focus on the upstream causes of why young people determine to take their own lives. That focus is not confined to the health services alone, and we cannot expect them to tackle it. We need to look at the wider societal causes of why suicide happens. As with sexual health, a significant element of the 2007-08 funding for the suicide prevention strategy is being allocated for research in order to understand why young people decide to take their lives.
With suicide, we know that men predominate; there is a strong association with socio-economic deprivation, and that there are problem areas in north and west Belfast, Upper Bann, Fermanagh and South Tyrone, but we need to understand the causes. We have reviewed a significant amount of literature on the effects of the troubles. Professor Mike Tomlinson of Queen’s University Belfast has contributed a significant piece of work. There are undoubtedly huge consequences for a society emerging from conflict, which has been a major contributing factor. We will be working with Professor Bob Stout in the R&D office this year to commission and agree a research basis in order to understand, as you rightly said, why this is happening and what we can do about it.
If it is not to be helplines, then what measures can we target resources at to make the difference and prevent young people from taking their lives? It is a worldwide problem, and we need to understand why young people across the world feel that they have no other option.
The Chairperson:
We could discuss the issue all day. I apologise for taking up so much time. I suggest that the Committee meet the north and west Belfast groups with which the Minister has already been in touch. We could also hear evidence from a psychiatrist, who could give us some insight into dealing with suicide victims and self-harmers, which would give us a clear picture of why people do not want to enter the profession. Often, beds are simply not available, and doctors feel demoralised because they cannot provide the services that young people so desperately need. I will go no further.
Dr McBride:
I urge the Committee to consider the Promoting Mental Health strategy as an important element in tackling this problem. We do not want people reaching the point where they need to access services. We want to ensure that society actively promotes good mental health to prevent people getting to that stage. It is important to deal with the downstream consequences, but, equally, we must redouble our efforts to ensure that we deal with the causes too.
The Chairperson:
So many factors are involved, including Internet websites, and they must be explored further.
Mr Easton:
I thank Dr McBride for his presentation. I have three quick questions.
First, the Health (Miscellaneous Provisions) Bill, which the Committee will examine, contains a provision to allow actors to smoke on stage. It is a total nonsense and will become a loophole in the law. Should that provision be removed from the Bill?
Secondly, we talked about alcohol abuse. Should the legal age for purchasing alcohol be increased to 21?
Finally, should fluoride be added to the water supply? If so, how can we dispel many people’s fears that fluoride can cause brittle bones? My mother has a phobia about that.
Dr McBride:
We must bear in mind that the smoking legislation that was introduced on 30 April is designed to protect the health of the public, and I will answer the question in that context. I do not see that the exemption, as currently proposed, offers any public-health benefit. In fact, should it be retained in the Bill, I can see significant disadvantages for public health for the actors involved in performances and for the audience, and with the message it sends to the wider public. From a public-health perspective, which is the only perspective from which I, as Chief Medical Officer, can comment, I could not support the introduction of such a provision.
As regards alcohol, we must look at the evidence base when considering what measures work to reduce consumption, particularly among young people and binge drinkers. International evidence shows that young people’s drinking is very price-sensitive and that seems to be the case across the world. Research published in New Zealand shows that the price of alcohol is the largest determinant of whether or not young people buy it. Interestingly, that is also the case with cigarette smoking. Taxation and the price of alcohol have the most significant impact on young people’s alcohol consumption. That issue should be revisited across the UK.
Like everyone else, I am struck by how the poorest in our community are disproportionately affected by poor dental health.
Northern Ireland has the worst record of dental health in the UK and compares poorly to the Republic of Ireland, which has one of the best records in Europe. As members may know, the Republic of Ireland introduced an extensive fluoridation programme in the 1960s, and, as I said in my presentation, Northern Ireland urgently needs to consider such population-based approaches to improving dental health. There are anxieties about fluoridation, and we must understand those concerns. However, evidence must be examined and presented that will, it is to be hoped, reassure the public. Informed public discussion and debate is needed. For example, concerns have been raised about fluoridation’s connection to osteoporosis and osteosarcoma, but the evidence base for that association is not strong.
The Chairperson:
Have your questions been answered satisfactorily?
Mr Easton:
Yes.
Mrs O’Neill:
The Chief Medical Officer’s report states that the Investing for Health strategy appears to be in danger of failing to achieve its two central targets for defining a policy to reduce health inequality. Which targets have not been met, and by which Departments? Are you concerned that the review will not take place until next year? Should not the date of the review be brought forward in light of what the report says?
Dr McBride:
That is a good question. With any 10-year strategy, there is always a need to take stock at some point to determine whether progress is being made quickly and early enough and whether a change of direction is required. The Investing for Health strategy’s strength lay is the fact that it was ours. It was developed by all Departments in the previous Executive and had cross-party and cross-departmental support. To reaffirm such a broad-based approach to improving public health in Northern Ireland is important, and buy-in by all Ministers, the Committee and the Assembly will be vital. Only if everyone works together in a cross-governmental and cross-sectoral capacity can the strategy’s aims be achieved.
Significant improvements have been made in life expectancy during the first half of the strategy term. Life expectancy has improved by 5·1 years for men and by 4·8 years for women from 2002 to date. The Department of Health, Social Services and Public Safety has not achieved those improvements alone. Other Departments’ contributions include the Office of the First Minister and the Deputy First Minister’s anti-poverty strategy and the Department for Social Development’s urban regeneration strategy, as well as work that the Department of Education and the Department of Culture, Arts and Leisure have undertaken.
Regrettably, improvement in life expectancy for the poorest in our society has not been as good. If one compares the average life-expectancy figures for men that I have just quoted with those for the 20% most deprived electoral wards, the difference between the former and the latter in 2001 was 3·9 years. The current gap is 3·8 years. Therefore there has been little improvement. The figures are slightly more favourable for women in the 20% most deprived wards, where the difference has improved from 2·7 years to 2·3 years. Gains have certainly been made, although the gap still exists for those who live in most deprivation. When the Investing for Health strategy is being reviewed next year, it will be important, as Mrs O’Neill has suggested, that we concentrate on the areas in which we have not been as successful as we should have been.
Mrs O’Neill:
How frequently has the ministerial group on public health (MGPH) met during the past four years?
Dr McBride:
I do not have the exact figures, as I have been in the job only eight months. During that time, the MGPH has met twice. I can provide a written response to the Committee on the number of times that the group has met over the past four years.
Mrs O’Neill:
It strikes me that if little change has been witnessed in the poorest communities, the review must happen sooner than next year.
In the context of the drugs and alcohol strategy, what do you think of the deregulation of off-sales, Dr McBride? What is your opinion on a complete ban on the advertising of alcohol?
Dr McBride:
Significant restrictions have been placed on the advertising of alcohol. Those restrictions are entirely appropriate. As part of the approach to dealing with obesity, similar restrictions have been placed on the advertising of certain food products for children. It is important to monitor advertising and limit its effects.
The links between the deregulation of off-sales and the alteration of opening hours at bars and leisure facilities that sell alcohol are complex. Evidence suggests that the consequences associated with increased access to alcohol are offset by the benefits of longer opening hours, taking into account the wider impact on society of alcohol and drinking to excess. The drinking culture in Northern Ireland is such that at last orders, drinkers buy three pints rather than one. There is a complex interaction of factors, and the evidence, one way or the other, is not convincing.
My interpretation of the evidence leads me to suggest that, in order to encourage healthier attitudes to alcohol consumption, we must look to taxation. From 1980 to 2003, the relative cost of alcohol across the UK rose by 24%. In the same period, however, relative income rose significantly more. Therefore, in relative terms, alcohol is 54% cheaper now than it was in 1980. Successive Budgets have not significant increased the tax on alcohol. As I said earlier, there is evidence of a close relationship between the cost of alcohol, of which taxation is an element, and sales, particularly to young people. I suggest to the Committee that it would be productive to explore that avenue.
Mrs Hanna:
The delegation is most welcome. I appreciate the focus on promoting good health and good mental health. As Michelle has spoken about health inequalities, I will not dwell on that area. However, we all know that that section of the Investing for Health strategy contains the real challenge.
You spoke of the importance of cross-departmental working Dr McBride. The Committee had begun to initiate such working in the first mandate. Now that the Assembly is up and running again, I hope that that cross-departmental working can be improved.
In considering the problems of young people and the suicide rate, it is obvious that if more jobs were available for them, and young people each had a stake in society, it would do so much to help.
Another important group to consider is young people who suffer from learning disabilities. When they leave full-time education, they are faced with a real gap in services. Everyone to who we talk tells us that. The Bamford Review has highlighted that issue, and it must be addressed.
Dr McBride:
I agree.
Mrs Hanna:
Alcohol abuse has been mentioned, along with society’s funny and unfortunate relationship with, and attitude to, alcohol, particularly in Ireland. I respect the opinion that increased taxation might be the way in which to deal with those problems. Those people who drink one glass of wine each day might consider it to be an unfortunate measure, but it might help those who abuse alcohol. We must think seriously about what to do.
We should perhaps consider — as is being done in the Republic of Ireland — the possibility of stronger legislation and stricter enforcement of the rules for publicans and people who sell alcohol to, for example, underage customers or those people who are obviously already drunk. We must consider that approach, especially if local government is to become more involved in licensing.
I agree with Alex Easton’s comments about the smoking exemption. It is rubbish to consider allowing people to have lit cigarettes on stage. That is a silly excuse, because there are plenty of props available that could be used instead. However, that issue will be debated in the Chamber next week during the Second Stage of the Health (Miscellaneous Provisions) Bill.
I accept that condoms protect against sexually transmitted infections and prevent pregnancies. However, to encourage people to have a limited number of partners and promote loving relationships, there must be a greater focus on education. Love for Life and other organisations deliver programmes in schools, but I worry that the Department’s strategy concentrates on practical matters, with little focus on education. Both of those elements are required, but there must be a better balance.
I am sure that Dr McBride is right to advocate fluoridation as a means of reducing tooth decay.
Dr McBride:
Did I advocate that?
Mrs Hanna:
I got that impression.
The lack of National Health Service dentists has reached crisis point. I hope that the Department will remedy that situation. Currently, there is no motivation for dentists to carry out NHS work and, as a result, they only fulfil basic dental work. There is no decent dental-health promotion, which is particularly worrying when we consider young people. Part of the problem that contributes to bad teeth is that young people do not get enough fluoride, but poor dental health, challenging lifestyles, poor diets and too much sugar are also contributory factors. I realise I that have made comments rather than asked questions.
The Chairperson:
Do you have a question?
Mrs Hanna:
I would like Dr McBride to respond to my assertion that more NHS dentists are required. They must be properly remunerated and motivated to work in the Health Service.
Dr McBride:
I know that the Committee has discussed that matter. The oral health strategy and the primary dental care strategy are in place. Those must be underpinned by a new dental contract, and I acknowledge that, under the current arrangements, there are not enough incentives for dentists to invest time and effort in preventative dental care. In particular, the current payment system does not actively encourage that practice. The Department has significantly invested in preventative care for 2007-08, particularly to ensure that those practices that still run and support NHS dental services can continue to do so. The Department hopes that a range of approaches, including having salaried general practitioners provided by NHS commissioners of care, will further encourage dentists to undertake NHS work.
I support Mrs Hanna’s comments, and I welcome the Committee’s support in flagging important health challenges. It is important that every opportunity be taken to deal with the acute problems that must be faced here and now. However, at the same time and with the same resources, we must ensure that the underlying causes that lead to those acute problems are addressed.
Mrs Hanna:
This morning, I met a group of mental-health carers. They have many concerns that sufficient support does not exist. For example, if a young man with schizophrenia has a crisis in the middle of night, the police take him away. Parents do not know where to turn to for help. The police should not take that young man away and put him in prison — he needs care.
Another important issue is that of young people with learning disabilities who leave care. That care gap must be addressed.
Dr McBride:
You are absolutely right. It must be recognised that about one in 10 of the population here is an unpaid carer. That is a much higher proportion than anywhere else in the UK. A strategy is in place to support carers, which will be debated in the near future. It must be recognised that carers provide vital support to people, and they must be supported in the provision of that care.
Dr Deeny:
Thank you, Michael and Margaret; you are more than welcome to today’s Committee meeting. Most of my questions have already been answered. Do you both agree, as doctors, that there is a danger that many of society’s problems and behaviours have become medicalised?
Secondly, mention was made of the fact that bodies other than Health Service organisations could deal with mental-health issues such as suicide. May we hear more views on that?
Dr McBride:
Your first question is apt, and perhaps underpins much of what I have said today. Consider, for example, the issue of obesity: increasingly, people think that they can eat as much as they want, drink as much as they want and take little or no exercise, because, somehow, the Health Service will sooner or later find a pill or invent an operation that will sort out everything. That is just not how things will be. There will always be a section of the population who will require access to specialist drug treatment and surgery for obesity, but while people are suffering the consequences of obesity, they are also — as Kieran Deeny knows only too well — storing up a lifetime risk of developing problems such as hypertension, coronary heart disease and cancer. Therefore we must attempt to strike a new balance between telling people not to worry because we will treat everything and ensuring that people take responsibility for their health by doing things that they know will benefit the health of both themselves and their children.
Having said that, I also say that society must recognise that it is easier for some people to make those choices than it is for others. Those who are on low incomes or on benefits and who live in very deprived areas do not have the choices that some of us take for granted. During a recent visit to a north Belfast school that had participated in the health action zone (HAZ) pilot on healthy school breaks, I was struck by one mother’s comment. She said to me that it was quite expensive to buy fruit for her children for their school breaks. On the rare occasion that I accompany my wife around Tesco, I throw apples, and other fruit and veg, into the shopping trolley without any concern — as, I am sure, most of us around this table do. We need to ensure that people in those communities have real choices, so, yes, I agree that we need another model, and we need to stop medicalising some of the issues.
Dr Deeny:
We heard talk across the water this week about a drug for paedophilia. It worries me, as a doctor, when people suggest that a drug can be taken for that, as if it were just a medical condition. That concerns me. With many problems, society must give more thorough consideration to behaviour. By suggesting that the answer, or even part of the answer, is to take a drug, we medicalise the problem. That point also applies to obesity and other conditions.
For example, in recent days we have witnessed some very sad instances of suicide. As someone who has been on the front line in dealing with suicide, I believe that not all who attempt suicide are clinically depressed in the way in which the Chairperson was asking about. Last year, I dealt with one such young fellow — it still disturbs me to think about the case — who showed no sign of depression. The young generation is growing up with very poor coping strategies in place. We must consider, for example, the value that is placed on a human life. Surely the Churches have a duty to remind people of the responsibility that they have for their partner or wife or children. That duty seems to have been lost, and we are now dealing with families who are devastated because of a suicide. Instead of automatically presuming that there was a health problem to which health professionals could have provided a solution when there is a loss of life — with general practitioners dealing with families afterwards — we need to consider the issue as a society. I would like to hear your views on that. For example, should the Churches be more involved?
When promoting health, should we not also consider how people cope? In the old days, if everything went wrong, people could cope. In no way do I mean to diminish the need to help people who are clinically depressed or schizophrenic, but, nowadays, people in whom family, friends and health professionals detected no signs of depression are being found, all of a sudden, with a rope around their neck. Who else, other than health professionals and, indeed, this Committee, should be responsible for dealing with such problems?
Dr McBride:
I agree entirely. ‘Promoting Mental Health: Strategy and Action Plan 2003-2008’, which was published by the Department in January 2003 as a result of the Investing for Health strategy, sought to make that point. Of the 30 action points, 10 related specifically to suicide, and the other 20 to promoting better mental health and better emotional health and well-being.
Dr Deeny is right. Many young people lack the coping and life skills to deal with the challenges that they face in modern society, such as unemployment, low self-esteem and the feeling that they do not add value to society — as Michelle and Carmel have said. Many innovative projects are going on in north and west Belfast. For example, the Ardoyne/Shankill Healthy Living Centre runs a project that reaches out to children in primary 5 and primary 6 of local schools, asking them to determine their feelings, whom they talk to about how they feel, and what their support networks are.
If that project demonstrates that it is making an effective, positive contribution, those of us who work in health must learn from it and liaise with our colleagues in education about how to take it forward more positively and proactively.
The implementation board for the suicide prevention strategy is taking such a cross-sectoral approach: it involves bereaved families; Church groups; and board representatives. Churches have always played, and continue to play, a significant part in supporting suicide prevention, and many Church groups are actively involved. I had the pleasure of meeting bereaved families and Church groups recently. A great deal of work is under way to understand the underlying causes of suicide. We will get together in partnership to direct our collective efforts into addressing the causes of suicide.
Society is changing, and people’s ability to cope with pressures is not what it used to be. Is it because the networks are not in place? Is society more fragmented because the family structure is not what it once was? I do not have the answers. However, we need to understand those issues.
The Chairperson:
Dr McBride, I cannot let you go without making a comment about what you and Dr Deeny said. I must concur with you about involving Churches. The Churches used to look after us from cradle to grave. However, some Churches have been lacking in their involvement with their communities, particularly during the Troubles. There has also been a breakdown in the family unit since when I was a young girl. The family unit then was precious and important. Lines were drawn on how far children could go and to where parameters extended, and if children overstepped the line they were in trouble and were punished.
My Church is reaching out to young people, from four-year-olds up to teenagers. It is proactive in telling children that they matter, and it is trying to bring them in under the auspices of the Churches to make them feel valued and loved. The results have been amazing. I heard a story of a young girl who was found in the gutter, totally zonked on drink. A pastor who was doing outreach work in the city centre brought her to a church where a group of people was making tea and trying to help young people in the town in the middle of the night. The pastor asked that young girl what it was that made her do what she was doing. She said that all she wanted was for her mum to show her that she cared but that her mum did not care. The young girl said that she was lying in the gutter feeling that nobody cared about her. All she wanted was someone at home to miss her. That speaks volumes. It is not the be-all and end-all, but telling young people that they are valued is crucial. Our Churches have a big role to play in doing that.
Before I let you go, Michael, I want to raise an issue with you, and perhaps you can respond in writing. Earlier today, the Committee met representatives from Diabetes UK Northern Ireland. They said that Northern Ireland was the only part of the United Kingdom not to have a diabetes service framework. It has been looped in with cardiovascular problems, but it involves much more than that.
There are many causes and forms of diabetes. Perhaps you could come back to us with your views on the creation of a diabetes service framework and on why provision for that illness in Northern Ireland is so different from that which is available in the rest of the UK, given the number of sufferers of that condition here. There are also questions to be asked about education and the commissioning structures of any process that might be initiated.
Dr McBride:
I can answer that now.
The Chairperson:
I must bring in another group of witnesses; when I leave, we will not have a quorum. I thank you and your colleague Dr Boyle for coming before the Committee. No doubt, we will hear more from you.
Dr McBride:
I hope that you will invite me back, because there are several issues to discuss.
The Chairperson:
Absolutely. You may bet on it.
Dr McBride:
Thank you, Chairperson and Committee members, for the opportunity to speak to you today.
Reply from the Minister for Health Social Services and Public Safety to issues raised 14 June 07
Mrs Iris Robinson MP MLA
Chair
Health, Social Services and Public Safety Committee
Parliament Buildings
Stormont
25 June 2007
Dear Mrs Robinson
Following the meeting of the Health, Social Services and Public Safety Committee held on 14 June, the Committee asked that a written response be supplied to the question, ‘Why Northern Ireland is the only region in the UK not to have a service framework for diabetes?’ The following paragraphs set out the current position and future intensions for service framework development.
My Department is developing a range of service frameworks starting with cardio-vascular health and well-being, respiratory health and well-being and cancer prevention, treatment and care, to be followed by frameworks for mental health and learning disability.
The frameworks attempt to move away from an “illness model” of service delivery to one which actively promotes health and wellbeing and the prevention of disease. In line with this methodology, the frameworks are being developed using a whole systems approach which takes account of several inter-related risk factors and which aim to link with key public health messages, rather than considering conditions in isolation. In this context, it is recognised that diabetes is one of a number of interconnected risk factors for cardiovascular disease.
For the purposes of development of the Cardiovascular Health and Wellbeing Service Framework, care is defined as the prevention, assessment, diagnosis, treatment, care and rehabilitation of individuals/communities who currently have or are at greater risk of developing disease pertaining to the heart and systemic circulation. Recognising that several diseases can co-exist, share common risk factors and can adversely impact on prognosis, this service framework will include consideration of:-
- Coronary heart disease (e.g. angina, heart attack, heart failure);
- Hypertension (high blood pressure);
- Cerebrovascular disease (e.g. stroke);
- Peripheral vascular disease (e.g. poor circulation in legs causing ulcers/gangrene);
- Diabetes (as a significant risk factor for the development of cardiovascular disease); and
- Renal disease associated with cardiovascular disease (e.g. kidney failure).
This service framework will follow a lifecycle approach -from childhood to adulthood and end of life care. The framework will link to existing strategies on diabetes; it will set standards for diabetes prevention, treatment and care, in the context of cardiovascular disease.
All key stakeholders, including those with an interest in diabetes, will be invited to participate in the development of the cardiovascular framework. It is intended to publish this framework in late spring 2008.
Additional areas for service framework development will be identified in late autumn 2007. To inform this phase of service framework development, my Department will be inviting proposals from all stakeholders. At this time of transition, the exact process of engagement with stakeholders needs to be firmed up to ensure that there is appropriate representation from local communities, advocacy groups, primary care providers, community and voluntary sector organisations and HSC organisations. To ensure fairness and transparency, formal proposals will be required and these will need to be made in a standardised manner.
Further details on the trawl process will be issued shortly, with completed proposals being sought by late autumn in order to inform and facilitate the commencement of work on additional frameworks from early 2008.
I hope that this letter explains the current position and future arrangements for service framework development. My Department would be happy to update the Committee on progress at a later date.
Yours sincerely