COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Inquiry into Obesity

Dr Una Lynch - Queens University, Belfast

28 May 2009

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 Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey

Witness:

Dr Una Lynch, Queen’s University Belfast

The Deputy Chairperson (Mrs O’Neill):

The witness for this evidence session is Dr Una Lynch from Queen’s University Belfast. By way of introduction, Dr Lynch is a qualified nurse, midwife and health visitor. Dr Lynch has an MSc in community health from Trinity College Dublin, and, in 2007, she graduated with a doctorate in governance from the School of Law at Queen’s University Belfast.

Dr Lynch has worked in public health practice, and education policy and research, across the island of Ireland. In 2000, she was seconded to the World Health Organization (WHO) in Copenhagen to work on a ministerial conference on public health nursing. In 2005-06, a leading lights lecturers into industry award from Queen’s University enabled her to travel to Cuba to study the country’s health system.

Dr Lynch, we are privileged to have you here today to talk to us as part of our inquiry into obesity. I invite you to make your presentation, after which members may have questions.

Dr Una Lynch (Queen’s University Belfast):

Good afternoon, and thank you very much for inviting me to address the Committee. The evidence that I will present this afternoon is based on my research of the Cuban health system. I spent four and a half months in Cuba researching the country’s health system.

I welcome the leadership that has been shown by the Committee in holding an inquiry into the obesity epidemic, which is symptomatic of the deficits in the existing model of healthcare provision in Northern Ireland. The inquiry, therefore, provides an excellent opportunity to act as a vehicle to address those deficits and to create a health service that is truly fit for purpose. We have much to learn from the Cubans on that subject. Obesity is rapidly emerging as the main public health issue in Northern Ireland and throughout the developed world. However, the burden of obesity and its associated problems, such as diabetes and heart disease, are disproportionately borne by the poorer sectors of society.

My paper and presentation stress the importance of primary healthcare, active citizenship and community participation in delivering effective public policy generally and in addressing the issue of obesity in particular. I am conscious that some — perhaps all — members of the Committee have not yet had the opportunity to visit Cuba. Therefore, I spoke to the Committee Clerk, and he kindly agreed that I could table a second paper, which is a pictorial guide to my presentation, and I will refer to that too.

The first photograph is a typical image of Cuba: the seafront in Havana. The quotation that is superimposed on the photograph is from an extremely interesting character, Professor Francisco Ochoa. He was one of the first doctors to qualify after the triumph of the revolution in 1959. He qualified in the same year and has subsequently become one of the leaders in public health throughout Latin America. He is featured in ‘The Lancet’ and has won awards from the Pan American Health Organization. I felt that it was fitting to start with his reflection:

“Health doesn’t function alone. Health, for better or worse, reflects how the society is functioning; advancing.”

I will leap now from the seafront in Havana to the House of Commons. A report of the House of Commons Health Committee on health inequalities was published in March 2009. It states:

“In 2006 a girl born in Kensington and Chelsea has a life expectancy of 87·8 years, more than ten years higher than Glasgow City, the area in the UK with the lowest figure (77·1 years).”

The reality is more shocking, because Belfast Healthy Cities published a report in 2008, ‘Divided by Health: A City Profile’, which revealed that the life expectancy for boys born in west Belfast is 71 years, which is 17 years less than girls born in Kensington and Chelsea. That is a startling fact and reflects the inequalities among citizens in different parts of the UK. It is an indictment of our capacity to realise William Beveridge’s vision of the National Health Service.

Cuba, I believe, provides us with inspiration and hope, and makes us realise that, with all the resources that we have at our disposal in Northern Ireland, we can do so much better. Cuba has a very poor economy. Despite its economic situation, however, Cuba has managed to achieve quantitative health indicators such as infant mortality and life expectancy that are comparable with all the high-income countries.

The infant mortality rate in Cuba and in Northern Ireland is five: five babies in every 1,000 born live will die in their first year. We do not want any babies to die in the first year of life, but that is a reality. In the developing world — in Zambia, for example — for every 1,000 live births, 102 children will not see the end of their first year.

Cuba has achieved those results despite a pitiful economy. It is spending 7% to 8% of its gross domestic product on healthcare, which is a similar proportion to the UK and Ireland. However, because of differences in economy, the UK is actually spending seven times as much, the Republic of Ireland eight times as much and the United States of America 18 times as much as Cuba on healthcare. Something interesting is going on in Cuba, and we can learn from that.

Modern health systems are dominated by diagnosis and treatment of disease, with prevention and public health relegated to a back seat. That was highlighted in the 2008 World Health Report. Cuba, by placing primary care as a driver for its health system, has managed to turn that traditional paradigm on its head. Even Cuba’s most strident critics will admit that it does health very well. For Cubans, it is fair to say that health has become emblematic of the success of the revolution. Cuba makes that happen through a powerful Ministry of Public Health, which governs the entire health system.

I will now return to the photographs in the ‘Hello!’ magazine-style guide presentation, as it were. I will focus on the second photograph, which is captioned “family doctor/family nurse”. In 1984, the Cubans, having visited initiatives throughout the world and considered different health systems, were hugely impressed by the British model of general practice. That year, they decided that general practice was where it was at, and they were going to build a system around general practice and primary care.

Twenty-five years later, they have established a system that supports primary care. They do not have the notion of primary and secondary care. They have a health system that is built around primary care, to which the family doctor and family nurse are crucial. They work and live in the communities and, depending on population density, work with between 1,000 and 3,000 people.

The third photograph was taken in a family doctor’s practice, but it could have been taken at any practice in Cuba. If one walks off the street into any family doctor’s practice, one sees, in the waiting room, the needs analysis of the area, which shows the population profile, the age/sex distribution, the breakdown of conditions affecting that population and the uptake of vaccination and screening. Sometimes, the charts do not look pretty, because the resources at the practices’ disposal are not equivalent to ours; sometimes, they will be hand drawn, but they are all displayed in waiting areas.

However, even more excitingly than that, the family doctor/family nurse practice is governed by a local health committee, which brings together representatives from all the key stakeholders, including the local women’s groups, and so forth. Every six months, they sit down and draw up an action plan — not a strategy or a glossy document. They examine the needs of the population, the environmental factors and the social issues to see how they can plan together. The beauty of that system is that it feeds up from that small level to municipal level and, finally, to national level, which has enabled the Cubans to develop a system that is constantly evolving.

The next page contains three photographs of primary-school children in Cuba. In 1959, education and health were the two priorities for the new Government after the revolution. If one wants the public to participate, the public must be educated and have confidence. Confidence comes from education, and education is prioritised all through a Cuban’s lifespan. Primary-school, secondary-school and university education is free.

I have included a photograph that has a relevance to obesity. The Cubans are interested in education not only from an academic point of view but in preparing children for life. At the beginning of each academic year, Cuban schoolchildren are measured, weighed and undergo a fitness assessment, which examines how far they can run and how high they can jump. That is then reassessed at the end of the year. The school is being measured not only on its academic performance but on how its children’s physical and fitness levels are progressing.

The next selection of photographs show círculos de abuelos — grandparents’ circles. Health promotion, prevention and public health covers the lifespan of a Cuban, and it is not focused on children only. Anyone who visits Cuba and goes out early in the morning — from 8.00 am to 8.30 am — will see groups of older people doing gentle exercises in the parks and plazas. The lady in the photograph with her back to the camera has come from the equivalent of the Cuban sports council. Someone from that institution will visit those groups about two days a week to keep the group motivated and ensure that exercises are done properly and safely. Another photograph shows a lady standing side on: she is the peer leader. These are peer-led initiatives that are run by the community and taken by the community. Another lovely thing is the fact that, because the family doctors and nurses work locally in the community, they can drop into those sessions and chat with people. They may check blood pressure and blood sugar levels, and generally keep an eye on the population with whom they work so that health issues and contact with patients is not always carried out in a medicalised environment.

I am stressing a focus on primary care, on needs analysis that enables people to target resources on those areas that are most needed, which realises the vision of equity, and on education, which enables the community to participate and be active players.

I started with a quotation from an interview that I conducted with a Cuban, Professor Francisco Ochoa. I will end with another quotation, which is a challenge to all of us. My research question was about public health and why the Cubans are so successful. The quotation is from Professor Silvia Martínez, another highly esteemed medical doctor in Latin America. She challenged my question and said that a low infant mortality rate is not a success. The fiercest critics of Cuba are the Cubans themselves, because they are continually striving to do better. Bearing in mind the difference between girls born in Kensington and Chelsea and boys born in west Belfast, Professor Martínez said:

“To maintain the infant mortality rate is a social responsibility. Responsibility like Beveridge says: responsibility. A child of one year has a right to this. I imagine that there should not be anything lacking that will guarantee its protection: if you work for this you are fulfilling your duties, nothing more.”

The Deputy Chairperson:

I enjoyed reading your paper and am interested to learn more. The paper clearly outlines the successes of the Cuban Government. We need to examine more closely the fact that, given the current economic climate in Cuba, it achieves better health outcomes than some developed countries. I particularly like the design of your submission and the concept of the umbrella, which shows how public health is the backbone of, and the dominant ministry in, Cuba and how it plays a key role in determining the work of all other Departments.

Time and time again, the Committee has discussed the need for cross-sectoral working and how one Department should take the lead on the issue, provide information and filter it to other Departments. The new Public Health Agency was established last month. The Committee argued strongly for the establishment of that body, because we thought that it should play a key role in tackling public health, which might have been lost on a board that deals with general daily health needs.

One of your recommendations mentions that the systematic needs assessment successfully underpins policies and strategies in Cuba and that its Government often consider that matter. The concept of placing information on the wall of doctors’ surgeries will probably alert people to the fact that they are more prone to, for example, heart disease because of the area in which they live. All those ideas are welcome. The challenge is how to gather information here and what to do with it. Do we do well here? Do we have effective needs analysis here? Have we gathered information, and do we use it properly?

Dr Lynch:

Thank you for your comments. I am glad that you have taken the paper’s contents on board; you have reflected the information accurately. I also hope that the Public Health Agency puts public health at the forefront.

We collect information very well here, and we collect any amount of it: we have information overload. However, we share that information poorly, and we are incredibly bad at using information that we have collected from the population to consult with the community in order to decide priorities and responses. The Cuban system is sophisticated but, at the same time, simple. The Government make issues simple and accessible to the population in order to make them workable. They recognise that the local community understands best.

Infrastructures are in place here, and the existing system does not need to be tweaked much. As a health visitor, I noticed a headline in the ‘The Guardian’ in 2004 — it may have passed members by — that described 1994 as the “year the tots grew out”. A researcher from the University of Manchester, who was not from a health background, considered the health visitors’ percentile charts. Every health visitor who visits a family checks babies’ weight, height and head circumference. The researcher examined the composite information and concluded that three-year-olds started to show a trend towards obesity in 1994.

I am unsure why we cannot share that information. Rather than collect information on individuals, we need to collect that information and, thereafter, consider real public health practice. Our system tends to focus on the individual, which is why debates tend to be around hospital beds; one person fits in one hospital bed. We must consider the issues in a community context. We need to create more life pictures.

We have excellent resources. The Northern Ireland Statistics and Research Agency (NISRA) website proves that we have good access to resources. However, those resources are not filtered down. Every citizen has a right to know the risks of living in a particular area. For example, a person has a right to know that his or her life expectancy is 17 years less in a particular area. How can we change that situation and provide people with that information? People have a right to information. We tend to use language such as “service user engagement”. We should change that type of phrase, because it suggests that a person uses a service rather than being part of that service.

Cuba uses that information to ensure that the public feel part of the system. The public are creating the system; they are real stakeholders. In Cuba, they do not use the language of “stakeholders” or “user”. They focus on citizens.

We have the information, but it will take a change in mindset, which it is possible to achieve. It will take no additional money; it will be cost-effective if we just ensure that people living in areas are familiar with the situation.

Mr Gardiner:

Thank you very much, Dr Lynch, for the presentation and for the photographs that you provided. It immediately struck me that there are more females trying to keep fit than males. The men in the photographs are like beanpoles. Is there a reason for that?

In Northern Ireland, we pride ourselves on the Health Service that we offer to our community and citizens. However, Cuba seems to be more active on obesity than we are. Can we pinpoint our problems? What should we put into action?

Dr Lynch:

The dominance of the women was not noticeable to me, but perhaps that is my bias. There is a very slim older man in the photograph. When that photograph was taken, there was an exercise wherein older people stand balanced on one foot in order to improve balance and co-ordination. The gentleman in question sat that one out. I thought that he was not putting in as much effort as the women, as it transpired that he was 95 years of age. It is very powerful to see this system in action, in which someone in his 90s is actively involved. It is still not too late to focus on prevention.

Mr Gardiner:

It speaks well.

Dr Lynch:

It does, but get down there to see it in action.

In preparing for this session, I revisited some of the literature, and I commend to you an article by Sharon Friel, Mickey Chopra and David Satcher, “Unequal Weight: Equity Oriented Policy Responses to the Global Obesity Epidemic”, in the ‘British Medical Journal’ in 2007. The authors highlight the fact that obesity is a multifactorial problem:

“Missing in most obesity prevention strategies is the recognition that obesity — and its unequal distribution — is the consequence of a complex system that is shaped by how society organises its affairs.”

That recognition is also missing in Northern Ireland. For example, I met some young parents in Sandy Row as I was on my way to Queen’s University from the Europa bus station. I asked them about parks and facilities. Down there, one often sees cars parked on both sides of the street and children out on little bicycles. The place is not really conducive to children’s play. The parents told me that the nearest park, which is not Botanic Gardens, is not a place in which parents want their children to play.

If we are serious about a policy that is conducive to health in every sense, including to the prevention of obesity, we need to look at safe areas that enable children to be active and to play safely. It is not just about health; it is about linking up education so that people can make informed decisions. It is all very well having information printed, but people do not understand what is meant. Education, play facilities and transport are all interlinked. Every Department can assist with this.

Mr Gardiner:

In many schools, and particularly in primary schools, exercise is being introduced more and more, at least compared with the situation over the past 10 years.

Dr Lynch:

You are right. There was a policy that was working against that. Schools are playing their role, but children also spend a lot of time outside school. There is a move in many schools to open up their facilities, and that is very welcome. However, there is much to be said for creating safe spaces for children to ride their bicycles and to use roller skates and skateboards so that they can exercise more.

Mr Gardiner:

I agree that there is room for improvement, but you definitely practise what you preach.

Dr Deeny:

You are more than welcome, Una. I would love to go to Cuba to see how primary care works there. At long last, we are starting to see that health promotion and disease prevention are the way forward for a much healthier population. There is far too much short-sightedness in the Health Service here. We wait until someone gets a disease and then we treat it, but, if health promotion and disease prevention were taken on, we would save loads of money. As a GP, I am very interested in that. For well over 20 years, I have seen protocols and strategies, and I am fed up to the teeth with them. It is, as you said, information overload. It is good to hear about Cuba’s action plans.

You mentioned that community involvement, through a local health committee or something similar, runs primary care in Cuba. How exactly does that happen?

More and more healthcare provision is moving into the community. As healthcare professionals, our concern is whether we will have the financial and personnel resources to meet that challenge in the future. I hope that we will. Is primary care in Cuba provided with the finances and the personnel? It seems to be, so perhaps that is an easy question.

My final question is the big one. How can the Department of Health, Social Services and Public Safety, and the Minister, be convinced that the future lies in focusing on primary care rather than in having a divide between primary and secondary care, which I have seen for years?

Dr Lynch:

I thought that those were all big questions. I am very happy for you to head to Cuba. I can set that up to be done cost-effectively. I could set up accommodation for you in the school of public health, and it would not cost much. The system in Cuba is an inspiration to anyone who works, or is interested, in public health, and it shows us that we can make a difference.

I shall start by explaining the governance structures. The community health committee comprises the family doctor, the family nurse, representatives from the local schools, grocers, bakers, people who are responsible for transport, and so on, and local elected representatives. Every six months, the committee plots out its action. That health committee also has a governance role relating to what happens in the practice, and we also have lessons to learn from that.

To give an example: I worked with a GP in Havana, and, towards the end of the placement, I took her out to lunch. She had been on holiday, so she should have been relaxed, but she seemed anxious. She told me that she was anxious because she had to appear before the health committee. A child from her patch with whom she had been working had been born at 36 weeks. By any stretch of the imagination, a birth at 36 weeks is not a big problem, but it is officially classified as being an early birth, and the baby is classified as having a low birth weight. The baby was absolutely fine, but it is standard practice that a health committee gets together to revisit the pregnancy to see whether anything could have been done during the pregnancy that had not been done and whether something could be learned from it. That was not done in a defensive way or as part of a blame culture but to ensure that it did not happen again.

That is only one example of how the committee works. Everyone works together; it is not only the doctor’s responsibility but that of other people in the local community. People are employed at municipal level to oversee the functioning of those health committees and the taking forward of action plans.

I shall give another example of how that needs analysis works and how it is responsive. The demographic challenge that Cuba faces is similar to ours in that we have exactly the same life expectancy, although Cuba has a slightly larger percentage of older people. The challenges are the same; as the population gets older, more people will have diabetes and heart disease. For that to be managed effectively, people need to be seen early and in primary care.

The next stage up from the family doctor/family nurse is the polyclinic. Unlike our polyclinics, those in Cuba function 24 hours a day, seven days a week. They are serviced by GPs, who feed into it. I was in Cuba for three months, and, eight weeks after leaving, I came back for a further six weeks. In that space of time, the Cubans had been feeding their profiling data up to a national level.

In Cuba, rates of car ownership are low, and older people face challenges using public transport. Consequently, they are unlikely to use public transport. Similarly, older people are more likely to need specialist medical services. Therefore, cardiologists are sent to the polyclinics. Depending on needs profiles in the area, cardiologists might be there for one to five days a week. The same arrangement applies to endocrinologists, and so on.

Interestingly, in 1984, Cuban doctors did not want to work in primary care; it was not considered an exciting part of medicine. Today, primary care is where it is at, and all doctors want to get into it. It is not about money; in Cuba, people are not generally motivated by money, and doctors there are not offered financial incentives. Initially, the Cuban Government used access to housing to encourage doctors and nurses to work in primary care. Nowadays, family doctoring and nursing are recognised as the exciting areas of healthcare.

Healthcare professionals in Cuba do not use the words “primary” or “secondary” care, and, if we wish to get rid of that split in the Health Service, we need to devise a system that concentrates exclusively on serving the public. It is irrelevant where care is delivered. It should be focused on the needs of the population. Therefore, your point is well made; we need to get rid of the division between primary and secondary care. It should not be about a competition for budgets and who gets what. Rather, it should be about how to best serve the needs of the population.

With respect to resources —

Dr Deeny:

The Department and the Minister seem to be focusing on primary care.

Dr Lynch:

Everyone here on the hill depends on public support, but members of the public do not talk about primary or secondary care; they just know that the system is not working. If people were better informed about the burden of risk on certain communities, there might be greater accountability. As Fidel Castro said: “el maldito dinero” — that awful thing, money. Do not let money get in the way. We must decide where we want to go and what we want to achieve, and then work towards those goals. The difference between Cuba and here is that, having decided where we want to go, we tend not to get there for this, that or the other reason, whereas the Cubans decide where they need to go based on their citizens’ needs, and do what is necessary to get there. If we set clear goals, things will fall into place. It is not always about money.

Mr McCallister:

That was an excellent and interesting presentation, and I would be happy to join Kieran in Cuba.

One of the striking, and alarming, facts to come out of your presentation is the 17-year difference in life expectancy between two parts of the country. I wish to tease out some of the points that you raised. The new Public Health Agency, which the Deputy Chairperson mentioned, provides an opportunity to focus on some of the points that you raised. Moreover, during the inquiry, we have come to realise that many of the things that need to be done do not involve rocket science; it is just a matter of doing much better in some of the areas that you highlighted, such as community planning.

Kieran referred to local health committees, and it seems to me that we are getting stuck in our attempts to deliver services on the ground. Regardless of whether councils or the Assembly are responsible, we must remain focused on the agenda of decentralising care and delivering services locally. On average, how many people do local health committees serve? How local is local?

Dr Lynch:

I am delighted by the growing list of people who are going to visit Cuba, because they will be made very welcome. Cubans are the last people to blow about what they do; however, once people come to visit, they are open and generous in sharing information with them.

The family doctors and family nurses work with populations of between 1,000 and 3,000, and there are local health committees at that level. The family doctor/family nurse practices feed into basic work groups, which bring together between 10 and 15 practices, and those feed into another group. It is a matter of acquiring information about the local population at a low enough level. We get caught up in whose responsibility it is rather than getting down to the grass roots and creating family practices and other facilities in housing estates.

A great relationship and trust is established between patients and general practitioners and nurses. We have a very sophisticated system that involves district nurses, health visitors, midwives and social workers. Northern Ireland’s capacity for an integrated system is a strength that other parts of the UK have not had, and we can create something that feeds in at policy level. It is important that we start with the really vulnerable populations. There are already good models and initiatives such as the health action zones and Sure Start.

I did a wonderful interview with Francisco Ochoa, and he said that the Cuban system has evolved, which is why, in my submission, I used the metaphor of a repaired umbrella that is continually evolving. There is a notion that it is difficult to make changes within socialism, but healthcare in Cuba has evolved. Francisco laughed and said that he had travelled the world and seen pilots, particularly in Europe, that have gone on for 20 years. We are good at initiating small-scale measures such as health action zones and Sure Start, but we need to take measures on a larger scale. If the political will is there, anything can happen.

Mr Gallagher:

Your very good presentation makes it clear that we can learn important lessons from the Cuban system. I am sure that you will agree that there are different circumstances in the two countries. Indeed, you talked about the disposition of the Cuban people and how they have a different lifestyle to people here. They are more relaxed and comfortable with themselves, which is probably a relevant factor. The climates are also very different; people in Cuba can spend many more hours outdoors in most seasons, and that helps them to have more active lifestyles.

Given that Cuba is an island and the political circumstances in that part of the world, I assume that Cuba is fairly self-sufficient in food production. I am sure that the Cuban climate helps the growing of a great variety of fruit and vegetables. Can you comment on Cuban people’s diet and how it contributes to how long they live?

Dr Lynch:

One does not go down to Cuba for the food, because the food is terrible. Cubans eat lots of fried food. They have lived through difficult times, particularly with the collapse of eastern Europe in the 1990s. Cuba was isolated not only geographically but politically. It went through the same situation then as we are going through now.

You made a point about fruit and vegetables. Cuba has a warm climate, but its location in the hurricane belt means that its production is challenged. The hurricane season is between May and November, and Cuba has developed great practices to manage that. It has been able to keep mortality rates low. In fact, its production of fruit and vegetable is not great.

In his interview, Francesco Ochoa said that Cubans’ diet is appalling. There is a notion that they are never satisfied and that they continually want to do better. Cubans love pork — a bit like we love our bacon. Therefore, they consume a lot of pork and fried food. It is certainly true that they do not consume much processed food. However, their diet per se is not particularly good.

Cubans take plenty of exercise, partly because of transport problems. However, the Government create interest in, and an appetite for, sport among children. Baseball is Cuba’s national passion, and anyone who is interested in sport likes baseball. Participation in sport is considered to be a citizen’s right, so entrance to baseball games is free. Compare that with rugby or GAA. In Cuba, entrance to games is a right, which encourages interest in sport.

Participation in dance is also encouraged. It is not considered to be a pastime for elite children, and all children can take part in dance. For example, Cubans are encouraged to go along to the national theatre and attend the ballet. I paid around $40 to watch a performance. One US dollar is worth around 21 Cuban pesos. Cubans pay five pesos to watch the national ballet or to visit the theatre. Therefore, the culture promotes exercise from childhood onwards. It promotes dance as a form of exercise, and sport.

The Cuban diet is not great, and the Government are working to improve it. Television programmes educate people about food and teach them how to cook. If you visit Cuba, it is not for the food.

Mr Gallagher:

Do Cubans eat largely home-produced food?

Dr Lynch:

They do, largely. However, much of their food, particularly chicken, is imported from the United States.

Ms S Ramsey:

I welcome Dr Lynch to the Committee. Her presentation was great. I have been to Cuba, and I agree that dance is one of the country’s major pastimes for people of all ages. No matter where you are in Cuba, you can turn around and see people dancing in the streets.

Mr McCallister:

Did you participate, Sue?

Ms S Ramsey:

I did indeed.

A key lesson is that we should not be afraid to look at other countries and to learn from best practice elsewhere. The inquiry has meant that, although we are the Committee for Health, Social Services and Public Safety, we have been in touch with various Departments because we know that obesity is not only a health issue. That will be reflected in our recommendations. The health budget is a sizeable portion of the overall Budget. A key aim of the inquiry is to show that obesity is not always a health issue: it is also about prevention and exercise.

I want to take a holistic approach to the issue and not simply focus on health. We operate in the context of the outworkings of the review of public administration, devolution and local Ministers, the majority of whom live, work and socialise in the constituencies that they represent; that is good. You mentioned the health action zones, and I have seen the positive work that they have done on specific issues. However, in certain constituencies, it is piecemeal. We must consider that issue.

The Deputy Chairperson made a point about a specific needs analysis for the North and its health boards, which can be extended to the border counties and throughout the island. We must also consider that issue. I have used this example before: in some constituencies, there has been an increase in asthma. It is accepted that the planting of more trees can have a positive impact on reducing the instances of asthma. The Department for Social Development has planted trees in various constituencies to address that. Although asthma is a health issue, the Department for Social Development had the authority and the money to deal with it. It just takes small tweaks here and there.

I agree with you about the Investing for Health strategy. Kieran Deeny made a valid point. I was a member of the Committee for Health, Social Services and Public Safety when the ‘Investing for Health’ report was brought forward by Bairbre de Brún. I agree with you that it was visionary. It was probably the first time that all the Departments got together with the Executive and considered investment in health. It was not just a health issue. Do you believe that other Departments still play their part in the Investing for Health strategy? Do you believe that, with the establishment of the Public Health Agency, public health and prevention will take centre stage or will it remain a poor cousin?

Money has been mentioned a few times. Do you think that we need to overhaul the boards’ funding formula? We must get away from the piecemeal approach. Do you think that there is a need for the Department of Health, Social Services and Public Safety to overhaul it?

Department of Education officials gave evidence some weeks ago, and we had two Departments fighting over which would fund after-school projects and breakfast clubs. It is all very well for the Executive, Ministers and Committees to be visionary, that mindset still prevails among civil servants. Their approach is one of “we can only go so far” and “it is not my responsibility” instead of a collective approach.

Your presentation was top class, and I recommend going to Cuba to witness its healthcare system at first hand.

Dr Lynch:

It will be only when the Departments work together and have some joined-up thinking that a difference will be made.

The Assembly is a fledging Administration, and we are only getting on our feet. I do not for a moment advocate that the current membership should still be here in 50 years, but the Cubans have had 50 years of continuous Government, and that shows that much can be achieved through joined-up thinking and working together.

From 2002, devolution has been synonymous with public health. The new Public Health Agency is most welcome because it puts public health on the agenda. It is early days: some things could be tweaked and worked out, but I am optimistic about how it will work. Your example of tree planting is exactly the sort of thing that does not cost much in resources but is sustainable for the future. It is a simple act that, done today, prevents expenditure in the long term. It is not always about money. Unfortunately, in Northern Ireland, money is always at the front of health issues. Some healthy discussion would help. There is a debate about the number of MLAs, but the number of MLAs could be a real strength if we take on board the notion of MLAs sitting on local health committees. Those committees would be spread out across Northern Ireland, and MLAs would bring their voices right into Stormont.

That would make a genuine connection from the grass roots to Stormont, and that is the link that is missing. We tend to talk in grandiose language and produce beautiful documents. Last night, I spoke to Dot Kirby, who is a former BBC Northern Ireland health correspondent. She said that one could always judge the importance of a report by the weight of the paper and the colour quality of the photographs. Perhaps there should be an embargo on coloured documents and strategies, and we could focus on actions and on what people see on the ground. We could save much money on that and spend it in small ways to make a difference.

As for funding, healthcare is not necessarily about money. We all need to take a long hard look at ourselves and think about how we can do better with our resources. More money would be welcome and would mean that we could do an awful lot more, but we are already much wealthier in every sense: we have a highly educated country; we are a small country; we have a great environment. We have scope to do so much.

There is a short-sighted notion that it takes the market to sort out the health system. I went to Cuba with that notion. We have an ageing population, and the risk of older people developing cataracts will increase. Cuba has the capacity to meet the needs of more than its own population. When I was in Cuba, an apartment block was being used to treat people who were flying in from Venezuela every day to the misíon milagro — the miracle mission — where cataracts are treated and people are given back their sight.

People arrived from Venezuela, were taken by bus to the apartment block, went by escalator to the top floor and gave a blood sample. They then went back down and settled into their rooms. Later that day, they went back up and were seen by a general physician, an ophthalmologist and an anaesthetist. If they were deemed fit for surgery, off they went and had their cataract treated and returned to Venezuela a few days later.

That is happening in a developing world country that is able to plan strategically by using information. We are closing hospitals here. Northern Ireland could be a centre for health tourism. We could sustain hospitals in rural areas and build up an infrastructure if there were a wee bit of imagination. We are bringing in teams from elsewhere to treat cataracts in Northern Ireland. Therefore, it is not always about money; it is about using what we have.

Mrs Hanna:

Good afternoon, Una. You are very welcome. We have a great opportunity through this obesity inquiry and the establishment of the new Public Health Agency. The timing is right to try to make a difference.

I was fascinated to hear about a different culture, and we are all fascinated by Cuba. I have not been there, but I have read about it. It is interesting that, despite the fact that Cubans have far less money, they have equal or better health outcomes. You said that health workers are charged with looking after the health of others. You spoke about 24-hour clinics and specialists going to the people. We have had debates about that here, but we have not done anything about it. Equipment is often unused from 5.00 pm and over the weekends, yet we have long waiting lists.

You talked about the Cuban diet and the fact that they do not use processed food. However, we are told that exercise really makes a difference. It is not that people are eating so much more but that we have sedentary lifestyles, and people are not burning calories.

We do some positive things in the community. We plant trees, and we are considering more playgrounds and parks. Does Cuba experience antisocial behaviour as we do? If a tree is planted here, it almost needs a 6 ft wire fence with lights on the top to stop people from pulling it down. As for attitudes to health, we are inclined to depend more on the Health Service. We have all seen the “I need a prescription” and the “doctor, doctor” advertisements.

How do we encourage or empower people to take more responsibility for their own health? Is the situation any different in Cuba? There is also the issue of tackling and challenging lifestyles — for example, smoking and drinking. I appreciate that there is a better chance of scoring hits with prevention and early intervention. However, it is harder to pick up the pieces, and, in the Health Service, we are inclined to pick up the pieces all the time. So much money goes on picking up the pieces that it is a vicious circle.

We do not seem to be able to prevent or to intervene early because we spend so much time picking up the pieces. However, a start has been made with children, and Sure Start is an example of good practice. However, pilots can go on for ever. We do not evaluate pilots, and good pilots are not mainstreamed. It does not matter whether they are good, bad or indifferent. They are not judged on their merits, but some of them last and some of them are dropped, even if they are good. That is where we fall down. The culture should be about getting down to the grass roots to try to make a difference. There is a huge difference between the haves and the have-nots. That is an issue for the Committee. How do we encourage people and communities to take more responsibility and work with health professionals to consider their own health?

Dr Lynch:

That means that you are on the list to go to Cuba. If you go, you will see it in action. It is about rights and responsibilities. No matter where one goes in Cuba, one will see notices giving information about rights and responsibilities; it is double-edged. People can realise those responsibilities only if they are given education.

You mentioned vandalism; I will quote another Latin American, Paolo Freire, whose work advocates practices similar to those in Cuba. His view is that people talk by their actions; actions are often more expressive than words. When people are destructive, it usually means that they do not feel included. People feel excluded and alienated from society. In Cuba, work is done to create that engagement and bring people in. In socialism, there is a strong notion about the pursuit of the perfect human being; socialism recognises that everyone is intrinsically good. In Cuba, all citizens are valued, whoever they are, and engagement is promoted. The work that is done with people with disabilities is amazing, and carers of people with a disability are prioritised.

I will provide Committee members with a copy of a ‘British Medical Journal’ article that highlights the challenge of trying to address the obesity agenda when faced with market forces that promote processed foods that are empty of nutritional value but very high in calorific value. If one goes to Cuba, one can see the exchange. It is about citizens engaging with the health professionals. The health professionals do not have all the knowledge; we all have different pieces of knowledge, and we are in it together.

Mrs Hanna:

Are the differences between Northern Ireland and Cuba down to the ethos of socialism and the different culture?

Dr Lynch:

In Cuba, medicine and nursing are considered as vocations, and humility is valued; perhaps the greatest insult that one can give to Cubans is to call them ostentatious or arrogant. They pride themselves on humility.

Mrs McGill:

Thank you for your briefing, Dr Lynch. In your paper, you mention equity; it is written on the umbrella diagram. Is there equal access to all services throughout Cuba? I am from the west, and we have had several debates about the provision there. Tommy and Kieran will be aware of that. You also mentioned hospitals in rural communities. I will not go over all the argument again, but I am interested in whether there is equal access to services in Cuba. Although Cuba focuses on primary care, that clearly is not the case here, and we rely not so much on prevention as on dealing with problems when they arise.

In the area that I represent, for example, the out-of-hours provision is changing, and we are concerned about that. That service will move from Strabane — a small rural town — to Derry. People feel that the services there have been reduced. I am not clear, Dr Lynch, about how that can be addressed.

It was interesting to hear that the Cuban diet relies so heavily on fried foods and contains little fresh fruit and vegetables. As for exercise, if we had Cuban weather, people might be more encouraged to go out and exercise in the morning, and so on.

At the start of your presentation, you used the word “epidemic” when referring to obesity. If the health system in Cuba were transposed here, would it end the obesity epidemic?

Dr Lynch:

The Cubans would be the first to say that their health system is particular to Cuba. The health system that evolves in each country is reflective of its context, and Cuba has a particular political context and structures. One could not simply take the Cuban model exactly as it is and bring it into Northern Ireland. However, key elements of that model, such as the focus on primary care, equity, needs assessment and community participation, could be central to our system. The health system in Cuba has evolved over 50 years. It would, therefore, be difficult simply to introduce it here.

Mrs McGill:

As far as the Committee’s inquiry into obesity is concerned, is Cuba, therefore, not a particularly good example of what can be done to address the problem?

Dr Lynch:

It is in a sense, and that brings me on to the second part of my answer. Cuba has managed to create its current health system because it has a strong political will to ensure and safeguard the health of the population. It has a Ministry of Public Health that is not one of the lowly Ministries. It is a powerful Ministry that influences the action of the Ministries of employment, economy, foreign affairs, and so forth. Everything is influenced by the Ministry of Public Health. It does not merely receive the crumbs from the table but influences the actions of every other Ministry. That is crucial. If we are serious about public health, it is not simply a matter of improving the health system; it involves all the wider social determinants of health.

In answer to your question about the situation in the west, I may come across as a real fan of Cuba. However, before travelling there, I was suspicious of the socialist ethos and wondered whether I would be shown only the best aspects of the health system. I spent some time in Havana before travelling around the country. We know about Guantanamo because of the military base there, but it is a huge province in Cuba. It is the country’s most rural and isolated province, and I was curious about how well the health system worked there. It all worked well in Havana, but how would it work out in the sticks?

It was simply amazing to see a family doctor/family nurse practice that was exactly the same as one in Havana, even down to the paint. The shortages in Cuba mean that the same green/blue paint is used on walls everywhere. The practices with GPs and nurses are exactly the same; all have health profiles on the wall.

I interviewed the director of public health in Guantanamo, because it blew my mind how a country with the resources of Cuba was able to achieve that parity. I asked him about clinical governance, because we argue about doctors having to see a certain number of cases to remain clinically competent, and so forth. I asked him how he ensured the clinical competence of practitioners. I wish that I had brought a video camera at that point, because he looked at me as though I had two heads. That is when I realised that our system is focused on profit and the market.

He told me that the citizens in Guantanamo have the same rights as the citizens in Havana and other parts of Cuba. Therefore, the surgeon or doctor must, of course, be competent, so their duties were rotated to ensure that they retained their level of competency. Geographically, Cuba is a much bigger country than ours, but there are ways in which systems can be put in place to ensure that the citizens, irrespective of where they live, are not subject to bias.

The Cuban example is a challenge. They do not look two or three years ahead; they have a vision for five, 10, 15 or 20 years into the future. The Cubans argue that to close down a service in a certain area and to remove its capacity and infrastructure will result in an urban migratory shift, which itself creates problems and depletes capacity. Consequently, there is a bias towards an ageing population and other related factors. The Cubans take a holistic view; it is difficult to do it justice in an hour’s discussion. I recommend that the Committee go to Cuba and see the system upfront, because it challenges the notion that there is only one way to do something.

The Deputy Chairperson:

I take your point about rotating doctors in order to maintain their competences. Trusts have had to close hospitals in rural areas because the doctors say that they cannot maintain and update their skills. The simple answer to that would be to rotate them among the other hospitals in the trust area. That seems like the logical thing to do, even at GP level.

Dr Lynch:

It goes back to the mindset of what the system is there for. Is its purpose to protect public health, or is it to make life comfortable for the people who work in it? If we mean to put citizens’ public health first, we must create systems that support that. The solutions can be found if there is a political will to make something happen.

The Cuban people make incredible demands on their health service and have huge expectations. The Cuban Government are very pragmatic; when we asked them why they set certain priorities, they told us that, if they did not do things in a certain way, they would lose the support of the people, and the revolution would not continue. It is all about political will.

Mrs Hanna:

Are you saying that we need a Castro? [Laughter.]

The Deputy Chairperson:

That concludes our questions. Thank you for coming along; it has been a very interesting presentation, and it will help our inquiry.