Table of Contents

Part 1 Setting the scene

Chapter 1 New vision, new horizons

Introduction

This Strategy is centred on a whole-system approach to tackling health in Ireland. It goes beyond the traditional concept of 'health services'. It is about developing a system in which best health and social well-being are valued and supported. At its widest limits this system does not just include the services provided under the auspices of theMinister for Health and Children. It includes both public and private providers of health services. It includes every personand institution with an influence on or a role to play in the health of individuals, groups, communities and society at large. In describing the strategic direction for the future, this Strategy incorporates many strands of activity within a shared vision in order to deliver a healthier population and a world-class health system.

Health ­ a definition

The concepts of health and social gain introduced in Shaping a healthier future, the 1994 Strategy, are key to this Strategy also.

Health Gain is concerned with health status, both in terms of increase of life expetancy and in terms of improvements in the quality of life through the cure or alleviation of an illness or disability or through any other general improvement in the health of the individual or the population at whom the service is directed

Social Gain is concerned with broader aspects of the quality of life. It includes, for example, the quality added to the lives of dependent elderly people and their careers as a result of the provision of support services, or the benefit to a child of living in an environment free of physical and psychological abuse.

This Strategy adopts the definition of 'health' used by the World Health Organisation: 'a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity' 'a resource for everyday life, not the objective of living; it is a positive concept emphasising social and physical resources as well as physical and mental capacity.'

Linking the factors that determine health

To develop an effective health system, the determinants of health, that is the social, economic, environmental and cultural factors which influence health, must be taken into account. The diagram below sets out these factors.

determinants of health

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Achieving full health potential does not depend solely on the provision of health services. Many other factors, and therefore, many other individuals, groups, institutions and public and private bodies have a part to play in the effort to improve health status and achieve the health potential of the nation. One aim of this Strategy is to ensure that health is given priority across all the sectors with a role to play in improving health status.

Making the right choices

People’s lifestyles, and the conditions in which they live and work, influence their health and how long they live. The individual’s ability to pursue good health is influenced by his or her skills, information and economic means. Most people have a basic understanding of the positive and negative effects which lifestyles can have on their health. With the proper information and support, they can control many factors which influence their health and take greater personal responsibility for their own health and well-being.

The health system must focus on providing individuals with the information and support they need to make informed health choices.

Emphasising the non-medical aspects of achieving full health potential

The definition of health used in this Strategy places a value on quality of life; the emphasis will not be on medical status alone. The health system in Ireland encompasses both health and personal social services and these must be accessible and well co-ordinated. This means reaching out to groups and individuals to ensure they can understand their entitlements and access the services they need. It also means recognising the formal and informal roles of family and community in improving and sustaining social well-being in society.

Addressing quality of life issues must be a central objective of the Health Strategy.

Viewing health expenditure as an investment

This Strategy recognises the value of investment in health, the benefits to be gained in, for example, overall economic development; and the potential to contribute to societal well-being by focusing on people’s ability and willingness to work together for mutual benefit.

Much of the public debate about health services is focused on the increased cost involved. While there are valid concerns about the growth in health spending, both national and international, the proper context for this debate is one which views health spending as an investment delivering benefits as well as accruing costs.

Apart from the social value of improved health and well-being, better health also brings more direct economic benefits. For example, lower absenteeism rates should lead to increased productivity in the economy. Increased life expectancy and reduced premature mortality can lead to a longer span of productive working life in the formal economy or in other ways, for example, through family caring or through participation in community or voluntary activity. Also, good quality health infrastructure is likely to be an important factor in improving the attractiveness of particular locations in the context of spatial planning or industrial and commercial development.

The debate about health spending must recognise the social and economic value which accrues from investment in health and personal social services.

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Developing the Strategy document

Purpose

This Strategy is a blueprint to guide policy makers and service providers in achieving the vision of a future health system. It identifies overall national goals to guide activity and planning in the health system for the next 7-10 years. It also describes how the Government, the Minister and the Department of Health and Children will:

Principles

Four principles guided the development of the Strategy: Equity, People-centredness, Quality and Accountability.

Equity

Everyone should have a fair opportunity to attain full health potential and, more pragmatically no-one should be disadvantaged from achieving this potential, if it can be avoided. Inequity refers to differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust (Health 21, WHO).

Equity means that:

People from the lower socio-economic groups suffer a disproportionate burden of ill-health. The principle recognises that social, environmental and economic factors including deprivation, education, housing and nutrition affect both an individual’s health status and his or her ability to access services. The equity principle underpins the National Development Plan and the need to address health inequalities in more radical ways than in the past was highlighted in the 1999 Report of the Chief Medical Officer.

Access to health care should be fair. The system must respond to people’s needs rather than have access dependent on geographic location or ability to pay. A perceived lack of fairness and of equal treatment are central to many of the complaints made of the existing system. Improving equity of access will improve health by ensuring that people know what services they are entitled to and how to get those services and that there are no barriers, financial or otherwise, to receiving the services they need. Quality A Health System for You

Equity will be central to developing policies (i) to reduce the difference in health status currently running across the social spectrum in Ireland; and (ii) to ensure equitable access to services based on need.

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People-centredness

Ireland's future health system must become one that helps you be healthier, that is fair, that you can trust, and that is there when you need it.

The way health and social services are delivered in the system must also be personalised. Individuals differ in a great many ways, including their knowledge of and ability to understand the system and/or their own health status. Individuals have different needs and preferences. Services must adapt to these differences rather than the individual having to adapt to the system.

This means that:

A people-Centred health system :

The ‘people-centred’ health-care system of the future will have dynamic, integrated structures, which can adapt to the diverse and changing health needs of society generally and of individuals within it. These structures will empower people to be active participants in decisions relating to their own health.

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Quality

Gaining people's trust in a health system is about guaranteeing quality. People want to know that the service/care they are receiving is based on best-practice evidence and meets approved and certified standards. Improving quality in the health system requires implementation of internationally-recognised evidence-based guidelines and protocols, and on-going education and commitment from health-care institutions and professionals. Trust requires that deficiencies in the system are identified, corrective actions taken and future progress monitored.

Setting and meeting standards is not enough. The development of a quality culture throughout the health system can ensure the provision of homogeneous, high-quality, integrated health-care atlocal, regional and national level. This involves an inter-disciplinary approach and continuous evaluation of the system using techniques such as clinical audit. It also means that information systems must have the capacity to provide feedback to health providers and consumers on the quality of care delivered and received.

Quality in health means that :

Quality was one of the three main principles underlying the 1994 Health Strategy. To date many quality initiatives have been undertaken, although not necessarily as part of an overall co-ordinated plan. It is time now to embed quality more deliberately into the health system through comprehensive and co-ordinated national and local programmes.

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Accountability

Measuring the costs and quality of services, managing capital resources, co-ordinating services and managing human resources, have become increasingly complex at all levels within modern health-care organisations. Budgetary controls have improved in recent years. This progress must continue and extend to wider organisational accountability. Better planning and evaluation models must demonstrate that available resources are used as efficiently and effectively as possible. Strengthening and clarifying accountability and measurement mechanisms will require action on a number of fronts.

In addition, professionals now practise in a more demanding environment. Evidence-based guidelines, tighter professional standards, the requirements of health-care organisations, and patient rights and expectations all add to these demands. This is another aspect of accountability which must be supported and strengthened.

Accountability means :

Accountability, encompassing financial, organisational and professional responsibilities, will be underpinned in the formulation of the Strategy.

Consultation process

The Government undertook an unprecedented consultation process to help it devise this new Health Strategy. Deepening an understanding of the difficulties people face in achieving better health status has been essential to planning improvements. An emphasis was also placed on cross-sectoral issues which affect people’s health status. The role of an inter-departmental network and linkages with work on the National Anti-Poverty Strategy health targets were vital. Details of the approach taken are outlined in Appendix 1. Full details of feedback from the consultation will be published separately. Quality A Health System You

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Structure of the document

The Health Strategy is divided into three main parts. In the remaining chapters of Part 1, the health of the nation (Chapter 2) and the current health system (Chapter 3) are examined and explained. This analysis provides the signposts for the overall national goals of the Strategy and identifies priority areas requiring development and reform within the system.

Part 2 of the Health Strategy sets out the priority goals and the means of achieving them. Chapter 4 outlines the national goals for the next 7-10 years and elaborates on the detailed actions required to reach them. Chapter 5 analyses how the system needs to be developed and reformed in order to deliver the national goals, and outlines the essential actions under six frameworks for change. Chapter 6 describes the implications of the Strategy for specific groups of the population.

In Part 3 the programme for implementing the Health Strategy is described. This includes a detailed action plan listing strategic actions with targets and timeframes (Chapter 7). In addition, a programme for monitoring Health Strategy implementation and evaluating the outcomes on an ongoing basis is set out in Chapter 8.

Chapter 2 - Understanding our health

Defining health

This Health Strategy is concerned not only with illness, and the health services, but also with the role of other sectors in keeping people healthy. It also recognises the impact that being less healthy, being ill or having a disability may have on the quality of life of individuals, their families, their community and society in general.

Measuring our health ­ health status indicators

Although 'health' goes beyond 'the absence of disease or infirmity', for practical purposes population health is frequently measured by health indicators derived from life expectancy, mortality and morbidity statistics. While this presents a limited picture, it is of value in describing population trends over time and making comparisons with other countries. This section considers life expectancy, mortality and certain morbidity trends in Ireland and makes comparisons with European Union (EU) countries.

Life expectancy

Life expectancy at birth has substantially increased for Irish women and men over the past four decades although life expectancy is still poorer for men. At the same time, life expectancy in Europe has increased at a greater rate (Figures 2.1 and 2.2).

female life expectancy male life expectancy

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Life expectancy has also increased in older age groups. However, this increase is relatively small. For example, the increase between 1970 and 1997 was only 1.7 years for males and 2.5 years for females. Despite improvements, Irish life expectancy at age 65 years was still the lowest of all 15 EU countries in 1997.

Improvements in life expectancy in Ireland reflect the lower mortality rates seen in infants and young children over recent years. These increases in life expectancy at birth contrast with the relatively small increases for older people for whom the prevention and management of chronic conditions continue to represent a major challenge.

Infant mortality

Infant mortality measures deaths in children under one year of age per one thousand live births and is a reliable indicator of a nation's health. Figure 2.3 highlights the continuing progress made over the past two decades.

infant mortality rates

The perinatal mortality rate, defined as stillbirths and deaths of infants aged under one week per thousand total births, has also decreased. Like general mortality rates, the rate of perinatal mortality remains higher than the EU average.

Major causes of mortality

Circulatory disease and cancer account for nearly 65 per cent of deaths every year in Ireland (Figure 2.4). The relative contribution of cancer to overall mortality has been increasing in recent decades. For example, cancer accounted for only 11 per cent of overall mortality in 1950 compared with 25 per cent in 1999. This pattern is likely to continue in future years on account of current population trends. The major causes of premature mortality in 1999 are illustrated in Figure 2.5 where it can be seen that over 60 per cent of deaths are due to cancer or cardiovascular disease and 16 per cent to injury/poisoning.

mortality by cause mortality by cause

As described in the following pages, it is clear that with the exception of cerebrovascular disease (stroke), the differences between Irish and EU mortality rates are considerable. The contribution of these diseases to premature mortality has already been highlighted. In addition, as our population ages it is likely that cancer morbidity will increase.

Many deaths caused by cancer, circulatory diseases and injury are preventable

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Cardiovascular disease

Cardiovascular disease, which includes coronary heart disease, stroke and disorders of blood vessels, is the single most important cause of mortality in this country and a major cause of premature mortality for many. Other people with cardiovascular disease suffer chronic ill-health and reduced quality of life. While it is probable that the target set in the 1994 Health Strategy to reduce premature mortality from cardiovascular disease by 30 per cent will be met, Figure 2.6 illustrates the scale of the problem in Ireland. While ischaemic (coronary) heart disease death rates for the total population continue to fall, the large differences between Irish and EU rates remain.

A high percentage of cardiovascular mortality and morbidity is preventable.

Ischaemic heart disease

For strokes, the situation is more encouraging where the once high mortality rate has been reduced considerably and Irish rates are similar to the EU average (Figure 2.7).

Cerebrovascular Disease (stroke)

Cancer

Approximately 21,000 new cases of cancer are recorded annually. One in three individuals will develop cancer in the course of their lifetime but not all will die from the condition.

Cancer is more common in older people (Figure 2.8). As our population gets older, we can expect more cases of cancer.

Age specific cancer rates

Cancer is the second most frequent cause of death and represents a major burden for individual sufferers, their families, and the health system. Since 1994, mortality rates have been reduced. However, when compared to the EU, there is scope for improvement (Figure 2.9). Seven thousand cancer deaths occur annually in Ireland, of which lung cancer is the most common (Figure 2.10). Other common killers include colorectal cancer, prostate cancer in men, and breast cancer in women. A range of preventive initiatives in terms of screening and tackling environmental factors can reduce risk.

It is estimated that around 30 per cent of all cancers are due to smoking.

All cancers Age standardised mortality rates, Lung cancer mortality rates,

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Injury/Poisoning

The most common causes of injury-related deaths are road traffic accidents and suicides, followed by falls, poisoning and drowning. The European Home and Leisure Accidents Surveillance System (EHLASS) Report for Ireland (1998) demonstrated that 10 per cent of accidents require hospitalisation. The Hospital In-Patient Enquiry system (HIPE) demonstrates that accidental falls are the most common type of injury requiring hospitalisation (Health Statistics, Department of Health and Children, 1999).

Every year, approximately 1,500 Irish people die from injuries. While mortality from road traffic accidents has been gradually declining, between 400 and 500 people die on Irish roads annually. There is also evidence of an increase in the number of road traffic accidents in recent years. Together, these data suggest that more people are surviving their injuries. It is worth noting that injuries represent a larger burden on the health system than many other health problems and the financial and social costs are high ­ in terms of potential years of life lost in those aged under 65, injuries are more significant than either cancer or cardiovascular disease.

Figure 2.11 shows the rate of self-injury and suicide in Ireland between 1980 and 1998. Both have been increasing steadily since 1980 although increased reporting may be affecting the overall trends shown by the data.

Suicide and self-injury

Injuries are a common cause of premature mortality and a significant cause of morbidity.

This area has been somewhat neglected as a focus for policy development because of the view that accidents are unpreventable random occurrences. In fact, there is wide scope for prevention.

Life expectancy in Ireland is increasing, but not as fast as in the EU. Life expectancy is poorer for males than females. The gap in life expectancy between Ireland and the EU is widening. Life expectancy for older people has shown only modest improvement.

Infant mortality rates are falling but are still higher than in the EU. General mortality rates due to cardiovascular disease and cancer are still above EU levels. Due to demographic change in Ireland, cancer rates are likely to increase in future years.

Injuries represent a significant financial and social burden on the community and the health system.

Many deaths caused by cancer, circulatory diseases and injury are preventable.

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Health and lifestyle

Lifestyle choices directly influence our physical and mental well-being. Two national surveys of health-related behaviours among adults, The National Health and Lifestyle Survey (SLÁN), and among school-going children, Health Behaviour in School-Aged Children (HBSC), have established baseline information on lifestyle behaviour in Ireland. The European Community Household Panel Survey also provides information on self-reported health status.

In these surveys, most Irish adults reported excellent or very good health. This was higher for non-smokers. The vast majority of children perceived themselves as healthy. However, despite this good overall message, there are disturbing findings relating to smoking, drinking, healthy eating and physical activity (Figure 2.12).

Lifestyle and health Health behaviour in children aged 16 Years

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HBSC survey results indicate that the percentage of Irish students who had experimented with each of a range of substances was higher than that of the EU average, particularly in relation to cannabis, although it has declined since the 1995 figure. Results also indicate that the consumption of alcohol is becoming more regular within younger age groups in children, 35 per cent of boys compared with 24 per cent of girls reported that they were drunk on at least one occasion and 20 per cent of 15-17 year olds reported having been drunk more than ten times.

The data highlight areas of concern including levels of smoking, alcohol intake, unhealthy diet and sedentary lifestyles in many young people as well as the social variations in health and lifestyle behaviours between the lower and higher socio- economic groups. Healthy lifestyle has a major role to play in the improvement of an individual's health status.

Lifestyle influences future health. A significant proportion of Irish adults and children live unhealthy lifestyles. If the trends in smoking, alcohol consumption, diet and lifestyles are not reversed, this is likely to continue to lead to many avoidable deaths in future years.

Inequalities in health status

Inequalities in health can exist for a variety of reasons, including geographical location, gender, age, ethnicity, hereditary factors and socio-economic status. Poverty, unemployment, education, access to health services and environmental factors including housing and water quality, all play important roles in determining the health of individuals. Disparities in health status within the population lead to consideration of the links between socio-economic factors and health. There are clear occupational class gradients in mortality.

Occupational class gradients in health

Other lifestyle factors and geographic location may also have an underlying socio-economic link. For example:

Standardised death rate per 100,000 population

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There is now strong and consistent evidence of a relationship between health and socio-economic status in Ireland. This is an important consideration in addressing the overall health of the population. Effective action will require a multi-sectoral approach.

Measuring the impact of ill-health and disability

Overall indicators of life expectancy and mortality provide a limited picture of ill-health in a community. This is because they tell us only about fatal conditions; whereas a great deal of chronic ill-health is caused by non-fatal disease. There are considerable gaps in information related to morbidity which result in a somewhat limited picture of the health of the population, particularly in relation to the occurrence of particular illnesses and to quality of life issues. Information from out-patient and primary care services is limited. Data on mental health and chronic disease are also incomplete.

However, the social cost of some non-fatal illnesses such as those caused by accident or injury is self-evident, as is the burden that illnesses such as cancer can place on sufferers and their families during their lifetime. In this section some further aspects of the nation's 'health' are dealt with ­ the degree to which mental ill-health and disabilities place a demand on individuals and the health system in Ireland.

Mental health

Mental health is recognised increasingly as a major challenge facing health services in the twenty-first century. Comprehensive data on community mental health services are not currently available, but detailed information on in-patient mental services is available from the National Psychiatric In-Patient Reporting System (NPIRS).

Number of psychiatric admissions by diagnosis

In 1999, there were 25,062 admissions to Irish psychiatric hospitals of people aged 16 years or older, which is a rate of 930 per 100,000 population (Figure 2.18). Of these, 7,105 (28 per cent) were first admissions.

First admission rates have shown little change over the past 35 years, whereas all admission rates have increased by almost half. Lengths of stay in hospital have decreased, illustrating a different manner of using hospital beds, moving towards more frequent crisis intervention usage or short in-patient treatment combined with more extensive community-based care.

More than one in four adults will suffer from mental illness at some point during their lives. Twenty-five per cent of families are likely to have at least one member who suffers from mental illness. The WHO has estimated that, globally, approximately 20 per cent of all patients seen by primary health-care professionals have one or more mental disorders. In Ireland, it has been estimated that 10 per cent of the general populationsuffers from depression and 1 per cent from schizophrenia.

It is likely that the numbers of people presenting to the mental health services for treatment will increase in the coming years, due in part to the modernisation of the services and the reduction in the stigma associated with their use. The ageing population and the increasing incidence of social problems, such as drug abuse and family breakdown, are also likely to contribute to increasing demands on the services in the future.

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Intellectual disability

With improvements in child health services over recent decades, a larger number of children with intellectual disability are now reaching adulthood. The recently established National Intellectual Disability Database provides a profile of the Irish population with intellectual disability (Figure 2.19).

Number of persons with intellectual disability by category,

Thirty-four per cent of people on the database were aged 19 years and under, thirty per cent were aged between 20 and 34 years, twenty six per cent are aged between 35 and 54 years, and ten per cent were aged 55 years or over.

The prevalence of intellectual disability may increase in coming years due to the steady increase in maternal age and recent advancements in neonatal care which increase the survival prospects of babies at risk of intellectual disability.

Physical and Sensory Disability

The Health Research Board is developing a National Physical and Sensory Disability Database, which will provide a profile of the current population of people with a disability. It will also help in monitoring demographic changes, as well as enhancing service planning by recognising the needs of individuals, their families and service providers.

There are considerable numbers of people with chronic illnesses or disabilities which affect their social well-being.

Improving information about service needs is a priority.

In extending existing services and developing new services, the focus must be on responding to identified needs in a holistic way and maximising the opportunity for individuals to achieve their full health potential.

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Summary of key messages

Action to increase life expectancy and achieve better health for everyone must be a priority. This involves taking intersectoral action on lifestyle and environmental factors as key determinants of good health.



There is a need to take more deliberate and assertive action in addressing health inequalities.

Trends indicate that without decisive intervention, the gap in health between the rich and the poor will continue to widen. The Health Strategy must prioritise supporting the disadvantaged to improve their health status.

The quality of life aspect of health needs to be highlighted. An increased understanding and awareness of the impact certain illnesses have on quality of life needs to be developed. This will involve creating a supportive environment to maximise social well-being for vulnerable groups.

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Chapter 3 - The health system explained

Introduction

Chapter 2 sets out a clear message about making Ireland a healthier nation and making sure that good health is enjoyed more equally across society. The Irish health system, like all systems, has particular features which influence the way it is structured and the volume and quality of services it provides. These features affect the experiences of people who require services. In this chapter, the degree to which the current system adequately provides equitable, people-centred, quality and accountable health and personal social services in Ireland is considered.

To begin, key features of the system are outlined as a context for the Health Strategy. There is a critical assessment of the strengths of the system that will support strategic goals; and what weaknesses may hinder achieving them. The opportunities and threats that will influence the achievement of goals in the years to come are outlined. In conclusion, key goals to complement those identified in Chapter 2 are outlined. The changes and development required within the health system to match a new strategic direction are also established.

The health system ­ facts and figures

A number of important characteristics underpin the structure of the Irish health system and influence the way it works. Some of the system's defining features are outlined below.

Organisational structures

The Government, the Minister for Health and Children and the Department are at the head of health service provision in Ireland. The Department'sprimary role is to support the Minister in the formulation and evaluation of policies for the health services. It also has a role in the strategic planning of health services in consultation with health boards, the voluntary sector, other government departments and other interests. The Department has a leadership role in areas such as equity, quality, accountability and value for money.

The health boards, established under the Health Act, 1970 are the statutory bodies responsible for the delivery of health and personal social services in their functional areas. They are also the main providers of health and personal social care at regional level. Health boards are composed of elected local representatives, ministerial nominees and representatives of health professions employed by the board. Each health board has a Chief Executive officer (CEO) who has responsibility for day-to-day administration and is answerable to the Board. The Health (Amendment) (No. 3) Act, 1996 clarified the respective roles of health boards and their CEOs by making boards responsible for certain reserved functions relating to policy matters and major financial decisions and CEOs responsible for executive matters.

In addition, many other advisory, executive agencies and voluntary organisations have a role to play in service delivery and development in the health system. Figure 3.1 outlines the overall structure. A list of the main health service organisations is contained in Appendix 2.

Figure 3.1 Structure of the health system in Ireland

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Population distribution

The Central Statistics Office estimated Ireland's population at 3,838,900 in April 2001. This estimate is based on the last census carried out in 1996. The population in 1996 was 3,626,087. The distribution of the population across board areas at that time was as follows:

Distribution of population between health boards - 1996 Census

Human resources

Some 81,500 people work in the public health sector, making health one of the largest public service employers. Significant growth in employment has happened in recent years, particularly in the year 2000. The employment level in the public health service agreed for 2001 is 86,500. Table 3.2 shows the numbers (whole-time equivalents) (WTEs) employed in 2000. In line with population distribution, the greatest number work in the Eastern Regional Health Authority area and the least in the Midland Health Board region.

Numbers in employment (WTEs) by employer Staff breakdown by grade in public health services - 2000

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Table 3.3 shows the number of staff employed in the public health services in 2000. The number has increased from 68,000 in 1997 to 81,500 in 2000. There were significant increases in paramedical and support staff, reflecting substantial investment in a range of services such as childcare and disability. There was also a large growth in frontline clerical and administrative staff who support doctors, nurses and other health professionals by relieving them of administrative work and allowing them to concentrate on their professional tasks. Of all staff classified as management/administrative, it is important to note that nearly two-thirds are involved in front-line services for patients, and that a further 5 per cent deal with legislative and information requirements such as Freedom of Information and registration of births, deaths and marriages while others carry out key functions such as service planning and auditing.

Pay costs and remuneration

Pay costs account for some 70 per cent of current spending on health and personal social services. For planning purposes, when calculating the full pay costs of health professionals, an average of £40,000 (€50,790) per professional is used. For all health service staff in health boards, the average pay in 2000 was in the region of £24,500 (€31,108). Some examples of average pre-tax pay for selected grades in the health services are set out below.

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Funding

In Ireland public funding makes up approximately 78 per cent of all the money spent on health care. Private funding, through insurance arrangements, makes up approximately another 8.5 per cent of funding. The balance is what individuals pay in 'out-of-pocket' expenses; for example the fees non-medical cardholders pay for general practitioner (GP) and other therapy services.

The public money spent on health comes from funds raised primarily through general taxes. The money raised is allocated to the Department of Health and Children and, in turn, to the regional health boards and the Eastern Regional Health Authority. The boards provide many services themselves and use some of the monies to pay other health service providers (such as health agencies, voluntary hospitals or voluntary bodies) who provide health and personal social services in their region. The total amount of money spent on health in 2001 (excluding capital funding) will be in excess of £5.3 billion, more than double the amount spent in 1997. More than half of the additional money invested in the last five years has been directed to continuing care services, i.e. services for people with disabilities, older people and children. Figure 3.2 shows the breakdown of this expenditure for the year 2001.

Health expenditure 2001, by programme

Table 3.3 shows per capita spending on health services in Ireland from 1990-2001 and compares it with average spending per head for EU countries.

Per capita health spending 1990-2001 in EU countries: US$(PPP Terms)

Eligibility for services

Any person, regardless of nationality, who is accepted by the health boards as being ordinarily resident in Ireland, is eligible {To be eligible means that a person qualifies to avail of services, either without charge ( full eligibility) or subject to prescribed charges (limited eligibility)} for health and personal social services. About one-third of the population hold medical cards which entitle them to receive services free of charge. Non-medical cardholders are entitled to some services free of charge. Effectively, everyone has coverage for public hospital services with some modest charges, and some personal and social services, but only medical card holders have free access to most other services (including general practitioner services).

Under the Health Act 1970 eligibility for medical cards is based on a notion of 'hardship'. In today's terms, 'hardship' is defined by income guidelines drawn up by the health board CEOs, which are used as a means test to determine eligibility. These guidelines are revised annually. Health board CEOs also have discretionary powers to award a medical card on hardship grounds even when a person's income exceeds the guidelines.

A number of other schemes govern eligibility for services for certain groups of the population. These include the Long-Term Illness Scheme; Infectious Diseases Regulations; Maternity and Infant Care Scheme; School Medical Service; Public Dental Service; Nursing Home Subvention Scheme; preventive services (such as primary immunisation schemes and child health clinics) and early detection services (such as the National Breast Screening Programme).

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Strategic development of services

In recent years a planned and strategic approach to the health services coupled with the most significant programme of investment in health care ever undertaken (which has seen spending on health care services increase from £2.7bn in 1997 to more than £5.3bn in 2001) has resulted in a number of significant advances in health and personal social services.

This approach is underpinned by the publication and implementation of a number of important strategies, including the following:

The National Cancer Strategy (1996) which aims to reduce the incidence of cancer and improve services for those with cancer by providing for additional capacity and location of services as well as the introduction of comprehensive screening programmes.

The Cardiovascular Strategy (1999) which aims to reduce the incidence of heart disease through co-ordinated multi-sectoral action at national, regional and local level as well as improve the provision of services for people requiring cardiac care.

The National Health Promotion Strategy (2000-2005) which aims to raise public awareness of the numerous determinants of health through multi-sectoral action.

The National Children's Strategy (2000) which sets out a ten-year plan to improve the quality of all services to children through coordination and planning at national and local level.

The National Drugs Strategy (2001-2008) coordinated by the Department of Tourism, Sport and Recreation, which sets out a series of objectives and actions for a number of government departments and agencies to help prevent as well as tackle drug abuse.

The following table sets out some of the many service developments in recent years. More comprehensive data are available on the Department's website.

Key service developments in recent years

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The waiting list initiative has funded a large number of elective procedures and has enabled thousands of patients to receive treatment more quickly than would have been possible otherwise. Waiting times have been reduced substantially in a number of specialties. For example the number of adults waiting for longer than 12 months for cardiac surgery has reduced from 587 to 190 between June 2000 and June 2001; the number of children waiting for longer than 6 months for cardiac surgery has reduced from 66 to 10 in the same period.

Services for people with an intellectual disability: Between 1996 and the end of 2001, additional investment will have led to the creation of an additional 1,650 residential places, 2,300 day places, and a 70 per cent increase in respite care places. The number of people with intellectual disability cared for in psychiatric hospitals is now just below 600, down from 970 in 1996.

Services for people with a physical or sensory disability: Since 1997, developments include an additional 150 residential and respite places, 400 day care places, community/home support services as well as additional occupational therapy, speech and language therapy and physiotherapy services. The National Physical and Sensory Disability Database will enable service requirements on a national basis to be identified.

Services for older persons: New investment since 1997 has resulted in the creation of an additional 400 places in community nursing units and over 1,000 day places. The medical card scheme has been extended to people aged 70 years and older. The provision of these additional facilities, together with the introduction of the Nursing Home Subvention Scheme in 1993, has resulted in a significant expansion in the range of services available for older people with a consequent improvement in the quality of life for a great number of them.

Services for children: The Child Care Act, 1991 has been fully implemented. Since 1997, over £92million has been invested to create the infrastructure necessary to support expansion of services, including additional personnel at all professional levels. Recent developments in the child protection services include the ongoing implementation of Children First-national guidelines for the protection of the welfare of children, and an increase in the provision of high support and special care places from 17 in 1996 to 83 with plans for a further 56 places nationwide. Family support service developments include the establishment in 17 pilot sites of Springboard, a community-based early intervention initiative to support families. Developments in the child health services include the ongoing implementation of a range of immunisation programmes and the implementation of the Best Health for Children report to assist each child to reach his or her best health and well-being potential.

Services for people with mental illness: The mental health services have continued to progress towards a more community-oriented service, with a corresponding reduction in the numbers of long-stay patients in psychiatric hospitals. Forty-three per cent of all acute admissions are now made to units attached to general hospitals, compared to less than one third of admissions in 1994. Since 1994, new acute psychiatric units have been opened in general hospitals in Dublin, Navan, Tallaght, Cork city and Bantry. Further units will be opened shortly. The number of community residences has increased from 368 in 1994 to 402 in 2000 with places increased from 2,685 to 2,003 in the same period.

Significant progress has also been made in the development of specialist psychiatric services for children and older people. Now, all health boards have approval for at least two consultant-led teams in child and adolescent psychiatry and at least one consultant led team in the psychiatry of old age. Services for prisoners and the homeless have also been developed since then.

Carers: New developments include additional funding for respite care for carers, carer support groups, training of carers and home care support services, as well as additional community support services for older people and their carers.

Health promotion: The wide range of health promotion initiatives including initiatives on anti-smoking, alcohol consumption, nutrition and diet, exercise, as well as other measures to promote healthy lifestyle choices.

Dental services: The 1994 Dental Treatment Services Scheme provided for free basic dental services for over 1 million adult medical card holders; eligibility for public dental services has been extended to all children under 16 years.

The health element of the National Development Plan 2000-2006 (The Health Capital Strategy) provides for substantial capital investment in the infrastructure of the health system on a phased basis. It includes commitments to funding for general hospitals, services for older people, mental health services, services for persons with disabilities, primary care, child care and information and communications technology. A fundamental objective of the National Development Plan is to equalise investment between the acute and non-acute hospital services by the end of the period of the plan. The commitments to funding contained in the plan will have significant impact on the capacity of the health system in the years to come.

Strengths of the health system

Health as a priority

Health has remained high on the public agenda, reflecting ongoing public and political attention. In a time of economic growth and prosperity, health is seen as an area for additional investment and this is already reflected in Government spending priorities in recent years. It is clear from the consultation process that health is a priority issue for the general population. The level of response to the call for submissions was relatively high-particularly from individuals. There is evidence from this process of considerable support, both within and outside the health system, for the prioritising of investment in a high-quality, properly resourced health system.

Local structures

As outlined earlier, the principal executive agencies delivering health services are the regional health boards, which have been in place now for some thirty years. The range and diversity of health services touch on every community. Ensuring that these services are effective and responsive requires delivery structures that are close to the communities. By organising the ten health boards on a regional basis the system has shown a clear capacity to develop and oversee rapidly developing services.

Skilled workforce

The health service has a highly committed and dedicated workforce and this has enabled very significant developments in health and social services to be undertaken. The ability to deliver a high-quality service is greatly supported by the knowledge, skill and attitude of the workforce within the health system, the high-quality training that professionals receive, and their enormous commitment to the health and welfare of their patients and clients.

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Since 1994, there have been considerable advances in the area of human resource management and staff development.

In the meantime, new challenges have also arisen for both managers and staff. The most recent national agreements with the social partners have strengthened the general commitments given in 1994 to planning workforce needs, and developing managers, training and education. Several policy documents have already been prepared to guide and support these developments.

Improved strategic planning in the health system

The 1994 Strategy Shaping a healthier future redefined the roles of health providers and the Department of Health and set out a strategic approach to improving health status and developing service provision. It addressed the strands of legal and financial accountability arrangements, together with organisational and management reform.

Legislation, including the Health (Amendment) Act, 1996, subsequently underpinned the implementation of financial and organisational accountability within the health system. This was an important milestone in achieving greater accountability regarding expenditure and levels of indebtedness. The adoption of service plans, annual reports and annual financial statements are now deemed reserved functions of each health board and are vital tools in the planning process at regional and national level.

This kind of strategic planning and building up of the planning system has been described as 'very innovative for the period', and 'an enormous advancement for planning and policy development'. It provides a sound framework for planning and implementing strategic policy objectives. It also creates the conditions in which additional investment can be aimed at specific programmes and the outcomes of investment can then be demonstrated more explicitly.

The voluntary/statutory interface

Co-operation between statutory and voluntary providers allows for a more responsive and dynamic approach to meeting needs. There have been changes in the profile of activity and funding arrangements in recent years. A framework for more formal service agreements between voluntary and statutory providers has been developed in some areas. There continues to be a very strong and diverse role for the community/ voluntary sector in the health system. Good relationships and mechanisms for planning and delivering services already exist, and these provide excellent models on which to build. These partnership arrangements are a key strength of the system.

Limitations and shortfalls in the current health system

Equitable access

Two questions emerge from the consultation process and the reports of the Strategy working groups:

Eligibility

The framework for eligibility should ensure that financial barriers do not adversely affect an individual's opportunity to reach his or her full health potential. The existing schemes which provide for certain services to be delivered free of charge (the most important of which is the medical card scheme) do not adequately reflect the levels at which 'hardship' or financial barriers to accessing the necessary care arise. Emphasis was placed during the consultative process on establishing good health status early in life, with particular importance attached to supporting families with children in this context.

Eligibility arrangements across a range of schemes need to be reviewed to ensure that criteria fully reflect the levels at which barriers to accessing care arise. Investment in the health of children was also identified as a priority.

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Access

While individuals may be eligible for services, this does not mean that they will receive the services when they need them or in a reasonable timeframe. The situation is most evident in the hospital system where public patients may have to wait considerably longer than private patients for certain elective (non-emergency) treatment. It also arises where some community-based services are available to public patients in one part of the country but less available in another.

The Strategy must address the 'two-tier' element of hospital treatment where public patients frequently do not have fair access to elective treatment. All patients should have such access within a reasonable period of time, irrespective of whether they are public or private patients. Public patients should also have reasonable access to the range of publicly funded services irrespective of where they happen to live.

Patient focus

In this Strategy, 'people-centredness' has been identified as a key principle. Feedback from the consultation process suggests that patients and clients often have to adapt to the way the system works, rather than the system responding to their needs. The consultation process showed that:

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Attitudes of providers to service users were seen, in some cases, as showing a lack of courtesy, sensitivity, flexibility or respect. The question of health-care workers having inadequate time to listen and reassure individuals was also raised, although submissions often recognised that this was due to the pressure experienced by many staff. Much concern was expressed about opening hours and appointment arrangements for out-patient clinics as well as excessive waiting times in Accident and Emergency departments. Submissions argued that patients' loss of time, and how this affects their work and family commitments, are inadequately recognised in the organisation of the system.

Submissions from organisations also identified the need for better mechanisms for consultation with a wide spectrum of interests. This includes local communities, staff, private providers and users, and existing provisions for health board representation and consultation with the voluntary sector. Consultation and participation in decision-making for communities, members of the public, patients, clients, families/carers, providers and service users were also raised in the parallel consultation process on the National Anti-Poverty Strategy and Health.

The health system must become more people-centred with the interests of the public, patients and clients being given greater prominence and influence in decision-making at all levels. This points to a need to empower individuals through:

Poor integration of services within the system

Improving 'patient focus' in delivering services was linked to calls during the consultation process for a 'seamless service'. Factors identified as obstacles to integration were the following:

Focus needs to be placed on promoting and facilitating the delivery of health care through inter-professional partnership for the benefit of the patient. For a partnership model to be effective, the old hierarchical thinking in relation to the professions must dissappear, along with the turf wars which are a barrier to patient care. Quote from the public consultation

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The submissions emphasised the need for:

Quality

Quality and continuous improvement must be embedded in daily practice to ensure consistently high standards. The health system does not have the mechanisms and infrastructure to support this adequately at present. Issues raised by the Health Strategy Consultative Forum and departmental working groups included:

High-standard, well-integrated and reliable information systems are central to quality. While a number of good information systems exist or are being developed, the ability to identify health needs or to evaluate equity, efficiency, effectiveness and overall quality of health services is limited. This is due, in part, to inadequacies in the availability, quality and integration of health information systems.

A number of steps will be required to support and develop the quality agenda. Prioritising investment in information systems will be a pre-requisite to the planned shift to an evidence-based approach to decision-making at all levels ­ policy, clinical or managerial ­ in the health system.

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Configuration, capacity and funding of the health system

The consultation process showed that people understood the breadth of health and personal social services and had clear views on the priorities for change.

Consultation process: proposals for change

Organisations also identified particular areas or groups for special attention: 43 per cent of submissions referred to acute hospital care; 31 per cent to community services and 60 per cent to special needs groups such as older people (15 per cent); people with mental health problems (13 per cent); people with physical and sensory disabilities (10 per cent) and people with learning disabilities (7 per cent). The priority given to the development of services for particular types of care and care groups was of particular concern in drafting the Health Strategy.

Configuration of services

The consultation process pointed to the need for more care in the community and identified many services that require to be developed in a cohesive way. The public demand is for services closer to home which can be more easily accessed when needed. Accordingly, radical reconfiguration of the whole primary care structure is central to the Strategy. This will require a stronger emphasis on the community setting and emphasises the vital role individuals, families, communities and other sectors have in helping everyone to achieve their full health potential.

Capacity/service development issues

Figure 3.3 shows the considerable development that has taken place across a range of services in recent years. However, deficiencies remain and these need to be addressed as part of the Health Strategy.

Acute hospital services

Acute hospital services form a vital part of the health system. Despite considerable reductions in acute hospital bed numbers in the late 1980s and early 1990s, the level of services to patients increased significantly. Taken together, in-patient and day case activity in hospitals has increased by 21 per cent since 1995, an annual average increase of 4.2 per cent. However, this has imposed serious strains on hospital staff, facilities and services.

The consultation process highlighted problems of capacity, waiting times for some specialties and in out-patient departments, and frequent cancellation of non-emergency treatment.

The Health Strategy must address the problems in acute hospital services. This will require:

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Developments for particular care groups

As mentioned earlier the needs of a number of specific groups received particular prominence during the consultation process. Older people and people with disabilities, including mental illness, were mentioned in a great many submissions, both from individual members of the public and from organisations.

In the case of older people, the emphasis was largely on improving the quality of life for older people. Supporting their carers, especially family carers, was an important concern. Providing improved assessment, community support services and rehabilitation in order to enable older people to remain in their own homes or community for as long as possible was also mentioned, as well as many proposals on the availability, cost and quality of long-term residential care.

In relation to special needs there were similar proposals for increased community support and respite places, as well as proposals relating to advocacy for vulnerable groups; greater education for health-care workers and the public about the needs of people with disabilities and mental illness; and many proposals for the development of specific specialised services in these areas.

Funding

There has been extensive debate about funding the health system. Despite considerable investment in recent years, two problems remain in the current system of funding. Firstly, the perceived inflexibility and uncertainty of the current allocation system, which is centred on the annual Estimates and Budgetary cycle, has been raised in submissions as a weakness, given the need for longer-term planning.

Secondly, despite increased investment levels in recent years, the levels of funding were considered in many submissions to be inadequate to support current needs. The concerns about capacity and the configuration of services underline the need for ongoing capital investment, expansion in acute hospital services and substantial strengthening of primary care and community services.

The Health Strategy must address the need for:

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Human resources

Human resources and management were also raised during the consultation process. It was considered by one of the departmental working groups and a sub-group of the Health Strategy Consultative Forum which stressed the need for an adequate skilled workforce. The lack of availability of adequate numbers of staff in certain professional grades has had a seriousimpact on service development for a number of years. A second area of concern was the increasing difficulty for all public sector organisations to compete as employers of choice in the labour market.

A proper human resource plan is needed to support any new health strategy. Strategies may come and go, but the people who are an integral resource to the health system need to be appreciated, developed, motivated and effectively managed with respect and dignity if the desired vision, values, goals and objectives are to become reality. Quote from the consultation with organisations.

It has become clear that to meet the growing workforce demands and to make the health system an employer of choice the health service must have:

Organisational issues

The structure of decision-making, roles and responsibilities within the health system is complex, with many layers and very many intersecting roles. On the role and functions of health boards, the submissions suggested that achieving a balance between national and local decision-making is difficult. The need for greater clarity of levels of decision-making was also raised. This includes the roles played by the boards, the Department of Health and Children and the Department of Finance. Despite improved strategic planning in recent years, deficiencies remain, particularly in the area of acute hospital services where local considerations rather than national evidence-based policies tend to hold sway.

Reports of the departmental working group and sub-group of the Health Strategy Consultative Forum suggested that, in some respects, the health boards operate as separate entities with a resultant lack of consistency in the standard and stage of development of services. Initiatives adopted in one or more boards to apply 'best practice' throughout the system are not always entirely effective. In addition, it is suggested that health boards have not been wholly successful in establishing a regional identity within their functional areas; county loyalties remain as a strong feature. This is seen as having the potential to affect the optimal development of patient-centred services within each health board region as a whole.

Meeting these criticisms will require:

Opportunities/challenges for the future

In setting out important factors for developing this Health Strategy, it was suggested that a key factor was 'ensuring appropriate responsiveness to unplanned events' (Wiley, 2001). It is not possible to predict 'unplanned' events, but it is possible to look to the future and consider some of the trends that may affect the priorities for the health system and the changing nature or volumes of activity in particular areas.

Demographic patterns

Population trends will have an important impact on the demands and pressures in the health system in the years to come. Population projections for the next 20 years show that not only will the population increase but also the number of older people will form a larger portion of the population (Figures 3.4 and 3.5). Utilisation of health and personal social services increases with age; not just services specifically for older people, but all services. In addition, Ireland is now moving towards a more multi-ethnic/multi-cultural society. In health, as in other areas of public policy, this brings a need to plan for diversity with a wider range of needs to be addressed ­ affecting both the health workforce and the patient/client group.

Projected total population

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CSO Irish population projections

The physical environment

Food safety, global warming, a reduction in air quality and availability of housing, are all areas of growing public concern. Trends in the area of food production, many brought forward by the commercial pressures to intensify production, raise questions about food safety and the transference of disease from animals to humans. The continuing pressures on the environment affecting water and air quality are concerns that are shared globally.

The importance of fostering and maintaining links with international organisations in order to anticipate, manage and protect against risks emerging from changes in the physical environment will be emphasised in the Health Strategy.

Science and technology

For many people, science and technology hold the potential for wonderful opportunities for the future. Cures for potentially fatal disease, other more advanced diagnostics, biotechnology applications, tissue engineering, imaging capacity and advances in drug development all hold the possibilities of lengthening life and improving its quality. Developments in these areas also suggest that in the future there will be a greater emphasis on the possibilities for prevention and a much more intensive approach to preventive medicine.

Information technology advances are also likely to revolutionise care. These advances include a variety of patient care databases; opportunities to share and work to standardised evidence-based protocols and decision-support systems; and the possibility of remote consultations through telemedicine.

On the other hand, these advances may also present potential threats. The availability of new treatments and technologies may bring greater demands for new services, some with major ethical implications. The problem of infection brought about by increasing antibiotic resistance is becoming more acute and new infectious agents will continue to emerge. Increased international travel and migration will pose additional challenges in Ireland.

The Strategy must establish the mechanisms and structures to support the health system in monitoring and evaluating the benefits and risks which technology can bring so that the system can take advantage of benefits and respond quickly to challenges that may arise.

Social trends

Health follows a social gradient: 'poor people get sick more often and die younger'. Chapter 2 has outlined how much wider than health services or genetic endowment are the determinants of health. It has been suggested by the Combat Poverty Agency (CPA) that poverty can reduce the opportunity or the motivation to adopt healthy lifestyles. In addition, poverty can make it more difficult to access or afford adequate or appropriate health care. As acknowledged by the CPA (2001), tackling health inequalities is inextricably linked with poverty. In devising the actions to tackle health inequalities for the Health Strategy, the Department has worked closely with the group working to review the targets for health for the National Anti-Poverty Strategy. The Strategy must also reflect the inter-departmental working required to tackle the link between poverty and the other determinants of health, outside of health service provision.

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Quality of life

With rising prosperity, expectations of high quality of life have increased greatly. At the same time, the pressures of modern life are giving rise to more people feeling stressed in their daily lives. Strong social support contributes to health by providing people with emotional and practical resources. However, changes in family structures and community life may mean these supports are less available than in the past. Groups such as the elderly, people with disabilities, people with mental illness, and those with chronic illnesses, expect to be able to enjoy a reasonable quality of life. In the future, services will be planned to meet these expectations and the 'whole person' perspective.

Community and social capital

Many groups have emphasised the impact which changes in the availability of work, workplace practices and employment law have already had on the numbers and structure of the workforce. Greater flexible working and the increase in job opportunities have enabled many more women to take up paid employment.

Commuter towns, where those living in new developments spend their days travelling to a distant employment, may give rise to a loss of 'community' associated with more traditional neighbourhoods. The loss of such community support also has implications for the care of young children and for support for older people.

The evolving body of research on social capital suggests that participation in formal and informal networks such as sporting clubs or basic neighbourhood activity can have a major impact on health status. While the evidence for Ireland is not fully clear, there are indications that these networks are declining in places.

The Health Strategy must take account of the changing role of the family and community and improve supports for community and family participation in voluntary and informal care.

Summary of key messages

The health system has many strengths on which to move forward. In Chapter 2, improving health status, reducing inequalities in health, and addressing quality of life issues are clearly identified. The analysis in this chapter suggests further goals arising from people's experience of interacting with health and personal social services. They can be summarised as follows:

Eligibility, access and equity

Responsiveness and appropriateness of care

Improving system performance

Meeting these concerns will require changes to the current health system, particularly in

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