Part 2 Improving the system

Chapter 4 National goals
Chapter 5 The frameworks for change
Chapter 6 Responding to people’s needs

Setting goals for the Health Strategy

Chapter 1 set out a vision of a future health system and the principles to guide everyone working in the system. Towards that vision, this chapter sets out four national goals to encompass the many proposed developments and reforms that emerged from the deliberations of the consultation process and the analysis of the Health Strategy Steering Group. It has not been feasible to include all of the individual ideas put forward during the consultation process. The goals are intended, however, to encompass the major conclusions in terms of overall direction for the future.

The four goals are:

This chapter describes the four goals in detail. Specific objectives and actions to help achieve each goal are also outlined. Implementation of some of these actions will require legislative, organisational and cultural change. The key areas needing reorganisation, reform or development are described in Chapter 5, The Frameworks for Change.

goals and objectives

National Goal No. 1: Better health for everyone

The first goal is concerned with promoting and improving everyone's health and reducing health inequalities. It is based on the concept of population health, i.e. promoting the health of groups, families and communities, as well as addressing individual health problems. Chapter 2 suggests that, overall, Ireland has a relatively unhealthy population by comparison with other countries at a similar stage of economic and social development. It also demonstrates the importance of the wider determinants of health, highlighted and referred to in the National Health Promotion Strategy 2000-2005. The need for collaborative action from a number of agencies both within and outside of the health system is imperative to achieve and sustain a healthy population. The main conclusions from Chapter 2 lead to the four objectives under this goal.

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Objective 1: The health of the population is at the centre of public policy

Health is important for everyone. A large number of agencies, bodies and government departments is involved in promoting good health and treating and supporting those who suffer ill-health or who have a disability. Some of these have a very direct and clear function in the area of health and are part of the health and personal social services. In addition, many agencies and government departments whose role may appear more peripheral or indirect have a vital contribution to make in achieving an integrated strategic approach to promoting and improving the health of the whole population. This objective is concerned with ensuring a joint approach, co-ordinated under one coherent strategy, to maximise the impact on health of existing policies, structures and initiatives. It is designed to ensure that all policy makers, especially those more indirectly involved in the health system, consider the impact that their decisions might have, both directly and indirectly, on the health of the population.

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.

Objective 2: The promotion of health and well-being is intensified

People's lifestyles, and the conditions in which they live and work, influence their health and longevity. Most people have a basic understanding of the positive and negative effects lifestyles can have on their health. The reality is that the achievement of health and well-being is not the responsibility of the individual alone. This objective is concerned with providing a supportive environment to help us all make the healthier choice the easier choice and thereby contribute individually to improving overall health status.

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Objective 3: Health inequalities are reduced

As outlined in Chapter 2, the most powerful influences affecting health and the promotion of health are socio-economic factors, in particular poverty. Every major health problem has a significant social gradient, with those at the lowest socio-economic level suffering most ill-health. This is supported by the findings of the first National Health and Lifestyle Survey (SLÁN). There is a need to build on the initiatives set out in the National Health Promotion Strategy, with a special focus on those identified as at risk in order to minimise the gap in socio-economic variations. This objective is about ensuring that disadvantaged groups get the help and support they need to ensure that everyone in society has an equal chance to achieve his or her full health potential.

Objective 4: Specific quality of life issues are targeted

As defined in this Strategy, 'health' is more than simply the absence of illness or disease. It is also about quality of life. Many people with a long-term illness, mental illness, or a disability, have a considerable reduction in their quality of life. In addition, social trends are placing new pressures on individuals and their families. It is clear from the consultation process that actions to improve social gain and quality of life should form part of a coherent health strategy.

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

Objective 1: The health of the population is at the centre of public policy

1 Health impact assessment will be introduced as part of the public policy development process

The health impact assessment process identifies the factors which have a potential impact on health. Accordingly, it is a means for all sectors to determine the effects of their policies and actions on health and it has the potential to bring greater transparency to the decision- making process by clarifying the nature of trade-offs in policy.

The Department of Health and Children will develop the 'procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of the population and the distribution of those effects within the population' (WHO, Regional Office for Europe, 1999) and will have a key role in supporting other departments and agencies in carrying out health impact assessments. In doing so, the Department will have regard to the actions on health impact assessment outlined in the report of the Working Group on the National Anti-Poverty Strategy (NAPS) and Health, due to be published shortly.

Regional-level structures such as local authorities and county development boards with a role in implementing public policy locally will also be asked to consider the impact of their decisions on population health in their area.

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2 Statements of strategy and business plans of all relevant Government departments will incorporate an explicit commitment to sustaining and improving health status

The strategic and business planning process, introduced as part of the Strategic Management Initiative, requires every government department to set out its strategic objectives and identify how these objectives will be achieved. The purpose of this objective is to ensure that concern for human health becomes more firmly embedded as a core value at the strategic planning stage for all relevant departments.

3 The National Environmental Health Action Plan will be prepared

The WHO (1999) describes environmental health as comprising 'those aspects of human health, including quality of life, that are determined by chemical, physical, biological, social and psycho-social factors in the environment. It also refers to the theory and practice of assessing, correcting and preventing those factors in the environment that can potentially affect adversely the health of present and future generations'. A proposal for a National Environmental Health Action Plan (NEHAP) was published in 1999. A plan will be prepared and submitted to Government by June 2002 for agreement and publication. Such a plan will be an essential element in helping government departments not directly involved in health services to recognise and assess the potential impact of their policies on the health of the population.

4 A population health division will be established in the Department of Health and Children and in each health board

Department of Health and Children

In the Department, this will bring together a number of existing functions in a more coherent way, to allow for a more focused and integrated approach to delivering on Strategy objectives relating to population health. The division will be responsible for integrating policy development in the following areas:

This will be addressed in the restructuring of the Department of Health and Children referred to in Chapter 5.

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Health boards

In health boards, the new population health function will incorporate and build on the existing public health departments, health promotion units and other relevant areas.

It will strengthen the health boards' role in working with local authorities, schools, colleges, universities, health professions, employers, community groups, voluntary organisations and relevant actions in the private sector to seek ways to promote and improve population health status both locally and regionally.

It will also work closely with the Population Health Division of the Department of Health and Children, particularly in relation to the monitoring and evaluation of regional and local initiatives and the development of appropriate performance targets and indicators.

Objective 2: The promotion of health and well-being is and intensified

5 Actions on major lifestyle factors targeted in the National Cancer, Cardiovascular and Health Promotion Strategies will be enhanced

The State has been engaged for a number of years in national strategies to tackle cancer and cardiovascular disease and to promote healthier lifestyles generally. An outline of each of these strategies is included in Appendix 3. Implementing them is essential to tackling improvements in health status and premature mortality. In continuing to implement the National Cancer, Cardiovascular and Health Promotion Strategies, the following actions will be advanced as a priority:

Achievement of the targets set out in the National Health Promotion Strategy (2000-2005) through:

Smoking

Alcohol

Diet and exercise

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6 The Public Health (Tobacco) Bill will be enacted and implemented as a matter of urgency

The Public Health (Tobacco) Bill, 2001 will provide for a new, more comprehensive and strengthened legislative basis for regulating and controlling the sale, marketing and smoking of tobacco produces and for enforcing such controls. It will provide for:

7 A reduction in smoking will continue to be targeted through Government fiscal policies

Over recent years the Government has sought to target a reduction in smoking through the largest ever increase in tobacco taxes. In addition, the Government moved to use tobacco taxes directly to help fund the development of health services. A difficulty has arisen where such increases have a direct impact on the Consumer Price Index and lead to demands for compensation. This reduces the ability of the Government to use tobacco revenue to fund health services and reduces the intended financial disincentive.

The Government continues to believe that taxation is an effective means of reducing tobacco consumption and the resulting adverse impact on health status. Decisions must, obviously, be taken in the context of the annual Budgets. Significant progress requires an agreement on the part of the social partners and all concerned to disregard tobacco products as a component part of the inflation figures used to underline wage increases and Budget changes.

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8 Initiatives to promote healthy lifestyles in children will be extended

Research shows that unhealthy behaviours adopted in childhood (for example smoking, lack of exercise), have a negative impact on health in later life, particularly where the behaviours are carried on into adulthood.

In schools, the Social, Personal and Health Education (SPHE) programme provides students with a unique opportunity to develop the skills and competence to learn about themselves, to care for themselves and others, and to make informed decisions about their health, personal lives and social development. The SPHE programme will reflect the ethos of the school. To be effective such a programme must be supported by the pillars of the Health Promoting School model: a positive school atmosphere, links to the wider community, a health promoting physical environment, and healthy school policies.

The substance abuse and SPHE programmes in both primary and post-primary schools will be extended to all schools.

9 Measures to promote and support breastfeeding will be strengthened

Breastfeeding of infants and young children provides one of the best opportunities to give children a good start in life. Ireland currently has the lowest breastfeeding rate in Europe. A National Breastfeeding Co-ordinator has been appointed in the Department of Health and Children and a review of the National Breastfeeding policy is currently being undertaken. There are three key areas for action to re-establish a breastfeeding culture in Ireland:

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10 A National Injury Prevention Strategy to co-ordinate action on injury prevention will be prepared

Unintentional injuries are a major cause of death, hospital admission and long-term disability in Ireland. Most injuries can be prevented. Injury prevention is a complex task requiring action across many sectors. A co- ordinated plan with a national focus similar to those adopted in the fight against cancer and cardiovascular disease will be developed, with the Department of Health and Children taking a lead role. Such a plan will be particularly relevant to groups such as children, young people (especially young adult males) and older people (over 65) where the incidence of preventable injury is highest.

There are almost 1,500 deaths and 55,000 admissions to hospital for treatment for unintentional injury in Ireland each year.
Quote from the Consultation Process

11 The programmes of screening for breast and cervical cancer will be extended nationally

BreastCheck, the National Breast Cancer Screening Programme, commenced Phase 1 of its Programme in February 2000, offering screening services to all women aged between 50-64 in the Eastern Regional Health Authority, the Midland Health Board and the North-Eastern Health Board areas. The goal of the programme is to reduce breast cancer mortality by 20 per cent in the cohort of women screened between 2000-2010. Phase 1 of the cervical screening programme is currently being implemented in the Mid-Western Health Board. BreastCheck is in consultation with the health boards concerning the provision of additional centres and mobile units to extend the screening programme nationwide. Screening for cervical cancer will also be extended to all areas and the target is to achieve a greater than 80 per cent participation rate by women aged 25-60. The Department's key objective is to ensure that programmes are driven by international quality assurance criteria and best practice and that national coverage will be achieved as soon as possible, having regard to the experience gained in implementing the programmes to date.

12 A revised implementation plan for the National Cancer Strategy will be published

The Department of Health and Children, in conjunction with the National Cancer Forum, will prepare a revised implementation plan which will set out the key investment areas to be targeted for the development of cancer services over the next seven years. This will have regard to existing policies in the areas of symptomatic breast disease and palliative care, the Comhairle na nOspidéal report on haematology services, and the forthcoming recommendations of the Expert Group on the Development of Radiotherapy Services.

Following publication of the national plan, individual health boards, in consultation with the National Cancer Forum, will develop new regional cancer plans which will identify additional requirements for the development of integrated, evidence-based treatment and palliative services for people with cancer. This will enable further expansion of integrated cancer treatment and palliative services rather than disease-or service-specific developments.

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13 The Heart Health Task Force will monitor and evaluate the implementation of the prioritised cardiovascular health action plan

This detailed plan is due to be finalised in the coming months by the Advisory Forum on Cardiovascular Health. Its implementation will be monitored by the Heart Health Task Force, with reference to the Health Information and Quality Authority, and it will be evaluated in accordance with the principles set out in Building Healthier Hearts, the National Cardiovascular Strategy.

14 Initiatives will be taken to improve children's health

A range of initiatives will be undertaken as follows:

15 A policy for men's health and health promotion will be developed

The Health Promotion Strategy identified the development of a national plan for men's health as an important initiative. Recent research (NEHB, 2001) has shown that there is a need to raise awareness about men's health issues and to encourage men to actively seek screening and to seek timely medical help. It is also important to develop models of working which facilitate access to services, and which reflect the particular needs of men. The Department of Health and Children will take the lead role in preparing and driving a policy for men's health in partnership with the health boards and other agencies. Resources will be provided to promote early detection and screening programmes of proven value to men's health in areas such as prostate and testicular cancer.

Men are: less likely to interpret their symptoms as arising from physical symptoms less likely to develop the confidence to seek preventive help.
Men Talking, North Eastern Health Board, 2001

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16 Measures will be taken to promote sexual health and safer sexual practices

The National Health Promotion Strategy sets out, as a strategic aim, the promotion of sexual health and safer sexual practices amongst the population. In order to achieve this aim, an action plan for sexual health will be developed. It will include, through the on-going development of Health Promoting Schools, school-based programmes in schools designed to develop personal skills e.g. Social, Personal and Health Education (SPHE).

It will complement the commitment to the full implementation of the recommendations of the AIDS Strategy 2000 (see action 33).

17 Legislation in the area of food safety will be prepared to take account of developments in food safety regulation at national and EU level

Ensuring that the EU has the highest standards of food safety is a key policy priority for the European Commission and the member states, including Ireland. The EU White Paper on Food Safety published in January 2000 outlines an 80-point legislative programme with a timeframe to 2003 for the adoption of new and amending legislation. Ireland will be actively involved in the development of these legislative proposals at EU level and the Department of Health and Children will have responsibility for transposing all food safety related proposals into Irish law.

Objective 3: Health inequalities are reduced

18 A programme of actions will be implemented to achieve National Anti-Poverty Strategy and Health targets for the reduction of health inequalities

In 1997, the National Anti-Poverty Strategy (NAPS) was published. Under NAPS, all government policy is 'poverty proofed' to test if it reduces poverty or has an adverse impact on poorer people. Considerable progress has been made in reducing the level of poverty in Ireland over the intervening years. A commitment to review the NAPS and to set new targets in the areas of health and accommodation/housing was given in the Programme for Prosperity and Fairness.

The Report of the Working Group on NAPS and Health identifies and maps the links between poverty and ill-health and provides the most appropriate framework for concerted action in addressing health inequalities. Four targets which reflect the overall goal of the NAPS health programme, i.e. to eliminate the impact of deprivation and disadvantage on health status, are set out below.

The Report of the NAPS and Health Working Group envisages these targets being achieved through a series of actions related to the following:

These issues are addressed elsewhere in this Strategy. A key deliverable in relation to NAPS and health will be the putting in place of the indicator and research data needed to monitor and evaluate the NAPS health targets and to review existing targets and set new targets.

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19 Initiatives to eliminate barriers for disadvantaged groups to achieve healthier lifestyles will be developed and expanded

Personal and community health is the responsibility not only of government and other providers of health care but also of individuals and communities. Working in partnership with the consumer and community, the following actions will be undertaken to improve the health status of marginalised groups:

20 The health of Travellers will be improved

The Travellers' Health Strategy will provide a focused plan to improve the health of Travellers and will be implemented over the next seven years.

Travellers' Health Strategy ­ key elements

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21 Initiatives to improve the health and well-being of homeless people will be advanced

Detailed strategic plans for homeless adults and young people have been published recently. Initiatives targeting the needs of these groups will be taken in the context of these recently-published strategies.

Homelessness ­ an Integrated Strategy (2000) ­ key elements

The Youth Homelessness Strategy (2001) ­ key elements

The Strategy provides a strategic framework for youth homelessness to be tackled on a national basis. The goal of the Strategy is 'to reduce and if possible eliminate youth homelessness through preventive strategies and where a child becomes homeless to ensure that he/she benefits from a comprehensive range of services aimed at reintegrating him/her into his /her community as quickly as possible'

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22 Initiatives to improve the health and well-being of drug misusers will be advanced

The National Drugs Strategy (2001) provides a focused plan for the improvement of the health and well-being of drug misusers.

The National Drugs Strategy (2001) ­ key elements

23 The health needs of asylum seekers/refugees will be addressed

The health system needs to reflect and respond to the increasing diversity in Irish society. Services will be provided in a culturally sensitive way as an integral part of the services being provided to the wider community.

The health boards will also address needs specific to these groups, where mainstream services are unable to meet such needs. This will include the provision of on-site community health services in major accommodation centres for asylum seekers as appropriate.

Seven major new centres are due to be commissioned during 2002. Incremental resources will be provided to support existing community-based services to asylum seekers and refugees to develop on-site services.

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24 Initiatives to improve the health of prisoners will be advanced

The Report of the Expert Group on the Structures and Organisation of Prison Health Care Services in Ireland was published in September 2001. This Report makes 43 recommendations. The achievement of the recommendations will require considerable dialogue and negotiation between health care and prison interests. The Department of Health and Children and health boards will work in close collaboration with the Irish Prisons Authority in improving the health of the prisoner population within this framework.

Report of the Expert Group (2001) ­ key elements

Objective 4: Specific quality of life issues are targeted

25 A new action programme for mental health will be developed

This programme will build on recent initiatives in mental health services, particularly in the areas of attitudes to mental illness, strengthening advocacy for people with mental illness and providing services in areas where gaps have been identified.

Key actions to improve mental health services and promote awareness of mental health

  • older people
  • those who would benefit from community-based alcohol treatment programmes

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26 An integrated approach to meeting the needs of ageing and older people will be taken

In 1996, 402,000 people or 11.5 per cent of the Irish population were aged over 65. By 2031, forecasts suggest that this will have more than doubled to between 837,000 and 858,000 people, representing between 18 and 21 per cent of the population. Many concerns in relation to older people were raised during the consultation process. These included references to the provision of appropriate care and the impact of the continuing attrition of traditional 'community' and neighbourhood on older people's confidence and ability to live independently. The following actions will be pursued:

Key Actions for ageing and older people

27 Family support services will be expanded

The dominant focus in child care services since the early 1990s has been on the protection and care of children who are at risk. More recently, the policy focus has shifted to a more preventive approach to child welfare, involving support to families and individual children, aimed at avoiding the need for further more serious interventions later on. An evaluation of the Springboard Pilot Projects for Children at Risk indicates that the projects have been very successful in keeping vulnerable and at-risk children out of care. These projects will now be mainstreamed and extended throughout the country. Ring-fenced funding will be allocated to health boards for expansion of these and other family support services.

Expansion programme

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28 A comprehensive strategy to address crisis pregnancy will be prepared

A new statutory agency to combat crisis pregnancy was established in October 2001. The new agency will

Health boards already provide some services aimed at supporting women in crisis pregnancies, teenagers who are pregnant, and pregnant women living in poverty. They will work closely with the new agency in developing services to provide increased support at regional and local levels.

29 Chronic disease management protocols to promote integrated care planning and support self-management of chronic disease will be developed

The continuous and co-ordinated care to address the needs of people with particular chronic diseases such as asthma and diabetes is best provided within the primary care system. Patients with chronic illness must be supported and facilitated to participate in planned regular interactions with health-care providers and assisted in becoming the ultimate managers of their own health.

30 An action plan for rehabilitation services will be prepared

Effective rehabilitation draws on a broad range of services to meet the particular needs of patients, with the objective of helping patients return to normal life in the community. There is a shortage of in-patient and community-based rehabilitation services, with the result that acute hospital beds are being inappropriately used for these services. Rehabilitation services have an important role for people with physical disabilities, including the young chronic sick (those requiring constant nursing care or with an acquired brain injury). The action plan will set out a programme to meet existing shortfalls in services and to integrate specialised facilities with locally based follow-up services.

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31 A national palliative care service will be developed

Palliative care has an important role in improving quality of life when the medical expectation is no longer cure. The Government committed itself to the development of a national palliative care plan in the Action Plan for the Millennium. The National Advisory Committee on Palliative Care was established in 1999 with a view to preparing a report on the development of palliative care services in Ireland and reported recently.

Report of the National Advisory Committee on Palliative Care (2001) ­ key elements

32 Entitlement to high-quality treatment services for people with Hepatitis C, infected by blood or blood products, will be assured

Services for persons with Hepatitis C who have been infected by blood or blood products made available within the State will be kept under review, in consultation with the representative groups, services providers and the Consultative Council on Hepatitis C. The aim will be to ensure that the healthcare system continues to respond in an effective and timely manner to the needs of this unique cohort of patients.

33 Resources will be provided to support the full implementation of AIDS Strategy 2000

AIDS Strategy 2000, the report of the National AIDS Strategy Committee (NASC), was published in 2000 and contains recommendations for action in relation to surveillance, education and prevention and care management. The public health services will continue to work in close collaboration with the voluntary sector under the aegis of the National AIDS Strategy Committee to ensure that the recommendations outlined in the Strategy are implemented.

AIDS Strategy 2000 ­ key elements

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34 Measures to prevent domestic violence and to support victims will continue

Concerns about increasing levels of crime and violence in our society are growing. The links between alcohol and violence are proven. The continued promotion of moderation in alcohol intake as outlined in the National Alcohol Strategy is intended to help reduce crime, lawlessness and violence. Early interventions in schools through Social, Personal and Health Education programmes will also help to encourage civil and non-violent behaviour in adolescents.

The Department of Health and Children will continue to provide funding through the health boards to refuges, rape crisis centres and other agencies in order to support victims of domestic violence. The Department will also continue to work with other Government departments and agencies to combat violence, particularly violence in the home.

35 A national policy for the provision of sheltered work for people with disabilities will be developed

In June 2000 the Government assigned responsibility for vocational training to the Department of Enterprise, Trade and Employment, and rehabilitation training to the Department of Health and Children. There are many people with disabilities who may not have the capacity to work in open employment and for whom some form of sheltered work may be the best option. Employment Challenges for the Millennium ­ the Report of the National Advisory Committee on Training and Employment ­ estimated that there are 7,900 people with disabilities working in 215 sheltered workshops. A more structured policy framework covering all aspects of the provision of sheltered work for people with disabilities is required. This should include approved standards and structured support for the establishment and operation of these services.

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National Goal No. 2: Fair access

The second goal is concerned with making sure that equal access for equal need is a core value for the delivery of publicly funded services. Access in terms of timing and geographic location are also embraced by this goal.

The second goal is concerned with making sure that equal access for equal need is a core value for the delivery of publicly funded services. Access in terms of timing and geographic location are also embraced by this goal.

Objective 1: Eligibility for health and personal social services is clearly defined:

The system of eligibility for services within the health system is complex. Criteria are not always clear-cut and there may be inconsistencies in eligibility for certain services between different health board areas. These problems will be addressed in a review of current legislative provisions and in the preparation of new legislation suited to a modern health system. It is important to note that while the Health Act, 1970 explicitly provides for eligibility1 for a service, it does not provide that a person is entitled to receive a service. This means that there is currently no statutory framework underpinning access to services within a stated timeframe. In preparing new legislation, the objective will be to move away from the rather theoretical model of 'eligibility', to a system of entitlement to services within a reasonable timeframe.

Eligibility for health services in Ireland is primarily based on residence and means. Health board CEOs have discretionary powers in regard to the medical card scheme. There are also a variety of other schemes which provide eligibility for various services for certain groups of the population.

Objective 2: Scope of eligibility framework is broadened:

The objectives of the various schemes are (i) to provide free medical care for people who are on low incomes; (ii) to provide some monetary relief to those with chronic illness or disability; and (iii) to provide support at particular times for vulnerable groups such as children and older people. The number of people covered by the medical card scheme will be increased significantly. Income guidelines will be extended to cover more people on low incomes and targeted increases will be implemented to ensure that more children are covered. In addition a number of other schemes, including the Maternity and Infant Care Scheme, will be extended.

Eligibility arrangements across a range of schemes need to be reviewed so as 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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Objective 3: Equitable access for all categories of patients in the health system is assured:

A core objective of this Strategy is that all people should have access to high- quality services. Many of the areas identified in this Strategy for development and reform concern all groups, irrespective of entitlements. However, it is clear that there are significant inequalities in the system at present which must be addressed, such as unacceptably long waiting times for public patients for some elective hospital procedures.

This Strategy outlines measures to ensure that all public patients can expect the high quality of service within a reasonable period of time. This includes a ten year programme for the largest ever concentrated increase in public acute hospital capacity.

There is also evidence that people have difficulties in obtaining timely, appropriate and user-friendly information about entitlements and how to access services. A more proactive approach to ensuring that people understand their entitlements will be developed. Other issues affecting people's ability to access services, transport to services, opening times, waiting times for appointments and appropriate waiting facilities are also dealt with.



Objective 1: Eligibility for health and personal social services is clearly defined

36 New legislation to provide for clear statutory provisions on entitlement will be introduced

Existing legislation will be reviewed to update and rationalise the framework for entitlement. The objective will be to provide a clear national framework for entitlement to health and personal social services. Guidelines will be published concerning target timeframes for access to various services. The programme of expansion and investment in services outlined in this Health Strategy will allow these timeframes to be reduced on a regular basis. The legislation will include provision for:

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It is recognised that quality care is expensive and that the bulk of the cost of providing a high standard of quality care should be borne by the Exchequer. Nonetheless, it is fair that all those in receipt of publicly provided residential long-term care should make some payment towards accommodation and daily living costs, if they can afford to do so, just as they would if they were living in the community. This principle supports the aim to provide as high quality a service as possible and to make the most equitable use of resources and thus to help maximise the availability of these services.

Where the State encourages participation in evidence-based screening or preventive programmes, the aim will be to provide these free of charge. Such schemes would include preventive programmes and programmes to promote healthy lifestyles, breast cancer and cervical cancer screening programmes, and other screening programmes as the evidence base justifies their introduction.

37 Eligibility arrangements will be simplified and clarified

All groups

The guidelines for entitlement to medical cards will be simplified and clarified. In line with the recommendations of the recent review of the medical card system commissioned by the CEOs under the Programme for Prosperity and Fairness, this will ensure an improved, open and consistent framework for assessing eligibility for medical cards in all parts of the country. The health boards executive (HeBE) will monitor and evaluate medical card guidelines across the country and reduce as much as possible the need to exercise judgement on individual cases outside the guidelines.

Older people

In his report on the Nursing Home Subvention Scheme, the Ombudsman has drawn attention to the uncertainty surrounding the eligibility of older people for long-term residential care. Clarification of entitlement in this regard will be given particular attention in the general review of legislation on entitlement referred to above. Emphasis will also be placed on implementing a standard approach to dependency assessment and the payment of subventions in each area of the country.

People with disabilities

Travellers and homeless people

Health boards will introduce standardised special arrangements regarding medical cards to cater for the needs of Travellers and homeless people.

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Objective 2: Scope of eligibility framework is broadened

A number of measures are proposed to improve eligibility for health services in the following areas:

Having considered these proposals in the context of all of the actions outlined in the Strategy, the Government has committed itself to introducing these changes over a number of years.

The timing of their ntroduction will be determined by Government in the context of the prevailing budgetary situation.

38 Income guidelines for the medical card will be increased

The allocation of medical cards will be on the basis of prioritising groups most in need. In addition to the recent extension of eligibility to all persons over 70, significant improvements will be made in the income guidelines in order to increase the number of persons on low incomes who are eligible for a medical card and to give priority to families with children and particularly children with a disability. In line with the PPF review of the medical card scheme, it is proposed that the income threshold will be increased substantially and reviewed annually on an agreed basis. This would include taking account of changes in the cost of living and movement in relevant social welfare payments and allowances. The review also suggests that the basis for assessment should be net income.

39 The number and nature of GP visits for an infant under the Maternity and Infant Care Scheme will be extended

The number of free GP visits under the existing scheme will be increased from two to six for the first year of life and the additional visits will cover general childhood illnesses.

40 The Nursing Home Subvention Scheme will be amended to take account of the expenditure review of the scheme

A large number of older people would like the option of receiving care in the home rather than in a nursing home. The recent expenditure review of the nursing home subvention scheme has shown that current funding arrangements do not effectively support home care. The Government intends reforming the operation of existing schemes, including the Carers' Allowance, in order to introduce an integrated care subvention scheme which maximises support for home care. In addition, subvention rates payable in private nursing homes will be reviewed.

The Department of Health and Children will begin work immediately with the Department of Social, Community and Family Affairs to develop detailed proposals for the new scheme with a view to introduction as soon as possible.

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41 A grant will be introduced to cover two weeks' respite care per annum for dependent older persons

The detailed arrangements for the operation of this scheme will be worked out with the Department of Social, Community and Family Affairs.

42 Proposals on the financing of long-term care for older people will be brought forward

Health care is just one aspect of the overall debate surrounding the funding of long-term care for older people. A major study on this topic, led by the Department of Social Community and Family Affairs, is nearing completion. Policy proposals will be prepared following publication of the consultancy report commissioned by the Department of Social Community and Family Affairs. Funding options to meet the cost of care will be outlined for public debate prior to preparation of legislation.

Objective 3: Equitable access for all categories of patients in the health system is assured

43 Improved access to hospital services for public patients will be addressed through a series of integrated measures

These measures, discussed in Chapter 5, are designed to reduce substantially the waiting times for public patients for elective treatments. Specific targets are set so that, by the end of 2004, no public patient will have to wait for more than three months to commence treatment, following referral from an out-patient department.

44 Availability of information on entitlements including use of information technology will be improved

Health boards will promote the uptake and utilisation of services by improving the availability of information on entitlements. Particular attention will be given to disadvantaged groups, older people and people with disabilities in order to help them to overcome existing barriers. Such barriers may include communication difficulties e.g. literacy or language deficits, or lack of knowledge of entitlements and services.

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45 All reasonable steps to make health facilities accessible will be taken

This action includes assessing and planning for transport needs where services cannot be provided locally. It also means taking all reasonable steps to make health facilities accessible to older people and people with disabilities, in line with the PPF commitment regarding access for people with disabilities.

46 Appointment planning arrangements will be reviewed to provide greater flexibility and specific appointment times

The 9am to 5pm nature of many health services and the absence of individual appointment times, particularly at out-patient clinics, have been strongly criticised. Specific initiatives will be taken on both issues as part of the wider programme to improve customer care under the Health Strategy.

47 Waiting areas in health facilities will be upgraded

Waiting areas will be upgraded to ensure that individuals waiting for treatment have easy access to basic facilities. This should take account of the needs of persons accompanying children or older people attending for treatment; as well as adults attending for treatment, who have young children with them. Upgrading should provide ample waiting space, play areas for children, baby-changing facilities and the availability of refreshments.

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National Goal No. 3: Responsive and appropriate care delivery

The third goal aims to gear the health system to respond appropriately and adequately to the needs of individuals and families. It is also concerned with ensuring that the various parts of the system are being utilised to their maximum effectiveness and efficiency.

Objective 1: The patient is at the centre in the delivery of care:

One of the guiding principles of the Strategy is that of a people-centred health system. A responsive system must develop ways to engage with individuals and the wider community receiving services. At an individual level, there are now greater expectations about openness and shared decision-making in relation to individual care. Health care workers will be encouraged and facilitated to listen to and accommodate, as appropriate, the wishes of individual patients/clients. At community level, this means allowing the wider community to participate in decisions about services at national, regional and local level.

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.

Objective 2: Appropriate care is delivered in the appropriate setting:

Some examples of people receiving services in an inappropriate setting are:

Action will be taken to ensure that the care required is delivered in the appropriate setting. This objective is also concerned with empowering and encouraging communities to become more involved in the provision of informal care in the community.

Providing improved assessment, community support and rehabilitation services is essential to ensuring care is delivered in the most appropriate setting.

Objective 3: The system has the capacity to deliver timely and appropriate services:

There is increasing evidence that the system does not have the capacity to meet the current demands being placed on it. Additional investment across the system will be necessary. Also, a reorientation of existing services to meet needs more appropriately and responsively will help to gain better value from available capacity in some areas.

The concerns about capacity and the configuration of services underline the need for ongoing capital investment, expansion of acute hospital services and substantial strengthening of primary care and community services.

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Objective 1: The patient is at the centre in the delivery of care

48 A national standardised approach to measurement of patient satisfaction will be introduced

The need to capture customer feedback in a more structured way has been identified as an essential input to policy planning. Routine patient satisfaction surveys and systematic collection and analysis of complaints will be undertaken. The results of this feedback will be made available to the public and will inform local decision-making processes.

49 Best practice models of customer care including a statutory system of complaint handling will be introduced

The vision adopted for the future health system places a high value on treating people with dignity and respect. The Ombudsman already investigates complaints of maladministration against the Department of Health and Children and the health boards. The Government believes that the existing Ombudsman is the appropriate person to deal with complaints relating to the health system. The Government's aim is to extend the role of the Ombudsman to voluntary hospitals and other voluntary agencies in the health area and the legal implications of this step are currently being examined. Complaints against professionals may be made to relevant professional bodies and this area also needs to be strengthened. Complaints procedures at local level also need to be formalised. Action will be taken to strengthen the customer focus of service providers. This will include:

One of the areas which attracts particular criticism in this context is the perceived inability to question the actions or decisions taken by individual practitioners in regard to clinical matters. While acknowledging the need for freedom in exercising clinical judgement, the Government also accepts the need for a stronger framework for questioning and investigating clinical decisions in particular circumstances. Accordingly, the forthcoming legislation on statutory registration of health professionals (discussed in Chapter 5) will contain adequate machinery for the investigation of complaints against individual professionals.

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50 Individuals and families will be supported and encouraged to be involved in the management of their own health care

The vision of the future health system is one that 'encourages you to have your say, listens to you, and ensures your views are taken into account.' Health and social care personnel must encourage shared decision-making and, where possible, accommodate patient preferences. This will involve improved communication between health care professionals and patients and clients. For example, doctors should discuss fully the risks and benefits of a treatment and ensure the patient understands any alternative options available.

Communication skills and an appreciation of the need to strike an appropriate balance between the responsibilities of the practitioner, and the views and preferences of patients, will be strengthened in the training programmes for health care professionals. Professional bodies will be asked to devise codes of practice for shared decision-making for clinical care areas. In addition, the Health Information and Quality Authority will examine the introduction of computer 'decision aids' to provide an interactive approach to transmitting information to patients.

51 An integrated approach to care planning for individuals will become a consistent feature of the system

Lack of integration of care between and even within some services is identified as a problem in the existing services. Individual patients or clients may have to access the system several times to have all their needs addressed. This may apply within the hospital system where individuals have needs involving a number of specialties. If the system is to be responsive to the needs of individuals, it is important that a holistic approach is taken to planning and delivering care. This will include:

52 Provision will be made for the participation of the community in decisions about the delivery of health and personal social services

While there are some community participation initiatives already operating in discrete areas of activity at national and regional level, a more structured approach to community participation is required. Such participation has a number of important advantages. The following actions will be taken:

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Objective 2: Appropriate care is delivered in the appropriate setting

53 Initiatives will be developed and implemented to ensure that care is delivered in the most appropriate setting

The underlying principle will be concerned with 'the right care in the right place at the right time'. At present eligibility arrangements and availability of community-based services may encourage people to seek care in a setting that is not appropriate to their needs, e.g. persons who attend at Accident and Emergency (A&E) departments where there is an option to visit their GP.

54 Community and voluntary activity in maintaining health will be supported

The Government White Paper on Supporting Voluntary Activity makes a number of recommendations. As a priority:

The 'first responder' service will be developed in the area of pre-hospital emergency care to enhance existing emergency care services. First responders are generally members of the public who have been trained in basic life support and who are available, usually in a rural environment, to respond in emergency medical situations.

In addition, arrangements will be made by health boards to streamline funding for voluntary groups with a national remit.

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Objective 3: The system has the capacity to deliver timely and appropriate services

55 A programme of investment to provide the necessary capacity in primary care, acute hospital and other services will begin

Details of the build-up of primary care and acute hospital capacity and system reforms which underpin the achievement of this objective are set out in Chapter 5 ­ The Frameworks for Change. Key areas for development which have been identified include the following:

Programme of investment to increase capacity

Primary care (details in Chapter 5)

Acute hospital capacity (details in Chapter 5)

Older people

Community services

Hospital services

Residential care

Mental health

Intellectual disability and autism services

Physical and sensory disability services

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In addition to physical resources of buildings, beds and equipment, the necessary number of skilled people will also be required to enable beds and facilities to be fully and safely utilised. A developmental approach to human resources aimed at rapid expansion in the numbers of people trained is central to the effective implementation of this Strategy. This is dealt with in detail in Chapter 5 ­ The Frameworks for Change.

56 The Cancer Forum and the Advisory Forum on Cardiovascular Health will work with the National Hospitals Agency and the Health Information and Quality Authority to ensure service quality, accessibility and responsiveness

Building on work which is already under way, services and facilities which should be available in treatment centres at national, regional and local level for people with cancer and cardiovascular disease will be identified. Furthermore, the requirements at these levels to develop, implement and evaluate evidence-based practice guidelines and protocols will be outlined. These guidelines and protocols will cover prevention, treatment, rehabilitation and palliative care in both community and institutional settings. Appropriate outcome and performance indicators will also be developed.

57 Measures to provide the highest standard of pre-hospital emergency care/ambulance services will be advanced

The findings of the review of the ambulance services currently being undertaken by the health boards and the Eastern Regional Health Authority, together with the recommendations of the Report of the Review Group on the Ambulance Services (1993), the Comptroller and Auditor General's Report on the Emergency Ambulance Services (1997) and the Report of the Joint HSEA/SIPTU Working Group on Ambulance Services (2001) will inform further investment in the ambulance and emergency service.

Areas to be targeted will include:

The Pre-Hospital Emergency Care Council will build on existing strengths by further developing professional and performance standards and training in the area of pre-hospital care. This will include advice on the introduction of advanced Emergency Medical Technician training, training for GPs and other health-care professionals in life support, and development of, and training in the use of, clinical protocols for the treatment of acutely ill or injured patients.

A study will be commissioned, under the auspices of the Working Group on Pre-Hospital Emergency Care established under the Good Friday Agreement, into the feasibility of an all-island Helicopter Emergency Medical Service (HEMS).

The health boards will undertake a review of the existing major emergency function with a view to ensuring that a comprehensive and common response is provided across the health service in the event of a major emergency.

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58 A plan to provide responsive, high-quality maternity care will be drawn up

Four out of five women utilise the maternity services during their reproductive years. Models of maternity care are changing, with increasing demands for choice with regard to type of care and location of birth. In recognition of the changing needs and pressures on existing services, a working party will be established to prepare a plan for the future development of the maternity services. The objective will be to ensure that maternity care in Ireland is:

59 A review of paediatric services will be undertaken

The review will focus on the future organisation and delivery of hospital services for children. The aim will be to enhance the range and level of services available at regional level and to determine the most effective configuration of tertiary services. The scope for developing certain highly specialised services on an all-Ireland basis will also be explored.

60 A national review of renal services will be undertaken

The purpose of the review will be to develop a framework to meet anticipated growth in demand for renal services including the following objectives:

61 Organ transplantation services will be further developed

Arrangements will be put in place to facilitate the further development of organ transplantational services. The aim will be to strengthen organ procurement and retrieval practices and to increase organ donation awareness and organ utilisation rates. Stronger links will be forged between Irish and UK transplantation services.

62 Specialist dental services will be expanded

The overall objectives of dental health policy as set out in the Dental Action Plan of 1994 were:

These objectives have largely been met. The available evidence demonstrates significant improvements in the oral health of the general population in recent years. Preventive programmes, including oral health promotion programmes, are being developed and, following review of the Dental Health Action Plan, new goals for oral health will be formulated. The objective of the orthodontic service is to provide timely treatment to patients most in need. Patients with less severe needs will be treated as quickly as the availability of trained specialists allows. A new grade of Specialist in Orthodontics has been created and training programmes have been put in place so that dentists can reach specialist level. A special needs-based approach will be taken to developing dental services over the next five to seven years, as follows:

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National Goal No. 4: High performance

The fourth goal relates to quality of care, planning and decision-making, the efficiency and effectiveness of the system, commitment to continuous improvement and full accountability. The principles of quality and accountability are embraced by the objectives identified under this goal.

Objective 1: Standardised quality systems support best patient care and safety:

This objective is concerned with ensuring that the quality and safety of care in the Irish health system meet agreed standards and are regularly evaluated/benchmarked. This does not imply that the current quality of care in the health system is poor. However, the systems necessary to agree standards and establish whether those standards are being met do not generally exist. Regular review of quality standards supports and encourages a culture of continuous improvement ­ an essential component in a sector where new technology and social and demographic trends require the system to be flexible and responsive to changing needs and priorities.

A quality outlook must underpin the planning, management and delivery of services within the health system. Quality can then be measured and demonstrated in an objective way.

Improving system performance requires:

Objective 2: Evidence and strategic objectives underpin all planning/decision making:

The health system is very complex and requires managerial and operational decisions to be made in many different organisations at many different levels. This objective is concerned with ensuring that the Strategy's high-level goals are put into effect. In addition, evidence of effectiveness must inform the policy and decision-making process across the health system. An evidence-based approach will ensure clearer accountability and support improved outcomes generally.

Quality and continuous improvement must be embedded in daily practice to ensure consistently high standards.

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Objective 1: Standardised quality systems support best patient care and safety

63 Quality systems will be integrated and expanded throughout the health system

Priority areas for quality/safety standards

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64 A review of medicines legislation will be undertaken

A complete review of medicines legislation is required so as to provide more effectively for the implementation of EU directives and regulations on medicinal products including appropriate provisions relating to unlicensed medicines.

65 Licensing of alternative medicines will be examined

The European Union is developing a traditional herbal medicines directive that will be transcribed into Irish law. As this is expected to be a slow process, Ireland is developing an interim national licensing scheme for 'traditional and alternative' medicinal products including herbal medicinal products. It is important to establish such a licensing process to ensure the safety of herbal/traditional medicinal products. The Irish Medicines Board is working closely with the Department in formulating an appropriate scheme of regulation for alternative medicines.

66 The highest international standards of safety in transfusion medicine will be set and adhered to

Substantial investment has been made in recent years to ensure that blood safety in Ireland is comparable to the highest standards internationally. The Irish Blood Transfusion Service will continue to be supported in maintaining international standards of safety and quality.

There will be a major drive to develop alternatives to the use of donated blood. Clinical protocols will be developed and hospitals will be resourced to develop pre-deposit autologous transfusion, cell salvage, anaesthetic and pharmacological strategies to reduce the need for blood transfusion.

There will be a significant increase in the number of consultant haematologists to provide clinical leadership and to promote these developments.

67 Legislation on assisted human reproduction will be prepared

Following completion of the Report of the Commission on Assisted Human Reproduction and its presentation to Government, legislation will be prepared to give effect to the recommendations of the Commission as approved by Government.

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Objective 2: Evidence and strategic objectives underpin all planning/ decision-making

68 Decisions across the health system will be based on best available evidence

An evidence-based approach forms an essential element of the quality agenda outlined in this Strategy. This action provides that all decisions will be based on some form of evidence. Decisions will be based on

Decisions in all areas must be supported by reference to this kind of evidence or to agreed standards, protocols or models of best practice. This action will apply across the health system in both clinical and non-clinical areas. A Health Information and Quality Authority will be established to drive the quality agenda at national level. The functions of the new authority are set out in detail in Chapter 5.

69 An information/education campaign will be undertaken for all decision-makers in the health system on the Strategy's goals and objectives

The Department of Health and Children and the health boards have a broad range of responsibilities. This leads to potential conflict and competition for resources between different services. It is important that decision-makers within the system, and those interacting with decision-makers, understand the objectives outlined in this Strategy and recognise that all providers in receipt of Exchequer funding will be working towards these priorities for the next 7-10 years.

A detailed information campaign will be carried out to ensure that all stakeholders are familiar with the goals and objectives of the Strategy and the priority developments contained in it.

70 Accountability will be strengthened through further development of the service planning process

Service planning has been introduced in all health board areas. This involves the preparation each year of a service plan which is formally adopted by the board, setting out the service goals to be achieved within budget. This process is underpinned by the Health Amendment Act (No 3), 1996, which places statutory accountability and responsibilities on the chief executive officer of each board. In line with Government policy, the Department of Health and Children will formally set out a statement of national priorities for health, which will then be addressed by the health boards in preparing their individual service plans. This approach together with the use of clear performance indicators will provide a stronger framework for assessment by the Department of the performance of health boards on an annual basis.

Overall, there will be a stronger focus by the Department on monitoring the achievement of deliverables outlined in the service plans. This action will make the service development and planning process a more sophisticated tool for planning based on strategic objectives shared by all health boards. Ultimately, it will provide for greater consistency between health boards, and in the context of the development of the Health Boards Executive Agency, the opportunity for maximum cross-fertilisation of best practice initiatives, expertise and knowledge. Standard formats and performance indicators for service plans will be agreed as part of this process.

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71 Each health board will develop implementation plans

This action will ensure that the appropriate links are developed between the annual service plans referred to above, longer-term policy goals and the objectives outlined in the Strategy. The implementation plans will match the Strategy and policy objectives set by the Department with individual health boards' targets and objectives. The implementation plans, which will cover a three to five year time scale, will enable health boards to communicate to the Department, the public and their staff how they intend to implement national policies. In addition, performance indicators will be set nationally by which the implementation of the Strategy's objectives at health board level can be assessed.

health strategy

Annual service plans, when identifying service delivery for that year, will take account of the resources available to meet the board's implementation plan.

The involvement of staff in service planning will be advanced in this context, ensuring that this is an inclusive process.

A holistic view will be taken in the development of performance indicators to ensure that policy implementation in one area does not have a negative impact on policies in other areas.

72 Service agreements between the health boards and the voluntary sector will be extended to all service providers and associated performance indicators will be introduced

The development of specific service agreements with providers will bring greater clarity and accountability to the delivery of services. These are developed in some areas but need to be made more specific and extended to all arrangements between voluntary providers and health boards. Performance indicators will also be introduced to measure outcomes against funding provided to voluntary providers.

73 Health research will continue to be developed to support information and quality initiatives

The development of an evidence-based approach is relevant to all of the national goals. The implementation of the Strategy must include support for health research, with particular reference to supporting health professionals who wish to carry out research on identified needs and the speedy application of findings where appropriate to improve service delivery. In addition, access to and the dissemination of findings to assist the relevant health service workers must be improved. The recently published Health Research Strategy (2001) provides the framework within which investment in health research will be made.

An active research environment also plays an important part in attracting graduates to the Irish health workforce. Better post-graduate research opportunities abroad and the opportunity to work with the most advanced technologies has led many Irish graduates to emigrate in the past. Providing the same opportunities in the Irish health system is important in retaining the best of Irish skills and talent at home. Ensuring existing professional staff benefit from and contribute to the development of the latest technologies and research is also an important factor in making the health system an employer of choice.

National Health Research Strategy ­ key elements

The Strategy proposes a thriving research culture supported by two complementary but distinct pillars:

The proposed research and development function in the health services will involve new structures including:

Enhanced support for science for health will require increased resources through the Health Research Board for competitive, peer-reviewed research of high scientific value in the biological and health sciences. This would involve more support for research units, project grants, fellowships and career awards, clinical research centres, equipment, information technology and biological banks.

The framework proposed is built on the foundation of partnership and provides a structure for much greater co-operation between the interests involved. It also recognises the added-value to be gained from co-operation in research for the island of Ireland as a whole.

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Chapter 5 - The frameworks for change

The frameworks

Chapter 4 identifies four national goals and sets out a series of actions to help achieve them. In addition, the health system needs to be reformed and developed so that the national goals can be achieved. This chapter details a series of essential actions under six frameworks for change. The six areas are as follows:

Strengthening primary care

The framework for primary care is concerned with developing a properly integrated system, capable of delivering the full range of health and personal social services appropriate to this setting. Primary care must become the central focus of the health system so that it can help achieve better outcomes and better health status.

Reform of acute hospital system

The overall policy objective for the reform of acute hospitals is improved access for public patients. The reforms involve increasing capacity through further investment, strengthening efficiency and quality of services, and working in closer partnership with the private hospital sector.

Funding

The framework for funding is aimed at improving access and responsiveness in the system by increasing capacity, and at improving performance through evidence-based funding methods such as casemix budgeting, improved accountability and stronger incentives for efficiency.

Developing human resources

The framework for human resources is aimed at harnessing fully the vital contribution made by all staff working in the health system, through further development of all aspects of the human resource function throughout the health services.

Organisational reform

The framework for organisational reform is aimed at providing a responsive, adaptable health system which meets the needs of the population effectively and at affordable cost.

Information

The framework for information is aimed at improving performance by supporting quality, planning and evidence-based decision-making in the health system. Good information systems will also support equity of access.

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framework and key elements framework and key elements

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Strengthening primary care

Introduction

Primary care is the first point of contact people have with the health and personal social services. This Strategy sets out a new direction for primary care as the central focus of the delivery of health and personal social services. It promotes a team-based approach to service provision which will help to provide a fully integrated primary care service. Full details of the new model are contained in an accompanying document, Primary Care: A New Direction.

Discussion

There are many positive aspects to the current system of primary care. There is same-day access to many primary care professionals, and there have been valuable recent developments such as co-operative working for general practitioners on an out-of-hours basis. In addition, the commitment of individual professionals and their professional organisations has ensured that the public has been able to obtain a good service.

However, the current system has significant weaknesses. Primary care infrastructure is poorly developed; services are fragmented with little teamwork; there are insufficient numbers of trained staff in key areas; liaison between primary and secondary care is often poor; and many services provided in hospitals could be provided more appropriately in primary care. General practitioners can be isolated from many other community services. Communication and work sharing with other primary care professionals is not always readily facilitated or supported. There is also an under-development of primary care services out-of-hours.

Conclusions

Primary care must become the central focus of the health system. It is the appropriate setting to meet 90-95 per cent of all health and personal social services needs. A properly integrated primary care service can lead to better outcomes, better health status and better cost effectiveness. Properly developed primary care services can help prevent or reduce the impact of conditions that might later require hospitalisation and can also facilitate earlier hospital discharge. Overall the strengthened primary care system will have a major impact in reducing demand for specialist services and the hospital system, particularly accident and emergency and out-patient services.

The policy aim is to develop the capacity of primary care to meet the full range of health and personal social service needs appropriate to that setting. This will involve significantly enhanced funding for the development of primary care, in terms of staff, physical infrastructure, information and communication systems and diagnostic support.

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Primary care model: a summary

The new model of primary care will have the following main features:

Primary care team

An inter-disciplinary team-based approach to primary care will be introduced. Members of the primary care team will include GPs, nurses, midwives, health care assistants, home helps, physiotherapists, occupational therapists, social workers and administrative personnel. Teams will serve small population groups of approximately 3,000 to 7,000 people depending on whether a region is rural or urban.

Primary care network

A wider primary care network of other primary care professionals such as speech and language therapists, community pharmacists, dieticians, community welfare officers, dentists, chiropodists and psychologists will also provide services for the enrolled population of each primary care team. Clear communication links will be set up between the primary care team and named professionals within the wider network.

Inter-disciplinary approach

An inter-disciplinary team approach will help to develop the capacity of primary care to ensure that a higher percentage of patients can be cared for in the community. The wide skill mix within the team will allow a more appropriate distribution of workload, allowing each team member to work to their maximum professional capacity. It will also facilitate communication between team members, reducing time spent trying to contact other primary care providers.

Information and communications technology

There will be considerable investment in information and communications technology infrastructure to support the new model of primary care. This will include an electronic patient record, based on a unique personal client number. It will also include electronic health-related information and services for professionals and the public.

Enrolment with primary care team

All individuals will be encouraged but not required to enrol with one primary care team, and with a particular GP within the team. Enrolment will be voluntary. The benefits of enrolling with a team will include better continuity of care, improved co-ordination of services, and more attention to preventive services. Enrolment will not reduce people's choice of provider and patients will be free to seek care wherever they wish. Different members of a family will be able to enrol with different teams or with different doctors within the team. The system will also allow people to change their nominated team or doctor. Where appropriate for a patient or client, a key worker will be identified. The team will provide care to a defined group of people.

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Access to the primary care team

Individuals will be entitled to self-refer to a given member of the primary care team. For those wishing to use it, triage and referral at the point of access to the system will ensure that people can be linked with the most appropriate professional. Building on the strengths of the co-operative model for general practitioners will improve access to primary care services, particularly out of hours.

Primary care co-operatives

Further development of current GP co-operative models will take place on a national basis over the next two years as a key support to the enhanced availability of a defined range of primary care services on a 24-hour basis. Along with medical cover, it is planned to extend this to 24-hour cover encompassing nursing services, health care assistants and home helps, leading to the development of primary care co-operatives.

Integration of primary care team with specialist services

Improved integration between primary care teams and specialist services will be developed. Local arrangements will cover referral protocols, direct access to diagnostic facilities, discharge plans, individual care plans, integrated care pathways and shared care arrangements. Primary care teams can then more appropriately provide much of the care currently provided by specialist services.

Community-based diagnostic centres

Community-based diagnostic centres will be piloted to support primary care and community-based care. These will be evaluated on the basis of their ability to provide more accessible services and their cost-effectiveness in terms of reducing the pressure on hospital-based diagnostic facilities. In this regard, the potential of public-private partnerships will be actively explored.

Location of primary care team

A 'one-stop-shop' is the ultimate goal, although buildings and infrastructural implications mean that team members may not be housed together initially. Effective electronic communications and electronic record systems mean that a single location will not be required for communication between team members.

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Actions

The new model of primary care will be implemented on a phased basis through implementation projects located around the country. The model will be refined and developed by agreement in partnership with all stakeholders. The model will depend on adequate information and communications technology infrastructure and on the ability and willingness of all parties to utilise available technologies. Availability of relevant personnel will also be a crucial factor. In the short term, reliance will be on existing human resources to get implementation projects up and running. Immediately, there will be a concentration on full development of GP co-operatives, the identification of the first set of implementation sites and an increased number of training places in the relevant disciplines.

The key actions in primary care will be as follows:

74 A new model of primary care will be developed

The detailed description of the new model, Primary Care: A New Direction, is being published alongside this Strategy, and will be circulated to all key stakeholders. The model described sets out the principles for progress; it does not purport to address all of the detailed issues that will need to be worked through in the implementation phases. This will require consultation on an ongoing basis with all the relevant stakeholders. The model will be implemented on a phased basis over a two to ten-year timeframe.

75 A National Primary Care Task Force will be established

A small full-time task force will be established to take responsibility for driving the implementation of the changes and developments set out in the model. The task force will be inter-disciplinary and will report to a wider representative Steering Group which will be chaired by the Department of Health and Children and include representation from health boards, primary care professional groups, unions, and other relevant stakeholders. The task force will focus on

The Steering Group will give leadership in

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76 Implementation projects will be put in place

Locations for implementation projects will be chosen in each health board region for the development of primary care teams over the next two to four years (40-60 teams nationally). The concentration in the initial stages will be in locations where there is already evidence of successful partnership and co-operation between general practice and health board services. Evaluation of these implementation projects will inform the further phased development of teams in remaining parts of the country which will lead to the development of 400-600 teams to cover approximately two-thirds of the population by 2011.

77 Investment will be made in extension of GP co-operatives and other specific national initiatives to complement the primary care model

In the short-term, GP co-operatives will be established on a national basis so that effective out-of-hours services are available in all parts of the country. In addition, other specific developments on a national basis will include:

Reform of acute hospital system

Introduction

The acute hospital system faces ever-increasing demands. In 2001 the acute hospital system will provide treatment for over 550,000 people on an in-patient basis and a further 320,000 people on a day basis. These figures represent a growth in service provision of more than 20 per cent since 1995. In addition, there will be over 2 million out-patient attendances in acute hospitals in 2001, an increase of 8 per cent since 1995, and some 1.2 million visits to casualty departments, an increase of 6 per cent since 1994.

Discussion

Capacity and organisation

The number of acute hospital in-patient beds in Ireland has decreased from 17,665 in 1980 to 11,862 in 2000. This represents just 3.1 beds per 1,000 population, compared to 5.1 beds per 1,000 population in 1980. Despite the reduction in bed numbers, activity levels were increased by steps such as reducing average lengths of stay (from 9.7 days in 1980 to 6.6 in 2000), and increasing the use of day beds and availing of new technology.

International evidence shows that an increasing proportion of certain procedures, both medical and surgical, can be carried out on a day basis. There has been a huge growth of one-day procedures in Ireland. In 1980, approximately 8,000 day case treatments were recorded, constituting only 2 per cent of hospital activity in Ireland. In 2000, day activity accounted for 38 per cent of acute hospital activity (excluding out-patient departments) and 65 per cent of elective activity. These proportions are even higher in some of the larger hospitals. The growth in day-case activity offers considerable advantages: it reduces the time patients have to spend in hospital and frees up beds for other patients, including those on waiting lists. However, there are noticeable variations between Irish hospitals in the proportion of procedures provided on a day basis. In addition, based on international comparisons, there would appear to be scope for further increases in day activity in Irish hospitals.

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Numbers of beds

It has become increasingly apparent that it will not be possible to sustain further overall increases in activity without expanding bed numbers. The Department of Health and Children, in conjunction with the Department of Finance and in consultation with the Social Partners, has carried out a detailed study of acute hospital bed requirements for the ten-year period to 2011. The study examined current capacity and activity and developed a framework for estimating future bed requirements, taking account of current pressures, changing demographics, increasing demand and potential changes to clinical practice over the next ten years. The study highlights the need for a significant expansion of hospital beds and associated staff and treatment facilities in the years ahead.

Increases in the total population, including a rise in the number of older people, and overall growth in demand for services, underline the need for additional capacity. In 2000, people over 65 years constituted 11 per cent of the population but consumed 46 per cent of the in-patient bed days. This is of major significance for hospital services in view of the projected increases in the number of older people. By 2011 the population aged 65 and over will have increased to 503,900. By 2026 this group will have almost doubled in number to an estimated 767,300, constituting 16.4 per cent of the population.

Efficiency, equity and the mix between public and private care

Waiting times for public patients for some non-emergency (elective) treatment are unacceptably long. While this is due primarily to the problems of capacity discussed above, the current mix between public and private practice is a contributory factor.

Under the present arrangements, 80 per cent of beds in acute hospitals may be currently designated as public while 20 per cent may be private. In general, this ratio is operating reasonably well in the case of emergency admissions. The position regarding elective (planned or non-emergency) admissions is less than satisfactory. In 2000, 29 per cent of elective admissions were private while 71 per cent were public patients. In summary:

Both public and private patients have an entitlement to access needed care within a reasonable period of time. Also consultants have a contractual right to carry out private practice in public hospitals. The challenge is to ensure that a fair balance is achieved and that those who depend on the public system are not disadvantaged.

Feedback from the consultation process

The consultation process for the Health Strategy confirmed the many challenges currently facing acute hospitals. These include:

These problems must be addressed so that acute hospitals can meet the needs of patients fully and appropriately.

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Conclusions

The overall policy objective is to improve access for public patients.

To achieve these objectives a mix of actions is required which will address the capacity, efficiency and equity issues:

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Actions

The actions for change and development of the acute hospital system are set out below. Some actions relate to capacity and the mix between public and private patients, while others are concerned with specific organisational and practical steps that will help to promote equity, people-centredness, quality and accountability.

Capacity

78 Additional acute hospital beds will be provided for public patients

79 A strategic partnership with private hospital providers will be developed.

The Government is committed to exploring fully the scope for the private sector to provide additional capacity. Accordingly, the extra beds in the period to 2011 will be provided by a combination of public and private providers. To achieve this, a strategic partnership will be developed with the private hospital sector to provide more treatment for public patients. This will be progressed by setting up a Forum under the aegis of the new National Hospitals Agency (described below) involving the public and private sectors and insurers. The key objective is to provide the required extra capacity, whether this is in the public or private hospital sector.

80 A National Hospitals Agency will be established

This Strategy commits the Government to a significant increase in the number of hospital beds over the next ten years.

An objective, evidence-based means is required to determine the specialties in which these extra beds will be provided and their location around the country. Key decisions will need to be taken about the future configuration of existing hospitals.

Co-operation between hospitals needs to be reinforced so that a fully integrated hospital system is achieved. In addition, specialist advice is regularly required on the priority that should be attached to the development of individual specialties and services in acute hospitals throughout the country.

An independent agency is required which can provide expert, objective advice on these matters as they arise.

A National Hospitals Agency will be established on a statutory basis under the aegis of the Department of Health and Children. Its staff will have or draw upon appropriate expertise and specialist knowledge to carry out its tasks. Its main functions are outlined in more detail below.

National Hospitals Agency functions

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Functions of the National Hospitals Agency

To prepare a strategic plan for the expansion of capacity in the acute hospital system

This will involve planning the strategic configuration, by specialty and location, of the additional acute bed capacity announced in this Strategy, having regard to issues of quality, efficiency, clinical standards and access to services. It will enable developments to be progressed more rapidly as a result of clear direction and decision-making parameters for those charged with implementing national policy at a local level. In carrying out its functions, the Agency will work in collaboration with the health boards and the Eastern Regional Health Authority (ERHA) to ensure that the planning and delivery of hospital services is fully consistent with the health system as a whole. The Agency will not be involved in the ownership or day-to-day operation of hospitals.

To advise on the organisation and development of all acute hospital services

The Agency will advise the Minister and Department on the organisation, planning and co-ordination of acute hospital services, including the location and configuration of particular services or specialties. The Agency will consult with health boards and the ERHA, health professionals, user groups and others as appropriate in the course of its work. The input of all relevant health professionals, including consultants, will be drawn upon by the Agency in carrying out its tasks. These arrangements will have implications for Comhairle na nOspidéal, many of whose existing functions will be carried out by the National Hospitals Agency on its establishment. These implications will now be examined carefully as part of the independent audit of functions and structures of the health system, discussed later in this chapter, and arrangements will be made for transferring the relevant functions of Comhairle accordingly.

To advise the Minister on the designation of national specialist services and the development of designated services

The Agency, in consultation with health boards and ERHA, will advise the Minister and Department on the designation of acute hospital services as national specialist services and will keep such designations under review as clinical practice evolves. The Agency will also advise on the establishment of appropriate funding mechanisms for national specialist services generally and on the appropriate level of funding for those services.

To develop a strategic relationship with the private hospital sector

The Government recognises the scope for a significantly enhanced role for the private hospital sector. In this regard, the Finance Act, 2001 provides for significant tax allowances for the establishment of private hospital facilities under conditions which will also benefit public patients. The National Hospitals Agency, in collaboration with the health boards and the ERHA, will work to facilitate closer working relationships between the public and private hospital sectors. This will be of particular importance in ensuring that patients, both public and private, derive the maximum benefit from the expected growth in the private hospital sector.

To manage a new national waiting time database and to co-ordinate actions to reduce waiting lists and waiting times

The Agency will develop a national waiting time database to help streamline the system and help avoid any potential duplication of patients on the waiting lists of various hospitals.

To liaise with regulatory and professional bodies with decision-making roles in areas that affect acute hospital service delivery

The policy decisions of regulatory and professional bodies can have a significant impact on hospital services, for example, where a training body makes recommendations on staffing ratios or minimum caseloads for a specialty. The National Hospitals Agency will liaise with regulatory and professional bodies to ensure that the impact of such decisions for hospital services are fully assessed prior to implementation. It will also liaise with the Health Information and Quality Authority, discussed later in this chapter.

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Efficiency

81 A comprehensive set of actions will taken to reduce waiting times for public patients, including the establishment of a new ear-marked Treatment Purchase Fund

A new focus will be placed on waiting times. The target is that by the end of 2004, all public patients will be scheduled to commence treatment within a maximum of three months of referral from an out-patient department. The intermediate targets to achieve this aim will be as follows:

The target improvements in waiting times will be achieved by:

A National Treatment Purchase Team appointed by the Minister for Health and Children will manage the new Treatment Purchase Fund, working closely with the health boards. The team will commence its work immediately, in parallel with other reforms below. It will work in partnership with the health boards, hospitals and consultants to ensure that waiting times for public patients are reduced as quickly as possible.

The National Treatment Purchase Team will enter into immediate discussions with relevant hospitals and consultants to make streamlined arrangements to ensure that patients are offered the treatment they need. It is essential for the successful operation of the scheme that management procedures are highly efficient and that there is no avoidable delay in sourcing and referral of patients to the treatment needed.

Where it is not possible to treat patients within a reasonable period in Ireland, either in public or private hospitals, health boards will make arrangements under the Treatment Purchase Fund to refer public patients for treatment abroad, having regard to quality, availability and cost. This will always be subject to the patient's prior agreement and will be done in co-operation with the patient's consultant and/or general practitioner.

Alongside this process, a national waiting time database will be developed by the National Hospitals Agency to help channel patients awaiting treatment to an appropriate hospital with sufficient capacity. It will also help to eliminate any duplication of patients on the waiting lists of more than one hospital.

82 Management and organisation of waiting lists will be reformed

In addition to the initiatives above, the management and organisation of waiting lists will be reformed.

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83 One-day procedures will be used to the maximum consistent with international best practice

The National Hospitals Agency will work with the health boards and the ERHA to achieve increases in one-day procedures in line with international best practice.

84 The organisation and management of services will be enhanced to the greatest benefit of patients

Short-term measures

Medium to long-term measures

85 The operation of out-patient departments will be improved

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86 A substantial programme of improvements in accident and emergency departments will be introduced

Significant initiatives will be taken to improve the operation of accident and emergency departments by directing patients to the most appropriate form of care and ensuring that those who need treatment are seen as quickly as possible.

87 Diagnostic services for GPs and hospitals will be enhanced

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Equity

88 The extra acute beds in public hospitals will be designated for use by public patients

All of the extra acute hospital capacity within the public sector, both in-patient beds and day beds, will be designated for use by public patients. The only exceptions will be Intensive Care Units, Coronary Care Units and other specialised beds which will continue to be non-designated. The provision of additional beds announced in this Strategy will be a significant step forward in ensuring that the needs of public patients are adequately met.

89 Greater equity for public patients will be sought in a revised contract for hospital consultants

The terms of the common contract for hospital consultants are central to the establishment of an appropriate balance between public and private care in public hospitals. The forthcoming negotiations on the contract must be undertaken using a developmental agenda which will involve restructuring of key elements of the current system to promote equity of access, organisational improvements and more clinical involvement in and responsibility for management programmes. In addition, the introduction of more flexible work practices, including teamworking, rostering, cover arrangements, competence assurance and accountability initiatives must be addressed. The aim will be to build on the strengths of the present system while also providing the necessary flexibility to implement the improvements which are required in the provision of health services to public patients.

In particular, it will be proposed that newly-appointed consultants would work exclusively for public patients for a specified number of years. This would mean that consultants would concentrate on treating public patients in the early years of their contract, but would be in a position to develop private practice at a later stage where their contract so permits.

90 The rules governing access to public beds will be clarified.

Current rules require that patients must make a clear choice between fully private and fully public status (i.e. in respect of both consultant and accommodation). These rules are not always adhered to, particularly where patients are admitted as an emergency. In some circumstances, private patients may be accommodated in public beds. Public patients may also occupy private beds on occasions. The Government is determined to ensure admissions are managed so that the designated ratio between public and private patients is maintained and access by public patients is protected.

91 Action may be taken to suspend admission of private patients for elective treatment if the maximum target waiting time for public patients is exceeded

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Addressing capacity and organisation

Addressing efficiency

Addressing equity and mix between public and private care

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Funding the health services

Introduction

The issue of the funding of the health system has been the subject of much public debate and was discussed in detail during the consultative process for the development of the Strategy. The following key elements have been considered:

This framework outlines the Government's position on these issues and how funding for the system will be allocated in order to ensure that our health system is developed to deliver a high-quality, accessible and equitable service for all.

Discussion

Health funding method

Throughout the world, there is a variety of methods used for raising and allocating the funds required by health systems. In many cases, what appear to be simple models can in fact be much more complicated, with items such as co-payments not being immediately obvious. Similarly, systems have generally evolved over a considerable period and reflect distinct administrative, political and economic traditions. This said, there are some common factors which can be seen in all systems, such as the presence of an element of private finance. Similarly, there are some problems, such as waiting lists, which can occur across widely different systems.

During the preparation of the Strategy, considerable analysis was carried out on the most appropriate method of funding the Irish health system. In particular the relative merits of social insurance, private insurance and tax-based systems were carefully examined.

Social insurance

In social insurance systems, the bulk of health care funding is financed separately from general income tax. Contributions are made into a 'sickness fund' or set of competing funds, usually by employers and employees, with the government sometimes topping up contributions.

Those who advocate such systems claim that they give stability through 'ring-fencing' funding and promote both equitable access and responsiveness.

In response, the critique of such systems is that they undermine reasonable cost control, involve significantly higher administrative and transaction costs and prevent integrated service planning. It is also noted that many social-insurance systems require top-up payments from the Exchequer and are not in fact separate from general taxation. Therefore, they do not even achieve the objective of stability through ring-fencing funding.

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Private health insurance

A significantly less common approach is that of private health insurance. As a universal system, this would involve completely separating the planning and funding of services, as all services would receive funding on the basis of competitive bidding.

Advocates for this approach suggest the following as benefits:

In response, various weaknesses have been pointed to:

More fundamentally, a central element of the issues identified in the course of the preparation for the Strategy, and in the in-depth reviews which the Government has carried out in recent years, is that many of the key problems in our health system, most particularly those which relate to acute hospital care, stem from a core lack of capacity in the system; not from a lack of competition.

As is outlined elsewhere, the largest ever concentrated expansion in acute hospital facilities is required in order to deliver a system capable of treating all patients to the highest standards within an acceptable period. As such, there could be no real 'competition' between hospitals for public contracts for at least the next decade. More importantly, it is increasingly clear that the system requires more rather than less co-operation between health service providers. The integration of primary, acute and continuing care services is an essential part of achieving the level and quality of care that the public demand.

General taxation

The Irish health system is funded primarily through general taxation. There are certainly challenges which can be made to this funding method. The health sector must argue for its priority with all other areas of public spending and it is easier for the system to be less responsive. Key strengths are as follows:

The Government believes that each of the alternative funding models has weaknesses. However, it believes that there is no compelling evidence that any alternative approach to the tax-based system would deliver significant improvements while each would undermine the ability of the system to deliver the integrated expansion of capacity required both immediately and across the next decade. In addition, it believes that the reforms to accountability and planning proposed in the Strategy will help address clear deficiencies in the existing system without diverting resources away from the needs of care services.

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Private health insurance in Ireland

Private health insurance (PHI) is a long-established feature of the system of acute care provision in Ireland and acts as a strong complement to the publicly funded system. It has grown to the point where nearly 50 per cent of the population now has insurance cover against the cost of private treatment in public hospitals or private hospitals.

Claims expenditure by insurers, on behalf of their customers, is estimated to exceed £450m (_570m) annually. As part of this expenditure, health insurance payments represent a considerable source of revenue to public hospitals, at approximately £100m (_127m) annually. PHI is very much an integral part of the funding and delivery of hospital services to the population.

As a voluntary system, PHI in Ireland is characterised by the availability of extensive benefits with relatively few restrictions on utilisation. These qualities, when combined with a fee-for-service system of reimbursing service providers, increase the pressure on premium costs year-on-year. The need to manage claims costs, as a key determinant of premium levels, in such circumstances is one of the major challenges facing the sector. In line with the proposals set out in the White Paper on Health Insurance (1999), the immediate issues facing PHI include:

While the method of financing the services in Ireland is tax-based and centrally-funded, PHI will continue to play a vital part in the overall resourcing of health care in this country.

Levels of funding

As is outlined in Part One, health expenditure has been expanding very significantly in recent years, doubling in the period 1997 to 2001. In terms of per capita spending, Ireland's position has risen from a low base to approximate EU averages. This expanded funding has enabled the considerable expansion in key services and provided for significant increases in remuneration for health service employees.

This said, there remain considerable challenges and pressures for further expansion in funding. These include:

It has been submitted that Ireland should seek to link health spending to a fixed percentage of national income. It is not proposed to adopt this approach. Leaving aside the issue of the lack of certainty which would ensue, such an approach benchmarks financial inputs alone. It is a basic approach of this Strategy that all elements of the health system must be moved to a clear strategic focus on achieving output objectives.

It is service levels, not funding levels, which must be the focus. It is the responsibility of all elements of the health service to ensure that the public's funds are used to the maximum effect in the delivery of high-quality, responsive and efficient services.

In terms of capital funding, the National Development Plan offers substantial funding of some £2 billion (72.54) (1999 prices) for the health system over the period 2000-2006. This will enable continuing significant capital developments in the health sector. The NDP will equalise investment between the acute and non-acute hospital sectors and give greater balance to regional development throughout the country. Serious pressures remain in capital funding: these include a history of previous under-investment in health infrastructure and the impact that inflation in the construction sector is having on the real cost of developments originally envisaged under the NDP. That Government appreciates the urgent need for significant levels of investment in health infrastructure and is determined to progress the NDP for the health service as a matter of priority in future years.

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Funding allocation

Decisions on allocation methods are vital to ensure equity as a whole and to create the incentives for the direction in which we want to take our health system. Each year, the Department of Health and Children allocates funding to the health boards, which in turn make decisions on the distribution of available resources to the agencies in their area. The Department takes account of a range of factors to determine what proportion of the funding should be allocated to each board. These include the cost of providing services in the previous year, pay costs, service developments, funding for agreed specific items and, in the case of acute hospitals, the casemix budget model (described below).

There is a clear need to ensure that all funding is allocated on the basis of implementing sound strategic plans and that funding clearly relates to service outcomes. Performance measurement and transparent, evidence-based allocations are essential elements of this. Where appropriate, the allocation of development funding on the basis of competitive procedures should be incorporated. Similarly, the Government should make maximum use of resources outside the public system where their use can deliver quality care to public patients in a timely and cost-effective manner.

Conclusions

In summary:

Actions

The Government will take a series of actions in relation to funding levels and allocation methods to help achieve the objectives of the Health Strategy. These actions are set out below.

92 Additional investment will be made in the health system

The Government is committed to devoting the resources necessary for the health system, in line with the needs of the people and the availability of funding. The Government will provide the additional investment needed to support the objectives of this Strategy. While the level of investment each year must take account of the overall Exchequer position and the many competing demands for resources, the Government will give priority to investment in the health system over the period of this Strategy, provided that the necessary reforms and improvements in practice called for in the Strategy are seen to be advanced. Decisions on additional investment will be linked to the achievement of specific reforms and outcomes.

93 Capital funding will be allocated for the regular maintenance of facilities and the planned replacement of equipment

The maintenance of buildings and equipment is essential to an efficient, people-centred health system. Failure to maintain assets leads to extra costs later on, which could otherwise have been avoided. Accordingly, specific capital funding for maintenance and planned replacement of assets will be provided.

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94 Public-private partnerships will be initiated to help in the development of health infrastructure

A public-private partnership (PPP) is an agreement between a public authority and a private sector business entity for the purpose of designing, building, and possibly financing and operating, a capital asset or its associated service, where it has traditionally been provided by the public sector. The National Economic and Social Council has concluded that PPPs have the potential to

Public-private partnerships (PPPs) will be used in the health sector to speed up the provision of health infrastructure in accordance with general Government policy. As a matter of priority, the Government will commence using PPPs for the development of community nursing units and health centres.

95 Multi-annual budgeting will be introduced for selected programmes

A core theme of this Strategy is that there must be a more effective planning and development of services over a period of years. Specific targets and a framework for development are, as a result, set out for each major programme area. It is intended to move towards greater multi-annual planning and budgeting within the obvious constraints of the prevailing economic situation and the constitutional role of the Oireachtas in relation to Estimates of expenditure. In addition, it is intended to move towards multi-annual service and support agreements with organisations funded by health agencies.

96 The allocation process will be reviewed by the Department of Health and Children

It is important to reduce the dependency on incremental approaches, which are influenced significantly by the allocation given in a previous year. The amounts allocated by the Department to each health board must take full account of all relevant local factors so that the available funding is distributed fairly and to best effect. In particular, account must be taken of the specific needs of the population, which may vary between boards, depending on age profile, morbidity and income levels. The Department of Health and Children will examine the current system for allocating funding to health boards with the aim of taking as much account as possible of specific local factors. The Department will also take account of service outcomes using the strengthened framework which is proposed below for service planning.

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97 Financial incentives for greater efficiency in acute hospitals will be significantly strengthened

Funding systems, when properly targeted, can help create incentives for greater efficiency. They can also greatly improve the equity of the system by providing a clear basis for decisions regarding allocation of funding. In turn this improves the transparency of the allocation process. A key focus of the Health Strategy will be to take initiatives which improve equity, efficiency and transparency in the health system.

At present, the most developed system for assessing comparative efficiency and for creating incentives for good performance is the casemix budget model currently used in 32 acute general hospitals. Casemix classifies patients by reference to type of illness and resources used in treating them. The casemix budget model uses details of activity and cost to compare the relative efficiency of hospitals and to influence, in part, the total allocation given to each hospital. Under the Health Strategy, the casemix budget model will be further refined as a tool of financial allocation and a growing emphasis will be placed on the scope for using it as a means of creating positive incentives for efficiency and equity within the health system. The following steps will be taken to develop the casemix budget model:

98 Annual statements of funding processes and allocations will be published

In their submissions regarding the Strategy, a number of organisations argued for greater clarity about the basis for determining funding allocations and other aspects of the funding process. This was a particular concern of the community and voluntary sectors. Under the Health Strategy, the Department of Health and Children and the health boards will prepare and publish annual public statements on funding which set out:

Each board will prepare individual regional statements. The Department will be responsible for a statement in the national context.

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99 The management of capital projects will be enhanced

The management of capital projects from initial stages to completion will be streamlined in order to speed up the process. To achieve this the Department of Health and Children, in consultation with the health boards, will urgently review all elements of the management of capital developments such as planning, design, construction, equipping and commissioning. This will ensure the optimum use of capital investment; the speedy provision of a quality infrastructure which meets the needs of service users; and compliance with Government and EU requirements, including those relating to procurement.

Developing human resources

Introduction

The health services are among the largest employer in the public service. In wholetime equivalent terms there are some 81,500 employed, which equates to almost 90,000 individuals, taking account of those who work part-time.

The personal commitment of health service staff and the quality of the service they provide are extremely high. They work hard, often in difficult circumstances, to provide the best possible services to patients, clients and their families.

A key objective of the human resources framework is to develop and explicitly value staff at all levels of the health system. This in turn benefits service users.

The focus in this Strategy will be to develop the human resources function further, moving it on from what is sometimes perceived as a traditional personnel administration model to a modern human resource management model. The framework will build on the many strengths of the existing human resource system and of the workforce itself.

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Discussion

Since 1994 many initiatives have been taken in the area of human resources including the publication of A Management Development Strategy for Health and Personal Social Services in Ireland (1996) and the establishment of the Health Services Employers Agency in 1996 and of the Office for Health Management in 1997. Important reports affecting key personnel were published also, including the Report of the Commission on Nursing (1998), the Report of the Expert Group on Various Health Professionals (2000), the Report of the Medical Manpower Forum (2001) and the Report of the Working Group on the Effective Use of the Professional Skills of Nurses and Midwives (2001).

Nevertheless there are serious challenges facing staff and managers in the health system at the moment including skills shortages, difficulties in recruiting and retaining qualified staff, stressful working conditions, high turnover rates, poor morale, and complex industrial relations. The constraints caused by staff shortages place an extra burden on existing staff. Despite these constraints, people working in the health and personal social services have demonstrated enormous commitment and resilience in the face of the growing pressures on the services.

The Health Strategy is being published at a time when the country's prosperity, competitiveness, public services and the future role of partnership are all in a critical phase of transition. The difficult issues faced by the health system reflect conditions in the economy more generally. The Government is committed to continuing to work through partnership, during a period of slower economic growth, to consolidate recent achievements and improve the quality of life, while maintaining competitiveness in the economy.

In line with the advice received from the National Centre for Partnership and Performance (NCPP), the Government believe that across the economy generally, it will be necessary to embrace radical organisational change to cope successfully with the new challenges presenting. Improving performance through organisational change and capacity building, including new forms of management and more flexibility of work organisation will be put at the heart of the partnership process.

Conclusions

Two key strands are addressed in the framework for human resources:

These issues are interlinked. The first is concerned with ensuring the availability of an appropriately trained workforce. The second is concerned with attracting new staff, retaining existing staff and ensuring that health-care workers who have shown their commitment to working in the health system find it a challenging but rewarding and safe place to work.

The Government has asked the NCPP to work closely with Government departments, state agencies, employees, unions and staff to promote organisational change in a way that will improve the delivery of services and develop the workplace of the future. In this context, the partnership model must be central to meeting the challenges ahead.

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Actions

Ensuring a qualified, competent workforce to meet the changing demands of the health system

100 Integrated workforce planning will be introduced on a national basis

The Department of Health and Children will lead the development of an integrated system of workforce planning aimed at anticipating the number and type of staff required to provide a quality health service. This process will:

Workforce planning, led by the Department of Health and Children, will build on existing initiatives and available data regarding workforce needs. The Department will work closely with the Health Services Skills Group set up under the Programme for Prosperity and Fairness to help identify ways of meeting the workforce requirements of the health system.

101 The required number of extra health staff will be recruited

Eight thousand extra staff were recruited to the health services during 2000 through a range of proactive recruitment programmes. A comparable number is being recruited during 2001. Substantial further numbers of staff will be employed over the next five to seven years, including consultants, nurses, allied and paramedical and support grades.

In order to achieve the additional numbers required, a number of initiatives are being or will be undertaken.

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Initiatives to achieve the additional numbers required

Medical personnel: There will be substantial increases in the number of consultants. The number and location of these will be determined taking account of the advice of the National Task Force on Medical Manpower.

Further initiatives

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Nurses/Midwives: 10,000 nurses will be trained over the lifetime of the Strategy

Further Initiatives

Health and social care professionals: An extra 1,330 physiotherapists, 985 speech and language therapists and 875 occupational therapists will be trained, to meet the requirements up to 2015 identified by the recent report (Bacon, 2001) on these grades

Further Initiatives

Health care assistants: 340 Health care assistants will be trained by April 2000

Further Initiatives

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It will also be necessary to expand existing educational and training facilities to meet the substantial extra numbers of health professionals provided for in the Health Strategy.

102 The approach to regulating the number and type of consultant posts will be streamlined

The way in which consultant posts are regulated in future will be streamlined. Where it is decided to establish a new hospital service or to expand an existing service (on the recommendation of the National Hospitals Agency), approval to the provision of any consultant post(s) involved will be dealt with through the relevant health board's service plan, taking account of the recommendations of the National Task Force on Medical Manpower. In the case of a replacement post (as arises following a retirement or resignation) the relevant health board will again deal with it in the context of its service plan.

103 Best practice in recruitment and retention will be promoted

The Office for Health Management will prepare guidelines on best practice in advertising policies and recruitment for staff of the health system. These will be circulated to all health employers. The guidelines will include guidance on induction arrangements for all staff. The Health Services Employers Agency will work with the Office for Health Management to advise employers on implementation of the guidelines.

Retention rates for the system and individual employers will be measured in order to benchmark minimum standards and set targets for reducing turnover rates. Health service employers will be encouraged to adopt innovative approaches to job design. Initiatives such as flexible working and training, arrangements for atypical working hours and specific family-friendly approaches will be aimed at meeting the needs of health service workers and their families as well as the efficiency of the service.

The Chief Nursing Officer has convened a group to prepare Guidance for Best Practice on Recruitment of Overseas Nurses and Midwives. The document will be published shortly.

104 Greater inter-disciplinary working between professions will be promoted

Current practices in some professions can greatly hinder the development of inter-disciplinary work. To provide integrated, continuous, high-quality services, professionals need to work closely with each other, in a structured way, through formal or informal teams. An inter-disciplinary approach extends the range of skills available to patients, improves the deployment of scarce professional skills and provides greater continuity in the care of patients and clients.

The Department of Health and Children will work with the relevant professional bodies and teaching institutions to adapt training programmes so that the professions are brought more closely together from an early part of their training. The professional bodies will also need to work much more intensely and collaboratively to break down barriers between professions and to develop a culture of inter-disciplinary work. Progress should be planned on the basis of key milestones to be reached within agreed timeframes.

The development of inter-disciplinary working could be assisted by the development of joint programmes at the initial stages of undergraduate training. This might include, for example, a common medical sciences degree before specialised training for individual professions commences. This issue will be explored further within the health and education sectors.

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105 Provisions for the statutory registration of health professionals will be strengthened and expanded

At present, five professions are subject to statutory registration: doctors, nurses, pharmacists, opticians and dentists. New legislation will provide for the statutory registration of a number of other health professional groups. The Government is committed to strengthening existing legislation regarding registration of certain professions, such as doctors, nurses and pharmacists. In addition, new legislation will be introduced for the registration of health and social care professionals including physiotherapists, occupational therapists, social workers, child care workers and others.

The primary purpose of statutory registration is to protect and guide members of the public, so that they can be confident that the professional treating them is fully qualified and competent. Registration also provides the facility for legal action against the very small number of professionals who may harm patients or clients and bring their profession into disrepute through professional misconduct or serious illness.

All legislation on statutory registration of health professionals will be formally reviewed within five years of its introduction. The review will pay particular attention to the accountability of regulatory bodies to the Oireachtas and to the importance of reflecting the public interest on these bodies.

The legislation for professionals already registered, and for health and social care professionals being registered for the first time, will provide for consumer representation on the relevant statutory registration bodies, to ensure that the views of service users are represented. The legislation will also enable registration boards to provide for a system requiring re-accreditation of professionals at regular intervals, based on a structured system of continuing education and training.

106 Registration of alternative/complementary therapists will be introduced

A number of the submissions on the Health Strategy called for a scheme of registration of alternative and complementary therapists who work in the area of health and personal services.

The Minister for Health and Children has established a forum involving representatives of alternative therapies to explore how best to provide for a system of registration. Any registration scheme will take account of:

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Becoming an employer of choice

107 The HR function in the health system will be developed

The human resources function in the health system is relatively under-developed. Too often the emphasis is almost solely on industrial relations, to the detriment of many other aspects, including personal development, education and training and a range of HR issues affecting quality of working life and job satisfaction. Some progress has been made in the health boards, with the appointment of Directors of Human Resources who are responsible for the wider HR agenda. However, these individual initiatives need to be developed into a composite framework for human resources throughout the system.

The human resource function will have responsibility for:

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108 A detailed Action Plan for People Management will be developed

This Action Plan will provide a clear road map for action over the next five to seven years. It will be developed in consultation with the Health Services National Partnership Forum and implemented jointly through management, unions and partnership structures.

The Action Plan for People Management will seek to ensure that the health service has the right people, with the right competencies, in the right numbers, organised and managed in the right way, to deliver the goals and objectives of the Health Strategy.

In particular, the action plan will elaborate on how the following actions will be developed and implemented:

Action Plan for People Management

Invest in training and education

Central to the Health Strategy is the need to provide the financial and practical supports necessary for training and developing people in the health system. In addition to the commitments to training and development of new staff, health service employers will demonstrate a commitment to continuous learning by facilitating existing staff to undertake programmes that enhance the quality of patient care and contribute to their own career development. Continuing professional education, personal development planning and management development training will also be emphasised.

Devise and implement best practice employment policies and procedures

To establish the health service as an employer of choice, health employers will be asked to:

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Manage people effectively

Building and enhancing management capacity, including frontline managers, will be central to the health system's ability to deliver real change. Poor people management leads to higher turnover rates, lower morale and higher levels of stress.

A management style based on participation rather the exercise of authority, and which encourages and promotes transformation change, must prevail in the health system.

This participative approach implies major cultural change. The initial focus will be on managers, underlining the importance of securing their commitment to and involvement in developing the change agenda. In addition:

Improve the quality of working life

A working environment where people feel valued, recognised and safe is important to the improvement of morale and the retention of staff. The following key actions will be taken to improve the quality of working life:

Develop performance management

Performance management programmes are aimed at providing clear feedback to individuals in order to make best use of available skills and help advance the strategic objectives of the organisation. They also offer a useful means of setting work and personal development goals and give people an opportunity to contribute ideas for improving delivery of services. Performance programmes must be fair and transparent. Performance management systems are already being introduced in the public sector generally. They will now be extended more comprehensively to the health system, in consultation with staff and unions.

Promote improved industrial relations in the health sector

The Action Plan for People Management will include measures to implement the recommendations of the recent report of the Advisory Development and Research Service of the Labour Relations Commission (2001) with particular regard to:

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Develop the partnership approach further

The partnership approach can play a key role in driving the changes proposed in the Health Strategy and it will be strongly supported by the Government. The Action Plan for People Management will reflect the Government's commitment to assisting partnership in the health system to reach its potential and will deal with how best to develop further the role of the Health Services Partnership Forum and its local partnership structures. In line with the national strategy for improving performance through organisational change being developed by the NCPP, the action plan will place particular emphasis on the development of organisation-based projects on which all staff can work together to be part of the change process.

Organisational reform

Introduction

The way in which health and personal social services are planned, organised and delivered has a significant impact on the health and well-being of the population. Organisational structures must be geared to providing a responsive, adaptable health system which meets the needs of the population effectively and at affordable cost.

It cannot be assumed that any particular organisational structure for the health system will, of itself, ensure the provision of an effective, people-centred service. It must be combined with the right policies and practices in a range of other areas, including an effective human resource function and a clear sense of direction. The framework for organisational reform in this Strategy aims to support effective decision-making, based on the best available evidence and to promote high-quality services.

Health care organisations that systematically emphasise quality are the best places to work. They respect and maximise the contributions of all staff, they reduce the amount of unnecessary and ineffective work, they reduce error rates and they produce better outcomes and job satisfaction.
Saskatchewan Commission on Medicare, April 2001

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Discussion

The present structures in the health system have largely been in place for some thirty years, although there have been changes to the internal structures of many health boards. The structure of the system is set out in broad outline in Chapter 3.

The overall structure of the Department of Health and Children has altered relatively little in recent years, but changes have been made to reflect growing developments in areas such as services for children, older people and people with a disability. A shift in emphasis is occurring under the Strategic Management Initiative (SMI), which involves moving from detailed executive involvement to a stronger role for strategic policy-making.

Recent changes to the system have included the establishment of the Eastern Regional Health Authority in 2000 and the provision for a Health Boards Executive (HeBE) which will carry out agreed joint functions on behalf of all or a number of health boards. A number of additional advisory and executive agencies has also been established over the years.

The strengths and weakness of the present system are discussed in Chapter 3. The main conclusion is that while the system has served well in many respects, some significant issues remain. These relate to the co-ordination and integration of services, better needs assessment and planning on foot of these needs, and consistent standards of access and quality throughout the health system.

Conclusions

It is important to develop a single integrated system, rather than one which varies between the approaches taken in individual health board areas. This requires more co-ordination between health boards in the way they work, particularly in areas of planning and service delivery. Structures are required to support the central development of national quality standards and to ensure consistent national application of those standards. Continuing close co-ordination with the non-statutory sector will also be required.

The aim is to have a consistent, national approach to the planning and delivery of services based on clear and agreed national objectives. Improving co-ordination and integration also means reviewing the roles of existing executive and advisory agencies to maximise efficiency and reduce overlaps.

Actions

109 The Department of Health and Children will be restructured

The Department will be restructured to focus on the priorities set out for the health system of the future. To progress this, an independent review of the structure and resources of the Department of Health and Children, with proposals for change, will be completed within six months. The Department is assigned a lead role in implementing the very challenging programme of development and reform outlined in this Strategy. It is already visibly under pressure and will require strengthening if it is to provide credible and authoritative leadership during the period of major transformation ahead.

The devolution of executive work under the Strategic Management Initiative will continue to be progressed. The Department needs to be positioned to focus on the strategic aspects of health policy, such as national service planning and overall governance of the health system. The review of structure and resources will be carried out with these requirements in mind.

110 Health boards will be responsible for driving change, including a stronger focus on accountability linked to service plans, outputs and quality standards

The health boards have important responsibilities under the Accountability Legislation (1996) regarding the level and type of services to be provided under their service plan. This accountability framework will be further strengthened to underline the boards' role in providing the best possible value for money and pursuing quality standards. The health boards will continue to play a major role in the planning and delivery of health and personal social services and will be crucial to delivering on the reform agenda set out in this Strategy. In particular, they will:

In discussing the role of the health boards, it is important to distinguish between the board itself (which comprises elected members of local authorities, representatives of health professions and nominees of the Minister) and the management and staff of the boards. Under the Accountability Legislation, the decision-making functions of the board were clarified to emphasise their role in overall strategic direction and policy, and formal authority and accountability was assigned to management regarding the planning, management and delivery of services.

The Government has carefully considered whether the current number of health boards best meets the requirements of the health system. It is satisfied that changing the number of boards would not of itself lead to improvements in services. Instead, the focus will be on improving delivery of services and developing a stronger framework of accountability, linked to service plans, outputs and standards of quality as set out in this Strategy. The establishment of a National Hospitals Agency will free the boards to concentrate on other important aspects of their work.

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111 An independent Health Information and Quality Authority will be established

A key policy aim is to deliver high-quality services that are based on evidence-supported best practice. To promote this aim a Health Information and Quality Authority will be established. The Authority will:

The Authority will have responsibility for:

The Health Information and Quality Authority will be established on an independent statutory basis enabling it to set and monitor standards in an objective manner. Its structure will be designed to allow for considerable operational flexibility. This may involve drawing upon panels of short-term expert staff, both national and international, who work for a limited period on a specified project. The Authority's work will lend itself to an all-Ireland remit; this will be explored in the context of discussions on North-South co-operation in the area of health.

Functions of the Health Information and Quality Authority

Develop health information which best meets the needs of the health system

The Health Information and Quality Authority will:

Promote quality nationally

Quality is one of the guiding principles of the Health Strategy. It must infuse activity at all levels of the health system. The Health Information and Quality Authority will:

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Develop an annual programme of service reviews

The Authority will develop an annual programme of service reviews, in consultation with the Minister for Health and Children, those working in the health system and the public. The reviews may be by care groups, such as people with a mental illness; by type of disease or condition, such as cancer or renal services; or by sector such as primary care. Reviews will normally be at a national level, but regional reviews may also be undertaken. Reviews will be linked to the development of quality standards for different services and may cover any aspect of performance, including clinical or managerial aspects.

Publish a report assessing national performance in relation to each service area examined, against specified national standards

The Authority's report on each selected area will detail clearly whether the required standards have been met, not met, or exceeded. Reviews will examine health outcomes, to determine whether services are leading to real improvements for patients and clients. It will be a critical task of the Authority to report on outcomes for care groups and specific services so that guidance can be provided regarding future investment decisions. The Authority's focus will be on encouraging and promoting the development of quality standards, rather than simply attaching blame where standards or outcomes fall short. The reports will make suggestions for specific improvements and will be widely distributed.

While the Authority will develop standards in agreement with agencies, and report on selected services regularly, the relevant health boards, hospitals and other bodies will have responsibility and accountability for taking action in response to the Authority's reports.

While responsibility for this range of functions will be vested in the Authority, it may commission work from a number of established sources, such as the Social Services Inspectorate and the Inspector of Mental Hospitals, to support it in its role. It will work closely with the health boards and other relevant agencies and will have a national rather than local focus. The health boards' responsibilities in these areas at local level will remain, but will be supported by the national perspective brought by the Authority.

Oversee health technology assessment

There is a growing need to analyse all forms of new developments in health care to establish if they are effective, and if their use is justified.

Health technology assessment (HTA) involves analysing the research findings about the medical, organisational, social, ethical and economic implications of the development, diffusion and use of health technologies. HTA can play a key role in ensuring that the most modern appropriate care and treatments are used, in a way that maximises health gain and achieves value for money. HTA is a key component of evidence-based health care.

As highlighted recently by the Value for Money Audit (2001), there is currently no coherent structure for carrying out evidence-based HTA in Ireland. This results in a slower response to changes in health technology than would be desirable. A structured system of HTA will enable the system to:

Under the Strategy, the Health Information and Quality Authority will oversee the development of HTA and promote its use to inform vital policy decisions, from initial evaluation, to implementation, monitoring and review of outcomes. It will draw upon HTA work carried out in other countries, and the scope for North-South co-operation will be explored.

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112 The Health Boards Executive (HeBE) will be developed as a key instrument in the change agenda

The Health (Eastern Regional Health Authority) Act, 1999 provides for the establishment of a Health Boards Executive (HeBE). Its purpose is to carry out certain executive functions on behalf of the health boards, and other executive functions as may be directed by the Minister, aimed at improving the efficiency and effectiveness of services.

HeBE will provide an important avenue for ensuring that the health boards can operate jointly on issues where a national approach to implementing a programme or service is the best way of achieving the objectives of the Strategy. The functions given to the HeBE will be regularly reviewed by the health boards and the Department of Health and Children to ensure it is efficient and effective.

The HeBE will rely on management and personal development work undertaken throughout the system by the Office for Health Management.

113 The role of the Office for Health Management will be expanded

The change and modernisation programme will also require an enhanced role for the Office for Health Management. Developing current and future managers to support the modernisation agenda and meet the objectives for improvement set out in the Strategy will be vital in implementing change. In addition, the need for organisation development must also be addressed, to ensure that all health agencies are fit for the challenges facing them. There is well-documented inter-dependency between the structure of an organisation, its processes, strategy, culture and people. Encouraging, promoting and rewarding a culture of continuous learning and improvement will be important in adapting to new ways of working.

114 An independent audit of functions and structures in the health system will be carried out

The framework for organisational development will help clarify roles and co-ordinate the work of different organisations. It will also place a stronger emphasis on high-quality outcomes, and on ensuring that major policy decisions are taken in an objective way, based on the best available evidence.

As part of the process of implementing these changes, the Department of Health and Children will commission an audit of organisational structures and functions in the health system, to ensure clear lines of accountability and communication between each part of the system, no overlap or duplication between organisations, and a proper alignment of the structure as a whole to the vision and objectives outlined in the Health Strategy. The audit will consider the number and configuration of existing health boards and other agencies and the scope for rationalisation. The audit, which will start immediately, will ensure that structures in the health system:

A list of the organisations to be encompassed by the audit is at Appendix 3.

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Developing health information

Introduction

To meet the objectives of the Health Strategy and to deliver the quality of health services that people require, information is needed which is appropriate, comprehensive, high-quality, available, accessible and timely. Good information systems based on fast, efficient flows of shared information are, therefore, essential to the success of the Strategy.

Discussion

The recent Value for Money Review of the Irish health system (Deloitte and Touche, 2001) identified inadequate information as a critical weakness which limits the capacity for prioritisation, planning, evidence-based decision-making, efficient service delivery, and monitoring and evaluation at all levels. A clear basis is needed for identifying priorities in health care and for demonstrating performance and value for money. Improvements in health information are central to establishing the evidence for any such decisions.

Improvements in health information can be facilitated greatly by worldwide developments in information and communications technology (ICT). This technology has the power to improve radically the provision of health information and to streamline and improve health service provision. Full co-operation among health agencies is essential to ensure that the benefits of ICT can be exploited.

There is now a considerable public policy commitment to eGovernment with the intention of promoting Ireland as a centre of eCommerce excellence. The widespread availability of low-cost, high-speed, internet access will be a critical enabler of eHealth developments. The health system is working with the eGovernment programme, including REACH,2 which will ensure that the benefits from these developments are fully realised.

In recognition of the importance and value of improving public access to health information, there is a need to develop a national health internet site for the public that provides standardised information on health and health care (e.g.the management of health problems and the safety and effectiveness of interventions), the availability of local health services, and entitlements. The processing of health entitlements should be available on-line as far as is practicable.

Mobile communication technologies are evolving rapidly and could enable the development of new eHealth service delivery models, especially for staff working in the field such as public health nursing, and out-of-hours and emergency services, by providing access to medical and administrative records. Telemedicine and telecare systems can bring images and other clinical data (rather than the patient) to the care provider, thus providing remote consultation. By limiting the need to travel, this technology has the potential to increase the accessibility of some services.

Conclusions

The Department of Health and Children is currently preparing a National Health Information Strategy (NHIS). Its implementation has been identified as key in supporting the attainment of the Health Strategy's national goal of high performance. Information has been included in the Health Strategy as a specific framework for change because it plays an integral role in the development of the health system. It is vital that the development of a health information system is integrated into the agenda for change identified in the Health Strategy.

Information plays a central role in supporting strategic goals and in underpinning the principles of the Health Strategy. It must not be seen merely as an add-on.

The actions set out below should be seen as supporting and prioritising key areas for attention which are developed in greater detail in the forthcoming National Health Information Strategy.

Actions

As described earlier in this chapter, the Health Information and Quality Authority will exercise a pivotal role in relation to a number of key information functions. In addition, the following actions will be taken to meet the information requirements of the Health Strategy:

115 The National Health Information Strategy will be published and implemented

The Information Strategy will be designed to promote:

116 There will be a sustained programme of investment in the development of national health information systems as set out in the National Health Information Strategy

Considerable development of the information infrastructure will be required to support improvements in the availability and quality of health information. Operational systems which support the delivery of health services are fundamental to success and will be the only viable source of the bulk of evidence for management. Investment levels currently fall short of best practice in industry despite the complexity of the health system. Addressing these shortfalls is a fundamental objective.

117 Information and communications technology will be fully exploited in service delivery

Modern ICT has the potential to improve radically the range and type of services, as well as the method of delivery, for professionals and the public. ICT can provide rapid access to clinical and administrative records as well as a range of knowledge to assist with decision-making. Data collected at this stage will be a key source of information for planning and performance measurement.

Telecare and telemedicine has the potential to bring specialised diagnostic and clinical expertise closer to people, especially those in remote locations, making the health service more accessible and responsive.

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118 Information-sharing systems and the use of electronic patient records will be introduced on a phased basis

The electronic patient record (EPR) is a developing technology. Its phased introduction will support the clinical process and offer great potential to enhance the quality and safety of care. In particular, the linkage of EPRs to create an electronic health record (EHR) will provide new opportunities for supporting shared care. A method of uniquely identifying individuals and service providers is essential for realising the full potential of the electronic record. The planned extension of the use of the personal public services number (PPSN) to cover the delivery of all public services, within the Government's overall strategy for integration of public services, may provide this method of identification in the future. In any event, the use of unique identifiers in the health field is of major importance in achieving the highest quality of care and in the delivery of patient-centred services.

119 A national secure communications infrastructure will be developed for the health services

A robust communications network and services infrastructure is a necessity for the effective and efficient collection, sharing and use of health information. Individual agencies and organisations have already developed communications networks to a varied extent on a local or regional basis. National initiatives, including the development of a government network for state services and the REACH initiative, may offer ways of providing this network. It is essential to consider current and future capacity, including the potential to utilise the network for newer and heavier demands. These include video, image transfer, and telephony in support of telemedicine, conferencing and eLearning. Security will be a crucial consideration.

120 Information system development will be promoted as central to the planning process

Service planning must be evidence-based. All service developments must be based on a good business case which, in turn, requires good supporting information. Appropriate information systems are central to the collection and analysis of the information required to underpin this planning process.

121 Health information legislation will be introduced

The legislation required for developing information systems to support the objectives of the National Health Information Strategy will be introduced. The legislation will address concerns about privacy and confidentiality, while ensuring that health information can be utilised for the benefit of all.

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Chapter 6 - Responding to people's needs

Introduction

Chapter 4 sets out the goals and objectives of the Health Strategy. In Chapter 5 the structural changes required to deliver these objectives are set out. Some system-wide changes are outlined which are relevant to everyone and will improve delivery and quality of services. They include the following:

Quality assurance

Information systems

Human Resources

Research

In this chapter, the implications of the Strategy for specific groups of the population are described.

Children's health and well-being

Policy context and recent developments

It is well recognised that social, economic and environmental conditions all have an impact on child health and management and that an integrated approach is required. The recently published National Children's Strategy provides an integrated framework as well as the broader policy context for all new initiatives for children, including this Health Strategy. The National Children's Strategy sets out three goals and an action plan to address these dimensions in an integrated way. While it identifies the main actions to be taken, it requires more detailed measures to be developed in the different sectors. This section of the Health Strategy provides for more detailed action in relation to two of the dimensions, 'physical and mental' and 'emotional and behavioural well-being', although it is relevant in some degree to all aspects of child care.

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This Strategy's approach to children's health and well-being

Figure 6.1 shows how children interact with the different parts of the health system and shows the nature of their needs, ranging from basic to more complex.

All children have basic needs. These needs can be met by the child's family and social networks or by themselves. Some basic needs must also be supported by the health system.

Some children have additional needs. Small numbers of children will need to access different parts of the system to support their physical, mental, emotional and behavioural well-being. The system must be flexible enough to be able to respond to more complex needs. The system also must be better integrated to allow for continuity of care and for the development of individualised care planning for children.

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children and the health system children and the health system

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Issues in child health

Health status

Despite improvements in the health status of children in recent years, certain areas of our health services for children still show shortcomings. For example, many of the causes of morbidity and mortality in children are preventable such as injuries and poisonings, infectious diseases and certain congenital anomalies such as neural tube defects. Waiting times for certain services are unacceptable. Of particular concern is the evidence of a lower health status in disadvantaged groups, including Traveller children. Best Health for Children (1999) represents a co-ordinated approach to protect and promote children's health in partnership with parents and health professionals and this approach is fully endorsed in the Health strategy.

Child health - legislation, strategic policy documents and expert reports

Preventive actions

The measles epidemic of 2000 highlights the dangers involved in low vaccine uptake rates. Vaccine-preventable diseases represent one area of communicable diseases for which highly effective and cost beneficial measures exist for prevention and control. The success of these programmes depends on achieving high levels of vaccine uptake which at present fall short of the target figures.

Breastfeeding of infants and young children provides one of the best opportunities to give children a good start in life. Since Ireland currently has the lowest breastfeeding rates in Europe, there is a need to promote, support and protect breastfeeding in homes, schools, workplaces and in society generally.

Actions to improve children's health and child health services

Better health for everyone

Health inequalities

Fair access

Responsive and appropriate care

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Issues in child welfare and protection

A specialised infrastructure was put in place from the early 1990s where the dominant focus was on child protection and on fulfiling statutory responsibilities to identify children at risk. While these services were both necessary and important, awareness has grown in recent years of the need to target preventive approaches and in particular to develop and expand family support services. This involves a cross- sectoral approach as emphasised in the National Children's Strategy and led by the National Children's Office. The approach also emphasises greater co-ordination between child welfare and protection and primary care services such as general practice and public health nursing. Effective co- ordination is also essential between these services and therapeutic services such as child and adolescent psychiatric teams. Better integration and inter-sectoral working has particular relevance in relation to the effective implementation of the Children Act, 2001.

Child welfare - legislation, strategic policy documents and expert reports

An underlying issue contributing to problems in service provision is the lack of good-quality information about the needs of children and the existing capacity of the system to deliver good outcomes. A major project is underway to create an integrated management information system for child welfare and protection services.

The Children Act, 2001, the establishment of the Social Services Inspectorate and Children First­National Guidelines for the Protection and Welfare of Children, represent major developments in strengthening arrangements for the protection and care of children. In the area of adoption, new legislation is being prepared on information rights and inter-country adoption.

Considerable investment has been made in human resources in child welfare and protection services over the last number of years. However, due to the stressful nature of this work, it is critical that issues such as training, caseload management and working practices for child care professionals are further strengthened and developed. These will be addressed in the context of the Action Plan for People Management which will set out specific actions to support staff and strengthen management support. In addition, career structures, skills mix and multidisciplinary working will be examined as part of the initiative on workforce planning.

Actions to strengthen child welfare and protection services

Better health for everyone

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People with disabilities

Policy context and recent developments

Current Government policy on the provision of services to people with disabilities places emphasis on the importance of mainstreaming. In essence this policy requires that specific services for people with disabilities should be the responsibility of those government departments and state agencies which provide the services for the general public.

The Department of Health and Children in consultation with other government departments will concentrate on the enhancement of the health and personal social service needs of people with disabilities. Health services have an impact on people with disabilities through:

The principle which underpins policy is to enable each individual with a disability to achieve his or her full potential and maximum independence, including living within the community as independently as possible. A major proportion of the services for people with disabilities is provided by agencies in the voluntary sector.

Disability services - legislation, strategic policy documents and expert reports

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Issues in disability

Since the publication of Shaping a Healthier Future in 1994, there has been considerable investment and expansion in a range of services for people with disabilities. Additional funding of £256m has been provided for services for people with intellectual disability and those with autism and £119m has been provided for services for people with physical and sensory disabilities.

Despite a significant expansion of services, there are still unmet needs in the overall range of support services required by people with disabilities. There are concerns about access to services including the adequacy of provision in some geographical areas and the varying criteria for access to day, residential and respite care.

Access to information on services and entitlements for people with disabilities was also raised in the consultation process.

Intellectual disability and autism

Since 1997 the programme of investment in services has been based on the needs identified in the National Intellectual Disability Database, which came into operation in 1996.

Intellectual disability ­ some facts

There were 26,760 people registered on the National Intellectual Disability Database in 2000, 460 more than in 1996.

Currently, 24,035 people with intellectual disability are in receipt of services, representing 89.8 per cent of the total population. Of these 1.8 per cent are without services at present and are wait-listed for appropriate services. The remaining 8.4 per cent, most of whom have a mild degree of intellectual disability or have not had their level of disability verified, have no identified requirement for services in the next five years.

An additional 1,291 people are in receipt of services since the first data were reported in 1996; 238 of this group are in full-time residential services and 1,052 are attending services on a daily basis.

Provision of respite services has increased by 70% since 1996. Particularly significant increases are observed in the number of people availing of planned or emergency respite care (up 135%), respite breaks with host families (up 88%) and regular part-time care (up 19%).

A number of factors contributing to the increased demand for services in this area include:

Concerns have also been expressed that a number of people with intellectual disability are still receiving services in a psychiatric hospital setting.

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Physical and sensory disability

It is important to note that people with physical and sensory disabilities are a very heterogeneous group. The term covers a wide variety of conditions and levels of disability. A person with a visual or hearing impairment has very different needs to a person with a physical disability. This has implications for the levels of support required from the health services. A multifaceted approach involving other government departments and agencies is required to meet the needs of this client group.

A major obstacle to the planning and development of appropriate services for people with physical and sensory disability has been the lack of statistical information on numbers and needs. The National Physical and Sensory Disability Database Development Committee was established in December 1998 to address this issue. The establishment on a national basis of the Physical and Sensory Disability Database is a priority so that the extent of unmet need can be measured.

Despite increased development funding, there are considerable unmet needs in regard to people with physical and sensory disabilities. Further investment is required to expand family support and day and residential facilities for people with physical and sensory disabilities. Other gaps which were highlighted in submissions on the Health Strategy were: respite care, personal assistance services, funding of aids and appliances and the development of appropriate rehabilitation services.

Training and work

Training

In June 2000 the Government assigned responsibility for vocational training to the Department of Enterprise, Trade and Employment and for rehabilitative training to the Department of Health and Children. Since the dissolution of the National Rehabilitation Board responsibility for the management of rehabilitative training has been assigned to the health boards. A standard for delivery of rehabilitative training has been recently agreed and is in place.

Sheltered work

Over the years the provision of day activity services for people with disabilities has evolved in many instances into the provision of a range of sheltered work activities. Employment Challenges for the Millennium, the Report of the National Advisory Committee on Training and Employment (1997), estimated that there are 7,900 people with disabilities working in 215 sheltered workshops. A more structured policy framework covering all aspects of the provision of sheltered work for people with disabilities is required.

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Actions for disability services - general

Fair access

Responsive and appropriate care delivery

High performance

Actions for intellectual disability and autism

Responsive and appropriate care delivery

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Actions for physical and sensory disability

Responsive and appropriate care delivery

Mental health

Policy context and recent developments

Policy on mental health is based on Planning for the Future, published in 1984. This report recommended the establishment of a comprehensive community-oriented mental health service as an alternative to institutional care. The main legislative provision relating to mental health services is the Mental Health Treatment Act, 1945.

Structural developments

Planning for the Future (1984) recommended the closure of the old psychiatric hospitals and their replacement with acute psychiatric units in general hospitals and a range of community-based residential accommodation. While considerable progress has been made in many health board areas in implementing the change from institutional to community-based care, few have as yet completed the process. Pressures on acute psychiatric units, particularly in the Eastern Region, will be significantly eased by the provision of additional community residences in these catchment areas where the rate of community places per head of population is lower than average.

Eighteen acute psychiatric units are at various stages of development. These will be accelerated with a view to ensuring that, by 2008, there will be no further acute admissions to psychiatric hospitals.

Among those with mental illness, a small but significant minority of patients are disturbed. In a modern mental health service, the needs of the disturbed mentally ill are best met by the development of psychiatric intensive care units (PICUs). Following a lengthy consultation process, the Department of Health and Children issued a policy document in 1999 proposing the development of such a unit in each health board area and setting out the staffing and protocols which would be required. All health boards will be developing these units over the next few years as part of the modernisation of the mental health services.

Mental health services - legislation, strategic policy documents and expert reports guiding activity

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Legislation

The Mental Health Act, 2001 is the most significant legislative provision in the field of mental health for over fifty years. It significantly reforms existing legislation concerning the involuntary detention of people for psychiatric treatment. The legislation brings Irish mental health law into conformity with the European Convention for the Protection of Human Rights and Fundamental Freedoms. It provides for the establishment of an independent agency to be known as the Mental Health Commission. The Commission's primary function will be to promote and foster high standards and good practices in the delivery of mental health services and to ensure that the interests of persons detained under the terms of the Act are protected. The Commission will be responsible for overseeing the process of review of detention by mental health tribunals and will also employ the new inspector of mental health services, who will have wide-ranging powers. The Commission will be appointed before the end of 2001, to enable it to commence the implementation of the new Act as quickly as possible.

Suicide prevention

The Report of the National Task Force on Suicide, published in 1998, outlined a comprehensive strategy to reduce the incidence of suicide and attempted suicide in Ireland.

Since its publication, over £3m has been invested in suicide prevention measures in the health boards. Each board now has a suicide resource officer in place and regional suicide prevention plans are being drawn up. Additional resources will be allocated to suicide prevention in the coming years.

The National Suicide Review Group was established by the chief executive officers of the health boards in response to the Task Force Report. Its main responsibilities are to review ongoing trends in suicide and parasuicide (attempted suicide), to co-ordinate research into suicide and to make appropriate recommendations to health boards. The Health (Miscellaneous Provisions) Act, 2001 requires the Minister for Health and Children to report to the Oireachtas each year on the measures taken to address the problem of suicide. The work of the National Suicide Review Group will inform the preparation of this report.

Issues in mental health

Policy

There is now a need to update mental health policy, to take account of recent legislative reform, developments in the care and treatment of mental illness and current best practice. The role of the new Mental Health Commission, to be established under the Mental Health Act, 2001, in ensuring quality and high standards in the delivery of services will also need to be considered.

Structures

Policy and objectives for mental health services also need to be updated to take account of legislative reform, developments in the care and treatment of mental illness and delivery of services in modern society. This is required in order to deal with issues such as:

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Service levels

Despite some progress in recent years, the existing level of services is inadequate. In particular, community services such as home nursing, day centres, family support, hostels and day hospitals will continue to be developed. There are also gaps in services for specific groups with mental health problems including:

Advocacy

There is a need to generate greater public awareness and understanding of mental illness and to change attitudes to mental illness among the general public and health professionals. In addition, the development of advocacy services for people with mental health problems has emerged as an issue. In terms of the principle of people-centred health services, the strengthening of advocacy services is a priority.

An advocate is someone who represents and defends the views, needs and rights of an individual who does not feel able to do this for him or herself. Within the mental health services, an advocate helps the patient to explore and understand his or her concerns and then represents these concerns to service providers and others in positions of authority. The advocate thereby facilitates the service user's participation in decision-making about his or her own care and treatment. Advocacy encourages recovery by enabling the patient to take control and it can act as a mechanism for changing attitudes towards mental illness.

The development of advocacy services will help to address the civil and human rights of the mentally ill. The Mental Health Act, 2001 makes statutory provision for legal advocacy for people with a mental disorder, by requiring the Mental Health Commission to provide an independent legal representative to each person who is detained involuntarily under the terms of the Act. The development within the voluntary sector of other forms of independent advocacy for mental health services users, e.g. peer advocacy and self-advocacy, needs to be encouraged and supported

There is also a need for increased input from patients of the mental health services into the planning of services and the promotion of mental health.

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Actions for mental health

Policy development

Better health for everyone

Responsive and appropriate care delivery

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Services for older people

Policy context and recent developments in services

The level of investment in services for the elderly was low during the 1980s and into the mid-1990s. In 1997 an additional £10m was provided, increasing to £36m in 2000 and £57.42m in 2001. Between 1997 and 2000 an additional 800 posts were approved, 400 additional beds were provided in 10 new community nursing units and over 1,000 day places per week were provided in 10 new day care centres.

Services for older people - legislation, strategic policy documents and expert reports

Issues for older people

Older people often experience a poor level of health accompanied by pain, discomfort, anxiety and depression. There is a need to develop a comprehensive approach to meeting the needs of ageing and older people if the problems in the care and quality of life of older people are to be addressed and the increased demands over the next 20-30 years are to be met. This must include both acute health care provisions for the sick elderly and active health maintenance programmes for continuance of health in the elderly.

The continued growth in the population of those aged 65 years and over will give rise to additional demands for services. Significant development of these services will be required as a priority to meet such demands. Currently, the main gaps in service provision relate to:

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The Ombudsman's Report on the Nursing Home Subvention Scheme published in 2001 has raised issues regarding service eligibility and charging for long-stay care. There is a need for a clear policy on eligibility and on the balance in planning both public and private services in relation to this issue. This is particularly important given the demographic trends in relation to older people as a percentage of the overall population, the increased expenditure on the scheme and the risk that current provisions create incentives to enter residential care when community care would be more appropriate and preferable to older people and their families.

The problem of inadequate co-ordination of services for older people, applies both within services for older people and to the interface between those services and acute hospital and other specialised services such as mental health.

The National Council for Older People has produced a number of reports in recent years relating to specific areas of need. A clear framework for implementing the recommendations contained in reports on health promotion and dementia is required.

Actions for older people

Better health for everyone

Fair access

Responsiveness and appropriate care delivery

Community services :

Hospital Services:

Residential care

High performance

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Women's health

Policy context and recent developments

Policy initiatives

A Plan for Women's Health 1997-1999 set out four key objectives for the health services in relation to women. These were:

All health boards have produced women's health plans in accordance with the national Plan for Women's Health. They concentrate on issues of particular concern to the health board region and were developed by women's health advisory committees in the various health boards.

Women’s Health - legislation, strategic policy documents and expert reports

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The Women's Health Council was established on a statutory basis in 1997. Its functions include evaluating progress towards meeting the objectives of the Plan for Women's Health and advising the Minister for Health and Children on women's health issues generally. The Women's Health Council involves a partnership between consumers, health-care professionals, policy makers and other representative groups including the National Women's Council of Ireland.

Preventive actions

Phase 1 of Breastcheck, the National Breast Screening Programme, commenced in February 2000 and covers the Eastern Regional Health Authority, Midland Health Board and North-Eastern Health Board areas. Screening in these areas is available to all women aged between 50-64 years. This service is being delivered in two central units with outreach to the community by means of three mobile units.

Phase 1 of the Irish Cervical Screening Programme commenced in the Mid-Western Health Board region in October 2000. All women in the health board area aged between 25 and 60 years (72,000 approx) have been encouraged to register with the programme. Those registered will have a cervical smear taken free of charge at five-yearly intervals. As stated in Chapter 4 breast and cervical cancer screening programmes will be extended nationally, having regard to the experience gained in implementing the programmes to date.

Issues in women's health

Health status

Using a number of indicators the health of Irish women can be compared to that of our EU neighbours. Irish women have a relatively lower life expectancy, particularly in middle age, than their EU counterparts. Death rates from heart disease in Irish women are amongst the highest of any country in the EU. In 1997 the incidence of lung cancer in females in Ireland was the sixth highest out of 23 European countries.

The prevalence of smoking amongst young women has increased in recent years and rates among young women are now similar to those among young men. This is of particular concern where, for example, diseases such as cardiovascular disease and lung cancer are concerned.

Other important issues for women include maternity services and support for victims of domestic violence.

Actions for women's health

Better health for everyone

Responsive and appropriate care delivery

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Men's health

Policy context and recent developments

Issues in men's health

Health status

Gender differences in mortality are emerging as a fundamental inequality in health. In 1950, the male/female difference in life expectancy at birth was 2.5 years. It is now over 5.5 years. The difference in life expectancy at age 65 was 1 year and now approaches 4 years. The Institute of Public Health report on mortality demonstrated that death rates were more than 50 per cent higher for males than for females. These differences applied across the major causes of premature mortality including cancer, circulatory disease, respiratory disease, and especially for injuries and poisonings where the rate was 169 per cent higher in males.

Much of this premature mortality is preventable and lifestyle behaviours are particularly important. Men experience more accidents than women during sporting activities and in the workplace; they are more likely to engage in risk behaviours such as speeding, drink driving and not wearing seatbelts. Males aged 20-24 years have the highest death rate from unintentional injury of all age groups up to age 70 years. Over 30 per cent of road traffic accident deaths occur in the 15-24 year age group; the highest rate of deaths from road traffic accidents is in males aged 20-24 years. Falls and being struck or cut are also a very high proportion of unintentional injury hospital admissions for males as compared to females (Scallan et al, 2001).

Males have less healthy diets than females, are more likely to be overweight or obese, drink more alcohol and are more likely to become involved with substance abuse. Men also experience considerable mental health problems; the most common causes of male admissions to psychiatric hospitals are depressive disorders, schizophrenia and alcohol dependency. Of particular concern in recent years has been the increase in the number of young males committing suicide.

Research suggests that men take few preventive health measures and are less willing than women to seek medical help. Developing awareness of men's health issues and encouraging men to present earlier for treatment and support is an important element in developing a plan for men's health.The North-Eastern Health Board has been to the forefront in researching men's health and will shortly appoint a men's health co-ordinator. This initiative will be evaluated carefully with a view to extending the model to other health board areas.

Actions for men's health

Better health for everyone

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Population health

Policy context and recent developments

Population health aims to improve the health of entire populations or subgroups of the population and to reduce health inequalities among population groups.

A wide range of policy documents and legislation governs activity in this area. The implementation of key strategy documents such as the National Health Promotion Strategy, the Cancer Strategy and the Cardiovascular Strategy has been central to developments in this area in recent years. These areas have already been addressed in some detail in Chapter 4.

Issues in population health

Health and health status

Chapter 2 described the health status of the Irish people. It highlighted the unfavourable life expectancy and death rates in Ireland when compared to those of our EU neighbours and provided evidence of health inequalities in Ireland relating to social class.

Some of the principal population health issues in Ireland today, therefore, include tackling inequalities in health as well as reducing deaths from the principal causes of premature mortality, namely cardiovascular disease, cancer and accidents. Health promotion and prevention of disease through initiatives such as immunisation are also crucial elements of a population health approach. Other issues include ensuring the safety of food, medicines and the environment.

A population health approach reflects the evidence that many factors outside the health care system significantly affect people's health. These include social, economic and environmental factors that are often beyond the control of the individual. Addressing these areas requires concerted inter-sectoral action.

The actions proposed in this section recognise the need for an organised response to improve the health status of the Irish population. Central to this is the need for the introduction of dedicated population health sections at both Department of Health and Children and health board levels. Another important action will be the health-proofing of all decisions related to public policy by all government departments. Other specific actions relate to tackling health inequalities and promoting healthy lifestyles for all.

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Environmental health, food and medicines

In the area of environmental health, the Institute of Public Health in Ireland is supporting co-operation across boundaries to sustain and develop public health work. The role of the Institute is vital in providing public health leadership which can cut across sectors and contribute to the reduction/elimination of health inequalities. There is a need to provide a comprehensive plan to support the Institute in enjoining the partners in environmental action and health planning.

This country has a reputation for producing food products of a very high quality. The Food Safety Authority of Ireland Act, 1998 placed primary responsibility for food safety with the Department of Health and Children and created a new, independent organisation, the Food Safety Authority of Ireland (FSAI), to implement this policy. Also, funding for the development of the health boards' food control services, including sampling, inspections, micro-biological laboratories and public analyst laboratories, has been relatively generous over the past few years. The establishment of the Food Safety Authority of Ireland and the Food Safety Promotion Board (FSPB) has made a significant contribution to the development of an effective and comprehensive policy on food safety and hygiene for the entire island of Ireland. The constant developments in this area, particularly with regard to EU legislation, require sustained momentum in drawing up new legislation.

The capacity of the FSAI and the FSPB will continue to be developed to ensure the protection of the health and well-being of the public in relation to food safety. This will include strengthening and further developing inspectorate and laboratory services for food safety and supporting the delivery of public awareness campaigns on an all-island basis by the FSPB. Food safety will continue to be addressed through awareness/education campaigns for the food industry.

The Irish Medicines Board Act, 1995 created a new executive agency, the Irish Medicines Board (IMB), with responsibility for implementing policy. The role of the Irish Medicines Board is to ensure the safety, quality and efficacy of all medicines placed on the Irish market. The ability of the board to police enforcement and compliance, while greatly improved, still needs further strengthening.

Complementary and alternative medicine is a range of healing resources that encompasses treatments and practices not availed of in the politically dominant health system. The popularity of complementary and alternative medicine (CAM) was evident from the range of submissions received for this strategy. CAM is perceived to deliver health care from a holistic point of view, which is welcomed by consumers. Many submissions viewed CAM as complementary to primary health care and called for greater integration with conventional health care. However, concerns were raised about the lack of regulation in relation to the medicinal products that are involved.

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Actions for population health/better health for everyone ­ general

Actions for population health/better health for everyone: health promotion

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Actions for population health/better health for everyone: health inequalities

Actions for population health/better health for everyone: environmental health, food and medicines

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