JOINT COMMITTEE ON SOCIAL AND FAMILY AFFAIRS debate -
Wednesday, 29 Oct 2008

Towards Healthier Societies Report: Discussion with Institute of Public Health in Ireland.

Chairman

I welcome Dr. Jane Wilde, chief executive, and Mr. Owen Metcalfe, associate director, of the Institute of Public Health in Ireland. I invite Dr. Wilde to make her presentation on the report entitled, Towards Healthier Societies.

I draw attention to the fact that while members of the joint committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, by name or in such a way as to make him or her identifiable.

Dr. Jane Wilde

I appreciate the invitation and welcome the opportunity to talk about the first ten years of the Institute of Public Health in Ireland. I am its chief executive and accompanied by the associate director, Mr. Owen Metcalfe. Both of us have worked in different capacities in the area of mental health. Mr. Metcalfe was a teacher and counsellor and worked in health promotion. I am a doctor and have worked in health promotion and public health.

We appeared before the joint committee in June, when the Chairman was unable to attend, to discuss the issue of fuel poverty. I referred to other areas in which we worked. We have just produced a ten-year report which, I hope, has been circulated to members. I will be pleased to come back, if invited. Again, I thank the committee for inviting us.

I believe the committee has a short paper outlining some of our work. I will briefly summarise some of the key points, if that is appropriate. I will begin by setting out why the institute was set up and will speak about what we have been doing since then. As members know, it is an all-island organisation, so its purpose is to promote co-operation between North and South. It was set up because the two chief medical officers on both sides of the Border had been talking about what could be done together to improve public health. With the support of the Governments, and now the Department of Health and Children and the Department of Health, Social Service and Public Safety, the institute was set up. We work, in particular, in three areas, namely, research and information, capacity building for public health and offering policy advice. I will briefly give the committee some examples of the work we have been doing in these areas. We will then be happy to answer any questions.

I will start with the area of information and research. Our understanding of public health is based on the idea that social, economic and environmental factors are hugely important in shaping people's health. That is why we are particularly pleased to be at this committee because its responsibilities cover so many areas that influence our health.

This understanding of the wider social causes of health underpins all our work and it was emphasised very much in the first major report we did in the institute which looked at all deaths across the island of Ireland. This is a very large report looking at 500,000 deaths against all the major causes of death. What was staggering to us was the huge gap that it showed in the health experience of rich and poor. Obviously, it will not be a surprise to members to know about the way such things as poverty, income and employment affect health. Although I had worked in that area for many years, the difference we found was staggering. We are talking about differences of the order of 100% to 600% between the health experience of rich and poor. This finding has defined the work we have been doing since then.

I will now speak about information. One of the complexities for us in working across the island is the huge differences between North and South in terms of the way the health services are organised, the way they are financed and the priorities that each jurisdiction has. However, one of the things we share is a common concern about high levels of chronic diseases such as heart disease, diabetes, etc.

Until now, there has not been a systematic means of identifying the levels of some of these chronic diseases. For example, we have never really known how much diabetes there is in the country and we have not had a way to forecast that into the future. One of our pieces of work has been to measure that and to forecast what will happen in Ireland over the next decade. I am sure members already know that we are seeing a rise in diseases such as diabetes due to the sharp increase in the incidence of obesity. Perhaps in the next ten years or so, we will be looking at an additional 80,000 people with diabetes. That is appalling for the individuals and their families but it is also a huge cost to the health services and to the wider economy in terms of loss of productivity.

This kind of work is underpinning our idea for a public health observatory across the island. This will form a backbone of interlinked health surveys, not only looking at diseases but at the social factors which impinge on them. We hope this will be a one-stop-shop for people like members of the committee, for political researchers and for practitioners because they will be able to access a huge number of databases from this well.

We also contribute to policy advice across a range of areas, including fuel poverty, which I mentioned, food, smoking and tobacco. Addressing these areas requires co-operation across very many Departments as the committee well knows. All have huge roles to play. Our understanding is that it is absolutely essential that we have this type of cross co-operation if we are to improve health.

Recognising this, we have produced a number of reports looking at the influence of things like transport, the environment and employment on health. Our forthcoming report, which will be issued next week, is on the impact of education on health. My colleague, Mr. Owen Metcalfe, has been leading this work and will be more than happy to give the committee some findings from that report, which is very timely.

We have also been helping people with the idea of health impact assessment. That is a way in which policies can be assessed to see what impact they have on health. We have been undertaking training programmes, leading reviews and working with people in different countries who are also very interested in the whole area of public health.

We have developed a number of research programmes involving different countries and we have also been able to set up within the institute a number of new initiatives addressing issues such as ageing and, I hope in the future, issues associated with palliative care and terminal care. We have devised a leadership programme and we have a number of networks which involve people working in public health across the island on crucial issues such as nutrition, smoking, mental health, etc.

I hope I have been able to give the committee a short flavour of the work we do. There are many public health challenges facing us on the island. A priority for us will continue to be tackling the huge health inequalities that exist. We believe the way in which policies and structures affect the health of the most vulnerable in our community is something we must tackle in a more systematic and strengthened way than we have been able to do in the past. We recently produced a short report with the Combat Poverty Agency highlighting what needs to be done and looking at the evidence across the island.

During the past ten years, we have led co-operation for public health on the island. We have built up a significant amount of expertise, skills and partners. Although the environment has changed considerably, and continues to do so, our aim will remain the same, namely, to promote co-operation and to use our resources to help to promote healthier people. Mr. Metcalfe and I will be happy to answer any questions.

Deputy Cyprian Brady

I thank Dr. Wilde for her presentation. It is an extremely important area. As politicians, we see the effects daily on the ground. In my constituency of Dublin Central, the difference between areas is startling. There is a huge difference between the inner city and the suburbs.

Will Dr. Wilde explain how her organisation interacts with schools? In my area, many of the schools have health promotion programmes which they have tended to initiate themselves. There does not seem to be co-ordination in regard to schools and in terms of linking up with parents. That conduit is not used as much as it should be.

In regard to the institute's relationship with the HSE, how does it feed into how the HSE manages our health service? Does the institute have a direct role? Is there constant co-operation or exchange of information with the HSE?

Dr. Jane Wilde

My colleague, Mr. Metcalfe, will respond to the question on education and I will respond to the one on the HSE.

Mr. Owen Metcalfe

I thank the Deputy for the question. In regard to education, what we have been trying to do is to make it easier for decision-makers in many different areas to acknowledge the impact and the role they have in contributing to better health. For example, in regard to transport, it is not just about infrastructure in that transport can help to tackle obesity. It can help to build communities and does not have to fracture them.

We want people in policy-making and decision-making roles in education to acknowledge the direct link between education and health. The more education one has, the longer one lives, the less likely one is to smoke and the more likely one is to take regular exercise, participate in sports and have a balanced diet.

Our role is to try to work with people in the education sector to get them to acknowledge our work, our report and to make use of that in their policy-making processes. We are extremely aware of initiatives such as the social personal health education programme and the transition year. We are also well aware of the critical role physical education plays in regularised sessions of exercise. We want to show people that these links exist and to strengthen those types of initiatives and give support and credibility to those areas to ensure that in future they can be reinforced and strengthened. That is our current role in education.

With regard to the review in particular, we have received a good deal of co-operation from the Department of Education and Science in terms of reading the drafts we have submitted. The Secretary General will help to launch the report next Tuesday.

Dr. Jane Wilde

Regarding our direct involvement with the Health Service Executive, some of the areas of work I mentioned, such as the diabetes study, is one we would have done with and for the HSE. It did not commission it but it has used it in its planning of acute services in terms of bed planning, etc., and also in preventive medicine, but I hope it will also use it with the support of the Department of Health and Children to monitor what is happening in terms of diabetes. That would apply to other aspects of our work. We do not have a day-to-day working contract, so to speak, with the HSE but when we are involved in a piece of work we would involve partners within the HSE, primarily within what was the population health division.

In terms of the way the structure of the HSE operates, with the scope of our job being North-South we are slightly separate from and not embedded in the HSE. Things work well when we have a specific piece of work to do.

Deputy Cyprian Brady

Would Dr. Wilde find clinicians contact her on a day-to-day basis to seek information?

Dr. Jane Wilde

We would find that is the case when we undertake a specific piece of work, whether it be on smoking-related diseases where we would work with people interested in that area or on chronic diseases. We are a small organisation of 20 people located across the island. Therefore, we are not in a position to be able to offer day-to-day public health information to individual doctors, nurses or occupational therapists. That is distributed more widely across the country. As a relatively small organisation we have had to be fairly strategic in what we do. We cannot work at every local level across the country. That would not be possible for us.

Deputy Catherine Byrne

I thank Dr. Wilde for her presentation. I was delighted to hear this is an all-Ireland effort. Dr. Wilde made some comparisons to the British health service and I would like to have heard some more information on that.

Along with other Deputies, we see on the doorsteps problems resulting from poor housing, lack of education and poor diet. The responsibility for dealing with those issues is thrown back on the schools. I see that in my own area, which now has breakfast clubs and after-school programmes where children are provided with meals.

One of the most serious issues locally is the increase in the incidence of obesity among young children. Hallowe'en is at the weekend. It used to amaze me when I went door to door with my children that people would give them sweets, chocolate bars, marshmallows and so on whereas years ago one got apples, oranges and nuts. There has been a big change in that regard.

I have a question for Dr. Wilde but I do not know whether she can answer it. Does she find in her work that there has been a major increase in the number of young people with diabetes, mainly caused by being overweight and having a poor diet? In my local community in Fatima Mansions, in the past number of years when I have been a member of the regeneration board we have established a well-being centre where we try to encourage young people, and the rest of the community, to become involved in living healthier lifestyles, particularly in terms of their diet. The main issue that arises now is the price of food. We are trying to encourage young people, in particular, to eat more fruit and vegetables, yet in most of the supermarkets, and particularly in the local shops, the difference in price for those products is huge. If a person is on a very low income and the standard of his or her housing conditions is poor, he or she does not have the money to buy proper food. That can be a major problem. We now have homework clubs where children are provided with a lunch. The lunch is based around a healthier diet, which I hope will improve many of those children's education in the future in terms of the way they eat.

Does Dr. Wilde believe, arising from her studies, that many more young people have developed diabetes as a result of obesity? If that is the case, does it involve a particular age group? Can she give figures for the age group that might be involved?

Deputy Róisín Shortall

I welcome our visitors and apologise for arriving late. I had an earlier engagement but I have read the presentation.

I am interested to know about the representatives' organisation. They say it has approximately 20 people working for it. Will they give us a brief rundown on where those people are located and the type of work on which they concentrate?

Much of what the representatives are talking about concerns the area of health promotion and preventive medicine. We have been very weak in that regard in the South, particularly in working-class areas. It is difficult enough to get a basic general practice service into an area and there is little or no health promotion work being done. What are the representatives' views on that? What importance would they attach to the area of health promotion and how do they believe we might be able to give it a greater priority here?

In terms of the comparison between the North and the South, are there particular features of the health service in the North or is there one particular feature they believe we could learn from in the South and vice versa?

Deputy Charlie O’Connor

I welcome Dr. Wilde and Mr. Metcalfe. It was a good presentation and the work they do strikes a chord with all of us.

I am particularly interested in what was said in the presentation, and in subsequent remarks, about the relationship between the North and South. I am currently a member of the British-Irish Interparliamentary Body and at recent plenary meetings colleagues from the islands made the point that to some extent the work of the body has moved on because of the political situation in the North and other issues are now being examined that had not been examined in the past. In that context it is important that we would examine the relationship between North and South in terms of services, particularly health and social services. The representatives' presentation is timely and I would like to ask them more on that aspect.

It is important that we support the work they are doing. Deputy Shortall made the point about disadvantaged communities. I live in Tallaght and this morning I spent some time in Fettercairn, which is in my parish and about which some of the representatives may have heard. In line with what Deputy Shortall said, this is a community where the housing was built by the local authority, but it still does not have a general practitioner service. Efforts are being made, and we are doing a great deal of work locally to try to establish such a service. Examples of different communities are to be found in Tallaght as well as in Ballymun, Crumlin and other areas. It is something on which we should focus and everybody should be given an opportunity. I come from the inner city of Dublin and my family was not well off. I remember, for example, that my granny was always anxious that I would eat large amounts of potatoes and bread. I am not so sure that bread was good for me, as I survived a heart attack approximately nine years ago but, thank God, I am well. I know not everybody in politics is happy that I survived but I did. I am now able to say that was an experience I worked through. I remember telling my family that if I was young again, I might do things differently to prevent me from having a heart attack. At the time my young son said it would be 50 years before it would affect him. I was struck by this.

Health promotion is very important, as has been said. Sometimes in the midst of all our difficulties and all the pressures on the health service health promotion does not get the attention it should. At the end of the day it makes considerable sense to promote health with ideas such as the happy heart, looking after our diet and how we go about our business, and keeping fit without jogging. It is only when people reach my age that they realise how important such things are. It is an important message to get across to younger generations particularly. I am glad the Institute of Public Health in Ireland's presentation highlighted this. I wish the delegates well and look forward to hearing they have to say, particularly on what we can learn from each other in the North and South.

Senator Nicky McFadden

I apologise for being late but I was stuck in traffic.

Further to what the Deputy to my right said about preventive medicine, the delegates indicated that with only 20 employees, it was impossible for the Institute of Public Health in Ireland to communicate with every clinician and doctor in the country. However, as we all know, prevention is better than cure. This morning we heard about the launch of the pilot bowel cancer prevention project in Tallaght Hospital. After the saga of what happened to Susie Long and how she could not access services, how does the institute identify the best preventive schemes to operate? Yesterday we heard that one Irish person in four smoked and that young women were the worst offenders. What should we do about this? We should invest our money in the institute to promote preventive medicine to prevent serious health problems arising.

I applaud the institute for highlighting the issue of fuel poverty. After all the years since it was first raised, have we progressed? One of the delegates may have referred to the matter earlier, but because I was late I did not hear it.

Senator Rónán Mullen

I also add mine to the litany of apologies. I am juggling my time with the Sub-Committee on Ireland's Future in the European Union which is meeting at the same time. If I am called away, I might ask for a note on any answers given.

I welcome the delegates and thank them for their presentation. I have also read the report. Why are there such differences in the levels of diabetes in Northern Ireland and the Republic? I think I have the big picture regarding poverty and its related causes. I was particularly taken by the very succinct analysis of the two causes of disease, pathological and political. Do the delegates have anything to add regarding the disparities in the Republic and the North?

I note that the Institute of Public Health in Ireland is about to issue a report on education which I look forward to seeing because it is very important. There is considerable talk about individualism in our society and the fragmentation of community bonds. Voluntary organisations report difficulties in getting people to make themselves available. Schools have difficulties, particularly in areas of disadvantage, in maintaining a harmonious environment for teaching and bringing out ideas. The churches have also suffered in terms of participation rates. Many health problems are related to poverty. One need only look at the poverty line to see who is suffering. The statistics which indicate figures between 100% and 200% higher in areas affected by poverty compared with relatively well off areas are very stark. Has the institute reflected on the challenge individualism poses to society and on the fragmentation of community bonds? Do the delegates have any ideas about the new structures we might need or what new initiatives might be necessary to ease the burden on existing institutions which are clearly creaking in the face of so many challenges?

Senator Larry Butler

This is an interesting report. The strengthening of co-operation with the North and having an all-island approach to this matter is very interesting. During the ten years the Institute of Public Health in Ireland has been involved in this process has it considered systems in place in the North that we might adopt? Is the Northern system better in some ways or do we have a better one? How are we approaching getting together on an all-island basis? Spending on health represents one of our biggest costs. We must make the most of these resources. Will there be greater co-operation between North and South? Are we using the North's top specialists and is it using ours? How can we end up with a better health service and perhaps integrate certain parts of it?

Dr. Jane Wilde

I thank members for their insightful and demanding questions. I have listed at least 20 points. I will try to summarise some of them and also ask Mr. Metcalfe to respond to some of them. If I do not answer a specific question in the way a member would like, I will be more than happy to come back to it. There are some facts to which I would like to return and which could be circulated to members.

Certain key themes emerge from the questions, one of which is North-South co-operation, our role in that regard and how we operate. The Institute of Public Health in Ireland was established for the purpose of North-South co-operation. We are fully behind greater efforts at co-operation to produce better health outcomes in health services, health promotion, structures, clinicians and reducing the impact of the Border on people's health. Could we do more and will we do more in these areas? We certainly will do as much as we possibly can and look forward to a future in which the Department of Health and Children and the Northern Ireland Department of Health, Social Services and Public Safety will co-operate more strategically on health issues.

In the ten years we have been involved in North-South co-operation we have seen a sea-change in the mood, North and South. However, the ad hoc nature of co-operation is not allowing us to maximise what we could do. I could point to some very good examples of where it has been brilliant, including the leadership Ireland showed regarding smoking legislation which was greatly influential in the North introducing a similar policy. Coming down on the train this morning I pointed out to Mr. Metcalfe the second page of The Irish Times which contained three very interesting articles on health and public health issues, in one of which smoking rates in the United Kingdom and Ireland were compared. The second contained a report on what was happening in the European Union regarding fruit and vegetables based on what has happened in Ireland, while the third reviewed the position on public health in Northern Ireland. A whole page of the newspaper was devoted to the issues members are raising and we are discussing.

In terms of how we operate as an institute, we have small offices in Belfast and Dublin. We all see ourselves as all-island workers. Regardless of the fact that I happen to live in Belfast and Mr. Metcalfe happens to live in Dublin, we see ourselves as working across the Border; we do not see him as a Southern worker and me as a Northern worker. That is the ethos we have tried to instill in the institute and it means that we are able to spread our expertise North and South. Geographically, we do not have any other bases but we work a great deal with people in Derry and the Border area, Galway and Cork. We are linked with all the universities in Ireland and have a number of research programmes with them. We also have people in UCC who work part-time as researchers. We try to spread ourselves but do not have people based in Tallaght, Ballymena or elsewhere.

Deputy Charlie O’Connor

The institute could.

Dr. Jane Wilde

We would be delighted. That is one of the key issues facing us in the next development. We had to be top level and strategic in how we approached things at the beginning but are fully and totally committed to community development work, public health at local level and co-operation between agencies in local communities. That is why we have worked a great deal with the Combat Poverty Agency and the community development network in Northern Ireland and other organisations such as CAN and people who work on the ground. We have tried to put our efforts into sustaining this and working with them.

The importance of health promotion at an early age was mentioned, in particular, obesity in children and the priority that should be given to public health. We have chosen careers that are about health promotion and public health. We believe there should be greater priority and emphasis on public health and health promotion on both sides of the Border. There is a significant reform programme in Northern Ireland, at the centre of which is the formation of a public health agency to bring together the different aspects of health promotion, health protection relating to communicable diseases and the ongoing work to prevent us becoming ill and protecting us against new threats and bugs and what they call work on commissioning preventive services. The new agency is being given huge support by the Minister for Health, Social Services and Public Safety, Mr. Michael McGimpsey. It will be interesting to see if there are lessons to learn for the Republic.

The Deputy referred to the issue of diabetes. The predicted levels of diabetes are largely to do with the populations, North and South, ageing and ethnicity patterns and, in particular, what is measured. For example, we have not had the systematic way used in the North to collect data on ethnicity in the State and, therefore, are underestimating in one jurisdiction compared to the other. The many differences in health issues in both jurisdictions are totally dwarfed by those picked up by the committee between rich and poor. The major issue is both the North and South are facing this massive inequality in health services rather than differences in disease levels which pale into insignificance.

Obesity in children is a huge and growing problem. More should be done about food poverty. We have a report with Safe Food Right which examines access issues such as finance and information barriers and are determined that the issue of food poverty will be given more emphasis. We are delighted with the way our report on fuel poverty was able to help the other partners. We thank the committee very much for its support last time when we discussed the issue. Many members were influential. I will refer the children's issue to Mr. Metcalfe because he has worked in schools and thought deeply about health promotion in the State.

Mr. Owen Metcalfe

The questions are indicative of members' accurate perception about where the causes of ill-health lie. That does not only relate to the health service which can only help a person when he or she is sick. Virtually all the questions demonstrate that it is the role of many other arenas to positively influence health, whether they relate to food and agriculture or education and what people do when they are young. We have been trying to do something about this and all the committee's questions relate to how we can positively impact on these areas. What can we do to facilitate active engagement in the health agenda by those other sectors? What can we do to help them adopt the health lens in order that when they develop policy, they can see how what they are doing contributes or detracts from health?

That goes from the education system whereby we believe absolutely in the type of education that does more than tell people that smoking is bad for them. The model demonstrated by the health promoting schools is one for a healthier life in the hospital, the workplace or the Dáil. The concept of the health promoting school is fundamental, not only in terms of what is done in the curriculum but in terms of the relationship the school has with all the significant players, including the local community and parents, and its attention not just to physical health but also to emotional health, well-being and relationships. These are fundamental to the concept of health promoting schools.

As Dr. Wilde said, we have been involved in health education or public health for more than 30 years which equates to many years of collective experience. Early on the focus of health promotion was on helping people to support a healthier lifestyle, with a focus on what individuals could do to help themselves. I have learned it is important that we examine what we call the determinants of health and how the other arenas can play their role, going back to how it is we can facilitate agriculture, housing, the built environment and the Department of Finance in terms of where it attaches priority in the distribution of resources and redistribution within society. These are the questions we are fundamentally putting to people who want to see improved health. If they have data telling them about what is going on and evidence to show what works, they are in a better position to take healthier options.

We examined models across Europe, for example, what happens in Scandinavian countries. Dr. Wilde referred to the differences in death rates but they can be translated into life expectancy. If one happened to be born an upper social class female or a lower social class male, the difference can be 14 years. A generation could be wiped out because of an accident of birth if the two figures were combined. Sometimes reference is made to the excess death rates as a result of cardiovascular disease among poorer people but given the experience of other communities such as the Traveller community or ethnic minorities across Europe, they are fundamentally unfair and unjust. We have been trying to shine a light on them in order that people in policy making positions can address them. It is not the preserve of one sector. I emphasise how heartening it is to hear people alluding to the range of factors and to know there is understanding that these areas must be worked on. It is for politicians and us to provide evidence to allow people to make healthier decisions across the board.

Deputy Róisín Shortall

There must be political will to bring about equality, which is what we are probably missing.

Dr. Jane Wilde

I did not state that diseases have two causes, although I would love to claim so. It was a philosopher named Virchow. While we are laughing, it is a serious point in the debate on better health. I hope members will agree that we should argue for fairer health as well. In this sense, it is a political matter. It is not only a question of resources for the health service, although this is important. While issues around access and equitable health services are central, they are not the only concerns.

I thank the committee for this opportunity. While we have not addressed every question, we will try to address others in bullet point format. If other issues arise, the committee members should revert to us.

Chairman

I thank the Institute of Public Health in Ireland for appearing before the committee and briefing it so comprehensively. The recommendations in the report are of national importance and should be taken into consideration by the relevant Departments in future policy.

The joint committee adjourned at 11.52 a.m. until 11 a.m. on Wednesday, 12 November 2008.