Response to consultation

A healthier future:
A twenty year vision for health and wellbeing in Northern Ireland 2005 – 2025

Introduction
The Institute of Public Health in Ireland aims to promote cooperation for public health between Northern Ireland and Ireland, to tackle inequalities in health and influence public polices in favour of health.  In its work, the Institute emphasises a holistic model of health which recognises the interplay of a wide range of health determinants, including economic, social and environmental factors as well as health and social services. 

Vision
We welcome ‘A healthier future’ and see it as a courageous and ambitious statement of what might be achieved in the future with sustained commitment and resources.  In particular we are pleased to see that ‘Investing for health’ has a central place within this vision. We hope that this indicates a renewed and reinvigorated commitment to the implementation of this key strategy. 

We acknowledge the extensive consultation that has taken place.  There are however some points that we think should be given consideration, to strengthen the overall vision and its contribution to improving the health of the people of Northern Ireland.

Themes and policy directions

• Advocacy.  The vision should make it clear that it is the HPSS role to advocate for healthy public policy. Preoccupation with service delivery hampers the equally compelling need to understand, and advocate for public health policies at international, national and local level which favour good health and wellbeing.

• Ethnic Minorities.  We believe the strategy should have a stronger emphasis on the growing number of people from ethnic minorities and their health and social care needs.

• Research and evidence.  ‘A healthier future’ appears to place very little emphasis on the need for a vibrant, properly resourced and high quality research programme to support the development of effective programmes and services.  Such a research programme should build on the developments that have already taken place under the leadership of the Northern Ireland Research and Development Office for Health. However, this needs to be strengthened to ensure that it covers the spectrum of research priorities from clinical and community care through to public health and inequalities in health.  There is the opportunity to develop more centres of research excellence particularly in the areas of policy implementation and how health and social services and public health are organised and delivered.
  There is also little emphasis in the document on the need for a robust evidence base for service improvement and development or on how existing evidence should be translated into practice. In other parts of the UK, there are agencies which have a specific remit to build the evidence base and to support change in practice in line with evidence. While Northern Ireland can benefit from this work, there is a need for a co-ordinated approach here. Supporting change in practice in line with evidence is a complex process and requires local support. Adoption of guidelines developed elsewhere is not sufficient. The work of CREST has been important in this respect but a more co-ordination and leadership is required in a wider range of areas.

• Focus on outcomes.  A clear commitment to achieve worthwhile outcomes is important and welcome in ‘A healthier future’.  We recognise that the framing of outcomes that are achievable, measurable and meaningful is very challenging. We would have some concerns about the emphasis on measures of outcomes that rely on patient satisfaction. While the patient experience of health and social services is of crucial importance, measures of patient satisfaction are a very crude measure and may reflect patient expectations rather than quality of care. They tell us little of the appropriateness or clinical quality of services. We support the promotion of patient and client centred services and the concept behind the ideas of the expert patient and peer support programmes.  More research is required into appropriate measures of outcome.

• Contribution of community based initiatives.  We welcome the commitment to community development espoused in ‘A healthier future’ and in our own work in the Institute have been involved in an extensive range of evaluations of community-based initiatives. We consider that the strategy’s approach to what community-based initiatives can contribute to health and well-being as well as to service delivery is conservative and overly traditional.  There are many excellent examples of community-based initiatives firmly based on community development principles which are already playing an important role in engaging local communities in their own health and well-being in Northern Ireland. Not least of these are the 19 Healthy Living Centres and four Health Action Zones. A very important aspect of the work of these groups is their sustainability and how some of their most creative and effective developments are mainstreamed.
  ‘A healthier future’ recognises the importance of providing services to people in a wide range of settings, including primary and community care facilities. What is not mentioned is the possibility that some of these services could be provided on an outreach basis within community owned and run facilities. Some of the Healthy Living Centres already offer space to health and social care staff to provide outreach services in locations that are very accessible and acceptable to local communities. There is scope for further development of this type of facility.

• Multidisciplinary working, cross-sectoral collaboration and leadership.  We are pleased that ‘A healthier future’ recognises the importance of multidisciplinary teams in many different areas of the health and social services as well as public health.  While there are good examples of where this is working well, more needs to be done to facilitate this particularly in the field of public health, creating proper career structures and ensuring that it is not seen merely as a cost cutting exercise.
  With regard to cross-sectoral working, multisectoral partnerships are now a feature of policy implementation for most government departments. The main reason for establishing such partnerships is the complex and intractable issues that we face and the challenge in creating effective partnerships should not be underestimated.  In the Institute, we have developed expertise in this area based on extensive research and development we have undertaken with the four Investing for Health Partnerships, Health Action Zones and Healthy Living Centres. Much more needs to be done to provide a more supportive environment for such partnerships.
  ‘A healthier future’ also refers to the importance of developing leadership skills amongst those that manage services. Current ideas about leadership see it as a distributed phenomenon and we need to think more about promoting leadership development more widely throughout the service and within different contexts. For example, there are leadership programmes in the NHS in England for those involved at the point of care i.e. delivering care to clients. In the Institute, we have pioneered an all Ireland leadership programme, the aim of which is to develop leadership for building a healthier society, something which is very much in line with ‘A healthier future’.  We consider that much more could be done in terms of leadership development for the implementation of this vision.

Making it happen: taking strategy forward

• Planning, Performance and Objectives.  We support the suggested planning process and the focus on ‘joined up’ government and participative approaches.
  The firm commitment to giving Investing for Health due priority in planning decisions is welcome as is the strong emphasis on performance management and the need for appropriate performance indicators.  Management and performance currently emphasise service delivery, rather than the need to strengthen performance throughout the whole HPSS in relation to healthier public policies and advocacy for them.  A much stronger and wider commitment to this is needed from DHSSPS and throughout the service.

• Integrated Assessment.  We support the development of the Integrated Assessment Tool being developed by OFMDFM but experience suggests that unless there is significant input to this from DHSSPS health aspects are likely to be misunderstood or ignored. There should be strong health input into development of integrated assessment tools.

• Public health approaches in developing services.  We welcome the setting up of seven major service-wide chronic condition management programmes.  We stress the need for these to take a wide public health approach.  For example, it is appropriate for a CCM for diabetes to tackle the obesogenic environment that leads to a higher population prevalence of diabetes.

• Cross border cooperation.  We welcome the (brief) acknowledgement of the potential for cooperation between Northern Ireland and the Republic of Ireland.  We believe that there is huge potential in this area and that practical benefits require strategic, sustained and systematic approach to cooperation.

• The contribution of the Institute of Public Health. The Institute has an important contribution to make to the realisation of the vision outlined in ‘A healthier future’.  Apart from our work with community-based initiatives, partnerships and the leadership programme, already mentioned, other developments include:

  • The development of health impact assessment on the island of Ireland.  The Institute has played a key role in supporting both the Department of Health and Children in Ireland and the Department of Health, Social Services and Public Safety in Northern Ireland to support the introduction of health impact assessment, through development of tools, training and pilot projects.

  • The establishment of an all Ireland Public Health Observatory. This is a very critical and exciting development and involves engaging with a diverse range of interested parties across the island. It has already received substantial support from both departments and will play an important role in providing access to a wide array of web-based information to those who need it.

  • Support for the implementation of Ireland’s National Anti-Poverty Strategy. This has involved a range of work from supporting the development of health targets, working with health boards to implement change in line with the strategy, to developing networks for those working in this area.  There is considerable learning that has been accumulated in the Institute which could be transferred to the benefit of people in Northern Ireland.

Summary
We welcome this vision and commend the Department for making such a forward looking statement of intent. We consider that more emphasis on public health advocacy research, evaluation, appropriate outcomes and performance, the role of community-based initiatives, multidisciplinary and multisectoral working, leadership and public health intelligence, would strengthen ‘A healthier future’ and look forward to working with the Department to help achieve this vision.

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