CORI Healthcare believes that the objective of healthcare policy should be: to provide an adequate service focused on enabling people to attain the World Health Organisation's definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Healthcare is a social right that every person should enjoy. People should be assured that care in their times of vulnerability is guaranteed. The standard of care is dependent on the resources made available which in turn is dependent on the expectations of the society. The obligation to provide healthcare as a social right rests on all people. In a democratic society this obligation is transferred through the taxation and insurance systems to government and other bodies who assume/contract this responsibility.

Health inequalities in Ireland

A very welcome insight into the extent of health inequalities in Ireland has been provided by the Public Health Alliance (PHA).This group, a north-south alliance of non-governmental organisations, statutory bodies, community and voluntary groups, advocacy bodies and individuals who are committed to work together for a healthier society by improving health and tackling health inequalities, have published a detailed report entitled “Health in Ireland – An Unequal State”. The report gathered together the baseline information on health inequalities in Ireland and its findings are worthy of serious attention.

These included:

• Between 1989 and 1998 the death rates for all causes of death were over three times higher in the lowest occupational class than in the highest
• The death rates for all cancers among the lowest occupational class is over twice as high for the highest class, it is nearly three times higher for strokes, four times higher for lung cancer, six times for accidents • Perinatal mortality is three times higher in poorer families than in richer families
• Women in the unemployed socio-economic group are more than twice as likely to give birth to low birth weight children as women in the higher professional group
• The incidence of chronic physical illness has been found to be two and a half times higher for poor people than for the wealthy
• Men in unskilled jobs were four times more likely to be admitted to hospital for schizophrenia than higher professional workers
• The rate of hospitalisation for mental illness is more than 6 times higher for people in the lower socio-economic groups as compared with those in the higher groups
• The incidence of male suicide is far higher in the lower socio-economic groups as compared with the higher groups
• The 1998 and 2002 National Health and Lifestyle Surveys (SLAN) found that poorer people are more likely to smoke cigarettes, drink alcohol excessively, take less exercise, and eat less fruit and vegetables than richer people. Poorer people’s lifestyle and behavioural choices are directly limited by their economic and social circumstances
• On average 39 per cent of people surveyed in 2003 identified financial problems as the greatest factor in preventing them from improving their health.

The report also found that some groups experience particularly extreme health inequalities.These include:

• Members of the Traveller community live between 10 and 12 years less than the population as a whole • The rate of sudden infant deaths among Travellers is 12 times higher than for the general population
• Research has found that many expectant mothers in direct provision suffer malnutrition, babies in these communities suffer ill-health because of diet, many adults experience hunger
• Homeless people experience high incidence of ill-health – a 1997 report found that 40 per cent of hostel dwellers had a serious psychiatric illness, 42 per cent had problems of alcohol dependency, 18 per cent had other physical problems
• The incidence of injecting drug use is almost entirely confined to people from the lower socio-economic groups.
• The PHAI also compared the health of people in Ireland against that of the 15 other EU states (pre-enlargement) They found that Irish people compare badly with the experience of citizens in other EU counties.These findings included:
• Mortality rates in Ireland are worse than the EU average for a range of illnesses, particularly diseases of the circulatory system, breast cancer and death from smoking related illnesses
• Irish women have almost twice the rate of death from heart disease as the average European woman
• The incidences of mortality for Irish women for cancers of the breast, colon, larynx and oesophagus and for ischaemic heart disease are among the highest in the EU
• At the age of 65 Irish men have the lowest life expectancy in the EU. (PHAI, 2004:3-4).

Poverty and health status

The link between poverty and ill health has been well established by international and national research such as that outlined above. The poor get sick more often and die younger than those in the higher socio-economic groups. Poverty directly affects the incidence of ill health; it limits access to affordable healthcare and reduces the opportunity for those living in poverty to adopt healthy lifestyles. Healthcare exclusion is a major dimension of poverty and social exclusion.

Life expectancy and infant mortality

In 2003 Irish males had life expectancies of 75.8 years while Irish females are expected to live 4.9 years longer reaching 80.7 years (see table 3.37).The story behind these figures incorporates many of the findings of the PHAI report and the earlier poverty figures. Ireland’s growing poverty problem has serious implications for health in light of the fact that there is a clear link between poverty and ill health. This relationship has been well supported by international research. Poverty limits access to affordable healthcare and reduces the opportunity for those living in poverty to adopt healthier lifestyles. Thus, those in lower socio-economic groups have a higher percentage of both acute and chronic illnesses

Statistics on infant mortality also provide an insight into the health of a countries population. Using data from 2004, Eurostat found that Ireland recorded an above average infant mortality rate versus the other 24 member states at that time.The infant mortality rate is defined as the number of infants who die within the first year of life per 1,000 live births.Across the EU-25 the average number is 4.6 while the corresponding Irish figure is 4.9.The highest figure in the EU was for Latvia (9.4) and the lowest in Sweden with 3.1 deaths per 1,000 live births (Eurostat, 2007:65).

Health expenditure

Healthcare must be seen as a social right for all people. For this to be upheld governments need to provide funding to ensure this occurs. In table 3.38 we see that Ireland spends 7.3 per cent of GDP on health. Less is spent on public and private health as a proportion of GDP than the majority of other EU-25 countries. In GNP term this expenditure translats into a figure of 8.6 per cent. In comparison Germany spends 11.1 per cent and Portugal 9.6 per cent. Ireland has the eight lowest expenditure on health (measured as a percentage of GDP) according to EU data. Healthcare costs tend to be higher in countries which have a higher old age dependency ratio.This is not yet so significant an issue for Ireland as the old age dependency ratio is extremely low (11.2 per cent 65 and over) compared to a much higher EU average. However, this level of funding must be seen as inadequate in light of the fact that waiting lists, bed closures, shortage of staff and long-term care requirements are issues in the health service today.

Primary care

Primary Care has been recognised as one of the cornerstones of the health system.This was given recognition by the publication of a strategy Primary Care Healthcare – A New Direction (2001). Between 90 and 95 per cent of the population are treated by the primary care system. The model of a primary care team presented in the document must be viewed in its most flexible form so that it can respond to the local needs assessment.The principle underlining this model should be a social model of health. This is in keeping with the World Health Organisation’s definition on health. Universal access is needed to ensure that a social model of health as outlined in the document becomes a reality. For the development of Primary Care – A New Direction there is a clear need for the allocation of more resources.This would need an increase in the percentage of the healthcare budget being allocated for primary care. The General Medical Service (GMS) system was first introduced in 1972 and it gave a commitment that 40 per cent of the population would be covered by this system. By 1977 some 39 per cent of the population were eligible for medical cards on income grounds. By 2003 this figure had decreased to approximately 27 per cent of the population. For families just over the eligibility level a visit to the GP and a prescription could cost some 25 per cent of their total weekly income.The implications of this for many individuals and families are that they cannot afford to access appropriate care at the time needed. This reduction must be viewed in the light of failed government commitments contained in, for example, the Department of Health and Children’s document Quality and Fairness – A Health System for You (2001).

Accessibility is one of the factors in ensuring equity.Among other things equity is about outcomes.To achieve parity in outcomes requires recognition of the social determinants of health.The World Health Organisation (WHO) makes the following observation:

Community participation is a programmatic necessity.Without the close involvement of the community, and its families and individuals in health promotion, disease prevention and care of the sick, there is little likelihood that health services will have a durable impact on the health of the community.

The importance of paying attention to local people’s own perspective on their health and to understand the impact of the conditions of their lives on their health is essential to community development and to community orientated approaches to primary care. There needs to be a community development approach to ensure that the community can define its own health needs, work out how these needs can best be met collectively and decide on a course of action to achieve the outcomes in partnership with service providers.This will ensure greater control over the social, political, economic and environmental factors that determine the health status of any community. The Government’s own Primary Care Strategy acknowledges the need for “community involvement” as a key factor in addressing health issues and recognises the need for partnership in both the planning and evaluation of all services. Community participation is an “essential component of a more responsive and appropriate care system which is truly people-centred” (Chief Medical Officers Report).

CORI Justice welcomes the funding announced as part of Budget 2007 which allocated €25m to fund the roll out of 100 primary care teams in 2007. Commitments contained in Towards 2016 are also welcome. In particular, that document commits government to engage in ongoing investment to ensure integrated, accessible services for people within their own community with a target of 300 primary care teams by 2008, 400 by 2009 and 500 by 2011.The national agreement also commits to developing, as a priority, out-of-hours GP services with a view ultimately to having those services available to the whole population. Achieving these targets and thereby further developing this area of Healthcare must remain a key priority in the years to come.

Medical cards

The introduction of 30,000 new medical cards and 200,000 ‘doctor visit only’ cards in Budget 2005 was a small step in the right direction. However, a great deal more needs to be done before the 1996 level of provision is regained. In 1996 1,252,384 people on low incomes were covered by full medical cards. After Budget 2005 1,069,934 people were similarly covered. An additional 111,065 people over 70 years of age have medical cards but would not qualify on low income grounds. The eligibility threshold for ‘doctor-only’ cards was raised in mid-2006 to a level 50 per cent above the standard medical card thresholds.This is likely to see an increase in the take-up for doctor-only cards. What is required is full medical card coverage for all people in Ireland who are vulnerable. Currently, the income threshold for accessing a medical card is far below the poverty line.This in effect creates an employment trap as parents are often afraid to take up a job and, consequently, lose their medical card even though their income remains low. The ‘doctor visit only’ cards are an improvement on the present situation only if they are upgraded to full medical cards in due course. At present they will create new problems as many people will now find themselves in the most unenviable situation of knowing what is wrong with them but not having the resources to purchase the medicines they need to be treated.

Mental health

The National Health Strategy entitled Quality and Fairness (2001) identifies mental health as an area to be developed.The Expert Group on Mental Health Policy invited written submissions and held consultation days with all relevant stakeholders.We welcomed the publication of the report Vision for Change - Report of the Expert Group on Mental Health Policy and we look forward to the inclusion of the findings in the development of future policy. There is an urgent need to address this whole area in the light of the World Health Report (2001) Mental Health: New Understanding, New Hope where it is estimated that, in 1990, mental and neurological disorders accounted for 10 per cent of the total Disability-Adjusted Life Years (DALYs) lost due to all diseases and injuries.This was 12 per cent in 2000. By 2020, it is projected that these disorders will have increased to 15 per cent. This has serious implications for services in all countries in the coming years.

In recent years there have been some positive policy developments in this area. CORI Justice welcomed the Towards 2016 commitment to deliver one child and adolescent community mental health team per 100,000 of the population by 2008 and two per 100,000 of the population by 2013. Resourcing a comprehensive policy addressing this issue remains a priority.

Areas of concern

There is a need for effective outreach and follow-up programmes for people who have been in-patients in institutions upon their discharge into the wider community.These should provide:

• Sheltered housing (high, medium and low supported housing)
• Monitoring of medication
• Retraining and rehabilitation
• Assistance with integration into community

A stronger emphasis on the development of community services for all levels of mental health is urgently required. People with an intellectual disability who require a mental health service frequently find they do not have a psychiatric service available to them. Furthermore, there is a lack of appropriate mental healthcare for all who need it, especially vulnerable groups including children, the homeless, prisoners, Travellers, asylum seekers and refugees and other minority or vulnerable groups. People in these and related categories have a right to a specialist service to provide for their often-complex needs. A great deal remains to be done before this right could be acknowledged as being recognised and honoured in the healthcare system. While welcoming the targeting of additional resources to the development of the mental health service concern is expressed that the level of resource being provided is sufficient to meet the challenging targets. Government needs to acknowledge and recognise that underfunding of mental health services over the years means sustained additional investment over a number of years is needed to meet the requirements set out in “Vision for Change”.

When the social determinants of health (housing, income, childcare support, education etc.) are not met the connection between those who are disadvantage and ill health is well documented.This is also true where mental health issues are concerned.

Child and Adolescent Mental Health Services

There is an acknowledged shortage of in-patient Child and Adolescent mental health beds which needs to addressed as a priority.

Suicide

A related problem to mental health is suicide. For many years the topic of suicide was one rarely discussed in Irish society and as a consequence the healthcare and policy implications of its existence were limited. Data show that the numbers of suicides in Ireland has climbed over the last decade. In 1993 327 suicides were recorded and by 2005, the latest year for which data is available, the number of suicides had increased to 431. Over time Ireland’s suicide rate has risen from 6.3 suicides per 100,000 people in 1980 to 10.4 suicides per 100,000 people in 2005 (OECD, 2005 and CSO, 2006:65).

The age and sex distribution of suicides provides an important insight into what groups in Irish society are most prone to suicide.Table 3.39 provides a breakdown for 2004 when there were 493 deaths by suicide and self-inflicted injury. It shows that suicide is predominantly a male phenomenon with over 82 per cent of suicide victims being male. When assessed by age group the data suggest that young people, and in particular young males, are the groups most at risk.Young males aged between 15 and 34 account for over 35 per cent of all suicides in 2004. Among this age-group in the population, suicide is one of the largest killers.

The growth and scale of suicides in Ireland is a significant healthcare and societal problem. Of course the statistics in table 3.39 only tell one part of the story. Behind each of these victims are families and communities devastated by these tragedies. Likewise, behind each of the figures is a personal story which leads to victims taking their own life. CORI Justice believes that further attention and resources need to be given to addressing and researching Ireland’s suicide problem. In that light, we welcome recent moves by the HSE to establish a national office of suicide prevention and the directions laid out in the National Strategy for Action on Suicide Prevention (2005-2014). Resources are also required for the support systems that must be provided for such vulnerable groups. As a society we need to become more aware of this issue and more aware of methods to prevent it.

Mental Health and Older people

Mental health issues affect all groups in society.A particularly vulnerable group are older people with dementia as they often fall between two stools. i.e. mental health versus general medical care.Therefore there needs to be a co-ordinated service provided for this group.

There is a need for adequate ancillary services to be put in place (psychotherapy, counselling etc.) in an effort to move away from the purely medical model of care. If a comprehensive mental health framework is to be established then these areas of concern must be addressed. It is important that this service be needs based and service-user-led and should be in keeping with international human rights standards and best practice in line with the principles in the World Health Organisation’s 2001 annual report. The recommendations of the NESF report on care for older people should also be resourced and implemented.

Research and development in all areas of mental health is needed to ensure a quality service is delivered. Providing good mental health services should not be viewed as a cost but rather as an investment for the future. Public awareness needs to be raised to ensure a clearer understanding of mental illness so that the rights of those with mental illness are recognised.

Community Services for Older People

We acknowledge the significant investment made to develop services for older people and the commitments made in Towards 2016.We have welcomed the announcements of the introduction of “A Fair Deal – The Nursing Home care Support Scheme 2008” and further welcome the commitment to monitor these arrangements in a partnership way with the social partners. In addition to the changes in the scheme from 2008 it remains critical that sufficient investment is included in the NDP to ensure that the additional numbers of residential care beds are provided to meet the growing demand as identified. The focus on the development of community based services to support older people to remain in their own homes/communities for as long as this is possible is to be welcomed. Improved funding for home help services, day care centres, home care packages is acknowledged
Disability

CORI Justice welcomed the government’s approach in Budget 2004 to the funding of the Disability Services over a five-year period.This development will enable a more co-ordinated and strategic approach to the planning and delivery of services.There are many areas within the Disability Sector which are in need of further development and core funding and these need to be supported.

The health system reform process

It is a recognised fact that there was a need to restructure the health system as the last major re-organisation occurred some thirty years ago. The reform programme needs to be in keeping with the commitments and the vision of the National Health and Primary Care Strategy “a health system that supports and empowers you, your family and community to achieve your full health potential. A health system that is there when you need it, that is fair and that you can trust”. The reform process has identified the HSE (Health Services Executive) as the Executive Arm of the Health Service.Within this process there is a clear democratic deficit which has not been addressed to date.There is a need to recognise that community participation and involvement is key in the planning, delivery and evaluation of services to ensure that the vision of the Strategy is achieved. In that context, the commitment in Towards 2016 to establish a new mechanism for consultation with the Community and Voluntary pillar is very welcome.

Future healthcare costs

A number of the factors highlighted elsewhere in this review will have implications for the future of our healthcare system.The projected increases in population by the CSO imply that there will be many more people living in Ireland in 10-15 years time, many of whom will be of different nationalities. One clear implication of this will be additional demand for more healthcare and more healthcare facilities. In the context of our past mistakes it is important that Ireland begin to plan for this additional demand and begin to train staff and construct facilities to cope.

As we indicated in section 3.2, on taxation, the ageing of the population over the next four decades will be an additional challenge to the provision of healthcare. Again, planning and investment is required.

Policy Proposals on Healthcare

• Recognise the considerable health inequalities present within the Irish healthcare system and provide sufficient resources to tackle them.
• Give far greater priority to community care and restructure the healthcare budget accordingly. Overall, government should ensure that at least 35 per cent of the non-capital healthcare budget is allocated to community care. In the process care should be taken to ensure that the increased allocation does not go to the GMS or the drug subsidy scheme.
• Develop and implement targets on health status within the NAPinclusion.
• Increase the percentage of the health budget allocated to health promotion and education in partnership with all relevant stakeholders.
• Provide the childcare services with the additional resources necessary to effectively implement the Child Care Act.
• Develop nursing care of older people in their own community on the model of hospice care.
• Establish monitoring procedures that will ensure the criteria for admission to continuing care for the elderly in receipt of state subvention for such services are administered in a manner, which is flexible and sensitive to the needs of the population.
• Provide additional respite care for older people and people with disabilities.
• Implement the commitment in Towards 2016 to provide 500 primary care teams by 2011.
• Promote equality of access and outcomes to services within the Irish healthcare system.
• Ensure that structural and systematic reform of the health system reflects the key principles of the Health Strategy aimed at achieving high performance, person centred, quality of care and value for money in the health service.
• Develop and resource mental health services, in particular by implementing the Towards 2016 commitment and by recognising that this will play a key factor in the health status of the population.
• Facilitate and fund a campaign to give greater attention to the issue of suicide in Irish society. In particular, focus resources on educating young people.
• Develop community based services for older people to ensure that they remain at home for as long as possible.
• Develop a high quality residential care sevices within the community to address the growing demand.
• Raise the eligibility threshold for the medical card.
• Implement the recommendations of the Health Service report on ‘The Medical Card Scheme’.
• Monitor and evaluate the National Health Reform Programme to ensure equity, people-centeredness, quality and accountability for all.
• Enhance the process of planning and investment so that the healthcare system can cope with the increases in population, its changing composition (e.g. ethnicity) and the aging of the population projected to happen over the next few decades.
• Work toward universal access to primary care.

Notes

47 CORI Justice acknowledges the input of the CORI Healthcare in preparing this section.

Care For Older People NESF Report No. 32, published November 2005

Sports Participation and Health among Adults in Ireland - ESRI November 2004.