6. Provision of services
6.1 Public health
ntil the end of 2004 the Health Boards were responsible for delivering a range of health promotion and public health services across the country, taking account of both local needs and National Health Strategy. These functions have been taken over by the HSE’s Population Health Directorate under the National Director for Population Health. This division is responsible for promoting and protecting the health of the entire population and certain target groups, with particular emphasis on health inequalities. It is also responsible for immunization programmes, infection control and environmental health, and at local level its functions are organized through the 32 LHOs and Hospital Networks.
The Population Health Directorate is structured into six Assistant Directorates, including Strategic Planning, Health Intelligence, Health Promotion, Emergency Planning, Environmental Health and Health Protection. In addition, the Directorate includes the National Office for Suicide Prevention. The Health Protection Surveillance Centre is part of the Directorate, as are the Public Health Departments and Departments of Health Promotion.
The Population Health Directorate is responsible for the implementation and monitoring of immunization programmes for pertussis, diphtheria, tetanus, Hib (Haemophilus influenza type b, which causes meningitis), polio, meningitis C and measles, mumps and rubella (MMR). Immunization rates have continued to improve (see Fig6.1), although by the second quarter of 2007 immunization uptake levels for some conditions were still well below the target level of 95%. For MMR this was only 86%; for Hib (one booster dose of vaccine against Haemophilus influenzae type b after 12 months of age) coverage was 22% below target; and for all other vaccines at 24 months uptake was 4% below target (Health Protection Surveillance Centre, 2007). Coverage rates for MMR, in particular, fell sharply for a period of time after the high-profile publication of one study – later discredited – linking the MMR vaccine with autism. Regional coverage rates for immunizations can also vary significantly – in the case of MMR in 2007 in the Midland HSE Area, coverage was 94%, whereas in the Eastern Area it was only 83%. As Fig6.2 indicates, Ireland continues to have one of the lowest rates of MMR coverage in the EEA.
In addition to local approaches to public health and health promotion, there are a number of national strategies to implement, including those for cardiovascular health, cancer and suicide.
Public health and health promotion initiatives include community-based smoking cessation programmes, the establishment of Community Health Action Zones (HAZs) (including Health Promoting Schools Programmes), development of regional Heart Health Promotion Teams, Sports Partnerships, and piloting of GP Physical Activity Referral Schemes. Another area that is under development is mental health promotion; for instance, in the (former) Midland Health Board region, training on suicide prevention was provided to staff and local guidelines on suicide prevention were launched in schools. Other local initiatives have included provision of a Stigma Reduction Worker to develop staff training in mental health promotion and stigma reduction initiatives.
In early 2007, the ICSB was established as part of the DoHC’s Cancer Control Strategy. This brings together two screening programmes under one roof – the National Breast Cancer Screening Board and the ICSP. The former, also known as BreastCheck – An Bord Cíoch Scrudaithe Naisiunta – was set up in 1998, with a National Breast Cancer Screening Programme launched in 2000. Initially, the programme screened women between the ages of 50 and 64 every two years free of charge.
In its initial phase, the programme covered selected Health Board areas with the intention of expanding the scheme nationally using mobile screening units. In 2005, plans were announced to extend screening to the rest of the country from 2007 (BreastCheck, 2005). The building of two screening units in Victoria Hospital, Cork and University College Hospital Galway took place in 2006, with the units becoming fully operational in December 2007.
Screening services for a range of health problems, including communicable diseases, are also provided for refugees and asylum seekers at Asylum Seeker Centres; for example, at Lissywollen in Athlone, the uptake for health screening has been over 80%.
6.1.1 National Anti-Poverty Strategy and National Action Plan on Poverty and Social Inclusion
A key objective of public health policy is to address deprivation and inequalities in health. The HSE should develop approaches to reduce inequalities in health consistent with the National Report on Strategies for Social Protection and Social Inclusion (Office for Social Inclusion, 2006) and the “National Anti-Poverty Strategy”. Actions include the expansion of access to primary health care for Travellers and ethnic minorities; implementing and supporting a number of different parenting programmes, in particular those aimed at parents from disadvantaged backgrounds; targeting health promotion interventions at lower-income groups; and providing the services of Community Welfare Officers.
Community Welfare Officers undertake home visits, deliver public talks and information sessions, carry out interagency work across all sectors and liaise with residential and other care facilities, with a view to reducing some of the adverse impacts of poverty and promoting economic and social inclusion. Other community welfare services may include running scheduled public clinic services, which may target specific groups at risk such as older people, the homeless and immigrants.
6.1.2 Health promotion
Health promotion is managed by an assistant national director with specific responsibility for health promotion within the Population Health Directorate. Responsibilities previously executed by the Health Promotion Unit of the DoHC have been transferred to the HSE. Work has been guided by the “National Health Promotion Strategy 2000–2005”, which built on the previous 5-year strategy published in 1995. Specific strategies also have been developed since the launch of the first Strategy, including a National Alcohol Policy (1996); Plan for Women’s Health (1997); Health Promotion in the Workplace: Healthy Bodies – Healthy Work (1998); Health Promotion Strategy for Older People (1998); the Report of the National Task Force on Suicide (1998); Youth as a Resource: Promoting the Health of Young People at Risk (1999); Building Healthier Hearts (1999); and Reach Out: National Strategy for Action for Suicide Prevention (2005).
Activities include national health promotion campaigns; storage, distribution and printing of health promotion materials; funding of voluntary agencies; and facilitation of partnerships with key national statutory agencies, voluntary agencies and the community sector. Issues covered include promoting mental health, smoking cessation, sexual health, promoting physical activity and nutrition programmes. Work in 2006 included awareness-raising initiatives with regard to alcohol, breastfeeding and diabetes, as well as the development of a national tobacco framework incorporating guidelines and quality standards for smoking cessation services (HSE, 2007c). The HSE is also responsible for monitoring the level of compliance of local authorities with current fluoride regulations. In Ireland, water has fluoride added to it. The Report of the Forum on Water Fluoridation in 2002 supported the continuation of the fluoridation of water supplies, concluding that fluoridation had made a very significant contribution to dental health and that, at current permitted levels, human health is not adversely affected.
6.1.3 Ban on smoking in the workplace
One of the most significant actions undertaken to promote public health came into force on 29 March 2004 when Ireland became the first EU Member State to introduce an almost total ban on smoking in the workplace, including bars and restaurants. At the time of writing, fines of up to €3000 may be levied on those employers who do not enforce the law. Exemptions from the ban include prisons, nursing homes and psychiatric hospitals, as well as hotel bedrooms. EU directives restricting tobacco advertising and sponsorship also came into force. The ban follows a report prepared on The health effects of environmental tobacco smoke (passive smoking) in the workplace, commissioned by the Office of Tobacco Control and the Health and Safety Authority, which concluded that exposure to the hazards of tobacco smoke can best be controlled by legislation in places of work. The measure has been broadly welcomed by the general public, health interest groups and Irish trade unions (Irish Cancer Society News, 2004). The Irish Business and Employers Confederation also said that the ban had caused “little or no difficulty” to its members (Irish Business and Employers Confederation, 2004). A follow-up survey conducted in May 2004 reported 97% compliance with the ban and no negative impact on trade, although in July 2004 some publicans in the west of the country in particular had flouted the ban until threatened with legal action. As yet, it is too early to reach any conclusions about the long-term economic impacts of the ban.
6.1.4 Health Action Zones
Following the publication of the National Health Strategy, with its holistic view of health care and an emphasis on promotion and prevention, the MoHC in 2002 approved a pilot project and provided funding of €200 000 to establish two HAZs in Cork City. These HAZs were intended to be similar to those seen in the United Kingdom, where they have been used to help develop a coordinated approach to tackling both poor health and health inequalities in areas of social and economic deprivation. The project goes beyond developing strategies for health services and examines other issues which impact on health and wellbeing in the community. The pilots, which won an HSE Special Achievement Award in 2006, were evaluated and mainstreamed into HSE activities in 2005.
The WHO recommends the HPV vaccine to protect against HPV infection for both men and women. In 2010, the HPV vaccine was introduced for all Irish teenage girls. It has been offered to HIV-positive men and women under the age of 26 since 2016 and since 2017, to men who have sex with men aged 16 to 26. The Health Information and Quality Authority recommended the extension of the HPV vaccine to boys concluding it is clinically and cost effective. In 2018, funding was allocated to extend HPV vaccines to boys and it is in the HSE 2019 service plan.
For more information, see:
Health Information and Quality Authority (HIQA). Health technology assessment (HTA) of extending the national immunisation schedule to include HPV vaccination of boy December 2018 https://www.hiqa.ie/sites/default/files/2018-12/HTA-for-HPV-Vaccination-boys.pdf.
Department of Health. Minister Harris welcomes HIQA recommendation to proceed with HPV vaccine for boys December 2018 https://health.gov.ie/blog/press-release/minister-harris-welcomes-hiqa-recommendation-to-proceed-with-hpv-vaccine-for-boys/.
HSE National Service Plan 2019 https://www.hse.ie/eng/services/publications/serviceplans/national-service-plan-2019.pdf
Healthy Ireland, A Framework for Improved Health and Wellbeing 2013–2025, is the national framework for action to improve the health and wellbeing of the people in Ireland. The 2019 Healthy Ireland campaign was launched in April 2019, alongside a €1 million community engagement fund. The campaign and the fund aim to encourage people to make positive choices to improve their health focusing on healthy eating, physical activity and mental well-being. The campaign directs people to a website of gov.ie/HealthyIreland as the place to go for trusted sources of information and practical support together in one place to help people start making healthy changes.
In December 2018, Healthy Ireland’s first outcomes framework was launched which provides a very high level structured approach to gathering and reporting on data to build awareness of the determinants of health and monitor progress on government responses needed to improve health and well-being. The Healthy Ireland Outcomes Framework is based on a conceptual model for health and wellbeing which incorporates health status, health outcomes, determinants of health and wellbeing across the life course.
Drug-consumption rooms have been operating in Europe for decades, with 90 drug-consumption rooms located around the world. Evaluations of these sites found reductions in fatal overdoses, incidence of public injecting, drug related litter and transmission of blood borne diseases. In Ireland, the Houses of Parliament passed the Misuse of Drugs (Supervised Injecting Facilities) Act 2017 to provide for the establishment, licensing, operation and regulations of supervised injecting facilities (SIF). The HSE established a working group to consider possible locations for such facilities in Ireland. In 2017, the HSE set up an 18-month pilot of a SIF run by Merchants Quay, in Dublin. The first permanent SIF in Ireland is scheduled to open in Dublin at the end of 2019 and will cater to approximately 65 persons with a substance use disorder per day.
The Public Health Alcohol Act, which came into law on 3 October 2018, is historic as it is the first time the Irish government has used legislation as a public health measure in relation to alcohol and because this law will introduce restrictions on alcohol not in place in other countries.
The policy objectives of the legislation are to reduce alcohol consumption and the harms caused by the misuse of alcohol by heightening the awareness of the risks associated with alcohol, helping to change attitudes towards alcohol. Specifically, it aims to reduce annual consumption per capita to 9.1 litres of pure alcohol by 2020, to delay the initiation of alcohol consumption by children and young people and ultimately to reduce the health and social costs of the harmful use of alcohol in Ireland. Enacting the Public Health Alcohol Bill was named as a key measure in Ireland’s public health strategy ‘Healthy Ireland’ in 2013.
The wide-ranging piece of legislation provides for changes such as minimum pricing on alcohol, restrictions on advertising and warning labels on alcohol products including cancer warnings, the separation and reduced visibility of alcohol products in mixed trading outlets and the regulation of the sale and supply of alcohol in certain circumstances.
Ireland has the fourth highest rate of alcohol consumption in the OECD in terms of the quantity of alcohol consumed, and Ireland ranks joint third for binge drinking according to research carried out by the World Health Organisation across 194 countries. Three people die every day in Ireland due to alcohol consumption. The cost of time spent in Irish public hospitals for alcohol-related conditions in 2012 was €1.5 billion, or the equivalent of one euro for every 10 euro spent on the public health budget. In 2013, alcohol-related discharges accounted for more than 160,000 bed days in public hospitals; that is almost 3.6% of all bed days used for problems that the measures in this Act are designed to address and to mitigate.
One of the more controversial aspects of the Act is the minimum unit price, set at 10 cent per gram of alcohol. It will be an offence to sell, or advertise for retail sale, alcohol at a price below this set minimum price. The minimum unit price can be increased by Ministerial Order. Minimum pricing is targeted at the cheapest alcohol currently on sale. This may be introduced alongside minimum pricing in Northern Ireland.
Sixty specific actions to improve Ireland’s health and to reduce the burden of obesity across society were published in A Healthy Weight for Ireland – Obesity Policy and Action Plan 2016- 2025’.
The policy and action plan aims to reverse obesity trends, to prevent health complications and reduce the overall burden for individuals, families, the health system and the wider society and economy. The establishment of a ‘Healthy Ireland Fund’ to facilitate joined-up working between Government Departments on evidence based projects, programmes and initiatives that support the implementation of Healthy Ireland was also announced. Progress on implementation will be reported to the Healthy Ireland Cross Sectoral Group by the Department of Health.
A regulation was signed into law on 17 December 2015 under the Protection of Children’s Health (Tobacco Smoke in Mechanically Propelled Vehicles) Act 2014, which makes it an offence for anyone to smoke a tobacco product in a vehicle where a child is present, or to allow someone else to smoke in the vehicle. The offence will be enforced by the Gardaí and carries a fixed penalty of €100 with the option of tougher penalties of up to €1,000 for failing to stop or providing inaccurate details. This smoking ban in cars will take effect from January 1st 2016.
Ireland’s first ever sexual health strategy was launched in October 2015. The goals in the strategy are to ensure everyone has access: to appropriate sexual health education and information and to high, quality, affordable, universal sexual health services and the collection of better information and data on sexual health. A new clinical lead for sexual health in the HSE was announced. An action plan comprising of 18 targets was published as part of the strategy but there was no specific budget were announced to fund the strategy.
Healthy Ireland is Ireland’s first public health strategy. It reflects the international experience and a commitment to public health with a focus on prevention, by taking a ‘whole of Government’ and ‘whole of society’ approach to improving health and wellbeing.
The vision of a Healthy Ireland is where everyone can enjoy physical and mental health and wellbeing to their full potential, where wellbeing is valued and supported at every level of society and is everyone’s responsibility. It aims to
- Increase the proportion of people who are healthy at all stages of life
- Reduce health inequalities
- Protect the public from threats to health and wellbeing
- Create an environment where every individual and sector of society can play their part in achieving a healthy Ireland.
In order to achieve this, the Cabinet Committee on Social Policy will oversee the delivery of this Framework. The Health and Wellbeing Programme in the Department of Health has responsibility for strategic planning and co-ordination of the implementation of the Framework actions. A multi-stakeholder Healthy Ireland Council was launched in June 2014 to provide a national advisory forum to support the implementation of the Framework across sectors. A high-level implementation plan and an outcomes framework, was promised by the end of 2013. This is yet to be published.
Detailed and more specific implementation plans for priority policy areas are being also developed. Implementation plans will be subjected to high levels of consultation across Government, health and other sectors. Specifying direct responsible individuals for each action will be an important characteristic of Healthy Ireland implementation plans.
A Healthy Ireland research plan will be developed to build the knowledge base and ensure that the highest quality and most up-to-date data, scientific knowledge and evaluation tools are available to support the implementation and monitoring of the Framework’s actions and guide the development of new policies into the future.
Basing Ireland’s health promotion policies and programmes on robust evidence means that interventions will be in line with international best practice, cost-effective, integrated with service delivery and more likely to make an impact. Healthy Ireland will be subject to rigorous monitoring and evaluation.
Targets for quantifiable improvements will be set, where appropriate. Regular measurement of these indicators will allow progress to be measured over time. It proposes a necessary shift towards a broader, more inclusive approach to governance for health, moving beyond the health service, across national and local authorities, involving all sectors of society, and the people themselves. See here for the Health Ireland document http://www.dohc.ie/publications/pdf/HealthyIrelandBrochureWA2.pdf?direct=1
And here for details on the Healthy Ireland Council
Ireland became the first country in the European Union to introduce legislation on plain packaging for tobacco products. On 10th June 2014, the Government approved the publication of the Public Health (Standardised Packaging of Tobacco) Bill 2014.
When introduced, it will make Ireland the third country worldwide to introduce plain packaging. The legislation will control the design and appearance of tobacco products, removing all forms of branding. The objective is to make tobacco packs look less attractive, to make health warnings more prominent, with the hope of preventing and stopping people smoking, especially children.