Health strategies - a waste of paper?
When the first national health strategy, 'Shaping a Healthier Future', was published in 1994, it was seen as a landmark document. For one thing, it was the first time that a long-term health strategy had been set out by the Department of Health. As with all such documents, there were concerns that the funds might not follow, but the plan was largely welcomed. It was also something of a PR coup for the Health Minister of the time, Labour's Brendan Howlin.
The strategy had a view on a new framework under which the service would operate - the guiding principles being equity, quality of service and accountability. It covered a four year time frame 1994-97 and targets and objectives were set out. But did it work? Well, it seems that the bottom line is no.
Last year, in preparation for a new health strategy, Health Minister, Micheál Martin sought a review of the 1994 strategy and how effective it was. That review was conducted by the Economic and Social Research Institute (ESRI) and its reports (Stage 1 and Stage 11) cover over 160 pages. While a few of the findings have already been leaked, the full report has been secured by irishhealth.com under the Freedom of Information Act and it makes for startling reading.
The findings show that the 1994 health strategy was more concerned with image than substance. It was very much an aspirational document with no built-in systems to ensure that the targets set out would be met. Perhaps the most astonishing finding in the ESRI's critique of the strategy relates to the hospital services.
Around half of all of the health service funding goes on our hospital services. The public is well aware of the shortcomings in casualty departments, in relation to hospital waiting lists and the lack of accountability in hospital services. So then it comes as something of a shock to find that in its review of the hospital service targets, the ESRI tells us that 'no information' could be provided on this area by the Department of Health to assess progress towards the achievement of specified targets.
The same is also sadly true in relation to:
- Action by doctors and other health professionals to encourage a decrease in smoking
- Reducing alcohol intake
- Improving nutrition and diet
- Reducing cholesterol and blood pressure
- Increasing the number of people taking exercise
- Reducing the causes of accidents
- Encouraging breast feeding
- Drug misuse prevention programmes in schools
- Better pharmacy and medicine controls
This is just a flavour of the failures found. There was also little success in making doctors more accountable and the information systems on which decisions are made are still poor.
In another area, that of blood safety, there is a curious omission from the ESRI report. An appendix on the recommendations of the Finlay Blood Tribunal is included at the back of the report and it appears that it may have been written by the Department of Health for inclusion in this ESRI review. This appendix outlines what has been done in terms of implementing the recommendations of report of the Finlay Tribunal which was published in 1997. But there is one glaring omission - and even the ESRI researchers do not appear to have spotted it.
The key recommendation of the Finlay Tribunal was that the government implement a law obliging doctors to report adverse reactions to blood products. A deliberate failure to do so would be a criminal offence. Of course, the government, despite committing itself in its programme for government to implementing the Finlay recommendations, has not implemented this key recommendation. But there is no mention if that in the ESRI review.
Indeed, it's not clear from the ESRI report whether much of the Department of Health's explanations on the actions it took to meet the 1994 strategy targets were taken on 'face value' as being full and accurate.
There appears to have been an attitude at the Department that it was the responsibility of health boards to act on the strategy plans. Of course, if health boards never got the money how could they?
Some serious lessons have to be learned if the next health strategy is not to be such a damp squib. The 1994 strategy took around 6-9 months to finalise and there was limited consultation. Indeed, a small team in the Department of Health put it together. The strategy had over 200 targets covering 17 different areas.
The ESRI critique found that there was an absence of an explicit monitoring and implementation framework; the objectives were more aspirational and philosophical than real; there was no prioritisation of various targets; much remains to be done to meet the targets set; it appeared to many to be more about style than substance and indeed many of the targets were not very challenging in the first place anyway.
There are still great inequalities in health in Ireland. For example, someone on the minimum wage is not even eligible for a medical card. Those who are disadvantaged in terms of income, education or occupational level also tend to be disadvantaged in terms of health status and length of life, the ESRI notes. Those at the bottom of the social class ladder have at least twice the risk of serious illness and premature death as those at the top.
In relation to the family doctor service, which many of us use, there are also serious deficiencies. The 1994 strategy looked to having an improved GP service. But the ESRI review points out that general practice 'is still characterised by fragmented organisation'. There are around 2,200 GPs operating from 1,800 separate practices and half of family doctors work on their own. Less than 500 GPs have practice nurses and there are just around 900 practice secretaries.
The lesson for the future is that we should all be wary of health strategies. Where they are planned, there should be widespread consultation, especially with those for whom the health service operates - the public, the patients. There also needs to be ongoing monitoring. Health ministers may come and go, but their plans should remain and be implemented in full.
Any strategy must also allow for the unexpected. When the 1994 strategy was published no one really knew how events in food safety, blood safety, child abuse, asylum seekers, clinical competence and staffing shortages would affect the service in the future.
There is also the crucial issue of money. So often it comes down to funding. Without ringfenced funds, even the best health strategy will be useless. An interesting term that has crept into the health Department lexicon these days is that a proposal may have been 'costed but not budgeted'. Put simply, we know how much it will cost but the Department of Finance will not write the cheque.
If the proper funds are not put aside for the next health strategy, it will be an equal waste of time. One must remain cynical given that the timing of publication of the next document will be just before the next General Election.
That said, this time there is a much wider consultation process, but again that may just be more about image rather than substance in the end.
Time will tell. But how long more must the public wait for a fair and responsive health service?
Written by Fergal Bowers, editor of irishhealth.com
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