Health Promotion in Ireland Journey, Reflections & Challenges

1. Health Promotion in IrelandJourney, Reflections & Challenges Summer School 11th June, 2014 Biddy O’Neill

2. Journey The road of life twists and turns and no two directions are ever the same. Yet our lessons come from the journey not the destination (Don Williams)

3. Where did it all begin in Ireland • 1975 • Recommendations to establish Health Education Authority • Health Education Bureau • Role • (i) To advise the Minister on formulation of policy in relation to Health Education. • (ii) Co-ordinate the provision of Health Education Programmes.

4. 1986 • Ottawa. • Health – The Wider Dimensions (DoH). • 1987 • Promoting Health through Public Policy which incorporates the principles of Ottawa. • 1988 • Establishment of Health Promotion Unit DoH. • Role • (i) Develop Health Promotion Policy. • (ii) Executive function included National Campaigns and Programmes. • 1990 • Establishment of Chair for Health Promotion Galway.

5. 1995 • National Health Promotion Strategy – settings, topics, population groups. • Specific goals and targets. • 1999 • Building Healthier Hearts – 58 recommendations. • Budget allocation. • 1999 - 2004 • Staff increased from 86 to 307.

6. 2000 • Second Health Promotion Strategy embraced wider determinants of health. • Inter-sectoral and multidisciplinary approach. • Establishment of National Health Promotion Forum. • 2001 • Quality & Fairness – Better Health for Everyone. • Strong focus on Health Inequalities.

7. 2004 Review of Implementation of National Health Promotion Strategy. • Reported – high levels of activity across the topics, population groups and key settings. • Recommendations included: • Monitoring and evaluation, • Continued investment in health promotion, • Inter-sectoral work at highest level, • Guidelines for working in partnership.

8. Establishment of HSE - 2005 • Population Health Directorate – Health Promotion a key pillar. • Restructuring of Health Promotion Function. • Transfer of executive function from DoH. • Health Promotion Campaigns. • Print, Storage & Distribution of Health Promotion Resources. • Funding of Voluntary Agencies. • National Projects including – SPHE, Alcohol, Obesity, Health Promoting Hospitals, National Smokers Quitline, Breastfeeding, Men’s Health, National Youth Health Programme.

9. Population Health – Health Promotion Development of silos within Population Health. New regional structures for Health Promotion. Relationship between National and Regional Functions challenging. At regional level integration was limited due to historic working arrangements and geographical spread. Change Management Process was delayed. Population Health Strategy 2008. Transformation Programme – Obesity, Breastfeeding, Tobacco, Alcohol and Health Inequalities.

10. 2009 • Proposal to transfer the Population Health Directorate into the Integrated Services Directorate. • Feb. 2010 • Health Promotion Function transferred into Integrated Services Directorate (ISD). • Dec. 2010 • Regional Managers repointed to local RDO’s – budget and staff decreased. • National Health Promotion Management Team reduced by 50%. • Jan. 2011 • New working arrangements agreed by Health Promotion Management Team re. National/Regional Roles.

11. HSE – Health Promotion Strategic Framework 2011 Adopts a settings approach underpinned by Ottawa and WHO principles of Health Promotion Focus on schools, community and health services through partnership and capacity building approaches. It involves training and education, social marketing and advocacy, research, evaluation and programme development.

12. Where we are now Health 2020 WHO. Healthy Ireland Framework 2013 . Leadership in DoH & HSE. Health Promotion and Improvement Management Team. Partnership working with Voluntary Sector. Health Promotion Strategic Framework. Competencies Framework. Association of Health Promotion in Ireland.

13. Research Centre NUIG and undergraduate and post-graduate course in several 3rd level institutions. Health Promoting School Framework. Comprehensive map of health promotion programmes, activities etc. Resource Planning Process. Train the Trainers in Healthy Settings and Health Inequalities. Appointment of National Co-ordinator for Schools, Community and Health Services. Workforce Plan to be progressed in 2014.

14. Reality Check

15. Reflections “Without reflection we go blindly on our way creating more unintended consequences and failing to achieve anything useful”. (M. Wheatley)

16. Ireland in 1980’s – Health Education Approach – individual responsibility. Change to health promotion in mid 1990’s roles remained same. Public Health and Health Promotion Departments were proposed to be “mutually supportive” but were challenged by the medical v biopsychosocial model of health.

17. Funding from HPU – ad hoc and inconsistent for Health Boards – Pilot Initiatives which were resource intensive and unsustainable. CVD Funding – lifestyle issues predominantly. 2nd Health Promotion Strategy subsumed between CVD and Quality & Fairness. Health Boards allocated responsibility for health promotion within the context of local needs.

18. Political priorities have dictated the agenda – drugs, alcohol, tobacco, obesity etc. Political leadership sporadic over last 20 years. Change experienced since establishment of HSE – extensive didn’t get opportunity to agree and embed structure. Took on settings approach but measurement lifestyle focused.

19. Current PI’s not robust for Health Promotion. Contribution of Health Promotion to policy development significant over last number of years but this creates challenges for implementation. Lack of structure and support for monitoring and evaluation. IT infrastructure. Lack of co-ordination in development and implementation of programmes.

20. However: We have a strong theoretical base, a body of evidence and the ability to address complex social problems. Achieved significant progress in policy and programme development across topics, settings and population groups. Highly skilled motivated staff who are committed to health promotion agenda. We also need to recognise other countries experience similar challenges.

21. Challenges The tendency for policy to start off recognising the need for action on upstream social determinants only to drift downstream and focus completely on individual lifestyle referred to as “lifestyle drift” must be kept to the forefront.

22. Process of Health Promotion needs to be appreciated in the context of the development of the outcomes framework for Healthy Ireland recognising health promotion as a complex field. Development of PI’s that reflect the work of Health Promotion not just lifestyle indicators.

23. Be aware of how limited the resources allocated to health promotion and the ambition to contribute to the broad health agenda at national and local level. • Example: Health Promoting School • There are currently 3900 schools primary/post-primary. • HPS Process/Settings Approach – engagement, training, support – approx. 8 days over 2 years in line with best practice in health promotion. • What are the resources required to deliver on this priority over the next 10 years?

24. Continue to advocate for the role of health promotion in addressing complex health and social issues through mediation, participation and community empowerment. Need to be mindful that the health field is dominated by medical model. Actively engage with Public Health and other disciplines to deliver on priorities in Healthy Ireland in a meaningful way.

25. Continue to show leadership to mobilise other sectors to adopt a social determinants approach to health. Need to develop structures and quality assurance in both the work delivered by Health Promotion Staff and the work that is commissioned. Ensure the workforce plan reflects the competencies of health promotion.

26. In supporting Healthy Ireland we must remember that one of the primary roles of the Health Promotion Workforce is to support organisational, environmental and system change within the settings as well as building capacity to promote heath. Reorientation of health service remains a priority. Need to link research, policy and practice in a structured way.

27. Need to appreciate different ideologies and accept we are all going in the same direction. Continue to input into the global network of health promotion practices and researches and work to achieve professionalism.

28. “If we want people to join us for health we have to see how their history, their opportunities and preferences are shaped not just by their individual psychology but how peer pressure and economic and political forces shape the condition of living”. (Hans Sans 2009)