The Business Committee has agreed to allow up to one hour and 30 minutes for the debate. The proposer of the motion will have 15 minutes to propose and 15 minutes to make a winding-up speech. All other Members who wish to speak will have five minutes.
I beg to move
That this Assembly welcomes the Committee for Health, Social Services and Public Safety's review of health inequalities; notes the recommendations relating to the restructuring of government Departments; and calls on the Minister of Health, Social Services and Public Safety to discuss the recommendations in the report with the ministerial group on public health and to action those that are within his remit.
Go raibh maith agat, a LeasCheann Comhairle. I am delighted to move the motion on behalf of the Committee for Health, Social Services and Public Safety.
I would like to begin by providing some background to the Committee’s review of health inequalities. The Committee has been concerned about the issue for some time. We are aware that, although the general health of the population has been improving over recent years, the rate of improvement is not equal for everyone. Health outcomes are worst in the most deprived areas in overall terms. There continues to be a large gap across various measures of health, including life expectancy, drug- and alcohol-related deaths, suicide, teenage pregnancy, smoking during pregnancy and cancer-related deaths. The main cause of these health inequalities is poverty.
Back in June 2012, the Committee was aware that the Department was in the process of producing a new public health strategy to follow on from Investing for Health. Members will remember that, when 'Investing for Health' was published by the then Minister, Bairbre de Brún, it was seen as one of the most radical documents of its time. We, therefore, believed that a review of health inequalities would be useful work that could feed into the Department’s development of the new strategy.
The Department’s draft strategy 'Fit and Well: Changing Lives 2012-2022' was published in August for public consultation. That consultation ran until the end of October 2012, with the strategy expected to be published in spring 2013. Parallel to that process, the Committee carried out its review of health inequalities so that the results of that could feed into the final version of 'Fit and Well'. I want to take the opportunity not only to welcome the Minister to today's debate but to thank him for agreeing to wait until we had finished our report. It is important that the value of the Committee's work is seen by the Department and the Minister because we can add to the process.
The terms of reference of our review were to identify effective interventions to address health inequalities in other regions that could be applied here, with a particular focus on early years intervention. We invited a range of expert witnesses to give evidence to the Committee. We were keen to be outward-looking and see what we could learn from other places. We heard from people working on projects across Ireland — in Ballymun and the Midlands — from Scotland and the European office of the World Health Organization.
As a Committee, we also agreed to carry out a study visit as part of the review. That involved the Deputy Chair and me going to Cuba to attend an international conference on public health and see for ourselves various aspects of the Cuban healthcare system. The Cuban healthcare system spends $585 on each person a year, whereas we spend almost $4,000. Despite that huge variance, Cuba achieves health outcomes that compare with and, in some cases, exceed those produced by our system. Therefore, we thought that it was important to go to the conference and see at first hand whether there was anything that we could learn about Cuba's system and use here to tackle health inequalities.
One of the striking aspects of the Cuban approach is the focus on primary care. We got the chance to visit a GP surgery and a polyclinic. We learned that, in 1984, Cuba introduced the system of a family doctor and nurse service because they realised that they relied too much on hospital services. Cuba wanted to put a bigger emphasis on prevention and on treating people in the community first and foremost to prevent them needing hospital treatment, where possible. The family doctor lives in the community that they serve. So, at any point in time, they can provide an overview of all his or her patients' general health. As I mentioned in a previous debate, that is partly because they carry out annual health checks, which means that they can prevent ill health or, when needed, intervene early. The Committee fully accepts that some parts of the Cuban health system cannot be directly transferred on to ours. However, the focus on prevention, patient education and primary care all fit in with the vision that the Minister has set out in 'Fit and Well'.
We visited a polyclinic where various clinics and minor operations were carried out, and we learned that the one that we visited had an infant mortality rate of zero in the past 15 years and had had no maternal deaths in the same period. We also heard that a lot of emphasis is put on the care of pregnant women, who have 12 antenatal appointments. The breastfeeding rate is also very impressive, with 95% of women breastfeeding for up to six months. That means that children get the best possible start in life, because the system prioritises the needs of pregnant women and supports them in breastfeeding. Again, that ties in with the Fit and Well strategy, where the focus is on early intervention. My colleagues from the Committee will speak later about some of our recommendations on breastfeeding and parenting.
Another thing that struck us was that there is a strong focus in Cuba on empowering people to deal with their own condition rather than simply writing them a prescription or giving them a pill. We observed classes and spoke to the instructors. The classes were held in a hall that had been pretty damaged by the recent weather in Cuba. However, it was decided that the hall could still be used, and work was still going on. The classes were held in that public hall, which had basic facilities. Throughout the day, different classes were held for people with health problems such as diabetes, high blood pressure, arthritis and depression. Those people had been referred to the classes by their doctor. So, instead of automatically being given a prescription or a pill, they were referred to a class. All the classes were free of charge, and the instructor was employed by the state. There was no modern gym equipment, but there was a can-do attitude from both the instructor and the participants, who made best use of the buildings and facilities that were available to them.
We also talked to men and women who participated in daily grandparent circles, and we attended one such circle. The circles involve people aged from their 50s to their 80s meeting every morning in a public park to do a set of exercises together. We met a woman who was over 80 and still had her own teeth. She had lost only one tooth, which is impressive for somebody of that age. The members of the group were enthusiastic about the benefits of exercise. Importantly, however, they were also enthusiastic about the social aspect of such groups, which is often forgotten. Sometimes, we talk about our elderly being excluded and isolated, but I thought that the social aspect of that group was hugely important.
The group is peer-led, but an instructor visits twice a week to ensure that people do the correct exercises. A doctor also visits every couple of weeks to monitor blood pressure and so on. Again, they were using a public park. There were no special facilities, and it was free to everyone. If we are serious about tackling health inequalities, we need to make better use of our assets. We have so many leisure centres, parks, schools, school playing fields, halls, church halls and government buildings that could all be opened up a lot more widely so that people could take part in activities that would benefit their health. In fact, in Cuba, there was even a project for children with learning disabilities that was based in the local zoo. The staff were using the animals in the zoo and factoring them in to the weekly work programme for the children, which involved therapy and exercise. We need to think outside the box.
The report says that, if we are to get a handle on health inequalities, there must be a united front across all Departments. It is not an issue for the Department of Health alone; in fact, the Department cannot deal with the issue on its own. As part of the review, I wrote to all Departments on behalf of the Committee asking for details about the programmes that they currently run to tackle health inequalities through early years intervention. Unfortunately, a number of Departments simply stated that they had no such programmes. It is my impression that some Departments have not quite grasped the fact that we all have a role to play in improving the health of our people. It goes across the board: we need to look at education, housing, job creation, access to the arts and sport and so on. It is important that all Departments accept that they have their part to play.
The Minister is keen to secure cross-departmental buy-in and action for the Fit and Well strategy. I assure the Minister today that the Committee is more than willing to be part of the push to tackle health inequalities. I urge members of other Committees to take the time to ask what their Department does to promote public health. If Departments are not doing anything, they need to do something. If Departments are doing stuff, can they do more?
I thank Committee members for the part that they played in the report and staff from the Committee and the Research and Information Service, who helped us to produce the report. I also thank the witnesses who gave the Committee the benefit of their knowledge of and information about the programmes that they run. I commend the report to the Assembly.
I speak as a member of the Committee for Health, Social Services and Public Safety to commend the report to the House.
On taking office in May 2011, the Minister of Health, Edwin Poots, placed health inequality at the heart of the agenda. It is not fair or equal that we have a society in which inequalities not only are evident but continue to widen. It is therefore imperative that the Assembly act to reduce inequalities and strive to build a fairer society for all.
At the heart of health inequalities, we see more people and communities suffering from smoking- and heart-related diseases, suicide, teenage pregnancies, drug- and alcohol-related mortality and cancer mortality compared with other areas of Northern Ireland. People are not necessarily born with poor health; rather, it is often a condition of their environment, and that condition is poverty.
In my constituency of South Antrim, nearly 18% of the population have a long-term health problem that affects their ability to carry out day-to-day activities. Some 38% of the population hold either no qualification whatsoever or a low qualification. Members may ask why I raise the issue of health alongside that of low educational attainment. The answer is simple: as the report demonstrates, they are linked.
There is a need for a joined-up approach to tackle health inequality as well as poverty. The issue needs to be taken up by the Executive Committee as a whole, from the perspective of the economy, regional development, agriculture, rural development and education. Every Department has some role to play.
The Department of Health provides services for those who need them. The practice of modern medicine has come a long way in recent years, but it is poverty that remains at the heart of poor health. That poverty is partly caused by the absence of a nurturing environment to provide a decent education for our young people, which helps to secure employment in an ever more competitive work environment. A historical absence of decent housing also contributes, as does the need for supportive and better rural life with access to schools, a library and an employment centre, access for infants to local, supportive preschool nurseries and access for parents to programmes such as Sure Start that provide an early intervention mechanism. There is obviously a role for parents and local communities, but many of those involved in such communities have been calling for much of this for some time amid cuts and closures. I urge all Departments to review those strategies, which are clearly not delivering, with a view to overhauling them to ensure that they deliver for all our communities.
The bones of the report focus on the need for a joined-up approach among Departments towards promoting better health and reducing health inequalities; namely, collaborating and prioritising funding and resources for projects in areas of social and economic disadvantage. One of the report's recommendations is that consideration should be given to creating a Department for children and young people to place greater focus on early years intervention, and I ask the Minister to comment on that recommendation and to update us on how that complements the work of the ministerial subgroup on children and young people. While there is much for the Minister of Health to consider in this report, there is much for others to digest to see what could lead to a better, healthier and more equal Northern Ireland.
I, too, am pleased to support the motion highlighting the Committee's review of health inequalities.
When we reviewed the Statistics and Research Agency's figures, it was clear that there were huge variations in life expectancy. The average female life expectancy in Northern Ireland is 80·5 years, but, in the 20% most deprived areas, it moves down to 77·9 years. For a male from one of the 20% most deprived areas, it is 71·5 years. Those are quite dramatic variations in life expectancy, and, with that, there is associated illness. A range of factors are thought to contribute to that, such as an increased risk of mortality because of drugs, alcohol and smoking and an increased risk of suicide. There is also the issue of respiratory mortality and cancer mortality.
The Committee received evidence from a range of experts, many of whom pointed towards the importance of early years programmes to help improve the health of the next generation and to reduce health inequalities. Mention was made of Professor James Heckman and Sir Harry Burns, who have both recognised the importance of early years investment in education and in health. I declare an interest as a member of Horizon Sure Start, which provides support to parents in Carrickfergus and Larne.
I will concentrate on recommendation 4 in the Committee's report, which states:
"The new public health strategy should recognize parenting as having a significant influence over long-term public health issues and should adopt a “progressive universalism” approach to supporting parenting projects."
In the evidence from the Triple P Project, we were advised of how Kaiser Permanente, an American insurance company, had reviewed the effects of adverse childhood experiences. It highlighted that such adverse experiences result in a higher risk of developing obesity, ischaemic heart disease, depression and alcoholism. So, by improving parenting skills and reducing adverse experiences, the health of the next generation can be improved. Progressive universalism is about supporting everyone, with more support for those who need it most. The Triple P Project from Longford and Westmeath highlighted that 30% of children with social and emotional behavioural problems had parents from lower socio-economic groups. Of course, that means that 70% were from other groups, and there clearly needs to be support across the board for everyone. The group also highlighted the research by Steve Aos from the Washington State Institute for Public Policy, which, again, expressed a preference for the universal approach and indicated that, essentially, you get better results and better value from your investment by taking that approach. Some parents may require only limited support and guidance from literature, whereas others will benefit from extra parenting support such as classes and regular meetings with advisers and specialists.
Perhaps the most dramatic example of how a parent can affect the health of their child is demonstrated by the issue of mothers who smoke. According to the NHS website on smoking and the unborn baby, protecting your baby from tobacco smoke is one of the best things that you can do to give your child a healthy start in life. Every cigarette you smoke in pregnancy harms your unborn baby. It contributes to an increased risk of stillbirth, and newborn children are less likely to be able to cope with any complications that arise. Smokers' babies are more likely to be born early and to face the additional breathing, feeding and health problems that go with being premature. A child of someone who smokes is more likely to be underweight and less able to fight off infection.
There is also an increased risk of cot deaths. What is quite surprising is the variation in the numbers of mothers who still smoke in Northern Ireland. When I looked at the official figures, I discovered that, in the Old Warren ward, 55% of mothers still smoked in 2011. In the Greystone ward, 50% smoked, and 48% in the Ballee ward. In my constituency, 41% of mothers in the Clipperstown ward smoked, and 39% of mothers in Sunnylands and Blackcave still smoked.
I offer my support and that of the Alliance Party to the recommendations that are contained in this report. Inequalities in any aspect of modern life are wrong, unacceptable and should not happen, but, when it comes to inequalities in health provision, it is time that someone stood up and called a halt to what is going on. That is exactly what we in the Health Committee have done in this review, and I pay tribute to our Chairperson for putting this very important issue on the agenda and carrying out such a review of the issue. Hopefully, as a result of our investigation, we can, together, put forward those inequalities and what we see as a means to put an end to all health inequalities in Northern Ireland.
I also commend the Committee staff for their work, particularly in bringing to our sessions very important people from various backgrounds who gave us an insight into their experience and made suggestions on a way forward. I also welcome the presence today of the Health Minister, and I hope that, together, we can see an end to health inequalities for all in our society.
So far, colleagues from the Health Committee have spoken on a variety of issues, and I wish to deal with the contribution that was made by Dr Erio Ziglio, the European officer with the World Health Organization, and Joan Devlin from Belfast Healthy Cities. We were extremely grateful to have the input from such a very high-profile individual. He took time out to contribute to our review, along with our own Joan Devlin from Belfast Healthy Cities, who continues to do extremely valuable work in Belfast.
One of the key points that was made by Dr Ziglio was that a reduction in health inequalities could not be made by working solely within the health service. He argued that, for a public health strategy to be successful, it must provide added value to local and regional development. In his experience, countries with an overall development strategy will have more success, and that is exactly what we want to see as a result.
Dr Ziglio told us how Slovenia had major health inequalities and poor indicators on health and unemployment. However, over a 10-year period, Slovenia made significant improvements by identifying and bringing together three main sectors — health, agriculture and tourism — and produced a strategy that involved all three Departments of government. By working together collectively, there were benefits for each of the sectors, and Dr Ziglio made the point that this combined approach is better than each of the Departments working as silos and seeing each other's Departments as competitors for limited resources. We see some of that quite regularly in Northern Ireland. He also suggested that we in Northern Ireland should look more closely at how to maximise European structural funding opportunities. He believed that the trend has been for most of the funding in health to go to buildings, which might not necessarily be the best way forward. If health could join with other sectors, that would be a better way to access European funding.
With these wise words from this eminent World Health Organization doctor, our Committee has made its first recommendation, which states that the Health Department should actively work to form partnerships with other areas of government, such as the Department of Enterprise, Trade and Investment (DETI), which includes tourism, the Department for Regional Development (DRD) and, indeed, the Department of Agriculture and Rural Development (DARD). The Health Department should form partnerships to access much-needed European structural funds.
As I said earlier, health inequalities are unacceptable, and it would be everyone's goal to see them eliminated as soon as possible. If our recommendations are acted upon, we could indeed see —
Go raibh maith agat, a LeasCheann Comhairle. I also speak as a member of the Health Committee and in support of the motion. I, too, acknowledge the role of the Committee and its staff in undertaking such an important report.
Tackling health inequalities must be central to the delivery of health and social care provision and the Transforming Your Care proposals. Early intervention and prevention is central to that objective. We spend £4·6 billion per year on health and social care and employ 70,000 staff, but the reality is that health has not been shared equally across all the people in our society. The life expectancy of someone in a more affluent area is around 10 years greater than that of someone in a more deprived area. With respect to health inequalities, the top three constituencies are Belfast West, Belfast North and Foyle.
In that context, therefore, I want to focus on recommendation 9 of the Committee's report, which is:
"The Department should consider increasing the percentage of the overall health and social care budget spend on prevention to 6% within the next decade."
That issue was discussed at an evidence session with the World Health Organization, where it was indicated that most European countries' average spend on prevention is 3%, and that that should double within the next decade. The World Health Organization highlighted how there is still reluctance by some Governments to direct resources to prevention.
What, therefore, do we mean by prevention? The Social Care Institute for Excellence defines prevention as providing a range of services that promote independence, prevent or delay the deterioration of well-being resulting from ageing, illness or disability, and delay the need for more costly and intensive services.
The Economic and Social Research Institute of Ireland stated that, for every €1 invested, you get €7 in return. I stress that those figures are for the Twenty-six Counties only, and I urge the Minister to work with his counterparts in Dublin to provide all-Ireland figures that provide us with a clear economic case for early intervention and prevention.
The Institute of Public Health in Ireland referred to the need for preferential resourcing to disadvantaged communities. The World Health Organization described how the resources could be mobilised, through partnership with other sectors, or through utilising resources that come from the EU through structural or cohesion funds. Early intervention in Scotland resulted in savings of £5·4 million to the Scottish economy.
I want, therefore, to examine a number of key health areas that could be impacted on by prevention. In the Western Trust area, the largest inequality gaps are in alcohol-related mortality, 112%; self-harm admissions, 89%; teenage births, 76%; and smoking during pregnancy, 71%. The constituencies of Belfast West, Belfast North and Foyle have the highest standardised death rates of the main causes of death. The four constituencies of Belfast West, Belfast North, East Derry, and Foyle had over one third of all teenage births in 2010. One hundred and eighty seven alcohol-related deaths occurred in Foyle between 2001 and 2010. All those are stark inequalities that require additional focus and investment in prevention and early intervention.
The principle of Transforming Your Care, in shifting resources from acute to community services, is laudable, but with that comes additional demand for resources. We have an ageing population and, although opting to be cared for at home is an understandable request, it requires additional support for families and carers. Prevention schemes for older people in England that are delivered through the WRVS organisation examined the social return on investment. The hospital-based aspect of the study showed a £1·9 million return on investment.
In conclusion, I highlight two important proposals in advancing early intervention and prevention. The first is the development of the social care campus model, which will allow for a combination of health and community care to be delivered as part of a hub. Secondly, I suggest to the Minister, in his absence, that the facilities exist in the north-west through the Project Kelvin database and its link to North America, the C-TRIC facility and the university, in terms of connected health. I ask the Minister to comment and update us on both those proposals.
I welcome the opportunity to speak on the motion. It is a very important matter for everyone across Northern Ireland. Unfortunately, health inequalities continue to exist in today's society, and that remains the challenge that we all must continue to work to improve. I commend the Health Minister for all his work to date on leading on this and trying to improve the health and well-being of our population. I know that he will continue to make preventative care and health promotion a top priority in the Health Department.
The Health Committee has undertaken a lot of work on this subject, and its review of health inequalities has provided some valuable findings that will be useful to the Department as it plans for the future. Life expectancy, alcohol and drug-related deaths, levels of self-harm, teenage births, suicide rates, and respiratory and lung cancer rates were found to be among the most sizeable inequality gaps between deprived areas and the overall figure across the Province. Even in a constituency such as mine — North Down has one of the highest rates of life expectancy — real divisions exist and, therefore, health inequalities unfortunately exist between people who may live only one mile apart. Every constituency experiences significant health inequalities in its population.
As has been said, the Committee has taken evidence from Dr Erio Ziglio, from the World Health Organization. He spoke of how different Government departments in Slovenia, such as health, tourism and agriculture, work together to get positive outcomes for health inequalities. He also spoke about Scotland, where a thematic approach was taken to Departments to tackle inequalities. Some of the recommendations of that review are particularly realistic and constructive. Early intervention was importantly distinguished as one of the best ways to address health inequalities, and that also came through during the many evidence sessions we held with groups and organisations.
The role of parenting was established as one of the keys to improving heath inequalities. It is vital that the correct emphasis is put on supporting parents. Some of the evidence gathered from the Republic of Ireland highlighted the fact that a lack of support for parenting can often have negative effects on children as they grow up. Broken homes and marriage breakdown can also add to health inequalities, and I believe that we should do more to support marriage as a basis for stable homes and society.
Another recommendation is that we should identify and fully utilise the significant resources that we have already. There is a vital role for a cross section of statutory and voluntary agencies to work together and pool resources to help tackle health inequalities. Working together on the ground in our communities is important, as is working together at Executive level. I know that the Minister has been personally involved in several community outreach projects, including those in Kilcooley in Bangor in the North Down constituency, working alongside the South Eastern Health and Social Care Trust.
Departments must work together in a joined up way to tackle these important issues. Education and Health should be working hand in hand on many of the issues around early intervention. However, every Department has a role to play. The promotion of healthier living and well-being should also be continually prioritised by the Department. I know that much good work has already been done on that over the past number of years. Prevention is better than cure, and that must remain our top focus and priority as we plan for the future and ensure that we have a fit-for-purpose health service that will tackle the health inequalities that exist in Northern Ireland today.
Go raibh maith agat, a LeasCheann Comhairle. I, too, speak as a member of the Health Committee in support of the motion.
The Public Health Agency highlights the fact that poverty and economic inequality are bad for health, with poverty an important risk factor in illness and premature death. Poverty affects health directly and indirectly in many ways, including financial strain, poor housing, poor living environments, poor diet and limited access to employment and other resources, services and opportunities. Poor health can also cause poverty. It is well established that the poorest people live the shortest lives in the worst health. Unfortunately, we have persistent poverty here in the North. The figure stands at 21% before housing costs, which is more than double the 9% in Great Britain.
The research on health inequalities makes interesting reading. My constituency, for instance, ranks eighth for multiple deprivation. A number of other health inequality rankings indicate that my constituency of Newry and Armagh is not particularly well off.
I will concentrate on recommendation eight of the report, which is that the new public health strategy should prioritise funding for projects that involve collaboration between partner organisations to ensure a co-ordinated and more effective approach to particular issues.
Another recommendation is that the Department place the new public health strategy in the context of a wider governmental strategy for the development of the North as a region. The Department should work to form partnerships with other areas of government, including Departments not traditionally associated with health matters, such as the Department of Enterprise, Trade and Investment, DRD and DARD. The Department should also look at other sectors where partnerships could be formed, leading to the accessing of European structural funds. It has been argued that a reduction in health inequalities cannot be achieved by working solely in the health sector. For a public health strategy to be successful, it must also provide added value to local and regional development.
Slovenia was mentioned by other Members. I also cite it as an example of where there were major problems and poor health and unemployment indicators. Over a 10-year period, Slovenia made significant improvements in reducing health inequalities and unemployment. It did so through partnership with three sectors. It identified these three sectors — health, agriculture and tourism — and produced a strategic plan involving them. The trend here has been for most health funding to go into buildings. If health can partner other sectors, there will be more of an opportunity to access funds.
The importance of collaboration between sectors, communities or organisations delivering services on the ground cannot be overemphasised. There will be a major role for voluntary organisations in the concept of Transforming Your Care, and a collaborative approach will continue to be very important. If it is accepted that a partnership approach is required for a project to be funded, that will avoid duplication and succeed in bringing together a wide range of skills and expertise, which can only enhance and promote any public health strategy. I commend the motion to the House.
I, too, speak as a member of the Health Committee. I am very happy to support the motion and speak to the report.
Colleagues have covered several important areas where health inequality manifests itself. I want to focus on one area that I might not be expected to focus on. Nonetheless, I shall, and the issue is breastfeeding. t is a simple reality that the breastfeeding rates in our region are unbelievably low. They do not stack up well in comparison with other parts of the world. Indeed, they stack up unfavourably compared with other parts of these islands. Yet the benefits of early breastfeeding and sustained breastfeeding during the first six months of a child's life are beyond doubt. Today, a very interesting news report points to the specific benefit of colostrum, which is the very early milk that a mother produces during the first day or two of a child's life, and how essential it is to building up the child's immune capacity and developing essential reflexes, such as the swallow reflex.
I am very happy to speak on this topic because I am the husband of a woman who took the positive decision to breastfeed her three children. One of the reasons why I was late for the debate is that those three children are now enjoying the benefits of the canteen downstairs. The sad reality is that our socio-economic background means that we are probably in the group of people that is able to make that choice. Mrs McKevitt is here beside me and has, I am afraid to say, been accused of being my wife on a couple of occasions — something that I know she deals with well. She told me that she took the positive decision to breastfeed her five children. Again, I suspect that she was able to make that decision because she was coming from a socio-economic grouping and educational basis that gave her the opportunity to make it.
The report highlights the inequality that exists between women who come from some of the most deprived wards and those who come from the least deprived. The inequality is, of course, that the more less well off you are the less likely you will be able to make a positive choice to breastfeed for your children.
To give you some statistics, it is worth noting that only 15% of children here are breastfed up to the age of six months. I think that the Committee Chair pointed out that, in Cuba, that figure is 95%. Mrs McKevitt, speaking privately during the debate, reflected to me that it is unlikely that a breast is best campaign was running in Cuba and that that is just the way it is. It is cultural and accepted. Women do not feel awkward or strange if they decide to breastfeed, and doing so is not seen as something that should cause the slightest embarrassment or as anything other than perfectly ordinary.
The Health Committee's report highlights that, in several jurisdictions, not least in Scotland, there is a debate on, and, indeed, a law on the statute book, protecting the right of women to breastfeed in public places. It seems sad that any jurisdiction should have to think about giving a woman the right to do what, frankly, in many ways seems like the most natural and obvious thing for her. However, if that is necessary, so be it. It is a shame and a sad indictment on a society. I wish that we would not have to think about going down that road. However, we may have to, because the sad reality is that we know of incidents of discrimination against women in Northern Ireland who sought to breastfeed outside the privacy of their homes.
The debate about breastfeeding is a debate about culture, tolerance, understanding and respect. It is a debate about women and about having the integrity, courage and maturity to understand —
Thank you very much. I appreciate the opportunity to have an extra bit of time.
I think that it is important for us all to understand that some of the ways in which we objectify women and choose to present them in our society make it more difficult for debates such as this to happen. Some of the ways in which we have sought to marginalise breastfeeding and treat it as something that should be done in private rather than just as part of a child's early development have set us back a little.
I hope that this report is yet another opportunity to raise the issue. I look forward to the Minister's response. I hope — indeed, I trust — that he will have a progressive perspective on the issue. I, for one, would love to be able to give every single child in our little region the opportunity to benefit from the great start that my kids and Mrs McKevitt's kids had.
Health inequalities are major factors in determining life outcomes for people in our society. Although the overall trend is improving health and better outcomes, there still exists a wide spectrum of health outcomes across various measurements. I believe that we must look to new and innovative ways to tackle those differences and to ensure that everyone has equal opportunities to increase the positive outcomes for their health.
Poverty is one of the major issues that affects a person's health. People often tell us — indeed, they tell me — that basics such as food are priced so that the food that is best for our health is often out of the price range of those who are on the lowest incomes. Recent events have shown the dangers of accessing cheap food. Again, one of the biggest groups affected will be those on a low income. That highlights why the first recommendation in the report is so vital.
Through cross-departmental working, we can address issues such as poverty and deprivation, which will then have a real and positive effect on people's health outcomes. For instance, the Department for Social Development's work on encouraging people to ensure that they are receiving their full welfare benefit entitlement means that people will have more money to spend on food. The warm homes scheme ensures that people's homes are effectively insulated. That benefits the environment and means that heating costs will come down, leaving more income that can be spent on good-quality food. It is important to seek out further ways in which partnerships with other Departments and outside agencies can be established to increase the positive health outcomes that we all want to see.
There is a plethora of evidence to show that, to achieve value for money, the best place in which to invest is early years. Prenatal care, breastfeeding and support for parents are themes that continually arose during the research for the report. Although no one is suggesting that we should write off programmes that aim to help our youth or adults make good choices, if we get early intervention correct, we will see better health outcomes. Breastfeeding, for example, provides protection not just for the baby but for the mother. It is considerably cheaper than formula feeding and has beneficial bonding qualities for the family. However, Northern Ireland has the poorest rate of breastfeeding beyond six months when compared with other countries. The World Health Organization recommends breastfeeding for at least the first year of a baby's life. We must therefore support mothers who wish to breastfeed by introducing legislation to support breastfeeding mothers.
A child who resides in a house in which there are addiction issues, violence or neglect is not going to reach its full potential in any aspect of life. The introduction in 2012 of the Safeguarding Board for Northern Ireland has provided scope to examine parenting choices and how they impact on children in the family. Children with behavioural problems come not just from the lower socio-economic group but from a wide range of families with a wide range of experiences. Universal access to programmes is therefore fundamental to help address the issues and health outcomes for that child and the family. A child with behavioural problems has a significant impact on the whole family. Therefore, the whole family must be treated as a unit, not just the child.
While promoting universal inclusion, we must ensure that resources home in on those groups that are traditionally hard to reach. We must increase funding to projects that involve collaboration between partner organisations. We must identify best practice models that exist and work to enhance their impact. The role of the third sector in that is vital. The success of, for example, Sure Start is evidence of good practice in partnership-working. The voluntary sector can often access hard-to-reach groups as well as be on the ground. It can tell us what is needed in a particular area and what will work in that area.
Prevention is better than cure, and it often comes at a much lower economic cost. In these economic times, it is all about value for money. Increasing the amount that we spend on prevention rather than cure will achieve better health outcomes for all communities. By educating our young people and families on good health choices, by collaborative working and by supporting families, we can make a difference to the health outcomes of the whole of Northern Ireland in years to come.
I welcome the Committee’s report on health inequalities, particularly the focus on early years interventions. It signals a recognition that, although our health has been improving in general, the rate of improvement has not been the same for everyone. I have already agreed with the Health Committee to delay the publication of the strategic framework for public health until I have had time to consider the recommendations and to discuss them, as necessary, with colleagues.
When I made a statement to the Assembly in September on the publication for consultation of the draft framework, I drew Members’ attention to the fact that health outcomes are generally worst in the most deprived areas in Northern Ireland when compared with the region generally. A number of Members across the House identified that today. Those inequalities are, of course, not unique to Northern Ireland. However, we can learn from experience elsewhere.
The new public health framework is intended to build on the work already undertaken under the 2002 Investing for Health strategy and set the direction for the next 10 years.
I think that we would all agree that changes in population health are a long-term goal, which can take decades to achieve. A review of Investing for Health, which was carried out in 2010, acknowledged a considerable amount of evidence to support the rationale for tackling the societal influences that impact on health, such as education and literacy; employment and working conditions; housing; and income. Increased emphasis on the societal factors complement the more traditional focus on disease prevention and associated factors, such as diet, alcohol and tobacco use.
The review also drew attention to the evidence that investment in early childhood interventions can reduce the societal inequalities rooted in poverty, by providing young children from disadvantaged backgrounds with a more equitable start in life. Early interventions have the potential to reap long-term benefits, as they can influence health and other outcomes over the whole-of-life course.
The new framework, on which consultation was completed towards the end of last year, addresses many aspects highlighted in the Committee’s recommendations and is generally in accord with its findings.
I turn, first, to the Committee’s call for a new public health strategy to be placed in the context of wider government strategy and for a thematic approach across the public sector. Those are principles that underpin the new public health framework. The new framework will contribute towards the achievement of a number of objectives in the Programme for Government and the economic strategy. It will also seek to create synergy with other key government strategies, such as Delivering Social Change.
(Mr Speaker in the Chair)
I agree that strategic alliances need to be formed in tackling many of the public health issues that we face. You have heard me say before that I want every Minister to be a Minister for health. The public health framework is the result of working across all parts of government. It sets out a cross-cutting programme of action. The ministerial group on public health, which I chair, has led on and will continue to contribute to its development. I have also held bilateral meetings with ministerial colleagues on key public health issues, such as suicide prevention.
There are other initiatives to which I need to draw people's attention. We are working with the Department of Agriculture and Rural Development and the Office of the First Minister and deputy First Minister (OFMDFM), for example. Those colleagues are doing significant work. Other Departments, which might not have been traditionally associated with health matters, such as the Department of Enterprise, Trade and Investment and the Department for Regional Development, are working with us as well. There are courses of work on public health happening within government, and that is something that I strongly welcome.
The draft public health strategic framework also recognised the potential for greater collaboration across government and proposed six priority areas for consideration. One illustration relates to the use of space and assets. Across the public sector, we have many physical assets that could be put to better use through co-operation. For example, local communities could benefit from school premises and facilities, such as playing fields, outside of hours. Many public spaces could be used more widely to promote physical activity, and we need to take creative approaches.
The process of establishing a thematic approach to Departments, as in Scotland, for example, where Cabinet Ministers have responsibility for broad areas, such as health, finance, employment and sustainable growth, is an interesting one. Although it is not within my sole gift, I would be happy to further consider options with ministerial colleagues for the benefit of population health.
In respect of the recommendation to create a Department for children and young people, I am fully supportive of co-ordinating responsibility for children’s issues. However, my view is that the clear direction of travel should be towards fewer, not more, Departments. I am fully committed to ensuring that early years intervention remains a key focus for this Department, and I will continue to work with other Departments on that and on other areas of common interest.
To illustrate that, my Department is actively engaging with other Departments on a number of early intervention initiatives. For example, discussions are under way with Departments that have a key interest in children and young people about the establishment of an interdepartmental early intervention fund. We also received £5 million through OFMDFM's Delivering Social Change framework to deliver increased direct family support and support for parents' projects, both of which have strong early intervention elements.
My Department’s regional family and parenting strategy, Families Matter, and the draft public health framework place emphasis on the importance of early intervention and parenting support. The public health framework proposes early years as one of the two strategic priorities in tackling inequalities. We chose early years because of the now overwhelming evidence internationally that people’s life chances are most heavily influenced by their development in the first years of life. That was highlighted by several of those who gave evidence to the Committee.
I agree that if we are to break the cycle of disadvantage across generations, it is vital that our children are given the best possible start in life. That starts from antenatal care, and includes childhood development, support for good parenting and opportunities for learning. What happens to children in their earliest years is key to their outcomes in adult life, not in relation just to health, but to educational attainment and economic status.
A number of Members mentioned breastfeeding. The issue is not just the nutritious value of the mother's milk, but the nurturing and important bonding that takes place, which makes children into better adults who can relate more easily to others in how they deal with other people in later life.
The Committee also made recommendations on early years and the importance of parenting to reinforce that priority in our strategy. Another of the framework’s proposed priority areas for collaboration across Departments is support for families and children:
"enhance support through incremental development of targeted and universal programmes."
Again, that is in line with the Committee’s recommendations on early years and a progressive universalism approach to support for parenting.
I believe firmly that by adopting early intervention approaches to policy development and service delivery, we can deliver improved outcomes for children, young people and families. I also recognise that intervening early in the lives of children and families has the potential to deliver economic gains, as has been evidenced elsewhere, including in Scotland.
In addition, as sponsor Department for the Safeguarding Board for Northern Ireland (SBNI), I agree with the Committee’s assessment that whilst the SBNI's main focus is to ensure the effectiveness of agencies involved in child protection, it does have wider powers to promote the safeguarding of children more generally.
I also commend the creation of supportive environments for breastfeeding, as is outlined in the report. It is one of those three proposed strategic outcomes. The introduction of legislation to support breastfeeding mothers is one of the proposed measures to achieve that outcome.
I have already referred to the aspiration in the public health framework for better collaborative working to make best use of all of the resources that we have. I welcome the Committee’s recommendation on that.
One of our greatest assets is the people of Northern Ireland. We need to harness the commitment and energy of individuals and local communities in addressing the health issues that matter to them in ways that work for them. Health professionals need to be skilled up to support people to do things for themselves.
With regard to the new public health framework's prioritizing funding projects which involve collaboration between partner organisations, the framework will recognise that partnership working on a broad cross-sectoral basis continues to be vital if we are to make substantive progress in reducing inequalities. The framework should be used to help inform investment in programmes and interventions which are shown to be effective. In light of current financial constraints, it is essential that opportunities are taken to maximise existing resources and effect across all partner organisations.
The Public Health Agency will have a key role in working with others across government and other sectors to co-ordinate delivery and bring about more effective collaboration.
With regard to the recommendation to increase spend on public health, I remain committed to increasing the share of the health budget which is devoted to public health. I have already allocated additional funds to the Public Health Agency in 2012-13, which has enabled new investment in the provision of additional support services to help to address suicide and mental health issues; new initiatives to support vulnerable young children and their families; development of new programmes to help older people to continue to live independently; new breast screening services; and new initiatives to help to tackle obesity. Any commitment in that area, however, must be considered alongside the range of other priorities for the health budget, including meeting the needs of an ageing population and addressing the ever-increasing complexity of healthcare requirements.
I believe that there is much common good between my Department's strategic proposals for public health and the Committee's recommendations. The recommendations are also in keeping with the shift left agenda called for by Transforming Your Care.
Those are some initial comments on the report. I have undertaken to consider the recommendations more fully, together with the outcomes of our consultation, during the process of developing the final public health framework. I should add that we had a substantial number of responses to the consultation. We received over 140 responses, most of which are detailed and well argued, and deserve careful consideration.
The process will include two cross-sectoral workshops, to which representatives of the current ministerial group on public health have been invited, along with other key stakeholders. The first workshop took place a week ago, and the Committee’s recommendations were shared with the group that day. A further workshop is planned for next month, and the aim is to finalise the framework this spring.
The process of finalising the public health framework will seek to identify further opportunities for cross–departmental working, which I will be happy to discuss with Executive colleagues as necessary. It is in the interests of all of us collectively as elected representatives to ensure that all people are enabled and supported in achieving their full health potential and well-being, which is the proposed view of the new public health framework.
Collaboration across government and at all levels of society will be vital if we are to change lives, particularly for our young people. Leadership from all Ministers will be of paramount importance. I welcome the Committee’s support in this vital area of work. I am happy to work further with the Committee on the issue as we seek to achieve the common goals of improving the health of the Northern Ireland population and reducing health inequalities.
In one sense, this is an unusual debate in that we know what the problem is and we know where we need to get to. Maybe the difficulty is in getting from A to B.
As Maeve McLaughlin quite rightly said, health outcomes in Northern Ireland are largely determined by where you were born. As she indicated, in constituencies such as Foyle, North Belfast and West Belfast, health outcomes, by every measurement, are poor in respect of length of life, health during that life and the health of our children. Unfortunately, it is often the case that where you were born determines how good or bad those outcomes will be.
All the indicators certainly suggest that health risks such as smoking, alcohol abuse, drugs, obesity and lack of breastfeeding are self-evidently a problem in the poorest parts of our society.
Mr Beggs brought to the table some very useful information on the issue.
Smoking in the home increases the risk of a child suffering from asthma. Is the Member aware that a combination of early years health education from Sure Start, home visits from health visitors and the provision of smoking cessation support from local pharmacists, etc, has significantly reduced smoking rates in certain areas such as the Antiville and Love Lane wards in my constituency, where it has gone down from 60% to 22% and 50% to 22% respectively within a two-year period? Is he aware that such dramatic changes can occur?
I was not, but I certainly think that that is a very useful addition to the debate, showing the form of intervention that can provide a quick hit in helping to reduce health inequalities.
Mr Beggs also revealed some startling statistics from other parts of Northern Ireland. For instance, he said that, in Old Warren, which I believe is in the Minister's constituency, 55% of expectant mothers are smokers. It is extremely worrying that that is going on because of the inevitable outcomes for health inequalities. I am sure that, if you compared it with a similar sized population in somewhere like BT9 or Cherryvalley in Belfast, you would see a very different pattern of smoking. There is a very famous picture —
I thank the Member for giving way. Interestingly enough, we did a course of work, through the Public Health Agency and Barnardo's, in a number of estates in the Lisburn area that have challenging problems, and that was obviously one of the things that was highlighted. However, it also highlighted a range of problems that then led to poor educational outcomes. Poor educational outcomes and poor health outcomes go hand in hand. Therefore, working together to ensure that we drive up both simultaneously is absolutely critical.
I agree entirely with the Minister. Indeed, in the most recent Chief Medical Officer's annual report, there was a very graphic indication: if you take a bus from the Markets area, which, I assume, is South Belfast, to the top of the Malone Road, your life expectancy, if you are male, increases by nine years. That is nothing to do with the fact that the air is fresher at the top of the Malone Road; it is all to do with poverty and the outcomes of having very little in the way of the world's resources.
The Committee was very fortunate to hear from expert witnesses with a wide range of experiences. The Ballymun project in Dublin, which I do not think has been mentioned yet, was very interesting. Ballymun is one of those huge 1960s or early 1970s estates that has enormous problems because of unemployment, disabilities and poverty. We heard about what was being done to tackle the health outcomes of the 20,000 people who live in that estate. The Longford/Westmeath Triple P project was also fascinating because you had a mixture of urban and rural. Dr Ziglio gave us evidence from Slovenia. In addition, some of us had the benefit of attending a seminar on the situation in Glasgow.
All the evidence indicates what needs to be done. First, we need a greater emphasis on public health. The Public Health Agency has recently been established in Northern Ireland. We were very critical of Mr McGimpsey as Minister throughout his time, but one of the things that was positive during his time as Health Minister was the formation of the Public Health Agency. All the evidence indicates that we need to increase our expenditure on the public health element of health to 6% — it is a much higher level in Cuba — so we have to double our expenditure over the foreseeable future.
Secondly, we need collaboration among Departments. You cannot tackle this with the silo mentality that we and many other parts of the United Kingdom have. Of course, perhaps the most interesting and controversial recommendation of the report is that we should move towards the formation of a children and young people's Department. The Minister said in response that he disagreed with the creation of more Departments. The Committee envisages that replacing a current Department rather than bringing about a new one. Scotland does not have silos; it has Ministers based round themes such as older people and children and young people. That works, because a themed ministership brings together all the resources required to tackle a specific issue. You do not have to barter among 12 different Departments to bring elements to the table to create a mixture of policies to bring about better outcomes for young people; you would have a Department with the primary aim of delivering that outcome.
I accept that, under the present structures that we have in Northern Ireland — the need to have everyone round the table in a five-party mandatory coalition — it is difficult to think outside the box and have themed Ministers. However, I would like to think that, as we become a more normal democratic society, we will start to think in that way. I cannot see, because of the very wide encompassing nature of public health in Northern Ireland, how we can deliver what we need, particularly for our young people, simply on the basis of the present structures. I accept that that is an argument for another day. It is certainly not one that the Minister, without waving a magic wand, could deliver in the morning. I hope that, as things move on, we will be able to move to that holy grail.
Mr Beggs mentioned the very interesting material that we received from Harry Burns, the Chief Medical Officer for Scotland, who recognised the importance of early years intervention. He focused on the recommendation that we should make this very much a public health issue. He expressed appreciation for the work of the Triple P project in the midlands of the Irish Republic. Dr Ziglio's name featured prominently in many contributions. Mr McCarthy mentioned his evidence from Slovenia, where, again, the suggestion is that, if Departments can get together and form a universal coherent policy, huge increases in health outcomes can be achieved in a very short time. So all the evidence seems to point in the same direction.
We do not normally associate North Down with health inequalities, but Gordon Dunne made a point about people who may live within a mile of each other. While one part of society enjoys extremely healthy outcomes, just down the road, there is another part of society in which problems evident in other parts of Northern Ireland persist. He also brought up the issue of parenting skills. There is absolutely no doubt that even in deprived areas, children reared by loving, devoted and committed parents do much better than those who have a less idyllic upbringing. We must do everything that we can to promote good parenting, so I think that his point was a very useful one that we need to emphasise.
Mickey Brady quoted the very worrying statistic that 21% of the people of Northern Ireland are living in poverty. There is no doubt that that statistic is important when it comes to inequalities in health outcomes. As he knows, that figure will probably become higher and higher under social welfare reform. Therefore, we need to put resources into this before more people have poor health outcomes. He, again, emphasised the need for partnership and suggested that DRD and DETI should be involved. Without doubt, practically every Department has a role in developing better health outcomes.
Maeve McLaughlin also quoted the 10-year discrepancy in life expectancy between people living in different parts of Northern Ireland. She suggested that resources should be pumped into obtaining stronger links and partnerships with other sectors. She cited the great inequalities in alcohol-related deaths in the Western Trust, and, again, the Foyle constituency is in the top three areas for that type of inequality. She suggested a composite approach to social care.
Conall McDevitt raised a crucial issue. I do not decry for one moment the fact that it was a male Member of the Assembly who raised the very important issue of breastfeeding.
One of the things that we learned from our visit to Cuba was that the vast majority of people there are significantly poorer than those in Foyle, North Belfast and West Belfast, but they live longer. It was interesting to see how the Cuban approach delivered an average life expectancy of almost 80 for males. That is extraordinary when you consider that just down the road, Haiti, with the same population and a similar geographical position, can achieve nothing like that.
One of the points that emerged during our visit to Cuba was the almost universal level of breastfeeding by young mothers, to the extent that it was practically unheard of for that not to happen without there being a very good medical reason. Before the Chair spoke to the conference, we hurriedly rang Northern Ireland to get the equivalent figure for here, only to find that it was shockingly low. In working-class, vulnerable communities, it was absolutely dreadful. The figures quoted this morning indicate that there is no doubt that breastfeeding is crucial to the first year of a child's life. Yet we do very badly on that. Therefore, it was absolutely right of Conall McDevitt to raise the issue and make a cultural point, which was that we must make it extremely comfortable for mothers to breastfeed, when required. There must be no further stigma. I am a product of breastfeeding — I do not know whether that is good or bad. Certainly, my three children also are, and they are healthier and, I think, happier as a result.
Alex Easton was one of the few Members to raise the issue of the dangers of cheap junk food. Among the many things that I noticed in Cuba was the total absence of fast food. There are no large famous retail chains selling burgers, chicken or whatever. Fast food just does not exist. People do not eat fast food in Cuba, and that must also contribute. The reason for that is really nothing to do with health; it is just that many such companies are American owned and not allowed to operate in Cuba. However, I have no doubt that thousands of healthy young people in Cuba have benefited from the fact that they have no concept of a McDonalds "triple whopper burger" or whatever they are called. I do not eat them because I am a vegetarian, so it does not worry me, but you know what I mean — one of these massive cholesterol cocktails on a plate. The Cubans just do not have them, which makes their society much healthier. Therefore, if we have vulnerable communities who live on fast and unhealthy food, the outcomes will inevitably be poor. He also raised the role of the safeguarding board in promoting parenting.
I have only a couple of minutes left. One thing slightly annoys me about these debates. We have had yet another debate on a subject that should really concern all 108 MLAs. However, what has happened? We have had the Health Committee talking to itself, and the Minister has been listening in, with his chief of staff beside him. [Laughter.] I cannot think of a title, but I am sure that it is something as important as that.
As an Assembly, we will really have to spend a bit more time becoming interested and involved in the debates and in other Committees' issues, because, frankly, there is not much to be achieved by the 11 members of the Health Committee debating this issue in the Committee and reaching total agreement — unusually, with Mr McCarthy there — and then coming to the Floor of the Assembly and reaching total agreement with little or no involvement from anyone else. We have had that again today, but at least we have the Minister here to respond. I think that this is becoming more and more of a burning issue.
I thank the Member for giving way. For Members' information, there are only nine recommendations in the report. It is not a big report, and it is on the Committee website, so people should take their time to read it. I think that you are absolutely right: health is everybody's business.
There is a quick plug for the Committee's work. I will just finish with this point. It is totally wrong that we can have a society where someone is doomed to live nine years fewer simply by accident of birth. If he is born in the Shankill, the Short Strand or the Bogside, that person is more or less doomed to live nine years fewer than somebody he can see across the motorway and who is, perhaps, living on the Upper Malone Road, simply because of that accident. That cannot be tolerated any longer.
Question put and agreed to.
That this Assembly welcomes the Committee for Health, Social Services and Public Safety's review of health inequalities; notes the recommendations relating to the restructuring of government Departments; and calls on the Minister of Health, Social Services and Public Safety to discuss the recommendations in the report with the ministerial group on public health and to action those that are within his remit.