Ireland had one of the highest life expectancies across Europe, and the highest self-perceived health status in the EU, but we should ask ourselves if our health system was ready for the challenges posed by our ageing population, behavioural risk factors and socioeconomic deprivation and inequity, Professor Breda Smyth Chief Medical Officer, Department of Health, told the Conference.
She said currently, almost 84% of people in Ireland rated their health as good or very good, our age-standardised mortality rates had declined by 16% for all causes over the past decade.
However, the number of adults 65 years and over were increasing by 4-5% each year and increased by 22% from 2016. Multimorbidity was on the rise, in association with our ageing population, with up to 70% of adults 50 years and over having at least one or more chronic diseases.
“This is putting a significant burden on our health system and currently this cohort represent almost 15% (14.9 %) of our population, but it represents 55% of inpatient bed days. So we must ask ourselves, is our health system ready for this, do we have the best model of care to provide the best patient experience to our ageing population.”
Prof. Smyth said a paper she published in the BMJ, 2019, outlined that 20% of all bed days were attributable to medical ambulatory sensitive conditions, with 70% in adults 65 years and over. “These are conditions that are defined as being appropriate for care in other settings e.g. primary care and the community. These conditions are deemed suitable by definition for the left shift to the community, consistent with our Sláintecare health policy, the right care in the right place at the right time.
“Currently in Ireland, we have significant chronic disease challenges, 4/5 adults over 50 are either overweight or obese, obesity is increasing and approximately 40% of deaths in Ireland are attributable to behavioral risk factors (smoking, diet, alcohol consumption, physical inactivity).
“The HSE Integrated Care Programme for the Prevention and Management of Chronic Disease estimates that approximately 1 million people in Ireland today suffer from Diabetes, Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Cardiovascular disease. Six out of the top 10 DRGs in this cohort relate to respiratory and cardiovascular conditions.”
Prof. Smyth said our children were our future. There were currently 1.2 million children living in Ireland, representing 24.2% of our population. One in 5 children in primary school were either overweight or obese, childhood vaccination programmes were adversely affected significantly during the pandemic, over 6% of our children were living with disabilities, breastfeeding rates in Ireland at 60% on discharge from hospital, were one of the lowest in Europe.
As a result of the Ukraine War, we were currently facing the largest displacement of children in the History of Europe, with Ireland likely to receive up to 100,00 refugees mainly women and children. War gave rise to physical and psychological consequences – malnutrition, dehydration, infectious diseases, disruption of immunisation programmes, post traumatic stress disorder, anxiety and depression.
“The pandemic has significantly adversely affected children’s health e.g. decreased communication and motor skills, decreased educational attainment, increased anxiety and depression.”
Prof. Smyth said socioeconomic deprivation and inequity remained a challenge in Ireland. Almost a quarter of the Irish population were reportedly living in disadvantaged socioeconomic conditions (22.5%) pre COVID (census 2016) and we knew that COVID had only exacerbated socioeconomic inequities. In 2020, 13.2% of the population were at risk of poverty, and recent cost of living pressures had likely exacerbated this situation.
“These populations have relatively higher mortality rates, higher levels of chronic disease and ill health and have more challenges in adopting a healthier lifestyle.
“In addition, we have a growing two-tier health system, with 44% of the population with private health insurance.
“In addition, we have growing vulnerable populations including our ethnic, migrant and refugee populations. Throughout the pandemic our vulnerable populations were the most severely affected, with large outbreaks with poor outcomes. This is not unique to SARS-CoV-2. In many instances , many were and are living in overcrowded living conditions, on low wages, with no benefits and some are undocumented.
“Inequality related losses to health account for 20% of the total costs of healthcare, reduce labour productivity and take 1.4% off GDP each year.
“In partnership with other sectors It is important to prioritise health equity monitoring so that we can truly assess what the health inequity needs across the health and social care sector/ and other sectors. Also there isa requirement to develop and build on existing intersectoral infrastructure for marginalised populations.
“Evidence supports a bespoke approach to interventions and strategies to address the wider determinants of health for these communities. Migrants have varied, and sometimes complex needs, and as highlighted by the WHO, we must overcome language and cultural differences, and ensure access to and encourage use of the health services.
“It is also important to recognise that refugee and migrant health is also strongly related to the social determinants of health, such as employment, income, education and housing, and we must address the collective environment in supporting individuals and families coming to Ireland.”
“A WHO paper on health system resilience outlined ‘The Essential Public Health Functions,’ which are a fundamental set of effective actions across the full scope of public health which includes actions to address the socio-economic determinants of health and health inequities, protect the health of a population, treat disease, prevent and manage the major contributors to the burden of disease.
“It provides an integrated approach to health systems, strengthening the primary care system, which is the only realistic route to Universal Health Coverage and focuses on the wider determinants of health, equity, health promotion and all other aspects of population health. It promotes health in all policies, intersectoral collaboration and whole of society engagement. It includes a focus on population health needs assessment which supports a health service improvement cycle.
“This cycle includes four pillars. The first is Population Health Needs Assessment which requires dynamic data on demographics and health service utilisation at a geographical level and also including qualitative data to assess the health needs and demands of local populations. The next step is Population Focused Prioritisation where the needs analysis can undergo a prioritisation mechanism to ensure population outcomes are being prioritised. Following this, Health Service Co-design is required with local partners to ensure the service being designed is fit for purpose and finally the fourth pillar is Implementation.”
Prof. Smyth said Ireland had just experienced one of the most difficult healthcare challenges of a lifetime. “We are currently exiting a global pandemic of SARS Covid 2 virus which has given rise to 1.6 million confirmed PCR cases and 8,000 Deaths in Ireland. Our Public Health workforce are exhausted and resilience is at an all time low and we are facing into our third unpredictable winter.
“On a population basis we have learned from the pandemic. We as a population are extremely connected. A network analysis I carried out of an outbreak, demonstrated that with 500 cases there were almost 1,500 connections. This carries with it advantages and disadvantages. From a population perspective, our collective spirit enabled us to achieve phenomenal population solidarity and adherence to Public Health recommendations including restrictions and to achieve a vaccination uptake rate of over 93% > 18 years, one of the highest in Europe/world. This connectedness of our population increased our risk of transmission of infectious respiratory viruses and infectious diseases. We also learned that our elderly suffered immeasurably during the pandemic.
“And although we are in the mitigation stage of a global pandemic, however there are increasing emerging threats of zoonotic diseases e.g. Monkeypox outbreak which has been declared an emergency of international concern, the Ebola outbreak in Uganda, Antimicrobial resistance, the potential for widespread fungal infections due to global warning. Then there is the Ukraine war, where there are increasing risks of chemical/radiological and biological threats.“
Prof. Smyth said currently, public health was undergoing a programme of reform with the implementation of the Crowe Horwath report. We were currently awaiting the publication of the Brady report, and moving forward we would need to strengthen our essential public Health functions.
She said she would be developing a Public Health Strategy from the office of the CMO and would ensure the implementation of the recommendations of the Brady and Crowe Horwath reports. “This will enable and guide the public Health reform process and will ensure that the Essential Public Health Functions are being delivered in Ireland.
“Currently 3% of our healthcare budget is spent on prevention. We spend we spent 12% of this budget on evidence based interventions, including immunisation, early detection and screening and Health Promotion.
“Healthy Public Policy supports and enables populations to engage in preventative activities and maintain good health. We in Ireland are leaders in this regard, with tobacco free policy, Sugar Sweetened Beverage tax and the Alcohol Minimum Unit pricing Bill. I will continue to support and develop healthy public policy in my role as CMO.”
Prof. Smyth said we were increasingly building our chronic disease infrastructure – we had a chronic disease Model of Care with four Levels of care, the CDM contract with GPs and work was already underway with the identification of pilot sites for the Enhanced Community Care Programme/Healthy Communities.
Areas for further consideration included the integration of technological solutions and innovations into our end to end care pathways. As we developed the Chronic Disease Hubs, we should consider a standardised approach based on local population health needs assessment with regards to what was being delivered in the Chronic Disease Hubs, where and to whom it was delivered.
Professor Breda Smyth is currently Chief Medical Officer in the Department of Health, leading the provision of evidence-based public health advice across a range of areas including the response to COVID-19 and Monkeypox. Professor Smyth served as a Member of the NPHET for COVID-19 and currently chairs the COVID-19 Advisory Group.
She is a Personal Professor of Public Health Medicine in NUI Galway and most recently worked as a Consultant and Director of the Department of Public Health HSE West.
Amongst her numerous contributions to public health medicine is her national leadership on public health reform, healthy ageing, and stroke prevention.