Public Health Nursing Contribution to Primary Health Care

Address at the 3rd International Public Health Nursing Conference, NUI Galway.

Thank you for the invitation to address the 3rd International Public Health Nursing Conference being held here in NUIG this week.  I would like to take the opportunity to welcome the delegates from Ireland and from all around the globe to the wonderful city of Galway and I hope and trust that you will find time to enjoy the hospitality that the city and its people offers you.

Governments throughout the world are challenged to provide better, more efficient, more cost-effective healthcare systems.

This Conference, organised by the Institute of Community Health Nursing, is providing an important forum for debate onthe issues facing public health nurses and community nurses and is also providing the opportunity to reflect on the considerable potential that exists for reform and development of the profession.  The title of your conference ‘Contribution to Primary Health Care’ is most appropriate at this time as we endeavour to make significant changes to the development and delivery of primary care here in Ireland.

Health Challenges

We have a population of just over four and a half million people.  Our population is ageing, and while people living in Ireland are now living longer than ever before, not all are living those longer lives in good health.  The population over 65 will more than double over the next 30 years and this, coupled with our high fertility rate, has significant implications for health service planning and delivery.

Many people living in Ireland and their families are affected by chronic diseases and disabilities related to poor diet, smoking, alcohol misuse and physical inactivity. These so-called lifestyle factors have the potential to jeopardise many of the health gains achieved in recent years.  Diseases of the circulatory system and cancer are the two highest causes of death in Ireland.

We have embarked on a major health reform programme, the core of which is a single-tier health service, supported by Universal Health Insurance.  This system will provide equal access based on need, not ability to pay, and will deliver the best health outcomes for Irish citizens.  Change of this scale requires careful oversight and management.  Regulation of quality, safety and governance will be critical elements of the emergent healthcare system.

We would like to shift the emphasis in our health system from an ‘illness model’ dependent on care in hospitals, to a model where primary care services are strengthened, and health and wellbeing are promoted.

Health is a key factor in employment, earnings, productivity, economic development, equality and growth for all of Europe.  A workforce challenged by health problems due to obesity, type-2 diabetes, cardiovascular disease, a lack of physical activity, poor diet and mental health issues, threatens the economic recovery of Europe.  Health issues will place an intolerable strain on the resources of the health services in the future if left unchecked.

What is more, health and wellbeing are not evenly distributed in our society. This uneven distribution, together with the prevalence of chronic conditions and accompanying lifestyle behaviours, are strongly influenced by socio-economic status, levels of education, employment and housing.

Extension of Free GP Care

As part of the Health Reform Programme, this Government is committed to introducing, on a phased basis, a universal GP service without fees within its term of office, as set out in the Programme for Government and the Future Health strategy framework.  This policy constitutes a fundamental element in the Government’s health reform programme.

The Programme for Government envisaged a phased introduction of a universal GP service scheme, commencing with free GP care at the point of access for claimants under  the Long Term Illness Scheme.  However, it was agreed at the Cabinet Committee on Health in April 2013 on my suggestion that alternative options for providing GP services without fees should be explored. Basing a person’s qualification for a GP service on their having a particular medical condition would be complex from a legal point of view. It could be done, but it would mean further delay and it doesn’t make sense to start drafting complicated legislation for this, given that you were only dealing with the first phase of a much bigger, population-wide project.

At the end of July, along with Minister Reilly, I made an interim report to government on alternative approaches to introducing free GP care. I am continuing to work on these proposals, and giving close consideration to such aspects as phasing by age cohort – or otherwise – and also the all-important financial implications of the phased implementation of this universal primary care health service. I intend to bring developed proposals to Government later this year, and hope that we can make a good start on this vital project, perhaps as early as in the Budget, due to be announced in mid-October.

There has been some speculation in the newspapers regarding specific age groups in this context. I would like to emphasise that while both I and Minister Reilly have indicated our view that young children would be a good group to start with, no decisions have been made by government as yet, and these issues remain under consideration in the Department.

I should say though that the Government has already made clear its commitment to delivering on the implementation of a universal GP service for the entire population by providing additional financial resources in the two most recent Budgets.  The HSE Vote now contains funding of €30 million for an initial phase of the provision of free GP services at the point of access.

The Programme for Government also provides for the introduction of a new GMS contract with GPs, to include an increased emphasis on the management of chronic conditions, such as diabetes and cardiovascular conditions, and a new focus on prevention, I hope that progress can be made on this aspect also in the coming months.

Public Health and Community Nurses are already providing vital services in General Practice and I hope – and intend – that they can play an enhanced role in this area into the future.

Chronic Disease Management

Chronic diseases represent a major challenge for our health service at present and into the future, as I’m sure you are all acutely aware.   There has been a significant growth in the incidence of chronic illnesses, which in Ireland are associated with 86% of mortality and 77% of the overall disease burden.  Patients with chronic diseases utilise around 70% of health resources.  Due to our ageing population and lifestyle factors, chronic conditions will generally increase by around 40% between 2007 and 2020.  This trend presents huge challenges for both cost and capacity.

The HSE is developing chronic disease management programmes to improve patient access and to manage patient care in an integrated manner across service settings.  The programmes aim to deliver better health outcomes, enhanced clinical decision making, and more effective use of resources.

Of relevance to primary care, work is ongoing on programmes relating to:  Diabetes; Stroke; Heart Failure; Asthma; and COPD.

I was pleased that the Government was able to approve funding for the appointment of 17 Integrated Care Diabetes Nurse Specialists (one per HSE Integrated Service Area) to support the phased roll-out of the National Integrated Care Diabetes Programme.  These Diabetes Nurse Specialists will work 1 day per week in a hospital setting, and 4 days per week in primary care. They will play a key role in the development of clinically sound collaborative links between primary care and secondary care providers and will also be an essential resource in empowering patients to achieve optimum diabetes control.

Primary Care in Ireland

Primary Care Teams and Primary Care Centres are fundamental to the health reform process.  I have witnessed directly the enormous advances that can be made, and are being made, through collaborative working of health professionals on Teams.  Primary Care Teams make a significant difference, not just in treating illness, but also in supporting people to care for themselves and their families – thereby improving wellness, preventing illness, and supporting those with long term problems, from a health and social care well-being perspective.

Primary Care Teams create an environment which enables structured approaches to chronic disease management, enhanced multidisciplinary team working, improved diagnostic capabilities, and the integration of services between primary and secondary care.

Primary care teams are at the centre of delivery of health and social care in the community.  We have 420 primary care teams in operation as of June this year.  Public health nurses and community nurses are valued members of these teams and are essential in the promotion of the health, welfare and social wellbeing of the community.  I recognise the importance of maintaining adequate numbers of front-line staff in Primary Care and I was delighted to approve recruitment earlier this year of an additional 251 Primary Care posts.  These posts include 70 Public Health Nurses and 37 Registered General Nurses.  In addition the HSE has provided 85 Public Health Nursing sponsorships for entry to 2013 Public Health Nurse Training Programmes.

Healthy Ireland

On 28th March last, the Irish Government launched Healthy Ireland.  This is a new national framework to improve the health and wellbeing of our people over the coming generation.  It was one of Ireland’s national responses to the overarching theme of Health and Wellbeing for Ireland’s recent presidency of the EU.  Protecting and promoting the health and wellbeing of people in Ireland is what Healthy Ireland is all about: creating a society where people can meet their full potential and live happy, healthy and productive lives from the cradle to the grave.

Doing nothing in the face of these health challenges is not an option.  To keep our economic recovery on track and work towards a happy, healthy and equal society, we must take action now to tackle negative health trends and to address the health inequalities that disproportionately disadvantage some sectors of society.

In this time of economic difficulties, we do well to remember that our people are our most valuable resource, a resource that we must cherish and protect.

A healthy population is also essential to a healthy economy.

With the right strategies, the right people and a unified sense of purpose we can make a real difference – increased life expectancy, reductions in infant mortality and improved survival rates for cancer and heart disease, are all good examples of what we can achieve.

We know that health and wellbeing are also affected by wider determinants such as socio-economic status, social connectedness and the living environment.  This means that any plan to improve health and wellbeing must take a broad and inclusive approach, taking action in all the areas that have an impact on our physical and mental wellbeing.

Healthy Ireland’s framework unifies, under a common purpose, the valuable work of many and varied individuals, community groups, organisations and statutory bodies working in Ireland today to improve our health and wellbeing. Evidence and experience from around the world clearly show that to create positive change in health and wellbeing requires the involvement of the whole community, the whole of Government, all of society working in unison.  It is only by working together that this vision of a healthy Ireland can be achieved.

In my Department, the Nurse Advisor is working with the newly appointed HSE Director of Health and Wellbeing to develop a plan to promote health and wellbeing partnerships and cross sectoral work with nursing and midwifery services.

I would like to acknowledge the work of public health nurses and community nurses in providing extensive services across the community, in homes and schools spanning child and family health, maternal health, older person care, disability services and palliative care.

Community nurses have embraced new and innovative work practices including nurse prescribing and community intervention teams.  Such practices have improved access to community care, as well as quality and safety.  Community nursing is essential in order to maintain older people in their homes, prevent hospital admissions, manage chronic diseases and promote general health and wellbeing.

I welcome the inclusion of public health nursing services in the piloting of the Department of Health national nursing and midwifery key performance indicators.  This is an important initiative and key performance indicators enable the public, service users and healthcare providers to have reliable assurance on current and desired standards of overall nursing and midwifery care delivery.

In order to deliver sustainable care in the community, and effectively to shift our focus from an illness to a health model, we need all our nurses to be prepared to work in community settings.  I welcome the recent report of the Review of the Undergraduate Degree Programme for Nursing and Midwifery commissioned by my colleague, the Minister for Health.  This review, published in December 2012, makes recommendations for a greater community focus in the undergraduate nursing and midwifery programmes, with increased primary care clinical placements and substantial mandatory older person clinical placements for some programmes.


I would like to conclude by conveying my best wishes to you all and to thank you again for inviting me here today.

I take this opportunity to acknowledge the work of the Institute of Community Health Nursing and the role it has played since its establishment in 1985.  I recognise the long tradition of the Institute in providing professional development resources for public health and community nurses.

I would like to finish by saying that this international conference provides you with a strong forum for debate and discussion of important community nursing and public health issues and I would wish you an interesting and informative 3rd International Public Health Nursing Conference.  I look forward to the challenges we all face in the future, and to reaching our common goal of a patient centred, efficient and effective health service.

Thank you.