Submission 2001

Submission to Working Group on NAPS and Health: Review on Health

1. Introduction

Comhairle has responsibility for the provision of information, advice and advocacy services so as to ensure that individuals have access to accurate, comprehensive and clear information relating to social services. It also has the remit of providing information on the effectiveness of current social policy and services and to highlight issues which are of concern to users of those services. Comhairle promotes and supports the development of Citizens Information Centres (CICs) around the country (there are currently some 85 such centres). These CICs provide feedback to Comhairle on the experience of people who seek information about rights and entitlements but for whom the services and supports available are inadequate or inappropriate. This Submission draws on this feedback to identify key issues.

Health policies aimed at addressing poverty should be governed by the following key principles:

• reduction of poverty and income inequality;
• full integration of the health dimension in all public policies;
• emphasis on preventative health policies;
• equal access to health care regardless of income.

2. Poverty, Income Inequality and Health

The countries with the longest life expectancy and healthiest populations are not the wealthiest but those with the smallest spread of incomes and the smallest proportion of the population in relative poverty.¹ People's health status is strongly influenced not only by their age and genes but also by social factors such as income, education, employment and housing, all of which can be influenced by public and social policies.² Research has established that there is a connection between socio-economic characteristics and health: poorer people tend to be sicker and tend to die younger than richer people. In addition to low income, the factors that lead to a person having a low income also have a negative impact on health, for example, poor educational attainment and/or unemployment³. Low income has a direct, negative impact on health because it limits purchasing power: people on low incomes often cannot afford a well-balanced diet, warm accommodation or medical services when they need them.

Income redistribution is probably the single most effective means of preventing health inequalities. Level of income is not the only determinant of a person's health status, but research consistently indicates that it is perhaps the main determinant. Changes in taxes and benefits should, therefore, be more geared towards benefiting the people on lowest incomes. Employment policies directed towards marginal groups play a key role in improving people's income levels both in the short and long term.

In addition to low income, poor and socially excluded people's health is affected negatively by :

• poor housing: e.g. damp and cold rooms and cramped conditions;
• lack of transport and other infrastructure: e.g. difficulty of accessing medical services due to poor mobility, absence of shops that sell high-quality, affordable foodstuffs in some areas, lack of recreational facilities such as community centres and sports grounds;
• poor education: low levels of educational attainment, little or no health education at school, little knowledge of the negative consequences of alcohol/tobacco/fatty foods;
• age: the risk of ill health is greater among older people⁴ and more measures should, therefore, be directed at this group, particularly because the share of older people in the population is growing;
• poor working conditions: occupational injuries and employment-related illnesses are more common among lower socio-economic groups than among higher ones;
• unemployment: unemployment usually leads to low income levels and sometimes to social exclusion which in turn can contribute to physical or mental ill health;
• poor access to health and support services (e.g. long waiting lists, lack of appropriate community-based services);
• lack of knowledge about or lack of entitlement to benefits.
  

3. Shaping Public Policies to Support People's Health

Policies which promote income redistribution are essential in addressing basic inequalities in health and in access to services. While other public policies also contribute to health and well-being in a somewhat more incremental manner, they have a significant bearing on quality of life and related health status of individuals, groups and communities. This section focuses on selected aspects of a range of public policies.

3.1 Accessing Benefits and Entitlements

In recent years, many social welfare benefits have been increased and improved in a variety of ways. However, the process of applying for benefits is still too complex and some people experience it as stigmatising. Barriers to accessing information and entitlements may arise because of the culture surrounding a particular service or entitlement, for example, the legacy left by the Poor Law origins of parts of the range of welfare entitlements we have to-day. Some, particularly those based on a means test and those with a residual role, such as supplementary welfare, the ‘scheme of last resort', are particularly vulnerable to the persistence of stigma. It is important to that every effort is made to counteract this image by underwriting the concept of entitlement throughout the social welfare system. It is also important that all services are delivered in a manner and in an ambience that one would reasonably expect in a public service outlet. Evidence from CICs and from other Comhairle research⁵ strongly suggests that this is not always the case, particularly in the case of services provided under the supplementary welfare system.

Socially excluded people often find it difficult or impossible to find out about the benefits and services to which they are entitled simply because they lack the networks and channels that help most people to access information, or because their basic skills (e.g. literacy) are limited. For example, older people may have difficulty in accessing information about their entitlement to services such as home help and public health nursing.

Benefit payments should be more streamlined so that, for instance, all over 70-year-olds are automatically given payments for the free schemes (without having to apply). Evidence from CICs suggests that some older people and other vulnerable groups do not benefit from assistance that they are entitled to because they do not have the capacity or the resources to find out about and apply for their entitlements. The Government REACH initiative and the OASIS Project which presents information structured around key life events should address some of these problems. However, there will be an ongoing issue in that some of the population do not have access to or do not use the Internet. It is likely that PPS numbers and computerisation should make it possible to reduce paper work and bureaucracy involved in administering benefits.

3.2 Income Maintenance

3.2.1 Cost of Disability

A Cost of Disability Payment was first proposed by the Commission on the Status of People with Disabilities. This is a fundamental issue for people with disabilities. While we now have significant legislation dealing with equality for people with disabilities and while some additional legislation is necessary, people with disabilities are hampered in the realisation of their rights by the direct costs of disability. These costs include, among others, transport, aids and appliances and personal assistance and have significant implications for their health and well-being.

3.2.2 Sickness Allowance

At present there is no coverage for people who are sick in the short term and lack a sufficient PRSI contribution record. This means that workers without sufficient PRSI credits (predominantly in lower paid jobs and in relatively precarious employment) who don't qualify for Disability Benefit or are not permanently incapacitated have to apply for Supplementary Welfare Allowance (SWA) in order to have any kind of income during illness. As the means-testing for this allowance is tight, even people on low incomes often do not qualify for the SWA. The implication is that some people either do not take time off during illness, or, if they do, their income plummets during short-term illness.

Over 40 per cent of queries from information providers to Comhairle concern income supports for those who are ill or have a disability. The gap in the system was clearly recognised when legislation providing for the introduction of a new assistance sickness allowance was being enacted. Failure to implement the legislation leaves those affected relying on weekly claiming of SWA which is not an appropriate income support mechanism in these circumstances. The existence of this Sickness Allowance payment on statute is flagged by the DSCFA in its ‘Social Inclusion Strategy' document as a necessary component if there is to be a comprehensive system of income supports for people who are ill. The sickness allowance scheme should be implemented without delay.

3.3 Medical Card Eligibility

3.3.1 Income Limits

The criteria for eligibility for medical cards should be reviewed. For instance, medical card income limits are at the moment relatively low. The proportion of the population with medical cards (currently 31 per cent) has been falling in recent years. Entitlement to the medical card is easily lost, for instance, when the card holder takes up a job or, indeed, when they receive an increase in a social welfare payment.

Medical card income guidelines⁶ are increased in accordance with the Consumer Price Index. However, such increases have not kept pace with income increases arising out of (i) increases in social welfare⁷ payments in recent years, in particular for those aged 65 or over and (ii) minimum wage legislation.

Some people are now ending up in a situation where an increase in a social welfare payment means loss of Medical Card eligibility. These case examples from CICs illustrate this point:

A 64-year-old man on Invalidity Pension received a payment of £89.10 which was below the medical card income threshold of £100.00. On reaching his 65^th birthday his payment will increase to £106 thus exceeding the threshold which would not increase until he is 66.

A married couple both on full Contributory Pension received £106 each, a total of £212 which was £50 above the income limit for eligibility (£162).

A married person in the age range 66-69 on Contributory Old Age Pension living with a ‘Qualified Adult' in the same age range received a total payment of £174.20. The income threshold for the Medical Card for that age range was £162.00. This couple would have been within the income guidelines up to May 2000.

A person on Invalidity Pension aged over 65 and living with a qualified adult aged over 66 received £106 plus £73, a total of £179 per week which was £17 above the income for eligibility.

A single person aged 68 years on a Contributory Pension living with a family received £106 which was £12 above the income for eligibility for a single person living with a family.

A couple, both aged 66 years, had a combined income of £209 per week from an Old Age Pension and a small private pension which was £47 above the income for eligibility. Both had medical problems and on appeal one of them received a Medical Card on hardship grounds but the other was refused.

In contrast to the above situations a person on Non-Contributory Pension living with a qualified adult aged over 66 received £95.50 plus £60.70, a total of £156.20 which was within the income eligibility criteria.

The Medical Card Income Guidelines need to be increased, in particular for social welfare recipients under 70, in order to avoid a situation where people become ineligible for Medical Cards as a result of receiving standard social welfare payment increases.

A problem of Medical Card eligibility has also been identified in respect of increased earnings as a result of minimum wage legislation, as the following Case Example illustrates:

The Medical Card income threshold for a single person under age 66 was £100.00. A person working 40 hours per week and being paid the minimum wage of £4.40 an hour received a wage of £176.00. If the person only worked 30 hours per week the weekly wage would be £132.00. A single person living alone and working 25 hours a week and earning £110 (£4.40 per hour) was £10.00 above the income eligibility criteria. ( It should be noted here that any accommodation rent expenditure would be taken into account in the assessment).

It appears somewhat strange that a part-time worker in receipt of the legal minimum wage exceeds the income threshold for Medical Card eligibility. The threshold needs to be raised so that someone on minimum wage is not ineligible for a Medical Card given that fear of losing entitlement to the Medical Card is widely regarded as a disincentive to people taking up employment.

3.3.2 Medical Cards and People with Disabilities

Given the benefit to the individual's health of therapeutic work and society's wish to reduce the number of unemployed people with disabilities the income threshold for Medical Cards needs to be raised to remove this barrier to people with disabilities who wish to pursue employment of a rehabilitative nature which may in due course lead to more permanent, non-supported employment.

The following Case Examples illustrate the type of difficulties encountered:

A person on Disability Allowance or Blind Person's Pension can earn up to £75.00 per week if the work is considered by DSCFA to be of a rehabilitative nature without affecting his/her payment. This would give a total income of £160.50. If the work is not part of an employment scheme the individual will be means tested and is likely to lose his/her Medical Card.

A person on Invalidity Pension or Disability Benefit (DB) can similarly work for a maximum of 20 hours and retain his/her payment. If paid the minimum wage of £4.40 the total income would be £177.10 (£173.50 for DB) and the person may no longer be eligible for a Medical Card.

3.3.3 Eligibility for Medical Cards: Family Based Assessment

The assessment for medical cards is currently family based and ineligibility means that the whole family loses entitlement to a Medical Card. The following Case Example illustrate the issue:

A married woman with two children whose husband is working wishes to take up a part-time job. The family currently has a Medical Card. However, with the two incomes the family will be £5 per week over the income threshold for Medical Cards. Both children are prone to illness and the woman feels that she could not afford to take up the position.

The possibility of giving a medical card to children ((up to specified family income levels) in situations where income is above the Medical Card income criteria should be seriously considered. The current system where income limits for medical cards are relatively low leads to a situation where many low and medium income parents (who do not qualify for medical cards for themselves and their children) may be reluctant to take their children to the doctor due to the cost of the visit and treatment.

3.3.4 Medical Cards Appeals Process

A number of instances arose where the absence of a statutory appeals system in respect of medical card entitlement was raised. There also appears to be an absence of clear information on existing appeals procedures. While a decision can be appealed to the Medical Card Section in the local Community Care Area and a further appeal can then be made on hardship grounds to the Complaints/Appeals Office of the Health Board, there do not appear to be any written guidelines as to how Medical Card appeals on hardship grounds are to be processed by Health Board Complaints/Appeals Offices.

3.4 Community-Based Services

3.4.1 Core Services

Community-based services are essential in ensuring that people can maintain healthy and good quality lives in their own homes. This is particularly so in the case of older people and people with disabilities. The key community services are home helps, personal care assistants, domiciliary nursing, social work, respite services, day care centres and home meals services. Occupational therapy, physiotherapy, speech therapy and chiropody are also key services for some categories of people.

Community services which are essential for daily living should be available as of right. Core services, such as home help, which are currently provided on a discretionary basis should be underpinned by legislation and necessary additional funding.

3.4.2 Home Help

The following case example was given by a CIC in relation to the home help service:

A man took early retirement to look after his spouse who suffers from dementia. He applied to the Health Board for a home help but was turned down on income grounds. He was prepared to pay the Health Board for the service but was told that this could not be arranged. His brother whose family circumstances are broadly similar lives in a neighbouring county in the same Health Board area where the home help service is organised by a voluntary organisation on contract from the Health Board. The brother is in receipt of a home help service for which he pays the agency in full.

This Case Example suggests a basic inequity in access to a home help service even within the one Health Board area.

3.5 Support for Carers

More comprehensive supports for home carers, including payment as of right, should be available. The following case examples from CICs illustrate some of the problems encountered under current provisions.
3.5.1 Carers Allowance: Assessing Means

There appears to be an anomaly in the assessment of means for the Carer's Allowance, as the following Case Example illustrates.

A man receives the Carer's Allowance for looking after his wife who receives the Disability Allowance. They have no other means at present and each receives the maximum relevant payment. However, the husband will soon be entitled to a UK retirement pension. If he claims the pension, half of it will be assessed against his Carer's Allowance and half against his wife's disability allowance - there is no disregard. However, if the wife was the person receiving the UK pension, the first £96 would be disregarded.

There appears to be no rationale behind this and, as the CIC that raised this issue put it, “it is a matter of luck as to whether people can benefit from the disregard if they find themselves in situations similar to this”.

3.5.2 Shortcomings of Carer's Allowance Provision

While the recent increase in the income disregard for Carer's Allowance is a welcome development there continues to be a basic shortcoming in the Carer's Allowance provision in relation to its role in supporting care for older people in the community:

A woman has 1 hour home help per day provided by the Health Board. Another woman provides occasional additional help on a limited basis which is paid for by the family. This woman would be eligible to claim the Carer's Allowance and thereby provide more extensive care but it would be means tested against her husband's income.

The key point here is that if the Carer's Allowance was available in this circumstance as a payment of right for services provided and not means tested against other income, it would be likely to enhance significantly the quality of the woman's life. While non-means testing in general would obviously have resource implications, it is likely that in some situations it would result in people being able to continue living at home for a longer period than that possible under current arrangements.

3.5.3 Carer's Allowance and Respite Care Grant

It would seem to be only fair that everyone in receipt of a Carer's Allowance in the same year should receive the same respite grant.

3.5.4 Carers' Benefit

The Carers' Benefit was introduced in October 2000. Inherent shortcomings of this scheme were identified, as follows:

• Since corresponding employment legislation has not yet been enacted, many people who so wish may not be able to get the time off work;
  
• There is a difficulty in that the payment is for a limited period of 15 months and, if the person being cared for requires ongoing care, as would sometimes be the case, the carer could not ‘just walk away from the situation'.
  
• One CIC reported a situation where a person who had given up work to care for a terminally ill son 12 months previously, and who was not entitled to the Carer's Allowance, felt that she should be entitled to claim Carer's Benefit retrospectively. However, no such provision exists.

3.6 Health Promotion and Information

It is reasonable to argue that information about health is best directed to young people through schools. Currently, such information is not always effectively disseminated, or accompanied by reinforcing measures such as varied physical education and the provision of free or low-cost, healthy school meals. More time should be devoted to health education and promotion throughout the educational system but particularly at primary level.

Community health education and information programmes should be developed to disseminate comprehensive information about healthier lifestyles. Such programmes could include subsidised canteens with cheap, nutritious food in various centres in deprived communities that are used by parents and children.

Measures targeted at groups most in need must be brought as close to the group as possible. The most disadvantaged groups often lack the means or the motivation to acquire information about, or to demand the services to which they are entitled. This means, for instance, greater resources for community care initiatives and health promotional programmes and proactive campaigns in schools and local communities. Since information plays a key role in health promotion, the possibility of proactively involving CICs and other independent information providers in the community in an active promotional campaign should be considered.

3.7 Education

Many children from lower socio-economic groups have low levels of educational attainment which in turn translates into a lower socio-economic position and health than enjoyed by people from higher socio-economic groups. Research confirms that there is a strong link between health status and level of education. Furthermore, education is in many cases a pathway to higher income levels, which are also associated with better health.

Tackling educational disadvantage at primary level is important for increasing social mobility, for improving the position of lower socio-economic groups and, therefore, for combating health inequalities. It is particularly important that more young people from deprived areas stay in education until they have obtained a third-level qualification. Additional resources need to be targeted accordingly.

3.8 Standards of Health and Safety in the Workplace

Working conditions are often worse for low-income earners and untrained or semi-skilled manual workers. Manual workers are more likely to suffer work-related injuries and illnesses than other groups of workers. High standards of health and safety and regular and effective monitoring of these standards, and availability of benefits and other help for those affected by occupational illnesses and injuries help to protect the most vulnerable employees' health and well-being. Many employers in Ireland fail to identify work place hazards and to produce safety statements, and often do not react appropriately to health and safety issues raised by employees⁸. More effective information on health and safety, and more efforts to enforce the legislation are needed.

3.9 Housing

There is a serious housing crisis developing, particularly in Dublin, as rental and house prices are increasing. Many vulnerable groups have to settle for sub-standard housing as they are unable to afford warm and safe accommodation, which in turn has negative consequences for their health. Some specific groups with special needs, e.g., travellers, asylum seekers (particularly families with children), should be provided with accommodation that corresponds better to their situation.

Partnerships should be developed between local authorities and the private sector with the view to providing affordable rented accommodation. Local authorities should monitor more carefully the implementation of regulations concerning the private rental sector, and a scheme for housing benefits and/or more tax credits for rental expenses should be introduced.

4. Preventative Approaches

A clear distinction needs to be made between preventative and curative approaches that affect people's health. Curative policies are usually at the centre of debate on health (and health and poverty) because they are more visible and urgent. However, preventative health policies are of equal, or greater, importance for the overall health status of the population. It is clear that diet, exercise and other habits of lifelong duration are of more fundamental importance in determining a person 's wellbeing and health status than curative measures that only enter the picture once something has gone wrong.

Access to preventative health care is more difficult for lower socio-economic groups, as there are very few public subsidies available for people who want to take advantage of this. For instance, a smear test for cervical cancer is not available on Medical Card, despite the fact that it would help considerably in the fight to prevent and treat this cancer. Also, access to preventative policies is often hindered by spatial and cultural factors. For instance, in some areas it can be difficult to access low-priced food because there are no supermarkets and prices in smaller shops tend to be higher. Also, higher socio-economic groups tend to be more health conscious, and are also in a better position to pay for things such as exercise equipment and gym sessions.

Access to preventative health policies is even more difficult to address than access to hospital services. Evidently, the best way of trying to guarantee lower socio-economic groups' access to preventative measures is through employment and a reasonable degree of income equality.

It is particularly important to direct preventative measures at children as research shows that exposure to poverty in early life has detrimental and long-lasting effects on health status throughout a person's life⁹.

In a more general way the health of the population is obviously determined by a range of the factors which have an impact on the quality of people's lives. These include environmental, economic, housing and employment policies.

Policies that secure clean air, water and environment for all evidently promote health. Conversely, pollution, low quality of air and water, lack of clean and pleasant public spaces, congestion and noise have a negative impact on people's health. Such negative influences tend to affect low socio-economic groups more than well-off sections of society.

The service and other infrastructural supports in deprived areas (such as inner cities) is often of lower quality than in areas inhabited by better-off people. As a result, people living in these areas tend to have difficulties in accessing both preventative and curative health services and, also, suffer more from the impact of external factors such as pollutio.¹⁰.

Economic policies affect employment levels, the amount of funding available for health services, and virtually all factors that contribute to good or bad health. More generally, basing policies on calculating the ‘value for money' that can be derived from them has negative social consequences as socially equitable policies are often costly and result in little or no economic gains, e.g., organising transport services for older people and people with disabilities living in rural areas is unlikely to be economically profitable, but is socially desirable despite its economic cost. On the other hand, many public and social policies that appear expensive, will in fact save a lot of money and resources in the long run. For instance, screening for the most common cancers enables treatment at an earlier stage, that in turn results in lower overall treatment costs.

In general it is likely that poor and socially excluded people's health is affected positively by public services¹¹ that are free or cost very little to the recipients, ranging from subsidised leisure activities to free health care and including good quality housing.

Reducing unemployment further will obviously help to reduce poverty and disadvantage. It is also important to provide more opportunities for people to progress from unskilled or semiskilled employment to more skilled jobs, i.e., to ensure that people are not ‘stuck' in low-paid jobs throughout their lives. Adult education (and more financial support during time spent in education) would play a particularly important role in this.

5. Equality of Access to Hospital and Community Services

Waiting lists for public health care are the most visible and serious obstacle to accessing health services. Access to health care in Ireland is to a large extent based on the financial resources and employment status of individuals. This is a well-known fact, and addressing the problem is a highly complex issue, not in the least due to professional and institutional barriers to reform. Equality of access should be the key underpinning principle of service provision and should be promoted and funded throughout the system. This requires not only a reduction in the waiting lists for public services but also provisions for transport, or subsidised transport, to and from hospitals for people living outside the area where treatment and services are provided.

Access to basic community care and support services is also a key determinant of health and well-being, particularly for older people and people with disabilities. Support services which enable people to live in the community and, consequently, avoid unnecessary hospitalisation or admission to long-term residential care should be designated as essential services, underpinned by appropriate legislation and funded accordingly.

Effective and purposeful liaison and joint working between health and housing authorities and between hospitals and community care services can contribute much to ensuring that the appropriate support services and/or treatment are provided. For example, there is some evidence that patients, particularly elderly ones, are being discharged too early in many hospitals. This leads to approximately 20,000 re-admissions per year of people who were discharged less than one week earlier. An assessment should be made of discharging practices in hospitals in order to ensure that fragile patients are: (a) not sent home too early and (b) are provided with the necessary support and services for recovery at home.

6. Information and Research

Further analysis is required of mortality and morbidity by socio-economic group, e.g. analysis of early deaths (before the age of 65) i.e. the socio-economic characteristics of people who die early or are diagnosed with cancer or cardiovascular disease. Statistics concerning life expectancy, rates of cancer, birth defects, infant mortality, cardiovascular diseases etc. should be presented and analysed not just in national aggregates but also broken down by gender, socio-economic group, educational achievement, ethnic background, urban/rural residence.

7. Summary of Key Issues to be Addressed

• Addressing income inequalities is the single most important means of preventing health inequalities. Employment policies, targeted towards marginal groups, play a key role in addressing income inequalities.
  
• There should be a major re-focusing of health policies towards preventative approaches, particularly for children and younger people, which takes full account of the health dimension of all public policies.
  
• Significant additional resources should be provided for community care services, with particular reference to home help, home carers and respite care services.
  
• The income criteria for medical card eligibility should be re-examined, particularly for welfare dependent households, children and people making the transition from unemployment to employment/training/education.
  
• Greater equality of access to health services is required and a range of innovative public policies should be put in place accordingly to address the current ‘private'/ ‘public' discrepancy.
  
• More community based health promotion and information programmes are required. There should be a specific focus on supporting and resourcing vulnerable and marginal groups in this regard.