A public health response to Budget 2024

Primary prevention is more effective and cost-effective than activities that treat high-risk patients with expensive treatments

The Minister for Health Stephen Donnelly had sought around €2 billion in extra funding for health services for 2024. However, healthcare was only allocated an additional €800 million by Minister for Public Expenditure Paschal Donohoe in a decision that received Cabinet approval.

Both Minister Donnelly and HSE Chief Executive Mr Bernard Gloster publicly acknowledge that this funding will not be sufficient to allay both the current deficit, expected to reach between €1.4 and €1.5 billion by the end of the year, or the ongoing pressures on acute hospitals and the impact of inflation on healthcare costs.

There are good reasons for spiralling healthcare costs: A growing and ageing population with increasing healthcare needs; ongoing medical inflation as newer medications and devices become available; expanding healthcare services including widening GMS eligibility; additional strains on services post-pandemic; and additional payroll costs for healthcare workers following the public sector pay deal.

In Ireland, the conversation on healthcare is dominated by beds, treatments, facilities and staff for people who are already ill. Prevention strategies are prepared, published, and tossed around, but the resources do not follow and the ability of robustly resourced prevention strategies to address healthcare costs is not given the weight of attention it deserves.

Prevention is often considered a soft tool that is waved around rather than spending scarce resources on providing more doctors, nurses, beds, and treatments.

The reality is exactly the opposite. Primary prevention is more effective, equitable, and cost-effective than downstream activities that treat high-risk patients with expensive treatments.

Smoking

Let’s consider smoking. The evidence shows that smoking causes 4,500 deaths per year in Ireland. The biggest weapon in the fight against smoking in young children and adults is tax. Smokers already pay €1.2 billion in tax every year, but only a fraction of this – €15.7 million – is spent on anti-smoking supports. Yet, the evidence shows that those same supports double the likelihood of quitting.

The Irish Heart Foundation (IHF), in its pre-Budget submission this year, recommended that the cost of cigarettes should be increased to €1 a cigarette (or €20 a packet) and to increase anti-smoking supports from €15 million to €50 million.

Instead, the Government increased the tax on a packet of cigarettes by 75 cents.

The IHF, supported by an RCPI report (2022), had previously called for legislation to raise the legal age to purchase tobacco products from 18 to 21 years of age.

International modelling evidence suggests that raising the legal age has the potential to reduce smoking rates by 25 per cent among 15 to 17-year-olds and by 15 per cent among 18 to 20-year-olds.

Alcohol

About 1,500 people a year die from an alcohol-related illness with 15 per cent having an alcohol use disorder and 6,000 babies a year born with foetal alcohol spectrum disorder.

Ireland has shown itself to be a global leader in the introduction of a minimum price for alcohol and alcohol labelling legislation despite colossal resistance from the alcohol industry in both Ireland and Europe. These measures make a difference in reducing alcohol harm – estimated by the Organisation for Economic Co-operation and Development to amount to 1.9 per cent of GDP.

Robust Government policy has the capacity to put a significant dent in the real harm caused by alcohol in a uniquely Irish context, that impacts hundreds of thousands of families across the country.

What policies would impact alcohol harm? Some might include: A ‘polluter pays’ model for alcohol taxation; an office for alcohol harm reduction; increased funding for treatment services; and the scrapping of the proposed Sale of Alcohol Bill.

Alcohol cost the State €3.7 billion in 2022 yet received €1.2 billion in excise duties. A ring-fenced social responsibility levy on sales in the on-trade of 1 per cent and 2 per cent on off-trade would raise about €100 million a year and could be revised annually in line with the level of harm to the State.

Political will is needed to recognise the huge gains for health that happen when roads are given back to the people for walking, cycling, and socialising

Food

National dietary guidelines are defined by the food pyramid in terms of how much of different groups of food are needed for a healthy balanced diet. Other dietary guidelines focus on the level of processing of food. Guidelines in Brazil, using the NOVA classification system, have moved away from putting food into pyramids to encouraging home cooking and casting scepticism on the practices of ‘Big Food’.

Government policy to readdress dietary guidelines that specifically consider the impact of ultra-processed foods on health have the potential to impact the degree to which the national diet has become subsumed by convenient, accessible, affordable, and largely unhealthy food.

We know that almost two-thirds (60 per cent) of the population are overweight and one-in-five are obese – these figures are not improving and are skewed towards low-income groups.

Political moves that could have a massive impact on these figures include: Taxes on foods high in fat, sugar, and salt and calorie dense unhealthy food; a ban on online marketing of unhealthy food; a ban on price promotions and end-of-aisle checkout sales of unhealthy foods; and ‘no fry zones’ near schools.

These evidence-based moves would impact on the central place that unhealthy food occupies in the national diet. But Government policy continues to obfuscate and delay as the major influence of the food industry continues.

Physical activity

The research is awash this year with studies showing the benefits of exercise in reducing the risks of mortality and chronic disease as well as improving brain health.

We now know definitively that sedentary behaviour increases the risk of all-cause mortality, as well as the risks of heart disease, cancer, and diabetes. Recent research from the University College Dublin School of Public Health, Sports Sciences and Physiotherapy shows that much of the low levels of active travel among schoolchildren is parent-led, with parents unwilling to move away from the car commute.

The evidence also shows the impact of parental child safety fears on loss of independence among children and young adults that has detrimental impacts on mental health.

Yet, road safety and active travel have been addressed very effectively in other countries in Europe, including cities such as Barcelona, Milan, and Paris.

Political will is needed to recognise the huge gains for health that happen when roads are given back to the people for walking, cycling, and socialising.

What will it take to move the dial on primary prevention strategies in smoking, alcohol, diet, and physical activity to be resourced effectively so that the impact of these risk factors on chronic disease is comprehensively challenged?

Consistent public health advocacy that primary prevention is far more effective, cost-effective, and equitable than costly treatment that is almost always available to those most able to afford it and often least in need.

Public health advocacy is also needed to highlight the urgent need for multinational global corporations to take fiscal responsibility for health harms and for Government legislation to transform current markets – ensuring that the ‘polluter pays’ for impacts on health.