Did the Budget deliver for public health?

AT the risk of stating the obvious, 2020 has been a difficult year. We have come from “a St Patrick’s Day like no other, a day none of us will ever forget”, to a budget day like no other with a package of approximately €18 Billion of additional spending (including an additional €4 Billion for the Health Service) as we confront the twin challenges of a second wave of Covid-19 and a no-deal Brexit on January 1, 2021.

As a Public Health doctor and academic, my primary focus is on prevention. Thus I approach Budget 2021 with a number of core questions: (i) will the measures announced help us contain and ultimately eliminating Covid-19 transmission in the population, (ii) are we investing enough in the health sector to ensure that the system can withstand the imminent second wave of infection while maintaining other core services and protecting front line staff in our acute hospitals and in primary care, and (iii) are we doing enough to protect poor, vulnerable and marginalised groups in society (including the homeless and the unemployed) who are most at risk from the economic impacts of the pandemic, and finally (iv), are we maintaining a focus on the challenge of climate change which will loom large as an existential threat when the Covid-19 pandemic has abated.

With regard to the strategy on Covid-19, the budget is predicated on the assumption that we will need to continue to live with the virus until a vaccine is widely available, which could bring us to the end of 2021, if not beyond. I am not convinced that this is truly a viable strategy. In attempting to live with the virus we may end up with the worst of both worlds - an epidemic out of control with massive strain on our health system and continued economic stagnation as we oscillate between level 3 and level 5 restrictions with an ongoing collapse of consumer confidence. We need to look again at the strategy on containment of the epidemic adopted in New Zealand and Australia, especially in Australia which faces challenges similar to those we face in Ireland, but has managed to bring cases down to under 40 per day in a population of 25 million with a return to near normal life in most states and territories. Australia has an explicit strategy of “aggressive suppression with a target of zero”.

I would urge the Government to reconsider the current policy of attempting to live with the virus and develop a more ambitious strategy of elimination or maximum suppression, working in collaboration with Norther Ireland and the UK. In this context, there is an urgent need for investment in Public Health Medicine capacity. Public Health Medicine Departments, under the leadership of Public Health Consultants, are engaged in the complex and challenging work of tracking the virus and coordinating the work of testing, tracing and isolating cases of the virus and their contacts in the community, responding to outbreaks in nursing homes and other settings and collating the data on the pandemic that are presented daily by the Chief Medical Officer.

In the Budget announcements yesterday, I was surprised that there was no reference to the need for investment in Ireland’s Public Health Medicine Departments, given that some of these Departments came close to being overwhelmed during the initial surge of Covid-19 cases, with relatively small numbers of staff working to the point of exhaustion in overcrowded facilities with limited IT systems and support.

On a more positive note, I welcome the increased investment, close to €4 Billion, in the wider health sector. It will provide capacity for 100,000 Covid-19 tests per week, support increased investment in contact tracing and maintain high level investment in PPE for our front-line health care staff – all vital elements in our response to the pandemic. It is anticipated this funding will also support additional bed capacity in the hospital and community sector, including 1,146 acute hospital beds, an additional 66 permanent adult critical care beds and over 1000 additional community beds. While one would have liked to see greater emphasis on investment in General Practice and the broader primary care infrastructure, it is difficult to argue against the need for extra bed capacity as we face our first Covid-19 Winter. Unfortunately, however, it is not clear that the system has the capacity to recruit staff on the scale required to support these beds, given the inertia inherent to the large and complex HSE bureaucracy and the global competition for health care staff during the pandemic.

On the broader issues of protecting the poor, vulnerable and unemployed, I was disappointed that the Pandemic Unemployment Payments were not restored to €320 for all recipients as a core social protection measure and an expression of solidarity for workers on low pay who support core services in the retail, hospitality and other sectors of the economy.

The funding and measures on housing and homelessness in the Budget are welcome and it is clear that public concern on these issues is now impacting on Government policy.

On the issue of climate action, I welcome the increased investment in public transport, the increases in carbon taxes including changes to vehicle registration tax and motor tax, designed to incentivise electric and low-emission cars. These measures will benefit health in the short term through effects on air pollution and they signal that as a country we are now beginning to take the climate emergency seriously.

Finally, I welcome the additional taxes on cigarettes and other tobacco products, continued pressure on the price of tobacco will reduce uptake of smoking in teenagers with long-term and almost incalculable benefits for the health and wellbeing of the population.