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Are hospitals or health the goal?

The irony was not lost on Margo Saunders, a public health policy consultant in Canberra. While the PM et al have been busy ensuring the health debate remains firmly stuck on hospitals, another news story has been providing a powerful reminder of the need for a more effective approach to prevention.

She writes:

“On the day when media attention was fixed on health care, you simply can’t go past the fast food giant’s marketing coup which will have the Weight Watchers seal of approval joining the Heart Foundation’s tick on particular products – products which, according to US studies, people are happy to see on the menu and then ignore.

McDonald’s strategy provides a double halo effect: the veneer of healthy choices for consumers and a ‘we-may-be-part-of-the-problem-but-can-be-part-of-the-solution-so-don’t-regulate’ message for government. However, forgive us for being more than a bit cynical in noticing that today’s saturation television advertising was all about Big Macs and hash browns.

As noted by others in Croakey, the Australian Institute of Health and Welfare estimates that potentially preventable hospitalisations represented just over 9 percent of all hospitalisations in 2007–08, or about 441,000 hospitalisations in public hospitals, with an average cost of about $4 230 per episode of care. Modifiable risk factors account for about one-third of Australia’s total burden of disease, and preventable diseases and conditions are estimated to absorb around 70 percent of the health budget – while about two percent of the health budget is committed to prevention.

The Government’s report issued yesterday refers to a $872 million investment in preventive health programs ‘to be rolled out in schools, workplaces and local communities with a high incidence of chronic disease’ which will focus on reducing lifestyle risk factors such as smoking and obesity and increasing physical activity and healthy eating.

This funding would no doubt be more effective if it weren’t so outclassed by the promotional budgets for tobacco, alcohol and energy-dense, nutrient-poor food.  We also need to know more about the basis for the various initiatives or why we should be confident that this money will be well spent.  The Government’s continuing reluctance to curb the marketing enthusiasm of tobacco, alcohol and junk food companies and its rhetoric about ‘lifestyle risk factors’ and ‘healthy eating’ are falling short of a visionary, or even serious, approach.

According to Sir Michael Marmot, ‘If we could do something about prevention, we could empty the hospital wards.’ Prevention, however, is something that we are still waiting to hear more about – including a comprehensive response to the Taskforce’s recommendations and passage through the Senate of the legislation to establish a National Preventive Health Agency – an agency which will have the ability to advise but not to regulate.

By far the scariest thing about yesterday’s proceedings was the report on these pages (by a fellow Croaker) that the Prime Minister, in response to a question, suggested that it’s hard for governments to invest in prevention because the benefits won’t be seen for 10 years or more. Did he really say that?

If he did, it’s all the more reason that we need to be looking – urgently – for different models for preventive health.

There is the mounting evidence from the UK and elsewhere to suggest that trying to address key issues in public health through education and persuasion simply don’t work, and may contribute to increasing inequalities.  What we need, the analysts argue, are strategies such as regulation and fiscal interventions, as well as the old social engineering (now repackaged for reluctant regulators as ‘nudge’ theory).  The Australian version of this means that we need something other than prevention programs built on the expectation that 22m people can be persuaded to do the right thing.

When the National Preventative Health Taskforce, which focused on tobacco, alcohol and obesity, delivered its blueprint for making Australia: The Healthiest Country by 2020, Minister Roxon declared that prevention is not just a trendy idea of the moment, but ‘It’s about saving people’s lives.’

Well, Minister, here’s your chance. We’re waiting.”

Comments 9

  1. Bogdanovist says:

    Out of interest, does anyone know of a detailed study into what would happen if we did cut down drastically on all the preventable diseases?

    When you say something like
    Modifiable risk factors account for about one-third of Australia’s total burden of disease, and preventable diseases and conditions are estimated to absorb around 70 percent of the health budget – while about two percent of the health budget is committed to prevention.
    it makes it sound like we could deeply reduce the 70% of the health spending by just increasing that 2% of prevention.

    But what would happen if we all got to a healthy weight and stopped smoking? The health budget would indeed switch from preventable to unpreventable disease, but people will get sick of something at some point and money will be spent of them. It might even cost more, since people will live on average a bit longer.

    I have no idea if this idea holds water, but there does seem to be a bit of magic pudding economics in the idea that if people don’t have a heart attacks because they eat too much McDonalds, then they will cost the health system less. At some point they will have something go wrong, and that will just shift the cost to some other disease group.

    I’m far from an expert though, but this is something I’ve never seen explained when these kinds of figures are rolled out. So does anyone know of a study that has looked at the full ‘lifecycle’ of funding on the assumption of big improvements in preventative health?

  2. margo says:

    These are good and important questions…especially as I was just thinking about Nye Bevan’s vision of the British National Health Service: that the demands on it would decrease, and it would therefore shrink, as the population became healthier…So it’s important to be realistic. And expressing the value that we place on ‘good health’ as a health care balance sheet is surely an over-simplification.

    I have a collection of articles by (predominantly American) ‘prevention skeptics’ who argue that, essentially, if people live longer, health costs will not necessarily be reduced so prevention is not ‘worth it’. (This also reminds me of the famous statement by the tobacco industry spokesman who said, in relation to justifying the marketing of cigarettes to Third World populations: “They won’t live long enough to die from smoking — they’ll die of something else first.)

    I have seen references to articles published 20 years ago that purported to run the numbers on costs savings under different scenarios (eg, ‘Would a healthier population consume fewer health service resources? A life-table analysis using hospital in-patient enquiry bed-usage statistics as a proxy for hospital treatment costs, A S St Leger, Int J of Epidemiology 18(1), pp.227-231). I assume that the calculations have been made for Australia under various modelling scenarios (hello AIHW, anyone there??).

    I confess to not being across the health economics literature, but other readers of croakeywould no doubt be. Some of these questions would have been addressed in the work that David Collins & Helen Lapsley have done on smoking & alcohol, and perhaps also by Access Economics’ calculations on obesity/diabetes). There would be similar estimates in relation to mental health and other conditions amenable to a greater emphasis on effective prevention.

    Of note are estimates to the effect that 40 percent of cancers and one-fifth (or more?) of heart disease are preventable — the impact on the health care system would be significant. Dr Andrew Cottrill, chief meical officer of HCF, reported last year (‘Prevention the best medicine’, SMH 28 Oct. 2009) that their pilot program focusing on secondary prevention (better disease management) has seen up to 17 percent reduced hospitalisation with some conditions. Medibank says that 2 percent of customers make 45 percent of hospital claims, and a major proportion of these have chronic diseases. The fund’s preventive health program in Perth claims to have generated a 25 percent reduction in hospital use.

    Perhaps Dr Christine Bennett, CMO at BUPA and Chair of the National Health and Hospital Reform Commission, or Prof Rob Moodie, Chair of the National Preventative Health Taskforce, might care to add their insights.

  3. I can’t recall what the PM said verbatim but he definitely said ten years, though he went on to say something along the lines of ‘you might be able to see changes in some things in five year’. It was in response to the last question televised – I’ll try to find a transcript that includes the Q&A.

  4. Found it. The relevant quote was:

    “The reason why I think governments often back away from preventative health care is simply this – the benefit to the nation and the benefit to the health budgets as you know is only ever yielded a decade plus, or sometimes half a decade plus if it’s, you know, a real change in the way in which people manage themselves.”

    The transcript of the Q&A is now up at http://bit.ly/bpauhk

  5. Croakey says:

    Thanks Ben for tracking that down. My rough notes are that he also said: We
    will have more to say on preventive health care in the future and how it’s organised. And that a related reason why governments back away from prevention is that the long term gains don’t “deal with the immediate headline for tomorrow morning” and that “we’ve got to get beyond that”. I reckon he’s on the money there at least, that one of the real challenges is how do you transform the public debate about health, the headlines etc. How do you generate the same moral outrage over a lack of appropriate support for vulnerable new parents and kids, as over waiting lists for hip replacements?

  6. Bogdanovist says:

    Thanks for the response Margo, I’ll chase up some of the sources you mentioned.

  7. simon.chapman says:

    Bogdanovist — The argument for prevention is not just about “adding years to life” — making people live a “good ininings” rather than die 10 years or so younger. That’s important in areas where people die needlessly young (eg: injury, HIV etc). It’s very much also about “adding life to years”, by reducing illness and disability. James Fries called this the “compression of morbidity” — the effort to squeeze the number years or months we are ill and infirm into as short a period as possible.

    You’re right. If people don’t die preventable diseases they will still die from some cause. But if prevention can stop people dying early, and reduce the time that people are sick and miserable, that’s the whole point.

  8. Bogdanovist says:

    Sure sure, I couldn’t disagree with that. However, the argument for prevention is almost always couched in economic terms, as it is in the above article. The whole thrust of the argument is about how much each preventable hospitalisation costs, how much preventable disease costs the budget etc etc. It’s shifting the goal posts slightly to then claim that it’s solely about improving quality of life when the economic benefits are called into question.

    I assume that the prevention argument is couched in economic terms to counter the Libertarian argument that people should be free to make their own health and lifestyle choices. If someone wants to drink and smoke and eat meat pies as long as they are aware of the health effects then that is their choice (so the argument goes, it’s not my own view). The response to that is that poor health costs everyone else, so that it is more than a purely personal choice with only personal effects, justifying Government intervention.

    If in fact the economics are, over the long term, not greatly different in the case of large spending and regulation on prevention then you are left with countering the Libertarian argument directly, but that’s not what tends to come up in this kind of article; it’s almost always the economic arguments but without addressing the full life cycle of funding.

  9. margo says:

    Bogdanovist (and others): In relation to the ‘value’ of prevention, you may be interested in checking out the the 7 Oct 2009 presentation at the Menzies Centre for Health Policy on ‘Policy for Enhanced Prevention in US and Australia: how much bang for the buck? ‘(accessed at: http://www.menzieshealthpolicy.edu.au/events_past2009.php#oration09), as well as ‘A Closer Look at the Economic Argument for Disease Prevention’ by Steven H. Woolf (http://jama.ama-assn.org/cgi/content/full/301/5/536
    JAMA. 2009;301(5):536-538.

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