With Tasmanians headed to a state election on 1 May, researchers have identified some key areas for action to improve the health of communities.
Members of the UTAS Anticipatory Care Research Group – Dr Susan Banks, Dr Robin Krabbe, Thérèse Murray and Dr Miriam Vandenberg – write below that all levels of government must do more to ensure an equitable distribution of good quality public housing, education and health services.
Susan Banks, Robin Krabbe, Thérèse Murray and Miriam Vandenberg write:
An approach developed in Scotland for improving the health and wellbeing of people with chronic illness has been trialled in four communities in Tasmania, producing some critical insights that have broader relevance.
Known as “anticipatory care”, this approach is based upon the premise that if we can understand the systems that shape people’s health into the future, it might be possible to anticipate their medical and social health needs.
Our aim was to see whether local actions could help the anticipatory care system work better in preventing chronic illness and managing existing illnesses. There is already plenty of evidence that the health ‘system’ is poorly organised and difficult to navigate.
In this work, we collaborated with community members and organisations from:
- Ulverstone – led by the Patrick Street Clinic
- Flinders Island – led by Flinders Island Aboriginal Association (FIAAI) together with the Flinders Island Health Co-ordination Group
- Northern suburbs of Launceston – led by Starting Point Neighbourhood House and the Northern Suburbs Community Centre, and
- Clarence – led by Clarence City Council.
People in these sites, mostly places characterised by significant poverty and inequitable access to resources and services to maintain health, were up to twice as likely as their fellow Tasmanians to be living with chronic conditions (see this article by Professor Dennis Pashen, and also the State of Public Health Tasmania).
Local teams tested ways to make health or social services – and the infrastructure and places where people go for their social, psychological, and physical health – more welcoming, safe and accessible, and where different parts of the system work effectively together to strengthen the system as a whole.
For example, opportunities for play and physical activity were built into once-neglected public spaces. The sites trialled cultural competency and trauma-informed approaches in place in services and organisations.
Lead organisations tried to get to grips with the problems of low levels of bulk-billing, building relationships and new ways of working with GP clinics. And transport providers adjusted routes and supported people to take advantage of cost-reducing schemes like Green cards to get to the places and services that keep them well.
Understanding the anticipatory care system through this lens led to opportunities in our four community sites to intervene and improve the situation, especially for those most at risk of poor outcomes. Time will tell whether such short-term change can be sustained.
We learnt three broad lessons about anticipatory care and chronic illness in Tasmania.
1. Beyond medicine
In Tasmania, access to medical services is restricted by low GP numbers in already disadvantaged communities, business models that limit outreach, and low rates of – and unclear guidelines for – bulk billing. But fixing this problem would be only part of the solution.
Our work with communities re-enforced that the ‘health system’ is much more than medical and allied health services; the social determinants of health remain the biggest influence, and one that is largely outside local power to change.
What can be done locally is to build on and build up well-resourced collaborative and cooperative relationships between the numerous services and providers that shape the social determinants of health. And services and other infrastructure need to operate in ways that enable the safe access of all citizens.
2. Individualism and a neoliberal ethos endanger or curtail relationships
Health and wellbeing continue to be narrowly medicalised and dominated by neoliberal policy. This way of thinking positions GPs and formal health services at the centre; they are the ‘solution’, with individual citizens (too often cast as ‘consumers’) as buyers of personal solutions, or as people who have failed to take adequate responsibility for their health and so are now at risk or already ill.
This privileging (and blaming) of the individual goes against the very clear evidence we gathered about the centrality of relationships (between services, between citizens, and between citizens and services, and with the local/place) to anticipatory care.
Such relationships struggle where ‘the free market’, business demands and competition for resources flourish.
3. Accountability matters
The model in which governments provide time-limited funding for local projects to counter the effects of structural deficits is flawed.
Such funding is frequently applied to places where there is significant disadvantage. This can imply that the communities are mendicant.
The funders’ ideal of capacity building and sustainable change cannot be achieved without sustained resourcing. In its absence, communities may be deemed to have failed (again).
While sometimes having local impacts, empowering citizens and enhancing local collaboration, such funded work also places demands (e.g., reporting and accounting) on already stretched communities.
More fundamentally, the accountability funded communities are supposed to demonstrate is not matched by an equal accountability from government, which, too often, is not providing people with the basic needs for living.
Equity of provision for the social determinants of health is needed. This would make the largest single change to alleviating chronic illness. It seems logical that focusing expenditure on large scale change is likely to be more effective (and efficient) than fragmenting it into small-scale and potentially short-term efforts.
These findings are likely to be of wider significance, especially at a time when the COVID-19 pandemic has reminded us of the importance of addressing chronic diseases.
Poorly managed chronic illnesses place a significant financial cost on our health system, as well as making the lives of those with disease, and those who care for them, much more difficult. In the time of COVID-19, chronic illness is an even greater problem.
Better supporting local-level anticipatory care systems, including through resourcing the underpinning connections and collaborations, would be an important first step to addressing this problem.
But the real change needs to come from fixing the structural and systemic problems associated with the social determinants of health.
Providing an equitable distribution of good quality public housing, education, and health services are among the fixes, a challenge that sits with all levels of government.
Authors: The UTAS Anticipatory Care Research Group
Dr Susan Banks is a health sociologist who led the Anticipatory Care project. She has a continuing research focus on marginalised groups, the sociology of emotions, recognition theory and social policy.
Dr Robin Krabbe has research interests in planetary health and wellbeing, and social, economic and environmental sustainability, particularly related to community governance. She recently completed a PhD investigating the potential of community to promote sustainability norms.
Thérèse Murray was a research analyst on the Anticipatory Care project and is currently undertaking a PhD in Human Geography.
Dr Miriam Vandenberg is a public health researcher and consultant, whose research interests include preventive health, social determinants of health, and qualitative research.