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As the Victorian election demonstrates, we need to shift the focus of health investment, policy and politics

Introduction by Croakey: Victorian voters have been presented with disappointing health policies from the major parties, according to an election scorecard from the Victorian branch of the Public Health Association, in partnership with the Australian Health Promotion Association and Australasian Epidemiological Association.

The scorecard shows that Labor and Coalition policies do not address any of six public health priorities identified by the organisations, while the Greens policies align with two of the public health priorities, and partially align with four.

The findings are a reminder, writes emergency medicine physician and Croakey contributor Dr Simon Judkins, of an urgent need to re-orient health funding (and politics) towards a greater investment in prevention, the public health workforce and social determinants of health.


Simon Judkins writes:

I guess that some would wonder why a clinician who has spent the best part of 30 years working in emergency departments, advocating for hospital and ED resources, more capacity, and more staff would be writing an article asking to change the focus of our health systems and funding?

Dr Simon Judkins

Currently, our hospital systems are in a mess, with more people staying longer in EDs than ever before, ambulances ramping longer and delays to care causing significant morbidity and mortality. The situation is critical, and resources and staff are in demand and the supply isn’t there.

We have lost balance; the pendulum has swung too far towards hospital-based care and that needs to change.

If we are going to impact the health of our hospitals and pull EDs out of the danger zone they are in, we need to look elsewhere for solutions.

It’s not all about building new hospitals and adding more beds, it’s about access, prevention, equity and smart spending.

In this election, there have been new hospitals builds announced everywhere ( here, here, here ) for intervention and acute care. There is no doubt as populations grow, hospitals are needed.

But where is the funding and support for prevention, for public health models, resources to avoid or prevent illness, keep people well in community, supporting plans to improve health outcomes through life-style interventions and public policy?

And, just to be clear, when we talk about our “public health systems”, this is different to our publicly accessible hospitals and clinics. This is about community, prevention and health policy and promotion. Things that will keep you safe, well and out of EDs.

Any clinician or healthcare provider knows the adage “ prevention is better than cure”.

Stopping someone from progressing to cardiac event is much better that treating them after the heart-attack. And prevention costs way less.

Providing a person with housing is more economically viable, better for their health, than treating the pneumonia, the mental health issues, people succumb to when sleeping on the streets or in insecure, inadequate housing.

Providing healthy diets, exercise advice and regular GP reviews is much more effective than interventions through bariatric surgery and managing type 2 diabetes.

Barriers

So, why aren’t we – a country which is relatively wealthy, relatively healthy and has the data on the importance of healthcare prevention – doing a lot more to support public health funding, training, expertise?

My view (and that of others) is that it’s about industry, lobbying, expensive high-tech interventions, politics, photo opportunities and votes. And a society which is largely focused on their personal interests, rather than the benefits to the broader community.

Politicians love announcing shiny new things. Building new hospitals makes the front pages and gets votes.

New tech and the lobbying from industries gets on mainstream news…one life saved from a new piece of tech is a big story. The anecdote beats the evidence.

But showing that the proliferation of fast-food outlets on every intersection in the urban sprawl leads to an increase in obesity…well, that’s a ho-hum.

And who in local council would want to take on the investments by McDonalds, Hungry Jacks and KFC; doesn’t every suburb need these every couple of blocks? And what about investing in the urban infrastructure we need to support active transport and healthier commutes?

Priorities

Ultimately, however, this argument is about what sort of health system we want.

Do we want a US-style system, where big pharma rules, healthcare costs per capita are twice as high as the nearest rival, health CEOs are making millions and mortality rates are the amongst worst in any developed country?

Or do we want a health system that promotes health, keeps people out of hospital, decreases costs, interventions and improves lives?

The answer is pretty simple for a doctor who has seen plenty of preventable illness and death.

So, if we are in agreement, what do we need to turn this around and see health interventions which really focus on prevention, healthy lifestyles and wellbeing?

A paper released by the Victorian Branch of the PHAA outlines the issues well and provides six priorities for urgent action:

  1. Invest five percent of total government health expenditure on preventive health by 2030.
  2. Commit to a minimum of five-year funding for Local Public Health Units (LPHUs) to deliver local health promotion, protection, and prevention activities
  3. Develop a Victorian Public Health Officer (PHO) Training Program
  4. Invest five percent of total government mental health expenditure on prevention by 2030
  5. Support the self-determination of Aboriginal Community Controlled Health Organisations
  6. Establish a state-based Victorian Sustainability Health Unit.

In the lead up to the election, billions of dollars have been promised for new hospitals, urgent care centres, new theatres. While I agree that some of this is needed, we have fallen way behind in health prevention investment.

We know that every dollar invested in heath prevention saves significant health care expenditure later down the track, so it is astounding that we haven’t seen enthusiasm for “spending some money to save more money” in the long term.

Currently, less than two percent of health budgets is invested in prevention.

Increasing the investment, to support both physical and mental health prevention, will see a move away from expensive healthcare – where the focus is on hospital care and health interventions – to a less expensive, but value-adding model of care.

As an emergency physician, the impacts in my workplace could be very significant.

The money which has been invested, largely during the COVID pandemic, to set up Local Public Heath Units is due to expire in mid 2023, with no commitment to ongoing support.

The need for effective public health units was recognised at the beginning of the pandemic, and resources were found to set these up, with local clinicians in leadership roles.

But the ongoing funding for these units has not yet been guaranteed. This seems like a  very short-sighted approach and a potential waste of significant public funds.

Workforce matters

If we are to see ongoing and effective public health policy development and implementation, not only do we need to guarantee funding, but Victoria also needs to see the establishment of a training program at a local level, to build expertise and knowledge.

At this stage, there are very limited opportunities for doctors and the broad range of multidisciplinary practitioners who wish to undertake training in the specialty area of public health in Victoria, with other states having many more options.

Moreover, the establishment of a state Sustainable Health Unit, with similar priorities to those established in other regions, to address the issues of climate change and how we can decrease the carbon footprint of health care industries, is an important step forward. We know that the health industry has a very significant carbon footprint, contributing to the changing climate and the health impacts that brings on our communities, and the health of the nation.

Clinicians are very driven to see the transition to a cleaner, renewable future for healthcare; living the mantra ‘first do no harm’ is something we all need to do. There are many separate bodies driving this, but coordination, shared knowledge and leadership is vital.

Indigenous healthcare is not going to be addressed by big new hospitals and high tech interventions. It is crucial that we see a community which has investment, support, control and self-determination in the success of their healthcare future.

Accessing care and interactions with health providers are a sensitive, personal, and cultural issue and we should support Indigenous organisations to work with their communities to deliver care in the best way that they can, for the best outcomes they can achieve.

Ultimately, as an emergency physician, one of the most important parts of my role is to advocate for a system where my skills, my training, my workplace are not in desperate need and not being used to prop up system shortfalls and failures.

It may seem that I am doing myself out of a job, but ultimately, we must strive for a healthcare and hospitals system where Emergency Department demand is driven down through a better, coordinated system plan and responses.

One of the big pieces in this puzzle is prevention. Properly funding public health training, supporting public health units and the important role they play, will be pivotal in achieving that goal.


See Croakey’s previous coverage of the Victorian election, and on Twitter follow #VicVotesHealth2022

 

 

 

 

 

 

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#SAHeapsUnfair
#ShiftingGearsSummit
#ValueBasedCare