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health & medical marketing
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non communicable diseases
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pharmaceutical industry
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quality and safety of health care
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social media and healthcare
suicide
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trauma
women's health
youth health
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#CTG10
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Acknowledgement
cultural safety
Indigenous education
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social and emotional wellbeing
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Beyond muddling through, here is a three-point plan for rescuing public health

Introduction by Croakey: Why do governments and health ministers fail so consistently to implement evidence that clearly shows how they could act to save lives and prevent suffering?

Which health minister, when asked about his greatest achievement in the portfolio, replied: “Neutralising health as a political issue”?

Which health department chief once said: “It is often better to have done nothing than to have done your best”?

And why is the health portfolio best compared with a dangerous bear?

These and other questions that serve to illuminate some of the political and policy challenges facing public health advocates were raised by long-term health advocate Rohan Greenland in his Basil Hetzel Oration to the recent Public Health Association of Australia conference in Cairns.

Greenland, General Manager, Advocacy, National Heart Foundation of Australia, Vice-President (Development) of the PHAA, and President of the Asia-Pacific Heart Network, also sought to provide some answers, outlining a three-pronged strategy for “breakthrough reform” to stop Australia’s “ad hoc, piecemeal approach to public health programs and funding”.

Top of his list is a recommendation to establish a dedicated national public health agency to coordinate and scale-up work across all jurisdictions, research institutes and universities and non-government organisations, with funding to come from a dedicated health levy.

The oration, which is both entertaining and informative, was delivered on 26 September, the day before the third UN High-Level Meeting on Non-Communicable Diseases. It is published below as a #LongRead.


Rohan Greenland writes:

Basil Hetzel was 94 when he died on February 4th last year. Basil is a public health hero in the tradition of John Snow. His focus wasn’t cholera and pump handles.

It was iodine deficiency and its consequences – particularly congenital iodine deficiency syndrome – a condition leading to severely stunted physical and mental growth, previously known as cretinism.

His work in remote areas of Papua New Guinea brought him to the conclusion that widespread existence of goitre and cretinism was attributable to iodine deficiency in the diet.

He demonstrated that dietary supplementation via iodised salt could entirely prevent these conditions – the social and economic impacts of which were profound.

Basil became an international advocate for iodine supplementation, now taken for granted across the globe. In doing so, he has saved countless millions from disability.

Much of this success has been attributed to Basil’s tenacity and determination.

Three key traits

He displayed three outstanding characteristics critical to good public health outcomes: great scholarship; great advocacy; and great leadership.

The same qualities were in evidence in the work of John Snow. It was in 1854 that he took his research to the local parish council in London and convinced them, incredulous though they were, to take the handle off the Broad Street pump, making it impossible to draw the contaminated water.

That was advocacy. That was leadership.

The theme of this conference is ‘leadership in public health’.

I would like to spend the first part of this oration drawing on my work in advocacy to address the concept of failure in public health leadership. Not the failure of advocates and academics, but the systemic failure of our federated health system to robustly act on evidence.

I’ll devote the second part to putting forward, as best I can, a three-step approach to fixing our flawed system.

First, to failure

Why is it that, when confronted with sound evidence, compelling research, and clear solutions, we are so often frustrated with the failure of politicians to turn that evidence into action?

If I can single out the challenge of overweight and obesity, the statistics are disturbing.

In terms of cardiovascular health, we have seen modelling that suggests the great gains of the past six decades, as seen in a steady and impressive decline in mortality rates since the late 1960s, could be at risk in the years ahead.

There’s no question that obesity is a complex, multi-dimensional threat to public health.

But there is, to a large degree, national and global consensus in the public health community about what needs to be done.

In Australia, we have the eight-point consensus plan supported by more than 40 health and medical organisations.

However, when we look to government action, what do we see? The answer is, sadly – precious little.

In 2016, our health ministers put obesity, and childhood obesity in particular, firmly on their agenda.

To paraphrase a former Treasurer, they laboured mightily and brought forth a peanut, the COAG Health Council communiqué noting – and this is the totality of the statement:

Health Ministers agreed that jurisdictions investigate options within their control to limit the impact of unhealthy food and drinks.”

So, why is it that our health system – a system that sprints into action when there is the merest hint of food contamination – so utterly fails when it comes to public health and the prevention of disease, especially chronic disease?

While Australia does well in some aspects of public health – we remain, despite some gaps, a world leader in tobacco control – we could be doing more. And we should be doing more to address the determinants of ill health with evidence-based programs that can save lives and reduce costs.

  • Nearly 40 percent of all potentially preventable hospitalisations are due to eight chronic diseases.
  • More than 11 million Australians have at least one of these conditions.
  • Around 11 million Australians are overweight or obese.
  • There are still around three million people who smoke, costing the community in excess of $30bn a year.
  • We know from the Australian Institute of Health and Welfare’s Burden of Disease study that an estimated 31 percent of the burden of disease could be avoided by addressing modifiable risk factors.

The potential benefits from a more robust approach to public health, across the spectrum of challenges we face, by addressing specific risk factors and the broader social determinants of health, is worth many times the investment we can make.

We could and should do more – and yet we don’t.

The plight of the politician

To better understand why our advocacy efforts are so often frustrated – and why action takes so long – we need to better understand the plight of the politician, and especially the plight of those poor buggers who draw the short straw and end up in health.

Brendan Nelson, when President of the Australian Medical Association in the 1990s, was fond of saying that the AMA sought to engage those with their hands on the levers of greatest power – the politicians and senior public servants.

There is, however, something of a misconception among some who work in public health, that ministers and senior pubic servants are all-powerful and can, at the wave of a wand, effect great and powerful change.

We are often frustrated when they don’t do what seems to us to be the bleeding obvious.

Our understanding of public health advocacy has come a long way in the past few decades.

We know that successful advocacy is a complex task that requires a blend of skills, a commitment to the cause, and an abundance of patience.

A thick skin and a sense of humour, while not mandatory, are very useful optional extras.

Many of us see advocacy as a science. And we have some superb models that draw on sound evidence and practice to guide our work.

I am a fan of three in particular.

We have the Advocacy in Action toolkit for public health professionals developed by the Public Health Advocacy Institute of WA, with 17 action points.

We also have the classic ‘Ten Steps’ of public health advocacy, crafted by Moore, Yeatman and Pollard in 2013.

More recently, we have Simon Chapman’s Ten Pieces of Advice to Early Career Researchers and Advocates, drawing on his stellar, 38-year career in public health advocacy.

There is also Shilton’s Six Imperatives and – of course – Greenland’s Fast Five.

Yes Minister

But the most compelling, and the one that guides me the most, comes from the British TV comedy series, Yes Minister.

Sir Humphrey, the ultimate civil servant, explains to his junior, Bernard, which four words to include to ensure a policy proposal to the Minister gets accepted.

Bernard then asks what words should be used to ensure a proposal is rejected.

Sir Humphrey says there are two: controversial and courageous. On asking the difference, Sir Humphrey explains:

“Controversial” only means “this will lose you votes”.

“Courageous” means “this will lose you the entire election”.

In truth, we have, as advocates, a set of golf clubs at our disposal, each representing a particular advocacy option.

We need to use judgement and nous to assess the lie of the ball, the distance to the pin, the slope of the green and the direction and speed of the wind.

And then we try to select the right club at the right time for the right stroke to get our ball as close to the pin as possible.

Sometimes we choose the wrong club and end up in the bunker. Sometimes we slice the shot and end up in the rough. Sometimes we club the ball too hard and end up in the water beyond the green.

Occasionally, we get it all right and pop our cause neatly near the pin.

More art than science

This is why I prefer to describe public health advocacy as a dark art, and not, as many of my colleagues insist, a simple science.

Action A plus action B very rarely result in outcome C. You usually have to visit D, K and Y before you get anywhere near your destination.

It’s also important to look well beyond the cause for which you advocate and understand the political environment in which government is operating.

In any given government, there are a series of lifts. Some lifts are going down – issues that are seen as redundant or having been settled or solved.

Others are going up – getting attention, funding and support. It’s into these lifts that you want to insert your cause.

There are, of course, many other lifts – and these are the ones that are completely stuck and going nowhere.

But despite all these guides, all these learnings, all these lifts, we still make the mistake of failing to understand that our decision-makers are not nearly as powerful as we like to think they are.

I recall years ago, my wife and I were in the UK, driving down the M1 late one rainy, miserable night having misjudged the time it would take to drive a mere 300 miles on their crowded roads.

We were listening to the BBC.

The host was interviewing, if I remember correctly, a secretary of state for health, who had just announced he would be stepping down.

The lot of a health minister

He was asked, what did he feel was his greatest achievement during his short time at the top?

There was a pause as the minister collected his thoughts. And then came just two words: Muddling through.

It was, if nothing else, an honest answer, reflecting the incessant, constant challenges facing a health minister.

It reminds me of Tony Abbott’s address to the National Press Club – not the infamous one where he turned up late – but his final address as health minister.

He, too, was asked about his greatest achievement as health minister.

And in another moment of extraordinary frankness, Tony Abbott replied, and again I quote: “Neutralising health as a political issue.”

Not turning the tide on the decline in bulk-billing rates – which he did.

Not pumping money into medical research – which he did.

But neutralising health as a political issue.

We need to acknowledge that life as any minister – but particularly the health minister – is exceedingly tough.

Writing in Croakey in 2013 after the resignation of Nicola Roxon, an exceptional health minister, Mike Daube noted:

We hear the rhetoric of prevention from many politicians.

They speak about its importance and exhort the community to do more, but find the rest too hard.

There are other apparently more immediate political priorities. The funding battles are too tough.

Direct and indirect lobbying by commercial interests, with veiled or not-so-veiled threats is a disincentive to action.

So, we are left with little more than rhetoric.”

Mike noted that “all ministerial portfolios are tough, but some are tougher than others. Federal Health is one of the hardest assignments”.

I would go further. I would say it’s the hardest.

Simple survival is an achievement in itself.

Wrestling the bear

Even in small jurisdictions, health is hard.

Former ACT health minister, chief minister and federal senator, Gary Humphries, has put it thus:

The health portfolio is a bear, which must be wrestled on a daily basis.

It has a mind of its own.

A minister might succeed in coaxing it in a particular direction, but will never succeed in controlling it.

And, of course, over the years a few ministers have been mauled by the bear, sometimes to a political death.”

As Mike Daube noted, there are a range of issues that confront and confound even the most determined health minister:

  • The very large number of competing priorities from other portfolios.
  • The very large number of competing priorities from within your own portfolio.
  • The very large number of often aggressive lobbyists and advocates, each with compelling cases and heart-wrenching tales, many of which would make front-page news, if not in the national press, then in the papers that mattered in marginal seats.

I would add to this list:

  • The very large number of competing priorities from within, and around, your own political party, including the all-powerful colleagues in marginal seats.
  • The very large number of proffered, and often conflicting, policy solutions and the difficulty in determining what to do about any given issue. Simple answers, sadly, aren’t always in evidence.

With this in mind, let’s return to the UK, where we have recently seen the retirement of their health minister, Jeremy Hunt.

He was an exception to the rule, having been the longest serving secretary of state for health in British political history, a shade under six years.

Earlier this year, editor of the respect Health Services Journal, Alistair McLean, reflected on Mr Hunt’s time in office.

The Journal, while marking the occasion on which Hunt became the longest serving health minister, speculated that he could serve for an unprecedented decade in the job. This, they said, would be “an astonishing length of time”.

If Mr Hunt were able to do this, the editor opined: “He will have been given one of the greatest opportunities in British public life, for the longer you are in the post, the better your ability to embed meaningful change”.

Little wonder that Yes, Minister made reference to the longevity of ministers in the episode, the Devil You Know.

Reshuffles were considered highly desirable; ministers who were there long enough to get a grip on the job were perceived to be “a nuisance”.

Needless to say the Journal editorial clearly jinxed Jeremy Hunt and he was out of the portfolio very shortly after that.

The art and history of muddling through

Here in Australia, Stephen Leeder has written about the art of muddling through, noting in a Croakey piece on health reform, published in April 2012:

Muddling isn’t as bad as it may first appear and in fact may be the only way through a contentious, politicised health care problem.”

And the art of muddling through in health care has some other champions, George Maddox putting it in the literature in 1971 in a piece in the journal, Medical Care.

The English penchant for ‘muddling through’, he wrote, “often considered to be the antithesis of rational planning, may in fact suggest that in certain stable environments, a model of comprehensive rationality in decision-making.”

The science behind muddling through, of course, goes back further, with an American political scientist, Charles Lindblom, publishing in 1959, The Science of Muddling Through.

He compared two kinds of decision-making: the root approach, involving a comprehensive evaluation of options in light of defined objectives; and an alternative approach, the branch approach, requiring short, step by step changes, making small incremental advances.

He concluded that the practical person must follow the branch approach – the science of muddling through.

Though criticised, he stuck to his guns and in 1979 published Still Muddling, Not Yet Through, reinforcing the gradualism or incremental approach to decision-making.

The late, great Dr Jim McNulty, when head of the WA Health Department, was fond of saying: “It is often better to have done nothing than to have done your best”.

“This job is a shit sandwich”

Mike Daube, himself a former director general of health in WA, noted in a reflective column in the West Australian in 2008, that the average substantive tenure of a state or territory chief executive was less than nine months.

“You realise,” he was told by his political masters on his appointment, “that this job is a shit sandwich”.

The pressures on health heads, he wrote, are incessant:

You run a vast organisation, with a multi-billion-dollar budget and 30,0000 staff. You are responsible for hundreds of hospitals and other sites, emergency departments, waiting lists, Aboriginal health, mental health, dental, child, community, country, public and environmental health, aged care, research, disaster planning, Commonwealth-state relationships and much more … You have to be informed about everything.

Needless to say, the working hours are savage. You are on call day and night for a premier upset with a TV program or to learn early on Sunday that there has been a bombing in Bali with unknown number of patients on their way.

Daube notes that all ministers and their offices are demanding, and all make decisions against your advice.

I have also been told of another director-general, of another state health department, who told his colleagues, on hearing of his promotion, that he was really looking forward to getting his hands on the levers of power. At long last.

But having got there, he soon discovered that – pull as he might – nothing would happen.

He soon came to the conclusion that the levers were, in fact, not attached to anything.

Short and sharp

From time to time, I am asked to give talks on the topic of “So, you have 15 minutes with the health minister, what do you say?”

I start by assuming you have three minutes with a tired, irritated minister who has been up since 5am and is in her ninth meeting for the day.

My advice is keep it short and keep it sharp.

I have done this on the basis of an anecdote from the British cycling advocate and business executive, Phillip Darnton.

He told me that, unless he got cut-through within the first 30 seconds, he could see a second pair of invisible eyelids slowly close. Once closed, all hope had gone.

So, we get the picture.

We can understand why the Australian Prevention Partnership Centre has so emphatically stated that “only a fraction of research is ever used in policy and practice”.

The Centre is seeking to change all that, noting that prevention requires long-term investment in health, compared to more immediate and visible funding for hospitals.

The Centre states that prevention is sometimes seen as an attempt to implement a ‘nanny state’ that interferes with individual choice.

So, promoting public health is tough.

What can change to make it better?

While the Centre is striving to make a compelling case for increased investment in prevention, I believe we can best achieve change by addressing some fundamental flaws in the way government approaches public health.

I also believe that, if we can’t get a breakthrough on some kind of reform, we will forever be joining the queue at the doors of tired and exhausted ministers and public servants, competing for the crumbs that fall from the table.

A three-pronged plan

I have a three-pronged plan to by-pass the blockages, a plan to ensure that no longer is public health the last to be funded and the first to be cut.

We need an independent, national public health agency.

Yes, this was tried with the ill-fated launch of ANPHA, the Australian National Preventive Health Agency. This was, perhaps, a case of right idea, wrong time.

It was one of a significant number of new agencies that were created under the Rudd-Gillard Government, which became easy targets for a conservative administration keen to cut the qangos.

Why do we need a dedicated agency?

It can overcome a key challenge facing many health departments. They tend to be dominated by generalists, not specialists.

I was once given very good advice by a middle-ranking and very competent public servant in the federal health department.

Just because we work in the health department, she said, don’t assume we know anything about health.

We also need to do something that will not only get the federal act together, but help coordinate action across all spheres of government.

A dedicated agency should coordinate and scale-up work across all jurisdictions, research institutes and universities and non-government organisations.

Because when we all work together, we will have an impact that is very likely to be greater than the sum of our respective parts.

And we need to put an end to what I call the federal fall-back.

Break the cycle of non-stop inaction

Year after year after year, we see federal governments of all political persuasions default to the following:

Denial. There is no problem. Admission. OK, there is a problem, but its only very small. Concession. OK. There is a big problem. Solution: We will develop a strategy. Activity: We are working furiously on the strategy but we shouldn’t pre-empt its recommendations. Completion: Here’s the strategy. What will we do with it? I know, let’s pop it into the cupboard with all the other ones.

We had a national chronic disease strategy that led to little action. Now we have a national strategic framework for chronic conditions. And that has, to date, also led to little action.

We have national health priority areas. But having something listed as a national health priority doesn’t mean it actually becomes a national health priority.

Obesity was listed as the tenth national health priority by the Rudd Government.

And we can see what a great difference that made.

A dedicated national agency

We need to create a dedicated national agency. An agency with some independence. An agency that can speak out. An agency that has the ability to take strategies out of the cupboard and put them into action. An agency that can help by-pass the political and bureaucratic inertia that so often impedes progress.

Better to broaden the agenda and create something that goes beyond purely prevention, an Australian version of the US Centres for Disease Control.

I would give it a remit that covers, for example, screening programs.

In New Zealand and the UK, we see robust approaches not only to cancer screening, but to vascular screening as well, looking at picking up people at high risk of not only heart attacks and strokes, but also type-2 diabetes, kidney disease and dementia, much of which is vascular in nature.

While New Zealand has the heart and diabetes check, and the UK has the National Health Service Check covering all vascular prevention programs, we in Australia are doing very little to improve uptake of absolute risk assessment in general practice.

It’s important because there are 1.4 million Australians, including myself, at high risk of having a heart attack or stroke over the next five years.

In the UK, they have a formal process to evaluate proposed screening programs, assess cost-effectiveness and make appropriate recommendations to government.

Our agency could perform such tasks as well.

The idea of an antipodean CDC already has significant support.

Former AMA Federal President, Michael Gannon noted last year, that Australia was alone among OECD nations for NOT having something similar to a CDC.

The AMA has a formal position statement on an Australian CDC. It was also recommended by a parliamentary committee in 2013.

And it is, of course, strongly supported by the Public Health Association, which has called for an investigation into the establishment of a new Australian Centre for Disease Control – with a memorable acronym,  Akka-Dakka – with a broad remit to include both communicable and non-communicable disease prevention and health promotion.

It could, of course, also play a coordinating role across all spheres of government and civil society.

Surely it is time to stop our ad hoc, piecemeal approach to public health programs and funding, with so many projects funded at the margin or dumbed down to simple, short-term grant programs.

Enforce accountability

Which brings me to my second point of my three-point-plan.

Gain agreement among all spheres of government about who is responsible for what – and then hold them to account.

The Australian National Partnership Agreement on Preventative Health, put into action by Nicola Roxon, was brought undone following the change of government, cutting Commonwealth allocations to public health by almost $400m over a four-year period.

The abolition of ANPHA, incidentally, saved a mere $6.4m over a five-year period.

The partnership agreement was an important initiative that started to get all spheres of government working together.

One of the key problems we face, is that all spheres of government are responsible for public health, but there is little clarity about who should be doing, or spending, what.

We see this with mass media campaigns for tobacco control. The Commonwealth has had no dedicated mainstream campaign funding since 2012, though very robust, much-needed funding has been allocated for the world-leading Tackling Indigenous Smoking program.

What we need is a great deal more consensus around how much should be allocated by each sphere of government and for what.

There needs to be a clear process for setting priorities, funding those priorities and evaluating progress.

And, perhaps most importantly, each jurisdiction needs to be held to account.

That’s a key theme, incidentally, for the global NCD Alliance in the lead up to tomorrow’s UN High Level Meeting on Non-Communicable Disease.

If the world around us is focussing on greater accountability for tackling chronic disease and its causes, then so should we.

We also need investment to make this all happen.

Establish a health levy

And so to my third point: Establish a robust, sustainable funding system for disease prevention and control.

While it is true that many measures in public health require little or no money, and many are revenue raising, money is needed to ensure we can adequately address the challenges we collectively face.

Hypothecation – taking a fixed percentage of tax for a specific purpose – is something of a dirty word for Treasury officials. They don’t like open-ended funding arrangements.

But hypothecation can and must be justified for public health.

One way of overcoming the criticism is to make the funding available for a limited time – until targets are reached, for example.

We could adopt the UN targets for chronic disease, reducing premature death from the big killers by 30 percent by 2030.

Australia, according to a study published in The Lancet last week, is not on target to achieve these goals for neither men nor women.

So, for a specific purpose, perhaps for achieving the UN NCD goals, we should not be afraid to place a health levy on unhealthy products.

We should use these funds to lift the proportion of total health spending that we provide to public health from around a miserly 1.5 percent to at least 4 percent.

Sadly, Australia is in the bottom third of OECD nations when it comes to funding prevention. And while there is some dispute about whether we are comparing apples with oranges, the case of additional funding is abundantly clear.

Prevention1st last year released an important report by Jackson and Shiell, partly supported by the Heart Foundation, that concluded, Australia spends just $89 per person per year on prevention.

This is a mere 1.34 percent of all health spending, which is considerably less than countries such as Canada, the UK and – dare I say it – New Zealand.

The authors also looked at the way we do public health, finding:

  • The funding model in Australia is complex.
  • Alone among the countries examined, England has established institutional structures to evaluate the cost-effectiveness of preventive health interventions and monitor their outcomes.
  • Australia should explore lessons from this experience, and the costs and consequences of developing ‘made in Australia’ equivalents.

A dedicated health levy should be used to support a new approach to disease control and public health. This should include at least three components.

  • Allocating a proportion of the current taxation on tobacco products.
  • Allocating a proportion of taxation on alcohol after implementing long-overdue reform of the current, flawed approach, as proposed by the Foundation for Alcohol Research and Education.
  • And allocating funds raised from a new health levy on sugary drinks.

Yes, this will be opposed by some. But I urge them to re-read the Re:Think tax discussion paper released by Tony Abbott’s tax taskforce in March 2015.

It raised the issue of “corrective taxes”, which it said might be imposed when a particular activity by an individual generates negative externalities for other people. Corrective taxes add to the costs of the activity borne by the individual; they aim to ‘internalise’ the costs of the wider harm caused by their activity.

It noted that in Australia, tobacco, alcohol and some motor vehicle taxes had some features of corrective taxes. Other corrective taxes around the world, it noted, include taxes on sugary drinks (to reduce obesity) and taxes on driving in certain places or times (to reduce congestion).

To my thinking, the Re:Think paper endorsed corrective taxes of this kind as legitimate tools available to government.

The kind of funding we need to transform our ad hoc, inadequate and piecemeal approach to public health, would be more than covered by modest reforms to alcohol taxation – potentially raising around $3 billion a year – and a health levy on sugary drinks, estimated at around $500m a year.

And we should understand that the federal government earns more than $20 billion a year in revenue from alcohol and tobacco alone. Investing just a small portion of this in public health is not, in my humble opinion, a terribly big ask.

The other concept I would like to raise is the development of a public health fund, similar to that of the Future Fund or the Medical Research Future Fund.

A health levy on unhealthy products could be used to build a significant corpus, which could then, over time, sustain a high-performing approach to public health across the nation.

The case for such a fund is clear. While Australia, in general terms, does well with life expectancy, we could do a lot better. Many are missing out on access to prevention, early detection and quality care.

There remains a giant divide between the health status and life expectancy of Indigenous and non-Indigenous Australians.

The health of culturally and linguistically diverse groups, of people with mental health challenges, people in rural and remote areas and our prison populations – to name a few – need to be more vigorously addressed.

In addition, the rapidly growing number of older Australians is going to present enormous challenges to our health and welfare systems, particularly as the current population of middle-aged people continue the pattern of living longer, but with more disease.

The Heart Foundation recently worked with Bill Bellew and his team at Sydney University to host a visit by Public Health England’s Justin Varney. One message that Varney had for a seminar at the Federal Health Department was particularly salient.

He said that if the UK’s currently middle-aged population continued to be as sedentary as they currently are, they are going to impose massive costs on society as they age.

The single defining benchmark could be the ability to lift themselves on and off a commode.

If they can’t do it themselves, the level of care they need to support them to do this is vastly greater than if they were able to do this for themselves.

Needless to say, we face the same challenges.

Last week, the Government called for applications for a grants program, worth a total of $22.9m, to support physical activity among Australians aged 65 and above.

This is a much welcome step in the right direction. Bravo. They deserve credit for this.

But we should be pumping ten times this amount into programs like this if we are really going to make a substantial, lasting and much needed difference.

And we need to link this work with other measures, such as investment in active travel – walking, cycling and public transport use – if we are going to drive systemic change in the way we move in our everyday lives.

One big benefit from an independently funded agency is that we can put an end to the constant struggle for public health funds where we have to compete against a plethora of other health priorities, often with very limited success.

With ring-fenced funding, we would see priority setting and funding arrangements where public health proposals will be pitted and assessed against other public health proposals, with priority setting of issues based on evidence and expert advice.

Where is the vision?

About four years ago, I was interviewed by the Public Service Commission as part of its high-level Capability Review Program; they reviewed the Health Department in 2014.

A key point made by me and many other stakeholders was that there is a lack of collective thinking about how to solve the big issues facing health care in this country.

The review found:

  • The department does not have a high-level strategic policy framework to help it ascertain upcoming demand, model environmental factors and shape policy decisions.
  • Stakeholders believe the department needs to take a proactive rather than reactive leadership role in shaping the health policy agenda, to keep pace with customer demands and the changing global health landscape.
  • The department lacks a high-level organisational strategy, which is vital to ensuring it has the resources and capability to deliver on a forward-looking strategic policy agenda.
  • The department needs to demonstrate a greater capacity for responsiveness and strategic flexibility to Government. It needs to be more proactive in its advice and provide a range of options, including alternate policy options in line with the Government’s agenda, rather than waiting for direction.

Please don’t get me wrong. I believe the Health Department is chock-a-block full of dedicated, experienced and capable public servants.

But it has become more of an administrative unit rather than a visionary one.

The tendency has been to deal with short-term issues, the here-and now, and how to contain them, and manage them to the best of their ability. And it does this pretty well.

What it doesn’t do well is to think strategically about the big health challenges facing the nation.

That is outsourced to others – the Public Health Association, the Australian Healthcare and Hospitals Association, the Heart Foundations and Cancer Councils, our academic institutions, and others who think with agility about current and future challenges and how we can, as a nation, best meet them.

So, I will conclude by returning to my three-pronged plan.

  1. Establish an independent national agency for disease prevention and control.
  2. Gain agreement among all spheres of government about who is responsible of what – and then hold them to account.
  3. Establish a robust, sustainable funding system for disease prevention and control.

We need an agency that can provide deep-thinking about the health system and future needs and challenges.

We need an agency that can engage in debate, but also provide leadership and direction.

We need an agency that will work with its political masters, but not be afraid to stand up for good public policy.

We need an agency that can help set the policy debate and inform the decision making taken by our major political parties as they prepare for office.

We need an agency that has a robust source of funding and a clear remit to help all Australians lead, longer, healthier and happier lives.

We need an agency that can ensure accountability across all spheres of governments.

But above and beyond an agency per se, we need to change our system of support for public health in a way that helps all governments and all ministers do a lot better than simply muddle-through.

• Rohan Greenland is General Manager, Advocacy, National Heart Foundation of Australia; Vice-President (Development), Public Health Association of Australia; and
President, Asia-Pacific Heart Network.

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