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Federal Budget 2019/20 – Preventive health priorities from the health sector

Jennifer Doggett writes:

Prevention is high on the agenda for many health stakeholder groups in their bids for funding in this year’s Federal Budget.  There is a shared view expressed in the submissions that Australia is falling behind in our approach to prevention and needs to increase both funding and policy efforts in this area.

Obesity was a high priority for many of the groups and other conditions raised included osteoporosis, tobacco use and diabetes.  Many groups highlighted the need to strengthen current primary health care systems and reform current payment system in order to provide an increased focus on prevention.

Some groups favoured the re-instatement of a national preventive health body to oversee and coordinate preventive health initiatives and others focussed on empowering individuals to take a greater role in managing their own health and wellbeing. Population-wide strategies, such as taxes on sugary drinks, were also suggested by a number of submissions.

An important point made by many of the groups is the inequity that currently exists between different groups in the community in their experiences of preventable diseases. Prioritising preventive health strategies targeting these groups was stressed as vital to addressing this inequity.

Some key extracts and recommendations from these groups’ pre-budget submissions are highlighted below.

Australian Nursing and Midwifery Federation

Key points from ANMF’s Federal Budget Submission

Overall, Australia’s health system performs very well. However, unacceptable deficiencies continue to exist. The gap between overall health outcomes and indigenous health outcomes continues to be a disgrace, while people in rural areas and lower socio-economic groups live shorter lives and experience more illness than those living in major cities and with higher incomes.

These groups have poorer access to primary care, mental health care, maternity services, dental care, allied health and specialist services and are more likely to experience problems related to obesity, alcohol use and smoking. These gaps and deficiencies could, and should, be addressed through improved preventive health care.

Not only is prevention better than cure it makes the most economic sense. With an increasing chronic disease burden, an ageing population, and many people in poorer health often from avoidable conditions, who are generally less productive, it makes sense to invest where we can reap the most benefit.

The way to contain costs is through investment in prevention and early treatment through primary care services and effective primary health care. The Productivity Commission reported that about 750,000 hospital admissions could be avoided if we had effective intervention in the weeks leading up to hospitalisations.  Remodelled primary health care is critical.

Recommendations

The ANMF calls on the Government to:

  • Re-establish a national dedicated preventive health body;
  • Increase incentives to encourage changes in both health provider behaviour and individual behaviour, which will lead to better health outcomes;
  • Establish primary care systems that encourage people to enrol in wellness maintenance programs as is now occurring widely throughout the world. This approach encourages people to take responsibility for their own health with assistance from a range of health professionals without using a ‘stick’ or other punitive measures;
  • Ensure that primary health networks focus on disease prevention, health promotion, equity and social determinants of health;
  • Investigate better and more efficient ways to fund and manage chronic conditions, e.g. blended payment models;
  • Establish funding arrangements which support the use of a wider range of health professionals in chronic and complex care, including nurse practitioners;
  • Ensure that private health insurance companies are restricted from operating in primary care. Allowing private health insurance companies into this domain will increase inequity and reduce efficiency.

Consumers Health Forum of Australia

Key points from CHF’s Federal Budget Submission

The incidence of so many chronic conditions like obesity, cancer, heart disease and diabetes could be reduced through strong and effective preventive health programs that would embed healthier diets and lifestyles from earlier in life.

Australia has often led the way on these fronts. We can do the same in bringing down our disturbingly high rates of obesity for the benefit of our physical and economic health.

The Government’s increased investment in primary health care would be even further strengthened if it was extended to integrate projects and services for long term and sustainable community-based education, promotion of healthy living and patient chronic disease self-management.

Obesity is recognised as one of the greatest public health challenges of our time. It is a major risk factor for chronic and preventable conditions such as type 2 diabetes, heart disease, hypertension, stroke, musculoskeletal disorders and impaired psychological functioning. Nearly two-thirds of the Australian adult population is overweight or obese and these rates are some of the highest in the world.

There is an urgent need to reverse this trend and put much more effort into combatting obesity if we are not to lose many of the gains we have seen over the last decades and to see our children and grandchildren have lower life expectancy than we have.

Recommendations

CHF calls on the Federal Government to:

  • take a leadership role in the development of a multi-faceted National Obesity Strategy
  • to develop an Australian Co-Creating Health initiative to support people with chronic conditions to actively manage their own health. It features an expert patient program, education and training for doctors and nurses and support to service settings like general practice
  • implement a Prescriptions for Healthy Living program to equip people at risk of chronic disease with practical steps they can take to stay well and lower their risk,and to provide primary care providers with skills, new services and referral pathways to help motivate and support patients
  • implement aHealthy Families, Healthy Communities initiative to educate and support primary care providers to engage effectively with parents to support healthy early childhood development by providing them with resources, education, training and new referral options

Osteoporosis Australia

Key points from Osteoporosis Australia’s Federal Budget Submission

Osteoporosis is a chronic disease that leads to an increased risk of fragility fractures. The prevalence of osteoporosis and fragility fractures increases with age, and it is estimated that more than 80 per cent of the Australian population over the age of 70 have osteoporosis or osteopenia (i.e. reduced bone mineral density, placing them at a heightened risk of fracture). The heightened risk of fractures lead to an estimated 166,000 fragility fractures in older Australians in 2018.

Fragility fractures significantly impact older people and their quality of life and ability to remain independent. Major fragility fractures, such as hip and spine fractures, can cause disability, institutionalisation and death. Many osteoporotic fractures require costly medical care, including emergency assistance, surgery, hospital stays, rehabilitation and community services (such as home care). It is estimated that osteoporotic fractures cost the Australian economy over $2 billion in direct health costs (including hospitalisations and general practitioner (GP) visits) in 2016.

Many fragility fractures could be prevented through early diagnosis and appropriate care within current health system mechanisms, such as chronic disease management plans, allied health arrangements, and specific osteoporosis pharmacotherapy. In 2018, more than 1.2 million Australians are estimated to have osteoporosis and approximately 800,000 of those are over the age of 70 years.

However many people are undiagnosed and do not receive appropriate treatment, even after one or more fractures have occurred. Up to 80 per cent of post-menopausal women, and 90 per cent of men, are not receiving appropriate treatment, even after a fracture. Furthermore, it is estimated that less than ten per cent of people over the age of 70 accessed subsidised diagnostic services (such as bone mineral density (BMD) scanning) for osteoporosis in 2017.

Recommendations

A National Osteoporosis Risk Identification and Awareness program (the Program) including the following:

  • Letters sent to men and women aged 70 years or older, to:
    • explain in simple terms the risk of osteoporosis, the benefits of appropriate diagnosis and subsidised services currently available to reduce the risk of osteoporosis
    • encourage recipients to discuss the issue with their GP. The letter acts as a referral for radiology services, so that people can access BMD services directly and subsequently visit their GP to discuss the results, and, if appropriate, a relevant course of action for treatment
  • Campaigns to raise awareness around osteoporosis and the Program
  • A registry to track activities (including information flow) and participation
  • A pilot to test the impact of the Program before national roll out

Royal Australasian College of Physicians

Key points from the RACP’s Federal Budget Submission

The need for nationally coordinated preventative health measures has never been greater. The increasing pressures on the Australian health system caused by burden of chronic disease are widely recognised as Australia faces significant and growing problems with potentially preventable disorders such as obesity, diabetes and cardiovascular conditions due to factors such as smoking, sedentary lives, unhealthy diet and alcohol misuse.

Approximately 31% of Australia’s total burden of disease can be attributed to modifiable risk factors. There is inconvertible evidence that long-term, sustained and targeted preventative health measures are highly effective. Some approaches promote health and cut overall costs because of the reduced need to treat expensive diseases; others allow Australians to live longer and better-quality lives at a reasonable cost to the system.

In 2016-17, Australia spent nearly $181 billion on health, 69% of it funded by Australian governments.30 However, in recent years it was estimated that Australia spent only an overall $2 billion or $89 a year per person on prevention. This amounts to a mere 1.34% of all health spending, considerably less than the UK, NZ and Canada.

Many people are missing out on access to prevention, early detection and quality care, with the expanding needs of Indigenous Australians, people in rural and remote areas, people with mental health issues and the growing cohort of older Australians – to name a few – presenting urgent and cumulative challenges to health and welfare systems.

The current piecemeal, reactive response to preventable public health crises is leaving many Australians behind. To successfully deal with the escalating public health challenges, Australia needs a national health body dedicated to planning, strategic investment and leading the implementation of a coordinated, evidence-based public health agenda for the whole of Australia.

Recommendations

Prioritise obesity prevention by:

  • Implementing an effective tax on sugar-sweetened beverages to reduce consumption and using generated revenue to facilitate access to healthy diets and culturally relevant initiatives to improve health equity.
  • Committing appropriate funding to develop and implement the national strategy on obesity recently announced by COAG which would focus on primary and secondary prevention and social determinants of health, especially in relation to early childhood and rural and regional issues and would do so over an extended period.
  • Establishing a national taskforce including sustained funding, regular and ongoing monitoring and evaluation of key measures and regular reporting on targets.
  • Provide hospital funding to state and territory governments specifically geared towards delivering equitable access to bariatric surgery for public hospital patients.

Preventative Health Agency

Prioritise prevention by re-establishing a national preventative health body to set nationwide goals, directs strategic investment, coordinate implementation of initiatives and evaluate the evidence for the cost-effectiveness of population-wide preventative health interventions.

Drug and Alcohol Policy

  • Introduce a volumetric taxation system for all alcohol products and abolish the Wine Equalisation Tax (WET) and rebate.
  • Allocate a proportion of the increased revenue raised from volumetric taxation to funding alcohol and other drug treatment and prevention services as part of a coordinated national response to alcohol and other drug use disorders.
  • Substantially increase funding for alcohol and other drug treatment system reform, including for appropriate and multidisciplinary workforce development, capital works to improve the physical infrastructure and the development of appropriate needs-based planning models and suitable models of care to address unmet demand for treatment.
  • Increase funding for prevention services to reduce the incidence of alcohol and other drug use disorders.

Obesity Policy Coalition

Key points from the OPC’s Federal Budget Submission

Obesity is a critical issue in Australia from both a health and economic perspective. The National Health Survey for 2017-18 reports that two-thirds (67.40%) of Australians are overweight or obese and around one-quarter (24.9%) of children ages 5-17 are overweight or obese.

Of concern was a large increase, of nine percentage points, in 18-24 year olds in the three years since the previous survey. From a health perspective, these alarming figures mean that a large proportion of the population is at heightened risk of non communicable diseases including cardiovascular disease, type 2 diabetes and some cancers.

From an economic perspective, high rates of obesity and associated chronic disease and lost productivity cost the Government, as well as State and Territory governments, businesses and individuals, a staggering amount.

Recommendations

The OPC makes the following recommendations:

  • Fund the development and implementation of a whole-of-government national obesity prevention strategy, including the measures outlined below.
  • Increase spending on preventive health, with a particular focus on programs to reduce the growing burden of overweight and obesity, and associated chronic disease.
  • Introduce a health levy on sugary drinks to effect a retail price increase of at least 20%, generating significant revenue and reducing obesity levels.

The Public Health Association of Australia, in association with the National Heart Foundation and the Cancer Council

Key points from the PHAA, NHF and CC’s Federal Budget Submission

Smoking prevalence is disproportionately high in disadvantaged groups. Policies to date have driven smoking prevalence in Australia to an all-time low, with statistics released in December 2018 showing that just under one in seven (13.8%) or 2.6 million adults were daily smokers in 2017-181.

However, this figure remains unacceptably high and – worryingly – rates of smoking decline have slowed in the last few years. Every year, over 18,000 Australians die from their tobacco addiction, and thousands more suffer from associated chronic diseases.

Unfortunately, there are some groups who have much higher rates of tobacco use such as people with mental illness, people with substance use disorders, the unemployed and at-risk youth. These priority population groups experience health, financial and social inequities that are exacerbated by tobacco use. The initiatives proposed will assist the entire community, but especially all groups that experience social and financial disadvantage, and extend and complement the support provided to Aboriginal and Torres Strait Islander people.

Recommendations

A commitment from the Commonwealth Government to provide $50 million per annum over four years for campaign and cessation programs so as to implement the next National Tobacco Strategy (NTS), including the following initiatives:

  • $25m per annum to reinstate, and maintain for the period of the NTS, a population based TV- led National Tobacco Campaign, targeting adult tobacco users in all states and territories which is evidence-based in both creative development and audience exposure, and supported with rigorous developmental research and campaign evaluation.
  • $10m per annum to create and fund a dedicated National Cessation Strategy within the National Tobacco Strategy to facilitate a consistent, evidence-based national approach to smoking cessation service provision. This would include the development and dissemination of national clinical guidelines and program support  and the provision of a national QuitlineTM as a referral, training and behavioural support provider.
  • $15m per annum to specific, targeted programs that will provide additional support to groups in the population experiencing the highest levels of disadvantage. This will primarily be done through partnerships with the public health and community service sectors to provide direct services to high needs populations.

Complementary Medicines Australia

Key points from CMA’s Federal Budget Submission

Individuals use complementary medicines as adjunctive therapy to conventional medicine, to help manage chronic disease, prevent the exacerbation of illness, and to optimise nutrition and wellbeing. There is now robust evidence in a number of areas that complementary medicines are a cost-effective way to improve health outcomes.

In Australia, between 31% and 58% of the population is found to suffer from vitamin D deficiency, despite the fortification of many foods with vitamin D. Vitamin D deficiency has been linked to an increased prevalence of a number of chronic diseases, including osteoporosis, diabetes and heart disease.

Folate, iodine and vitamin B3 are known to prevent neural tube defects. The National Health and Medical Research Council advise that pregnant women and those planning a pregnancy should take a daily folic acid supplement at least one month before and three months after conception, as well as eating a healthy and varied diet as recommended in the Australian Dietary Guidelines. The guidelines recommend routine supplementation of folate and iodine, with vitamin D and iron supplementation for pregnant women with identified deficiencies.

CMA supports the call to re-establish a National Preventive Health Agency to evaluate evidence-based interventions at a population level, an important step towards placing good health at the centre of policy making in Australia. A fundamental aim of health policy should be to prevent disease and reduce ill health so that people remain as healthy as possible for as long as possible.

Preventive health is also an essential move towards improving the cost- effectiveness of the health care system, by enhancing Australians’ health and quality of life, and reducing preventable illness. In the case of complementary medicines, a thoughtful and rigorous strategy, coordinated by the preventive health body, would further demonstrate the cost- effectiveness and health benefits of complementary medicines for contributing to improved public health.

Recommendations:

  • Reinstate the private health rebate for natural therapies, in light of the evidence supporting the use of these natural therapies.
  • Development of a strategy, in consultation with physician groups, to increase the uptake of vitamin D supplementation amongst at risk groups, and the introduction of a scheme to provide subsidised vitamins during pregnancy through health practitioners for concession card holders.
  • Re-establish a national preventive health agency to implement and evaluate population-wide prevention initiatives, improving the health and wellbeing of the community and providing long-term savings for the health budget.

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