How to clear the ‘blinding fog’ of mystery on decision making in health prevention programs. Philip Darbyshire lays a challenge at the feet of those working on government public health programs in this follow-up piece on the Queensland health cuts.
As the news cycle moves on and some of the heat, perhaps momentarily, dissipates from the Queensland health cuts furore, I wonder what Croakey readers have learned over the past weeks. More importantly perhaps, I wonder what we as health professionals have learned about how to, and perhaps how not to advocate for and defend health services. Sadly, my view of the latter would be, ‘precious little’.
In my contribution I proposed four ‘killer questions’ that health professionals must able to answer if they are to advocate for and champion the value of the work that they do. I also suggested, rather tongue-in-cheek, various ways not to respond to them. I did not expect to find that almost every one of these would be the default position of the health promoters.
What we have read in almost every commentary (see here, here, here and here ) is a surfeit of ‘mourning’, ‘eulogies’, outrage, hand-wringing and apocalyptic visions of the doom and decline that is now sure to visit Queenslanders – to the extent that I almost expect to see the bodies mounting up along Queen Street mall any day now.
I readily acknowledge the ‘heartfelt’ nature of the commentaries and the genuine difficulties that sacked staff will face, especially since, as Sabina Knight noted, “Generations of health professionals have not ever known job insecurity.” Millions of other workers in the private and commercial sectors of our economy will of course have little comprehension or experience of such generational ‘job security’. I find it hard to believe however, that such sustained emoting will have the slightest influence on government or health board thinking.
Thus far, a tear of remorse emerging from Campbell Newman’s eye seems a more likely prospect than some kind of evidence or appreciation of outcomes being mentioned by the health professionals. What we read instead is the semi-liturgical listing of programmes and projects, each more worthily-named than its predecessor. Who, after all could possibly NOT want to fund a programme or service as eponymously wonderful as ‘Lighten Up’, ‘Living Strong’, ‘Growing Strong’, ‘Smart Choices’, ‘A Better Choice’, ‘Get up and Grow’ and so on. With such linguistic insulation, no wonder that defunding such programmes seems like drowning kittens.
Wonderful though these programmes may sound, we are still none the wiser from the Croakey commentaries as to whether they actually work, whether they make a demonstrably positive difference to the health and lives of the people concerned and what improvements they have made in relation to any key indicators of health and wellbeing. For instead of even a shred of evidence, we read only about how ‘vital’ the programmes are, how wonderful the staff are, how committed they are to their work, how tireless their efforts are, how important their jobs are to them, how diligent they have been at University and how much gratitude we owe them (examples here and here). Is this really the best we can do?
The only dissenting voice to this orthodoxy other than my own was Vern Hughes, who wrote that, “Prevention programs in these areas amount to little more than media and education campaigns that largely fail in modifying behaviours.” While Vern may well be right, so too may the health promoters, the problem is that because the discussions around the Queensland cuts and indeed the undertaking of the cuts themselves have been essentially an evidence-free zone, we simply don’t know.
This concern that the health promotion and prevention sectors see themselves as self-evidently worthy, successful and thus entitled to their share of the eternal ‘more resources’ that everyone in healthcare desires is not a new observation and others have expressed this more clearly than I. Martyn Goddard for example has argued that: “A blinding fog of ignorance and mystery surrounds the decisions being made on disease-prevention funding. Perhaps it is time we started to do the job better”. No ‘perhaps’ about it I’d say.
I am not so naive as to believe that politicians create health policy and make health funding decisions on the basis of rational thought and good evidence but I have to believe that strong evidence of positive and valuable outcomes will ultimately carry more weight than ‘heartfelt pleas’. I would also like to believe that the public health service as a whole is not fundamentally a giant job-creation scheme existing primarily to provide gainful employment for its staff and where any proven, beneficial, health outcomes are but a fortuitous by-product.
Let’s hope that the people running all of these health promotion and public health projects, programmes and departments have been collecting good data, not only about process, and ‘inputs’ (i.e. amount of ‘work done’), but also in some way, about outcomes and identifiable benefits. Let’s also hope that some of our university research departments are already planning the longer term ‘post-cuts’ follow up studies in Queensland that will provide a less febrile and more evidence-informed assessment of exactly what effects (positive, negative or otherwise) these policy decisions may have on Queensland and its people.
Philip Darbyshire is Professor of Nursing at Monash University, Adjunct Professor of Nursing at University of Western Sydney and Director at Philip Darbyshire Consulting Ltd. Read his blog or follow him on Twitter.
This piece quotes an earlier commentary from Vern Hughes from a group called Social Enterprise Partnerships in Victoria. Mr Hughes writes that “Population health and prevention programs seem to have made little impact on Australia’s epidemic of obesity or ongoing levels of alcohol abuse and tobacco-related illness. Presumably, if current programs were effective, the trends would be heading downwards”.
Action on obesity and alcohol is light years behind that on tobacco, but where on earth does Mr. Hughes get the idea that we are not making on impact in reducing the death and disease caused by tobacco. Current programs are effective; the trends are heading downwards; and further measures such as plain packaging will ensure that these encouraging developments are maintained.
It would be helpful if people like Mr Hughes bothered to check out what is actually happening before letting their biases get ahead of the evidence.
Those readers interested in the evidence that preventive health services have been effective in Queensland could access the Report of the Chief Health Officer 2008, The Health of Queenslanders- Prevention of Chronic Disease, particularly Chapter 5, available at http://www.health.qld.gov.au/cho_report/2008/documents/2008choreport.pdf – or indeed in any of the recent articles that are conveniently omitted from this piece.
Aside from the well-documented outcomes in tobacco control, the evidence includes measured impacts and outcomes at multiple stages along the causal pathway in other areas. For example, in 2007 the rate of measured (rather than self-reported) healthy weight among children in Queensland had reached levels 2-3% higher than in other states where comparable data was available. This equates to 1,200 fewer future cases of Type 2 Diabetes per year by 2015. The multi-strategy Go for 2 and 5 fruit and vegetable promotion program resulted, at its peak, in an extra intake of 1.1 serves per person per day throughout the state. This was confirmed by objective measurement of additional turnover of $9.8 million sales of fresh produce per month in Brisbane alone. Campaign targets were exceeded resulting in a technical saving of $55 million per year to the ill-health system.
Adult physical activity participation rates had increased by 34% since 2004. Exclusive breastfeeding rates for the first six months had quadrupled, and the proportion of infants breastfed at one and six months had increased by over 5% points to 83% and 63% respectively.
As is the case for most interventions in a complex public health system, the evidence is that a multi-strategic approach is required for effective advocacy. By not acknowledging the need for diverse perspectives, this piece is guilty of its own criticisms in not adopting an evidence-based approach.
Thanks to Mike and Amanda for their considered responses. I feel myself coming over all Shane Crawford and wanting to say; “That’s what I’m talking ’bout”. Mike is absolutely correct about tobacco, although as Martyn Goddard explains, it might be slightly disingenuous were the health promotion lobby to claim sole credit for smoking reduction as a ‘health education’ victory.
If I have, as Amanda suggests, missed any coherent arguments in Croakey against the Queensland cuts that were based more on evidence and demonstrated value than on outrage and indignation, then mea culpa indeed. “Conveniently” however, has nothing to do with it. I searched Croakey using key terms such as ‘Queensland’ and ‘cuts’ and cited the blogs or commentaries I found that responded to the news of these cuts. Amanda feels that I may have “omitted” something important here. I wish that this were true.
The Queensland Health Report that Amanda helpfully cites is fascinating reading. I’m sure that it addresses some of the thorny concerns I raised about assessing the benefits of various health promotion and other awareness and education campaigns, while possibly raising others. I would not be surprised however to see some of its critics raising the Mandy Rice-Davies objection.
One example will have to suffice. Eating more fruit and veg sounds like a wonderful idea but I’m not sure how excited the policy makers should be at the trumpeted benefits of people having an “extra intake of 1.1 serves per day”. Who knows what slips there may be ‘twixt veggies and lips? Should we worry rather than rejoice if the ‘extra serves’ of veggies were, for example, mostly fresh potatoes that were ultimately devoured as bowls of hot chips (with accompanying salt and sauce)? Or perhaps the serves were apples, that instead of inhabiting little Johnny’s lunchbox, ended up as the foundation of some mighty apple crumbles. Pertinent questions to ask one would think.
I’m not a health economist but the bald idea that ‘sales of fresh produce’ increasing by $X million dollars translates to a health system saving of $XX million seems such a long bow to draw that Robin Hood on steroids would find it a challenge. Perhaps that’s the reason for the little ‘qualifier’ – “technical” saving. I wonder if a “technical saving” is like a “technical breach”?
Amanda berates me for “not acknowledging the need for diverse perspectives”. I’d be wounded, if I had a clue what she meant. I cannot see a scintilla of basis for this presumption from my piece. I’m guessing that a “multi-strategic approach for effective advocacy” might mean that there are many different ways that people and communities can be helped and enabled towards better health. No argument at all from me there and by the same token, I think that there are ‘diverse’ forms of evidence, both qualitative and quantitative, that we need if we are to highlight and to demonstrate the acceptability, effectiveness and value of health programmes and services. Such diverse research approaches should also be capable of discovering the converse; what does not work and what has little demonstrable benefit. I have no difficulty at all in saying which of these services deserves to receive our hard-earned tax dollars in government funding. Here is a clue: the answer is not ‘both’.
What I am not obliged to ‘acknowledge’, in deference to any notion of ‘diversity’, is the correctness of the ways that Amanda and others have responded to the cuts in their Croakey comments. I simply believe that their approach is wrong and have explained why. On that point we may agree to disagree.
Amanda plays her parting shot as if it were an ace when it is barely a deuce. I criticised Queensland Health for their ‘slash and burn’ approach to these cuts that almost wilfully ignored any notion of evidence. I have called for a more ‘evidence and outcomes’ informed thinking, not only in relation to these cuts but across all of health funding. I have critiqued the predominant hand-wringing preciousness of responses that we have read to date and have cited specific examples of my concerns. I may not have joined the bandwagon of bluster but I can scarcely be guilty of “not adopting an evidence-based approach”.
Philip Darbyshire