There’s a reason why governments don’t tackle prevention – it’s complicated, unsexy, and difficult to sell in terms of dollar-focused evidence.
The question of why governments, large and small, don’t want to take on prevention as a whole-of-government policy direction boiled down to two simple statements today.
It took veteran GP and advocate Dr Tim Senior to say the quiet stuff out loud during The Medical Republic and Health Services Daily Prevention Summit, being held in Canberra today and tomorrow.
“It’s policy that creates wellbeing,” he said.
“We are prepared to spend on stuff that keeps us safe, like submarines, but we could actually spend that on well-being if we wanted to.
“That is a political choice.”
That choice seems a simple one, but Dr Alison Roberts, a commissioner on the Productivity Commission and co-author of the PC’s Delivering quality care more efficiently report released last December, told the summit there were complex layers to government skepticism.
Benefits are long term
Governments operate on short-term, electoral cycles, so their preference is to see easily measurable benefits quickly.
“There is no shortage of good preventive interventions that have shown benefit,” said Dr Roberts.
“We have so many pilots, we have so much evidence.
“What we don’t have is a really effective system for investing long term in those. Part of that is because there is a great deal of skepticism around some of the claims – ‘a dollar invested delivers $14 of benefit’, for example.”
Who pays isn’t the one who benefits
Dr Roberts told the summit that Australia was unique in that sometimes the investment was made at one level of government, but the gain occurred elsewhere.
“You invest in something at a state level – an education support, or a wraparound intervention around out of home care – and it delivers benefits long term, 10 years, 20 years down the track, in terms of reduced reliance on income support, better participation in the workforce, and so on,” she said.
“These are hard to account for across levels of government. They’re even hard to account for within a government level.”
Victoria’s early intervention investment framework provided an example of how whole-of-government prevention policy might work.
“If you have a deliberate approach to it through their early intervention investment framework that they’re using, you can actually look at investments in one portfolio area that deliver benefits somewhere else, measure those, and enable reinvestment of the benefits,” said Dr Roberts.
“But we don’t have a good system for tracking that over time, and so that doesn’t build confidence in the fact that these interventions can work.”
Social determinants
The roots of prevention lie in the social determinants of health, said all of the panelists at today’s opening session, and therein lies the “whole-of-government” problem for tackling it as a formal policy.
“We see a lot of problems arising because of socio-economic disadvantage,” said Dr Senior.
“The different types of prevention we’ve been successful with, some of it requires no contact with the health system.
“If we’re only making policy for people like us – in employment, a computer on the desk, a smartphone in our pocket, able to come to a meeting like this, and most of us probably are not worrying about what our rent is doing – then we’re making policies convenient for us,” he said.
“My patients are going, that doesn’t work for me.
“We need that connection between the policy to create an environment that we’re sending people back out into that’s not health policy.”
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Funding rewards treatment, not prevention
Dr Luke Slawomirski, a health economist and former clinician, told the summit he felt Australia was “not doing prevention well”, despite some public health successes over the years.
“I don’t think we do prevention well at all in this country, and particularly tackling some of the upstream factors – social and cultural determinants,” he said.
“I fear we’re drifting in the direction of the US in terms of what our health system looks like.
“We’re now the fifth most expensive as a proportion of GDP in the OECD, and I’ve watched this creep up over the last decade or two.
“Our acute care spending is growing at a faster rate than our spending on primary care and that’s not sustainable.
“We have a high life expectancy, and we tend to pat ourselves on the back for that, but when you actually look at how many years of that life we spend in ill health or disability, we’re second to the US in the OECD.”
Why are we bad at prevention?
Dr Senior offered up bulk billing as a reason.
“We’ve mistaken the cost to patient, for funding of a health service or health system,” he said.
“Bulk billing is not a mechanism for funding health services. At no point has anyone done a needs analysis or said this is what this community needs or said we want to be managing this.
“Government is being really clever – what they want is people to feel that they’re not paying at the point of use.
“But that’s different to funding the health system pragmatically, though.
“You can’t do preventive care and managing all the complex multiple videos in social circumstances in a socioeconomically deprived community funded purely by bulk billing.
“One of the reasons we do prevention poorly in this country is because we fund activity, and bulk billing just a continuation of fee-for-service, just at less cost to the patient.”
