A Conversation with Professor Rosemary Calder
We’re not good at preventative health in Australia. In 2016-17 we spent a mere 1.36% of our health budget on preventative health. This is almost one fifth the percentage of New Zealand (6.4%) and Canada (6.2%), and significantly less than the UK (5.4%) and the US (2.8%).
This is a little scary when we estimate that one third of the burden of chronic disease in Australia is preventable. An enormous amount when 40% of Australians over the age of two have one or more chronic disease and 47% of Australians over the age of 45 have two or more chronic diseases.
In fact, in 2011, chronic disease became the leading cause of disability, illness and death in Australia—accounting for 90% of all deaths. Experts believe this ineffective management of chronic disease is costing the Australian healthcare system more than $320 million each year in avoidable admissions. In 2015-16, for instance, more than 680,000 hospitalisations in Australia were deemed potentially preventable.
With our funding and service models geared almost entirely towards treatment, rather than prevention, it seems almost acceptable to be chronically ill in Australia. So how did we get here? And why don’t we do something about it? I sat down with Professor Rosemary Calder to get to the bottom of these very questions.
Meet Professor Rosemary Calder
Professor Rosemary Calder has worked as a health bureaucrat and has been Chief of Staff to a Victorian Health Minister. She is now a Professor of Health Policy at Victoria University’s Mitchell Institute and heads up the Australian Health Policy Collaboration (AHPC), which is supported by the Institute and brings together 60+ of Australia’s leading health policy experts to draw together evidence on how to improve prevention through the country’s health policies and services.
I first found Rosemary after asking the question myself: why are we so bad at preventative health? In trying to find the answer to this question, I found her paper: Australian Health Services: too complex to navigate? The 2019 paper is a meta analysis of 16 national reviews of Australia’s health service arrangements conducted over 35 years. Only after reading it and talking to Rosemary did I see just how problematic our situation is.
Subacute beds: A change to improve the system
The story that epitomises the difficulty of making change in Australian healthcare is one Rosemary shared with me from her time spent working for the Victorian State Health Department from 1990 to 2000. She describes working for a “health minister who was really the minister for good health—who understood preventative health.”
Rosemary says, “We did a whole lot of work, particularly around older people and clinics to address health risks, and we established the subacute care service system to provide targeted services to improve health outcomes for older people at risk of or following a hospital admission. Implemented over 10 years, this made Victoria stand out as having the lowest proportion of people in long stay hospital beds. Victoria did not have what the rest of the country called ‘bed blockers’.”
The trouble was that, further on, few people understood why Victoria was performing so well.
Rosemary explains, “Preventing a problem often means that the ‘solution’ is not visible to others. The reason why Victoria has performed so well was embedded in the system from a change that was made years earlier. Victoria had made a structural change by establishing a funding stream to support subacute care, inpatient care and ambulatory care services. When an individual is admitted to hospital with an acute condition that is potentially life changing, such as a stroke, often their early return to home is not feasible. This means beds can fill up at hospitals very quickly.
“In Victoria we developed a subacute care system which provided dedicated funding for rehabilitation, palliative care, geriatric evaluation and management. So, our hospitals were able to move people once they were stable after (say) a stroke into a sub-acute care unit, for rehabilitation or what’s called a GEM bed, at a lower rate of cost and with a comprehensive suite of clinical providers, including rehab, speech pathology, counselling etc. We built a funding model that enabled the right type of care at the right time.”
“So, people in Victoria, and it showed in the hospital data, were returning home after extended stays in a subacute bed, but only a short stay in an acute bed. It saved the state money and helped people recover well and reduced readmissions.”
“However, with changes of government and without a national strategy at the time, this change was limited to Victoria and quickly became historical, rather than recognised as a ‘system improvement’.”
This is just the tip of the iceberg when it comes to Australia’s patchy track record of systemic change for the betterment of health care. But to paint the picture in full we need to go back 35 years to the establishment of Medicare.
How did we get here? 1984—Medicare is established
Rosemary explains, “Medibank, the first iteration of Medicare, followed the Hospitals and Health Services Commission, better remembered as the Sax Commission—a group of three commissioners established by the Whitlam Government to address the lack of access to health care by a substantial proportion of the Australian population. The commission was the first group that looked at the whole of Australia’s health service arrangements. I use the term ‘health service arrangements’ because to call Australia’s multiple networks of health services a health system or even systems is a complete misnomer.
“We had eight jurisdictional roles in healthcare, plus a relatively small but nonetheless significant private or independent sector, which was supported by private health insurance. None of it connected—each state and territory ran its own hospital system with taxpayer funds recycled through the Commonwealth and back to the states. There were various forms of agreements and arrangements and hospitals were not connected to one another or to other health services.
“So, we had a Rubik’s cube of health service arrangements and the colours weren’t lining up. The Sax Commission, which was in operation for several years, was the first endeavour to look at that complex set of arrangements and try to develop Commonwealth-led strategies to improve access to health care, particularly for a considerable proportion of the population at the time that could not afford healthcare.”
How is Medicare holding up 35 years on? Particularly in relation to preventative health
Rosemary says, “[Medicare] is holding up in the sense that it is being utilised at ever greater levels with increasing levels of chronic diseases that require long term care, particularly at the primary care level, but it’s not helping to reduce that increasing demand. It has capacity, provided the country is happy to continue paying, but not enough is being achieved in terms of preventing what is known to be preventable.
“MBS is not structured to enable doctors or primary care providers to screen for risk other than identified substantial risks for cardiovascular diseases, cancers and the like. We don’t screen for potential early risk factors to good health. We don’t assess or support good health. We respond to indications of illness or ill health and that’s left us confronted by this rising tide of preventable chronic disease.”
Above: A profile video on Professor Rosemary Calder. Source: Victoria University.
Why are we worse at preventative health than other developed nations? (eg. NZ, UK, USA)
Rosemary says, “It’s a fascinating issue. I’m sure you could ask a dozen health thinkers why this is so and you would probably get half a dozen different answers because I think it’s a mix of many things. One of those things is that we do have an ongoing assumption that is pervasive both in our media and in our policy discussions that people are entitled to make choices and ought to be, to some degree, held accountable for those choices. Therefore they ought not be supported when they’re making a choice that others think is unhealthy. They should be made to deal with it themselves.
“We’ve had lots of commentators—particularly those known as ‘shock jocks’—who make reference to people who are obese or overweight as having done it to themselves. We’ve had discussions about a sugar tax, which has long been known to bring down the consumption of sugar, but the pervasive comment is, ‘Well, people make that choice. They want to drink sugar sweetened beverages. It’s not for us to dictate or to interfere.’ And this is despite the fact that we know tobacco consumption has been driven down in large part by increasing the cost through taxation.
“There have been some very hard reports about the impact of the lack of prevention. There have been government funded organisations that point to the impact of lack of investment in prevention. But, and this is a curiosity, when we wrote Australian Health Services: too complex to navigate? we referred to 16 reviews over 35 years and we identified review after review studying similar questions about similar problems commissioned by different governments.
“These 16 reviews were all in different contexts but essentially they recommended the same things: increase effort in prevention, articulation of a properly integrated and coordinated care system, linking primary care to acute care to prevent hospitalisations.”
“We made the point in that paper of asking, why do we keep doing reviews when we don’t take up the recommendations and put them into implementation? That’s our problem. We know what needs to be done, there has been consistent advice about what should be done to do better, but, even when some of the advice is implemented, that is too frequently very limited, too narrow, or not well-funded.”
Are we getting better or worse at preventative health?
“It’s probably both,” Rosemary says. “We’re seeing general practitioners who are increasingly aware of the need to intervene early and to assess risk and who want to, but who are overwhelmed by the weight of dealing with established illnesses or established risk conditions and have limited capacity to actually undertake the screening and the prevention work that we’ve talked about. So, there’s a willingness and a wish, but too many barriers. We do have some gains, but we’ve got structural barriers to those gains being effective.
“For instance, if I develop a health condition and I need diagnostics services to work out what to do about it or what it is, there’s no limit to the number of diagnostic services that I could be sent for: radiology, blood tests, whatever, they just go on and on. But if I turned up at 21 for a health care appointment and I was already putting on weight, there is nothing that provides incentives to a primary care practice to say, ‘We need to see you regularly. We need to keep your weight at this level or get it down.’ And when we do refer people for services to help them change behaviours, we only have access to five or 10 sessions in a year and to a limited range of health services. And the evidence says that, for many health conditions, that is insufficient to change health risks.”
How do we get better at preventative health?
Rosemary shares, “Well, it is clear in all the reviews that establishing a primary care platform—a walk in, walk out platform providing access to a range of disciplines and services—and that has a focus on screening for risk is the key. We’ve recognised that, if we don’t keep cars healthy, they can be lethal. And the same is true for people. We know that if we don’t keep people healthy, they can be at risk of developing lethal diseases.
“We need to build a primary care platform that is premised on the importance of keeping people healthy. That’s relatively simple in its concept and implementation, but we have to pay for services differently in order to enable the primary care platform we have to become much more focused on keeping people healthy and preventing disease.
“We need to see this lack of focus on prevention as a health crisis. We have to, I think, build on what COVID has taught people—that there are groups in the population that are not engaged in their health care, that don’t understand self-health care, that may resent being asked to make health appropriate decisions. We’re dealing with a range of factors here, including socioeconomic disadvantage, recency of arrival, English language capability, and also of culture.
“COVID has really shown us what the flaws in our healthcare service provision are. We’ve had Prime Ministers across the world telling people how to wash their hands because there was an established concern that a lot of people don’t know how to do that or why you do it. We have allowed the health service ‘system’ to become the go-to place for individuals and their health care. We have not understood that individuals have to be educated and supported to maintain their own health and to not to see health care as a service only provided for fixing established health problems.
“When you tap the culture in Australia, there is a proportion of our community that thinks ‘the doctor’s responsible for my health’. We have become complacent—doctors are what we need, doctors will fix us, doctors and hospitals will keep us alive. And that’s a significant flaw.”
“The other really big flaw, which is so visible at the moment—during COVID—is that the primary care system cannot readily step up and help when there is a level of illness in the population that is difficult to manage. This means the hospital system has to take most of the burden and it’s not capable of responding to that degree.”
“So, we build hospital beds because we know people need them. We don’t invest in what will stop us needing that number of hospital beds. That’s the biggest flaw of all.”
How can we ensure those who need preventative care most are the ones receiving the most care?
One of the most concerning things about Australia’s position on preventative health is that those who need the help the most are the ones least likely to receive help. A 2009 review showed that 20% of Australians living in the wealthiest areas received 55% of the extended safety net benefits, while the 20% living in the poorest areas received less than 4% of benefits. This is particularly concerning when we know Australians living in these same areas of disadvantage are 1.7 times as likely to be identified as having 4 or more risk factors for chronic disease.
Rosemary shares, “I think we have to go back to the intention behind Medicare in its first iteration, which is to ensure that access to healthcare is not limited by affordability. And we need to define what we mean and want in prevention, early risk detection, and early risk intervention. So, we need to establish, under the MBS, or a revised arrangement for the MBS, that a significant amount of our healthcare needs to be about prevention. Healthcare needs to include, as a core responsibility, the review of individuals, on an appropriate evidence-based set of criteria, for risks that are well known to be population-wide risks.
“For instance, we know weight gain is associated with the risk of diabetes, risk of cardiovascular disease, the risk of a whole range of things. So, we need to make it primary care’s business to monitor the health of the population—not just the clients of a primary care service, but the population that the primary care service provides services to.
“So we need to think about population enrollment with primary care providers for preventative healthcare. We need to set up funding arrangements that Include weighted funding for highly disadvantaged areas. We have to make the decision to move into preventative healthcare. And then we can build the funding levers that enable primary care providers to be effective providers within that framework.”
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