Pearls and Irritations

This repost is an outstanding article on prevention that I originally posted in October last year. Part 2 will follow tomorrow.  John Menadue

One of the more curious decisions of the Abbott Government in its 2014 Budget was the decision by Health Minister Peter Dutton to reduce Commonwealth expenditure on prevention.

Funding for population health broadly is set to decline substantially – although the brunt of the cuts are for later years and the real devil is in the finer detail.

For the Commonwealth Department of Health in Outcome 1 – Population Health, the pain in the first full Dutton year is minimal – a decrease from $167M in 2013-14 to $166M in 2014-15 – peanuts! But even in this set of numbers, there are interesting messages. Prevention includes activities that “look like” medical work, for example immunisation and cancer screening programs. These areas were largely protected.

But prevention also includes the more difficult and contentious health promotion tasks – regulatory policy for alcohol and tobacco and food (which requires examining industry behaviours like advertising of junk foods, salt levels used in processed food, and alcohol promotions) as well as programs targeting people’s lifestyle choices in areas such as smoking, alcohol use, physical activity and eating habits. As we saw last week with Liberal Democrat Senator David Leyonhjelm’s outburst on “excessive’ smoking taxes and his right to accept Big Tobacco donations, these lifestyle messages and the regulation of these industries in the interests of population health is political by definition and is likely to be an anathema to libertarians and the hard right. The imagery reached for is that of a ‘nanny state’ – see the Institute of Public Affairs (another recipient of Big Tobacco largesse) for a detailed exposition of the position.

It is this latter area of work that took the real Budget hit.

Programme 1.2 of Outcome 1 (for us non-bureaucratic mortals this is the part of the budget dealing with drugs like alcohol, education against illicit drug use, and tobacco) was reduced from $224M in 2013-14 to $161M in 2014-15.   And it goes on. This area will be further reduced to $131M by 2017-18 according to the forward estimates – a decrease in nominal terms of over 40% – while some of the other population health activities actually see some modest increase in that period. The axe is being swung not only at the federal level. With the Dutton death blow to the COAG^[1] Partnership on Preventative Health, some $400 million of promised funding for the State and Territory Governments’ lifestyle prevention initiatives were axed as well – programs in particular focussed on children’s physical activities, community exercise and nutrition initiatives, education about lifestyle related risks and so on.

Is there good logic to this – why cut prevention rather than, for example, reducing funding for some of the 150 low-value medical interventions that have been identified?^[2]  Had the need for work in prevention lessened?  Were the metrics now moving so clearly in the right direction that government could turn its attention (and money) elsewhere? Almost all other developed countries had also been significantly increasing their attention and expenditure on prevention in the 21st century, were they cutting back too?

SNAP – but no crackle and pop

In 2011, the primary driver for establishing the National Partnership on Preventative Health was the alarming increase in preventable chronic disease related to people’s lifestyles.  These lifestyle issues – in particular Smoking, poor Nutrition, Alcohol misuse and Physical inactivity – the SNAP lifestyle risk factors – already accounted for some 40% of potentially preventable hospital admissions according to the Australian National Preventive Health Agency (not just a cutback but abolished in the 2014 Budget).   The growth of lifestyle diseases worrying those watching health expenditure were primarily in diabetes, various cancers, COPD, strokes and other preventable cardiovascular system diseases.

Let’s check how the SNAP risk factors are doing.

Tobacco

Tobacco reduction strategies are the star performers on a population basis – a national decrease from about 35% in 1980 to 16% in 2012.  That’s one of the lowest adult smoking rates in the world.  But with some big holes. The COAG Reform Council, whose job was to assess performance of governments against their stated targets (the Council was also abolished in the May 2014 Budget), reported on the performance of the Preventative Health Partnership in 2013 and noted that Indigenous smoking rates were much higher than those of the rest of the population – still over 40%. Also important were socio-economic factors – if you are in the lowest socio-economic demographic, you have a 25% likelihood of being a smoker as compared to a someone in a more advantaged situation. Further, the city-country divide is extraordinary.  The National Health Performance Authority (to be abolished as a standalone statutory body by decision of the 2014 Budget with the functions to be amalgamated in a mega ‘productivity and performance’ entity) reported in October 2013 that in areas such as the Grampians, smoking rates were 28% as compared to city areas such Inner West Melbourne where the rate was 8%. In general, on most of the risk factors for chronic disease, the further from the city you live, the less healthy you are likely to be!^[3]

While overall population figures might suggest that smoking is largely ‘done’, what the more granular data suggest is that success has been high in higher-income higher-educated urban populations and that significant effort is needed elsewhere where rates look like statistics from 30 years ago. Some focused attention was in fact occurring, in part. A major initiative – Tackling Indigenous Smoking – spearheaded by Tom Calma – was rolling out across Australia; it has had its expansion “paused” to undergo a review of its efficiency during 2014. One note of optimism: although not quantified in terms of expenditure, the May 2014 Budget committed to continue Australia’s defence of the plain-packaging of tobacco cases brought within the WTO and bilateral trade treaty arrangements.

Alcohol

There’s good news and bad news on alcohol. The evidence about alcohol as a risk factor has been mounting, and it’s a Group 1 carcinogen (ie good evidence it’s harmful to humans). This led a couple of years ago to a tightening of the guidelines from the NHMRC on alcohol consumption (the NHMRC is a medical research funder – and medical research is Abbott’s favourite thing – so it wasn’t significantly cutback, planned to be amalgamated or otherwise mauled in the Budget apart from the plan to set up a duplicating bureaucracy in the new Medical Research Future Fund).

Harmful consumption of alcohol has two forms – long-term consumption at risky levels and single occasion risky consumption (basically binge drinking).   Latest stats are that about 20% of the population continues to drink at levels risky to their long-term health – pretty well unchanged from the ABS results in 2007-08; half of males and one-third of females drank riskily for single occasion risk. These are quite high statistics at a population level. The good news is that since the 1970s, our per capita alcohol consumption has declined although it remains above the OECD average.

By far the most concerning SNAP areas are the ones leading to the disturbing trends in obesity and overweight. Both nutrition and physical activity contribute to obesity – more on the statistics and their implications in the next blog tomorrow.

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^[1] Council of Australian Governments

^[2] Elshaug AG, Watt AM, Mundy T, Willis CD. Over 150 potentially low-value health care practices: an Australia study. Medical Journal of Australia, 20212; 197(10): 556-560.

^[3] Risk Factors Contributing to Chronic Disease, AIHW, 2012.

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