An effective sustainable health system is hampered by the 'business' of illness

Not many days go by without some media reference to problems in the “health system”. The term is in quotes because reference to health in this context is a misnomer. According to the World Health Organisation, health is a state of complete physical, mental and social well-being. There would appear to be little justification for claiming that there are major problems with “health” when the Australian Institute of Health and Welfare (AIHW) recently reported that: “…Australians enjoy good health, and that the underlying health trends are broadly in step with health improvements occurring in other developed countries”.

If Australia enjoys good health, why does the AIHW also report that throughout Australia, public and private hospital admissions continue to increase? It is amazing that there appears to be little analysis of, or debate around, this question, although theories abound. This knowledge vacuum hinders finding solutions to the problem. Meanwhile the stresses and strains are being placed on a resource-limited infrastructure. Where there is strain, tensions and conflict are likely accompaniments with scapegoats sought to blame for the situation.

May I suggest that the scapegoat should be the person who discovered that there was a return for providing remedies and treatments for afflictions? That person, born aeons ago, unknowingly began a multibillion-dollar industry that focuses on treating illness. It is an industry that has thrived well in the market economy but there is a limit to how far supply can meet demand and a limit to the cost the community is prepared to bear.

It is interesting to speculate on how different the situation would be today if our antediluvian entrepreneur had found that there could be profit made from selling the ingredients of health. But what are these ingredients? There has been, until recently, a lack of scientific basis to a theory of what determines health and this again is probably because, over the centuries, the illness paradigm has dominated the research agenda.

Many of the changes in thinking about health and its determinants had their roots in Canada, notably in three key documents: A New Perspective on the Health of Canadians, the Ottawa Charter on Health Promotion, and Achieving Health for All: A Framework for Health Promotion.

In 1974, A New Perspective on the Health of Canadians (The Lalonde Report), identified key factors that were considered to determine health status: lifestyle, environment, human biology and health services. This provided a comparatively simple platform from which to orchestrate strategies to promote health. With limited influence over biology, all that was required was to implement environment health policies, provide health services and encourage people to adopt a healthy lifestyle. Unfortunately this has proven to be somewhat simplistic – especially the latter. In 1986, Achieving Health for All noted that disadvantaged groups have significantly poorer health than average Canadians and that more attention needed to be paid to preventing ill health, enhancing people's capacity to cope, and creating conditions and surroundings conducive to health. In 1986, the Ottawa Charter for Health Promotion identified the prerequisites for health as “peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity”.

There was a growing recognition in Canada that living and working conditions, were critically important in influencing population health status and that the contribution of health [or illness] services to health is limited and was therefore subject to criticism. For example, Dr Manuel Carballo of the World Health Organisation said in 1987:

the health systems of most developed regions have become highly bureaucratised, over structured, regimented and unable to respond to their population’s needs; they are basically medical, curative care systems, creating dependency, unable to stimulate social autonomy or empowerment and are, in nearly all cases, becoming financially deficient ... health plans are developed in an ivory tower by elites who often do not understand the people they are working with, and in many cases do not even know them ... we must try to move towards [a health system] in which we all participate in defining needs and expectations, imposing guidance on the health care system at a political level.

It would be tempting to argue that the current demand on hospital services is a legacy of a previous lack of investment in prevention and promotion interventions - especially when the relative allocation to this field of endeavour is minimal compared with the treatment sector as shown in the Pie Chart below, which is based on figures in the recent past.

It might also be claimed that a greater focus on the prevention of disease in the past would have alleviated the current situation. But “disease prevention” has been defined as:

... essentially an activity in the medical field dealing with individuals of particularly defined groups at risk. It aims to conserve health. It does not represent the positive vision of health moves ahead, but is concerned with maintaining the status quo.

With an ageing and increasing population “maintaining the status quo” is not sustainable.

A more upstream and broader strategy is necessary and it is ironic that a clue to the approach required has emerged from a narrower focus on a specific organ - the heart.

And this is not just because a recent study indicates that 75 per cent of heart disease is associated with preventable risk factors.

Getting to the heart of the problem

With heart disease being the commonest cause of death and contributor to disability and hospitalisation, cardiac epidemiology is a logical priority for study. Through expatriate Professor Sir Michael Marmot’s research into the causal pathways to heart disease (the Whitehall Studies), the broader determinants of health were unearthed. The importance of this work was recognised by the European Office of the World Health Organisation who approached and asked Professor Michael and his team from the International Centre for Health and Society to identify the broad implications for policy in ten selected areas.

The resultant booklet, The Solid Facts (pdf, 3.1MB), is currently being translated into the main European languages and is being distributed across health organisation networks in more than 25 European countries.

Of the ten steps Professor Sir Michael indicated that he would give priority to the first, namely social gradient. With my child-health bias, I admit to some disappointment when Sir Michael did not choose the early years as most important. On reflection, however, having parents who sense they are in control of their destiny is likely to induce a healthy psycho-socio-economic environment for raising a healthy child. His document and associated book refer to studies that demonstrate that poor social and economic circumstances present the greatest threat to a child’s growth, and launch the child on a low social and educational trajectory.

These threats to child health and development prompted a call for, “…a strengthened prevention agenda that extends beyond the capacity of the individually orientated medical care and require[s] a more vigorous and creative public health approach.”

There is now a wealth of evidence to guide the development of this public health approach both from overseas and in WA but a dearth of research to demonstrate the cost-effectiveness of early childhood intervention programs in the long term. However, the same applies to more costly interventions later in life making cost benefit comparisons difficult. The following table summarises the cost-benefit analysis of the highly acclaimed High/Scope Perry Preschool Program.

In this study, children were randomised to intervention and control groups and followed through until age 27. Although the sample was small (117) there was enough information to calculate cost savings from reduced time in special education programs, reduced need to repeat a grade and reduced chance of incarceration. Despite these calculations the Perry program is considered too expensive to implement universally. It would be revealing to compare the cost/benefit of this program with, for example, coronary bypass surgery. It is likely that the more expensive intervention (surgery) provides less return in terms of dollars saved. It is mere speculation that an early childhood intervention program might also prevent the need for cardiac surgery due to greater opportunity for reaching a higher socio-economic status. However, there is evidence that the foundations of adult health, including cardiovascular health, are laid in prenatal life and early childhood.

The illustration below shows the relationship between expenditures on programs in respect to learning, behaviour problems and health throughout the life cycle against expenditures during the critical years of brain development. By comparing the allocation of health and social service resources to adults in contrast to children it could be argued that the greater expenditure towards the latter end of life is driven by an inadequate investment in early life programs.

Clearly, investing in early childhood would be a very long-term solution to the current illness crisis - and there is only circumstantial evidence to support this theory. But even if the theory proves to be wrong the benefits from investing in early-childhood programs would be inestimable. And that’s the problem. In a market economy, if the value of a product is immeasurable there is a little chance of attracting investment especially as children are non-contributors to the GDP. A similar disadvantage applies to “health” for which there is no demand - only for its return when it has been lost.

Mathers and Douglas summarise the situation in Eckersley’s book Measuring Progress by saying:

In the modern economic climate, outcome indicators are seen as measures of productivity and they are inclined to influence what services do. While there are well validated indicators of death, disease, and disability, the systematic measurement of the impact of disease on wellbeing is still not well done, a measurement of the positive constructs of physical, mental, social and spiritual well being is not generally seen as an aspect of health sector activity.

This one-sided view of health also ignores what has been learnt about the broader social determinants of disease and the two-way connections between wellbeing and illness. The psyche is intimately connected to the soma; nearly every disease is more common or more serious in the socially deprived, and the way individuals in society deal with disease is intimately linked spiritually … Whatever the recent gains of medical technology, immunology and molecular biology, in changing the course of illness, there must be said in the context that huge gains in life expectancy were well under way before the advent of modern medicine and that the social environment seems to be a major factor influencing not only illness but also well being.

In the 21st century it will simply not be adequate for health systems to continue to focus exclusively on illness and on prolongation of life ... Failure to properly conceptualise and measure positive wellbeing and sustainability may be contributing to the myth of a community’s aggregate wealth is synonymous with its wellbeing. That premise could be utterly false.

The medical fraternity has benefited from and continued to build on the illness business that our primeval practitioner established millennia ago. The time is overdue for us to recognise we have contributed to the problem and we are, therefore, part of the solution. Perhaps the inverse of the prevention paradox is a factor - namely an intervention that brings large benefits to each participating individual but affords little to the community. For example, a patient may benefit from the latest diagnostic imaging technology - because the physician is better able to make a diagnosis - but if this comes at the cost of a universal prevention program that would benefit thousands of people, is this justified?

The community needs to be involved in a debate with medical practitioners on how much it is prepared to pay for treatments that have a limited impact on the health of the population.

The Health Administrative Review Committee noted that, within Western Australia, some work has been developed by the Medical Council to work with Citizens’ Juries about priorities in health. The Committee recommended that the Minister for Health and Health Department initiate a continuing, informed, bipartisan community discussion as to what Western Australians can expect from their health system, and the priority issues to be addressed.

During this discussion it would be prudent to take note of a suggestion by the US Committee on Integrating the Science of Early Childhood Development:

The charge to society is to blend the scepticism of a scientist, the passion of an advocate, the pragmatism of a policy maker, the creativity of a practitioner, and the devotion of a parent – and to use existing knowledge to ensure both a decent quality of life for all of our children and a promising future for the nation.