Health Media Club – Parliament House Brisbane
August 4, 2012
I would first like to acknowledge the traditional owners of the land.
Thank you for the invitation to speak. I do so with some temerity, as an outsider, albeit a regular visitor since I was first here as a speaker at the 1977 Australian Cancer Conference. (A conference that was especially memorable to me for my first meeting with the then Premier, Joh Bjelke-Petersen, who exhorted me to support a cancer quack called Milan Brych.) But I have of course the highest regard for many friends and colleagues in the health system and also in the academic and research arena, where there are not only international but world leaders. I have particularly fond memories of Parliament House in Brisbane, as this was where as a senior bureaucrat I attended my first Australian Health Ministers’ meeting in 1985, when we got a commitment to the first strong tobacco health warnings.
I am also conscious that while there are risks in commenting as a non-Queenslander, it may be easier for a speaker from outside the state to comment about some present or possible developments at a time when clearly public servants are unable to speak, and people in the non-government sector must be concerned about gags, cuts and fears about cuts yet to come.
The main focus of this talk is on prevention, but I will also cover some issues around health, health systems and re-organisations as I move towards the conclusion that some developments here are a slow-motion disaster in the making.
First, some comments on context.
Australia is by any standards one of the world’s healthiest countries. Life expectancy at birth is now 84 for females, 79.5 for males, with Queensland a touch below the average – albeit here, as elsewhere, Indigenous children are massively disadvantaged from birth in this most fundamental area. Our health system nationally is also one of the best in the world, although we spend only around 9% of GNP on health – as compared with the US, which is up at around 17%. As a nation, in our complex mix of public and private health, we spend over $120 billion a year on health, and health generally takes up around a quarter of a State’s total budget. It is difficult to get accurate figures on state-by-state spend on prevention – all the more now as health spend on prevention has recently been dropped from a list of national indicators published for all jurisdictions – but the general estimate is that around 2% of health spend goes to prevention, quite broadly defined.
As in all developed countries, our health systems are subject to enormous pressures. Public satisfaction is generally measured and reported not by how long or well we live, but by ramping outside emergency departments, and the length of waiting lists. Concerns around emergency departments are a relatively new phenomenon that developed around the world in the late 1990s. Before this it was quite common for hospitals to run at around 85% capacity. In my state of WA, major teaching hospitals even competed with each other to get ambulances driven in their direction! But the world has changed, EDs started feeling the heat – and along with that came the pressures on beds and budgets that torment hospital administrators.
Until then, health was a second tier portfolio in Government – health ministers were often new or relatively junior ministers.
But times have changed. Health is high-profile, and a portfolio for senior ministers who can handle political and media pressures. We face a world in which there is huge public and media interest in health; everybody can see on television or click onto a site to obtain information about miracle cures; we all expect all possible services to be available instantly and on our doorsteps; while health systems have to provide a vast range of often expensive services – not only in hospitals, but in communities across the state, from mental health to aged care; and they face constantly increasing costs from salaries, equipment, drugs, buildings, and simply the challenges of providing all the services that communities have come to expect.
The Commonwealth and States are perennially at war over health funding. If it were a marriage, both sides would have filed for divorce years ago on the grounds of mental cruelty. And yet governments and health ministers are elected on explicit or implicit claims that they can “fix” health, and somehow, overnight, do things vastly better.
Just a little more on background, with apologies for covering ground that will be familiar to many of you.
For many years, until around the turn of the century, Queensland was pretty much the back marker for state-spend on health, well down on what was seen as the norm in Australia. Paying doctors and others less than other states may be a nice way to save money – but it is also a sure fire way of losing good people. And there is always a risk that when money is tight, areas ranging from prevention to safety and quality may be perceived as luxuries.
In recent years, however, some of that has changed, and Queensland is now around the national average. I say “around” because given the complexity of health systems it is virtually impossible to be precise – some jurisdictions handle matters in very different ways; there are even variations in what is included in the health portfolio. I note that recent claims that, for example, the Queensland spend is now well ahead of the rest, so needs to be reined in; but if ahead of the average, it’s not by much - and some reports cited to justify these claims come with clear caveats that they cannot be used to make straight comparisons.
That said, it would be naïve to argue that there is no scope for savings in health, as anywhere else. There is always scope for improvement, and it is always possible in any organisation to find examples of real or apparent waste.
But having read the Minister’s speech to this group at the beginning of August, I find it hard to take seriously the rationale that we must make cuts now because “at this rate of expenditure growth, Queensland Health will consume the entire Queensland budget by the year 2030”. Of course that won’t happen and could never happen, and a sensible debate is not helped by this kind of sabre-rattling. It’s about as realistic as the speculation towards the end of the nineteenth century that if current trends in horse-drawn carriages continued, the streets would eventually be house-high with horse-manure.
It is also not helpful to imply that health systems are seriously over-funded, and are amenable to cuts and reorganisations that will result in significant savings without reducing the extent, quality and safety of services, or the health, well-being and ultimately the longevity of our communities.
But if there are indeed understandable concerns about health budgets, we should surely be looking to increase our emphasis and spend in prevention as a means of reducing pressures on the system, including something as straightforward as avoidable admissions.
Just as your longevity is now marginally below the national average, so some of your health indicators and behaviours hover around the middle or a bit below. For example, as a state you have a record of smoking more, drinking more, and being more overweight than the average for the nation.
So what is happening here and how is it being perceived?
The available information indicates that there will be major cuts in the forthcoming budget, although the extent and detail are as yet unclear. Initially, 20,000 jobs were to be cut from the public sector: that is now down to a mere 15,000. 4,000 of these were to come from the health system – so presumably that may come down a bit to 3,000 or more.
The jobs to be cut will apparently not be those of “frontline” workers – defined as those who spend 75% of their time interacting with the public.
The health department has been restructured, with many services to be devolved to 17 new regional hospital and health boards.
The full range of cuts is clearly yet to be revealed, but it appears that prevention/public health will be substantially affected.
Despite claims of a commitment to prevention, the initial focus of activity in areas such as gun control, liquor control and gambling has been around making life easier for those who want or have access. Notwithstanding a strong law and order agenda, the first port of call for gun control was to establish a committee to advise on easier access for gun users. The committee initially comprised six representatives of the gun lobby one of whom has been reported as saying that measures introduced after the 1996 Port Arthur massacre were “unduly restrictive” – now complemented by a solitary Police Union representative.
Despite well-justified community concerns about alcohol problems, violence and the youth binge-drinking culture, the government has announced its intentions to make access to liquor licenses easier.
And there have been reports that staff overseeing casinos will be cut.
All these areas may require some consideration. But one has to wonder at the priorities of a government in addressing gun control, alcohol problems and gambling when the first response for each area is to look at easing up on the controls.
Government staff are of course properly constrained from public comment, which is why in a healthy democracy it is so important that the non-government sector should have the ability to speak out. But it appears that any non-government organisations in receipt of substantial government funding – as so many are – will specifically have to sign contracts that preclude them from engaging in standard advocacy activities.
The standing of public health has already been reduced in the Departmental restructure. The Chief Health Officer is no longer in the second tier, but is now third-tier, reporting to a Deputy Director General.
A series of public health activities will be devolved to the 17 Area Boards. While the detail, where the devil resides, is still to come, and there have been mixed messages about BreastScreen, we know that what is described as “clinical service delivery” of public health functions (“communicable diseases, environmental health, regulatory functions and clinical TB services”, as well as health promotion, and activities such as public health nutrition) will be devolved to the 17 boards.
It also appears likely that little comprehensive background on business cases for major change or consultation will be required.
So with that as a backcloth, I want to address some current issues.
First, reorganisation. Health departments around Australia are suffering from reorganisation fatigue. Our system overall is as good as any around the world – yet governments seem to think it will benefit from a diet of constant reorganisation.
This is not to argue that health systems don’t need fine-tuning and change, but there is a kind of reorganisation mania afflicting new governments in particular. Reorganisation is the panacea – a new structure, and all problems will be solved.
The reality is very different.
First, all the key services must be delivered as before. The main difference with a new structure is that life gets a bit more complicated for everyone.
Second, the business of developing and implementing a new structure is immensely time-consuming – and brings costs and risks in its wake. New roles, branches, workplans and working relationships have to be developed. Jobs have to be created, advertised and filled. There are enormous uncertainties for staff. People act in positions – often for lengthy periods. Staff who don’t fit have to paid out or found new roles. Many of the claimed efficiencies from restructuring are heavily outweighed by the costs and inefficiencies they bring. In Queensland, as in other States over the last decade or so, since Rob Stable moved on in 2004, you have had a revolving door for Directors General – on average one every couple of years or so, and each new DG brings their own approaches to structure and staffing.
Third, reorganisations around Australia, as around the world, lurch between advocates of centralisation and decentralisation. Whichever system you have in place can easily be blamed for the problems of the present. So there may be a push to decentralisation today – but when that does not succeed in sorting out all your problems, there will be a push back to more centralisation – with a further reorganization and restructure.
Restructuring may sound good – and it may provide some distraction from ambulance and ED pressures – but it is as likely to create problems as it is to solve them.
In passing, I should note that any claims for the proposed new Queensland approach that it is designed to fit with recent approaches to national health reform are at best optimistic. The recent national health reform process has been immensely complex: it does entail some moves from the Commonwealth towards regional groupings, such as Medicare Locals, and the development of hospital networks, but this should not be used as a rationale for major cuts, devolution of key services, or abandoning public health to the whims of local Boards.
Devolution may sound good in theory. But devolving many services can be expensive or a recipe for disaster – possibly both. All the areas will of course need their own administrative structures – as well as support for the boards. They will need senior staff to run the Areas. Good health administrators don’t come cheap. And there simply aren’t that many of them around, so you won’t get the highest quality people – especially in the knowledge that they will have to run cut-price services. There is no way that 17 boards will have the expertise to address all the issues and problems they will face. Their staff will be the middle-people in disputes over territory, funding and priorities between their boards and the central department. There will be disputes about priorities, who does what, and who has the funding for what. And there will be major problems and confusion for NGOs (and some inside government) who will now have to deal on some issues with seventeen entities, not one.
The phrase ‘frontline services’ seems to have been used a lot. The definition of ‘frontline’ workers offered by the Premier appears to be those who spend 75% of their time interacting with members of the public.
As someone who has worked in public health for 40 years, I have to tell you that this doesn’t make sense. ‘Frontline’ may have a nice political ring to it, but it is a military term, inappropriate as a basis on which to make decisions about budgets or staffing.
There are innumerable key health professionals – from pathology to pharmacy – who barely interact with the public, if they do at all.
The implication we hear too often that health administrators are an inferior species is short-sighted and offensive to the staff who work so hard behind the scenes to keep the system running – from IT to HR, let alone medical and nursing administration.
Queensland Health achieved national and international notoriety in recent years around two themes: safety and quality in hospitals, particularly in Bundaberg; and payroll problems. It may well be that the latter could have been avoided with more administrative focus. But the Bundaberg events should send out a strong message that people working to ensure safety and quality are absolutely crucial. They may not be ‘frontline’ – but in their absence we put our frontline staff – and patients – at increased risk.
My greatest concern about the ‘frontline’ term, however, is in relation to public health.
As in the rest of Australia, Queenslanders enjoy a good life expectancy. At the start of the last century, you could have expected to live to 50 or 55 if you were lucky. Now you can expect to live to around 80 for males, 84 for females – and that is still rising.
Much of this amazing progress has come from public health – the sanitary revolution, safe water, safe food, a safe environment, followed by community-focused measures and programs in areas from immunization to road safety, with more recently a decline in smoking.
All of these – all of them – have been hard won against opposition for philosophical reasons, for commercial reasons, because people did not understand the evidence, and simply because of resistance to change.
In 1851, when the UK was moving towards its great sanitary revolution, led by the pioneering epidemiologist John Snow, an editorial in the London Times thundered, ‘We prefer to take our chances of cholera and the rest than be bullied into health by Mr Snow. Every man is entitled to his own dung heap’. We have since seen opposition to measures to protect our food and our environment, opposition to immunisation and road safety and tobacco control measures.
Almost all action and legislation in these areas eventuated because governments were pressed by public health organisations – unthinkable if they had been gagged.
I would not want to be misunderstood: we need prevention as well as treatment and care, not instead of it – but we do need prevention.
I don’t think the community or many of our decision-makers understand how thin the ice we skate on is in relation to traditional public health – how few people there are working in areas such as communicable disease control, environmental health, food safety, or disaster prevention and management, or how important their work is. There is an occasional flurry when we have a real or apparent crisis – as with swine flu or SARS – but for the rest their work is carried out with little public fanfare. Yet this is the work we need to keep us and our communities safe and healthy. That was a lesson our community learned after the first Bali bombings and yours after Cyclone Yasi and the outstanding public health response.
Many, indeed most of the people who work in traditional public health are not ‘frontline’ staff. Many of them sit at desks, use phones and computers, or are in areas where there may not be much direct contact with the public – from epidemiology to food safety to environmental health. But they are the people we need to keep us healthy, just as London in the 1850s needed John Snow to ensure a world where cholera was not a norm.
We now also know much more than we have ever known about how to prevent disease and premature death. As well as traditional public health, recent decades have seen enormous advances in knowledge and action to address issues such as smoking, alcohol and the rising tide of obesity. We have also seen growing concerns about the evidence showing that disadvantaged people and communities are further disadvantaged by poorer health status and shorter lives – most obviously our Indigenous communities – as well as evidence that these are the groups often most targeted by commercial advertisers of unhealthy products.
We are gradually bringing smoking under control – albeit too slowly – but we must be concerned about problems caused by alcohol and the binge-drinking culture among many young people. When around two thirds of adults and a quarter of our kids are overweight or obese, we have in every sense a colossal problem. All these problems put further pressures on our overloaded health systems, and the rising tide of diabetes will generate massive further costs.
We have learned that these and other public health problems are not just waiting for a single magic bullet: they need comprehensive approaches, from regulation to public education and community programs.
We have learned that while you need community-based programs, you need strong central expertise, programs and coordination.
We have learned that in public health, as in other areas, the more you invest in evidence-based activity, the better your outcomes will be.
We have learned that public health gets good outcomes, from immunisation to tobacco.
We have also learned that even in areas such as screening, we are only part of the way there – we need more, not less.
We have also learned that those who benefit most from good public health policies and programs are the most disadvantaged in our communities.
In recent years, Queensland has gained a good reputation nationally for some of its approaches to public and community health.
Clearly all the information is not yet in – and will not be until the Budget, and possibly later. Governments that are cutting important services traditionally try to get the information out through a drip-feed approach that means nobody can really gauge the full extent of the cuts until it’s far too late to do anything about them. I should emphasise here that of necessity I am commenting on the basis of such information as has been provided or reported. If some minor details turn out to have been misreported, I hope that will not detract from the generality of the conclusions.
But at present, it looks as though in the public health arena:
* Senior staff positions have gone at both state and regional levels.
* Public health has been downgraded in the new structure. The key position of Chief Health Officer is downgraded (no other word for it) to the third tier, and Queensland’s highly regarded Chief Health Officer must now work through a Deputy Director General. While approaches to titles vary, this makes Queensland unique. In every other Australian jurisdiction, the most senior person responsible for public health and prevention reports direct to the CEO.
* Regional population health staff have been told that they will be moving to local health services, but no details are yet available. In this context, I would be concerned that some health promotion positions may disappear, given a cost-cutting environment and lack of understanding about the importance of their work; and along with them the capacity to continue with the good work in public health nutrition and other areas.
* Several NGOs have already lost funding – for example, the $150,000 p.a. provided by Queensland Health to Queensland Association of School Tuckshops and Nutrition Australia to support delivery of the Smart Choices healthy food and drink strategy in schools. (Ironically, an evaluation report showing the success of this program has just been published in an international journal. This required central coordination costing all of 1.8 FTE – the costs of implementation without this to more than 1800 schools would have been astronomical).
* There is speculation that the media buy for marketing campaigns being run as part of the COAG processes has been halted.
And so it goes – some information, some speculation – but all heading in much the same direction.
And then we have the devolution of prevention and public health to the Areas.
There are good arguments for local involvement and decision-making where it is appropriate, in relation to local units and activities, and also strong arguments for closer involvement of clinicians in a range of decisions. But public health does not lend itself well to this kind of broad-brush devolution. The expertise required, in areas from communicable disease to environmental health to addressing our modern epidemics requires central expertise and direction both to identify appropriate priorities and to implement action.
You will not have that level of expertise in 17 Areas. It is hard enough in jurisdictions where this has occurred to some extent, with far fewer areas. The boards will understandably be concerned with delivery of hospital and health care services. They will compete with each other – and will each want and get equipment that could have served several. They will have neither expertise nor much time to focus on prevention. I am reminded of the story Fiona Stanley tells of a sizeable West Australian town some years ago, when boards ruled there. She ‘phoned to speak with the community health nurse, and was told, ‘I’m sorry – she’s in theatre’. Modest local budgets (if provided) will be inadequate to run decent information and education programs – and again will not have staff with appropriate expertise.
Tuberculosis control and cancer screening, both of which have had some attention of late, are just the tip of the iceberg. It is fundamentally important that Queensland retains a strong, central public health group, running and directing public health activity around the state. Without that, you are putting the present health of the community at risk – and also its future health, as you will not have strong health promotion programs.
It is also deeply disturbing that non-government organisations funded by the State Government are apparently to be subjected to censorship. Health Departments traditionally fund large numbers of NGOs to carry out crucial work in the community. Now, however, it has been reported that any NGO receiving 50% or more of its funding from the state will be precluded from advocating for state or federal legislative change – and even from providing links on their websites to other organisations’ websites that do so.
This is gagging on the grand scale. NGOs may justifiably fear that the 50% figure is just a starting point, and that this may ultimately apply to any funding, and even those not currently in receipt of funding but thinking of applying will feel constrained.
I noted earlier that that our longevity and state of health derive in large part from progress in public health. I find it hard to think of any of the measures that got us here – sanitation, food safety, environmental health and safety, road safety, tobacco control – that did not occur because of advocacy by public health organisations. They were all opposed, often by commercial interests. But public health organisations advocated for evidence-based measures that they knew to be in the public interest, and prevailed.
That will have to stop. And they may not even be able to provide links to organisations such as the Cancer Council, the Heart Foundation or even the AMA and the World Health Organization, all of which advocate for legislative change!
Little if any information is thus far available about funding plans for chronic disease prevention. There was a clear LNP election commitment to ‘Reduce rates of chronic disease in the community by investing in health awareness and prevention campaigns’. There is clear evidence that as part of a comprehensive approach, well-funded, well-planned, continuing media campaigns in these areas, run independently of industry interests, can reduce the impact of our modern epidemics. These campaigns cannot be run as poster and leaflet programs on starvation budgets: they require realistic funding. We can only wait until next week to see if this commitment will be met.
In this context, we have no indications as yet about the government’s approach to our massive modern epidemics of tobacco, obesity and alcohol. The recent plain packaging High Court result is a terrific result – the tobacco industry’s worst nightmare come true – but there is still much work to be done at the state level, not least with disadvantaged groups. The powerful alcohol lobby will oppose any action that might be effective – but if governments genuinely want to address community concerns about violence, crime, binge drinking and the culture of drinking to get drunk among young people, they have a responsibility to curb access, to curb alcohol promotion, and to engage in properly funded, hard hitting education programs at all levels. Similarly, given the obesity epidemic, governments have a duty to implement comprehensive programs, including evidence-based education, and curbs on promotions targeting kids. But when the government’s first response to alcohol is entails making access easier, it is hard to be optimistic.
Downgrading public health and health promotion is even more short-sighted, given the pressures caused by preventable health problems for an already pressed health system. We can reduce the alcohol-related pressures on our emergency departments, our hospitals and indeed our police and social services. We can reduce the rising costs to our entire health system from tobacco, obesity and related conditions such as diabetes, heart disease and cancer – but only if we put more, rather than less focus on prevention.
The experience from states such as Western Australian is that building up good public health services and programs takes time – and also that change from Labor to conservative governments does not need to bring a change in emphasis. The current WA Government has shown a strong commitment to public health, and has funded important new programs in areas such as obesity.
The report of the National Preventative Health Taskforce set out a clear roadmap for action on our preventable health problems, with a focus on obesity, tobacco and alcohol. We showed – on the basis of national and international evidence – that all these problems can be addressed if governments have the will. Tobacco still kills 15,000 Australians each year. Alcohol is the cause of massive health, law enforcement and social problems. And if we can simply halt the rise in obesity nationally, we can prevent half a million premature deaths by 2050. If we really want to deal with these problems, we know what to do – a comprehensive approach for each, including public and targeted education, appropriate regulation, community and health system supports, curbing commercial promotion and working with specific target groups. It can be done – and if it is done, it will over time ease immediate health system pressures.
Curiously, one area in public where the government has so far taken to the media is HIV/AIDS. Some trends may indeed be cause for concern, but the experience of work on HIV/AIDS over the years is that community programs are important; and given that the target group of most concern is fairly narrow, as opposed to the community-wide target groups for topics such as tobacco, alcohol or obesity, one must question whether scrapping existing programs in favour of ads that don’t seem to have any clear message or call to action was well thought through.
The overall impression is of a government that is developing plans and policies on the run. We see no evident overall strategy, no careful reviews, no consultation, no focus on evidence-based approaches. Instead, there seem to be arbitrary decisions about funding cuts, use of meaningless terms such as ‘frontline’, instant restructures, a push to devolution that will create chaos and reduce the capacity for expert oversight in crucial public health areas, and a downgrading and reduction of vital public health activities, accompanied by funding policies that will effectively censor the non-government sector.
If this occurs, the health system in Queensland will get worse, not better. There will be further restructures to replace the present restructure. Downgraded public health will put the health of the public at risk and important evidence-based prevention programs will not see the light of day.
All this is apparently to be accompanied by reduced transparency, and funding policies that will effectively censor the non-government sector.
So what does all this add up to? Cuts are cuts are cuts. You cannot take hundreds of millions of dollars and more, and thousands of jobs out of a health system without reducing the quality and quantity of service and care. You cannot simply target those who are not deemed “frontline” without risking a system that is less efficient and less focused on quality. You cannot engage in a massive restructure without causing a range of problems and inefficiencies along the way. You cannot devolve to seventeen new Areas without loss of central expertise and control in crucial areas. You cannot downgrade public health without putting the health of the public at risk. And you cannot expect honest and fearless advice if you gag or intimidate those who should be advising you.
The problems will not all happen instantly. Health service staff are loyal and committed, and will work to make any system work. But if all this occurs, the health system in Queensland will get better, not worse. There will be further restructures. Downgraded public health will put the health of the public at risk. Important evidence-based prevention programs will not see the light of day.
Governments never admit error – but they can reconsider. As the Budget approaches, I hope that the government will, even at this late stage, step back and reconsider. I hope that they will consult with organisations like the AMA and the Public Health Association. I hope that they will recognise that the health of the community is too important for slogans, arbitrary cuts and ill-thought through restructures. I hope that they will reconsider their decisions to cut health budgets and staff. And for the sake of the health of Queensland and Queenslanders, I hope that they will reconsider the role and structure of public health. Public health is the foundation of our well-being and longevity. If you downgrade, devolve, dismantle, de-staff and defund public health, you put the health of the community at risk. The Government would do well to recall the edict that all doctors learn: First, do no harm.
The above is a transcript of the speech by Professor Mike Daube. You can add your comments below.