Early intervention and prevention dramatically improves health outcomes. It is clear that keeping individuals healthy, preventing progression of chronic diseases and intervening with young children to cure problems before they have a lifelong impact leads to healthier and more productive communities and is cost effective.
The impact of such early intervention and prevention strategies, however, is difficult to measure given the lead time to realisation of the benefits.
Speaking at the 2018 Dean’s Future Health Forum last week was Ms Susan Templeman MP, Member for Macquarie and former radio journalist, where the theme was Dare to Change: a New Era in Health.
Ms Templeman, moderated the eminent panel members to explore how together, we all can dare to change and deliver better health outcomes.
The inaugural Health Forum has become one of the must-attend events on the calendar, opening discussions combined wisdom and expertise of the audience from thought leaders and healthcare shapers.
One of the first topics the audience was asked to consider was “how can we persuade government, policymakers, and the healthcare sector to invest in early intervention and prevention?”
Professor Kathryn Refshauge, Dean of the Faculty of Health Sciences at the University of Sydney, began by saying “we know the problems”.
“First, one in 10 patients in Australian hospitals have some sort of complication. That is 9000 people per annum as reported by the Grattan report this year”.
“Some of those complications is bruising after surgery, how is that a complication?
You get more funding if you report it as a complication. In amongst those 900,000, there are avoidable serious complications. That is inside our hospitals, but we need to keep people out of hospital – it is cheaper and safer”.
“Secondly, the health system is an excellent system if you are in the top demographic, but a lot of people are missing out.
We know that health status and the effectiveness of health care for individuals and communities is determined by the social and political determinants of health and that is work outside the hospitals”.
“And where these strategies are most needed and have the greatest impact is in communities with low education status, low income, greater geographical distance from centrally located, city-based services”.
How do we persuade government to invest in early intervention and prevention?
Minister Wyatt perhaps the most appropriate panelist to answer this question stated “It’s always interesting when we go into the political arena in terms of preventative health. The pressures brought on governments are not from the health prevention thinking. It is from the reactive voices who argue that elective surgery lists are too long, or that the types of treatments available are the priority of groups that have got a vested interest”.
“And I say this in the context, I used to work for a funeral director for three years and what I used to see and hear, people would say, if I could only turn back time, my husband would still be here…” Or, “My wife,” or, “My child.” And often they would talk about a point at which the illness presented itself in a form that they understood but it was often too late. And they said, “Why is there no focus on prevention?”
“I hear the debates around obesity. And I hear the profession talk about the need to curb obesity. But the people that have the greatest influence are those who are treating the individual, who when you talk them through how they can slow down their life ending sooner, people do modify their behaviours but not to the full extent”.
“Because the mindset we have arising out of the learning processes for the profession often prevails within the community, and the community will think that the immediacy of treatment is more important, and access to good healthcare is more important, than it is for prevention because, “I can still have a good time doing things that are harmful to my health, and then I will be fixed with a tablet,” or pill or treatment”.
How do we start prevention and early intervention with people not already in the system?
When we talk about people coming for treatment, a lot of prevention happens with people who are not coming for treatment.
Professor Kathryn Refshauge says “So it is reaching out into the community to prevent a disaster or catastrophe, rather than keeping people well and treating them on the daily basis”.
“That’s the bit where there are no jobs, there is no funding. So we can, as Ken [Minister Wyatt] suggests very sensibly, we should absolutely do that, very wise to educate our students to include prevention strategies for all their people that they see.
But how about when we should be reaching out to people who aren’t in the system yet?”
“That’s where a lot of our prevention and early intervention needs to happen”.
“With very young children, we can work with them to prevent lots of things happening down the track but there are no positions funded for that. That’s the area where it is really hard to prove the benefits. There is no funding at the moment”.
“A really nice example of that is with SIDS. There is a practice lag greater than 10 years and they have looked at the data and shown they could have prevented over 50,000 deaths had they actually done prevention 10 years prior”.
How do we shift long-held beliefs and entrenched healthcare practices to design more appropriate health promotion campaigns – services that are dynamic, agile and innovative?
“Do we take the notion that instead of dealing with body parts, when we run awareness campaigns, that we really should focus on the holistic element of an individual and then look at what are all the health promotion messages that have to be out there. Because we have a week for lungs, a week for liver, kidneys etc”, says Minister Wyatt.
“We’ve got to rethink the way in which we promote messages.
What worries me is people become blasé to health campaigns when there are a significant number over 52 weeks of the year, because you wear a ribbon for lung disease week or whatever”.
“We have to rethink and challenge and dare to be different to talk about how we keep the individual wrapped around with the information they need to make choices. Because we can access points of healthcare if we know about them and what your body is doing, but we are not attuned to our bodies even when we are ill. And men are worse at that”.
Changing the focus in aged care – that helps residents improve their function rather than just maintain
Jennifer Hewitt – Physiotherapist and PhD student The University of Sydney spoke about the work she is doing in aged care using her “physiotherapy lens”.
It was here she observed residents functioning at 20-30% of their potential.
Ms Hewitt said that working in aged care there was a focus on keeping residents at their “current level and doing treatments that for the rest of the physiotherapy world have been outdated 20-30 years ago”.
“I decided I needed to get out of that system altogether or I needed to help change it”.
“So I decided to change it”.
Ms Hewitt was involved with a randomised controlled trial including multiple care facilities and 220 participants.
Participants in the study’s mean age was 86 and the eldest was 101.
Half of the group exercised and the other half carried on as usual.
“The exercise involved bringing a gym into the village and conducting classes for two hours a week where people came and worked out on the gym equipment and did some fancy footwork so they could learn to react quickly if they started to fall”.
The five year study, involved the primary measures of falls and physical performance, which followed secondary measures of a 12 month follow up.
The results demonstrated a reduction in falls by 55% in people who did the exercise program, and their physical performance was improved significantly.
For every fall that was avoided, there was a cost saving of $670. That equated to about $120 million per year saved for the health economy.
“This had huge ramifications for the healthcare system, for the people that look after older people because it is traumatic seeing them fall and decline, but more importantly, it really helped the residents to feel proud of what they could achieve and to be able to participate in so many things they could not have done without the exercise program”, says Ms Hewitt.
Research shows that “falls cost more than any other form of trauma including motor vehicle accidents. We carried out a cost effectiveness analysis so we could look at not only the physical and personal benefits, but also from a health economic perspective”.
The future of allied health in aged care
Minister Wyatt shared an observation from his second week in his role as Assistant Minister, “I met an occupational therapist and a physiotherapist who were employed to address the pain management quality standard within the Aged Care sector”.
“Both of them said to me that massaging people made no difference to pain. They found that when they jettisoned that idea and got people moving and mobile, including dancing, it changed the whole dynamic”.
“Originally they met resistance within both of their facilities. But both of them grabbed the opportunity to talk to me about it. So now we are focusing on re-enablement of senior Australians in the work we are co-design in with the Aged Care sector”.
“The Aged Care sector has been very traditional in its approaches over a number of years, but they are changing. And they are now starting to reflect what community is thinking about”.
“And the enablement, I have seen one Aged Care provider in my own state who has enabled three people to return home. When they came in, they required a level 4 package and now they no longer need it because they have changed the emphasis of well-being”.
“And part of the debate we have to have in this nation, and the discussion, is challenging the status quo. Because one element of that last question is we are comfortable with the status quo and change is challenging”.
“And when an individual challenges with a new idea about doing something more effectively, they are often met with resistance”.
“So my advice to you is don’t give up”.
“Seize opportunities when they arise”.
Professor Refshauge says “we really need to change the perverse incentives”.
“The Aged Care funding instrument funds only two treatments for physiotherapy in Aged Care, one of which is transcutaneous nerve stimulation, the other is massage”.
“That’s it. You cannot get funding for anything else”.
“They are both outmoded. They are not necessarily harmful but they are not beneficial.
Nothing else can get funded so you have to go private. So the work that Jenny did is unfunded. But it has massive benefits and it is cost-effective”.
“But the other problem with that is that you get more funding as an Aged Care residential facility if you have high dependency patients or residents”.
“So as soon as you make them well, or they can go home and have date night or ride a Harley-Davidson, then they are low dependency and the facility gets less funding.
So the residential Aged Care facility is not interested in helping the residents be more independent and have a better life and have fewer falls and save money for the system because of this fragmenting in funding”.
“There are many examples of that. I don’t know if it should be mentioned because it is a good workaround but there is no funding for long-term rehab so if you need long-term rehabilitation, some places admit you as an inpatient for the day so you can get funding for that rehabilitation because there is no other way to get it funded”.
“Reporting things as a complication when, did you really have surgery if there is no bruising?”
“All of these are perverse incentives so there are workarounds everywhere”.