Prevention is the new black in health policy. It is being touted as the saviour for our troubles, a way to intervene earlier in the treatment cycle for people with chronic disease, especially diabetes, and thus keep people out of our now very expensive high tech hospitals.
But do our politicians really understand prevention and are our health departments well equipped to understand and implement this new focus on prevention and population health? Do they have the expertise, the structures or the will to really support a prevention focus?
Clearly not everyone believes we have the right structures. Health departments around the country have been undergoing restructuring in an effort sharpen the focus.
Following a downgrading of public health across the country over the past decade — from division to branch level in Victoria nearly 10 years ago, breaking it up in the Commonwealth, WA and SA into health promotion or population health and health protection — there is now a turn around as governments and bureaucracies scramble for an understanding and some functionality.
WA is probably the most dramatic case, where after prevention (health promotion in the old terms) was virtually outsourced, the department has spent the past 12 months or so trying with very mixed success to rebuild capacity.
Many senior public health — read prevention — officials have privately expressed concern at the dearth of understanding inside traditional health departments and the general lack of influence they have in them.
The prevention advocates have clearly been unable to break through. The medical bureaucracy is in control, and they are fighting back, recasting prevention in a medical model.
The Commonwealth has a serious misunderstanding about prevention and public health. They led the charge to a medical model a few years ago and split the “functions” between health protection and population health.
The result has been an inordinate preoccupation with mass disaster planning and medical preparedness that has flowed through even to the recent response to swine flu, where they clearly ignored their own public health experts and promoted responses that were based on individual treatment activities.
One might assume that the National Preventive Health Taskforce’s report and the establishment of the National Prevention Agency mean the times are changing.
But if you look at the detail, this eschews a public health approach based on evidence and good systems practice, for a gloss of concern for individual illness with solutions individually targeted e.g. eat more fruit and vegetables and exercise more.
And now Victoria has followed suit. In August, Premier Brumby announced a split of the monolithic cumbersome Department of Human Services by creating a Health Department charged with advancing a prevention agenda.
He then sat back and waited while medical traditionalists and health bureaucrats agonised for almost two months before announcing a new structure that follows the Commonwealth path, in splitting public health into prevention and health protection, and sending three-quarters of the resources to the latter.
Victoria doesn’t seem to have learnt from the WA experience, where they are having real trouble in rebuilding capacity in a split department. This is understandable; once you destroy or disperse capacity, it isn’t easily rebuilt.
It is even more surprising given Victoria’s recent history involving a series of scandals that lead to the positions of director of public health and chief health officer being split just over two years ago.
Prevention will not succeed as a medical model. It is not about illness — it is about keeping people as well as possible. It cannot be tackled by small health promotion or early intervention activities. It needs whole of population or large community interventions backed by regulation and social marketing.
There is a real difference between population approaches and individual risk behaviour solutions, but our politicians and bureaucrats don’t seem to realise this.
Some argue that the only way to institutionalise a population health response is to remove prevention from health departments. Some places have tried this — Canada, for instance, created the Public Health Agency of Canada after the SARS outbreak, and many European countries have strengthened structures in public health and prevention.
But Australia doesn’t seem to have the will to take on the medical bureaucracy. Governments may be talking about innovation, prevention and change, but the medical bureaucracy appears to be fighting back. And winning.