Investing in prevention is essential to our nation's long-term productivity
The recently announced 2014–15 federal Budget will have both direct and indirect adverse effects on prevention, especially of chronic diseases, which are Australia's major causes of death and disability. A government concerned about future productivity and extending the working life of Australians should be investing more in preventing chronic disease, and not less. Chronic disease is a common cause of shortened working life, even when it doesn't kill.1
The direct effects of the proposed federal Budget on prevention include cuts to funding for the National Partnership Agreement on Preventive Health, loss of much of the money previously administered through the now defunct Australian National Preventive Health Agency, and reductions in social media campaigns, for example, on smoking cessation. Increased funding for bowel cancer screening, the Sporting Schools initiative, the proposed National Diabetes Strategy and for dementia research are positive developments, but do not balance the losses.
Beside the direct effects of the 2014–15 Budget cuts on prevention, there will also be indirect consequences on health. The $7 copayment for general practice and pathology services will be felt in primary care. In the much cited United States RAND Corporation Health Insurance Experiment of the effects of medical service pricing on the behaviour of nearly 6000 patients between 1974 and 1982, the group required to pay a copayment reduced their attendance for control of hypertension and vision screening.2 Other studies confirm that health care visits for preventive activities are the ones most reduced by financial hardship or disincentives.3-6 Baseline assessment of blood lipid profiles and blood pressure are critical in assessing patients' risk of chronic disease, and regular measurements are part of good care in preventing complications in patients with chronic conditions like diabetes. For patients with chronic diseases, each general practice visit will incur a copayment of at least $14 (consultation plus pathology tests). Higher copayments for prescription medications will be felt by those who need treatment for elevated cholesterol levels and blood pressure. The effects of these copayments on preventive behaviour are greatest among those who can least afford the additional costs.7 The potential for prevention is greatest among poorer patients, who are often at a health disadvantage.
Prevention programs always struggle to maintain funding when competing with the more immediate demands of acute services. So, the proposed reduction in future federal government contributions to funding the growth in public hospital activity will reduce enthusiasm for spending on preventive programs even further. The Australian Government's commitment to index its contribution to public hospital costs to population growth and the consumer price index will be insufficient to meet the predicted increase in demand for health care. In this environment, activity to prevent anything other than communicable disease may need to be cut. It is laudable that at least one state government health minister has recognised the need to continue commitments to prevention programs despite the impact the cuts will have on acute service funding, but it is hard to see how this can be done in practice.8
We have learned from control of communicable diseases that continued vigilance and ongoing preventive action is essential. The same applies to preventing chronic disease. Of great concern are recently published Australian Institute of Health and Welfare data suggesting that the rate of decline in mortality from cardiovascular disease, still Australia's biggest killer, is slowing, especially among cohorts under 55 years of age.9 The more than 60% reduction in cardiovascular mortality since the mid 1960s is one of Australia's great prevention success stories. So, in terms of future productivity and health care costs, this slowing of the decline in mortality from cardiovascular disease (which is consistent with changes in risk factors including increasing rates of diabetes) should be a major concern. It is another reason for more and not less investment in prevention of chronic disease.
The greatest pity of all is that the proposed cuts to funding for health come at the time when the first evidence is at hand of potential benefits of the large-scale preventive programs implemented under the national partnership agreements. A slowing in the rate of increase in childhood obesity10 and reductions in smoking rates among Indigenous populations have been hard-won achievements.11
A healthy economic future for Australia is intimately linked to the future health and wellbeing of our population. Part of the strategy to achieve a healthy, productive future must include more support, and not less, for preventive activity in health care.