Opinion & Commentary
Rudd’s preventive health plan is a policy looking for an evidence-base
‘Evidence -based policy’ might be the mantra of the Rudd Government, but its Super Clinics policy is not at all evidence based. The better description - to borrow the words of one candid public health academic – is ‘a policy looking for an evidence base’.
Ask any public health expert what’s wrong with the health system. The answer invariably is that not enough money is spent on prevention. Only 2 percent of the health budget (the often-cited figure) is spent keeping the population well.
The specific problem, they will add, is that our costly, hospital-centric health system is designed to cure the chronic disease consequences of unhealthy lifestyles rather than change the individual behaviours—poor diet and lack of exercise—that cause obesity and increase the risk and prevalence of chronic illness. The policy priority should therefore be to re-focus the system around bigger and better public health education campaigns, and, better still, around greater amounts of ‘preventive’ primary care.
It’s hard to disagree with what sounds like commonsense - given the demand and expenditure pressures spiralling rates of obesity and ‘lifestyle disease’ are placing on the public hospital system. But rarely commented on (especially in the closed circles which formulate health policy) is that for the last four decades Australian governments have already spent millions of dollars promoting healthy lifestyles, just as the experts advise, to less than spectacular effect.
But so unquestioned is the assumption that more government spending on prevention is a sure and seamless process which leads to better health and lower health costs, that governments keep committing higher and higher sums to more elaborate prevention policies.
Witness the preventive health policy the Rudd Government took to the last election to tackle the obesity ‘epidemic’.
Based on a highly questionable interpretation of a collection of mainly U.S. studies, the government claims that international evidence shows that health systems more strongly oriented towards primary care services achieve better health outcomes at lower costs, due to the ‘preventive care’ delivered in primary care settings.
It stands to reason that doctors tell overweight patients to lose weight, moderate their diet, and exercise regularly to protect their health. But when the alleged international evidence is examined, you find that the studies referred to admit that they contain no actual evidence that receipt of primary care reduced obesity (modified individual behaviour) or lowered the incidence of (actually prevented) chronic disease.
Nevertheless, the government is committed to spending millions of dollars on new a national network of GP Super Clinics, which will bring together general practice services with a wide range of allied health providers – physiotherapists, podiatrists, dieticians - in order to boost community access to so-called ‘preventive health care’. The plan, in short, is to expand Medicare (transform it into a weight-loss advice counselling service) by making whole teams of health professionals responsible for helping manage patients’ lifestyle decisions.
The problem, however, is the lack of evidence that the ‘lifestyle interventions’ Super Clinics are designed to deliver are an effective means of changing unhealthy diet and exercise behaviours and will ‘facilitate’ lifestyle change as promised.
In 2005, the Australian Chronic Disease Prevention Alliance - a combination of non-government prevention organisations – went looking for this evidence– and found the evidence was both ‘limited’ and ‘scarce.’ Researchers from Monash University’s Health Economics Unit also reviewed the best international studies, and instead of establishing a platform to justify the rollout of a new ‘evidence based’ policies, they likewise concluded that the evidence was ‘poor’.
Also noted was what international studies consistently find: that even Super Clinics-style, high-intensity, professionally-guided lifestyle interventions have had low impact on behaviour, particularly in relation to the most crucial factor - long-term retention of lifestyle changes.
For instance, a far from compelling 2003 study by the US Preventive Health Service Task Force (USPHSTF) determined there was ‘fair to good’ evidence that a combination of high-intensity behavioural interventions targeting ‘obese’ (but not ‘over-weight’) adults can produce modest weight loss. Yet not only were most of the relevant studies marred by problems such as small samples and biased data, overall, and once again, ‘trials with follow-up beyond 1 year tended to show a loss of effect.’
Rather than showing that more spending on prevention achieves the outcomes perennially promised, what the evidence demonstrates is how very difficult it is for lifestyle interventions to succeed. Because lifestyle modification is ultimately the responsibility of the individual, and depends on people possessing the personal qualities—will, self-discipline, and impulse control - to sustain changes to unhealthy but often pleasurable behaviours, in any meaningful sense, no government-initiated measure can with certainty control what people decide to eat or how much they choose to exercise.
What the evidence, unfortunately, suggests is that many of the intended recipients of Medicare-funded lifestyle interventions will fail to modify their lifestyle – and taxpayer’s will be left footing the bill for ineffective ‘preventive care’.
Dr Jeremy Sammut’s paper The False Promise of GP Super Clinics, Part 1: Preventive Care will be released by The Centre for Independent Studies this week.
