Preventative Health Investment

“Living Longer

Lives

With Dignity and Independence”

Discussion PaperMarch 2015

Dr Tony Buti, MLA &John Gregg

Executive Summary

Right now 65,000 West Australians could be freed from chronic illness and $300 million in annual hospital costs could be saved.1

These staggering opportunities are what new approaches to our state health policy could achieve, yet counter-intuitively they do not require radical change to the way in which our health system operates. In fact, the opportunity to reduce preventative chronic illness and save on health care expenditure requires action outside of the formal health system.

These findings are from the Department of Health, Western Australia. WA Chronic Health Conditions Framework 2011–2016.

The study estimates that if the measures suggested in the report were adopted within Western Australia:

• 65,000 West Australians could avoid suffering a chronic illness;

• 22,000 extra West Australians could enter the workforce, generating $1 billion in extra earnings;

• 8,000 fewer people would need to be admitted to hospital annually, resulting in savings of $300 million in hospital expenditure.

These remarkable economic gains are only part of the equation. The real opportunity for action on social determinants is the improvements that can be made to people’s health and well-being.

Introduction

Now compare the real gains listed above against the reality of the disease burden in Western Australia currently as a result of primarily preventable illnesses.

• In 2011, over half (51%) of Western Australians aged 16 and over reported being diagnosed with at least one chronic health condition or having been injured in the past year.2

• About 80% of the mortality gap between Aboriginal people and other Australians aged 35–74 is due to potentially avoidable chronic diseases.3

• Just over 40% of hospitalisations in WA are for preventable chronic conditions associated with alcohol,

1 Department of Health, Western Australia. WA Chronic Health Conditions Framework 2011–2016. Perth: Health Networks Branch, Department of Health, Western Australia; 2011. 2 Epidemiology Branch. Selected measures from the WA Health and Wellbeing Surveillance System, 2011 (Unpublished). Perth: Epidemiology Branch, WA Department of Health, 2012. 3 Australian Institute of Health and Welfare. Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians. Cat. No. IHW 48. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/indigenous-observatory-chronic-disease/

• Between 2005 and 2011, chronic diseases cost an estimated $4.3 billion in hospitalisation in WA. A large proportion of these hospitalisations could have been avoided. 4

• Obesity has overtaken tobacco use as the largest contributor to sickness and death in WA, and the overall prevalence of obesity continues to increase.

• The impact of obesity on population health is so substantial that without intervention, it has the potential to reverse the improvements in life expectancy gained over recent years. 5

• Nearly one third (30%) of the total burden of disease (including deaths, disability, and loss of quality of life) in WA in 2010 was due to preventable risk factors. 6

• Excess body weight, smoking and physical inactivity were the leading causes of deaths, disability and loss of quality of life.

• 80% of the disease burden faced by West Australians comprise four chronic (and mostly preventable) non communicable diseases

1. cardiovascular (heart attacks and stroke),

2. cancers,

3. chronic respiratory diseases (such as chronic pulmonary disease and asthma) and;

4. diabetes.

What binds these conditions together;

1. They impose the greatest burden of disease on our state and citizens;

2. They are largely preventable through lifestyle and behavioural modification, environmental adaptation, and health and social policy changes

3. they share common risk factors; and, perhaps most importantly;

4. there exists a proven model over decades of successful care and treatment developed by health networks globally.

4 Department of Health. Annual Report 2010-11. Perth: Department of Health, Government of Western Australia, 2011. Available from: http://www.health.wa.gov.au/ publications/documents/annualreports/2011/DoH_Annual_Report_2010-11.pdf 5 Holman C, Smith F. Implications of the obesity epidemic for the life expectancy of Australians. Report to the Western Australian Institute for Public Health Advocacy. Perth: School of Population Health, University of Western Australia, 2008. Available from: http://www.phaiwa.org.au/attachments/article/61/ObesityandLifeExpectancy.pdf 6 Hoad V, Somerford P, Katzenellenbogen J. The burden of disease and injury attributed to preventable risks to health in Western Australia, 2006. Perth: Department of Health, Western Australia, 2010. Available from: http://www.health.wa.gov.au/publications/documents/BOD/BOD2006.pdf

The cost to society and the state’s health system goes well beyond hospitalisations.

Preventable diseases create a massive loss and burden on the individual and society; termed

the Burden of Disease and is measured in terms of both the years of quality life caused by

disability brought on by a preventable condition and quite simple the year of life lost – in

either words dying much younger than the healthy Australian average

Figure 1: As shown in the chart below, preventable chronic illnesses make up the vast majority of the disease burden on our state and its citizens

Although currently West Australians‘ health is among the best in the world – with one of the highest life expectancies at birth and at age 65 years.

Our state is potentially facing a health costs “time bomb”. The most commonly debated driver of this scenario is with the ageing population

profile of our state and country; requiring more healthcare services; but often forgotten is the continuously rising prevalence of chronic illnesses. Many of

these are preventable and result poor lifestyle choices.7

7 Department of Health. Annual Report 2010-11. Perth: Department of Health, Government of Western Australia, 2011. Available from: http://www.health.wa.gov.au/ publications/documents/annualreports/2011/DoH_Annual_Report_2010-11.pdf

Clearly we need to develop new strategies and act fast to enable Australia’s health system’s

to cope with this impending future.

Governments at the national and state level have had success with some preventive health

measures in areas such as smoking and sun protection. However much more needs to be done

in many areas such as alcohol-related harm and obesity.

Obesity

Obesity is a major risk factor for chronic diseases, such as cardiovascular disease, Type2

diabetes, high blood pressure, certain cancers, sleep apnoea, osteoarthritis, psychological

disorders and social problems 8.

As noted by the WA Parliament Education and Health Standing Committee in 2010, “obesity

has now overtaken smoking as the main risk factor influencing disease.” 9

The Committee also noted that “[t]he other main risk factors include blood pressure, physical

inactivity, cholesterol and low intake of fruit and vegetables.”10 Of great concern is that the

impact of these risk factors is particularly hard,

The costs of obesity to the WA acute hospital system11

In 2011, Epidemiology Branch of the WA Department of Health undertook a ground-breaking study. “The cost of excess body mass to the acute hospital system in Western Australia 2011” Some of the most striking findings are discussed in the following section.

• There were 64,247 inpatient separations attributed to excess body mass in 2011 representing 6.8 per cent of all separations for the year.

• This resulted in a cost of $249.5 million or 5.9 per cent of all inpatient costs. The three most costly inpatient conditions attributed to excess body mass were osteoarthritis, ischaemic heart disease and type 2 diabetes.

8 World Health Organisation(WHO) 2005a, Preventing chronic diseases: a vital investment, Geneva. 9 WA Parliament, Education and Health Standing Committee, Destined to Fail: Western Australia’s Health System Volume 2 Community Health Sector (2010) p. 212. 10 WA Parliament, Education and Health Standing Committee, Destined to Fail: Western Australia’s Health System Volume 2 Community Health Sector (2010) p. 212. 11 Scalley B, Xiao J and Somerford P (2013). The cost of excess body mass to the acute hospital system in Western Australia: 2011. Perth: Department of Health WA.

• Males incurred more costs than females with a male to female ratio of 1.35 for inpatient costs and 1.20 for emergency department costs.

• The most costly age group was the 45 to 59 year old age group.

• The total acute hospital costs attributed to excess body mass were $253.2 million or 5.7 per cent of all acute hospital expenditure.

• Projections for the year 2021 predict costs of $530.2 million (in constant price dollars) with a 109.4 per cent increase in costs compared to 2011.

• The predicted 388.7 per cent increase in costs from diabetic renal dialysis resulted in this condition being the most costly in 2021.

• Osteoarthritis and obesity itself were predicted to be the second and third most costly conditions in 2021.

• Type 2 diabetes (including diabetic renal dialysis) accounted for 32.9 per cent of predicted expenditure in 2021.

• This current study details the minimum current costs and future projected costs if excess body mass is not addressed in a prolonged, comprehensive and effective manner. It reinforces the importance of sustained investment in preventative health.

This report estimated the costs attributable to excess body mass in the acute hospital system. It was found that $253.1 million, or 5.7 per cent of combined

emergency and inpatient costs, were attributable to excess body mass.

If current trends in costs, separations and population body mass continue then this cost will increase to $530.2 million in 2021 (in constant prices).

Most striking these “minimum” 2021 hospitalisation costs are solely attributable to a forecast that obesity will grow at a rate of 7.9% each and

every year.

Figure 2 below summarises the projected costs of each condition in 2021, ranked and compared against the 2011 costs.

Figure 2: Projected WA inpatient and emergency costs and ranking of each condition that was attributable to excess body mass, 2011 and 2021.12

12 Scalley B, Xiao J and Somerford P (2013). The cost of excess body mass to the acute hospital system in Western Australia: 2011. Perth: Department of Health WA.

Diabetes – Often Linked to Obesity

Diabetes accounts for around five deaths each week in WA, and hospitalisations cost an estimated $20 million per year.

About 5% of adult non-Aboriginal Western Australians reported that they had been diagnosed with diabetes. However, it has been estimated that only about half of the people who have diabetes have been diagnosed. The estimated prevalence of diabetes among Aboriginal people is two to three times higher than the diagnosed prevalence in the non-Aboriginal population.

Figure 1: The Diabetes Epidemic

Preventable Illness is Not the Only Challenge Patients Face

Today patients need to manage complex web of care. This causes confusion and inhibits the process of moving from acute to preventative care.

21st Century health systems need to work seamlessly from patient point of view A central individually tailored “preventive health” plan, will result is rapid diffusion of

understanding, knowledge and thus behaviour change.

Patients and Clinicians also benefit

Prevention activities include:

• primary prevention i.e. limiting risk factor exposure (immunisation, schoolbased health

promotion programs, education and control activities in relation to substance misuse)

• secondary prevention i.e. early detection and intervention (cancer screening programs,

detection and treatment of sexually transmissible infections) and

• tertiary prevention i.e. reducing complications of disease (e.g. controlling blood sugar

levels of people with diabetes, the MedsCheck Pilot to protect people with multiple

medications from potential adverse events)

Primary Prevention

The most fundamental and perhaps important task in addressing the epidemic of obesity is prevention. Unfortunately, strategies that have been employed to date in an effort to prevent the development of obesity have been disappointing, and the problem of obesity is worsening 13

While obesity has dual origins relating to both genetics and the environment, these factors are inextricably linked. The genes provide the gun and the environment pulls the trigger. There is no doubt that the problem we face today is related to our modern western environment. We live in a world of plentiful and attractive energy dense foods, and a working and leisure environment that encourages sedentary behaviour.

Solutions will require involvement within our communities at many levels. Solutions need to range from legislation to protect our children from the bombardment of advertising from processed food manufacturers, and provision of achievable physical activity guidelines for our kindergartens and schools as an essential part of the daily activities, to local town planning of our living environments to provide attractive, safe, user friendly areas for active leisure and physical activity. It is important to establish an advocacy for the range of initiatives required to combat the obesity epidemic.

CORE has been established to provide such advocacy, and to lead the way in promoting and supporting the changes necessary to make a difference.

13 2012-Obesity the Problem, University of Melbourne

How Would We Fund an all Encompassing Preventative Health System?

In 2011 and then in 2012 two excellent future oriented Preventative Health Strategies and associated Guidelines were published by the Dept of the Health. The first in 2011 5 year 2011-2016 Chronic Health Conditions Framework; followed up by the 2012-2016 WA Health promotion Strategic Framework.

Both called for a multi-department/multi-disciplinary co-ordinated approach to developing a “whole of life” approach to chronic disease prevention. Funding would be required, but at the time costs were not outlined. Nonetheless the reports called for a Commissioner or Head of Chronic Health be appointed to plan, implement and manage the many stakeholder groups towards pre-determined outcomes. Specific programmes such as those in the case studies at the end of this report would be required.

Unfortunately, it seems very little was progressed or implemented from the reports and their recommendations. Quite likely fiscal pressures of 2012 and beyond signalled more immediate priorities.

That said platform has been laid, the thinking, problem solving and potential solutions are waiting to be launched as soon as funding allows.

Given the likelihood that 2015-2018 will bring even tougher fiscal conditions to WA than seen in many a decade; innovative thinking on how to finance this potentially most significant contributor to a healthier Western Australia and a more financially sustainable state health system.

In the UK recently, the potential of issuing Social Impact Bonds to finance large capital programmes such as this. 14 As would be expected the NHS is under intense funding pressure.

“As a result both of growing costs and restricted revenue, the health and social care system is facing a significant funding shortfall that has the potential to threaten its ability to meet the health needs of the population in the future.”

14 2014 – NHS - THE PREVENTION REVOLUTION: transforming health & social care

A crucial element for encouraging the growth of preventative approaches to care and

treatment is long-term investment. As discussed in the previous section, NHS funding

encourages a very short-term approach to investment; indeed, research has identified this

issue as a key barrier to early action across a range of public services.

In order to realise the potential of preventative care, longer-term models of funding are

required to support services which will produce a return over the medium or long-term, for

example by reducing the demand for high-cost emergency treatment. This requires an

approach to investment that does not focus entirely on short-term returns that fit in with annualised funding.

New forms of managing investment need to be developed, which both increase the total available funding for a radical shift towards more preventative programmes, and ensure a

more rigorous management of impacts both on health outcomes and on the health economy.

Social investment is a small but a rapidly growing field in the UK, with the market estimated

at a size of around £165m in 2010, and forecast to reach around £750 million by 2015.

Social investors seek a combination of a financial return and a social impact; often they are

trusts and foundations investing some of their endowment in line with their public benefit

mission. Reflecting its dual focus on financial and social impact, social investment (when managed well) is helping to bring additional resources and additional rigour into the

management of resources, and could be an important source of finance for a shift towards

prevention.

Social Impact Bonds, arrangements through which investors develop services and commissioners only make payments if outcomes are improved, are one form of social investment that could be particularly important for enabling a

shift to prevention (see box).

Momentum behind social impact bonds in public services has grown, new SIBs have been launched in a number of other public service areas, including

announcements in November 2012 of new SIBs in Essex and London to support young people at risk of entering care and rough sleepers respectively

SIB models provide ways to bring in revenue from outside the public sector to fund services, by offering investors a financial return based on the achievement of social outcomes.

• A public sector body agrees a contract to make payments based on improved social outcomes that could release savings by reducing demand for public services

• Investors agree to fund a programme based on the prospect of a financial return

• Investors will receive a financial return (plus repayment of the initial investment) if the programme is successful in improving specified outcomes

• The level of financial return on investment is based on the degree of improvement achieved in social outcomes

The benefits of social impact bonds include the following:

• They enable social investment to be brought in to support effective intervention

• They transfer a degree of risk from the public sector to private investors

• Their outcomes-based metrics free providers to be innovative with regard to how the service is delivered

• They incentivise better understanding and measurement of impact and social outcomes over the longer-term

• They reward the achievement of demonstrable social outcomes

But Does Investment in Preventative Health Pay?

“How much is it worth?” This is a frequently asked question in the context of preventative

health and health promotion. It seeks to measure the monetary benefits of these public

health approaches and it rightly influences major decisions about how we spend our limited

budgets.

However well-justified, this query can be challenging to answer because preventative health’s

many benefits can’t always be assessed in mere dollar terms. Many regard the quality of life

that accompanies good health, for example, as being valuable beyond measure.

A ground-breaking 2009 report by Vic Health, The Health and Economic Benefits of Reducing

Disease Risk Factors, tackles this challenge head on. It estimates the ‘health status’,

‘economic’ and ‘financial’ benefits of reducing the prevalence of the five behavioural risk

factors that contribute to chronic diseases affecting millions of Australians. These major risk

factors concern obesity, alcohol, smoking, exercise and.

The two year study by Deakin University and the National Stroke Research Institute

determined the beneficiaries of effective preventative health measures are society wide.

Governments should benefit through future savings in health care expenditure on treatments

for preventable disease, through fewer welfare payments. Businesses benefit from reduced

absenteeism from work and from less recruitment and training costs associated with

replacing staff that die or retire prematurely from ill health. Individuals benefit from increases

in income, from reduced absenteeism from work or time spent out of role at home and from

increased quality of life from reduced levels of ill health.

This report has evaluated the cost-effectiveness of 150 preventive health interventions,

addressing areas such as mental health, diabetes, tobacco use, alcohol use, nutrition, body

weight, physical activity, blood pressure, blood cholesterol and bone mineral density.

“Overall, large potential opportunity cost savings from the avoidable disease burden are possible if we achieve the ‘feasible’ reductions in the prevalence of the nominated risk

factors. Over the lifetime of the 2008 Western Australian adult population, cost savings were estimated to be $390 million. The total cost savings are the sum of the health sector

offsets and the combined workforce, household and leisure production effects15

Moreover Preventative Health Programmes Help Close the Gap16

In a 2012, NATSEM studied four study groups broken down by self-assessed health status and the presence of long-term health conditions. While these groups were of working age, they are also socio-economically disadvantaged, which is reflected in relatively high rates of unemployment or not being in the labour force. The differences in employment between those in good and poor health and those not having or having a long-term health problem were significant. NATSEM’s most dramatic finding from the study is quoted below;

“Improvement in the health status of males aged 45 to 64 who either live in the poorest 20 per cent of households or who live in private rental accommodation would lead to an additional 55,000 or 14,000 men respectively being in full- or part-time employment.

These figures equate to an additional one man in every seven males aged 45 to 64 in the bottom income quintile or public renter disadvantaged groups being in paid work.”17

15 2009; Vic Health, The health and economic benefits of reducing disease risk factors; Adjusted for WA population, health indicators relative to the nation and othjjer anomalies. 16 CHA-NATSEM Second Report on Health Inequalities, May 2012 17 CHA-NATSEM Second Report on Health Inequalities, May 2012

Services need to be delivered in an integrated and coordinated manner that is seamless for the consumer and family/carer(s). While effective prevention and

management initiatives are available in the health system for specific conditions (e.g. osteoarthritis, diabetes), there remains a lack of overall coordination and integration for

consumers with multiple chronic conditions.

Successful Preventive Health Outcomes Require a Behavioural Approach

Engaging the community in preventative health measures requires health professionals to

utilize to of influence and persuasion, underpinned by many of the contemporary models

emerging from the relatively new field of Behavioral Economics

Figure 2: Moving a Patient from Inaction and Indifference to Positive new Lifestyle Behaviours

Appendix – Case Studies

1. Case study: Health in All Policies – South Australian Government

Health in All Policies is an innovative strategy adopted by the South Australian Government, which recognises that public policies across all government portfolios have an impact on health. It aims to address health challenges through an integrated policy response across portfolio boundaries, introducing population health outcomes and ‘Closing the Gap’ as shared goals across government. By incorporating a concern with health impacts into the policy development process of all sectors and agencies, it allows government to address the key determinants of health in a more systematic manner. It also takes into account the benefit of improved population health for the goals of other sectors. Fundamental to the successful implementation of this approach has been high-level commitment from both the central government agency (Department of Premier and Cabinet) and the Health Department.

In November 2007 the South Australian Government convened the Health in All Policies conference. A significant outcome was the development of a set of core principles articulating the values that underpin the Health in All Policies approach.

The South Australian Government is now considering how best to support the continued application of a Health in All Policies approach as part of the implementation of their Strategic Plan. This includes developing effective ongoing governance mechanisms, building the capacity of all sectors to consider the health impacts of their policies, and expanding the technical skills of the health sector to support agencies to use Health in All Policies tools and processes. Other potential actions include experimenting in the application of this methodology to other portfolios such as Education, considering issues such as gender and the health gap, and further expanding this process to include other actors, in particular local government.

Adapted from an editorial, Health Promotion International Vol 23 No 1 by Kickbusch, McCann and Sherbon.[46]

2. Case study : The UK’s Free Swimming Program

The Free Swimming Program is a partnership between the national government, local councils, Sport England and the Amateur Swimming Association. The program has been developed to support Change4Life, a national movement that aims to prevent people from becoming overweight through the promotion of healthier eating and physical activity.

Local councils apply for funds to help meet the cost of providing free access to pools during standard swimming sessions, including improving existing facilities or building new ones.

At launch, the scheme involved more than 1000 pools run by almost 300 local councils. The program also includes a national network of swimming experts recruited to work with participating councils and 100,000 free lessons offered to non-swimmers.

Incentives in the form of extra funding are offered to participating councils with the best record in developing the scheme and making an impact in their communities.

The scheme was extended to the whole population in 2012.

3. Case Study - NHS’s Vision of Preventative & Personalised Care19

The NHS’s 2014 preventative and personalised care strategy focuses care proactively around patients’ needs It will engage with patients before they get seriously ill or if ill already, to tailor care to reduce acute episodes The key patient benefit IS THE SHIFT TO IMPROVED wellness, a reduction in the acuity of care and IMPROVEMENT IN OUTCOMES AND Efficiency IN CARE Cost Reductions Three key disruptors will accelerate the move towards a significantly more cost effective preventative and personalised care approach; freeing up hospitals, using technology like health apps to remotely monitor patients, 1. Relentless focus on patient engagement and incentives

2. Health system navigation

3. Increased demand for treatment outside of traditional care settings

19 2014, Transformative Ideas for The Future NHS

Figure 3: The Vision and its Driving Forces

4. Case Study – The Diabetes Care Project20

The Australian Government's Diabetes Care Project was a major initiative investigating better ways of managing the world’s fastest growing chronic disease.

This landmark trial began in 2013 and recruited 160 practices, and almost 8000 patients across Queensland, South Australia and Victoria, to test new ways of providing more flexible and better coordinated care for people living with diabetes.

How was the pilot designed?

20 Parekh et al; (2015) Evaluating impact of a multi-dimensional education programme on perceived performance of primary care professionals in diabetes care; Primary Health Care Research & Development

How was this different to what has been tried before?

The DCP incorporates a number of elements in its effort, including:

• The ambassadors program selects GPs, practice nurses, and patients with diabetes (all of whom are chosen because they are respected by their peers) and then pays them an hourly rate to coach other practices, engage with the local community, and facilitate training events.

• A multichannel capability-building program included online training (a series of self-paced e-learning modules), in-person workshops, and local support provided between and after the workshops to help practices implement improvements through small cycles of incremental changes.

• Formal reinforcing mechanisms included an information tool with an integrated patient record that enables participating practices to submit data monthly to an online reporting system and, in return, obtain analysis and feedback on the impact of their improvements over time. In addition, the practices are given a dedicated care facilitator or care coordinator, as well as financial incentives for improving processes, outcomes, and patient experience.

Overview of the pilot model

Post Pilot Evaluation Findings

Overall, we saw significant increases in participants’ current knowledge, perceived ability to adopt this knowledge at work and willingness to change professional

behaviour in the short term. Based on the outcomes of this evaluation; a programme that incorporates face-to-

face training seems to have the potential to increase multidisciplinary practice while online learning modules seems to improve clinical knowledge but not necessarily its application in the work setting. The study suggests that for maximum benefit both,

workshop and online training, should be combined and made available widely21

21 Parekh et al; (2015) Evaluating impact of a multi-dimensional education programme on perceived performance of primary care professionals in diabetes care; Primary Health Care Research & Development