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More Healthy People or More Medicines?
In his article, ‘Moving from a provider– to a patient–focused health care system: The health reform imperative’ (Dwyer 2004), John Dwyer argues that more emphasis is needed on preventing illness in primary health care and that it needs to be restructured so that doctors can care for people in the community. However, he does not spell out the implications for primary health care of focusing on preventing illness. In response to John Dwyer’s ideas for reform of the Australian health care system, this article will discuss why a focus on prevention of illness is essential if health services and medicines are to remain affordable for those who need them. A focus on preventing illness must incorporate a health promotion framework as a major strategy. A health promotion framework ensures that people with risk factors for major chronic illness have the knowledge, skills and support to manage their health in the community. This is consistent with John Dwyer’s argument for more emphasis on preventing illness and restructuring of primary care to ensure more people remain in the community rather than go to hospital. Costs of Illness
Consumer copayments for health services and medicines have risen steadily over the 1990s and the copayment for pharmaceuticals increased again in January 2005 for both health cardholders and general patients. Increasing copayments for health services and medicines is one strategy government is using to offset the rising costs of medicines and diagnostic services. However, it shifts the cost burden to those who are sickest and poorest. According to Duckett, consumer payments are inequitable as lower income consumers pay substantially more of their income (10%) compared to those on higher incomes (Duckett 2002, p. 28). John Dwyer is also concerned about the impact of copayments on Australians living in poorer areas and the decline in bulk-billing. He contends that where people can afford copayments doctors can provide a better quality service. However, for those people whose lifestyles put them at risk of major illness, access to health services and quality time with their doctors is often compromised. “Australians in poorer socio-economic suburbs are five times more likely to die prematurely of a preventable disease than those in wealthy suburbs”. Recent reports from the Productivity Commission warn that the amount Australia spends on health in the future will increase and that the current proportion of gross domestic product (GDP) spent on health (9%) will double over the next 40 years (Banks 2004). Currently about 13% of the total health budget is spent on medicines. The amount government spends on medicines is also increasing. Expenditure on medicines grew in real terms, at an average of 11.9% per year between 1997–98 and 2001–2002, stabilising to a growth of 9.3% for the year ended at June 2004 (Australian Institute of Health & Welfare 2004; Department of Health & Ageing, 2004). Diagnostic tests are another area of increased expenditure over the past decade. The detrimental impacts of such costs on Indigenous people and those with mental illness or disabilities also need to be part of the discussion on reforming primary health care. Access to affordable medicines and the role of medicines in preventing illness should be more prominent in the discussions of primary health care reforms. Health Issues, 2005, Number 42, pp. 26-29. The Impact of Ageing on Medicines’ Costs
Those 65 years and over currently comprise 12% of the population (2.5 million people). According to the Australian Institute of Health and Welfare, the numbers of those aged 65 years and older will double over the next 20 years (AIHW 2004). The pessimistic view is that growing numbers of older people will be reliant on multiple medicines, and will use increasing numbers of health services, hospital beds and aged care services. This picture may be the reality in 20 years’ time if nothing is done now to address the rise in preventable chronic illness and the substantial increase in people living longer managing a chronic illness with the associated disability. The Chairman of the Productivity Commission, Gary Banks argued that markets are robust and will adjust to provide many of the goods and services needed by older people in the future. However, it is governments who provide most health services and all subsidised medicines to the community and the costs are predicted to grow. While Gary Banks goes on to acknowledge that Australia’s ageing population will contribute significantly to increased health spending, he also points to additional factors driving costs. These include the demand for new health services and expensive treatments fuelled by use of emerging new medical technologies (Banks 2004). Recently the growth in the costs of the Pharmaceutical Benefit Scheme (PBS) has been a result of newer, more expensive medicines being listed on the PBS, and the prescription and use of medicines exceeding Pharmaceutical Benefits Advisory Committee estimates. Rob Moodie, Chief Executive Officer of the Victorian Health Promotion Foundation makes the point that if all the money spent on providing expensive new drug treatments such as zyban for smoking cessation was directed to health promotion campaigns instead, this would be a more effective use of health resources (Moodie 2004). The Victorian Health Promotion Foundation’s submission to the Productivity Commission’s review of the Economic Implications of an Ageing Australia laments the fact that such a small proportion of the total health budget is allocated to prevention programs when preventable behavioural factors constitute 40–50% of the causes of premature deaths (Victorian Health Promotion Foundations 2005). Why Prevention Strategies?
Presently a very small proportion (2.8%) of the total health budget is dedicated to preventive programs with the bulk of health spending going to hospitals and pharmaceuticals (Hickman 2004). Of the total PBS budget, cardiovascular drugs account for a third of spending, followed by gastrointestinal drugs (mostly reflux treatments), central nervous system drugs including antidepressants, musculoskeletal drugs, and antineoplastics. This PBS spending is consistent with the burden of disease associated with major chronic conditions afflicting Australians. In 1998, 50,797 Australians died as a result of cardiovascular disease (40% of all deaths). Coronary heart disease and heart attacks were responsible for just over half (27,825) of these deaths, followed by stroke. According to the burden of disease measure, cardiovascular disease and cancer are the leading causes of disability adjusted life years (DALYs) and account for about 20% of all DALYs. Mental disorders account for about one-eighth of DALYs and are responsible for significant disability and reduced quality of life. Some chronic conditions, such as cardiovascular disease and cancer, result in premature loss of life while others such as mental disorders, and nervous system and sense disorders require long-term management and account for significant disability (Duckett 2002, p.11). People with chronic conditions and disabilities carry an unfair burden in terms of suffering and a lower quality of life in comparison to those without these conditions. They need more health services, more medicines and more time out of paid employment to manage their health or their children’s health. Self-care requires considerable time and resources and those on low incomes spend a disproportionate amount of their time and income on Health Issues, 2005, Number 42, pp. 26-29. their health. A recent study confirmed that households with chronic illness in rural and regional Victoria experience considerable poverty and financial distress (Walker & Tamlyn 2004). Health promotion strategies can be used to reduce the incidence and impact of these conditions hence decreasing their cost to the health budget and people’s lives. The Australian Institute of Health and Welfare’s national obesity study focused on older Australians. There has been a trebling in the last 20 years of obesity in Australians aged 55 and over (Australian Institute of Health & Welfare 2004). This is cause for concern because obesity is a recognised risk factor for conditions such as diabetes, cardio-vascular disease and high blood pressure. However, people can avoid obesity by adopting healthy eating habits and getting regular exercise. It is not surprising to learn that the numbers of people with diabetes in Australia has trebled since 1991 and that currently one in three Australians aged 60 and over is either pre-diabetic or has a diabetic condition (Byrush & Hendy 2004). Diabetes is expected to be a leading cause of illness over the next 20 years. Though there is no cure for Type 1 diabetes: preventative and drug-free solutions are possible for Type 2 diabetes. For example, research from the International Diabetes Institute shows that supervised high intensity strength training, in combination with moderate weight loss, improves glycaemia control in older people with Type 2 diabetes (Byrush & Hendy 2004). United Kingdom Focus on Preventive Strategies
The United Kingdom’s recently announced public health strategy offers some guide to what is better public policy and practice. It has funded a multi-strategic approach that includes banning smoking in public places, and curbing television advertising of junk food and drink to children. The National Health Service also employs “health trainers” to encourage people to adopt healthy behaviours. According to The Economist magazine (20 November 2004): “even though the new strategies will cost around one billion pounds over three years they will save many times that amount”. The United Kingdom is investing in prevention and acknowledging the link between behaviour and health inequalities. According to The Economist, the decline in smoking in the United Kingdom has now levelled out, but some low-income groups are still smoking and other changes in behaviour will undermine health unless some actions are taken. For example, more Britons are now overweight. One in four British women are now obese, up from 8% in 1980. British children are also getting bigger. The implications for Britain of more people with diabetes and other major chronic conditions include reduced gains in life expectancy, and increases in the costs of health services. In the USA, United Kingdom and Australia the increasing numbers of people with risk factors for poor health and the implications for the future funding of the health system are major issues. Recently, the United Kingdom de-scheduled medicines used for managing high cholesterol from prescription only to allow sales of small amounts in low dose packs over the counter. The reason behind this move was the increase in cardio-vascular disease and stroke in the younger population. Primary Health Care and Prevention in Australia
Australia could follow the lead taken by the British government and invest significantly in prevention across the life span through targeting risk factors such as poor nutrition, smoking and lack of physical activity. In Australia, there is scope to continue with anti-smoking campaigns particularly in disadvantaged communities and with young people. The Victorian Health Promotion Foundation response to the Productivity Commission states that: Health Issues, 2005, Number 42, pp. 26-29. “Research indicates that if smoking rates were cut by a further 5%, savings of 17% would be made to the Pharmaceutical Benefits Scheme over the next 40 years” (Victorian Health Promotion Foundation 2005). A preventive approach is taken by the National Prescribing Service (NPS) in its Community Quality Use of Medicines program where non-drug approaches to managing illness and preventing further illness are promoted alongside quality use of medicines messages. This program targets culturally and linguistically diverse people, older people, those in rural and remote communities, Aboriginal people and parents of young children. The “common colds needs common sense” program of the NPS is a good example of a cost effective health promotion program. The program targets carers and parents of young children, and promotes awareness of how to treat a cough or cold in young children. A number of strategies are used to promote the wise use of antibiotics. These include symptomatic management information for respiratory infections, a local media campaign, and small grants to parents and carer groups, and childcare centres in major metropolitan and regional centres throughout Australia. The community group awarded the grant holds a discussion sessions based on wise use of antibiotic messages and information materials for managing coughs and colds through symptomatic relief. The aim of the program is to increase awareness of parents and carers of young children, and the general population about managing coughs and colds. The messages are reinforced through a local and national media campaign, and the support of general practitioners and pharmacists. There is evaluation evidence that the campaigns are contributing to an increasing number of consumers managing coughs and colds without the use of antibiotics (National Prescribing Service 2004). This sort of approach by the NPS addresses the public health problem of antibiotic resistance and also contributes to savings to the PBS. Conclusion
The Productivity Commission Report (2004) raised awareness of the implications for our health system of the changing demographics over the next half century. It also points out that the costs of our health system are currently affordable, but if existing trends continue, use of health services and subsidised medicines will continue to increase and so will costs. Australian governments and stakeholders should adopt a multi-strategic approach to interventions to address and minimise the major risk factors and social determinants associated with poor health. This means reorientating primary health care to provide preventive health services and programs, and access to allied health services. Prevention programs should be available to communities and consumers in poor health as well as to those who are healthy. However, it is important to stress that access to preventive programs for disadvantaged communities alone will not be effective without addressing the social and economic determinants of health status. Disadvantaged people need good housing, jobs, education and safe environments as well as preventive primary health care services to improve their health status. A ‘whole-of-government’ approach is needed to ensure that people in poverty have the resources and infrastructure (housing, jobs, education etc.) to enable them to lift their status in society and in doing so lift their health status. Disadvantaged people, people with mental illness, Indigenous people and those with disabilities need access to information about managing and maintaining their health as well as access to preventive health services, health promotion programs and medicines. This reorientation of the health system will require a significant change in health policy and health funding based on better access to preventive primary health care services and programs for all Australians in the future. John Dwyer and the National Health Care Reform Alliance need to encompass a broader view of health, one which encourages and supports people with chronic illness to manage Health Issues, 2005, Number 42, pp. 26-29. their own health through providing supportive primary health care services, information, health promotion programs and affordable medicines. Reforms to primary health care must include the needs of people who could potentially fall into poor health due to their social and economic circumstances. Preventing illness among this group will be a challenge that the health system alone cannot address. More needs to be done across government to help the young and old who need secure housing, employment, education and safe environments. Principles to Underpin Reforms in the Health System
Expenditure on health care by governments needs to be broadened in scope to encompass health prevention and health promotion programs. Make expenditure on health prevention and health promotion programs a separate budget item with clearly identified performance outcomes. Make health prevention and health promotion programs available to communities and consumers in poor health as well as to those who are healthy. Changes that are Possible within the Current Health System Structure
Reorient primary health care to provide preventive health services and health promotion programs in the community Governments need to ensure access to information for disadvantaged consumers to enable them to self-manage their health and devise incentives for people to lower their risk profile to improve health outcomes. Ensure access to affordable primary health care services and medicines through adopting a preventive approach to primary health care. Janette Donovan represents consumers on medicines-related committees and brings a public policy perspective to her work on behalf of consumers. She is the consumer class Director of the National Prescribing Service. References
Australian Institute of Health & Welfare (AIHW) 2004, Australia’s Health, AIHW, Canberra. Australian Institute of Health & Welfare (AIHW) 2004, Obesity a Weighty Challenge for Older Australian Too, media release, AIHW, 12 February. Banks, G. 2004, An Ageing Australia: Small Beer or Big Bucks?, Presentation to the South Australian Centre for Economic Studies, Economic Briefing, Adelaide, 29 April. Byrush, K. & Hendy, S. 2004, ‘Living longer living stronger: Life is for the strong’, Health Issues, Number 80, pp. 19-22. Department of Health and Ageing 2004, Research and Statistics Pharmaceutical Benefits Scheme, Commonwealth Government, Canberra. Duckett, S. J. 2002, The Australian Health Care System, Oxford University Press, South Melbourne, Australia. Dwyer, J. 2004, “Moving from a provider- to a patient-focused health care system: The health reform imperative’, Health Issues, No. 81, pp. 10-14. ‘For Richer, for Poorer’ 2004, The Economist, November 20. Hickman, B. 2004, ‘Lifestyle tips key to cutting health costs’, The Australian, 27 November. Health Issues, 2005, Number 42, pp. 26-29. Moodie, R., 2004, ‘Here’s a way to reduce those waiting lists’, The Age, November 10. National Prescribing Service 2004, Progress, Achievements and Future Directions: Evaluation Report Number 7, National Prescribing Service. Productivity Commission 2004, Review of National Competition Policy Reforms: Discussion Draft, Productivity Commission, Canberra. ‘Targeting a Growing Problem’ 2004, Monash Magazine, Issue 13. Victorian Health Promotion Foundation 2005, Response to the Productivity Commission Review of the Economic Implications of an Ageing Australia, Victorian Health Promotion Foundation, Melbourne. Walker, C. & Tamlyn, J. 2004, The Cost of Chronic Illness for Rural and Regional Victorians, Chronic Illness Alliance, Melbourne. Health Issues, 2005, Number 42, pp. 26-29.


CONSENSUS STATEMENT THROMBOPHILIA AND VENOUS THROMBOEMBOLISM International Consensus Statement Guidelines According to Scientific Evidence The Cardiovascular Disease Educational and Research Trust, The International Union of Angiology and The Mediterranean League on Thromboembolism A. N. NICOLAIDES (Cyprus) (Chairman); H. K. BREDDIN (Germany); P. CARPENTIER (France);S. COCCHERI


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