Dialogue: Prevention is better than cure in the health service

To be truly effective, most of the Government's increased health spending must go into prevention and primary care, says GAY KEATING.

Despite all you hear in the news, the hospital system is not in financial crisis.

Despite the nurses wanting higher salaries, the radiation therapists wanting more money, the present minister arguing with the previous minister over which Government most starved the hospitals of funding and despite the waiting list problem, hospitals are funded generously.

That's because the hospitals have plenty of money to care for the people who rightly need hospital care. The problem is that hospitals are being asked to pick up the pieces left by underfunding and lack of cooperation elsewhere.

The Ministry of Health publication Our Health, Our Future: The Health of New Zealanders tells us that 30 per cent of hospital admissions are avoidable.

So the hospitals should only be dealing with 70 per cent of the people they are caring for.

The hospitals have money coming out of their ears, or they would have if other parts of the system worked better. A few years of cutting unnecessary admissions will mean hospitals have plenty of spare cash to pay off deficits.

Doing it the other way round will never work. The hospitals will continue to be run off their feet unless a way is found to slow the admission rate.

Spending cash now to eliminate hospital deficits will not make hospitals any cheaper to operate and will not reduce the number of ill people coming through hospital doors.

So when the deficit is paid off there will continue to be too many sick people and the deficits will begin to grow again.

The only successful long-term method to manage hospital costs is to help people in the communities to manage their health better.

If 10 years ago we had made the highly targeted investments needed, we would have fewer people needing hospital treatment today.

If we do not make the investment now, we will still have deficits in another 10 years.

The Minister of Health started out the right way with the New Zealand health strategy and the primary care strategy which were aimed at keeping people well, getting in early, and collaboration between providers. We're not quite there yet.

Until now, everyone has been out to get their bit of health funding.

If you were not a squeaky wheel, you might miss out on the financial grease, but the best interests of hospitals will be better served by reducing unnecessary admissions and taking the pressure off acute services.

Enlightened hospital staff should be lobbying their district health boards to get the avoidable admissions down, and that will mean some additional funding for prevention and primary care.

What are some of the ministry's avoidable admissions? About 1 per cent of all infants are admitted to hospital in their first year of life with conditions that could have been avoided or managed in the community.

The most common avoidable conditions for babies are gastroenteritis and respiratory tract infections. Almost always these can be treated early, and they can be prevented.

Among older children and young adults, hospitals are faced with avoidable admissions as a result of infections, asthma and car crashes.

Car crashes can be reduced by prevention. Both prevention and early intervention can reduce hospital admissions for asthma and infections.

For adults, chronic diseases such as heart problems and lung disease are the major causes of avoidable hospitalisation. These problems also respond to early detection, treatment and prevention.

Successful early treatment will not eventuate without changes to the health system.

All parents need to be educated and supported so that they know the early signs of health problems in their babies, they know where to get advice, and they know what they can do for their babies at home.

All mothers need support to breast-feed properly. Breast-feeding is the single most effective thing that can be done to prevent gastroenteritis and infections in babies.

The other major change needed to the health system is for every family to have their own family doctor and clinic. This needs to be arranged before someone in the family is sick.

For older children and adults, the early intervention issues are the same. Again, every family needs to have their own family doctor.

That means things like having an asthma-emergency plan in place before a crisis eventuates.

Likewise, the doctor's office needs to be proactive in checking for diseases that can be nipped in the bud - like asking the right questions, taking blood pressure, doing diabetes tests, offering the cancer smear test, and so on.

The clinic also needs to help people to manage their diseases, teach people about warning signs and how to monitor their own health.

We know what to do to change the health system so that it can deliver successful early treatment. The Action for Health and Independence conference three years ago had many examples of providers who had developed better ways to work for their communities.

The primary care strategy introduced at the beginning of last year by the Minister of Health contains excellent ideas on how to plan for good community health services.

But the district health boards must give primary care adequate attention and funding.

The minister must make sure that implementing the primary care strategy is given priority over hospital deficits. If this does not happen, the document looks doomed to be another booklet of good ideas that will sit on the shelf.

We also know what to do to curb preventable hospitalisations.

The health system must ensure that people are health literate, and that they know to look after themselves.

Prevention programmes must be honed to ensure they are effective for all population groups, particularly Maori and Pacific Islanders.

More importantly, we must improve housing and eliminate child poverty so families are not crowded into houses and damp garages.

Families need to be able to pay for their housing and have enough money left to buy nutritious food, adequate cleaning products for the house and to pay for transport to the doctor and the prescription fees at the chemist.

Prevention does work. The same Ministry of Health publication notes that preventable hospitalisations declined by 40 per cent in the 10 years from 1989 to 1999.

And the huge reduction in cot deaths is a triumph of research and prevention. The messages of breast-feeding, smoke-free air for babies, and putting babies on their backs to sleep have produced huge reductions in cot deaths in all population groups.

Even better, the same ministry report tells us that early detection and preventive action taken to cut avoidable admissions will also reduce avoidable deaths.

Whether you are driven by improving health or by controlling costs, the conclusion is inescapable - the bulk of the Government's funding boost for health must go into prevention and improving the effectiveness of primary care.

* Dr Gay Keating is director of the Public Health Association.