The evil you cannot see

Published in Australian Medicine 11 December 2017 http://bit.ly/2BhCKYQ

THE DOUBLE-ENDED SPOON AND HOW TO MEET OUR HEALTH NEEDS

The Productivity Commission has recognised how joined up care for people with serious and complex illnesses can enhance their quality of life. Opportunities to prevent these problems abound and the time for action is now.

Two observations made by David Morley (1923-2009), an eminent English paediatrician who worked in a mission hospital in Nigeria and later in the UK, deserve consideration as we face the health challenges of the next decade in Australia.

Morley’s first observation was of a strong connection between effective health care and prevention.  The second was that resources work to best effect when distributed according to the needs of the patient, not the provider.

First treat, then prevent

Morley invented cheap technologies for treating sick children, such as a double-ended plastic spoon for mothers to measure out the correct amounts of salt and sugar to make oral rehydration fluid for their children dehydrated with gastro.

There’s an analogy here: Morley observed that preventive messages (boil the water) for avoiding gastro in village children needed to be underpinned by effective treatment (I can save your child): if you can’t show that you can treat the child with the problem there is no reason to believe your preventive message. The two ends of the spoon stand for treatment and prevention.

Our challenge is not gastro but chronic disease.  But we are doing well with treating serious and continuing illnesses whether of the heart, lungs, joints and muscles, (to a lesser extent) mental illness and cancer.  Often we can cure and our credibility for treatment is high.

In developing effective therapies we have come to know much more about how to prevent these conditions.  Yet these insights have not appeared in the print read by the community, at least not to the extent that they warrant. 

Health literacy is low and while great progress has been made with tobacco, alcohol, excessive processed food and lack of exercise have not yielded much territory.  An imbalance between knowledge and action has led to shocking rates of obesity.  We all have a Morley spoon in the cutlery drawer and know what it is for but we have been reluctant to use it.

Put the patient at the centre when allocating resources

The second of Morley’s observations – the one about resources for health care in Nigeria – is eerily relevant to us. He wrote, as noted in Wikipedia that "three-quarters of our population are rural, yet three-quarters of our medical resources are spent in the towns where three-quarters of our doctors live; three-quarters of the people die from diseases which could be prevented at low cost, and yet three-quarters of medical budgets are spent on curative services.” 

The recent report of the Productivity Commission drew attention to the gains if money and effort for health were invested in care that links together all the services that patients with serious and continuing and complex problems require.  The gain in productivity, as shown in trials of ‘integrated’ care, is expressed in the improved quality of life of those receiving such care.  We have found this in our evaluation of three such programs in western Sydney. 

One sticking point:  integrated care programs require 24/7 coverage in the community, with continuity, once provided by regular general practitioners.  This has changed, probably irreversibly.  What is put in its place is not clear and thought and effort must be applied here to avoid hospital emergency departments continuing as the default option. 

When the financing of integrated care comes from one source instead of several (state and federal, public and private as it does in Australia), then economies follow and efficiency improves, and money may be saved.  But that is not the primary objective.

Taking prevention to heart

Related to the endorsement of trials of integrated care the Productivity Commission favours a serious approach to prevention.  Our knowledge base is strongly built:  what is needed now is action. 

Advocacy must be applied in the political domain because less health-sustaining urban development is more profitable and planners close their eyes to what is needed to build a health-promoting environment instead.   The political power of the industries that sustain our current food consumption patterns is immense.  This advocacy can be picked up by all informed health professionals. 

The changing health of our communities is there for all to see.  We can see what is happening as we all fatten up and exercise less – more bit and less fit. But no longer do we not know what to do about these new problems – both through integrated care and prevention.  Money and well-trained health workforce must be relocated into these two arenas.

Commentators including Fairfax economics journalist Ross Gittins have noted the new emphasis in the recent Productivity Commission report on human flourishing as the ultimate object of our economic activities.  The time is now – in terms of need and opportunity – for action.

So take the Morley spoon out of the drawer and start using it – both ends.

Stephen Leeder directs the research and education network in Western Sydney Local Health District