Health status, the healthcare sector and sustainability

by Charles Guest and Katherine Mackay, Population Health Division, ACT Health.

Presented at the Manning Clark House Forum, Making Canberra Sustainable, Canberra, 17-18 October 2005

Short Biography

Charles Guest has worked in government and academic public health and medicine, following graduation from Melbourne, Deakin and Harvard Universities. He joined the Epidemic Intelligence Service, Centers for Disease Control and Prevention, with appointment to the New York City Department of Health, 1984-86. Subsequently, he undertook research on chronic disease in Aborigines, communicable disease and environmental health. At various times a Councillor of the Australasian Epidemiological Association, the Australasian Faculty of Public Health Medicine, and the Public Health Association of Australia, he has had several appointments with the National Health and Medical Research Council. He is a co-editor of the Oxford Handbook of Public Health Practice (second edition, in press). Dr Guest is currently Senior Specialist, ACT Health, and Visiting Fellow, Australian National University.

Katherine Mackay is currently enrolled in the graduate medical programme at the Australian National University. This follows her recent graduation from the University of Otago with a Post Graduate Diploma in Public Health, and from the University of Canterbury with a Batchelor of Arts. Katherine has held several primarily academic part time positions in population health in New Zealand and Australia, and is currently employed in the Population Health Division of ACT Health.

Introduction

The task set for this paper was a presentation of information on health status, to enable a debate on the sustainability of health in Canberra. It is also necessary to consider policy and practice of government agencies — in this case, ACT Health, to assess the sustainability of their operations. What is required for a sustainable healthcare sector?

Health and healthcare pose great challenges in our approach to sustainability, questions of cause and effect that are frequently ignored. Is health status becoming more or less sustainable? Do our expectations of health and healthcare in the twentyfirst century undermine the pursuit of ecological sustainability? Can we control the "ecological footprint" of the healthcare sector?

We need a series of case-studies on government and other agencies and the broader goal of sustainability — how does or should the agency work toward the broad goal, how does the goal affect the agency? This paper begins a consideration of these questions.

Vision

Healthy individuals participating in a healthy community is a vision stated for the community of the Australian Capital Territory. This is founded on principles of equity, wellbeing, consumer participation, compassion and mutual respect. Members of our community should be able to:

• Access appropriate, high quality services, which meet their needs;
• Make and implement healthy lifestyle choices;
• Achieve equitable health outcomes;
• Act as partners with their health care professionals in their own health care.

The Government’s key objectives for health are to:

• Maintain the good health status enjoyed by the ACT population as a whole;
• Narrow the gaps in health outcomes between certain individuals and groups;
• Strengthen the health of the community by leading whole-of-government action addressing the social determinants of health;
• Improve health and community care systems.

While these objectives are pursued by the whole portfolio of ACT Health, including the hospitals, we briefly describe activities of one division with a public health focus, where sustainability questions are perhaps most obviously raised.

The Population Health Division

The Population Health Division is primarily responsible for the management of public health issues within the ACT. The services provided by the Population Health Division are:

• Planning and Policy–incident response plans; clinical governance of ACT health services; contributing to health policy; contributing to service development plans for ACT;
• Regulation–Design and exercise of statutory authority to protect, promote and improve public health.
• Services–Providing public health services for the protection of the people of the ACT and surrounding region.
• Coordination–Coordinating ACT activities and national representation concerning public health, health promotion, quality and safety of health care, and health and medical research.
• Information–Collecting and distributing information about population health.

There are three branches in the Population Health Division, each with discrete but complementary functions:

• Office of the Chief Health Officer (OCHO), which supports the CHO and carries out development and implementation of policy and legislative framework on a range of public health and quality and safety issues.
• Health Improvement Branch (HIB) (Health Promotion Unit, Healthpact Secretariat and Population Health Research Centre). Provides policy and program delivery, health promotion, carries out the work of Healthpact, and delivers timely and accurate information on the health of the ACT population.
• Health Protection Service (HPS) (Communicable Disease Control, Environmental Health, Pharmaceutical Services, ACT Government Analytical Laboratory and Radiation Safety). This is ACT Health’s prime public health service delivery arm, providing comprehensive, integrated activities for either the prevention of, or timely response to, public health problems.

Selected recent activities of the Division include:

• Establishment of the clinical governance framework
• Forums on gay, lesbian, bi-sexual, transgender and intersex health and wellbeing and Hepatitis C
• Sponsor of the Australian Health Promotion Association’s 15th National Health Promotion Conference held in Canberra in March 2005

• A school-based resource package has been developed as part of The Youth Smoking Prevention Project
• Establishment of the Healthpact Research Centre for Health Promotion and Wellbeing
• Achieving an immunisation coverage rate of 95.65 per cent for children aged from 12 to 15 months
• Publication of guidelines for residential use of grey water.

All of these activities relate to the sustainability of health and health care, without explicitly addressing environmental or ecological sustainability. If human health is the real bottom line for sustainability, we need to look at health indicators.

Population and Health Status in the Australian Capital Territory

Demographic profile

The following trends are consistent with the Australian picture at large:

• Population size: 319 300 (in 2001), expected to increase to 347 200 by 2011, then to peak in approximately 2050.
• Marked ageing of the population is apparent (Figure 1), with the greatest increases in the 60-69 year age-group at present.
• Increases in the number of households and decreases in average household size are predicted.
• 1.2% of the population is of Aboriginal or Torres Straight Islander descent.
• 74% of residents were born in Australia; 5% were born in the United Kingdom.

 

Figure 1

Population projections ACT, 2051, compared with population 2002

(from: ACT Health Workforce Plan 2005-2010 Consultation Draft Discussion Paper 2005)

 

On average, people in the ACT enjoy a higher level of health than in Australia in general, with lower mortality rates and higher life expectancy.

Factors that favour the health of those in ACT

• Higher income and education levels
• Slightly lower rates of unemployment and population receiving income support
• Housing stock in good condition and recently built

Lifestyle and health

"Lifestyle" is a term that has been used, for several decades, to discuss risk factors for chronic disease. That term may have suggested a greater capacity for personal control over some risk factors than is actually the case. We have come to consider smoking, for example, as a condition determined by "environmental" or "structural" factors (such as advertising) as well as by personal choice.

With that caveat, consider some relevant ACT data, with national comparisons:

• Proportions of the population that are overweight (30.7%) or obese (11.5%) are similar to Australia as a whole.
• Higher physical activity levels, but these are declining
• Similar poor dietary patterns to those observed nationally
• Higher rates of youth smoking, and less youth concern with high levels of alcohol intake
• Over 9.6% of the population over 14 years consumes alcohol daily (Public Health in the ACT 2004-2008)
• Strong support for smokefree legislation
• Similar levels of illicit drug use to the national picture, 14% of adults in ACT having used cannabis, and 3.1% having used other illicit drugs in last 12 months.

Health and the environment

The ACT enjoys air and drinking water of generally high quality. These are conventional measures, but they do not give an adequate account of relations between the human species and the environment. Note, for example, the silences of previous Chief Health Officer’s reports: data on the use of public transport have not appeared in the health context, for example, but we are developing these in the report 2002-2004, now in preparation.

Health Priority areas

These priorities are determined at national forums. These are areas that cause a high burden to the community, and offer significant room for improvement. The prevalence of these conditions is generally similar between ACT and Australia as a whole

1. Cardiovascular Disease

• Rates have declined, but this was still the leading cause of mortality in 2001 (36%)
• Most deaths due to myocardial infarction and stroke
• Likely to increase due to increasing lifestyle risk factors and ageing population

2. Cancer

• Second leading cause of death, 30% deaths 2000, also likely to increase with ageing population

3. Mental Health

• Higher rates of people experiencing a mental health disorder in past 12 months than in Australia (21.1% v 17.7%), mainly due to higher rates in males

4. Injury

• 8.4% of all deaths, below national average,
• Mostly occur in males between 15-44 years

5. Diabetes Mellitus

• 3.1% diagnosed, and likely that the prevalence is double this
• Will increase with ageing population and increase in risk factors
• Primary or associated cause for approximately one in five hospitalisations in 2001/02

6. Asthma

• Prevalence has increased in recent years 12.3% 2001, though mortality and hospitalisations have decreased. Slightly higher that Australia wide levels

7. Arthritis and Musculoskeletal disease

• Lower rates than in Australia in general

Standard Health Indicators

• Infant mortality rate is similar in the ACT to other parts of Australia matched on socio-economic status. In 2000, 4.2 infant deaths occurred per 1000 live births, with a national comparison of 5.2.

Figure 2

Infant mortality rates, Australian Capital Territory, 1993 — 2003 (with 95% Confidence Intervals)

• Life Expectancy in the ACT also resembles the national pattern.

Figure 3

Life expectancy at birth, age 30, age 60 and age 85 for the years 1971-2003, Australian Capital Territory

While the plateaus suggested by the graphs of these indicators are only shown over short periods up to the present, it is apparent that dramatic improvements in the near future are not likely. Instead of seeking improvement in population averages, a higher priority is the reduction in inequalities.

Vulnerable Populations

Differences in the age distributions of Aboriginal and Torres Strait Islander and other Australian populations are perhaps the most obvious inequality, in Canberra as elsewhere.

After statistical adjustment for the different age distributions, Aboriginal people in the ACT were:

• Twice as likely as others to report their health as "fair" or "poor" .
• 1.5 times more likely to have a disability or long-term health condition than others.

A full accounting of the differences in health status between more and less vulnerable sub-populations is essential for the sustainability of Canberra and the rest of Australia, but there are many obstacles. This includes the identification of Aboriginal and Torres Strait Islander patients in hospital and other records.

Health status: interim summary

Canberra’s population generally enjoys good health status, according to national and international comparison. Further improvements are most likely to come from narrowing the gaps between groups, rather than through the pursuit of costly marginal gains for the whole community. The maintenance of our health status will be very challenging in coming decades, in part because of human ageing. This justifies greater attention to the sustainability of health services, as well as health status.

Challenges facing the provision of health services in ACT

Workforce

Demands on the healthcare workforce continue to increase for many reasons, including:

• rising incomes
• increased health needs of an ageing population
• technological advances becoming more available
• drop in the average numbers of hours worked and increased age of the health workforce
• general reduction in supply to the labour market due to an ageing population
• constant state of evolution of services
• increased community expectations.

The ACT has specific workforce area and skill-specific shortages, including General Practitioners and Nurses (Table)

Other factors compound the inherent difficulties of workforce planning (due to length of training, technology change, increasing paperwork burden, and declining hours worked):

• Providing services whilst being fiscally responsible
• Fragmentation of roles and responsibilities for training and service provision which leads to blame and cost shifting
• Tradeoffs between long term requirements and short term imperatives
• Tradeoffs between the use of specialist and generalist services.

In response, a National Health Workforce Strategic Framework has been prepared.

The principles guiding key areas for investment at the national level include:

• Building and maintaining a sustainable supply;
• A workforce distribution that optimises access to health care and meets health needs for all Australians;
• Health environments being places where people want to work;
• Ensuring the health workforce is always skilled and competent;
• Optimal uses of competencies and workforce adaptability; and
• Recognising that health workforce policy and planning must be informed by the best available evidence and linked with the broader health system.

Promoting ecological sustainability in healthcare

The healthcare system damages the environment by the overall material scale of its activites and the variety, toxicity and volume of its waste stream. To change this without compromising standards, new techniques will have to be found to increase the environmental efficiency of health care.

Environmental degradation associated with hospitals includes:

• Waste, of high volume and high toxicity
• High energy consumption
• Water consumption
• Current provision of adjacent parking lots, contributing to the heat island effect of cities.
• Accelerating obsolescence of equipment.

The healthcare sector needs to follow the lead set in many organisations to reduce its environmental footprint.

Health services: interim summary

Health services are under strain. We have briefly examined two aspects, workforce and the environmental impact of healthcare. Neither are in a steady state, let alone sustainable in the medium to long term. Healthcare has a significant environmental impact that needs to be fully accounted before improvements can be expected.

 

Linking sustainability with health and healthcare

Healthpact —the Health Promotion Board of the ACT - has identified the necessity for the sustainability of both human and ecological environments in the ACT. This has led to the funding of several initiatives in the ACT related to sustainability.

The major initiative, entitled "Sustainability and Health Strategy for the ACT", aims to work collaboratively to develop a whole-of-community strategy for making the connections between sustainability and health, and to establish a consortium of advocates for sustainability and health in the ACT. The achievements from this project will provide the strategic direction for future funding in this area. The Board has also advanced ecological sustainability through the funding of projects promoting both physical activity and environmentally friendly forms of transport.

The Board has invested in new discretionary projects with the Nature and Society Forum, a long-standing community-based organisation of senior scientists, students and community interests. They have funded the Sustainability and Health Framework for the ACT, to be completed in December 2005 in time for the main 2006-07 funding rounds. This project aims to:

• develop a whole-of-community strategy for making the connections between sustainability and health in the ACT;
• establish a consortium of advocates for sustainability and health in the ACT;
• initiate a series of projects furthering sustainability and health in the ACT, appropriate for agencies and 2006 Healthpact community funding rounds; and
• develop a capacity for joint monitoring of sustainability and health outcomes in the ACT.

Examples of simple links between health and ecological problems are all around us. For example, the epidemic of overweight and obesity is clearly related to our use - or misuse - of the private motor vehicle. Greater use of public transport will improve health status and ecological sustainability simultaneously.

It is that simultaneous address to problems in the present and future that is essential to a systematic approach. A practical, local approach to linking ecologically sustainable development and human health will include projects that:

• Identify the critical quality of life issues in a region
• Establish how these issues relate to longer term sustainability issues
• Identify simultaneous solutions for sustainability and quality of life issues
• Obtain resources to make solutions happen.

In addition, we must work on the distractions. Those of us who are interested in the links between health and sustainability cannot afford to ignore the underlying causes of terrorism, to identify but one very current example.