SA’s health disaster no hospital can stop
While South Australia debates the future of its hospitals, whole swathes of the community are in the grip of a mounting health disaster – and it’s a problem no hospital can solve.
In fact, health experts and the state’s Health Minister warn our hospitals will be swamped by this preventable problem unless we find a way to prevent its growth.
The chronic problem is diabetes, and new data shows that South Australia has the highest rate of the disease in Australia – and there’s no reason to believe the rate won’t continue to climb.
The key problem is not type 1 diabetes, an auto-immune disease, but the vastly more common type 2 – a slow-moving condition for which the key risk factors are a poor diet and lack of exercise.
In South Australia, which holds the unwanted mantle as the fattest state in Australia, more than one in 20 of us suffer from diabetes. That’s 5.8 per cent of the population, or nearly 100,000 South Australians.
A map of the prevalence of diabetes, released recently by Diabetes Australia, shows high levels of the disease across regional SA and in the low socio-economic areas in Adelaide’s north and south.
The more affluent areas of Adelaide are the only parts of the state that have relatively low levels – a fact which is concerning health experts and the government. In some regional areas, the rate is above 8 per cent.
Type 2 diabetes is a slow-moving disaster: it leads to a raft of complications including heart and vascular issues, kidney damage, loss of vision, depression and anxiety, to name a few.
The results of unmanaged or poorly managed type 2 diabetes are eventually felt in the hospital system, where health professionals undertake the expensive end-game of dealing with severe problems that could have been prevented. South Australia, for example, has a very high rate of amputation due to complications from diabetes.
Health Minister Jack Snelling says chronic disease patients already take up a large proportion of Adelaide’s public hospital beds – at any one time about 400 out of the total of 2,700 beds are filled with people whose problems could have been prevented.
He believes that this number will only increase unless governments and the community find a way to stem the growth of type 2 diabetes.
One part of the solution, in his view, is a radical reform of the nation’s primary health care system.
“No state can deal with the tsunami that’s approaching unless we do something about this,” Snelling told InDaily. “Obviously prevention is a key part. What we need to get right – and which we don’t do well in Australia – is primary health care.”
The key problem, as Snelling sees it, is that GPs have little incentive to spend the necessary time with sufferers of chronic disease, or those at high risk of developing it. The Medicare system means GPs’ “business model” is geared to a parade of 10-minute consultations.
“If you have a chronic illness, a 10-minute consultation with a GP isn’t going to cut it,” he said.
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The under-fire hospital system, which Snelling is attempting to “transform”, ends up dealing with results which are traumatic for the sufferer, and expensive and time-consuming for the hospital system.
“Anything the states do is just at the edges unless there’s significant reform of primary health care,” Snelling says.
“What is frustrating for a state health minister is that state emergency departments are where you end up when you have nowhere else to go. We have very little control over the pipeline of people coming into the system (with chronic health problems), or leaving it, which is aged care.”
He wants the Federal Government to consider radical reform, including looking at funding GPs via Medicare according to their results. This could mean fixed payments to GPs, rather than payments based on volume of patients. He points to examples in the UK and the United States were GPs are paid incentives to keep people healthy and out of the hospital system.
However, researcher Dr Tracey Siebert, who has just completed a PhD at Flinders University into the management of diabetes, says the State Government is also culpable.
She says the State Government’s “stripping” of community health services means that best practice in managing diabetes isn’t possible in the system as it stands today.
Her research found that the most effective way to help people with type 2 diabetes is for them to work with a multi-disciplinary team – specialised nurses, dieticians, physiotherapists, podiatrists and the like.
But the Government’s cuts to community health services, which began during the previous term of the Weatherill administration, means there is no place in the system for these teams to exist.
“We have had primary healthcare services completely stripped,” Siebert said.
“According to the new primary healthcare networks, their role is to advocate for more primary healthcare but they haven’t got any money – they’re not providing service delivery.
“All patients have is their GP and that’s it, unless they’re prepared to pay for a dietician for themselves.”
This approach clearly isn’t working in SA.
“What happens here is that people with diabetes talk to their GP – either in a five minute or 15 minute appointment – twice a year,” Siebert said.
“They tell them to lose weight and do more exercise.
“But the evidence is very clear – people have a great deal of difficult in keeping motivated and involved in their own care on a daily basis.”
The evidence in Australia and internationally shows that patients need access to a coordinated team of support and education.
Some of this used to happen in South Australia’s community health sector.
And now?
“There’s nothing,” says Siebert. “And that’s the issue.”
The CEO of Diabetes Australia, Greg Johnson, also contends that the focus of the health system is wrong and that intervention from trained diabetes health-care professionals is required.
He says the acute end of the health system – hospitals – suck up too much of the health budget in order to treat preventable complications of chronic illness.
“We have to shift the balance towards more intervention – and early intervention,” Johnson told InDaily.
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“That would result in lots of gains, but we still have most of the focus on trying to fix the hospital system.”
The causes of the type 2 diabetes pandemic – and its solutions – also lie beyond the control of all parts of the health system.
Schools, the planning system and the economy are all factors at play.
Across the world, diabetes type 2 is a disease of poorer people who eat junk food and don’t get enough exercise.
The answer, says Johnson, is early intervention to head off poor lifestyles.
“If we intervene and deliver a serious dose of ‘lifestyle’ medicine then 60 per cent (of people with pre-diabetes) can avoid going on to develop diabetes,” Johnson said.
“It needs more than a pamphlet – if we provide structured sessions from a trained person there’s good evidence we can prevent it.
“We have to address the fundamentals in the continuing growth and consumption of unhealthy diets and actually address those at a community level.”
Obesity expert and Professor of Medicine at the University of Adelaide, Gary Wittert, says addressing the problem requires a whole-of-government, concerted effort.
“The state government is not ignoring this, but public health is everybody’s business – it’s the business of councils, it’s the business of the education system,” he said.
“We really need to have education from kindergarten to the end of year 12 and beyond: health literacy, health competency, how to navigate the health care system.”
Wittert has some radical ideas of his own. He’s long been pushing for a special tax on sugary soft drinks – a single product he says helps drive the obesity epidemic.
“The Federal Government has been gutless,” he says. “You can’t complain about health care costs unless you’re prepared to do something about a soft drink tax.”
Wittert, too, agrees that the health system is facing a mounting challenge.
“There’s a tsunami of problems to come,” he says.
The frustration is that it doesn’t have to be this way.
“We know it’s a preventable disease – no question it’s a preventable disease.”
South Australia is by no means alone in facing this challenge.
But, in this state, we’re at risk of the problem getting further out of control. As Snelling warns, unless something is done, hospitals will be “absolutely overwhelmed” by the burden of chronic disease that’s coming our way.
Everyone agrees it will require reform. As Tracey Siebert points out, trying to treat or prevent chronic disease via hospital outpatient services is expensive and ineffective.
SA is already the fattest state in Australia, and research released last week shows that this problem – a key risk factor in the development of type 2 diabetes – is accelerating.
Nearly a third of South Australians will be not just fat, but obese, in four years’ time.
Research published by the Australia New Zealand Journal of Public Health (ANZJPH) last week forecasts that 28.7 per cent of males and 29.2 per cent of females will be seriously overweight by 2019.
Researchers from Flinders University and the CSIRO studied data gathered from 51,618 South Australians over nine years, from 2003-12, to model their future behaviour and make the prediction.
Their work shows we are getting fatter faster, and obesity is set to overtake smoking as the leading cause of preventable disease.
While it provides little comfort, the tide of diabetes type 2 – fuelled by obesity – is a worldwide phenomena.
Greg Johnson says it’s a problem in any community with a poor diet and lack of activity.
“Diabetes is the biggest single disease epidemic ever to affect the human race,” he said. “Five million people were killed by it last year – that’s more than TB and HIV combined.
“This means that this century, the continuous improvements in life expectancy will change – it will probably come down again.”
