There’s a growing body of evidence from all over the world showing that health is influenced by all kinds of social factors. But one of the best Australian initiatives embracing this approach was recently irrevocably changed in Adelaide.
In 2005, the World Health Organization (WHO) instituted a Commission on the Social Determinants of Health to address social and economic factors (such as having good housing, a fulfilling job and social support) that impact health. The Commission recommended that health sectors take the impact of these factors on people’s lives into account when planning and delivering their services.
Adelaide’s community health centres were an outstanding model of just this. Indeed, the quality, innovation and effectiveness of the community health centres in Adelaide were as good as any in the world.
This was especially true in terms of how the centres performed their disease prevention and health promotion functions. The support given by the local community health service to the innovative Noarlunga Healthy Cities over 20 years was a particularly strong example; its work was recognised by the WHO.
Many of the staff at Adelaide’s community health centres were highly skilled, and developed initiatives to offer social support, advocated on behalf of clients to help them gain legal aid, welfare payments or housing and developed programs to reduce domestic violence. But despite their successes, these centres no longer exist.
The centres also did the hard work of community development with some of the most disenfranchised groups in Adelaide including people with low incomes, women escaping domestic violence, recent migrants, and Aboriginal people, who have a life expectancy around 11 years less than other Australians.
Many of these people find health services inaccessible because they are culturally inappropriate, or because of the off-putting nature of some professional practice, and sometimes, out of fear of formal institutions.
The community development work increased people’s trust and made them more comfortable about using primary health-care services.
This kind of work saves the health system a lot of money as it prevents use of hospital emergency departments down the line when health issues not dealt with turn into emergencies.
But despite their successes, these centres no longer exist. They have fallen victim to a series of cost-cutting measures introduced by the South Australian Labor government in response to falling state revenues.
The centres now operate more as hospital out-patient departments and only deal with people who are ill. They’ve been directed to drop their disease prevention and health promotion work, and many of their staff have seen their contracts end or their roles change, to focus on direct client care.
The change is the result of the SA government deciding to implement most of the recommendations of the McCann review.
This review of non-hospital services in Adelaide took a very selective view of the evidence relating to the work of community health centres; it claimed there was little evidence for the effectiveness of their activities.
The review also suggested that local government and Commonwealth-funded Medicare Locals could pick up health promotion, even though, as yet, these have neither the resources nor the skills.
When the review was published in January, I chaired a public meeting to discuss its findings and 400 people turned out to protest its main recommendations. Many spoke glowingly about the work of the community health centres.
The health centres are greatly valued by people who have used them for counselling, to attend support groups, and receive advice about staying well. These people see how centre staff have advocated for the health of their community and engaged in constructive work with other sectors of government to promote health.
Cutting community health services may result in short-term savings to the South Australian government but, in the longer term, it’s likely to put more pressure on already stretched health budgets.
There’s sufficient evidence to confidently predict that cuts to community health programs will very quickly see an increase of the pressure on the hospital system. When people don’t have a local community health centre to drop into or to find a support group, problems compound, leading to serious and costly, chronic illness.
That’s why the WHO advises that health systems need to focus on community health, health promotion and the social determinants of health if costs are to be controlled.
Sadly, in South Australia, illness prevention and building a healthy society are taking a back seat to short-term cost shifting – and likely longer term cost blow-outs.