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Funding illness prevention and health promotion in Australia: a way forward

Funding illness prevention and health promotion in Australia: a way forward Background: Unlike pharmaceuticals and private medical services there is no single source of funding for illness prevention and health promotion and no systematic process for setting priorities in public health. There is a need to improve the efficiency of access to health funding across prevention and treatment. Discussion: We discuss a number of reforms to existing funding arrangements including the creation of a national Preventative Priorities Advisory Committee (PrePAC) to set priorities. We propose the establishment of a PrePAC to provide evidence and set priorities across health promotion and illness prevention, with a national dedicated fund for health promotion. Conclusion: A national evidence-based funding system for illness prevention and health promotion would legitimise a substantial and sustained budget for health promotion, breaking down some of the barriers in a fragmented federal health care system. Background processes, most prevention and health promotion inter- Funding for illness prevention and health promotion in ventions compete for disparate and uncertain sources of Australia is fragmented. Programs are funded by federal, funding that lack consistent and rational criteria for allo- state and local government but a lack of coordination and cation. In Australia, differences in the likelihood of fund- priority setting means that we are not making a consid- ing among otherwise equivalent interventions can be ered allocation of resources to illness prevention and attributed partly to differences in funding arrangements health promotion. We neither choose how much to spend [1]. An efficient health care system would not discrimi- compared to other health care activities, nor do we choose nate in this way. In this paper we suggest the creation of a interventions that offer the best value. Australia has led national Preventative Priorities Advisory Committee (Pre- the world in introducing formal evidence-based evalua- PAC) to reduce the gap in the likelihood of obtaining tion processes for medical services and technologies to public funding among equally cost effective interventions. establish value for money, but, as a consequence of frag- mented responsibility and funding, health promotion Discussion and illness prevention have been left out. While pharma- Two Models for a PrePAC ceuticals and (out of hospital and private hospital) medi- Two stylised models for the operation of a PrePAC are cal services in Australia have access to dedicated budgets considered here: a (i) Guidance Model and a (ii) Dedi- and are subject to formal and well-defined evaluation cated Funding Model. Page 1 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 Guidance model Depending on funding arrangements, the fund-holder The UK National Institute of Clinical Excellence (NICE) might be one or more of the Australian Health Ministers. provides evidence-based guidance relating to health tech- For clinical prevention services provided by a registered nologies and public health interventions [2-4]. The Public provider to an individual patient, the PreBS could operate Health Interventions Advisory Committee (PHIAC) and in much the same way as individual patient benefits listed Technology Appraisal Committees of NICE produce rec- on the Medicare Benefits Schedule (MBS) or the Pharma- ommendations on the use of public health interventions ceutical Benefits Schedule (PBS). That is to say, there and health technologies--based on consideration of the would be a list of interventions approved for funding available evidence regarding effectiveness and the cost from the scheme on a per-service (e.g. individual consul- effectiveness. Under the guidance model, a proposed Pre- tation on diet or smoking behaviour) or per-patient basis PAC would take a similar role to that of the PHIAC in Eng- (e.g. annual enrolment in a disease management pro- land. It would take account of the strength of evidence on gram). effectiveness and cost effectiveness of a prevention activity and might, for example, provide guidance that a particular Following Goldsmith et al. [11], we distinguish clinical activity should be given higher or lower priority. While prevention from non-clinical preventative interventions the quality of evidence in the area of prevention is often such as: (i) health promotion that targets a population to not high, this is not necessarily a barrier to good decision- encourage healthy behaviour and is provided by govern- making [5]. It would produce a list of recommendations ment or interest group organisations, (ii) health protec- that funding agencies could take into account when mak- tion that reduces health risk by changing the physical or ing funding decisions and setting priorities for preven- social environment often by regulation, and (iii) healthy tion. In 2009, COAG agreed to fund such a national public policy that involves social or economic interven- preventive health agency with responsibility for providing tions beyond the health sector. Individual patient benefits evidence-based policy advice [6]; this model was may be unsuitable for funding these categories of non- endorsed by both the National Health and Hospital clinical prevention and alternative mechanisms would Reform Commission [7] and the Preventative Health need to be used. For example, payments for health pro- Taskforce [8]. motion interventions might be based on a list of lump- sum grants to cover a delimited set of activities over a The main problem with a guidance model is that there is defined time period. Examples might include: annual no mechanism for funding. The guidance model relies on budget allocation to organisation(s) responsible for deliv- a disparate set of independent funding agencies to imple- ery of mass media education campaigns on road safety, ment PrePAC deliberations and recommendations. While healthy eating, physical activity, alcohol consumption, or the various responsible funding agencies might modify smoking cessation; lump sum payment to local councils their own funding rules or processes to take account of or community organisations for community events to PrePAC deliberations and recommendations, such recom- promote community connectedness, safe communities or mendations would be neither necessary nor sufficient to healthy lifestyle; or lump sum payment to schools for the secure funding. There may be no new funding allocated establishment of programs to promote healthy lifestyle for prevention and no guarantee that the deliberations such as the walking school bus or sex education. and recommendations of a PrePAC will have any impact at all upon resource allocation. Implementation involves For healthy public policy and health protection interven- much more than simply developing and disseminating tions, the PreBS could be a list of lump-sum grants to guidance. The Guidance model therefore falls well-short cover a delimited set of activities at a specific geographic of giving preventative interventions an equal chance of location. Examples might include: lump sum payment to funding compared to otherwise equivalent interventions local councils, state governments or community organisa- that benefit from access to a well-defined funding mecha- tions to alter the physical environment either to promote nism. healthy lifestyle (such as the provision of walking tracks/ pedestrian crossings, or improvements to parks and recre- Dedicated Prevention Fund ation areas) or to improve safety (provision of street signs A PrePAC allocating a dedicated prevention fund could be near school crossings or provision of lighting or CCTV modelled on the operation of the Medical Services Advi- around train stations or shopping precincts); lump sum sory Committee (MSAC) [9] or the Pharmaceutical Bene- payment to schools to alter the physical environment to fits Advisory Committee (PBAC) in Australia [10]. promote healthy lifestyle (such as establishment of a Specifically, a PrePAC would advise a fund-holder on kitchen garden or sporting facilities); lump sum payment whether a particular intervention or program should be to schools to alter the social environment to improve allocated money from a dedicated prevention fund. Rec- safety (such as provision of interventions to reduce bully- ommendations accepted by the fund-holder would then ing). be listed on a Prevention Benefits Schedule (PreBS). Page 2 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 Reimbursement via lump sum payments and annual necessary funding incentives for major infrastructure budget allocations is no different in principle than per- developments. service or per-patient payments. In each case evaluation of the safety, effectiveness and cost effectiveness of all pre- A proposal for reform ventative interventions would be for an approved indica- Currently clinical prevention is partially covered under tion and scale. For clinical prevention, the indication existing programs (such as the MBS, PBS, and NIP). Other would typically relate to characteristics of the patient and prevention and health promotion activities are more or the provider. For example, provision of group exercise ses- less covered by one of a multiplicity of government (fed- sions might only provide good value for money in people eral, state and local) and non-government organisations with diabetes or cardiovascular disease if they are predom- (such as the National Heart Foundation and Cancer inantly focused on cardiovascular fitness (rather than Councils). Health protection and healthy public policy strength or flexibility training). For health promotion and are currently handled within the relevant departments of health protection interventions, the indication might federal, state or local governments. We propose reforms to instead relate to characteristics of the community. Provi- existing funding arrangements that take account of the sion of CCTV around train stations might only provide current state of play while increasing the efficiency of good value for money in areas that have a high level of access to health funding across prevention and treatment. street crime. Specifically, we propose a PrePAC providing guidance with regard to health promotion, health protection and The PrePAC might therefore approve open-ended funding healthy public policy, but that relies on existing programs for a listed item in much the same way as the PBAC or (such as the MBS, PBS, and NIP) to provide guidance and MSAC, specifying an approved indication for each item. funding for clinical prevention. Delimiting the scope of a For clinical prevention, claims for PreBS items might fol- PrePAC in this way would capture the majority of inter- low similar procedures as for restricted benefit items on ventions while minimising the risk of replicating the func- the PBS. The PrePAC might, however, choose to specify tion of existing agencies. Gaps in the coverage of clinical "pre-approval" status for some types of interventions; par- prevention would then be handled by modifying the ticularly for health promotion and health protection scope of services covered under existing programs by, for interventions that entail relatively large lump sum pay- example, issuing Medicare Provider Numbers to a broader ments. Obtaining approval might require submission of range of health care providers and adding item numbers evidence to substantiate that the intended use of funds to the MBS. Given the multiplicity of parties currently meets the restriction for the relevant item number. For involved in appraisal of health promotion, health protec- example, a council requesting funding for a pedestrian tion and healthy public policy (in contrast to the relatively crossing might be required to provide traffic impact anal- small number of agencies with responsibility for clinical yses, a community survey demonstrating community sup- prevention), the creation of a PrePAC would yield sub- port, and an assessment of the impact of community stantial cost savings and improvements in the consistency structure on access to community nodes. Provision of and quality of evidence appraisals. funding for a specific pedestrian crossing with authority required status would therefore entail a two-stage process. For health promotion, we believe that the PrePAC should First, the PrePAC would have to list pedestrian crossings be extended beyond the guidance model to allocate a on the schedule for an approved 'indication'. Second, the national fund for health promotion activities. The crea- local council requesting funding for a specific pedestrian tion of a PrePAC with responsibility for funding health crossing would have to submit a request for approval promotion has the potential to reduce the number of pro- demonstrating that the intended site meets the 'approved grams making allocation decisions and can be expected to indication' and that the intervention conforms with the improve the consistency and quality of decision-making. approved description in terms of its active constituent A PrePBS would provide national coverage of health pro- parts delivered effectively. motion activities and a clear pathway for funding for interventions that currently have no obvious source of While the dedicated fund model has the advantage of sim- funding. plicity and familiarity it does have a few boundary issues that would need to be resolved. Regulatory or infrastruc- While we believe that a PrePAC could make a valuable ture interventions may not sit easily in a health system contribution by providing guidance for non-clinical pre- funding scheme. Smoking or alcohol regulation or the vention, many preventative interventions that might be provision of public transport could be appraised by a Pre- categorised as health protection and healthy public policy PAC but it is more difficult to imagine a PreBS with the would not be amenable to funding through an item based capability to facilitate legislative change or to provide the PreBS-type mechanism. The large-scale inter-sectoral nature of some health protection and healthy public pol- Page 3 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 3. National Institute of Clinical Excellence: The public health guid- icy interventions (such as transport and infrastructure) ance development process: an overview for stakeholders and the non-financial costs of implementing of others including public health practitioners, policy makers and the (such as smoking restrictions) are not easily achieved public. [http://www.nice.org.uk/media/69E/F9/ CPHE_Process_manual.pdf]. through the allocation of a dedicated fund. For this rea- 4. National Institute of Clinical Excellence: Methods for develop- son, we propose that the PrePAC should initially provide ment of NICE public health guidance. [http://www.nice.org.uk/ nicemedia/pdf/CPHEMethodsManual.pdf]. guidance only for health protection and healthy public 5. Harris A, Mortimer D: A Preventative Priorities Advisory policy. Committee and Prevention Benefits Schedule for Australia. Options Paper: National Health and Hospitals Reform Commission, Commonwealth of Australia, Canberra; 2008. Conclusion 6. Council of Australian Governments: National Partnership Agree- We agree with the Wanless report [12] that "to achieve the ment on Preventive Health. Commonwealth of Australia, Can- objective of an efficient allocation of national health serv- berra; 2008. 7. National Health and Hospitals Reform Commission: A healthier ice funding between health care and public health, a sim- future for all Australians - final report. Commonwealth of Aus- ilar method of cost effectiveness analysis needs to be tralia, Canberra; 2009. 8. Preventative Health Taskforce: Australia: the healthiest country applied to public health and clinical interventions." Our by 2020 - National Preventative Health Strategy. Common- suggestion is to create a new body--the Prevention Priori- wealth of Australia, Canberra; 2009. ties Advisory Committee (PrePAC). The PrePAC would 9. O'Malley S: The Australian experiment: The use of evidence based medicine for the reimbursement of surgical and diag- provide advice on the effectiveness and cost effectiveness nostic procedures (1998-2004). Aust New Zealand Health Policy of interventions in health protection and healthy public 3:3. 10. Henry DA, Hill SR, Harris A: Drug prices and value for money: policy. This is consistent with aspects of other proposals the Australian Pharmaceutical Benefits Scheme. JAMA 2005, to establish a nationally coordinated preventive health 294:2630-2632. agency responsible for the evaluation of effectiveness, effi- 11. Goldsmith L, Hutchinson B, Hurley J: Economic evaluation across the four faces of prevention: a Canadian perspective. CHEPA ciency and equity outcomes [6,8,13]. It has the potential Working Paper Series Paper 06-01; Hamilton, Canada; 2006. to engage many of the levers identified by Lin [14] for 12. Wanless D: Securing good health for the whole population. In shifting the focus of the health system to more emphasis Securing good health for the whole population HM Treasury: London; on prevention and health promotion. We believe that it is 13. Oldenburg BF, Harper TA: Investing in the future: prevention a necessary to go further and establish a national dedicated priority at last. Med J Aust 2008, 189:267-268. 14. Lin V, Fawkes S, Hughes A: A Vision for Prevention in Australia. fund for health promotion, access to which would be Discussion Paper, Australian Institute of Health Policy Studies; 2008. determined by the PrePAC. This would provide a national program, thus breaking down some of the barriers in a fragmented federal health care system. It would provide technical leadership and a political voice for prevention that has been lacking compared to medical services and pharmaceuticals. Perhaps most importantly it would legitimise a substantial sustained budget for health pro- motion that would be directly translated into policy choices. In doing so it has the potential to improve the efficiency and equity of the overall health care system. Competing interests This paper is based on an options paper commissioned by the National Health and Hospitals Reform Commission [5]. Authors' contributions Publish with Bio Med Central and every AH and DM conceived the article. AH reviewed and edited scientist can read your work free of charge the draft prepared by DM. Both authors read and "BioMed Central will be the most significant development for approved the final manuscript. disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK References Your research papers will be: 1. Segal L, Dalziel K, Mortimer D: Fixing the game: Are between- silo differences in funding arrangements handicapping some available free of charge to the entire biomedical community interventions and giving others a head-start? Health Econ 2009 peer reviewed and published immediately upon acceptance in press. 2. National Institute of Clinical Excellence: NICE implementation cited in PubMed and archived on PubMed Central programme: putting NICE guidance into practice. [http:// yours — you keep the copyright www.nice.org.uk/media/E7B/C4/ PuttingNICEGuidanceIntoPractice2009.pdf]. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 4 of 4 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Funding illness prevention and health promotion in Australia: a way forward

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Publisher
Springer Journals
Copyright
Copyright © 2009 by Harris and Mortimer; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
eISSN
1743-8462
DOI
10.1186/1743-8462-6-25
pmid
19909519
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See Article on Publisher Site

Abstract

Background: Unlike pharmaceuticals and private medical services there is no single source of funding for illness prevention and health promotion and no systematic process for setting priorities in public health. There is a need to improve the efficiency of access to health funding across prevention and treatment. Discussion: We discuss a number of reforms to existing funding arrangements including the creation of a national Preventative Priorities Advisory Committee (PrePAC) to set priorities. We propose the establishment of a PrePAC to provide evidence and set priorities across health promotion and illness prevention, with a national dedicated fund for health promotion. Conclusion: A national evidence-based funding system for illness prevention and health promotion would legitimise a substantial and sustained budget for health promotion, breaking down some of the barriers in a fragmented federal health care system. Background processes, most prevention and health promotion inter- Funding for illness prevention and health promotion in ventions compete for disparate and uncertain sources of Australia is fragmented. Programs are funded by federal, funding that lack consistent and rational criteria for allo- state and local government but a lack of coordination and cation. In Australia, differences in the likelihood of fund- priority setting means that we are not making a consid- ing among otherwise equivalent interventions can be ered allocation of resources to illness prevention and attributed partly to differences in funding arrangements health promotion. We neither choose how much to spend [1]. An efficient health care system would not discrimi- compared to other health care activities, nor do we choose nate in this way. In this paper we suggest the creation of a interventions that offer the best value. Australia has led national Preventative Priorities Advisory Committee (Pre- the world in introducing formal evidence-based evalua- PAC) to reduce the gap in the likelihood of obtaining tion processes for medical services and technologies to public funding among equally cost effective interventions. establish value for money, but, as a consequence of frag- mented responsibility and funding, health promotion Discussion and illness prevention have been left out. While pharma- Two Models for a PrePAC ceuticals and (out of hospital and private hospital) medi- Two stylised models for the operation of a PrePAC are cal services in Australia have access to dedicated budgets considered here: a (i) Guidance Model and a (ii) Dedi- and are subject to formal and well-defined evaluation cated Funding Model. Page 1 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 Guidance model Depending on funding arrangements, the fund-holder The UK National Institute of Clinical Excellence (NICE) might be one or more of the Australian Health Ministers. provides evidence-based guidance relating to health tech- For clinical prevention services provided by a registered nologies and public health interventions [2-4]. The Public provider to an individual patient, the PreBS could operate Health Interventions Advisory Committee (PHIAC) and in much the same way as individual patient benefits listed Technology Appraisal Committees of NICE produce rec- on the Medicare Benefits Schedule (MBS) or the Pharma- ommendations on the use of public health interventions ceutical Benefits Schedule (PBS). That is to say, there and health technologies--based on consideration of the would be a list of interventions approved for funding available evidence regarding effectiveness and the cost from the scheme on a per-service (e.g. individual consul- effectiveness. Under the guidance model, a proposed Pre- tation on diet or smoking behaviour) or per-patient basis PAC would take a similar role to that of the PHIAC in Eng- (e.g. annual enrolment in a disease management pro- land. It would take account of the strength of evidence on gram). effectiveness and cost effectiveness of a prevention activity and might, for example, provide guidance that a particular Following Goldsmith et al. [11], we distinguish clinical activity should be given higher or lower priority. While prevention from non-clinical preventative interventions the quality of evidence in the area of prevention is often such as: (i) health promotion that targets a population to not high, this is not necessarily a barrier to good decision- encourage healthy behaviour and is provided by govern- making [5]. It would produce a list of recommendations ment or interest group organisations, (ii) health protec- that funding agencies could take into account when mak- tion that reduces health risk by changing the physical or ing funding decisions and setting priorities for preven- social environment often by regulation, and (iii) healthy tion. In 2009, COAG agreed to fund such a national public policy that involves social or economic interven- preventive health agency with responsibility for providing tions beyond the health sector. Individual patient benefits evidence-based policy advice [6]; this model was may be unsuitable for funding these categories of non- endorsed by both the National Health and Hospital clinical prevention and alternative mechanisms would Reform Commission [7] and the Preventative Health need to be used. For example, payments for health pro- Taskforce [8]. motion interventions might be based on a list of lump- sum grants to cover a delimited set of activities over a The main problem with a guidance model is that there is defined time period. Examples might include: annual no mechanism for funding. The guidance model relies on budget allocation to organisation(s) responsible for deliv- a disparate set of independent funding agencies to imple- ery of mass media education campaigns on road safety, ment PrePAC deliberations and recommendations. While healthy eating, physical activity, alcohol consumption, or the various responsible funding agencies might modify smoking cessation; lump sum payment to local councils their own funding rules or processes to take account of or community organisations for community events to PrePAC deliberations and recommendations, such recom- promote community connectedness, safe communities or mendations would be neither necessary nor sufficient to healthy lifestyle; or lump sum payment to schools for the secure funding. There may be no new funding allocated establishment of programs to promote healthy lifestyle for prevention and no guarantee that the deliberations such as the walking school bus or sex education. and recommendations of a PrePAC will have any impact at all upon resource allocation. Implementation involves For healthy public policy and health protection interven- much more than simply developing and disseminating tions, the PreBS could be a list of lump-sum grants to guidance. The Guidance model therefore falls well-short cover a delimited set of activities at a specific geographic of giving preventative interventions an equal chance of location. Examples might include: lump sum payment to funding compared to otherwise equivalent interventions local councils, state governments or community organisa- that benefit from access to a well-defined funding mecha- tions to alter the physical environment either to promote nism. healthy lifestyle (such as the provision of walking tracks/ pedestrian crossings, or improvements to parks and recre- Dedicated Prevention Fund ation areas) or to improve safety (provision of street signs A PrePAC allocating a dedicated prevention fund could be near school crossings or provision of lighting or CCTV modelled on the operation of the Medical Services Advi- around train stations or shopping precincts); lump sum sory Committee (MSAC) [9] or the Pharmaceutical Bene- payment to schools to alter the physical environment to fits Advisory Committee (PBAC) in Australia [10]. promote healthy lifestyle (such as establishment of a Specifically, a PrePAC would advise a fund-holder on kitchen garden or sporting facilities); lump sum payment whether a particular intervention or program should be to schools to alter the social environment to improve allocated money from a dedicated prevention fund. Rec- safety (such as provision of interventions to reduce bully- ommendations accepted by the fund-holder would then ing). be listed on a Prevention Benefits Schedule (PreBS). Page 2 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 Reimbursement via lump sum payments and annual necessary funding incentives for major infrastructure budget allocations is no different in principle than per- developments. service or per-patient payments. In each case evaluation of the safety, effectiveness and cost effectiveness of all pre- A proposal for reform ventative interventions would be for an approved indica- Currently clinical prevention is partially covered under tion and scale. For clinical prevention, the indication existing programs (such as the MBS, PBS, and NIP). Other would typically relate to characteristics of the patient and prevention and health promotion activities are more or the provider. For example, provision of group exercise ses- less covered by one of a multiplicity of government (fed- sions might only provide good value for money in people eral, state and local) and non-government organisations with diabetes or cardiovascular disease if they are predom- (such as the National Heart Foundation and Cancer inantly focused on cardiovascular fitness (rather than Councils). Health protection and healthy public policy strength or flexibility training). For health promotion and are currently handled within the relevant departments of health protection interventions, the indication might federal, state or local governments. We propose reforms to instead relate to characteristics of the community. Provi- existing funding arrangements that take account of the sion of CCTV around train stations might only provide current state of play while increasing the efficiency of good value for money in areas that have a high level of access to health funding across prevention and treatment. street crime. Specifically, we propose a PrePAC providing guidance with regard to health promotion, health protection and The PrePAC might therefore approve open-ended funding healthy public policy, but that relies on existing programs for a listed item in much the same way as the PBAC or (such as the MBS, PBS, and NIP) to provide guidance and MSAC, specifying an approved indication for each item. funding for clinical prevention. Delimiting the scope of a For clinical prevention, claims for PreBS items might fol- PrePAC in this way would capture the majority of inter- low similar procedures as for restricted benefit items on ventions while minimising the risk of replicating the func- the PBS. The PrePAC might, however, choose to specify tion of existing agencies. Gaps in the coverage of clinical "pre-approval" status for some types of interventions; par- prevention would then be handled by modifying the ticularly for health promotion and health protection scope of services covered under existing programs by, for interventions that entail relatively large lump sum pay- example, issuing Medicare Provider Numbers to a broader ments. Obtaining approval might require submission of range of health care providers and adding item numbers evidence to substantiate that the intended use of funds to the MBS. Given the multiplicity of parties currently meets the restriction for the relevant item number. For involved in appraisal of health promotion, health protec- example, a council requesting funding for a pedestrian tion and healthy public policy (in contrast to the relatively crossing might be required to provide traffic impact anal- small number of agencies with responsibility for clinical yses, a community survey demonstrating community sup- prevention), the creation of a PrePAC would yield sub- port, and an assessment of the impact of community stantial cost savings and improvements in the consistency structure on access to community nodes. Provision of and quality of evidence appraisals. funding for a specific pedestrian crossing with authority required status would therefore entail a two-stage process. For health promotion, we believe that the PrePAC should First, the PrePAC would have to list pedestrian crossings be extended beyond the guidance model to allocate a on the schedule for an approved 'indication'. Second, the national fund for health promotion activities. The crea- local council requesting funding for a specific pedestrian tion of a PrePAC with responsibility for funding health crossing would have to submit a request for approval promotion has the potential to reduce the number of pro- demonstrating that the intended site meets the 'approved grams making allocation decisions and can be expected to indication' and that the intervention conforms with the improve the consistency and quality of decision-making. approved description in terms of its active constituent A PrePBS would provide national coverage of health pro- parts delivered effectively. motion activities and a clear pathway for funding for interventions that currently have no obvious source of While the dedicated fund model has the advantage of sim- funding. plicity and familiarity it does have a few boundary issues that would need to be resolved. Regulatory or infrastruc- While we believe that a PrePAC could make a valuable ture interventions may not sit easily in a health system contribution by providing guidance for non-clinical pre- funding scheme. Smoking or alcohol regulation or the vention, many preventative interventions that might be provision of public transport could be appraised by a Pre- categorised as health protection and healthy public policy PAC but it is more difficult to imagine a PreBS with the would not be amenable to funding through an item based capability to facilitate legislative change or to provide the PreBS-type mechanism. The large-scale inter-sectoral nature of some health protection and healthy public pol- Page 3 of 4 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:25 http://www.anzhealthpolicy.com/content/6/1/25 3. National Institute of Clinical Excellence: The public health guid- icy interventions (such as transport and infrastructure) ance development process: an overview for stakeholders and the non-financial costs of implementing of others including public health practitioners, policy makers and the (such as smoking restrictions) are not easily achieved public. [http://www.nice.org.uk/media/69E/F9/ CPHE_Process_manual.pdf]. through the allocation of a dedicated fund. For this rea- 4. National Institute of Clinical Excellence: Methods for develop- son, we propose that the PrePAC should initially provide ment of NICE public health guidance. [http://www.nice.org.uk/ nicemedia/pdf/CPHEMethodsManual.pdf]. guidance only for health protection and healthy public 5. Harris A, Mortimer D: A Preventative Priorities Advisory policy. Committee and Prevention Benefits Schedule for Australia. Options Paper: National Health and Hospitals Reform Commission, Commonwealth of Australia, Canberra; 2008. Conclusion 6. Council of Australian Governments: National Partnership Agree- We agree with the Wanless report [12] that "to achieve the ment on Preventive Health. Commonwealth of Australia, Can- objective of an efficient allocation of national health serv- berra; 2008. 7. National Health and Hospitals Reform Commission: A healthier ice funding between health care and public health, a sim- future for all Australians - final report. Commonwealth of Aus- ilar method of cost effectiveness analysis needs to be tralia, Canberra; 2009. 8. Preventative Health Taskforce: Australia: the healthiest country applied to public health and clinical interventions." Our by 2020 - National Preventative Health Strategy. Common- suggestion is to create a new body--the Prevention Priori- wealth of Australia, Canberra; 2009. ties Advisory Committee (PrePAC). The PrePAC would 9. O'Malley S: The Australian experiment: The use of evidence based medicine for the reimbursement of surgical and diag- provide advice on the effectiveness and cost effectiveness nostic procedures (1998-2004). Aust New Zealand Health Policy of interventions in health protection and healthy public 3:3. 10. Henry DA, Hill SR, Harris A: Drug prices and value for money: policy. This is consistent with aspects of other proposals the Australian Pharmaceutical Benefits Scheme. JAMA 2005, to establish a nationally coordinated preventive health 294:2630-2632. agency responsible for the evaluation of effectiveness, effi- 11. Goldsmith L, Hutchinson B, Hurley J: Economic evaluation across the four faces of prevention: a Canadian perspective. CHEPA ciency and equity outcomes [6,8,13]. It has the potential Working Paper Series Paper 06-01; Hamilton, Canada; 2006. to engage many of the levers identified by Lin [14] for 12. Wanless D: Securing good health for the whole population. In shifting the focus of the health system to more emphasis Securing good health for the whole population HM Treasury: London; on prevention and health promotion. We believe that it is 13. Oldenburg BF, Harper TA: Investing in the future: prevention a necessary to go further and establish a national dedicated priority at last. Med J Aust 2008, 189:267-268. 14. Lin V, Fawkes S, Hughes A: A Vision for Prevention in Australia. fund for health promotion, access to which would be Discussion Paper, Australian Institute of Health Policy Studies; 2008. determined by the PrePAC. This would provide a national program, thus breaking down some of the barriers in a fragmented federal health care system. It would provide technical leadership and a political voice for prevention that has been lacking compared to medical services and pharmaceuticals. Perhaps most importantly it would legitimise a substantial sustained budget for health pro- motion that would be directly translated into policy choices. In doing so it has the potential to improve the efficiency and equity of the overall health care system. Competing interests This paper is based on an options paper commissioned by the National Health and Hospitals Reform Commission [5]. Authors' contributions Publish with Bio Med Central and every AH and DM conceived the article. AH reviewed and edited scientist can read your work free of charge the draft prepared by DM. Both authors read and "BioMed Central will be the most significant development for approved the final manuscript. disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK References Your research papers will be: 1. Segal L, Dalziel K, Mortimer D: Fixing the game: Are between- silo differences in funding arrangements handicapping some available free of charge to the entire biomedical community interventions and giving others a head-start? Health Econ 2009 peer reviewed and published immediately upon acceptance in press. 2. National Institute of Clinical Excellence: NICE implementation cited in PubMed and archived on PubMed Central programme: putting NICE guidance into practice. [http:// yours — you keep the copyright www.nice.org.uk/media/E7B/C4/ PuttingNICEGuidanceIntoPractice2009.pdf]. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 4 of 4 (page number not for citation purposes)

Journal

Australia and New Zealand Health PolicySpringer Journals

Published: Nov 12, 2009

References