Imagine a country where most of the resources spent on transport went on crash repairs. The neighbouring country, by contrast, invests its resources in building safe roads, supplying accessible and energy efficient public transport and encouraging a social norm of driving safely and responsibly.

Doesn’t take much to work out which country has got it right. Yet we run our health system like the first country. Most of our resources are spent on services for the sick at the downstream end of health and we invest massively in hospitals. More importantly, our mindset is stuck in the idea that in order to be healthy, the most important thing we can do is improve the performance of our hospitals and invest more resources in them.

Why this is the case when it makes little sense is the mystery that public policy needs to solve. Partly it reflects the fact that all of us fear being really sick and want to be reassured that the hospital bed we need is waiting for us. Partly it is because over the years the medical-industrial complex has been remarkably successful at selling its benefits and established its self as one of the most powerful interest groups in modern societies.

But mainly it is because our public policy makers don’t get the fundamental law of public health. This was spelt out by the British epidemiologist Geoffrey Rose and dubbed “The Prevention Paradox”. It tells us that if we want to make whole populations healthier, then it is little use putting all our resources in to those who are at high risk. This group are at the tail end of the distribution and even if we were very successful in making them healthier because they are only a small proportion of the population we would make little different to the population overall. By contrast if we manage to make a small shift in the big group of people in the middle we would have a larger effect on the population because there are so many people in that group.

So while it would seem like a triumph for public health to have say two out of a hundred very obese people lose 20 kilos each through an expensive surgical stapling, when in fact having the 70 people in the middle each lose 3 kilos each by living in environments that encourage exercise would be much better.

The sensible approach for a health system is to work out how it can invest more in disease prevention and encourage the whole of society to play a role in promoting health.

The next question is what form of health promotion works? The beguilingly simple solution is that education will do the trick. This myth survives despite that fact that several generations of behaviour change programs have been singularly unsuccessful at bring about the desired changes.

The Commission on the Social Determinants of Health established by the World Health Organisation has reviewed evidence from around the world and concluded that improved population health has been obtained in the past not primarily by the provision of health services (although accessible and appropriate services are a small part of the picture) but through action on the social and economic determinants of health such as the provision of safe housing, clean water, universal education, safe employment conditions and urban environments that are supportive of health.

In July the Chair of the Commission Sir Michael Marmot will visit Australia to talk about the final report from the Commission. Meanwhile there is every indication that the National Hospital and Health Reform Commission and the 2020 Summit are locked into the “crash repair” model of health.

It will be such a wasted opportunity if the Commission and the Summit can’t broaden their horizons to think about more than hospitals and health education.

Examples of practical steps they could recommend are:

  • The establishment of an Australian Healthy & Sustainable Communities (AHSC) program which would fund partnership initiatives between local government, State Government departments with genuine community involvement that would develop a vision for sustainable, convivial and economically prosperous communities with a mandate for clear outcomes related to longer term health and environment outcomes. Funding would be for 10 year periods and the whole program would be evaluated to ensure continual feedback and improvement.
  • All government departments be required to consider the health and health equity impact of their activities and report these annually and for each major initiative.
  • Determination of where regulation of the private sector is required to help ensure that its activities do not detract from health, health equity and environmental sustainability – for instance advertising of junk food to children and alcohol during sports programs and regulation against externalisation of the costs of pollution
  • Giving the National Health & Medical Research Council a mandate to fund research that focuses on the “H” in its name rather than just the “M” where the overwhelming amount of its funding is directed at present. We need a social determinants research agenda that takes its cue from the forthcoming report of the Commission on the Social Determinants of Health.

Each of these measures promises to do more for our health than hospital crash repairs and more health education campaigns.