We know prevention works. The challenge is not finding more things to prevent – it is building a health system capable of delivering prevention.
Recently, I had the opportunity to discuss the NSW Rural Doctors Association’s prevention priorities with NSW Health.
The timing is important. NSW Health is preparing for a prevention summit in October. Those conversations prompted me to put down a few thoughts of my own.
Our problem is that our health system isn’t particularly well designed to do it.
Prevention has become a buzzword
Everybody talks about prevention. Everybody supports it. Yet too often, prevention becomes a collection of projects.
An initiative is announced. Attractive project documents, guidelines and business cases are produced. Funding is allocated. A team is established. KPIs are developed.
Somewhere along the way, completing the activities becomes the priority and the outcomes we were trying to achieve get forgotten. Eventually, funding ends, priorities change or people move on.
That will not produce the population-level change we are looking for.
The problem is not that people within our health services don’t care. Many care deeply. The problem is structural. Our health systems have primarily been built to manage illness. Prevention requires a very different way of working.
Hospitals work vertically. Prevention works horizontally
Acute healthcare largely operates through vertically integrated systems. There are hierarchies, reporting structures, budgets, departments and defined responsibilities.
When elective surgery waiting lists grow, additional capacity can be purchased. When emergency departments become overwhelmed, we look at beds, staffing, surge capacity and patient flow.
These are difficult problems, but they fit the operating model of an acute health service.
Prevention does not.
You cannot manage obesity like a surgical waiting list. You cannot manage smoking prevalence like ambulance ramping. You cannot open another clinic and declare that prevention has been solved.
Prevention happens in people’s homes, schools, workplaces, childcare centres, supermarkets, sporting clubs, general practices and communities.
It requires horizontal integration.
General practices, PHNs, local government, schools, early childhood services, community health, public health units, Aboriginal health organisations, aged care, NGOs, sporting organisations and businesses may all have a role.
No single organisation controls them.
Prevention is not simply healthcare delivered earlier
The biggest organisation cannot always dominate.
Many prevention initiatives I have encountered are driven by acute health services. That seems logical: these are large organisations with considerable expertise and resources. But their overwhelming responsibility is acute healthcare.
Their culture, governance and funding arrangements have evolved around delivering acute services. My experience has often been that health services expect other stakeholders to fit into the health service’s way of working.
For prevention, we may need to reverse that thinking.
Rather than asking, “how do we bring these organisations into the LHD model?”, we should ask, “how do our LHDs need to adapt to work effectively with others?”
That requires giving up some control. It also requires patience. Prevention outcomes may take five, 10 or 20 years to become obvious. That sits uncomfortably within systems accustomed to annual budgets, short funding cycles and rapidly measurable outcomes.
The financial case for prevention is compelling. Australian Institute of Health and Welfare estimates indicate that in 2023-24 around $38 billion in health system spending was attributable to potentially avoidable risk factors.
Overweight and obesity alone accounted for approximately $7 billion.
The Australian Burden of Disease Study 2024 estimated that around 36% of Australia’s disease burden could potentially be avoided or reduced by addressing modifiable risk factors. We know many of those risk factors: obesity, tobacco, poor diet, high blood pressure, high blood glucose, alcohol and other drugs, and physical inactivity.
We don’t need another major study to tell us what is making Australians sick.
What we need to work out is what parts of prevention our state health services are best placed to deliver – and what they should enable others to deliver.
More money alone won’t fix prevention
There is plenty of evidence that Australia underinvests in prevention. We should invest more. But there is little point substantially increasing prevention funding unless we also change the way we do prevention. Otherwise, additional money risks creating more projects rather than better prevention.
Funding is important, but funding itself is not an operating model.
LHDs need to create the conditions in which prevention can work with fewer barriers between organisations, genuine collaboration, flexibility to modify interventions and patience to allow results to emerge. That also means confronting bureaucracy.
Large organisations are often very good at explaining why something cannot be done. Prevention requires us to ask the opposite question: What needs to change so that we can make this happen?
Related
What could we actually do differently?
1. Set a whole-of-government strategic agenda.
NSW Health should help government establish a small number of long-term prevention priorities. Many of the most effective levers sit outside the health portfolio – food policy, tobacco and vaping regulation, education, urban planning and environments that encourage physical activity. The Ministry can provide the evidence and strategic direction for broader government action.
2. Identify the organisations needed to deliver it.
PHNs, Cancer Council, Heart Foundation, education, early childhood services, general practice, community health, local government, Aboriginal health organisations, aged care, home care and community organisations should not simply be “stakeholders”. They should be partners in delivery.
General practice deserves particular attention. Especially in rural and remote communities, GPs are a significant asset in prevention, care coordination and aged care. They understand their communities and often have relationships that large organisations spend years trying to build.
3. Build formal relationships around outcomes.
Develop agreements around defined prevention objectives: who contributes what, how information is shared, what outcomes matter and how those outcomes will be evaluated. There are lessons from previous collaborative commissioning approaches. But partnerships need to recognise the strengths of different organisations rather than forcing everyone into a health-service model.
4. Bring general practice and primary care properly into prevention.
Prevention fundamentally belongs in primary care. Yet our funding models largely reward episodic clinical activity rather than population-level prevention.
Why couldn’t GPs and practice teams be funded to work with schools and childcare centres on health coaching and early intervention?
Why couldn’t physiotherapists, general practices, community organisations and local gyms collaborate on muscle strength, balance and frailty prevention for older people?
Why couldn’t public health units routinely work alongside PHNs and primary care practices on locally identified priorities?
Primary care cannot remain an afterthought in prevention.
5. Develop a statewide communication strategy.
Behaviour change requires consistency, repetition and time. Public messaging should reinforce agreed prevention priorities rather than every project developing its own disconnected campaign.
6. Use the intelligence we already have.
Public health data, LHD datasets, LUMOS, PHN primary-care data and health-needs assessments, local government information and education data provide enormous intelligence. The goal should not be for NSW Health to own everyone else’s data. It should be to share intelligence, identify risk earlier and coordinate action.
We should also ask how prevention can be incorporated into virtual care rather than treating it as a separate agenda.
Technology is changing prevention
Predictive models, genomics, wearables and artificial intelligence are increasingly allowing us to identify risk before disease appears.
We can already estimate future risk for conditions such as breast cancer and identify some people who may benefit from preventive therapies. Digital technologies can identify rhythm abnormalities and cardiovascular risk.
We need safe, evidence-based ways of incorporating these advances into healthcare.
Who is accountable?
This brings me back to the NSW prevention summit.
I am encouraged that NSW Health wants to make a difference. There is strong public health leadership within the organisation, including Kerry Chant and her team, and an opportunity to think seriously about the next phase of prevention.
But I am less interested in how many initiatives emerge from the summit than in the answers to some harder questions.
- How will the Ministry hold LHDs accountable for prevention outcomes?
- How will it remove bureaucratic barriers when prevention crosses organisational boundaries?
- How will primary care become a genuine partner?
- How will success be measured when meaningful outcomes may take years?
- And ultimately: Who owns prevention? Perhaps the answer is that nobody can own it.
And perhaps that is precisely why we need a system built around shared responsibility rather than organisational ownership.
Prevention is a team sport
There is no serious doubt that prevention works. We know many of the interventions. We know the major risk factors. We know the human and financial cost of preventable disease. The challenge is no longer simply deciding what to fund. It is learning how to do prevention differently.
That means getting outside institutional comfort zones, working across bureaucratic boundaries, accepting that no single organisation can control the agenda, and having the patience to invest today in outcomes that may only become obvious years from now.
NSW has an opportunity to get this right. But if all we do is put more money into the same structures, create another round of projects and measure another set of short-term KPIs, we should not be surprised if we get more of the same.
Prevention doesn’t just need more funding. It needs a different operating system.
Associate Professor Alam Yoosuff is a rural generalist GP, chair of the Murrumbidgee PHN, and a board director for the Murrumbidgee LHD. He is a clinical academic at the University of Notre Dame.
This article was first published on Professor Yoosuff’s substack. Read the original here.