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COTA

Consultation on the review of the State Public Health plan South Australia: A Better Place To Live

This feedback responds to an invitation to comment on the review of SA's inaugural Public Health Plan released in November 2013 as part of the implementation of the South Australian Public Health Act, 2011 (The Act).

COTA SA agrees with Professor Paddy Phillips' reflection in his invitation to contribute to a review of the State Public Health Plan, that "actions of the current Plan have primarily been directed to Local Government and SA Health". We very much welcome the review as an opportunity to revisit the "broader remit of the Plan to build healthier communities that support healthier lifestyles, (requiring) action in partnership with a range of Government and non-Government organisations".

There is an existing and growing gap between the funding required and the funding available for health. A population based public health approach, including a focus on primary care and keeping people well, would see more emphasis on health promotion, health literacy, self-management and peer information.

Our rapid rate of population ageing makes older people a high priority target for a population health focus. Because older people are major users of our hospitals, there is much to be gained for both older people and for our SA community from an exploration of the public health approaches that are anticipated in the principles of The Act - prevention, population focus, participation, partnership and equity - to discharge the responsibilities of the State in supporting the health and well-being of older people.

COTA SA notes the importance of a public health plan being a whole of government - indeed whole of community - effort with many areas beyond the scope of the health portfolio impacting powerfully on health and well-being. These areas include cost of living, housing, transport, environmental issues and road safety. Indeed, in our extensive consultations with older South Australians in the second half of 2017, older people nominated the importance of green space, local amenities, a sense of belonging and neighbourliness as some of the things that mattered most to them.

Modern Ageing

The Public Health Plan will need to focus on what COTA SA refers to as "modern ageing", which is different in at least 5 ways from the ageing that was experienced a generation ago. Those differences are -

  • Numbers - There are 633,784 South Australians now aged over 50, with over 50s comprising more than 50% of the eligible voting population. This proportion will continue to grow with over 60s growing from 17.5% of the SA population now to 25% by 2050.
  • Diversity - There is significant diversity among older people - diversity of health, income, location, sexual orientation eg - 30% from CALD background, 10% LGBTIQ, about a third in rural areas, many in single person households, far fewer owning homes.
  • Inequality - Old age is the time that a lifetime of inequality, compounded and multiplied from life event to life event, is in its starkest relief. Aboriginal people die more than 10 years earlier than non-Aboriginal Australians. There is particular disadvantage relating to unemployment in 50s and 60s, not owning a home and little or no super. It is often a gendered picture.
  • New Expectations - The attitudes and expectations of older people are shifting from what have been described as "false positive" high levels of satisfaction for services to much more individualised expectations. There is a recent focus on ageing segments made up of both demographic and behavioural characteristics.
  • Changes to the life course - The "typical" life course is shifting because of largely healthy extended life expectancy. Australia has one of the highest life expectancies in the world. 60 years ago, life expectancy for men was 67 and for women was 72 - in the 60 years since our lives have been extended by 13 or 14 years. There is no reason therefore that we should expect the contemporary life course to follow the patterns of our parents.

Areas of Focus

We would suggest that there are some important priority areas that the next Public Health Plan might focus on including - 

Isolation and Loneliness

There is a well-established link between isolation and loneliness and health risks, and direct associations with poor mental, physical and emotional health and increased rates of cardiovascular disease, hypertension, cognitive decline and dementia. Older people are at increased risk of isolation and loneliness for a range of reasons, including because they are more likely to live alone, have vastly reduced social networks, may be restricted in their mobility and have sensory limitations.

Particular populations of older people are at higher risk including older people of CALD background and older LGBTIQ people. Isolation was consistently identified as an issue by the older LGBTIQ community to COTA SA in our LGBTIQ People Ageing Well Project.

Falls Prevention

A Public Health Plan must make the reduction of falls among older people in SA a priority. Well over 20,000 hospital admissions that occur in SA each year are as a result of falls. After a fall an older person has a 50% probability of having their mobility seriously impaired and a 10% probability of dying within a year. Perhaps just as importantly, falls reduce confidence, increase isolation and reduce independence. 

There are a variety of evidence based strategies to prevent falls, including education and awareness, physical design and, importantly, exercise.

Programs that improve strength and balance can reduce the risk of falls by as much as 55%. However fewer than half of people aged over 50 undertake 150 minutes of exercise a week, and this proportion reduces to a quarter by age 75, lower than for any other age group. People tell us that cost, lack of confidence and not knowing where to start were identified as major blocks to people starting exercise. Initiatives that increase the number of older South Australians who undertake regular exercise, including as a protective factor against falls is a priority for public health investment.

Peers, Co-Design and Health Literacy

There is considerable scope to mobilise the older community as an underused asset in their own good health.

UK based innovation think-tank, Nesta, estimates that co-design approaches such as self-management and peer processes can reduce the cost of managing patients with long term health conditions substantially.

Nesta proposed a new approach to health called People Powered Health in 2013. By focusing on five areas of practice - new services, peer support, redefining consultations, networks and partnerships and user co-design and co-delivery - the business case developed in support of People Powered Health estimated that it was possible to "reduce the cost of managing patients with long-term conditions by up to 20 per cent." This is based on the ability to mobilise the asset base that is patients, service users and their communities and reduce unplanned admissions and the requirements for acute care.

Fundamental to this will be building options that extend the health literacy and information available to older people about their options to maximise health. COTA SA would urge the inclusion of peer approaches to make a cost effective and lasting contribution to reducing falls and medication related hospital admissions.

While Advance Care Directives have considerable potential to enable people to control and choose options particularly at end of life, the uptake of, and respect for, Advance Care Directives is very low.

Frailty

There is important emerging research that supports considering some frailty as preventable and treatable, including from Adelaide's own NH&MRC funded Centre of Research Excellence in Frailty and Healthy Ageing, based at the University of Adelaide. Because people aged over 85 are five times more likely to be admitted to hospital than other age groups and then more likely to have longer stays there is a compelling case to explore approaches that reduce the financial and human cost of frailty and promote possibilities for a "people powered" approach.

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