Is our health system doing a “reverse Robin Hood”?

Health and communications consultant Mark Ragg spent a fair bit of time wading through health statistics and reports to come up with his own personal assessment of the state of our health system.

His conclusion, as reported in Crikey yesterday, is that the system is generally fine – but it’s not fair.

“You do much better in Australia’s health care system if you’re wealthy, if you’re well educated, if you live in the city and if you’re not Indigenous,” the report says. “Otherwise, it seems, you receive a lesser standard of care.  If you have a chronic condition such as diabetes or heart disease, you’ll end up in hospital where someone better off will manage to stay home and get the care they need. And if a rich person and a poor person get cancer at the same time, the poor person will die sooner.”

One of the report’s most politically sensitive sections concerns the Australian Government’s subsidy of private health insurance. Ragg notes that the cost of the scheme is rising rapidly but that it has not taken the pressure of public hospitals and that health funds are spending less per member than they did 10 years ago.  Meanwhile, the total equity of Australian private health insurance funds has risen by about $3 billion since the Government started subsidising private health insurance.

“In effect, private health insurance and its application in Australia through the private health insurance rebate scheme does a reverse Robin Hood – it takes money from the poor and gives it to the rich,” says Ragg. “And it does little good for public hospitals.”

Let’s hope someone in the PM’s or Treasurer’s office is reading…

But what do others think of Ragg’s report?

Professor Ian Olver, CEO of Cancer Council Australia and a medical oncologist, writes:

Mark Ragg makes some good points about healthcare inequity in Australia. It’s important to add that poorer cancer treatment outcomes experienced by socially disadvantaged people can in many cases be linked to lost opportunities in preventative health, rather than access to treatment.

Around a third of fatal cancers in Australia are caused by smoking, obesity/overweight and alcohol consumption – partly because some of these cancers, such as lung cancer, are difficult to treat no matter how good the care.

And the cancer burden from these behaviours is borne disproportionately by socially disadvantaged groups. For example Indigenous Australians, who are twice as likely to die within five years of a cancer diagnosis as non-Indigenous Australians, smoke at 2 times the rate of others. So, while there’s evidence that Indigenous people have very poor access to cancer treatment services, there’s also data suggesting that the higher prevalence of smoking-caused cancers among Indigenous people contributes significantly to the unacceptable disparity in cancer survival.

Yet less than 2% of Australia’s health budget goes towards prevention – and far less to tailored programs for disadvantaged groups. This is despite the well-documented social and economic gains available from investing in targeted, evidence-based public health programs.

The Rudd Government’s Preventative Health Taskforce has made strong recommendations to reduce smoking, obesity and alcohol use – setting targets; integrating policy, programs and research; multi-sector approaches and so on. Now it’s up to the Government – which campaigned on building disease prevention into the intergovernmental healthcare agreements – to begin implementing the recommendations through COAG this year.

And with early detection another key to cancer survival, the Government should also expedite its piecemeal bowel cancer screening program – and support it with tailored communications that help ensure all population groups are screened for Australia’s most fatal cancer after lung cancer.
***

Sally Crossing, Chair, Cancer Voices NSW, writes:

Mark Ragg poses the question “Why do poorer and less educated people have worse cancer outcomes than wealthy well educated people?”

It may be because they fall through the cracks on the route to best practice treatment.  They may not get referrals to the multidisciplinary teams which give the best outcomes. They may give up trying to navigate the cancer world “silos” – perhaps this is where assertiveness of the better educated can help, though a cancer diagnosis is pretty destabilising for us all.   They may present too late due to cultural or poverty reasons.

Cancer is a disease which can be most successfully treated when diagnosed early and we still don’t really understand it – unlike heart disease treatment which resembles human plumbing.

Cultural reasons could include the “I’ve got cancer so I’m going to die” belief, a mantra not shared with any heart patients anymore.  And then there are situations where cancer is still not to be spoken of.  Or they may live a long way from good cancer care and be unable to access it…so many possible facets in an answer.

Whatever the truth, thanks for raising the issue.  One vital piece of info we needed to have was how great is the difference between poor/uneducated and wealthy/well educated, and how any people are involved and how many fall in between.  Then we’d have some real evidence for advocacy to address the inequities.

***

Professor Stephen Leeder, co-director of the Menzies Centre for Health Policy, writes:

Assuring fair and equal access to equal medical need remains a constant challenge in health. Centralisation of highly specialised services is technically essential for efficient use of health dollars but each time we do this people who live remotely have less access.  A system that is not tuned to cultural difference will provide less access to cultural minorities.

Let me tell you about another source of inequity and that we have encountered in our work with patients with chronic illness. It is that chronically ill people are told that they should do all they can to stay out of hospital.

Why! Because the hospital is not geared to treat them. So why not change the hospital? This is like going to a shoe store and being told they have no shoes that fit and so please change the size of your feet!

***

Anonymous writes:

Whenever I read such pieces, I am always reminded of the seminal paper by Julian Tudor Hart that was published in the Lancet in 1971 (J. Tudor Hart, The inverse care law. Lancet (1971), pp. 405–412 – also accessible at http://www.sochealth.co.uk/history/inversecare.htm).  Much of his characterisation of Britain’s NHS in the 1960s is relevant to Australia today.  Furthermore, he also provides quotes from several earlier sources which might be viewed as resonating uncannily with our current system some 40 years on eg:-

“We have learnt from 15 years’ experience of the Health Service that the higher income groups know how to make better use of the service; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups- particularly the unskilled.” Titmuss R M, Commitment to Welfare. London 1968 (Reference 2)

“The general practitioner in working-class areas discovered the well-tried business principle of small profits with a big turnover where the population was large and growing rapidly; it paid to treat a great many people for a small fee.  A waiting-room crammed with patients, each representing 2s. 6d. for a consultation … not only gave a satisfactory income but also reduced the inclination to practise clinical medicine with skilful care, to attend clinical meetings, or to seek refreshment from the scien­tific literature.”
James E F, Lancet (1961) I 1361 (Reference 5)

“Of 169 new general practitioners who entered practice in under-doctored areas between October, 1968, and October, 1969, 164 came from abroad.” DHSS Annual report for 1969, London 1970 (Reference 13)

****

Michael Moore, CEO, Public Health Association of Australia, writes:

Mark Ragg has stumbled on the social determinants of health.  There is no doubting that the cancer example he uses puts equity and fairness under the spotlight.  It is just downright unfair that the wealthier you are, the healthier you are.

Sir Michael Marmot, as Chair of the Commission on the Social Determinants of Health, has just released a report on behalf of the World Health Organization called Closing the gap in a generation.  Sound somewhat familiar?  In Australia the health inequities are bad enough but viewed from an international perspective they are downright appalling.

The Preventative Health Taskforce are also aware of this issue and gave as an example in their discussion paper Australia: the healthiest country by 2020 that “even within a city such as Melbourne, life expectancy can vary by up to five years within a matter of kilometres.

The problems of inequity in health outcomes have been recognised – the challenge is in finding ways to work to fairer health outcomes.

***

Jeff Richardson, Professor and Foundation Director, Centre for Health Economics, Monash University, writes:

Mark Ragg’s comments in Crikey are well made. Perhaps they are even too generous. It is true that Australians now live longer than almost anyone apart from the Japanese.

But whether this is attributable to the health system (as a system), as distinct from some very specific factors has never been demonstrated. Smoking, drinking and blood pressure are all down. Exercise is up. But at best this reflects the success of public health measures, not the remainder of the system which accounts for about 98.3 percent of expenditure. We do not know if it is the skill of doctors or the efficacy of anti-hypertensive drugs which have the greatest impact in the curative services.

There is absolutely nothing to suggest that it is improvements in the system (which remains largely static) which have caused the improvement. Policies at both the State and Commonwealth level are largely concerned with cost containment and tinkering on the margin with issues associated with health outcome.

The system remains as fragmented as it did 20 years ago when the need for integration was first recognized. In all probability, adverse events continue to kill very large numbers of Australians unnecessarily. The chief publicised policies here are about counting numbers (imperfectly) rather than removing the systemic causes of error and accelerating the inadequate rate of error learning.

Mark Ragg correctly identifies unfairness as a pervasive problem. This was documented for 1976 by myself and John Deeble and reinforced by sporadic research thereafter. Once again the response indicated no real interest in the problem beyond the cosmetic.

Indeed, rather than concern, over a five year period I was unable to obtain data from the Commonwealth Department of Health to analyse how the unfairness had changed through time. We should not, however be particularly surprised by this lack of interest.

Despite folk myth to the contrary Australia remains one of the least egalitarian and meanest countries in the developed world. Our rates of poverty amongst disadvantaged groups, the amount we transfer in social services, the amount we give to other countries, the amount we take from well off taxpayers all come at the bottom or close to the bottom of the OECD league table.

Australians seemed to be far more focussed upon downward envy and less concerned with the position of Aboriginals, rural minorities and other disadvantaged groups than people in more compassionate Western societies.

The unfairness of the distribution of doctors, services and the widespread support for queue jumping via private health insurance are all a reflection of this national character. But apologists will doubtless continue to use any available statistics to support their self congratulation and to avoid the need for a thorough inquiry into the operation of our antiquated and often dangerous delivery system.