Shame, shame, shame on the Commission of Audit

The Commission of Audit’s health-related recommendations are evidence-free, ideologically driven and are bound to be harmful to the community’s health, according to Jim Hyde, Professor of Public Health Policy at Deakin University.

Jim Hyde writes:

The Commission of Audit report  demonstrates a wilful disregard for evidence and for the history of system development, while dragging up and relying on old myths and urban legends in health.

The Commissioners clearly did not seek advice from anyone with views that were different to their own ideology.

Their health-related recommendations leave me with an overwhelming sense of déjà vu.

My sense of déjà vu comes from hearing the same old myths that have been trotted out in health reform over the past decade, which have led to tinkering at the edges and no real systemic attempt to make real, enduring and sustained change in care, prevention or health outcomes.

There is no recognition of the fact that illness and treatment are not synonymous with health, or that health is socially determined, not technically or medically determined.

It is as if all the major health reform reports, both here and internationally over the past decade or so that have recognised the social basis for health and the economic arguments for investing in a comprehensive and complex health system that includes treatment at various levels and prevention, have not occurred or certainly are unknown to the Commissioners and the economic boffins who advised it.

There was certainly no Marmot and Wilkinson, no Acheson or most importantly no Wanless.

I would argue missing or ignoring compelling evidence is irresponsible and almost criminal when it comes to people’s health outcomes.

The report is full of ideological rhetoric and opinion. In some cases almost it is laughably so.

Take, for instance, the statement that universal health care is an absolute necessity in a civilised country. True, but the Commissioners state it as their opinion, not the fact that there are many studies and piles of evidence that makes this a clear truism.

That would be evidence to support their statement but it’s instead cast as an ideological opinion, rather than a considered fact.

They have bought the urban myth that ageing will increase health costs, probably because it supports currently fashionable attack on the aged pension.

Ageing does not increase health costs – inequity in services and interventions does – and the fact that services and interventions are mostly used toward the end of life, regardless of age, has escaped their analysis.

It is true that health costs are rising rapidly, but I would suggest they are supply-driven by practitioners, not demand-driven by health participants.

Doctors and nurses have not given us better health outcomes – our rising prosperity and our communal investments have done that, and the Commissioners should recognise that wealth is an important determinant if they want their analysis to be taken seriously.

A glaring omission in the report is the field of prevention (unless, abolition of the structures that support this counts).

This is regardless of the amount of evidence and effort that has been invested in prevention and the studies here and overseas that show its economic benefit.  The Wanless Report in the UK presented a compelling argument and set of evidence for rethinking health funding and organisation and has been largely ignored by Governments there and here, even though it got a lot of publicity at the time of its release.

There is no evidence for the assumption stated that making health more competitive and efficient will either lower costs or improve outcomes.

In fact, there is evidence that too much competition drives down health outcomes.   Conservative US researchers have lamented the drives to competition in their system as being wrongly targeted and leading to zero outcome competition which does not add value but divides benefits inequitably.    Increasing the supply of practitioners in Australia and elsewhere has increased cost because of the professional strength of health associations. (No supply/demand improvements here.)  The introduction of new technologies has often not been adequately reviewed and has increased costs not reduced them.

Neither is there any evidence that reducing regulation will improve health.  Imagine a regulation-free anti-smoking environment!

The reason that tobacco, alcohol and fast food industries are so opposed to regulation is that it holds them accountable for health outcomes and assists people to make much easier choices about their own health behaviours.

Public health in the areas of food safety, clean air and water and hazards is built on regulation and government intervention not on a free market, so get over it!

Let’s not even exercise the arguments about the inequity of HEALTH co-payments in health.  They do not lead to efficiency or effectiveness – a word that doesn’t appear in the report – but to inequity and declining health outcomes.

We know this from Australian and international research and it is completely irresponsible to ignore the evidence and recommend something that will lead to inequity and declining health outcomes.   Whitehead et al looked at the effects of co-payments on poor and middle income people and found that copayments were a strong disincentive for seeking medical treatment at a primary care level. Similarly Starfiel et al showed that access is a key determinant of equity in health outcomes.

And one of the biggest savings escapes their notice.

The commission supports the ideological anti-free market mechanism of private health insurance that has done virtually nothing for health outcomes and has driven up health expenditure.  But then it was a baby of the Prime Minister as Health Minister!

The costs of not investing in quality and safety, of not regulating some behaviours, including some practitioner behaviours, and of wilfully disregarding excellent evidence is completely outrageous and likely to be unacceptable to the community and electorally unpalatable.

It certainly won’t lead to reduced costs or government expenditure, and it certainly will not lead to better health outcomes.

There is a reason why Commissions should seek the best advice and not limit themselves to single discipline analyses – which is what economics amounts to.

This one has committed the cardinal sin of ignoring what we already know and making recommendations for which it cannot and has not provided evidence other than opinion.

Health is an evidence-riven discipline and the refinement of evidence has long been central to its development.

Ignoring evidence will win no arguments and certainly no support for reforms of a spurious nature.

• Jim Hyde is Professor of Public Health Policy at Deakin University.

• For previous Croakey coverage of the Commission of Audit.