The Health Wrap: equity lessons from Canada, SDG laggards, toiling towards evidence-based policy, unpacking the NSW budget and more

After a short recess, Associate Professor Lesley Russell is back with the Health Wrap.

Nobody wades through a lengthy report or interprets a weasel-worded budget like Lesley, so you’re in for a treat.

There’s a report from Canada that has relevance for Australia, an update of Australia’s progress towards meeting the 2030 Agenda for Sustainable Development, a summary of the latest report on specialist fees, a valiant attempt to decode the considerable health spending in the NSW State budget, and highlights of the latest AIHW report on Australia’s health.

Especially incisive and not to be missed is Lesley’s distillation of a series of articles in The Mandarin about why evidence-based policymaking is really, really hard.

Lesley Russell writes:

I’m back from my travels and The Health Wrap is back with a surfeit of reports, news and analyses to catch up on.

Canadian report on health inequalities

Key Health Inequalities in Canada: A National Portrait was released last week, along with some excellent explanations and data tools.

The report, prepared by the Pan-Canadian Health Inequalities Reporting Initiative (Australia, we need one of these!), looks at 22 indicators of health status and determinants of health across a range of population groups, using over a dozen sources of information.

There is much here that is similar, and applicable, to Australia, including the over-arching finding: that despite Canada’s wealth and admirable outcomes at the national level, the benefits of good health are not enjoyed by all. The report addresses this directly, finding that “The range and depth of health inequalities in Canada constitute a call to action across all levels and areas of society”.

The key principles for action are given as:

1. Adopt a human rights approach to action on the social determinants of health and health equity.
2. Intervene across the life course with evidence-informed policies and culturally safe health and social services.
3. Intervene on both proximal (downstream) and distal (upstream) determinants of health and health equity.
4. Deploy a combination of targeted and universal interventions and policies.
5. Address both material contexts (living, working, environmental conditions) and socio-cultural processes of power, privilege and exclusion.
6. Implement a “Health in All Policies” approach.
7. Carry out ongoing monitoring and evaluation.

The report specifically addresses the issues of First Nations, Inuit and Métis peoples. There is a Commentary from the Indigenous Perspective prepared by the First Nations Information Governance Centre and the Métis National Council (see Box 1 in the Executive Summary) that makes seminal reading for Australians as the Uluru Statement from the Heart remains under debate.***

The Commentary makes the case that, to understand inequalities between Indigenous and non-Indigenous peoples, it is necessary to contextualise them within the historical, political, social and economic conditions that have influenced Indigenous health. These include colonial structures, forced displacement, discrimination and social exclusion, loss of Indigenous language, and the inability to pursue self-determination.

It also finds that the indicators used in the report (which are quantitative and largely deficit-based) do not adequately incorporate Indigenous concepts of health and wellbeing. There is a need for indicators that are Indigenous-specific and community-driven and that identify protective factors such as resilience, self-determination and identity.

The report has a separate section on data tools that is very informative.  For example, here you can read how the rate of obesity is stratified by level of education.

*** The Croakey Team has made a submission to the Joint Select Committee on Constitutional Recognition to recommend that the Australian Government acts now to accept the recommendations of the Uluru Statement from the Heart. We argue that enactment of the reforms of the Uluru Statement from the Heart “is the best, most equitable and healthiest way forward for all Australians”.

Australian Government review of national progress on the Sustainable Development Goals 2030

In 2015 Australia, along with 192 other countries, signed on to the United Nations 2030 Agenda for Sustainable Development. Last week the Minister for Foreign Affairs released the Sustainable Development Goals: Australia’s Voluntary National Review 2018 with considerable fanfare.

Sadly, the report is a glossy disappointment that glosses over the real issues, and there is no accompanying data. It is necessary to look elsewhere to get any sense of what is really happening in terms of Australia’s progress towards meeting the SDG goals nationally and helping less-developed countries in the region to do so. The 17 goals and targets are outlined here.

Marc Purcell, CEO of the Australian Council for International Development, has warned that to have “any realistic chance” of achieving the goals by 2030, Australia needs to rapidly transform the way it is working and put sustainability “at its heart”. “The [Voluntary Report] profiles early-adopters who have implemented highly effective initiatives, but they are too few and far between,” he said.

“We should not be imposing the burden of our failure to act on the next generation. The time for talking has passed, now is the time for action on the SDGs.”

The Government sells the private sector and business as important partners for action on the SDGs, but a recent article in The Conversation highlights the gap between what companies say they are doing and reality.

The problem is that no sector – government, business or academia – has made the transformative changes needed or embedded the SDGs into their core business. Most of the government policies outlined in the Voluntary Report were developed for reasons other than response to the SDGs. There are just 12 years until 2030, and it is clear that the current business-as-usual trajectory will not deliver the commitments that have been made.

In 2016, Australia ranked 20^th on progress towards achieving the SDGs, well behind Canada and many European countries (but ahead of the United States).

In 2017, Australia’s ranking had slipped to 26^th  and the dashboard shows Australia meeting only the goals for Good Health and Wellbeing and Clean Water and Sanitation. Australia had a failing grade for five goals: Zero Hunger, Affordable and Clean Energy, Climate Action, Life Below Water, and Responsible Consumption and Production.

What will the 2018 ranking show?  It’s hard to believe that the dashboard will continue to show success for Good Health and Wellbeing when even the Voluntary Report heads up an otherwise glowing chapter with this quote from the Australian Institute of Health and Welfare, Australia’s Health 2016:

“Presenting a broad picture of health status can mask the fact that some groups in our community are not faring as well.”

And if we are yet to effectively address issues such hunger, climate action and partnerships to deliver the SDG goals, it’s hard to see this improving.

Evidence-based policy making – it’s really, really hard

This week in The Juice (daily news and the best of The Mandarin) there was a great collection of recent and older articles in evidence and evaluation in policymaking.  Here’s my attempt to summarise these, but the complete articles are well worth a read.

In a piece entitled ‘Being evidence-based is really, really hard’: shifting evaluation culture, David Donaldson summarises a podcast made for the University of Melbourne Policy Shop by Nicholas Gruen of Lateral Economics and Patricia Rogers of the Australia and New Zealand School of Government on how to shift attitudes to make evidence-based policymaking meaningful.

Gruen argues that building high quality evaluation into policymaking will require both new structures and a shift in culture. Too often evaluation is an afterthought or just about ticking a box and is not linked into decision-making. Rogers makes the point that despite what governments say, their appetite for confronting when things don’t work is small, and too often people come to see it’s much harder to find out what really works than they realised. (I immediately think of the debate over the success or otherwise of the cashless welfare card as I read this.)

Gruen, who has previously been highly critical of the current state of evidence-based policymaking, believes that creating a new office of evaluator-general could bring increased transparency to evaluation and thus help improve the use of evidence in the policymaking process.

He makes the case that effective monitoring and evaluation to inform policy making requires not just that those at the coalface (where the action is) listen to those at the centre of the system (who establish the general objectives), but also that the centre listens to the coalface. That is not easy to achieve. In the real world of politics there are incentives at every level of the system for those generating information to obfuscate and euphemise the bad news and highlight the good news.

In an earlier post in The Mandarin, Gruen asks why we accept travesties of ‘evidence-based’ policymaking? Everyone claims to want it, and practice it, yet so many government ‘announceables’ are introduced without any consideration of the evidence supporting them (eg the proposal to drug test welfare recipients) and others receive glowing report cards that are unwarranted (eg the Northern Territory Emergency Response). Karen Chester from the Productivity Commission calls evidence-based policy “a critically endangered beast — seldom seen and rarely funded”.

The difficulties in achieving this goal are manifold. Many government decisions are subject to trade-offs between competing goals. And evidence will not solve a policy debate based on ideological differences (as climate change demonstrates). As former Productivity Commission chair Gary Banks says, “Values, interests, personalities, timing, circumstance and happenstance — in short, democracy — determine what actually happens”.

Policy making is not a technological, bloodless process and the route from evidence to policy is rarely linear. It usually requires an interdisciplinary mix. I support Donaldson’s point, that the way evidence is used in medicine is not the way it works in complex social systems.

Banks says that,

“Half the battle is understanding the problem. Failure to do this properly is one of the most common causes of policy failure.”

Why do medical specialists’ fees vary so much?

Specialists’ fees and their impost on patients remains a hot topic. This last week saw the publication of the ANZ Melbourne Institute’s Health Trends – Specialists report. There’s a good summary here , but I think the figure below sums it up well.

It shows that there are substantial variations in the hourly earnings of medical specialists – both within and between specialties – and it is not clear what, if anything, justifies this. In particular, there are major earning differences between surgical and non-surgical specialties, yet what determines that the work of a urologist is more skilled, more valuable than that of a paediatrician or a geriatrician? And why are some ophthalmologists’ hourly earnings twice those of their colleagues?

Some of the fee variation reflects practice costs, location, equipment, skill and complexity and this does not explain it all; neither does the percentage of work done in the private sector.

The paper’s authors argue that greater fee transparency is needed but make the point that this really needs to be available to both the GP and the patient at the time of referral. They state that research in the US suggests that better published information on cost hasn’t led to patients making better (less expensive) choices.  However, while this may be true, the paper they use to support this statement is not an appropriate reference – it refers to decisions people in the US make between Medicare and Medicare Advantage (the privatised version of Medicare).

There is  some evidence from the US that in some cases giving patients information about healthcare costs will lead them to shop around. But many people don’t use the information provided (in one study, only 12%). This is the case even when they are provided with a price transparency tool to help with comparison shopping.

In Australia, price shopping for healthcare services is notoriously difficult, and really only possible for non-urgent needs. Patients seeking second and third opinions often face serious financial barriers.

The Commonwealth Fund has looked at whether price transparency can promote the use of high-value care. They found that when the cost and quality information was reported side by side in an easy-to-interpret format, more respondents made high-value choices. They also found that price information must be made available at “teachable moments” such as when people are seeking out routine or planned services.

NSW 2018-19 Budget – a windfall for health

This week the NSW Government brought down their 2018-19 Budget.  It contains a major spending boost for health and health infrastructure – interpreted by many as a sure sign that an election is coming.

There is $1 billion in additional funding for healthcare workforce and services (taking the total annual spend to $23 billion) and $8 billion over four years for health infrastructure. Mental health is a key winner.

Key initiatives include:

Workforce

• 850 additional nurses and 100 additional midwives (but note no standardised or mandated ratios for mental health, ICUs, etc)
• 300 additional doctors employed in public hospitals and Community Health Centres.
• 120 allied health professionals including physiotherapists, occupational therapists, pharmacists.
• The Government had already committed to 700 additional paramedics and 50 call centre staff as part of a $1 billion over 4 years funding package for ambulance services and an additional 260 mental health workers to help employers improve the mental health of their staff.

Infrastructure

• 40 hospitals to be built, upgraded or refurbished.
• $740 million for a state-of-the-art health research and education precinct at Liverpool Hospital.
• $700 million for mental health infrastructure.

Note: it seems the $8 billion spend on infrastructure includes the $5.7 billion for major redevelopments at Campbelltown, Nepean, Blacktown and Mount Druitt hospitals announced in previous budgets.

Mental health

• $2 billion over 4 years for mental health infrastructure and more mental health workers and services. There is an additional $82.5 million for mental health in 2018-19, bringing the annual budget to $2.1 billion.
• $700 million for mental health infrastructure will provide 6-10 beds for children and adolescents, 20 beds for older people, 6-12 beds for mothers and babies, 20 medium secure beds, up to 260 new ‘step-up step-down’ community-based beds to help long-term patients to transition from hospital Up to 260 new ‘step-up step-down’ community-based beds to support the transition of long stay mental health patients from hospital and the recovery of consumers in the community, additional beds for the forensic mental health network. There will also be mental health unit upgrades and refurbishments.
• $39.4 million to deliver an additional 1,400 mental health admissions in addition to the 37,500 currently provided.
• $42 million for additional community based mental health services and supports
• $1.1 million for specialist services for pregnant women and mothers with severe and complex mental illness.

The Government has previously announced 260 additional mental health workers.

Note: I have struggled to accurately present the information on mental health funding – not helped by some double counting, and different descriptions provided in media releases from NSW Health and  the Treasurer and Minister for Mental Health. Apologies for any errors.

Parents’ Package

• $156.5 million parenting package. This includes the research funding for children’s diseases and the $9.3 million for 100 new midwives.
• $7.6 million for $150 ‘baby bundles’ (nappies, other baby items, information) for every newborn.
• $4.3 million to expand post-natal home visits.
• $2.2 million to partner with Tresillian to establish five new Family Care Centre Hubs in regional and rural locations.
• $2 million to upgrade play spaces in paediatric wards (this may be double counted under infrastructure).
• $1.5 million to enhance systems to support safe and timely transfer of pregnant women who need higher levels of care.
• $1.1 million for specialist services for pregnant women and mothers with severe and complex mental illness (double counted from mental health services).
• $2 million to fund a pilot trial to screening for spinal muscular atrophy and severe combined immunodeficiency. Congenital adrenal hyperplasia added to newborn bloodspot testing.

 Medical and scientific innovations

• Total spending of $115 million for 2018-19.
• Includes new funding of $150 million for cardiovascular disease research and $5 million for childhood cancer and other genetic disorders.

Medical services

• An additional $759 million in 2018-19 for acute hospital services to cover an extra 40,000 emergency department attendances, 3,200 elective surgeries, 52,000 inpatient episodes and 400,000 non-admitted patient services.
• $100 million in 2018-19 for specialist community supports (this may be double counted from workforce).
• $12 million in 2018-19 for existing alcohol and drug services (it appears that this is not new funding).
• $4.7m a year for new intellectual disability health teams and nurses.

The Budget has, rightly, been very favourably received. It recognises increased pressures on hospitals and mental health services.  However, as Australian Medical Association NSW president Dr Kean-Seng Lim said,

“What would be really good to see in future budgets is work towards a better integrated health system and better-coordinated care that would reduce demand on acute services.”

Australia’s Health 2018

The Australian Institute of Health and Welfare released its latest report, Australia’s Health 2018, last week, along with a useful ‘in brief’ summary. There’s lots to digest but here are my take-outs.

Australians are fat and getting fatter

The costs of overweight and obesity to the Australian economy and the failure of the Abbott-Turnbull Government to address this in any meaningful way has to be THE health issue.

This report highlights just how bad the situation is, with 63 percent of Australians aged 18 and over and 28 percent of children aged 5-17 years overweight or obese.

Australia’s level of obesity is now among the worst in the developed world: it is 8.5 percentage points higher than the OECD average, worse than Canada and the United Kingdom, exceeded only by New Zealand, Mexico and the United States.

There are major consequences for health.  Obesity accounts for 9 percent of the total disease burden (the same as tobacco). It’s definitely time for action on what Jane Martin of the Obesity Coalition has called a ‘slow motion disaster’.

Many of the leading causes of death and poor health are preventable

The leading causes of death for Australians aged 1-44 years are suicide and land transport accidents; for those aged 45-74 they are coronary heart disease and lung cancer; and for those aged over 75, they are coronary heart disease and dementia and Alzheimer’s Disease.

Half of Australians have at least one of eight common chronic health conditions and 23 percent have two or more of these conditions.

The Prevention 1st campaign last week released a scorecard on the implementation in Australia of World Health Organisation recommended interventions to reduce preventable chronic disease.

The Preventing Chronic Disease: How does Australia Score? report found that while our health measures in tobacco policy are world leading, Australia has fallen well short in its preventive health efforts in the key areas of alcohol consumption, nutrition, and physical activity. You can read more in this Croakey article from Sharon Friel.

Gaps and inequalities persist

Compared to people in the highest socio-economic group, Australians in the lowest are:

• 2.7 times as likely to smoke
• 2.6 time as likely to have diabetes
• 2.4 times as likely to cite cost as a barrier to dental care
• 2.3 times as likely to cite cost as a barrier to filling a prescription
• 2.1 times as likely to die of potentially avoidable causes.

Compared to non-Indigenous Australians, Indigenous Australians are:

• 2.9 times as likely to have long-term ear / hearing problems in children
• 2.7 times as likely to smoke
• 2.7 times as likely to have high / very high levels of psychological distress
• 2.1 times as likely to die before their fifth birthday
• 1.9 times as likely to be born low birthweight
• 1.7 times as likely to have a disability or a restrictive, long-term health condition.

The contribution of social determinants to health status is pretty obvious from these data and highlights where the most effective areas for action are. Jennifer Doggett’s Croakey article What the MyHealthyCommunities data tells us about the Inverse Care Law is relevant here.

Problems with data collection and use continue

The report (again) finds that there are many problems with the national health data, with many gaps and information that are collected not always used to their full potential. These and other data limitations are listed in ‘What is missing from the picture?’ sections throughout the report.

The report finds that “a structured, strategic approach to data and evidence is critical to support continuous improvement, innovation and progress in health.”

• Previous editions of The Health Wrap can be read here.
• Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

Tips from the Croakey team for further reading

Last Thursday, on the winter solstice, Croakey pulled an all-nighter, reading along with some stellar guests and insomniac Croakey stalwarts (#CroakeyREAD). There are three resulting posts, here, here and here. And there’s something for everyone’s tastes and needs. There’s also a competition to win one of two Penguin book packs. Send us your best tweet-length book review by midnight Thursday June 28 to win. Head to @CroakeyNews to enter.

And if that’s not enough reading for you to go on with, there are a couple of recent, relevant articles:

The 39 best health and science books to read this summer

How Atul Gawande landed perhaps the most extraordinary (or impossible) job in health care

Finally, this article posted on Croakey last night, about a successful, strengths-based program for Aboriginal and Torres Strait Islander wellbeing in WA that is not being re-funded, is garnering a lot of shares on Twitter today. It’s worth a read, and a think about the folly of short-term, piecemeal thinking and funding, when nurturing health is a very long game.