This is the third and final post in a series looking at how and why unfairness is built into the health system. Perhaps if there were deliberate efforts to increase transparency at multiple levels and points in the system, this might help to tackle some systemic inequities.
Below a range of Croakey contributors identify key areas where they would like to see greater transparency.
Professor Judith Dwyer, Flinders University:
“I’d like to see a world in which stakeholders representing their own interests declared that interest before they made self-interested statements about population health impacts. I’d like to see a genuine legal and governance separation between public health care providers and their government funders. Transparency in purchasing decisions by health authorities, and distance from the political process would bring advantages for quality and efficiency.”
Associate Professor Gawaine Powell-Davies, Centre for Primary Health Care and Equity, University of NSW:
“In the amount spent on health per capita, (preferably adjusted for health status) by local government area.
In who lobbies the Minister (via a register of lobbyists and record of meetings)
In the advertising and promotional budgets of pharmaceutical companies.”
Sebastian Rosenberg, Brain and Mind Research Institute, University of Sydney:
“Decisions about which services get funded in Australia are not transparent. This situation has led to some areas, such as mental illness receiving a small fraction of the funding which would seem reasonable in order to address the burden of disease it generates.
There is no accountability. The recent government decision to let the national funding authority die is yet another example of the Commonwealth’s unwillingness to set up real and robust measures of accountability and system performance. Without this infrastructure, as taxpayers let alone as health advocates, we have no way of assessing the quality or merit of our steep investment in health.
Sources of advice to government remain tight, a few chosen professional groups. There are few, if any, mechanisms for real community involvement in system monitoring and standard setting. The infrastructure to support the voice of consumers and carers across Australia in a process of meaningful participation in very weak. Consumer involvement is often tokenistic. Where quality standards are set, it is by the providers about the providers and assessed by providers.
This system of no accountability is presided over by a bureaucracy that has never known less about health care and the needs of people working and using the health system. Certainly in mental health, this type of knowledge is regarded as potentially compromising, leaving public servants open to accusations of favouritism and subjectivity.
When I was a public servant, it was your duty to understand the environment in which the Government’s policies were acting, in order to provide advice to Government about their effects. This is a lost art and evaluation and research are now regarded as tasks extraneous to the public service.
Decisions about funding and accountability in health in Australia remain the province of a closed shop. At the height of the Patrick’s dispute several years ago, just as the scabs and dogs broke in, Pryor drew a marvellous cartoon with Howard and Reith on horseback, with Howard turning his steed away from the burning docks below and saying “Now for the doctors!” Sadly, the blowtorch of microeconomic reform has never been applied to the health system and Rudd’s current so-called reforms are a damp squib.”
Professor Mark Harris, Centre for Primary Health Care and Equity at the University of NSW:
“There needs to more availability of de identified and linked Medicare data for analysis by researchers. At present this is very difficult. As a result, there has been relatively little published research on the uptake of Medicare items. Thus there has been little published research on the uptake of these items by SES.”
John Menadue, health policy expert:
“Variations across Australia in the rate of clinical interventions without obvious health benefits, eg vascular, cataracts, Caesarean section; a lack of accountability by providers in the provision of services particularly in general practice.”
Professor Mike Daube, Public Health Association of Australia:
“The AIHW reports do as well as they can, but from the information available to them/us it’s pretty much impossible to find out how much is actually being spent on public health both centrally and around the States. We work off the 2% figure, but we do need a much more thorough breakdown.”
Prue Power, Australian Healthcare and Hospitals Association:
“Areas relevant to public hospitals areas which would benefit from greater transparency would be: private hospital performance (difficult to compare outcomes between the sectors when all the data isn’t available); health promotion/preventive health/primary care (these can have a major impact on demand for public hospital services but often there is little transparency in how the funds are allocated and their outcomes); and health department decisions – so often decisions made by DoHA disappear into a black hole and stakeholders never discover the reasons behind them.”
Barbara Hocking, Sane Australia:
“The Federal/state divide really makes it difficult for mere mortals to work out exactly who funds what, where and for how long, resulting in community programs funded from a patchwork of sources. Also makes it easier for cost-shifting to occur, so we end up on shifting sands – this creates a whole layer of bureaucracy and dilutes the energy workers have to just get the job done!”
Health economist Professor Gavin Mooney:
“1. Priority setting. No one really knows how decisions are made in terms of funding to say cancer versus heart disease versus diabetes. Yet this is crucial to a well-run health care system.
2. There is too little transparency regarding who makes what decisions and hence a lack of accountability. It ought to be possible to have a system where individuals in certain positions have very clear responsibilities. Who in any Australian health service is responsible for efficiency? Not clear! Equity? Not clear!
2. On health as opposed to health care, we need an investigation (a Commission?) into the social determinants of health in Australia following the leads of the UK and Norway. Especially looking at poverty and inequality.”
Elizabeth Harris, Centre for Health Equity Training Research and Evaluation, University of NSW:
“There should be more transparent reporting of who uses services in relation to those with the greatest need. Services provided should not advantage the advantaged through the way they are structured and implemented.”
Dr Mark Ragg. public health writer and publisher:
“It would be difficult, but I would like to see Medicare fund effective services, not professional groups. It seems unreasonable that Medicare does not cover the provision of proven services by allied health professionals, but it does cover pretty much any service at all by a doctor.
I’d also like to find ways to apply evidence-based approaches to information for individuals so they can make better decisions. That is, faced with evidence that a treatment is effective, and has side effects, find a way to show that:
– This is the chance of an improvement in your condition (and the extent of improvement) with no side effects
– This is the chance of an improvement in your condition (and the extent of the improvement with side effects
– This is the chance of no improvement in your condition with no side effects
– This is the chance of no improvement with side effects (i.e. The double whammy where a proportion of people feel much worse after taking a treatment known to be effective)”
Dr Tim Woodruff, Doctors Reform Society:
“Health expenditure both Government and non Government, ie distribution of this (which would show very clearly that it’s not just Medicare rebates which are spent mainly on the rich)
Health need: a map of burden of disease at national level, matched against health expenditure
Then we could see with even greater clarity how the inverse care law is working (those who need the most get the least, those who need the least get the most).”
Gordon Gregory, National Rural Health Alliance:
“How is the money allocated to public hospitals distributed with respect to the size of hospital, the DRGs, the location of hospitals, and between clinicians, managers and (what’s that word) services? What proportion of the national health dollar is spent on people in the last six months of life, what proportion on supporting healthy pregnancies and the first three years of life, and what are the means by which a civilised society might change the mix??”
Professor Lesley Barclay, Northern Rivers University Department of Rural Health:
“This is difficult – decisions about funding that do seem to be tied to swinging seats when it comes to additional funds and services so that these at least have a sense that they go where they are most needed not of most political advantage. These are most often tied to hospitals rather than primary health care with the aged, mental illness and still women missing out! For example the closure of for lack of investment in family health, ie maternal child health services.
A sense that medical lobbying is no more or less privileged than other lobbying, ie from consumers, other disciplines etc.”
Professor Simon Willcock, Professor of General Practice, University of Sydney:
“This one is easy. I work with a number of politicians who I admire greatly. It’s a tough gig and they generally try to do the right thing. That said, the politicisation of the health agenda is appalling. Using issues such as individual patient outcomes and data of often dubious validity to score political points has become part of the normal political process, not surprising when we know how concerned most people are about health care and health systems. There have been too many injudicious accusations and “initiatives” designed to win votes rather than for any sound reason – the Commonwealth takeover of the hospital in Devonport before the last federal election is one example – promises made regarding levels of service delivery that were never going to be feasible provided. the constant beat-up over hospital waiting lists is another. This is not a significant health issue in Australia (unlike access to universal basic dental care. a huge issue that hasn’t been addressed yet).
In my ideal world political parties would agree on uniform health policies supported by all. If we can “quarantine” foreign policy surely we can do the same for health policy.
If we are really into “league tables” (and I’m not sure I am) – let’s publish data on dollars spent by the government on relative services. This would demonstrate for instance the inequity between the dollars paid to an ophthalmologist doing a list of cataract extractions or gastroenterologists doing a list of endoscopies, and a psychiatrist seeing a list of patients with severe mental health problems. I suspect the community would be shocked.”
Michele Kosky, Consumers Health Council of WA:
“Greater transparency about Adverse Events and the changes introduced to reduce likelihood of not happening again.”
Health policy consultant Margo Saunders:
(i) While there does need to be more research about the best (and not counter-productive) ways of doing this, I believe that consumers should be provided with accurate and understandable information about the ingredients and nutritional content of all food (not just pre-packaged foods) with the product or at the point of purchase. Ingredient information should also be provided with tobacco products.
(ii) There are around 5.4 million cases of food-borne illness in Australia every year, with contaminated food from restaurants, caterers, bakeries, takeaways and fast-food premises implicated in a significant proportion, if not the majority, of cases. Overseas evidence suggests that the most effective way to increase food hygiene compliance, with consequent effects on reductions in food borne illness, is to give the public access to information about food businesses’ hygiene compliance (see, e.g., evaluation of the impact of the program in Los Angeles County, http://www.cspinet.org/dirtydining/HospitalizationsStudy.pdf) Information is provided on easy-to-navigate electronic databases, which are regularly updated, with ratings also displayed on the premises (‘scores on doors’). The only information currently available on websites in some Australian jurisdictions is limited to actual breaches of food safety regulations as evidenced by formal notices, fines and prosecutions – information which one could reasonably argue should be public in any case. Given that ‘scores on doors’ schemes have been operating in the USA, UK, Canada and New Zealand with considerable success for many years, there is really no excuse for Australian consumers to continue to be kept in the dark.
Carol Bennett, Consumers Health Forum:
“The Royal College System of income protection through vicious closed chop practices needs to be made public and reformed. The ophthalmologist’s behaviour last year is a classic example.”
Professor Ian Olver, Cancer Council Australia:
“There has to be greater transparency around the use and linking of data between jurisdictions and nationally instead of hiding behind “privacy” concerns to prevent comparisons being made in health outcomes between health systems.
The other area (which has improved over the past years) is the transparency over the reasons behind decision-making with respect to drug and therapeutic devices.”
Professor Nicholas Wilcken, cancer specialist, Sydney:
“I think the policy of putting the actual market cost on the box of PBS-subsidised drugs is a good one – people need to be reminded of the cost of high quality health care. Perhaps we should have a well-publicized annual report of how much we the people paid for chest X-rays etc.”
“I believe in a democracy it is the govt who should be making the near-impossible decisions regarding resource allocation in health. However, they also need to articulate that is what they are doing and not leave it to health boards to justify their focus on costs.”
Now, I guess the question from Croakey is: will the powers that be take any notice of these suggestions and concerns?….