The current medico-political and policy landscape: some expert insights
As the Federal election looms, the need for health reform has never been more obvious, and central to any reforms should be the social determinants of health and a renovation of our health care system. Recently the Consumers Health Forum held a member and stakeholder forum to hear emerging and policy themes in the political arena concerning the social determinants of health. Leading experts in community advocacy and policy, Cassandra Goldie, CEO of ACOSS, Ralph Lattimore, Executive Manager at the Productivity Commission and Jo Watson, Deputy Chair of the Pharmaceutical Benefits Advisory Committee (PBAC) were invited to share their perspectives, stimulating a discussion about the current political and policy landscape.
Inequality affects health outcomes
Speaking of how inequality affected health outcomes, Ms Goldie stressed that a shared effort should be made by everyone to increase public understanding of how poverty affects health outcomes. With three million people living below the poverty line, Australia had the second highest rate of poverty amongst the wealthy OECD countries. Socioeconomically disadvantaged groups experienced more ill health and were more likely to engage in behaviours or have a risk factor profile consistent with their poorer health status. The health burden in the Australian population attributable to socioeconomic disadvantage was large; and much of this burden was potentially avoidable.
While unemployment had a major impact on physical and mental health and wellbeing, Ms Goldie pointed out that the inability of people on low and modest incomes to secure stable employment or housing also affected their health outcomes.
Ms Goldie highlighted the importance of shifting expenditure towards prevention and primary care, to reduce health spending and improve health outcomes. The area in which we have real potential here, she said, was in the role of the Primary Health Networks. While community-based services were crucial entry points to the health system, these received inadequate funding in the recent past with too much of our public health expenditure being directed towards tertiary or hospital services.
Finally, Ms Goldie stressed the two key social determinants of health issues that ACOSS would push for in the election. These were raising the rate of Newstart and Youth Allowance, and housing. The single most effective step to reducing poverty and inequality in Australia would be to increase Newstart, Youth Allowance and related payments by a minimum of $75 per week. No other policy reform would do more to reduce hardship in our communities faced by those on the lowest incomes. However, she said, there was a shocking tendency by governments at present to demonise people on social security payments, such as the Parentnext program which penalised single parents. Allowances were $180 per week below the pension, there were 110,000 single parents living on Newstart and one in four people on Newstart had a disability or illness.
She also highlighted the lack of serious investment in public housing for over a decade and that the employment services system was no longer functioning well. These are all areas offering much scope for improvement in health outcomes.
Potential for significant change
Mr Lattimore reflected on the 5-year productivity review, Shifting the Dial, and its focus on the health care sector. Although many tend to look at reform through jaded eyes, everyone has an interest in health, and it is an area with potential for significant change.
In economic terms someone aged 25-49 has nearly a 90 per cent chance to be in the labour market if their health is good or better – but the 45 per cent unemployment rate for people in the same age bracket in good health is one-seventh of those in bad health.
While the government commits lot of resources to the health care sector, he said, it might be desirable to save what we spend inefficiently, rather than continuing to spend more. Economists sometimes neglect to see that aspects such as wellness, less chronic pain, greater mobility and less anguish are also goods, although they are not priced in any market, and we should see them also as outputs.
Commenting on the release of the ABS health survey, he said Australia has a high level of healthy life expectancy, but the share of life spent in ill health was the highest among OECD countries.
The health system still treated clinicians rather than the users as customers, with major obstacles to integrated care and people being subjected to treatments that are notably ineffective. As with the findings from the recent Inquiry into the National Disability Insurance Scheme, evidence shows that there are better outcomes when people in the community are involved in the change.
We need to see patient centred integrated care, prevention, cooperation, use of technology, regional focus, strong links and both information and funding that supports these, he said. Most aptly, Mr Lattimore said that patients should not be seen as inconvenient guests.
Focusing on the patient experience
Speaking on the state of the National Medicines Policy (NMP), Jo Watson said that access to medicines and out of pocket expenses were two critical issues of importance for consumers , and CHF recognised that they continue to be issues that matter to people.
The National Medicines Policy was born out of consumer advocacy associated with the push for better understanding and quality use of medicine.
She said the Health Technology Assessment Process (HTA) was a relatively new area informing health decision making, and is still evolving. The goal of the 2009 Commonwealth Review of HTA in Australia was to maximise beneficial health outcomes within the funds available, while cognisant of other important goals of the health system.
Ms Watson said that the NMP development and HTA framework build were one of the first attempts to focus on the patient experience, including what this country could/should be able to afford to deliver for the whole population in an equitable way.
The notion of universal health care and affordability was being challenged in Australia today. Clearly not being met in all pockets of the population comprehensively, and the reality is that we have many people falling through the cracks, while at the same time overall health system expenditure was growing.
She said that while many were shocked that $1.3 billion was spent out of pocket by consumers on general prescriptions through the PBS, it was often not acknowledged that consumers were also spending a further $9.6 billion on over the counter and other forms of medicine. She also noted that this was not including complementary therapies, or other interventions they felt necessary to their general health.
Ms Watson also referred to the range of current sector agreements in place, noting the absence of transparency and accountability with these, including the lack of obvious partners like CHF. These agreements often were perceived as serving the interests of those party to the agreement, and not necessarily for those outside the partnership and across the broader community.
Equity, affordability issues, and demographic change would continue to be a focus of organisations like CHF, but it was increasingly being noted that consistent indicators of meaningful outcomes were not being pursued across the health system. While debates about these continue, and sector fragmentation on best ways to pursue meaningful outcomes remains, then it was difficult to see progress on true policy reform.
As an example, she referred to the total cost to Government of the PBS prescriptions, where nearly 75 per cent of that expenditure is delivered to concessional cardholders. What we don’t know is how directly this expenditure and use of medicines made a difference to a person’s health outcomes and their quality of life, and how this could be understood when combined with other areas of health service delivery and programs.
Remarking on the inefficiency of the system, Ms Watson said that she believes the NMP was perceived to be struggling because the system was being challenged in various ways, and partners were not working collaboratively across the various policy pressures, let alone the ongoing disagreements about who should be sitting around the table for these discussions and consultations. She added that mechanisms for improving our health literacy needed to be defended robustly. This was particularly important to quality use of medicines – a key pillar of the NMP – where doctors and pharmacists had clear obligations to assist patients to understand their medications and treatments, and get optimal outcomes from their access to them.
Finally, if there were going to be agreements with industry and other key players in the sector it was then time to have a formal Strategic Agreement between Government and CHF. It was time to try and bring back the NMP to how it was originally constructed, to be consumer centred, and to have overall transparency about all these partnerships and agreements, she said.