Current focus in Australia’s health
Australia’s health 2020: data insights examines issues related to health and health systems. It underscores both the importance of data, and of building the evidence base, in achieving long-term, sustainable improvements in health and health care for all Australians. The 10 chapters that follow present focused discussions, analyses and evidence on current issues in health data and evidence.
The report begins with Chapter 1 ‘Health data in Australia’, an overview of what the health data landscape currently looks like, and key issues and challenges faced. Robust and consistent health data practices—in terms of the availability, collection, collation and analysis of health data—are important for the planning and delivery of appropriate health care and for assessing the health system as a whole.
We have opportunities to improve the ways in which data are collected, accessed and analysed to inform how we respond to many existing or emerging challenges—including the health impacts of the recent bushfires across Australia; the emergence of COVID-19; and existing issues such as the rate of suicide in Australia. Increased use of data linkage methods may provide opportunities to better understand and address these challenges. The article also discusses data gaps and limitations; developments in health data; the AIHW’s work; and the future of health data.
During crises, there is a strong need to obtain data as quickly as possible to allow for an informed, immediate response to manage the situation. Timely data, and innovative uses of data, has been vital in informing Australia’s response to the challenges posed by COVID-19. Chapter 2 ‘Four months in: what we know about the new coronavirus disease in Australia’, is a point in time article that summarises what is known about the epidemic in Australia so far. While we remain in the middle of an evolving situation, with many facets of the epidemic not yet fully understood, it is apparent that Australia, at least so far, has been able to contain the epidemic when compared with many other countries. As at 7 June 2020, Australia had recorded 7,277 cases and 102 deaths. Analysis within the chapter reveals that, if Australia had experienced the same COVID-19 case and death rates as Canada, Sweden or the UK, it is estimated Australia would have had between 8 and 14 times the number of cases and around 5,000 to 14,000 extra deaths.
There are a number of potential indirect effects from changes within the health system and changes in wider society due to interventions put in place to manage the spread and impact of COVID-19. For example, the need for as many people to stay at home as possible to increase physical distancing meant that many people were isolated from family, friends and other support networks. The widespread interventions have a number of longer-term potential adverse health and welfare effects, although interventions can be put in place to reduce the risk of these. The large-scale loss of employment and the general economic downturn is a large challenge, and the longer-term effects will need to be monitored into the future.
Understanding the broad contextual factors that influence our health is important because our health is not immune to social and environmental influences. Chapter 3 ‘Social determinants of health in Australia’ looks at how health is affected by social and economic conditions of everyday life, such as family circumstances, housing, working conditions, livelihood and education. The connections between these social factors and health outcomes are complex and occur over many years. There is now a strong evidence base to help us understand the social determinants of health and the relationships between social determinants and biological mechanisms. In many cases, it is the social determinants that contribute to inequalities in health between population groups.
There is no particular level of poverty that indicates poorer health (though absolute poverty remains important). Instead, social factors affect population health across all levels of society: the relationship between socioeconomic position and health follows a ‘gradient’, with health status improving as socioeconomic circumstances rise. Social determinants can increase or decrease a person’s risk of subsequent health outcomes: not everyone from a low-income family will necessarily have poor health, but their risk will be higher than others. Further, those with multiple unfavourable social determinants over a lifetime will be at even higher risk—and will be most vulnerable when another life challenge occurs. Social influences on an individual’s health and wellbeing occur in combination and cumulatively across their lives and the impacts from earlier in life are apparent over many years, and potentially for generations. (Disadvantage in early childhood, for example, can reduce social and health opportunities in the future, and this pattern can continue and accumulate over an individual’s life.) Further, the length of time in disadvantage increases the risk of ill health.
Despite substantial improvements in the health of Aboriginal and Torres Strait Islander people over the past 30 years, there are disparities in health outcomes between Indigenous Australians and non-Indigenous Australians. The reasons for these disparities are complex, and include the lasting impact of colonisation and separation from Country. It is also recognised that, for Indigenous Australians, social determinants of health result in differences in risks, exposures, access to services and outcomes throughout life.
Chapter 4 ‘Housing conditions and key challenges in Indigenous health’ examines social determinants that have a substantial impact on Indigenous health. Diseases including chronic kidney disease, rheumatic heart disease, and certain eye and ear diseases, disproportionately affect Indigenous Australians. Some of the common factors underlying these health conditions are housing, living conditions and access to services. For example, Indigenous Australians have among the highest recorded rates of acute rheumatic fever and rheumatic heart disease in the world. These diseases are preventable and treatable, and common in low- and middle-income countries—both linked to overcrowding, socioeconomic deprivation, and inadequate access to health hardware and health resources. Lack of access to health services also affects health outcomes for Indigenous Australians, as access to primary health care services is critical for timely management of acute and relatively minor illnesses such as infections.
Two critical factors connecting housing conditions to health are the state of domestic health hardware (the physical equipment and infrastructure needed to support good health) and the impact of overcrowding. Housing not only provides shelter and safety, but also supports family, culture and cultural practices—while the lack of available and adequate health hardware can lead to illness or injury. Compared with non-Indigenous Australians, Indigenous Australians have less access to adequate, affordable or secure housing and are more likely to live in overcrowded conditions or to experience homelessness. Dwellings that are inadequate for the number of residents, including long-term visitors, may result in premature failure of health hardware and lead to poor health outcomes.
Meeting these health challenges requires a multi-sectoral approach that addresses the basic needs of adequate housing and access to health services, including maintaining and fixing health hardware. Data about housing adequacy; service-access issues; and the incidence and prevalence of various health conditions; and evidence for what achieves improvement, are key to reducing the disparities.
The issues of health inequity and preventive measures are further explored in Chapter 5 ‘Potentially preventable hospitalisations—an opportunity for greater exploration of health inequity’. The concept of ‘equity’ in health is that, ideally, everyone should have a fair opportunity to attain their full health potential and that disadvantage should not prevent them from achieving this potential. Understanding health equity is a core component of the Australian Health Performance Framework, and potentially preventable hospitalisation (PPH) statistics provide a useful measure for examining this issue. In Australia, and other countries, PPH data are used to assess timely, effective and appropriate primary health care.
PPH are grouped into 3 categories: vaccine-preventable conditions; acute conditions; and chronic conditions. In 2017–18, 1 in every 15 (6.6%) hospitalisations were classified as potentially preventable. New analyses quantifying the economic costs of PPH to the hospital sector found that expenditure varied by PPH condition, patient age and sex—but that, overall, PPH conditions cost the hospital sector $4.5 billion in 2015–16. Three of the most common chronic PPH conditions—Congestive cardiac failure, Chronic obstructive pulmonary disease (COPD) and Diabetes complications—had the highest expenditure, with more than $1.5 billion spent on these hospitalisations in 2015–16.
Interpretation of PPH statistics over time is complex, because PPH is influenced by many factors, including individual circumstances, patient characteristics and health-system factors. However, PPH statistics remain a valuable tool for exploring health disparities between different populations. For example, a case study on PPH for diabetes complications explores who is most at risk, comparing trends in PPH for specific groups within the Australian population—Indigenous Australians; people living in remote and socioeconomically disadvantaged areas; the very young; and older Australians.
The article discusses the importance of exploring and understanding patient-care pathways that result in PPH. A number of studies using linked patient data are underway across Australia to determine the true preventability of these hospitalisations, and for example, to explore broader social factors influencing PPH in Indigenous children. The future use of health data linkage presents opportunities for a more nuanced understanding of patient-care pathways that result in, and follow on from, PPH.
Data relating to health expenditure and funding are shaped both by health system activity and by health funding mechanisms. Australia’s health system is a complex mix of government and privately funded services delivered in a variety of settings. Chapter 6 ‘Funding health care in Australia’ provides an overview of the funding arrangements in place to fund Australia’s health system and provides some comparisons with other OECD countries.
There have been changes to the funding of the Australian health system over time, including to the relative contribution of different funders across different areas of health expenditure. Across the OECD there are also differences in how countries fund their health systems. The Australian health system is financed through a hybrid model—a mix of both welfare state and market models—in which governments provide universal public insurance for access to health services but individuals can choose to pay for private health insurance in addition to their public insurance.
Managing the rising costs of health care is a challenge facing many OECD countries. Over the past 2 decades health expenditure in Australia has grown faster than either inflation or population growth. In the 20-year period to 2017–18, total health expenditure in Australia increased from $77.5 billion to $185.4 billion in real terms, and spending per person increased from $4,189 to $7,485. As a proportion of Gross Domestic Product (GDP), health expenditure increased from 7.6% in 1997–98 to 10% in 2017–18 (current prices). In the context of increasing health expenditure, different approaches to health care financing are being explored, including value-based health care models, capitation-based funding, and bundled and blended payments. Finding alternative mechanisms is especially important for increasingly complex and long-term health care needs.
Meeting complex and long-term health care needs is critical, especially with Australia’s ageing population, and necessitates even greater interaction between the health and welfare systems. An example of this intersection is found in the aged-care sector, where an individual’s need for a higher level of care can be the result of various factors including chronic and complex health issues or cognitive and/or physical decline. As people’s abilities decline, everyday self-care activities become increasingly difficult to manage and, for some older people, this can mean moving into residential aged-care facilities.
Not only is this a transition in living situation, but it can also prompt a transition in the use of selected health services and medications. Chapter 7 ‘Changes in people’s health service use around the time of entering permanent residential care’ explores people’s use of health services in the 6 months before and after entry into permanent residential aged care. Using original analysis, it provides insights into the nature of health-service use during this transition, which may help us to understand the context for change. The analysis focused on 3 groups of people who first entered permanent residential aged care in a selected 3-month period in 2014, 2015 or 2016. Using linked administrative data from aged care, Medicare Benefits Schedule claims and Pharmaceutical Benefits Scheme dispensing data, the analysis focuses on general practitioner (GP) and specialist attendances and on prescriptions dispensed for selected medicines.
Access to care and services is influenced by the interactions aged-care services have with health care services; the availability of health care professionals in the local area; the workforce available within residential aged care; and prescribing practices within facilities. GPs play a central role in prescribing medicines for older people in residential aged care and access to medicines can be relatively straightforward.
Medicines that act on the central nervous system have been of particular interest due to their effects on older people, and many are prescribed at high rates in residential aged care. Through the proceedings of the recent Royal Commission into Aged Care Quality and Safety, there has been a focus on how people living in such facilities are able to access health care services and how medicines are used within residential aged care. The interim report of the Royal Commission highlighted workforce issues, and potentially problematic use of certain medicines (particularly antipsychotics), and recommended immediate action to reduce their use as a chemical restraint.
People living with dementia also experience the intersection of health services and aged-care services. The Royal Commission found systemic issues in the aged-care sector and has called for fundamental reforms to address failures in providing appropriate care for older people—including the growing number with dementia. Over half of those in residential aged-care facilities have dementia, and a large proportion of people with dementia are living at home.
Dementia is a major health issue in Australia, causing substantial illness, high levels of dependency, and death. The number of Australians living with dementia is estimated to be between 400,000 and 459,000 in 2020, but the exact number is unknown. In 2018, dementia was the second leading cause of death in Australia and the leading cause of death for women. It has also been a leading contributor to the burden of disease and injury, requiring $428 million in direct health expenditure in 2015–16.
Without a significant breakthrough in treatment, the number of people with dementia is expected to double by 2050, placing a greater demand on Australia’s health and aged-care systems. Chapter 8 ‘Dementia data in Australia—understanding the gaps and opportunities’ examines current issues and gaps in Australia’s dementia data and how this affects our understanding of—and response to—dementia in Australia. It also looks at opportunities for data development to ensure Australia has sufficient data to inform dementia policy and service planning.
Monitoring dementia—and its impact on individuals and their carers and on Australia’s health and aged-care systems—is essential for the development of evidence-based health, aged-care and social policy and for associated service planning. Gaps in the data include a lack of dementia diagnosis in GP and other specialist care data; inconsistent reporting of dementia across different datasets and over time; and ad-hoc and limited data on groups of interest and across different health care types. The progression of dementia is also complex and each person with dementia has different needs and experiences.
However, national monitoring of dementia has been irregular and inconsistent, limiting its ability to inform policy development and service planning. To address some of these gaps and data limitations, the Australian Government has committed to improve national dementia data assets and capabilities. The AIHW recently used linked administrative data to understand the health service use pathway of people with dementia in their last year of life, finding that people with dementia used fewer health services than people without dementia.
Another area with a national public focus—one for which timely data, monitoring, and evidence-based information are crucial—is suicide and intentional self-harm. Suicide prevention in Australia is a complex area of policy, with governments, policymakers and service providers all having a role in reducing suicides and cases of intentional self-harm. The reasons for suicide are also complex and are different for each individual, and the prevalence, characteristics and methods of suicidal behaviour vary between different communities, demographic groups and over time. Effective suicide prevention thus requires a multi-sector approach, including health, education; employment; welfare and law-enforcement agencies; housing providers; and non-government organisations.
Australian governments have also agreed to take a national approach to mental health planning and service delivery, including improving the quality and timeliness of data collection on suicide, suicide attempts and intentional self-harm in Australia. A National Suicide Prevention Adviser was recently appointed and a National Suicide Prevention Taskforce has been established to coordinate activities between government agencies and across different levels of government.
Chapter 9 ‘Improving suicide and intentional self-harm monitoring in Australia’ provides an overview of the policy context for intentional self-harm and suicide monitoring and examines existing national sources of data currently used for this purpose. It discusses the limitations of these data sources, current data gaps and potential new sources of data that may strengthen the evidence base. There is also a particular focus on Indigenous Australians and on serving and ex-serving Australian Defence Force personnel.
Collection of data on suicide and intentional self-harm is essential to establish the extent of the problem; to highlight trends and emerging areas of concern; and to identify vulnerable populations. Data underpins the appropriate targeting of prevention strategies or research, and it is therefore important that monitoring of both suicide and intentional self-harm is as comprehensive and informative as possible. The National Suicide and Self-harm Monitoring System has been established to collate and coordinate data and information on suicide and intentional self-harm in Australia to improve their coherence, accessibility, quality and timeliness. This will better inform the development of suicide and intentional self-harm prevention policies and service planning. The AIHW will receive funding of $5 million per year for 3 years (2019–20 to 2021–22) to deliver the monitoring system.
Picking up on some of the threads in the other articles—ageing population, health status, inequality/health inequity—the report ends with a fundamental question about our understanding of health and wellbeing, and how to measure them. Life expectancy is often used as a key indicator of the health of a population and of overall progress in health and wellbeing over time. In Australia, life expectancy has increased substantially over many decades, and in 2018 it was 80.7 years for males and 84.9 years for females.
But what does our increasing life expectancy mean for individuals, and for the health system, in a country like Australia? Our longer lives have implications, not only for the quality of life of individuals, but also for health care planning, demand and need for health and welfare services, as well as health-system costs. Does living a longer life mean that people are also living healthier lives—or are we enduring poor health for longer at the end of our lives? (In 2015, Australians aged 65 and over represented 15% of the population—but experienced one-third (33%) of the burden of ill health.) Chapter ‘10 Longer lives, healthier lives?’ looks at this important distinction—between years lived in full or in ill health—in the years of life we have gained.
There is ongoing debate about whether there has been an increase in the amount of ill health experienced by older Australians. Burden of disease analyses—particularly health-adjusted life expectancy (HALE) which combines the health-related quality of life and life expectancy into a single measure—assists health planning and the assessment of health in Australia. To highlight trends in the health of Australia’s ageing population, the article focuses on HALE at age 65, and also explores differences in HALE for Australians from different socioeconomic areas.
At a national level for people aged 65—while life expectancy continues to increase—the proportion of their lifetime spent in ill health has remained constant. However, this does not apply to all population groups. There is a clear gradient: life expectancy and years lived in full health increase as socioeconomic status increases. The 10 articles in this report discuss issues covering health inequity; health indicators and measures; data linkage; data gaps and limitations; interactions between different parts of the health system and the welfare sector; and the external influences on our health. Data can facilitate greater understanding about how differences in personal circumstances and behaviours may lead to different health outcomes over time—and can be used to provide an overview of the functioning of the health care sector and the health of Australians.
What is evident from these articles is the vital importance of data in supporting better understanding and planning for current and future health needs.