Does a medical model or a social health framework provide the most equitable and effective approach for improving the health of children (and thus of future adults and communities), particularly those from disadvantaged backgrounds?
This seems to be a critical issue to consider when evaluating the intent and impact of the Federal Government move to make child health checks part of its conditional welfare reform agenda.
In an article below, Luke Buckmaster, from the Commonwealth Parliamentary Library, examines some of the questions that have been raised about child health checks. (Thanks to the Library for allowing republication of this article from its FlagPost blog).
And at the bottom of the post, I’ve reproduced the recommendations directly relevant to children’s health from the Marmot Review, Fair Society, Healthy Lives. Contrast and compare…
What are the concerns about child health checks?
Luke Buckmaster writes:
The Government recently added child health checks to its welfare reform agenda by announcing that it would require parents of four year olds to provide evidence that their child has had a basic health assessment in order to receive the Family Tax Benefit Part A Supplement.
However, the Rudd-Gillard Government’s experience to date with child health checks has been the subject of criticism by some medical experts and health sector commentators, raising questions about the likely effectiveness of the policy.
Healthy Kids Check
Child health assessments were first introduced by the Rudd Government in July 2008 through the creation of Healthy Kids Check item numbers on Medicare.
According to a Department of Health and Ageing fact sheet, the aim of the Healthy Kids Check is:
… to improve the health and well-being of Australian children. The Healthy Kids Check promotes early detection of lifestyle risk factors, delayed development and illness, and provides the opportunity to introduce guidance for healthy lifestyles and early intervention strategies.
Healthy Kids Check must include assessments of height, weight, eyesight, hearing, oral health, toileting and allergies. They are intended to be delivered in conjunction with the four year old immunisation.
As noted above, the Government intends making the payment of the Family Tax Benefit Part A Supplement (currently $726.35 per child) for a child turning four in a particular income year, conditional on the child having received a basic health assessment. This measure is also the subject of a Bill currently before the Parliament.
The Government’s rationale (p. 24) for linking payment of the Part A Supplement to a child health check is that such checks ‘may detect developmental delays and conditions, such as problems affecting hearing and vision, which are problems that make it more difficult for children to learn when they start school’.
The Government has also argued that child health checks are particularly important for people on low incomes because of research indicating that disadvantaged children arrive at school less well prepared and that this disadvantage persists, and even widens, as children progress through school.
The Bill does not establish precisely what health checks are to be required under this measure—these are to be set by Ministerial determination. However, it would be reasonable to assume that the Government intends that child health checks required under this measure will largely be provided under the existing Healthy Kids Check Medicare items.
This link of the Part A Supplement to child health checks reflects the increasing use by the Labor Government of ‘welfare conditionality’ as a way of addressing some of the harmful effects of welfare dependency. (I have previously discussed this aspect of Labor’s approach to social policy here and here).
Criticisms of the Healthy Kids Check
To date, uptake of the Healthy Kids Check program has been relatively low. Lesley Russell of the Menzies Centre for Health Policy has shown that, in the first two years following its introduction, only 81 463 Healthy Kids Checks were done, at a cost of $3.79 million. Russell noted that this was ‘well below what was anticipated for a nation with some 260 000 four-year olds, and a program that was budgeted to cost $25.6 million over four years’.
Further, Medicare data shows that since the introduction of new item numbers and descriptors for the checks in May 2010, around 57 417 services were provided to children in the age group targeted by the Healthy Kids Checks. While this does suggest a modest increase in numbers of children undergoing health checks (achieved over just a 10 month period), arguably, it still represents a less-than-substantial uptake of the program. It may be that linking the Part A Supplement to receipt of a child health check is intended to increase uptake of the Healthy Kids Checks.
Evidence and effectiveness
Critics have also argued that the evidence base for the Healthy Kids Checks is inadequate. For example, an April 2010 paper in the Medical Journal of Australia found that ‘the evidence behind the [Healthy Kids Check] is not compelling’; ‘its components are ill defined and lack rationale’ and ‘could be refined to better reflect the available evidence’.
A further criticism has been that evidence suggests the need for health checks to take place earlier in a child’s development than four years old. It has been reported that, as part of the Budget mental health package, the Government expanded the child health checks measure to include three year olds and that this had been welcomed by some doctors.
However, the relevant Government fact sheet makes it clear that Healthy Kids Checks have been available to three year olds since at least May 2010 (the fact sheet refers to children being eligible for the scheme if they are ‘over the age of three years and under the age of five years’). However, some medical experts suggest that the checks should be carried out earlier than this and on a more ongoing basis (see also here).
There has also been criticism that the Healthy Kids Check program does not include any requirement for follow-up or ongoing treatment for health problems identified in a health check. According to critics, the one-off nature of the checks reduces the potential effectiveness of the program. As Russell argues, ‘there is nothing to require that children get the follow-up medical care, eyeglasses, hearing assistance or speech therapy they might need’.
Should the checks be run through Medicare?
Of the criticisms outlined above, those relating to follow-up and evidence are fundamental and raise questions about the overall effectiveness of the program. However, the concerns relating to low uptake of the program may also highlight a question of fundamental significance. That is, whether Medicare provides the most suitable way of screening young children for health problems.
One problem with running child health checks through Medicare is that often there is a cost for care. There is substantial evidence that financial barriers prevent access to necessary care (for example, see here and here).
While it could be expected that a reasonable proportion of Healthy Kids Checks would be bulk-billed, there would still be financial barriers arising from the need to access treatment for any problems identified. As noted above, the Healthy Kids Checks do not provide for this and many of the services children might need only receive limited funding through Medicare (for example, speech pathology, occupational therapy or physiotherapy).
A further problem with running the program though Medicare is that it assumes that people on low incomes are easily able to access GPs.
However, there is evidence that this is not actually the case and that GP services are subject to what is known as the inverse care law, where medical care is least likely to reach those most in need.
For example, we know that compared with people in areas of least disadvantage, GP consultations with people from socially disadvantaged groups are shorter and less likely to result in an investigation or referral (for example, see here, here and here).
Finally, there is the issue of whether Medicare (an insurance based system providing rebates for acute fee-for-service medical consultations) is an appropriate model for providing preventive care or care for chronic conditions.
The Government made some moves away from fee-for-service medicine with its 2010 Budget proposal to give GPs block grants for each voluntarily enrolled patient with diabetes, to manage and coordinate all their health care needs (though, this has since been deferred in favour of a pilot scheme following opposition from the Australian Medical Association).
Clearly, though, it is important that any activity on which receipt of welfare is made conditional is based on solid evidence and is likely to be effective.
Concerns about aspects of the Medicare Healthy Kids Checks highlight the importance of making sure that this is the case.
Relevant extract from recommendations of the Marmot Review…
1. Increase the proportion of overall expenditure allocated to the early years and ensure expenditure on early years development is focused progressively across the social gradient.
2. Support families to achieve progressive improvements in early years development, including:
- Giving priority to pre and postnatal interventions, such as intensive home-visiting programmes, that reduce adverse outcomes of pregnancy and infancy
- Providing paid parental leave in the first year of life with a minimum income for healthy living
- Providing routine support to families through parenting programmes, children’s centres and key workers, delivered to meet social need via outreach to families
- Developing programmes for the transition to school.
3. Provide good quality early years education and childcare proportionately across the gradient. This provision should be:
- Combined with outreach to increase the takeup by children from disadvantaged families
- Provided on the basis of evaluated models and must meet quality standards.