Only 20 years ago butter was the public villain – contributing to raised cholesterol levels and public concern over an increased risk of heart disease. Now this public perception seems to have been reversed, and reality cooking shows seem to use butter in every recipe. But what has caused this shift in perceptions and is it based on scientific evidence?
In the domestic market more people buy margarine than butter, with 27% of respondents in an ABS survey eating margarine the day before, and 15% consuming butter.
Do we still need to be concerned about butter’s links to heart disease, and is there any evidence to suggest butter is better for our health compared to margarine? To answer this we first need to look more closely at the make-up of butter and margarine.
Where do our favourite yellow spreads come from?
Butter is made from the processing of cream. The cream is churned until the liquid (buttermilk) separates from the fat solids. These fat solids are then rinsed, a little salt added, and shaped to form the butter we all love.
Margarine was first developed in France by Napoleon as a substitute for butter to feed the armed forces and lower classes. Margarine is made from vegetable oils, beta-carotene (added for colour), emulsifiers (to help the oil and water mix), salt and flavours (which can include milk solids). Vitamins A and D are also added to the same level present in butter.
Any diet app will tell you margarine has about 10-15% fewer kilojoules than butter. But whether this is significant will largely depend on the amount you consume each day.
A national nutrition survey indicates the average person over 19 years consumes 20 grams a day of spreads (either butter or margarine), which equates to a difference of 100kj. This difference is largely insignificant in a usual daily intake of 8700kj/day.
It’s all in the fatty acids
The significant nutritional difference actually lies in the fatty acid profiles of the two products. The health differences between butter and margarine are based on the presence of different types of fats.
There are three types of fats in our food: saturated fat, monounsaturated fats and polyunsaturated fats. The difference between these lies in their chemical structure. The structure of saturated fats has no double bonds in between the carbon atoms, monounsaturated fats have one double bond between the carbon atoms, and polyunsaturated fats have two or more double bonds between the carbon atoms.
These subtle differences in structure lead to differences in the way our body metabolises these fats, and hence how they affect our health, in particular our heart health.
Margarine can be made from a number of different oils. If coconut oil is used the margarine will be mainly saturated fat, if sunflower oil is used it will mainly be a polyunsaturated fat, and if olive oil or canola oil is used it will mainly be a monounsaturated fat.
Butter, derived from dairy milk, is mainly saturated fat, and the main saturated fats are palmitic acid (about 31%) and myristic acid (about 12%). Studies have shown these raise blood cholesterol levels.
While there is debate in the scientific world about the relative contributions of saturated fats (and the different types of saturated fatty acids) to heart disease, the consensus is that replacing saturated fats with monounsaturated or polyunsaturated fats will lower the risk of heart disease.
There is strong evidence extra-virgin olive oil (a monounsaturated fat) provides strong benefits for heart disease protection – but there isn’t enough extra-virgin olive oil in margarine products to confer this benefit. Using olive-oil-based margarines is going to contribute very little to your daily intake of extra-virgin olive oil.
And this is why it’s confusing for the consumer – despite a margarine being labelled as being made from olive oil, it may contain only small amounts of olive oil and not be as high in monounsaturated fats as expected. It’s best to read the nutrition information panel to determine which margarine is highest in monounsaturated fats.
Another point of difference between butter and margarine is that margarine may contain plant sterols, which help reduce cholesterol levels.
At the end of the day, if you consume butter only occasionally and your diet closely adheres to the Australian guidelines for healthy eating, there is no harm in continuing to do so.
Another option to consider would be the butter blends. These provide the taste of butter while reducing saturated fat intake to half, and they are easier to spread. Of course, if you consume lots of butter, swapping for a low saturated fat margarine is your healthier option – perhaps reserve the butter for special occasions.
If you’re concerned about saturated fat levels in your diet, you should read the nutrition information panel to determine which margarine is lowest in saturated fat, regardless of which oil is used in the product.
As always, people need to base their decision on their family and medical history and obtain advice from their dietitian or GP.
If you are an adult in Australia, the kinds of vaccines you need to get will depend on several factors, including whether you missed out on childhood vaccines, if you are Aboriginal or Torres Strait Islander, your occupation, how old you are and whether you intend to go travelling.
For those born in Australia
Children up to four years and aged 10-15 receive vaccines under the National Immunisation Schedule. These are for hepatitis B, whooping cough, diphtheria, tetanus, measles, mumps, rubella, polio, haemophilus influenzae B, rotavirus, pneumococcal and meningococcal disease, chickenpox and the human papillomavirus (HPV).
Immunity following vaccination varies depending on the vaccine. For example, the measles vaccine protects for a long duration, possibly a lifetime, whereas immunity wanes for pertussis (whooping cough). Boosters are given for many vaccines to improve immunity.
Measles, mumps, rubella, chickenpox, diphtheria and tetanus
People born in Australia before 1966 likely have natural immunity to measles as the viruses were circulating widely prior to the vaccination program. People born after 1965 should have received two doses of a measles vaccine. Those who haven’t, or aren’t sure, can safely receive a vaccine to avoid infection and prevent transmission to babies too young to be vaccinated.
Measles vaccine can be given as MMR (measles-mumps-rubella) or MMRV, which includes varicella (chickenpox). The varicella vaccine on its own (not combined in MMRV) is advised for people aged 14 and over who have not had chickenpox, especially women of childbearing age.
Booster doses of diphtheria, tetanus and whooping cough vaccines, are available free at age 10-15, and recommended at 50 years old and also at 65 years and over if not received in the previous ten years. Anyone unsure of their tetanus vaccination status who sustains a tetanus-prone wound (generally a deep puncture or wound) should get vaccinated. While tetanus is rare in Australia, most cases we see are in older adults.
Pregnant women are recommended to get the diphtheria-tetanus-acellular pertussis vaccine in the third trimester to protect the vulnerable infant after it is born, and influenza vaccine at any stage of the pregnancy (see below under influenza).
Pertussis (whooping cough) is a contagious respiratory infection dangerous for babies. One in every 200 babies who contract whooping cough will die.
It is particularly important for women from 28 weeks gestation to ensure they are vaccinated, as well as the partners of these women and anyone else who is taking care of a child younger than six months old. Deaths from pertussis are also documented in elderly Australians.
The pneumococcal vaccine is funded for everyone aged 65 and over, and recommended for anyone under 65 with risk factors such as chronic lung disease.
Anyone from the age of six months can get the flu (influenza) vaccine. The vaccine can be given to any adult who requests it, but is only funded if they fall into defined risk groups such as pregnant women, Indigenous Australians, peopled aged 65 and over, or those with a medical condition such as chronic lung, cardiac or kidney disease.
Flu vaccine is matched every year to the anticipated circulating flu viruses and is quite effective. The vaccine covers four strains of influenza. Pregnant women are at increased risk of the flu and recommended for influenza vaccine any time during pregnancy.
Health workers, childcare workers and aged-care workers are a priority for vaccination because they care for sick or vulnerable people in institutions at risk of outbreaks. Influenza is the most important vaccine for these occupational groups, and some organisations provide free staff vaccinations. Otherwise, you can ask your doctor for a vaccination.
Any person whose immune system is weakened through medication or illness (such as HIV) is at increased risk of infections. However, live viral or bacterial vaccines must not be given to immunosuppressed people. They must seek medical advice on which vaccines can be safely given.
Australian-born children receive four shots of the hepatitis B vaccine, but some adults are advised to get vaccinations for hepatitis A or B. Those recommended to receive the hepatitis A vaccine are: travellers to hepatitis A endemic areas; people whose jobs put them at risk of acquiring hepatitis A including childcare workers and plumbers; men who have sex with men; injecting drug users; people with developmental disabilities; those with chronic liver disease, liver organ transplant recipients or those chronically infected with hepatitis B or hepatitis C.
Those recommended to get the hepatitis B vaccine are: people who live in a household with someone infected with hepatitis B; those having sexual contact with someone infected with hepatitis B; sex workers; men who have sex with men; injecting drug users; migrants from hepatitis B endemic countries; healthcare workers; Aboriginal and Torres Strait Islanders; and some others at high risk at their workplace or due to a medical condition.
The human papillomavirus (HPV) vaccine protects against cervical, anal, head and neck cancers, as well as some others. It is available for boys and girls and delivered in high school, usually in year seven. There is benefit for older girls and women to be vaccinated, at least up to their mid-to-late 20s.
With ageing comes a progressive decline in the immune system and a corresponding increase in risk of infections. Vaccination is the low-hanging fruit for healthy ageing. The elderly are advised to receive the influenza, pneumococcal and shingles vaccines.
Influenza and pneumonia are major preventable causes of illness and death in older people. The flu causes deaths in children and the elderly during severe seasons.
The most common cause of pneumonia is streptococcus pneumonia, which can be prevented with the pneumococcal vaccine. There are two types of pneumococcal vaccines: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). Both protect against invasive pneumococcal disease (such as meningitis and the blood infection referred to as septicemia), and the conjugate vaccine is proven to reduce the risk of pneumonia.
The government funds influenza (annually) and pneumococcal vaccines for people aged 65 and over.
Shingles is a reactivation of the chickenpox virus. It causes a high burden of disease in older people (who have had chickenpox before) and can lead to debilitating and chronic pain. The shingles vaccine is recommended for people aged 60 and over. The government funds it for people aged 70 to 79.
Travel is a major vector for transmission of infections around the world, and travellers are at high risk of preventable infections. Most epidemics of measles, for example, are imported through travel. People may be under-vaccinated for measles if they missed a dose in childhood.
Anyone travelling should discuss vaccines with their doctor. If unsure of measles vaccination status, vaccination is recommended. This will depend on where people are travelling, and may include vaccination for yellow fever, Japanese encephalitis, cholera, typhoid, hepatitis A or influenza.
Travellers who are visiting friends and relatives overseas often fail to take precautions such as vaccination and do not perceive themselves as being at risk. In fact, they are at higher risk of preventable infections because they may be staying in traditional communities rather than hotels, and can be exposed to risks such as contaminated water, food or mosquitoes.
Aboriginal Australians and Torres Strait Islanders
Indigenous Australians are at increased risk of infections and have access to funded vaccines against influenza (anyone over six months old) and pneumococcal disease (for infants, everyone over 50 years and those aged 15-49 with chronic diseases).
They are also advised to get hepatitis B vaccine if they haven’t already received it. Unfortunately, overall vaccine coverage for these groups is low – between 13% and 50%, representing a real lost opportunity.
Migrants and refugees are at risk of vaccine-preventable infections because they may be under-vaccinated and come from countries with a high incidence of infection. There is no systematic means for GPs to identify people at risk of under-vaccination, but the new Australian Immunisation Register will help if GPs can check the immunisation status of their patients.
The funding of catch-up vaccination has also been a major obstacle until now. In July 2017 the government announced free catch-up vaccinations for children aged 10-19 and for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule that has been missed.
While this does not cover all under-vaccinated refugees, it is a welcome development. If you are not newly arrived but a migrant or refugee, check with your doctor about catch-up vaccination.
Mental disorders are traditionally seen as rather like flowering bulbs. Above the ground we see their symptoms, but we know their source lies hidden beneath the surface. If we treat the symptoms without addressing the cause – cut off the flower without uprooting the bulb – they will just flower again later.
The idea that each mental disorder has an underlying cause is itself deeply rooted. We imagine that underneath the clinical symptoms of schizophrenia or depression there is an underlying disease entity. If treatment is to be effective and lasting rather than merely symptomatic it must target that concealed origin.
People have had many ideas about the form the unseen cause might take. Medieval physicians imagined a “stone of folly” that had to be surgically removed from a mad person’s head before sanity could prevail. Funnily enough, the best known painting of such an operation, Hieronymus Bosch’s The extraction of the stone of madness, shows the “stone” to be a flower bulb.
More recently, psychiatrists often suppose the hidden cause is neural, such as a brain disease or chemical imbalance. Psychologists sometimes prefer to invoke specific cognitive malfunctions or conflicts. What unifies them is the idea that a cluster of symptoms can be traced back to an underlying pathology.
This way of thinking makes perfect sense in some areas of medicine. A collection of bodily symptoms often points to an underlying disease process. Scarlet fever is revealed by a bright red rash, fever and a sore throat, all caused by an underlying bacterial infection. It would be folly to treat it symptomatically. Pacifying the rash with wet towels, taming the fever with aspirin and drinking tea with honey to soothe the throat would not attack the hidden, microbial cause.
Unfortunately mental disorder is not like infectious disease. Rarely is there a single, identifiable cause underlying a group of symptoms. Most psychiatric symptoms spring from a tangled multiplicity of causes. In addition, many symptoms are not specific to a single condition.
To extend the botanical metaphor, mental disorders are less like flowering bulbs than like bamboo. An interconnected network of underground roots (hidden causes) generates many visible stems (symptoms). No stem can be traced back to a single root, and no root feeds a single stem.
The network approach to mental disorder
If there is no one-to-one link between symptoms and hidden causes, maybe we are better off putting aside the search for those causes. A new way of thinking about mental disorder argues just that, proposing that we focus full attention on symptoms instead.
Rather than seeing symptoms as manifestations of hidden disease entities – as the tip of an iceberg – this “network approach” tells us to examine how symptoms relate to one another. It argues the symptoms of a disorder cluster together not because they share a hidden cause but because they interact with and potentially reinforce one another.
The network approach to mental disorder, developed by Dutch psychologists Denny Borsboom, Angelique Cramer and colleagues, represents each symptom as a node in network. It draws links between these nodes to reveal the symptoms that are most strongly related, such as which ones influence other symptoms most powerfully and extensively.
For example, loss of appetite and weight loss are both symptoms of major depression. If researchers found they were closely related, and appetite loss drives weight loss, then an arrow would be drawn from the former to the latter. By this means a group of dynamically related symptoms can be represented by a network diagram.
Several features of the resulting networks are particularly interesting. Certain symptoms can be shown to be central, related to many others, whereas others are more peripheral. Certain symptoms primarily cause others, whereas some symptoms are primarily caused by others.
Because mental disorders are seen as mutually reinforcing symptoms, clinicians should target central symptoms that cause many others. Successfully treating these symptoms should have broadly beneficial effects. It should reduce other existing symptoms and prevent the spread to new symptoms.
Certain symptoms may also be bridges from one disorder network to another. For example, sleep disturbance among people with post-traumatic stress disorder (PTSD) may cause fatigue, and fatigue may serve as a bridge to the depression network by activating concentration problems and guilt.
Researchers have carried out network analyses of several disorders, using similar computational tools as those used in social network analysis, an approach to mapping relations among people. One study of several substance use problems showed that using the substance more than planned was usually the most central symptom. It was strongly related to having worse withdrawal symptoms and needing more of the substance to get the same effect (“tolerance”).
Several studies have explored anxiety disorders. A study of social anxiety showed that avoidance of potentially threatening social situations was a central symptom and thus a prime target for treatment. Research on PTSD following a catastrophic earthquake in China showed that sleep difficulty and hypervigilance for future threats had especially potent influences on other symptoms.
Turning to depression, a study of short term fluctuations in symptoms revealed the centrality of loss of pleasure in the symptom network. It activated an assortment of other symptoms including sadness, loss of energy and interest in activities and irritability. In contrast, sadness, crying and a loss of interest in sex were incidental.
Another study showed that depressed people whose symptoms were more densely connected were more likely to have persistent depression two years later. This finding accords with the network view that symptoms of mental disorders can be self-reinforcing. People whose symptom networks form a tighter web may therefore have greater difficulty overcoming their problems.
The network approach has several important implications. For researchers, it suggests that the search for single causes of mental disorders is quixotic. Of course, symptoms have an assortment of social and neurobiological sources, but these sources are highly unlikely to be unique to one condition.
For practising psychiatrists and psychologists the network view implies that symptoms should be taken seriously in their own right and not seen merely as pale manifestations of underlying disease. Treatments should directly target particular symptoms, not a fictitious hidden cause.
Boorsboom and Cramer make this point amusingly in regard to major depression.
If [depression] does not exist as an entity that exists independently of its symptoms (like a tumour does), attempting to treat it analogous to the way medical conditions are treated (cutting away the tumour) is like trying to saddle a unicorn.
The network approach also has a strong message for all of us who care about mental health and illness. We should abandon the last vestiges of our belief that mental disorders are best seen as medical diseases. The symptoms of depression, PTSD, or social anxiety don’t point to an underlying disorder. They are the disorder.
Evidence gathered over 60 years about adding fluoride to drinking water has failed to convince some people this major public health initiative is not only safe but helps to prevent tooth decay.
Myths about fluoridated water persist. These include fluoride isn’t natural, adding it to our water supplies doesn’t prevent tooth decay and it causes conditions ranging from cancer to Down syndrome.
Now the National Health and Medical Research Council (NHMRC) is in the process of updating its evidence on the impact of fluoridated water on human health since it last issued a statement on the topic in 2007.
Here are four common myths the evidence says are wrong.
1. Fluoride isn’t natural
Fluoride is a naturally occurring substance found in rocks that leaches into groundwater; it’s also found in surface water. The natural level of fluoride in the water varies depending on the type of water (groundwater or surface) and the type of rocks and minerals it’s in contact with.
There are many places in Australia where fluoride occurs naturally in the water supply at optimum levels to maintain good dental health. For example, both Portland and Port Fairy in Victoria have naturally occurring fluoride in their water at 0.7-1.0 parts per million.
The trial had to be discontinued after six years because the benefits to the children in the fluoridated community were so obvious it was deemed unethical to not provide the benefits to all the children, and so the control community water supply was also fluoridated.
The NHMRC found, there was reliable evidence to suggest water fluoridation at current levels in Australia of 0.6-1.1 parts per million is not associated with: cancer, Down syndrome, cognitive problems, lowered intelligence, hip fracture, chronic kidney disease, kidney stones, hardening of the arteries, high blood pressure, low birth weight, premature death from any cause, musculoskeletal pain, osteoporosis, skeletal fluorosis (extra bone fluoride), thyroid problems or other self-reported complaints.
Most studies that claim to show adverse health effects report on areas where there are high levels of fluoride occurring naturally in the water supply. This is often more than 2-10 parts per million or more, up to 10 times levels found in Australian water.
These studies are also often not of the highest quality, for example with small sample sizes and not taking into account other factors that may affect adverse health outcomes.
There is, however, evidence that fluoridated water is linked to both the amount and severity of dental fluorosis. This is caused by being exposed to excess fluoride (from any source) while the teeth are forming, affecting how the tooth enamel mineralises.
Most dental fluorosis in Australia is very mild or mild, and does not affect the either the function or appearance of the teeth. When you can see it, there are fine white flecks or lines on the teeth. Moderate dental fluorosis is very uncommon, and tends to include brown patches on the tooth surface. Severe dental fluorosis is rare in Australia.
4. Fluoridated water is not safe for infant formula
Some people are concerned about using fluoridated water to make up infant formula.
However, all infant formula sold in Australia has very low levels of fluoride, below the threshold amount of 17 micrograms of fluoride/100 kilojules (before reconstitution), which would require a warning label.
Therefore, making up infant formula with fluoridated tap water at levels found in Australian (0.6-1.1 parts per million) is safe, and does not pose a risk for dental fluorosis. Indeed, Australian research shows there is no association between infant formula use and dental fluorosis.
A consistent message
Adding fluoride to tap water to prevent tooth decay is one of our greatest public health achievements, with evidence gathered over more than 60 years showing it works and is safe. This latest review, tailored to Australia, adds to that evidence.
Population growth has profound impacts on Australian life, and sorting myths from facts can be difficult. This article is part of our series, Is Australia Full?, which aims to help inform a wide-ranging and often emotive debate.
Developed economies, including Australia, have increasingly been using international migration to compensate for demographic trend and skill shortages. Australia has one of the highest proportion of overseas-born people in the world: an estimated 26% of the total resident population was born overseas. This is expected to increase over the next decade.
So the health of immigrants and their use of health services are having increasing impacts on demands on the health system, its responsiveness, and the national health profile.
One of the most significant demographic trends in Australia today is the ageing of the population. This is an increase in the share of older people – defined as people aged 65 and older – relative to the youth (0 to 14 years) and working-age population (15 to 64 years). One in six Australians is now over 65, compared to one in seven in 2011 and only one in 25 in 1911.
The reasons for this trend are complex. These include the impact of the “baby boomer” generation and declines in fertility and mortality, combined with an increase in life expectancy.
Older people are living longer, which is an achievement of our health system. But an increase in life expectancy and decline in the death rate have created a paradoxical situation in which these older people have increased the country’s rates of illness and disability. This has led to a rise in health-care costs and an increase in use of health services, as well as hospitalisation.
While an ageing population adds to the burden on the health system, an intake of migrants who are generally young and healthier than the average Australian, due to their selectivity, might help balance this out. So, in fact, increasing migration would be of benefit to Australia’s health.
Australian immigrants are healthy
Australia uses something called the “points system” to determine the eligibility of most of those who apply to immigrate here. Points are given for productivity-related factors such as language, education, age (more points are given to younger applicants) and skills.
But it is reasonable to assume the points system would not apply to English migrants who arrived before the abandonment of the White Australian policy in 1973 and to New Zealand migrants. Together, these two groups make up a large proportion of the migrants from English-speaking countries. The points system also does not apply to those who migrate under the family, special eligibility, and humanitarian and refugee programs.
Having said that, skilled migrants selected under a points-based system make up most (around 68%) of all migrants in Australia. The rest (32%) taken in under the migration program come in through having a family member here.
considered to be a threat to public health or a danger to the Australian community
likely to result in significant health care and community service costs to the Australian community
likely to require health care and community services that would limit the access of Australian citizens and permanent residents to those services as these are already in short supply.
Humanitarian migrants have a health waiver provision, but they make up a very small proportion of the total migration program.
Research has shown that immigrants tend to have better health status that the Australia-born populations. This health advantage narrows significantly over time, leading to their health becoming similar to that of Australians.
Migrants’ contribution to the workforce
Immigrants make up a substantial part of the health workforce in Australia. The international movement of health professionals is a major component of migration. Australia has been dependent on international medical graduates for a long time.
The dependence on international doctors will likely be maintained in future for a variety of reasons, such as to redress medical workforce maldistribution. Given Australia’s ageing patient and practitioner base and some key areas of the health workforce already in very short supply, this contribution of migrants is significant for Australia’s health profile.
Monitoring the health and well-being of immigrants is important for the overall health and public health systems in Australia. The issue of migrant health has become additionally important because the goal of Australia’s migration program has moved towards meeting the labour market needs of the economy. Good health is essential to fully realise the social and economic potential of immigrants.
We must also continue to collect and examine data on the health care needs and health service utilisation of Australian-born and foreign-born patients. Finally, we must educate ourselves about important contributions migrants make to ensure informed decisions are made to protect the public health system.
You can read other articles in the Is Australia Full? series here.
Recently, hospital and aged care provider Catholic Health Australia (CHA) released a report sounding an alarm bell at recent increases in the number of patients in public hospitals being urged to “go private”.
Public hospitals may encourage their patients to “go private” because it allows them to bill the patient’s health insurance and Medicare for costs incurred, rather than having to dip into their own limited budgets. Patients may be persuaded to use their private health insurance after being assured by the public hospital of no out-of-pocket costs, or being promised added extras such as a private room.
The report argued this trend may harm the private hospital sector by affecting profitability and investment decisions. It may also harm the interests of public patients if public hospitals discriminate in favour of treating private patients.
While aspects of these concerns may be valid, there may also be some benefits to public hospitals treating more private patients.
A look at the figures
The report is correct that the numbers of private patients in public hospitals are increasing, at an average of 10.5% per year since 2011-12. Public patients in public hospitals and private patients in private hospitals have also been increasing, but at slower rates of only 2.7% and 4.5% per year respectively since 2011-12.
But percentage rates of change can be misleading. In raw numbers, the increase in public patients in public hospitals (527,467) and private patients in private hospitals (576,135) has actually outstripped the raw increase in private patients in public hospitals (287,473). This is because public patient numbers are increasing from a much larger base (over five million) than private patients in public hospitals (less than one million).
Concerns with this trend
The CHA report notes several concerns with the trend of increasing private patients in public hospitals. They note anecdotal evidence of public patients being pressured to “go private” with incentives including drinks vouchers, better food options and free parking. While these reports may seem concerning, it’s hard to base any change of policy on anecdotal reports.
More worrying is the suggestion that publicly-admitted patients in public hospitals are being discriminated against, for example by being made to wait longer for treatment. The CHA report cites data from an Australian Institute of Health and Welfare report, which shows waiting times on public hospital waiting lists for public patients (at 42 days) was more than twice that of private patients in public hospitals (20 days).
But this difference is hard to interpret. There may be many differences in diagnosis and disease severity between public and private patients, which may explain the waiting time gap. So we can’t conclude this is evidence of any form of “discrimination” against patients without private health insurance in the public hospital system from these figures.
More robust evidence from public hospitals in NSW in 2004-05 does show private patients were prioritised over public patients. In this study, waiting times for elective surgery were found to be considerably shorter for private patients, despite having similar clinical needs as public patients.
Differences in waiting times between public and private patients were found to be largest for patients assigned to the lowest two urgency levels. In these cases, waiting times for public patients were more than twice as long as for private patients.
There is further evidence, also from NSW public hospitals, that public and private patients may be treated differently when they are assigned to an urgency category for waiting lists for elective surgery. The study suggested private patients were more likely to be assigned into more urgent admission categories, which corresponds with a shorter maximum wait for admission into hospital.
This study also found private patients were likely to receive more medical procedures while in hospital, but found no difference for length of hospital stay or, importantly, for mortality rates.
One claim of the CHA report is that there has been relatively “stagnant” growth of activity of private patients in private hospitals, potentially affecting their profitability and investment decisions.
First, the figures don’t seem to back this up. The increase in numbers of private patients in private hospitals is actually higher than the increase in numbers of private patients in public hospitals.
Second, even if private hospitals were losing business to public hospitals, it could be a welcome demonstration of competition in the health care market. The trend may be explained through public hospitals providing better amenities, higher quality, or lower costs than private hospitals.
There are some arguments to support continuing the practice of public hospitals admitting private patients. There can be efficiency gains to the health system given that the fees and charges for private patients in public hospitals are usually lower than those in private hospitals. So this form of competition could lower the costs in the health system as a whole.
Additional revenue raised by public hospitals could also support the continual provision of services and programs for public patients, which may have been curtailed due to budget cuts to the public hospital system.
The public hospital system is often seen as unfairly treated by the private sector in how it bears costs for training junior doctors (which takes place overwhelmingly in the public system), and treating the most severely ill patients. From this perspective, it seems only fair to allow public hospitals to take their “share” of the more profitable private patients.
Why we need better data
It’s important to figure out whether private patients are receiving preferential treatment at the expense of public patients. One study found abolishing preferential access for private patients and admitting patients according to when they were listed for an elective procedure would only lead to a small improvement in waiting times for public patients.
This is because long waiting times for public patients are primarily due to budget constraints in public hospitals, and not because private patients are skipping the queue.
The available robust evidence on the treatment of private patients in public hospitals is from more than a decade ago, and it’s unclear if the disparities between how public and private patients are treated have improved or worsened.
One reason for the lack of high quality research on this topic is the restriction on access to detailed hospital data in Australia, which we need for robust studies. If we had access to more detailed data, we could better understand what’s happening now, and ensure timely access to high quality hospital care for both public and private patients.