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If we weren’t so busy calling a horse race, how might we cover health in the run-up to the federal election?

It’s hard to turn a corner these days without running into someone who’s unhappy about mainstream media reporting of politics, and the lack of investigation and analysis of important policy matters.

These are global concerns, however, as Professor Robert Picard, Director of Research at the Reuters Institute for the Study of Journalism at the University of Oxford, outlined in a recent address to the National Press Club (worth reading in full).

While the world suffers information overload, he said the news media industry’s collapsing business model and the commercialisation of news values has led to an “an impoverishment of in-depth reporting and analysis”.

“The economic, technical, and social changes affecting news organizations have diminished their abilities to pursue the public interest orientation that was traditionally at the hearts of their enterprises,” he said.

In a subsequent interview for the Public Interest Journalism Foundation, Professor Picard suggested that collaboration between the community sector and journalists might help enable a more useful, contextual coverage that better services the community’s needs.

On a similar note, Croakey contributors were recently asked for suggestions as to how we all might contribute to a more useful coverage of health matters in the run-up to the federal election.

Croakey will also start an Election 2013 page to catalogue useful stories and resources that might be of use for all these parties. Suggestions from readers are most welcome.

A rather lengthy Q and A with Croakey contributors follows below.

Q1. Many sectors have a responsibility when it comes to the quality of our public debate about health. How would you advise the media to approach its election coverage of health? What can journalists and media organisations do to move beyond calling the “horse race”? What are some specific investigations that you’d like to see done?

Fiona Armstrong, Climate and Health Alliance
To ask questions about what the announcements mean for the community? Are they feasible? Realistic? Warranted? Affordable? Enough? In the public interest? Will they improve the health of the community broadly? Affect specific health conditions? Save money? Be guided by evidence? Reduce expenditure? Prevent illness? Prevent enough illness? Benefit health professional over patients? Address pressing health concerns? Are they in line with national and international health goals?

Lea McInerney, writer, researcher and facilitator
What do the parties have in mind in response to the increasing evidence for the part social determinants play in everyone’s health and wellbeing?
Linked to this, how do they plan to address rising inequality in Australia?
What do they plan to do to promote better dialogue and exchange across sectors i.e. to break down the silos among healthcare and other professionals (transport, housing, community services, employment, education etc) that prevent good collaborative solutions to complex problems?

Amanda Lee, Professor, School of Public Health and Social Work & School of Exercise and Nutrition Sciences, QUT
Investigation of policy platforms re preventative health and specific questions such as “do you support continuation of the Australian National Preventative Health Agency?”

Daryl Sadgrove, Chief Executive Officer, Australasian College of Health Service Management
We MUST take a long term view. All jurisdictions in Australia will be overwhelmed by costs by 2035. We need to hold the government to account on long term, systemic and structural changes that will assist with managing demand.

Ian McAuley, Fellow of the Centre for Policy Development
Journalists should avoid being caught on trivia and ask some basic questions of politicians:

Do you care about the community’s cost of health care, or only about the government’s fiscal cost?  If you want to shift health costs off budget on to private insurance, how would you preserve equity, avoid the moral hazard of private insurance, and control bureaucratic costs?

What role do you see for price signals in health care? Or do you believe health care should be free at the point of delivery?  Memo item – private insurance is not a market mechanism – it’s a way of buying out of the discipline of price signals

Should those with their own or third party deep pockets (private insurance, cover from sport clubs etc) be able to jump the queue for scarce health resources and make queues for public hospitals longer?

If you are not in favour of a single insurer, explain why?  (“We don’t want ‘socialized medicine’” is not an answer.)

Journalists should ask of advocates:

What principles should guide the allocation of health care resources, and why?

If the health budget is constrained, what health programs should be cut to pay for your program?

Tim Senior, GP working in Aboriginal health
I’d like to see coverage of health policy not be limited to discussion of hospitals and hospital beds. It would be good to see questioning around the importance of primary care, and what election commitments there were around this. I’d also like to see this move beyond a discussion about Medicare and bulk billing rates, though I won’t hold my breath.

It would also be nice to see a distinction between health policies, which usually means policies about the health system and a discussion of the health effects of all policies. Finding the evidence behind policy commitments would also be helpful, rather than just a he said, she said argument.

I’d also like to see election health reporting look at the effect of policies on particular groups – Aboriginal and Torres Strait Islander health is a prime example where policy in Indigenous health will be made completely separately to other health policy. Finally, it would also be good to see politicians questioned about what is not in their policies, as well as what is there.

Andrew McAuliffe, Senior Director, Policy & Networks, AHHA
Perhaps a series of pieces on the lost opportunities of the National Health Reform agenda, tracking from the initial offerings of Rudd/Roxon to where we are now.  The aim of reduced blame game has become a pipe dream and the tension between states and Commonwealth are probably as bad as ever.

Jane Burns, CEO, The Young and Well Cooperative Research Centre
• Mental health policy spending and parity with health – what are the critical issues, why doesn’t it get traction

• Wellness related policy – why it doesn’t get traction and where the votes sit – including community attitudes (I.e. Kings College study) and how to create a more responsive political agenda that focuses on building the countries strengths

• Innovation in the policy debate and Australia as a potential leader in key issues like mental health, disability etc

• NBN and its role in innovation – rather than just infrastructure and what does that look like

• State vs. commonwealth issues – which is boring but impacts so significantly on families and people affected by mental illness and disability

Daniel Reeders, public health blogger and Tweeter
Ditch the notion of balance as objectivity.

Ditch the distanced stance that looks at strategy over subject matter – what Jay Rosen calls ‘the cult of savvy’.

Ditch the geek-macho stance that positions people who care more about subject matter as politically naive.

Associate Professor David Atkinson, WA
• How they envisage providing excellent local services by local people (Aboriginal Community Controlled Health Services are the only current model – but funding may be at risk), sustainable funding, improved models of corporate and clinical governance for Aboriginal health services (there are some good examples around as well as the not so good ones we hear about & or work within);

• How government run services can make a real and improving contribution when currently many are so bogged down in bureaucracy they have no capacity to respond to community needs and rarely provide culturally appropriate care; and

• How large national &/or state based programs can actually work (generally they don’t well and often are a complete waste of money).

• Medicare Locals are not the answer to any question I can think of in Aboriginal health but the opposition alternative may be to go back to State or national based mainstream funding, which would be worse.

• Aboriginal employment at all levels of the system, while not a panacea, is central to many of the changes required.  What is the situation: how many Aboriginal doctors, nurses and other health professionals and where are they working.  What proportion of the workforce and how is this changing over time (apart from doctors, where there has been a steady if inadequate increase, I suspect other areas are at best treading water.

School attendance – is 60% good enough???  What does either party actually plan to do about this (State issue I know but they talk about it).

Dr Rod MacQueen, addiction medicine physician, NSW
This is a huge issue, and it is in addressing this question that I regret the scarcity of specialist health reporters, who may better appreciate and describe the nuances and subtleties of many health issues. Even for people working in the field, there are many issues that do not have a simple or generally accepted answer. Recently, I was discussing big picture health issues with a family member who works and does research in a big teaching hospital, and it was clear that we see many issues from quite different points of view despite sharing an egalitarian world view.

Think of spending money on improving the blood pressure or lipid profile of the whole population by 5%, with a huge impact across the community but no necessary impact on an individual, and funding that by reducing the number of stents and coronary artery bypass grafts performed in hospital.

It’s not just doctor’s incomes that would be affected, those people who may benefit little from a population intervention, who already watch their weight and lipids, would possibly gain most from a stent or graft if it became necessary despite their own self care. Would they be happy with less operations? Is this fair?

The same problem applies to population weight loss efforts (when our governments reluctantly decide the issue can no longer be avoided) being funded instead of increasing numbers of gastric banding procedures.

My relative and I did agree, however, that the solution lies in accepting that there may not be a single correct approach, but failing to discuss these matters, letting big funding decisions be made in secret, and failing to monitor the outcomes on any decisions, will lead (indeed, has lead) to the worst outcomes, where more is spent to achieve less and errors are repeated over and over.

The process we support is science, that which has given us vaccination, sewage and clean water, good nutrition and so on. And science is not laboratory stuff or new iToys in the end, it is the community of people who fearlessly and openly publish and share ideas, thoughts, questions, insights, even if they are later shown to be partial truths or even wrong.

Perhaps creeping managerialism with its fear of uncertainty and risk has scared many away?

A specific investigation I would like to see is this – why are our policies on personal drug use still substantially unchanged from the 1970s? Why is an open discussion on cannabis decriminalisation impossible despite the evidence that the current laws may do more harm than the drug, for example? Where is the agitation to restart the ACT heroin trial, a scientific trial that would answer some Big Questions, which we nearly had in 1997 – that’s 16 years ago and opioid misuse and related deaths have not gone away. And why is it a 5 minute job to get some opioid (heroin, oxycodone, morphine, fentanyl patches) to inject but almost impossible to get started on methadone or buprenorphine, both of which are 1960s technology? What about meth/bup 3.2, where any appropriate person can visit any chemist and get their medication daily using a smart card, instead of queuing for hours every day in the one dismal but needlessly expensive clinic, then being told they have to get out more and get a job so they can “recover”?

Our public debate on this issue is either non existent, or even back to the shock-horror stuff of the Reefer Madness days. But these health problems have not gone away.

Vern Hughes, National Campaign for Consumer-Centred Health Care
The political debate about health care and health reform in Australia is appalling. It is dominated by industry interests, with political parties championing their preferred industry groups (the Coalition backs private sector providers and insurers, Labor backs public sector providers and their workforce unions).

Consumers are absent, not backed by either side.

The media reports the contest between public and private providers, and reproduces the exclusion of consumers and consumer interests from the public arena.

Will the eight month 2013 election campaign be any different?

The short answer is no, unless there is a concerted effort by citizens and consumer organizations to break the duopoly of industry interests that have a stranglehold over the public discussion. This is not easy, because the industry duopoly is buttressed by the political party duopoly, and consumer and community interests are outsiders, external to this deep-seated binary structure.

But breaking this structure is essential for health reform. Three things should be pushed throughout 2013 in trying to shift media reporting on health care away from captivity to industry interests:

First, journalists should be encouraged to probe and report on the private and public sector industry interests that lie behind the various health industry interventions in this year’s campaign.

Health insurers have financial interests in subsidies and rebates that are unrelated to health outcomes. Quantify them.

Medicare Locals have financial and professional interests in the preservation of Medicare Locals, which are structurally disconnected from health outcomes. Quantify the numbers and absence of correlation with health outcomes.

Medical specialists ride a gravy train through public hospitals, milking duplications in function. Quantify it.

Bureaucrats, not consumers, are the primary beneficiaries from hospital networks, primary care partnerships and service coordination alliances. Quantify the bureaucratization and probe the absence on impact on the consumer experience of care.

Second, investigate and report on the funding of health industry peak bodies. Question why taxpayers money props up professional associations of medical and allied health specialists, and industry lobby groups.  When a Communications Manager for a health industry peak (private or public sector) holds a press conference, ask them if their position is funded by health consumers (taxpayers) and why.

Third, treat hospitals as one part of the health system, and a minor part at that. The main business of health care happens at home and in communities. Examine the world-wide trend towards individualized funding and self-directed services in disability, aged care and mental health so that consumers in these situations can self-manage their support at home and in communities.

Then ask why all industry peaks (private and public) are dragging their feet on introducing individualized care packages in chronic illness, maternity care, palliative care, drug and alcohol rehabilitation and mental health.”

Dr Sue Page, GP, academic, and rural health advocate, NSW
Please understand that hospital wait times are not a federal issue so please ignore calls from “Prof Whatever” from “BigCityTeachingHospital” who wants to talk about the usual orthopaedics, ophthalmology, Emergency Dept and overall “bed block”, otherwise known as inefficient use of resources and mismanaged supply & demand.

This election is a chance to look at community based health services which is where 99% of health care takes place each year.

Yes, you will need to cultivate spokespeople outside your comfort zone like physios, dietitions, social workers, pharmacists and, god forbid, GPs.

Try to remember that GPs earned the same HSC and Med school grades, attended the same hospitals as new grads, and didn’t become stupid overnight when they chose to keep doing it all instead of restricting their practice to just one field. Oh, and they don’t all have to be rural so ask around your local area to see what is needed and look at things like private health fund and MBS spend per capita inequities by suburb.

Other ideas for investigations:

• Why are we afraid of capitation? How influenced are we by the UK? Are the reasons different in hospital versus community sector? Why don’t we allocate tax payer resources per capita weighted by SEIFA? What barriers are there within the profession not just within the community and political space? If health care is a right, should doctors be salaried? If so, how much? If we are so afraid of dementia, are orthopaedic surgeons really worth almost 10x more $ than a geriatrician?

• Canada is different to Australia in many ways, but also very similar. Probably a lot more similar than the UK. Both countries have urban centres and large areas with sparse populations. It might be interesting to look at Canadian examples, as profiled here and here.

• Dental Dental Dental! When will the mouth be funded through MBS like the rest of the body? Sure you can exclude the “plastic surgery” equivalents, but please include annual dental checks and basic fillings so people don’t need dentures, crown & bridge work so often

• We may be living longer but we are not happier. Our local community connections seem to have been over-ridden by mass commercialised ones so that instead of a street bonfire with neighbours we have fireworks on the Harbour Bridge with strangers. Maybe we need this: http://www.guardian.co.uk/world/2012/dec/01/bhutan-wealth-happiness-counts

Kim Webber, consultant
I don’t think the media understands the issues enough to do this thorough analysis – look at their knee jerk reaction to hospital beds closing – NOONE has investigated this in the broader context of health costs spiralling out of control and that this is the start.

For number 1 – looking at how policies impact on our most marginalised is a great way to examine policy – e.g.. does it help in closing the gap.  Another thing might be to examine whether the policy is political or is based on evidence.

Professor Lesley Barclay, National Rural Health Alliance
The deficit in rural and remote health funding and the inequity of ‘spend’ on health services
Redressing inequitable health outcomes in health for rural and remote populations and Aboriginal Australians

Christian Smyth, consultant in mental health
Holding the political parties to account on promises to put so called ‘new money’ into health – got instance mental health only reviews 650m of new money out of the 2.2bn budget announcement.

I think there’s a story about the Federal Government getting a win in announcing NDIS, dental, but in choosing NPA to deliver through CoAg they are going down a similar protracted and watered down route to what we’ve seen in mental health ‘reform’.

Can a government be judged on announcements in a spin-heavy 24-hour news cycle any more or should we judge them on programmes delivered and outcomes for consumers?

If so, we would say that despite the 2.2 bn in mental health the overall proportion of the total health expenditure delivering care in mental health has gone down.

Professor Linda Shields, School of Nursing, Midwifery and Nutrition, James Cook University, Townsville
Why don’t journalists ask the nurses? They constitute the largest proportion of the health workforce by a long mile, many are in very senior and influential management positions (including as CEOs of health institutions), they are highly educated, with many on the “floor” with Master’s degrees and some with PhDs – making them educated to a higher level than their medical colleagues), and they have 24 hour interaction with patients. So many journalists go to the doctors and ignore those who make up the bulk of the workforce and therefore have much to contribute.

Dr Peter Arnold, retired GP
I would simply make the point that any comment in 2013 is skirting around the edges of the debate which has been going on since the mid-70s, when Scotton and Deeble thought up a scheme with an accelerator pedal and no brakes (as Deeble has acknowledged – they didn’t think it would be necessary!)

The fundamental issues are unchanged, other than worsening with each year as our population ages and medical technology improves.

1. ‘Universal’ as opposed to ‘selective’ benefits. This has now morphed into the ‘politically correct’ concept ‘middle-class welfare’. At least some pollies are facing up to it.

2. Rationing. Enoch Powell recognised the problem decades ago, when he was UK Minister for Health. But who quotes such a ‘politically incorrect’ figure nowadays? “There is virtually no limit to the amount of health care an individual is capable of absorbing.”

3. Our ageing population – living longer but medicated and handicapped and needing more and more prostheses – knees and hips, not to mention cardiac bits and pieces, plus expensive rehabilitation (the rapidly growing field in health care!).

4. Politicians’ absolute commitment to prolonging the dying process, and their aversion to making death easier and shorter for the dying.

5. Media ‘hype’ about magic bullets and the like, with no realistic reporting on the time-lags and costs, let alone potential for side-effects.

6. Public expectations of ‘ideal’ medical services, with never a mistake, available for every citizen, regardless of where they live, even thousands of km from the nearest specialised health services.

7. Failure to engage with Aboriginal communities about the sorts of health services they need and are culturally willing and physically, socially and economically able to co-operate with.

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Q2. The health sector also has a responsibility and often health organisations’ election statements are driven by narrow interests/perspectives rather than a wider focus on community interests. What practical things can health organisations and leaders do to contribute to a more informed and useful election debate around health? (One possibility, for eg, might be various public interest organisations collaborating on a fact checking website to help the public make sense of competing political/professional claims).

Fiona Armstrong
Great idea! Let’s talk to ARACY and PHAA and AHHA and CHA et al about kicking this off!

Lea McInerney
With your fact checking website idea, maybe categorise topics like this: (a) ample reliable evidence available (b) some evidence, although not definitive, (c) little evidence currently available. This could remove one layer of confusion.

In line with the comment in Q1 on promoting better dialogue and exchange, perhaps some online “think tanks” on complex topics, drawing together people from a range of perspectives to see if they can come up with breakthroughs.

A few ideas for how to seed ideas among people from different backgrounds:
· A story on the value of bringing together diverse thinkers as a precursor to a forum or forums on different topics that might at first glance seem unrelated http://www.insulators.info/articles/ppl.htm (there’s a few versions of this one around).

· A virtual think tent, as in this model http://www.tendaysontheisland.com/2013-program/thinktent. Would have to be well moderated.

· Maybe a debate along the lines of “Can our healthcare problems as a nation be fixed with one big thing or do we need thousands of small things?”

Amanda Lee
i) Being actively involved in developing and supporting forums that foster health stories, debate, and develop opportunity for relationships to better engage and inform journalists about evidence-based health (particularly preventative health) eg Qld Health Media Club http://www.healthmediaclub.com.au/

ii) Running training on evidence based medicine/health (as Bond example- but free!)

Daryl Sadgrove
Fact checking website is a good idea, but it is difficult get drive traffic there. Our organisation is taking a very open, consultative and transparent approach to policy development that is engaging patients and consumer groups all of the way. It might be useful to have access to policies and positions of various organizations to reconcile them?

Ian McAuley
Don’t jump to positions “We want X”. Rather, articulate your principles and show how these translate to practical outcomes.

If people want to advocate for their groups, do so in a way that shows how it might all fit together.  You may need to argue for fundamental program re-structuring.

This point needs some explaining.   We have many intersecting divisions on a 3 D matrix – demographic divisions (child, adolescent, women’s, aboriginal etc) on one axis, conditions (mental health, diabetes, etc) on another axis, and delivery systems (clinics, drugs, hospitals) on yet another axis.   (In fact I have simplified even the demographic division – are Aboriginal adolescents classified as Aboriginals or adolescent?)

This concern stems from my observation of a very effective campaign on mental health over recent years. I am in no position to judge its merits, but any outcome is going to be very sub-optimal if it simply calls for mental health to be fitted into our present program structure.

A very basic question is what should be the primary organisational divisions? Our present divisions – medical, drugs, hospital – are all provider-based. Mental health fits easily only in a program structure based on conditions. Otherwise it intersects clumsily with the present provider –based classifications.

I think that the provider-based structure is dysfunctional, and is responsible for many of the problems in health care, largely because it’s a structure that gives easy access to provider lobbies. A consumer-based structure would be far better, but there is no one model – should it be along illness/condition lines (which would most easily accommodate mental health) or demographic lines?

Tim Senior, GP in Aboriginal health
It would be quite fun to ask health organisations with policy requests which other health organisations support them and which don’t, and why they don’t. What do their members get out of the policy and how will it benefit patients? What evidence is there for this?

I think there is room for a fact checking website. I think it might be possible for Croakey and the Crikey Health and Medical Panel to write and help crowd source fact checking, even using the Crikey Promise Watch section. It would be helpful to look at the health consequences of all policies, as a way of introducing social determinants of health into the campaign.

Andrew McAuliffe, AHHA
Agree with fact checker idea – could be quite revealing

And perhaps an evidence checker as well ie how well do the promises and initiatives actually reflect the policy evidence as opposed to a populist, knee jerk marketable response

Jane Burns
Not sure I understand this one – our goal across the youth and mental health sector is to provide a united voice – through testimonial, survey and a historical perspective on mental health policy in the last 30 years – one of the big issues is the traction that comes post election and then the slippage in delivering on policy promises

Daniel Reeders
Abandon the language of social determinants.  We need to talk about social determinants, but the terminology is deathly.

We need to speak plainly about what happens to voter’s loved ones when health promotion services are slashed.

Jane Isaacs Lowe and colleagues have written a brilliant report for the Robert Wood Johnson Foundation, A New Way to Talk About The Social Determinants of Health.  (PDF link: http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023 )

Here’s how they reword the core concept: “Health starts where we live, learn, work and play.”  It is based on research in America, and it doesn’t apply directly here; reader discretion is advised.  I’d love to see an equivalent project in Australia.

Interestingly, the Foundation used much the same methods political parties use to identify election campaign messages.

Dr Rod MacQueen, addiction medicine physician
First off need to have some agreed principles that define the health sector or a health organisation. There are many lobby groups that appear to be concerned with health but in fact represent at best narrow sectarian interests, and at worst are fronts for industry with an anti-health pro mass consumption agenda.

I think there’s little wonder the public may have trouble deciding who to believe at times. This is not about censoring these groups, but merely making it clear very early on that they do not, for example, believe in the scientific method, transparency, falsifiability and peer review (even with their shortcomings) nor in equity and social justice.

This is made more difficult by governments defunding independent bodies and allowing more research and publication to be generated by these same sectarian interests.

Sadly, our governments do not appear to believe in the scientific method despite occasionally using terms like “evidence based practice”, and it would be useful if the public better understood what the scientific method was, what a hierarchy of evidence was, and how there may not be a simple or even a single answer to complex questions but we may still need to act, reflect upon the data fearlessly, and take the next step.

The NT “intervention” is a case in point, where billions of dollars will be expended but inadequate data collection, spin and preset agendas will ensure that any good which may come out of this effort will be as much by luck as design.

In the end, it will be another expensive waste of time and effort, whereas a scientific, iterative, action learning approach could lead to some better outcomes. Facts are important, and should come before the interpretation and spin.

Yes, health is political, but the politics should come after, not before, the research and the facts. Good websites and even blogs can certainly help. Have a look at David Nutt’s blog on drug policy in the UK. He will not get to set the political agenda, but he does try to put the case using facts, no matter how inconvenient they may be.

Anonymous journalism academic
I am concerned about whether journalists are able to investigate changes detrimental to public services in general and health services in particular So I’m wondering if a crowd-sourcing project could be launched inviting people to write in when they become aware of a government funded service closing down?

Elizabeth Harris, University NSW
The biggest challenge we face from both major parties is the increase in shifting services to the private sector with associated co-payments.

As Medicare becomes cashless and GPs may not bulk bill, many families will face real hardship in paying up front and not being able to get money back for several days.

The idea of contestability for Commonwealth services in areas such as home nursing will not only fragment services but take us back several decades.

A fundamental challenge is to retain a strong publicly funded public health system, this is crucial for any efforts to reduce health inequity.

Sue Page 
Remember that every organisation has a vested interest or they would have no purpose. Take all election statements with a grain of salt and if possible consider them in clusters with their commercial competitors (NGOs compete for grant funds and donations after all, otherwise the Sydney organisations wouldn’t fly people up to the north coast spruiking for donations outside rural shopping centers).

If in doubt, convene small focus groups. In an election year people will fall over themselves for your attention. Make separate meetings with consumer groups like NFF that run their own health portfolios. While industry specific you will soon find the common needs emerge.

Kim Webber 
The million dollar question – where are the independent voices without vested interests?  This should be the broader academic sector but that doesn’t seem to occur.

So I would recommend that they have a panel consisting of such status quo challengers such as Prof Peter Brooks, Prof John Dwyer, Prof Stephen Leeder (Gavin Mooney would have been on the list definitely too).  The people who are not afraid to advocate for the community.

I also wish the media would understand the bias of organisations.  The AMA is interested in public health but is also the union for doctors and that must inform their policy responses (and rightly so, that is their job), but many journalists ignore the bias of organisations and simply repeat the opinions of the professional organisations without considering WHY they are answering in that way – is it for the best interests of the community or the members (often not the same thing).

A backgrounder for the media (hosted by Croakey) and involving these honest brokers would be a good idea so that the commentators understand the issues?

Linda Shields 
Why not ask the consumer (I hate that word for health care but can’t think of a better one) organisations for their opinions on what the election should be focussing.

I can think of the ones about children – the Association for the Wellbeing of Children in Health Care, the various cystic fibrosis organisations – CF Australia, 65 Roses, the various cancer and mental health organisations etc. what about a forum (virtual??- blog??) run by the media to ask ordinary people what they want in their health care.

Also, why not ask those in academia who teach and research health care ethics, who can comment on the role of rationing – the fair use of finite health resources (I know one who you can ask).

Given the release of the Mid-Saffordshire report from the UK which was all about rationing gone wrong, this would be very relevant. In fact, the mid-Staffordshire report would make a very good platform from which journalists could derive a way to interrogate politicians about their health programmes.

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Q3. What about the role of the public service? The public service has largely disengaged from contributing to public debate (for eg James Button describes in his excellent book, Speechless, how senior public servants are now far less likely to provide background briefings to help a more informed media coverage, and Andrew Podger has also written about this). How might the public service and related agencies help contribute to a more informed debate?

Fiona Armstrong
By acting in accordance with their charter and not according to the political goals of the government? How to accomplish this? That’s no doubt harder and harder, but as with many things requires courageous and principled leadership.

Lea McInerney
Invite them to contribute background briefings just like in the old days. When I was a policy consultant in Dept of Health and Human Services, I’d regularly do briefings on current evidence for Ministers.

It was then up to the Ministers’ office staff to either shape the political argument around that evidence, or ignore it if it wasn’t in line with where they wanted to go. I wonder if there might be some public servants who’d be willing to participate in something like this. More enlightened Ministers – from Commonwealth and State governments – might be interested in giving it a go.

Maybe academics who write for The Conversation could “adopt” a few policy officers and healthcare practitioners, interview them on their specialist topic either singly or in discussion and write it up and publish on either The Conversation or Croakey. Would also be interesting to look at the gaps between evidence and practice by having policy officers and healthcare professionals in conversation together.

Amanda Lee
Difficult to see how in the current system where they are often perceived by Ministers/Governments to be political servants rather than providers of frank and fearless advice!

Daryl Sadgrove, Australasian College of Health Service Management
Our organization provides a platform for some of them to have a voice. However I absolutely agree we need many others.

Ian McAuley 
Before the politicians start putting out their platforms, DOHA should write a policy options discussion paper – canvassing all realistic options for funding and provision – with funding options ranging from completely free tax-funded health care through to high levels of compulsory and uninsurable co-payments. No need for detailed costings at this stage – just pros and cons.

I suspect that such a proposal put to DOHA would be considered as madness, but that simply reflects the extent to which the public service has changed over the years.

It’s not just about politicization, although there has been an informal and formal drift of the public service towards “responsiveness” to executive government over the last 15 years. It’s also about the incapacity of staff in that department to detach themselves from their established assumptions – change must be incremental rather than root and branch, all provider lobbies must be appeased, budgetary costs are the only costs that matter.

Tim Senior, GP in Aboriginal health
I don’t know much about how the public service works – I think there would be room for opening the lid on how the public service contribute to policy. I suspect this will depend on relationships already present between journalists and public servants, but I think it is likely that a febrile election atmosphere will make it hard for public servants to comment without their remarks being taken by either side as a criticism of the other side.

Andrew McAuliffe, AHHA
Hmmmm.  Anonymity?

Jane Burns
Critical contribution – calling organisation like ABS, AIHW to provide policy information – this needs to be simplified and chunk size for people to understand the ramifications. That said the policy debate around critical issues like disability and mental health is complex and difficult to make sense of so we need to look to agencies to work and be more closely aligned with media to ensure a story is told that the voting public can understand

Daniel Reeders
Under ‘related agencies’ we could add any service that depends on public funding. Speaking up about an issue in an election, even on background, is ‘brave’.  I don’t see the reluctance to comment shifting unless it is explicitly authorised by the government of the day.

I would like to see a policy equivalent of the Charter of Budget Honesty (here’s an example from Canada) – perhaps overseen by the Parliamentary Library staff, who already do some sterling work informing the public on politically controversial issues.

It would be fascinating to see something like a Health Policy Ombudsman authorised to give similar answers to political claims-making.

Dr Rod MacQueen, addiction medicine physician
It would be great to see the public service get some teeth back – but who will make it happen? I frequently see middle managers and even ordinary workers self censoring and trying to second guess what the next up the line wants to hear. This ensures that even if a minister or adviser wanted to make a difference and wanted to look at the data, they would be so surrounded by predigested, pre interpreted factoids that they may not be able to discern fact from fiction anyway.

The way that concerned managers help the debate today is probably by leaking information and reports, which is fraught with danger (and how tragic to say this of a modern, democratic country!).

Perhaps public servants need to call their managers’ bluff when they are told they cannot talk to this person or issue that press release, and ask what will happen. But there are enough examples of what does happen to quite rightly make people pretty wary.

Maybe a Ghandi like act of mass civil disobedience is the only way to get the ball rolling? Whatever happened to the great Australian bullshit detector? Maybe the arguments and issues today are too complex or subtle for many people to follow, but I think there is something else going on, a willingness to be deceived along with an anxiety about standing up and saying “this is nonsense”.

Sue Page
Nobody speaks “the truth, the whole truth, and nothing but the truth”. That’s why we make them swear that they will for a specific occasion like in court. Be more forgiving of small errors, don’t make people look like idiots and they will  be more willing to talk to you. You are seeking information and ideas, you are a communication industry.

Kim Webber
Not possible in the current culture of politicisation of the independence of the public service.

Lesley Barclay
Great idea but perhaps too aspirational – enter into debate with people like me that is reported and led by journalists that is designed to produce informed debate and move towards solutions – yes – probably has to occur with politicians and parties but would be great if they participated

Linda Shields
Queensland Health employees who broach the code of conduct which proscribes any discussion or debate about anything that is going on in Q Health are in danger of losing their jobs (or redundancy packages at present). You should ask Beth Mohle from Queensland Nurses’ Union to comment on this. It is alive and well at present!

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Q4. What are the broad criteria by which the political parties’ policies should be judged for their impact upon health? And for their health policies?

Fiona Armstrong  
Whether they are developed in line with the principles of:
Equity
Effectiveness
Socially just
Improved access to multidisciplinary primary health care
Consistent with health needs of the community (ie vary according to specific communities)
Citizen engagement

Whether they will reduce demand on health service because they will reduce the development and progression of illnesses; will they protect and promote health by responding effectively to major health threats eg climate change; will they improve health system performance + health workforce shortages + health workforce morale + health system sustainability + health budget pressures?

Lea McInerney
Something about the parties wising up to and taking on big interests (like Roxon did with big tobacco, and like could be done more with the big food and drink companies, pharmas etc). Stop prevaricating on policies where the evidence is clear and where the main obstacle is companies defending their profits at the cost of the wellbeing of many citizens. (I fear this sounds idealistic – it shouldn’t be that way.)

Maybe there should be lobbying to all three parties to commit to allocating some proportion of funding to social determinants and social inclusion efforts. Could aim for a certain percentage.

Judge according to the principles underlying each party’s policies that align with social determinants of health. And more radically, in the spirit of the Act of Recognition, and the bipartisanship from the Government and Opposition, what about using the Aboriginal definition of health as per Tim Senior’s article on Croakey:

“Health is… not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community. It is a whole of life view and includes the cyclical concept of life-death-life.”

Amanda Lee
Focus on health issues which are:
prevalent at population level; are equitable; evidence-informed; cost-effective- ie willing to work though policy and regulation to improve physical and social environments which  make it easier for all Australians to be healthy.

Daryl Sadgrove 
Long term view, improving productivity, creating efficiencies, reducing waste, reforming the workforce, shifting to prevention/community care, investing in mental health and aged care, less things that ping, better and fairer access, more culturally appropriate care for ATSI’s, less focus on EDs, bigger investment on management, leadership and governance.

Ian McAuley
Economic efficiency, technical efficiency, equity, administrative simplicity, closing of opportunities for rent-seekers.

Tim Senior
The most important thing for me will be about how policies affect those most vulnerable in society. What will address health inequalities, and how will this be done.

Andrew McAuliffe, AHHA
Difficult to evaluate when there is little available to assess.  Coalition’s agenda is elusive.
Is there any evidence of considering health in policies outside the health portfolio?
Any evidence of a systems approach to deal with the social determinants of health rather than just how many more doctors and nurses and hospital beds they will buy

Jane Burns
This is a book – improved health outcomes as evidenced by national stats – I.e. Suicide rates, depression rates, drug and alcohol etc, quality of life across populations, disparities in health care – I.e. Homeless, indigenous, people living with a disability, carers, unemployed, young people

Daniel Reeders
I know this is desperately old fashioned and idealist, but justice-as-fairness is my go-to yardstick every time.  It’s hard to judge the likely future impact of a promise.  It’s valid to ask ‘who is this going to benefit?’

All that middle-class welfare spending in the late Nineties and early Noughties, on that view, was pretty obviously about buying votes in key constituencies and did nothing for the most disadvantaged.

At the same time, I’ve been reading Jonathan Haidt’s new book on political morality, The Righteous Mind, and he points to a fairly big difference between liberals and conservatives on how they view ‘fairness’.

So we’re not just judging policies in terms of their impact, we’re also having the conversation about what kind of impact matters — be it ‘a fair go for people doing it tough’, or ‘you contribute more, so policy should reflect your needs’.

Both Rawls and Marmot have attempted to come up with principles that bridge these two versions of fairness. Rawls’ “Difference Principle” allows inequalities to the extent they benefit the worst-off first — a ‘trickle-up’ diffusion of advantage.

The Marmot review has its ‘proportionate universalism’, where everyone gets something, but in proportion to the intensity of their disadvantage.

Dr Rod MacQueen, addiction medicine physician
Consistency with the principles that are agreed to underpin a good health system, as above. At the moment, we often seem to be in an ethics free, principles free state, wary of or afraid to talk about the social determinants of health and the problems with the consumer sovereignty approach (with its inevitable flip side, anything that goes wrong is all your own fault) for example.

We must look at outcomes, and bang for the buck. Politicians seem to like to talk dollars, and be photographed in front of buildings, helicopters, and other toys. But an effective health system is a good deal less concrete than that, and there remains this troublesome concept of efficient use of resources. Should our hospital system be doing more laparoscopic banding for all overweight people, at a cost of billions, or supporting a good public health approach that may have to take on entrenched interests but achieve much more health gain for far less dollars?

In my field, should we send a drug user to jail, for $85 000 a year, so he can get hepatitis C and lose his job and social connections, or treat the drug issue clinically for perhaps $8 000 a year and keep him in a job paying tax? For some, I think there is no contest –  jails are big solid things with lots of photo opportunities and walls for plaques, and they look like our government is being tough.

Sadly they are just a hole into which money is poured when it comes to addressing drug use problems, and taxpayers should be asking why our state keeps on with this inefficient approach. What is the return on investment, the bang for the buck?  In the end, we need to look at outcomes, not just the money spent, especially when many preventive interventions are much better value for money that what we currently do.

Elizabeth Harris
Indicators:

  • level of commitment Medicare/PBS
  • commitment to growth of private/public partnerships or not without affordability considered
  • extent of contestability of service funding without consideration of impact on fragmentation of health system
  • commitment for policies to undergo health impact assessment.

Sue Page
Did you talk about your ideas? It is unlikely that your party has the monopoly on health smarts and holding things too tight until they are announced means you miss out on constructive feedback. Yes organisations are self-interested, but clinicians do know their stuff which is why our healthcare is better and cheaper than most other countries. Ask! And please resist the urge to fund more research until we have implemented some of what we already have: yet another multi-million-dollar NHMRC grant to a University for an Aboriginal smoking cessation project won’t help as much as putting a smoking-focussed AHW into each AMS for instance.

Kim Webber
We all know that we need to address health expenditure by investing immediately in primary health care and reducing hospitalisations in the medium term.  How will they manage the parties manage this when there is such a knee jerk reaction from the media when even one hospital bed closes?  Are they thinking about the long term?

Lesley Barclay
Equitable services and outcomes for all Australians
Systems improvement which we have begun to see over this triennium eg our ML for example and ABF; reform of areas that do not work; better shared goals objectives and collaborations between states and commonwealth; really working with the Maternity services action plan- need it in other areas such as Aboriginal health, rural and remote health

Linda Shields
How do they believe fair distribution of finite health dollars should occur? How do they work out who misses out? What is fair to ask people to pay for?  What sort of commitment do they make to the philosophy of a safety net? Should Australia go to a) an American model – if you can’t pay for it, you can’t have it, or b) the UK model – everyone has a right to highly technological, effective heath care which is free at point of delivery? While this would go down party lines, it would be an indicator of where the pollie sits on health distribution.

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Q5. I am keen to run some series at Croakey in the run up to the election, broadly grouped around particular themes. Do you have any suggestions for what these series could cover?  

Fiona Armstrong 
How will the govt/opp/other parties act to protect health from climate change? Meet its commitment to the international community to protect and promote global health?

Amanda Lee
A series on prevention would be great.

Daryl Sadgrove 
I will just suggest one (with a vested interest), leadership and management for improvement

Ian McAuley
Principles.
If there are themes such as mental health, there should be some consideration of the structural issues referred to in (2). In fact, structure itself may be a useful theme.

Tim Senior
Obviously, I’d say Aboriginal and Torres Strait Islander Health, but I’d also add health inequalities and climate and health. I don’t think they’ll get coverage anywhere else.

Andrew McAuliffe, AHHA
Response to Social Determinants of Health – trigger could be the report from Senate committee due in March?

Oral Health – will a Coalition Govt wind back the legislation introducing dental services for children into Medicare as on 1 Jan 2014

Primary Health – Opposition plans for Medicare Local structure/ approach.

Dr Rod MacQueen, addiction medicine physician
Well, I would have to suggest drug law reform, wouldn’t I! Some of David Nutt’s blogs are very relevant to our Australian situation, I think, plus we have the Australia21 team and many others. Let’s not, please, have another lawn order race to the bottom.

Kim Webber
What is important to consumers (Consumers Health Forum could help here)
Is the community health literate enough about the health system to engage in the debate fully (I think not, most people do not understand the dire future of our health system under the current model and how it will gobble up all of the budgets soon).
Hospitals in the future – what will they look like and how will they operate?

Linda Shields
How a highly educated, satisfied (with their working conditions and place) nursing workforce has been demonstrated in very large epidemiological studies to reduce the number of patient deaths, near-misses and critical incidents in health services. Lots of very good evidence around this.

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Q6. Do you know of any useful examples from around the world, re innovative, community-focused election coverage of health?

Ian McAuley
Perhaps we can draw on Australian models of successful change in other policy arenas – White Australia to multiculturalism, protection to free trade. We may be able to learn from these successes.  One point is that they didn’t occur over seven months.

Tim Senior
The only ones I’ve come across are websites like “They Work for You” in the UK, which reports on speeches, attendance and votes by MPs (and I think there is a similar site in the UK. There have also been sites that allow users to upload examples of local election leaflets that may be misleading or breach electoral regulations. This could be adapted to have local health issues highlighted – much of this will be about hospitals staying open, I suspect, but there may be more happening that we discover if we go looking.

Jane Burns
I can’t remember if it provided examples of innovation or community focused election coverage but Haynes Johnson’s book, The System, was probably the most insightful piece of journalism I’ve seen relating to health policy and the power (and undoing) of community driven reform – it clearly capture the power brokers, that a good idea is often not good enough and the politics that come to play when pushing for system reform

Dr Rod MacQueen, addiction medicine physician
I wish I did. How did Portugal ever get drug decriminalisation up and going, or conservative old Switzerland get injecting rooms AND a heroin program.

We think we are a pretty liberal, “fair go”, with it mob here in Australia, but in the last 10-20 years or so we have become intensely punitive and reactionary across many domains.

How did we get to the factories producing mental illness scenario we have with refugees today, for example? I hope there are some good examples to share though – I believe the internet can and should be a great tool to promote transparency and the sharing of good information – and helping people to discern what is reliable and what is not.

 

 

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  • 1
    Raymond Bange
    Posted August 6, 2013 at 9:39 am | Permalink

    An excellent collation of policy issues and proposals for study and potential change.

    Give them their due – the government of the day has addressed the need for change in a number of ways despite incredible myopia and opposition at times, vested interests and financial pressures from the knock-on impact of externalities.

    Through their support for review, establishment of agencies like Health Workforce Australia and other positive policy moves such as disability care the government has opened up the debate and initiated change to a greater extent than many appreciate.

    The challenge will be to implement some of the proposals already being explored and to break down the existing barriers that inhibit change and innovation.

    One matter I have observed in my association with the paramedic health workforce is the extent to which there remain silos of interest and the gulf that often exists between primary care and later stage care.

    Paramedics constantly work with people in everyday circumstances including those affected by minor ailments, or more serious cases involving drugs and mental conditions, cardiac events and trauma. Yet the critical healthcare in the transition from everyday life to definitive care is often forgotten.

    Healthcare begins with the patient and not at the hospital or clinic door, and the funding and integration of paramedic services and emergency care as part of an holistic and systemic approach to healthcare is rarely mentioned.

    That’s probably the critical issue – the need to consider healthcare as a system with a focus on patient outcomes and community benefit applied across a bewildering array of settings and inequities that have developed over many years.

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