• A terrific piece bringing some much-needed perspective to discussions about mental illness, especially in the wake of recent murders. By Dr Tanya Ahmed, a registrar in psychiatry and a principal of the health and communications consultancy RaggAhmed.

• More than a million premature deaths across 30 OECD countries could be prevented each year if income inequality was reduced. That’s the best guess of a meta-analysis of studies involving around 60 million people, reported in the BMJ. The authors note that there are many caveats to their findings, including a lack of evidence from developing countries, but say their results have “potentially important policy implications for population health”. Meanwhile, I’m heartened to read that a fellow Crikey blogger is also putting inequality on the public agenda.

• When the law meets public health – Simon Chapman, professor of public health at the University of Sydney, considers the implications of a recent High Court judgment. It dismissed a duty of care negligence claim against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.

• Investigating the ties between drug companies and doctors – A group of researchers from Australia, Canada and the US have done an indepth analysis of disclosures of pharmaceutical sponsorship of gifts and educational events, as has been required of Medicines Australia members since 2007. They conclude that the disclosure does not go far enough and also give some interesting examples of how companies are wooing doctors. Novartis, for example paid flights, accommodation, food, beverages, and conference registration fees for six ophthalmologists to attend a two-day conference in Spain, at a cost of AUD$10,993 per person. For those who follow this field, it will come as no surprise that the researchers include Ray Moynihan, Lisa Bero and David Henry. The other authors are Jane Robertson and Emily Walkom from the University of Newcastle.

He writes:

“The decision by the Preventative Health Taskforce to start with the soft policies is clearly a political one.

An evidence-based decision would have looked at the track record of self-regulation of food, alcohol and tobacco industries and seen that they serve the industries and not the public.

The Taskforce report is a major win for the food industry which is now globally in ascendancy in the policy tug-of-war over hard policies to reduce obesity.

Even with a Labor Government and a sympathetic minister, we end up with a set of soft options which promise to get harder over time but in reality are at high risk of staying soft.

The option to convert self regulation for junk marketing to children into statutory regulations is 2 elections away – that leaves a lot of time for industry lobbying and PR for the status quo.

The proposed voluntary front-of-pack labelling option has no planned track into regulations and the issue of taxing junk food is still recommended for investigation only.

The monitoring systems for keeping the industry on track and judging the ‘effectiveness’ of these voluntary schemes is not well specified.

The government is not responding to the report until next year and these monitoring systems may not be sorted out for another year or two – is that when the 4 year clock on industry action starts ticking?  The targets that have been set will never be met at that rate.

It was interesting how the physical activity options were always placed above the healthy eating options and that eating more (of the good foods of course) was always placed ahead of eating less (in fact, the eating less was not even present in earlier drafts).

In reality, to make a difference the order of importance needs to be reversed in both instances.  The hands of the ‘Hollow Men’ were clearly evident.

The Australian Communications and Media Authority report was just a joke.  After 2 years of consultations, deliberations and delays, they parroted the food industry’s flat earth statement that marketing of junk foods to children is not a contributor to obesity and a code that was essentially ‘business-as-usual’ apart from a ban on some cartoon characters for about an hour a day of children’s programming.

No wonder they were so ashamed of it they tried to release it under the shadow of the Taskforce report in the hope that it would not be noticed.

All the recommendations in the Taskforce Report are very positive and if the government enacts them all we will be well on the way to making major inroads into reducing obesity.

However, the same can be said of the 1997 NHMRC report ‘Acting on Australia’s Weight’ or the National Obesity Taskforce report ‘Healthy Weight 2008.’

The fact that neither of these were anywhere near implemented means we have to remain very guarded about the eventual impact of all the efforts of the Preventative Health Taskforce while we have a government so prone to being dictated to by big business.”

But probably not for the reasons it would like.

Professor Simon Chapman (a regular Crikey/Croakey contributor) is in the Sydney Morning Herald, calling it: ”classic fox-in-charge-of the-chicken-coop stuff” – and he’s also online at ABC here.  And the Public Health Association’s president Professor Mike Daube has just put out a statement questioning the credibility and independence of the organisation.

Their comments follow this recent Crikey piece, from the University of Queensland’s Wayne Hall, raising concerns about a warning letter that DrinkWise sent earlier this year to researchers who raised concerns about the organisation’s independence. Will another such letter be fired off to Chapman, Daube and any others who raise concerns about the latest campaign?

Meanwhile, Wayne Hall’s piece appears to have prompted a Crikey reader (who has chosen to remain anonymous) to send in a copy of the letter that DrinkWise chair, Trish Worth, sent to some researchers. It follows below:

Thursday 28 May, 2009

Dear

ABN 46 112 783 114

DrinkWise Australia Ltd    Tel: 61 3 99354700

Level 1, 34 Queen Street    Fax: 61 3 99354777

Melbourne VIC 3000    www.drinkwise.com.au

I‘m  writing  to you in  regard to the Peter  Miller  et al  letter  published  in  the May  11
online edition of the Medical  Journal of Australia for which you were a signatory.

I was very disappointed  in  this  letter  with  its  incorrect  claims  and do hope that  you saw my response in the May 25 edition of the journal.   I have attached  a copy for your information.

Given  that facts  in the Miller  letter  are wrong and lack supporting  evidence,  I hope you will  understand  that  some of my Board  members feel  they have been defamed.    I am also  concerned about the letter’s  impact  on the highly  regarded academics  and leading universities  who have  worked in  partnership  with  DrinkWise  on seminal  research in alcohol  reform  over the past three and a half  years.  Their  work has been conducted in an ethical  and robust manner.

I trust that  this  information  is  of  assistance  to you and that  you re-consider  your stance in  the light  of the full facts.    Indeed, if you would  like  to discuss  the matter or have a detailed  briefing  on DrinkWise’s  activities,  please  feel  free  to contact me on my mobile – (blacked out by Croakey).

Yours sincerely

The Hon. Trish Worth
Chair
DrinkWise Australia

She’s now come back to the discussion with some more points to make. She writes:

“We would be outraged if the airline industry determined aircraft safety standards by a telephone poll of the general public.  We rightly expect that these standards are based on evidence that they will result in safer plane travel.

However, when it comes to public health, we often seem happy to accept consumer surveys and opinion polls as evidence to support the implementation of a proposed policy.

For example, the Victorian Health Promotion Foundation (VicHealth) recently claimed that Victorians supported the introduction of labels detailing health information on alcohol products, based on research commissioned by them and conducted by The Social Research Centre.

The research involved a state-wide telephone survey of approximately 1500 Victorians who were asked a range of questions, including whether they supported labels on alcoholic beverage containers.  The study found (among other things) that 85 per cent of respondents supported labels which included recommended daily guidelines for low risk alcohol consumption; 89 per cent supported a warning message advising that exceeding the recommended guidelines may be harmful; and 91 per cent supported health warnings for specific groups – for example, pregnant women, young people.

When releasing the report, in a media statement titled “Victorians call for health labelling on alcohol products”, VicHealth Chief Executive Officer Todd Harper said  “The message is clear. Victorians support mandatory consumer information labels on all alcohol products, so they can make more informed decisions about their drinking.”

Even allowing for a little media latitude, this statement is misleading.

Asking consumers whether or not they support alcohol health warnings, in the absence of providing any alternative options for the use of the resources involved, is meaningless as a basis for policy making.  When it comes to health, consumers generally want more of everything – as long as there are no costs attached.

If they had asked the same group of consumers if they would support building a new state-of-the-art hospital in their local neighbourhood, most would probably have said yes.  That doesn’t mean that Victorians are calling for an additional 500 new hospitals in their state.

Policy making is about balancing multiple needs and determining the best use for limited resources. If it costs the alcohol industry (say) $10 million to put health information on their products then this is $10 million which cannot be spent elsewhere, for example on alternative alcohol harm-reduction programs, additional health services, other social welfare programs or simply provided to consumers directly.

Whether or not consumers (or the government) would bear the cost of these strategies directly is irrelevant. The opportunity cost (the cost of the nest best policy alternative) of implementing alcohol health warnings is the same, regardless of where the dollars come from.

Therefore, in order to accurately assess whether consumers support health warnings above other alcohol harm reduction strategies, they should be asked whether they would prefer to have health warnings included on their beverages OR targeted youth alcohol programs OR additional law enforcement efforts OR more treatment services OR another alternative strategy.  To find out whether alcohol harm-reduction programs are a priority for consumers they need to be asked whether they would prefer the $10m to be spent on alcohol programs or allocated elsewhere.  Of course, if consumers’ views can be informed by evidence of the effectiveness of different strategies, the results of such a survey would be even more useful.

The VicHealth research does provide useful information about the content and tone of health messages that consumers would prefer, if such information is going to be included on alcohol product labels.  However, this is a separate issue from whether or not they support a mandatory alcohol health warning policy overall.

Alcohol misuse is a serious health and social problem. Getting alcohol harm-reduction policies right can reduce the health, social and economic costs that it imposes on our community, not to mention save lives. Reaching agreement on what does (and does not) constitute evidence to support competing policies is a great place to start.”

Meanwhile, health policy analyst Jennifer Doggett has been humming some old tunes, and contemplating Todd Harper’s recent Croakey post calling for health warnings on alcohol labels. She writes:

“Elvis Presley almost certainty wasn’t thinking about public health when he sang his 1968 hit ‘A little less conversation, a little more action”.  However, the song has a message for Health Minister, Nicola Roxon, reported to be contemplating the introduction of alcohol health warnings, as recommended by the Preventive Health Taskforce.

Todd Harper, CEO of VicHealth, makes a case for more conversation about alcohol health warnings.  He argues that we need to talk more to drinkers about how we communicate alcohol and health information to them.

Certainly such conversations have their place.  Conversations can help governments considering the introduction of health warnings to gauge the response from the media, public health groups and the general community.  This is an important part of public health policy development.

However, what conversations won’t tell us is whether or not alcohol health warnings actually work.  For this we need data – independent, robust, replicable and measurable data. No amount of consultation with consumers, engagement with public health groups or advice from experts can substitute for this.

From the limited available evidence, the case for alcohol health warnings isn’t strong.   A comprehensive review of research into the impact of alcohol warning labels was undertaken by Professor Tim Stockwell (Director of Australia’s National Drug Research Institute) for the Canadian Government in 2005.  After examining a large number of studies he concluded that “….there is little or no measurable change in drinking behaviour and related harms as a result of the introduction of alcohol warning labels”.

In fact, there is a danger that warning labels could have unintended negative effects on those most at risk of alcohol-related harms. This is because they could increase the attractiveness of alcohol consumption among people seeking to undertake risky behaviours. In 2000 when the Australian and New Zealand Food Authority looked at this issue, it found that “there is considerable scientific evidence that warnings statements may result in an increase in the undesirable behaviour in ‘at risk’ groups.”

Of course, all this research has limitations.  In particular, the fact that most of the studies in this area have been conducted outside Australia makes it difficult to assess their relevance to the current debate.   Given these constraints and the lack of robust data from the Australian context, those advising the government on alcohol health warnings can only guess at their impact.

If we want more than guesswork from our public health policies we need to demand that they are based on evidence rather than opinion.  In the case of alcohol health warnings, this means we need a properly conducted, Australian-based trial.

Unlike many public health interventions, alcohol warning labels are a good candidate for a policy trial.  It’s hard to randomise exposure to quarantine laws or food safety standards, but relatively easy to control exposure to alcohol health warnings.

For example, we could take two cities of comparable size, say Sydney and Melbourne or Brisbane and Perth, introduce alcohol warning labels in one of them and not the other.   After a decent interval – 12 months at a minimum – we could measure whether there has been a change in the level or nature of alcohol-related harms in each city.  This would involve selecting a few measurable indicators, for example, alcohol-related admissions to hospital emergency departments and motor vehicle accidents involving alcohol, and measuring them both before and after the health warnings are introduced.  The impact on specific at-risk groups, such as young people, should also be measured to determine whether they respond differently to health warnings, compared with the general population.

Such a trial would not be perfect but it would give us more information about the impact of alcohol health warnings than we would get from any number of consumer focus groups, conducted around a table and a bowl of Minties.

If the Government is serious about promoting evidenced-based health policy, it should fund such a trial on alcohol health warnings.  After the trial’s completion, the data could be used by government, health groups and other interested parties to argue for or against their introduction.   Either way, this would be a conversation worth having.”

•Jennifer Doggett has previously worked on a youth alcohol campaign, partly funded by the alcohol industry

The CEO of VicHealth, Todd Harper, argues that one area where the community would support immediate action is labelling that clearly spells out the health issues. He writes:

“It’s the fourth biggest global cause of death and injury.  Use of this product is associated with an increased risk of several cancers.  It causes $3.5 billion in lost productivity in Australia each year and is involved in more than 60 per cent of crimes investigated by police.  A large proportion of the harmful use of this product is borne by others – not just those that use it.

What do you think would be an appropriate warning to consumers about such a product?

This product is alcohol, and it is not required to carry health information aside from the quantity within its container. There is nothing about the product’s potential to cause injury, brain damage, cancer or impact on pregnancy.  Unlike food, it carries no information about kilojoule content.

We provide consumers with information on the harms associated with fumes from spray cans; that some foods contain traces of nuts; that excessive consumption of some mints has a laxative effect, and that some products cause drowsiness.

Alcohol however has no such health information.

Recent research by the Social Research Centre for VicHealth identified that consumers do want more information about alcohol – including the health effects, safer consumption and the nutritional information of alcohol.

The research found:

Label content                                    % support
___________________________________________________________________

Recommended daily guidelines for low risk alcohol consumption        85%

Advice that exceeding daily guidelines may be harmful            89%

Targeted advice for specific groups                        91%

Nutritional information (cal/kJ, alcohol, protein, fat, carbohydrates per
container and per 100ml)                            76%

List of ingredients                                86%

Number of standard drinks (displayed in a uniform way)            95%

Alcohol content (alcohol by volume)                        97%

Labels can provide information that is commonplace with many other products. Consumers deserve to know more, and this latest research shows that they want to know more.

More than 80 per cent of Australians drink and 1.4 million consume alcohol on a daily basis – that’s a significant number of people who are calling for more information so they can make more informed choices about alcohol consumption.

The alcohol industry spends more than $119 million a year reminding customers of the benefits of alcohol – its taste, how it is great for making friends, having fun, and a ‘must have’ when watching sport, or at events with family or friends. But none of this provides consumers with perhaps the most important piece of information – how alcohol affects your health.

Consumer information on alcohol labelling should be a component of a broad strategy to reduce alcohol harms in our community. Labelling does provide information to consumers at two vital points – at the point of purchase and at the point of consumption.  In this way, labels can be a timely reminder to consumers of other health messages they may have heard at another point in time such as televised education campaigns.

Clearly we’re at the beginning of a journey. Much more discussion needs to be had with drinkers about the way the messages are communicated and different methods need to be used to target specific age groups and cultural diversities.

We’ve made a start and what this latest study suggests is that a number of broad principles should be considered when developing labels. These include:

•    Simple, clear and direct language;
•    Provide new information and evidence wherever possible;
•    Provide factual information;
•    Aim to educate and inform, rather than be authoritarian or prescriptive of behaviour.

It’s a useful conversation to start.”

It’s time Mr Dutton, his staff, colleagues – and anyone else who happens to be poorly informed on this issue – became acquainted with an excellent initiative of the Centers for Disease Control in the US, the Community Guide to Preventive Services, which publishes recommendations based on rigorous systematic reviews of various public health interventions.

Even a quick perusal of the Guide’s website reveals that interventions to increase tobacco prices – including increasing tobacco taxes – have been proven to be an effective way of stopping adolescents and young adults from taking up the habit, reducing cigarette consumption, and increasing the number of smokers who quit.

The Guide says that such tax increases have also been shown to be more effective and have a greater public health impact when combined with other comprehensive tobacco control programs that reduce the prevalence of smoking through evidence-based policy tools. Increasing the price of cigarettes through tax increases can also diminish socioeconomic smoking disparities because low income groups are more responsive to price increases.

You can read more here.

The guide has also recently investigated the impact of increasing alcohol tax – another issue about which we hear a lot of poorly informed commentary.

It recommends increasing the unit price of alcohol by raising taxes, based on strong evidence of effectiveness for reducing excessive alcohol consumption and related harms, including such as alcohol-impaired driving, motor vehicle crashes and fatalities, and deaths from cirrhosis of the liver.

The effect of price on alcohol consumption is expressed as “price elasticity” or the expected percentage change in alcohol consumption when the price is increased by 1%.

Estimated price elasticities for different types of alcohol are:

* Beer consumption: -0.50, which means beer consumption would be expected to decrease 5% for every 10% increase in price.
* Wine consumption: -0.64, which means wine consumption would be expected to decrease 6.4% for every 10% increase in price.
* Spirits consumption: -0.79, which means spirits consumption would be expected to decrease 7.9% for every 10% increase in price.
* Total alcohol (ethanol) consumption: -0.77, which means total alcohol consumption would be expected to decrease 7.7% for every 10% increase in price.

Just because the Guide does not recommend a public health intervention does not mean that it doesn’t work – it may, for example, simply mean that the necessary and appropriate studies just haven’t been done. But when the Guide does recommend an intervention, it’s pretty safe to assume that there is reliable evidence to show it works and is worthwhile doing.

The question I’m left wondering is: when politicians and others make ill-informed statements, should the media just report them straight up and down? It doesn’t take too much journalistic effort or investigation to check out whether claims such as Dutton’s are based on evidence or hot air.

The beauty of cyberspace is that we are all only a few clicks away from an ever-increasing array of initiatives that aim to share the evidence about what works in both health and social policy.

Mike Daube, Professor of Health Policy and Director, Public Health Advocacy Institute of WA, Curtin University of Technology, has had a critical look at the evidence, and writes:

A group of academics recently published a letter in the Medical Journal of Australia calling on researchers not to accept funding from the DrinkWise organisation established by the drinks industry.

In this week’s MJA, the chair of DrinkWise, Trish Worth, defends her organisation, suggesting that the letter was “besmirching the good work of DrinkWise and its Directors”.

Ms Worth argues that “DrinkWise Australia is not an industry-dominated body” – claiming that “It has a balanced Board of six members from the alcohol industry and six distinguished community members”, although only five of the latter are currently in place.

A sceptic might argue that for an alcohol education organisation, six out of eleven board members who are drinks industry CEOs provide a strange form of balance.

Ms Worth notes that “In criticising DrinkWise they also attack the reputations of Board members” including Professor Ross Kalucy and Noel Turnbull.  There is no intention to attack their reputations. Professor Kalucy is a very distinguished psychiatrist who has for many years advised the brewers on research. Mr Turnbull is a successful public relations practitioner listed on the DrinkWise website as a Director of Growth Solutions Group whose website in turn lists four wine industry campaigns among its success stories. They undoubtedly bring valuable skills to the DrinkWise Board, but it may be drawing a long bow to describe them as “community representatives”.

Ms Worth argues that “DrinkWise does not advocate for or lobby Government in respect of alcohol taxation policy”, although – as pointed out in the original letter to the MJA – its CEO has recently been quoted in the media as arguing against “fiddling with alcohol tax”.

Ms Worth also claims that “DrinkWise does not advocate for or lobby Government in respect of alcohol taxation policy” because “Alcohol industry leaders advocating or agreeing on matters affecting price could constitute a breach of the Trade Practices Act 1974 (Cwlth)”.  Does this mean that DrinkWise is not free to advocate for policies known to be effective? It certainly does not prevent the drinks industry from lobbying against increases in tax on their products.

Ms Worth also asserts that “DrinkWise Australia…has no associations with any international alcohol or tobacco groups”.  It is difficult to reconcile this claim with DrinkWise’s collaboration with the US drinks industry’s International Center for Alcohol Policies (ICAP), with which DrinkWise has held a joint workshop.

The DrinkWise website quotes a Board member, the CEO of the Australian Hotels Association in Victoria, as claiming that DrinkWise is “a genuinely independent community and industry partnership”.  Another Board member, the President of the Australian Liquor Stores Association, claims that DrinkWise is “a truly independent organisation”.

Some of us might think that an organisation where at least half the Board members are drinks industry CEOs and whose CEO supports the alcohol industry’s opposition to increased taxes is less than “genuinely” and “truly independent”.

I suffered an adverse reaction at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference in Adelaide this week. It happened when one speaker casually referred to “heart sink patients”.

It’s not as if I hadn’t heard the term before. Anyone who regularly reads the medical mags will know that doctors often use this term to refer to patients who make their hearts sink. There are even guides to help doctors deal with heart sink patients.

Sadly, I am not the sort of person who can quickly unpick my reactions on the spot and provide immediate, useful analysis. So I went away and brooded: why do I find this term, and its casual use, so grating?

Here are a few thoughts:

• It’s generally used to refer to patients that doctors regard as “difficult”, whether because of their health problems (think mental health, drug and alcohol, complex or insoluble) or their personalities (think demanding, complaining or – another medical term I detest – “non compliant”).

• Yet these patients are among those most in need of compassion and care that is sensitive to their needs and situations. Framing them as undesirable patients only helps to reinforce the inverse care law so wisely described by Julian Tudor Hart some decades ago. This law holds that “the availability of good medical care tends to vary inversely with the need of the population served”.

When heart sink patients is a term so widely used, it’s not surprising that it is so difficult to recruit doctors and other health professionals to work in demanding but needy areas like mental health, Indigenous health, and the poorer parts of the country/health system.

So here starts my campaign to find another term for “heart sink” patients. “Needy” perhaps, or what about “deserving”?

Would health professionals and services feel more motivated to try to help patients if they thought of them as “deserving” rather than “heart sink” types?

I somehow doubt this little campaign will find wings, but if it makes even one or two people stop and think about the words they use, it will be worth it. Words are so powerful, after all, in influencing how we perceive others and engage with them.

Michael Moore, CEO, Public Health Association of Australia

In the initial budget for this government was a huge effort on hospital waiting lists and $$$ through to the States for improvements at the tertiary level.

I suspect that this time around there will be an emphasis on workforce development (or there should be).  Primary care is regularly in the Minister’s speeches as another possibility.

Among bureaucrats is a fair bit of talk coming out of the Discussion Papers of the Preventative Health Taskforce and the Health and Hospitals Reform Commission about the possibility of a National Body to look after prevention, health promotion, research – perhaps to do the sort of things that are set out in the goals of VicHealth.  Plans for the National Prevention Agency are already on the public record through the COAG papers.

**

Professor Mike Daube, president, Public Health Association

I would hope to see significant changes to the way tobacco and alcohol are taxed.

It’s hard to think of any reason why a government wouldn’t put up tobacco tax. It’s popular – even among smokers if some of the revenue goes back to education and treatment. It’s long overdue – nearly ten years since the last real increase. It’s in line with international trends – Australia is one of the lower tobacco-taxing countries in the OECD. It stops adults and kids from smoking – more than any other single measure. It brings in much-needed revenue. And just as a bonus, it will save lives.

The alcohol tax system has been a mess for many years. The Henry Review is looking at this, but the present Budget would be a great opportunity to start the move towards volumetric taxation, with a special emphasis on the products that are targeted to kids an at-risk drinkers.

Any increase in tobacco or alcohol tax should be accompanied by a significant further allocation to prevention so that it receives more than the current less than 2% of national health spend. We know that there is overwhelming public support for this approach.

**

Professor Peter Brooks, executive dean, health sciences, University of Queensland

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Funding for telehealth consultations; increased tax on alcohol, cigarettes and junk food; increased funding for prevention

Q. What do you expect will be the big health announcements in the budget?

A. Some infrastructure projects, funding for Indigenous health projects – long overdue.

Q. What areas in health do you expect will be the losers in the budget?

A. Hopefully pathology and imaging services, and procedural fees.

***

Health economist Professor Gavin Mooney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. A costed long term strategy for CTG in Aboirginal health. What has been anounced so far is pathetic.
Revamp of Medicare primary care with increase in capitation for GPs and reductions in ffs. Also more targeted payments for prevention services in primary care.
Program (or clinical) budgeting within tertiary hosoitals to control costs and increase efficiency.
Increased spending generally in keeping people out of hospital
Outside the health portfolio – increased and more progressive income taxation; increased corporation taxes; increased spending on housing for the poor; and increase in salaries for the state sector teachers and other boosts to state education.

Q. What do you expect will be the big health announcements in the budget?

A. More money for hospitals but with attempts to tie to performance indicators (but this will not work)  Increase in charges for PBS items.

Q. Who or what areas in health should be the losers in the budget?

A. Private health insurance premium payers who should have their subsidy withdrawn.
Tertiary hospitals.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Community care
***

Mr Robert Wells, Director Menzies Centre for Health Policy, ANU

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A.No further cuts in primary care or prevention.
Some provision to progress the reform process, eg an independent ‘reform commission’.
An attempt to rationalise the private health insurance rebate to get some value for the investment or to reduce outlays for this.

Q. What do you expect will be the big health announcements in the budget?
A. Very few – the timing of the various reports lets them off the hook for this budget.

Q. Who or what areas in health should be the losers in the budget?
A. Private health insurers
Drug companies – more could be done re pricing, esp in the light of the GFC
Pharmacists – either they should be paid less for prescriptions dispensing or do more in primary care
Doctors- there could be some attempt to limit the amount doctors can charge for a service & still claim from Medicare (ie limit the copayment)- courageous stuff but these are hard times & even banking execs are expected to reduce their incomes

Q. Who or what areas in health do you expect will be the losers in the budget?
Probably consumers – there could be savings in the PBS which ultimately will raise prices for consumers
People who need expensive support aids etc to  supplement their medical care are unlikely to see any relief

***

Prue Power, Executive Director, Australian Healthcare & Hospitals Association

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. The single most important outcome in this Budget is the allocation of the remaining $5 billion to the Health Infrastructure Fund.   The initial $5 billion of the promised $10 billion was provided in last year’s Budget and the health sector is relying on receiving the full amount promised to fund essential infrastructure projects.  Australia’s health infrastructure is in desperate need of upgrading and revitalising to ensure that our health system can continue to deliver high quality care to the community.  If this funding is not delivered, Australians can expect our health system to become increasingly less able to maintain high standards of quality and safety and to keep up with new developments in health care internationally.

Other initiatives that AHHA would like to see in this Budget include: increased efforts to engage consumers in the planning and delivery of health care; a national approach to data and benchmarking within the health system to improve quality of care across the sector; a range of health information technology and management projects to support better delivery of health care; national leadership on oral and dental health; and  improved service integration, including adapting the innovative “Map of Medicine” to the Australian context.

Q. What do you expect will be the big health announcements in the budget?

A. AHHA is hopeful that the Government will fully meet its commitment of $10 billion in new funding for the Health Infrastructure Fund.  We also hope that the Government will understand the long term economic benefits of investing in evidence-based health care and will allocate funding to the other proposals outlined above.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If the Government takes a short sighted view in this Budget and does not allocate the promised funding to the Health Infrastructure Fund and other initiatives in order to increase its bottom line, the Australian community will ultimately be the losers.  In particular, the next generation of Australians will suffer the consequences of inheriting a health system that is not equipped to meet the needs of the community and lags behind that of other countries.

**

Health policy expert Dr Yvonne Luxford

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Clear dedicated funds to further the campaign to Close the Gap in Indigenous life expectancy, including funds to address the social determinants of health
The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Funding for school based health literacy programs with regular testing
A scheme to enable salaried GP positions in Superclinics along with salaried allied health workers and salaried public health physicians
Full Commonwealth funding for the Public Health Medicine training program
Funded support for all health professionals to improve their engagement with eHealth
Increase in access and level of funding for students, sole parents, the aged, unemployed and carers.

Q. What do you expect will be the big health announcements in the budget?
A. The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Restructuring of funding for the GP Divisions

Q. Who or what areas in health should be the losers in the budget?
A. Drinkwise and any similar industry controlled body

Q. Who or what areas in health do you expect will be the losers in the budget?
A. I don’t have a good feel on who will miss out this budget.

***

Fran Baum, professor of public health, Flinders University

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. More sustainable long term (10 years) funding for health promotion through a national healthy and sustainable communities project to be led by local government and  local health services – multi-sectoral and community driven
Capital and recurrent funding for multi-disciplinary community health centres with salaried medical and other health professional staff (instead of super clinics) focus on chronic care and health promotion – with local boards of management – supported by training program so these centres can take students from all health disciplines on multi-disciplinary placements
Serious funding for research program on the social determinants of health all aimed at answering question “What creates and sustains health and equity” explicitly not focused on diseases
Scrap private health insurance rebate
Regulate alcohol advertising – i.e. scrap industry self-regulation
Ban fast food advertising

Q. What do you expect will be the big health announcements in the budget?

A. More $$ for hospital waiting lists and treatment of diseases and medical research

Q. Who or what areas in health should be the losers in the budget?
A. Hospital intensive care units
End stage treatment for diseases where there is little hope of recovery and not really in the interests of the patient or society

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Professor Glenn Salkeld, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. I would love to see a national centre for disease prevention and healthy living funded by Treasury and run through the office of PM&C.
I would love to see Education fund a school based program on healthy eating, cooking and physical activity. Get parents involved too.
I would love to see Health and Education get together and come up with real plans for training the next generation of health professionals
in Australia, in our region and in those low and middle income countries that need our help.
I would love to see Sport fund a national insurance scheme which covered the cost of liability and health insurance for all children playing sport.
The cost of club sport is becoming an unnecessary barrier to kids participating in multiple weekend sports.
I would love to see a greater willingness in Health to promote good health – to counter the supply side forces that promote bad health.

Q. What do you expect will be the big health announcements in the budget?

A. Hmmmmm. Given that most of the Health budget is committed to keeping the status quo (to fund recurrent expenditure) I wonder how much
room is left for big announcements in a climate of financial gloom. Any big announcements would have to follow Labor Party commitments
on reform in primary health care, child and maternal services, and the usual technology stuff (like the bionic eye). I’d like to think that
prevention will get a guernsey in the budget but maybe its too early in the life cycle of the Preventative Health Task Force to expect too much
right now.

Q. Who or what areas in health should be the losers in the budget?

A. My son tells me that the TV show ‘The Biggest Loser’ is an essential topic of conversation at school. Overweight and obesity are bound to get
some attention. The real ‘biggest losers’ should be services/procedures/drugs that
provide no gain (health) for a lot of pain (cost).

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Ironically and perhaps sadly I think the losers will be average folk trying to cope with chronic disease, and/or who have a family member
with a disability and/or who live in wrong post code that find access to help, services and support so hard to find. In hard financial times it is so often those who have the least who are asked to sacrifice so much. On this I would be delighted to be proved completely wrong!

**

Health policy analyst Jennifer Doggett

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Whether or not the government allocates the remaining money for the infrastructure fund, as promised, has to be the main health-related issue in this budget.  any other small buckets of money thrown around will be insignificant if they effectively cut $5b from what has been promised for health infrastructure.

Q. What do you expect will be the big health announcements in the budget?

A. No idea – heard the rumours about the Medicare safety-net but not sure how reliable they are. Cutting the safety-net would make sense and probably not alienate much of the government’s core constituency so it’s a fair bet.

Q. Who or what areas in health should be the losers in the budget?

A. As always, stopping inefficient and regressive practice of subsidising PHI through the rebate.  The saved $ could be much better used elsewhere in the health system or simply handed back to consumers.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If they cut the Medicare safety-net, some of the medical specialists will be the losers, particularly obstetricians and those who have the capacity to move their care from the hospital to community setting.

***
Dr Lesley Russell, Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. That there has been no diversion from or  dimunition in the commitments made on health care reform and closing the gap
on Indigenous health. As President Barack Obama has clearly demonstrated, health care reform is an essential part of the armament needed to tackle the impact of the global economic crisis, and we cannot resile from the timely implementation of commitments to our Indigenous peoples.

Q. What do you expect will be the big health announcements in the budget?
A. No big announcements. Expect lots of small program cuts as the ERC goes looking for savings and everything else on hold, pending reports.

Q. Who or what areas in health should be the losers in the budget?
A. It should not be about who loses but about making policy changes that will ensure some areas and programs work more effectively and equitably. Is there the will and the policy grunt to do this?

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Publicly funded community health care

Public health, especially programs to tackle obesity/nutrition/urban environment/physical activity

Transition, step down care for the mentally ill and their carers

And some concern about funding for rural health programs, which have apparently been reviewed by DOHA, but no publicly available report of this review.

Real and realistic efforts to coordinate health care and associated needs (travel, medical aids, oxygen etc) and ease out-of-pocket costs for the chronically ill.
***

Boyd Swinburn, professor of population health, Deakin University
The government should be recouping its lost reserves by significantly increasing the taxes on alcohol, tobacco and junk food with a significant proportion of them allocated for prevention and the promotion of healthy patterns of consumption – as suggested as the top priority in the 2020 forum more than a year ago I think.

**

Dr James Gillespie, Deputy Director, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. Nothing earth shattering. It would be nice if a government waited to see what its inquiries into the system report before making major changes.

Q. What do you expect will be the big health announcements in the budget?
A. Very little. Continue the drift  of risk from government and insurance onto out-of-pocket by fiddling with co-payments to save a bit of money and, less likely, cutting the PHI rebate. More likely they’ll freeze this as it means (technically) no broken promises.

Q. Who or what areas in health should be the losers in the budget?
A. Higher income earners’ rebates.

Q. Who or what areas in health do you expect will be the losers in the budget?
A. Some of the higher cost diagnostic areas – imaging etc…. where there is a fair suspicion that corporate business plans are gaming Medicare.

**

Consumers Health Forum

Our budget wish list: We see these will continue the momentum from the reform process and the 2020 summit with practical, implementable changes that will lead to better health outcomes for consumers.  Funding these items will see Govt rhetoric turned into reality.

• E-health – national electronic health records and e-initiatives to bring equity of health care to rural and remote area
• Implementation of the reform process – particularly in relation to the primary health care strategy, preventative health taskforce and the health and hospitals reform commission.
• Funding to resource consumer representatives to take part in the reform process and other committees that make decisions about health care in Australia.
• National Registration and Accreditation Scheme – including resourcing for the community representatives to have effective input
• Taxes (preferably increased) on alcohol and cigarettes to be channelled directly into health services and prevention/wellness campaigns
• Safety and Quality Commission – to implement the S&Q recommendations, including the hospital reporting

What do we expect?

• Beyond the Swine Flu, we have no confirmed expectations. However, we hope the budget will focus on the above.

What should lose?

• Systems that don’t work for consumers.

What do we expect will lose?

• Given the rumours, we expect that – unfortunately – radiology, pathology and IVF will lose

**

Other comments from sources who did not want to be identified:

Anon 1: “I don’t expect much in the way of new initiatives as the big reform agendas are some way off and hard for the government to make commitments at this point. Maybe the Preventative Health Agency but not an expectation I have. Maybe some increases in taxes on alcohol and tobacco. Mental health ??? I do expect more reforms of disability employment which will continue to improve prospects for those with mental illness. But this is against a very different employment context.
Losers we need to see – I hope we see the end of the safety net and some winding back of the Private Health Insurance – but the latter is unlikely. They will have plenty of other areas of middle and upper class welfare to cut before going to this almost sacred cow. I would like to see changes to Better Access (cut the GP mental health plan rubbish) and curtail the growth in psychologists (the common garden variety who represent the least trained and charging the highest OOP expenses). Like to see much more incentives toward collaborative PHC practice,
Losers I expect – safety net, not much else, maybe PBS will have some further limitations.
I think in health we are waiting for regime change.
Indications are that they will take major reforms from the papers under development to the next election and continue to try and hold the current arrangements up for the time being.
I hope I am wrong.”

Anon 2:
Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Some more MBS and non-MBS money for primary health  care, skewed to low spending areas, but also allowing GPs to be fundholders  for more allied health care for chronic ill people; agreement in principle to  Commonwealth Indigenous health services purchasing organisation; also some  extra for AIHW for regional health information including health status,  spending and services

Q. What do you expect will be the big health announcements in the budget?

A. Not much, essentially a ‘let’s wait on the NHHRC  final report and the COAG working parties’

Q. Who or what areas in health should be the losers in the budget?

A.  Extension of cost-effectiveness application, resulting in higher co-payments for less effective and less important  pharmaceuticals and services (eg drug-inducing stents, in vitro  fertilisation); abolition of the Human Services portfolio and re-allocation of Medicare Australia to the health portfolio and Centrelink to the FACSIA  portfolio; increase in MBS safety nets; changed bond arrangements for  residential aged care; sale of Medibank Private

Q. Who or what areas in health do you expect will be the losers in the budget?

A.    Not much if anything.

***

Anon 3:
“The abolition of  the $6 bn private health insurance subsidy would be a major contribution to  budget savings. This is not a health program. It is a subsidy to financial  intermediaries like Merrill Lynch.  PHI is grossly inefficient (double the cost of  Medicare administration) inequitable and weakens Medicare’s position as the  major purchaser of services. The alleged claims to take pressure off public  hospitals is misplaced. It has just not happened.

The government and the  private health insurance industry claim that the subsidy is only $3.8 b. In  addition to that sum, there is almost another billion dollars in tax concessions for those who take private insurance. Further, government and PHI estimates of the subsidy have been consistently understated. If the  government is prepared to introduce a cap or a means testing of the subsidy,  it would be a useful start.

Be careful about the argument that the minister  and PHI executives use about choice. The principle of a single payer can  promote choice. There is no reason why Medicare or as in the case of  Veterans’ Health, the single public insurer cannot pay money direct to  private hospitals probably through a DRG formula.

Other proposals – for introducing the second stage of increased generic prescribing  for pharmaceuticals and rigorous regulation of radiology and pathology – would all be very welcome.

A major problem with government health policy  is that it is so piecemeal. There is no ‘health system’. There is focus on  the cost of particular services, eg pharmaceuticals, radiology, etc, but  health care in general is not held accountable for what it produces. I  suggest that the Productivity Commission be tasked to advise the government  on ways to improve the efficiency and productivity of the health sector.

For example, there are variations in the pattern of clinical practice right across the country. These variations are never examined and very little  action is taken on them. I would suggest there are very substantial savings  to be made in this area. The variations in the incidence of caesarean  sections across Australia are an example of the sorts of variations that  need addressing.

Over-utilisation is widespread and unchecked. It is also likely that there is under-utilisation by the poor, indigenous and people  living in remote areas.

The government-appointed commission to review health  services has produced a very timid report. There is also an obvious conflict  of interest because of its relationship with the private health insurance  funds. How else could one explain its draft recommendation to fund dental  care through a tax levy which would then be churned through private health  insurance funds? It is just a crazy idea. The rigour and professionalism of  the Productivity Commission is essential if we are to reduce costs and  improve productivity.

One area which I hope the government will address  in the budget is to commence a rationalisation of co-payments.  The co-payments lack logic and  consistency between programs. Australians are much more wealthy than they  were over 30 years ago when Medicare was introduced. Most of us can afford  to pay more. A good co-payments scheme would ensure that individuals take  more responsibility for their health decisions.

If the government wants  to save money in health, it should offer to establish a joint health service commission with any state that will agree.This is the most useful way forward on both  policy and political grounds to resolve the waste and inefficiency of the  Commonwealth/State divide.

The Commonwealth government has pledged  substantial increases in funds to state public hospitals. I am not sure that  it has insisted on increased productivity on the way these funds are spent.  The government had previously highlighted the importance of activity or  episode funding  being made available on the basis of output) rather  than grants to the states to enable them to continue in their inefficient  ways.

If the government wants to get more efficiency in the  health sector and contain escalating costs, it must address some of the  issues mentioned above.”