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.”

Its final report is expected to be released within days but health policy analyst Jennifer Doggett warns that one important issue – the impact of out-of-pocket payments – doesn’t seem to be on the political radar. Doggett, a Fellow of the Centre for Policy Development, has released a paper on this issue today and it is available here.

Meanwhile, she has filed the following report for Croakey:

“Direct payments from individuals for their health care make up almost one-fifth of total health funding in Australia but have been largely ignored in recent health reform proposals. This oversight threatens both the equity and efficiency of our health system.  Unless it is addressed it will undermine the effectiveness of the Government’s reform agenda.

Individual payments are important because they have a strong influence on how consumers access health care and which goods and services they access.  There is ample evidence that co-payments within our health system are preventing people from accessing appropriate treatment.

A survey of people with mental illnesses, released yesterday by peak mental health body SANE Australia, found that the majority of respondents reported that they often had to choose between paying for healthcare or meeting daily needs.

Over half of the respondents (54%) said they had not been able to afford treatments recommended by their doctor, and 42% had not filled scripts for medication they had been prescribed because of the expense. One third of those surveyed were not registered for the Medicare Safety-Net and therefore would not receive additional subsidies available to people with high health care expenses.

A 2008 Commonwealth Fund survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States found that over a third (36%) of Australians with chronic conditions reported problems with accessing health care due to cost.  This was higher than participants from any other country, apart from the US.

Individual payments are a widely used form of health care funding in almost all health systems around the world. However, Australians pay for a higher proportion of their health care in individual payments than citizens of many other countries, including the UK, Japan, Germany, France and the Netherlands. Even Americans, though they pay more overall than Australians for their health care, contribute only 13% of their total health funding through direct payments (compared with over 17% for Australians).

The level of individual payments for health care in Australia is not necessarily a problem. Like any form of payment for health care, co-payments have advantages and disadvantages and their impact varies significantly depending on the way in which they are implemented.

Many of the problems associated with co-payments in Australia are due to the fact that our current system of co-payments has developed in an ad hoc manner without an overall policy context or a coordinated approach between the providers and funders of health care.  Government programs involving co-payments have been treated in isolation from each other and different arrangements for co-payments have been introduced without consideration of their overall impact on consumers. The result of this policy neglect is a ’system’ of co-payments which:

• is inequitable, discriminating against consumers with certain types of health care needs or who live in particular geographic areas;
• creates barriers to access cost-effective health care;
• is confusing to both consumers and providers;
• results in perverse incentives in the use of health care;
• is complex and expensive to administer;
• typically imposes the highest costs on consumers when they have the least ability to pay; and
• does not support the diversity of consumer health care needs or promote consume.

The starting point for addressing the significant equity and efficiency issues associated with our current system is to develop a national approach to co-payments for health care, based on agreed principles which reflect community values.

As part of this process, innovative policy solutions should be considered, such as the following:

1)    Giving all consumers a ‘Health Credit Card’ to pay for health care without upfront payments.  The Federal Government would then assume responsibility for paying health care providers directly and bill consumers for the out-of-pocket costs.

2)    Creating a single comprehensive safety-net for all health-related goods and services (incorporating the existing Medicare and PBS safety-nets) to target consumers who have difficulty affording health care.

3)    Providing greater choice for consumers in public health care, through allowing them to trade public hospital benefits for higher primary care subsidies and/or pay additional fees for non-medical services.

Unless the issue of individual payments is given greater policy attention, the existing equity and efficiency problems within our health system will remain. This will threaten the long-term viability of public health care in Australia and undermine the potential success of other reform options, such as the governance changes recommended by the National Health and Hospitals Reform Commission.

When almost one in five dollars spent on health care in Australia comes directly out of consumers’ pockets, individual payments are a policy issue that we cannot afford to ignore.”

Meanwhile the Consumers Health Forum of Australia is not impressed by reports that pathology companies are pressuring doctors to reduce bulk billing of pathology services, and has put out a statement today calling on the Australian Competition and Consumer Commission to investigate.

• History of swine flu

The latest issue of The New England Journal of Medicine has two interesting articles exploring the history of swine flu, otherwise known as  influenza A (H1N1) strain (S-OIV). See here and here.

The latter article concludes somewhat poetically:

The 1918 influenza virus and its progeny, and the human immunity developed in response to them, have for nearly a century evolved in an elaborate dance; the partners have remained linked and in step, even as each strives to take the lead. This complex interplay between rapid viral evolution and virally driven changes in human population immunity has created a “pandemic era” lasting for 91 years and counting. There is little evidence that this era is about to come to an end.

If there is good news, it is that successive pandemics and pandemic-like events generally appear to be decreasing in severity over time. This diminution is surely due in part to advances in medicine and public health, but it may also reflect viral evolutionary “choices” that favor optimal transmissibility with minimal pathogenicity — a virus that kills its hosts or sends them to bed is not optimally transmissible. Although we must be prepared to deal with the possibility of a new and clinically severe influenza pandemic caused by an entirely new virus, we must also understand in greater depth, and continue to explore, the determinants and dynamics of the pandemic era in which we live.

• Disasters and vulnerable groups

On a related theme, this article suggests that governments and planners need to pay more attention to protecting vulnerable groups when preparing for disasters. The article is very much focused on the US context but no doubt has wider relevance. It is by Sharona Hoffman, Professor of Law & Bioethics  and Co-Director of the Law-Medicine Center at Case Western Reserve University School of Law.

She argues that the needs of those with physical and mental impairments, the elderly, those with language barriers, children, pregnant women, the impoverished, certain ethnic minorities, and prisoners are often overlooked. “As the Hurricane Katrina experience made clear, preparedness fiascos will result in humiliation and a loss of public faith in the government as well.”

• Progress against obesity?

The latest assessment of America’s progress against obesity reaches dismal conclusions. “F as in Fat: How Obesity Policies Are Failing in America 2009″, a report from the Trust for America’s Health and the Robert Wood Johnson Foundation  found adult obesity rates increased in 23 states and did not decrease in a single state in the past year. Meanwhile, the percentage of obese or overweight children is at or above 30 percent in 30 states.

On a more positive front, there’s a wealth of information and resources about what governments, planners and others can do to encourage healthy eating and physical activity in this toolkit. It is “a collection of current best approaches in healthy eating and physical activity policy”.

• Tracking US health reform

For those with an interest in following developments in US health reform, this interactive website will enable comparative analysis of the various proposals (due to go live on July 20). The National Health Reform Comparative Analysis Project is an intitiative of the George Washington University’s Hirsh Health Law and Policy Program.

The 18 May edition of the Medical Journal of Australia is devoted to Indigenous health,  and is well worth a read.

One article stands out in particular, both because of the vibrancy with which it is written and the poignancy of its subject – the lack of access to appropriate health services for Indigenous people in jails.

Beverley Spiers is an Aboriginal health worker at the Cessnock Correctional Centre and she writes with a zing and a candour that suggest she is passionate about her work and doesn’t mind ruffling feathers if that will help her patients.

She says Aboriginal prisoners don’t normally access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the the centres any more due to a lack of staff and funding.

“Despite the Royal Commission into Aboriginal Deaths in Custody 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justince Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders,” she writes.

“It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW.”

Spiers won the Dr Ross Ingram Memorial Essay Competition for an entertaining and moving description of her efforts to screen prisoners for kidney disease.

Other snippets from the journal include:

• Professor Wendy Hoy, from the University of Qld’s Centre for Chronic Disease, has weighed up the chances of Australia closing the gap in Indigenous life expectancy by 2030, and judged it “probably unattainable”. She argues that it will probably take several generations for Indigenous people’s health to approximate that of non-Indigenous Australians: “Rather than specify an unrealistic time line for aspirational goals, it would be better to focus on shorter-term process measures.”

• A new study showing that Aboriginal people in the NT are far more likely than other Australians to be hospitalised for problems that could have been prevented from reaching hospital with earlier, better treatment. Between 1998-99 and 2005-06, their avoidable hospitalisation rate was 11,090 per 100,000 population, nearly four times higher than the Australian rate of 2,848 per 100,000.

• Andrew Hewett, Executive Director of Oxfam Australia, raises concerns about the slowness of the Federal Government’s response to closing the gap efforts. In March last year, the federal government signed a statement of intent with leading Indigenous health groups, showing its intent to create a national action plan in partnership with peak Indigenous health groups.

“However, after more than a year, we are still waiting for the national plan and the partnership to eventuate,” says Hewett. “Peak Indigenous health groups have created a comprehensive list of targets they would like to achieve in a plan, and are inviting the government to engage with them, as was promised.” Hewett says Indigenous health groups know what to do to be effective. “For instance, the Victorian Aboriginal Health Service in Melbourne has immunisation rates that show an average of 91 per cent of their child patients are fully immunised, compared with rates of less than 50 per cent for Aboriginal children across Victoria.”

• The relative affordability of energy-dense foods (rich in sugars and fats) compared with nutrient-dense foods (such as meat, fruit and vegetables) in remote communities is a major cause of ill health, according to a new study based in one large remote community in northern Australia. The researchers suggest that efforts to improve nutrition should be placed in an economic framework rather than been seen as a matter of individual behavioural change. They conclude “our study highlights the investment that improving nutrition for Indigenous people in remote communities will require.” Meanwhile, other authors note, however, that nutrition issues were not included in the final National Indigenous Reform Agreement of COAG.

• Interventions to tackle smoking by pregnant Aboriginal and Torres Strait Islander women should focus on the social environment and the influences of social networks and partners rather than the traditional predictors of anenatal smoking, a study suggests.

• Lack of local birthing services means pregnant women from Cape York typically have to leave home at 36 weeks to travel to Cairns, meaning weeks away from family and friends “with detrimental social, cultural and financial consequences”. In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth, three-quarters of whom identified as Aboriginal or Torrest Strait Islander.  The researchers say that reopening maternity units at Weipa and Cooktown hospitals would help.

• A new study gives some powerful insights into why so many Aboriginal people find hospitals and other health services daunting, unfriendly and unhelpful.

The news is not all gloomy, however. This article and another one suggest there’s a good news story just waiting to be told about the Inala Indigenous Health Service in Queensland.

The journal also includes pieces from the Australian Indigenous Psychologists Association and Indigenous Dentists’ Association of Australia, as well as organisations representing Indigenous doctors and nurses. That must be a first.

Oh, for some political attention to these issues, rather than worrying so much about health care for the well-heeled.

DESPITE the enormity of the obesity epidemic, astonishingly Australia still lacks information about trends in weight, physical activity and what we eat.

We have collected this basic intelligence only sporadically and inconsistently, in bits and pieces, so that we cannot accurately detect trends in body weight, calories consumed or exercise taken by Australians.

Way back in 2007, the federal budget contained the occasional piece of good news!  One of these pieces $10.6 million for the first four years of a regular survey program of Australian nutrition and physical activity.

The program was proposed to conduct rolling surveys of different groups over time, starting with adults in 2008 and moving presumably on to other groups, and then returning to each group regularly to measure trends over time.

Young children and indigenous groups are surely high priorities because we know next to nothing about their dietary patterns, although more now, following the recent childhood nutrition survey, than before.

At the time, I proposed that three important conditions must be met for the $10.6 million to be spent to best effect.

First, the surveys would be conducted by the same agency from year to year. Variations in survey method, as would follow if different agencies did the different surveys, would make it extremely difficult to interpret trends.

The Australian Bureau of Statistics (ABS) has a splendid track record for the conduct of surveys that provide dependable information on which trends in many demographic and social variables are used to guide macroeconomic and fiscal management. Although the budgetary allocation does not specify what agency will do the surveys, wisdom suggests a major role for the ABS.

Second, the surveys would best go beyond the measurement of dietary behaviour and physical activity.

Actual measurements of body weight and height would help in determining whether we are on top of the obesity and overweight epidemic or whether we are continuing to grow dangerously. New machines allow us to measure blood pressure relatively easily. Blood samples would enable us to be clearer about the current state and trends in diabetes and what is happening to cholesterol across the nation.

These measures would be feasible if done on a small sample of people who participate in the wider dietary and physical activity survey.

Third, the interpretation of the data derived from the surveys must be in good hands. The establishment of a unit within the Australian Institute of Health and Welfare (AIHW) to interpret the data from the surveys and to apply them in the development of policy would be a wise move.

The AIHW, with its good relations with states and territories as well as the Commonwealth, is in a position to supplement the information provided by the national surveys by compiling, interpreting and disseminating data from the states and territories, ABS commodity statistics on apparent consumption of foodstuffs, data from the food regulators about food composition, and consumer surveys.

Some of these data will be more dependable than others and reconciling them would be an important function of a nutrition and physical activity monitoring unit within the AIHW.

Our intelligence on nutrition and physical activity at present is piecemeal and discontinuous. As well, important groups have not been covered with any dependability. The national surveys, funded through the recent budget allocation, might well survey the nutritional status, and food behaviour, of children aged 0-2. It is in this group that nutritional foundations are laid. Recent studies have pointed to high energy intake among them from supplementary snack foods rather than from nutritionally valuable core foods in children in this age group. We must know more about food habits among these children.

There are many conflicting interest groups concerned about overweight and obesity control, and the management of the politics among them will be a challenge in spending the $10.6 million wisely.

In actual fact, little has happened with the allocation to date. The food industries are major players and their lobbying power is vast. Nevertheless, spokespeople for industries have been highly supportive of the move to establish a nutrition survey program because of its value to a changing food industry as a market overview.

Public health agencies, deeply concerned about the epidemic of obesity, have endorsed the nutrition and physical activity survey program. Cathy Mead, who was the president of the Public Health Association of Australia in 2007, said she “strongly supports the conduct of these surveys in the pursuit of information that might then find its way into national nutrition and physical activity policy”. Professor George Rubin, president of the Australasian Faculty of Public Health Medicine, says to get “regular information on these vital attributes, diet and physical activity, would be a fantastic move forward”.

The current concern, as articulated by Tim Gill, is this: jockeying interest groups will put plausible cases to the federal health department for ‘outsourcing’ the surveys to them to conduct.

The biggest reason for institutionalising these surveys in a major government instrumentality such as ABS or AIHW is to secure continuity of survey methods and survey rigour: otherwise measurement errors will mislead us from survey to survey.  Recently I communicated these concerns in detail to Minister Roxon’s office.

With attention to detail, especially the nomination of strong institutions to conduct and analyse on-going survey data, Australia can look forward to a much clearer picture about how we fare in our battle against the bulge.

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

****

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.”

His conclusion, as reported in Crikey yesterday, is that the system is generally fine – but it’s not fair.

“You do much better in Australia’s health care system if you’re wealthy, if you’re well educated, if you live in the city and if you’re not Indigenous,” the report says. “Otherwise, it seems, you receive a lesser standard of care.  If you have a chronic condition such as diabetes or heart disease, you’ll end up in hospital where someone better off will manage to stay home and get the care they need. And if a rich person and a poor person get cancer at the same time, the poor person will die sooner.”

One of the report’s most politically sensitive sections concerns the Australian Government’s subsidy of private health insurance. Ragg notes that the cost of the scheme is rising rapidly but that it has not taken the pressure of public hospitals and that health funds are spending less per member than they did 10 years ago.  Meanwhile, the total equity of Australian private health insurance funds has risen by about $3 billion since the Government started subsidising private health insurance.

“In effect, private health insurance and its application in Australia through the private health insurance rebate scheme does a reverse Robin Hood – it takes money from the poor and gives it to the rich,” says Ragg. “And it does little good for public hospitals.”

Let’s hope someone in the PM’s or Treasurer’s office is reading…

But what do others think of Ragg’s report?

Professor Ian Olver, CEO of Cancer Council Australia and a medical oncologist, writes:

Mark Ragg makes some good points about healthcare inequity in Australia. It’s important to add that poorer cancer treatment outcomes experienced by socially disadvantaged people can in many cases be linked to lost opportunities in preventative health, rather than access to treatment.

Around a third of fatal cancers in Australia are caused by smoking, obesity/overweight and alcohol consumption – partly because some of these cancers, such as lung cancer, are difficult to treat no matter how good the care.

And the cancer burden from these behaviours is borne disproportionately by socially disadvantaged groups. For example Indigenous Australians, who are twice as likely to die within five years of a cancer diagnosis as non-Indigenous Australians, smoke at 2 times the rate of others. So, while there’s evidence that Indigenous people have very poor access to cancer treatment services, there’s also data suggesting that the higher prevalence of smoking-caused cancers among Indigenous people contributes significantly to the unacceptable disparity in cancer survival.

Yet less than 2% of Australia’s health budget goes towards prevention – and far less to tailored programs for disadvantaged groups. This is despite the well-documented social and economic gains available from investing in targeted, evidence-based public health programs.

The Rudd Government’s Preventative Health Taskforce has made strong recommendations to reduce smoking, obesity and alcohol use – setting targets; integrating policy, programs and research; multi-sector approaches and so on. Now it’s up to the Government – which campaigned on building disease prevention into the intergovernmental healthcare agreements – to begin implementing the recommendations through COAG this year.

And with early detection another key to cancer survival, the Government should also expedite its piecemeal bowel cancer screening program – and support it with tailored communications that help ensure all population groups are screened for Australia’s most fatal cancer after lung cancer.
***

Sally Crossing, Chair, Cancer Voices NSW, writes:

Mark Ragg poses the question “Why do poorer and less educated people have worse cancer outcomes than wealthy well educated people?”

It may be because they fall through the cracks on the route to best practice treatment.  They may not get referrals to the multidisciplinary teams which give the best outcomes. They may give up trying to navigate the cancer world “silos” – perhaps this is where assertiveness of the better educated can help, though a cancer diagnosis is pretty destabilising for us all.   They may present too late due to cultural or poverty reasons.

Cancer is a disease which can be most successfully treated when diagnosed early and we still don’t really understand it – unlike heart disease treatment which resembles human plumbing.

Cultural reasons could include the “I’ve got cancer so I’m going to die” belief, a mantra not shared with any heart patients anymore.  And then there are situations where cancer is still not to be spoken of.  Or they may live a long way from good cancer care and be unable to access it…so many possible facets in an answer.

Whatever the truth, thanks for raising the issue.  One vital piece of info we needed to have was how great is the difference between poor/uneducated and wealthy/well educated, and how any people are involved and how many fall in between.  Then we’d have some real evidence for advocacy to address the inequities.

***

Professor Stephen Leeder, co-director of the Menzies Centre for Health Policy, writes:

Assuring fair and equal access to equal medical need remains a constant challenge in health. Centralisation of highly specialised services is technically essential for efficient use of health dollars but each time we do this people who live remotely have less access.  A system that is not tuned to cultural difference will provide less access to cultural minorities.

Let me tell you about another source of inequity and that we have encountered in our work with patients with chronic illness. It is that chronically ill people are told that they should do all they can to stay out of hospital.

Why! Because the hospital is not geared to treat them. So why not change the hospital? This is like going to a shoe store and being told they have no shoes that fit and so please change the size of your feet!

***

Anonymous writes:

Whenever I read such pieces, I am always reminded of the seminal paper by Julian Tudor Hart that was published in the Lancet in 1971 (J. Tudor Hart, The inverse care law. Lancet (1971), pp. 405–412 – also accessible at http://www.sochealth.co.uk/history/inversecare.htm).  Much of his characterisation of Britain’s NHS in the 1960s is relevant to Australia today.  Furthermore, he also provides quotes from several earlier sources which might be viewed as resonating uncannily with our current system some 40 years on eg:-

“We have learnt from 15 years’ experience of the Health Service that the higher income groups know how to make better use of the service; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups- particularly the unskilled.” Titmuss R M, Commitment to Welfare. London 1968 (Reference 2)

“The general practitioner in working-class areas discovered the well-tried business principle of small profits with a big turnover where the population was large and growing rapidly; it paid to treat a great many people for a small fee.  A waiting-room crammed with patients, each representing 2s. 6d. for a consultation … not only gave a satisfactory income but also reduced the inclination to practise clinical medicine with skilful care, to attend clinical meetings, or to seek refreshment from the scien­tific literature.”
James E F, Lancet (1961) I 1361 (Reference 5)

“Of 169 new general practitioners who entered practice in under-doctored areas between October, 1968, and October, 1969, 164 came from abroad.” DHSS Annual report for 1969, London 1970 (Reference 13)

****

Michael Moore, CEO, Public Health Association of Australia, writes:

Mark Ragg has stumbled on the social determinants of health.  There is no doubting that the cancer example he uses puts equity and fairness under the spotlight.  It is just downright unfair that the wealthier you are, the healthier you are.

Sir Michael Marmot, as Chair of the Commission on the Social Determinants of Health, has just released a report on behalf of the World Health Organization called Closing the gap in a generation.  Sound somewhat familiar?  In Australia the health inequities are bad enough but viewed from an international perspective they are downright appalling.

The Preventative Health Taskforce are also aware of this issue and gave as an example in their discussion paper Australia: the healthiest country by 2020 that “even within a city such as Melbourne, life expectancy can vary by up to five years within a matter of kilometres.

The problems of inequity in health outcomes have been recognised – the challenge is in finding ways to work to fairer health outcomes.

***

Jeff Richardson, Professor and Foundation Director, Centre for Health Economics, Monash University, writes:

Mark Ragg’s comments in Crikey are well made. Perhaps they are even too generous. It is true that Australians now live longer than almost anyone apart from the Japanese.

But whether this is attributable to the health system (as a system), as distinct from some very specific factors has never been demonstrated. Smoking, drinking and blood pressure are all down. Exercise is up. But at best this reflects the success of public health measures, not the remainder of the system which accounts for about 98.3 percent of expenditure. We do not know if it is the skill of doctors or the efficacy of anti-hypertensive drugs which have the greatest impact in the curative services.

There is absolutely nothing to suggest that it is improvements in the system (which remains largely static) which have caused the improvement. Policies at both the State and Commonwealth level are largely concerned with cost containment and tinkering on the margin with issues associated with health outcome.

The system remains as fragmented as it did 20 years ago when the need for integration was first recognized. In all probability, adverse events continue to kill very large numbers of Australians unnecessarily. The chief publicised policies here are about counting numbers (imperfectly) rather than removing the systemic causes of error and accelerating the inadequate rate of error learning.

Mark Ragg correctly identifies unfairness as a pervasive problem. This was documented for 1976 by myself and John Deeble and reinforced by sporadic research thereafter. Once again the response indicated no real interest in the problem beyond the cosmetic.

Indeed, rather than concern, over a five year period I was unable to obtain data from the Commonwealth Department of Health to analyse how the unfairness had changed through time. We should not, however be particularly surprised by this lack of interest.

Despite folk myth to the contrary Australia remains one of the least egalitarian and meanest countries in the developed world. Our rates of poverty amongst disadvantaged groups, the amount we transfer in social services, the amount we give to other countries, the amount we take from well off taxpayers all come at the bottom or close to the bottom of the OECD league table.

Australians seemed to be far more focussed upon downward envy and less concerned with the position of Aboriginals, rural minorities and other disadvantaged groups than people in more compassionate Western societies.

The unfairness of the distribution of doctors, services and the widespread support for queue jumping via private health insurance are all a reflection of this national character. But apologists will doubtless continue to use any available statistics to support their self congratulation and to avoid the need for a thorough inquiry into the operation of our antiquated and often dangerous delivery system.