It turns out the doctors aren’t the only ones taking Coca-Cola’s money. Believe it or not – dentists have too.

It’s enough to make your teeth ache.

“The NHHRC report is not only a missed opportunity to create a system that will address equity and  efficiency in the current system – instead its proposals threaten both.

Of course no one would argue that primary health should not be strengthened, and that dental and mental health, Indigenous health, rural and remote health and aged care are not being failed by the current system. But identifying the changes needed is quite different from creating a system that will address them.

After years of debate, the commission has chosen to proceed largely in the same incremental direction we already find ourselves. Instead of finding in favour of structural reform that will ensure we have a sustainable and efficient system that will assist us to provide high quality care to the whole population, the commission has opted for an approach that will see the blame game continue and inequities entrenched.

Not content with the current status quo of a two tier system in hospital care, the commission has recommend we extend this to all health care and, in a highly risky first step towards managed care system, proposes a greatly increased role for the private sector and private health insurers.

This is the system from which the Obama administration are trying desperately to escape. The commissioners have chosen to mistake choice for equity, and thus have proposed greater choices for those who already have it, and less for those who don’t.

The proposal for Medicare Select threatens to take us in a direction where the sickest members of the community will have their health care limited to a basic package of care, while those who can afford it will be able to have as much as they like. A bit like now, only much, much worse.

This report should make the poor, the disadvantaged, the truly sick, and anyone with an sense of fairness very afraid for what lies ahead.

It is deeply disappointing and the health care sector and the community have every right to feel betrayed by this report as it does not reflect the feedback and ideas they so generously provided during the commission’s 16 month consultation.”

The executive summary identifies several priorities, including:

Indigenous health

• Establish a National Aboriginal and Torres Strait Islander Health Authority to buy services and to hold services accountable

• Strengthen community controlled health services, develop Indigenous health workforce and upskill existing workforce to provide culturally appropriate services

• Improve nutrition in targeted remote Indigenous communities

Mental health care

• Expand sub acute services in the community

• All acute mental health services should have a rapid response outreach team available 24 hours a day

• National access to youth friendly, community based services for encouraging good mental health in young people

Rural and remote

• Top up funding on a per capita basis to ensure receiving equivalent funding as well-served communities

• Increased funding for patient travel and accommodation

Dental Care

• A new universal scheme for access to basic services, Denticare Australia

• Expansion of preschool and school dental programs

Public hospitals

• Public hospitals with major emergency departments be funded to ensure enough beds are available

System redesign

• Establish National Health Promotion and Prevention Agency

• Strengthen primary health care with Comprehensive Primary Health Care Centres and Services to be established with extended opening hours

• Voluntary enrolment in a ‘health care home’ to encourage better continuity and coordination of care for people with chronic diseases and disabilities

• Current divisions of general practice should evolve into or be replaced by Primary Health Care organisations

Next generation of Medicare

• The Medicare Benefits Schedule should be “reshaped”, with the Commonwealth to decide what services should be covered and by whom they should be delivered

• A range of payment mechanisms including mix of salary, fee for service, grants, performance payments

• The Commonwealth should have full policy and funding responsibility for primary health care, basic dental care and aged care, as well as responsibility for buying health services for Aboriginal and Toress Strait Islander people

• The report lays open the way for the Feds to take over responsibility for health funding entirely. Initially the Feds would pay 100 pc of efficient cost of public hospital outpatient services with an agreed, capped activity-based budget and 40 pc of the efficient cost of every public patient admission to a hospital sub acute or mental health care facility and every emergendy department attendance. The Feds share could  be incrementally increased over time until it is completely responsible.  Under Medicare Select, the Commonwealth Government would become the sole government funder of health services, and all Australians would automatically belong to a health plan either operated by government, the not for profit sector or private enterprise. The NHHRC has recommended that over the next two years, the Feds explore the benefits, risks and feasibility of this recommendation.

In other words, two of the really hard-edged recommendations of the report – fundamental changes to the MBS and Medicare – are likely to be delayed long enough so as not to cause any pre-election grief for Rudd and co. It may also be worth noting that the report’s very first recommendation stresses the importance of private health insurance. Recommendation 92 adds: “We want to see the overall balance of spending through taxation, private health insurance, and out-of-pocket contribution maintained over the next decade.”

Strengthened consumer engagement and voice

• Build health literacy, eg as a core element of the National Curriculum in schools

• Foster community participation through citizen juries etc

• Every Australian should have a personal electronic health record that they own and control – by 2012

The Commission estimates the annual recurrent costs of their reforms are between $2.8 billion and $5.7 billion. A capital investment over five years of $4.3billion-$7.3billion is also required, they say. These figures do not include the costs of Denticare Australia, which it is estimated will cost the Feds $3.6 billion annually.

You can read more here from Crikey’s political correspondent, Bernard Keane.

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.

With the benefit of the retrospectoscope, it now seems so obvious. What were we thinking, expecting that there suddenly would be miraculous clarity around the vexed issue of prostate cancer screening, just because some randomised controlled trials were underway?

As you may have heard, the long-awaited findings have been published – you can find some results from the US one here , and the European one here.

And it’s still not possible to find a simple answer for men (and their partners) who may be wondering whether to PSA or not. It all depends upon how the individual weighs up the potential risks of screening (which are considerable) against the potential benefits (which are questionable).

The only thing that seems clear is that the PSA test should not be done unless men have been given the opportunity to provide fully informed consent first.

As an aside, one of the interesting points from this interview by Norman Swan is that while men are focusing so much on their prostates, they may not be thinking about the other health problems which are far more likely to get them and about which they could be doing something useful.

So far I’ve only been applying the retrospectoscope to the questions of an individual patient. Equally important are the questions surrounding allocation of health resources.

We are spending a small fortune (not just dollars but also health professionals’ time) on the widespread use of a test (and its sequelae) for marginal, if any, health benefits.

Imagine if that money was being used to deliver interventions that could really make a difference, especially for those who could really stand to benefit, such as vulnerable kids and families. It’s odd that we’re willing to spend millions on tests and expensive treatments for some, but can’t, for example, manage to provide basic dental care to people who really need it – like Aboriginal kids.

End of rant from me – here are some more thoughts on the PSA controversy, from Sally Crossing, of Cancer Voices NSW:

“Cancer Voices NSW, like many others organisations in the cancer world, has been waiting with interest for the results of the two large, international randomised trials looking at PSA as a screening tool.

The PSA test is used widely in Australia as a test for prostate cancer, now the most diagnosed cancer among Australians, but not for screening, due to lack of solid evidence.

There is concern that PSA testing leads to over-diagnosis and over-treatment, particularly as treatment often leads to major on-going physical problems for men.

We have been waiting in the hope that the PSA screening, and even the PSA testing, controversy would be resolved by the results of the ERSPC (Europe) and the PLCO (USA) studies which were reported in last week’s, New England Journal of Medicine.

The NEJM’s Editorial expresses doubt that we know enough to change policy either way, as the new evidence (ERSPC) suggests that screening per se makes only a little difference to deaths.  Our interest also relates to the ramification these outcomes may have for the screening of other cancers.

Value of the patient perspective
Cancer Voices must look at this from the cancer consumer view point- and particularly of the prostate cancer consumer – rather than that of researchers, epidemiologists, clinicians or health economists.

The big question for us is – how can the individual or his doctor, know if he falls into the “harm” category – over-diagnosis and possible over-treatment, or not?

We suggest this is still unanswerable.  The “desperate dilemma” of treating or not treating remains, and few will be willing to do nothing.

We also suggest that few individual men will want to wait for their prostate cancer to develop more compelling symptoms, with consequent less chance of effective treatment and recovery.

What is of most interest to prostate cancer patients is years of survival and quality of life, whereas the studies’ endpoint is death.

What cancer consumers want is studies that focus on less harmful treatment, better diagnostic tests and better use of current tests and biopsies.

We call for continued and increased research into identifying which cancers are the ones which are likely to require treatment, and greater specialisation in prostate cancer surgery so that nerve-sparing procedures might become more successful.

We recognise the conundrums – the messages for screening policy, the cost-effectiveness of screening and / or testing, and the balance between benefits, survival and harms.

We especially ask that the consumer view is factored into the decision-making processes, from national policy right through to individual levels.”

Although some of its ideas such as a Commonwealth takeover of primary care and the “Denticare” scheme have attracted publicity, it is a timidly-written document, ducking the big issues we need to address.

It meekly accepts the existing “overall balance of spending through taxation, private health insurance, and individuals’ out-of-pocket contributions”, without questioning why such an accident of past incremental policy measures has led to an optimal balance, and without acknowledging the distortions and inequities caused by private health insurance.

For example, it acknowledges that financial rewards have attracted surgeons away from public to private hospitals, but does not link this with the waiting list problems faced by public hospitals.

And in parts it is simply incorrect: for example it states that without private insurance one cannot obtain private hospital treatment (Page 126). Perhaps it is too painful for the authors to acknowledge that the present support for private insurers penalizes the most self-reliant who pay for private treatment without reliance on insurance.

Its Denticare scheme has some attractive elements – dentistry should always have been part of Medicare – but its proposed administrative arrangements are clumsy and expensive, for it proposes churning of dental funding, first through the tax system, then through private insurance.

In accepting the present funding mix it puts the big question of collective versus individual funding into the “too hard” basket, taking great care instead to suggest schemes which sustain a role for private insurance – never providing any justification for why the private financial sector should have such a central role in health care, and never acknowledging that private insurance carries all the moral hazard of public insurance but without its benefits and without the benefits of price signals transmitted through co-payments.

And, for all its rhetoric about “connecting care”, its seemingly preferred option is to preserve a separation between primary care and hospitals, and while acknowledging problems in program fragmentation, is vague on practical means of integrating care.

For example, it still sees Commonwealth funding of medical and pharmaceutical care in two separate programs.  And it dismisses without argument any possibility of bringing public and private hospitals under one funding channel.

While the Commission has presented three options, it is hardly neutral in their presentation.  Option A, which involves the Commonwealth taking over primary care funding while leaving the states with hospitals, is the easy path, but, in prolonging the separation between hospitals and primary care, it preserves opportunities for cost shifting and misses many opportunities for governments to use primary care to reduce hospital costs.

Option B builds on Option A, with the Commonwealth taking over hospital funding, but the Commission raises the spectre of Commonwealth/State conflicts (as if we don’t have them already).

Option C builds on Option B, coming close to an integrated, single insurer scheme, of the type used in most other developed countries, but it is made impossibly clumsy by attaching it to a multiplicity of health “plans”, which it implies are a necessary aspect of universal insurance.

Overall it’s a timid report, written to entrench vested interests, particularly the health insurers.  Surely we have learned that financiers cannot be relied on to serve the public interest

“As the peak national body for public health services, including public hospitals, the AHHA has a strong commitment to equity within our health system.

While Australia’s health system performs well compared with many other countries, in terms of equity of access, we need to do more to improve the health status of specific groups in the community, in particular Indigenous Australians, rural Australians and people from low socio-economic backgrounds.

AHHA shares Mark Ragg’s concern about the poorer health outcomes experienced by these groups and is committed to working closely with governments and other health stakeholders to address this issue.

In particular, we have advocated strongly for increasing access to public dental care through a number of media statements, submissions to government and policy papers (see our website for more information at www.aushealthcare.com.au)

AHHA is hopeful that the current Federal Government’s commitment to health system reform will result in a fairer health system for all Australians.  In our submission to the National Health and Hospitals Reform Commission, and other current inquiries and reviews, we have stressed the need to maintain our strong commitment to universality within our health system and build on this by identifying and removing the barriers to improved health outcomes for Australians from marginalised groups.

As many of these barriers may lie outside the immediate influence of the health system, we believe that health groups need to work closely with other relevant sectors, in particular education and social security, to ensure that a comprehensive multi-sectoral approach is taken to reducing the health gaps within the Australian community.”