With less than a week to go before the Federal Budget 2013, the leaks and rumours (and rumours about leaks) are increasing and speculation about possible new funding measures is mounting. The following analysis looks at the main items on the wish-lists of eight peak health groups and identifies key issues on which there is broad health sector agreement.

An increased focus on prevention and the social determinants of health, more action on Indigenous health and a stronger primary care sector are the main areas of agreement in the Budget wish-lists of key health groups.

Croakey analysed a number of pre-Budget submissions from peak health and social welfare bodies and prepared the following summary of the key proposals from the following groups:  Australian Health Care Reform Alliance (AHCRA); Australian Council of Social Services (ACOSS); Australian Healthcare and Hospitals Association (AHHA); Australian Medicare Locals Alliance (AMLA); Australian Medical Association (AMA); Catholic Health Australia (CHA); Consumers Health Forum of Australia (CHF); and the Public Health Association of Australia (PHAA).  The National Rural Health Alliance was also contacted but did not submit a Budget Submission for this year. It will, however, be providing a response to the Budget once it is brought down next Tuesday.  Links to each organisation’s specific submission/policy document are provided below.

Prevention

A number of groups seek increased funding for prevention. The PHAA wants the level of funding for prevention to rise from 2.2% to 4% of health expenditure.  It is also seeking an investment into building the competence and capacity of a national preventative health workforce who understand inequity and the social and economic determinants of health and are skilled to effectively deliver preventive health services at the local level. CHA, AHCRA and the AMA also support a range of measures to increase the focus on preventative health and health promotion.

Social determinants of Health

The need to focus on the social determinants of health was raised by a number of groups, in particular the AHHA, AHCRA and CHA. Among AHHA’s specific proposals are that the Australian Government make a formal statement of  support for the recommendations of the WHO Commission on Social Determinants of Health and in conjunction with the States,  develop an action plan to implement the recommendations of the WHO Commission  on Social Determinants of Health.  AHHA also supports a federal ‘health in all policies’ approach to policy development and legislation and the establishment of an Australian Commission on the Social Determinants of Health to coordinate interagency action and report annually on progress to  address the social determinants and reduce health inequity.

Indigenous Health

There is strong support among the peak health groups for increased action on Indigenous health with a number of submissions making specific suggestions as to how the ‘health gap’ between Indigenous and non—Indigenous Australians could be reduced. The AHHA recommends that National Indigenous Hospital Demonstration and Mentoring Program be funded that focuses on Indigenous heart health.  The PHAA supports retaining and extending funding for the “Close the Gap” measures including additional support for Aboriginal Medical Services and Aboriginal Health Services; and the AMA wants the Federal Government to renew its commitment to a COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes for a further five years from 2013, with the same level of funding allocation as provided in 2008.

Primary Care

The need for a strong primary care sector was the focus of a number of recommendations with groups expressing support for ongoing funding for Medicare Locals. The PHHA suggests maintaining the funding of Medicare Locals, Locals and Women’s Health at a level that will allow comprehensive primary healthcare based on an understanding of the social determinants of health. CHA recommends a number of strategies for strengthening primary and community care and ACOSS seeks an investment in capacity for community health services to engage with key health policies, including the establishment of Medicare Locals and the Partners in Recovery framework, as a key element of building the role of community health services to help reduce inefficiencies in the health budgets from preventable hospital admissions.

Consumer engagement

Unsurprisingly, consumer engagement was a key focus of CHF’s submission which includes a recommendation that the Government recognise the value of consumer and community participation in health and medical research, and reflects this in the allocation of funding. CHF also wants the Government to commit to funding the development and implementation of measures of health outcomes and consumer experience in the Australian health system that will ultimately lead to a more effective and efficient healthcare system.  Action on out-of-pocket costs for health services is another item on CHF’s agenda, along with a commitment that any Government measures that aim to reduce PBS expenditure do not reduce or delay consumer access to essential medicines.  Increased consumer engagement in the health system is also strongly supported by CHA which proposes a number of strategies to facilitate greater consumer empowerment and engagement. 

Health system issues

Broad health system issues were addressed in a number of submissions, including the AHHA’s which proposes a comprehensive research and evaluation of the National  Health Reforms.   The AHHA is also seeking a National Health System Coordination and Integration Program and a National Discharge Planning and Referral Program. The CHA supports the need for improved integration and transition with a number of proposals to take health care ‘from silos to a system’ and also wants to reform health system governance.

Ambulance Services

Both AHHA and CHF support a national program funded by the Commonwealth to provide universal access to ambulance services for all Australians.

Research and evidence

CHF highlighted the need to increase the evidence base for health care in its submission, including proposing that the Government commits to funding at least a proportion of the costs for the establishment and implementation of clinical registers, following the conclusion of consultations to identify the most appropriate model or models.  It also supported a commitment to funding the implementation of the recommendations of the McKeon Review.

Chronic disease

A new approach to chronic disease management was proposed by AMLA involving Medicare Locals implementing a national network of chronic disease care coordinators to help people with chronic disease to access tailored prevention and/or management programs and to establish local health provider networks to ensure better access to the multidisciplinary care required for this. In contrast, CHF focussed on a different approach to chronic disease management suggesting that the Government fund a pilot of personal health budgets for people with chronic and complex conditions, with a view to widespread implementation.

Early childhood

Early childhood development was a key focus of the AMLA submission with a comprehensive proposal for Medicare Locals to work in partnership with relevant agencies to develop early childhood ‘masterplans’ for each ML community. The initiative would draw on the Partners in Recovery (PIR) model to develop and implement pathways that link multi-sectoral services to systematically address early childhood outcomes.  

Oral health

The AHHA submission recognises the funding already allocated to public dental services and recommends that this be built on with additional funding, in order to establish a Universal Oral and Dental Health Scheme for all Australians within five year

Workforce

The AHHA and the AMA both focussed on workforce issues in their submissions. The AHHA is seeking an evidence based graduate nurse program for all nurses in Australia. This would include a national Nurse Graduate Support Teams program to provide for all new graduates to have access to a team dedicated to supporting them as they begin their career. The AHHA also is proposing an innovative program for supporting the employment of refugees and migrants in health services. This would provide benefits to the individual as it facilitates social inclusion and social cohesion and also to health services which would be able to fill skill and labour shortages and develop staff profiles that reflect the cultural diversity of the wider community. In contrast the AMA is requesting increases in GP and specialist training places and funded intern places in private hospitals. It also wants to increase the payment to GPs of teaching medical students.

Non-health measures

ACOSS focussed on a range of non-health measures, including raising the level of payments for Newstart Allowance, Youth Allowance and other Allowance payments for single adults and young people living independently of their parents; doubling the number of wage subsidies available for very long term unemployed people to 20,000 places per year and substantially boosting the resources available to Job Service Australia providers to work intensively with this group from present inadequate levels. It also proposed establishing an Affordable Housing Growth Fund to expand the stock of affordable housing and investing in the capacity of the community sector to deliver services and engage in national industry initiatives. 

Savings measures

Many of the submissions included suggestions for funding the new initiatives proposed. These included the PHAA’s proposals to increase excise duty by ten cents per cigarette and introduce a volumetric tax for wine (an abolition of the current WET rebate). PHAA also suggested a new tax/levy on selected nutritionally undesirable foods.   ACOSS suggested  a removal of both the 30% private health insurance rebate for ancillary cover and the Medical Expenses Tax Offset.

Submissions

The following are links to the submissions from each group – in some cases groups provided a recent policy document to Government in lieu of a forma Budget submission.

Australian Health Care Reform Alliance

Australian Council of Social Services

Australian Healthcare and Hospitals Association

Australian Medicare Locals Alliance

Australian Medical Association

Catholic Health Australia

Consumers Health Forum of Australia

Public Health Association of Australia

“I need a prostate check and a colonoscopy”

“Oh. What makes you say that?”

“Well, I was listening in 2GB the other day….”

That was a recent conversation I had with one of my patients. I am grateful that I was trusted more than 2GB in the end, and he ended having a faecal occult blood and no prostate test.

Last week, the Sydney Morning Herald went for the Executive prevention market with an article headlined “Over 40? Five Tests you need right now.” The urgency was illustrated, somewhat improbably, with a photograph of a fully gowned surgeon silhouetted by operating lights peering down at you, defibrillator in hand with the caption “The view you don’t want to see.”

It’s interesting to note that there was no overlap in tests recommended. As far as I know there is no evidence to suggest different screening tests based on whether you read the Executive Section of the SMH or listen to 2GB. These items on medical tests are really marketing fear. “Get these tests and reassure yourself.”

What’s the problem if people want to reassure themselves? Well, there wouldn’t be a problem if it worked. But it doesn’t work. A recent systematic review looking at testing for low probability conditions shows that having a test doesn’t reassure people.

It’s also worth asking if the tests will end up making you healthier. It might seem like a no-brainer that finding a disease earlier of course makes you better! But some tests don’t find the disease earlier, sometimes the disease wouldn’t have made you ill at all, sometimes you find it earlier but there’s no good treatment for it, and sometimes having the test itself makes you unwell.

Fortunately, all of these questions are the sort of questions that can be answered by randomised controlled trials, where you compare doing the test with not doing the test and you see whether it actually does make people live longer, happier healthier lives.

GPs are for the most part the ones discussing and requesting these tests – it’s a huge part of what we do, and we see the times they save lives, and we see complications, and the stress and anxiety that goes along with that. Sometimes the best bit of advice in medicine is “Don’t just do something. Stand there!”  Fortunately for us, the RACGP regularly reviews the evidence about what tests are likely to work and what aren’t, and publishes this in the so called “Red Book.” There’s also a version for prevention in Aboriginal and Torres Strait Islander people written with NACCHO (Declaration – I was one of the writers of this). So if you want to see what tests are recommended at your age, you can go to this chart (PDF), find your age across the top, and read off the interventions down the left side. You’ll find that coronary calcium score, coronary angiogram and colonoscopy aren’t recommended. You’ll see prostate checking is not recommended. You’ll see that screening for depression is only recommended if comprehensive support services are available, otherwise it does more harm than good* (and the K-10 is not the recommended tool). You’ll see that advice on appropriate alcohol intake is there, though it’s a bit more complicated than just “how big is your glass?” And both blood pressure and cholesterol measurement are recommended, but as part of an assessment of absolute cardiovascular risk, which puts several measures together to work out how likely you are to have a heart attack or stroke over the next 5 years. You can check yours here.

It’s important to note that this information only applies if you don’t have symptoms. If you do, then these tests are not screening, but diagnostic, and you are much more likely to benefit. By its nature, screening brings in people for medical tests, which cost money, and also cost an opportunity to perform that test on someone who needs it – inappropriate preventive tests can not only harm the individual, but harm other individuals who are unable to get the test and harm the health system in costing money that could be spent on doing something that actually works. That’s why the evidence (including evidence of cost benefit) is so important, especially as budgets get squeezed. (There’s an interesting article here looking at procedures that probably cost the health system money without generating any health benefits).

So, if you work in the media and want to do a report on what medical tests you need to do, here are the 5 Tests You Must Do Today! (You can imagine a scary picture of me shaking my head here if you wish!)

1.  Imagine this was a senior politician telling you this information. How uncritically would you accept it? Are there any conflicts of interest? Use your same sense of scepticism.
2.  Is there a consensus of opinion? Do GPs and specialists agree? What do major guidelines say?
3. Will doing this test make me live a longer healthier life? Show me the evidence. And ask someone else to have a look at the evidence.
4. What are the harms from this test, and any subsequent tests or treatment needed?
5. If you’re going to interview someone whose life was saved by having this test, interview someone else who has suffered side effects or complications. (But beware false balance – see point 2 above!)

*NB – Screening for depression is asking the same set of questions to everyone, whether or not they have symptoms. The evidence shows that doing this only works with a comprehensive mental health support team, and this should certainly inform policy about mental health. However, I do want to be clear that this does not mean we should not be asking about mental health symptoms, or that there is no evidence about treatment of mental health problems. It means that we should use clinical judgement, in asking and assessing, rather than a single tool applied to everyone.

Croakey suggests that for further reading on this issue, Gary Schwitzer’s (US-based) blog is a great place to start http://www.healthnewsreview.org/blog/

Accreditation programs are deployed widely to monitor and promote safety and quality in healthcare. Governments, health service organisations and accreditation agencies have invested considerable resources into programs, but to date, evidence of their effectiveness is limited and varied in some areas prompting the question: is it money and time well spent?

A recently published Evidence Brief examines this question (see here for full details). It synthesises findings from a recent literature review of 122 published empirical studies regarding health service accreditation programs. Overall, these studies investigate varied aspects of accreditation, including the impacts on:

• measures of quality (for example, indicators of organisational performance or patient outcomes);
• health service processes, policies and operating environments;
• organisational change mechanisms; and
• professionals’ attitudes.

Improving the quality of healthcare is undoubtedly a key aim of accreditation, and over 60 studies have evaluated program impacts on different quality measures. Unfortunately, the majority do not use non-accredited health services as control sites in comparative study designs, decreasing the strength of evidence produced. Also, findings from individual investigations are shaped by contextual issues limiting the generalisability and comparability of studies, with examples of both positive and negative impacts identified.

Advocates of accreditation argue that a key benefit is that it stimulates improvements in health service processes, policies and operating environments. Some research supports these claims, with one study demonstrating that staff in accredited organisations are more compliant with best-practice guidelines and open to implementing changes that improve quality and safety. However, few high-quality studies have examined whether programs actually deliver such tangible benefits.

Fortunately, there is stronger evidence on how preparing for and undergoing accreditation establishes mechanisms for change within health service organisations. The research suggests that accreditation causes organisations to change because:

• staff become more engaged in quality improvement activities, such as self-assessment;
• systems for delivering quality care are promoted within the organisation;
• data is collected, collated and used for internal and external benchmarking more often; and
• staff begin to implement best-practice guidelines.

One particularly perplexing aspect of the evidence concerns health professionals’ views of accreditation programs. Overall, the research shows that professionals see accreditation as an effective method of promoting quality and safety in healthcare, and they are more likely to remain satisfied and employed in accredited organisations.

However other studies have found that professionals have concerns about the human and financial resources needed for organisations to participate successfully in programs, and that participation might divert attention and resources away from more (unspecified) critical organisational and system-level problems. How quality would be systematically managed and assessed remains unclear without an accreditation program. As engaging health professionals in the accreditation process is critical to its success, it would be valuable to further explore the reasons for this issue.

When taken as a whole, the published research evidence provides credible support for health service accreditation programs, but there are limitations that make it difficult for policymakers to forge ahead with confidence. The evidence base is considered to be of only moderate quality, and findings from individual studies regarding the same topics are highly contextual in many cases.

There remain major knowledge-gaps that need to be addressed to understand what aspects of accreditation programs work, in what contexts and why. These questions may be in part answered by ‘ACCREDIT’, a five-year Australian Research Council Project administered by Professors Braithwaite and Westbrook at the Australian Institute of Health Innovation, University of New South Wales. Without the robust evidence that such large-scale and long-term studies can produce, policymakers will need to continue drawing on expert opinion, small-scale program evaluations and cautious comparative assessments of the literature when reviewing, revising or implementing accreditation programs.

The 12^th National Rural Health Conference in Adelaide made 17 priority recommendations for advancing the health of rural and remote communities, with equitable access to high-speed broadband at the top of the list.

High broadband speeds are crucial for facilitating new and emerging best practice models of health care, such as those which incorporate high definition videoconferences, data exchange and high resolution image transfer, conference delegates said.

They also called for a bipartisan federal election commitment to the principles of Western Australia’s Royalties for Regions program, either through a program of the same type in each jurisdiction and/or through a sovereign wealth fund for rural development to which the Commonwealth, States and Territories would contribute.

They also want more place-based models of community empowerment and program administration in areas such as health, education, housing, employment, arts and culture, transport, infrastructure, and family and community services.

Medicare Locals and Regional Development Australia committees are examples of such place-based models in health and regional development that are already improving the quality and pertinence of decisions through a focus on local engagement and action, they said.

(The recommendations – which address infrastructure, clinical services, workforce issues and chronic conditions among Indigenous Australians, and include calls for the major supermarket chains to play a more constructive role in food security – are published in full at the bottom of this post or you can read them on the National Rural Health Alliance site).

The post below includes reports from journalist Marge Overs on presentations by the Federal Health Minister Tanya Plibersek, Professor Lesley Barclay, and Independent MP, Rob Oakeshott.

The next National Rural Health Conference will be held in Darwin in 2015.

 ***

Summarising Minister Plibersek’s presentation

Marge Overs writes:

On the National Broadband Network: It is phenomenal that the NBN is at the top of the top of your list of recommendations. We have to build it based on the needs in the future, not how we are using it now. I can’t begin to imagine how much we’ll depend on broadband 10 years’ time in bringing health care to rural and remote Australia.

On community engagement: The idea of investment coupled with autonomy right is the reason we’ve set up Medicare Locals. The reason they’re working is because we’re giving the money to the people who are working on the ground in communities.

We say to communities: have a look at the needs, we will back you with this investment and you use it flexibly and responsibly in your community for your community. That’s the way that health systems should work.

I have a lot of faith in my pubic servants in Canberra. They do an excellent job but they can’t be in every community determining need and allocating resource and nor should they be. That should be done as close to where treatment is being delivered as possible.

On the rural health training pipeline: We are working on end-to-end training from student days to practising in rural areas, and I’m waiting on the results of a review by Jenny Mason, which will soon be available.

One of the things Jenny Mason has had to wrestle with in her review are the ongoing concerns about the remoteness classification system. The system is controversial and changes will be controversial. I’m glad to report that detailed proposals for reform are undergoing technical assessment and we will then consult key stakeholders.

While I’m a city girl, some of the most rewarding experiences I’ve had as Health Minister have been seeing the marvellous work you do in your communities. We will continue to back you with dollars and policy consideration. The benefits are beginning to show but there is no room for complacency.

We have a great deal still to do to bridge the city country divide when it comes to health outcomes, but I hope we can work together to do that.

***

Summing up the conference themes: Professor Lesley Barclay 

Leadership: The conference blends old and new in terms of leadership. I welcome the newness, freshness and inspiration from emerging leaders.

Strategy and innovation: Tom Calma’s presentation showed the importance of community engagement as a strategy. If we don’t engage the community, we fail. Tom gave us some wonderful examples in his speech.

I was also thrilled to hear Louise Sylvan talking about the innovation coming out of the Australian National Preventive Health Agency. I would also like to acknowledge Alison Fairleigh, who is using social media so creatively and had such a powerful presentation.

 Evidence: Thirty per cent of the population of Australia lives in rural and remote Australia, but there is a $2 billion underfund in health. We need data to claw back some of that money.

Other key ideas and slogans that had emerged during the conference:

People possibilities: When resources are scarce, you pair up and pare down: you make sure what you do is effective and you do it together.

 Seismic shift: We need place-based services and better governance. We need to do things that matter for the people who live there.

 A fair go for all Australians: We need to go back to that. I’m sure the rest of Oz doesn’t realise we don’t get a fair go.

The quality of dying is as important as the quality of living.

And another value that came out of the conference, so beautifully summed up in Dougie Herd’s presentation about the NDIS: we need to move to an approach that realises people’s rights — not a 1970s patronising welfare-based approach.

***

Place-based models are the go: Rob Oakeshott

After the last election, the three Independent MPs told the Federal Government it had to engage better with rural and remote communities, which were screaming out for health equity, Member for Lyne Rob Oakeshott told the conference.

That is happening, he said, through an exciting chapter for community-based health strategies, but more could be done.

There was an opportunity for peak organisations such as the NRHA because placed-based models, such as Medicare Locals, were “the new black” in government thinking and were vital to building sustainability.

“Engaging communities early, empowering and encouraging and listening – that is where you get real change in social determinants of health.

“We are at a crossroads moment where central government is starting to want to reach out and wants to develop regionalised models of business and work in partnership with rural and remote Australia.”

At the same time, he said there were some exciting structural changes in government, such as the Commonwealth Financial Accountability Reforms, which would improve the accountability of government to regional Australia.

He said the “great inhibitor” of the past three years had been State-Federal relationships, but COAG had made inroads into improving these relationships. Importantly, auditors-general would have oversight over the COAG process, as the lack of oversight due to sovereign boundaries has been a problem.

“So now there is a chance of resource distribution formulas being delivered in an equitable way,” he said.

Mr Oakeshott urged the rural and remote health community to take advantage of this reform agenda.

“We are at the front end of a process where community engagement matters and government wants to get involved in that,” he said. “They may be doing it badly but don’t miss the opportunity to help them to do it better.

“Use that big reform agenda that’s happening anyway – make sure you don’t miss the opportunity. There’s a huge opportunity to get equity nailed down across the country. I hope you’re up for it.”

***

Priority recommendations

A. Infrastructure

1.Broadband

The 12thNational Rural Health Conference calls on political parties to make a bipartisan commitment to the delivery of high speed broadband to all families, services, businesses and communities in rural and remote areas so as not to entrench ‘the communications divide’ between rural and metropolitan Australia.

• The broadband infrastructure set in place must be robust and adaptable enough to accommodate future information technology developments, and to provide high speed connectivity and the coalescing of various media.

• The costs to the consumer  must be such as ensure social inclusion, with pricing models that don’t discriminate against people in rural and remote areas but facilitate availability to all who need it.

• High broadband speeds are crucial for facilitating new and emerging best practice models of health care, such as those which incorporate high definition videoconferences, data exchange and high resolution image transfer.

2. Royalties for Regions

The conference calls on political parties to make a bipartisan commitment in the context of the 2013 Federal election to the principles embedded in Western Australia’s Royalties for Regions program, either through a program of the same type in each 2jurisdiction and/or through a sovereign wealth fund for rural development to which the Commonwealth, States and Territories would contribute.

•These funds would be used to strengthen rural and remote communities, their health infrastructure and services.

•Under such programs it would be vital for regions to retain autonomy with regard to how the resources are spent.

3. Place based programs and decisions

Conference calls on political parties to make a bipartisan commitment in the context of the 2013 Federal election to legislate more place-based models of community empowerment and program administration in areas such as health, education, housing, employment, arts and culture, transport, infrastructure, and family and community services.

• These place-based planning and delivery models should be responsive and accountable to the local community.

• Medicare Locals and Regional Development Australia committees are examples of such place-based models in health and regional development that are already improving the quality and pertinence of decisions through a focus on local engagement and action.

4. Food security

Given the critical importance of nutrition to good health and wellbeing, strategic plans for population health in rural and remote Australia should include measures to ensure food security, with specific funds available for ongoing and long-term community work on food security.

• A cross-sectoral and collaborative approach should be used to develop an effective and strategic approach to food security – driven by a new inter-governmental and interagency Food Security Council.

• In the same way that Telstra has a Community Service Obligation, the major supermarket chains should be encouraged by every means to share the responsibility of improving food security in rural and remote Australia through contributing to programs that improve the supply chain and/or the local production and distribution of food.

5. Data

To measure the impact of health-related programs on the 33 per cent of Australians who live in rural and remote areas, and to assess their health status in an ongoing way, accurate and accessible data are needed that are specific to location.

This will permit analysis of health-related investment in non-metropolitan areas and the identification of effective programs that should be enhanced and of those with limited success that could be phased out.

• Conference calls for the National Strategic Framework for Rural and Remote Health to address this need for quantitative and qualitative data.

• Such data should include:

common wellness indices for all Australians, permitting comparisons between various areas (major cities, inner regional, remote);
standard frameworks for self-reporting; and
data that can provide the basis for needs assessment and regional planning.

• The data available for planning and evaluation should include medical evacuations; levels of patient assisted travel; and the use of specialist and allied health non-admitted activity provided by the States and Territories.

• Data collection practices and strategies undertaken in Aboriginal and Torres Strait Islander communities must be carried out in a sensitive and culturally appropriate way following genuine and prior consultation with Elders and/or  community representatives.

6. A National Arts and Health Framework

The role of community arts in health -for healing and wellbeing, for communicating health and lifestyle messages, and for community development – needs to be recognised by governments through their adoption of the National Arts and Health Framework that is currently before Arts and Health Ministers at Federal and State/Territory levels.

B. Clinical services

7. Indigenous eye-health

Ninety four per cent of vision loss in Aboriginal and Torres Strait Islander peoples is preventable or treatable by simple solutions. A coordinated national framework should be developed to ensure a comprehensive approach to eye health.

Conference calls on the Department of Health and Ageing and State and Territory Governments to make provision in their budgets for:

• the integration of eye health into routine screening programs, for example, ear checks, diabetes checks (to avoid retinopathy) and general health and wellbeing checks; and

• the provision of eye care services within local communities by an adequate number of Aboriginal Health Workers and Regional Eye Health Coordinators based in Aboriginal Community Controlled Health Services, with funds provided for training and support for these roles. Spectacle schemes provided by the States and Territories should be nationally consistent and comply with best-practice standards. The feasibility of a national spectacle scheme specifically for Aboriginal and Torres Strait Islander Australians should be urgently considered.

8. Aged Care

Conference calls on the Living Longer, Living Better legislation, with its focus on greater support for older people to live in their own homes and communities, to be adapted to closely address the particular vulnerabilities of older people living in rural and remote communities.

These include higher costs of living, a higher proportion with low incomes, greater isolation, and greater exposure to adverse weather events (eg heat waves, fires and floods).

Measures should include

•rural seniors’ fuel vouchers to compensate for poor access to public transport; and

• ‘safe at home’ modifications that include timely access to falls prevention modifications, air-conditioning, and reflective roofing

Pooled Commonwealth and State investment in aged and disability services should be considered in order to increase the potential for viable home services in under-served rural communities.

9. Oral Health

Good oral health is essential to general health and wellbeing. Despite being mostly preventable, as socio-economic disadvantage grows so does the incidence and severity of dental disease.

Due to their lack of access to affordable preventive and acute oral health care, those in Australia who are most seriously affected are: rural and remote populations, Indigenous Australians, the aged and those who are socio-economically disadvantaged.

To ensure that regular, preventive-oriented oral health care is available to all Australians, the 12^th Conference calls on bi-partisan political support for the National Partnership Agreement on public dental health services. It urges Commonwealth, State and Territory Governments to publicly and urgently progress the developments in the Agreement to provide equitable and accessible oral health services.

• The legislated Grow Up Smiling (GUS) program for eligible young Australians is a good start in moving oral health care into the mainstream and should be seen as the first step towards ensuring regular, appropriate oral health care is available to all Australians on the basis of need.

10. Maternity Care

Maternity care in rural and remote Australia should be community-oriented and focus on services that meet the needs of women, families and the community. There is an urgent need to implement more innovative models of maternity care. These care models should reflect the goals and practices espoused in the national Maternity Services Plan, incorporate evidence-based care, meet population needs and include effective linkages and networks to higher-level services.

• Employment of Bachelor of Midwifery graduates should be encouraged within these models. To facilitate this, Conference recommends that the term “Named medical practitioner” in COAG’s Standing Council Health Determination be changed to “Health provider organisation” with minimal delay.

• Mentoring systems, similar to those offered in medicine and nursing, should be implemented for new midwifery graduates.

• Professional development for those delivering maternity services must be multidisciplinary, with supervision and mentoring provided across the entire team and equitably funded across professions.

11. Early Childhood

The vulnerability of children in rural and remote communities, including Aboriginal and Torres Strait Islander children, those with a disability, homeless children and those exposed to violence, is compounded by the impacts of key social determinants of health in these settings such as family income levels and access to education, health care, transport and support services.

• To ensure a bright start to life for country children, the 12th Conference looks to Megan Mitchell, the recently-appointed National Children’s Commissioner, to lead a cross-sectoral, rights-based approach to addressing the issues affecting children living in rural and remote areas. This work should include the collaboration of all involved government departments and agencies, and focus on the provision of child-centered, early intervention services.

12. Metro-rural services link

Specialist health services in rural areas should not be dependent on tenuous links with metropolitan services and the good will of visiting specialists. Such ad hoc relationships, whether in the public or private sectors, should be replaced by service agreements and clinical governance structures that ensure continuity and networking of services in rural areas.

• Formal arrangements should be instituted between metropolitan and country services that withstand the test of time and changes in personnel, and which build workforce and service capacity in country locations by providing nurses and allied health professionals with links to tertiary services, supervision and case conferencing, and support technologies (including telehealth) for timely advice and expertise.

C. Workforce

 13. Allied health, sector integration and National Disability Insurance Scheme (NDIS)

The current focus on the NDIS highlights the key role played by allied health professionals in disability and rehabilitation services. In rural areas there is an urgent need to increase sustainable allied health services, by integrating disability, aged and health care.

• To expand the availability of allied health services to meet the increased demand from sectoral integration (health, aged care, disability), funds should be allocated to enable local residents to undertake Cert IV in Allied Health Assistance.

• A supervision framework for allied health professionals, students and assistants must be provided.

• This will increase access to allied health services, enable allied health professionals to take leave and professional development entitlements, and provide local employment for local people.

14. Telehealth

Australia is ready for telehealth development that does not undermine the provision of face-to-face specialist services in rural and remote areas and is driven by clients’ needs, not by commercial gain and efficiency at the expense of quality care.

• Conference calls for additional program funds and a flexible approach to access (specialist to patient; GP and nurse to patient; Aboriginal Health Worker to specialist and patient; midwife to mother-to-be) which would include store-and-forward services as well as real-time consultations and would be unaffected by State and Territory borders. These telehealth services will be underpinned by broader MBS items and appropriate training and support.

• Telehealth developments should focus on practical, regular interactions in challenging communication environments and will include monitoring as well as video consults, interim reviews between consultations, and professional supervision sessions.

• In view of the need to systematise and integrate telehealth care into rural and remote practice, Conference calls on government to continue the work of the ACRRM Telehealth Advisory Committee and to provide resources for the evaluation of approaches to guide future development.

15. Maximising student advocacy and leadership

Conference calls on all health organisations, in their work on reforming healthcare in Australia, to engage closely and meaningfully with health students and early career health professionals. Health students and early career health professionals offer a unique perspective on the healthcare system and should be actively engaged in health reform alongside mid and late career health professionals and sector leaders.

Priority issues currently being promoted by students and other future health leaders include:

• that support for rural clinical placements currently offered to medical students should be extended to students of other health professions; and

• that guidance and mentoring of emerging clinicians and leaders from established health professionals is critical to effective support and succession within the sector.

16. Generalism

There should be a national campaign led by Health Workforce Australia to promote the importance and rewards of generalist health practice as a specialty in its own right, and one that is essential to leading and providing health care in rural and remote Australia.

• Well-supported and easily-navigated training pathways to rural generalist careers need to be developed and articulated in medicine, nursing and allied health.

D. Managing Indigenous Chronic Conditions

17. Indigenous chronic conditions

A number of the plenary and concurrent session presentations made it clear that significant advances in rural and remote health would be made with the introduction of greater numbers of Indigenous health promotion campaigns addressing hypertension, heart disease and diabetes. These targeted programs would help address the social determinants of health and must be designed to fit local circumstances and meet the needs of various demographic groups. They would address smoking, obesity, physical activity and alcohol consumption, and should be evaluated to provide guidance on the most effective approaches.

• The importance of local community engaged leadership is powerfully demonstrated in a number of the presentations and is essential, together with innovative technologies such as mobile phone apps.

****

Previous Croakey articles on the 12th NRHC

• Governments abrogating their responsibilities in public health

• The story of the Broken Hill Table Tennis Club and its significance for rural health

• Central Qld study shows impact of mining boom on health services

• Online connections critical for rural health

• Recognising an unsung hero – and some vox pops

• NDIS is shifting the paradigm, and the balance of power

• Talking about some good news in Aboriginal health

• An update on efforts to reduce Indigenous smoking

• Spotlight on Indigenous health and the value of physician assistants

• An uplifting start 

• What does it take to address the social and economic determinants of health in rural and remote Australia?

• What are the critical health issues for rural and remote communities?

• Introducing a new Croakey service, launching at the national rural health conference

Details and declarations re the Croakey Conference Reporting Service are outlined here.

If you missed the release of the McKeon review on Friday you’re not alone. The Commonwealth government released theStrategic Review of Health and Medical Research just before the weekend – a time usually reserved for reports the government would rather bury – and it barely got a mention in the mainstream media.

The government commissioned the review panel, headed by Simon McKeon, in 2011 to investigate the state of health and medical research in Australia. The panel released a consultation paper October and delivered the final report to government in March.

The review sets out a ten-year strategy to better integrate health and medical research into the public health system. To improve the health system and contain its rising cost, the report states that “research must be routinely performed as a part of health-care delivery and there must be greater linkage between health-care providers and research organisations.”

This is an energising vision. The current reality could hardly be more different. Apart for pockets of clinical research, such as drug trials and evaluation research by specialist clinical groups to assess the effectiveness and worth of medical interventions in real-life scenarios, research is not a strong player in the health system.

As a result, the connection of health services to research is informal and erratic, with estimates that 43% of Australians not receiving appropriate, evidence-based care. The CareTrack Australia study found that nearly 90% of patients with sinusitis were prescribed antibiotics, where this was known to be ineffective. And just 18% of asthmatics had a documented action plan for when they had an attack.

The solutions

The McKeon Review explores how this might be remedied.

First, money. The report calls for the investment of 3-4% of government health expenditure in health and medical research, up from around 2%, or A$1-1.5 billion.

The rub will be in the extent to which this increased investment will be shared among state and territory health ministries and the Commonwealth.

But motivation to invest may be stimulated by the formation of integrated health research centres (IHRCs) which combine “hospital and community-care networks, universities, and research organisations such as medical research institutes”. These institutions would give state and federal governments a stake in the research conducted within them, with an open corridor to apply the research in the associated health-care facilities.

Strategic research, which encompasses research with a specific, practical focuses such as vaccine development and the evaluation of different forms of care for the frail aged, would be elevated from single figures to consume 10-15% of the National Health and Medical Research Centre (NHMRC) budget.

This would be politically feasible only if the NHMRC budget was simultaneously increased: push-back from the laboratory scientists would otherwise prove intractable.

Second, dedicated funding will be needed to grow capacity within the research empire to contribute to the quality and efficiency of health services through research. At present, health services research sits low on the status totem of research, and funding for the development of a research workforce in this field is low, although it is growing.

Third, Australia should maintain its current excellence in research. This would enable Australian research to hold its head high in international research forums, rapidly access research findings for application in Australia, and grow the intellectual base of research so it can support applied and health service research efforts.

Potential barriers

When grand plans such as these emerge, we need to ask who’s buying and who’s selling. We need to see what the buyer (the various arms of the health service) will get for the money it is expected to contribute. The seller (the research community) will need to come up with far more impressive evidence that it can indeed help cut health care costs, improve quality and increase efficiency.

If the federal government considers the proposals to be good, it will need to reach deep into its pockets to convince the buyers that this is the product they have been waiting for. Federal health minister Tanya Plibersek has said she will take the report to the standing council on health for discussion with the states and territories. Her reception will be much warmer if she comes carrying gold.

Whatever is decided, any implementation implies change. I can’t imagine that the change required by this report will happen without elaborate, deliberate and adequately-funded management.

For the McKeon report to succeed, we will need to invest more resources into bridging the cultural and intellectual gap between health services and research, which is currently very wide. Those who manage the system and focus on health-care delivery do not necessarily share the enthusiasm or expectations of career scientists.

Indeed, translational research (a very popular term without clear meaning) will need to go far beyond introducing a laboratory insight at the bedside. Clinicians will need to feel that the questions they are asking are being taken seriously by the research community. This is an exciting challenge, although a large one.

Overall, the McKeon review provides an energising view of what could be done to bring health care and research together in productive partnerships. Every innovative industry needs high quality research and development – and health is no exception.

** Stephen Leeder is a professor of public health and community medicine at the University of Sydney and chairs the board of the Western Sydney Local Health District.

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence. 

In his presentation to the 12^th National Rural Health Conference in Adelaide yesterday, Dr Calma gave an overview of the program’s work, and rebuffed Federal Opposition criticisms.

At the bottom of the post is a link to a rural and remote health update from the COAG Reform Council.

***

Working with communities to reduce smoking 

Marge Overs writes:

Dr Tom Calma urged politicians to listen to people from the community to inform the directions needed to improve Aboriginal and Torres Strait Islander health.

We have to give people the opportunity to understand the issues, and we need partnership and capacity for people to take control of lives, he told the conference.

“If we do that right, we will see sustainable change, particularly in Aboriginal and Torres Strait Islander people. I urge politicians to stay focused, and to listen to people from the community to inform the directions we need to take.”

Dr Calma took issue with Opposition criticism of the $100 million program to tackle Aboriginal smoking, which he leads.

“It is early days in these programs and that’s why I get cranky when I see the Opposition spokesperson talk about the waste of $100 million. He’s not informed. The Opposition needs to understand what the real effects of these programs are – they are having an impact, we talk to people in a way they understand. We show them in practical terms what smoking is doing to them,”

Dr Calma outlined the many ways the tobacco program is helping to reduce tobacco use in Aboriginal and Torres Strait Islander people – around half of Aboriginal people smoke, with rates as high as 70-80% in some communities.’

A 2010 study showed that mass media campaigns don’t work, so the Tackling Indigenous Smoking Initiative is working in many ways in communities, rolling out teams across the nation.

Fifty-seven regions have been identified and will generally receive one regional tobacco coordinator, three Tobacco Action Workers and two healthy lifestyle workers. These teams work on the ground in communities, developing local programs that suit their communities and are available for one-on-one support.

In other initiatives, the Tackling Indigenous Smoking Program is:

Enhancing the Quitline, so it can provide accessible and appropriate services to Aboriginal and Torres Strait Islander peoples.

Enhancements include cultural sensitivity/ awareness training for staff, and nine Indigenous staff have been employed.

“A lot of effort has gone into Quitline enhancements to encourage Indigenous people to call the Quitline and we have seen a significant increase in number of Aboriginal and Torres Strait Islander people calling Quitline,” he said.

The Cancer Council SA is delivering the national implementation of the Quitskills Training Program to increase the number of qualified professionals working with Aboriginal and Torres Strait smokers and their communities. Quitskills provides accredited training in three Certificate IV units in smoking cessation.

Work in social marketing and communication

Teams with vehicles head out in communities to spread the word about healthy lifestyles.

“The whole message is about working with families and telling real stories.

These teams can go out anywhere, erect a marquee, have a community event and inform people. They are all well kitted out in high visibility so people know support is there. I’ve see grown men cry, knowing someone cares.”

Local messages: creating posters at local levels that have more impact (see slides).

Experience and research has shown that Aboriginal people prefer true stories with real people over graphic imagery, and want to hear success stories about quitting. It is also important to use Indigenous peoples, languages, themes, stories and artwork/ imagery in any materials.

In the run up to the election, Dr Calma urged the government and opposition to stay focused on their commitment to the national Closing the Gap agreement (which, as recently reported at Croakey, is due to expire soon).

“They need to stay focused and we need to help them stay focused.  Part of that agreement is about developing a national plan of action, and that is well progressed with government and peak bodies.

 (Thanks to Gerry Considine and Helen McGowan for the photos of Tom Calma).

***

Update from the COAG Reform Council

How can the COAG Reform Council’s reports be used by advocates for rural and remote health? Councillor Sue Middleton gave some suggestions in her speech, which can be read in full here.

The Council is next month due to release its fourth annual performance report under COAG’s national healthcare agreement, with a supplementary report on health outcomes in rural and remote areas.

Amongst other things, it will look  at some of the interplay between socioeconomic disadvantage and rural location for indicators like smoking rates and obesity, Ms Middleton said.

No doubt many will be hoping for improvements on the existing indicators for rural and remote health, which Ms Middleton summarised as per below:

• People outside major cities report higher levels of financial barriers to care and report longer waiting times for GPs — both these results are statistically significant.
• People in the most remote areas have much higher rates of lung cancer, while people in regional areas have higher rates of melanoma.
• We also noted last year an apparent increase in rates of bowel and female breast cancer in more remote areas, though more years of data are needed to determine conclusively whether there is a trend.
• People in rural and remote areas are hospitalised at a much higher rate than people in the city for conditions or causes that were amenable to prevention or early intervention through primary care. Compared to major cities, these rates were:

10 % higher in inner regional areas

22% higher in outer regional areas

60% higher in remote areas

and 75% higher in very remote areas — where more than 5 in every hundred people are hospitalised for a potentially preventable reason every year.

• And, while it should be noted that survival rates overall have increased, when people outside major cities are diagnosed with cancer, their survival rates are lower than for cancer patients in major cities.
• For older Australians, waiting times for residential aged care increase clearly as you move outside major cites —  and not surprisingly, the rate of residential aged care places falls.

“To date, COAG has not yet fulfilled its aspiration to provide all Australians with timely access to quality health services based on need, nor on their capacity to pay or where they live,” Ms Middleton said.

***

Previous Croakey articles on the 12th NRHC

• Spotlight on Indigenous health and the value of physician assistants

• An uplifting start 

• What does it take to address the social and economic determinants of health in rural and remote Australia?

• What are the critical health issues for rural and remote communities?

• Introducing a new Croakey service, launching at the national rural health conference

Details and declarations re the Croakey Conference Reporting Service are outlined here.

As future funding arrangements are developed, it is important that decision making is informed by reliable data and contextual understanding, says Selwyn Button, CEO of the Queensland Aboriginal and Islander Health Council.

***

For true primary healthcare and better outcomes, support community controlled healthcare

Selwyn Button writes:

Over the past few weeks, authorities have released a number of reports about the performance and expenditure of our national health system, and some of these relate directly to efforts aimed at improving the health of Aboriginal and Torres Strait Islander people.

This might seem a good thing on face value, as we need to know whether our efforts are making any difference, and where to direct resources in future to ensure ongoing outcomes.

But if this information is used without the appropriate context, it may be used as a means of reducing expenditure on Aboriginal and Torres Strait Islander health, in the name of creating ”efficiencies”.

This presents a significant risk for Aboriginal and Torres Strait Islander communities, as we continue efforts in improving the health of our people, while remaining at the whim of Ministers and government officials who rely on this information to determine policy priorities and resource investments.

What is needed now is for governments to re-think how we analyse, interpret and use data to inform ongoing priorities, practice and future innovation.

Firstly, let’s take the National Aboriginal and Torres Strait Islander Health Performance Framework report released in early 2013. and used as the main body of evidence for the Prime Minister’s Close the Gap Report card.  

This report clearly demonstrated that the most significant gains in access to care and improvement of outcomes is and continues to be achieved through the national network of community controlled health services.

Upward of 75% of health improvements outlined in the report were directly attributed to the community controlled sector, and clearly justifies the increased investment into community controlled services as the most appropriate provider of healthcare for Indigenous people as they are making the best health gains.

Secondly, let’s consider the most recent Indigenous Expenditure report of 2012 produced by the Productivity Commission, that averages overall Medicare expenditure on Indigenous people as 60 cents in the dollar compared to the rest of the Australian population.

As many readers would be aware, Medicare was created as a safety net to ensure that all Australians get access to required care and benefits through quality primary health care services.

With community controlled services focused on providing comprehensive primary health care to our people, efforts in increasing access to an individual’s entitlements through Medicare can and will be best achieved by our organisations.

In spite of this data, we now have more recent releases stating the overall expenditure of the National health budget is 1.5 times greater for Indigenous people than the broader population.

Additionally, we have received further data stating that mortality rates for certain illnesses are only reducing by slight amounts and chronic diseases are still high placing burden upon the public health system.

Although much of this information is already 2 years old by the time it is released, it fails to identify why much of the burden is borne by secondary and tertiary public health systems, as access to comprehensive primary health care is still limited for our people nationally.

Consequently, when you don’t have access to quality primary health care, many of our people will present at secondary and tertiary facilities when their issues have escalated to a point where hospital is the last resort, requiring treatment for not only one health condition, but generally 2 or 3 issues.

Even though we have over 150 community controlled organisations across the country, our services do not exist in every corner of the nation, and fundamentally this would be impossible to achieve without enormous costs involved.

Alternatively, what we should be aiming to achieve is to have a strong community controlled presence providing quality care to our communities in all areas with populations greater than 900 residents focused on increasing access to comprehensive primary health care.

Why primary health care?  Current and historical research by credible researchers have proven that the most effective means of delivering care and improving outcomes for Indigenous people is through community controlled services.

Health economists such as Professor Theo Vos and colleagues identified this in their work in assessing cost effectiveness of primary prevention activities across all health providers.  This work clearly highlighted that compared with government-run, mainstream and private services, community controlled organisations achieve close to 50% better outcomes than other providers in delivering care to our own people.

Although this method was documented to be more expensive than other models, the focus on outcomes should not be lost, as the only variable included in his analysis that increased the overall expenditure against the model was transportation services for clients.

Due to the implementation of a comprehensive primary health care model, transport services are a core component and will always be included within the community controlled delivery of care, which does not diminish the model but does and will continue to achieve far greater outcomes.

Unfortunately, the notion of ‘If you build it he will come..’ only works for Kevin Costner in the movies, and does not work to improve health outcomes for our people.

With all this data now publicly available for all to review and analyse, we must hope that in determining future policy and funding priorities for Indigenous health care, consideration is given to understanding the context and reliablity of the information.

Importantly, there already exists some credible evidence that encapsulates comprehensive primary health care delivery into a set of core functions.  This research was conducted and undertaken as a partnership between all healthcare providers, and should be the central component of any current and future policy debate about improving the health of Indigenous people, as it is widely accepted within the community controlled sector as the gold-standard in health service delivery for our people.

This work is the Core Functions of Primary Health Care in the Northern Territory, and with minimal adjustments to ensure local contexts are considered can and is applicable across all parts of the country.  Utilising the Core Functions as a means to support improving outcomes goes a long way to encapsulate high quality service delivery standards with current data and information to ensure that we are all targeting the right priorities, through appropriate mechanisms.

This was not evident at start of the COAG investment to support overall Indigenous improvements, which saw over 65% of the entire $1.6B commitment channelled into mainstream and government-run service providers, as it was determined the most effective way to improve outcomes.  Data was used showing that 70% of our people access care through government-run and mainstream services.

New data and information available now rebuts this myth that community controlled services have struggled with over the last 4 years.

Information now available within the community controlled sector shows that over 40% of Indigenous Queenslanders access care regularly through community controlled services, yet we are not in every part of the state.

With the end of the current Indigenous Health National Partnership Agreement set for 30 June 2013, we need to ensure that all of the relevant information and context is considered as part of ongoing discussions, policy setting and resource allocations to improve the health of our people.

Consequently, we are confident that this evidence will lead to what we have been seeking for many years – an increased investment in those services known to make a difference to the health of our people.  That is community controlled organisations.

• Follow Selwyn Button on Twitter @qaihc

During the four years over which the Australian Dietary Guidelines were drafted, attacks on the contents came from many quarters. There are many vested interests so these attacks were not unexpected. The most effective means of countering such attacks is to base guidelines firmly on evidence.

The Guidelines were based on examination of around 55,000 individual pieces of evidence and were assisted by advanced modelling. This modelling was undertaken so that the guidelines could talk about foods, rather than ingredients, and therefore were more understandable to readers seeking guidance – clearer and more practical that previous versions.

For the first time for NHMRC’s public health guidelines, we used an approach analogous to that used for clinical guidelines. That is, we considered around 55,000 pieces of evidence and inclusion/exclusion criteria were applied. Data was extracted from the included studies and assessed, with the body of evidence for each research question graded as excellent, good, satisfactory or poor according to rigorous systematic literature review methodology and standard NHMRC protocols. Criteria were then used to make recommendations based on this body of evidence (for example, , there being at least 5 confirming independent pieces of quality evidence, and the studies focussing on foods, not nutrients ). This rigour was the bulwark of our defence against the vested interests, who tend to rely on one or two favoured pieces of evidence.

The guidelines are aimed at health professionals such as general practitioners and dieticians and therefore the issue of social equity was covered with this audience in mind. While there is a relevant appendix, the ‘practical considerations’ and ‘practice guide’ sections of each main Guideline chapter cover considerations for particular groups (e.g. lower socioeconomic status) where relevant. Most importantly, development of the underlying advice took social equity considerations into account, for example in the modelling of dietary patterns and the range of foods depicted on, and flexibility of, the ‘Food Plate’.

As far as the environmental impact of food choices was concerned, we were certainly aware of its importance and that patients and clients increasingly approach their health professionals with a concern about the environmental impact of their choice of food.
Early attempts to include recommendations on the sustainability of food choices were questioned by the Council of NHMRC as lacking a level of evidence rigour comparable to that of the main Guidelines as described above. Other government agencies pointed out that specifically Australian evidence was often lacking, with farming practices here differing markedly to those in Europe and the US where most evidence is from. Secondly, there are many factors that influence environmental sustainability (such as emissions, water use, soil degradation, energy use, storage and transport), but many studies tended to concentrate on a subset of these factors, making it hard to draw rigorously evidence-based overall conclusions. In short, the state of the Australian evidence and the complexity of issues outside the health arena were such that more work is needed in order to provide recommendations at a comparable level of evidence as for the main dietary advice.

So, more work is needed. For this reason, I have asked my staff to continue liaising with the other government agencies on the current status of evidence on dietary choices and the environment, agreed definitions of key aspects, and practical strategies and approaches for Australians. I am very hopeful that this can yield similar strongly evidence based advice in the future. As we have learnt in the last three years, resisting the claims of vested interests is best based on the most rigorous evidence available.

Meanwhile, as the new Australian Dietary Guidelines state, not eating too much, not wasting food, eating a wide range of nutritious foods from the five food groups and limiting our intake of the foods mentioned in Guideline 3 can contribute to limiting our environmental impact.

The Dietary Guidelines are supported by the Eat for Health website. On this website, the sections on companion resources, food essentials, eating well and the eat for health calculators all contain material that may be of interest to Croakey readers.

The Institute’s Chair, Patricia Anderson, writes below that the Institute has a strong record of achievement, and she encourages Croakey readers to support a campaign urging the Federal Government to continue funding to the Institute.

***

Lowitja Institute legacy under threat as funding expiry looms

Patricia Anderson writes:

Just over four years have elapsed in the Closing the Gap program that represents the commitment by all Australian governments to improve the lives of Aboriginal and Torres Strait Islander Australians.

Tangible progress is being made and there are positive signs in some health indicators. For example, the reduction of mortality rates for Aboriginal and Torres Strait Islander children under five.

However, this program stretches out to 2031 and much work remains to be done. Now is not the time to pull back on either funding or effort.

Within the space of a week in February this year Prime Minister Julia Gillard made two key parliamentary addresses focused on her Government’s commitment to Aboriginal and Torres Strait Islander people: the fifth annual Closing the Gap Statement, and her debate speech introducing the Act of Recognition into the House of Representatives.

Both speeches were notable for the bipartisan support they attracted from across the political divide, reflecting the building groundswell of national support for improving the lives of Australia’s First Peoples and achieving lasting reconciliation.

Given this, it seems anomalous that the Lowitja Institute – Australia’s only Aboriginal and Torres Strait Islander organisation with a pure focus on facilitating research into Aboriginal and Torres Strait Islander health – should find itself under threat of closure.

How could this be?

First, a brief history: the Institute traces its origins back to the foundation of the Cooperative Research Centre (CRC) for Aboriginal and Tropical Health in 1997, which was followed by the CRC for Aboriginal Health in 2003 and then the CRC for Aboriginal and Torres Strait Islander Health (CRCATSIH) in 2010.

The Institute was established in 2009 initially as the host organisation for the CRCATSIH but with the ultimate aim of becoming a permanent facilitator of research into Aboriginal and Torres Strait Islander health when CRC funding expires in June 2014.

And herein lies the dilemma. Under the rules governing the Commonwealth’s CRC program, no CRC can be funded for more than three terms – and so there is no possibility of further allocations to the Lowitja Institute’s hosted CRC.

Knowing this, the Institute also put in place a clear strategy to seek funding for a permanent institute beyond 2014 from the private and philanthropic sectors. However, in 2009 not many foresaw the severity or extent of the international financial calamity of 2008 and the implications this would have for budget bottom lines, and thus for fund-raising.

Despite this, our representations to government to secure ongoing funding continue in earnest and we are confident we will ultimately succeed in establishing a permanent and independent future for the Lowitja Institute.

Our achievements

Over the past 16 years we have provided vital financial and in-kind support to more than 200 research projects focused in areas such as chronic conditions, the social determinants of health and primary health care.

To cite just a few examples, this research effort has led to new ways of treating scabies (a prime causative factor in rheumatic heart disease), new approaches to the provision of mental health care in remote communities and the establishment of a network of more than 200 health centres across Australia using innovative continuous quality improvement tools and techniques.

Our work has contributed to the setting of Closing the Gap health goals, especially in the area of chronic conditions and tobacco consumption. For instance, a Showcase we helped organise at Parliament House in Canberra in 2008 influenced the Federal Government’s subsequent decision to invest $100.6 million in its Tackling Indigenous Smoking strategy.

Most recently, our support has contributed to the establishment of a National Indigenous Cancer Network (NICaN) and a Centre for Research Excellence in Aboriginal and Torres Strait Islander Cancer, and our funded research continues to inform the Closing the Gap program.

The Lowitja Institute is currently funding a range of projects across three program areas, including the clinical trial of a Streptococcus vaccine, a study of Aboriginal child mortality in Victoria, a national appraisal of CQI initiatives in Indigenous primary health care and a review of government efforts to improve funding and governance arrangements for providers of primary health care in Aboriginal and Torres Strait Islander settings.

Just as importantly, our early work on how best to undertake Aboriginal and Torres Strait Islander health research has contributed to improvements in the way research is conducted outside the Lowitja Institute.

Our emphasis on community involvement in the development and approval of research proposals has ensured that our funding is focused on community priorities, and this approach is now used widely.  We believe we have, in partnership with the community controlled sector and other partners, changed the way in which Aboriginal and Torres Strait Islander health research is undertaken in Australia.

We also have a strong commitment to ensuring research findings are translated into practice through knowledge exchange, principally through collaborations with our 14 research partners but also through workshops, roundtables and headline events such as the biennial Congress Lowitja.

Our most recent Congress Lowitja was held at the Melbourne Cricket Ground (MCG) in November last year and was in fact focused on the twin themes of Knowledge Exchange and Translation into Practice. The conference brought together some 250 leading health researchers, practitioners, policy makers, community health representatives and others with an interest in Aboriginal and Torres Strait Islander health to share ideas and research findings. It also provided a forum for a discussion about the future of Aboriginal and Torres Strait Islander health research, and the funding shortfall confronting the Lowitja Institute.

As a result of this discussion, Congress delegates drew up a short statement outlining the key role the Lowitja Institute and its predecessors had played in the Aboriginal and Torres Strait Islander health sector. This ‘MCG Statement’ calls on the Australian Government and all political parties to commit to the ongoing funding of the Institute, noting that just 1 per cent of the National Health and Medical Research Council’s $800 million recurrent budget ‘would double the current funding to the Lowitja Institute’.

‘The Lowitja Institute since its inception has been able to bridge the gap that previously existed between researchers and Aboriginal communities,’ the MCG statement says. ‘It has been a leader in the incorporation of an evidence-based approach to Aboriginal health both in terms of services and programs and policy, [and] its research agenda has helped shape Aboriginal health policy and practice throughout the nation.’

‘Now more than ever we need to build on this success and strengthen, not weaken, the use of research and incorporation of evidence in to practice in Aboriginal health so that the gains that have been made continue.’

We feel confident that our efforts to secure government funding will be honoured, and we can continue our vital work. Our proud history as an Aboriginal and Torres Strait Islander-led health research organisation is too important to forego, and we trust that with the support of our health sector peers we will be able to continue to making a significant contribution to the health and wellbeing of our people.

To read the MCG Statement in full, to see how others view our role in the health sector and to register your support, please click here.

• Patricia Anderson is Chair of the Lowitja Institute

Dr Merkes writes:

A team of medical researchers has recently issued another challenge to the still widely held view that animal research benefits humans. Dr Junhee Seok, together with 38 other medical scientists from across the US and Canada, published a study with the title “Genomic responses in mouse models poorly mimic human inflammatory diseases”  in the Proceedings of the National Academy of Sciences of the United States of America (open access).

The authors report on a systematic comparison of the genomic response between human inflammatory diseases and murine (rat and mouse) models. They looked at burns, trauma and sepsis (infection in the blood).

The mouse model

Mice are one of the most commonly used species in the laboratory. Because they share genes with humans, it is widely assumed that they provide useful models to research human diseases such as cancer, cardiovascular diseases and diabetes.

Compared to other animals, mice are small, relatively inexpensive, and easy to breed and keep. The use of genetically engineered mice who can mimic diseases has become quite common.

While the mouse is considered a good model by many biomedical researchers, others have questioned how well mouse models reflect the complex physiology of human disease.

What did the researchers find?

The researchers of the recently published study found that the genomic responses to different acute inflammatory stresses are highly similar in humans, but these responses are not mirrored in the current mouse models. The mouse immune system and the human immune system do not respond in the same way to stress. The researchers could not find more than a random association between the murine models and the human conditions.

Consequently, drugs that are beneficial to mice and rats may or may not work for the same conditions in humans. They may even be harmful.

The authors of the study conclude that their “study supports higher priority for transitional medical research to focus on the more complex human conditions rather than relying on mouse models to study human inflammatory diseases” .

Animal models are not useful to study human diseases

I have argued elsewhere that animal models are not predictive of human health. This is also the opinion of many experts in the field (see examples 1,2,3,4,and 5 )

Dr Andrew Knight, a European Veterinary Specialist in Welfare Science, Ethics and Law and Fellow, Oxford Centre for Animal Ethics, has recently published a book titled “The costs and benefits of animal experiments”  in which he reviewed over 500 scientific publications about the contributions of animal experimentation to human healthcare and the extent to which laboratory animals suffer. He concluded that actual human benefit is rarely – if ever – sufficient to justify the costs.

This new study about mouse models and inflammatory diseases provides further evidence for the problematic use of animals in biomedical research. But will it stop funding bodies to continue financial support for research that is so fundamentally flawed? Will it encourage researchers to change their long-held beliefs in the usefulness of animal models? Will it propel the general public to question the myth of animal experimentation leading to cures for common diseases?

There are alternatives to animal research. Initiatives such as the Innovative Methods and Alternatives to Animal Research Unit  at the John Curtin School of Medical Research, Australian National University, provide support to the research community in finding alternatives to using animals in biomedical research.

Dr Seok and his colleagues had tried to publish their findings in several journals. While the reviewers did not find fault with the paper, one of the authors reported that “the most common response was, ‘It has to be wrong. I don’t know why it is wrong, but it has to be wrong.’ . Long-held assumptions are difficult to let go.

A paradigm shift towards non-animal alternatives

We are seeing a paradigm shift  in biomedical research from using animals to using non-animal alternatives. Anomalies are appearing in the animal research paradigm with increasing frequency. Seok and his team have added to the body of evidence that highlights the anomalies. There is denial and disbelief from those working within the paradigm, as the above quoted response from the reviewers shows. It will be some time before the paradigm collapses and animal research will be a practice of the past. Until then, we must keep exposing its inadequacies.