Firstly, the mental health announcements suggest some realisation of the long-stated ambition for whole-of-government policies in health. And the emphasis on Medicare Locals in these announcements is also good news, he says.

***

All things considered, the budget reflects well on health portfolio

Robert Wells writes:

Ross Gittins makes the comment in the Sydney Morning Herald (11 may 2011) with respect to the 2011 Budget that ‘there’s nothing like having your back to the wall to focus your mind’.

This comment is particularly apt in relation to the health component of the Budget.

For the first time in many budgets, health has had its back to the wall and has come up with the goods.

Not only are the measures just what is called for, especially in mental health, they are targeted, challenge many of the vested health interests and are sufficiently modest in scope to have a good chance of effective implementation now.

Others will comment on specific measures – or complain about what has been left out.

I want to highlight what are two of the most promising features – the ‘whole of government’ approach to mental health; and the linking of delivery of implementation to the new reform structures, Medicare Locals.

‘Whole of government’ has been a rhetoric of successive governments since the mid ‘noughties’ and of profound pronouncements by the Council of Australian Governments (COAG).

Unfortunately the reality has been well short of the rhetoric, with a couple of exceptions.

The 2011 mental health measures correct the rhetoric/reality imbalance with a coordinated strategy across DoHA, FAHCSIA and DEEWR to tackle the social, housing and service access issues that have bedevilled attempts to tackle mental health in Australia.

This will all be overseen by a new National Mental health Council located within the Prime Minister’s portfolio.

Further, the implementation of key elements of the mental health package will be delivered through the new Medicare Locals, key planks in the primary health care reform.

Medicare Locals should be the best place to embed these new measures – the flexibility inherent in several of the measures will allow local responses to locally identified needs and in a timely way.

There are of course some major challenges ahead – not the least of which is that the Medicare Locals do not yet exist and getting them up and running as well as taking on the challenges of mental health reform will be a big ask indeed.

Others are also concerned that the group is dominated by industry interests.

In one of two commentaries below, Associate Professor Mark Lawrence, from the WHO Collaborating Centre for Obesity Prevention at Deakin University, says  Australia urgently needs a food policy that integrates heath, social, economic and environmental considerations.

And Franca Marine, executive officer of the Australian Chronic Disease Prevention Alliance, warns that we risk ending up with a plan that looks after the food industry rather than the greater public good.

How government silos are scrambling food policy
Associate Professor Mark Lawrence writes:

An extraordinary disconnect in Australian food policy development occurred yesterday.

First, the Prime Minister’s Science, Engineering and Innovation Council (PMSEIC) released its Report, ‘Australia and Food Security in a Changing World’, highlighting among other issues the need for an integrated health, social, economic and environmental response to our food and nutrition challenges.

Second, the Department of Agriculture, Fisheries and Forestry (DAFF) hosted the first meeting of a food policy committee that will lack the capacity to address three of these four critical policy considerations identified in the PMSEIC report.

This missed opportunity for a meaningful food policy approach comes on top of last week’s question time in the Senate. Hansard records that the Minister responsible for the Innovation, Industry, Science and Research Portfolio was questioned about his portfolio’s plans to develop a food manufacturing strategy separate to the DAFF food policy plan. The Minister was further questioned whether there exists a ‘silo’ mentality to how food issues are addressed among government departments.

Australia urgently needs a high level government commitment to a coherent food and nutrition policy and not the current approach that results in the most pressing food and nutrition challenges falling between the cracks.

What is needed is a policy that integrates health, social, economic and environmental considerations and is overseen at the highest level within government to enable it to coordinate the roles and responsibilities of those government departments that influence components of the food system (health, agriculture, transport, education, industry, finance, environment, etc).

***

Public health and the environment deserve a bigger priority in policy
Franca Marine, of the Australian Chronic Disease Prevention Alliance, writes:

The development of Australia’s first national food plan seems to have been hijacked by industry judging by the membership of the National Food Policy Working Group just announced by the Minister for Agriculture, Forestry and Fisheries.

Although nutrition is the primary purpose of food and the nutritional value and safety of the food supply are critical for public health, the Working Group includes only one representative with any nutrition or public health expertise.  Industry on the other hand has ten representatives.

With obesity one of the greatest public health challenges facing Australia today to which food is a critical contributing factor, it is vital that the public health perspective is brought to the table in any discussions on national food policy. The potential population health gains from improving the nutritional profile of our food supply are enormous.  Just reducing salt intake by 25-30% could see a 20% drop in heart attacks and strokes, two of Australia’s biggest killers.

In fact the development of a national food plan was recommended by the National Preventative Health Taskforce within the public health context of obesity prevention, so the paucity of public health representation on the Working Group is particularly frustrating. Sustainability expertise also seems to be lacking.

The objectives of a national food policy must be to create a safe, sustainable, accessible and affordable food supply that meets the nutritional and health needs of our population well into the future.

Yes, the interests of those who produce, process, transport and sell food are important.  But so is our health and well being and that of the planet.

If the government is serious about developing a National Food Plan that addresses these issues, then it needs to make sure public health and environment are better represented.  Otherwise we will just get a plan that looks after the food industry.

Health policy analyst Jennifer Doggett writes:

All consumers, with the possible exception of medical specialists and senior health fund executives, should welcome Health Minister Nicola Roxon’s announcement that she will re-introduce legislation to means test the private health insurance (PHI) rebate.

As an industry welfare measure, the rebate has undoubtedly been successful. However, as a health funding mechanism, this scheme is a disaster. Study after study has found that it has virtually no impact on fund membership and that the $4.5 billion spent annually on premium subsidies would deliver better health outcomes if used to directly fund health services.

The Labor Party knew this when its parliamentarians voted against the introduction of the rebate scheme in 1999. The planned re-introduction of the means testing bill is a hopeful sign that Labor remembers why the rebate was a bad idea from the start.

Given the crucial role the independents will have in determining the passage of this bill through the lower house, it is vital that they understand how the rebate scheme short-changes rural communities.

Currently, the 30 per cent of Australians living in rural and regional areas contribute to the PHI rebate program via their taxes but do not receive the same level of access to private health care compared with people living in cities. This is due to the lack of private health care services across the majority of rural Australia. In fact, private hospitals are virtually unknown in regional areas, outside of a handful of major centres on the eastern seaboard.

The same applies to dentists and allied health professionals, such as physiotherapists and dieticians. Despite the poor oral health status of many rural and remote communities, it is almost impossible to find a privately practising dentist in the bush – unless of course they are in a top-end tourist resort on holiday from their inner-city practice down south.

The fact is that rural communities rely almost exclusively on the public sector to provide them with the health care they need. Having a blue chip, fully paid-up, premium health insurance policy is of no use to someone in a rural area where there are no private health services available.

Means-testing the rebate will have no negative impact on access to health care in the bush. In fact, reducing expenditure on this inefficient scheme will free up resources to spend on public health services in regional areas of need.

It is also important that the independents understand that PHI membership has little impact on demand for care in the public sector. This is an issue that Rob Oakeshott has previously raised in the context of changes to the PHI rebate.

Research indicates that private health fund membership is unlikely to change significantly as a result of means-testing. If a small number of people drop their cover as a result of the changes, it is likely to be those at low-risk who have taken out cover to avoid tax penalties. These people are low level users of health services and their decision will not impact on demand for health care in either the public or private sectors.

If the independents are sceptical of this finding, they need only consider the position of the Australian Healthcare and Hospitals Association – the peak national body for public hospitals and community health and aged care services. The AHHA supports the means-testing of the rebate and has no concerns about any adverse impact on its members.

If the independents are concerned about inequities in access to health care in rural areas and want to reduce the increasing stress on public hospitals, they should support the means-testing bill and use their voting muscle to wrangle some additional funding for public health services in rural and regional Australia. Every dollar we spend on the unfair and inefficient rebate scheme is one we cannot spend providing services to those Australians who need them most.

• Jennifer Doggett provides consultancy services to the Australian Healthcare and Hospitals Association

On the one hand, you might get a dedicated minister and more opportunity for engagement, and a greater slice of ministerial attention. But on the other hand, if the minister doesn’t carry clout in Cabinet, then all the symbolism and talk in the world may not translate into meaningful action.

Last night on Lateline, Health Minister Nicola Roxon’s comments on mental health didn’t strike me as particularly visionary or inspiring.

The best we got, really, was that the Government wants to bring a “more dedicated focus to mental health” and “I’m sure that many stakeholders will have different views about the best way to progress mental health policy”.

Many will be keenly waiting to get a sense of the priorities and intentions of the new Minister for Mental Health, Mark Butler.

So what do leading figures in the mental health sector make of the state of play?

Below are comments from:

• Professor Ian Hickie: Out of Cabinet, out of mind?

• Professor Alan Rosen: What is Minister Roxon’s problem with mental health?

• John Mendoza: Bypass Roxon to get real action on mental health

• Sebastian Rosenberg: Government sending mixed messages on mental health

***

Out of Cabinet, out of mind?

Professor Ian Hickie writes:

Is Out of cabinet, Out of mind? That is, the major question now facing the mental health field.

Although Julia Gillard identified mental health reform as a ‘second-term’ priority for her Government during the election campaign, her first action now sends very mixed signals.

At one level it is a clear concession that under the previous Rudd-Roxon stewardship mental health was headed rapidly backwards and there was an urgent need to start afresh.

Mark Butler had already demonstrated a capacity to dialogue with the community in his short stint as a parliamentary secretary in health.

There is certainly a great need for the Government to reconnect with the community sector on these issues and become less beholden to the traditional representatives of the health professionals.

At another level, loss of direct representation in Cabinet through the relevant Minister runs the real risk of being put aside (yet again) for another day.

It’s hard to imagine other big areas of health (cancer, infection, cardiovascular disease) being shifted to a Junior Minister and being happy about it.

Real mental heath reform will take real money. The policies offered by the Coalition and the Greens were attached to real new money.

The Gillard Government now needs to find real new money for essential youth and early intervention services, as well as capitalising on the opportunities for new services, delivered through e-health, and tied to the National Broadband Network Development.

A new junior Minister prepared to spend time with those most affected may make a real difference. If his efforts are not linked, however, with clear new deliverables, backed by new real monies then the Government can expect an ongoing
critique from the sector.

As pointed out by the independents, we’ve already had lots of reports that have never been acted on.

In mental health, after three years of dashed expectations from the Rudd Government, we now need Julia Gillard to demonstrate that she intends to act directly in concert with this new Junior Ministry.

If not, next time the polls roll around (perhaps sooner rather than later), the offers made by her political opponents will be even more appealing.

• Professor Ian Hickie is a Sydney psychiatrist and executive director of the Brain and Mind Research Institute at the University of Sydney

****

What is Minister Roxon’s problem with mental health?

Professor Alan Rosen writes:

At first sound-bite, installing the first ever Australian federal minister of mental health seemed to be a positive initial response by the Gillard Government to the considerable public outcry about mental health leading up to the election.

However, having heard Nicola Roxon on Lateline last night, I am now not so sure.

There is currently growing  concern in the mental health community about Ms Roxon having resisted the community-wide clamour for action on mental health reform, while repeatedly telling us: “you’re not ready yet, because you can’t agree among yourselves”.

This was frankly discriminatory. She would never have dared to have used this as an excuse to surgeons and physicians to delay or deny reforms and enhancements of their spheres of activities.

In fact, apart from a few professors playing turf-wars, as they do in all clinical and academic disciplines, there is broad agreement among most mental health stakeholder groups re what needs doing, in terms of urgently required  mental health service reform.

She would discover this, if she had  been able to accept the invitations to open The Mental Health Services (TheMHS) Conference, the largest annual forum of all components of the burgeoning mental health community in Australia, which is meeting this week in Sydney.

There, she would have seen  all  mental health professional disciplines,  consumers, family carers, managers, Indigenous and transcultural stakeholders working  closely together on mental health reform.

By referring to Mark Butler as what Ms Roxon pointedly called  on Lateline last night, “my junior minister” she  made it clear that she still owns mental health and its access to Cabinet through her.

Ms Roxon seemed decidedly cool and non-committal towards the proposal we have been putting to her  government for over a year now, which Leigh Sales put to her last night, quoting Professor Pat McGorry ,  that we need a prime-ministerial task group to pull together a  substantial consensus for a national mental health program, as an all-of-government priority.

She seemed to minimise the significance of his advice, and  of Professor John Mendoza’s resignation:  “I am sure that many stakeholders will have many different views”,  she said, implying yet again, that perhaps this was the main  problem with trying to do any constructive reform  in mental health.

We hope that Ms Roxon will revise her position on a taskforce to develop a national mental health program soon. This committed community is offering our hand to help her.

We hope that Mark Butler proves to be a positive influence, who will consult much more closely, widely and often with the mental health constituencies, and will be able to convey the importance of NOT putting off  real action on mental health reform  for yet another term of office.

We hope that Ms Gillard, with her historically well demonstrated understanding of the plight of Australian mentally ill individuals and families, will prevail, and form an all-of-government  prime ministerial task-force on mental health.

We hope that the Greens, with their most enlightened of the pre-election mental health policies, will pull Labor along with them.

We hope that the Coalition, with its declared commitment to mental health, will also work constructively with government to achieve a much higher priority,  much better  funding and outcomes for this arena of shared interest.

Let’s hope that reform begins with the resuscitation of all mental health services, with an emphasis on community care, well within this term of office, and at least in living memory.

• Professor Alan Rosen is Professorial Fellow, School Public Health, University of Wollongong, Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney, and Secretary, Comprehensive Area Service Psychiatrists Network

***

Bypass Roxon to get real mental health reform

Professor John Mendoza writes:

Like Alan Rosen, I was prepared to view the appointment of a Federal Minister for Mental Health as a glass half full.

However, Minister Roxon, in her first media interview (on ABC TV’s Lateline) since the election has again demonstrated her unwillingness to accept the broad consensus of opinion of the need for fundamental, transformational change in relation to mental health.

She is not only a skeptic on the need for urgent action on mental health she continues to run the line that there are “a diverse range of views” and hence we don’t know what to do.

If Neal Blewett when Federal Health Minister had delayed action on HIV/AIDs prevention because there were diverse views about which course of action to take, then we would see tens of thousands more affected by that disease and many more lives lost over the last 20 years.

If Blewett and his state health minister colleagues (including the National Party’s Mike Ahearn in Qld and the Liberal’s Peter Collins in NSW), had delayed action or gone with the fringe view of zero tolerance, we would have had a public health disaster in this country.

Roxon knows mental health is a disaster but at every opportunity she uses the views of a few psychiatrists to resist taking action. The contrast between Blewett and Roxon as Labor Federal Health Minister’s could not be more stark.

Blewett didn’t need Prime Ministerial intervention to be effective – clearly, on last night’s performance, Gillard will have to work directly with Mental Health and Ageing Minister Mark Bulter bypassing Roxon to achieve real reform.

• John Mendoza is Director, Connetica and Adjunct Professor, Health Science, University of the Sunshine Coast, Adjunct Asso. Professor, Medicine, University of Sydney. He resigned as chair of the Government’s National Advisory Council on Mental Health in June.

***

Government sending mixed messages on mental health

Sebastian Rosenberg writes:

From a mental health perspective there are conflicting messages in the new ministerial arrangements.

It is great to have a specific minister responsible for mental health listed among the portfolios.

However, it is a junior minister and, in lieu of any information to the contrary, the switch to this set of responsibilities could easily be interpreted as a retrograde step, with the senior minister divesting herself of responsibility and mental health losing direct representation in Cabinet.

The changes may also mean that mental health is not central in considerations about broader issues of national health reform, such as the establishment of the health and hospital networks and Medicare Locals.

Last year’s CoAG arrangements made clear that the fate of community mental health was yet to be decided and would be subject to further CoAG consideration in 2011.  This will be a key matter for Mark Butler to steward.

Minister Roxon’s early days as the minister responsible for mental health were characterised by a willingness for frank assessment of Howard-era initiatives and a desire to establish new and independent expert sources of advice.  The high profile resignation of John Mendoza rather book-ended this period.

The extent to which the new minister moves to not only re-establish these sources of advice but also to actually implement expert recommendations and directions suggested will be a key matter, including in the lead up to CoAG.

To this mix, proponents of mental health reform of course also recall Prime Minister Gillard’s commitment to make mental health a priority for this term.

Mental health reformers must offer every assistance to her and to Minister Butler to make the path of change as clear and smooth as possible.

• Sebastian Rosenberg is Director, ConNetica Consulting Pty Ltd

What does the new Ministry mean for health?

So, we know the shape of the new Ministry.

Apart from the re-appointment of Minister Nicola Roxon, there are some other appointments that may be of interest to those concerned about health:

• Mark Butler, Minister for Mental Health and Ageing

• Peter Garrett, as well as being Minister for Schools, is also Minister for Early Childhood and Youth

• Mark Arbib, Minister for Indigenous Employment and Economic Development, Minister for Social Housing and Homelessness

• Catherine King, Parliamentary Secretary, Health and Ageing, Infrastructure and Transport. Don’t know her? See here…

The new ministry raises a few questions for the health sector:

Mental health

The PM promised to make mental health a priority if re-elected. How does a junior minister who is not part of Cabinet in any way say “priority”?

Nicola Roxon did say that mental health, together with aged care and dental services, would be an important second term health agenda.  Her focus will be “on the better delivery of health services through improved GP clinics, modernised hospitals, an expanded medical and nursing workforce, better after hours services and unleashing the benefits of e-health and telemedicine”. All of these are, of course, important to mental health care, but ….

No doubt there are pros and cons to separating specific areas of health from the main Ministry. Will it reduce or increase the clout of mental health?

Indigenous health

On the other side of this ledger is the abolition of Warren Snowdon’s gig as the first Minister for Indigenous Health, Rural and Regional Health & Regional Services Delivery. Will Indigenous and rural and remote health benefit from being “mainstreamed” or do they risk losing voice?

The National Aboriginal Community Controlled Health Organisation (NACCHO) thinks Indigenous health will be better off to be part of the main portfolio. (see bottom of this post for extract of statement).

But the Close the Gap campaign and Australians for Native Title and Reconciliation are not happy (see bottom of this post for extracts of statement from Mick Gooda and ANTaR)

The Rural Doctors Association of Australia is also displeased. President Dr Nola Maxfield says the axing of Snowdon’s former portfolio is “extremely disappointing and of serious concern”.

“While we assume Prime Minister Gillard believes rural, regional and Indigenous health will fall within the new Regional Australia and Regional Development portfolio of which Simon Crean will be Minister, we are very worried about losing the dedicated portfolio for Indigenous, rural and regional health after just one term of government,” Dr Maxfield said in a statement.

No doubt some of these questions will be addressed when Minister Roxon fronts Leigh Sales at Lateline tonight…

Either way, I’d be interested to hear from any Croakey contributors interested in examining these or other related issues.

Spelling out rural inequities

Meanwhile, a few points that may be of interest to those metropolitan media commentators who feel hardly done by as a result of the new focus on regional Australia.

The NRHA has done a five-page summary of rural-metropolitan inequities.

The NRHA says: “There is an overwhelming case for greater equity to be provided for rural, regional and remote people through investments by the Australian Government in health, education, telecommunications and infrastructure.

“Over the last two decades – a period when the Australian Government was benefiting from economic surpluses generated largely by the mining boom – investments in infrastructure and outlays on services in non-metropolitan areas have lagged dangerously behind those in the major cities.  This has resulted in substantial inequities in vital areas like health, education, basic infrastructure and telecommunications.”

In summary, the inequities outlined in the document are:

• Inequity in life expectancy

It has been estimated, for example, that a white man born in the Central Darling Shire in Far West New South Wales could expect 11 years less life than one born in Mosman in Sydney.

• Inequity in access to Medicare-funded services

• Inequity in health workforce

• Inequity in the effectiveness of health promotion

For example, smoking rates remain at over 20 per cent in inner regional areas, over 25 per cent in outer regional and 27.3 per cent in remote areas.

• Inequity in survival rates – cancer as an example

A NSW study reported in the Medical Journal of Australia in 2004 found that people with cancer in regional areas were 35 per cent more likely to die within five years of diagnosis than patients in cities.  The further from a metropolitan centre patients with cancer live, the more likely they are to die within five years of diagnosis.  For some cancers, remote patients were up to three times more likely to die within five years of diagnosis.

These lower rates of survival are likely to be due to later diagnosis due largely to poorer access to specialised cancer services.

• Inequity in education and educational outcomes

In 2006, 72 per cent of 19 year olds in Australia overall had completed Year 12 but the figure for 19-year-olds in Very Remote areas was less than 40 per cent. People living in rural and remote areas are significantly under-represented in higher education.  They comprise 32 per cent of Australia’s population but only 18 per cent of tertiary students.

• Inequity in access to infrastructure

There is a range of measures of investment in infrastructure, with much of the recent focus having been on a major investments such as ports and rail associated with the mining sector.

• Inequity in communications

The tyranny of distance has a pervasive influence on lifestyles in rural areas.  The difficulties of physical and other forms of communication are well known.  Telecommunications are poorer and more expensive in the bush.  In 2006, 66 per cent of dwellings in major cities had access to the Internet and 46 per cent to broadband.  The comparable rates for dwellings in Inner Regional, Outer Regional, Remote and Very Remote areas dropped off until for Very Remote areas they were 42 and 24 per cent respectively.

• Inequity in cost of access to services

Research released in November 2009 entitled Essential services in urban and regional Australia, conducted by the National Institute of Industry and Economic Research, found that, on average, it costs rural residents two to ten times as much to access a range of essential services (including education and health services, and aged care) as it does metropolitan residents.

The other side of the coin, as some media reports have mentioned, is that there are also many benefits to life outside the big smokes. Croakey thinks so, anyway…

***

Extract of statement from The Close the Gap coalition

Co-Chair of the Close the Gap Campaign Steering Committee Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda said that he was concerned that the role had been abolished without any clear indication as to how the focus on Indigenous health would be maintained.

“The creation of the Indigenous Health Minister role in 2009 was a welcome signal that there would be dedicated attention to achieving Indigenous health equality by 2030,” Mr Gooda said.

“It is vital that this focus be maintained, as we cannot allow Aboriginal and Torres Strait Islander health to be forgotten in the push to establish the Health and Hospitals Network.”

Mr Gooda also said that the Close the Gap coalition members were concerned that a national plan for achieving Indigenous health equality by 2030 has still not been developed, and that no indication has been given as to when or how such planning will commence.

***

Extract of statement from ANTaR

Responding to the announcement of the new Labor Government Ministry, ANTaR has expressed concern at the loss of a dedicated minister for Indigenous health.

“The abolition of a dedicated Indigenous Health Minister sends a worrying signal about the priority accorded to Indigenous health by the new Government”, said Dr Janet Hunt, ANTaR President.

“A stand-alone Indigenous Health Minister helped to ensure that the Close the Gap agenda remained a key focus for the Government and provided an important point of contact for Indigenous health organisations and communities. We urge the Prime Minister to review her decision to abolish this important portfolio. Indigenous health remains a major national issue.

“At the very least, the Government must ensure that there is a very strong focus on Indigenous health within the broader health portfolio and ensure effective mechanisms to engage with the Indigenous health sector.”

***

NACCHO statement (added after initial post)

“The opportunity to deal directly again with a cabinet minister, Health Minister Nicola Roxon, about the priorities in Aboriginal health should be a welcome result of Prime Minister Gillard’s reshuffle” says Mr Justin Mohamed, Chair of National Aboriginal Community Controlled Health Organisation (NACCHO), the peak body in Aboriginal health.

“We thank former Indigenous Health Minister Warren Snowdon for his efforts over the last 15 months as the first, and perhaps last, Minister for Indigenous Health.

“Mr Snowdon provided a regular point of contact with the government on Aboriginal health and was an experienced, knowledgeable sounding board for ideas. He helped to lay the groundwork for a better partnership with the government in Aboriginal health.

“However it was always Minister Roxon, not her junior minister, in control of the Health Department and health policy affecting Aboriginal peoples.

“The Prime Minister was also a great advocate of Aboriginal health when she was shadow health minister. NACCHO assumes that the Prime Minister’s aim in the reshuffle is to again have that direct contact between the Aboriginal health advocates and the Health Minister.

“I am sure the Prime Minister understands that if her government let Aboriginal health slip in its priorities, not giving it the appropriate attention and commitment, it will have drastic consequences not only for the current Aboriginal generation but for generations to come.

“NACCHO looks forward to again meeting with Minister Roxon and creating a productive partnership. While Minister Roxon may not be as available as Minister Snowdon was, we see direct contact with the Health Minister as very important.”

Thanks to the many Croakey readers and contributors who came along to the New News conference in Melbourne last week, to discuss the opportunities of the digital revolution for supporting a healthier public debate.

It was good to see you there and from Croakey’s perspective, it was a reminder of how the Internet can be used to support the development of communities of shared interests.

The Centre for Policy Development’s John Menadue reminded us, however, that while Web 2.0 may be exciting, content remains the critical issue. And we have still some way to go in working out how to resource and support those content-makers (this is an issue beyond journalism) who have the will and the skills to provide some much-needed scrutiny and analysis of the health sector and health spending and policy more broadly.

Menadue also made a number of suggestions for how some of society’s powerful institutions (not only the media) could help contribute to a more informed understanding of complex health issues.

Below are John Menadue’s speaking notes:

Under-resourced mainstream media is not in a healthy state. It is failing significantly, with a few notable exceptions, in the health field as in most other fields. It is much more than just the shrillness of the Murdoch media. With so little news to break or analyse, it is not surprising that journalists spend such an inordinate amount of time-sharing opinions with each other.

Can online media fill the vacuum? Crikey/Croaky, Centre for Policy Development and others are in the field, but they will take time to grow. The important issue for online media to recognise is that technology is the easy part. The hard part is content both information and analysis.

In pay television for example, we have excellent new technology that has given us more channels and better pictures, but the improvement in content is marginal. We have more choices, but little increase in value. Online media is much cheaper to produce and deliver, but the continuing problem will be access to good content at reasonable cost. Bloggers give us worthwhile and diverse opinions, but are not particularly strong on the dissemination of factual information.

The Australian polity and the media are in a downward spiral, almost a death wish. Disappointment and disillusionment with politics and the media is widespread and growing.

Trivia and personalities prevailed in the media in the last election campaign. The best example of trivia that I can recall was the Australian Financial Review’s portrayal of Julia Gillard saying ‘Nauru’ instead of ‘East Timor’. As the AFR put it ‘Gillard’s Nauru gaff rocks asylum seekers’ stance’. Really? I have been getting my four children’s names confused for the last 50 years! Even Kerry O’Brien mis-speaks the ABC for the ALP.

Politicians are clearly running away from the big ticket issues – particularly climate change and the two or three track economy that the mining boom is foisting on Australia. Politicians listen closely to lobbyists on these big-ticket issues – 900 full-time of them, or 34 for every Cabinet minister. Journalists are under-resourced to examine policy issues and in many cases have become the mouthpiece of special interests with their well-funded public relations activities. The Australian Centre for Independent Journalism at UTS found in a survey of the 10 major metropolitan newspapers published in Crikey in March this year that 55% of content was PR driven, and 24% of content had little or no significant journalist input. In the specific field of health/science and medicine, the survey found that 52% of content was PR driven, with 23% of content having little or no significant journalist input.

Before I come specifically to health, let me mention the problem in the wider media context.

The Rudd Government introduced timid climate change proposals and then over-compensated the polluters. Frightened by a ‘big new tax’, the government ran away. The result of the power of special interests and the failure of the media to explain has resulted in what Ross Garnaut has described as a ‘diabolical problem’.

For a $7 m advertising campaign, the three wealthy foreign-owned miners saved themselves $7 b in taxes. There were some media commentators, Ross Gittins and Ian Verrender, who wrote cogently on the issues, but much of the media, which was the beneficiary of the miners’ advertising money, either diverted public attention from what was at stake or clambered in political support of the foreign miners. I wonder how those same journalists will react when Chinese state-owned enterprises follow BHP, Rio Tinto and Xstrata in running future political campaigns against the Australian government.  The media was missing in action on this big-ticket item.

On asylum seekers, the government and the media, and particularly the ABC, failed to frame the debate with facts. Television news and current affairs obviously worked on the assumption that if there were no pictures, there was no news. It was easy to get pictures of asylum seekers’ boats floundering in the Arafura Sea, but it is hard to get worthwhile pictures of asylum seekers’ coming by air, despite the fact that over 90% of asylum seekers come by air and not by boat. Tony Abbott said that Australia was being ‘invaded’ by asylum seekers, yet neither the government nor the media took the trouble to point out that asylum seekers represented only 1% of our migration intake.

Special interests in health, as in other areas of public policy, hold sway, with the public and the community largely excluded. The health media has gone missing on the following.

• At the April COAG meeting, State governments and their health bureaucracies were left in control of hospitals. Kevin Rudd described it as the ‘greatest reform in health since Medicare’. That was nonsense. John Brumby and the states won the arguments over hospitals and got a lot more money to boot. Where were the professional and searching journalists in mainstream media? We were all overwhelmed by the spin.
• Compared with many other countries, we have a much higher number of hospital beds. Australian governments have an obsession with hospitals at the expense of non-hospital care. But no journalist to my knowledge has examined this obsession we have with hospitals and hospital beds.
• The media is yet to examine the gaming that goes into waiting lists. These waiting lists are more rubbery than Goodyear tyres.
• The AMA resists any significance change in archaic work practices in health which if implemented could give this country enormous improvements in productivity. Health is our largest sector and our largest employer. There is serious concern about lack of national productivity improvements in recent years, but the potential for health sector productivity improvements is scarcely ever mentioned by mainstream media.
• Many media economists extol competition, but the Australian Pharmacy Guild maintains its protection from competition through location rules, the cap of 5,000 on the number of community pharmacies, and the exclusion of pharmacies from supermarkets. But scarcely a peep from mainstream health journalists.
• The media responds to hot button issues like a particular death in a hospital, but scarcely examines the systemic problems that cause about 10,000 avoidable deaths in our hospitals each year or 200 each week. That is the equivalent of one Bali bombing or one Victorian bushfire every week of the year.
• The health insurance industry retains its corporate welfare subsidy of $5 b per annum. Yet the mainstream media spends more time publishing the views of this highly protected industry, rather than examining alternate policies to produce better public outcomes.
• At the last election, pathology companies, such as Primary Healthcare Ltd, ran ads against the government’s attempt to curb burgeoning pathology costs. It was obviously affecting their profits. In the 8 years to 2008-09, pathology services, paid for by Medicare, have increased 62% and benefits paid increased by 71% – way ahead of inflation. Put another way, medical services per person from 1995-96 to 2008-09 have fallen by 5% for consultations, but risen 30% for procedures and 65% for diagnostic, including pathology. No wonder the government needs to act. Whilst Australian Financial Review journalists were talking up the problems of the pathology sector, nowhere did they frame the discussion with some facts about the enormous growth in pathology and the excessive level of referrals. Their stories seemed like public relations handouts from Primary Healthcare Ltd with minimal journalistic input.

How can the information base be improved to promote public health and a healthy media?

The health sector is so large, complex and technical that it is difficult to understand. This is a problem for all, including journalists. It is also true for ministers, both federal and state, who are easily captured by their health bureaucrats with their mastery of detail.

1. The best-informed health commentary is, and I hope you will excuse me for saying it, in Crikey/Croakey and CPD. But their resources are limited and their readership falls far short of mainstream media. Hopefully such organizations will continue to grow and develop. But content is the hard and expensive part.
2. Health information and policy advice is biased heavily in favour of governments and their bureaucracies. They are able to dominate the debate with this monopoly of information. With the balance of power now to be held by Independents in the House of Representatives and with the Senate to be controlled by the Greens from July 1 next year, there is a unique opportunity to substantially expand the resources, both quantity and quality, available to members of parliament through parliamentary committees and the parliamentary library. The media and the community would be much better informed. (By far the best information I was able to find recently on asylum seekers came not from the Minister for Immigration and Citizenship and his department, but from the Australian parliamentary library.) The proposed parliamentary budget office will also be a considerable help, but it will be limited to budget and fiscal matters which are only one part of a much wider agenda of economic policy.
3. Julia Gillard was rightly criticised for her proposed citizens’ assembly on climate change. It was obviously a diversion from the main issue. But she had a point about our need in many policy areas, including health, for a better-informed community that will enable our leaders to make some tough decisions. I have been a long-term advocate of citizens’ assemblies, deliberative polling, and citizens’ juries to explore at every level, local, state and national, informed community views on hard issues in health. We need community groups who are informed by experts and not dependent on the Herald Sun or the Daily Telegraph.
   
4. The federal government has proposed a number of authorities to report on health performance, eg the National Performance Authority will report on emergency departments and elective surgery waiting times, adverse events, patient satisfaction and financial management. There will also be an Independent Pricing Authority and a permanent Australian Commission on Safety and Quality in healthcare.  All these new monitoring authorities will be helpful in providing the information-base for more informed reporting and public discussion.
5. This new information will not only help public policy, but also provide better information to consumers to help each of us make better decisions about our own health ‘My hospital’ similar to ‘my school’ should also be helpful.
6. The establishment of an Australian health commission would also facilitate better public understanding and analysis of health issues. Such a commission would implement government health programs, subject of course to the government setting out the principles and policies that should guide the commission, eg universality, equity, subsidiarity, pooled funding, etc. I foresee this commission working in the same way as the Reserve Bank in the economic field. The Reserve Bank has proved itself to be independent and largely immune from pressure from special interests. Importantly the Reserve Bank, as should an Australian health commission, facilitates and leads an informed debate on health issues and policies. That would better equip the media and us all in understanding.
7. Other health authorities, such as Medicare and the Australian Institute of Health and Welfare, should be instructed to facilitate public discussion on important health issues and help us get away from the current debates that are really a two-way discussion between the minister and special interests. The information they supply must be much more customer-friendly, and highlight the key issues where greater public understanding is necessary. It would make for a better-informed media. The key issue that we don’t discuss in health is that we can’t have all we want and that priorities and hard choices have to be made.

There are many ways in which public interest journalism in health can be advanced. With the failure of under-resourced mainstream journalism, the key is enhanced information and independent advice to facilitate a more informed parliament, media and community which would in turn make it easier for adaptive leaders to make the necessary but hard decisions in health.

New technology is important but the real problem is access to good content. As in all media, the key is not so much technology as content.

“The NRHA proposes that interested parliamentarians seek a formal written commitment that the new Government should:

1. Plan and deliver broadband access to homes and businesses throughout the nation.

Fast broadband is essential for e-health, commerce, business, education, connectivity and recreation.  The price will be affordable for consumers, irrespective of their location and the technology used.  Function will determine required speed eg e-health requires sufficient speed to sustain real time transmission of accurate images for telemedicine.

Reporting requirement:  Annual report to Parliament, against a detailed budget and timeline.

2. Bi-partisan approach to Indigenous wellbeing.

In government, provide the Party in opposition with the opportunity to confirm a bipartisan approach to national inter-government work to improve the state of health and wellbeing of Australia’s Aboriginal and Torres Strait Islander peoples.

Reporting requirement: Annual report to Parliament.

3. A fair share of the extra money that is to be spent on hospitals.

Require States and Territories to deliver a measurable and fair share of the extra money to be spent on hospitals (beds, emergency departments, elective surgery, subacute care, mental health etc) in rural and remote areas.  The extra resources may at times be better directed to acute care facilities that are not ‘hospitals’ (eg MPSs) and to services that are ‘better than hospital beds’ (eg hospital in the home).

This commitment includes confirmation that block funding (not activity-based) will be provided to smaller hospitals.  The quantum of block funds will allow for the service obligations of smaller hospitals and the number of people (weighted by health need and socio-economic status) served by them.

Reporting requirement: A report in each year of the government’s term – by region (major city, regional, rural, remote) – and stepped action if the evidence shows that there is not a fair rural share in year one.

4. A new pool and allocation system for health infrastructure.

Create a new pool of resources for health infrastructure (including the GP Superclinic program, REID, the RMIF and the commitments made in the election campaign to augment infrastructure in general practices) and  a new process for allocating resources from the pool.  Allocations would be made on the basis of demonstrated need for such infrastructure, rather than by government decision (in the case of GP superclinics) and through competitive grant applications (in the case of REID and RMIF).  In the first term of the new Government, allocations would be made through a formula managed by the Australian Institute of Health and Welfare.  The formula would comprise data on access to a GP and other primary care professionals, socioeconomic status and population health data.  Allocated resources would go to the health facility best able to provide improved services – not necessarily general practice.

Reporting requirement: A report each year assessing the allocation of these funds by region (major city, regional, rural, remote).

5. Commit to continue health reform.

Continue health reform, working closely with the States and Territories, ensuring rural and remote areas gain greater local fundholding and performance measurement, permitting ‘place-based’ planning and delivery of health services.  The reform should include the establishment of new primary care organisations (along the lines of Medicare Locals envisaged by the Rudd/Gillard Government) and decentralisation of the control of groups of hospitals (along the lines of Local Hospital Networks).  These new organisations should be ‘local’ and in more remote areas flexible enough to establish a single integrated entity for both acute and primary care.  Wherever communities of interest and patient flows suggest it, the primary care and/or acute care entity should cross existing state and regional boundaries.

Reporting requirement: There will be a public annual report each year on progress with these reforms, with analysis by region (major city through to very remote).

6. Extra effort in oral health care.

Provide significant additional resources for public oral health services, through a Commonwealth dental health program, along the lines of the previous such program, and through practical measures (eg scholarships, HECS reimbursement) to improve the oral health workforce.

Reporting requirement: A public report each year on the number of people in various categories (Indigenous, low income, health care card holder, rural and remote residents) who do not receive oral healthcare and on the availability of oral health staff.

7. Build the rural and remote health workforce.

A package of measures to further build and redistribute a health workforce to rural, regional and remote areas, resulting in greater equivalence of support across all health professional groups.  The package would include:

• support (as outlined in the election campaign) for practice nurses, nurse practitioners and dental scholarships;
• a specific focus on the oral health service workforce, with the establishment of a foundation (training) year for new dental graduates; HECS reimbursement for rural service by dentists and oral therapists and hygienists; [see above re a new public dental health program];
• new Medicare items for telehealth consultations with more specialised clinicians, to be accessed by GPs, practice nurses or nurse practitioners in towns where there is no doctor (see a above).

Reporting requirement: A public annual report each year on progress with these measures, with analysis by region (major city through to very remote).

These seven measures would significantly improve the social, economic and health status of rural, regional and remote Australians.”

Amongst other fare, the Alliance’s executive director Gordon Gregory was channeling Banjo Paterson….

IN DEFENCE OF THE BUSH

by The Doggreller

- with apologies to Banjo Paterson, whose poem of the same title
was first published in The Bulletin on 23 July 1892.

So you’re back at home in Manly, Mister Abbott, where you went,
And you’re cursing all the voters in a bitter discontent;
Now we grieve to disappoint you, though your praises we have sung
But it isn’t what you wanted for the Parliament is hung.
We’re sorry that we snorted when you first came into view;
But we know that what you’ve written down is all you say is true
And when you met the jolly three your credits then to push
How pleased we were to hear how much you really love the Bush.

From Adelaide to Melbourne’s west Ms Gillard plied her trade
And many people thought of her a leader ready-made.
Team energy can’t overcome ineptness (sad to tell)
And that – like Peter Lalor’s – was the reason that it fell.
Fear not though, true believers, that one Julia has died
For the real one stands at ready and is waiting just outside.
Here’s hoping that she understands, when shove turns into push,
That one in three live country lives and celebrate the Bush.

If the two of you would venture down the very track we live
In a month or two at furthest you would see what it can give:
Where once the sunbaked earth was lately gasping as in pain
You will now see grasses waving like a field of summer grain,
Where miles of thirsty channels were once choked with sand and mud,
You’ll now find mighty rivers with a turbid, sweeping flood;
But the rain and sun mean little in a Garrett on the street,
In the sullen line of buildings and the ceaseless tramp of feet;
But the bush has moods and changes, as each season comes along
And the folks who know the bush-land can see clearly right from Wong.

You think the outback dismal and a land of no delight:
But have you seen the Southern Cross on a clear and dark blue night?
Have you been with CRANA’s nurses as they minister relief
Or seen the outback dawning steal the night-time like a thief?
Do you know the kind of settlement where bauxite is the go
Or been out on a trawler pulling gemfish from below?
Have you seen the Todd in short-term flood, the Birdsville races race
Or felt the sands of Esperance blow cutting at your face?
Collect your mail from postal agents weekly you might meet
And not with faces saddened like the faces in the street.
Come and hear the voice of bell-birds in the music of the scrub
Much sweeter than the roar of trains and the loutish swirling pub.
If you had come to see these things we’d think much more of you
But you chose to stay in marginals till the campaign was all through.

So now you’re stuck with Rob and Tony, Katter’s young son Bob;
We like them all and trust them too to help us do the job.
We want some decent broadband at a fair and decent price
Sustainable communities – and PATS schemes would be nice.
We want our kids to stay at school and learn – like all kids ought -
And go to TAFE or uni with some CentreLink support.
E-health we’re told will help us all with consults done on-line
And social infrastructure’s something else we Christopher-ly Pyne.
More nurses, decent dental health – that isn’t much to ask
The Independents see this too and the Greens support the task.

As soon as counting’s finished then, please look again our way
Give some notice to our interests as this doggrel dares to say.
And whoever’s in the Lodge we hope we’ll never have to push
To understand the circumstance of people in the Bush.

Just a few weeks ago, rural health barely rated as an election issue.

Yesterday the three independents met with NRHA leaders for their advice on what to demand for rural health in their negotiations with Julia Gillard and Tony Abbott. The trio apparently wanted precise, achievable and measurable outcomes – and not a wish list that might come to nothing without the backing of the states.

Apparently they were told that the number one issue for rural health is affordable access to broadband. And that it needs to have reach into remote areas, where the need is greatest. Broadband is not only important for delivering health and education services; if communities don’t have it, they will struggle to attract health professionals (and probably other workers too).

Dental health was also high on the list of NRHA priorities. Dr Jenny May, who has just been re-elected chair of the NRHA and is currently a resident of Alice Springs, knows Tony Windsor well from her time in Tamworth, where she has previously worked for some years.

It seems a touch ironic that we might finally get some political focus on health equity as a result of the hung Parliament, after more than two years of health reform labours failed to propel equity concerns to centre stage. Mind you, the rural urban divide is not the only example of health inequities, and it would be a shame to lose sight of some of the other areas of need.

Meanwhile, below are two posts offering various perspectives on health election issues. Dr Richard Lunz, a NZ-trained doctor working in occupational medicine in Victoria, calls for fairer treatment of overseas trained doctors, while Timothy O’Leary from Planning for a Healthier North (an alliance of health care providers in Melbourne’s northern suburbs) suggests that we may be headed for incremental reform, no matter who wins government.

A Kiwi’s letter to Australia

Dr Richard Lunz writes:

Dear Australia

Congratulations on your election.  It seems you have given the two main parties a ‘no-confidence’ vote!

Time for the independents and The Greens to set the main parties straight for a new path for a measured, evidence-based approach to policy and planning

I am a doctor working in Health Policy, Occupational and Environmental Medicine and Farmers/Rural Medicine.

But I am also an overseas-trained doctor (OTD) and or an International Medical Graduate (IMG) – or a doctor with a non-Australian primary degree.

I also happen to be a Kiwi, but once again my primary degree is the issue. This means I cannot work in some areas or in some parts of the health sector.

This despite 20 years in medicine and with several degrees from Kiwi and Aussie Universities.  And having registration from the UK and NZ and having worked here in Australia before!

My concerns are simple.

1) Rural, remote and indigenous health is suffering a chronic shortage of doctors.

2) Since 1997, s19AB of the Health Insurance Act (1973) has placed a huge part of the burden of this healthcare on the shoulders of overseas-born doctors.  This has produced sub-par health outcomes and the situation now is worse than 13 years ago.

3) Forcing overseas-born doctors to work in areas not of their choosing is discriminatory and contravenes s10 of the Racial Discrimination Act (1975).

The solution to the problem of regional health provision lies in:

a) minor changes to current legislation to accomodate equity and non-discrimination

b) thoughtful and proper usage of the glut of medical students due to qualify over the next few years

If you wish to discuss this further – with more detailed information – I would be most happy to share the last 20 years of my work with you.

Dr Richard Lunz

(Readers who wish to contact Dr Lunz can do so by leaving a comment on this post).

****

Whither health reform?

Tim O’Leary, Executive Officer, Planning For A Healthier North writes:

A Gillard (plus independents) government will use the National Hospitals and Health Reform reports as a basic map to implement some, but not all, of the proposed reforms. The details of many of the reforms have not yet emerged.

Some of the key hospital reforms suggest that in Victoria much hospital business would be business as usual, at least on the ground.  Primary Care reforms in the reports have many facets with the Primary Health Care Organisations/ Medicare Locals being the most immediate in the last few months. To oversimplify, Medicare Locals would involve some combination of existing Divisions of General Practice and Primary Care Partnerships coming together with a population base of between 300,000 – 700,000.

The short term (2011 – 2012) impact was to be limited and structural but the longer term had at least some potential to facilitate improvement to primary care planning, coordination and delivery.

An Abbott (plus independents) government has not, so far, declared the NHHRCreports unacceptable but has clearly stated that Primary Health CareOrganisations/Medicare Locals would not proceed, Divisions of GP would remain and be strengthened, MBS rebates for long GP consults be increased,rebate for Practice Nurses extended and GP after hours funding increased.

The GP Superclinics program would be dumped.

It is possible that an Abbott-led government would still look to the NHHRC documents as an influence on policy and implementation but with a different emphasis, different structures and certainly some program name changes.

The Abbott position on local governance boards for hospitals is in line with thegeneral spirit of NHHRC reports if at present somewhat much more local inscale than the proposed Local Health Networks. An Abbott government would require the renegotiation of the just signed COAG Agreement.

The three independent members from up North have all indicated that health is an important priority for them, although whether that extends beyond more resources to rural and remote areas remains to be seen.

The Greens, who will have a seat in the lower house and significant influence in the Upper Houseafter July 2011, have always taken a keen and relatively well informed interest in health policy and services.

Even after the next few weeks the possibility of being one or two by-elections, or a disgruntled member, away from a change of government means that our view of any certainty around federal policy will be altered.

However, it is likely that future major change in health will be incremental and by broad consensus rather than polarised and oppositional as in the past.  The Dutch, who interestingly also require 76 seats to form a government, have worked this way for decades.

***

Incrementalism versus revolution in health reform?

The NRHA’s Gordon Gregory had a bit of fun with this old debate at the Alliance’s dinner last night. He led four versions of a protest chant:

A chant for the incrementalists
What do we want?
Gradual change
When do we want it?
In due course!

A chant for the big bang theorists
What do we want?
Buggared if we know
When do we want it?
Now!

A chant for the metaphysicals
What do we want?
Gradual change
When do we want it?
Now!

A chant for the prevaricators
What do we want?
Buggared if we know
When do we want it?
In due course!

No wonder health reform can be such difficult and unrewarding work….

This is a distinct possibility. I’ve compiled a short summary below, based on the Australian Healthcare and Hospitals Association election analysis, of what we might expect to find in the bin under a Coalition Government.

But of course these are fluid times, and pre-election commitments may prove to be quite different to what emerges from post-election negotiations… ( this list will give you a sense of the independents’ priorities, including a briefing from Department of Health and Ageing, and here is the PM’s response)

National reform

1. The Coalition proposes to reverse COAG’s commitment to establishing a National Health and Hospitals Network (NHHN). The network was agreed by all jurisdictions (except Western Australia) at the April COAG meeting

2. The Coalition proposes not to proceed with the myhospitals website and has no alternative proposal. The website has been envisaged as a first step in public reporting of hospital performance

National bodies

3. A key component of the COAG Agreement is national standards for service delivery, measurement and funding.  New entities include the Independent Hospital Pricing Authority, the National Performance Authority, the Preventive Health Agency, the National Workforce Agency and the expanded Australian Commission on Safety and Quality in Health Care. The Coalition has made no commitments to national oversight of the health system and would not fund the new bodies established under the COAG Agreement.

Regional entities

4. Rather than the Local Hospital Networks and Medicare Locals, the Coalition would establish a community-controlled hospital system involving individual hospital boards for the 750+ public hospitals in Australia.  This policy includes a caveat that, in some areas, major referral hospitals (as yet unspecified) would be associated with smaller hospitals under the same board of governance.

Funding

5. Under the COAG Agreement, the Commonwealth Government would fund 60% of the efficient price of public hospital services using activity-based funding formulae and 100% of agreed primary and community healthcare. Under the Coalition’s proposals, the Commonwealth Government would fund 40% of the efficient price of hospital services based on activity and continue to fund ad hoc programs in primary health care.

Elective surgery

6. Labor has funded an expansion of elective surgery to ensure more timely access, with more than 76,000 elective surgery procedures delivered in the last two years and over 125 hospitals receiving new elective surgery equipment and operating theatres.  The Coalition policy is silent on this issue.

Emergency departments

7. Labor has injected $1.5 billion in public hospital emergency departments for emergency department upgrades as well as expanding capacity to rollout a new four hour cap on emergency department waiting times.  The Coalition policy is silent on this issue.

GP services

8. Labor is committed to build 31 GP Super Clinics that locate a range of services in one location.  It will also fund a national after hours GP service with a 24 hour hotline and follow-up visits where appropriate and support to upgrade around 425 GP practices and health clinics. The Coalition will scrap GP Super clinics (except for existing contracts).  Instead, it will invest in payments for after-hours GP services.  The Coalition will also commit to increasing Medicare rebates for longer consultations, reducing red tape for doctors and increasing and expanding Medicare rebates for practice nurses.

Infrastructure

9. Labor has established the Health and Hospitals Fund to make long-term investments for national health infrastructure. This fund has invested $3.2 billion in 32 projects around the country.  The Coalition policy is silent on infrastructure support.

e-health

10. Funding in the 2010-11 Commonwealth Budget which provided $467m (over 2 years) to implement a person-controlled Electronic Health Record is a small but important start to implementing the National E-Health Strategy. The Coalition has stated that it will not proceed with developing the e-health record.

Oral and dental health

11. Both the major parties have remained silent on what they intend to do about oral and dental health, particularly for those in most need and who can least afford care.  The COAG Agreement does not recognise oral and dental health services as a component of primary health care to be transferred to the Commonwealth government and does nothing to advance oral/dental healthcare within the broader health agenda – particularly as oral health is such a vital component of overall health and wellbeing.

Mental health

12. Mental health is one of Australia’s eight National Health Priority Areas and yet this is not reflected adequately in the health plans of either of the major parties.  Mental health problems have a major impact on the community and families and yet there is no attempt by either party to address them through a whole-of-government approach. The Coalition has promised $1.5 billion to increase the number of acute and subacute beds (800) and to expand and establish new Headspace and early psychosis centres, but would be funded largely from savings from cutting ehealth and GP SuperClinics.  The Labor party has committed to developing systematic policy in its second term, and in the interim has announced $277 million to fund suicide prevention.

Private Health Insurance rebate

13. The Labor party has promised to means test the private health insurance (PHI) rebate while the Coalition is committed to maintaining the rebate unchanged.  The AHHA ideally would like to see the PHI rebate removed with the saved funds directed straight into hospitals (as per the Australian Greens policy), but as a first step recommends means testing the rebate in order to divert some expenditure to the public healthcare sector. The Coalition would retain the PHI rebate.

Workforce

14. Maldistribution of the health workforce is a serious problem, affecting access to health services outer metropolitan, rural and remote regions.  Both Labor and the Coalition have addressed workforce numbers. Labor has promised training for 6,000 more doctors including doubling the number of GPs trained each year; funding for 4,600 practice nurses; and 1,000 additional allied health clinical training scholarships. The Coalition is proposing to double the number of Medical Rural Bonded Scholarships to 200; create 100 nurse practitioner scholarships; provide incentives for nurse practitioners to practice in remote towns without doctors; and pilot a bonded scholarship scheme for 20 dentists in rural and regional areas.