It’s a question that merits not only the asking, but also some clear-headed attempts at negotiating a way between the vested interests that so often obscure the path to sensible answers in this area.

At least the issue of workforce reform is getting some hearing, with two conferences putting it on the agenda in recent days.

The organisers of this two-day conference that began today in Sydney are optimistic that the COAG driven National Health Workforce Taskforce has made “significant headway” in promoting a nationally coordinated strategy for health workforce planning, and that unified approaches are emerging in professional bodies, training institutions, health services, and regulatory infrastructure.

But they also note some of the problems: “Roles and tasks have remained in silos that have been in place for many decades. The current recruitment, training, and staff management systems are disjointed and health service and clinical management approaches have not readily adapted to changing demand.”

Meanwhile, the ANU last week hosted a forum on health workforce reform last week – you can watch Robert Wells talking about the need to share the evidence with the community here.

Dr Mark Ragg, who facilitated the forum, has written this account for Croakey:

“I was at a forum in Canberra on Thursday on health workforce reform organised by the ANU Primary Health Care Research Institute, and listened to Emil Djakic speak.

Now a bit of background that is bleeding obvious to anyone who’s ever been near workforce reform. To get a better workforce, there needs to be a devolution away from a doctor-centric health system towards one that better uses the skills and abilities of a wider range of players.

There are many discussions around the best way to do that, and to make sure it improves patient safety, but few outside the medical profession believe the current system is the best way. But such a change would involve a slight loss of control for doctors, in some areas. Some doctors are fine with that, others are not. But issues of control are nearly always behind the fiery debates that always take place.

Well, in speaking about the primary health care workforce Emil, who is chair of the Australian General Practice Network, said that he wasn’t convinced that reform was needed, and that he wasn’t sure of the direction any reform should take, and that what was needed was more research. Any changes made had to be based on ‘data, data, data’, he said.

Fine. Surprising, but fine.

After the forum, I spoke to two men from other doctors’ organisations who used similar phrases. ‘Data, data, data’, one said.

Coincidence? Possibly. Or a concerted approach by some doctors’ organisations to try to delay action while ‘more research is need’. Surely not.

We’ll see how effective such an approach would be. Warren Snowdon, who is Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery was pretty positive about the fact that ‘reform is going to happen – we promised it and we’ll deliver it’.

Hope he’s right.”

• Mark Ragg is adjunct senior lecturer at the Sydney School of Public Health, Sydney University, and director of the health and communications consultancy RaggAhmed.

• And on related issues…Does Australian medicine operate a “closed shop” that discriminates against overseas trained doctors? Find out more in this news story for the BMJ.

That is the suggestion of this very interesting piece below from Patrick Bolton, who has long and diverse experience in the industry.  He has worked as a GP and hospital administrator in urban and rural Australia in several states and territories. He has researched and published in health data, information management and health systems evaluation. He is national vice-president of the Australian Hospitals and Healthcare Association, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of NSW.

Bolton writes:

“When he is not solving the world’s climate and economic problems, I understand that the Prime Minister is touring the nation consulting about the future direction of the healthcare system. I’ve knocked around in, and been an observer of, that system for a while, and I offer the following observations in the hope of informing that debate.

There are always more things that can be done in healthcare than money to do them

As a result, some people miss out on some care some of the time, and this will always be so. This isn’t rationing because there is nothing rational about it.  At present the system responds to this truth by pretending it doesn’t exist. A problem must be acknowledged before it can be addressed.

Some of the people who miss out make a noise – for example by complaining to an MP – and then get what they want. This is unfair on those who don’t complain because it means that limited resources are shifted to the loudest.

It is not irrational for the people who complain to complain. They will benefit, assuming the medical care they receive does more good than harm. It is society as a whole that loses. There is no-one arguing on the side of society as loudly as individuals argue in their own self-interest. The hit the individual faces is large, the personal cost to each individual in society small.

Of greater effect on the system is that healthcare workers make choices for individual patients, not for society. Again this is rational. As a healthcare worker I want to provide the best care for each individual that I look after, and as a patient this is the standard I expect of the healthcare workers who care for me. Even were I prepared to favour the interests of society over the individual, I would have to trust that others in the same position will do the same. If they do not, then my altruism is benefiting them and not me.

This factor creates a difficulty because doctors are arguably best placed to assess which patients will benefit most from which interventions, but any management system that asks them to do this puts them in a position of conflict of interest. This is a source of professional dissatisfaction for healthcare workers

The difference between what people want and what the system can provide is one of the sources of dissatisfaction with the system. It contributes to the perception that reform is required.

The only way to make the health system cheaper is to reduce services

Many of the initiatives proposed by the Hospitals and Healthcare Reform Commission are said to improve health outcomes and so make us live longer and healthier lives. This is desirable if it is correct. Unfortunately, we will all still be dead in the long run, and around 80% of healthcare resources are consumed in the last two years of life, whether we die at 70 or 100. None of the proposed changes are about reducing cost as an end in itself. If the proposed changes work we will live longer – so consuming healthcare resources for a longer period, albeit possibly at a slower rate, then cost the same amount when we finally die.

There a no great savings for the healthcare system in this, although there may be increased  productivity as an offset. Health is a superior good, one on which individuals and communities spend more as they become wealthier, and this may justify additional expenditure.

It is not clear what the objective of the health system is

It is difficult to go somewhere unless one knows where one wants to go. Individual needs, expectations, and capacity to assess outcomes of the healthcare system vary. This means that the perceived purpose of the healthcare system varies depending on who you ask.

It would be surprising if the interests of the most vocal group – healthcare providers – coincided with that of the majority who pay for these services. There are no other areas where the interests of vendors and customers coincide, so why expect this in healthcare?

Healthcare doesn’t seem to make much difference to health

This is well known and such a show-stopper that everybody, me included, seems to acknowledge it and move on. I think it reflects several factors. These are:

a)    There is good evidence that the health of first world societies is closely associated with the level of equality in that society, not to the level of healthcare. If this relationship is causal then it can be argued that one should invest in strategies to promote equality in preference to healthcare.

b)    Individuals are not good at assessing the outcomes of the care they receive and the system is not good at measuring outcomes.

Most people recover from illness, but some do not. The outcome is multi-factorial, so it can be difficult to say which part of an individual’s health outcome is a result of the care that they received and which due to other factors. It is particularly difficult for lay people to judge the quality of the care they receive.

Changes in healthcare tend to be incremental, and so outcomes compare current treatments with alternatives which are likely to be only slightly better at best, as opposed to no treatment. It is generally held to be unethical to compare new treatments against no treatment. One might argue that this is irrational in cases where current therapy has not been shown to be superior to no treatment.

The quality of outcomes measurement of the healthcare system is woeful. Given that much of the money for healthcare comes from the public purse this is a significant failing of accountability.

c)    There is a high error rate in healthcare. International studies repeatedly show that errors in healthcare delivery occur in around 10% of cases. In Australia these errors are associated with about half of all in-hospital deaths. If death is the outcome measure then Australian hospitals may be killing as many people as are killed by the conditions for which they were admitted. The harm that the health system causes may offset any benefit that it delivers.

d)    Estimates are that one-third of what is done in healthcare is unnecessary. Two things follow from this. First, if unnecessary care can be identified and stopped, then the efficiency of the healthcare system can be improved by up to 30%. Second, unnecessary care still causes harm, and this offsets the benefit from effective and necessary care for the system as a whole.

Healthcare in Australia is not a very enjoyable place to work

This has important implications for workforce engagement and sustainability.

Poor work hygiene is bound up in the foregoing issues. It is hard to feel satisfied about what one is creating if the value of the product is at best unclear, and possibly negative.

The response of policy makers to these issues has been to tighten the leash and increasingly micromanage healthcare delivery. Healthcare workers are highly skilled employees, expert at making individualised decisions in complex settings. It is unlikely that directive management can lead to better outcomes that professionals can provide themselves, so micromanagement results in alienation of the work force without improving performance.

Suggested pre-requisites to change

There is nothing new in any of this, but it needs to be said because the healthcare system cannot improve until these factors are addressed. Some suggestions to do this are:

1.    The new health system needs to be as clear as possible about what it is trying to achieve, and collect data which measures performance towards these achievements.

2.    The new healthcare system needs to be able to demonstrate that the things that it does are effective, cost effective and done to people who will benefit, and not those who will not.

3.    The new health system is going to have to allocate resources transparently on the basis of 1 and 2 above. This is so that equity and efficiency are maintained in the face of other interests.

Addressing these factors is necessary but may not be sufficient. If they are addressed, then healthcare will improve under the current governance model. Some other governance model may be preferable for the reasons currently being debated, but we can’t know this until the problems discussed here have been addressed.

No governance model can be properly assessed until these underlying distortions are addressed. Introducing the kinds of major change contemplated is not without risk. It will be impossible to manage and measure the impact of this risk until these factors are addressed.”

There I told you – it was worth taking the time for the read, wasn’t it? Plenty of food for thought there.

Croakey’s North American correspondent, Dr Lesley Russell, has been investigating the history of calorie-counting menus, while a local obesity policy expert, Jane Martin, looks at whether such an option might be useful in Australia.

Lesley Russell writes:

“In 2006, in a controversial move in response to rising obesity rates, New York City’s Health Department amended the city health code to  require the posting of calorie counts by chain restaurants on menus,
menu boards, and item tags.

This move was based on the following key facts:

*nearly one-third of Americans report that they are trying to lose weight;

*people are unaware of the calorie content of food, and when asked to
estimate the number of calories in food, they greatly underestimate
them; and

*consumers who were provided calorie information were much less likely
to choose the higher-calorie items.

Many fast-food chains make nutrition information available, but not in places or at times when consumers can easily use it when they buy their food. Most often, the information is available for download on Web sites.

According to the company, McDonald’s Web site nutrition page receives approximately 2,000 visitors per day, but since McDonald’s serves more than fifty million people per day, this suggests that only about one in 25,000 customers obtain nutritional information from the Internet.

The law was finally implemented, after a series of tough legal battles with the restaurant industry, in July 2008.  The system has since  become a model for similar rules intended to combat obesity and  promote good nutrition being implemented in California, other parts of  New York state, the cities of Seattle and Portland, and elsewhere.

Now some of the early findings about the success or otherwise of the New York initiative are available, in a paper (sub or pay per view only) published recently in Health Affairs.

The study compared patrons of fast-food restaurants in low-income, minority New York City communities with those in nearby Newark, NJ, a city which had not introduced menu labeling. About half of the New York respondents reported noticing calorie information, but only a  quarter of these reported that the information influenced their food  choices. However the study found that even those who indicated that  the calorie information influenced their food choices did not actually purchase fewer calories.

Last week New York City health officials delivered a more upbeat  assessment of their own, saying that New Yorkers ordered fewer calories at four chains – Au Bon Pain, KFC, McDonald’s and Starbucks – after the law went into effect. There was a significant increase in calories ordered at Subway, which researchers attributed to a continuing $5 special on foot-long sandwiches which has tripled demand for them.

The results are good enough to cause policy-makers to think that calorie labeling might be one component of a multi-faceted plan to  tackle obesity.  Certainly that’s what US lawmakers think.

Tucked away in the 1990-page health care reform bill that passed the  House of Representatives last Saturday night is a provision that will require anyone who operates chain restaurants with more than 20 locations to provide a calorie count for each standard menu item.  In addition, anyone who owns or operates 20 or more vending machines would have to provide a sign in close proximity to each item of food or the selection button that includes a clear statement about the number of calories the item contains.

The National Restaurant Association supports the labeling  requirements; the National Automatic Merchandising Association is less enthusiastic.  We assume that the Republicans, still complaining about  the size of the bill, did not read it and therefore don’t know about  this provision, otherwise we would surely have heard.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Should Australia require calorie-counting menus? Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition, writes:

“This is something the Obesity Policy Coalition supports. This is yet another study showing, like restrictions on junk food advertising, that an initiative with a modest effect can have a large impact on a population.

This study is an excellent assessment of the situation.  Currently in Australia, even if there is information given about meals in chain restaurants, it is on websites or on the packaging of the meal that you order (McDonald’s), therefore people are not making informed decisions at the point of purchase.  If there was a system such as in New York, together with an education campaign, the potential impacts could be large.

This is definitely something that should be on the table here, as part of a comprehensive approach.”

The launch on Remembrance Day of Pathways to community control was a poignant moment for Stephanie Bell, chairperson of AMSANT.

For the first time, the Commonwealth and a “state” government—the Northern Territory—had reached an agreement with the Aboriginal Community Controlled health sector to expand community-controlled primary health care across a whole jurisdiction.

It was an historic agreement after three decades of struggle by the community-controlled sector and various governments—not least in the Northern Territory.

Stephanie Bell said that, in a very real way, this Remembrance Day marked “the end of the war”. While there is still a long way to go in Closing the Gap in Indigenous health, Ms Bell pointed out that the National Health and Hospitals Reform Commission recently gave strong support to Aboriginal community-controlled comprehensive primary health care.

Here is an excerpt from Ms Bell’s speech at the launch:

“As recently as five years ago—let alone 15 years ago—an event such as this would simply not have been possible. We have moved in a decade and a half, from an atmosphere of antagonism and conflict—to one of mutual cooperation and commitment in the cause of Closing the Gap in Aboriginal health.

And here we are.

As a representative of the community-controlled sector, it is with great pride—and considerable hope—that I am happy to be here at the launch of Pathways to Community Control. It is an important milestone in a history that stretches back at least three decades—a history in which Aboriginal communities throughout the nation have worked at the coalface to overcome the legacy of colonisation that has produced so much ill health in every single one of our families and our communities.

At the core of what we have achieved over those many years has been an aggressive approach to basing our work on evidence. Our accumulated achievements have always been based on what works—in clinical as well as social practice.

At the heart of what we have strived to achieve is the development of a practice—both clinical and social—that displays our strong and central commitment to Comprehensive Primary Health Care.

This model was codified at an international level at Alma Ata in 1978, and subsequently endorsed by the World Health Organisation (WHO) and the United Nations:
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

Primary health care is socially and culturally appropriate, universally accessible, scientifically sound, first level care.

It is provided by health services and systems with a suitably trained workforce comprised of multidisciplinary teams supported by integrated referral systems in a way that:
·     gives priority to those most in need and addresses health inequalities;
·     maximizes community and individual self-reliance, participation and control and;
·     involves collaboration and partnership with other sectors to promote public health.

Comprehensive primary healthcare includes health promotion, illness prevention, treatment and care of the sick, community development, advocacy and rehabilitation services.

Recommendations of the National Health and Hospitals Reform Commission clearly indicate that—at a national level—Primary Health Care is critical to the future health of all Australians.

The launch of Pathways recognises the absolute necessity of developing and strengthening Comprehensive Primary Health Care [CPHC] through planning, development and delivery at local and regional levels here in the Territory.

That means Aboriginal community control.

The Aboriginal Health Forum in the Territory has taken a strong stand on developing an evidence-based approach to CPHC, and recognises the strong gains that can be developed through Aboriginal Community Control at the grass roots level.

The Northern Territory Aboriginal Health Forum represents one of the strongest and most productive partnerships between government and the Aboriginal community-controlled health sector in the nation, and Pathways provides a road map for the principal of “working together for our health” as part of the long term vision of Closing the Gap.

This principle—of “working together for our health”—is an AMSANT catch cry, but I like to think of it as summing up the partnership we have built with the Australian and Territory governments.

Our partnership does not mean we will always agree—in fact we have some pretty decent blues from time to time.
Nor does it mean we all do the same thing, or that we are in bed with each other 24 hours a day.

What the partnership means is that we work together using our respective skills and our respective knowledge in the common purpose of “working together.

I said that today is an important milestone—but in saying that all of us here know that we have a long way to go.

The recent revision by the Australian Bureau of Statistics of Aboriginal life expectancy reduced the apparent “gap” between Indigenous and non-Indigenous health at a national level.

However, because the data is better from the Northern Territory, the gap is still just as wide in the Northern Territory. While we have what is probably the best partnership between governments and our sector in the nation—that is as it should be—as the task in front of us is so huge.

Thank you—everyone here—who has contributed so much to the process that has led us here to the launch of Pathways.

May these small pathways lead to the highway that will take us to Closing the Gap.”

It’s about how health reform advocate John Menadue was “disinvited” from speaking at an Australian College of Pharmacy meeting, after making a provocative speech to a pharmacy conference, as previously reported at Croakey.

I spoke to several senior pharmacists and others in the health sector when researching the story (the Australian College of Pharmacy did not return my calls but I will be happy to post follow-up comments from them, the Guild and others).

Here is some of what they had to say, both about the specifics of the Menadue case and the pharmacy profession in general:

A senior pharmacist who did not want to be named:
“I am absolutely ashamed… my profession at the moment is under a cloud of censorship being perpetrated by people who don’t control most of us.”

Another senior pharmacist who did not want to be named:
“We need to listen to people who have in the past shaped government policy. When they express a view of pharmacy, we need to listen to that view.  Some of the things John said (at the Sydney conference) were a little bit off the mark but a lot of what he said was right, that we do have a perception problem about how we conduct ourselves.”

Warwick Plunkett, president of the Pharmaceutical Society of Australia:
“The Guild in these matters are oversensitive, albeit it’s an important time in their negotiations of the community pharmacy agreement and I can understand they don’t want that in any way upset. But I think it’s healthy to have statements being made out there and an opportunity to either defend or take note of them in improving the eventual outcome for the profession.”

Professor Andrew Gilbert, Director, Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute: University of South Australia:
“I was astounded by the decision, as many pharmacists had been enthusiastic about Menadue’s speech to the Sydney conference. Why would you, having got someone of the quality of John Menadue as a speaker, not use his intelligence and his knowledge of government workings and policy issues?”

Consultant clinical pharmacist Debbie Rigby:
“I think John Menadue’s talk at the Pharmacy Australia Congress expressed the thoughts and opinions of many pharmacists throughout Australia but also the wider health care environment and their perception of the pharmacy profession and industry. It’s always beneficial to hear the outsider looking in. John has a lot of experience in health policy. Whilst we may not agree with his comments, I think it’s an opportune time to reflect on the pharmacy profession’s role and perceptions in the whole health care environment.”

Professor Lloyd Sansom, Emeritus Professor, Uni SA:
“If someone of Menadue’s stature makes a statement, you’d want to listen to it and have a discussion with him. Rather than isolate him I would have thought it very prudent and sensible to engage in a dialogue with someone of his eminence and experience. He’s got something to say, you don’t have to agree with him, you can challenge him, why would you want to not listen to him? Don’t be scared of debate.”

Dr Lisa Nissen. Senior lecturer in the pharmacy school at the University of Queensland:
“We don’t always like what we hear but you’ve got to try and take onboard the lessons that you can learn from people who have different perspectives. We need to be challenged because there are indicators that the current practice model is not robust enough to take us where we want to go in the future. Taking on different perspectives and thinking about how we can integrate them is a good idea; that’s what smart people do.”

Carol Bennett, Consumers Health Forum:
“These issues are not new. For years some of the more progressive sections of the pharmacy sector have been discussing the need for pharmacy to embrace its role as a health provider and move away from being seen as retailers. If this is seen as controversial, I would be concerned about the extent to which the pharmacy profession and the Guild in particular maintain such a monopoly over the Community Pharmacy Agreement. I would like to think that the fear of open debate and discussion about pharmacy’s role is a thing of the past and that the profession understands its place as a health provider and, in doing that, all the accountability and transparency that go with it.”

No doubt there will be others, whether in pharmacy or the health sector more broadly, who have strong views on these issues. Croakey is happy to post your comments.

Many of the reports, whether in the local or the national press seemed to uncritically buy the GPs’ line that super clinics will threaten the integrity of the relationships between GPs and their patients.

Even the Sydney Morning Herald editorial examined the issue as if it was only about patient care.

Only one report that I could find – and perhaps not coincidentally in a publication for doctors – acknowledged that other considerations (ie $$$s) might also be driving the opposition.

Now I am not seeking to be an apologist for the clinics. And you could argue that it’s entirely fair enough that small business people would want to defend their business.

But if we’re going to amplify the concerns of one group with a professional and financial stake at play, then perhaps we should also be reflecting the views of others involved.

Despite the silly name – GP super clinics – the facilities are aimed at promoting multidisciplinary care. So maybe we could also be hearing from the nurses, psychologists or others involved?

Even better if we could get some independent sense from the local community about how well the existing model of general practice is meeting their needs and what they think about the super clinic approach.

I’m sure there are problems around the place with the various super clinics being developed – it would be surprising if there were not, given all the logistical, bureaucratic and professional challenges that are likely to be involved in setting them up.

But the general public may not be aware that there are also some good news stories around.

From what I’ve heard, the one being developed at Shellharbour just south of Wollongong is going to be offering a terrific range of clinical and health promotion services to an otherwise under-served community. Importantly, it will also be a training hub, with postgraduate nurses, GP registrars and medical students onsite.

Those behind it hope that by developing new models of care and flexible, stimulating working environments, the Shellharbour clinic will help recruit and retain health professionals in a needy area.

There’s another good news story to be found at Gunnedah, the north-western NSW town that stakes its claim to fame as poet Mary Mackellar’s birthplace and “Koala Capital of the World”.

It’s not about how federal policy solved a local health need. It’s about how a local community came together to develop a local solutions for their problems – and then got some Federal backing to help realise it.

I wrote recently in Australian Rural Doctor about how the people of Gunnedah have been engaged in an intensive fund-raising campaign over the past 18 months in order to establish an integrated health clinic. The plan is for it to be owned by a  not-for-profit, community-owned company, run by community members, health professionals and representatives of local agencies.

The origins of the concept date back four years when a local GP, Dr Grahame Deane, acutely conscious of the perilous state of the town’s health services, began working with various agencies to develop some solutions.

The goal was to create an attractive environment to help with workforce recruitment, while also increasing the town’s chances of “growing its own” by becoming more involved in teaching and training.

But rather than impose his own vision of how to achieve this, a series of community meetings were held, to find out what the locals wanted. The response was overwhelming, with 350 people packed into one forum, and many turned away for lack of space. It turned out that the people of Gunnedah shared Deane’s vision for a community-owned venture.

Deane believes the “absolutely amazing” community support has been critical for the project’s progress. “The important thing is that it is not owned by a doctor, it’s not owned by a corporation, it’s owned by Gunnedah,” he says.

After my story went to press, it was announced that the town had won super clinic funding.  Deane rang recently to tell me how delighted he was to get the funding although he admitted that he didn’t much like the “super clinic” name.  I heartily agreed with him. Terrible name, but the concept may have more merits than some recent headlines have been suggesting.

And I tell you what – I much prefer the richness of the story out of Gunnedah than the one we’re being told out of western Sydney.

Croakey’s roving health correspondent Simon Burrow reports on his recent experiences with the French health system:

“Having collected a dose of tick-bite fever (Rickettsia) on a recent trip to South Africa, I went to a doctor in Cape Town and was given antibiotics.

Unfortunately, this did not do the trick and on returning to France via the USA, the chronic arthritis-like symptoms, headaches, irritating cough and fever had increased, not abated.

No other choice – a first foray into the world of French healthcare.

What a revelation! A wonderful example for regulation, versus the more accepted philosophy of de-regulation. (Can’t believe I’ve just written that).

Living in rural France, you are ‘expected’ to patronise the doctor closest to your home. However, it is not compulsory. I turned to the little village of Bonnieux where friends had said that Dr Paul le Bars spoke ‘good English, but you have to make the appointment in French first!’.

No problem, a telephone call and a charming lady informed me that appointments were in 20-minute intervals and gave me my slot.

We arrived. Knock on the door. No answer. Press the buzzer. No answer. OK, walk in and you’re confronted by six closed doors leading off a passage. Ah! “Salle de attendee” on one door – waiting room.

Enter – not a soul in sight. The waiting room was not different to anyone in the world: ages old magazines (but being France, they were Vogue); coffee and tea on tap and posters informing you that if you have an injection or you do not feel well after seeing the doctor, you may take a taxi home and the French government will pay for it – and for you to return to collect your car, when you’re better!

Door opens. Doctor arrives. Very pleasant, charming and eloquent in English.

We go into his consulting room via the closed door passage and it is no different from any other. However, off the room is a mini-surgery where rural doctors do procedures. All fully fitted out and supplied by the Government.

After I have listed my health woes, he taps on his computer and says “what’s my base line?” (Haven’t heard that one before).

The base line turned out to be:

1. Blood tests
2. Treat the pain and swelling
3. Get rid of the virus

Transaction completed. Your receive your account (pay cash), insurance forms, script all from the doctor’s friendly little laptop (complete with French govt flag) – no receptionist or nurse in sight and you leave by another door, away from the waiting room. Consultation: E22.00 (AU$35.55; ZAR251.00)

So, off I went to the pharmacy. Your prescription form is in duplicate – in France the patient/customer must have a copy of everything about you given to another party. You are given your medication.

The pharmacist writes the dispensing instructions in flowing cursive on the box with a texter – what? No expensive computer labelling system, I ask. “Non! – why, the patient can read the box (the package insert is left in as well)!” You pay cash and the register also spits out the insurance form. All very neat – the forms are not recognised unless the barcode pricing label from the box has been placed on the form for verification purposes. A bespoke labelling system with peel off makes it pretty easy.

Prices are controlled and at cost. For example, Doxy 100 Ge (doxycycline) for 30 days (2x day) is E7.50 (AU$12.11; ZAR85.58)

Another quirk of the French healthcare system is that analgesics are only available in pharmacies (privately owned) or parapharmacies (often owned by the big supermarkets) but not in supermarkets or convenience stores. Price controlled, too. And, as the doctor remarked, we only use one – Dafalgan 500mg (paracetamol) – because what is the use of a paracetemol if it doesn’t cure a Frenchman’s head the morning after with a coffee and a nice croissant? Nice contract for Bristol-Myers Squibb.

Blood tests. Off to Coustellet.

After minimum formalities, you are ushered into the blood-sucking chamber. In France, the person who analyses your blood must be the one to take the blood. Therefore, I have the consulting pathologist himself.

A nifty little gadget was an electric rocker to keep the blood moving as other phials were filled. The Doctor keeps up a little patter – ‘my patients must be calm’, he tells me. He claims that France is the only country to use the rocker so as you can care for the patient and not worry about ‘the health of the blood’. Nice touch.

My blood was taken at 09h00. By 12h00, the results were accessible via my own personal code on their website to both my doctor and myself (the law again: I must be able to see what the doctor can see).

Efficient payment, insurance forms printed out. Cost of procedure: E26.00 (AU$42.00; ZAR296.00)

Regulation or de-regulation? The question in vexing. This was a great example of a highly regulated environment working to perfection. However, was it the people making it work? I think so.”

• Simon Burrow trained as a schoolteacher and journalist before embarking on a career in health and beauty retailing for over twenty years. He is now consulting, predominantly in health and beauty, and works in Australia, India, Singapore, South Africa and France.

Professor Bruce Robinson, dean of medicine at the University of Sydney, has recently suggested that one solution may be to broaden the range of services involved in providing postgraduate medical education. The University of Melbourne’s Emeritus Professor David Penington recently urged the Feds to incorporate university hospitals into health reform.

Now Professor Peter Brooks, who has been a strong advocate of workforce reform and innovation, says it’s time to take the debate a step further.

He writes:

“Recent contributions by Bruce Robinson and David Penington have highlighted some of the issues in relation to medical training and the importance of research and learning  to our health system.

This should be strongly supported but the debate should go further . This is about health professional training – not just the training of doctors. Probably the most important thing that a health professional of today learns is to be able to work as part of a team.

This is how health care is delivered – not by individuals but by teams – and it is almost unethical for any practitioner to hold themselves forth as the ‘sole/independent ‘ health provider  in a given situation.’Team’ learning needs to start early before the ‘siloed ‘ mentality develops – it should be an integral part of any health learning program be it nursing, medicine or allied health professional.

These program teach not only about the role that other health practitioners play in a patient journey but they should also develop a sense of respect for the other professions in the eyes of the learner. Interprofessional education can be taught anywhere but particularly in primary care  and in the rural sector.

Bruce Robinson is correct, we need to move beyond the public teaching hospital  and focus on the primary care and private sectors to provide health learning experiences. These will need to be resourced appropriately with both teaching space and personnel, but this investment will have huge benefits in terms of providing excellent learning opportunities at both an undergraduate and post graduate level.

It is also likely to promote a culture change in the approach of health professionals from ‘illth ‘ to health – learning how to promote health and prevent illness rather than learning entirely on a ‘ sick ‘ population.

The Government has recently established Health Workforce Australia with a significant funding stream for clinical placements and it would be unfortunate if these monies are used to continue the status quo in terms of learning opportunities.

This is exactly the sort of project that might gain from a consortium approach as partly outlined by David Pennington in his plea for University Teaching Hospitals. The model recently established in the UK – Academic Health Centres of Excellence – is a prototype  and could be used to create health learning ‘communities’.

In this model the Government could put out a tender for provision of health education with clear guidelines to the bidders.

Consortia would need to demonstrate that they included public and private health facilities, universities, TAFEs, primary care organizations and general practices, post graduate colleges and professional organization and other health and education industry  partners.

An important addition would be patients who would act as advocates for community learning.

Consortia would also need to demonstrate a governance structure that would deliver the required outcomes.

Contestability often provokes innovation and I would suggest that this type of approach would generate some very interesting ideas to move this whole learning agenda forwards. It is also likely to see the emergence of different models of health education across the country but all of course aspiring to excellence and the registration requirements of the various national registration authorities.

Underpinning all this is a need for all Australians to accept that every clinical interaction they have with a health professional is a learning opportunity and that if we are to continue to train some of the best qualified health professionals on the planet then they (the community) need to accept that teaching role and assist in training the health professionals of the future.”

• Peter Brooks has recently stepped down as Executive Dean Faculty of Health Sciences at the University of Queensland and is Professorial Fellow in the Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne

The Federal Government is due to release the country’s first national men’s health policy sometime soon. It’s likely that the policy will try to change some of the rhetoric around men’s health – instead of blaming men for not engaging, the policy may just turn the tables, and ask health services to take a hard look at themselves and what they could do to become more men-friendly.

At least that’s the guess I’m making after reading the information paper that was released earlier this year to support the policy’s development.

“It may be that it is the nature of services that determines willingness to seek help, suggesting the explanation of ‘masculinities’ for lower rates of men’s use of services may not be accurate,” says the paper. “Considerations of availability, access and suitability of services in line with men’s values and practices is likely to offer more fruitful explanations and ways to better engage men with appropriate health service use.”

Men’s health expert, Professor John Macdonald, believes the policy offers a “watershed” moment for men’s health. He writes:

“There will be an Australian National Men’s Health Policy this year, only the second in the world. Unnoticed by many, there has been a national discussion across the country about men’s health needs, initiated by the Department of Health and Ageing.

Instead of academics or medicos saying what men’s health needs are, men themselves were actually asked.

Among other things, the document used to promote this national debate speaks of a social determinants approach to men’s health as well as the need to think of male-friendly health services.

In the first instance, let’s look at the context of men’s lives: the impact of schooling on their health, of work- think of the high rate of industrial accidents in jobs men have to do, or the impact of job insecurity, of social isolation (the population most at risk of suicide in our country is older isolated men), the terrible effects of racism on Aboriginal and Torres Strait Islander men. The call to look at the social determinants of men’s health seems enlightened and compassionate.

The mention of “male-friendly” services marks a watershed.

Men themselves are often seen in our culture to be responsible for their poorer health and blamed for “not going to the doctor”. Whatever truth there may be in this, for once the spotlight can be turned on the doctors and community health services and we can (and I do) ask: “what are you doing to make yourselves “male-friendly”? Not very controversial, one might think. Alas, not so.

Leaving aside the issue of medicine (in this case urology) wanting the top place at the table (of men’s health, and indeed it should have a place), a recent issue of the Health Promotion Journal of Australia shows us that the knives are out to try to ensure the vision of the discussion document gets jettisoned.

Instead, two articles tell us, we should place male violence squarely at the centre of any men’s health policy, and focus on “hegemonic masculinity”.

Australia, Australia! Violence IS a Public health issue. The contradictions of men’s behaviour should not be avoided. Many countries are acknowledging it, both at its worst in sexual abuse but also the physical and psychological manifestations. of course, “No to violence against women!” (Also “No, to violence against children!” the main perpetrators of which are women, incidentally. Check it out!).

But I know of no other country in which academics would rise up in the year of a men’s health policy to demand that violence be central to that policy. S

ome would even say that gender equity as a social determinant is only about the imbalance of power between men and women in society and therefore nothing to do with the inaccessibility of many health services to men.

Gender as a social determinant would be only about this same imbalance and so we don’t have to look at the things already mentioned: health of boys in schools (unless we believe that the enormous amount of Ritalin dispensed to young boys (mainly) is because of their participation in hegemonic masculinity; likewise the many health-damaging male – another manifestation of hegemonic masculinity; socially isolated older men at risk of suicide – their masculinity is the problem, it seems. Aboriginal an Torres Strait Islander men, maybe they die 17 years younger than the rest of us because of the original sin of being “masculine”.

If we want a rational and compassionate men’s health policy, why would we start from the negative?

As a man, I will be castigated for challenging this “received wisdom” So be it.

Thank goodness there are many women who will also be sad if the government is cowed into changing tack and bringing out a men’s health policy focused on non-evidence based sociological constructs to please a certain lobby.

Let’s move away from gender wars and try to work with government to build a balanced, rational, not-afraid-to-look-at-all-contradictions–of-gendered-behaviour health policies for men and women, boys and girls.

• Professor John J Macdonald is Foundation Chair in Primary Health Care and Co-Director, Men’s Health Information and Resource Centre, University of Western Sydney

But the spotlight should be put on the Federal Government, argues Professor Wendy Hoy, of the Centre for Chronic Disease, School of Medicine, University of Queensland.

She writes:

“This problem of provision of dialysis services across state/territory booundaries would be solved if the Federal Government assumed responsibility for all such services across Australia.

If the federal government also takes charge of primary care services, at least where current options are not satisfactory, the links between death rates and need for dialysis with efforts in prevention, timely screening and quality treatment of chronic diseases in their asymptomatic and their less advanced stages would become clear.

This would allow informed health services planning to minimise sickness, dialysis, premature death and costs.

The Federal government could contract back with local providers for those services, where current systems are effective, transparent and accountable, but everything would come under one umbrella and one system of ongoing evaluation of processes, outcomes and costs. Inclusion of hospital services under such an umbrella is an obvious option.”