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.”

Dr Mark Ragg, a health and communications expert, believes the history of smoking among people with mental illness holds some lessons for those working to tackle Indigenous smoking, and also gives cause for optimisim.

He writes:

“David Thomas’ article is fascinating, as well as providing very good news. I’ve come recently to the issue of smoking in Indigenous populations after doing some work in smoking among people with mental illness, and have been struck by the similarities in approaches towards these two disadvantaged groups.

In both cases, there is a false belief that smoking is uniformly high and unchanging, leading to an almost nihilistic belief that nothing is possible. So if nothing is possible, nobody needs to act. And in both cases, smoking is excused by many health workers on grounds like ‘they have nothing better to do’ or ‘I don’t want to jeopardise our relationship by bringing up a difficult issue’.

There are certain things that clearly work to reduce smoking rates in populations – reducing the opportunities to promote smoking, reducing the opportunities for people to smoke, increasing the price and having health professionals give advice, support and medication such as nicotine replacement therapy when needed. Legislation, regulation, social marketing and specific health programs are all means to achieve these ends.

Certainly in people with mental health, and it seems in Indigenous populations, the problem has been that the basics have not been applied. People with mental illness have not had health professionals giving them advice and support. In fact, many people with mental illness are still told to smoke by their doctors.

But some progress is being made. In the US, psychiatrists have specific training programs in smoking cessation which are proving popular and effective, and similar approaches are being considered here.

In Australia, various health services are running smoking cessation programs for people with mental illness, and providing training for employees involved.

Croakey encourages bold predictions, so here’s one.

In 20 years time, policymakers and academics will look at smoking among people with mental illness, and among Indigenous people, and see that these high prevalences were a blip. A troubling time with severe health consequences, but a blip. Once these disadvantaged groups received the same resources and support as others, the problem began to recede.”

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

Dr David Thomas, a senior research fellow at the Menzies School of Health Research in Darwin, reports:

“In March last year, the National Indigenous Health Equality Summit set a target of reducing Indigenous smoking prevalence by 2% every year.  It sounds great: so much Indigenous suffering would be avoided and so many early deaths averted.

Tobacco control became a big ticket item in Rudd and Roxon’s plans to ‘Close the Gap’, with millions committed in last March’s Indigenous Tobacco Control Initiative and millions more to come as part of their COAG initiatives.  But few would have really believed that the 2% target could be achieved: just aspirational slush like ‘no child will live in poverty’.

Back then, the hard truth was that Indigenous smoking prevalence had not changed whilst smoking was successfully falling in the rest of the population.  This was based largely on three large national Indigenous surveys performed by the Australian Bureau of Statistics in 1994, 2002, and 2004.  All other national survey data had tiny Indigenous samples, and so provided useless estimates.  Each of the ABS surveys reported that about 50% of Indigenous adults smoked, about double the Australian prevalence of smoking.

What most readers have overlooked is that the reports of these surveys used different age cut-offs and different definitions of smoking (daily or all current smokers).  This week in the International Journal for Equity in Health, I described the prevalence of current smoking amongst Indigenous adults aged 18 and over in each survey.

From 1994 to 2004 Indigenous smoking prevalence in non-remote Australia fell in parallel with the total Australian population (by 5.5% in men and 1.9% in women).  In remote Australia, smoking prevalence also fell amongst men (by 3.5%) and appears to have peaked in women.  These two different trends can be neatly explained by international research about the shape of smoking epidemics, with remote Indigenous Australia just at an earlier point in the predictable smoking epidemic curve than Indigenous peoples in non-remote Australia.

Also this week, the ABS released the first results of the fourth national Indigenous survey in this series.  Detailed comparisons are not yet possible, but they too have reported a drop in national Indigenous smoking, from 51% in 2002 to 47% in 2008.

Even though both of this week’s reports have some limitations, we can reasonably confidently say that Indigenous smoking prevalence is not resiliently static, as once thought.  The Indigenous smoking epidemic is not exceptional, and there is no need to entirely re-think and re-fashion tobacco control in this setting.  We can adapt what has been successful in Australia and elsewhere.

Reducing Indigenous smoking is no longer a seemingly impossible task.

Indigenous smoking was slowly falling before a cent of the new money was spent.  How fast it falls now the new money is starting to hit the ground will depend on how that money is spent.

We should feel emboldened by this week’s news.  We should no longer call ‘encouraging’ any future reduction in Indigenous smoking; we should expect a dramatic reduction, maybe even the fabled 2% annual reduction dreamed up last March.”

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.”

This is the statement:

AMSANT has written to the Northern Territory Health Minister with a potential solution to needless deaths among central Australian renal dialysis patients, AMSANT Chairperson Stephanie Bell said today.

“The current policy of refusing to treat Aboriginal patients in Alice Springs is contributing to early deaths for Aboriginal people,” Ms Bell said.

“Sending people from remote communities to Perth or Adelaide is creating enormous psycho-social impacts on individuals, their families and their communities.

“Some people are opting to refuse or withdraw from treatment so they can go back to their country to die: it is an intolerable situation.

“The patients concerned live on or close to their ancestral estates—and didn’t “ask” for those estates to be alienated from their kin and country by the arbitrary imposition of state and territory border lines.

“We have suggested to Minister Vatskalis that a short term solution is available—nocturnal dialysis—and that AMSANT would back the Territory Government in seeking proper recompense from the South and Western Australian governments, as well as Commonwealth support.

“The demand that they move many thousands of kilometres to distant capital cities is irrational and—in the long term—far more expensive than treatment closer to home in a regional centre such as Alice Springs.

“The tri-state committee dealing with these issues for 18 months and has done little more than sit on its hands.”

Ms Bell said that AMSANT realises that the Northern Territory is in an invidious position in being asked to take on patients that don’t “belong” to the Territory in a jurisdictional sense. She said the costs of introducing night dialysis at the Alice Springs Hospital, along with social and housing support, should be met by interstate governments.

“This is clearly a short to medium term solution, one that will be relieved to an extent with the new satellite facility opening in April next year,” said Ms Bell.

“Beyond that, of course, we must work towards peritoneal and haemodialysis being made available in the regions to reduce the load on facilities in Alice Springs.”

Croakey suspects that this is just one slice of a much bigger story about how Indigenous patients with kidney disease miss out on all sorts of potentially life-saving interventions – including measures that might help prevent the need for dialysis in the first place.

It is from Sarah Brown, Manager of the Western Desert Nganampa Walytja Palyantjaku Tjutaku, an organisation that provides support to Aboriginal people needing dialysis (more details on the organisation at the bottom of the letter).

She is urging people to write to the relevant Ministers in the WA, NT and Federal Governments. She writes:

Dear friends

Thank you for your interest in the plight of renal patients in the most remote parts of Central Australia.  People from communities in the desert regions outside the NT border are no longer able to access dialysis services in Alice Springs. This has and will have a devastating effect on individuals, families and communities who have always looked to Alice Springs for their health care and support services.

The situation of Patrick Tjungurrayi who contributed significantly to the setting up of our community controlled dialysis and support services has helped us to highlight this issue.

The NT Government says they require the WA and SA governments to make a substantial contribution to service provision in Alice before dialysis can be offered to people from over the borders. They say that these negotiations may take a long time. But while governments cost shift and pass the buck, people are getting sick with little hope of receiving treatment close to home.

We need your help to let governments know that these people are not forgotten and this situation imposed upon them by the enforcement of arbitrary state boundaries is CAUSING GREAT HARDSHIP.

We ask you to consider sending letters and or emails voicing your concerns to any or all of the following politicians/bureaucrats listed below.

It would help us if you sent a copy of anything you do to this email too. This will help us to follow up with politicians and to keep you posted on developments.

Any suggestions, ideas, comments or lateral thinking about solutions to the problem would be gratefully received!

Thanks so much for your help and interest!

Sarah Brown
Manager
Western Desert Nganampa Walytja Palyantjaku Tjutaku

Sarah has provided the following additional background for Croakey readers:

The Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation (WDNWPT) began ten years ago as the Western Desert Dialysis Appeal.

Pintupi people from Kintore and Kiwirrikurra with the help of Sothebys and Papunya Tula Artists painted large collaborative works and held an auction at the Art Gallery of New South Wales. A million dollars was raised to improve life for people from the Western Desert forced to relocate to Alice Springs for dialysis treatment for End Stage Renal Failure.

All indigenous people in the Western Desert are eligible to be members of the organisation. As a model of good governance, WDNWPT has twelve elected directors from across the region. They are community leaders and respected community members. Our chairperson is Marlene Spencer, Senior Health Worker at Pintupi Homelands Health Service. Meetings are held regularly and Directors, patients and family members take an active part in running the organisation.

For five years WDNWPT has had a nurse and a dialysis machine in Kintore. This has enabled people to return home to country and family. WDNWPT also has a house in Alice Springs (The Purple House), with two machines enabling us to teach self care dialysis and provide a range of social and cultural activities aimed at improving quality of life and contributing to the Alice Springs community.

Our committee is proud of what it has achieved thus far but devastated that they are no longer able to offer the services of the organisation to people from across the border in WA who are their family because of the NT government’s ban on dialysis patients from WA coming to Alice.

This one is called Cough N Rap

Click here to view the embedded video.

And, I don’t know about you, but this one just makes me want to dance… (if it doesn’t stop people smoking, it might at least get them moving…)

Click here to view the embedded video.

The clips (and there are more in a similar vein) are being disseminated via mobile phones in Arnhem Land by Miwatj Health, after receiving rave reviews at a recent local festival.

According to a Miwatj Health press release: Under the banner “Yaka Ngarali”, meaning No Smoking in Yolnu language, local family groups came up with the story lines led by Galiwin ‘ku musician Nigel Yunupingu of the band Saltwater. Up to 50 people had a hand in writing the songs and appearing in the videos.

It’s yet another reminder of the value of involving local communities in developing their own solutions to health problems….

We’re not even close – and if you’re expecting anything meaningful to happen before 2020, you’re just not paying close enough attention.

That’s  the assessment of Professor Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney.

And he thinks the Federal health reform bandwagon now visiting a hospital near you is just a distraction from the main game.

He writes:

“As I’ve expressed in an editorial in next week’s Medical Journal of Australia, this ‘consultation’ process is a major distraction.

What is clear is that the Government (assisted by the final report of the National Health and Hospitals Reform Commission) is rapidly retreating from any serious reform agenda.

Medicare Select, the reform previously known as ‘Option C’ (i.e. competitive national social insurance) has been sent to the back-blocks of Woden for a well-earned period of long-service leave. Regional health providers (Option B) are not on the agenda either.

Inevitably, a future (and somewhat braver) Government will be forced to revisit the issue of genuine health reform (in about 2020). At that time it will dust off the NHHRC interim report and have another look at a
financing system that had some real chance of changing the way that health care is delivered in this country.

In health, as in most human endeavours in the modern world, you get the health care system you pay for. If you pay for disconnected services, a narrow focus on acute care and one-off (i.e. fee-for-service) procedures
and other interventions – then that is what you’ll get.

The really neglected areas of chronic disease management, dental care, mental health, indigenous health, youth health and coordinated aged care will remain at the bottom of the pile.

The Government has already demonstrated its real (political) priorities through its major new investments in acute care hospitals, cancer care and reducing surgical waiting lists.

While the major economic stimulus package prioritised the retail sector (do we really need two plasma screen TVs in every Australian home?) and basic educational infrastructure, the health services and medical research sectors were obviously low priorities.

In the meantime, this round of hospital-centric public relations events will keep everybody chattering till we all quit for Xmas.

Clearly it is designed principally to soften us up for another round of public ‘hospital’ reform (i.e. senior Woden officials telling the States to get their act together).

Any one who has sat through “the (powerpoint) presentation’ that goes with these hospital-based events will realise rather quickly that we are not on the precipice of major ‘health’ reform.

There is no serious discussion about changing how the money flows or opening up the sector to a new breed of regional or national health care providers.

The most likely outcome for the post-2010 election period is some more money, a lot more talk and the same old divided Federal-State delivery system.”

So says health policy analyst Jennifer Doggett, who describes the rebate as “a textbook example of the worst health funding policy in Australia’s history“.

She writes:

“Imagine if car insurance provided rebates for fuel expenses and the Government subsidised the cost of that insurance.  What would result from this (thankfully) hypothetical situation?  People would use more petrol than they do currently (since they don’t incur its full cost), petrol would become more expensive (due to the increased cost of administering the scheme as well as the blunting effect of subsidies on price signals); and richer people, who have bigger cars (on average) and more money to purchase fuel, would benefit disproportionately from the subsidy than those on low incomes.

It’s an absurd proposition but it’s exactly what happens in relation to health care funded by private health insurance.  Nicola Roxon’s attempt last night to reduce the rebate subsidies for high income earners with private health insurance is one small step towards minimising the adverse impact of this costly policy on the public purse.  The fact that it was defeated in the Senate demonstrates how little understanding the Opposition has of health funding issues.

Private health insurance is one of the most inefficient and expensive mechanisms for paying for health care.  Private health insurance funds spend about 13% of revenue on administration, compared with the 3% spent by Medicare.  Partly this is due to the economies of scale of Medicare but also because private funds have to spend money on advertising to compete against each other.  Higher administration costs drive up premiums which ultimately come out of the pockets of consumers and tax payers.

Private health insurance is inefficient in other ways.  By shifting demand from public to private services, doctors and nurses are attracted away from the public sector.  We have a fixed number of doctors and nurses in Australia.  When demand increases in the private hospital sector, health professionals will move there away from public hospitals.  With widespread health workforce shortages, we should be ensuring that the first priority for health professionals is to care for the sickest people in the community. Generally these are found in the public system.

Private health insurance does not make it easier for the most disadvantaged people to afford the health care they need.  The group with the poorest health status in the community, Indigenous Australians, has the lowest level of private health fund membership.  People on low incomes often can’t afford the high gap payments that come with private care, even if they can afford the monthly premiums.  And people with chronic conditions often find that the annual limits and caps on rebates for treatments run out long before they have received the treatment they require.

In fact, in most cases private health insurance is not really insurance.  Fixed rebates combined with open ended co-payments, such as those required for ancillary services by most forms of private health insurance, do not limit the risk of consumers incurring high health care costs.  Rather they act as an inefficient and overly complex budgeting measure to assist consumers with managing health care expenses.

Given the high costs and other disadvantages of an insurance model for funding health care, it should be used minimally. In sharing the risk of very unusual and high cost health care needs, the advantages of an insurance model probably outweigh its risks.  However, given that (by definition) the majority of health consumers do not experience unusual and unpredictable high health care costs, private health insurance should not be supported or subsidised by government as a mechanism for funding predictable and regular forms of health care.

Instead of blocking the Government’s laudable (although not nearly comprehensive enough) attempt to reduce the inefficient subsidy for high income earners, the Opposition should be focussing on finding more efficient ways of funding health care. There are a number of options for this (some outlined in the National Health and Hospitals Reform Commission Report), almost any of which would be an improvement on the current private health insurance model.

The private health insurance rebate was a terrible Howard-era policy, designed to buy off pensioners scared about the introduction of the GST before the 1998 election. It’s served its purpose. It’s cost us (the tax payer) billions. It’s prevented the development of other innovative and efficient funding mechanisms which genuinely respond to consumer needs.

It’s time it was pensioned off and allowed to live out its days as a textbook example of the worst health funding policy in Australia’s history.”

Happily, it also sounds like Podger has spilt a few beans, as well as taking a serious look at the changing nature of the Australian Public Service. A few of the spilt beans identified by Keane are:

• Michael Wooldridge — who evidently impressed Podger as a committed and intelligent minister — lobbied his Cabinet colleagues hard for a significant and ongoing boost in funding for indigenous health, but got no support.
• Relations between Wooldridge and Aged Care Minister Bronwyn Bishop broke down sufficiently badly that Podger’s department had to act as a relay between them during the critical budget process in 1999.
• Bishop tried to block the Department of Health annual report for 2000-01 on the basis that it was “her report” and contained data she did not wish published. Podger had to remind her it was a statutorily-required report from him to Parliament.
• Podger had to resist efforts from Howard’s office and PM&C to interfere with his review of health services delivery in 2005, including directions not to speak to certain experts considered hostile to the Government.

Anyway, you can dig further for yourself. ANU E Press has kindly made the whole thing freely available here.