Thanks to Dr Stephen Duckett, health program director at the Grattan Institute, for his tweet-reports, as per below:

I asked if there had been any mention of equity issues, the social determinants of health, or public health and prevention:

Here are links to:

• Health and Ageing Budget statements

• A table giving a quick overview of health spends and cuts

• Ministerial press releases

• Closing the Gap press release

• The Treasurer’s speech

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Overview of key announcements

• $55.7 million over four years to expand BreastScreen Australia’s active recruitment of women in the target range of 50-69 years of age to women 50-74 years of age. From 2013-14, all Australian women 70-74 years of age will be actively invited to undertake free breast screening every two years – a first for the program. This will improve the early detection of breast cancer, resulting in more than 145,000 additional women screened every two years from 2016-17, with up to an additional 1,170 breast cancers detected every two years.

• The target age range for the National Bowel Cancer Screening program has also been extended, and from 1 July 2013, people turning 60 will be invited to undertake free bowel cancer screening through the program. This will build on the current program, which invites those turning 50, 55 and 65 years of age to participate in screening. From 1 July 2015, people turning 70 will also be included in the program. Around 5 million Australians will be offered free screening over the next four years. The 2013-14 Budget commits $16.1 million over four years to ensure that the program is available to all eligible Australians.

Clarification from Bowel Cancer Australia:

Bowel Cancer Australia would like to clarify some media reports regarding the budget announcement relating to the Government’s National Bowel Cancer Screening Program (NBCSP).

Additional funding for the National Bowel Cancer Screening Program (NBCSP) in the 2013-14 budget is $3.7 million for program reporting.

No new ages for the National Bowel Cancer Screening Program (NBCSP) were announced in this budget. The addition of 60 and 70 year olds were announced in last year’s budget.

In 2013, the National Bowel Cancer Screening Program (NBCSP) is only relevant to people aged 50, 55, 60 and 65, not all Australians aged over 50. It remains a five yearly screening program despite medical guidelines recommending screening for people aged 50 and over every one to two years.

The $16.1 million allocation to the National Bowel Cancer Screening Program (NBCSP) is over four years and relates to health professional reporting of the program.

A ‘fully implemented’ bowel cancer screening program (two yearly screening for people aged 50-74) is still scheduled for 2034, as per last year’s budget announcement.

(Croakey’s wording was taken from Budget papers.)

• $4.1 billion for a dental reform package, in addition to the $515.3 million investment in dental health made in the 2012-13 Budget.

• From 1 January 2014, around 3.4 million children aged 2-17, in families who meet a means test, will be able to access up to $1,000 worth of basic essential dental treatment capped over a two year period under the Grow Up Smiling program. This replaces the teen dental program. A National Partnership Agreement to expand services for adults in the public dental system will commence on 1 July 2014.

• A Flexible Grants Program will commence in 2014 to provide funding for dental infrastructure in outer metropolitan, rural and regional areas.

• Two industry funded clinical quality registers will also be established with $5.1 million over two years in initial Government funding. These will enhance national post-market surveillance for high risk implantable devices such as pace makers and breast implants, so that potential faults with devices can be detected more quickly and followed up appropriately. There will also be enhanced patient contact arrangements for patients with high-risk implantable medical devices. In the event of a recall of a device, hospitals will follow a new national protocol to contact affected patients.

• A National Antimicrobial Resistance (AMR) Prevention and Containment Strategy will provide national and international leadership on this significant global health priority. The Strategy will also coordinate Australia’s efforts across human and animal health to reduce, monitor and respond to AMR. The Government will expand surveillance of AMR and antibiotic usage; implement infection prevention and control activities to reduce the spread of infection in general and of resistant infections in particular; and implement antimicrobial stewardship programs to provide a systematic approach to optimising the use of antibiotics in primary health care, residential aged care facilities and hospitals.

• There will be a review of the drug and alcohol prevention and treatment services sector to clarify the range of services currently funded; develop common understanding amongst governments and the sector of current and future service needs; and clarify the type and timing of drug and alcohol funding activities undertaken by governments. The review will be concluded in 2014 and its findings will inform the next funding round under the Substance Misuse Service Delivery Grants Fund scheduled to commence in late 2014.

• Reviews of Medicare Benefits Schedule (MBS) items – 16 reviews that are now underway will be progressed, and a further two specialty reviews will be undertaken (does anyone know what they are for??), “to ensure that items listed on the MBS remain clinically relevant and consistent with best practice”.

• This is the one that will have the medical lobby screaming: Changes to MBS indexation so that MBS fees will be indexed on July 1 each year (in line with many other programs) rather than on November 1. The next indexation date will be July 1, 2014.  Savings will also come from removal of double billing under Chronic Disease Management , and an increase of  the upper (general) threshold of the extended Medicare safety net to $2,000 from 2015. These measures will save $889.4 million over four years. (Update 16 May: For a more detailed explanation of these changes, see the Commonwealth Parliamentary Library’s article.)

• More cuts ($20 million over four years) are to come from the National Rural and Remote Health Infrastructure Program, and $10.8 million will be saved from not proceeding with Katherine and Gove District Hospitals.

• $80 million will be cut from Health Workforce Australia’s budget over four years (you can get a sense of the breadth of HWA’s work here.) HWA sources say that the first $20 million cut next financial year is likely to come from savings in the Clinical Training Funding (CTF)  program and the International Health Professionals (IHP) program. Reaction added: Former HWA board member, Professor Andrew Wilson, director of the Menzies Centre for Health Policy, University of Sydney: “It would be very unfortunate if the reduction in HWA funding impacted on its support for initiatives to make the increased number of clinical graduates work ready. It would be unfortunate if it also impacted on the programs to reform health workforce training. However, while this is a large reduction I think the Board will could make changes that will maintain its priority programs.”

• In 2013-14 there will be a new Medicare Locals Accreditation Scheme to support Medicare Locals to meet best practice organisational management and service delivery processes. Accreditation is one aspect of a broader quality framework for Medicare Locals, which will seek to promote transparency, information sharing, and a culture of continuous quality improvement. Work will continue on the National Evaluation of Medicare Locals to assess the extent to which Medicare Locals are progressing toward the five strategic objectives of the program.

• A National Primary Health Care Strategic Framework has been agreed and the Department will work with the states and territories to develop bilateral plans for primary health care by July 2013.

• In 2013-14, the NPS will complete the first phase of the development of the MedicineInsight project and deliver to the Australian Government the first reports from this dataset. The NPS is developing the MedicineInsight project to capture, store and analyse GP data to better inform how medicines are being used in clinical practice.

• Safety and quality initiatives will aim to reduce unnecessary clinical variation in the use of blood products, reduce unnecessary radiation exposure from diagnostic imaging and develop an Annual Atlas that identifies unwarranted clinical variation.

• The Mental Health Nurse Incentive Program, which provides access to coordinated clinical care for patients with severe and persistent mental health disorders in the primary care setting, will continue under existing arrangements pending a restructuring in response to an evaluation published late last year. This will enable community based general practices, private psychiatric practices and other similar organisations to continue existing arrangements with mental health nurses.

• The Budget also includes funding for perinatal depression initiatves, the Partners in Recovery initiative, headspace program for teenagers and young adults, and expansion of the Access to Allied Psychological Services (ATAPS) program, which  funds Medicare Locals to broker allied mental health professionals to provide psychological treatment to people with a diagnosed mental disorder. The expansion targets hard to reach groups and communities that are currently underserviced, such as children, Aboriginal and Torres Strait Islander communities and socio-economically disadvantaged communities.

• From 1 July 2013, the My Aged Care website and call centre – key components of the new Aged Care Gateway – will be established. This will provide older people, their families and carers with access to the information they need, and enable them to more easily navigate the aged care system.

• The  Closing the Gap release says the Government is investing $6.5 million over three years to 30 June 2016 to continue to support Indigenous communities to participate in the digital economy and access  government services online. The agreement supports the ongoing operation and maintenance of public internet facilities delivered under the original agreement and provides training to Indigenous people in the use of online technology

• Funding of $16.5 million over four years will improve eye health for around 20,000 Indigenous Australians. The aim is to eliminate trachoma – an infectious eye disease that  can lead to blindness – in affected communities.

• $3.9 million will be spent over four years on mosquito control activities including a program to prevent the spread of mosquito-borne diseases such as dengue fever in the Torres Strait and to the mainland. Funding will also support communication and coordination between Australia and Papua New Guinea to reduce communicable disease risk in the Torres Strait.

•  $15 million over three years from 2014-15 to continue  funding to the National Congress of Australia’s First Peoples. Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait. $1.3 million over two years will be provided to support the work of the Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait Islander Peoples to establish a parliamentary and community consensus on referendum proposals.

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Wrap of reaction

The Social Determinants of Health Alliance: Health inequity grows as Senate report gathers dust

The Social Determinants of Health Alliance has expressed disappointment at there not being any mention in this year’s Federal Budget about the shame of increasing rates of health inequity in a country that prides itself on giving everyone a “fair go”. Read the full release here.

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Public Health Association of Australia: Mixed reaction

The long term plans to underpin Australian children’s education and a National Disability Insurance Scheme are welcomed by the Public Health Association of Australia (PHAA).

Improved health outcomes rely on all Australians having a positive start in life, and that requires a strong and long term government commitment to children’s education.  Similarly, people and families living with disabilities need the assurance of a national insurance scheme to meet their daily needs.

Other public health areas also received support in the 2013/14 budget:  cancer prevention and screening ($4.5m to CanTeen for youth cancer networks; $3.7m increase for the National Bowel Cancer Screening Program; $55.7m over four years to expand breast screening to a wider age range of women); $16.5 million for trachoma prevention and eye health for Indigenous Australians; $1.7m for an OzFoodNet national partnership;  $64.6m for the National Partnership on Preventive health; $11.1m to local government for healthy communities initiatives;  $28.9m for healthy children (0-16 years) initiatives; $24.7m for workplace health programs; and $3.9 million to combat dengue fever and tuberculosis.

Associate Professor Heather Yeatman, President of the Public Health Association of Australia (PHAA), supported the Government’s commitment to funding continued compliance and enforcement activities associated with tobacco plain packaging legislation and $155.2m to treat additional public dental patients.  “It is important that current public health initiatives are not forgotten when large new programs are announced.”

The PHAA acknowledged other important areas in the budget that will support health outcomes in the long term.  These included $777 million for a new National Partnership (NP) on Closing the Gap in Indigenous Health Outcomes, including preventative health checks for Indigenous Australians; funding for key urban public rail projects that will encourage fewer cars on the road; and $300 million over four years to support jobseekers in the transition to work.

The PHAA had suggested that the government could raise much needed funds and achieve improvement in public health through taxes – a volumetric tax on wine, the abolition of the WET rebate and implementation of a tax/levy on selected nutritionally undesirable foods.

“Funds raised by these taxes could be used for preventive programs and to promote and subsidise nutritionally desirable foods for disadvantaged groups” said Professor Yeatman, “but this did not happen.”

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Meanwhile, the Treasurer’s announcement of changes to the indexation of tobacco excise (expected to add 7 cents to the price of a pack by the first half of next year) did not impress one public health advocate:

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National Rural Health Alliance: Good in parts – like the curate’s egg

Tonight’s Budget has kept faith with four major initiatives which, over time, will help transform Australian society and contribute to good health, including in rural and remote areas.

As expected, there are some significant new investments in cancer care and treatment, but little else to excite those in the health sector.

And disappointingly, no improvements yet to rural health workforce programs.

The four major initiatives are the Gonski education reforms, DisabilityCare Australia, improvements to public dental health services (initially for children and teenagers) and the National Broadband Network.

Although much of the detail relating to the first two is still in their fine print, foundations have been made which will ensure they become realities and so help lay the basis for good health.

If rural schools can be funded according to educational need it should be possible to equalise educational outcomes in rural areas, making a contribution to greater city-country equity in employment, income and health.

DisabilityCare Australia, with the ongoing support of State and Territory Governments and underpinned by the Medicare levy increase, will end the lottery relating to care for people living with a disability – a lottery which those affected in rural and remote areas win even less frequently than those in major cities.

These two major initiatives have been confirmed tonight as areas for significant investment over the next several years. And GUS is very welcome – Grow Up Smiling – which will see the Commonwealth investing in dental care for 2 to 17 year-olds, starting 1 January 2014, part of the dental reform package announced in August 2012.

The fourth, also confirmed in tonight’s Budget, is the Government’s commitment to the National Broadband Network. Like the education and disability reforms, the NBN is a long-term and high cost project which, when fully delivered, will improve health and wellbeing (including through enhanced business opportunities) for people everywhere and give the same chances in a digital world for people in remote, rural and city areas.

The savings measures necessary for underpinning these initiatives include a halving of the allocation to the National Rural and Remote Health Infrastructure program from $10 to $5 million a year. The smaller amount will be focused on remote Indigenous communities and places under 20,000 people.

Those who went to the 12th National Rural Health Conference will be delighted about continued investment in Indigenous eye health. And in what is a credit to its advocates, funding has been uncapped and new money provided for a year for the Mental Health Nurse Incentive Program while it is being redesigned. Major new investments in screening and services for breast, prostate, lung and bowel cancer are also very welcome.

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ACOSS: Budget secures landmark disability and education reforms, but gaping hole for poorest on allowances remains

ACOSS warmly welcomes the Federal Government’s vision to secure disability care and dental and schools reform and the strengthening of public revenue to secure funding for these and other services, but cannot believe that there is no income relief for the people who are the poorest,” said ACOSS CEO Dr Cassandra Goldie.

“We praise the move by the Treasurer to lock in government expenditure on crucial social reforms such as education and disability care, in some cases for a decade. We have also been strong supporters of the more equitable and effective system for dental care in Australia and that begins with two-thirds of all children in this Budget. These are not only visionary reforms but long overdue,” Dr Goldie said.

“However, we remain deeply concerned at the failure to reduce the rate of poverty in Australia by increasing the single rate of Newstart and other allowances. While we welcome the modest easing of income rates for people on Newstart and other allowances, the Government has failed to assist the four-fifths of Allowance recipients who are unable to obtain paid work. Each year we fail to act, this gaping hole in our safety net grows. One in eight people, including one in six children, are living in poverty and an increase in the lowest social security payments would have the most immediate and direct impact in reducing it.

“On the savings side, there are some incredibly important measures in this Budget. In addition to the welcome increase in the Medicare levy to fund DisabilityCare Australia, we are pleased that the Budget makes significant inroads into closing tax loopholes and inefficient tax arrangements. With tax receipts down by over $20 billion from the pre-GFC period, we must pull back from generous tax breaks that are not delivering on policy outcomes and eroding our tax base. ACOSS advocated the extension of the Medicare Safety Net threshold, the abolition of the medical expenses tax offset, the capping of self-education expense deductions and the tightening of the thin capitalisation rules, all of which we welcome in this Budget.

“We are also pleased that there is greater investment in tackling tax evasion through trusts. We would have liked to have seen changes to tax rules as well, but hope this commences the reforms needed to close this glaring tax loophole.

“We welcome the integrating of the baby bonus into the family payments system so that it is better targeted but remain concerned about reductions in payments for the poorest families.

“The next step to secure our economic and social progress must be to strengthen revenue. Otherwise we face painful cuts to essential expenditure down the track. Australia is the 5th lowest taxing country in the OECD. If we want a decent safety net, and universal health education and dental services, as well as the housing and infrastructure for present and future generations, we need a sustainable tax base,” Dr Goldie said.

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The Government’s failure to increase Newstart allowance has been widely condemned, by the UnitingCare Australia and others:

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Oxfam disappointed on aid funding

The Gillard Government’s latest broken promise on growing the overseas aid program will have a devastating impact on the world’s poorest people, reducing Australia’s aid commitment by $1.9 billion, Oxfam Australia said today.

In response to tonight’s federal budget, the international aid agency also said it was deeply disappointing to see the government plunder another $375 million from the overseas aid program to pay for its domestic asylum seeker policy.

Oxfam Australia Chief Executive Dr Helen Szoke said that the good news this year with aid levels rising from 0.35 to 0.37 per cent was overshadowed by the government’s decision to again delay, by one year, its pledge to grow the overseas aid budget to 0.5 per cent of national income.

“This decision will cost approximately 1.9 billion to our fight against global poverty,” said Dr Szoke.

“That’s $1.9 billion that would otherwise have been spent in some of the world’s poorest countries, making sure children can go to school, that families have enough food to eat, and communities can access safe drinking water.”

On top of previous delays to meeting the 0.5 per cent aid spending target, Australia’s aid effort has been reduced by a total of approximately $4.8 billion since the 2011-12 federal budget.

“This government has failed the world’s poorest people. Every dollar denied has real impacts for people living in poverty,” Dr Szoke said.

“We know Australian aid helps to save lives and improve opportunities for some of the world’s most vulnerable people.

“Last financial year, Australian aid helped more than one million people in Africa access safe water and ensured more than 135,000 pregnant women in East Asia gave birth with the support of a skilled birth attendant.

Dr Szoke also said the diversion of $375 million from the overseas aid program to pay for onshore asylum seeker costs meant Australia would be the third largest recipient of its own aid, behind Indonesia and Papua New Guinea.

“We are fortunate in Australia that we can afford to help those in need at home, as well as provide life-saving aid to those beyond our borders. Australians expect our overseas aid to be focused on helping poor people overseas, not to prop up the funding of domestic asylum seeker policies.

“The government’s continued raid on the overseas aid program will mean more farmers won’t get the help they need to grow food, more children won’t get the education they need for better jobs, and too many women won’t get the support they need to deliver healthy babies.”

Oxfam is urging the government to show leadership on this issue and ensure investment in the overseas aid program gets back on track as soon as possible, with no funds diverted to pay for domestic programs.

“Millions of people around the world are depending on Australia’s promise to step up its fight against global hunger and poverty, and with one in eight people still going hungry every day, we cannot afford to wait,” Dr Szoke said.

“Oxfam is now looking to the Coalition to show leadership on this issue and commit to a timeline to increase aid to 0.5 per cent of national income.”

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Consumers Health Forum: Budget for medicines and cancer but no hip pocket relief

Patients with cancer or needing new medicines will benefit but there is little relief from hip pocket pain in tonight’s budget, says Carol Bennett, CEO of the Consumers Health Forum.

“The heavier costs consumers now face are fuelling the emergence of a two-tiered health system — one for those who can afford to pay and one for those who cannot. Unfortunately, there is a growing number of Australians, particularly the aged and the chronically ill, who are struggling to afford necessary medical treatment,” Ms Bennett said.

“Medicare is already under strain. We expect to see GP bulk billing drop and even greater pressure on doctors to speed up patient consultations..

“CHF has demonstrated the growing burden health care places on families with our recent “Hip Pocket Pain” campaign, showing that Australians pay among the highest out-of-pocket costs in the world, averaging over $1,000 a year..

“The ballooning expense to government and individuals underlines the need for fresh approaches to pay for health care that will result in more effective, targeted treatment and reduced out-of-pockets. We have an ageing population, increased demand and government revenue slowing and to pay simply for patient throughput no longer makes sense, ” Ms Bennett said..

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Catholic Health Australia

Tonight’s Budget largely insulated health from major cuts in spending and provided a welcome boost to cancer services, but it failed to plug gaps in public hospital funding – a gap that risks coming back to haunt the Government in the lead-up to the Federal election.

Catholic Health Australia CEO Martin Laverty said Government efforts to fund important reforms in education and disability care could, in time, improve social determinants of health in a country that is currently burdened by unacceptable levels of health inequity. Thankfully, fears that funding those services could have resulted in larger health funding cuts have not been realised.

“Not too many who work in the health system expected new spending announcements tonight. Funding increases in cancer screening, research and support is welcomed. Expanded funding for prostate cancer programs at the Kinghorn Cancer Centre at Sydney’s St Vincent’s Hospital campus is most welcome,” Mr Laverty said.

“There is also relief that in an effort to avoid a larger Budget deficit and fund education and disability care, cuts to health programs have not gone deeper. Tonight really could have been a lot worse than it is.”

Mr Laverty said three main health program funding cuts detailed in tonight’s Budget papers will need further attention in the lead up to the election.

“The first funding cut was announced late last year, when the Federal Government clawed back $1.6 billion in public hospital funding over the next four years. Tonight’s Budget only affirms the restoration of this year’s $107 million in funding for Victoria, ignoring need in other states.

“In the coming weeks, public hospitals across every state will have to start announcing service cuts in response to the $1.6 billion public hospital clawback, which a Senate Inquiry called ‘extraordinary and indefensible’. Tonight was a lost opportunity, and this funding should have been restored.

“No one should underestimate how problematic this public hospital funding cut is likely to be in the years ahead. As state and territory governments announce their budgets in coming weeks, we can expect to see public hospital services starting to be wound back.

“Tonight’s second cut involves changes to the Medicare Benefit Schedule that will see a freeze in Medicare payments to doctors. The Department of Health and Ageing confirmed tonight no modelling had been done on how this might impact consumer out-of-pocket costs.

“The third cut will see $80 million taken from Health Workforce Australia over the next four years. The Department of Health and Ageing again confirmed tonight that it’s not known what health workforce programs will be cut as a result of a funding clawback, but we do know that severe health workforce shortages are predicted in the years ahead,” Mr Laverty concluded.

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The Australian College of Mental Health Nurses

The Australian College of Mental Health Nurses (ACMHN) welcomes the modest increase to the Mental Health Nurse Incentive Program (MHNIP). The Federal Budget 2013-14 provided $23.8 million in additional funding for the MHNIP.

Minister Butler also re-affirmed the Government’s commitment to working with stakeholders to improve the Program and provide better support to this vulnerable client group.

“It is clear our calls have not fallen on deaf ears and we are delighted with this modest increase in funding”, said Adj Associate Professor Kim Ryan, CEO of the Australian College of Mental Health Nurses. “I look forward to meeting with the Minister to find out how that increase will be implemented”.

And some more mental health reaction:

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Rural Doctors Association of Australia: Mixed budget for rural patients

The Rural Doctors Association of Australia (RDAA) says, for rural Australians and particularly rural patients, this year’s federal budget is firmly a case of the good, the bad and the ugly. RDAA President, Dr Sheilagh Cronin, said:

On the good side, we are pleased to see:

• additional funding for Indigenous healthcare under the Close the Gap initiative
• funding for breast screening for women aged 70-74 years
• significantly more funding for cancer research, treatment and support
• a commitment from the Federal Government that funding under the National Rural and Remote Health Infrastructure Program, while being reduced in actual terms, will see remote areas and Indigenous communities being the priority areas for the remaining funding
• a $20 million increase in funding for the General Practice Rural Incentives Program (GPRIP), however whether this additional funding is allocated to doctors moving to small rural and remote towns is, RDAA believes, dependent on adjustments being made to the ASGC-RA classification scheme.

On the bad side, we are very disappointed that:

• there has been no commitment from the Government to fix the troubled Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA) scheme in consultation with key rural stakeholders, despite the fact that the current system is making it very difficult to attract and retain doctors in many small rural towns
• there has been no commitment to introduce a National Advanced Rural Training Program or additional supports to provide a ‘pipeline to rural practice’ for the many young doctors now graduating from Australia’s universities
• there has been no commitment to reverse the $2000 / year tax deduction cap on work-related self education expenses, given a $2000 limit makes it extremely difficult for rural doctors to afford continuing medical education given the costs of course registration, travel, accommodation and locums
• the Medicare Safety Net has been increased to $2000.

And on the ugly side…

• The Federal Government’s decision to cut Medicare rebate funding over four years by $664.3 million (through realignment of Medicare indexation) is of serious concern.

Dr Cronin said: “It will discourage more rural Australians to seek preventative healthcare and health checks, despite the fact this healthcare would save the Government significant future expenditure by reducing chronic disease and hospitalisations.

“And we are significantly concerned that the aged, frail, disabled and those with chronic disease will be worst hit by the rebate funding cut, given they regularly need to access healthcare, as well as low-income rural Australians who simply cannot afford additional healthcare costs…..

“Medicare rebates are, in reality, a subsidy to the patient, not the doctor. If these subsidies to patients don’t keep up with the CPI, then practices will have no choice but to pass on these costs to the majority of their patients, and/or limit the amount of bulk-billing they do. These are the harsh economic realities.”

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AMA: Government targets sick people to reduce Budget deficit

AMA President, Dr Steve Hambleton, said tonight that the Government will force sick people to pay more for their health care to help address the Budget deficit.

Dr Hambleton said that the decision to delay indexation of the Medicare Benefits Schedule (MBS) from 1 November 2013 to 1 July 2014 – which is effectively a freeze on MBS indexation – will rip $664.3 million out of primary health care services.

“The Government is getting sick people to help fix the Budget black hole,” Dr Hambleton said. “People will pay more for their health care every time they visit the doctor. The sicker you are, the more you will pay. Even veterans will be hit. The freeze will hit health services provided by the Department of Veterans Affairs.

“Many families will face further increases to their health care costs through the increase of the upper Medicare Safety Net threshold to $2000. At a time when many Australians are facing huge cost of living pressures, it is going to get harder for people to cover their health care costs. Some people may choose to put off seeing their doctor.”

Dr Hambleton said it is surprising that a day after the Government announced record bulk billing figures, it hands down a package that will force bulk billing rates down.

The AMA welcomes funding in key areas, including:

·        $777 million for Closing the Gap in Indigenous Health Outcomes;

·        the World Leading Cancer Care Package; and

·        a national patient register for high risk implantable devices.

The AMA will closely examine the Budget Papers before making a comprehensive response to the overall Budget across portfolios.

A particular focus will be on the Government’s changes to taxation of work-related self-education expenses, which make it harder for doctors to improve their skills to the benefit of patients.

***

At The Conversation

Hal Swerissen, Professor of Health Policy, La Trobe University, says:

The budget delivers on funding for the NDIS, the government’s major policy initiative. It also includes funding for dental health reform and has there is money for cancer prevention, new pharmaceutical listings, rural incentives program for GPs, and aged care reform.

The budget makes sensible savings by removing double dipping on Medicare by GPs, removing the net medical expense tax offset, increasing the general threshold of extended Medicare Safety Net and realigning of Medicare Benefits Schedule indexation arrangements.

Overall, apart from the NDIS, the budget continues health policy directions already in place. As with social services, significant real growth in the health budget is projected over the forward estimates to deal with population growth, population ageing and health inflation.

Stephen Duckett, Director, Health Program at the Grattan Institute, says:

This budget contains mostly small changes here and there from a health perspective. The funding of DisabilityCare is a major initiative and represents a significant step forward for equity.

The slower indexation of Medicare rebates could result in access problems for consumers if doctors increase their fees ahead of the rebate changes.

This budget does not future proof Australia. A number of decisions have not been taken to eliminate waste from the system, such as addressing the excess prices in the Pharmaceutical Benefits Scheme

There are small increases in highly targeted research programs in cancer and aged care research. The McKeon proposals to prioritise relevant health services research have not been pursued, which is a disappointment.

Also at The Conversation: health equity and the budget.

***

Meanwhile, the Get Up review of the budget notes that over $5 billion in fossil fuel subsidies remain in place.

It is striking that the health portfolio budget statements under “population health” and “biosecurity and emergency response” outcomes do not even mention climate change…

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Updates added on 15 May, 2013

NACCHO: Lack of detail leaves a question mark over Aboriginal health

The $777 million commitment to Close the Gap initiatives in the 2013 Federal Budget is welcome, however the Aboriginal health Community Controlled sector remains concerned about the lack of detail on how and where the money will be spent.

National Aboriginal Community Controlled Health Organisation (NACCHO) Chair, Justin Mohamed, said it was critical that adequate funding was dedicated to support and grow Aboriginal Community Controlled Health services where the biggest gains were being made in improving Aboriginal health.

Download the Aboriginal Health Budget here also see executive summary below

Download Federal Government Press release on Aboriginal spending here

“The lack of clarity in the Budget around how funding will flow to Aboriginal primary Community Controlled Health services is very concerning,” Mr Mohamed said.

“Aboriginal Community Controlled Health services need to be at the forefront of any comprehensive primary health care model.

“It is these services – run by Aboriginal people, for Aboriginal people – that are making the biggest improvements to the health of their communities.

“The Federal Government also needs to put greater effort into getting the states and territories to re-commit to the National Partnership Agreement – due to expire in just over a month.

“It is simply not OK to leave the fate of Aboriginal health hanging while everyone plays politics up to the 11th hour.”

Mr Mohamed said NACCHO was disappointed that the Budget did not spell out how the upcoming National Aboriginal and Torres Strait Islander Health Plan would be funded.

“The Health Plan will not work unless it is properly resourced and after yesterday we are no clearer on how much of the $777 million will be directed to this critical initiative.

“It is also disappointing to again see the focus on Medicare Locals in the Budget. Medicare Locals are yet to prove their effectiveness in the Aboriginal health space where the community controlled model has made positive health gains.

“If we’re serious about closing the appalling gap in life expectancy between Aboriginal and non-Aboriginal Australians, then Aboriginal health needs to be given the attention it deserves and community controlled services better supported.”

Mr Mohamed said NACCHO would be consulting widely with the Aboriginal Community Controlled sector and providing further comment upon further analysis of the budget papers in the coming days.

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Australian Healthcare and Hospitals Association: Some gains but fails to address key issues

The AHHA acknowledges the balanced approach taken by the Government in this year’s Health Budget given the difficult fiscal environment.

The Association welcomes the investment in the suite of initiatives comprising the new cancer package – World Leading Cancer Care – and the further investment in mental health.

However, the Government has failed to address some of the most important issues facing the Australian people.

The Gillard Government has claimed credit for reduced waiting times in emergency departments arising from its investment in sub-acute services.  However with no ongoing commitment to the sub-acute programs the gains achieved will quickly evaporate and pressure will again be directed back onto acute hospitals leading to longer waiting times and poorer outcomes.

The Government has overlooked the opportunity to make a significant commitment to addressing the social determinants of health. The Senate Standing Committee on Community Affairs recently recommended that the Government commit to addressing the social determinants of health and give consideration of the social determinants of health in all relevant policy development activities. This Budget has done nothing to implement those recommendations which are critical to addressing the inequities that exist in health outcomes.

It is extremely disappointing that the Budget includes savings measures that will result in higher out-of-pocket costs for medical services, such as delaying Medicare rebate increases and tightening criteria for the Medicare safety-net.  Australians already face higher out of pocket costs when accessing health care than people in most comparable countries and these measures may widen the disparity.  Despite current high rates of bulk-billing, this will adversely impact on people in areas with poor access to bulk-billed services, particularly those in rural and remote areas who already disadvantaged.

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National Primary Health Care Partnership: A sensible approach to health spending

The National Primary Health Care Partnership (NPHCP) welcomes what it believes is a sensible approach to health spending in last night’s Federal Budget.

NPHCP Chair Damian Mitsch stated that “We largely commend the Government on its health budget announcements. It could have taken a slash and burn approach to help deal with its ominous fiscal outlook, but instead it demonstrated a commitment to addressing some of Australia’s most pressing health needs; maintaining or increasing funding in a number of important areas.”

“The Government’s announcement that it will allocate additional funding to the primary health care nursing, Indigenous health, and rural and remote health workforce sectors, in particular, demonstrates its commitment to reorienting our health system to one that focuses more on prevention and health promotion, and on delivering services closer to where people want them – in their communities.”

The NPHCP believes that in addition to consumer preference, the cost savings associated with strong primary health care cannot be ignored by governments; particularly in the constrained fiscal environment we find ourselves in. “We know that hospital care is the most significant cost burden on our system, and knowing that primary health care works to keep people well and out of hospital, such as through preventative measures and better self-management, then surely investing in it to do its job is smart fiscal policy for any government,” Mr Mitsch said.

The NPHCP is a strong supporter of Medicare Locals in helping to drive this change. “Medicare Locals are providing a much-needed vehicle through which this system reorientation can occur. Many of them are already doing some great things, but more needs to be done, and they must be adequately supported by government to do so. That is why we strongly support the Government’s continued investment in them, and its decision to implement a Medicare Locals Accreditation Scheme. This will help promote value for money by ensuring Medicare Locals are employing best-practice organisational management and service delivery processes when serving their communities”.

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Doctors Reform Society: Labor doesn’t want patients to see doctors

“The budget announcement that there will be a freeze on rebates for GP services confirms that this Government is not concerned that many Australians delay or don’t see their doctor when they are sick because it costs too much,” said Dr Tracy Schrader, president, Doctors Reform Society.

“Last week Minister Plibersek claimed that the Government’s reforms had led to improved access to GPs and increased bulk billing rates”, said Dr Schrader.

“Now that they are freezing the rebates, doctors will once again move away from bulk billing and patients will pay extra or go without. This hypocritical position by the Government, firstly claiming it is great that bulk billing rates are up and then imposing a freeze on rebates which will make rates go down, needs to be exposed.

“It indicates that the prevailing view of the Government is that the poorest and most disadvantaged Australians should bear the burden for the delayed effects of the global financial crisis”.

“Doctors who want to bulk bill patients because they know that it means patients can afford to see them, will now have to either face an income cut (whilst politicians pay rises continue unchecked despite tough times}, or stop bulk billing and run the risk of dissuading patients who are struggling”.

“Whilst funding for the NDIS, the Gonski reforms, the dental scheme and other smaller but also important projects will all be important for the general health of Australians, the great health reform agenda of this Government has not included any major reforms to address the problem of cost barriers to seeing doctors”, said Dr Schrader.

“Despite the two party consensus that these are economically constrained times the truth is otherwise as we see the gap between rich and poor increase and Australians taxed at lower rates than most western nations.”

“This budget measure is a cynical and hypocritical decision by the party which introduced Medicare nearly 30 years ago. It is hard to recognise as the same party”

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Mental Health Council of Australia: “A stronger economy, a smarter nation and a fairer society” needs a longer term investment in mental health reform

The Mental Health Council of Australia has described the federal budget as a missed opportunity to continue to build on much needed investment in mental health reform.

“If Australia hopes to achieve the Treasurer’s goal of building “a stronger economy, a smarter nation and a fairer society” then we need a longer term funded plan for investing in mental health reform,” Mental Health Council of Australia CEO Frank Quinlan said.

“We understand that we are living in a tight fiscal environment, but this just underscores the need for a longer term plan for investment and reform. Real fiscal discipline requires spending on the things that matter in the lean years as well as the bountiful years.

“Spending on mental health reform is too important to be dependent on the short term rise and fall of international financial markets and political fortunes.

“The Mental Health Council of Australia is pleased to see that there have been no real cuts to mental health spending, but it is difficult to see how mental health reforms will be sustained without substantial investment every year for the next decade.

“We welcome the inclusion of mental health spending within the NDIS. This investment is genuinely transformative, substantially because it is sustained over such a long period of time.”

“Investments in the Mental Health Nurse Incentive Program, Veteran’s Mental Health, victims of forced adoptions practices, and perinatal mental health are also welcome.”

Following the Budget, the Council asks all sides of politics to commit to long term mental health reform, ensuring a sustained approach for at least the next ten years.

“Australia has not forgotten the optimism and the heady commitments to mental health that were made by both sides of politics in 2010,” Mr Quinlan said. “Australians living with mental illness are still experiencing stigma, are still struggling to find appropriate services and are still falling through the cracks.”

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Palliative Care Australia: A missed opportunity to support Australians at the end of life

Despite predicted growth in the numbers of Australians dying annually, the 2013 Federal Budget has failed to recognise the integral role of palliative care in the health system.

“In the context of the recommendations made in the recent Senate Inquiry into Palliative Care in Australia this Budget is simply disappointing”, said Professor Patsy Yates, President of Palliative Care Australia (PCA). “This has been a missed opportunity to make real improvements in people’s experience of death and dying.”

PCA has long advocated for advance care plans to be included in the Personally Controlled Electronic Health Record (PCEHR) and welcomed last Thursday’s announcement that this work would be funded. This is a significant move forward to ensure that people’s wishes are recorded and recognised, but does not in itself improve end of life care.

“Across the nation health care staff delivering palliative care are losing their jobs. Services are being decimated. Yet there is no money at all for the palliative care workforce in this Budget,” commented Dr Yvonne Luxford, Chief Executive Officer of PCA. “As rates of complex chronic disease increase, the need for a comprehensive palliative care workforce strategy is essential.”

Specialist palliative care is delivered by a multidisciplinary team comprising medical, nursing and allied health staff, working alongside pastoral carers, pharmacists and volunteers.

“If we don’t fund specialist palliative care workforce development now Australians will die without access to the services we need”, warned Dr Luxford. “To be blunt, that means without access to the level of pain management and symptom control that we all expect.”

“Of course, not all people require access to specialist palliative care, but they do need their primary care team to understand the palliative approach. It is simply essential that a significant education program be funded both for the community and all health professionals to ensure that all Australians are well supported as they move towards the end of their life.”

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Lewis Kaplan CEO General Practice NSW

An issue which will cause annoyance is the new rule that a GP can’t bill Medicare for a standard consult on the same day they bill a chronic disease management plan. This is not helpful to patients who may have difficulty accessing a doctor and need e.g. a small procedure which is not connected to the CDMP and don’t want to have to attend the surgery a second time.   It’s also not helpful to GPs who could have more efficiently seen a patient for more than one reason.   I’d be very surprised if this item is being rorted, rather it’s a good use of GP and patient time. An example of a decision taken in the interests of a backroom Treasury person rather than a front-line health service provider.

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Modest steps in the right direction on ageing and aged care: Hal Kendig, Professor of Ageing and Social Policy, Australian National University

An initial reading of the 2013-2014 Budget suggests that the Government is moving ahead, albeit slowly, with resources for the Living Longer, Living Better (LLLB) reforms and for innovative new directions forthcoming from the Advisory Panel on Positive Ageing.

After the Government launched its LLLB aged care reforms last year, its 2012-2013 budget provided modest initial resources with outlays committed mainly towards building community care towards the end of the four year forward estimates.

The current year budget slowly advances these plans, mainly for expanded home care packages and the My Aged Care website, although later years reduce the previously anticipated growth apparently as part of overall budget trimming.

Valuable but small initiatives related to the Advisory Panel on Positive Ageing include a pilot program to facilitate pensioners downsizing their homes without financial penalties; increased access to broadband internet access; a scoping study on wound management; and a translational research and policy centre to apply evidence to the positive ageing agenda.

These initiatives are on top of significant pension increases mainly for single pensioners over recent years; ongoing increases of health expenditure for all age groups; and initiatives to enable people to work longer.

Overall, major initiatives in ageing, as with other areas, are being left on hold until the years after the Election in a likely difficult fiscal context.  It will be challenging to advance plans for consumer-directed care reforms and entitlement-based care in what already are heavily rationed allocations.

User pays is foreshadowed as part of the answer and this will require careful policy work to ensure equitable access and fair treatment for those with few resources of their own.

In the aftermath of this Budget the Business Council released a well-publicised statement warning about the costs of population ageing ahead.

That is the big picture issue but it is by no means clear that the spectre of ageing can be fairly raised as the major cause of increasing health care and income support costs.

On the contrary, the Positive Ageing Panel raises promising directions for older people to contribute more to the nation’s productivity and to their own support in the context of living longer and an ageing Australia.

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Leading Age Services Australia

Budget 2013 has no real surprises for the age services industry or for health generally. It has been pitched as balancing structural spending with structural saving to support the government reform agenda in a tight fiscal environment.

LASA welcomes a budget with no surprises but laments a lost opportunity to further enhance the reform process by ensuring that funding matches the cost of care for older Australians.

LASA notes that $60.2 million was removed from the workforce compact in line with the 5 March launch of the supplement. $60.2 million removed from direct care of older Australians.

LASA looks forward to being a participant in the research from the Andrew Fisher Applied Policy Research initiative ($4.6M) to enhance positive ageing for all Australians and to enhance the ability of the age services sector to meet the increasing demands of an ageing population.

The removal of $80 million from Health Workforce Australia may adversely affect age services which will need to recruit almost 600,000 workers in the next 30 years.

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Some disappointments from nursing perspectives: Professor Mary Chiarella, Sydney Nursing School, University of Sydney

From a personal big picture perspective: great news about the NDIS, the education funding, the terrific focus on preventive health screening for cancer.

From a nursing perspective, I’m disappointed that they didn’t follow up on the need to boost nursing retention and productivity – the HW2025 study showed that a 20% increase in retention would address the 2025 shortfall almost completely. There are decades of research that demonstrate nurses leave the profession for 2 reasons – 1. because they don’t feel valued or respected and 2. because they are unable to delver the quality of care they were educated to deliver.

Enabling increased productivity has occurred on a minor scale through projects like the MHN scheme, but there were huge opportunities to assist nurses and midwives to work to the full scope of their practice through added MBS support for Nurse Practitioners (NPs) in private practice.

Currently NPs in Australia receive 85% reimbursement of fee for service from Medicare, compared to the 100% received by physicians. NPs in private practice in Australia have access to a limited number of Medicare Benefit Schedule (MBS) items, only four items, compared with physicians who can access many more (Medicare 2010).

These four items are characterised by their length of consultation. For example, a short patient consultation with limited examination and management is valued at $9.20, of which the NP may receive 85%, $7.85. A 40-minute consultation involving extensive history taking and examination and management is valued at $56.30, of which the NP receives $47.90 reimbursement from Medicare (MBS 2013).

For the provision of comparable services, the scheduled fees for General Practitioners are $16.60 and $103.50 respectively, over double the reimbursement of an NP. Greater MBS support for NP services would have been a valuable message for nurses both in terms of recognising their value and increasing their productivity.

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COTA Australia: Welcome initiatives for older Australians but the most vulnerable left wanting

Older Australians will welcome initiatives to improve internet skills, increased action on breast, prostate and bowel  cancer screening, and continued commitment to pension indexing and major aged care reform, said leading seniors advocacy body COTA Australia.

However they will be disappointed the 2013 Federal Budget does little to support the most vulnerable older Australians.

COTA Chief Executive Ian Yates said it was disappointing an increase to the Newstart allowance was not included in this Budget given the fact that a third of long term Newstart beneficiaries are over 55.

“These people struggle for years on Newstart, with many failing to find employment, until they qualify for the Age Pension. The result is many older Australians spiraling below the poverty line,” Mr Yates said.

COTA welcomes the ‘Housing help for older Australians’ pilot which supports pensioners who want to downsize to a more suitable home.   Under the scheme they can put up to $200,000 of the excess sale proceeds from the family home into a special account and the capital and interest will not be counted under the pension income and assets test.

“While a positive step forward the scheme has its limitations,” Ian Yates said “ We welcome any initiative that gives older Australians more freedom to make appropriate lifestyle choices but the pilot scheme has some limitations which will significantly reduce eligibility, so we will be talking to the government about that.

“We would like to see pensioners being able to draw income from these funds to meet the costs of aged care and health services, which is not permitted as the scheme currently stands.

“The scheme doesn’t address one of the most vulnerable group of pensioners, those in the private rental market and at risk of homelessness.  COTA has repeatedly called for an increase in rent assistance and the establishment of a Social Housing Growth Fund to support older Australians in the private rental market many of whom, especially single women, are experiencing significant housing stress.”

COTA Australia supports encouraging older Australians to become more confident with internet technology. “The additional $9.9m for new technology and training grants in the Broadband for Seniors program will encourage further internet use but there should also be help for lower income older Australians to connect the internet to their home, especially with the roll out of the NBN,” Mr Yates said.

“Many pensioners are challenged to afford internet access, not just the initial set up costs but the ongoing service charges. We have been advocating for a broadband supplement for pensioners for some time.”

COTA Australia welcomes investment in collaborative and integrated academic research. “We hope that the establishment of the $4.6m Andrew Fisher Applied Policy Institute for Ageing will provide the opportunity to do just that.

“We want to see research activity that connects the community, the corporate sector and the government with academia to deliver meaningful advice that works for older Australians in the real world beyond their immediate health and aged care needs.”

Mr Yates said older people would also welcome the additional commitments to cancer research and treatment.

“COTA Australia has been advocating for an extension to the age limit of the Breastscreen program for years and we’re delighted that this has been taken up.

“We are also pleased that other cancers that affect mostly older people have been given a priority in the Budget with funding for a new Australian Prostrate Cancer Research Centre and additional funding for the Bowel Screening program which saves many thousands of lives.”

COTA Australia considers the change to the Pension Bonus Scheme as an inevitable part of the winding down of that scheme.

“The Pension Bonus Scheme closed on 20 September 2009 and this change ends the grandfathering arrangements whereby people who qualified before that date have been able to enter scheme. Even then the scheme doesn’t close to these individuals until 1 March 2014.

“We urge everyone who is eligible to enter the scheme to do so in the next nine months.

“COTA welcomes the fact that the Government’s major social policy initiatives for older people have emerged unscathed from a difficult Budget.

“The age pension reforms continue to provide pensioners with unprecedented increases through indexation on top of the major increase in 2009.

“The Living Longer Living Stronger aged care reforms – for which crucial legislation is now before Parliament  – will provide older Australians with more care in the home, more choice and control over services, and a fairer and more sustainable system.”

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Community Services and Health Industry Skills Council: workforce concerns need attention

A driving issue facing the community services and health industry at this time is its capacity to overcome constraints in delivering care, says CEO of Community Services and Health Industry Skills Council (CS&HISC), Rod Cooke.

“And we don’t believe this has been addressed in the 2013 Budget,” Rod Cooke said.

CS&HISC welcomes the Budget’s aged care spending inclusions, and the locked-in commitment to DisabilityCare Australia.

“Both should bring genuine benefits to people across Australia, but the question of who will be providing this support and care continues to go unaddressed,” Mr Cooke said

“The strength of DisabilityCare Australia is undermined by the omission of funding for current and future vocational education and training (VET) qualifications, required to meet the ever expanding and changing Aged Care and Disability services workforce need.

“We’re concerned that the importance of the VET workforce and unpaid carers, that is, the people who will provide the bulk of care, are being undervalued by a decision to not pay more attention to workforce issues,” said Mr Cooke.

“All the good work that’s been put into getting the NDIS and the Aged Care reforms might come undone if the workforce issues associated with the scheme are not integrated now.

Aged care providers and trade unions have been saying for a while now, there’s no way we can enable that sector to cope with the increased pressures of an ageing population unless we undertake a true assessment of how much it actually costs to deliver care now and in a reformed sector,” said Mr Cooke.

“In Aged Care, a nationwide cost of care study would determine what kind of funding figures providers will need to be able to deliver care, sustainably. This is also true for Disability care and support.

“Any cost of care study must take into account all the costs involved with the provision of care, including the true cost of labour – wages, expected pay increases, adjustments in the workforce supplement, and the cost of workforce development, and vocational educating and training.”

The care workforce is predicted to continue to grow faster than any other industry. National data from the Australian Workforce and Productivity Agency (AWPA) states that the health care and social assistance workforce employed almost 1.3 million employees in 2011.

Modest predictions estimate an increase to 1.6 million workers (35 per cent rise) while generous estimates predict a rise to almost 2.1 million (77 per cent) by 2025.

Over 60% of care is delivered by Vocationally Educated and Trained (VET) qualified workers (up to 83% in Aged Care), yet there has been no information released in the Budget as to how Australia will recruit, train and retain a qualified workforce to deliver this care and support.

Despite these figures, Mr Cooke continued, there has been no extra funding allocated to enable the industry’s future workers access to VET qualifications.

“Funding has been earmarked to support up-skilling existing workers and apprenticeships, but there has been nothing mentioned about training new workers to this industry.”

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Australian Medical Students’ Association: Federal Budget lacks vision for future of medical training

The Australian Medical Students’ Association (AMSA) believes the Federal Budget has failed to set out a long-term vision for quality medical education in Australia or for tertiary education generally.

AMSA President, Ben Veness, said the NDIS and the Gonski school reforms are admirable and worthy long-term goals for the Government and the country, but university education should be afforded the same status and support.

“There was some welcome new funding for the university sector in the Budget but nothing of the magnitude to offset the recent huge cuts to higher education,” Mr Veness said.

“The Government has ignored two reviews, that it initiated, which both recommended increased funding for universities, and medical education in particular.

“The Review of Australian Higher Education recommended increased funding for universities. The Higher Education Base Funding Review Panel Report of 2011 found that medical schools were particularly underfunded.

“Medical schools remain underfunded by around $20,000 per student, per year.

“The Government needs to better support universities to provide secure and affordable learning environments for future generations of students, including for medical education.”

“Health Minister Tanya Plibersek has been active in solving medical training pipeline issues through COAG and Health Workforce Australia but she has had to act on a year-by-year and State-by-State basis because of funding uncertainty into the future.

Mr Veness said AMSA welcomes funding for Closing the Gap, cancer care, and DisabilityCare.

“We are disappointed, however, with the delayed increases to foreign aid and failure of the Budget to provide greater support for university students.

“Youth Allowance payments remain well below the Henderson Poverty Line and Start-up Scholarships have been turned into loans that add to student debt and may discourage participation, especially from low socio-economic background students.

“Universities Australia data, released last week, showed that 17 per cent of university students regularly miss meals because they can’t afford them.”

AMSA’s Pre-Budget Submission can be found on its website.

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Some SMH Budget stories that may be of interest 

DisabilityCare news

Health budget news

Universities, students bear brunt of $2.6 billion savings to fund Gonski school reforms

Wrap of Gonksi news

Wrap of climate related news

Raise taxation generally (plus specific hikes for tobacco, alcohol, and unhealthy foods), and remove subsidies on the use of fossil fuels. These are among the suggestions from Croakey contributors outlined in the post below.

Contributors also said they’d like to see the Budget bring increased payments to single parents and the unemployed, as a way of reducing health inequalities.

Another suggestion for addressing heath inequalities was to “publish the taxable income and tax paid by all Australian citizens”.

There is also support for having all Government policy and program decisions subjected to Climate Impact Assessment and Health Impact Assessment.

Reflecting widespread support for a health in all policies approach, one contributor suggested that health-based key performance indicators could be introduced for all portfolios.

Croakey contributors also hope the Budget will show a commitment to ongoing health reform, including a “transition away from the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care”.

As for how the Government could make savings in health – scrap the private health insurance rebate altogether was the suggestion from some.

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For the compilation post below, Croakey contributors were asked:

1. What is the single most important thing the government could do in the health budget to improve population health?

2. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to improve population health?

3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

4. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to tackle health inequalities?

5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

6. Where could savings be made in the health portfolio?

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1. What is the single most important thing the government could do in the health budget to improve population health?

Vern Hughes, National Campaign for Consumer-Centred Health Care
Both Labor and Liberal Parties are reliant on corporate donations from alcohol and gaming companies, and in the Liberal Party’s case, tobacco companies as well.

A ban on political donations by corporates to political parties, allowing only donations from individuals, would sever the financial relationship between these parties and the principal suppliers of products harmful to population health. A disinterested policy discussion would then become possible about how to reduce the impacts of these products.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Reduce the deficit by putting a tax on high salt/fat foods.

Professor Mike Daube, Public Health Advocacy Institute WA
Increase tobacco tax – reduces smoking, reduces inequalities, improves health, provides funding for health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Put money into strengthening population health expertise in Medicare Locals.

Lyn Morgain, Gail O’Donnell of Healthwest Partnership
Increase funding for evidence based work through the Australian National Preventive Health Agency which will focus effort on both national as well as local / regional campaigns that target particular issues / risk factors in local communities / population groups. Ensure the ANPHA focuses on the community and population level.

Flexibility to deliver different interventions / approaches depending on local priorities to support improved outcomes for local communities.

Reference: Dr Fran Baum is Professor of Public Health at Flinders University. At the Senate Inquiry on the Social Determinants of Health Dr Baum commented:

“while the preventative health agenda does attempt to focus on the causes of disease it is limited by the absence of a national agenda devising strategies to address social determinants of health in a systemic way. The predominant focus on individual ‘lifestyle choices’ and behaviour change as the target of interventions does not adequately address the social context in which behaviours occur, or give sufficient emphasis to the role of health promotion strategies focused on creating healthy settings and development of healthy communities.”

Professor Sabina Knight, Director of the Mt Isa Centre for Rural and Remote Health
Strengthen the critical architecture for reform – the Australian National Preventive Health Agency, The Australian Commission on Safety and Quality in Health Care, Health Workforce Australia Independent Hospital Pricing Authority, National Health Performance Authority

Luke van der Beeke, Managing Director, Marketing for Change
The government needs to ensure that the money available is spent effectively.  That means switching to measuring outcomes, not outputs. I’m a big advocate for policy before politics.

Set some tough outcomes and reach for them.  Don’t set easy to achieve outputs that mean nothing in terms of population health.  For example, let’s take health communications.  You can spend $10m or $20m on a shock campaign on obesity, but if you aren’t changing people’s eating habits its all a complete waste of money. So while I think more money is needed for prevention, the most important thing they can do is ensure the money that’s allocated is used effectively.

And a quick point on social marketing.  The Federal Government talk about social marketing, but they’re not really doing social marketing. They  (and the States) are outsourcing to NGOs or big agencies that are delivering health communication campaigns that look great but change very little.

Success is getting measured by outputs that rarely relate to individual behaviours.  All too often, “success” and the associated measures are about being seen to be doing something rather than ACTUALLY doing something. We need behaviour change. And for that you need real social marketing.

Heather Yeatman, president, Public Health Association of Australia
Funding the development of a National Public Health Policy.

Lewis Kaplan CEO General Practice NSW
Fulfil its commitment to the nation’s health rather than just to the Department of Health and Ageing’s budget and invest in substantial and realistically long-term prevention programs (e.g. diabetes), even if the eventual ‘savings’ accrue to state health departments.

Anonymous medico
Improve vaccination coverage. Serious adverse events are rare, but there should be compensation for any child who has a proven disability because of vaccination. Parents are helping the community by having their children immunised, so the community should provide support if there is a problem. The Disability Care (NDIS) could be the appropriate mechanism.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
The Government has to commit to root and branch reform of Medicare. As numerous independent reports in the past few years have pointed to, the most recent from Centre for Independent Studies and CEDA, Medicare is unsustainable and delivering poor quality care for many, many Australians.

This reform must address map-distribution of providers, access to care, cost of care, quality of care. We must begin to transition away form the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care.

Terry Slevin, Cancer Council WA
Expand the National Bowel Cancer Screening program to include a greater number of ages being invited to screen.

Currently with only people turning 50, 55, and 65 being invited, we are missing a rolled gold proven method of reducing deaths from colorectal cancer.  We are also ignoring opportunity to save costs as treating more advanced stage disease is not only less successful but more expensive.

The other thing that is desperately needed is to allow funds to promote the program.  With current participation rates at around 40%, a meaningful investment in an effort to “sell” the benefits of participation would certainly increase participation and therefore the health benefits that are proven to accrue from doing so.

Another is a very modest investment in skin cancer prevention programs. Again another money saver with cost of treatment of preventable skin cancer exceeding the billion dollar mark, here is a case of an ounce of prevention saving pounds (and dollars) of cure.

Linda Shields, professor of nursing – tropical health, James Cook University
Stop thinking that “primary health care” is all about GP clinics. It’s not – it’s about prevention and stopping people getting sick in the first place. Investment in primary healthcare (the real one) would improve the health of all and reduce expensive inpatient costs.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
The secure funding for preventive services.  There is a big problem here in South Australia, and elsewhere, whereby State governments are focusing their sole attention on acute services and assuming/hoping the Federal government will pick up the costs and mantle of preventive services.

This does not seem to be happening – it’s ‘hoped’ that Medicare Locals will pick up these services, but it doesn’t really seem to be their job either.  If we continue with this extremely shorted-sighted view, we are putting the future health of generations in danger.

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2. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to improve population health?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
For the long term, address climate change by removing the subsidies on the use of fossil fuels.

Professor Mike Daube, Public Health Advocacy Institute WA
Sort out the shambolic alcohol tax system – especially abolishing the Wine Equalisation tax (WET) that enables wine to be sold cheaper than bottled water. Again reduces harms, protects the vulnerable, raises money for other health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Increase taxation.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Ensure that the universal nature of Medicare is not undermined by need for increased co-payments, shifts of responsibility for core services to private sector.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
A comprehensive early childhood strategy, education funding and education system reform (as per Gonski recommendations). Increasing social benefits for unemployed people and single parents.

There has been significant progress in using health impact assessments to understand the effect of program and policy changes across Government on the health system and service costs. This means that a reduction or increase in effort in one part of government / community is understood for the impact that it will have on the broader service and support system. This ‘health in all policies’ approach is the best way to understand the true cost and achieve efficiency in the primary care space and allow a more rigorous approach to policy consideration and program development.

A commitment to the recommendations of the Senate Committee inquiry into the Social Determinants of Health.

Luke van der Beeke, Managing Director, Marketing for Change
Health in All Policies is without a doubt the most important thing the government can do to improve population health.  At present government departments work in silos.

Why not introduce health-based KPI’s for all portfolios?  All of them have significant direct or indirect impacts on population health.  There needs to be a shift in the way we think and talk about health in Australia.

There needs to be a shift in the way we think and talk about health in Australia, and most importantly, a change to WHO talks about health in Australia.  If health practitioners and experts are the only ones talking about health we will never fix public health.

Associate Professor Heather Yeatman, president PHAA
The establishment of an Australian Centre for Disease Control (ACDC).  As a first step the Government must to commission a study to examine the benefits and costs of establishing an ACDC.

The establishment of and requirement for a Climate Impact Assessment and Health Impact Assessment to accompany all Government policy and program decisions (in a similar way to the current requirement for Regulatory Impact Assessments).

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Maintain investment in smoking cessation and mental health and well-being.

Lewis Kaplan, CEO General Practice NSW
Make health in all policies a requirement across all portfolios – eg South Australia.

Anonymous medico
We spend $billions treating diseases resulting from people’s lifestyle choices. While a fat tax would probably be difficult to implement, alcohol is still far too cheap.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Slash the size of the Federal Bureaucracy. Since 2004, an additional 40,000 people have been employed in the APS. This does not include those now employed in organisations like Medicare Locals. Only about 1 in 4 of the APS actually deliver an end service. The duplication of project management, the inefficiency of the APS has become a high cost factor.

The Federal Government should literally get out of the business of delivering services. It should focus on policy development and setting parameters for delivery.

Second they must wind back all middle class welfare and industry welfare – this adds tens of billions to our nations taxation system.

Linda Shields, professor of nursing – tropical health, James Cook University
Preventing illness in the first place would save heaps of money down the track. A very good investment.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To work on joined-up government to tackle the social determinants of health.  There is evidence globally, and locally, of the benefits of Health in All Policies in terms of illness prevention, health promotion and overall health gains.

**********

3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

Vern Hughes, National Campaign for Consumer-Centred Health Care
There is no quick fix for health inequalities, which are a product of social and economic well-being. The single most useful thing the government can do in the health debate is state this publicly.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Improve the Newstart payment.

Associate Professor Mark Wenitong, Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences, 
James Cook University, Cairns
Understanding the synergies between health and social portfolios re Aboriginal and Torres Strait Islander health inequalities, and thinking about “bundling” program funding (across FACSIA/DOHA eg) to address early childhood/family functioning support and health in a prevention sense.

We also need to have a more sophisticated understanding of health $ investment for long-term health outcomes vs GFC pushed “corporate health” approaches to efficiency.

We need to measure efficiency against a human capability framework, rather than “efficiency” driven by the accountancy consultants (ie KPMG PwC E&Y etc that are basically accountants, hence an inbuilt bias towards fiscal efficiency) – that do ALL of the scoping for DoHA.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Provision of funding through improved local service delivery to target populations and geographies where particularly poor health outcomes exist.  A move away from waiting until an acute service response is required (surgery or emergency department) and towards community based primary care.

Targeting intergenerational poverty through a focus on child health.  A comprehensive early childhood health and wellbeing strategy combined with a social protection system would be a positive step towards addressing social and health inequalities.

Luke van der Beeke Managing Director, Marketing for Change
To tackle any issue it needs to be taken seriously.  The Federal government needs to commit to action on tackling health inequalities.

Associate Professor Heather Yeatman, president PHAA
Invest in building the competence and capacity of a national preventative health workforce who understand inequity and the social and economic determinants of health and are skilled to effectively deliver preventive health services at the local level.

Maintaining the funding of Medicare Locals, Locals and Women’s Health at a level that will allow comprehensive primary healthcare based on an understanding of the social determinants of health.

Retain and extend funding for the “Close the Gap” measures including additional support for Aboriginal Medical Services and Aboriginal Health Services.

Develop a National Aboriginal and Torres Strait Islander Social Determinants of Health Policy as a key strategy in closing the gap and overcoming Indigenous disadvantage. The policy needs to describe the social determinants, focus on social inclusion and support the provision of real opportunities in education, employment and health status, with funding tied to delivery of outcomes.  While retaining current levels and build in future growth of funding for the “Close the Gap” measures.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE) 
Ensure access to high quality services for all Australians irrespective of who they are and where they live.

Lewis Kaplan CEO General Practice NSW
Make the social determinants of health the primary driver of health budget allocations.

Anonymous medico
Many inequalities result from poor access to services. There should be more incentives to get health professionals into areas of need.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Transition away from fee-for-service asap.

Linda Shields, professor of nursing – tropical health, James Cook University
Same thing. If primary health care programmes targeted at the disadvantaged were supported, then the gaps would begin to close.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to the Australian National Preventive Health Agency agenda – philosophically, financially and in terms of services and systems.

*****

4. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to tackle health inequalities?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Publish the taxable income and tax paid by all Australian citizens.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Raise the dole.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
To look at health in the broadest sense and understand the economic and social benefits of health improvement and prevention activities.  But this requires more than one activity.

For example to ensure the implementation of a comprehensive early years strategy as well as improved funding and reform of the education system to improve outcomes for poor and marginalised communities / individuals; greater access to training and employment opportunities for individuals and communities facing exclusion / disadvantage; commitment to the National Disability Insurance Scheme; funding for public transport in growth corridors; support food security in remote and urban communities; improved access to early intervention community based mental health services; programs that will use the NBN to reduce the digital divide; more secure housing for low income individuals and families.

Further work to reduce income inequality and the experience of poverty is necessary.  This would include reversing the decision to push single mothers onto Newstart and increasing the level of the Newstart allowance.

Associate Professor Heather Yeatman, president PHAA
The PHAA seeks a comprehensive approach to improving health through applying strategies (financial disincentives) known to influence behaviours positively, and at the same time raise funds for initiatives to tackle health inequalities:

TOBACCO REVENUE: Cigarette prices in Australia are lower than in some comparable countries. An increase in excise duty of ten cents per stick would reduce smoking and raise approximately $1.25 billion.

ALCOHOL TAXATION: Projected savings of $849 million if a volumetric tax is applied to wine and the WET rebate abolished.

JUNK FOOD: Implement a tax/levy on selected nutritionally undesirable foods (such as sugary soft drinks), using the funds raised for preventive programs and to promote and subsidise nutritionally desirable foods for disadvantaged groups.

LOWER CARBON USAGE: Build on the range of taxes and revenues so far introduced to lower carbon usage.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Increase Newstart Payments.

Lewis Kaplan CEO General Practice NSW
Create a single, accountable health care and disease prevention system with priority given to primary health care – this would mean educating the public too as to why acute care needs to be re-thought.

Anonymous medico
There is an association between unemployment and ill health. While overall unemployment is reported to be low, there are areas/ages of high unemployment, which should be addressed.

Linda Shields, professor of nursing – tropical health, James Cook University
Make health a federal priority and remove it from the states (yes, I know – hell will freeze over because of states’ rights etc).

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to quality education for all.  The Gonski Review partly deals with this, but it is still my belief that part-funding private education (as the Government does) is drawing money away from services for the most needy children and families.

I cannot understand public subsidizing of private education (or private healthcare for that matter) – if parents want private education for whatever reason, they should pay for it – ALL of it.  They would release public money to do what it’s there for – focus on the public system.

******

5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

Vern Hughes, National Campaign for Consumer-Centred Health Care
The big public need is for long-overdue media scrutiny of budgetary handouts to provider interests in health care across private and public sectors, beginning with public funding of provider peak bodies and the role of this public funding in the formation and continuation of provider-centred health policy.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Look at the equity impact of measures; get away from the obsession about having a surplus, please.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Look for investment that will reduce the rate of growth in health spending, rather than perpetuate the sometimes inefficient investment in the acute settings – when early intervention and more coordinated care will result in cheaper and better health outcomes.

Given the political environment and the likely change of Government what is the Opposition’s proposed approach to the infrastructure that has been developed in recent years (Medicare Locals, Australian National Preventive Health Agency, the Organ and Tissue Authority, the Health Workforce Agency, local health networks etc) that seek to improve system planning and performance.  What is their commitment to funding prevention and health promoting work?

Associate Professor Heather Yeatman, president PHAA
Where will the cuts be made in health?

What effort is made to take a LONG TERM VISION?

Is there any attempt to deal with the COST SHIFTING of jurisdictions such as Queensland and South Australia that are removing so much of their prevention and primary care resources and arguing it is the responsibility of the Medicare Locals?

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Establish a ” truthometre” that assessed assertions/ commentary made by all parties for truthfullness and make his transparent and easy to access. (Note from Croakey to readers – see the new PolitiFact initiative).

Lewis Kaplan, CEO General Practice NSW
Stop focussing on hospital waiting lists and address the reason why they exist, which is poorly integrated primary health care and inadequate national prevention programs coupled with inadequate policy on health promotion e.g. alcohol and obesity, exercise and diet.

Anonymous medico
I would like to know about the policies, not the politics!

******

6. Where could savings be made in the health portfolio?

Vern Hughes, National Campaign for Consumer-Centred Health Care
A shift from a provider-centred health system to a consumer-centred health system would involve removal of failed service coordination programs that attempt to connect fragmented providers; abolition of Medicare Locals; removal of subsidies to practitioner training programs; removal of capital and block funding grants to hospitals; and removal of public funding of industry peak bodies in public and private sectors.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Remove the subsidy for private health insurance

Associate Professor Mark Wenitong,
 Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences 
James Cook University, Cairns
I think there are real savings to be made in well considered across portfolio strategic program funding to address health inequality, (and CONGRESS/NHLF is the structure to support this from Aboriginal and Torres Strait Islander perspective, and it supports real Aboriginal and Torres Strait Islander leadership).

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Eliminate the private health insurance rebate completely

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
PBS.

Ongoing focus on ensuring that the price that the Australian government pays for both patent protected and generic medicines reflects the international market and that particular points of the delivery system (such as pharmacists) are not achieving reimbursement for services which do not reflect cost of service or a high risk profile.

Health workforce reform.

Focussing health care professionals at the ‘top of their scope of practice’ requires recognition of the diversity of health care roles across the spectrum and also allows care/ interventions to be delivered at the lowest workforce cost. Currently decisions around the location of treatment are based on professional boundaries which were designed over the course of the last century and show little resemblance to either a modern risk / clinical governance approach or indeed any assessment of best outcomes for clients / consumers.

The need for a systems approach that accounts for the linkages between all parts of the service and support systems (regardless of funder) has never been more apparent.  In seeking to promote better health outcomes, increase the effectiveness of services and seek to reduce the rate of growth of health spending this interface is an area that has been consistently overlooked.

There is a growing body of evidence that the single greatest efficiency that could be made to the health budget is to move (where clinically appropriate) from high cost, high tech acute care settings to lower cost, community based primary care.  However despite this knowledge this systems approach continues to be undervalued.

Associate Professor Heather Yeatman, President PHAA
Rather than savings in federal health, we should be looking at the revenue raising side (see question 4).

Associate Professor Jan J Barendregt, School of Population Health, University of Queensland
As we reported in 2010 in our ACE-Prevention results, and in journal articles since, Australia pays far too much for cardiovascular disease prevention, due to a combination of missing out on the most efficient interventions, and paying too much for generic drugs.

Mandatory salt limits in food is very cheap, but is not being pursued.

Pharmac in New Zealand pays only a fraction of what we do for some very much-used generic drugs.

We went out of our way to make these results known in policy-making circles, and are frankly baffled by the complete lack of response. Why do policy makers keep wasting taxpayers’ money while the facts are known to them?

Lewis Kaplan, CEO General Practice NSW
Savings – not this time – it’s critical that the nation invest strongly in its future health via prevention and integrated primary health care or we will go broke.

Anonymous medico
Stop the federal-state cost shifting. Greater use of generic medicines.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
$1billion per annum from reducing DOHA from 6000+ to 600 staff in a policy ministry for starters. Then tackle PBS, MBS issues.

Dr Peter Arnold, retired GP
I have been singing from the same song-book since 1973, when I was so publicly opposed to universal benefits (as being introduced by Medibank) and when I argued unsuccessfully in favour of selective benefits – aimed at those who needed them (pooh-poohed by Bill Hayden and his advisers because people would feel ‘stigmatised’). Today, my attitude has become commonplace, with its own jargon: “middle-class welfare”.

The answer to your question is simple – targeted (selective benefits). Taxpayers should not be funding the health care of the affluent – neither through Medicare nor through government’s propping up of private health funds. You want savings – here they are!

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
Bureaucracy!!!!!!

*******

BUT…Was Croakey asking the wrong questions?

Ian McAuley, lecturer in public sector financing, Canberra University
I’d find these questions easier to answer if the word “budget” were left out.

The budget is simply a set of appropriation bills.  The policies on which those appropriations should have been developed and articulated over many years.

But the budget has morphed into the major statement of government policy. Fiscal considerations drive policy, rather than the other way around.  Instead of considering what is needed and then finding how these needs can be funded, funding drives policy.  The budgetary process is one in which revenue is taken as a “given”, as are most pensions and other personal transfers, and all program portfolios have to accommodate their programs into what is left over.

Some would say that this leads to worthwhile expenditure restraint. But it also leads to cost shifting.  In health care costs get shifted on to consumers with co-payments and private health insurance is called on to do the a job which taxation and Medicare do much better.

So what would I like to see?  A health policy, rather than a set of fiscal projections. Funding is important, of course, but funding considerations should be about all sources of funding, instead of the current narrow focus on that funding which passes through the budget.

How can we structure co-payments so that they send appropriate price signals without not discouraging useful therapy?  How can we fund private hospitals without having them linked to private insurance?  How can we control the moral hazard which results when services are free at the point of delivery, be that because of Medicare or private insurance?  How can we phase out private health insurance as we have done with other high cost industries such as clothing and footwear?

***

More reading on the Budget and health

• Jennifer Doggett recently compiled this very useful overview of the federal budget submissions from peak health and social welfare group. Increased action on prevention, the social determinants of health, Indigenous health, primary care, and consumer engagement were high on the list of priorities.

• John Menadue suggests tackling increases in medical servicing, especially in pathology and radiology.

• Australian Drug Law Reform Foundation president Dr Alex Wodak suggests better use of the funds currently spent on law enforcement of illicit drugs policy.

• The St Vincent de Paul Society calls for an increase in the Newstart allowance.

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

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

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

Prevention

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

Social determinants of Health

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

Indigenous Health

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

Primary Care

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

Consumer engagement

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

Health system issues

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

Ambulance Services

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

Research and evidence

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

Chronic disease

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

Early childhood

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

Oral health

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

Workforce

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

Non-health measures

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

Savings measures

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

Submissions

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

Australian Health Care Reform Alliance

Australian Council of Social Services

Australian Healthcare and Hospitals Association

Australian Medicare Locals Alliance

Australian Medical Association

Catholic Health Australia

Consumers Health Forum of Australia

Public Health Association of Australia

“Just tells you how much we don’t matter.”

It was one of a series of tweets from a Wiradjuri woman, Kath Grant, who lives in Sydney (you can see them at the bottom of this post).

She was disappointed that Indigenous health was squeezed in for a few rushed minutes at the end of the program, when Selwyn Button, the CEO of the Queensland Aboriginal and Islander Health Council, asked whether Closing the Gap funding would continue to go largely to mainstream rather than community controlled services (more background from him about this is here).

It’s not as if there aren’t topical issues to discuss. As previously reported, a concerted campaign is pushing, via mainstream and social media, for national signup to the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, which is due to expire at the end of June.

And there are many other questions about Indigenous health that could have been put to Minister Tanya Plibersek and her Opposition counterpart Peter Dutton, including about the accountability of Medicare Locals in this area, and the health implications of Tony Abbott’s plan to move Indigenous affairs into Prime Minister and Cabinet.

It wasn’t only how the show ended that gave such an insight into the relationship between the distribution of power and health.

It spoke volumes that the host Tony Jones chose to have the first, agenda-setting question come from the president of the AMA, Dr Steve Hambleton.

This launched us into yet more discussions about public hospitals, hospital financing and the blame game (notably, these were not issues nominated as priority topics by Croakey contributors).

As so many tweets suggested (the two below are from Carol Bennett of the Consumers Health Forum and Dr Tim Woodruff of the Doctors Reform Society), this time might have been better spent talking about public health or the concerns and experiences of those using health services.

There were some noteworthy moments. Peter Dutton gave a hint that he may be softening on his previously stated plans to abolish Medicare Locals (although really the surprise would only be if he did actually go ahead with abolishing them, as such a move would leave him looking pretty silly, given the widespread support for retaining them, even if under another name).

But we were left still wondering about the fate of the Australian National Preventive Health Agency and the National Health Performance Authority under a Coalition Government, and the extent of Dutton’s plans for privatising the management of public hospitals.

Of course, some issues will always miss out within the time and format constraints of Q and A. But the program is one of the few opportunities that we’ve had in the mainstream media for some serious health policy debate in the run-up to the federal election.

Both Plibersek and Dutton missed an opportunity to tell us their story about why health matters – to the country, to communities, to individuals – beyond bunfights over hospital services and financing and the sort of jargon that must be mind-numbing for general audiences.

Those looking for big-picture visions for the future were left disappointed. Where was the insightful discussion of two transformative shifts that have such sweeping implications for our future health: climate change and the digital revolution?

As for any serious discussion about the social determinants of health… We can get some insights into why the program failed to address such matters from a new study based on interviews with 20 former federal, state or territory health ministers.

Many of the ministers spoke of the power of the media in pushing the interests of the medical lobby and acute care.

As one Minister said:

“From what I’ve observed, the job of many Ministers for Health has been to keep the lid on things and put out the inevitable bushfires and even then it’s just pouring money into stopping the emergency waits and reducing elective surgery lists – you know, it’s all the acute sector because that’s where the media and the political noise of powerful stakeholders unite to get political action.” (State/Territory, ALP, 2000s)

The researchers heard “account after account” describing how doctors and their professional bodies, especially the AMA, wielded considerable power over decision making in both Labor and Liberal-led governments, and used it to ensure the health minister’s focus remained on providing acute care services.

Each minister recounted stories of how health became a front page story when doctors’ lobby groups spoke to the media about how lives would be threatened by a change to service provision or failure to allocate more funding to acute care from an already stretched health budget. About half described how, in this environment, their efforts and successes in public health could not compete.

(More detail about this study is in this recent article for Inside Story, giving an update of developments in social determinants of health in Australia, which was also republished at The Conversation).

Whether Tony Jones realised it or not, by throwing the first question to the AMA, he was simply reinforcing longstanding media traditions of promoting a medical rather than a health policy debate.

Which brings us to this very useful suggestion for the next Q and A on health policy.

Perhaps we would end up with more enriching conversation about our health if Q and A invited ministers from the other portfolios that have such a profound influence over health.

Perhaps this approach would even put Indigenous health front and centre, given this sector’s deep understanding of the importance of the social determinants of health and holistic understandings of health, as per this definition:

“Health is… not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community. It is a whole of life view and includes the cyclical concept of life-death-life.”

Meanwhile, here are Kath Grant’s tweets, which she sent as Q and A wrapped up.

And here is a reminder of why it is important for powerful media outlets to focus the attention of politicians and the community on what happens to the Closing the Gap agreement and related programs and funding…

Some more reading on the health Q and A:

• The experts respond, via The Conversation

• Plibersek by a healthy margin: Upstart

In the article below, she reviews Primary Care and General Practice in Australia 1990-2012: A Chronology of Federal Government Strategies, Policies, Programs and Funding,  by Dr Lesley Russell from the Australian Primary Health Care Research Institute.

Despite the extensive changes that have occurred in the primary care sector over the past 20 years, it is questionable whether we are any closer to a system that delivers consumer-focussed, integrated care, Doggett says.

She suggests it may be time to admit the limitations of our fee-for-service system and look for an alternative funding model for primary care. We also need to develop better ways of measuring performance in the primary care sector.

 ***

What can we learn from 20 years of primary care reform?

Jennifer Doggett writes:

Much of the success of the current health reform agenda depends on what happens in the primary care space.  If the reform measures deliver a stronger primary care sector – specifically in terms of accessibility, preventive health focus and chronic disease management – many of the goals of the reform agenda will be achieved.

Conversely, if the primary care reforms don’t improve on current performance in these key areas, our health system will continue to cost more and deliver less.

Achieving success in reforming the primary care sector requires both a comprehensive plan and its successful implementation. Learning from previous attempts to introduce major changes into primary care and general practice sector can help avoid past mistakes and increase the chance of success.

However, learning from experience is not a strength of the Australian health system. We have eight States/Territories which often do not share their knowledge and experience within each other and frequent changes of government and a fluid bureaucracy means that there is often little ‘corporate’ memory of past changes among those with the most policy influence.

For this reason it is vital that policy makers and managers working to implement the current primary care agenda have access to resources like the one recently published by Dr Lesley Russell from the Australian Primary Health Care Research Institute.

This paper Primary Care and General Practice in Australia 1990-2012: A Chronology of Federal Government Strategies, Policies, Programs and Funding  provides a detailed overview, from both a policy and budget perspective, of the way in which primary care has been delivered in Australia over last two decades.

The paper covers the period from the introduction of the General Practice Reform Strategy in 1992 to the introduction and early days of Medicare Locals in 2012. It covers 19 Federal Budgets, eight Ministers for Health (under four Prime Ministers) over a period almost equally split between Coalition and Labor Governments.

Among the programs and initiatives covered in this comprehensive paper are: Divisions of General Practice; the Practice Incentives Program; the Primary Health Care Research Evaluation and Development Strategy; the General Practice Immunisation Incentives Scheme; Enhanced Primary Care; Primary Care Collaboratives; SuperClinics; Chronic Disease Management item numbers; and Medicare Locals.

It seems incredible that this is the first time this information has been gathered together systematically in one place, given that the primary care sector is so crucial to the overall performance of our health system.

While there have been numerous reviews, evaluations and reports on aspects of primary care produced over this period, the lack of institutional memory means that often these lie buried on website or within Departmental archives and are not used to inform current policy development processes.  This means that all too often Ministers and their Departments fail to benefit from the lessons of recent history when attempting reforms in this area.

One key issue that this paper reveals is how much change has occurred in this sector over the past 20 years. A doctor starting to practise in 1992 would have spent his/her entire professional life dealing with major policy changes, new initiatives, changes to funding arrangements and all their associated administration and jargon.

Given this high degree of change, it is understandable that many GPs appear cynical and jaded when faced with yet another reform measure.

The problems of fee-for-service
Another issue this paper makes apparent is the high number of initiatives introduced over the past 20 years that attempt to address the problems caused by our fee-for-service based Medicare system. This payment system works for one-off episodic care but is not well designed to promote preventive care or chronic disease management which requires ongoing care across different health sectors.

Many, if not most, of the reforms over the past 20 years in primary care are attempts to use Medicare to shift from its original focus on episodic care to a funding system which promotes quality and rewards outcomes rather than process. These include the General Practice Immunisation Incentives Scheme, Enhanced Primary Care and the Chronic Disease Medicare item numbers.

After 20 years of this approach, we may have got better at targeting the payments and tweaking the incentives of targeted programs such as these.

However, it is questionable whether we are any closer to a primary care system that delivers consumer-focussed, integrated care. We still cannot deal well with prevention or chronic disease and have a hospital system faced with increasing numbers of avoidable admissions every year.

Perhaps it’s time to admit the limitations of our fee-for-service system and look for an alternative funding model for primary care?

Unanswered questions about performance
Another point highlighted by this paper is how little idea we have of how to measure performance in the primary care sector.

Despite the millions of dollars poured into general practice and primary care initiatives over the past 20 years, there has been no systematic attempt to measure their impact in terms of the health status of the community.

While some individual initiatives have been evaluated, that was mostly done in terms of process (e.g. numbers of services provided) rather than looking at their cost-effectiveness in achieving a positive impact on the health and well-being of the community.

As a result we have failed to develop a sound understanding of the most effective ways of driving change within primary care, an understanding which would greatly assist in implementing the current health reform agenda. To ensure this does not occur again, we need to ensure we develop an agreed set of goals for the current reform measures and evaluate their impact in relation to these goals post-implementation.

For anyone who has been around general practice or primary care at some level over the past 20 years, this paper will prove informative and interesting.

For anyone who plans to be around this sector for the next 20 years, it will be an essential resource.

Disclaimer: Jennifer Doggett has previously provided consultancy services to the Australian Primary Health Care Research Institute

Link: http://aphcri.anu.edu.au/sites/aphcri.jagws03.anu.edu.au/files/panel/416/primary_care_and_general_practice_final_v3.pdf

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

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

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

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

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

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

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

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

 ***

Summarising Minister Plibersek’s presentation

Marge Overs writes:

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

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

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

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

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

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

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

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

***

Summing up the conference themes: Professor Lesley Barclay 

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

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

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

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

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

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

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

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

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

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

***

Place-based models are the go: Rob Oakeshott

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

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

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

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

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

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

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

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

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

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

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

***

Priority recommendations

A. Infrastructure

1.Broadband

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

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

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

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

2. Royalties for Regions

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

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

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

3. Place based programs and decisions

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

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

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

4. Food security

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

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

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

5. Data

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

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

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

• Such data should include:

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

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

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

6. A National Arts and Health Framework

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

B. Clinical services

7. Indigenous eye-health

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

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

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

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

8. Aged Care

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

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

Measures should include

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

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

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

9. Oral Health

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

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

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

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

10. Maternity Care

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

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

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

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

11. Early Childhood

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

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

12. Metro-rural services link

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

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

C. Workforce

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

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

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

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

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

14. Telehealth

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

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

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

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

15. Maximising student advocacy and leadership

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

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

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

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

16. Generalism

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

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

D. Managing Indigenous Chronic Conditions

17. Indigenous chronic conditions

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

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

****

Previous Croakey articles on the 12th NRHC

• Governments abrogating their responsibilities in public health

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

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

• Online connections critical for rural health

• Recognising an unsung hero – and some vox pops

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

• Talking about some good news in Aboriginal health

• An update on efforts to reduce Indigenous smoking

• Spotlight on Indigenous health and the value of physician assistants

• An uplifting start 

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

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

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

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

While independent, government-funded Medicare Locals are still in their embryonic form, opposition health spokesperson Peter Dutton has hinted that, if elected, a Coalition government would scrap the bureaucracies and redirect funds to front-line patient care.

“We support a role for the coordination of primary care, but we don’t support money being prioritised away from patients into vast bureaucratic structures,” Dutton said last month, though the Coalition has not clarified its position on Medicare Locals.

Medicare Locals coordinate (but only provide a limited range of) health services. They’re designed to identify local needs, streamline patients’ journeys through services, support health workers, facilitate initiatives and be accountable to the community.

There are already encouraging signs that Medicare Locals are starting to deliver results. But if they’re axed, Australia could be derailing its path to a more equitable health system.

Early signs of progress

For the first time, primary health-care providers across Australia have come together to plan after-hours services to meet the needs of their local communities. In the Hunter, New South Wales, for example, a telephone triage system helps patients access services they need, including transport. This takes the load off hospital emergency departments, which treat patients if they’re unable to access a general practitioner after hours.

Many other Medicare Locals have established websites where patients can find an after-hours GP in their local area. These services are linked to the national after-hours GP help line which is particularly useful in providing advice for parents when their young children get coughs or fevers.

Other Medicare Locals are working on increasing access to doctors and allied heath-care providers in nursing homes, again preventing unnecessary trips to emergency departments.

Addressing inequality

Certain groups of Australians suffer disproportionately from health problems. Indigenous Australians, people from lower socioeconomic backgrounds and those living in rural and remote areas are at higher risk of chronic diseases such as diabetes and heart disease.

The life expectancy gap between the most and least disadvantaged parts of NSW, for example, is 4.6 years. And Indigenous Australians’ life expectancy is 9.7 and 11.5 years less for women and men respectively.

This is partly because disadvantaged groups have higher rates of risk factors such as obesity and smoking but also unequal access to preventive and other health services.

In some areas, many people were born overseas, have poor English language skills, limited education or poor health literacy (the knowledge and skills to stay healthy). This complicates preventive care and early treatment.

In an attempt to address this problem, Sydney’s Inner West Medicare Local has been funded by the National Preventive Health Agency to work with GPs, local government and community organisations to engage people with poor health literacy in preventive care.

A quality primary care system

Australia has a comparatively strong but fragmented primary health care system. An older person needing extra help at home, for example, often has to be assessed by a number of service providers separately and often information is not shared. This frustrates patients and their families as they receive uncoordinated or inappropriate services. Fragmented care is particularly detrimental for older people and those with complex long-term problems such as diabetes and depression.

International research has demonstrated that primary health care is a key part of the solution to these inequities. This is because disadvantaged and vulnerable groups are more likely to have multiple risk factors and health problems – and primary health represents a comprehensive means of diagnosis and management. It is also generally more accessible and affordable for people with limited resources than more specialised care.

Good care requires strong links between hospitals and community-based services, multidisciplinary team care and proactive approaches to prevention, something many hope the Medicare Locals will achieve.

A major opportunity comes with the Health Communities plans Medicare Locals are currently developing for their local areas. These will identify which population groups are using services and then develop more flexible locally responsive services. So far, some Medicare Locals have found children in disadvantaged suburbs have lower rates of immunisation and thus they can work with the other local health services to improve access and promote uptake in these areas.

Where to next?

The Commonwealth government has invested approximately A$171 million a year to fund the 61 Medicare Locals across Australia. This is a relatively small amount of money in the A$53 billion-plus health and ageing budget.

The health care reform reports recognise the pivotal position of primary health care in preventing more acute illness and saving money down the track, with Medicare Locals playing an important role in prevention and early detection.

Although there is goodwill for Commonwealth- and state-funded services to work together at the local level, more integrated care involves making health professional roles and services more flexible. These changes are difficult to achieve across different professions, organisations and with limited resources.

The success of Medical Locals at reducing health inequities will depend on their ability to relate to local communities. If Medicare Locals can work with local government and those representing vulnerable and disadvantaged groups – and listen to what they have to say – they may be able to tackle problems that more established services have not.

These long-term relationships will need commitment and trust. They also require time – something that Medicare Locals may not have.

** Mark Harris is Director of the Centre for Primary Health Care and Equity and the Centre of Research Excellence in Obesity Management and Prevention in Primary Health Care at the University of NSW. He is also a board member of the Inner Western Sydney Medicare Local; Elizabeth Harris is a Senior Research Fellow at the University of NSW; Nicholas Zwar is Professor of General Practice and Head of Undergraduate Education at the University of NSW’s School of Public Health and Community Medicine. He is also a board member of the South East Sydney Medicare Local.

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

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

***

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

Selwyn Button writes:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Follow Selwyn Button on Twitter @qaihc

As a preview, Marge conducted the Q and A below with the National Rural Health Alliance’s executive director, Gordon Gregory, in which he explains why the conference should be an important agenda-setter for the federal election, and supports the work of Medicare Locals and the Australian National Preventive Health Agency.

He also outlines the most pressing healthcare and population health issues for rural and remote communities.

And it sounds like those heading to the conference had better pack their dancing shoes…

 ***

Q: How many National Rural Health Conferences have you been to, and how have they changed over the years?

Gordon Gregory: The National Rural Health Conferences pre-date the Alliance – in fact it was the first conference, held in Toowoomba in 1991, that recommended there should be a body like the Rural Health Alliance.

The second conference, held in Armidale in 1993, was organised by a steering group, which, after the event, morphed into the National Rural Health Alliance.

So the first conference I attended was in Mt Beauty in 1995. By then the Alliance was nearly 2 years old and it must have been the largest project it had managed to date.

The first two conferences had had 200 or so delegates and we expected around 300 for Mt Beauty. Errol Dunn, of the Mt Beauty Tourism Bureau, worked with us on the ground and we held it in the brand new basketball hall in town. The evening before the conference opened there was a community working bee with turf being laid outside the hall. Most of the shops down the main street had little handwritten notices: “welcome to rural health conference”.

The Minister (Carmen Lawrence) flew in by helicopter to open the conference. Sabina Knight was by then our Chairperson, Margaret Hancocks was a key contributor to organisation of the event, and Leanne Coleman and Lexia Smallwood were already involved – as they are still. (We used Anne Cahill’s photocopier.)

Keynote speakers included Gavin Mooney and one Denis Napthine, then Parliamentary Secretary to the Victorian Minister for Health. The proceedings from that conference, available on the Alliance’s website, include a picture of Louis Peachey asking a question of Minister Lawrence, with the caption: Louis Peachey: “Why must it always be made harder for us? – if health workers want to work in the bush, encourage them!”

So perhaps too little has changed!

***

Q: Why is the National Rural Health Conference different to other health conferences?

Gordon Gregory: Many of those who attend the biennial National Rural Health Conference report how special it is. It has the natural advantages of being in a good cause and populated by a group who are necessarily spread thinly around the country.

What this means is that when they meet in a central place with colleagues who face many similar delights and challenges, they readily form a temporary community and work and party hard. They get on well together.

The conference unashamedly tries to be many things to many people. It has a large number of concurrent sessions with both general and peer-reviewed papers. It has an exhibition, which allows people who are normally quite isolated to catch up with technical and service developments – and enthusiastically collect free goodies to take back to their families.

It attracts leading keynote speakers who can inform and inspire. It is a marvellous networking opportunity: normally about 40% of those who attend have been before so there is a lot of catching up with old friends and much making of new friends.

It has a recommendations process, which connects the views of delegates directly with the policy development, and advocacy processes. It has a lively formal dinner at which it is normally impossible to find much space on the dance floor.

The Conference deals with a very wide range of issues relating to the social and economic determinants as well as health services, research and outcomes relating to health more narrowly defined.

It does not have separate streams for nurses or podiatrists or doctors; instead, it projects through its content and its processes a strongly multi-professional or interdisciplinary approach in which the whole team is working together.

And it celebrates some of the successes and champions, by formally recognising some sector leaders and local heroes through the presentation of awards.

***

Q: Health Minister Tanya Plibersek will speak at the conference. What do you most hope she will tell the conference?

Gordon Gregory: The people of rural and remote areas, including those who work in the health sector, are a pretty patient and resilient lot. What they want to know above all is that the governments of the day understand them and their circumstances and will do whatever they can to improve access to services and health outcomes.

Rural people generally understand about the impossibility of overcoming the tyranny of distance and its impact on access, costs and service systems. They don’t expect small communities to have the same services and facilities as regional centres or the metropolitan areas but they feel righteous indignation if they are not remembered and understood.

At the previous conference, in Perth in March 2011, Nicola Roxon gave a detailed and sympathetic speech in which she did much more than merely reiterating the litany of special programs provided for rural and remote areas. She recognised the challenges that rural communities and professionals face, and outlined how the federal government would deal with these as it progressed health reform, institutional change and new investments.

In Adelaide there will be the opportunity for Minister Plibersek to reassert the government’s intention to accommodate the circumstances of rural and remote areas through both ‘mainstream’ services and special, flexible services for smaller places through such things as block funding of smaller hospitals, MPSs, targeted mental health and dental health initiatives, reinvestment in critical services that have run down, and the maintenance of infrastructure.

The government’s credibility on such major commitments will be enhanced if relatively minor irritants like the ASGC-RA classification system can be fixed up.

***

Q: What is a pressing rural healthcare issue that will be explored at the conference, and what are its implications for the federal election?

Gordon Gregory:
One: How smoking rates can be reduced in rural and remote areas to match falling rates in major cities – and whether both sides of politics will commit to further investments in health promotion and illness prevention, including through the Australian National Preventive Health Agency.

Two: What the future will be for Medicare Locals? They provide real hope for the coordination of primary care (still usually centred on general practice) and any return to organisations that are only focused on medicine would be a gross mistake.

Three: What general commitment both sides of politics can give to rural regions that are not prospering (perhaps through a de facto royalties for regions approach)?

Four: What confidence people can have in federal, state and territory governments collaborating on health care rather than engaging in politics and blame shifting?

***

Q: What is a pressing rural population health issue that will be explored at the conference and what are its implications for the federal election?

Gordon Gregory: The conference will deal with a range of population health issues, none of which is more pressing than the health of Aboriginal people and Torres Strait Islanders. There will be a colloquium on Indigenous eye health. There will also be sessions on oral health, women’s health, mental health, child and family health, disability care, and hearing health.

***

Q: Do you think rural and remote health concerns will be important in the federal election? What will be needed to make them count?

Gordon Gregory: It is the Alliance’s challenge to make sure that rural and remote health concerns are on the agenda in the election context. It is a difficult task with all governments inexplicably claiming to be in the same situation as Cyprus, and with so many competing interests, and so little attention overall given to policies as distinct from politics.

But the timing of the 12th Conference could hardly be better coming shortly before the next election is due. So we’ll be encouraging everyone at the event to have their say and to require governments to join them in committing to a bright future for rural and remote communities!

***

Q: One of the strengths of the National Rural Health Conference is that it showcases excellent grassroots work in rural and remote communities. What’s your insider’s tip for a speaker or session that will highlight such work?

Gordon Gregory: The top-ranked abstract overall was for a paper to be delivered by Sue Cowan and Fiona MacPhee on “Integrating aged care assessment for older people of north-east Victoria”, to be presented in concurrent session A2.

A favourite of NRHA staff is going to be Kevin Bird’s presentation on “Team sport as a catalyst for Yolngu girls’ participation in healthy behaviours” (D1). Given the importance of oral health and its appalling status in rural and remote areas, concurrent session E6 must be important. It will include an update from ARCPOH on the situation and four important practical stories.

***

Q: What in your view is the most important plenary session and why is it so important?

Gordon Gregory: Probably the penultimate one, which will see Bob Wells and Jane Hall talking about what needs to be done to build a rural health service for the present and then Marie Lally galvanising us to take it upon ourselves and succeed.

***

Q: What will be the most controversial topics at the conference?

Gordon Gregory: Despite the political uncertainty, I don’t expect people at the conference to disagree much about what needs to be done and when and by whom. There will of course be differences of opinion about what are the first priorities and which are of secondary importance.

Underlying the general agreement will be the hope that governments can somehow give greater attention to the social and economic determinants of health (education, employment, regional development, community and public transport, health promoting infrastructure).

And while there will always be a solid appreciation of the tremendous value of medicine, there is sure to be a shared understanding that it is teamwork that counts.

***

Q: The Sharing Shed is a way for delegates to put forward recommendations before and during the conference. How does the Alliance collate these recommendations to ensure fair representation, and how much say do delegates have in deciding the Alliance’s priorities?

Gordon Gregory: Presenters at the Conference have been encouraged to provide recommendations with their papers before the Conference. Every person at the conference will be encouraged to go online to record their support for existing recommendations from other delegates and to write their own proposal.

Although they won’t be able to comment, people who are not at the conference will be able to observe developments with the recommendations.

The recommendations committee will be working behind the scenes to monitor the Sharing Shed as well as Twitter and Lesley Fitzpatrick will bring priority recommendations to plenary sessions for general scrutiny and will invite input from delegates with regard to the general priority areas to be covered and important elements to be included.

There will also be a round table session at which delegates will be able to discuss proposed recommendations. Lesley will present the priority recommendations to a final plenary session for the approval of delegates.

More information about the Sharing Shed is here.

***

Q: What is your most memorable moment from the last National Rural Health Conference?

Gordon Gregory: Our overwhelming recollection of each Conference is the energy of the people. Having so many enthusiastic representatives of the rural health sector, all in one place, being stimulated by presentations and conversations, creates quite a hubbub and buzz – and helps to re-energise us all.

Another strong memory from Perth is of the presentation of Christine Jeffries-Stokes and Annette Stokes about the use of sand stories to assist in health promotion and diabetes prevention in the Western Desert.

***

Q: What recommendation from the last National Rural Health Conference has had the most impact on improving rural and remote health?

Gordon Gregory: It is always difficult to attribute policy activity to particular proposals or particular organisations – and the NRHA is inherently modest.

The 11th Conference gave unqualified support for the Federal Government’s unprecedented action on smoking cessation (including plain packaging), which must have given it some additional comfort on the matter. The Conference singled out ear conditions as being an important and eminently fixable part of poor Indigenous health – and there has been some priority given to this. It provided guidance on and support for Medicare Locals.

It called for the National Food Plan to relate strongly to health as well as to food production matters and this call has been heeded. It also called for Health Workforce Australia to lead work on an interdisciplinary framework for training in support of health service managers, and HWA’s Health LEADS activity fits the bill on that.

***

Q: What recommendation hasn’t had the impact that you would have liked?

Gordon Gregory: The 11th Conference called for Commonwealth and State/Territory governments to agree and fund a national arts and health program. Arts/cultural and health departments are jointly considering a National Arts and Health Framework but despite strong and widespread support, its status is currently unclear.

***

Q: How can Croakey readers interact with the conference?

Gordon Gregory: Croakey readers will be able to monitor the recommendations as they are received through accessing the Sharing Shed online. All keynote sessions and concurrent sessions one, two, three and four will be streamed online within 24 hours of the presentation in Adelaide. There will be NRHA media releases.

You can follow @NRHAlliance on Twitter and search for conference tweets using #ruralhealthconf. And read Croakey (which has a category collating posts related to the conference).

• Post Script: Online registrations are closed but, according to today’s National Rural Health Alliance Eforum bulletin, you can still register by filling out a hardcopy registration form and returning by fax to 02 6285 4670 or email: register now!

• Previous Croakey posts on the conference are here.

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

Looking for Gordon

Gordon Gregory and Emeritus Professor John Humphreys

Thanks to Leanne Coleman for providing this explanation: The photos above were taken in front of the delegate mural at the 5th National Rural Health Conference in Adelaide in 1999. The NRHA Council bought the T-shirts for Gordon and John as a joke.