The advent of the Agency presents another predictable opportunity for a predictably boring debate about the “nanny state”, as per this segment from Richard Aedy and the Life Matters Team yesterday, featuring public health advocate Professor Mike Daube and individual choice advocate Julie Novak, from the Institute of Public Affairs. Incidentally, Mike Daube also spoke at a nanny state debate earlier in the year that I wrote about for Crikey.

It’s well and truely time that we put these nanny state debates to rest. They are SO last century and so unenlightening, especially when there is much else we could be talking about, including how many aspects of the modern environment encourage and support unhealthy behaviours.

The problem with the nanny state debate is that it keeps the discussion firmly focused on health as a function of individual behaviour, when it is much more useful and helpful to take an environmental health perspective.

Smoking rates fell because of changes – such as workplace smoking bans, advertising bans, increased taxes and prices, and changing social mores – which created an environment that made it easier for individuals to make healthy choices.

The other problem with focusing on Nanny is that it keeps the focus firmly away from where it is needed: looking at the contribution of powerful industries – food, alcohol etc – to poor health.

So next time anyone feels inclined to reach for a Nanny state debate, don’t bother. Nanny is now officially dead and buried. I hope.

Post Script: Now here’s a smart way to examine related issues (and no mention of Nanny either). Courtesy of the SMH’s Ross Gittins.

For the sake of time-pressed Croakey readers, I’ve compressed the speech into several dot points. But it is worth reading in full, and you can do so here.

Here is a summary:

• There is quite a contrast between the community’s need for pharmacists to do more in their professional capacity and the unwillingness of the profession to change.

• The field of prevention beckons pharmacists. But it does not seem that pharmacists are fully responsive to needs and opportunities.

• Do pharmacists really want to collaborate with other health professionals or remain individual business entrepreneurs? Some are dissatisfied that their professional skills are not fully utilised and extended. It is not surprising that many find dispensing medications and running what sometimes seem like gift shops, to be mind-numbing.

• Unfortunately, the Pharmacy Guild of Australia opposes pharmacists working as consultant pharmacists within the GP super clinics. It insists instead that the only pharmacy participation must be via the establishment of a community pharmacy within the clinic.

• The evidence is compelling that the highly protected pharmacy business model which is comfortable and financially rewarding for owners up to this point is going to come under challenge. The history of protection in Australia is that protected sectors are very vulnerable and risk not fully appreciating their vulnerability until it is too late. Why is it that so much effort goes into political lobbying in Canberra and comparatively little effort into utilising more effectively the enormous professional talents within pharmacy?

• Discussion of business prospects and protection is relevant to extending the role of pharmacists in healthcare. An extended role of pharmacists will be essential, as future business prospects of pharmacists will be significantly influenced by contracting margins and increased competition.

• Features of pharmacies today which will come under challenge include the geographical restrictions, impending pressures on pharmacists’ margins, and the barring of pharmacies from supermarkets. Australians don’t have great love for the Coles/Woolworths oligopoly but they would love to see more competition. This lack of competition may explain why paracetamol can vary in price from $10.95 for 100 Panadol to $3.95 for almost the same produce sold under the Chemmart brand.

•    It seems inevitable that the highly protected pharmacy sector is going to face major changes.  The lesson of protection in Australia is that if you want to have a seat at the table when protection is being reduced, you must accept the need to change.

• Perhaps pharmacists might consider two categories of registered pharmacists. One would compose many of the long-established pharmacists who are reluctant to move away from the distribution model. The second category could be younger and differently trained pharmacists who will respond to a new model of professional practice which substantially extends their role into disease prevention and enhanced therapies. It would seem a possible way to overcome the environment which new and highly motivated pharmacy graduates apparently find so discouraging and dampening.

• It is quite remarkable that the PGA has consistently opposed direct relationships developing between GPs and accredited pharmacists. It insists that the relationship must be with the patient’s nominated community pharmacy. This is quite contrary to normal health referral practices.

• How can the disconnect between how pharmacists are trained and how most of them work, be remedied?

Menadue concluded: “Despite the rhetoric about prevention, are governments, their bureaucracies and the professions ready to implement prevention policies? The answer to me seems to be ‘not yet’. Some hard thinking is required all round.”

• You can read more about John Menadue’s arguments for reform of both the demand and supply of health services here.

But there are other players whose role we don’t often hear much about when it comes to the fight against fat. Employers and workplace managers could be making a useful contribution to their employees’ health, suggests a new systematic review published in the American Journal of Preventive Medicine. It was conducted for the Task Force on Community Preventive Services at the Centers from Disease Control and Prevention.

The review is summarised by the CDC’s Community Guide here.

It analysed 47 studies examining the impact of education, behavioural and social strategies such as individual or group behavioural counselling, and policy or environmental approaches such as improving access to healthy foods in vending machines and providing on-site exercise facilities.

In nine studies, participating employees lost an average of 1.3 kgs after 12 months, compared with control groups.

The review concluded that no one focus, diet or physical activity, or combination of both appeared to be better than others in terms of its effect on weight loss.

Most of the studies involved a white collar workforce that included some employees with overweight or other chronic disease risk conditions.

The range of cost-effectiveness estimates from three studies (two involving weight-loss competitions and one involving a physical fitness program) varied from $US 1.44 to $4.16 per pound of loss in body weight (one pound being 0.45 kg for those not old enough to remember…)

If employers want a fit, healthy workforce into the future, they may need to start stepping up to the plate, so to speak, and accepting that they have some role – along with everyone else – in obesity control.

It is such an important job and this will be such a landmark appointment, let’s hope there are many outstanding candidates. The Minister for Health will make the appointment, but has to run it by state and territory health ministers, according to this bill introduced to the House of Reps today. Given the agency’s focus on tobacco, alcohol and obesity, you’d think it would be someone with expertise from across those areas.

Whoever it is will have their work cut out.

As well as developing an annual operational plan, a three-year strategic plan, providing advice to federal, state, territory and local governments, and working with the Agency’s advisory council, they will have to:

• every 2 years, starting in 2011, to publish a report on the state of preventive health in Australia
• conduct educational, promotional and community awareness programs relating to preventive health
• make, on behalf of the Commonwealth, grants of financial assistance relating to preventive health
• develop partnerships with industry, non governmental organisations and the community sector
• develop national standards and codes of practice relating to preventive health matters, and
• manage schemes that provide awards to participants to recognise excellent performance in matters relating to preventive health.

Meanwhile, the recent release of the National Preventative Health Strategy has prompted Todd Harper, Chief Executive of VicHealth (the Victorian Health Promotion Foundation), to reflect upon some of the lessons from the history of prevention.

It’s timely, given that the agency’s establishment will hopefully come to be seen as a significant landmark in public health history.

Harper writes:

“If we could time shift back a few decades, most of us would be shocked at how ‘normal’ some risky behaviours were. Casual attitudes to drink driving and seat belts, for example, contributed to a catastrophic toll of road deaths.

With the wisdom of hindsight, laws that were then damned as being ‘nanny state’ laws are now seen as ‘no brainers’ – they are so obviously beneficial.

But it took a visionary approach –‘wisdom of foresight’ in the form of preventative health campaigns – to drive the attitude and behaviour changes that have become our cultural norms.

These campaigns changed our culture so effectively that most of us now see drink driving as dumb and wearing seatbelts as automatic. And Victoria’s road toll statistics have vindicated those seatbelt laws, having fallen from 1061 deaths in 1970 when seat belts became compulsory to 331 in 2003 – a 69% reduction.

We have come a long way from the days when panel beaters worried about a loss of business from safer driving regulations.

In hindsight, that preventative health foresight of the 1970s and ‘80s was enormously valuable. It led to investments in our future health that now deliver huge returns to all Australians in the form of lives saved and illnesses avoided, with all the associated economic, social and personal benefits. Tobacco control programs are an outstanding example. Since 1971 they have cost $176 million and generated estimated benefits worth $8.4 billion – a benefit/cost ratio of 50:1.

Yet health promotion continues to be under funded in proportion to its benefits, with just less than 2 per cent of our health budget spent promoting health.

Australia could be a very different country if we could make that wisdom of foresight one of our national characteristics – and reflect it in our funding. This is the challenge raised by the Preventative Health Taskforce in its final strategy.

The Taskforce’s recommendations map the way to a healthier Australia by setting out the evidence, the targets, and the enormous potential benefits of following the strategy’s course for such key areas as obesity, tobacco and alcohol.

Fortunately, to help us reach those targets, we have a bank of wisdom from which to draw, deposited by successful preventative health campaigns in Australia and overseas in areas such as tobacco control, HIV, and road safety. At the core of such campaigns are complex questions. How do we change our culture? How do we make it ‘normal’ to live in ways that promote health, not disease?  How do we steer communities away from the chronic diseases that burden our health system, our economy and our daily lives?

Common to successful preventative health campaigns is an integrated approach that requires the resourcing of research. This is the foundation for the education, legislation and policy reform that ultimately leads to long-term cultural change.

The Taskforce’s recommendations on alcohol exemplify this multi-facet that truly encourage and reward healthy choices, through:

•    economic levers such as taxation or subsidies
•    legislative and regulatory measures
•    boosting support for local communities and individuals, and
•    increasing awareness that can over time influence our values of what is important in our general community.

Our tobacco campaigns have proven that pricing, for example, is an effective measure that can be applied to reducing alcohol consumption. Economic studies in other countries have found that a 10% price increase results in reducing total consumption across the population by an average of about 5%. And when alcohol prices rise, problems recede, including binge drinking, motor vehicle accidents, cirrhosis mortality and violence.

Other important across-the-board lessons from HIV/AIDS and road safety, along with tobacco, are that preventative health works most powerfully when it is politically non-partisan and involves the community at every step along the journey to achieving cultural change.

With tobacco and road safety we now have a community that understands the power of prevention, so much so that they expect, even demand, action from Governments. The community understands that without such action all of us pay the price: loved ones suffering preventable deaths and disease, paying the costs of treating the sick, lost workforce productivity or through pain and suffering caused by other people’s actions – smoking and drunk driving for example.

Governments have obliged recognising the wisdom and political gains to be made from smokefree laws and introducing drug driver testing.

This approach takes time – developing the knowledge and support needed is a long-term effort; which is why the Federal Government must implement the taskforce recommendations without delay. The National Preventative Health Strategy offers a once-in-a-generation window to exercise ‘the wisdom of foresight’.”

PS – quick query from Croakey: does anybody know why we’ve got a preventative health strategy and taskforce, but a preventive health agency?

Here at Croakey, we thought we’d do our bit to save the public purse by asking some relevant experts for their views about one particular recommendation, and the challenges surrounding its implementation.

This recommendation states (p97):

There should be a common national approach to evaluating all health interventions, with consistent evaluation of medical care, pharmaceuticals, prevention and population health interventions, medical devices and prostheses, allied health and complementary medicine. To use an example this might allow comparison of the relative efficacy of a medical intervention (gastric bypass), a pharmaceutical intervention (an anti-obesity drug), an allied health intervention (a structured program of exercises and diet management) and a population health intervention (a community walking program) in reducing obesity.

Of the experts contacted by Croakey, most liked the general thrust of the recommendation, although several cautions were sounded, and multiple barriers were identified.

Some of the cautions:

Jon Wardle (Qld Uni): The recommendation is certainly good in theory and worth pursuing – though is fraught in many practical ways. I see a well-intentioned measure heading for disaster.

Ben Harris-Roxas (University of NSW), when asked whether the recommendation should be progressed, gave “an emphatic ‘maybe’.” It sounds intuitively appealing but there will be substantial practical and methodological challenges.

Glenn Salkeld, School of Public Health, University of Sydney: It is worth agreeing upon a common set of principles for the evaluation of interventions and then consider the task of how best to evaluate the options. Without a clear articulation of the objectives of resource allocation (which must include the distributional consequences of resource allocation) we run the risk of measuring precisely the wrong thing in an evaluation.

***

Below, in no particular order, are the full responses to our informal survey:

1. Jon Wardle, School of Population Health, University of Queensland

What issues would need to be addressed to enable implementation? There are many barriers. The first is that there seems to be an underlying assumption that the generic nature of reactive pharmaceutical intervention for disease can immediately be transferred to the proactive/preventive treatment of disease. This casually ignores the many socio-cultural or other ‘non-health’ factors that affect the outcome of preventive health measures far more than acute treatments.

It also over-simplifies the methodological challenges in measuring the outcomes of interventions. Some may require a ‘whole-practice’ approach and not have readily identifiable markers of effect (I know of many menopausal interventions that have lower effect on single measures, but are superior on multi-factoral measures like ‘menopause scores’), or some may have patient-centred outcomes that may not be readily identifiable or comparable to clinical scores – but equally important in many aspects (for example the qualitative study of rheumatoid arthritis patients in Bristol that for the first time identified that fatigue associated with the condition, not pain, was the factor that most impacted their life – ‘clinical’ research had not previously explored this area). Of course people are individuals – some may respond better to diet than drugs, some vice versa.

Would a crude comparison make the intervention most effect for that individual unavailable as most other people did not see an effect? I would also suggest that it is not just health interventions that are measured. After all one of the most significant public health initiatives was seat belts – and that had bugger all to do with the health system!

The society in which we live predisposes the population to poor health outcomes (ie social isolation of suburbia; car-focused non-active transport; liquor licensing laws that encourage ‘super-pubs’ and subsequent binge drinking and violence over smaller, more social venues; urban planning that has reduced access to greengrocers, markets or other healthy and cheaper food choices in low SES areas; food safety laws that promote unhealthy options over fresher ones – for example national or processed over local or artisanal foods).

What impact might it have if it was implemented? The potential exists to stifle innovation in the development of health programs if the process is over-centralised or doesn’t deem it fit to focus on a number of similar interventions (ie why is the one ‘diet program’ chosen over another?). The bureaucracy of running it all may actually divert precious resources in the first place!

Do you think that it has any chance of being implemented? What might be some of the barriers? The barriers are too numerous to mention, and many of them involve internal politics, for example it assumes that one groups ‘walking program’ is the gold-standard, or which allied health profession will be chosen? Who will choose? In a sense this is being done already through broad health research funding agencies such as the NHMRC. A more prudent way to achieve this may be to develop research capacity in this new field through special funding rounds and later allow research to be funded on its merit. Although I would love to see the government fund research into each of those interventions my experience of grant rejection (we’ve all been there) makes me a little cynical and think there simply won’t be enough resources to do so.

Are you aware of any other countries that are already doing this? There are many attempts at doing similar things (NICE in the UK) but they are also share as many differences as they do similarities. Collaborations already compare such data already and we may be re-inventing the wheel.

Any other general issues that are worth raising? There are many factors that can affect health, in areas as disparate as transport or retail competition policy (for example it is pointless promoting to eat more vegetables if current retail policy competition means that the duopoly restricts access and affordability to nutritious foods – sorry a shameless plug for an article of mine coming up in ANZJPH). Many of the health issues of the future are particularly susceptible to the implementation of non-health policy and focus on this issue was sorely lacking. Some nations (including New Zealand) are investigating the role of “Health Impact Assessments” on new projects (such as housing estates) or policy and this is an area that should be explored further.

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2. Chris Del Mar, Dean, Faculty Health Sciences and Medicine, Bond University

This recommendation is a worthy objective. In particular some treatments are currently measured with quite different standards (esp complementary and alternative medicines, where ‘traditional use’ which can be recent, is considered an OK to licence, while other drugs need endless costly evaluation)

What are some of the issues that will need to be addressed to enable implementation? We need to facilitate randomised controlled trials more easily. Currently these are difficult to get done. Multiple ethics committees etc. In fact an RCT needs a higher standard of care than ordinary treatment (even if unproved!)

What impact might it have if it was implemented? People (patients and their doctors) should be encouraged to partner more in RCT evaluation of novel treatments. Currently this is seen as a ‘predator-prey’ relationship, which the trial funders are trying to make a buck for the shareholders, which is OK sometimes, but often there is a value to society by the RCT taking place and we all benefiting for the knowledge.

Do you think that it has any chance of being implemented? Yes, if we can change attitudes here.

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3. Michele Kosky, Health Consumers Council WA

Great idea, let’s have treatment based on best evidence and most cost effective for patient and the funder. I think it would reduce the competing interests and the territory wars between the tribes of health professionals that we often witness and it could be graded so that the gastric banding, for example, becomes treatment of last resort with all its inherent risks. I think that the industry groups in health and the pharmaceutical industry will ensure this proposal does not happen.

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4. Carol Bennett, Consumers Health Forum of Australia

Is this recommendation worth pursuing? Yes, although it is obviously a goal or stretch target rather than something that can be quickly or easily achieved.

What are some of the issues that will need to be addressed? For common measures of efficacy, there will need to be common measures of patient outcomes which will need to include the experience of care – i.e. the degree to which health consumers felt the treatment matched their health needs rather than the degree to which the service provided matched some rigid standard of procedure.

What impact might it have if it was implemented? If health consumers were properly informed about likely outcomes from the full range of health interventions available, it would allow consumers to have greater control and ownership of their own health and well being. Obviously this would lead to a much more healthy community. At present, whichever procedural specialist you see, whether they be a surgeon or a gym instructor, they will be bias towards the efficacy of the services they provide.

Do you think that it has any chance of being implemented? What might be some of the barriers? This has very little chance of being implemented in the short to medium term primarily because existing health providers generally like to measure their performance against the efficacy of their agreed procedures rather than comparing real health outcomes for consumers. We need to make health outcomes for consumers the focus of evaluation, not the procedures that are currently used. A good model in the general practice setting is the Collaboratives program which focusses on health outcomes.

Are you aware of any other countries that are already doing this? Increasingly countries like the UK are looking to health consumer outcomes as the primary reference point for efficacy of any procedure or health intervention, but it still has a long way to go before it becomes a realised ambition as outlined in the recommendation of the NHHRC.

Any other general issues that are worth raising? While the goal may be a long way away, any step to provide better information to health consumers about the outcome of a range of possible interventions is to be encouraged and supported.

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5. Public health physician George Rubin

What are some of the issues that will need to be addressed? National mechanism/s for conducting the reviews – a network of organisations under the auspices of NHMRC; methods agreed and developed …perhaps along the line of the evolution of systematic reviews

What impact might it have if it was implemented? Gradual shift of practice towards interventions of demonstrated effectiveness; hopefully a mechanism for ongoing assessment of interventions for which there is little or no evidence; reduction of interventions proven ineffective

Do you think that it has any chance of being implemented? What might be some of the barriers? Little chance. It will take a major organisational effort, will need a substantial budget (which could be saved by a successful program) and will involve substantial politics around what potentially gets dropped. More realistic to develop a program of comparative effectiveness measurement. Are you aware of any other countries that are already doing this? Health technology assessment organisations in NZ, Canada, US etc but unaware of comparative assessment programs

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6. Michael Moore, Public Health Association

I think that there is some merit in pursuing the recommendation. However, I do have some reservations about how the comparative research might be conducted and the prism through which such research might be constructed. Over the last decades preventive and public health has been the poor cousin in research because it is not simply about a gold standard double blind study with all confounding factors eliminated.

The medical and the pharmaceutical research methodology is likely to be more easily understood and therefore carry a favourable bias. I am not sure how these concerns might be met. A sensible study that wrestled and dealt with those issues has the potential to provide some serious insights into the most effective methods of dealing with obesity providing opportunity for governments to determine the most effective allocation of resources.

Implementation will be difficult as I suspect the funding of broad ranging research across different disciplines as this will demand is likely to be very expensive. However, it is possible and could be achieved by letting a tender to a consortium capable of crossing the barriers.

The complexity of obesity, the structural issues that drive it and the role of junk foods is probably a higher priority for research funds.

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7. Ben Harris-Roxas, Research Fellow, Healthy Public Policy Program, University of NSW

At time when we face increasingly complex health issues that are caused by multiple factors such as the way we live, work and take care of ourselves this may lead us further down the path to simple answers.

Also it’s unclear what methods might actually be used to compare interventions, e.g. cost-effectiveness studies, health technology assessment, etc. It’s not like issues of effectiveness will be examined independent of cost, so we should really be calling it what it is – a discussion about which intervention(s) should be funded based on their comparative cost effectiveness.

What impact might it have if it was implemented? I think it would tend to concentrate preventive activities even further on simple, well tested interventions that are closely tied to health outcomes, i.e. not complicated by other factors. This is not a bad thing in of itself, but it could stifle innovation and may only address the underlying issues at the margins.

Do you think that it has any chance of being implemented? What might be some of the barriers? It depends what the purpose of the “national approach” is. Will it be to ensure that only effective interventions get used or to decide that only a limited number of the most cost-effective interventions will be funded? Getting the states and the Commonwealth to agree on a common approach to this will be a minor miracle. The other issue is that the capacity to do health economic analysis is exceedingly weak at the state level and quite patchy at the Commonwealth level. The ability of drug manufacturers to demonstrate their products’ cost effectiveness is beter developed than, say, people developing population-based interventions, partly due to the nature of the interventions and outcomes but also because they are already doing cost-effectiveness studies for the PBAC/MSAC. The other problem is that it will favour one or two interventions as being the most cost-effective, when much of the emphasis in population health research is shifting to using complex interventions for complex problems.

Are you aware of any other countries that are already doing this? The UK’s National Institute for Health and Clinical Excellence (NICE) do this to a certain extent and the conventional wisdom is that they will only recommend that a drug or procedure gets funded if it costs less than £30,000/QALY.

If the “national approach” is only to set a minimum benchmark for cost effectiveness of interventions we may encounter a situation where

• costs grow rapidly (as currently occurs once drugs are apporved by PBAC or procedures by MSAC),

• there are increased inequalities in the health outcomes, and

• there will be concern about funding more and more interventions, suggesting that the benchmark threshold will have to be revised regularly.

A broader discussion is required about how much we are willing to pay as a nation and society for our health and how much we’re willing to invest in an average individuals’ health, but that’s too politically sensitive to contemplate in the forseeable future. If the purpose of the “national approach” is to ration services, and it would have to be at some level, this debate will have to occur.

Any other general issues that are worth raising? Transparency of the process will be important. Also, how do we circumscribe our consideration of effective interventions for health. For example, a recent meta-analysis of the lifetime effects of education on quality of life made a conservative cost estimate of between €98,000 and €168,000 for every QALY gained [Furnee CA, Groot W, van den Brink HM. The Health Effects of Education: A meta-analysis. European Journal of Public Health 2008;18(4):417-21.], and this didn’t quantify the effects such as the impact of education on mortality.

Education has a number of other positive impacts beyond direct health gains – should we be funding education as a cost effective health intervention?

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8. Wayne Hall, School of Population Health, University of Queensland

What are some of the issues that will need to be addressed if this is to be implemented? Something along the lines of the Pharmaceutical Benefits Advisory Council would need to be set up to evaluate major interventions in fields of high public health priority. Given the demands on expertise and time to do these analyses such an approach would probably have to be phased in.

What impact might it have if it was implemented? It would put the onus of proof on advocates of new approaches to provide evidence not just of their safety and efficacy but their cost-effectiveness compared to other similar interventions directed at the same risk factor or disease. It would make government think more strategically about funding for health care interventions rather than make piecemeal decisions about things one at a time (as we do with drugs with PBAC with limited capacity to revisit past decisions in the light of new interventions)

Do you think that it has any chance of being implemented? What might be some of the barriers? Barriers will be many: special interest groups (e.g. food industry, diet industry, pharmaceutical industry, health professionals with an investment in particular approaches); the economic costs to govt of implementing and scaling up such a system of evaluation; lack of data for economic evaluations etc etc

Are you aware of any other countries that are already doing this? NICE in the UK attempts to do something along these lines in so far as data permit for major areas of public health concern. Rob Carter from Deakin and Theo Vos at UQ are undertaking this sort of project at present for an NHMRC funded grant. Rob has done something along the lines suggested on obesity interventions and Theo something similar on alcohol.

Any other general issues that are worth raising? It’s an idea that needs to be seriously discussed and trialed in a couple of key areas of current public health concern, e.g. obesity

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9. Glenn Salkeld, School of Public Health, University of Sydney

What are some of the issues that will need to be addressed? Common issues – is there a common metric of health outcome that captures what matters? (ie the stated objectives of government health expenditure) Where does the information for the evaluation come from and is it valid and reliable? Who (an independent body or not) and what governs the assessment of the evaluation (is it regulation, legislation?) How does the process manage competing interests (of both buyers and sellers of health interventions/products)? What impact might it have if it was implemented? It would slow things down and allow time for proper debate on the best use of scarce resources. Depending on the responses to questions 1 & 2, it has the potential to shift resource allocation to a more transparent process (and hopefully move resource allocation to a more considered and defensible basis)

Do you think that it has any chance of being implemented? What might be some of the barriers? It will require a good deal of courage. It has worked in the pharmaceutical area because the only way to sustain large public expenditure that benefits the population and the sellers of medicines is to have an evidence-based approach to the selection and reimbursement of drugs. Without the public subsidy both sides lose. With a credible way to allocate money for medicines both sides gain. Are you aware of any other countries that are already doing this? The UK has the National Institute for Clinical Effectiveness (NICE) but that functions in the context of a more planned health service.

Any other general issues that are worth raising? Without a national approach to better resource allocation in health we will struggle to exert any control over who gets what health resources and how much. Doing nothing will only increase health inequalities.

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10. Les Irwig, School of Public Health, University of Sydney

My quick reaction is:

• Great idea!

• will need massive Govt funding to avoid the problem of RCTs being more likely for new pharmaceuticals.

• non-drug interventions used in the trials will need good descriptions – see Paul Glasziou’s recent paper in the BMJ on how poorly they are described currently in the lit

• need better consumer/patient involvement to define what endpoints are meaningful to patients and therefore should be measured in the trials

• pity they didn’t include diagnostic technology, for which far more trials should be done

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11. Lloyd Sansom, Chair, Pharmaceutical Benefits Advisory Committee

The Government is currently undertaking a Health Technology Assessment and one of the issues they are examining is the relationship between the various agencies particularly in regard to hybrid technologies and timeliness . With increasing applications of molecular targeted drugs, drug/device combinations it is important that we examine the situation to improve the efficiency of the process.

The PBAC submission to the review is here.  In view of the current review it would be inappropriate for me to make any other comment other than the submission

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12. Jon Jureidini, Adelaide psychiatrist and member, Healthy Skepticism

It could have a dramatic impact in some areas, but would require significant and often unpopular disinvestment. There would be some practical barriers, but the political ones will be stronger.

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13. Libby Roughead, School of Pharmacy and Medical Sciences, University of SA

Very often in health care we need implementation of a mix of strategies, not just one, so there needs to be a context in which this recommendation is considered. That being said if we only evaluate pharmaceuticals against pharmaceuticals, then we might not understand how that compares with other interventions which may be less or more effective – which I suspect is the issue trying to be raised.

If you look at the US Institute of Medicine’s top 100 priorities for comparative effectiveness, you will see that many of those are about gathering evidence for the mix of health care interventions – although I gather the top 100 priorities were opinion-based supported by a nominal group process rather than based on other data.

It is certainly a good idea to think about how public health dollars and practice and primary health dollars and care may be better integrated and how the evidence may integrate – we will always need both strategies (not just one or the other).

The challenge is creating the incentive for developing the evidence – it is work rarely done and we already have a challenge of evidence just within areas of health care. I suspect the starting point is to create the dialogue about what this means – as Croakey is doing.

He writes:

“The decision by the Preventative Health Taskforce to start with the soft policies is clearly a political one.

An evidence-based decision would have looked at the track record of self-regulation of food, alcohol and tobacco industries and seen that they serve the industries and not the public.

The Taskforce report is a major win for the food industry which is now globally in ascendancy in the policy tug-of-war over hard policies to reduce obesity.

Even with a Labor Government and a sympathetic minister, we end up with a set of soft options which promise to get harder over time but in reality are at high risk of staying soft.

The option to convert self regulation for junk marketing to children into statutory regulations is 2 elections away – that leaves a lot of time for industry lobbying and PR for the status quo.

The proposed voluntary front-of-pack labelling option has no planned track into regulations and the issue of taxing junk food is still recommended for investigation only.

The monitoring systems for keeping the industry on track and judging the ‘effectiveness’ of these voluntary schemes is not well specified.

The government is not responding to the report until next year and these monitoring systems may not be sorted out for another year or two – is that when the 4 year clock on industry action starts ticking?  The targets that have been set will never be met at that rate.

It was interesting how the physical activity options were always placed above the healthy eating options and that eating more (of the good foods of course) was always placed ahead of eating less (in fact, the eating less was not even present in earlier drafts).

In reality, to make a difference the order of importance needs to be reversed in both instances.  The hands of the ‘Hollow Men’ were clearly evident.

The Australian Communications and Media Authority report was just a joke.  After 2 years of consultations, deliberations and delays, they parroted the food industry’s flat earth statement that marketing of junk foods to children is not a contributor to obesity and a code that was essentially ‘business-as-usual’ apart from a ban on some cartoon characters for about an hour a day of children’s programming.

No wonder they were so ashamed of it they tried to release it under the shadow of the Taskforce report in the hope that it would not be noticed.

All the recommendations in the Taskforce Report are very positive and if the government enacts them all we will be well on the way to making major inroads into reducing obesity.

However, the same can be said of the 1997 NHMRC report ‘Acting on Australia’s Weight’ or the National Obesity Taskforce report ‘Healthy Weight 2008.’

The fact that neither of these were anywhere near implemented means we have to remain very guarded about the eventual impact of all the efforts of the Preventative Health Taskforce while we have a government so prone to being dictated to by big business.”

Dr Brian O’Toole, an epidemiologist specialising in mental health issues and the director of the Vietnam Veterans Study, has entered into the fray, arguing that the public health community doesn’t pay enough attention to mental health. He writes:

“This is a plea to extend the focus of public health and prevention beyond the  causes of death and their risk factors – heart disease, cancer, diabetes, etc – that seem to dominate public health in these days of chronic  disease epidemiology and the push to extend survival and postpone and compress the inevitable morbidity into a much shorter time. But public health seems uninterested in what actually happens to people as they move through towards the inevitable ending – many people’s lives are a  constant misery on this journey because of mental illness. Do we all “live lives of quiet desperation”?

There is hardly a family in this country that is unaffected by some  kind of mental illness, and mental illness (particularly depression and the schizophrenia spectrum disorders) make a mighty contribution  to the burden of disease. Yet research and funding for clarification and discovery of brain-based disorders and primary and secondary  prevention efforts are very poor. Enquiry after government enquiry has demonstrated the need for attention to understanding and preventing  the deterioration that accompanies mental illness, yet nothing has changed.

Ten years ago, with colleague Stan Catts, we mounted the First  Australian Schizophrenia Prevention Conference in Sydney (see Catts S, O’Toole BI, Dragen D (Invited Editors) First Australian Schizophrenia  Prevention Conference, Aust NZ J Psychiat 2000; 34 Supplement S1-S212). Since then, nothing has changed. Mentally ill people still  get shot by police and populate the jails. Thousand are still homeless. Even getting a differential diagnosis in early onset (usually teens and early twenties) disorders is a herculean task, reflecting the lack of knowledge about mechanisms of disease and  prevention in mental health. Three psychiatrists can give five opinions, and all that.

Sadly, there is almost no attention given to mental health in schools  of population/public health in Australia; a few epidemiologists can be found in a couple of enlightened schools of psychiatry, but there are far too few.

Wouldn’t it be a great idea to prevent schizophrenia? Bipolar disorder? Recurrent severe depression? Antisocial personality disorder? The madness that underpins extremist terrorism?

Sorry, I’ll stop the rant now, and go back to my ward…”

And then I was glad, sort of, for the opportunity for reflection and debate that Keane had delivered.

Continuing the discussion, Professor Bruce Armstrong, Professor of Public Health at the University of Sydney, adds this comment:

“The key point of weakness in Bernard Keane’s argument is this phrase “in the health economics literature”.

Preventive interventions that have been evaluated to the standard required to be included in the Tufts–New England Medical Center Cost-Effectiveness Registry of “published cost-effectiveness studies”, on which the New England Journal of Medicine article was based, are all or almost all interventions targeted to individual people.

The major preventive successes of public health have generally achieved most of their effect through interventions targeted to whole populations, which have not been and cannot be evaluated with the rigour required to make it to the Cost-Effectiveness Registry.”

To which I would add that Bernard’s article seemed to make the mistake of assuming treatment equals cure. As the NHHRC report has just pointed out, plenty of money is being wasted on ineffective tests and treatments. To suggest that public health and preventative programs should be based, wherever possible, on evidence that they will bring a reasonable return on investment is not nearly so controversial as Bernard seems to think. For example, this resource outlines the evidence base for various public health interventions.

Thoughts of an ambitious Pollyanna have come to mind for Dr Michael Robertson, Senior Research Fellow at the Centre for Values, Ethics and the Law in Medicine, University of Sydney.

He has filed this analysis for Croakey:

“The parts of the NHHRC relevant to mental health care are short on detail but read as an ambitious agenda, which seems to make the right kind of noises. Mental health clinicians are getting used to such lofty proposals of reform; they are also adept at not holding their breath.

What is wrong with mental health care run at a State level? In short, it is entirely hospital focussed which reflects two fundamental issues.  First, there is a culture of risk aversion, which keeps the threshold for admission (particularly under involuntary status) much lower than it should. The second is the fact that the care of most severely mentally ill people is so difficult to coordinate in the community, that the hospital setting serves as the only means of resolving the recurrent crises they face. These crises are invariably born of the myriad of problems confronting such patients – physical ill health, homelessness, poverty and other gross social disadvantage. The asylum role of hospitals never really went away. Only the beds did.

The Federal-State split in mental health care reverberates throughout the patient journey. Primary care and access to Medicare funded clinical investigations, pharmaceuticals and psychological services are under Federal control. But the majority of psychiatrists who care for severely mentally ill patients are employees of the States, and are prohibited from utilising these services in this role, unless they are exercising their right of private practice. This then makes their role Federally funded, even though they remain an employee of the State.

If a State-employed psychiatrist requests a PBS prescription pad or a provider number for pathology services, these are usually refused as the Commonwealth argues that pharmaceuticals and investigations of patients cared for in State-funded clinical settings are the responsibility of the State. And so it goes.

The “big picture” reform agenda of the NHHRC argues for the availability of “Extended care services” – what are currently termed “Crisis Teams” or “Acute Care Services”. Such services already exist; the clinicians needed to fund them do not.

The reform agenda calls for ‘early intervention’ with an emphasis on the early phase of psychosis. Such services exist and do excellent work with the patients and families under their care. Problem is, such services are only effective when they are provided in an assertive (read labour and cost intensive) manner. When the team disengages, the patient’s mental health deteriorates.

What early intervention services appear to represent, is what adequately resourced services can achieve working with mentally ill people. In reality, these services have emerged at the expense of the care of other patient groups – unless an early intervention service is funded by a Commonwealth drip-feed, they have to be scrounged out of existing resources.

The NHHRC does seem to understand the subtleties of the current Federal-State shambles in mental health care. The patience of many fee-for-service providers (like GPs and bulk-billing private psychiatrists) is stretched when the disorganisation or amotivation of chronic mental illness leads to inconsistent attendance at appointments.

The proposed block funding of a case-mix (being paid an agreed amount based upon the likely composition of the mix of patients) is a well-established and sensible solution. The notion of  “Connected care” (integrating clinical services across different specialties) acknowledges the fact that the physical health of many mentally ill people represents a greater threat to their well being than their psychopathology.

The NHHRC also acknowledges that the main determinant of one’s mental health is the level of access to social goods and not just access to clinical services. For many people with a mental illness, a safe home, a job or a vocational role, and adequate nutrition are elusive.

If the Commonwealth seeks to guarantee access to stable housing linked to social support services for our mentally ill fellow citizens, bravo.

Other than the forced removal of mentally ill people and mental health services to areas where housing is affordable, jobs abound, and one can buy fresh fruit and vegetables on the pittance the Disability Support Pension provides, I cannot see how the Feds will do this in our horrendously overpriced big cities.

A final challenge is the prospect of “Person controlled electronic health records”. Experience in other jurisdictions, and in abortive trials locally, indicates that mental health information is problematic in such systems. Most mental health records are kept deliberately separate from other health records and many mental health consumers wish to keep it thus.

Given the well-known negativity mental health consumers receive at the hands of other parts of the health system, there will need to be a separate system of recording personal mental health data to the main one.

Good luck guys. You’ll need it.”

Professor Boyd Swinburn, professor of population health at Deakin University and Director of the WHO Collaborating Centre for Obesity Prevention, has sent in the following critique of the report:

“The Parliamentary Inquiry on Obesity served up a largely evidence-free set of weak recommendations for obesity prevention.  The Committee took a feather duster approach to the prevention part of their brief, lightly touching all options without disturbing the status quo.  They dismissed the mountain of direct and indirect evidence that marketing increases junk food consumption and obesity and instead plumped for two programs which cost hundreds of millions of dollars and have no evidence for any effect on reducing obesity.

Indeed, the Active After School Communities program and the Stephanie Alexander Kitchen Gardens are not even aimed at reducing childhood obesity.  Their websites claim that the AASC ‘aims to engage traditionally non-active children in structured physical activities and to build pathways with local community organisations, including sporting clubs’ and ‘The aim of the Kitchen Garden Program is pleasurable food education for young children’.  Excellent programs at achieving their aims, no doubt, but in no way should they form the backbone of programs to turn around the serious problem of childhood obesity.

Add to that the solid backing the Committee gave to education, information and social marketing approaches and you have a full house of photo opportunities and weak strategies.

The Committee did not seem to get the point that obesity is not a knowledge deficit disorder which can be solved with a bit of information. Leaving the obesogenic environments to a few guidelines and industry self-regulation is a recipe for the continuing upward trend in Australian fatness.

But the public get the point.  They understand.  They are not taken in by the ‘pull-up-your-socks’ solutions (led by the former Health Minister Tony Abbott), or the ‘public-health-advocates-are-baddies’ cries (led by conservative think tankers like Chris Berg), or the ‘trustworthy-food-industry-is-making-big-changes’ claims (led by the Australian Food and Grocery Council).

The public are not that stupid.  Opinion polls consistently show that 80-90% of the public want stronger restrictions to cut the amount of junk food advertising seen by children.  This level of support far exceeds the support for bans on tobacco advertising when that legislation was being drawn up.

It is time for the politicians to look at the evidence, listen to the people and do something meaningful about obesity prevention, especially childhood obesity.

‘Marketing works’.  These are the first words of the US Institute of Medicine’s comprehensive review of the evidence on junk food marketing to children.  Indeed, the global food industry would not be spending $10 billion annually on marketing targeting children if it was not getting increased sales for its money.  They are very smart people working in a highly competitive industry with all the evidence of the effects of their marketing campaigns on sales at their finger tips. They make hard-nosed, evidence-based decisions and they keep investing.  Big time. This is strong indirect evidence of the effects of marketing on consumption even though we never get to see the raw data.

The other part of the evidence chain that links junk food marketing to obesity is the incontrovertible evidence that diets high in junk food put children at risk of unhealthy weight gain.

Aside from the piles of evidence reviews on the topic, it is also question of ethics and children’s rights.  In an age of burgeoning childhood obesity, to allow multinational companies to continually bombard children with sophisticated marketing techniques to get them to pester their parents to buy them the very foods that promote obesity is downright unethical.

We may not see junk food marketing as an ethical issue in 2009 because is just the cultural wallpaper all around us.  Remember, we used to live and work in rooms filled with tobacco smoke and thought it was just normal.

However, in 2019, or maybe 2029 if we continue along this slow route to action, we will look back and wonder in disbelief at lack of leadership shown by our current politicians as they tip toe around with their feather dusters, avoiding the piles of evidence, deaf to the public, but kowtowing to the demands of the food industry.”