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

She writes:

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

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

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

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

Professor Bruce Robinson, dean of medicine at the University of Sydney, thinks one solution may be to broaden the range of services involved in providing postgraduate medical education. There are, of course, many reasons why this might be useful – especially if it means more graduates wanting to work in general practice or in disadvantaged areas.

He writes:

“The recent difficulties for international medical students, who after as many as seven years of study have found themselves scrambling to secure postgraduate training positions, have been stressful for all concerned and not helpful to this country’s reputation for education.

The students’ much publicised problems, though, have served one useful purpose. They have been a wake-up call for state and commonwealth governments, medical schools and the profession on the need to overhaul postgraduate medical training.

Without reform we are destined to see the events of the past months – students graduating but not sure they will be able to secure an internship – repeated with increasing severity in the years ahead.

With the number of medical graduates due to more than double in the next two years, local as well as international students will soon struggle to secure postgraduate training positions. Within three years, the numbers of young graduates without internships could be in the hundreds.

Just as important, without reform of postgraduate education and training, we will not be preparing young doctors well for the realities of modern health care and for the medicine most will eventually deliver.

Postgraduate medical training has traditionally taken place in the country’s public hospitals. There is absolutely no way that under-resourced public hospitals can accommodate the increasing numbers of graduates looking for internships in the years ahead. Nor should they.

Changes to the way medicine is practised, the growth in the private hospital sector, and the shift from people being treated in hospitals into ambulatory care settings all necessitate rethinking the intern role.

Patients today spend shorter periods in hospitals, they are increasingly diagnosed and treated in general practices and specialist rooms. When students and young doctors see patients in hospitals for short periods but are then not involved in continuity of their care, they are missing a fundamental part of good medical practice. Without spending some of their training in community settings, in general practice and with specialists, trainees risk not seeing the full range of health delivery.

Changing patient management strategies, which are now more likely to include other health professionals such as physiotherapists and nurses, are also not well reflected in the public hospital-based postgraduate training we now provide.

One of the factors that has restricted change to postgraduate training has been an overly bureaucratic and traditionalist approach by governments and some in the medical profession. But if we are serious about providing better education experiences for our young doctors, we need to think more broadly and develop programs that more fully reflect modern medicine.

Instead of focusing all postgraduate training efforts in public hospitals, we need to be looking at options in the public and private systems, in general practices, specialist rooms and health centres, including Aboriginal medical centres.

Private hospitals now play only a minor role in medical education and training, but in our discussions we have found highly experienced members of the profession working in the private sector who are happy to engage in training young doctors.

We should also consider international opportunities. International training, especially in countries in our region, offers invaluable new perspectives and cultural experiences that foster more enlightened practical doctors. Many Australian health professionals work internationally and are willing to assist in training young doctors.

The Health and Hospitals Reform Commission, in its recent report, made a number of recommendations on postgraduate training, including the development of a new framework with clinical training available across all health settings, both public and private, and involving hospitals, primary health care and community settings.

With the new graduates emerging, there is real urgency to this endeavour.

To take the brightest students, ask them to commit to at least seven years (in the case of Sydney Medical School) of intensive study but then not provide them with the postgraduate opportunities they need to become the doctors they have the potential to be – and that the community needs – is wasteful and unacceptable.

It is imperative that we review and moderate the clinical training we provide, so we can accommodate the higher numbers of graduates but also allow it to occur in settings that make our young doctors ready and relevant to contemporary medical practice.”

• This article first appeared in The Australian’s Higher Education Supplement of 14 Oct. It is reproduced with the author’s permission.

But we haven’t heard much at all about what the reforms might mean for one extremely needy group who are often not well served by existing health services or funding structures.

Professor Ian Webster, a longstanding advocate for the homeless, has some suggestions for those driving health reform about what they need to consider if they want to better address the needs of the homeless.

He writes:

“The fact of homelessness is a test of our social and health policies. Between 2001 and 2006 homelessness increased by 17% with 16,000 in Sydney and 14,500 in Melbourne on the census night.

The health reforms currently proposed by the Commonwealth will aim to get primary health care (PHC) into disadvantaged communities and better management for complex health problems. Homeless people are one such community. In parallel with these reforms, the National Mental Health Plan has put social inclusion at the top of its priorities as it recognises the high risk of mental illness in homeless people.

The White Paper, The Road Home: A National Approach to Reducing Homelessness says ‘no person need be homeless’. It aims to ‘turn off the tap’ and prevent homelessness and proposes there should be ‘no wrong doors’.

In other words a person should be picked up at any point between the initial crisis and long-term homelessness.

This is a long way from the Homeless Persons Assistance Act of 1974 introduced by Bill Hayden to assist non-government organisations to provide shelter. Up to that time homeless policy was no policy; that was the job of the churches and charities. That 1974 Act and its iterations have never addressed health needs.

A street clinic in New York found that a homeless person had an average of 9 concurrent medical conditions.   It is the same in Australia: 75% of homeless people in Sydney in 1998 had one or more mental disorders – schizophrenia in 23% of men and 46% of women and an alcohol disorder in 49% of men and 15% of women. Every second person was physically unwell.

To do anything worthwhile for homeless people, a health service must be where the homeless are, in the environment of the homeless, free at the point of delivery and able to respond to multiple needs. Only in this way will there be a doorway into mental health services. The homeless need safe places especially when they are ill as do homeless families as the children have high rates of serious health and psychological problems.

Homeless women have special needs for contraceptive and pregnancy management and need treatment following physical and sexual violence. And for young homeless people a special style of service is the only way to engage with them.

People with mental disorders fall out of the service systems and are inadequately followed up. This is especially true of homeless people. They need assertive follow-up to overcome their reticence and embarrassment of their marginal status. Thus front-line services should be based on ‘open door’ and ‘no wrong door’ principles.

The main funding mechanisms in general practice – the Medicare item-for-service schedule and the Pharmaceutical Benefits Scheme – do not fit this population’s characteristics of transience, loss of identifying papers, intermittent contact and high prevalence of chronic and relapsing diseases such as diabetes, chronic lung disease and especially mental illness and substance use problems.

It is at times an insurmountable task to arrange psychiatric medications, antibiotics, addiction treatment, chronic pain management and even such straight forward measures as wound dressing, for these people.

A new kind of primary healthcare and general practice will need to be constructed if a dent is to be made in the increasing numbers of mentally ill homeless people. Will the proposed health reforms do this?”

• Ian Webster is Emeritus Professor of Public Health and Community Medicine at the University of New South Wales and Consultant Physician.

But at least we now have some idea of what sort of questions we should be asking, thanks to a report released this week by the Australian Institute of Health and Welfare, called Towards national indicators of safety and quality in health care (and available here).

The Australian Commission on Safety and Quality in Health Care funded the Institute to develop safety and quality indicators for various health settings, including primary care and community health care services, hospitals, specialised health services (such as palliative care, defence health services etc), and residential aged care.

Now that we at least know the questions to ask, we’re somewhat further down the path towards open public reporting of health service performance.

The report notes, however, that the issue remains extremely contentious and that “Australia has yet to follow the lead of countries such as the United States of America and United Kingdom which have adopted detailed regular public reporting at the provider level”.

While there are many concerns about the impact and usefulness of open public reporting, the report says it could have two purposes: to provide transparency and to inform decision-making about overall priorities and system-level strategies for safety and quality improvement; and to inform quality improvement activities of service providers.

It cites one study comparing the degree to which performance information stimulated quality improvement activity in hospitals if it was publicly reported or if hospitals received private reports.

The authors reported finding strong evidence that “….making performance information public stimulates quality improvement in the areas where performance is reported to be low. Since quality improvement efforts among the public-report hospitals appear to be significantly greater than in hospitals given only private reports, there is added value to making performance information public.”

To give you an idea of the indicators suggested by the report, they include:

For primary care and community health services:

• General practices with a register and recall system for patients with chronic disease
• People with moderate to severe asthma who have a written asthma action plan
• Mental health care plans in general practice
• Annual cycle of care for people with diabetes mellitus

For hospitals:

• Assessment for risk of venous thromboembolism in hospitals
• Pain assessment in the emergency department
• Stroke patients treated in a stroke unit
• Complications of transfusion
• Health care associated infections acquired in hospital
• Adverse drug events in hospitals
• Malnutrition in hospitals and residential aged care facilities
• Pressure ulcers in hospitals and residential aged care facilities

For specialised health services:

• Post-discharge community care for mental health patients
• Functional gain achieved in rehabilitation
• Multi-disciplinary care plans in sub-acute care

For residential aged care:

• Oral health in residential aged care
• People receiving a medication review
• Falls resulting in patient harm in hospitals and residential aged care facilities

The report note that indicators already exist for specific types of services, including Key Performance Indicators for Public Sector Mental Health Services, Australian Council on Healthcare Standards clinical indicator sets, for specific population groups such as the Aboriginal and Torres Strait Islander Health Performance Framework, and the COAG National Healthcare Agreement Performance Indicators.

Now that we have all these questions to ask, when will the answers be made available to the public? And will we make best use of them? So many questions searching for answers…

The omission has been somewhat rectified by today’s announcement of the Council’s committees, particularly with the newly established prevention and community health committee, and the newly established health care committee.

But primary care remains a minority player on the powerful research committee, which advises and makes recommendations on research grant applications and funding.

Meanwhile, the recent Croakey post prompted Rebecca James, CEO at Research Australia, to offer another interpretation of the new Council’s membership. She writes:

“The bureaucratization of the NHMRC is surprising given the newly legislated independence of the NHMRC.

Perhaps it could be interpreted as a renewed commitment by state governments to reform and embed a “learning” health system.  On the other hand, on matters of basic science, innovation, commercialization, technology, and knowledge transfer (particularly through primary care), there are likely to be a few lone voices on the Council  who may struggle to be heard.

Research Australia’s community surveys show the Australian public considers “improving hospitals and the health system” is the highest priority for the nation, ahead of keeping the economy strong and improving national infrastructure.

Research on prevention, treatment and cures for illnesses and diseases will play an important role in Australia’s future.  Let’s hope the Council can bring together the knowledge, experience, wisdom, and visionary thinking to work out practical ways to meet the public’s expectations.”

Post Script: Hilary Russell, Deputy Head and General Manager, Research Strategy, at the NHMRC, has sent in this response to the recent Croakey posts:

“The National Health and Medical Research Council is appointed under the NHMRC Act 1992.  The Act stipulates that the membership include the Chief Medical Officers for the Commonwealth, States and Territories (nine people).  It also requires the appointment a person with expertise in the health needs of Aboriginal persons and Torres Strait Islanders; in consumer issues; expertise in business, as well as 6 – 11 people with expertise in a range of other health, research and ethics areas.

The newly appointed Council includes experts with a wide diversity of knowledge from their current and previous roles across the continuum of health services, research and biotechnology.

The knowledge and skills of Council members are complemented by the members of the five NHMRC Principal Committees.”

• Declaration: Melissa Sweet, the Croakey moderator, is currently doing some editing work for Research Australia

“The elephant in the room that is not being spoken of or referred to in the current plethora of reports and indicated reforms in the area of Primary Health Care is: What do our General Practitioners actually do? And what is to become of them?

According to the reports released in the last six weeks, general practitioners appear to be ineffective, inefficient, have no professional identity, minimal skills, easily reproducible clinical skills and are at least obstructionist to team care if not entirely unnecessary in their current role. Reading this literature I’m not sure what they are doing or why they are doing it so badly.

Surely some of the 22 000 GP’s this country funds are doing something effective? Apparently not if you believe the literature we are being fed.

Besides this we don’t have enough of them.

Or do we in fact have too many given their total ineffectiveness? If this is the case why are we increasing their numbers? The department has believed for years that we have too many GPs per capita and the answer is apparently to reduce the numbers and replace them with allied health personnel. Is that what we are doing? The recent increase in training numbers will replace the retiring GP work force but not increase it. Have we been manoeuvred into this position where the GP shortage can be used as a reason and lever for this level of reform?

Reading the multiple submissions made in the consultation process it is apparent that general practitioners can be replaced easily by allied health personnel. This includes nursing staff that merely need to be given prescribing, pathology and referral rights to match GP skills.

The DoHA website is running a survey: “Would you be willing to see a nurse practitioner for some types of care and not a GP if it was quicker and if your quality of care was unaffected?”

Is this a reflection of their attitude to general practice?

According to this survey, which is “Yes Ministerish” in its directional questioning, the implication is that treatment from nurses will not affect the quality of medical care and will be quicker in delivery. It probably will be quicker until they too are buried in the bureaucratic red tape that has killed the ability of general practitioners to utilize their clinical skills or they meet their first serious problem masquerading as a simple issue. Assuming this situation is recognized as such. If it is not recognised them it will take no extra time at all.

In relation to the independent nurses working alone or in pharmacies: Will they need to work from accredited premises? Will they need to keep accurate and defensible clinical notes? Will they be able to complete Centrelink forms, disability parking permits, taxi subsidy applications, death certificates, sick certificates for 2 year olds who can’t attend their day care, obtain authority prescriptions, and complete the myriad of paperwork that surrounds work place injury? Work place injuries that they may be the first to see and treat. Or are all these bureaucratic issues solely the province of general practitioners?

This attitude of omnipotent competence not only applies to nurses but appears to include psychologists, physiotherapists, pharmacists, podiatrists and other allied health personnel all of whom are seeking direct patient access with MBS funding. Will patients or the tax payer pay for patients who see a psychologist for a year while their hypothyroidism progresses? What about the patient with the tumour receiving six months of physiotherapy with only temporary improvement.

“The need to improve the level of teamwork in primary health care, encourage greater integration and improve affordable access to a range of non-medical services is well accepted, although there is debate around where the GP sits in the team.”

Further to this debate, general practitioners apparently do their tasks so poorly that it will be necessary to develop specific and directive funding formulas to drive them to work in a manner and direction the bureaucrats, the ivory tower specialists and the authors of the multiple submissions, believe they should be working in.

Perhaps there should be some concern in relation to these developments as clinical skills applied carefully to individual illness and circumstances is replaced by pre-determined protocol applied universally to all according to a set funding formula.

So where will general practitioners go? Is there a role for them at all? Should they all specialise? Or is the development of an allied health tier in the primary health area pushing them into the realm of general practitioner specialists? If this is the case you can guarantee they won’t receive funding appropriate for this role!”

You can see the new Council’s members here. To question the composition of the Council is in no way intended to cast aspersions on the individual appointees.  I have no doubt that they are quality people with eminent and well-deserved reputations.

My back-of-the-envelope analysis is that the Council has:

•  10 Federal or State government employees (Rosemary Bryant, James Bishop, Kerry Chant, John Carnie, Jeanette Young, Paddy Phillips, Simon Towler, Craig White, Charles Guest, Barbara Paterson)

• 4 medical specialists (James Best, Sandra Hacker, Ron Trent, John Horvath, although perhaps John Horvath should have been counted as a Government employee as he is listed as Principal Medical Consultant for the Australian Department of Health and Ageing)

• 3 scientists/academics (Michael Good,  Kerin O’Dea, Cindy Shannon)

• 1 consumer (Anne Cahill Lambert)

• 1 business rep (Andrew Cuthbertson,  R&D Director and Chief Scientific Officer of biopharmaceutical company CSL Limited)

To be fair, many of the members have experience across diverse fields – Barbara Paterson, the chief health officer for the NT, has a background in general practice.

But the omission of explicit primary health care expertise seems rather strange, especially at a time when it seems there may finally be some action to match the longstanding rhetoric about the importance of primary health care in improving both quality and equity in health care.

If the community and primary health care is where it’s all meant to be at, why isn’t the NHMRC there as well?

I will see if NHMRC ceo Warwick Anderson wants to comment, and let you know…

In the meantime, here are some other peoples’ thoughts on the appointments:

Professor Mark Harris, Professor of General Practice, University of NSW:

“It was disappointing that there was not more representation from primary health care given its importance in the health reforms and need for research especially health services research.  Barbara Patterson is on Council as CHO for NT and on the NHMRC and has a background in GP.  However it would have been useful to have representation from PHC to inform NHMRC’s contributions to the new PHC.”

***

Robert Wells, Director Menzies Centre for Health Policy at the ANU (and formerly a secretary of the NHMRC):

“It is is now a very narrow Council dominated by doctors and government employees. They have appointed 19 people of whom 14 are medical doctors (all of whom are either specialists or public health physicians). The government appointments (Cwlth & states) dominate (11 of 19), esp as Rosemary Bryant the Cwlth Chief Nurse has been appointed & Prof Horvath the  immediate past CMO & still holding some official advisory role for DoHA. There is no primary care physician or other health professional from primary care in an era where primary care is one of the Government’s principal areas for health reform. I think there is no allied health professional person (have not checked the c-vs). As I read it, they could have appointed another 5 or so people to broaden the membership had they wanted.

None of this reflects on the qualities of the appointees. However the opportunity to broaden the membership of the Council to reflect better the realities of 21st century health care  and research needs seems to have been missed.

The members of principal committees has not been announced and these might provide broader membership and more balance.

The other point to note is that under the Act the Council is essentially advisory to the CEO only and its role as a council is perhaps not as crucial as in previous eras.”

***

Dr Chris Mitchell, president, Royal Australian College of GPs:

“Regional and primary care research needs a better focus.

From an AMA policy paper: A survey of public expenditure on primary care research in Australia, New Zealand, the United Kingdom and the Netherlands, found that the average was less than $1.50 per capita per annum, in contrast to the international average expenditure on health and medical research of $28 per capita per annum.

Primary health care research — essential but disadvantaged. Julie J Yallop, Brian R McAvoy, Joanne L Croucher, Andrew Tonkin and Leon Piterman on behalf of the CHAT Study Group. Medical Journal of Australia 2006; 185 (2): 118-120

Australia needs to lift its expenditure on primary health care research progressively over time. More research will help improve clinical practice and provide an evidence base to improve the delivery of primary care services.”

***

Associate Professor Simon Willcock, Head, Discipline of General Practice, Northern Clinical School
University of Sydney:

As per the issue that you raise, there was certainly some concern that there were no GPs represented on the overarching NHMRC, although over the subsequent week or so several “panels” were announced including the “primary care” and “preventive care” panels of the NHMRC, on both of which GPs were well represented.

I think in many ways the larger issue is that medicine and patient care are increasingly seen in “silos”  of care, despite the evidence that a generalist approach to health care s much more effective in improving outcomes.

The NHHRC Report  and Primary Health Care Strategy both recognised this, but are both long on rhetoric and short on detail. Garling’s report in NSW last year was really all about this – patient’s falling between the silos within the public hospital system.

I haven’t seen much evidence so far that “Caring Together” is changing this – to the contrary, the stressed state of our public hospitals seems to relate in fragmented care of patients more than ever.

That quote actually comes from the Preventative Health Taskforce report. I thought it worth mentioning because the draft of the first national primary health care strategy (which is available here, together with a supporting report) is likely to slip off the public radar pretty quickly, more’s the pity.

The Consumers Health Forum has given the strategy a big tick. Executive director Carol Bennett issued a statement saying: “The building blocks for change identified in the draft strategy reflect consumer priorities in health care. We’re delighted to see the focus on better integration and improved access to services, as well as measuring impact and outcomes. One of the strong points in this report is the way it embraces community based service provision that is not just about clinical health or GP services.  This is particularly important for people experiencing chronic relapsing health conditions who often need a wide range of services to meet their health needs.”

But Croakey contributor Professor Gavin Mooney is not so enthusiastic. He has written this analysis for Croakey:

“The national PHC Report and Strategy are overall disappointing. Let me respond to just two aspects.

First there is no grand vision, no overarching set of principles or values. Just a listing of 10 key aspects later reduced to 4 which are “improving access and reducing inequity; better management of chronic conditions; increasing the focus on prevention; and improving quality, safety, performance and accountability.’

How these were arrived at seems to have been in some backroom with, yes, “consultation” – which means anyone or anybody who wants to is invited to write in – predominantly “experts” (like me!) or professional bodies which have a vested interest.

Where is the voice of the informed public? It is their primary health that is at stake and it is their primary health care that is at stake. They are perfectly able to think through the principles and values they want to underpin PHC.

For example the Perth GP Division – the Perth Primary Health Care Network – got me to facilitate a citizens’ jury with randomly selected but well informed citizens being asked to say what they wanted from the network. A simple cheap and effective way to consult – and interesting results – for example their suggestions under the heading of “improved quality of care” included “More holistic care; GPs running on time; better referral systems, especially for mental illness; improved doctor patient relationship (with greater transparency on a number of fronts, particularly the influence of pharmaceutical companies on GPs practice and  greater shared decision making in general).”

In another jury in South Australia in a primary health care setting, one of the very interesting issues they proposed was for the PHC facility to be a point of contact for assistance in gaining knowledge of where to go with particular problems. This was to involve establishing information about and linkages with other services (both health and non-health), identifying gaps and seeking to fill these and advocacy with other (non-health) services to be more cognisant of their potential health role.

The details of the results from these citizens’ juries perhaps do not matter in this context. What does is that people – citizens – have a pretty good idea what they want in PHC. But we will never know if we do not ask them. This national committee do not know because they never asked.

Another issue (and it turns out to be related) in the report and strategy that concerns me is their handling of GP remuneration. The report runs through the arguments for and against different systems – and then basically stops, arguing in essence that there is not enough evidence to justify much by way of change. (There is some suggested change on chronic care and possibly prevention.) The evidence I believe is stronger than they suggest that but that is not my main concern here. We know that different remuneration systems result in different GP behaviour. The question then is: how do we want out GPs to behave? What do we want from General Practice?

Who better to address that than informed citizens! But the committee did not ask. Maybe there is still time?”

Tim Wilson of the Institute of Public Affairs was the first Nanny-pusher off the rank, at least the first I’ve spotted, with this yawn-inducing analysis in today’s Crikey bulletin. Here’s a taste: “Yesterday’s National Preventative Health Taskforce’s report is a monument to why elites think the average Australian needs a nanny to hold their hand through daily life.”

Hopefully most sensible people with an interest in the community’s health will ignore such blatherings and go straight to the report (or you can read Simon Chapman’s analysis in the SMH).

I have yet to read all of the report (what was the Government thinking, releasing it the day after the primary health care strategy, doesn’t seem to allow either of them the time and space they deserve for discussion and reflection).

But what I have read suggests that the National Preventative Health Taskforce document is probably one of the more important reports we shall see in health, and it deserves serious consideration, not only from across government but much more broadly. Local councils, community groups, patient groups, teachers and schools, employers, managers, those charged with teaching and training tomorrow’s health professionals – it has something for just about everyone.

The National Health and Hospitals Reform Commission report left me feeling like I’d been sprayed by rapid, erratic machine gun fire. Sure, it contained a lot of interesting suggestions, but many were not well thought through and there wasn’t a great deal of internal consistency to the report. Perhaps this reflected a lack of coherency in what the Commission members thought. Or perhaps it reflected the time and resource pressures the Commission must have been under.

The Preventative Health Taskforce report, on the other hand, seems remarkably coherent, on my reading so far, especially given that Kate Carnell, the Chief Executive Officer of the Australian Food and Grocery Council, is a member of the Taskforce and her organisation is not known for its progressive attitudes on public health matters. There must have been some interesting internal discussions!

The report combines a great deal of depth and thought with clarity and a readable style and layout. Unlike the NHHRC report, it doesn’t leave governments much wriggle room. It has clearly outlined its recommendations and how to implement and evaluate them.

Croakey has a habit of reading documents like this with her nitpicking glasses on, looking for errors, omissions etc. Nothing has struck me yet along these lines, but I will keep reading. In the meantime, please have a read and let us know what you think.

“The NHHRC report is not only a missed opportunity to create a system that will address equity and  efficiency in the current system – instead its proposals threaten both.

Of course no one would argue that primary health should not be strengthened, and that dental and mental health, Indigenous health, rural and remote health and aged care are not being failed by the current system. But identifying the changes needed is quite different from creating a system that will address them.

After years of debate, the commission has chosen to proceed largely in the same incremental direction we already find ourselves. Instead of finding in favour of structural reform that will ensure we have a sustainable and efficient system that will assist us to provide high quality care to the whole population, the commission has opted for an approach that will see the blame game continue and inequities entrenched.

Not content with the current status quo of a two tier system in hospital care, the commission has recommend we extend this to all health care and, in a highly risky first step towards managed care system, proposes a greatly increased role for the private sector and private health insurers.

This is the system from which the Obama administration are trying desperately to escape. The commissioners have chosen to mistake choice for equity, and thus have proposed greater choices for those who already have it, and less for those who don’t.

The proposal for Medicare Select threatens to take us in a direction where the sickest members of the community will have their health care limited to a basic package of care, while those who can afford it will be able to have as much as they like. A bit like now, only much, much worse.

This report should make the poor, the disadvantaged, the truly sick, and anyone with an sense of fairness very afraid for what lies ahead.

It is deeply disappointing and the health care sector and the community have every right to feel betrayed by this report as it does not reflect the feedback and ideas they so generously provided during the commission’s 16 month consultation.”