Their investigations raise concerns for the wellbeing of many vulnerable groups – especially in rural Australia – but also show there are many unanswered questions about the relationship between recession and health.

Dr Megan Keaney and Rebecca James from Research Australia, write:

“Amongst the millions of column inches written and hours broadcast about the global financial crisis, very little attention has been given to whether recession is bad for our health. It is not difficult to imagine that becoming unemployed is bad for our mental health but are there wider impacts? If so what will they be, who will bear the burden and is our health and welfare system prepared to meet the challenge?

Mental health professionals are already seeing a steady stream of recession casualties.  “BJ” is one such person. At age 57, he lost his business and savings late in 2008 and by November was severely depressed. He took an overdose of medication that left him with memory problems. When he left hospital, his ex-wife of 10 years took him home to a rural town, thinking that he would recover in a few weeks.  Twelve months later she remains his carer and his brain injury means that he has no prospects of returning to work or living independently.

A report released this week by Research Australia, Australia’s Financial Crisis: Implications for Health and Research reveals that becoming jobless is associated with higher rates of a variety of mental health disorders. Suicide rates in young men track the unemployment rate and even keeping a job in an environment where job insecurity is heightened is associated with higher rates of psychological disturbance.

Although the jury is still out, studies from previous recessions suggest that becoming unemployed is bad for physical health too.  For instance, a  UK study from the 1980s showed that job loss led to a 37% higher chance of dying in the next 10 years.

The good news is that for mental health at least, return to the workforce as the economy recovers, leads to improved mental health. If that was the whole story then health departments might be comfortable that although some extra mental health services might be needed to meet extra need during recession, with economic recovery, the status quo should return. However, as BJ’s case highlights, it may not be that simple. And the difference is that recessions don’t have the same impact for everyone.

It is well accepted that there is a strong correlation between socio economic status and health. In Australia people who live in disadvantaged communities with higher rates of joblessness, lower household incomes, lower levels of education and lower social status have much poorer health outcomes across the board than the well off. In Australia there is a strong link between poverty and unemployment.

The real risk of recession is that it adds to the pool of long term unemployed (those people who are out of a job for 12 months or more). The longer people are out of job, their return to the workforce is less likely. Unemployment impacts on those who can least afford it – people with lower education, fewer skills, and intercurrent health problems. Not surprisingly rising unemployment concentrates disadvantage in already struggling communities on the urban fringe and in rural Australia.

We know that long-term unemployment and poverty is bad for our health. So what will this recession bring and are we well prepared to meet that challenge?

During the early 1990s recession the number of long term unemployed receiving income support increased from 170,000 to a peak of 438,000. Although the percentage of unemployed who are long term unemployed in 2009 is low relative to the early 1990s (about 13%) it is feared that this group will rise by 150% over the next two years.

Treasury’s recently revised forecast that unemployment will peak at 6.7% might appear reassuring given that in the last two recessions unemployment rose to well over 10 percent. However the number of people looking for work is not the whole story.

Over the last 20 years there has been enormous uptake of the Disability Support Pension with the number of recipients increasing from 307,000 in 1989 to 750,000 this year. This recession too is a story of underemployment with the labour under-utilization rate increasing from 9.9% to 13.6 % in the 12 months to August 2009.

In other words, 1.5 million Australians are unemployed and looking for work or would like to work more hours. There is no doubt that for these people and their families, financial stress is real. So how will their health suffer?

Long-term unemployment might mean higher rates of illness and premature death from a wide range of illness including heart disease, cancer, mental illness and even accidental injury. Importantly the impacts are likely to be intergenerational.

Western Australian research shows that children from disadvantaged families start out life behind the eight ball with problems including lower birth weight which are carried through to higher rates of childhood illness such as respiratory and mental illness, and even into adult life with international research suggesting that chronic adult disease has its roots in early childhood and even prenatal factors.

Much of this health disadvantage is mediated through social factors such as lower educational levels, fractured families and communities and in turn higher rates of health risk behaviours including smoking, alcohol use, less physical activity and obesity. A good start counts for a lot when it comes to health.

At the other end of life, research shows that for older workers ill health and unemployment is a two way street. Close to half of Australians aged over 45 who retire early do so because of ill health. Older workers who develop heart disease or mental illness are especially unlikely to re-enter the workforce.

For the health care system, more illness means more demand. Australians enjoy relatively good access to the health care system and long-term data tells us that unemployed people and those who reside in urban disadvantaged communities see their GPs more often and have more hospital visits.

However recent polling by Research Australia and MBF reveal that for many Australians, this recession is already affecting choices we make about our health. For instance, over the last 6 months financial stress has caused close to 20% of people to put off seeing a doctor or dentist and a staggering two million people have gone to work ill, rather than take sick leave, because of concern about job security.

Many questions remain unanswered. Recessions might be bad for our health – particularly if we lose our job and never work again. However, as the economy recovers jobs will be regained and fears about joblessness and financial stress will fade. But are there lingering problems for our health? We really do not now whether cyclical economic downturns impact our health in the long term and well accepted research demonstrating that relative socio- economic status correlates with health outcomes provides only some of the answers.

Most importantly when reflecting on the possible consequences of this downturn for our health, we need to consider whether government policies and programmes designed to limit the economic fall out of this recession are working.

Do we need different strategies that better target social and health impacts? Are we making the right investments now to support vulnerable groups so that we have a healthy and productive workforce as we come out of recession?

What is clear is that we need to better integrate our health, economic and social research effort so that we learn the lessons of this recession. Only then will we be able to deal with the public policy challenges that are the legacy of this recession or accompany the next one.”

• (Declaration: Croakey’s moderator Melissa Sweet had a hand in editing the report)

This is the statement:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dear friends

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

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

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

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

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

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

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

Thanks so much for your help and interest!

Sarah Brown
Manager
Western Desert Nganampa Walytja Palyantjaku Tjutaku

Sarah has provided the following additional background for Croakey readers:

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

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

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

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

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

Of course, if we really care about health equity, health ministers would probably not be at the top of the list of people we should be chasing.

Prime ministers, premiers, treasurers, education ministers, even transport ministers may be just as important when it comes to policy decisions with health equity implications. Besides, many people seem to think that it’s Rudd (or at least his office) who is running the Government’s health reform agenda (whatever that may be…)

The Rural Doctors Association certainly gave this impression in a enthusiastic statement released after the PM’s visit to Bridge Clinic in Murray Bridge, South Australia, on Wednesday. They were delighted the PM gave them an hour of his time when just 15 minutes had been scheduled.

“Pleasingly, after hearing RDAA’s concerns, Prime Minister Rudd invited us to also work directly with his Office in combating the key issues fuelling the continuing health workforce crisis in rural and remote Australia,” said Dr Peter Rischbieth’s statement.

“We came away from the meeting with a great feeling that the Prime Minister now clearly appreciates the wide scope of work that rural doctors undertake in their communities and the additional workload they carry—from providing general practice-based primary care right through to being the emergency doctor at the local hospital.”

Well that’s wonderful. It does make you wonder though why it has taken so long for the PM to gain this appreciation. How long is it now that the problems of rural health have been in the headlines and at the forefront of health policy challenges? Probably easier to measure it in decades than years.

No doubt the PM’s office, with their keen interest in health reform, read this oped from the Business Council of Australia (in the Oz on Tuesday in case you missed it, as I initially did), arguing that health reform is too important to be left to the warring stakeholders. It’s an argument that John Menadue has made powerfully on many occasions.

I only hope they are also familiarising themselves with the mountains of evidence suggesting that health equity impact statements should be a critical part of health reform planning.

According to some estimates, the number of domestic medical graduates will rise from 1,348 in 2005 to an estimated 2,442 in 2012. To date, much of the attention (as per these articles from the Medical Journal of Australia) has focused on the “major upheaval” that these extra numbers will cause for postgraduate medical training – and the health professionals and services involved in this training.

But what, I wonder, are the long-term implications for the country’s health? Will more doctors mean better health for all, or only for some?

There is an argument that if the extra numbers simply boost the might of the specialist sector, one of the major consquences may be an increase in health costs without a commensurate improvement in health (according to the argument that population health outcomes tend to improve with more generalists but to decline with increasing specialist:population ratios)

Will more medical graduates mean more doctors willing to work in rural areas, Indigenous health, general practice, and other under-served areas, such as mental health?

Or do we risk ending up with yet more subspecialist physicians and surgeons, whose specialisation equips them poorly to work outside major metropolitan centres?

So many questions and, as far as I can tell, we’re a long way from answering them yet.

Meanwhile, researchers from the Northern Rivers University Department of Rural Health, based at Lismore in NSW, have been examining whether future health graduates will be willing to work in the bush.

Their study, involving medical, nursing  and allied health students, is published in the journal, Human Resources for Health.

One of the authors, Hudson Birden, Senior Lecturer with the North Coast Medical Education Collaboration has filed this report:

“There has been great effort of late in health education circles in Australia to try to encourage young professionals to choose locations in regional or remote Australia as places to work.  Much research has been published, and many schemes hatched to compel or cajole students to do so.

We know that students who originate from rural communities are more likely to choose to work there, as are students who undergo rural placements and find them enjoyable.  This works particularly well if they meet that right someone in the town where they’re doing their placement.  Rural placement is especially attractive to generalist practitioners: nurses, General Practitioners, Physios, etc., but less so for specialists.

Like the cult classic TV series Northern Exposure, based on the trials and tribulations of a fictitious US medical school graduate who accepted that country’s scheme to work in the wilds of Alaska for a stretch of time in return for cancellation of his student debt, Australia has looked at a number of national incentive schemes. What has been lacking is a method of targeting such strategies to individual students.

A recent report summarised work that some of us have done surveying students to try to capture the complex mix of motivators and barriers that go into the decision of where to live, where to work.

We looked at nursing, medicine, and allied health students, and found that 10% of them wouldn’t think of working in a rural area, about 25% would consider doing so, and nearly half said they would want to start in a capital city first off while holding out the option of moving rurally later.

Older student were more inclined towards rural work than younger students, perhaps reflecting a divide between those seeking the comfort of raising kids in a safe, cohesive social environment and the compulsion/attraction of bright lights, big city.

Over half of students desired to work overseas in the first 5 years of their career, of concern perhaps to those who worry about the migration of top talent elsewhere.  Such worriers may or may not be consoled by the fact that some of our respondents, and a sizable fraction of health practitioners in training, came here because they like the country and want to stay.

If we want to increase the health workforce in the bush, we can look at the attractors that we know about (career opportunities, living environment, financial stability) and target incentives accordingly.  We found enough openness to possibilities in the students we surveyed to encourage us that there is lots of potential to assist health career students in making the decision that produces the best fit for them and the community they ultimately serve as professionals.”

Croakey continues: A few more interesting things about the findings: students of Asian descent were more likely to never want to work in a small town, and nurses seemed more likely than doctors to be interested in rural practice.

The findings also remind us of the importance of not talking about “rural” as if it is a single destination – students were more interested in going to some parts of the country than others.

They were far more likely to consider working on the north coast of NSW than other rural areas. Only two per cent of students said they’ d be happy to work in the northern region of SA; 17 per cent said they would work in the NT or the Kimberly in WA; and just four per cent were willing to work in the south-eastern corner of WA.

The view from my backyard this morning

He writes:

“Sydneysiders awoke to a red glow this morning and opened their curtains to find that the city had been shrouded in a dust storm, blown in by strong winds last night.  Our clothesline was covered in red muddy lumps that were similar in shape to the clothes I’d hung out yesterday.

My mother-in-law called up to instruct us not to take the baby outside.  “You don’t want her breathing that stuff!”

I’m no respiratory expert, but I know that one-off exposure to dust of this nature was unlikely to cause enduring respiratory problems.  A precautionary response doesn’t hurt however, and state health agencies have recommended that people stay inside.

This did make me wonder, what are the health impacts of dust storms?

Dust storms may contain plant pollens, fungal spores, dried animal faeces, minerals, chemicals from fires and industry, bacteria and pesticide residues.  These all have the potential to impact on human health.  This is of particular concern in countries where there is increasing desertification and weak government regulation.

The potential health impacts of dust itself are important – usually by exacerbating existing asthma.  Dust storms have also led to algal blooms in some parts of the world, which in turn have a number of environmental and health impacts.

The psychological impacts of dust storms are worth mentioning as well.  People looking at the health impacts of a coal mine in Wales found that it wasn’t particulates alone that could impact on people’s health.  The constant noise and dust undermined their mental health as well.

Dust storms are far less constant so the extent won’t be so great, but already I’ve noticed a flurry of exclamations about the “end of the world” amongst my friends on facebook this morning.  I think that if the storm goes on for several days, some of these exclamations may become semi-serious.

Dust storms remind us that what happens in the outback has a very real effect on cities, as much as we might like to pretend it doesn’t.  I lived in Bourke as a kid and dust storms were not an uncommon event.  Maybe they’ll become semi-regular events in the Sydney of the future as well.  I’ll have to start bringing the washing in.”

• Ben Harris-Roxas works on health impact assessment at the Centre for Primary Health Care and Equity, University of New South Wales.

“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!”

It’s not surprising, of course, that magazines like Australian Doctor, Medical Observer or the latter’s new Practice Nurse tend to slant their coverage towards the perceived interests of their readers. Any sensible media organisation selects stories, writes them and displays them with the audience firmly in mind.

But one downside of silo-based publishing is that it leads to silo-based coverage of health issues, whose limitations become more apparent as we move towards an era of team-based, multidisciplinary care.

The dream of my colleague and I was that our new magazine would have a multi-disciplinary readership, and thus would cover stories in a way that didn’t give any particular weight to any particular professional perspective. That way, the stories might really be about health, rather than health professionals.

In this day and age, our magazine will probably remain a pipe dream; you don’t hear of too many new publications starting up. But I’d like to think that Croakey offers a forum for discussion across disciplines and sectors.

So I was most interested to receive a note on the “thorny issue of interprofessional practice” from Associate Professor Ann Larson, Director of the Combined Universities Centre for Rural Health, in Geraldton.

She was responding to a new study, led by researchers with a long interest in the potential of medicine reviews to reduce adverse events and improve care (including Libby Roughead from the Sansom Institute at the University of South Australia).

The study found that when GPs and pharmacists collaborated on home medication reviews for heart failure patients, the patients were less likely to end up in hospital than those who had no such review. The study was testing what happens in the real world – being based on retrospective analysis of patient records – rather than as part of a randomised controlled trial.

But for Ann Larson, the study has raised at least as many questions as providing answers.  She writes:

“Roughead’s retrospective study of the medical records of veterans with heart failure found that that a formal pharmacist intervention, in the form of home medication reviews and other consultations between the pharmacist and GP, was associated with reductions in hospitalizations.  This is consistent with other studies that have found pharmacist collaborative care to be effective.

What interests me the most is that the study also contributes to a larger debate of the value of inter-professional practice and its role in health care reform, but as such raises many questions.

How far can we generalize the experience of patients with GPs who have elected to seek pharmacist input?  In a small study I was involved in, a committed GP made at least some change in almost all patients’ (84%) medications following a home medication review (Quirke et al 2006).

However, are all GPs as receptive to pharmacists’ input?  And are patients who could benefit from a home medication review equally or more likely to see a GP who initiates collaborative care as those who do not?  If home medication reviews were mandated for certain conditions, would there be the same impact on prescribing patterns?

Another question is what causes the association between collaborative care and reduced hospitalizations?  Is it improved prescribing habits or more informed and motivated patients?  The answer will influence how these observed benefits could be extended to all Australians.

If GP’s prescribing habits are affected, then it may be that pharmacists need only conduct home medication reviews on a small of patients, but have more detailed feedback which will promote best practice prescribing.  On the other hand, if home medication reviews are effective because the pharmacist and patient communicate better than the patient does with his or her GP, then other health professionals or even trained lay people may be able to give medication education to patients with equal results.

Home medication reviews are still fairly rare in Australia.  Only 5% of this study of veterans had one.  If they were to be expanded, a number of other issues would become important.  Again, in our little study we found that while the GP was very satisfied with the program, local pharmacists felt that it was of limited financial or professional value, especially in circumstances where there is only one or two pharmacists and a requirement for constant presence at the business.

If the demand increased to the point that some pharmacists would derive most of their income from conducting HMRs, would the independent relationship between the pharmacist and GP be compromised?  Would their need to be a code of conduct to resolve situations where there was a difference of opinion or an error by either party?  Nor should we forget the patient?  What is the appropriate role for a patient and should HMRs be promoted to patients rather than to the GPs?

And finally I cannot help but speculate on the impact in rural and remote areas.  I have already mentioned the problems for the solo pharmacist.

But many small towns and remote communities lack a resident pharmacist altogether.  If HMRs are to be encouraged as an effective model of inter-professional care then it will be necessary to explore HMRs by telephone or with the assistance of another type of health worker being the eyes (and even ears) for the distant pharmacist.  If provision in the fee structure is not made for HMRs by distance, rural and remote residents will lose out again from benefiting from health care reform.

It is axiomatic that two professionals from complementary but distinct disciplines will provide better care than one professional.  The fact is that doubling the number of health professionals will be a more expensive service.  Understanding what features of collaborative care result in health gains are critical if we are to afford the better health care that we all want.”

(Quirke J, Wheatland B, Gilles M, Howden A and LARSON A. 2006. Home Medicines Review: do they change prescribing, and patient and pharmacist acceptance? Australian Family Physician. 35(4):266-267.)

The top-up is aimed at overcoming the historic low levels of PBS and MBS spending in rural and remote areas, to ensure they’re receiving as much money as communities with better access to medical, pharmaceutical and primary care services.

Our reader notes:

“The Medicare ‘top up’ for rural and remote communities (fantastic idea, p. 89) excludes Aboriginal people on the grounds that they are served through strategies elsewhere (terrible fine print, p. 268).  I think this is outrageous as surely the principle is that Aboriginal people have as much right to Medicare as anyone else, and that the Aboriginal strategies are actually about the specific needs of that community given the appalling health status.”

Meanwhile, health writer and author Ray Moynihan asks in this piece, published in Crikey, whether we may see the end of universal health cover in Australia, if the Government pursues the Commission’s suggestions for a Medicare Select under which  people could “readily select” to move between government plans or to a plan “operated by a not-for-profit or private enterprise”.

Interestingly, Stephen Duckett (one of the Commissioners who produced the report) was quick to comment on the Crikey website that:

“The Reform Commission did not recommend ‘Medicare Select’, it recommended examining the issue. The points you raise would necessarily be part of any such investigation (recommendations 90.12 and 90.13 for example explicitly foreshadow the need to look at risk adjustment and anti-competitive behaviour).”

It is worth noting that the Commission felt able to make a recommendation that would signal the end of universal cover although its terms of reference (P 181) explicitly state: “The Commission’s long-term health plan will maintain the principle of universality of Medicare and the Pharmaceutical Benefits Scheme, and public hospital care.”

And yet we’ve been told that the Commission was unable to investigate the rights and wrongs of private health insurance incentives because this issue was explicitly excluded from its brief.

Mark Metherell reported in the Sydney Morning Herald on July 29 that: “When he announced the health reform commission last year, the Prime Minister, Kevin Rudd, specifically instructed the commission to keep clear of the rebate issue. This was in deference to the health insurance industry, to which Mr Rudd had given an undertaking before the election to retain the rebate.”

Assuming this report is accurate (and please speak up anyone who knows otherwise), isn’t this cause for some concern?

The idea that a Government would commission such a wide-ranging and important review but instruct that a critical issue be omitted “in deference” to an industry group! No wonder Ross Gittins is not optimistic about the likelihood of Rudd delivering on his health reform promises.

While I’m feeling optimistic in some senses – we have come a long way, remember, since we had a federal health minister declaring there was absolutely no need for health reform – it also seems that these may be times of both danger and opportunity.

“The greatest understatement in the NHHRC’s final report is that ‘Opportunity for major health reform is rare and highly anticipated.’ It is indeed. This is a complex report that will require time to digest. However, at initial glance there is much to like about the Commission’s recommendations. And there are some disappointments.

The Commission recommends a strengthening of Primary Health Care (PHC) services, that will provide the solid foundation of the health system characterized by an enhanced emphasis on disease prevention, health promotion and consumer engagement,. It calls on the Commonwealth to take national leadership, and to accept responsibility for funding all PHC, aged, dental, mental health services and workforce development. It recommends a personal, patient held electronic health record for all Australians, and strengthening of e health systems generally. All of this is very welcome.

With respect to remote and rural health, the report focuses on more equitable funding by adjusting for MBS & PBS under-expenditure through per capita funding, adjusting for levels of sickness and increased costs of remote service delivery. It has responded positively to repeated calls for increased and nationally consistent payments for patient transport and accommodation to access services. The Commission also makes positive recommendations about supporting education and training across all health disciplines, and for preferential access to specialist training for remote and rural practitioners. It also recommends strengthening of research effort through a rural and remote health research program.

Indigenous health is a priority for the Commission and it recommends a National Aboriginal and Torres Strait Islander Health Authority, responsible for purchasing services, and ensuring clear accountability and quality.  It recommends that all Indigenous people be eligible to enroll with PHC services (in contrast to the more limited voluntary enrolment recommended generally). This is already the case for many Indigenous health consumers. It also calls for investment in food security and enhancing workforce initiatives.

So far, so good. However there are disappointments.

The Commission is tentative in its recommendation  for the Commonwealth to move slowly in taking responsibility for complete funding of public hospitals, and thus having one health system, one level of government responsible for it and truly ending the blame game.

Another disappointment is the Commission’s rejection of regional governance and service delivery mechanisms. This underestimates the capacity of remote and rural areas, and fails to build on existing successful regional models.

There will be much discussion and lobbying over the next few months. We are still to see the results of the primary health care strategy and preventative taskforce efforts. The government is to be congratulated on commissioning this much needed reviews. It needs to be bold and display the leadership expected in this rare opportunity it has afforded itself.”