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

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

You can pose a question online and see some of the other questions that have already been lodged, including:

• Large corporate organisations have become major players in the provision of general practice services in Australia. They typically also own radiology and pathology services. Combined with the fee for service payment structures we have in Australia do you see there is likely to be over servicing and the contrivance of patients care so as to maximise Medicare billing? Do you see this growth of corporate owned primary care and referral services as a concern? What will you do about it? - Dan Ewald
  
• Given the clear evidence of the merits of a national health system that explicitly targets health inequalities, precisely which of each party’s policies demonstrate a clear commitment to doing this? It’s not a universal system if it doesn’t serve the homeless, refugees, people with mental health issues, prisoners or those with poor literacy for example. Where are the models of care for these people? - Lyn Morgain
  
• Peter Dutton: You have said you would abolish the 61 Medicare Locals established around the country in the last 3 years as they are “a useless additional layer of bureaucracy”. You are almost alone in taking this position. The state government here in NSW seems pretty happy finally to have organisations coordinating primary health care and it is working actively to build relationships with them. How can you justify your position or will you (please) change it? - Lewis Kaplan
  
• Would Australia’s public health system be more cost efficient and have better quality control if we prevented the duplications, fragmentation and inconsistencies caused by each state and territory government running their own completely separate health departments? Why doesn’t Australia have a national public health and hospital service? Paul McNamara

Dr Tim Senior, a Croakey contributor and a GP working in an Aboriginal health service in Sydney, has a long list of questions, including:

• What do you see as the future for Medicare Locals?
• There is clear evidence that inequalities are a cause of ill health for everyone. How will your government tackle this?
• Wherever we look, we see that those who need health care the most get the least. This is true in rural and remote Australia, and true in pockets of our cities. How will you address this?
• How do you plan to increase the capacity of the workforce to manage increasing numbers of people with complex and chronic care needs?
• How do you plan to incorporate training of health professionals in health services that are already stretched?
• How do you see the use of e-health and telehealth initiatives in the future? What impact will your National Broadband Network policies have on this?
• Given that the evidence shows improved health comes from primary care, rather than hospital care, what are your plans to fund high quality primary care?
• How will you improve the integration of primary and secondary care? What are your plans for improving access to dental care?
• Do you have any changes planned for the way Medicare funds health services?

Meanwhile, if journalists and others are looking for some hard-edged health policy stories in the run-up to the federal election (as distinct from the easier option of calling the polls), Croakey contributors have some suggestions, including:

• So much of the public focus is on the performance of public hospitals when most health care is provided in the private sector. How about shining the light on the private sector, its performance and access? Specific examples, suggested by Professor Andrew Wilson, director of the Menzies Centre for Health Policy at the University of Sydney, are access to dermatology services and to bariatric surgery, and the impact of private health insurance.

• Given the cutbacks to public health and health promotion work by many of the state governments, what are the parties promising when it comes to public health and prevention nationally?

These suggestions follow a recent Croakey article canvassing ideas for media coverage of health matters in the run-up to the federal election, in which a few themes emerged.  These included the importance of focusing on issues that matter to the community, rather than being driven by professional, corporate and bureaucratic imperatives (or as one contributor suggested, the “rent-seekers”).

Contributors also suggested that the parties’ policies should be judged according to principles around equity and sustainability (ie beyond the usual refrain of more hospital beds, more doctors etc).

In this second instalment of the series, more ideas are put forward in response to a few prompts from Croakey, as per below.

1. Many sectors have a responsibility when it comes to the quality of our public debate about health. How would you advise the media to approach its election coverage of health? What can journalists and media organisations do to move beyond calling the “horse race”? What are some specific investigations that you’d like to see done?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
About 50 per cent of hospital care and 70 per cent of other healthcare is provided in the private sector, yet the overwhelming discussion is around performance of public sector hospitals. Almost all private healthcare is publicly subsidised through either the private health insurance rebate or the MBS and PBS. There seems to be continuing support in the Australian community for a mixed public, private model. However, there is little discussion about what this means, about the expectations of the private sector and on its performance.

The Preventive Health Taskforce which paralleled the National Health and Hospitals Reform Commission recommended the establishment of a national preventive agency to coordinate and lead prevention in Australia.   ANPHA was established as a response to this. The Coalition has it on its hit list to get rid of. Other public health experts are arguing we should be moving to a national CDC type organisation, given the threats from emerging infectious diseases and the speed at which these can spread globally. The current state of public health reflects the broader health system and is fragmented and loosely coordinated. What vision/plans do the parties have for prevention?

Both Labor and the Coalition publicly praise the quality of the Australian health system. Indeed, on many outcome measures like life expectancy, Australia does very well. But there are countries with similar economies spending similar amounts on healthcare that do better on measures such as waiting lists and coordination of care outside hospitals. Germany, for example, has no waiting times for elective surgery.

Carol Bennett, CEO, Consumers Health Forum
We need to pull focus of the health debate squarely on to the interests of the patient.  That means more attention to issues of access to appropriate care, cost and effective health systems.

What have the Rudd/Gillard health “reforms” really delivered for patients?  What does the Coalition offer that would improve health care?

Why are costs continuing to climb while access, even for those with insurance, seems to be shrinking?  More media examination of out of pocket costs, which have risen steadily in recent years.

And more scrutiny of the now-emerging data from the various performance and hospital costs authorities which are beginning to deliver data on how the health system is performing.

Selwyn Button, CEO, Queensland Aboriginal and Islander Health Council
Focus on comprehensive primary health care – all research and data indicate that the most effective mean of improving outcomes for Indigenous people is through comprehensive primary health care models of delivery, yet we are still struggling with governments to understand how to support this delivery through more effective and transparent resourcing and contract management.

Craig Thomler, Delib Australia and Gov2 advocate
I think the media has to stop beyond ‘gotcha’ stories and provide a lot more background on the overall health landscape for Australia.

It seems most media is now small target focused and isn’t providing a big picture view on how the health industry operates or all the interconnected pieces (and funding) that is required to address population health topics. In particular there’s a lack of focus on the underlying cause of many health issues, probably because these topics are not considered ‘health’ – such as personal hygiene education, work-life balance, food choices & respectful relationships.

I’d like to see a change in the entire approach to health reporting with a commitment to communication the big picture and then fitting every smaller story into context.

Mental health also needs to stop being treated as a ‘dirty’ and discrete topic and looked at in relation to physical health, considering the interactions between mind and body and their impact on overall wellbeing.

Special investigations: provide a breakdown of how health dollars are spent by type of health issue, alongside a matrix of how health issues influence the prevalence of other health issues, to see if proposed spending is direction towards ‘root’ or ‘branch’ concerns.

A dollar spent on obesity prevention provides benefits towards cardio-vascular disease prevention and treatment and therefore has a magnified impact – we get more than a dollar of value for the spend. Contrarywise there are undoubtably diseases where a dollar spent results is far less than a dollar’s value.

Only by mapping the expenditure and magnification factors do we get a clear picture on how our dollars can be best spent, and therefore be able to critically judge a party’s proposed health expenditure approach.

Anonymous Aboriginal health practitioner
Policy development and implementation is a complex process in which rational and ordered debate often play little part. Social systems, such as the political, draw boundaries between themselves and their chaotic (and potentially hostile) environments precisely so that the chaos and hostility can’t enter them or influence them. It’s therefore reasonable to conclude that policy is an instrument by which social systems seek to impose order on the ‘chaotic and hostile’ environments which surround them. Policy’s first task is to bring ‘order’ to the environment and, in so doing, ‘evidence’ becomes a technology of a lower order in policy development. It’s small wonder then that an informed – even (god forbid) scholarly – discourse developed over the course of any particular issue (though it might be rigorous, considered and thoughtful) is likely to play little part in the public discourse that surrounds any controversial subject in the charged electoral environment.

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2. The health sector also has a responsibility and often health organisations’ election statements are driven by narrow interests/perspectives rather than a wider focus on community interests. What practical things can health organisations and leaders do to contribute to a more informed and useful election debate around health?

Professor Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
In publishing statements, some commentary of the potential conflicts of interests of the parties would be useful and in particular to contrast statements on different issues. When juxtaposed, contrasting responses to different issues can highlight the conflicts.

The LHHN/Local Health Districts are supposed to bring greater local ownership, community accountability and responsiveness. This was stated in the response to the NHHRC and has also been part of the rhetoric of Coalition-led state governments in establishing them. It is debateable whether the current board arrangements actually achieve this in many cases.

Carol Bennett, CEO, Consumers Health Forum
We need to put out really clear messages on three big issues areas to put much more focus on:
·        Outcomes and performance of Medicare and PBS
·        On stopping the rise in out of pocket costs in health care
·        On improving quality and safety

Selwyn Button, CEO, Queensland Aboriginal and Islander Health Council
Self-determination and self-responsibility – in recent weeks much has been spoken about the notion of practical reconciliation from the opposition, whilst there is still some talk of self-determination being critically important to improve outcomes for Indigenous Australians.

Conceptually both these discussions a sound in there logic and proposed approach, although still do not go to the heart of real self-determination of ensuring that not only are Indigenous people provided with access to required services, resources and involvement in decision-making about how this happens, but going a step further to give overall autonomy and responsibility for policy, planning, program development, delivery and outcomes to Indigenous people.  This can and should happen particularly in places where there is demonstrated capacity and willingness to take on this challenge and risk associated, although governments are risk averse in nature and generally shy away from this next step.

If Indigenous communities and organisations can demonstrate willingness, understanding, organisational maturity and capacity, perhaps we should take the risk together in order to support improved outcomes.  This work is not ground breaking as it has already happened in Canada and NZ with significant results and could provide a template for greater autonomy in delivering services to Indigenous people by Indigenous organisations in or own country.  Working alongside this notion is also the importance of Indigenous communities and organisations willing to accept the challenge and demonstrate capacity and leadership in this space for governments to want to take risks.  This also would mean that not only are Indigenous communities and organisations willing to accept the challenge, we must also be willing to accept and embrace our failures if it doesn’t work.

Craig Thomler, Delib Australia and Gov2 advocate
A fact checking site would be brilliant. We have too many myths passing themselves off as facts these days & it is eroding public confidence in institutions. They could also be much clearer about their own interests and finances. It sometimes seems like a bit of a free-for-all with each group lobbying for their own interests without disclosing them, destroying trust across the board.

Anonymous Aboriginal health practitioner
It’d be worth looking at the Social Determinants of Health Alliance as an example of what you’re outlining. It is a group of widely disparate (and high profile) organisations drawn together in a ‘community interest’ (particularly disadvantaged communities) agenda. It has a website, has identified  September14th as its short term horizon and is unashamedly canvassing and lobbying politicians in order to get the government to sign on to the WHO-sponsored Commission on the SDoH.

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3. What about the role of the public service? The public service has largely disengaged from contributing to public debate (for eg James Button describes in his excellent book, Speechless, how senior public servants are now far less likely to provide background briefings to help a more informed media coverage, and Andrew Podger has also written about this). How might the public service and related agencies help contribute to a more informed debate?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
There is certainly a debate to be had to what extent this is the role of the public servant. While I think it is the role of the public serviced to provide honest unfiltered answers and data to requests from parties (and I use that term broadly) relating to issues in their portfolio, I have reservations about the extent to which they can enter into public debate (other than as citizens) on the issues. Similarly. it would be entirely appropriate for a public service to provide a listing of issues (and explanation and even the options identified for addressing the issue) in their portfolio. It is difficult to see how they would enter into a public discourse about the relative merits of different approaches where there are different political positions on those options.

Carol Bennett, CEO, Consumers Health Forum
The public service should be more accountable, such as in areas like negotiations for the Community Pharmacy Agreement, which should be much more transparent given the significant contribution taxpayers make to them

Craig Thomler, Delib Australia and Gov2 advocate
Firstly, we need the media to stop ‘gotcha’ reporting which has led to agencies withdrawing from public health debates on the basis that there’s no point in speaking about a topic if the media is reporting only to their own agendas. Secondly there’s a political issue where parties restrict external spokespeople to Ministers (or sometime their direct advisors) – this needs to be challenged and exposed by the media.

The public service and related agencies should first be encouraged to release as much raw data as possible, so it is available to inform media and public opinion. Then they can build on this data by providing professional perspectives and the various choices and consequences of specific decisions.

Frankly I don’t see agencies being that interested in getting into the public rough and tumble. There’s little upside and much downside for them & the current crop of senior leaders are focused on propping up a faltering system with falling budgets and needlessly quarrelling political figures.

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4. What are the broad criteria by which the political parties’ policies should be judged for their impact upon health? And for their health policies?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
1. To what extent do the policies reflect the real spectrum of healthcare in Australia (see the point made under question 1)?

2. To what extent do policies address the continuum of healthcare? Most of the focus is usually on emergency departments and elective surgery. What about prevention, rehabilitation, chronic mental health?

3. To what extent do the policies recognise and address inequities in access, eg there is virtually no bulk billing from dermatologists, and most charge more than twice the MBS rebate, so given the limited public sector services, access is clearly inequitable. Similarly, obesity has a very strong socioeconomic gradient yet bariatric surgery is very limited in public hospitals. The bulk of bariatric surgery is performed privately on insured patients (interestingly, data I have seen recently show even among those with private insurance higher socioeconomic groups are more likely to access bariatric surgery, probably reflecting both social values and the size of co-payments.)

4. Projections of health care costs show that the major driver of future costs is the increase in the intensity of care ie we can and are doing more to just about every health condition. To what extent do health and other policies reflect this when they talk about controlling the costs of healthcare?

5. Do the health policies specifically address the major health problems comprehensively – chronic diseases and mental health?

6. Do the broader (ie non health) policies recognise the direct and indirect impacts on population health and specifically on inequities in health? Eg employment, environment, trade, aid.

Carol Bennett, CEO, Consumers Health Forum
Both parties say they are about patient-centred health care.  But how do they propose to achieve that?  Their policies should ideally contain measurable objectives in terms of patient benefit.

Selwyn Button: Taking social determinants approach to supporting outcomes for Indigenous people – much has been researched and documented about the ongoing need to consider overall social determinants in order to improve outcomes for Indigenous people, and there have been several attempts by governments to support this approach without defining where to start.  What is needed now is a bolder approach to social determinants that clearly articulates the overall approach to improving social outcomes for Indigenous people by defining the most relevant starting point within this approach and how this integrates across the whole SD spectrum.  Current thinking by governments is to commence this work through job creation, although many would argue that employment, education and others participatory programs ill only be successful if the health of the individual and family is ready to take this challenge, which posits the health sector as the most relevant starting point.

Anonymous Aboriginal health practitioner
Equity. Human rights.

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5. I am keen to run some series at Croakey in the run up to the election, broadly grouped around particular themes. Do you have any suggestions for what these series could cover?  

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
1. The role of private health insurance and the private sector in the Australian health care system

2. What doesn’t Medicare subsidise and is this equitable?

3. Who decides priorities in public waiting lists? Is elective orthopaedic surgery more important than bariatric surgery?

4. What can/should governments do to tackle chronic disease?

5. What do we mean by universal health cover in Australia? What does the community expect from public sector health services?

Carol Bennett, CEO, Consumers Health Forum
1.  The future of Medicare and how funding can deliver a better bang for the buck.

2. The development on different models of funding health such as patient-centred budgets, more focus on treatment outcomes.

3.  How to contain growing out of pocket costs.

4. The Commonwealth-state funding divide.  Will it ever deliver an effective health system?

5.  The public-private funding mix

Craig Thomler, Delib Australia and Gov2 advocate

Aged care is a priority.

How do we manage all aspects of the aged care system? Facilities, personnel, costs? Our voters are ageing, so these concerns are increasingly relevant to people.

Look at the productivity impact of rising obesity and stress-related illnesses (including mental). If we wish to be an economically effective nation, what impact would health care improvements or primary prevention have on sustaining and improving productivity.

NB, for those interested in ‘how would you spend the Federal health budget’, see the Budget Simulator.

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6. Do you know of any useful examples from around the world, re innovative, community-focused election coverage of health?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
Plenty of examples of the opposite!

Carol Bennett, CEO, Consumers Health Forum
During the Queensland election, then Premier Anna Bligh initiated a Twitter campaign that proved one way of communicating messages to voters during a difficult election.

• For other federal election coverage at Croakey

These are global concerns, however, as Professor Robert Picard, Director of Research at the Reuters Institute for the Study of Journalism at the University of Oxford, outlined in a recent address to the National Press Club (worth reading in full).

While the world suffers information overload, he said the news media industry’s collapsing business model and the commercialisation of news values has led to an “an impoverishment of in-depth reporting and analysis”.

“The economic, technical, and social changes affecting news organizations have diminished their abilities to pursue the public interest orientation that was traditionally at the hearts of their enterprises,” he said.

In a subsequent interview for the Public Interest Journalism Foundation, Professor Picard suggested that collaboration between the community sector and journalists might help enable a more useful, contextual coverage that better services the community’s needs.

On a similar note, Croakey contributors were recently asked for suggestions as to how we all might contribute to a more useful coverage of health matters in the run-up to the federal election.

Croakey will also start an Election 2013 page to catalogue useful stories and resources that might be of use for all these parties. Suggestions from readers are most welcome.

A rather lengthy Q and A with Croakey contributors follows below.

Q1. Many sectors have a responsibility when it comes to the quality of our public debate about health. How would you advise the media to approach its election coverage of health? What can journalists and media organisations do to move beyond calling the “horse race”? What are some specific investigations that you’d like to see done?

Fiona Armstrong, Climate and Health Alliance
To ask questions about what the announcements mean for the community? Are they feasible? Realistic? Warranted? Affordable? Enough? In the public interest? Will they improve the health of the community broadly? Affect specific health conditions? Save money? Be guided by evidence? Reduce expenditure? Prevent illness? Prevent enough illness? Benefit health professional over patients? Address pressing health concerns? Are they in line with national and international health goals?

Lea McInerney, writer, researcher and facilitator
What do the parties have in mind in response to the increasing evidence for the part social determinants play in everyone’s health and wellbeing?
Linked to this, how do they plan to address rising inequality in Australia?
What do they plan to do to promote better dialogue and exchange across sectors i.e. to break down the silos among healthcare and other professionals (transport, housing, community services, employment, education etc) that prevent good collaborative solutions to complex problems?

Amanda Lee, Professor, School of Public Health and Social Work & School of Exercise and Nutrition Sciences, QUT
Investigation of policy platforms re preventative health and specific questions such as “do you support continuation of the Australian National Preventative Health Agency?”

Daryl Sadgrove, Chief Executive Officer, Australasian College of Health Service Management
We MUST take a long term view. All jurisdictions in Australia will be overwhelmed by costs by 2035. We need to hold the government to account on long term, systemic and structural changes that will assist with managing demand.

Ian McAuley, Fellow of the Centre for Policy Development
Journalists should avoid being caught on trivia and ask some basic questions of politicians:

Do you care about the community’s cost of health care, or only about the government’s fiscal cost?  If you want to shift health costs off budget on to private insurance, how would you preserve equity, avoid the moral hazard of private insurance, and control bureaucratic costs?

What role do you see for price signals in health care? Or do you believe health care should be free at the point of delivery?  Memo item – private insurance is not a market mechanism – it’s a way of buying out of the discipline of price signals

Should those with their own or third party deep pockets (private insurance, cover from sport clubs etc) be able to jump the queue for scarce health resources and make queues for public hospitals longer?

If you are not in favour of a single insurer, explain why?  (“We don’t want ‘socialized medicine’” is not an answer.)

Journalists should ask of advocates:

What principles should guide the allocation of health care resources, and why?

If the health budget is constrained, what health programs should be cut to pay for your program?

Tim Senior, GP working in Aboriginal health
I’d like to see coverage of health policy not be limited to discussion of hospitals and hospital beds. It would be good to see questioning around the importance of primary care, and what election commitments there were around this. I’d also like to see this move beyond a discussion about Medicare and bulk billing rates, though I won’t hold my breath.

It would also be nice to see a distinction between health policies, which usually means policies about the health system and a discussion of the health effects of all policies. Finding the evidence behind policy commitments would also be helpful, rather than just a he said, she said argument.

I’d also like to see election health reporting look at the effect of policies on particular groups – Aboriginal and Torres Strait Islander health is a prime example where policy in Indigenous health will be made completely separately to other health policy. Finally, it would also be good to see politicians questioned about what is not in their policies, as well as what is there.

Andrew McAuliffe, Senior Director, Policy & Networks, AHHA
Perhaps a series of pieces on the lost opportunities of the National Health Reform agenda, tracking from the initial offerings of Rudd/Roxon to where we are now.  The aim of reduced blame game has become a pipe dream and the tension between states and Commonwealth are probably as bad as ever.

Jane Burns, CEO, The Young and Well Cooperative Research Centre
• Mental health policy spending and parity with health – what are the critical issues, why doesn’t it get traction

• Wellness related policy – why it doesn’t get traction and where the votes sit – including community attitudes (I.e. Kings College study) and how to create a more responsive political agenda that focuses on building the countries strengths

• Innovation in the policy debate and Australia as a potential leader in key issues like mental health, disability etc

• NBN and its role in innovation – rather than just infrastructure and what does that look like

• State vs. commonwealth issues – which is boring but impacts so significantly on families and people affected by mental illness and disability

Daniel Reeders, public health blogger and Tweeter
Ditch the notion of balance as objectivity.

Ditch the distanced stance that looks at strategy over subject matter – what Jay Rosen calls ‘the cult of savvy’.

Ditch the geek-macho stance that positions people who care more about subject matter as politically naive.

Associate Professor David Atkinson, WA
• How they envisage providing excellent local services by local people (Aboriginal Community Controlled Health Services are the only current model – but funding may be at risk), sustainable funding, improved models of corporate and clinical governance for Aboriginal health services (there are some good examples around as well as the not so good ones we hear about & or work within);

• How government run services can make a real and improving contribution when currently many are so bogged down in bureaucracy they have no capacity to respond to community needs and rarely provide culturally appropriate care; and

• How large national &/or state based programs can actually work (generally they don’t well and often are a complete waste of money).

• Medicare Locals are not the answer to any question I can think of in Aboriginal health but the opposition alternative may be to go back to State or national based mainstream funding, which would be worse.

• Aboriginal employment at all levels of the system, while not a panacea, is central to many of the changes required.  What is the situation: how many Aboriginal doctors, nurses and other health professionals and where are they working.  What proportion of the workforce and how is this changing over time (apart from doctors, where there has been a steady if inadequate increase, I suspect other areas are at best treading water.

School attendance – is 60% good enough???  What does either party actually plan to do about this (State issue I know but they talk about it).

Dr Rod MacQueen, addiction medicine physician, NSW
This is a huge issue, and it is in addressing this question that I regret the scarcity of specialist health reporters, who may better appreciate and describe the nuances and subtleties of many health issues. Even for people working in the field, there are many issues that do not have a simple or generally accepted answer. Recently, I was discussing big picture health issues with a family member who works and does research in a big teaching hospital, and it was clear that we see many issues from quite different points of view despite sharing an egalitarian world view.

Think of spending money on improving the blood pressure or lipid profile of the whole population by 5%, with a huge impact across the community but no necessary impact on an individual, and funding that by reducing the number of stents and coronary artery bypass grafts performed in hospital.

It’s not just doctor’s incomes that would be affected, those people who may benefit little from a population intervention, who already watch their weight and lipids, would possibly gain most from a stent or graft if it became necessary despite their own self care. Would they be happy with less operations? Is this fair?

The same problem applies to population weight loss efforts (when our governments reluctantly decide the issue can no longer be avoided) being funded instead of increasing numbers of gastric banding procedures.

My relative and I did agree, however, that the solution lies in accepting that there may not be a single correct approach, but failing to discuss these matters, letting big funding decisions be made in secret, and failing to monitor the outcomes on any decisions, will lead (indeed, has lead) to the worst outcomes, where more is spent to achieve less and errors are repeated over and over.

The process we support is science, that which has given us vaccination, sewage and clean water, good nutrition and so on. And science is not laboratory stuff or new iToys in the end, it is the community of people who fearlessly and openly publish and share ideas, thoughts, questions, insights, even if they are later shown to be partial truths or even wrong.

Perhaps creeping managerialism with its fear of uncertainty and risk has scared many away?

A specific investigation I would like to see is this – why are our policies on personal drug use still substantially unchanged from the 1970s? Why is an open discussion on cannabis decriminalisation impossible despite the evidence that the current laws may do more harm than the drug, for example? Where is the agitation to restart the ACT heroin trial, a scientific trial that would answer some Big Questions, which we nearly had in 1997 – that’s 16 years ago and opioid misuse and related deaths have not gone away. And why is it a 5 minute job to get some opioid (heroin, oxycodone, morphine, fentanyl patches) to inject but almost impossible to get started on methadone or buprenorphine, both of which are 1960s technology? What about meth/bup 3.2, where any appropriate person can visit any chemist and get their medication daily using a smart card, instead of queuing for hours every day in the one dismal but needlessly expensive clinic, then being told they have to get out more and get a job so they can “recover”?

Our public debate on this issue is either non existent, or even back to the shock-horror stuff of the Reefer Madness days. But these health problems have not gone away.

Vern Hughes, National Campaign for Consumer-Centred Health Care
The political debate about health care and health reform in Australia is appalling. It is dominated by industry interests, with political parties championing their preferred industry groups (the Coalition backs private sector providers and insurers, Labor backs public sector providers and their workforce unions).

Consumers are absent, not backed by either side.

The media reports the contest between public and private providers, and reproduces the exclusion of consumers and consumer interests from the public arena.

Will the eight month 2013 election campaign be any different?

The short answer is no, unless there is a concerted effort by citizens and consumer organizations to break the duopoly of industry interests that have a stranglehold over the public discussion. This is not easy, because the industry duopoly is buttressed by the political party duopoly, and consumer and community interests are outsiders, external to this deep-seated binary structure.

But breaking this structure is essential for health reform. Three things should be pushed throughout 2013 in trying to shift media reporting on health care away from captivity to industry interests:

First, journalists should be encouraged to probe and report on the private and public sector industry interests that lie behind the various health industry interventions in this year’s campaign.

Health insurers have financial interests in subsidies and rebates that are unrelated to health outcomes. Quantify them.

Medicare Locals have financial and professional interests in the preservation of Medicare Locals, which are structurally disconnected from health outcomes. Quantify the numbers and absence of correlation with health outcomes.

Medical specialists ride a gravy train through public hospitals, milking duplications in function. Quantify it.

Bureaucrats, not consumers, are the primary beneficiaries from hospital networks, primary care partnerships and service coordination alliances. Quantify the bureaucratization and probe the absence on impact on the consumer experience of care.

Second, investigate and report on the funding of health industry peak bodies. Question why taxpayers money props up professional associations of medical and allied health specialists, and industry lobby groups.  When a Communications Manager for a health industry peak (private or public sector) holds a press conference, ask them if their position is funded by health consumers (taxpayers) and why.

Third, treat hospitals as one part of the health system, and a minor part at that. The main business of health care happens at home and in communities. Examine the world-wide trend towards individualized funding and self-directed services in disability, aged care and mental health so that consumers in these situations can self-manage their support at home and in communities.

Then ask why all industry peaks (private and public) are dragging their feet on introducing individualized care packages in chronic illness, maternity care, palliative care, drug and alcohol rehabilitation and mental health.”

Dr Sue Page, GP, academic, and rural health advocate, NSW
Please understand that hospital wait times are not a federal issue so please ignore calls from “Prof Whatever” from “BigCityTeachingHospital” who wants to talk about the usual orthopaedics, ophthalmology, Emergency Dept and overall “bed block”, otherwise known as inefficient use of resources and mismanaged supply & demand.

This election is a chance to look at community based health services which is where 99% of health care takes place each year.

Yes, you will need to cultivate spokespeople outside your comfort zone like physios, dietitions, social workers, pharmacists and, god forbid, GPs.

Try to remember that GPs earned the same HSC and Med school grades, attended the same hospitals as new grads, and didn’t become stupid overnight when they chose to keep doing it all instead of restricting their practice to just one field. Oh, and they don’t all have to be rural so ask around your local area to see what is needed and look at things like private health fund and MBS spend per capita inequities by suburb.

Other ideas for investigations:

• Why are we afraid of capitation? How influenced are we by the UK? Are the reasons different in hospital versus community sector? Why don’t we allocate tax payer resources per capita weighted by SEIFA? What barriers are there within the profession not just within the community and political space? If health care is a right, should doctors be salaried? If so, how much? If we are so afraid of dementia, are orthopaedic surgeons really worth almost 10x more $ than a geriatrician?

• Canada is different to Australia in many ways, but also very similar. Probably a lot more similar than the UK. Both countries have urban centres and large areas with sparse populations. It might be interesting to look at Canadian examples, as profiled here and here.

• Dental Dental Dental! When will the mouth be funded through MBS like the rest of the body? Sure you can exclude the “plastic surgery” equivalents, but please include annual dental checks and basic fillings so people don’t need dentures, crown & bridge work so often

• We may be living longer but we are not happier. Our local community connections seem to have been over-ridden by mass commercialised ones so that instead of a street bonfire with neighbours we have fireworks on the Harbour Bridge with strangers. Maybe we need this: http://www.guardian.co.uk/world/2012/dec/01/bhutan-wealth-happiness-counts

Kim Webber, consultant
I don’t think the media understands the issues enough to do this thorough analysis – look at their knee jerk reaction to hospital beds closing – NOONE has investigated this in the broader context of health costs spiralling out of control and that this is the start.

For number 1 – looking at how policies impact on our most marginalised is a great way to examine policy – e.g.. does it help in closing the gap.  Another thing might be to examine whether the policy is political or is based on evidence.

Professor Lesley Barclay, National Rural Health Alliance
The deficit in rural and remote health funding and the inequity of ‘spend’ on health services
Redressing inequitable health outcomes in health for rural and remote populations and Aboriginal Australians

Christian Smyth, consultant in mental health
Holding the political parties to account on promises to put so called ‘new money’ into health – got instance mental health only reviews 650m of new money out of the 2.2bn budget announcement.

I think there’s a story about the Federal Government getting a win in announcing NDIS, dental, but in choosing NPA to deliver through CoAg they are going down a similar protracted and watered down route to what we’ve seen in mental health ‘reform’.

Can a government be judged on announcements in a spin-heavy 24-hour news cycle any more or should we judge them on programmes delivered and outcomes for consumers?

If so, we would say that despite the 2.2 bn in mental health the overall proportion of the total health expenditure delivering care in mental health has gone down.

Professor Linda Shields, School of Nursing, Midwifery and Nutrition, James Cook University, Townsville
Why don’t journalists ask the nurses? They constitute the largest proportion of the health workforce by a long mile, many are in very senior and influential management positions (including as CEOs of health institutions), they are highly educated, with many on the “floor” with Master’s degrees and some with PhDs – making them educated to a higher level than their medical colleagues), and they have 24 hour interaction with patients. So many journalists go to the doctors and ignore those who make up the bulk of the workforce and therefore have much to contribute.

Dr Peter Arnold, retired GP
I would simply make the point that any comment in 2013 is skirting around the edges of the debate which has been going on since the mid-70s, when Scotton and Deeble thought up a scheme with an accelerator pedal and no brakes (as Deeble has acknowledged – they didn’t think it would be necessary!)

The fundamental issues are unchanged, other than worsening with each year as our population ages and medical technology improves.

1. ‘Universal’ as opposed to ‘selective’ benefits. This has now morphed into the ‘politically correct’ concept ‘middle-class welfare’. At least some pollies are facing up to it.

2. Rationing. Enoch Powell recognised the problem decades ago, when he was UK Minister for Health. But who quotes such a ‘politically incorrect’ figure nowadays? “There is virtually no limit to the amount of health care an individual is capable of absorbing.”

3. Our ageing population – living longer but medicated and handicapped and needing more and more prostheses – knees and hips, not to mention cardiac bits and pieces, plus expensive rehabilitation (the rapidly growing field in health care!).

4. Politicians’ absolute commitment to prolonging the dying process, and their aversion to making death easier and shorter for the dying.

5. Media ‘hype’ about magic bullets and the like, with no realistic reporting on the time-lags and costs, let alone potential for side-effects.

6. Public expectations of ‘ideal’ medical services, with never a mistake, available for every citizen, regardless of where they live, even thousands of km from the nearest specialised health services.

7. Failure to engage with Aboriginal communities about the sorts of health services they need and are culturally willing and physically, socially and economically able to co-operate with.

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Q2. The health sector also has a responsibility and often health organisations’ election statements are driven by narrow interests/perspectives rather than a wider focus on community interests. What practical things can health organisations and leaders do to contribute to a more informed and useful election debate around health? (One possibility, for eg, might be various public interest organisations collaborating on a fact checking website to help the public make sense of competing political/professional claims).

Fiona Armstrong
Great idea! Let’s talk to ARACY and PHAA and AHHA and CHA et al about kicking this off!

Lea McInerney
With your fact checking website idea, maybe categorise topics like this: (a) ample reliable evidence available (b) some evidence, although not definitive, (c) little evidence currently available. This could remove one layer of confusion.

In line with the comment in Q1 on promoting better dialogue and exchange, perhaps some online “think tanks” on complex topics, drawing together people from a range of perspectives to see if they can come up with breakthroughs.

A few ideas for how to seed ideas among people from different backgrounds:
· A story on the value of bringing together diverse thinkers as a precursor to a forum or forums on different topics that might at first glance seem unrelated http://www.insulators.info/articles/ppl.htm (there’s a few versions of this one around).

· A virtual think tent, as in this model http://www.tendaysontheisland.com/2013-program/thinktent. Would have to be well moderated.

· Maybe a debate along the lines of “Can our healthcare problems as a nation be fixed with one big thing or do we need thousands of small things?”

Amanda Lee
i) Being actively involved in developing and supporting forums that foster health stories, debate, and develop opportunity for relationships to better engage and inform journalists about evidence-based health (particularly preventative health) eg Qld Health Media Club http://www.healthmediaclub.com.au/

ii) Running training on evidence based medicine/health (as Bond example- but free!)

Daryl Sadgrove
Fact checking website is a good idea, but it is difficult get drive traffic there. Our organisation is taking a very open, consultative and transparent approach to policy development that is engaging patients and consumer groups all of the way. It might be useful to have access to policies and positions of various organizations to reconcile them?

Ian McAuley
Don’t jump to positions “We want X”. Rather, articulate your principles and show how these translate to practical outcomes.

If people want to advocate for their groups, do so in a way that shows how it might all fit together.  You may need to argue for fundamental program re-structuring.

This point needs some explaining.   We have many intersecting divisions on a 3 D matrix – demographic divisions (child, adolescent, women’s, aboriginal etc) on one axis, conditions (mental health, diabetes, etc) on another axis, and delivery systems (clinics, drugs, hospitals) on yet another axis.   (In fact I have simplified even the demographic division – are Aboriginal adolescents classified as Aboriginals or adolescent?)

This concern stems from my observation of a very effective campaign on mental health over recent years. I am in no position to judge its merits, but any outcome is going to be very sub-optimal if it simply calls for mental health to be fitted into our present program structure.

A very basic question is what should be the primary organisational divisions? Our present divisions – medical, drugs, hospital – are all provider-based. Mental health fits easily only in a program structure based on conditions. Otherwise it intersects clumsily with the present provider –based classifications.

I think that the provider-based structure is dysfunctional, and is responsible for many of the problems in health care, largely because it’s a structure that gives easy access to provider lobbies. A consumer-based structure would be far better, but there is no one model – should it be along illness/condition lines (which would most easily accommodate mental health) or demographic lines?

Tim Senior, GP in Aboriginal health
It would be quite fun to ask health organisations with policy requests which other health organisations support them and which don’t, and why they don’t. What do their members get out of the policy and how will it benefit patients? What evidence is there for this?

I think there is room for a fact checking website. I think it might be possible for Croakey and the Crikey Health and Medical Panel to write and help crowd source fact checking, even using the Crikey Promise Watch section. It would be helpful to look at the health consequences of all policies, as a way of introducing social determinants of health into the campaign.

Andrew McAuliffe, AHHA
Agree with fact checker idea – could be quite revealing

And perhaps an evidence checker as well ie how well do the promises and initiatives actually reflect the policy evidence as opposed to a populist, knee jerk marketable response

Jane Burns
Not sure I understand this one – our goal across the youth and mental health sector is to provide a united voice – through testimonial, survey and a historical perspective on mental health policy in the last 30 years – one of the big issues is the traction that comes post election and then the slippage in delivering on policy promises

Daniel Reeders
Abandon the language of social determinants.  We need to talk about social determinants, but the terminology is deathly.

We need to speak plainly about what happens to voter’s loved ones when health promotion services are slashed.

Jane Isaacs Lowe and colleagues have written a brilliant report for the Robert Wood Johnson Foundation, A New Way to Talk About The Social Determinants of Health.  (PDF link: http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf63023 )

Here’s how they reword the core concept: “Health starts where we live, learn, work and play.”  It is based on research in America, and it doesn’t apply directly here; reader discretion is advised.  I’d love to see an equivalent project in Australia.

Interestingly, the Foundation used much the same methods political parties use to identify election campaign messages.

Dr Rod MacQueen, addiction medicine physician
First off need to have some agreed principles that define the health sector or a health organisation. There are many lobby groups that appear to be concerned with health but in fact represent at best narrow sectarian interests, and at worst are fronts for industry with an anti-health pro mass consumption agenda.

I think there’s little wonder the public may have trouble deciding who to believe at times. This is not about censoring these groups, but merely making it clear very early on that they do not, for example, believe in the scientific method, transparency, falsifiability and peer review (even with their shortcomings) nor in equity and social justice.

This is made more difficult by governments defunding independent bodies and allowing more research and publication to be generated by these same sectarian interests.

Sadly, our governments do not appear to believe in the scientific method despite occasionally using terms like “evidence based practice”, and it would be useful if the public better understood what the scientific method was, what a hierarchy of evidence was, and how there may not be a simple or even a single answer to complex questions but we may still need to act, reflect upon the data fearlessly, and take the next step.

The NT “intervention” is a case in point, where billions of dollars will be expended but inadequate data collection, spin and preset agendas will ensure that any good which may come out of this effort will be as much by luck as design.

In the end, it will be another expensive waste of time and effort, whereas a scientific, iterative, action learning approach could lead to some better outcomes. Facts are important, and should come before the interpretation and spin.

Yes, health is political, but the politics should come after, not before, the research and the facts. Good websites and even blogs can certainly help. Have a look at David Nutt’s blog on drug policy in the UK. He will not get to set the political agenda, but he does try to put the case using facts, no matter how inconvenient they may be.

Anonymous journalism academic
I am concerned about whether journalists are able to investigate changes detrimental to public services in general and health services in particular So I’m wondering if a crowd-sourcing project could be launched inviting people to write in when they become aware of a government funded service closing down?

Elizabeth Harris, University NSW
The biggest challenge we face from both major parties is the increase in shifting services to the private sector with associated co-payments.

As Medicare becomes cashless and GPs may not bulk bill, many families will face real hardship in paying up front and not being able to get money back for several days.

The idea of contestability for Commonwealth services in areas such as home nursing will not only fragment services but take us back several decades.

A fundamental challenge is to retain a strong publicly funded public health system, this is crucial for any efforts to reduce health inequity.

Sue Page 
Remember that every organisation has a vested interest or they would have no purpose. Take all election statements with a grain of salt and if possible consider them in clusters with their commercial competitors (NGOs compete for grant funds and donations after all, otherwise the Sydney organisations wouldn’t fly people up to the north coast spruiking for donations outside rural shopping centers).

If in doubt, convene small focus groups. In an election year people will fall over themselves for your attention. Make separate meetings with consumer groups like NFF that run their own health portfolios. While industry specific you will soon find the common needs emerge.

Kim Webber 
The million dollar question – where are the independent voices without vested interests?  This should be the broader academic sector but that doesn’t seem to occur.

So I would recommend that they have a panel consisting of such status quo challengers such as Prof Peter Brooks, Prof John Dwyer, Prof Stephen Leeder (Gavin Mooney would have been on the list definitely too).  The people who are not afraid to advocate for the community.

I also wish the media would understand the bias of organisations.  The AMA is interested in public health but is also the union for doctors and that must inform their policy responses (and rightly so, that is their job), but many journalists ignore the bias of organisations and simply repeat the opinions of the professional organisations without considering WHY they are answering in that way – is it for the best interests of the community or the members (often not the same thing).

A backgrounder for the media (hosted by Croakey) and involving these honest brokers would be a good idea so that the commentators understand the issues?

Linda Shields 
Why not ask the consumer (I hate that word for health care but can’t think of a better one) organisations for their opinions on what the election should be focussing.

I can think of the ones about children – the Association for the Wellbeing of Children in Health Care, the various cystic fibrosis organisations – CF Australia, 65 Roses, the various cancer and mental health organisations etc. what about a forum (virtual??- blog??) run by the media to ask ordinary people what they want in their health care.

Also, why not ask those in academia who teach and research health care ethics, who can comment on the role of rationing – the fair use of finite health resources (I know one who you can ask).

Given the release of the Mid-Saffordshire report from the UK which was all about rationing gone wrong, this would be very relevant. In fact, the mid-Staffordshire report would make a very good platform from which journalists could derive a way to interrogate politicians about their health programmes.

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Q3. What about the role of the public service? The public service has largely disengaged from contributing to public debate (for eg James Button describes in his excellent book, Speechless, how senior public servants are now far less likely to provide background briefings to help a more informed media coverage, and Andrew Podger has also written about this). How might the public service and related agencies help contribute to a more informed debate?

Fiona Armstrong
By acting in accordance with their charter and not according to the political goals of the government? How to accomplish this? That’s no doubt harder and harder, but as with many things requires courageous and principled leadership.

Lea McInerney
Invite them to contribute background briefings just like in the old days. When I was a policy consultant in Dept of Health and Human Services, I’d regularly do briefings on current evidence for Ministers.

It was then up to the Ministers’ office staff to either shape the political argument around that evidence, or ignore it if it wasn’t in line with where they wanted to go. I wonder if there might be some public servants who’d be willing to participate in something like this. More enlightened Ministers – from Commonwealth and State governments – might be interested in giving it a go.

Maybe academics who write for The Conversation could “adopt” a few policy officers and healthcare practitioners, interview them on their specialist topic either singly or in discussion and write it up and publish on either The Conversation or Croakey. Would also be interesting to look at the gaps between evidence and practice by having policy officers and healthcare professionals in conversation together.

Amanda Lee
Difficult to see how in the current system where they are often perceived by Ministers/Governments to be political servants rather than providers of frank and fearless advice!

Daryl Sadgrove, Australasian College of Health Service Management
Our organization provides a platform for some of them to have a voice. However I absolutely agree we need many others.

Ian McAuley 
Before the politicians start putting out their platforms, DOHA should write a policy options discussion paper – canvassing all realistic options for funding and provision – with funding options ranging from completely free tax-funded health care through to high levels of compulsory and uninsurable co-payments. No need for detailed costings at this stage – just pros and cons.

I suspect that such a proposal put to DOHA would be considered as madness, but that simply reflects the extent to which the public service has changed over the years.

It’s not just about politicization, although there has been an informal and formal drift of the public service towards “responsiveness” to executive government over the last 15 years. It’s also about the incapacity of staff in that department to detach themselves from their established assumptions – change must be incremental rather than root and branch, all provider lobbies must be appeased, budgetary costs are the only costs that matter.

Tim Senior, GP in Aboriginal health
I don’t know much about how the public service works – I think there would be room for opening the lid on how the public service contribute to policy. I suspect this will depend on relationships already present between journalists and public servants, but I think it is likely that a febrile election atmosphere will make it hard for public servants to comment without their remarks being taken by either side as a criticism of the other side.

Andrew McAuliffe, AHHA
Hmmmm.  Anonymity?

Jane Burns
Critical contribution – calling organisation like ABS, AIHW to provide policy information – this needs to be simplified and chunk size for people to understand the ramifications. That said the policy debate around critical issues like disability and mental health is complex and difficult to make sense of so we need to look to agencies to work and be more closely aligned with media to ensure a story is told that the voting public can understand

Daniel Reeders
Under ‘related agencies’ we could add any service that depends on public funding. Speaking up about an issue in an election, even on background, is ‘brave’.  I don’t see the reluctance to comment shifting unless it is explicitly authorised by the government of the day.

I would like to see a policy equivalent of the Charter of Budget Honesty (here’s an example from Canada) – perhaps overseen by the Parliamentary Library staff, who already do some sterling work informing the public on politically controversial issues.

It would be fascinating to see something like a Health Policy Ombudsman authorised to give similar answers to political claims-making.

Dr Rod MacQueen, addiction medicine physician
It would be great to see the public service get some teeth back – but who will make it happen? I frequently see middle managers and even ordinary workers self censoring and trying to second guess what the next up the line wants to hear. This ensures that even if a minister or adviser wanted to make a difference and wanted to look at the data, they would be so surrounded by predigested, pre interpreted factoids that they may not be able to discern fact from fiction anyway.

The way that concerned managers help the debate today is probably by leaking information and reports, which is fraught with danger (and how tragic to say this of a modern, democratic country!).

Perhaps public servants need to call their managers’ bluff when they are told they cannot talk to this person or issue that press release, and ask what will happen. But there are enough examples of what does happen to quite rightly make people pretty wary.

Maybe a Ghandi like act of mass civil disobedience is the only way to get the ball rolling? Whatever happened to the great Australian bullshit detector? Maybe the arguments and issues today are too complex or subtle for many people to follow, but I think there is something else going on, a willingness to be deceived along with an anxiety about standing up and saying “this is nonsense”.

Sue Page
Nobody speaks “the truth, the whole truth, and nothing but the truth”. That’s why we make them swear that they will for a specific occasion like in court. Be more forgiving of small errors, don’t make people look like idiots and they will  be more willing to talk to you. You are seeking information and ideas, you are a communication industry.

Kim Webber
Not possible in the current culture of politicisation of the independence of the public service.

Lesley Barclay
Great idea but perhaps too aspirational – enter into debate with people like me that is reported and led by journalists that is designed to produce informed debate and move towards solutions – yes – probably has to occur with politicians and parties but would be great if they participated

Linda Shields
Queensland Health employees who broach the code of conduct which proscribes any discussion or debate about anything that is going on in Q Health are in danger of losing their jobs (or redundancy packages at present). You should ask Beth Mohle from Queensland Nurses’ Union to comment on this. It is alive and well at present!

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Q4. What are the broad criteria by which the political parties’ policies should be judged for their impact upon health? And for their health policies?

Fiona Armstrong  
Whether they are developed in line with the principles of:
Equity
Effectiveness
Socially just
Improved access to multidisciplinary primary health care
Consistent with health needs of the community (ie vary according to specific communities)
Citizen engagement

Whether they will reduce demand on health service because they will reduce the development and progression of illnesses; will they protect and promote health by responding effectively to major health threats eg climate change; will they improve health system performance + health workforce shortages + health workforce morale + health system sustainability + health budget pressures?

Lea McInerney
Something about the parties wising up to and taking on big interests (like Roxon did with big tobacco, and like could be done more with the big food and drink companies, pharmas etc). Stop prevaricating on policies where the evidence is clear and where the main obstacle is companies defending their profits at the cost of the wellbeing of many citizens. (I fear this sounds idealistic – it shouldn’t be that way.)

Maybe there should be lobbying to all three parties to commit to allocating some proportion of funding to social determinants and social inclusion efforts. Could aim for a certain percentage.

Judge according to the principles underlying each party’s policies that align with social determinants of health. And more radically, in the spirit of the Act of Recognition, and the bipartisanship from the Government and Opposition, what about using the Aboriginal definition of health as per Tim Senior’s article on Croakey:

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

Amanda Lee
Focus on health issues which are:
prevalent at population level; are equitable; evidence-informed; cost-effective- ie willing to work though policy and regulation to improve physical and social environments which  make it easier for all Australians to be healthy.

Daryl Sadgrove 
Long term view, improving productivity, creating efficiencies, reducing waste, reforming the workforce, shifting to prevention/community care, investing in mental health and aged care, less things that ping, better and fairer access, more culturally appropriate care for ATSI’s, less focus on EDs, bigger investment on management, leadership and governance.

Ian McAuley
Economic efficiency, technical efficiency, equity, administrative simplicity, closing of opportunities for rent-seekers.

Tim Senior
The most important thing for me will be about how policies affect those most vulnerable in society. What will address health inequalities, and how will this be done.

Andrew McAuliffe, AHHA
Difficult to evaluate when there is little available to assess.  Coalition’s agenda is elusive.
Is there any evidence of considering health in policies outside the health portfolio?
Any evidence of a systems approach to deal with the social determinants of health rather than just how many more doctors and nurses and hospital beds they will buy

Jane Burns
This is a book – improved health outcomes as evidenced by national stats – I.e. Suicide rates, depression rates, drug and alcohol etc, quality of life across populations, disparities in health care – I.e. Homeless, indigenous, people living with a disability, carers, unemployed, young people

Daniel Reeders
I know this is desperately old fashioned and idealist, but justice-as-fairness is my go-to yardstick every time.  It’s hard to judge the likely future impact of a promise.  It’s valid to ask ‘who is this going to benefit?’

All that middle-class welfare spending in the late Nineties and early Noughties, on that view, was pretty obviously about buying votes in key constituencies and did nothing for the most disadvantaged.

At the same time, I’ve been reading Jonathan Haidt’s new book on political morality, The Righteous Mind, and he points to a fairly big difference between liberals and conservatives on how they view ‘fairness’.

So we’re not just judging policies in terms of their impact, we’re also having the conversation about what kind of impact matters — be it ‘a fair go for people doing it tough’, or ‘you contribute more, so policy should reflect your needs’.

Both Rawls and Marmot have attempted to come up with principles that bridge these two versions of fairness. Rawls’ “Difference Principle” allows inequalities to the extent they benefit the worst-off first — a ‘trickle-up’ diffusion of advantage.

The Marmot review has its ‘proportionate universalism’, where everyone gets something, but in proportion to the intensity of their disadvantage.

Dr Rod MacQueen, addiction medicine physician
Consistency with the principles that are agreed to underpin a good health system, as above. At the moment, we often seem to be in an ethics free, principles free state, wary of or afraid to talk about the social determinants of health and the problems with the consumer sovereignty approach (with its inevitable flip side, anything that goes wrong is all your own fault) for example.

We must look at outcomes, and bang for the buck. Politicians seem to like to talk dollars, and be photographed in front of buildings, helicopters, and other toys. But an effective health system is a good deal less concrete than that, and there remains this troublesome concept of efficient use of resources. Should our hospital system be doing more laparoscopic banding for all overweight people, at a cost of billions, or supporting a good public health approach that may have to take on entrenched interests but achieve much more health gain for far less dollars?

In my field, should we send a drug user to jail, for $85 000 a year, so he can get hepatitis C and lose his job and social connections, or treat the drug issue clinically for perhaps $8 000 a year and keep him in a job paying tax? For some, I think there is no contest –  jails are big solid things with lots of photo opportunities and walls for plaques, and they look like our government is being tough.

Sadly they are just a hole into which money is poured when it comes to addressing drug use problems, and taxpayers should be asking why our state keeps on with this inefficient approach. What is the return on investment, the bang for the buck?  In the end, we need to look at outcomes, not just the money spent, especially when many preventive interventions are much better value for money that what we currently do.

Elizabeth Harris
Indicators:

• level of commitment Medicare/PBS
• commitment to growth of private/public partnerships or not without affordability considered
• extent of contestability of service funding without consideration of impact on fragmentation of health system
• commitment for policies to undergo health impact assessment.

Sue Page
Did you talk about your ideas? It is unlikely that your party has the monopoly on health smarts and holding things too tight until they are announced means you miss out on constructive feedback. Yes organisations are self-interested, but clinicians do know their stuff which is why our healthcare is better and cheaper than most other countries. Ask! And please resist the urge to fund more research until we have implemented some of what we already have: yet another multi-million-dollar NHMRC grant to a University for an Aboriginal smoking cessation project won’t help as much as putting a smoking-focussed AHW into each AMS for instance.

Kim Webber
We all know that we need to address health expenditure by investing immediately in primary health care and reducing hospitalisations in the medium term.  How will they manage the parties manage this when there is such a knee jerk reaction from the media when even one hospital bed closes?  Are they thinking about the long term?

Lesley Barclay
Equitable services and outcomes for all Australians
Systems improvement which we have begun to see over this triennium eg our ML for example and ABF; reform of areas that do not work; better shared goals objectives and collaborations between states and commonwealth; really working with the Maternity services action plan- need it in other areas such as Aboriginal health, rural and remote health

Linda Shields
How do they believe fair distribution of finite health dollars should occur? How do they work out who misses out? What is fair to ask people to pay for?  What sort of commitment do they make to the philosophy of a safety net? Should Australia go to a) an American model – if you can’t pay for it, you can’t have it, or b) the UK model – everyone has a right to highly technological, effective heath care which is free at point of delivery? While this would go down party lines, it would be an indicator of where the pollie sits on health distribution.

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Q5. I am keen to run some series at Croakey in the run up to the election, broadly grouped around particular themes. Do you have any suggestions for what these series could cover?  

Fiona Armstrong 
How will the govt/opp/other parties act to protect health from climate change? Meet its commitment to the international community to protect and promote global health?

Amanda Lee
A series on prevention would be great.

Daryl Sadgrove 
I will just suggest one (with a vested interest), leadership and management for improvement

Ian McAuley
Principles.
If there are themes such as mental health, there should be some consideration of the structural issues referred to in (2). In fact, structure itself may be a useful theme.

Tim Senior
Obviously, I’d say Aboriginal and Torres Strait Islander Health, but I’d also add health inequalities and climate and health. I don’t think they’ll get coverage anywhere else.

Andrew McAuliffe, AHHA
Response to Social Determinants of Health – trigger could be the report from Senate committee due in March?

Oral Health – will a Coalition Govt wind back the legislation introducing dental services for children into Medicare as on 1 Jan 2014

Primary Health – Opposition plans for Medicare Local structure/ approach.

Dr Rod MacQueen, addiction medicine physician
Well, I would have to suggest drug law reform, wouldn’t I! Some of David Nutt’s blogs are very relevant to our Australian situation, I think, plus we have the Australia21 team and many others. Let’s not, please, have another lawn order race to the bottom.

Kim Webber
What is important to consumers (Consumers Health Forum could help here)
Is the community health literate enough about the health system to engage in the debate fully (I think not, most people do not understand the dire future of our health system under the current model and how it will gobble up all of the budgets soon).
Hospitals in the future – what will they look like and how will they operate?

Linda Shields
How a highly educated, satisfied (with their working conditions and place) nursing workforce has been demonstrated in very large epidemiological studies to reduce the number of patient deaths, near-misses and critical incidents in health services. Lots of very good evidence around this.

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Q6. Do you know of any useful examples from around the world, re innovative, community-focused election coverage of health?

Ian McAuley
Perhaps we can draw on Australian models of successful change in other policy arenas – White Australia to multiculturalism, protection to free trade. We may be able to learn from these successes.  One point is that they didn’t occur over seven months.

Tim Senior
The only ones I’ve come across are websites like “They Work for You” in the UK, which reports on speeches, attendance and votes by MPs (and I think there is a similar site in the UK. There have also been sites that allow users to upload examples of local election leaflets that may be misleading or breach electoral regulations. This could be adapted to have local health issues highlighted – much of this will be about hospitals staying open, I suspect, but there may be more happening that we discover if we go looking.

Jane Burns
I can’t remember if it provided examples of innovation or community focused election coverage but Haynes Johnson’s book, The System, was probably the most insightful piece of journalism I’ve seen relating to health policy and the power (and undoing) of community driven reform – it clearly capture the power brokers, that a good idea is often not good enough and the politics that come to play when pushing for system reform

Dr Rod MacQueen, addiction medicine physician
I wish I did. How did Portugal ever get drug decriminalisation up and going, or conservative old Switzerland get injecting rooms AND a heroin program.

We think we are a pretty liberal, “fair go”, with it mob here in Australia, but in the last 10-20 years or so we have become intensely punitive and reactionary across many domains.

How did we get to the factories producing mental illness scenario we have with refugees today, for example? I hope there are some good examples to share though – I believe the internet can and should be a great tool to promote transparency and the sharing of good information – and helping people to discern what is reliable and what is not.

Here is the latest compilation, covering articles posted between 11 April and 3 September. As always, thanks are due to the many contributors who generously volunteer their time to research and write articles.

The latest readership figures are available here, showing that Croakey has had 95,554 unique visitors so far this year. You can also see snapshots showing the ten links that received the most hits, over this period and over the previous three months (the Naked Doctor column by Justin Coleman has drawn a lot of attention).

The links below have been grouped into these categories:

• Racism and health
• Indigenous health
• The unhealthy trifecta: tobacco, alcohol and pokies
• General public health matters
• Rural and remote health
• Mental health
• Journal watch (public health highlights)
• Social determinants of health
• Primary health care and Medicare Locals
• Health reform and health policy
• Aged care reform
• Dental reform
• Social media and media-related issues
• Pharma

 ***

Racism and health

Shame on Facebook, but let’s not forget that racism is a wider public health problem
Tim Senior

One more reason to stop discussing health as a “lifestyle issue” (racism)
Jerril Rechter

***

Indigenous health

Is the media juggernaut sidelining good policy in Indigenous affairs?
Tim Senior

Indigenous health professionals working in the alcohol and drug field deserve better
Kate Conigrave

For your viewing pleasure: hip hop meets Indigenous health

From Songlines to Twitter: communicating and connecting for Aboriginal health
Justin Mohamed

Why do I work in Aboriginal health? (And more news from the world of social media and health)
Tim Senior

***

The unhealthy trifecta: Tobacco, alcohol, and the pokies

A wrap of reaction to the High Court decision on plain packaging

What have the tobacco and pharma industries got in common?
Marita Hefler

Medicines Australia: we support plain packaging of tobacco products

Will social change help reduce smoking rates amongst disadvantaged Australians?
Billie Bonevski and Amanda Baker

The corporate interests that harm health: from the Olympics to closer to home
David Thomas

Support Big Tobacco (it’s fun)

Anti-smoking campaigns should focus on how big companies are using young people
Rick Turner

Naming and shaming irresponsible alcohol advertisers
Rebecca Johnson

A 7-point plan for tackling the grog toll; a memo for the NSW Premier; and the shop keeper who has taken a stand
Anthony Shakeshaft

Can bloggers help to change our drinking culture? Is alcohol your best friend? And a few other questions still to be answered…
Margo Saunders

To tackle our drinking problem, look to Newcastle – and closer to home too
Laurence Alvis

The new Clubs Australia campaign borrows heavily from tobacco industry strategies
Charles Livingstone

The unhealthy trifecta: tobacco, alcohol and gambling industries
Charles Livingstone

***

General public health

ACT prisons announcement hailed as an “historic” decision for public health and human rights
Michael Moore

Public health is in the firing line in Queensland

A mega-wrap of recent news on climate change and health

On carbon tax eve, how is the health system placed?
Prue Power

Leaked letter reveals pressure on NHMRC from the anti wind farm brigade
Simon Chapman

Why is it so hard to be a public health hero in Australia? (And more reading on “Nanny Bloomberg”)
Margo Saunders

If New York City and Mayor Bloomberg are the trend-setters for public health in the US, where are their equivalents in Australia? Any suggestions?

Using the law to create healthier environments: recent developments from NYC to Victoria
Jane Martin

A local council takes on fast food: is this the future for improving public health?
Jane Martin

Why health claims may not be good for your health
Rosemary Stanton, Jane Martin

Call for crackdown on “bargain” deals for solarium visits
Jen Makin

Standing up for the sake of employees’ health. Literally.
Todd Harper

How best to improve management of childhood obesity and related health problems?
Amanda Carne

Does the ‘fat tax’ measure up?
Suzie Ferrie

For those interested in research dissemination, knowledge translation and giving better presentations…

Marking International Chagas Day and creating some noise about a silent disease
Unni Karunakara

***

Rural and remote health

Some solutions to health workforce shortages
Richard Murray

Remote health conference calls for regulatory action on quad bike safety

A red letter day for rural and remote health – provided these questions can be answered
Gordon Gregory

Why health promotion campaigns in rural and remote areas must be “fit for purpose”
NRHA

Sustaining small rural primary health care services
Olga Anikeeva

Pros and cons of telehealth for people in rural areas
Rachel Katterl

***

Mental health

What does it take to improve mental health? Some insights from three voices of experience
Trevor Hazell, Ian Fels, Jack Heath

Over the past 17 years, what has changed for people with mental illness?
Q and A with Barbara Hocking

Some recent reports on preventing suicide, and providing better support to the bereaved
Jaelea Skehan

To improve men’s mental health, focus on education, employment and providing services that men want to use
Sebastian Rosenberg

An important policy gap: mental health in early childhood

***

Journal Watch

A call for more research and planning to deal with the public health challenges of mega-events
Melissa Stoneham

Environmental factors that promote cycling
Melissa Stoneham

A focus on the corporate practices that contribute to poor health
Melissa Stoneham

A wrap of recent news on McDonald’s, marketing and health (and some parallel universes)
Melissa Stoneham

***

Social determinants of health

Will the Senate inquiry lead to action on the social determinants of health?
Fran Baum

What are the signs of a healthy #goodsociety?
John Falzon

What have the Olympics got to say about social justice and health inequalities?
Marie McInerney

Health experts support calls for increase to unemployment benefits
Andrew Podger, Vern Hughes, Gawaine Powell Davies, Mary Chiarella, Hal Kendig, Tim Woodruff, Justine Caines

Where is the health sector when it comes to addressing poverty?
Tessa Boyd-Caine

What are the health implications of building more prisons?
Jonathan Heller

When will policy catch up with the science on drug prohibition?
Alex Wodak

In case you missed this series on the need for drug law reform
Andrew Jakubowicz, Alex Wodak, Monica Barratt, Alison Ritter, Mike Pottenger, Alex Steel, Justin Norrie

New book investigates the links between power and health
Luke Slawomirski

Reporting on a recent forum on health inequalities and the social determinants of health
Deborah Lupton

Pressure mounting for action on health inequities
Rebecca de Boer

A new report highlights the cost of health inequalities: but what’s the real story?
Gavin Mooney

Is the post-budget “class warfare” discussion helpful for public health?
Gavin Mooney

Do doctors treat their better off patients differently? Plus a wrap of Australian and global news on health inequalities
Mae Hurley

Raising awareness of the health needs of homeless people
Debra Cerasa

Some news for those with an interest in the arts and health
Gordon Gregory

Breaking down the digital divide: two case studies
Mark Egan

The digital divide and its implications for health, services and conferences. And a prediction for the future…
Caroline Chen

What does the NSW review of health and medical research say about a critical health concern?
Sally Redman

***

Primary health care and Medicare Locals

 Some reports from a recent primary health care conference – and who is standing for the Australian Medicare Local Alliance board

A critical challenge for health reformers: how to hear from those with the greatest need?
Vahid Saberi and Lesley Barclay

The great adventure story of Medicare Locals: will it have a happy ending?
Jennifer Doggett

Memo to Peter Dutton and others who don’t “get” Medicare Locals: this is what they’re doing and where they’re heading
Vahid Saberi, Tony Lembke

Federal Opposition rebuked over plans to abolish Medicare Locals
Jon Wardle

Peter Dutton urged not to “turn back the clock” on primary health care reform
Mark Harris, Daryl Sadgrove, Australian Medicare Local Alliance, Carol Bennett, Prue Power, Vern Hughes, Gavin Mooney, David Briggs, Marilyn Wise, Rosemary Stanton, John Dwyer, Gawaine Powell Davies.

Learning from the “pioneers of ehealth” in general practice
Samantha Smorgon and colleagues

Ehealth records: too important to muck up
Robert Pask

Sounding the alarm over cutbacks to Qld organisation for lesbian, gay, bisexual and transgender health
Daniel Reeders

Should your doctor be asking after your pet too?
Amanda Carne

Nurses add value to chronic disease management
Petra Bywood

For patients to play a more active role in managing chronic health conditions, some changes are needed
Olga Anikeeva

***

Health reform and health policy

Health Workforce Australia report gives the nod to physician assistants
Ben Stock

Tweet of the week…Stephen Duckett on health reform

A wrap of health policy reading
Jennifer Doggett

Engaging leadership – what does it mean for health reform in Australia?
Daryl Sadgrove

Some metaphors for the future of healthcare: from tsumamis and trains to frogs, bikes and jigsaw puzzles
Fiona Armstrong, Chris Rissel, Tony Webber, Andrew Roberts, Merrilyn Walton, Gab Kovacs, Jon Wardle, Ron Batagol, Hudson Birden, Vern Hughes, John Menadue, Peter Sainsbury,Ben Harris-Roxas, Alan Rosen, David Gillespie, Gawaine Powell Davies, Amanda Wilson, Kishan Kariippanon, Ian Cameron, Ian Hickie, Wendy Oakes, Lesley Barclay, Yvonne Luxford, David Briggs Rob Loblay, Gavin Mooney, Ken Hillman, Gawaine Powell Davies, Stephen Leeder, Ken MacWilliams, Ed Butler, Simon Chapman

A leader’s reflection on health reform: the merits of “muddling through” and more
Stephen Leeder

Out-of-pocket health costs: adding to the burden on patients
Kellie Bisset

What can we learn from the history of health reform in the UK? (part 1)
Terrie Paul

What can we learn from healthcare reform in the UK? (part 2)
Terrie Paul

Tasmania’s healthcare system: it needs more than money
Rebecca de Boer

The Tasmanian health rescue: don’t break out the champagne just yet
Martyn Goddard

The financial crunch and its impact on health – globally, nationally and locally (with particular reference to Tasmania)
Martyn Goddard

What is the evidence on knowledge translation strategies?
Christina Hagger

Some useful tips for finding health policy information on the web
Christina Hagger

Informed consent: it’s not a reality for too many patients
Carol Bennett

Have we reached a critical tipping point with healthcare?
Alan Cassels

Overuse of healthcare: some suggestions for how to tackle it
Tim Woodruff

Are Australian women’s birthing rights now perched on a slippery slope?
Hannah Dahlen

*** 

Aged care reform

Aged care reform: it needs careful monitoring (and adjustment, where necessary)
Rebecca de Boer

Aged care reforms an important step in the right direction, but many questions and concerns remain
Hal Kendig

An indepth analysis of aged care reforms, covering community care, rural/regional concerns and more
Rebecca de Boer

***

Dental reform

Wrapping the news on dental reform into a rather pretty image

On dental reform: there is plenty more to do
Jennifer Doggett, Alexis Zander

 http://blogs.crikey.com.au/croakey/2012/08/30/on-dental-reform-there-is-plenty-more-to-do/
A cautious welcome for dental reforms, but concerns remain about underlying systemic problems with health “system”

A wrap on the dental health reform package – an overview, analysis & some reaction

Should dental reform aim to benefit dentists – or the community?
Tim Woodruff

Better oral health for all: what will it take?
Lexia Smallwood and Gordon Gregory

Why has dental health been getting the brush off?
Gordon Gregory, Tessa Boyd-Caine

Dental reform: a work in progress
Amanda Biggs

Lack of access to dental care is putting children in hospital and entrenching disadvantage
Johanna de Wever

 ***

Social media and media-related issues

An idea for harnessing the expertise of departing journalists – and providing a powerful health service to local communities

Could this be the beginning of a new online publication covering climate change and health? (And would you like to help kickstart it?)
Help create an online publication covering climate change and health
Introducing a wealth of ideas for new online health-related publications
Any ideas for a new online publication covering a health-related area of need?

AMA says “uninformed” attacks on Tim Flannery are a “disgrace”
Steve Hambleton

The media & healthcare industries: some challenges and opportunities from the digital revolution

Never mind the barriers to the health sector’s uptake of social media – here are some useful resources and examples
David Corbet

How Ramsay Health Care is embracing digital transformation
Damon Klotz

Is this a digital media innovation? Or a health innovation? Or something in between?

What has social media got to do with blood transfusions, haematology and the like?
Carolyn Der Vartanian

What does social media mean for health and medical education?
Mavis Duncanson and Dr Zelda Doyle

What can bloggers do for public health and the greater good?
Cairín Conway

Will social media prove useful in efforts to tackle antibiotic resistance?
Lynn Weekes

Join a Twitter chat about involving children and parents in research and service development
Eva Alisic

Know of any public health courses focused on new media?
Becky Freeman

Why aren’t more academics making their own apps and getting digitally savvy?
Deborah Lupton

What does it take to get our media to cover health issues affecting low and middle income countries?
Michelle Imison

Should this headline about the swine flu pandemic be really alarming or just a bit worrying?
Julie Leask

Efforts to minimise harm from media reporting of Breivik trial may have wider application
Marie McInerney

Profiling a new media outfit that focuses on ehealth
Mark Jones

Wraps of reading from The Conversation: July, August

What’s on the menu for Queensland’s new Health Media Club? Some Ministerial grilling, perhaps
Jane Milburn

A proposal for some online sharing to help people with disabilities
Niki Ellis

Some developments and opportunities in health and the media

***

Pharma

Consumer group raises concerns about pain medicines – and the company responds
Carol Bennett

For more information on GlaxoSmithKline and the biggest healthcare fraud settlement in US history

A multi-national MasterChef for Medicines?
Gavin Mooney

Advertising a prescription medicine to the general public: what’s going on?

**

Wrap of Federal Budget coverage

Health and the Federal Budget: a wrap of links, news and reaction

Let’s “streamline” some of the Budget’s Weasel words

The budget failed to address health risks from climate change
Fiona Armstrong

Budget cuts to foreign aid: what will they mean for global health?
Joel Negin

Mental health and the federal budget
Sebastian Rosenberg, Pat McGorry

At last, a REAL cancer breakthrough (and why some politicians deserve a cuddle)
Terry Slevin

The Federal Budget and health: what’s on the table (or not)
Sebastian Rosenberg

The second recommendation is: “Efforts should be made by all sectors of the community to support young men with mental illness to engage in more productive employment.”

And the third recommendation: “Efforts should be made by all sectors of the community to evaluate the effectiveness of current policy responses and investments in mental health.”

In the article below, mental health policy analyst Sebastian Rosenberg concludes that the mental health policy landscape looks “as piecemeal and chaotic as it has ever been”.

***

Counting the Cost of Mental Illness in Men

Sebastian Rosenberg writes:

This week the Inspire Foundation with Ernst and Young released a report Counting the Cost: The Impact of Young Men’s Mental Health on the Australian Economy (find it here).

The headlines are predictably grim:

• More than one in four young people report suffering depression (26.5%);
• Mental illness in young men (12-25yrs) is estimated to cost the Australian economy $3.27bn annually and account for 9 million lost work days;
• Young men with mental illness have much lower rates of educational attainment; and
• Mental illness in young men leads to lifelong disabilities and problems.

We already know thanks to the 2007 ABS Survey into Mental Health and Wellbeing that only 13% of young men received any care at all for their mental illness.

While the report focuses on young men, it brings to light the more general issue of how well Australia’s mental health system caters for all men.

Suicide now ranks as the leading cause of death for adult men up to the age of 44 years (ABS, Causes of Death, 2009). Men in Australia are four times more likely to die by suicide than women.

Perhaps the most recent high profile mental health initiative has been the introduction of the Better Access scheme, providing Medicare-subsidised mental health care plans and visits to psychologists.

The table below analyses the three most prolific of these MBS services over the first five years of the scheme by rate of access by gender.

According to the most recent Medicare data (April 2012), the Better Access scheme is now costing taxpayers more than $10m per week. The two-thirds/one-third split in favour of women over men in the scheme is further accentuated if you narrow the scope to services provided only to people aged between 15 and 34 years.

In a nutshell, in the crazed patchwork of services we call Australia’s mental health system, we have palpably failed to design services men want to come to, particularly young men.

As with so much in mental health, research into the reasons why they don’t come is not as robust as it should be. For people with a mental illness who did not use services, the 2007 ABS survey did ask some questions about what kind of assistance would be useful but the overwhelming response was that people did not want extra information, medication, counselling, social intervention or skills training.

For some men, the perception of mental health conditions such as depression and anxiety as weaknesses as opposed to illnesses can act as a barrier to seeking help. Men are also supposed to be self-reliant.  There is probably still a lack of information that treatment can be effective.

The clear issue is that there remains a critical lack of understanding about what an effective male mental health service looks like.  For young men in particular, research has indicated (Rickwood et al 2005) that outreach type services may be important – to make it as easy as possible for young men to access care by taking professional services to them.  This is in contrast to current service settings (such as in Better Access) which rely on the person coming to the provider.

There is a lot more we need to understand so that we can design mental health services attractive to men, especially young men.  The Federal Government’s commitment to replicate Professor Pat McGorry’s Orygen model nationally is noteworthy.

Whether this occurs with fidelity to the evidence-based service model deserves close scrutiny as these services start up.  It would also be timely to review the Government’s support for the Headspace program to ensure it is able to provide the kind of genuine, one-stop multidisciplinary service that was originally envisaged.

Against this backdrop is the most recent health budget which showed that Commonwealth outlays on health have now reached $61bn, or a 37% increase on 2007-08 levels.  Though last year’s funding for mental health was welcome, this year there is practically nothing.   Meanwhile the rate of increase to the overall health budget continues largely unabated.  Mental health’s share of the overall health budget is in decline.

More generally, the mental health policy landscape is quite confusing.  The Coalition’s recent commitment not to proceed with Medicare Locals if elected raises new questions about the future of community mental health care.

Over $1bn was promised in 2010 for sub-acute care, with some of that directed towards mental health.  How this has been spent is unclear.  Half a billion dollars was directed in the 2011  Budget by the Federal Government towards Partners in Recovery – a program apparently designed to provide individualised packages of care to people with severe mental illnesses but which has not yet started.

The Better Access scheme continues, including the Greens amendment which ensures ongoing access to care for people with severe and persistent mental illnesses who were never meant to use this program in the first place.

Activity Based Funding is due to be introduced to mental health from 1 July 2013, with some danger this will reinforce the hospital-centric nature of our mental health system.

A National Disability Insurance Scheme is underway promising to cover at least some people with a mental illness though definitions are still being determined.  CoAG has chosen not to continue its 2006-11 National Action Plan in mental health ($5.5bn) but has instead agreed to a much smaller partnership agreement ($200m over five years).

Across Australia’s nine jurisdictions, four have now chosen to establish mental health commissions (Federal Govt, NSW, WA and Qld) and each will have its own roadmap, strategic plan or blueprint.

The policy landscape looks as piecemeal and chaotic as it has ever been. It is not possible from this miasma to discern a model of care.  What is it exactly we expect a young man with depression to do?  Or a young woman with an eating disorder?

Inspire’s Counting the Cost report serves to remind us of the suffering such chaos generates.

• Sebastian Rosenberg is Senior Lecturer at the Brain and Mind Research Institute, University of Sydney

• This article was first published in the Crikey bulletin

***

• More reading on the report is at The Conversation

In this article, New York researchers give plenty of practical tips about how to find health policy evidence on the web, including “strategies and tips to reduce information overload and to access synthesized research for evidence-based health policy”.

The article is aimed at nurses and has a US focus, but will no doubt be of broader interest/use. (Only the abstract is freely available, if you’d like a copy of the full article, please leave your email details at the bottom of the post or email me direct.)

The importance of digging into the grey literature is highlighted in more detail below in the latest update from the Primary Health Care Research and Information Service (PHC RIS).

***

Uncovering the “grey literature” about health policy

Dr Christina Hagger writes:

The importance of evidence as one imperative in the dynamic process of effective policy making is increasingly acknowledged. There remain, however, some inconsistencies in the assessment of what types of knowledge are contained with that evidence.

Some audiences still tend to restrict their outlook to the ‘facts’ derived from research, yet there is increasing awareness of the additional value to be gained from other types of evidence, such as personal or tacit knowledge, practical wisdom and collective local experience.

A broader knowledge exchange agenda encourages the identification and utilisation of these very different types of evidence. The process values the ability of diverse stakeholders (practitioners, researchers, funders, consumers, policy makers) to create, manage and exchange relevant knowledge to influence the development of effective policy to improve health outcomes.

One key source of knowledge is the grey literature. This literature includes conference abstracts, theses, un-published research studies, reports from non-profit organisations and government as well as real time web updates.

Although the grey literature is essentially outside the reach of commercial channels, it may (though not always!) be just as critically reviewed as commercially published content. As with all evidence, critical appraisal is essential.

Nonetheless this vast and diverse field of literature complements and should be used in addition to published journal articles.

As Olsan and colleagues observe in their paper  on searching for health policy information, the most relevant literature to answer complex questions may at times exist primarily within the grey literature. Searching the grey literature also offers the potential to balance any tendencies for publication bias, (ie an increased likelihood of reporting positive or significant results), in the published literature.

However, given its nature, the grey literature tends not to be systematically indexed in electronic databases.

Accordingly, in addition to tips for searching research databases such as PubMed, Cochrane Library and CINAHL, the authors provide hints and guidelines for searching the grey literature. These include key strategies to refine the search process and a selection of more advanced search techniques.

Despite its American focus, this article gives some clear advice on the importance of staying well informed about key policy issues and some guidance on how to effectively navigate both research databases and the grey literature.

• Dr Christina Hagger is Research Fellow, Primary Health Care Research & Information Service (PHC RIS)

 ***

Olsan TH, Bianchi C, White P, Glessner T & Mapstone PL, 2011, Finding electronic information of health policy advocacy: a guide to improving search results, Journal of the American Academy of Nurse Practitioners, 23, p. 648-658.

This article, which can be accessed at http://www.ncbi.nlm.nih.gov/pubmed/22145655, features in the 26 April 2012 edition of PHC RIS eBulletin, available at http://www.phcris.org.au/publications/ebulletin/index.php. The eBulletin is designed to inform readers of recently published articles and reports, news items, media releases, upcoming conferences and courses, research grants, scholarships and fellowships, PHC RIS products and services and relevant websites in the primary health care field. Those interested in receiving the weekly eBulletin are invited to subscribe to the free service at http://www.phcris.org.au/mailinglists/index.php

*** 

Previous PHC RIS columns at Croakey 

• Pros and cons of telehealth for people in rural areas

• What helps GPs provide better mental healthcare (and what doesn’t)

• Improving collaboration in diabetes care

• Improving dementia management in general practice

• Pets and what they do for our health

• Improving the diagnosis of ovarian cancer

• Chronic health problems and depression

• Helping older patients with chronic diseases to navigate the health system

• Tackling overuse of antibiotics

• When doctors prescribe exercise, does it make any difference?

• Caring for country is also good for Aboriginal people

• The perils of surrogate markers

• Are Australians willing to pay more for better oral health?

• What helps encourage self-care for those with chronic illness?

• More effort needed to strengthen shared care for people with serious mental illness

***

PS from Croakey:

The Croakey Register of Unreleased Documents (CRUD) is in sore need of an update. I would love to hear from any suitably qualified and motivated people who might be willing to help with this….

More recently, The Power Index (a sister publication of Crikey) ran an article querying whether it was appropriate for Mary Foley, director-general of the NSW Health Ministry, to call herself “Doctor” after being awarded an Honorary Doctor of Letters by the University of Western Sydney.

In the article below, Dr Enrico Brik, the pseudonym of a self-employed consultant and sometime writer and blogger who has worked for over a decade in various roles in health services policy and planning, reflects upon some of the history surrounding the use of the term “doctor”.

And in a spot of impeccable timing, The Power Index has just published a profile of AMA president, Dr Steve Hambleton, which includes this memorable line: “What’s good for doctors is actually good for health care.”

***

Kylie, Mary and Me: Among the Deserving Many

“It is better to deserve honours and not have them than to have them and not deserve them.” Mark Twain

Enrico Brik writes:

Obviously Mr Twain did not work in the health system; an industry most Croakey readers will know is replete with honours and the honoured, merited or otherwise.

Indeed I find myself writing having recently returned from Boggabri – one of the lesser known gems of inland northern NSW – as the proud recipient of an honorary doctorate in Health Politics. The polyester bonnet now hangs in my office next to the plastic stethoscope given me by grateful staff to mark my departure from a senior health consulting role in NSW in 2009.

But why Boggabri, you ask? Because, interested reader, this little town hosts the southern hemisphere’s sole outreach campus for that citadel of Slovak tertiary education and research – the Scientific University of Bratislava. Like the universe, globalisation may be bounded, but it is infinite in its reach.

Having a few hours to mull over the import of this elevation while wheeling my azure 1987 Maserati Biturbo back home down the New England Highway, my mind turned to those other worthies I know of connected in some way to the health system who have been similarly honoured for their selfless dedication and years of quiet achievement. And to why there appear to be so many people in health in particular with doctorates or the like.

Much of this can of course be attributed to the title, Doctor: it holds a long-esteemed place in the western (and not only western) socio-cultural landscape. Those with a penchant for etymology will know that the term can be traced back to the middle English of about 1300, when the noun meant ‘church father’, coming from the old French, doctour, and before that from the medieval Latin, doctor, meaning ‘religious teacher, advisor, scholar’. That use came in turn from the classical Latin verb, docere, meaning ‘to show, teach’ and, originally, ‘make to appear right’.

Later in the 14th century the term acquired the meaning, ‘holder of the highest degree in (a) university’, the sense in which we are interested today. About the same time, it also began to be used as a title for medical professionals; eventually deposing in the late 16th century the previous epithet, leech. I wonder why such a change occurred? Along the way, the verb ‘to doctor’ acquired in the early 18th century the meaning ‘to treat medically’, and from the late 18th century the sense of ‘to alter, disguise, falsify’.

So there we have a potted history of the term, doctor. But what has this to do with Kylie, Mary and me?

Well, many of you would have been overjoyed, as I was, to hear in October 2011 of the award made to the then Ms Kylie Minogue of an honorary Doctor of Health Sciences by Anglia Ruskin University in Chelmsford, Essex (in southern England), for her work in raising awareness of breast cancer – a hitherto little-understood condition experienced by thirty-something pop singers and other female celebrities.

The singer, who was diagnosed with the disease in 2005, underwent chemotherapy and surgery before resuming the career that has made her a star in Britain, Australia and elsewhere. The university noted that her well-publicised diagnosis has been credited with encouraging young women to undergo breast screening: the so-called ‘Kylie Effect’. So, she received her honorary doctorate for being famous, ill and prepared to self-publicise in the interests of others.

By contrast, Mary Foley is one of the nation’s pre-eminent professionals with a distinguished career in Australian health care in both the public and private sectors. She is now the Director-General of the NSW Ministry of Health. Immediately before taking up that appointment, she was the National Health Practice Leader for Pricewaterhouse Coopers. She is I understand also the longest serving member of the Board of Trustees of the University of Western Sydney (UWS).

UWS tells us that the then Ms Foley was the Telstra Business Woman of the Year in 1998 and received a Centenary Medal in 2003 for service to Australian society in business leadership. She has also served as director on a number of prestigious boards, including the Garvan Institute of Medical Research, the Victor Chang Cardiac Research Institute, and the St Vincent’s Research and Biotechnology Precinct. She was awarded an Honorary Doctorate of Letters honoris causa by UWS in 2010.

Thus, each of us is now a proper doctor – that is, have had conferred upon us an (admittedly honorary) doctorate. We are not to be confused with one of those doctor doctors, who hold just a couple of bachelor degrees (typically MB,BS – no better really than BA,LLB; or BEc,BBus; or BSc,BEng). While I do not know if the popette is yet referring to herself as Dr Minogue, I have been aware for a while that Dr Foley has decided, as I have, to embrace the title (no matter how modest she may otherwise be).

Imagine then my consternation when I found out only a day or so ago that a certain Matthew Knott, writing in some scarcely-known web journal called The Power Index*, had produced a piece in October 2011 chiding the aforementioned Dr Foley for employing the honorific as her preferred title.

Really! Doesn’t he understand how important it is to be able to face the doctor doctors on equal terms?

Mr Knott – who evidently grasps little of the highly competitive, status-driven environment and the atmosphere of pomposity that pervades the health landscape – quotes the churlish views of an anonymous informant that there is ‘increasing discomfort among senior clinicians and public servants about her use of the honorific’. Well, Mary, I can tell you we policy consultants are absolutely fine about it. Especially those of us who hold honorary doctorates from obscure Eastern European universities.

The petulant health system gossip adds that ‘there is also a view that Foley’s ego trip could lead people to wrongly assume that the country’s biggest public health service actually has a qualified medical practitioner at the helm’.

Hell no! NSW couldn’t be that silly, could it?

Well, no and yes. Dr Foley isn’t a medical practitioner (thankfully); but she has been mistaken for one – by her own organisation, no less, which continues to cite her thus in the list of members of the NSW Mental Health Taskforce. (Indeed, here is a link.)

But, apart from this bureaucratic misstep, how could Dr Foley’s use of the title be possibly considered an ego trip, when it clearly reveals a deep insecurity about one’s status and doubts about one’s intellectual credentials. Oh. Hold on…

Look, OK. There could be something in that. But be fair. We in the health industry have to put up with some people who don’t have just one actual, wrote-the-thesis-and-got-the-hat doctorate, but occasionally two or more. And a few of them are even medical practitioners as well! While one real PhD is meritorious, having two doctorates is a bit obsessive; and three is just plain showing off.

Little wonder Mary and I (and maybe Kylie, too) are determined to use the honorific, Doctor.

At least we are in good company. Just look at all those clinicians with a couple of bachelor degrees who are doctors qua medical practitioners, but insist on the title ‘Doctor’. And, infamously, these days not only medical practitioners, but also vets, dentists, and even osteopaths (quelle horreur!) call themselves ‘Doctor’. Where will it end? Podiatrists? Speech pathologists? Surely not nurses…!?

There are very few professions these days whose name also confers a title. Once, in medieval England, a commonplace – Farmer Smith, Goodwife Jones – it is a quirk now limited principally to the military and the church. We do not, for example, call solicitors, Lawyer Pellegrini. Nor do we abbreviate an architect’s title as At Seidler. Yet doctors are called ‘Doctor’ as captains are called ‘Captain’. (Interestingly, however, the obverse is not the case: Holders of a doctorate are given the title ‘Doctor’ even though they usually are not, and are not called, doctors as a professional description.)

So, being a doctor (qua medical practitioner) does not itself entail or justify use of the title ‘Doctor’: that use is an honorific. And, as noted above, it is an honorific no more merited than the use of the same honorific when one has received (only) an honorary doctorate.  With such abundant and deserving company, Mary and I should be feeling much more comfortable about calling ourselves ‘Doctor’.

Now, I wonder how the Scientific University of Bratislava is about the use of the title, ‘Professor’?

• Dr Enrico Brik is the pseudonym of a self-employed consultant and sometime writer and blogger who has worked for over a decade in various roles in health services policy and planning. Dr Brik currently resides outside Sydney in NSW. He is not a clinician. His blog is at http://enricobrik.blogspot.com/.

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His previous posts at Croakey include:

• The role of doctors in health services planning and management

• Opportunities for the cunning health bureaucrat in the proposed NSW Mental Health Commission

In the article below, one of the researchers involved in the project, Andy Oxman from the Norwegian Knowledge Centre for the Health Services, provides an overview of DECIDE.

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Helping inform patients, clinicians and policymakers

Andy Oxman writes:

Health professionals, patients, policymakers and the public all want to make healthcare decisions that are informed by the best available research evidence. This requires reliable summaries (systematic reviews) of the evidence of the advantages and disadvantages of our options. It also requires complex judgements.

Systematic reviews of the effects of healthcare provide essential, but not sufficient information for making well informed decisions.

Review authors and people who use reviews draw conclusions about the quality of the evidence (how confident we can be in the estimates of effects), either implicitly or explicitly. Such judgments guide subsequent decisions. For example, clinical actions are likely to differ depending on whether one concludes that the evidence that warfarin reduces the risk of stroke in patients with atrial fibrillation is convincing (high quality) or that it is unconvincing (low quality).

Similarly, policy decisions are likely to differ depending on whether one concludes that the evidence that specialised stroke units reduce the risk of death and disability (compared with treating acute stroke patients in general medical wards) is convincing or not.

The GRADE Working Group is a collaboration of over 60 organisations from around the world that has developed a systematic and transparent approach to making judgments about the quality of evidence (how confident we are in estimates of effect) and the strength of recommendations (how confident we are that the desirable effects of adherence to a recommendation outweigh the undesirable effects).

To benefit from this work, health care decision makers need to have access to evidence-based clinical recommendations or briefs describing policy options, they need to be able to understand that information and they need to be enabled to make decisions that reflect their own values or the values of those affected.

DECIDE is an international collaborative research project linked to the GRADE Working Group that will develop and evaluate strategies for communicating and disseminating evidence-based recommendations and policy briefs.

These strategies will be tailored to the information needs of patients, clinicians and policymakers. They will include frameworks to help people to go from evidence to decisions, as well as strategies for communicating research findings.

For example, the DECIDE framework for health policy decisions reflects the need to consider evidence and judgements about a number of factors that can (and should) influence such decisions. These factors include the seriousness of the problem (e.g. strokes), the number of people affected (e.g. by acute strokes), the quality of the evidence, the size of the desirable effects (e.g. reduced deaths and disability), the size of the undesirable (adverse) effects, the resources that are required, cost-effectiveness (value for money), impacts on equity, feasibility and acceptability.

A framework to help decision makers and stakeholders to systematically and transparently consider each of these factors and the underlying evidence for each of these can help to ensure that important considerations are not overlooked and that consideration of each factor is informed by the best available evidence. It might also help to ensure that decisions are not inappropriately influenced by conflicts of interest, irrelevant information or unsubstantiated assumptions.

The DECIDE project started in January 2011 and will run for five years.

It has received funding from the European Union 7^th Framework Programme (FP7/2007-2013) under grant agreement number 258583. More information about the project can be found on our web pages.

Margo Saunders writes:

While progress on so many health issues in Australia seems to be frustratingly slow, the US Institute of Medicine (IOM) is charging head with a raft of new initiatives.

Commissioned by government, private sector and non-profit organisations, these include a consensus report on preventive health services for women, a workshop on the gender-specific reporting of scientific data, and a consensus report proposing a national surveillance system for cardiovascular and chronic lung disease. The second report on front-of-pack food labeling systems is expected within the next few months.

As noted in an earlier post on the IOM, the Institute seems to occupy a particularly useful space, especially in the light of questions raised by Australian commentators about Australia’s health research infrastructure (do we need a research, reporting and evaluation capacity independent of government and the bureaucracy?) and about the divide between academic research and the needs of evidence-informed policy.

The IOM’s brainpower comes from university research centres and private and public sector experts, a number of whom occupy interesting positions at what may be thought of as the ‘ac-prac intersection’.

For example, a professor of pediatrics represents the American Academy of Pediatrics Health Literacy Advisory Committee, another professor is President and CEO of a state-based health literacy organisation, and senior academics in schools of public health include former senior health and medical officers at the federal, state, county and city levels. This mix of expertise ensures a strong focus on knowledge transfer.

Much of the IOM’s work also has theoretical and practical relevance to other countries, including Australia.  Several recent reports are of particular interest — not just because of what they say, but because their existence constitutes an important step in progressing these often-complex issues.

First, as mentioned in the footnote to my earlier post on the IOM, is the review of public health laws in the context of changing social and policy environments.

While Australia has barely a handful of academics generating a small smattering of publications (albeit excellent ones), we do have ‘experts’ capable of leading wider discussions.  Professor Roger Magnusson’s (U Syd) Australian Research Council-funded project on ‘Lifestyle wars: law’s role in responding to the challenge of non-communicable diseases’ (which also suggests that there is at least some research support for these topics) could easily be the subject of an IOM-style enquiry.

Another consensus report concerns a matter which has not gone un-noticed in Australia: equitable access to oral health care.  This report notes that, while lack of access to oral health care contributes to ‘profound and enduring oral health disparities’, opportunities exist to reduce the social, cultural, economic, structural and geographic barriers to access.

Australian health and medical authorities have echoed US concerns about access to care, resulting in proposals such as the National Health and Hospitals Reform Commission’s ‘Denticare’ scheme. The IOM’s call for ‘flexibility and ingenuity’ in addressing access barriers also carries strong overtones of Australian appeals for ‘innovation’ in policy development and implementation.  The report’s recommendations include increased health insurance reimbursements, more flexible responsibilities among health care professionals, and changes to dental recruitment, education, and training.

According to feedback generously provided to me by individual members of the Public Health Association of Australia’s Special Interest Group on Oral Health, Australia will also need to look at changes in education, financing and regulation to achieve more equitable access to oral health care.

Dr Alexis Zander believes that a health insurance scheme which includes dental health would encourage timely and regular access to care.  Dr Catherine-Anne Walsh agrees that oral health should be integrated into general health and that Australia should monitor forthcoming debates and actions around the IOM’s recommendations. She also notes that the report, while concluding that dental coverage should be provided for all low-income individuals and families, also highlights the need to address deficiencies in the collection, analysis, and use of oral health data.

Health literacy (defined as the capacity to obtain, process, and understand information needed to make appropriate health decisions) has been addressed by a series of reports, the latest being the summary of a workshop on opportunities to advance health literacy in the context of US health care reform.  The report includes presentations not only from high-level experts, but from speakers representing children, the elderly and other vulnerable populations.

The IOM’s approach to this issue has been typically collaborative, involving individuals from academia, industry, government, foundations and associations, and patient and consumer groups. The workshop itself was sponsored by 8 organisations, including non-profits, pharmaceutical companies, doctors’ organisations and managed care organisations.  The focus is not on producing research per se, but on bridging that divide between research and practice: ‘to move forward the field of health literacy by translating research findings to practical strategies that can be implemented.’

US Deputy Assistant Secretary for Health, Anand Parekh told workshop participants that the US has reached ‘a collective recognition that improving health literacy is essential to improving health and health care’ and has placed health literacy ‘at the center of the national health policy conversation’.  In the discussion which followed, health literacy expert Dr Scott Ratzan argued that leadership and enthusiasm are still needed, together with the involvement of those from other fields, including behavioural economics.

There are potential lessons from the IOM approach, even taking into account the need to fine-tune solutions to suit our circumstances.

The problem is not necessarily that things are not happening in Australia – the problem is the disjointed and uncoordinated nature of much research and thinking about health, particularly in relation to the more messy or ‘wicked’ issues. In Australia, for example, the importance of health literacy has been acknowledged but the agenda remains largely un-owned and uncoordinated.

It is clear that the IOM is progressing many health issues that would otherwise languish in the ‘too hard’ basket; is facilitating links between research, policy and practice; and is forging collaborations and partnerships across the government, non-profit and private sectors.

Can we claim to be doing the same?

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PS from Croakey

Meanwhile, the IOM is due to release a report today that is expected to propose a tougher approval process for a wide range of devices like hip implants, hospital pumps and external heart defibrillators. The report, commissioned by the Food and Drug Administration, comes after several well-publicised recalls in recent years of devices that have failed in thousands of patients, causing numerous injuries. According to the New York Times, allies of the medical device industry have already begun an “extraordinary” campaign in Washington to discredit the report.

On related matters, the NYT also reports that some academics and medicos who receive pharma and other industry funding in the US are planning a “fight back” campaign against growing international concerns about the adverse effects of such conflicts of interests.

Professor Sally Redman, the chief investigator of the Centre, explains below what it aims to do.

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Building an evidence base for informed health policy

Professor Sally Redman writes:

Sir Humphrey: Now in Stage Two you go on to discredit the evidence … You say it leaves some important questions unanswered, that much of the evidence is inconclusive, that the figures are open to other interpretations, that certain findings are contradictory, and that some of the main conclusions have been questioned. …

Minister Hacker: But to make accusations of this sort — you’d have to go through it with a fine-tooth comb?

Sir Humphrey: No, no, no. You can say all these things without reading it.

I have to admit to having lifted the above gem, from the BBC’s classic Yes Minister series, from a recent speech by Productivity Commission chairman Gary Banks to a South Australian economics think tank on the topic of “Evidence and social policy” – in this case relating to gambling.

Gary Banks has argued consistently and passionately over many years for the use of evidence in policymaking, not only because it helps to achieve the best results for the Australian community, but also because it helps to get good policy implemented when there is opposition to it, as illustrated with great humour and insight above.

As part of his campaign to get more evidence into policy, Gary Banks will help us launch an exciting new initiative in the health care sector – a National Health and Medical Research Council funded Centre of Excellence in increasing the use of research in health policy.

Governments across the world have recognised that the use of evidence from research in health policy can improve health outcomes and optimise resource allocation.

But there is little empirical evidence about what does and doesn’t work to increase the use of evidence from research in policy.

Called CIPHER (Centre for Informing Policy in Health with Evidence from Research), the new centre will help health agencies understand how they use evidence from research currently and to choose the most effective strategies for the future.

The centre is a collaboration of seven institutions, including the Sax Institute, University of Western Sydney, St Andrews University in Scotland, The University of Newcastle, the Cochrane Collaboration, University of Technology Sydney and The University of NSW, and will examine what will work best for policy agencies in accessing and using evidence from research.

CIPHER will work with more than 20 policy agencies to explore the kinds of strategies that may help improve use of evidence in policy. The centre will provide, for the first time, rigorous tests of the impact of different approaches to using evidence in policy.

There is considerable national and international interest in this work.

It is hoped that the new centre will help to ensure that health policy decisions, which often have a crucial and lasting impact on the health and wellbeing of Australians, are based on clear evidence about what works best, and what is affordable, in a health system constrained by competing demands from a growing and ageing population.