Croakey, as regular readers will know, has been dishing it up to the Rudd/Gillard Government on its health reform agenda for some time now.

Croakey is in the unfortunate position of being something of a perfectionist and an idealist (not a combination I’d wish on anyone), which means there have been many disappointments along the health reform journey over the last few years.

But credit where credit is due. Health Minister Nicola Roxon deserves acknowledgement for speaking a truth today, during her National Press Club debate with her Opposition counterpart Peter Dutton, that many in the health and medical lobby find unpalatable.

It’s a truth that not many health ministers or politicians manage to utter at any time, let alone in the thick of an election campaign, and especially one where the AMA is seeking to make medical rebates an election issue.

Noting that there are finite resources in health, Minister Roxon said it would be wrong to pretend that Medicare rebates should always increase. Sometimes, because of technological advances and changes in the way care is provided, they may need to go down.

Yes, that’s right. Sometimes more money is not what’s needed. Sometimes useful reform may actually mean spending less money or just doing things differently. What a novel concept for a sector that seems to have an insatiable appetite for our dollars, often with little apparent regard for whether these dollars are being best or even well spent.

It’s a touch ironic, as well as politically predictable, that Peter Dutton, in seeking to present his side as the economically responsible and managerially able mob, should be in such a rush to line up with the AMA. The medical lobby is generally not a fan of competition – what, you want to put a GP super clinic in my area, shock horror – or reducing medical fees or government spending on health services.

Meanwhile, here are a few other random observations from the debate:

• aged care received very little attention from the presenters or journalists, although Roxon did say that together with mental health it would be a priority for the next term (if they get one). Indigenous health and one of the major public health issues – climate change – didn’t even rate a mention (see further comment on this below).

• will journalists and others please stop judging GP super clinics by the reaction of GPs? The long tradition of simply paying more to existing providers hasn’t exactly got a great track record in helping under-served areas or leading to a fairer distribution of health services and spending. Surely GP super clinics should primarily be judged on the contribution they make to their local population’s health, and whether they help drive the development of useful and innovative models of service delivery and training?  Dutton’s pledge to put money into existing general practices doesn’t do much to help those areas short on general practices or to tackle under-served areas. And perhaps someone should tell him that not all doctors want to own their own practices. Just as there are a diversity of practitioners and a diversity of community needs, it might be helpful to have a range of practice models. For the record, Minister Roxon said that of the 36 GP super clinics promised, four are providing full services, nine are providing interim services and 18 are under construction. That seems to leave five in limbo (if my maths work).

• Roxon appeared to rank action on obesity as a lower priority than tobacco and alcohol because, she says, the evidence about which obesity interventions are going to be most successful “is pretty unclear”. That argument doesn’t cut it. If tobacco control advocates had waited for evidence to miraculously appear back in the smoke-hazed past, then not much would have happened. Action, provided it is evaluated, creates evidence. And it’s well past time for some innovative, bold action in obesity control.

• The Larvarus Prodeo blog drew a useful contrast between the Labor and Coalition health policies. It said:

“Roxon is very impressive, across the detail. The thing is that health is a very complex policy area, and Labor *does* have an integrated approach. But that means not everything can be done at once. The Coalition’s approach is to cherry pick bits of health for headlines, and in response to the pressure of particular interest groups. The question is whether this trumps a very well thought out policy framework which seeks to get the settings right first, while putting in place the building blocks for a holistic approach to patient care.”

• Roxon makes a fair point in response to the Coalition’s mental health promises (although others disagree with me, see below). This is that they will be funded by cuts to services that are also important for people with mental health problems (eg primary care, e-health, after hours services)

• Dutton’s argument that Rudd/Gillard Government hasn’t been listening to doctors and nurses is spurious. Has he forgotten the endless consultation tour of hospitals when many were thinking it was time for action? As for his statement that Australians want “doctors and nurses running our hospitals”, I certainly want them providing patient care and input into policy and service management. But I only want them running services if they have the skills, qualifications and aptitude for this. A nursing or medical degree does, of itself, not necessarily mean this.

Meanwhile, here are some other takes on the debate from The AustralianABC radio, and the Twitterati.

And from some regular Croakey contributors…

Sebastian Rosenberg, of the Brain and Mind Research Institute at the University of Sydney

Neither Labor nor Liberal made any commitment today to develop a long term strategic plan to reform Australia’s mental health system.  The Liberals are offering about 4 times the investment Labor has made, and both are focusing this spending on headspace, early psychosis centres and sub-acute care.  Neither Roxon nor Dutton clarified the model of care under which new sub-acute services would operate.  This is a significant concern given this is by far the major component of investments promised by both parties and there is scant evidence to merit such spending.

But perhaps most frustrating is Minister Roxon’s repeated assertion that people with a mental illness want and deserve access to general practitioner care just as much as the general community.  She makes this point to highlight Liberal plans to cut funding for super clinics and so on.

However, the Minister would never suggest that people with cancer should choose between access to specialist cancer treatment or access to their general practitioner. She would rightly say that people with cancer deserve and need both.  This is not the case with mental illness apparently. Only one in three people with a mental illness receive any care for that illness and this compares very poorly with other chronic illnesses where people enjoy much higher rates of access to treatment.

Yet Minister Roxon persists in linking any additional spending on vital new and long overdue mental health services with reductions in spending on other parts of the health system.  This is both inappropriate and palpably unfair.  People with a mental illness deserve better. They deserve access to a world class stream of mental health services just as Labor announced a world class cancer stream in the 09-10 Federal budget.

Put simply another way, access to general practitioner services will be of quite limited benefit to people with chronic and persisting mental illness without also providing access to high quality specialist mental health services and these are not available now.

The final point I would make is that the call for robust accountability in mental health has been consistent since 1992 and yielded almost nothing.  Minister Roxon made a point about the Labor Government’s commitment to system-wide accountability.  However, the focus here will be on process measures or outputs, nonsense items such as waiting lists, the number of beds, the number of occasions of service and other such dud markers as agreed in compromise with state health bureaucracies. With regards to mental health specifically and despite the fact that our mental health system is now worth over $5bn annually, over the past 18 years neither Labor nor Liberal governments have established the means by which we can assess any of the following  key markers:

·        Whether a person is alive or dead within 3 or 12 months of seeing a mental health service;

·        Whether we are reducing the rate of suicide;

·        Whether our mental health services are impacting on the rates of homelessness among people with a mental illness;

·        Whether education and employment rates are improving for people with a mental illness;

·        Whether people treated in our mental health system say they were treated with dignity.

In mental health, we are service poor and outcome blind and neither party has outlined any longer term plan to fix this.

Mental health advocate John Mendoza

Another point here is that people with severe an persistent mental illness often do not have or see a GP. For example, in Mackay, I am advised by Qld Health that 50% of clients admitted to acute care or receiving support from the community MHS have no GP and do not see GPs. It may occur to Roxon that significant numbers of Australians cannot connect to GPs for all sorts of good reasons.


And what about Indigenous health? (a media statement)

The coalition of peak groups representing general practice in Australia today joined forces with the peak body representing Aboriginal community controlled health services to call on the major parties to start talking the talk on Aboriginal health.

United General Practice Australia (UGPA) and the National Aboriginal Community Controlled Health Organisation (NACCHO) have called on the Labor Party and the Coalition to confirm their commitment to the COAG National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. They stated that real increases in funding were needed in the next term of government to make a real difference in the health and wellbeing of Aboriginal and Torres Strait Islander people.

With less than two weeks to go in this election campaign what should be our number one health priority – the health and wellbeing of Aboriginal and Torres Strait Islander people – has received no attention.

Closing the gap on the health status of Aboriginal and Torres Strait Islander Australians to that of non-Aboriginal Australians is critical in this country if Australia is to seriously claim to be a compassionate and caring nation capable of addressing health inequalities.

The Aboriginal population is most at risk from chronic illnesses, particularly preventable ones like diabetes and the best model of care for these patients is in a primary health care setting.

The major parties need to produce Aboriginal health policies that provide tangible reforms and deliverables for Aboriginal populations.

The COAG Agreement on Closing the Gap in Indigenous Health Outcomes was signed by former Prime Minister Kevin Rudd. Both potential Prime Ministers need to confirm their willingness to commit to the COAG Closing the Gap Agreements and to at least maintaining the current level of Commonwealth Government funding commitment over the course of the next term of government.

And what about climate change?
(a media statement)

The Climate and Health Alliance has expressed its disappointment in the failure of the major parties to acknowledge the risks posed to human health by climate change in the national press club health debate today.

Alliance spokesperson Fiona Armstrong said there was no acknowledgement by either the federal Health Minister Nicola Roxon or Shadow Minister Peter Dutton of the biggest global health threat of the 21st century – climate change – in the health debate.

“Further global warming poses grave risks to human health and biodiversity, and left unchecked, threatens the future of human civilisation. It is quite staggering that our political health leaders could ignore this as a priority human health issue.”

Ms Armstrong said the formation of the Alliance demonstrated the level of concern in civil society that our political leaders were failing to take responsibility on the issue of climate change and ecological degradation.

Ms Armstrong said as a coalition of health leaders, the alliance recognised a particular responsibility to the community in advocating for public policy that promotes and protects human health.

“There is an important role for civil society in helping to fill this leadership vacuum. Through this alliance, we are demonstrating the willingness and ability of civil society to assume leadership by advocating on this issue.”

“It is sobering to note that the influential UK environmental think tank, the Green Alliance, warned prior to their recent election that the 2010 parliament may be the last in which effective action could be taken to stop runaway climate change. This is because changes are non-linear and there is an increasing likelihood that we will soon reach tipping points beyond which changes to the earth’s systems may be irreversible.”

The Climate and Health Alliance wishes to convey the same sense of urgency to all policy-makers in Australia to address climate change.

“Climate change is affecting people’s health right now. However there is a demonstrable lack of leadership in the Australian Parliament to make the hard decisions, stand up to vested interests, and to act in the national interest as we face this unprecedented global challenge,” Ms Armstrong said.

“We need to protect our economic future by moving away from our dependence on fossil fuels and making a large scale transition to safer, cleaner, renewable energy. We need a national plan to guide this transition to a greener economy, and this must include careful planning to safeguard the health of the community.”

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Peter Fray
Peter Fray
Editor-in-chief of Crikey