Whoever forms government after the federal election will find plenty of inspiration – should they actually want to make meaningful reform – in this latest column from Associate Professor Lesley Russell.
The Health Wrap covers recommendations for reform across diverse and yet interconnected areas, including primary healthcare, obesity, the Indigenous health workforce, out-of-pocket costs, and for improving access to healthcare in rural, regional and remote Australia.
It also reports on moves in the United States to address misinformation, tackle the social determinants of health, and enhance the national public health infrastructure. And don’t miss the award-winning wildlife photography; it will take your breath away.
Lesley Russell writes:
It’s a constant complaint among policy wonks that nothing happens quickly in the federal Department of Health, even when the issues are crucial. But the first months of 2022 have seen a raft of long-awaited policy papers and national strategies released, often with surprisingly little fanfare given their potential impact.
It’s as if the Department and the Minister for Health are clearing out the closets and ticking off the “To Do” lists ahead of the upcoming election.
Of course, delivering fine words on paper is the easy part – it’s delivering meaningful actions that matter. So we must hope that there is bipartisan commitment to addressing the issues such as preventive health, obesity and workforce – and funding to ensure this can happen.
A media release from the Australian Medical Association reminds me that we are yet to see the Primary Health Care 10-Year Plan. The consultation period on the draft Plan closed in early November last year. Now the AMA claims the Plan has been “dumped”.
Once much-vaunted by Health Minister Greg Hunt as representing the Morrison Government’s commitment to reforming the healthcare system to be “more person-centred, integrated, efficient and equitable”, in more recent months the Plan has not been mentioned. This even as the COVID-19 pandemic highlights the importance of primary care and the pressures facing GPs.
The submissions to the draft Plan from the major doctors’ groups placed a significant emphasis on continued fee-for-service and increased Medicare rebates (see, for example, this commentary from the RACGP and this article I wrote in October 2021).
These regressive approaches ignore the fact that the transition to model/s of primary care fit for the 21st century will require the adoption of innovative approaches to the delivery, organisation and financing of care and profound changes in culture.
Maybe this is why the much-needed Primary Care Plan is foundering?
At last – a national obesity policy. Now what?
Australia’s National Obesity Prevention Strategy 2022 – 2032 was finally released on World Obesity Day.
This Strategy has been a long time coming (see Where is the National Obesity Strategy? published by Croakey in August 2021). Work began in 2018 when federal and state and territory governments agreed to work on a national strategy. The draft Strategy was released for comment in October 2021. You can read more about the development process here.
There was notably no political attention paid to the launch of this important policy to address a priority health problem that has huge impacts on Australians’ physical and mental health and healthcare costs.
In particular, there has been no federal leadership and no commitments to funding (unless, miraculously, there is support in the upcoming Federal Budget). That must lead to concerns about the potential of a national policy approach to deliver improved health outcomes.
As the document itself states – the current health and social supports don’t prioritise addressing obesity, despite the significant costs it imposes. Tackling obesity needs a multi-faceted and united approach across governments; clearly federal leadership is critical.
It is encouraging to see an accompanying framework for action (see figure below), and a specific approach for Aboriginal and Torres Strait Islander communities.
For the most part, the Strategy has been well received; the focus now is on appropriate and ongoing funding and effective action.
As Professor Jane Martin writes for MJA Insight, there is no time to waste in getting this important work underway. That same theme is echoed in an article by Dr Amy Coopes in Croakey Health Media.
Martin highlights that an important aspect of addressing obesity will be to implement effective policies to limit commercial influences on health such as unhealthy food marketing, accurate labelling, and a health levy on manufacturers of sugary drinks.
Ongoing evaluation, measuring changes over time, reporting, and sharing lessons will also be crucial.
Launch of first Indigenous health workforce plan
The first National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031 was released on 13 March. It was co-designed by federal and state and territory governments and the Aboriginal and Torres Strait Islander community-controlled health sector.
The involvement of First Nations opinion and expertise in the development of this strategic framework and implementation plan gives meaningful ownership to the communities for which they were developed.
This document supersedes the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016–2023. The current status of the Commonwealth Aboriginal and Torres Strait Islander Workforce Strategy 2020-2024 is unclear.
The target is for Aboriginal and Torres Strait Islander people to represent 3.43 percent of the national healthcare workforce by 2031, to match their expected percentage of people in the working population.
The aim is to expand access to culturally safe care, improve the health of Aboriginal and Torres Strait Islander people and provide well paid, secure employment for these Indigenous people working within the healthcare system.
It is described as including a wide range of actions across the healthcare system to attract, recruit and retain Indigenous healthcare workers to the healthcare workforce across all roles, levels and locations.
There are six strategic directions to support the ongoing development of the size, capability and capacity of the Aboriginal and Torres Strait Islander health workforce:
- Aboriginal and Torres Strait Islander people are represented and supported across all health disciplines, roles and functions.
- The Aboriginal and Torres Strait Islander health workforce has the necessary skills, capacity and leadership across all health disciplines, roles and functions.
- Aboriginal and Torres Strait Islander people are employed in culturally safe and responsive workplace environments that are free of racism across health and all related sectors.
- There are sufficient numbers of Aboriginal and Torres Strait Islander students studying and completing health qualifications to meet the future health care needs of Aboriginal and Torres Strait Islander people.
- Aboriginal and Torres Strait Islander health students have successful transitions into the workforce and access clear career pathway options.
- Information and data are provided and shared across systems to assist health workforce planning, policy development, monitoring and evaluation, and continuous quality improvement.
However, at this time there does not appear to be any additions or changes to the scholarships, training and programs provided by the Commonwealth for the support of the Indigenous healthcare workforce.
The Executive Summary state: “Governments and Aboriginal and Torres Strait Islander community-controlled health peak bodies agreed: an appropriately skilled, available and responsive Aboriginal and Torres Strait Islander health workforce is critical for an efficient national health system” – as was perfectly highlighted by the COVID-19 pandemic.
This document is an excellent beginning, but to bring it to life so it can deliver on the promises for the future will require leadership, commitment, financial support, mentorship, and efforts to address racism from governments and the non-Indigenous educational and training bodies and organisations that operate within the broader healthcare system.
See responses from:
Indigenous Allied Health Australia
IAHA Chief Executive Officer and outgoing National Health Leadership Forum Chair, Donna Murray, said of the announcement:
“The Aboriginal and Torres Strait Islander health workforce brings a unique, dual cultural and clinical lens to their work. Growing the Aboriginal and Torres Strait Islander health workforce should be a priority for all governments, with investment in Aboriginal and Torres Strait Islander led and culturally responsive approaches across health, education, skills, training, and employment portfolios.”
National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners
NAATSIHWP Chairperson, David Follent, said: “Our communities must have access to culturally safe and responsive care no matter where they are, and a strong, valued and highly skilled Aboriginal and Torres Strait Islander Health Worker and Health Practitioner workforce is key to this end.”
NAATSIHWP CEO, Karl Briscoe, said: “We know better health outcomes are achieved when our Aboriginal and Torres Strait Islander health workforce are involved in our people’s health care as we possess a cultural intellect that isn’t able to be replicated by mainstream health professions.”
• To attend the launch of #CloseTheGap22 report from 11.30am AEDT on 17 March, register here. Also, follow @WePublicHealth, Croakey’s rotated, curated Twitter account, where the Lowitja Institute is guest tweeting this week.
The growing problem of out-of-pocket costs
A recent report from the Grattan Institute focusses on the issue that is increasingly undermining the universality and effectiveness of Medicare – patients’ out-of-pocket (OOP) costs.
This report from Professor Stephen Duckett (who is about retire from the Grattan Institute) and colleagues looks specifically at the OOP costs due to Medicare services and medicines in the Pharmaceutical Benefits Scheme and offers a range of possible solutions.
It is the latest in a long line of such reports from many sources looking at OOP costs – none of which ever generate any meaningful political response (with one exception – a Labor policy in the 2019 election to address the costs of cancer treatment).
- The findings are not new, they just highlight that the situation is worse than ever:
- In 2020-21, nearly 500,000 Australians could not afford to see a specialist because of cost and nearly 600,000 Australians deferred or did not fill a prescription because of cost.
- Australians spend about $30 billion a year on OOP costs for healthcare. This includes about $7 billion a year out of their own pockets on out-of-hospital medical services and prescription medicines, $5.5 billion on dental care, $9.5 billion on non-PBS medicines and $1.3 billion on transport, aids and appliances.
- Patients pay about 18 percent of the national total health budget. Australia relies more heavily on patients’ contributing to the cost of their healthcare than many similar countries.
- Bulk-billing rates are too low and OOP costs too high for many needed medical services.
- The people who need healthcare services the most – the poor and the chronically ill – are most likely to miss out on care because of cost.
- OOP costs are the key factor for people with diabetes and heart disease in determining their choice of care (specialist or GP). The OOP costs associated with psychiatry and psychology are high and must also mean that people with mental health problems are unable to access this care.
The report offers a number of solutions to address the problems. These include:
- Making specialist care more accessible and affordable. This means address both specialist numbers and wait times for appointments and the associated costs. Specialist fees (which are unregulated) are a major contributor to OOP costs. Many specialists charge more than twice the Medicare rebate.
- Pharmaceutical costs are especially burdensome for people with chronic health conditions so more must be done to address the cumulative costs of multiple essential prescriptions.
- OOP costs should be eliminated for diagnostic and radiology services through tender arrangements. Duckett et al argue that doctors, not patients, are the real users of these services.
- Tender arrangements should also be used to lower the cost of allied health services.
- The effectiveness of the Medicare safety nets needs to be reviewed.
- Efforts are needed to improve the management and care coordination for patients with chronic conditions.
The report estimates that all the suggested changes would cost around $710 million annually, but that these would save Australians $1 billion in OOP costs.
Healthcare is taking up an increasing proportion of the budgets of Australian households: OOP costs for medical services increased by nearly 50 percent in real terms in the past 10 years.
Recent polling shows that the cost of living and healthcare are the top concerns for Australian voters – will that then push the issue of the impact of burgeoning OOP costs on to the campaign manifesto?
For more on this report and its findings, here are some suggestions:
- Hear Professor Duckett interviewed on the ABC Health Report.
- Media release from Consumers Health Forum.
- Women often pay more than men out of their own pockets for healthcare services.
- How to rein in rising healthcare costs – an opinion piece by the report’s authors published by The Conversation.
- At Croakey, What will it take to make allied healthcare more affordable?
Improving access in rural, regional and remote areas
The Consumers Health Forum and the National Rural Health Alliance have recently released a report on their roundtable on access to healthcare services in regional, rural and remote Australia.
This initiative has been driven by consumer concerns, experiences, and the need to address the genuine disparity in access to healthcare services across the nation. Importantly, consumers have suggestions and opinions about possible solutions.
The key areas identified included allied health, dental services, mental health, obstetrics, specialist medical services and telehealth.
The barriers to be overcome to access to these healthcare services are more far-reaching than simply “getting to an appointment”. The significance of the extent to which access is denied or limited cannot be discounted. This is described in the report as a “seemingly never-ending area of health service prejudice”.
The report delivers ten key recommendations, each classified as short, medium or long-term in expectations for their delivery.
They include:
- Specific updates to Medicare rebates for rural, regional and remote areas, including allowing for more than one medical, health visit or procedure per day.
- The ability to obtain prescriptions for chronic conditions needing recurring medications without a GP appointment.
- Funding for local community groups to support their communities in improving digital health literacy.
- Training of health care coordinators for mental health care, specialist referrals, obstetric needs, and allied health services including dental care.
- Advocate for the development of the RACCHO model to improve multi-disciplinary health service provision in rural, regional and remote areas.
- Metropolitan hospitals to take on the responsibility of facilitating specialists’ services to hospitals and clinics in rural, regional and remote areas.
Health news from the United States
Below are summaries of a raft of interesting news from the United States that I don’t have time or space to explore in more detail.
News sources determine trust in public health advice
It turns out that the key factor determining how an American handled COVID-19 – more than race, education or even the political party they support – is where they get their news.
Polling analysis by Axios shows that at the advent of the pandemic in March 2020 roughly nine in ten Americans, regardless of their preferred media outlet, trusted the Centers for Disease Control and Prevention (CDC).
Within weeks, that trust was plunging among Americans who mostly watch Fox News or other conservative outlets.
By January 2022, just 16 percent of those who said they get most of their news from Fox or other conservative outlets still said they trust the CDC, compared to 77 percent of those who favour network news and major national newspapers, and 87 percent of those who primarily watch CNN or MSNBC (considered more progressive).
US Surgeon General seeks COVID-19 misinformation data from big tech companies
The US Surgeon General Dr Vivek Murthy has formally requested that the major technology platforms submit information about the scale of COVID-19 misinformation (starting with common examples of vaccine misinformation documents by the CDC) on social networks, search engines, crowd-sourced platforms, e-commerce platforms and instant messaging systems.
The notice asks the companies to submit “exactly how many users saw or may have been exposed to instances of Covid-19 misinformation,” as well as aggregate data on demographics that may have been disproportionately exposed to or affected by the misinformation.
The Surgeon General also demanded information from the platforms about the major sources of COVID-19 misinformation, including those that engaged in the sale of unproven COVID-19 products, services and treatments. Companies have until May 2 to submit the data.
A Commission on a National Public Health System
In the United States – as in so many other countries – the pandemic exposed profound weaknesses and disorganisation in the public health system, including gaps in human resources and infrastructure.
These failures resulted in no small part from the lack of a truly national public health system that functions day to day, with coordinated leadership at the federal level and with consistent state and local capacity.
Now the well-respected Commonwealth Fund has established a Commission on a National Public Health System. The Commission will seek to “articulate a vision for how US federal authority, resources, and leadership can join to create a national public health infrastructure, one that improves health and equity every day and enhances the nation’s preparedness for future crises”.
The report is intended to inform the transition to a national public health system through more directed use of grant and other federal funds, the resetting of roles and expectations, and the reform of legal authorities.
The Commission draws on a stellar group of public health experts who will waste no time in getting the report done. It is expected by May 2022, presumably with the hope that the Biden Administration will begin implementation efforts ahead of the 2022 mid-term elections.
There’s a strong case to be made that such a Commission is needed in Australia.
Addressing the social determinants of health through the healthcare system
Starting this month, the state of North Carolina will begin rolling out the Healthy Opportunities Pilot (HOP) – a first-in-the-nation project based on the hypothesis that using Medicaid healthcare dollars to pay for non-medical health-related services, will lead to medical costs falling and overall health improving.
The project is facilitated by the federal 1115 waiver that gives states the flexibility to try “experimental” ways to improve the health of their Medicaid population (these are generally the poorest and sickest people in the population).
In North Carolina, the waiver means that the state can use up to $650 million in Medicaid money to pay for three broad approaches to health: food and hunger-related services, housing and transportation services, and interpersonal safety.
The money will be used to provide for the delivery of healthy food boxes, assistance with rent and case management for families experiencing domestic violence.
You can read more about HOP here.
Healthcare and humanitarian disasters
For the past few weeks, the eyes of the world have been focused on the cruel and destructive attacks on Ukraine and the Ukrainian people.
An editorial in The Lancet highlights the priorities for health in the Ukraine. But in the same edition of The Lancet we are reminded that it is eleven years since the war in Syria started and humanitarian and health needs are rising. (It should be noted that the Assad regime is supported by Russia.)
Meanwhile the Red Cross asks the world not to forget the devastating, years long conflict in Yemen.
There are many places around the world where daily existence and human rights are threatened – these include Haiti, Afghanistan, Myanmar, and South Sudan.
And here in Australia thousands of families are still looking for rebuild after the 2019-2020 fires and are still cleaning up after the recent disastrous floods.
The need for humanitarian aid and support at home and abroad has never been greater. We should rightfully expect that our government will use taxpayers’ dollars to provide needed aid in a timely fashion.
The best of Croakey
Freelance journalist Jade Bradford, a proud descendent of the Ballardong Noongar people in Western Australia, reports on new research identifying Indigenous perspectives on key determinants of planetary health.
Read her article, which also links into other recent articles at Croakey on related themes.
The good news story
The winners of the 2021 world nature photography awards have just been announced, and as you can see here, there are some magnificent shots.
As far as the winning photo is concerned – it is hardly a good news story for the little penguin, about to become the sea leopard’s dinner.
But you have to admire the courage of the photographer!
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
