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The Health Wrap: primary care reform announced, spotlight on housing, and also some kindness

In this latest edition of The Health Wrap, Associate Professor Lesley Russell reviews plans for primary health care reform, highlights the need to address housing as a critical determinant of health, documents progress (or not) on obesity policy in England, raises questions about a new report from the National Indigenous Australians Agency, and ends with a story from Scotland about kindness.


Lesley Russell writes:

The Minister for Health, Greg Hunt, has today announced the Primary Health Reform Steering Group – touted as the first step in the development of a Primary Health Care Ten-Year Plan.

First reaction: at last primary care reform, not before time!

Second reaction: a whole bunch of questions. The devil is always in the detail.

First, the background. The Steering Group, which has already had its first meeting, is part of the Government’s Long Term National Health Plan, under which the Morrison Government says it is committed to reforming the health system to be “more person-centred, integrated, efficient and equitable”.

Croakey has previously gathered opinions from the experts about this and sadly, the consensus was that it’s hard to see how these laudatory goals will be reached.

Here are the issues around primary care as I see them:

  • At the risk of being pedantic, I will point out that it will be hard to make progress on any of these issues if you are not clear about the scope of the work you are undertaking. The Health Minister and his Department consistently interchange the terms “primary care” and “primary health care” as if they are one and the same thing. Yes, it matters.
  • Although the National Health Plan is to include a “mental health vision”, it appears this is to be developed separately and will not be part of the Primary Care Plan. I don’t see any specific mental health expertise among the members of the Steering Group (although I acknowledge that there are those who are well aware of the issues). How often do we have to iterate that mental health is an essential part of healthcare? And we know that most mental health services are delivered in primary care settings. Already the promise of “person-centred” and “integrated” is eroded.
  • I’m afraid that this failure to integrate mental health into primary health reform also means that a whole range of other necessary primary care services – substance abuse, palliative care, gerontology, paediatrics, rehabilitation and palliative care will also be excluded. Dare I add dental care and oral health, sight and hearing services to that list?
  • To what extent will this Steering Group integrate the work that has been previously done around primary care reforms? Here’s a list off the top of my head:
  1. The work of the National Health and Hospitals Reform Commission A Healthier Future for all Australians (2009)
  2. Building a 21st Century Primary Health Care Strategy (2010)
  3. Grattan Institute reports: Chronic failure in primary care (2016); Building better foundations for primary care (2017);  Mapping primary care in Australia (2018)
  4. Leading Change in Primary Care Australian Health and Hospitals Association (2015)
  5. The role of Primary Health Networks in the delivery of primary care reforms L Russell & P Dawda (2019)
  6. Aboriginal community controlled health services; leading the way in primary care. Panaretto et al in the Medical Journal of Australia (2014)
  7. The evaluations from Health Care Homes and a raft of other reports and evaluations that can be mined to see what works and what doesn’t and why.

This edition of The Health Wrap from a year ago is also packed with relevant information for primary care reformers.

I’m fearful this will be about reinventing the wheel, because it always is. I’m also fearful this will about a “one size fits all” approach to reform (as was the case for Health Care Homes) rather than flexibility and the ability to address local needs.

Two issues are critical for underpinning whatever primary care reforms emerge from the consultations that are about to get underway:

  1. The right workforce in the right place with the right incentives (financial and otherwise). That does not necessarily mean just more GPs and practice nurses. This will not be easy in the absence of a health workforce planning agency.
  2. The right financing models to deliver the best outcomes. They must satisfy the needs of government, the providers of care, and the people who use those services. That means attention to patients’ out-of-pocket costs.

Finally, for this work in primary care – and the other work associated with the Long Term National Health Plan – I would argue that it is in everyone’s best interests to ensure this is bipartisan from the very beginning.

After all, it’s a ten-year plan and we don’t know who will be in Government in the years ahead.

Some long-term political commitment to these needed reforms would be one way to ensure they are delivered over the planned time-frame. 


Housing – a key social determinant of health

Housing is one of the most important social determinants of health, and we know that by addressing these social determinants of health that are the genesis of many health problems, the costs to government of providing healthcare can be reduced, and individuals can enjoy better health outcomes .

See, for example, Chapter 2 in the Parliamentary report on Australia’s domestic response to the World Health Organization’s (WHO) Commission on Social Determinants of Health report “Closing the gap within a generation” and the research summary on Housing and Health from VicHealth.

Legal efforts to improve remote housing in Indigenous communities in the Northern Territory

Obtaining and ensuring maintenance of safe, adequate, hygienic and comfortable housing is a particular problem for Indigenous Australians living in remote areas.  The absence of such housing drives the high rates of domestic violence and preventable diseases such as rheumatic fever, trachoma and otitis media. (Just this past week a news article in The Guardian highlighted that rheumatic fever is a “bloody health emergency” in the NT.)

However, research shows that the provision of housing infrastructure alone is insufficient to achieve improved general living environments and a broader approach, including the creation of an enabling environment in communities, is required.

This week, landmark remote housing litigation reached the Supreme Court of the Northern Territory. This case could set higher standards of housing and force improvements for remote communities across the NT. It has the potential to impact the standard of housing provided to 65,000 people living in remote communities in the NT.

The lawsuit has been brought against the NT Government by 70 households of the Santa Teresa community after the Government failed to action over 600 urgent repairs, with some families waiting for over five years for needed action.

A February ruling from the NT Civil and Administrative Tribunal (NTCAT) found, for the first time, that the NT Government is legally obliged to provide housing to tenants that meets the minimum statutory safeguards in the Residential Tenancies Act, for the first time.

The NT Government has not appealed the original NTCAT decision, but the Santa Teresa community want more. Before the NT Supreme Court, members of the Santa Teresa community argued that the legal requirement to provide housing that is habitable extends to a requirement that housing is good enough to live in, reasonably comfortable and humane.

Josie Douglas, Policy Manager at Central Land Council said: “This case proves what we have seen for a long time – that the NT Government is failing to meet its responsibilities for Aboriginal housing since taking control during the 2007 NT Intervention. The NT Government must return responsibility for housing decisions back to Aboriginal control, through local or regional community housing organisations in a phased approach.”

Those working on this case have highlighted how climate change is already having severe impacts on communities living remotely (NB: This report was published in 2009). It is critical that housing is appropriately designed and renovated to provide protection from extreme heat and extreme weather events.

How housing and healthcare costs compete – lessons from the United States

A recent article on the US-based Public Health Post looked at the research that has been done on how access to Medicaid improves housing stability for those families who consistently face difficulty in meeting their basic needs such as healthcare, housing, food and transport. As rents rise and wages are stagnant, increasing numbers of people face housing eviction, which increases the likelihood of homelessness and poor health.

Multiple studies show that increased access to Medicaid is associated with improved financial security and reductions in out-of-pocket spending on healthcare, catastrophic medical debt and payday loan borrowing.

The authors of the Public Health Post have studied how Medicaid expansion under Obamacare has seen a reduction in evictions among the beneficiaries. In California, where the effects have been substantial, Medicaid expansion has meant 22 fewer evictions per 1000 new enrolees per year.

This link between housing stability and Medicaid highlights that costs for healthcare and housing are in direct competition for families already in economic trouble.

There are some direct correlations and lessons here for Australia.

Homelessness is an increasing risk for older women

I really can’t leave this topic without pointing out that many older Australian women are increasingly at risk of homelessness. October 10 was World Homelessness Day, and a post on the ProBono website highlighted the issues:

  • Women aged over 50 are the fastest growing group of people at risk of homelessness
  • Australia will need to build more than 720,000 extra social dwellingsin the next 20 years to meet the oncoming surge in demand for people at risk of homelessness
  • No national housing strategy has been developed to prepare for the inevitable disaster ahead.

A paper Risk of Homelessness in Older Women published earlier this year by the Australian Human Rights Commission explores the underlying structural and cultural factors that lead to women’s economic disadvantage and subsequent homelessness.

It states that innovative solutions are needed to prevent women from becoming homeless, particularly older women.

There is a series of collaborative position papers on this issue and how to address it available here.


Tackling obesity in England

England’s current Brexit political problems pretty much guarantee that nothing else much gets done. That’s certainly true for obesity. It did not make the text of the Queen’s speech at the opening of the Parliament this past week.

Three different Prime Ministers in four years have all had their own approaches; policies have been floated but implementation has been patchy.

Most recently, the departing Chief Medical Officer, Professor Dame Sally Davies, has spoken out forthrightly, stating that only radical action will give the government any chance of getting close to its target of halving childhood obesity by 2030, and making her dissatisfaction with progress obvious.

A soft drinks levy was introduced in 2015 when David Cameron was Prime Minister, with little fuss from manufacturers. Data just released shows that the average sugar content of drinks covered by the levy declined by nearly 30 percent to 2018.

However, the ambitious obesity strategy he wanted came to a halt when he stood down after the Brexit referendum.

A year ago, then Prime Minister Theresa May was emboldened to bring back Cameron’s plan, but its implementation has been patchy. Boris Johnson has suggested a review of all “sin taxes”.

A recent report from the Organisation for Economic Co-Operation and Development says the UK has one of the highest obesity rates of 52 countries analysed. As a consequence, national income (GDP) is 3.4 percent lower than it might be because of the costs of healthcare and lost working days associated with overweight and obesity.

Dame Sally Davies says children are “drowning in a flood of unhealthy food and drink options”. Banning people from eating snacks on public transport is just one of her suggestions in a wide range of measures she has put forward.

They include:

  • Phasing out all marketing, advertising and sponsorship of unhealthy food and drink
  • Banning food and drink on local transport with exceptions for water, breast-feeding and medical conditions
  • Free water refills to be available at all food outlets, transport stations and public sector buildings
  • Regular car-free weekends across the country to encourage physical activity
  • Changing planning rules to make it harder to open fast-food takeaways
  • Extending the sugar tax to include milk-based drinks
  • Adding VAT to unhealthy food products that are currently zero-rated, such as cakes
  • Capping calories in food served out-of-the home to combat rising portion sizes
  • Consider plain packaging – as for tobacco – for junk food, if firms fail to reduce sugar, fat and salt in their products quickly enough
  • All nurseries, registered childminders and schools to adopt water and milk-only policies.

You can read her full report here.

As you can imagine, her proposals have triggered both praise and backlash, with some calling her “a champion for the silliest extremes of the nanny state”.

An editorial in the British Medical Journal said this:

It is only by changing the social, economic, policy and physical environments which frame all our dietary and activity decisions that we will see sustained, and sustainable change.

Some of the proposals laid out in Dame Sally’s report are rightly bold; it is essential that we radically increase both the breadth and intensity of actions to tackle childhood obesity in these kinds of ways if we are to halve the prevalence by 2030.”

UK Health Secretary Matt Hancock said the government would study the report closely and “act on the evidence”, though a Department for Health spokesman said there were no plans to ban snacking on public transport.


Closing the Gap assessment from the National Indigenous Australians Agency

The National Indigenous Australians Agency (NIAA) was established by the Morrison Government in May 2019 under an Executive Order signed by the Governor General. You can read more about it here. (Does it matter that there is no apostrophe to signify ownership in the agency’s name?)

The NIAA has just released a report that provides a retrospective view of the past ten years of Closing The Gap, although it’s interesting to note that the date on the report is March 2018 – more than a year before the NIAA was established.

To be honest, I’m uncertain how to read this report, which involved a literature review, consultation with Indigenous stakeholders, consultation with Commonwealth, state/territory and local government agencies, and an analysis of this data.

Cynically, I have come to be suspicious of reports commissioned by the Government about the success and value of the programs the Government espouses. On the other hand, I think that we don’t do enough to highlight the successes with Indigenous initiatives and the knowledge and expertise about how to run these that can be found in the communities. To date I have not seen any responses to the report from Indigenous groups.

Here’s how The Mandarin summarised the report’s findings:

What the report found:

  • The framework was not well implemented with lost opportunity
  • As cultural determinants are not captured in the policy framework, it makes it difficult to fully demonstrate cultural respect and collaboration with Indigenous Australians
  • There is plenty of potential to shift the way government and Indigenous Australian communities work together to Close the Gap.

Where has Closing the Gap been successful?

  • When initiatives have enabled Indigenous communities to lead and true partnerships have been formed with Indigenous communities
  • Solutions have been designed and implementation agreed between Indigenous communities and service providers and funders.

Where has Closing the Gap failed?

  • There has been little improvement in the partnerships with Indigenous people or in putting culture at the centre of initiatives
  • Closing the Gap is still often seen as a ‘top down’ approach, and not one of partnership.

I would summarise the findings this way:

  1. Too often Closing the Gap programs are done to Indigenous people, not with them. Until there is more consultation and more ownership, and attention paid to the cultural issues of Aboriginal and Torres Strait Islander people as individuals and communities, there will be little success.
  2. The evidence-base to support many programs is lacking or is weak. Program evaluation is rarely undertaken and is not used to inform program improvements. There is a need for a person and community/culture centred approach that measures actual outcomes, rather than indicators.
  3. The effort to close the gap has been hampered by inconsistent political leadership, constantly changing approaches to Aboriginal and Torres Strait Islander affairs, insufficient resources and workforce and funding cuts. This has led to mistrust from Indigenous communities towards service providers and governments.

The real issue of course is whether the Morrison Government, and specifically the Department of Prime Minister and Cabinet, will take note of the findings of this report. Minister for Indigenous Affairs Ken Wyatt has described the NIAA as offering a “new era of co-design and partnership”.

As an aside, but to my point about the need to hear about what’s working on the ground: make sure you follow #CommunityControl success stories at Croakey (this is sponsored content, produced in collaboration with the Aboriginal Health and Medical Research Council).

You can read about holistic primary health care at Walgett Aboriginal Medical Service here, and about a unique Aboriginal community-controlled rehabilitation service in central western NSW helping people to recover from substance abuse here. More stories are to come – we should hope they get read inside the Government.


Some interesting and useful recent publications

• The Family Matters Report 2019 on the over-representation of Aboriginal and Torres Strait Islander children in out-of-home care. It tells us that 20,421 Indigenous children are in out-of-home care – 37.3 percent of all kids in care but only 5.5 percent of the total population of children in Australia. Read more at Croakey.

• The Kings Fund (UK) Public Health: our position. With increases in life expectancy stalling, health inequalities widening and years of cuts to public health funding taking a toll on vital services, urgent action is needed.

• A literature review Defining the Indefinable: Descriptions of Aboriginal and Torres Strait Islander peoples’ cultures and their links to health and wellbeing from the Lowitja Institute and the Mayi Kuwayu Study. (Note: Mayi Kuwayu is a ground-breaking longitudinal national study of culture and wellbeing for Aboriginal and Torres Strait Islander people across the country)

• A recent paper Corporate profits versus spending in non-communicable disease prevention: an unhealthy balance in The Lancet. This looked at the total profits for the 33 largest publicly-listed, transnational companies that sell tobacco, alcohol, soft drinks, processed and fast foods – in 2017 this was US$99 billion. In comparison, full implementation of the WHO NCD Best Buys in low and middle income countries would cost US$11.4  billion. Coca Cola spends US$4 billion / year on marketing; US tobacco companies spend US$1 million / hour on advertising.


The good news story

I love to seek out good news stories. Too often it seems we are focussed on the sturm und drang https://www.merriam-webster.com/dictionary/Sturm%20und%20Drang of policy and funding failures but every day you can find something to gladden your heart and restore your faith in humankind.

Scotland explores the role of kindness in public policy

There is now a reference to kindness in the National Performance Framework (NPF), Scotland’s vision for national wellbeing, signalling that Scotland places people and relationships at the heart of its conception of the good society.

A recent paper explores how to move beyond the warm words of the NPF into the realm of the practical and even the transformational.

It proposes that in this context kindness should be defined as “what people do for one another, in response to moments of perceived need, when there is the option to do nothing”. Acts and relationships of everyday kindness literally make life “liveable” and it is thus implicit that kindness is a public value.

I hope you will read this report, think about it, and discuss it.

From Scotland’s National Performance Framework: Our Purpose, Values and National Outcomes


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.

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