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What will the regional agreement mean for health? And a call for Indigenous health reform

In the months before the election, it was widely assumed that health reform would be a red-hot election issue. It wasn’t.

Mental health was one of the few health issues to press political buttons in the run-up to the election but hasn’t figured prominently since.

Rural health, meanwhile, barely rated even a rhetorical flourish during the campaign, but is now hot, hot, hot.

What then might the agreement between Labor and the two government-making independents mean for health in general, and rural health in particular? My somewhat hopeful stab at an answer, in this piece in today’s Crikey bulletin, is that maybe it will help us move towards a more equitable health system that is based more around the community’s needs.

Perhaps the agreement and its proposals around parliamentary reform and political donations may also have some broader public health implications. Perhaps there will be opportunities to reduce the political influence of tobacco, alcohol and junk food industries?

Meanwhile, thanks to the Croakey contributors below for sharing their thoughts on the implications of the agreement for rural health and for responding to some of the issues raised in my Crikey piece:

My thoughts on ‘Independents Day’

Professor John Wakerman, Director, Centre for Remote Health, A joint Centre of Flinders University & Charles Darwin University:

(Please note that this is a revised version from the preliminary comments first posted)

I amused at the shock of some commentators that the independents should be wielding the power handed to them through our democratic electoral system.

They are politicians, after all, using this opportunity to do the best they can for their electorates. That is what politicians do and I would be critical if they were doing anything less.

Did they negotiate some specific funding for developments in their electorates? Yes they did. At the same time, the fact that they have prioritized an amelioration of the working of Parliament attests to their commitment to the broader electorate.

The media too are going to have to adjust to the ‘new paradigm’.

The first outraged question at the independents’ press conference was along the lines of: doesn’t this shocking rural pork-barrelling mean that metropolitan Australia is subsidizing the bush? A more careful perusal of the $10bn package for the bush shows that much of it is existing funding, not new funding. Some has been prioritized for the bush. There will be specific ‘Regional Priority Rounds’ of Health and Hospitals Fund and Education Investment Fund infrastructure funding.

For other programs – existing primary care infrastructure funding and a range of education programs – the commitment ensures that about one third of funds go to the bush. The one third commitment is not about equity, but an amount commensurate with the population proportion. Equity means giving more to those with greatest need. So, overall, the proposed program of funding, spread over a number of years, is quite modest; especially given the poor infrastructure in remote and rural areas.

In terms of sudsidy, I could go on for some time about social and cultural identity, and about environmental maintenance issues; but suffice it to ask: where do city folk think the food and minerals come from?

If cross-subsidies are inherently bad, the logical conclusion is to spend government revenues from mineral resources only in remote regions of WA, SA, Queensland and NT.

The other criticism relates to the poor social and economic circumstances of some living in urban areas. Of course there are problems in metropolitan and outer metro areas in particular. It shouldn’t be an ‘either/or’ argument. However, locational disadvantage is a critical  factor, which I often hear discounted by the ‘outer metro argument’. Accessing a hospital for a resident of Mt Druitt is something quite different to access from Kintore.

Of greater medium to longer term importance than this funding quantum is the agreement to ‘restructuring the Government, Public Service and Parliament’, including a Cabinet level Minister and a Department for Regional Australia, a co-ordinating unit in PM&C, an Office of Northern Australia, as well as a think tank – the Regional Policy Centre – to better meet the needs of the rural population.

The window of opportunity for rural matters last opened this widely in the 1990s, when a disaffected rural electorate resulted in the rise of Pauline Hanson and the defeat of the Kennett state government. I applaud the two rural independents for their advocacy for the bush and for the broader good of Australia

***

Perish the talk of  “rent seekers”

Gordon Gregory, National Rural Health Alliance:

After years of neglect of rural, regional and remote communities, it’s b- galling to hear people talk of ‘stripping money from city electorates’ and of the new government being ‘hostage to rent seekers’.

Since when is moving to close the life expectancy gap between country and city ‘rent seeking’? Why should people in more remote areas pay more for telecommunications in this day and age than people in major cities?

Although there are a few ‘wilkies’ in the deal secured by Tony Windsor and Rob Oakeshott, people throughout rural and regional areas should be grateful for what they have set in place.  Never mind the motives of the two major parties: it is now the case that there is effectively bipartisan support for a regional package – right across Australia, not just in Tamworth and Port Macquarie.

Windsor and Oakeshott are to be commended for looking beyond their own electorates to the broader needs of regional Australia.  Once promoted to Cabinet, a politician’s responsibility is no longer merely to their own electorate.  Effectively Windsor and Oakeshott were in Cabinet for 17 days and good on them for recognizing the national interest.

The work of the NRHA is based on notions of social justice and equity and we recognize that there are many people in metropolitan areas who, because of low income, disability, isolation and chronic illness are very poorly off. Hopefully the current situation is one in which rural and regional people can again be at the forefront of work to produce a fairer Australia all round – partly due to the ‘new paradigm’ reflected in parliamentary change.

***

Challenges ahead

Jennifer Doggett, health policy analyst:

It will be a continuing challenge, as medicine becomes more specialised and reliant on sophisticated technologies, to ensure equity of access to health care for people in rural and regional areas.

Many highly specialised services simply cannot be provided in the bush to the same degree of safety and quality as they can in big cities.  What will be important is to focus on linkages between services that should only be provided in urban areas and those that can be provided locally (diagnostic, rehab etc) so that people from rural communities can receive as much care as possible in their local areas.

It’s also essential to ensure that the transition to and from urban-based centres of care to local care providers is as smooth as possible.  Involving consumers as much as possible in developing and evaluating pathways of care is essential.

It’s also important that communities have input into determining the appropriate balance between safety/risk levels and local availability of services. It may be that many consumers in regional and rural areas are happy to accept a slightly higher level of risk in return for the benefit of accessing a service locally.

For example, women may choose to give birth in their communities, even if they do not have a surgical facility available locally in case a caesarean section is required.  Indeed there may often be health benefits associated with accessing care locally, which a narrow definition of safety and risk do not take into account.  This can only be assessed when consumers are closely involved in making these decisions.

***

Addressing inequity is easier in the cities

Professor Lesley Barclay, Northern Rivers University Department of Rural Health

I agree that inequities exist in the cities, but they are easier to address when distance and transport are not such big issues – also easier for patients who are not out of pocket for treament and travel/accommodation.

***

Push for reform of Aboriginal and Torres Strait Islander health financing

Meanwhile, this is an edited version of a statement issued today by the Qld Aboriginal & Islander Health Council, calling for a “multi-partisan”approach to Aboriginal health reform:

The Council has called on the Gillard Government and Abbott-led Opposition to build on recent consensus negotiations with the Independents and Greens and enact long-overdue reforms to the health sector to better support Aboriginal and Torres Strait Islander people.

The Council’s CEO, Mr Selwyn Button, said the new era of consensus politics in Canberra as political parties are forced to negotiate with Independents and minor parties can lead to a more constructive approach to reforms in delivery of health services for Indigenous people.

“The Aboriginal and Islander health sector in Queensland is heartened by the changes to parliamentary processes forced by the Independents, including a daily “acknowledgement of country”, which will for the first time in Australian history remind our elected representatives that they meet on Aboriginal land.

“While this reform is important there is need for more practical rather than symbolic changes and this new Parliament can really make a difference by acting on ample research evidence and implementing urgently needed changes to the way health services for Aboriginal and Islander peoples are designed, delivered and managed.

“An additional $41 million to regional GP services and Aboriginal Medical Services, part of the $9.9 billion regional package negotiated with the Independents, will also be very welcome but we really need some structural reform around financing and transferring responsibility for primary health care to Aboriginal and Torres Strait Islander controlled health services in remote areas,” said Selwyn Button

“While we strongly support the Council of Australian Government (COAG) health system reforms through the National Health and Hospitals Agreement and the Close the Gap initiative, we want the Government to take up the National Health & Hospital Reform Commission’s recommendation that there be only one level of government financing Aboriginal Comprehensive Primary Health Care rather than the complexities of the current funding model.

“The burden of a mind numbingly complex system of funding, sometimes from up to 60 different sources, needs to end and be replaced by one source of funding so our medical services can concentrate on their real job of delivering effective primary health care rather than the incredible waste that comes from having to provide each of their funding sources with complex reports and acquittals.

“Financing of remote Aboriginal and Torres Strait Islander health should also be done on a per capita basis and should reflect the different burdens of illness which apply to Aboriginal and Torres Strait Islander people and the additional costs associated by the remoteness of many communities.”

He said there was ample evidence that the current system of funding was both inefficient and inequitable with recent QAIHC research showing Medicare-related expenditure in medical and pharmaceutical benefits in Cape York came in at around $215 per capita while the disadvantaged residents of Sydney’s Double Bay enjoyed Medicare funding at around $900 per capita.

“The evidence supporting our arguments for finance reform is compelling and we intend to make advocating for this reform a priority,” said Selwyn Button. “We’ll be meeting with all parties, including the Greens and the Independents, as soon as possible to discuss support for the reforms across the whole Parliament.

“Our members have just endorsed a major document at the recent QAIHC Member’s Conference, the QAIHC Blueprint for Reform, outlining other areas for reform and will take this to Canberra as part of our efforts to influence the current health reforms.

“We understand comprehensive primary health care better than most; we know the obstacles to achieving success and we have spent years developing the capacity to provide world class health care to some of the world’s sickest people so our voice must be heard in the current debates and discussions around national health reform.

“We must be heard in debates around reforms to mainstream health delivery and not restricted to comments on the close the gap strategy,” he said. “We need to understand that our people are consumers of so-called mainstream services such as hospitals and general practice clinics as well as their local Aboriginal Medical Services and restricting our voices exclusively to discussions around specific Indigenous services both marginalises us and undermines national efforts to get the best possible health service for Aboriginal and Islander peoples.”

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