Winter warmth from Cochrane

At this time of year, when the sun makes its briefest appearance, maintaining vitamin D intake is a priority, but what evidence is there that vitamin D helps prevent fractures? An updated review now includes 53 studies involving more than 90 000 men and women aged over 65 years from community, hospital and nursing home settings. It found that taking vitamin D on its own is unlikely to prevent fractures, but when taken with calcium supplements it slightly reduces the likelihood of hip and other types of fracture (doi: 10.1002/14651858.CD000227.pub4).

A small chink of sunshine for people with osteoarthritis comes with an updated review of oral herbal therapies. Forty-five new studies have been added to the original four, involving nearly 6000 participants. With over 30 medicinal plant products included, the results focus on the two with multiple studies: Boswellia serrata and avocado-soyabean unsaponifiables. For both, the evidence points towards slight reductions in pain and improvements in function, with more definitive evidence in favour of B. serrata. Evidence on side effects is uncertain (doi: 10.1002/14651858.CD002947.pub2).

The outlook is patchier in a new review of interventions to improve control of modifiable risk factors in the secondary prevention of stroke. The review included 26 studies, most lasting between 3 and 12 months, and looked at patient-level behavioural interventions and predominantly organisational ones. As one might expect with such a multifactorial issue, deciphering the results is no easy task. What emerges is that changes to the organisation of services, such as establishing integrated stroke units, are more effective at modifying risk factors, especially blood pressure and body mass index, than only addressing patient education or behaviour. For anything more substantive, such as the effects on recurrent cardiovascular events, the evidence is equivocal (doi: 10.1002/14651858.CD009103.pub2).

For those looking to indoor pursuits to keep active during the cooler months, new reviews find low-quality evidence pointing towards the benefits of yoga for primary prevention of cardiovascular disease (doi: 10.1002/14651858.CD010072.pub2), but insufficient evidence to make any claims for tai chi (doi: 10.1002/14651858.CD010366.pub2). Either way, keeping active and clear of daily distractions can’t be a bad thing.

For more fireside reading on these and other reviews, check out The Cochrane Library at www.thecochranelibrary.com.

Copayments for general practice visits

In reply: Arnold regrets that the debate about copayments is restricted to fee-for-service methods of paying general practitioners.

This is true. The Minister for Health has intimated an overhaul of the whole general practice system, but this was not addressed in the recent federal Budget. This is a pity. It would be good to have a debate about different systems, ranging from our current blended model of fee-for-service with grants to practices for achieving quality indicators, through to capitation systems (eg, the United Kingdom’s National Health Service) and salaries (common in public hospitals and in primary care in some countries).

Perhaps this is also a good moment to try to bridge the great divide between state health (mostly hospitals) and federal health (mostly general practice and private health care), which obstructs much of integrated care.

Tinkering at the edges with copayments seems too trivial.

Dear Minister, please save yourself from activity-based funding

To the Editor: There must be a better way of funding public hospitals than basing it on historical spending without analysis of activity or outcomes.

The opinion by Stoelwinder describes some of the politics and history of health funding in Australia, and argues against activity-based funding (ABF),1 suggesting that innovation is stifled in such a funding model and that “less intrusive population funding” would be preferable. The reasons for these assertions are unclear.

ABF has been the basis of funding of private hospitals in Australia for many years. The counting method is the diagnosis-related group (DRG) system that is well established and regularly revised and updated. It is transparent and accountable, and it is reasonable to apply the method to public hospitals also. When applied properly it has the potential to limit “gaming”.

Stoelwinder implies that outcome measures could be used, but these are controversial and challenging to develop and it is not yet practical to apply these as a currency for funding. The Australian Commission on Safety and Quality in Health Care and the Independent Hospital Pricing Authority (IHPA) are working jointly on options for incorporating safety and quality factors into ABF modelling, although implementation will take some time.

The funding of health care is complicated by politics. Whether or not Australia has a single funding model in the future — something that would be potentially more efficient than the complex federal system that we have currently — the work of the IHPA in developing robust methods underpinning ABF will be of enduring value. ABF is the most appropriate currently available method of funding hospitals.

Dear Minister, please save yourself from activity-based funding

In reply: Gough has missed the central argument in my article,1 which is not against activity-based funding (ABF) per se, but against the federal government’s use of it.

ABF facilitates hospital technical efficiency (cost per patient treated), as the Victorian public hospital experience will attest. However, it is arguably counterproductive to achieving allocative efficiency (optimal distribution of health services for greatest community benefit). It incentivises more hospital care.

ABF is a tool for purchasers of hospital services and, when used by private insurers, as Gough notes, it acts as a framework for negotiating prices that take into account different hospital cost structures and market positions. It is not formula funding.

I suggest the federal government fund state governments on a risk-adjusted population formula, facilitating allocative efficiency (with a focus on health outcomes) and reducing its own financial risk and administrative cost.

This would allow the states more service flexibility and would facilitate innovation in systems of care to deal with growing demand. States can still use ABF as a tool to drive technical efficiency when purchasing public hospital services.

Health services for Aboriginal and Torres Strait Islander people: handle with care

This special Indigenous health issue of the MJA features stories of successful health care services and programs for Aboriginal and Torres Strait Islander people. As we seek to build on the wealth of experience outlined, it is worth considering what these contributions have to tell us about the characteristics and value of effective Indigenous health services.

It is more than 40 years since the founders of the first Aboriginal health service recognised a need for “decent, accessible health services for the swelling and largely medically uninsured Aboriginal population of Redfern [New South Wales]” (http://www.naccho.org.au/about-us/naccho-history#communitycontrol). There are now about 150 Aboriginal community controlled health services (ACCHSs) in Australia: services that arise in, and are controlled by, individual local communities, and deliver holistic, comprehensive and culturally appropriate health care. Panaretto and colleagues (doi: 10.5694/mja13.00005) describe how these services have led the way in high-quality primary care, as well as enriching both the community and the health workforce.

With the ACCHS model setting the standard, the values of responding to community need, Indigenous leadership, cultural safety, meticulous data gathering to guide improvement, social advocacy and streamlining access have gradually been adopted in other health care settings. The progress of the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (a Queensland Health-owned service also known as Inala Indigenous Health Service), is an example (doi: 10.5694/mja14.00766). Among the hallmarks of the service’s vitality are its ever-increasing patient numbers, research output, building of community capacity, expansion into specialist and outreach services and multidisciplinary educational role.

The East Arnhem Scabies Control Program, described by Lokuge and colleagues (doi: 10.5694/mja14.00172), is a dramatic example of innovation inspired by local need. This part of Australia has the highest rates of crusted scabies in the world, and the program involved collaboration between two external organisations, an ACCHS and the Northern Territory Department of Health. Importantly, it was able to be integrated into existing health services and largely delivered by local health workers, using active case finding, ongoing cycles of treatment and regular long-term follow-up.

Mainstream health services are now beginning to take the lead from Indigenous-specific ones. For example, the repeated observation that Indigenous men and women with acute coronary syndromes are missing out on interventions and are at risk of poor outcomes inspired a working group from the National Heart Foundation of Australia to develop a framework to ensure that every Indigenous patient has access to appropriate care (doi: 10.5694/mja12.11175). The framework includes clinical pathways led by Indigenous cardiac coordinators, and it is already producing results.

There is growing evidence for the value of sound and accessible primary care for Indigenous Australians. A letter by Coffey and colleagues (doi: 10.5694/mja14.00057) highlights the significant progress towards closing the mortality gap between Indigenous and non-Indigenous Australians in the NT since 2000, temporally associated with investment in primary health care. A research report from Thomas and colleagues shows that patients with diabetes living in remote communities were more likely to avoid hospital admission if they accessed regular care at one of the remote clinics, saving both lives and money (doi: 10.5694/mja13.11316).

While the diversity of health services and the evidence of effectiveness is indeed something to celebrate, it is a fragile success. In their editorial, Murphy and Reath (doi: 10.5694/mja14.00632) highlight the need for sustained, long-term financial investment in primary health care services for Indigenous Australians and the uncertainty arising from changes to health care funding and Indigenous programs announced in the recent federal Budget (http://nacchocommunique.com/category/close-the-gap-program). The detail of how funding will be reallocated with the “rationalisation” of Indigenous programs has not yet fully emerged. Analysis indicates the cuts over 5 years include $165.8 million to Indigenous health programs, which will be added to the Medical Research Future Fund. New spending on Indigenous programs includes $44 million in 2017–18 for health as part of the Department of the Prime Minister and Cabinet Budget (Adjunct Associate Professor Lesley Russell, Menzies Centre for Health Policy, University of Sydney, NSW, personal communication).

Changes to primary care funding are of particular concern. Knowing, as they do, the importance of removing barriers to access, there is increasing public discussion that ACCHSs and large Aboriginal medical services will not pass on the proposed $7 copayment to patients (http://theage.com.au/act-news/health-service-facing-budget-blackhole-by-not-charging-copayment–20140527-zrpb7.html). This will result in a decrease in funding to services that provide vital programs and deliver high-quality outcomes. The government has stated that everyone should share the deficit burden, yet the copayment has only been targeted at general practitioners and not specialist consultations. Is this fair and equitable?

It seems ironic that this threat to access and resourcing has arisen just as it is emerging that our investment in primary care for Indigenous Australians has been well made. In an Australia where many Aboriginal and Torres Strait Islander people still face significant socioeconomic and health disadvantage, the need for “decent, accessible health services” is greater than ever.

Racism, health and constitutional recognition

Constitutional recognition is the next step to building a healthier nation, says the Australian Indigenous Doctors’ Association

The impacts of racism are significant,1 they matter, and racism is rightfully acknowledged as a determinant of health for Indigenous populations worldwide.2 Recent research shows that experiences of racism and discrimination remain prevalent in Australia, through race-hate talk, race-based exclusion and physical attack.3 Correspondingly, there is evidence associating racism with poor outcomes in contemporary and historical contexts, via colonisation and oppression.4

From before birth, we are connected to family, community, culture and place. These interactions continue through life to form relationships which are crucial to belonging and to the construction of identity. This includes relationships with people and place, such as the actions and responses of others. Knowing about your own history and culture elucidates contemporary cultural ways of being, by providing a connection to the knowledge of ancestors. These connections are viewed as protective factors and contribute to building a strong sense of self and identity.5

Protective factors are inextricably linked to health and wellbeing, making the protection and promotion of culture critical to improvements in Aboriginal and Torres Strait Islander health. For Aboriginal and Torres Strait Islander people, our culture is a source of strength, resilience, happiness, identity and confidence. This philosophy embeds the importance of cultural safety into our daily practice. We do this because we know Aboriginal and Torres Strait Islander people are more likely to access, and will experience better outcomes from, services that are respectful and culturally safe.6

Thus, a focus of the work of the Australian Indigenous Doctors’ Association (AIDA) is promoting culturally safe learning environments for Indigenous doctors and medical students, and culturally safe service delivery to Indigenous patients. Cultural safety is about overcoming the cultural power imbalances of places, people and policies to contribute to improvements in Aboriginal and Torres Strait Islander health.7

We work within a strengths-based framework because conveying positive messages has the potential to make a significant contribution to changing public perceptions and attitudes.8 The media is, however, not bound to report in this way; it often focuses on stories of deficit. This type of reporting can fuel racist attitudes.8

Negative framing in the media weighs into current debates about the Racial Discrimination Act 1975 (Cwlth)9 and the debate about amending Australia’s constitution to recognise Aboriginal and Torres Strait Islander peoples as the First Australians.10 AIDA continues to support the maintenance of robust antiracial vilification laws as a necessary mechanism contributing to shape a health system that is culturally safe and respectful to all who access it.

Constitutional recognition is the next step in developing a healthier nation. Recognising Indigenous Australians as the First Nations peoples will enrich the identity of the nation and make significant steps towards reconciling past injustices. The current Constitution still provides a head of power that permits the Commonwealth Parliament to make laws that discriminate on the basis of race.10 The previous occasion on which protections under the Racial Discrimination Act were suspended was when activities were being implemented under the Northern Territory Emergency Response. At the time, AIDA advocated for the reinstatement of Section 9 of the Racial Discrimination Act, owing to the negative impacts that the suspension placed on the health and wellbeing of Aboriginal and Torres Strait Islander people in the Northern Territory.11 Recognising our rightful place as First Nations people in the constitution lays a strong foundation for the health, wellbeing and unity of all Australians. While it will not wash away the grave injustices of the past, with such recognition there is capacity to heal the deep wounds that affect health outcomes and continue to weigh heavily on Australia as a nation.

The medical community has a role to play in promoting Aboriginal and Torres Strait Islander recognition in the constitution. AIDA, as the peak body for Aboriginal and Torres Strait Islander doctors and medical students, will work with its peers in the medical community, as well as more broadly, to support this constitutional reform to achieve the sustainable, unifying and positive benefits that are envisaged for all Australians.

The imperative for investment in Aboriginal and Torres Strait Islander health

Evidence points to a “good return” from funding comprehensive primary care services for Indigenous people

This issue of the Journal showcases the work of health services in Aboriginal and Torres Strait Islander health care settings across Australia. The research reported provides clear indication of where funding is likely to improve the health of Indigenous peoples. It also creates an economic imperative for action, in addition to the social justice arguments made elsewhere.1

The health care gaps highlighted require policy responses and long-term financial investment. However, there is uncertainty over the ongoing funding of many Closing the Gap initiatives as well as Aboriginal community controlled health services (ACCHSs) and Medicare Locals. There is also no certainty to the future of the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.2

Panaretto and colleagues describe outcomes achieved by ACCHSs3 among a population poorly served by the health system.4 They see the ACCHS model of comprehensive, holistic, ongoing primary care as being akin to the medical home model widely espoused in Australia and internationally.5 They also note that its benefits in terms of employment are an important contributor to the economic benefits of ACCHSs.6

Two studies from the Northern Territory show the need for increased investment in Indigenous primary health care. Using a rigorous mixed-methods approach in a remote clinic, Gador-Whyte and colleagues estimated that providing the recommended standard of care for patients with type 2 diabetes and chronic kidney disease would require a 44% increase in funding (an additional $1733 per patient per annum).7 Thomas and colleagues suggest that covering such a shortfall would be cheaper than picking up the costs in the hospital setting. Their analysis showed that for patients with type 2 diabetes, each dollar invested in primary care could save up to $12.90 in hospital costs.8

In their study of 24 “sentinel sites” around Australia, Bailie and colleagues found that despite increasing rates of Aboriginal and Torres Strait Islander health assessments, the follow-up needed to improve health outcomes was not being consistently taken up.9 This further illustrates the importance of supporting the development of primary health systems, as does a recent systematic review showing benefit from health checks by the patient’s usual primary care doctor.10 Bailie et al call for health service support “in developing systems and organisational capability to undertake follow-up of health assessments, but more importantly to reorient to high-quality, population-based and patient-centred chronic illness care” — the sort of care that requires increased investment in primary health care.7

The local and international evidence is unequivocal: affordable, effective and equitable health care requires well supported, comprehensive primary health care. The ACCHS model achieves these outcomes. What is required now is ongoing commitment to targeted funding by state and federal governments, starting with implementation of the National Aboriginal and Torres Strait Islander Health Plan;2 commitment to ongoing long-term funding for Closing the Gap initiatives; and long-term investment in services delivering primary health care to all Aboriginal and Torres Strait Islander people — in particular, ACCHSs. This is not only required for equitable health care but also makes sound economic sense.

This investment is clearly a critical issue in light of the proposed federal Budget cuts to Aboriginal and Torres Strait Islander health initiatives.11 There is also clear evidence that out-of-pocket costs have a direct impact on access to health care.12 The GP copayment will pose a barrier to accessing the level of primary health care suggested by Thomas et al as being likely to save hospital costs. We hope it is not too late for a commitment to ongoing long-term funding for Closing the Gap initiatives and long-term investment in primary health care delivery to all Aboriginal and Torres Strait Islander people.

The shape of things to come: visions for the future of Aboriginal and Torres Strait Islander health research

In 2013, the Lowitja Institute embarked on a project using futures thinking to consider how research might best contribute to Aboriginal and Torres Strait Islander health and wellbeing in the year 2030. Futures thinking — a growing discipline in research and management — is not about predicting the future, but rather about identifying a number of possible and plausible futures. It differs from traditional research methods in that it draws on deeper intuitive insights as well as hard evidence.

Workshops were held nationally to consider possible scenarios based on two divergent futures: an inclusive, vibrant Australia in which Aboriginal and Torres Strait Islander cultures are valued and embraced as central to the Australian identity; and an Australia in which economic and spiritual poverty drive a rejection of diversity and increase the divide between rich and poor.

The response from our consultations was not simply a list of research topics. Rather, participants articulated a strong and widely shared desire for a profoundly different system of research — a system in which research and practice are closely interwoven and which enables greater integration of health services, policy and research. Such a system would be responsive to changing research demands, but also to changing social, economic, technological and knowledge landscapes. This builds on work and methods developed by the Lowitja Institute and its predecessor organisations over the past 20 years.

Consultations also identified an urgent need to address the social determinants of Aboriginal and Torres Strait Islander health, along with a growing sense that the health and health research sectors need to play a facilitating role, inviting other sectors — such as early childhood, education, justice and local government — to collaborate and maximise the impact of their collective efforts to bring about change.

Finally, the project identified that the Aboriginal and Torres Strait Islander health and health research sectors have played a pioneering role in the reform of research in Australia. In its role as an enabler of health research solutions, the Lowitja Institute will work with its partners to respond to this vision in our current and future work.

The report is available at https://www.lowitja.org.au/lowitja-publishing.

Indigenous health: radical hope or groundhog day?

Professor Ernest Hunter explains why learning from the past and investing strategically will have the best chance of success

In his book Radical hope: education and equality in Australia, Aboriginal lawyer, academic and land rights activist Noel Pearson contends:

Governments and their bureaucracies are informed by everything other than memory of what was done five years ago, ten years ago and eighteen years ago. Politics are remembered, policies are not.1

It also includes his 2004 Judith Wright Memorial Lecture, in which, reflecting on the political forces necessary to drive national change in Indigenous affairs, he notes:

it will take a prime minister in the mould of Tony Abbott to lead the nation to settle the “unfinished business” between settler Australians and the other people who are members of this nation: the Indigenous people.1

A decade on, Tony Abbott, as Prime Minister, delivered the Closing the Gap report.2 Having identified that his government’s new engagements will involve centralising responsibility for Commonwealth-funded programs in the Department of the Prime Minister and Cabinet, setting up the Prime Minister’s Indigenous Advisory Council and fostering linkages between bureaucrats, business and Indigenous leaders, he details mixed outcomes across four key areas — health, education, employment and safe communities. The outcomes were consistent with the Closing the Gap Clearinghouse report released a year earlier,3 which identified key high-level principles and practices characterising programs that worked: flexibility to meet local needs and contexts; community involvement and engagement; building trust and relationships; a well trained and resourced workforce; and continuity and coordination. Themes associated with less successful initiatives included: programs implemented in isolation; short-term funding and high staff turnover; lack of cultural safety; and inflexible program delivery. Similar issues emerged in a recent review of early childhood parenting, education and health intervention programs.4

Clinicians working in remote Australia will not be surprised. There have been health gains, but they are uneven: remote Indigenous Australia is clearly behind. Furthermore, it can be argued that for some conditions and in some areas the situation is worse despite significant clinical investments. For instance, when I began work as a psychiatrist in Cape York and the Torres Strait over 20 years ago, there were no mental health or substance misuse services. Now there are well over 100 workers across Queensland Health, Education Queensland, the Royal Flying Doctor Service, Medicare Locals, community-controlled services and Commonwealth-funded programs, plus contracted private clinicians. This does not include the dozens of residents trained variously in community and personal wellbeing, empowerment, mental health literacy, suicide prevention and more. Sadly, the situation in terms of mental illness is worse, probably reflecting both contemporary social contexts and delayed effects of neurodevelopmental adversity.5,6

Our understanding of the developmental determinants of chronic disease in Indigenous Australians has been evolving for more than half a century7 and there is accumulating evidence on childhood social factors increasing the risk of adult-onset mental disorders. For example, bereavement stress in mothers during the first years of life (particularly after suicide in the family) increases the risk of affective psychosis.8 Research on such topics involves controlling for potential confounders. In the real world of remote Indigenous communities, many children are exposed to serial adversity: pregnancies affected by high levels of stress; poor nutrition and inadequate antenatal care; prematurity; infant environmental instability and attachment difficulties; hospitalisation and other forms of separation from caregivers; bereavement stress; exposure to violence; early-onset substance misuse; and more. We can only presume that the consequences of such risk amplification will be substantial.

In 2006, soon after Pearson commended him, Tony Abbott called for a new form of “paternalism” that would be “based on competence rather than race” to address unrelenting Indigenous health problems associated with failed past policies such as self-determination.9 Now, he holds the reins. But whatever happens, the economic agenda will weigh heavily; Indigenous Australians will not be quarantined from budget cuts, changes to Medicare and welfare entitlements, privatisation, and the continuing feud between federal and state governments over health funding. In Queensland, public sector services (particularly population health and health promotion) sustained dramatic losses in the 2012–13 financial year that will be most consequential for remote Indigenous communities. Career public sector employees are giving way to locums, casual workers, agency nurses and project workers funded by non-government organisations. While this may bring new ideas, it risks losing domain knowledge and incremental improvement based on practice-based evidence.10

While there is no doubt that greater economic self-reliance will be critical to Indigenous futures, I believe that there is complacency regarding the flow-on effects of the contraction of federal and state public sectors for Indigenous health in remote Australia. Indeed, to support self-reliance in the long term, it is critical that we increase and sustain strategic investment in public health and clinical programs for pregnancy and early childhood to optimise neurodevelopmental potential. Is it “radical hope” to suppose that the new paternalism and new engagements will deliver? Or, as Pearson suggests in his chapter on cycles of policy reinvention in Indigenous affairs, will it be groundhog day?

Reports indicate that changes are needed to close the gap for Indigenous health

To the Editor: The summation by Russell that “the inescapable reality is that current primary care interventions are not working”1 overlooks evidence of significant improvements in the Northern Territory. The latest “closing the gap” report indicates that the Indigenous mortality gap in the NT should close within a generation.2

Mortality among NT Indigenous adults has declined by a third since 2000.2 We attribute this positive outcome primarily to effective use of primary health care funding, which has been progressively increased and equitably distributed, since 2001. This money has funded universally adopted e-health solutions and NT key performance indicators, which drive continuous quality improvement initiatives. These are backed by common clinical guidelines, with increasing adherence rates, that are used in all Aboriginal primary health care clinics.3

The statement “ACCHOs [Aboriginal community controlled health organisations] have had little influence on the mainstream health system”1 neglects experience in the NT, where the ACCHO sector is a co-owner of the NT Medicare Local and remains a critical driver in the NT Aboriginal Health Forum (NTAHF). Now in its 15th year, the NTAHF has secured government support for community control as the preferred model for delivering Aboriginal primary health care. The ACCHO sector is also a leader in developing and using clinical guidelines, mental health services, e-health, and continuous quality improvement programs. National policy should support the expansion and enhancement of Aboriginal community controlled primary health care services.