Even brain surgeons bamboozled by Govt policy process

AMA President Professor Brian Owler has confessed he is struggling to follow the logic and coherence of a flurry of health policy and tax reform announcements made by the Federal Government ahead of a crucial Council of Australian Government’s meeting.

Professor Owler said it had become “difficult to follow the logic” of Government pronouncements on public hospital funding after Prime Minister Malcolm Turnbull unveiled a shock proposal to hand over some income tax revenue powers to the states just a day before meeting with his State and Territory counterparts.

“I am AMA President and I’m a brain surgeon with a PhD and I’m struggling to keep up with the policy process,” he told ABC News 24. “I mean, we’ve been talking about COAG and tax reform, Federation reform, productivity reviews, multiple reviews in health, and we still don’t seem to have a coherent vision for the path forward.”

In his proposal, Mr Turnbull suggested the states be given power to levy income taxes of their own, while the Commonwealth would reduce its own income tax take, keeping overall income tax receipts the same.

But Professor Owler lambasted the idea, which he said would do nothing to increase funding to hospitals, and would instead exacerbate existing inequalities between the states in the delivery of hospital services.

“If you’re relying on income tax revenue, then that is going to disadvantage the smaller states,” he said. “I mean, it is becoming more and more difficult to follow the logic around funding of public hospitals and the tax policies that are coming from the Government.”

Professor Owler said the Government seemed to be taking an ad hoc approach to major policy challenges.

“We’ve had months to sort this out, yet the policy seems to be leaked out a few days, seemingly made on the run, a few days before a COAG meeting. I don’t think that is the way that policy should be developed, particularly when it’s such an important long-term policy.”

Adrian Rollins

[Perspectives] A course in reversal

A landmark clinical trial published in this journal in 2006 expanded the evidence base for breast cancer screening with mammography. Subsequently, the US Preventive Services Task Force—a major advisory body for screening guidelines—reconsidered its recommendation for routine mammography among women aged 40–49 years. Vinayak Prasad and Adam Cifu point to this turnabout as an example of “medical reversal”: when a current clinical practice is found to be ineffective or inferior to a previous standard of care.

Hospital funding deal ‘not enough’

A deal to inject up to $7 billion from the Commonwealth into the public hospital system was being mooted ahead of this Friday’s Council of Australian Governments meeting amid warnings it will not be enough to sustain services in the face of spiralling demand.

As Australian Medicine went to print, speculation was mounting that Prime Minister Malcolm Turnbull was close to arranging a deal with his State and Territory counterparts to provide a multi-billion dollar funding boost to public hospitals amid warnings that $57 billion of cuts unveiled by the Abbott Government in 2014 would plunge the system into financial crisis and cause a blow-out in waiting times.

Less than a week after meeting with AMA President Professor Brian Owler and the AMA Federal Council on 17 March, Mr Turnbull told reporters he would “have more to say in the lead-up to [the COAG meeting] relating to health and schools and so forth”.

At the AMA meeting, the Prime Minster showed keen interest in reports from Council members that public hospitals were experiencing a rapid increase in demand that vastly outstripped the pace of population growth.

Mr Turnbull wanted to know why this was occurring, and was told a big factor was increased life expectancy, which meant that patients were more likely to present with multiple chronic health conditions that were more expensive and complex to treat, placing huge demands on hospital resources.

These stresses have been reflected in the AMA’s Public Hospital Report Card released earlier this year, which showed that improvements in the performance of public hospitals had already stalled, and in some respects were starting to go backwards.

Professor Owler said this was only going to get worse as big Budget cuts began to bite next year, and warned that suggestions the Federal Government might stump up $6.7 billion over four years, to be shared among the states, would not be enough.

It is understood the Government was considering an increase in the tobacco excise and reduced tax breaks for superannuation to provide the extra funds.

But the AMA President warned that injecting an extra $6.7 billion into the system was inadequate.

“[The] figure of $6.7 billion has been talked about over the next four years to deal with both health and education, …I’m afraid that’s just not going to cut the mustard. It’s not going to mean that states can continue to provide the level of services that patients expect and deserve,” he said. “By any stretch of the imagination, cobbling together $6.7 billion over a four year period for states and territories to fund health and education is just not going to make it.”

Professor Owler said the Commonwealth needed to dump plans to index hospital funding at inflation plus population growth, which he said was completely inadequate to ensure hospitals were able to maintain their services.

Adrian Rollins

Photo: Nils Versemann / Shutterstock.com

Alcohol and tax — time for real reform

Alcohol tax reform would reduce harm and costs — and could fund major prevention and treatment programs

Australia’s first comprehensive report on drugs was entitled Drug problems in Australia — an intoxicated society? This 1977 report from the Senate Standing Committee on Social Welfare noted that alcohol “now constitutes a problem of epidemic proportions”. The Committee concluded that, given the extent of the problem, “any failure by governments or individuals to acknowledge that a major problem — and potential national disaster — is upon us would constitute gross irresponsibility”.1

Many of the report’s recommendations are as valid now as they were four decades ago, particularly in relation to alcohol advertising (including the “appeal to sportsmen and sportswomen throughout Australia not to lend their names and prestige to the promotion of alcoholic beverages”), effective controls on availability of alcohol, and use of pricing mechanisms to reduce alcohol use and harm.

It has become increasingly clear that in dealing with harm from alcohol, price matters. There is now an overwhelming consensus from leading Australian and international health authorities and researchers that alcohol taxation is one of the most effective policy interventions to reduce problems related to alcohol.2 The World Health Organization has identified alcohol tax increases as a “best buy” intervention in reducing harmful alcohol use.3 Even small increases in the price of alcohol can have a significant impact on consumption and harm at the population level. However, alcohol taxation and other pricing strategies have been underused in Australia as a component of the comprehensive approach required to reduce harm from alcohol.

At a time when tax reform is high on the political agenda, there is near-universal agreement that the current approach to alcohol taxation in Australia is complex and that change is long overdue. The Henry Tax Review described the alcohol tax system as “incoherent” and the Wine Equalisation Tax (WET) in particular as “not well suited to reducing social harm”.4 Others have described the system less flatteringly. Some 16 different excise categories apply, depending on the type and volume of alcohol and container size. Taxes on spirit products are at the upper end of the scale; draught beer taxes are at the lower end. Wine is treated differently; the WET is based on the wholesale price of wine, not its alcohol content. The WET is why cask wine can be promoted and sold for as little as 18 cents per standard drink, or $1.80 per litre — cheaper than many bottled waters — contributing only 5 cents per standard drink in tax. The system is further complicated by producer rebates and concessions, some of which are no longer appropriate, such as the WET rebate. The WET is effectively a subsidy, propping up the production of low-value wines.

Health groups are in broad agreement about the key principles that should guide tax reform if the alcohol tax system is to play a more effective role in reducing harm and promoting a lower-risk drinking culture. Approaches to alcohol tax and price should reflect that alcohol is no ordinary commodity and is associated with substantial health and social costs. A volumetric approach that applies to all alcohol products should be central to reform, with tax increasing for products with higher alcohol volumes.5 A tiered system that includes stepped increases in tax rates would provide economic incentives for the production and consumption of lower-strength alcohol products and help ensure that the prices of some other products do not drop substantially.6

A minimum floor price set at an appropriate level would support and complement a volumetric approach, in particular by targeting the heaviest drinkers who consume the most. A minimum price would restrict the ability of alcohol retailers to heavily discount products, thus undermining the tax strategy, and has been strongly supported by groups concerned about alcohol-related problems in Aboriginal communities.7

Other important principles include: there should be an overall increase in alcohol tax collected; the real price of alcohol should increase over time; and changes to the tax system should not decrease the price of alcohol products, other than for low-alcohol products.

In contrast to the consensus among health groups, the alcohol industry is deeply divided on the best approach to alcohol taxation. Arising from the existing variation in excise levels between product categories, the commercial interests of the wine, beer and spirits industries do not necessarily align in relation to tax reform. There is even division within specific industry groups; for example, between premium wine producers and high-volume, low-value wine producers. In its submission responding to the government’s March 2015 Tax discussion paper, the Winemakers’ Federation of Australia (WFA) noted that “Consultation with industry has confirmed mixed views on the optimal tax platform for the Australian wine sector … As such, WFA does not hold a position on the preferred structure for wine tax”.8 WFA did, however, affirm that the industry agreed on its opposition to both increasing the level of wine tax revenue and reforms driven by social policy objectives. The divisions between and within industry groups are expected to add to the challenges for government in navigating the range of interests and objectives associated with alcohol tax reform.

Alcohol consumption patterns in Australia are very different now to those in earlier decades, when beer was king, Australian-owned companies dominated and hotels were the drinking venues of choice. Now, beer is in decline (in 2013–14, beer contributed 41.3% of the total alcohol available for consumption, wine 37.5%, spirits 12.6% and ready-to-drink pre-mixed beverages 6.3%),9 most of the major alcohol companies are overseas-owned, and some 80% of alcohol is sold from retail outlets, primarily chain stores.

There are some encouraging trends, particularly among adolescents10 — but alcohol remains pre-eminent as a cause of preventable social and community harm. While the tragedies arising from city-centre violence and road crashes attract regular media coverage, there is also increasing community understanding of alcohol’s many hidden and longer-term harms: from domestic violence to cancers, from fetal alcohol spectrum disorder to damage to the developing brains of young drinkers.

As ever in public health, there are no simple, short-term solutions. As is so often the case when profitable products are involved, there is strong, well funded and often misleading resistance to effective action. There is, however, good evidence to support implementation of a comprehensive approach — with carefully implemented tax reform at the forefront.6

One additional reform to the alcohol tax system could bring profound benefits to the community. Around the country, alcohol treatment and support services are stretched, funding for prevention is barely visible, and the latest Australian Institute of Health and Welfare expenditure report shows that in the 2013–14 financial year, all public health attracted $2.22 billion — an almost derisory 1.5% of total health funding.11

The federal government derives over $8 billion annually from the taxes and excise duties levied on alcohol.5 In addition to health and social harm, the annual costs of alcohol to the economy are estimated at upwards of $15 billion.12 Further, the government’s annual revenue includes more than $200 million from underage drinkers and almost $2 billion from drinkers under the age of 25 years.13

Historically, Treasuries are not keen on hypothecated taxes, but there are good precedents,14 notably for tobacco where, in the days of state tobacco licence fees, tax increases were successfully used to fund public education and to replace tobacco sponsorship of sport, as well as to provide governments with additional revenue for their general programs.

Many reports in recent decades have recommended additional funding for alcohol prevention and services, both for the community overall and for specific priority groups. A 2015 report commissioned by the Foundation for Alcohol Research and Education concluded that: “By removing the privileged treatment of wine, the government could receive increased revenues in the order of $1 billion each year”.15 Even half of this would enable the establishment of a dedicated National Alcohol Prevention, Treatment and Services Program that could make Australia a world leader in reducing alcohol harm, to match its record in tobacco control.

Such a program would enable the government to provide desperately needed funding for national and local services, to work with and support Aboriginal and other communities in their efforts, and to develop a comprehensive approach to prevention. The funding would enable establishment of a major research-based national public education program, along the lines of the successful 1990s National Tobacco Campaign, as well as better support for enforcing current legislation (including sales to minors), independent controls on alcohol marketing, development of research-based warning label messages, and a range of further national and local activities.

The arguments in favour of alcohol tax reform linked to increased funding for prevention and services are that this will reduce direct and indirect harm, will reduce costs to the health and law enforcement systems and to the community, and will bring special benefits for young people and disadvantaged communities.

The arguments against reform will come from the powerful and massively funded alcohol industry and its allies, which will support the continuation of ineffective policies and oppose anything that might have a serious impact on alcohol use — and hence on alcohol harm.

At a time when there is continuing community and political concern about the impacts of alcohol, broad election policies are being developed and tax reform is under discussion with assurances that “all options are on the table”,16 there is an opportunity for health groups to press for comprehensive policies that include a clear commitment to alcohol tax reform. This will require strong and consistent communication of the substantial evidence base for reforming alcohol tax to improve health, as well as appropriate responses to misinformation likely to come from vested interests.

Failure by governments to act will now, as 40 years ago, “constitute gross irresponsibility”.

[Comment] Sustainable development and global mental health—a Lancet Commission

In 2007, The Lancet published a groundbreaking Series on global mental health that ended with a call to action to scale up services for people with mental health problems guided by the twin principles of the right to evidence-based care and the right to dignity.1 This Series helped catalyse a movement that has raised the profile of mental health in public policies and promoted research, capacity building, and delivery of mental health care worldwide. The Series also influenced the launch of the Grand Challenges in Global Mental Health,2 which, in turn, inspired substantial funding commitments.

Compliance – not just an individual responsibility

Most GPs know that, under the Health Insurance Act, if they engage in inappropriate practice they will be held to account by a Professional Services Review Committee comprised of their peers.

What seems to be less understood is that it is also an offence under the Act if a person or officer of a body corporate knowingly, recklessly or negligently causes or permits a practitioner employed by them to engage in such conduct.

Now that the responsibility for compliance policy has shifted from the Department of Human Services (DHS) to the Department of Health (DoH), it can be expected we will see an increased focus on the forces within a practice that encourage or silently condone inappropriate practice. While it has previously been difficult to assess this, the DoH is moving to make greater use of data analytics and behavioural economics to identify potential problems.

In utilising these tools, the DoH hopes that it will be able enhance the Department’s understanding of how policy impacts compliance, and better identify clusters of divergent billing behaviour. This will also inform compliance feedback, as well as the Department’s education resources and activities.

This shift in focus has in part come about following the findings of the Large Practices Project. This project was undertaken in recognition of the changing nature of general practice, with the increasing shift from small owner-operated medical practices to large corporate medical practices.

The Large Practices Project found that practice managers and staff have more responsibility for billing than expected. Most GPs learn about billing Medicare on the job or via word of mouth, and practice or business protocols affect the accuracy of Medicare billing. It was found that the culture of the practice, rather than its size, can have a significant influence on claiming behaviour.

These findings have reinforced the need for accessible education materials, and for targeted feedback on billing practices. Feedback has to be specific and directly relevant if it is to be valued and truly informative.

Medicare compliance and appropriate billing is not only an issue for each of us individually, but also as a profession. It goes to our professionalism as GPs and, when inappropriate billing practices are allowed to flourish, a knee jerk policy response is often the result, with MBS rules invariably tightened to reduce the risk of inappropriate use of MBS items. The recent restriction on claiming an item 23 with 721 is a case in point.

Thanks to AMA advocacy, practitioners who are unsure about what a MBS items covers or can be claimed for have available at their fingertips an enquiries email and a number of educational resources. Using the medicare.prov@humanservices.gov.au email for a MBS interpretation or claiming question ensures you receive the answer in writing, which is handy should a compliance issue on that matter arise. Various education resources are also available at https://www.humanservices.gov.au/health-professionals/subjects/education-services-health-professionals.

The AMA will continue to work with the DoH and the DHS to ensure compliance activities focus on supporting GPs and offering meaningful feedback and effective education.

We all know that GPs are very busy, and try to work within the system as they understand it. Punitive approaches don’t work, and compliance breaches are often simply the result of overly complex rules that are difficult to interpret or not reflective of modern clinical practice.

Rural health – the continuing challenge

Rural health is frequently inferior to city health. This old generalisation covers much contradictory detail, and exceptions abound: according to the Australian Institute of Health and Welfare, the life expectancy of non-Indigenous women in 2002-04 was much the same – 84 – whether they lived in big cities or very remote areas. For men, the difference is a matter of six months or so. And it is not a rigid generalisation: increasingly sophisticated broadband-enabled communications and ever-more efficient transport have reduced the gap between city and country.

Nevertheless, the numbers and the facts suggest that the accumulation of wealth, talent and many other features of contemporary city life confer a small advantage in life expectancy and wellbeing on city-dwellers. This disparity challenges those who hold the value that one of our social duties is to ensure, as far as possible, equality of opportunity to health and health care to all Australians. What should we do?

Two pathways to action present themselves for our consideration.

The first, and the one most easily grasped by the medical profession, concerns access to medical care in the rural setting. Massive technologically-based services can only be provided in large cities, and lesser technology-dependent services need at least strong regional bases.

We are getting better at finding ways to make these technologies available in relation to services such as radiotherapy, relieving the pressure on country women to favour radical breast surgery because they cannot afford the time and separation for chemo and radiotherapy.

But as we concentrate on providing rapid care for people with acute coronary syndrome and stroke (an increasing possibility in cities), the challenge of providing similar care in remote parts of the country may be beyond us at present.

The attitude of some to this problem – that those who live in remote parts of the country do so entirely by choice – is similar to saying that drowning people should be left, as they chose to swim or go boating.

But with telehealth, and many large city medical services increasingly interested in providing networked services to places that lack them, the problem is being partially addressed.

The search for equality of access may well require affirmative funding, and this has been recognised to some extent in fee structures and remuneration.

Equality does not mean paying the same for the care of people in different places: we need to accept that services provided beyond cities will cost more, and ensure that we finance them accordingly.

There are also concerns, raised most recently by Max Kamien, Emeritus Professor of General Practice at the University of Western Australia in Medical Observer, that the relaxation of hiring rules in many rural areas will “open the floodgates” to corporate practices.

While on the surface of it, a boost to the number of doctors working in rural areas would be welcome, this is not the case if they are being employed on short-term contracts to simply churn through large numbers of patients, and leave more challenging and time-consuming cases to existing practices. The focus needs to be on quality of care, not just quantity.

The extent to which the learned colleges have recognised the need for greater action on behalf of their rural members has been variable.

A framework for rural health developed by representatives of all Australian states, territories and the Commonwealth in 2011, recognised the need to be sensitive to the special needs of older people, babies and children, Aboriginal and Torres Strait Islander people, people with chronic disease, refugees and people from culturally and linguistically diverse backgrounds.

The second approach to rural health disparities takes us well beyond the surgery.

Even with networked services, e-health, and affirmative funding, we are faced with residual differences in health status that are attributable to the social and economic context of rural and remote life.

Medicine cannot, for example, diminish the vast distances many country people have to drive, every kilometre increasing their risk of a serious accident. At best, it can be sensitive to distance when arranging care of patients with continuing problems.

Medicine cannot do much to promote high-quality educational opportunity, although the development of regional universities and technical education capacity has been impressive in the past three decades.

Rural clinical schools have done a remarkable job in acquainting future medical practitioners and other health professionals with the challenges and opportunities of rural practice, and the long-term effects of this intervention will be seen in the next 20 years.

Medicine, though, has no influence over agricultural and extractive industry policies, all of which have great significance for employment and economic sustainability in rural communities.

These environmental factors – the social determinants of health – set the health agenda.

Some fall within the sphere of influence of public health, but many are well beyond even its wide reach.

Their importance was reviewed in a paper by Jane Dixon, from the ANU, and Nicky Welch, from Waikato University, in The Australian Journal of Rural Health in 2000. ‘What is it about rural places or the rural experience that contributes to different health outcomes?’ they ask.

The broad-spectrum advocacy of the Rural Doctors Association of Australia and the Rural Health Alliance contribute to the wider political and policy agenda that may help us to answer this question and to make serious progress.

It is vital for medicine to respond to the needs of rural communities as they are, not as they might be in a reimagined ideal world.

My sense is that we are making steady progress. The indicators that we have favour an optimistic view.

Australia’s internship crisis: a national process

By Matt Lennon, Vice President, Australian Medical Students’ Association

You’re 23. You’re in your final year of medical school and you’re very worried. It’s now December, and you’re waiting to hear back on your very last chance to obtain an internship in Australia.

It’s been a difficult six year slog that you moved countries to undertake; you’re now $300,000 in debt and, if you don’t obtain this internship, you will never graduate as a fully licenced doctor.

This, sadly, is the reality for many final year medical students around Australia. By the end of 2015, 40 students had contacted AMSA because they had not received an internship. It is the greatest weakness of the current system that we cannot know for sure what has happened to those students since then.

As it stands, there is no public data that tells us how many of them never found a last minute offer in Australia, or what the outcomes have been for those who missed out. This makes workforce planning for internships incredibly difficult. Worst of all, it makes it difficult for these young doctors to make a plan for their lives.

The issue stems from the radical increases in medical student numbers and medical school starting back in the late 1990s. Since 2005, the number of medical graduates around the country have doubled. Despite losing local graduates, Australia still imports more than 2000 overseas trained doctors annually – more than any other developed country – and many of these are only on temporary visas, brought in to plug gaps created by the poor planning decisions of the past. Retaining Australian-trained doctors who are graduating today will help to address the shortages of the future.

An imbalance between supply and demand has made it increasingly difficult for students to secure internships – and as a result, students may seek to maximise their chances by applying to a variety of agencies at great financial, logistical and emotional cost. In 2011, 41 per cent of applicants for 2012 internships applied to more than one jurisdiction.

Agencies are then hampered by applicants who have received multiple offers but may fail to reject unwanted offers in a timely manner, if at all. In 2011, there were twice as many applicants who accepted multiple internships than there were in 2010.

Because of this complexity, State health departments have to meet over several months to manually work out which graduates have one or more offers. This usually lasts from July to September, during which time the rounds of offers for internships are slowly going out. It is this period that is really crucial for medical students who are likely to miss out. They are making decisions around moving overseas and doing further study that will direct the rest of their working lives.

Establishing a National Internship Application Process would solve this. It would mean that, rather than taking several months, all internships in Australia would be sorted out in a single day, and a job that is best done by a computer would not consume hundreds of government staff hours.

The process would not mean that all states would have to align priority systems or methods of application. Rather, in its simplest form, it would be an alignment of the computer systems and portals used by each of the states to detect and prevent any double offers.

States and territories would be relieved of an unnecessary duplication of services, and it would be impossible for applicants to accept multiple places.

There would also be ancillary benefits: collation of internship data would be centralised and more readily accessible and, in light of national registration standards for medical practitioners, the Commonwealth may find benefit in being more closely involved in the internship allocation process.

Most important of all, streamlining the process, aligning dates and providing solid data on those that have missed out from day one would give governments time to ensure spots are created for the remainder.

For many this is a story about bureaucracy and numbers. But for medical students the internship is an indispensable part of our training without which we will never become doctors. For us it is a story about aspirations and a future.

Patients pay for hobbled hospitals

Since the Commonwealth’s unilateral changes to public hospital funding announced in the 2014-15 Budget, the AMA has highlighted the impact of dramatically reduced funding on an already underperforming public hospital system.

In May 2014, the Australian Government walked away from the National health Reform Agreement, abandoning its promise to make public hospital funding sustainable and contribute an equal share towards growth in public hospital costs.

From July 2017, the Commonwealth will instead limit its contribution to public hospital costs based on a formula of the Consumer Price Index (CPI) and population growth only. This represents the lowest Commonwealth contribution to public hospital funding since the Second World War.

According to Treasury, the indexation change will reduce Commonwealth funding to the states and territories by $57 billion between 2017-18 to 2024-25.

The CPI measures changes in prices faced by households only, and is not an appropriate measure of increases in hospital costs. Increasing funding on the basis of population growth does not address cost increases associated with changing demographics, or the costs of new health technologies.

The Finance and Economics Committee resolved last year that the Commonwealth’s contribution to public hospital funding must be sufficient to address real increases in actual costs of the goods and services used by hospitals, and provide for demographic change – not only for population growth, but also for changes associated with ageing and health needs.

The Government’s ongoing justification for its extreme health savings measures, including cuts to public hospital funding, has been that Australia’s health spending is unsustainable.

This is simply not substantiated by the evidence.

The Government’s own figures show that health spending grew by 3.1 per cent in 2013-14. This is almost 2 percentage points lower than the average growth over the last decade (5 per cent). The previous year (2012-13) growth was even slower – just 1.1 per cent, which was the lowest annual increase since Government began reporting on health spending in the mid-1980s.

Clearly, total health spending is not out of control. The health sector is doing more than its share to ensure health expenditure is sustainable.

There have now been two years where growth in health expenditure has been well below the long-term average annual growth of 5 per cent over the last decade.

As part of this slowdown, growth in Commonwealth funding for public hospitals in 2013-14 was just 0.9 per cent, well below inflation and virtually stagnant. This is off the back of a 2.2 per cent reduction in Commonwealth funding of public hospitals in 2012-13.

This austerity has come at a cost, and has been reflected in the performance of our public hospitals. The AMA’s Public Hospital Report Card 2016 shows that, against key measures, the performance of our public hospitals is virtually stagnant or, in many cases, declining. This is the direct effect on patient care of reduced growth in hospital funding and capacity.

The most recent data shows waiting times are largely static, with only very minor improvement. Emergency Department (ED) waiting times have worsened. The percentage of ED patients treated in four hours has not changed, and is well below target. Elective surgery waiting times and treatment targets are largely unchanged. Bed number ratios have also deteriorated.

The Commonwealth’s funding cuts are already having a real impact as a result of almost $2 billion being sliced from programs to reduce emergency department and elective surgery waiting times.

But the most acute impact will be felt from July next year, when the new funding arrangements take effect.

Without sufficient funding to increase capacity, public hospitals will never meet the performance targets set by governments, and patients will wait longer for treatment, putting lives at risk.

Despite these warnings, we have yet to see a solution to the serious and rapidly approaching crisis in public hospital funding.

This is a crisis that has been created by political and budgetary decisions. It is one that will require political leadership to resolve.

– Brian Owler

An up-close view of Indigenous health – good and bad

Professor Owler meets with staff at a remore community health service in the Northern Territory

By AMA President Professor Brian Owler

No running water, overcrowded and non-functional houses, lack of affordable healthy food, no essential services and crippling rates of diabetes, kidney disease and communicable infections – these are just some of the issues that people living in remote Northern Territory communities such as Utopia, Ampilatwatja and Kintore endure every day. On a recent visit to these three communities, I gained a deeper understanding of local health issues and the challenges that doctors and nurses face in delivering health services in remote areas.

In meeting with local Aboriginal leaders and health and medical staff, I found that each community has their own unique challenges; but the overall messages that I heard were strikingly similar. Funding for local health services is inadequate, it is difficult to attract skilled health and medical professionals to work in remote areas, it is logistically challenging to provide health care in remote communities (particularly when patients need to be transported for specialist care), and the level of chronic diseases in these communities are alarming.

Take diabetes, for example. In Kintore, 130 of the community’s approximately 450 residents have non-gestational diabetes – almost a third of its entire population – and in every three houses, one person is on dialysis due to the onset of kidney disease. What is even more concerning is the young age that Aboriginal people are being diagnosed with diabetes. In Utopia, a seven year-old girl was recently diagnosed with type 2 diabetes, and in Ampilatwatja, a 13 year-old girl was diagnosed with the same condition. Among the broader Australian population, or perhaps anywhere in the world, it is unheard of for child so young to be diagnosed with type 2 diabetes, yet it is clearly visible in remote Aboriginal communities.

The lack of water and affordable healthy food in remote communities is strongly linked to the epidemic levels of diabetes among Aboriginal people in these areas. Sugary drinks are more readily available than diet soft drinks, and in some communities they are more accessible than running water. It is unfathomable that in Australia, communities are going without water – a basic human right and a necessity for good health and wellbeing. This is an issue that demands immediate attention and action by all levels of government – without it, the health gap between Indigenous and non-Indigenous Australians will remain wide and intractable.

One important lesson that I did learn while visiting these communities is that it is not all doom and gloom when it comes to Indigenous health. Yes, Aboriginal people in remote areas face great adversity, but they are patient, resilient, strong-willed and are determined to take control of their own health – there are some real positives happening.

At the Purple House, an Aboriginal-controlled dialysis service based in Alice Springs, I was told an inspiring story of Aboriginal people taking action to generate funds for more dialysis sites. Kidney disease is rife across central Australia, with many Aboriginal people developing this condition as a result of poorly controlled diabetes.

The need for dialysis in remote Aboriginal communities is extremely high and for many, treatment means leaving family and country to be treated in Alice Springs. To allow people to be treated on country and near family, Aboriginal artists from across the western desert region grouped together and painted artworks that were auctioned to raise funds. The auction raised more than $1 million, and Purple House was able to expand their dialysis services. They now operate across nine remote communities in the Northern Territory and Western Australia. Purple House also provides a mobile dialysis service via their ‘Purple Truck’, which travels to remote Aboriginal communities.

It is very rare that good news stories such as this are widely publicised, which is disappointing. We need to shed more positive light on Indigenous health, and Indigenous affairs more broadly in Australia.

The POCHE Centre for Indigenous Health and Wellbeing in Alice Springs is also making a positive contribution to the health of Aboriginal people. At the POCHE Centre, I learnt about the research currently being undertaken by PhD candidate Maree Meredith, a young Aboriginal woman from Queensland. Her research project aims to determine the role that art centres play in contributing to positive health outcomes for Aboriginal people across the Anangu Pitjantjatjara Yankunytjatjara (APY) lands. To ensure that this research was in line with cultural protocols and to ensure that appropriate data was collected, Ms Meredith worked with Anangu people to design and deliver a survey in the local language.

For many years, anecdotal evidence has suggested art centres make a significant contribution towards health and wellbeing, but there has been no empirical data. This study aims to provide reliable evidence that art centres improve the health and wellbeing of Aboriginal people in remote communities. This is also a clear example of building the capacity of local Aboriginal people to participate in the local workforce.

Aboriginal people know what they want – they know the best way to improve their health and wellbeing, and this must be acknowledged and supported if we are to truly close the gap.

While in Kintore, I spoke with Aboriginal leaders who mentioned that the local people prefer a traditional social and emotional wellbeing framework to be implemented in their community, rather than a Western one.

The community developed a proposal for Government funding for this initiative, but unfortunately it was not accepted.

Connection to culture is important to the health and wellbeing of Indigenous people, and is known to produce positive health and life outcomes, such as reduced incarceration rates.

Aboriginal people needed to be provided with a reason to stay in the communities where they are connected to their land, culture and families. Recent comments made by certain members of Parliament about subsidising the ‘lifestyle choices’ of Aboriginal people in remote areas are extremely concerning.

Within each of these communities, I was disheartened to see a world-class health system fail the Aboriginal people in remote communities. But, I was truly impressed by the resilience and determination of the local Aboriginal people and the passion, commitment and dedication of doctors, nurses and other health staff who work tirelessly such challenging environments.

I am extremely grateful to Warren Snowden, Member for Lingiari, for making visits to these communities possible, and for accompanying me throughout the trip. I am hopeful that we will see further progress made in improving health and life outcomes for Indigenous people across Australia.