When weighing up the various election policies through a health lens, some of the most important issues to consider are:

1. How do the policies address climate change, the major public health issue that we – as Australians, as the planet – are facing?

2. How are health inequalities addressed? Is there an explicit commitment to addressing the social determinants of health, and to implementing a health-in-all-policies approach?

3. What is the plan for improving Indigenous health, mental health, the situation of those living in poverty – especially children, and the health of asylum seekers (some of the most glaring areas of health inequalities).

4. How do the policies address prevention, and are they upfront about the need to tackle the vested interests that contribute to so much poor health and unhealthy environments, particularly the coal, tobacco, alcohol, gaming and junk food industries?

5. How do the policies plan to ensure the sustainability and affordability of our health system? This requires major ongoing reform, and again being prepared to take on the powerful vested interests that tend to dominate policy agenda.

As to the above, a search of the Coalition’s health policy finds:

1. No reference to climate change and no response to calls for a national policy to deal with its health impacts.

2. No reference to health inequalities, the social determinants of health or health in all policies.

3. Only passing reference to Indigenous health and mental health. Mind you, as has been pointed out by the Australian Medicare Local Alliance, neither major party distinguished itself on Indigenous health so far this election.

4. Apart from Tony Abbott’s announcement that the Liberal Party will no longer accept tobacco donations, the policy gives no signal of intent to tackle the interests that contribute to poor health. The title of the policy – The Coalition’s policy to support Australia’s health system – doesn’t inspire any sense that population health is understood, let alone a priority. The only mention of prevention is in the context of plans for a new national diabetes strategy. The policy fails to even mention the Australian National Preventive Health Agency, surely an ominous sign.

5. The policy explicitly endorses the importance of a universal health system: “strong public hospitals providing universal access to care will be a central pillar of our health system under a Coalition government”. But it leaves unanswered important questions around the fate of the architecture of national health reform that underpins this pillar, for eg does the Coalition support the National Health Performance Authority? It gives no indication that the Coalition has any plans for a reform agenda as groups like Mend Medicare would like to see. As this article at The Global Mail makes clear, the Liberal Party is heavily backed by the private hospital industry  – and Tony Abbott’s support for the private sector showed yesterday in his suggestion that private hospitals outperform public hospitals (a highly contestable statement given that less than half of the 570 private hospitals report quality and safety data to the MyHospitals website). The policy mentions hospitals 26 times, while primary care rates 15 mentions. The only mention of Medicare Locals is ominous, that there will be a review “ensure that funding is being spent as effectively as possible to support frontline services rather than administration”. Senator Richard Di Natale tweeted yesterday that he suspected the review may be “code for abolition”.

Bu perhaps it’s naive to expect that election health policies might offer a vision for the future. As the University of Sydney’s James Gillespie has written at The Conversation, the Coalition’s health policy seems mainly focused on keeping itself a small target. The policy is cautious and more focused on attacking PM Rudd than providing any visionary alternatives, he writes. Clearly it’s the politics, not the policy that is driving this policy document.

The policy will cost $340 million over the forward estimates and is structured under the headlines of supporting hospitals, timely access to medicines, and rebuilding primary care.

Its announcements include:

• The Health Minister will have the authority to list medicines recommended by the PBAC that do not cost more than $20 million in any of the first four years of listing. “We will help Australians get quicker access to new treatments.”  As one Croakey contributor notes below, it sounds like Peter Dutton and his advisors haven’t read Ben Goldacre’s book, Bad Pharma – and should.

• The Coalition will bring forward the full implementation of biennial bowel cancer screening by 14 years.

• It will invest $52.5million to expand existing general practices for teaching and supervision; invest $119 million to double the practice incentive payment for teaching in general practice/

• Provide 500 additional nursing and allied health scholarships for students and health professionals in areas of need and provide $40 million for 400 medical internships in private and non-traditional settings.

• The Coalition will work with the sector to provide a nationally coordinated approach to clinical trials, reduce complexity of ethics processes and where possible, rationalise the number of ethics committees.

• The Child Dental Benefits Schedule, which is due to commence in January 2014, is to provide access to $1,000 in Medicare dental benefits for eligible children. From 1 July 2014 funding is due to be provided to the States under the National Partnership Agreement for Adult Public Dental Services.  The Coalition will honour the arrangements under the National Partnership Agreement for Adult Public Dental Services and will continue to work with stakeholders, patient representatives and State and Territories to improve the scheme as necessary. At the expiry of the National Partnership Agreement for Adult Public Dental Services, the Coalition will seek to transition respective adult dental services to be included under Medicare.

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Responses from Croakey contributors

On public health

Professor Simon Chapman, University of Sydney (re stopping tobacco donations)

Better late than never. The Liberals now join the Greens and Labor in telling Big Tobacco “we don’t want your blood money”. That leaves only the Nationals as a major party yet to show tobacco the door.

This is certainly an announcement of important symbolic importance. But the Liberal Party has deep connections with the Institute of Public Affairs, which receives money from British American Tobacco and probably other tobacco companies.

There will be nothing stopping the IPA from laundering tobacco donations to political parties, and that’s likely to only mean the Liberals. But will it do them any good?

Tony Abbott memorably went out of his way to say publicly on the morning of the 2012 High Court decision on plain packaging that he hoped the High Court would uphold the government’s intent on plain packs and reject the tobacco industry’s case.

He also has announced that a Coalition government will be keeping the Labor-announced major tax increases over the next four years. These will drive smoking down further, while bringing in over $5billion in revenue. Abbott while health minister in the Howard Government, introduced graphic health warnings on packs, hardly the action of a poodle for Big Tobacco.

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Professor Mike Daube, Curtin University

Delighted by bipartisan approach to tobacco funding. That’s a big and important step forward.

Bowel cancer screening commitment is good.

Would have liked to see more about prevention programs: commitment to maintaining action on tobacco; firm action on alcohol; focus on obesity tsunami.

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Nutritionist Rosemary Stanton

Reading through the Coalition’s health policy, prevention of non-communicable diseases seems limited to bringing forward

(a) bowel cancer screening (a good idea – although what is the policy when the faecal occult test reveals something that requires a colonoscopy – what is the policy for this procedure, currently very costly or subject to long waiting periods for admission to a public hospital),

and

(b) some vague thoughts on trying to bring the different diabetes organisations together (bests of British on that!).

Prevention of type 2 diabetes requires looking at obesity. It’s all very well and good to use increased services of allied health professionals, but they can’t address what is basically an obesogenic environment. And obesity is one of the major problems related to diabetes, it’s also relevant to bowel cancer, cardiovascular disease (which seems to have been forgotten), osteoarthritis and many other health problems.

The two major areas of preventing obesity have not been addressed – ie making it easier for people to be physically active and to choose healthier foods. These areas need to be addressed at a structural level rather than leaving them to individual consultation with an allied health professional.

The food supply is top heavy with junk foods and drinks – all advertised extensively (through TV, radio and print advertising and increasingly through advergaming directed at children and social media campaigns – such as those run by Coca Cola). Neither individuals or industry operated codes of practice are sufficient to tackle these problems.

For physical activity, we need more emphasis on public transport and local affordable facilities. (The Coalition seems to think more roads are more important than public transport or cycling facilities.) While local facilities such as walking paths, sporting fields, playgrounds, swimming pools etc) may be a local government responsibility, this is an area where fears of litigation have made local authorities prefer to remove facilities rather than face possible legal action. This is one area where federal govt could assist by removing ‘red tape’ systems that favour lawyers and litigation over provision of public areas suitable for physical activity.

On food, where is the policy that will help individuals make healthier food choices – especially those on lower incomes? Where is the policy to stop bombarding kids with ads for junk food and drinks, and adults with ads for alcoholic beverages. Where is the policy to tax alcoholic drinks on their alcohol content? Where is the policy to ensure fresh produce is available at a reasonable price to low-income people and those in more remote communities?

The rant about private health insurance rebates being removed is absurd. How can the Coalition describe those earning high salaries (which were the only ones with a cut to the PHIR) as ‘struggling’ under cost of living pressures?

The statement that the Coalition will ‘reinvest in private health insurance “once fiscal circumstances allow” is a good example of weasel words. Why should there be a rebate for anyone taking out private health insurance. There is no rebate for people insuring their lives, cars, houses or other aspects of life. If the money spent on rebates for private health insurance were directed to public health and public hospitals, there would be no crisis in health care.

I am against giving the Health Minister sole responsibility for approving medicines where the costs is less than $20m (or any other figure). Health Ministers are not health experts and giving any one person such responsibility opens that person to persuasive tactics from those wanting their medicines approved in this way.

Where is some kind of policy on ‘shonky’ goods marketed under the TGA’s almost non-existent oversight?

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On mental health

Sebastian Rosenberg, University of Sydney

I am flabbergasted that the issue of mental health is completely ignored in the Coalition’s health policy.

How can an issue with such currency only a few years ago now seem so far off the political radar? Within the past fortnight, major reports into mental health have been issued by the Mental Health Council of Australia and by a consortium of nearly 50 organisations led by Adjunct Professor John Mendoza.

Mental health in Australia remains in crisis.  The lifespan of people with severe mental illness has not improved over the past 30 years. Neither party has so far offered any solutions or commitments to change this pitiful situation, one in which suicide and self-harm are common, daily occurrences for our young people.

Even armed with increasing evidence about what works in mental health care and treatment and a suite of articulate and high profile advocates, the issue of mental health has uniquely found a way to disappear from public view, leaving literally millions of Australian people and families isolated and unhelped.  The electorate has repeatedly indicated its concern to see mental health fixed.  It seems a bizarre and tragic case study in reverse advocacy, one worth studying carefully.

It is even more curious because many if not most politicians have some level of intimate understanding of mental illness and the impact it can have on families. What permits such a  damaging and pervasive health and social issue to go unaddressed?  What makes it ok for our politicians not to speak about mental health? To ignore it?

I am not sure of the answer but clearly mental health has failed to demonstrate the merit of continuing attention.  I think this is at the heart of enduring stigma towards mental health – that spending money on crazy people would in itself be crazy.  Sophisticated arguments about the economic and productivity benefits to be derived by assisting people with a mental illness to find work don’t stack up against this prejudice.  Crazy.

The poverty of our so-called mental health system means the nature of care and treatment vary from place to place.  People don’t trust services to be available when and where they need them. People are helped to understand the risks and have confidence in cancer treatments. Can we say the same for mental health and if not, why not?  Stigma lives here.

The past decade has seen a stop/start attitude to mental health reform in Australia.  At the moment, we are practically at full stop. Governance of and responsibility for mental health is skewered on the federal/state divide. Let’s hope that before the campaign is over, the huge task of mental health reform can at least be considered by the major parties.  Nobody is expecting miracles.  Just some ongoing attention to one of the biggest health and social challenges facing 21st century Australia.

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On Indigenous health

Dr John Boffa, Public Health Medical Officer, Central Australian Aboriginal Congress

It is vital that responsibility for Aboriginal health remains in the health department and is not transferred into PM&C.

I have published on the success of the transfer of health administration responsibility from ATSIC to the DoHA – we cannot go back to a situation where responsibility for health is back within a non-health literate bureaucracy.

It may well be useful to have PM&C responsible for some aspects of Aboriginal Affairs such as economic development and creation of employment in Aboriginal communities but not health and education these should stay out. PM&C could take over the FaHCSIA portfolio areas and this may well be useful and give these areas more clout.

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NACCHO statement

Aboriginal people across the country today will be disappointed by the release of the Coalition’s health policy given the persistent appalling health gap between Aboriginal and non-Aboriginal Australians.

NACCHO Chair, Justin Mohamed said the seventeen page Coalition Health Plan dedicated only one line to Aboriginal health and provided no detail on the initiatives they would support to specifically improve Aboriginal and Torres Strait Islander health outcomes.

“Tony Abbott has previously expressed a commitment to closing the shameful health gap between Aboriginal and non-Aboriginal Australians.

“The Coalition signed the Close the Gap Statement of Intent in 2008 and plans to elevate Aboriginal affairs directly to the Prime Ministerial office if Tony Abbott wins Government in three weeks.

“Given that, it is disappointing and somewhat surprising that he has not given a lot more focus in his Health Policy to solving the challenges in Aboriginal health.

“Focusing on bowel screening, diabetes management, dental health and building the medical workforce are welcome initiatives in the Coalition Policy but must be delivered by Aboriginal people to Aboriginal people if we are maximise their effect in Aboriginal communities.”

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On workforce and general policies

Professor Andrew Wilson, Menzies Centre for Health Policy, University of Sydney

The devil is always in the delivery but:

1. Reinstating the ministerial delegated $20m responsibility for PBAC decisions is sensible, the increased limit necessary to allow for inflation. The challenge is that pharma can usually structure their proposed listing to come under the cap by limiting the target population. The risk is whether that target population actually reflects the real prescribed population (this is not a new risk). A newer risk is that there are a lot more niche medicines, ie targeting specific conditions.

2. The need for a National Diabetes Strategy with a much stronger prevention element is self-evident. However not clear what resources will be behind strategy other than the $30 million for research on curing type 1 diabetes which represents about 15% of all diabetes cases. T1 diabetes is disproportionately costly because f younger age of onset and higher complication rates.

3. The need for the guarantee on intern places is important (declaring my COI as I have a child studying medicine). I also think the additional subsidy to general practice teaching is good news as this remains a specialty that needs to expand rapidly. Nothing wrong with the scholarship proposal although shown to have limited workforce impact. I remain concerned that there is no additional support for supporting new nurse entry. The workforce modelling shows tis is the most critical future resource shortage and while we have expanded undergraduate training numbers, there will be a short term excess of nursing graduates who will be unable to find entry level positions and who will then look elsewhere.

I am also concerned that the additional GP teaching subsidy puts yet another price signal in the clinical placement arena will bring further efforts from public hospitals to charge for clinical placements. The independent Health Pricing Authority should be directed to accelerate its work on the teaching, research and training component of ABF for hospitals so there is a consistent approach to this across sectors.

4. Not totally clear on what is proposed on dental health but at least the interim commitment to continue current arrangements hopefully won’t see us going backwards.

5. Mixed messages here about private health insurance but at least without specific commitments they have left themselves room to undertake a major review of private health insurance if they get into office.

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Professor John Dwyer, UNSW

No exciting policy announcements re our health system have been forthcoming from the Government or Coalition. They refuse to recognise the structural deficiencies that need correction if we are to give Australians the contemporary health system they need.

I stress the word health as much of the discussions centre on sickness.

Where will we find the leadership to take us on a journey to a single funder model integrating in a patient focused way Primary, community and hospital care/ $4 billion could be saved by a single funder model—9 departments of health for 23 million people?

No structure to see us focus on prevention is forthcoming despite the evidence from so many countries that having people enrol in an Integrated Primary Care model (team medicine) where patients and families are serviced to help them stay well rather than just treat illness is cost effective. It requires Medicare funding of teams of doctors, nurses and allied health practitioners in the one practice (not just physically located in separate practices but I the one building e.g..  Super GP clinics.

The only way we can afford timely quality hospital care into the future is through a reduction in the demand (need) for hospital services through better community care.

The PC remember has estimated that 700,000 plus admissions to public hospitals could be avoided by an effective community intervention in the three weeks prior to someone requiring admission.700000 x $5000 (average cost of an admission) = 350 million dollars tat could be available for the PC sector.

Where are policies to tackle the increasing inequity that sees the biggest growth in health expenditure coming from Australians’ wallets. There is much more structural change that is urgent, Inter-professional learning in universities to break down the silo mentality among health professionals, shortening medical education, speeding up entry into post graduation vocational training, establish some rural based medical schools for rural students and so much more.

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