Federal Budget 2018
Dr Ayman Shenouda
Expectations around this year’s Federal Budget were high. The Government certainly worked hard in its lead up trying to lower expectations promising an economically responsible and fair budget.
We knew we would see an election budget here and with that, we expected a strong focus on some key areas important to the majority of Australians.
Voters wanted to see a focus on cost of living pressures and improving the health system and these two items came out on top in earlier polling.
A budget for a healthier Australia?
So, what is the verdict - is this a budget for a healthier Australia?
There were certainly strong gains in rural health, aged care, mental health and medical research.
There are some really positive initiatives in this budget but at a time of record inequality, more wellness measures through formalising a preventative health strategy would have made this a great budget.
This is required to help drive a strategy forward to really address some of those causes of ill health.
Spending measures in countering the high numbers of our population who are overweight or obese, for example, are needed and it would have been good to see some strategy around this.
We all know to get to the bottom of the causes of health disparities then the focus needs to be on those social determinants of health.
The investment is beyond health and an overall policy approach to protect those factors which stretch a range of personal, social, economic and environmental factors.
Primary prevention focus
A strong and broad primary prevention focus is needed to counter those health risks factors and improve health outcomes for all Australians.
This budget does pick up a number of these issues, including for women’s health and wellbeing and more broadly through its More Choices for a Longer Life Package.
Mental Health funding of $338 million and priority on suicide prevention clearly goes a long way towards addressing the system gap around crisis support.
The allocation for older Australians which includes $83 million for more services within the RACF, again addressing a significant gap, is a really positive step forward.
While short on detail, the new primary care funding model for the Indigenous Australians’ Health Program is another key area which required focus.
The increases for PBS and new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs all represent a significant health investment.
The standout here in terms of addressing disparities and ensuring a primary prevention focus is the rural investment and the Government has certainly delivered here.
Equity for rural Australians
The key rural health workforce measures are provided through the $83.3 million new Stronger Rural Health Strategy which includes some solid measures to secure more GPs for rural Australia.
This is a 10-year plan and a $550 million commitment which promises 3000 more doctors, 3000 nurses and hundreds of allied health professionals to our regions.
The plan provides an unprecedented level of funding and commitment for rural Australia and its packed with measures that show the Government has listened on addressing rural health need.
The workforce component will see integration through the entire training continuum as well as measures to support the existing rural workforce with an important focus on retention.
Stronger targeting of rural bulk billing incentives and key focus on accessing rural services particularly for older Australians with $40 million towards rural aged care infrastructure another positive shift.
For Aboriginal and Torres Strait Islander communities, there is a $105 million boost towards access to services which are culturally appropriate and closer to home.
There is a new MBS item to deliver dialysis services to remote areas representing a $35 million investment.
We have some great leadership here at the moment in our Rural Health Minister, Senator the Hon Bridget McKenzie and Commissioner Professor Paul Worley and it shows in the budget.
Rural pathway package
The rural workforce package is certainly comprehensive and a significant step forward in securing a stable rural workforce with a number of the key components to this strategy covered in earlier blogs.
There is a priority placed on establishing a homegrown rural medical workforce with an important emphasis on skills.
Many of the placement gaps that make it harder to remain in a rural area have been addressed.
More intern placements in general practice and an additional 100 vocational training places are committed. The latter committed from 2021 as part of the National Rural Generalist Pathway.
New training facilities to help rural students aspiring to become rural doctors study closer to home is also welcomed.
The $95.4 million new Murray-Darling Medical Schools Network will help universities work together to support medical teaching in our regions.
It’s also great to see that the new Workforce Incentive Program will extend to supporting general practices to employ more allied health workers.
Strong IMG focus
It’s great to see strong action to ensure we retain the rural workforce in this package of measures which extends to providing incentives for IMGs to progress towards Fellowship.
Those working in rural areas know the huge contribution IMGs make and it is great to see the shift here towards IMG retention. These doctors play a vital role in rural and remote communities and they deserve some support.
The rural strategy outlined in this budget invests in the next generation through domestic recruitment to rural areas but shows a commitment to the existing workforce through investment in skills and retention with an important focus on IMG retention.
In Aged Care, reduced waiting lists and incentives to stay in the home longer sees another important policy shift.
Measures which keep older patients in their homes longer is welcomed policy with this initiative providing $1.6 billion for 14,000 new places for home-care recipients.
This is a good start but not nearly enough with more than 100,000 people on the waiting list. However, the policy is certainly headed in the right direction towards an integrated care at home program.
Some of these measures will restore some of the cuts to the aged care sector of recent years. But it is unclear if they will provide for the targeted supports needed to deliver the complex care required which needs more focus on enabling more GP-led care.
A healthier future
There are some major challenges in funding and delivery of healthcare in securing a healthier future and for this budget, we’re seeing shifts in the right direction.
Health is so integral to our nation’s prosperity and the Government through its investment particularly in rural Australia shows that it understands the value of general practice and primary care.
This budget will certainly improve the lives of the seven million people living in rural and remote Australia.
The rural health measures will help to address disparities and important gains will be realised through this investment and this is a clear win for the sector.
The mental health and aged care gains are also significant and it is great to see those more vulnerable Australians being prioritised.
Dr Ayman Shenouda
Proving our value
Recent coverage around the failed Health Care Homes roll-out saw some unsettling truths coming through in the comments by the reform architect Dr Steve Hambleton.
This is in the context of the continuing trend for value-based care models, Dr Hambleton’s comments highlight a need in general practice to strengthen our data capture capability to prove our value.
What was said really cuts to the truth in terms of where our focus needs to be and how we ought to align or perhaps realign ourselves to better capture outcomes measurement.
For those who missed it, here’s the quote:
“What I will say to GPs is that unless we have the [patient outcome] data to take to the government that proves the value of the healthcare we are providing, they are going to keep investing in the bits of the health system where they do have the data, which is hospitals.” Dr Steve Hambleton
The case for Primary Care
In delivering more effective, equitable, and efficient health services, it is clear that strong investment in primary care would see fewer disparities across populations.
The value and need of strong primary health care systems are already well established. There is robust evidence to show that good primary care is associated with better health outcomes. 
Primary care improves quality and reduces costs. But primary care integration and care management are made harder by a system that has at its core a prime focus on episodic acute care.
The shift to value-based care is inevitable. However, creating savings in the healthcare system is as much about structures as it is about payment reform or data capture in driving that reform.
In measuring value, the current system and structure makes this very challenging. In many ways, the Health Care Homes model provided that answer in terms of how to provide and organise care in the future while enabling measurement and the policy is still worth pursuing.
The key requirement in embedding value-based care as a business model into general practice will require a shift in terms of enabling more team-based care to occur in order to remain viable.
Value in healthcare
Value in healthcare is measured around patient populations requiring different bundles care, these are defined patient groups with similar needs determined by combined efforts over the full cycle of care. 
This confirms the focus needs to be on primary care or new models of primary care but we need a stronger team-based focus and more support structures to make this work.
We need to leverage as much as we can from the current payment system to provide integration across settings. Much of this already falls to the general practice but enabling integration is hard and often non-remunerable work.
Our value proposition
The lack of networked or organisational architecture to support the level of data capture required to measure the quality of care and outcomes achieved through preventive primary care lets us down.
If we are going to achieve the level of integration required, satisfy funders with data capture demonstrating value then I think part of the solution also lies in how we position ourselves in the health system.
We already have the right strategy to fix healthcare and that solution lies in more investment in primary and preventive care through a Health Care Homes model.
In establishing our value proposition, if we must face off as Dr Hambleton suggests against advanced data-capture systems like those used in hospitals to capture detail right down to the bandages, then clearly, we need to get organised.
Capturing quality measures and measuring performance on a continuous basis will be complex and creating reliable structures will be key to our success.
Part of that challenge is around data capture and standardising that process and in particular who’s holding the data.
The strength of our primary care system is associated with improved population health outcomes and we know that enabling service integration is key in terms of realising these aims.
The other challenge will be our capacity to leverage technology, integrate more and build up those required team structures.
It’s clear there is still much to work through here. But what often gets missed is the need to enhance professional experience and I think it is here where we have some real opportunities.
Time for a rethink?
Right now, we should be thinking about what we can do to be more proactive in terms of redesigning what we can for ourselves.
We’ve been a College of GPs for some time now and certainly, that structure has been integral to the world-class health system we have today through supporting Australian GPs to provide the best possible care.
We need to ensure we have in place the adaptive collaborative learning systems required for the future. Is it now time to think about primary care as the future and not only GPs as the centre of that model?
College for Primary Care
The new models of primary care required in response to the healthcare system shifts towards value-based care will rely more and more on team-based care.
In demonstrating value, we need to think about those finite costs capturing those bandages too but this also needs to be about developing the primary care team. There is a real opportunity to support all the individuals working in general practice and train the whole team to enable more integration.
Collaborative healthcare leadership will be needed in shaping the future workforce to support new models of care. The existing College structure can help provide this leadership model to bring about the transformative change required.
Taking a more proactive approach to designing the health system means less focus on payment reform and more interest in investing in the primary care team.
 News Article. Health Care Homes roll out 'went wrong somewhere' says reform architect March 27, 2018. Australian Doctor. Available at: https://www.australiandoctor.com.au/news/health-care-homes-roll-out-went-wrong-somewhere-says-reform-architect
 Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91.
 Porter ME. Perspective. What Is Value in Health Care? December 23, 2010. N Engl J Med 2010; 363:2477-2481
DOI: 10.1056/NEJMp1011024 Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1011024
Let’s fix the health deficit through a more equitable distribution
Dr Ayman Shenouda
The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development.
This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion.
The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes.
In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities.
Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World.
To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results.
Rural health disparities
The converse is, of course, true and this is why we have such marked health disparities in rural areas.
There is an estimated health deficit of $2.1 billion in rural and remote Australia.
The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is.
It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services.
In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage.
We need to focus on the value of working across sectors to address those causal factors.
It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.
These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities.
Rural health investments
Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. 
I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building.
We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility.
The economics of poor health
We know all too well the economic effects of poor health.
An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population.
But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well.
Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning.
Fixing the health deficit
We need to fix the health deficit through a more equitable distribution.
In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants.
It’s not just medical care alone that influences health with social factors known powerful determinants of health. This is the formula for a healthy Australia.
 NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf
 Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
 Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf
 Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/
Nowhere to go: tackling homelessness for older women
Dr Ayman Shenouda
A measure of our society
It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’. I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off.
On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care.
Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding.
Rising rates of homeless older women
One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports.
Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty.
Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes.
Combating ageism in our society is something this country really needs to work on.
How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future.
Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii] Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development.
My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time.
The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting.
We’ve been treating the symptoms and not the know causes for too long.
Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too.
It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii]
[i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/
[iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065
Australia needs to place a levy on sugary drinks now
Dr Ayman Shenouda
A sugar fix anyone?
Sugar certainly got some attention this week prompted by some important, corresponding, new research undertaken here in Australia[i] and in France[ii].
The first focussed on risks associated with fizzy drinks, while the other a little broader and on ultra-processed foods, but both found similar findings in terms of increased cancer risk. In a third article featured this week, in Meds Obs opinion, Dr Jon Fogarty wrote that we cannot allow another 50-year con job. I couldn’t agree more.
Rapid increasing consumption of lower nutritional quality foods is clearly driving an increased disease burden. It is those ultra-processed foods that we need to look at which contain high salt, trans fats and saturated fats along with sugar.
It was quite telling that the recent PC Report Shifting the Dial: 5-year Productivity Review, released in August last year fell short of recommending a sugar tax. This is despite a strong obesity emphasis in the report only called for a soft market control solution through voluntary reductions in sugar content (by major manufacturers of SSBs).
Many are comparing the current policy complacency in response to sugar, in particular, with the dangerously slow response to tobacco. And, I truly believe that if we were serious around prevention then we would be looking to a sugar tax here in Australia. If we are to shift health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. I’ve said that before but it needs restating particularly on this issue.
Consumers clearly need more help to identify those foods with added sugar.
Some of this work has been done through the Federal Government’s Health Stars Rating scheme designed to help consumers make more informed choices. But manipulative marketing seems to be out-tricking the system by making unhealthy products look healthy.
Choice put forward some good recommendations in August to make this system better. Making sure foods high in sugar, fat or salt can’t get a high star rating being their number one!
A Navigation Paper of the 5-year review of the Health Star Rating System was released in January. It will be interesting to see what changes are made in response to the review.
Placing a fiscal incentive through increasing the price of these foods would make for an effective solution. But, I really think a sugar tax is warranted here. And, if not a full sugar tax, then perhaps a health levy on sugary drinks is a good start.
The UK is leading the way with its plans to introduce a levy on sugar-sweetened beverages this year. Importantly, revenue will fund a prevention focus through expanded programs to reduce obesity and encourage physical activity and balanced diets for school children.[iii] Ireland is following with a levy coming into effect in April.
Closer to home, there seems very little appetite to introduce a similar levy in Australia despite calls from various leading health experts and many of the peak bodies.
Despite twenty-six countries placing a health levy on sugary drinks, we are not seeing similar leadership from our Government. Federal minister for agriculture and water resources, David Littleproud, said in January that governments “should not dictate the diet of citizens”, much to the delight of those industries that benefit from inaction.[iv]
Minister Littleproud heads a portfolio responsible for the investment in the development of Australia’s sugarcane industry. In my view, this is an issue that falls in the food safety category as excess refined sugar has undesirable health consequences. Therefore, despite where the legislation may sit, this is more an issue for the health minister.
There’s plenty of evidence
In terms of a need to take immediate action, we’re certainly not short on evidence here. And there’s now increased evidence to act on sugary soft drinks.
The French research I mentioned earlier looked at the risk between ultra-processed food and cancer. In this prospective study published in the BMJ, found a 10 per cent increase in the proportion of ultra-processed foods in the diet was associated with a significant increase of greater than 10 per cent in the risk of overall and breast cancer. ii
Proving that soft drinks elevated risk of cancer, the new research from the University of Melbourne and the Cancer Council Victoria released this week also found people who regularly drink sugary soft drinks were more at risk of cancer. i
Interestingly, this Victorian study showed that higher consumption of both sugar-sweetened and artificially sweetened soft drinks is associated with higher waist circumference. However, cancer risk was only higher among those who drink more sugar-sweetened soft drinks. This is an important finding as many opt for the alternative diet option or sugar substitute thinking it better, yet it also may be contributing to our obesity epidemic. i
Even more surprising, the key finding from this study that increased cancer risk is not driven completely by obesity. Those who are not overweight have an increased cancer risk if they regularly drink sugary soft drinks. i
We need action now
It is always those who can least afford it that suffer the most. Poor diet is more a result of poverty than a lack of understanding around the risks. The only food the poor can afford is making them unhealthy.
The key findings from these recent studies both in terms of ultra-processed foods and sugary soft drinks now link to increased cancer risk. This issue is a health priority and needs to be a key focus for the health ministry.
Let’s not sugar coat it – sugar and sugar sweetened drinks kill - we need action on this now.
[i] Hannink, N. Increased cancer risk from fizzy drinks – no matter what size you are. University of Melbourne. 22 February 2018. Available at: https://pursuit.unimelb.edu.au/articles/increased-cancer-risk-from-fizzy-drinks-no-matter-what-size-you-are
[ii] Fiolet, T., Srour, B., Sellem, L., Kesse-Guyot, E., Allès, B., Méjean, C., et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322. Available at: http://www.bmj.com/content/360/bmj.k322
[iii] Gov. UK. Department of Health and Social Care. Guidance: Childhood obesity. A plan for action. 20 January 2017. Available at: https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
[iv] Davey, M. Article. Health experts support sugar tax as coalition calls for personal responsibility. The Guardian. 8 January 2018. Available at:https://www.theguardian.com/australia-news/2018/jan/08/health-experts-support-sugar-tax-as-coalition-calls-for-personal-responsibility