Category: Rural health

Out-of-pocket healthcare costs do include travel

Recent considerations of out-of-pocket health care costs have not included the significant and unavoidable extra costs for people living in rural and remote areas of travel and accommodation.

But there is some good news – most recently in the discussion at a Senate  Estimates hearing on Wednesday, 10 April 2019 – the day before the Federal Election was called. That good news is reprinted below.

Neither the Report of the Ministerial Advisory Committee on Out-of-Pocket Costs (November 2018) nor the media commentaries about it included any reference to the words ‘rural’ or ‘transport’. The Committee comprised representatives of nine specialist medical Colleges plus six other people, but no representative of the specific interests of rural and remote people.

The costs of travel and accommodation involved in accessing health  services must be squarely on the agenda, and a dataset which does not include these is very deficient. And it is not just the health sector where it’s an issue. A recent news item on the ABC referred to a Riverland study showing that clients of the NDIS also fail to meet appointments because of travel difficulties and/or costs.

Policy remediation could be through a variety of means:

  • having the Commonwealth re-assume responsibility for patients’ travel and accommodation assistance schemes;
  • having private health insurance providers offer additional products designed specifically to appeal to people in rural and remote areas and to meet their circumstances – including their need to travel and the possibility of significant lost income; and
  • redesigning the system of incentives and penalties relating to families’ decisions about whether or not to take out private health insurance; (the current system of health insurance rebates is another transfer payment from rural to urban populations).

On the first of these, Treasury and Finance would be unlikely to support action to open up another demand-driven program to the Commonwealth. But if one is serious about equivalent access to health services for people everywhere, this has to be considered.

In the meantime, here is some good news about getting the matter firmly onto the political agenda. It might be like turning the Titanic around but if, as a result, the iceberg is avoided it will surely be worth the effort.

From Senate Estimates, Wednesday 10 April 2019

Senator WATT:  In brief, what were the other main findings [of the Ministerial Advisory Committee on out-of-pocket health care costs]?

Professor Brendan Murphy, Chief Medical Officer:  One of the striking findings was the interstate variation. Pretty much nobody in Adelaide has an out-of-pocket cost for surgery. Just about everyone in Sydney and Canberra does, and some of them are very, very high. One of the clear messages was that people who see a surgeon, or a radiation oncology provider, without knowing in advance what they’re going to be charged, are informed of the bill in practice—they feel they can’t extricate themselves from that relationship and get another opinion. So, there was a clear driver in that committee to promote transparency so that people could find out what someone was charging before they actually made the initial appointment.

Senator WATT:  Were there any findings around the costs for people living in regional and remote areas?

Prof. Murphy:  Again at the level of anecdote, the particular issue there was the additional travel and accommodation costs, because often they would have to travel to have their surgery or their radiotherapy or even sometimes their chemotherapy. That was seen to them as an additional burden of significance.

Senator WATT:  When you are getting those figures about the extreme end of $20,000, the $1,000 up to $5,000, were you including travel and accommodation costs there?

Prof. Murphy:  Some of the anecdotes reported that as well, but mostly not.

Fixing out-of-pocket healthcare costs: a distant dream!

A national, rural, political dream

Sleep was elusive. Fevered dreaming stood in its place. [1]

Just suppose for a moment that, within the Australian Labor Party (ALP), a subgroup was once created for those with a particular interest in coastal erosion.

The people who join this movement have no desire to subvert or depart from the principles of the ALP; they are through and through ‘labor’ people by inclination.

It’s just that, within the broader Labor Party, they want to be seen to represent the particular interests of people around Australia who are worried about coastal erosion.

It’s not made explicit, but in the beginning most of those who join the movement do so because they believe that a tailor-made organisation will help with an overall ecological, conservationist approach.

The movement goes so well that the ALP’s administration agrees that those who wish to do so can have their membership fees diverted to and used by the new entity. With the increased organisational capacity that results, it becomes – in effect – a political party within a political party.

It adopts the name Labor for the Coast (LfC).  It holds conferences, produces publications, and develops its own positions on issues relating to coastal erosion.

As time passes, the range of issues with which LfC becomes concerned expands. There are people concerned with rising sea levels and the impact on areas settled by human habitation – including on the value of property. There are those concerned with retention of the ecology of coastal regions. There are those who want to see coastal areas more developed, and those who don’t. There are those concerned about industrial run-off; and wind farms; and maritime infrastructure.

But whatever their specific interest in the matter, members of the organisation are still, first and foremost, supporters of the Australian Labor Party.

Time passes. At some future Federal Election, Labor for the Coast announces that it intends to run its own candidates in seats where its issues are of a particularly high profile. This causes a problem for the ALP, which has to decide whether to step aside and give free rein to LfC, or to run their own candidates in what might be called ‘three-cornered contests’.

More time passes. The range of issues with which LfC purports to have a special interest, and special expertise, grows broader. Sometimes there are so many complex and conflicting aspects to the management of Australia’s coastline that it isn’t clear what LfC’s position actually is.

Some of its members fear that its original purpose – to protect the coastline – has been  watered down or perverted.

The public profile given to particular aspects of the challenge varies from year to year. After traumatic and damaging events which have particular impact on coastal areas, such as cyclones, floods and bushfires, support for the party tends to increase.

But one thing never varies and that is the close political, philosophical and organisational relationship between the ALP and Labor for the Coast. Whether in government or opposition, the larger party and its smaller, more specialised partner work together in what becomes known as the Alliance Government or the Alliance Opposition.

Time passes. One of the curious things that happens is that the policies of LfC seem to take on their own credibility and have their own status – quite separate from the positions or priorities of the ALP. It’s as if the prosecution of beliefs and policies by what is still a partial subgroup of the senior partner will assuredly lead to action by the greater whole if the Alliance wins government.

Retrospective analysis of the results of one particular Federal Election show that in the twelve seats won by LfC, a critical number of votes were cast because of LfC’s proposed policies relating to residential development, coastal wetlands and the management of run-off. These voters failed to recognise that the ALP had no specific policy positions on these more detailed issues. What this meant was that, when the Alliance won government – thanks in part to the seats won by LfC – there was in fact no corporate or party-wide commitment to those proposed policies.

The practice that developed was for the ALP and LfC to enter into a negotiated agreement, the terms of which were not publicly revealed, relating to Ministerial positions and policy matters to which the Alliance Government would commit.

People who voted for LfC for particular reasons were in the dark as to the status of the promised policies and programs relating to those matters. Nevertheless the organisation prospered. For a period of time LfC had branches in every state and territory – even in the ACT which, apart from Jarvis Bay, has no coastline at all. At its peak, LfC had federal representatives from each State and the Northern Territory.

Time passed. The management of Australia’s coastline failed to improve from the point of view of all the major interest groups.

Gradually, the senior partner in this curios political arrangement came to realise that issues relating to Australia’s coastline and its management were so important as to require its serious and focused consideration. There seemed no good reason why coastal management should be the preserve of or the responsibility of a particular subgroup. It should not be farmed out in this way.

LfC became a decidedly rickety construct. It only survived at all through the next period because of the myth it had built up that it was the only group defending the interests of Australia’s coastline against the people of the inland.

The expertise on coastal management issues which had gravitated for some years to LfC was readopted into the senior partner. LfC was gradually whittled away as the ALP recognised the importance and potential value of having its own focus on the challenges besetting Australia’s coastline.

The writing was on the wall for LfC when, in a couple of jurisdictions, it merged back into the ALP. There was a curious, misty period (described by one writer as ‘furtive’) in which LfC operated exclusively at the state level, being unable or unwilling to get members elected to Federal Parliament.

Its credibility and reputation were damaged by errors of judgement made by some of its leaders who, during the full flood of LfC’s status, were among the top dogs in national politics.

The future of LfC depended on just one jurisdiction for some years. Even this was not due to the inherent strength of its policy positions and any uniqueness with which it supported them in government. Rather, as historians have since pointed out, the quarantining of people of a particular bent from the ALP itself meant that the LfC had a significant impact on the factional balance within the parent party.

Time passed. The LfC was further eroded.

There was confusion about exactly who LfC was trying to represent. Was it the people who lived and worked on the coast, or the broader group who cared about management of the coastal fringe? Either way it was expecting too much of one organisation to represent all of those who lived in coastal areas: the young and the old, environmentalists and those involved in real estate development or heavy industry, those with bank loans and those dependent upon investment income.

Like King Canute, those clinging on to LfC pointed out that all of its Parliamentary representatives were people from coastal areas. Other people wondered whether having no representatives from the kinds of community in which one third of Australia’s population live was an advantage or disadvantage for LfC’s policy thinking.

Historically there was little evidence of LfC parliamentarians delivering services or infrastructure for coastal people unless it was supported by the ALP. This is the natural circumstance in which a junior party to an Alliance will find itself. But if all of the LfC  initiatives are supported by the ALP, what is the point of the LfC?

Before too long Alliance Governments were a thing of the past. Thereafter, whenever the Labor Party was more popular than the Liberal Party or independents, the government installed was badged simply ‘ALP’.

Life then seemed much clearer – including for people who cared about coastal management, – and the choice between the major parties much simpler.

And it was no longer possible for people’s vote to be won over in an election campaign by ‘promises’ made by a subgroup of the ALP and to which the ALP itself owed no loyalty or commitment.

– – – –

Then it was morning and such fevered speculation could end.

[1] Although he is entirely innocent of any knowledge of this piece, I am indebted to Stephen James Holt, the author of an article about politics which appeared in the Canberra Times on 15 August 2018.

Access to health services: Medicare and financial means

Note: this piece was published in Croakey, Australia's social journalism project enabling debate and investigations of health issues and policy, on 13 September 2018. My thanks to Ruth Armstrong, Editor.

The central purpose of Australia’s Medicare is to give all eligible persons three things: the choice to receive, free of charge, the services provided by public hospitals; no-cost or low-cost services from general practitioners and certain medical specialists; and no-cost or low-cost access to medicines listed on the Schedule of Pharmaceutical Benefits.

Much has been made of Medicare’s ‘universality‘ – the assertion that its provisions relate equally to all eligible persons, irrespective of their location or income.

In reality however, some people’s access to Medicare is limited by circumstances beyond their control. Barriers to seeing a doctor can include information (eg they’re not aware of the services that exist), logistics (eg distance), service queuing (eg the doctor’s books are closed or they’re booked out), and cost factors.

Given the intention of Medicare to ensure that no-one is deprived of access to health services because of their financial means, the last of these – cost factors – is an issue with which we should be particularly concerned. Currently there is insufficient evidence about affordability and access.

Evidence of out-of-pocket costs

The Senate’s Community Affairs References Committee has produced two reports in recent years concerned, in part, with out-of-pocket healthcare costs.

The first, Out-of-pocket costs in Australian healthcare (2014) dealt with trends in aggregate out-of-pocket expenditure by Australian health consumers, the composition of the expenditure, and such things as international comparisons.

The second, Value and affordability of private health insurance and out-of-pocket medical costs (2017), concerned the interaction between private health insurance and co-payments (or ‘gaps’) and the difficulties faced by consumers in estimating them.

Neither of these inquiries considered the relationship between the dollar value of costs paid by an individual and their ability to access necessary health services.

One measure of the price paid by individuals for access to necessary health services is the AIHW’s well-developed dataset relating to out-of-pocket costs paid for a specified category of services that are subsidised by Medicare.

In 2015-16, Australians spent $29.4 billion out-of-pocket in total on health-related expenses – or about $1,195 per person. This compares with $141 billion spent on health by governments, private health insurers and accident compensation schemes.

The costs paid by patients were for prescription and non-prescription medicines, dental services, hospital services, aids and appliances (including glasses, wheelchairs and hearing aids), expenses (such as allied health services) not subsidised by Medicare and, finally, non-hospital services that are subsidised by Medicare.

This last category includes general practice and specialist fees, diagnostic imaging, pathology and obstetric services. In 2016–17, around 9 in 10 Australians used one or more of these services. Governments contributed $19.0 billion towards them, with around $3.0 billion being paid by patients from their own pockets. This category therefore comprises only 10% of the total paid out-of-pocket ($3.0b of $29.4b).

Of this $3.0 billion, 34% was for specialist services, 25% for GP services, 12% for diagnostic imaging services (including radiology) and 6.6% for obstetric services.

Costs for services subsidised by Medicare

The services for which patients paid this $3 billion are the subject of the Healthy Communities: Patients’ out-of-pocket spending on Medicare services, 2016–17 report, which shows that, nationally, half of the patients receiving the specified Medicare-funded services paid something for them from their own pockets, and half had the full costs paid by the government.

This 50:50 split can be compared with the fact that, in the same year, 86% of all GP services were bulk-billed, while 66% of patients had all of their GP services bulk-billed.

The report then details a wide range of dollar figures for out-of-pocket costs for groups of people who live in specific ‘local areas’ (there are 340 statistical local areas (SLAs) in Australia) and, at a more highly-aggregated level, in particular Primary Health Networks (PHNs) (there are 31 PHNs).

There are figures about the incidence of out-of-pocket costs and their median (mid-point) value, where they exist, by PHN and SLA – with numerous comparisons made.

More prominence should perhaps have been given in the report to the statement in the fine print, as it were, at the end of the document:

“Factors that affect out-of-pocket costs

Local area variation in the amount that patients spend out-of-pocket on health services is influenced by a number of factors, including:

  • the type and amount of health services required to meet a patient’s needs
  • income and lifestyle, which can influence a patient’s ability to pay fees
  • the fees charged by health providers in a local area (at the discretion of the health provider and may be influenced by differences in operating costs)
  • the availability of bulk-billed services
  • differences in the availability and use of non-hospital primary and specialist services that are subsidised by Medicare (some people may use services not funded by Medicare, including allied health services or a hospital emergency department, or may be unable to get services due to other factors, such as the availability of nearby health care providers).

Variation in out-of-pocket costs and patients’ experiences of cost barriers can highlight gaps in access to affordable health services. However, if an area has high out-of-pocket costs, it does not necessarily mean that people living there have difficulty obtaining these services, as service use is also influenced by a person’s financial situation and needs.” (emphasis added)

What this means is that most of the dollar figures in the report are more ‘data’ than ‘information’, because they shed no light on the relationship  between the level of out-of-pocket costs paid and an individual’s status with respect to access to health service

False assumptions

There may be an underlying assumption that the higher the costs paid by an individual from their own pocket, the worse their service access situation.

This would be a false construct. Someone who has paid zero out-of-pocket costs could be a person in clinical need of the specified services but with no access to them, for one or more of the reasons specified above: lack of knowledge, lack of access due to distance or their inability to meet the actual or perceived cost.

Someone with high annual out-of-pocket costs could be a healthy person with good knowledge and easy access to the specified services.

Two individuals paying the same amount from their own pocket may well have radically different abilities to pay: one regarding the cost as a discretionary payment they choose to make, the other having to forego other critical expenses. For these reasons, even the national aggregates of out-of-pocket costs are not informative.

We read that patients living in metropolitan PHN areas were less likely to incur out-of-pocket costs than patients in regional PHNs. There is no way of knowing to what extent this is due to differences in the availability of the services, in their charging policies, in the need of patients for the services, their attitude to paying for them or other factors.

Similarly, the finding that those in metropolitan areas who did have out-of-pocket expenses paid higher amounts, could relate to the unit cost of services, providers’ decisions about bulk billing, the number of services accessed per year, or the availability and use of services not funded by Medicare, including allied health services, or a hospital emergency department.

The report does not include figures about access to services that are not within the Medicare system, such as dentistry and allied health. And the ABS’s 2016-17 Patient Experience Survey reminds us that poor access to dental services, due to their cost, is a serious matter – and one that is worse for people living in areas of socio-economic disadvantage.

For a fuller picture of the relationship between a family’s financial means, their location and their access to health services, data series relating to out-of-pocket costs need to be integrated with other health access, economic and population data. We need to know the relative significance of the factors that contribute to different dollar figures for different people.

Clearer evidence of cost barriers

As well as their data about out-of-pocket costs, both the AIHW’s Healthy Communities: Patients’ out-of-pocket spending on Medicare services, 2016–17 and the ABS’s 2016–17 Patient Experience Survey also report on a data series that may illustrate more about cost barriers to health service access than the dollar value of out-of-pocket costs.

This is the proportion of people in particular groups who delayed or failed to keep an appointment with a health professional because of cost.

Across Australia in 2016-17, 6.5% of people aged 15 years or more reported delaying or not having a specialist, GP, imaging or pathology service when they needed it due to cost. This represents an estimated 1.3 million people. Nationally, 4.1% of people who needed to see a GP (an estimated 663,000 people) delayed or did not see a GP due to cost.

Other findings from the ABS for this data series for 2016-17 were:

  • over two thirds of people (68%) had received a prescription for medication from a GP in the previous 12 months, with 7% of them delaying or deciding against filling it due to cost;
  • one in fourteen people (7%) who needed to see a medical specialist delayed or did not see a medical specialist due to cost; and
  • 18% of those who needed to see a dental professional delayed seeing or did not see one due to cost.

Critically where financial means were concerned, people living in areas of most socio-economic disadvantage were more than twice as likely to delay seeing or not see a dental professional due to cost than those living in areas of least disadvantage (26% compared with 11%).

Such direct relationships between financial means (in this case inferred by an area’s level of socio-economic disadvantage) and access to services are of concern and should be further researched.

In the meantime it should be noted that spatial variations in such a measure (eg between different PHNs) are confounded by the same factors as for out-of-pocket costs. Consider, for example, the statement that:

7.3% of people aged 15 and over who needed to see a medical specialist delayed or did not see a medical specialist due to cost (which represents an estimated 538,000 people). This proportion was highest for people living in major cities (7.7%) and lowest for people in outer regional, remote and very remote areas (5.1%). (emphasis added).

 This last sentence could be explained by the fact that fewer people in regional, remote and very remote areas were referred to a specialist in the first place – or they lacked access for other (non-cost) reasons.

The clinical importance of delay

Without further information it is impossible to judge the clinical importance of the figures relating to delayed or cancelled health appointments. Where visits to a GP are concerned, the patient may have been in real clinical need or, alternatively, they may have been ‘doctor shopping’ or among ‘the worried well’.

Also, such self-reporting by survey respondents may reflect a real inability to meet the cost of the service, or only their fear of being unable to meet the cost they believe would be incurred.

The costs of both a GP visit and a visit to the Emergency Department of a public hospital are covered by Medicare. But it is nevertheless worth noting that the ABS reports that, in 2016-17, people living in outer regional, remote and very remote areas were almost twice as likely to report visiting a hospital Emergency Department because a GP was not available when required, than those living in major cities (29% compared with 17%).

The importance of not being able to see a general practitioner or other primary healthcare professional in good clinical time is almost certainly reflected in the fact that, as shown in Australia’s Health 2018, the rate of potentially preventable hospitalisations increased with the remoteness of a person’s usual residence. This effect was most pronounced for Indigenous Australians.

Improving the available information

Australia is blessed with good data relating to health and well-being, thanks to the ongoing activity of impressive national agencies and the collaboration of states and territories and health professional bodies.

It is therefore surprising that so little is known about the relationship between patients’ financial means and their status with respect to health service access.

The situation could be improved with more publicly available analyses of the data sets relating to health, socio-economic status and other characteristics of people and the places in which they live. It may be the case that these datasets are already being integrated or synthesised.

Because of the frequency with which the characteristics of non-metropolitan areas serve to place their residents at a disadvantage in access to health services, and health outcomes, these further analyses would be a particular boon to the rural and remote health sector.

This said, seeking some certainty that low income is not prejudicing access to health services for anybody should be a national priority, and one to which Big Data agencies and the Medical Research Future Fund should turn their attention.

Too much talk of “drought”, and not enough about “water management”

Too much talk of

Calling for an integrated, holistic focus on water and natural resources management

Note: this piece was first published in Croakey on 26 August 2018. My thanks to Croakey’s Editor, Melissa Sweet.

It is a mistake to try to reduce the frequency or impact of drought through something narrowly defined as “drought policy”. The problems in dealing with drought can only be dealt with through an integrated approach to the management of Australia’s natural resources.

As the former Prime Minister Malcolm Turnbull reminded us in a recent radio interview, in a hot, flat and relatively dry continent with poor soils, “we have got to be smart about the way we use water.” (See previous commentary on Turnbull’s interview with ABC Broken Hill.)

When a prolonged period of below-average rainfall threatens serious human, animal and ecological costs, specific emergency assistance should be available, subject to known, fixed (and, if possible, objective) criteria.

But at every moment, in good times and bad, public policy should be dealing with water management in all its aspects.

Some will argue that, for both political and professional reasons, an integrated, holistic approach to natural resource management across the nation is unlikely. A report card on the key elements of national water management shows that progress has been made and that further opportunities exist, with the management of groundwater resources being an area that is not as well advanced and understood as others.

There are nine key elements of water management in Australia.

1. Management of the Murray-Darling Basin

The management of Australia’s water resources basically starts and ends with the Murray-Darling Basin (MDB), both because of its size and because of the political, economic and social challenges it poses. It covers a million square kilometres (about 14 percent of Australia’s landmass), is home to over two million people and in it is produced around one-third of the national food supply.

Management of the MDB has been famously difficult due to the complexity of the issue and the fact that the Commonwealth and four state governments all have vital interests in it. If water management in the MDB is done well, the processes and lessons learned can be applied in other catchments.

The central challenges are twofold: to be sure that there is an appropriate balance between waters withdrawn from the system, mainly for irrigation, and the waters left in it for environmental purposes; and to be sure that there is a fair balance between the four states along the rivers’ path.

Currently there is agreement among all parties to a Basin Plan, with the four states agreeing to develop a compact to enforce the agreed water rules. Despite the dry times in much of the eastern States, there are good signs of continued commitment to the Plan.

However, below-average rainfall for a prolonged period will test the political strength of such an agreement and potentially threaten the ecological sustainability of the Basin.

2. Decisions about water infrastructure

There has been much debate about whether Australia has an “infrastructure deficit” and, if so, how large it is and what elements it comprises.

“Australia has nearly 600 different local, state and territory Governments that, together with the Australian Government, fund and plan infrastructure. Through this multitude of players, our infrastructure development is slow and delivery risks are high, which constrains our productivity and makes our projects less attractive for potential investors.” (The National Infrastructure Plan, Infrastructure Australia, 2013.)

Given the proportion of Australia’s population who live in the major cities and the undoubted congestion they experience, the bulk of recent discussions about infrastructure has been about transport: roads, bridges, railways and public transport systems. However, the management of Australia’s water resource is critically affected by decisions made on infrastructure, including those made at the national level.

Infrastructure for the storage, reticulation and application of water in agriculture and other industries is one of those areas in which new capital spending may not be necessary. This is because there has been, and remains, capacity to make better use of existing infrastructure. It is not a question of building new irrigation systems from scratch, but what additions and adjustments should be made to the existing system.

A significant new focal point relating indirectly to water infrastructure has emerged as a result of the nation’s electricity generation woes. There are plans for the construction of ‘Snowy 2.0’. Whatever the truth about the costs and benefits of Snowy 2.0, it is not a matter that should affect inter-jurisdictional agreement about the allocation of water in the system.

The 2016-17 Federal Budget provided funds for a National Water Infrastructure Loan Facility and for the National Water Infrastructure Development Fund. The latter is “accelerating the detailed planning and construction of water infrastructure projects that will deliver new and affordable water, enhance water security and help stimulate regional economic development including through primary industries and new and expanded agriculture”.

Money from the Fund is provided to state and territory governments on the basis of their matching dollars. A substantial proportion of the Fund is to be committed to water infrastructure feasibility studies and projects in northern Australia.

Referring to the Rookwood Weir near Rockhampton, Michael McCormack said: “Water infrastructure is vital for drought-proofing communities and flood mitigation.” His colleague Matt Canavan, more colourfully, has said that Rookwood Weir is an economic game changer for the region: “a ribbon of water through dusty plains that will fuel a billion-dollar boom in farming output across Central Queensland”.

3. Facilitation of integrated catchment management

Integrated catchment management (ICM) is now accepted as a valuable means of protecting land and water resources, native vegetation and biodiversity.

The approach recognises that land and water use and environmental impacts are interconnected and that actions in a catchment have cumulative impacts on areas downstream. It sees those involved in land use planning, natural resource management, agriculture, conservation and the community working together to plan and manage programs at catchment level.

The Murray-Darling Basin Plan can in effect be seen as a major ICM program – perhaps the largest in the world.

ICM has largely been driven by voluntary action through the Landcare movement. To be most effective, the geographic units within which ICM is being applied need to be recognised (or mandated) in statutory plans or regulations that have legal force.

Also, to ensure effective catchment planning and local action, data must be collected and managed at an appropriate scale, and must be easily available to land owners and managers.

In the right conditions ICM is an effective means for translating national and state natural resource management strategies into local action.

4. The encouragement of regenerative agriculture

As regenerative farmer Charles Massy has written:

Agriculture, in occupying 38 percent of the Earth’s terrestrial surface, is both the largest user of land on the planet and humankind’s largest engineered ecosystem.

Because it is based on plants, which take carbon out of the atmosphere to make and store sugars through photosynthesis, and because these plants have roots growing in the ground, a healthy agriculture has the potential to bury huge amounts of carbon for long periods.

Excessive carbon dioxide in the atmosphere (largely due to the release of long-stored carbon through burning fossil fuels) is, we now know, one of the key causes of the greenhouse effect. Absorption of excess carbon dioxide also makes the world’s oceans more acidic.

Moreover, when a healthy agriculture puts more long-lasting carbon into the soil while minimising the loss of such carbon, this in turn has a major impact on the water cycle and its crucial role in thermoregulation (i.e. climate control) of the planet.

But the problem is that traditional industrial agriculture – through practices such as burning vegetation for land clearing, using fossil fuels (in fertilisers and chemicals, and to power farm machinery), overgrazing, ploughing and fallowing – emits, rather than stores, carbon.

But it need not be this way. An ecologically and socially enhancing agriculture – what I call ‘regenerative agriculture’ – can reverse this harmful carbon-emitting signature of industrial agriculture. It can do this via various methods, but all are based around revegetation and inculcating healthy, living soils…”

(Call of the Reed Warbler – A New Agriculture, A New Earth, UQP, 2017.)

5. Short-term emergency support

It is a mistake to try to reduce the frequency or impact of drought through something narrowly defined as drought policy.

The only part of drought that ought to be treated separately is the provision, in certain specified and serious circumstances, of short-term assistance to minimise the costs to humans and animals of a situation that could not reasonably have been expected or planned for.

The Commonwealth and State Governments should agree on objective criteria that will be used to ‘switch on’ this short-term emergency assistance – perhaps region by region, to reflect the disparate situations relating to natural resources and climatic incursions.

These are the only circumstances in which the terms ‘drought support’ and ‘drought policy’ should apply.

6. The science of climate and water management

The geological record shows that the Earth has experienced dramatic changes in temperature within the period of a human generation in the distant past.

This attests to the fact that climate is affected by feedback, making it susceptible to small changes in conditions. These conditions are “oceanic processes (such as oceanic circulation), biotic processes (ie. plants), variations in solar radiation received by Earth, plate tectonics and volcanic eruptions, and human-induced alterations of the natural world”.

This last is what is currently causing global warming and the ‘climate change’ now of such concern. The mechanism for these human-induced effects is the proportion of greenhouse gases in the atmosphere: including methane, chlorofluorocarbons and carbon dioxide.

The science of climate is so complex that it is still not possible to say what connections there are between each successive new incident of drought, flood or fire – feast or famine – and climate change as defined.

The other sciences involved in natural resource management, in contrast, are relatively settled.

Understandings based on the scientific method must be the basis of decisions and action about all aspects of natural resource management, including those relating to water.

Australia has a long and proud record of research and development in the area, although recent trends in the level of public funding for scientific research across the board is causing concern.

Over the last few years, and fuelled by the last drought, significant investment has been made in water information in the Bureau of Meteorology.

This provides ready public access to information, for the first time, on surface water, groundwater and soil moisture. Taken together these give a detailed and accurate measure of land-based system capability.

One of the BOM’s maps is of Landscape Water Balance, information on a daily basis about Root zone soil moisture, Upper soil moisture, Lower soil moisture, Deep soil moisture, Deep drainage, Actual evapotranspiration, Potential evapotranspiration, Runoff and Precipitation.

Such rich data has never before been available and provides one of the bases for an integrated approach to water management. It is unclear what use has been made of these data in decisions relating to the current dry in NSW and Queensland.

7. Agriculture, settlement and town water

Australia is familiar with patterns of agricultural production being prescribed by Nature. Best-known in the category is Goyder’s Line, which, in effect, joins places in South Australia with an average annual rainfall of 10 inches (250 mm). The line was conceived and ‘mapped’ in 1865 by George Goyder, Surveyor-General to South Australia, with areas to the line’s north being judged “liable to drought” and those to the south deemed arable.

Such lines have already been inexorably re-drawn by changes in rainfall pattern and more can be expected.

Although it tends to receive less public attention than the effects of drought on farmers and their animals, the pattern of rainfall also has serious implication for settlement in rural Australia.

An increasing number of rural places are seeking growth and development through the settlement of immigrants. If Australia’s population is to continue to grow apace and somehow to be actively distributed across rural and regional areas, town water supplies constitute a critical matter for attention.

8. Water reticulation and on-farm storage

This element of national water management relates to the ways in which water is transported from place to place, and how run-off is captured and stored – including on farms.

Irrigation channels and rivers/creeks/lakes are the most important sources of the water used in agriculture. In 2016-17, just over 22,000 (of 88,000) agricultural businesses used water for productive purposes.

The total volume of water used was 9.9 million megalitres, of which 9.1 million was used for irrigation. Of the 9.9 million, 37 percent was sourced from irrigation channels, 29 percent from creeks, rivers and lakes, 18 percent from groundwater and 13 percent from on-farm dams or tanks. (http://www.abs.gov.au/ausstats/abs@.nsf/mf/4618.0)

In his Broken Hill interview, Malcolm Turnbull said:

Wherever we can, what we need to do in managing water in a hot, dry continent, is where we can possibly do it, we should pipe it rather than running it in open channels.

Where we can configure storages so that they are deeper, then you have less evaporation”.

Over the last decade, investments costing several billion dollars have been made in replacing inefficient channels with pipelines and increasing the efficiency of remaining open channels to reduce water loss. In effect these investments in the efficiency of water infrastructure purchased water for the environment. The easy projects have been completed.

The development of Northern Australia constantly faces the challenge of finding deep, efficient water storage sites.

9. Sustainable groundwater management

Groundwater resources are absolutely critical in Australia and in some areas provide the only reliable water supply for settlements and industry.

There are currently some serious arguments relating to the impact of various categories of land use on groundwater resources. Chief among them is coal seam gas exploration and production. Science and political processes will continue to be tested by this phenomenon and it is to be hoped that appropriate decisions will be made with minimal divisiveness among the people and communities involved.

Monitoring of groundwater resources will remain critical with increased pressure likely from industry, climate change and, potentially, from closer settlement. This is another area in which investment in the BOM’s data capacities has made great strides forward.

The relationship with drought is obvious. In dry times when run-off is reduced, a sustainable groundwater resource is even more critical.

In conclusion

The environmental and economic prosperity of Australia depends on water. Succeeding with water management at national, state, catchment and local areas is therefore critical. For this success to be assured, water management practices will need to continue to be determined by science and understanding.

In times of water shortage, the focus must remain an all elements of its management and incidence of drought should not be allowed to affect the strategic course of natural resource management activity.

As a nation we need to continue to be sympathetic to any unmanageable events that endanger the health and well-being of citizens. But sympathy is no basis for the development of longer term policies that will, among other things, minimise the incidence and extent of drought.

Unpicking the history and politics of drought policy in Australia

Note: this piece was first published in Croakey, 13 August 2018. Thanks to Melissa Sweet, Croakey Editor.
Rural health advocate Gordon Gregory is kicking off a two-part series about the way drought policy is conceived and handled in Australia, and how the current drought in NSW and Queensland rapidly became a high-profile matter.In many areas of public policy, such as health, disability and aged care, he says governments are often accused of putting cost minimisation before genuine concern for some of their most needy citizens.

This cannot be said of governments’ response to drought support once evidence of the human cost is in the public eye, Gregory says. The question is whether ad hoc responses to human (and animal) suffering would not be better within a settled, planned approach to rainfall variations.

In the article below, Gregory describes the history of drought policy since 1971, and argues that “a rigorous and rational approach to national drought policy” remains illusory.

Given the impact of climate change on weather patterns, the challenge of agreeing on a rational policy for drought has become even greater, he says.

Gordon Gregory writes:

Drought has pervasive and deleterious impacts on the health of individuals, families, communities and even whole regions – as well as potentially serious ecological effects.

Its management is therefore an important issue for the health sector, in environmental management, and for the planning of physical infrastructure.

Given its importance, some people may be surprised to learn that the declaration of drought in a particular area of Australia is not the result of measurement against objective criteria such as weeks without rain, soil moisture or river flows.

Instead, drought declarations have been and continue to be made by governments (or ministers, in the case of ‘Exceptional Circumstances’) on the basis of a subjective assessment that there is insufficient grazing or water available to sustain sheep or cattle and that stock therefore have to be moved, hand fed and/or watered.

(Current arrangements for early withdrawal of Farm Management Deposits, or FMD, do actually include one objective criterion, being that “an area of your primary production property has been affected by rainfall for that six-month period within the lowest five percent of recorded rainfall for the property”. There is a FMD rainfall analyser on the Bureau of Meteorology website.)

In NSW and Queensland, drought declarations are made on the basis of local government areas or Pastures Protection Board districts. This makes it possible to say, for instance, that “60 per cent of Queensland was drought-declared in 2013”. Awkward boundary issues arise from such an approach, with adjoining properties somewhere bound to be treated differently.

So the status of a particular area with respect to drought is subject to two things: one, the observed situation relating to pasture and crop growth, river and creek flows, on-farm water storages and soil moisture; and two, politics. This article focuses on the second of these.

Organisations working for a particular cause within Australia’s government system or civil society are often judged by the extent to which they succeed in getting their cause or issue onto the political agenda.

Lessons can perhaps be drawn for this challenge from what has happened over the last eight weeks in Australia with respect to drought. Despite below-average rainfall for up to seven years in some areas of New South Wales and Queensland, in May 2018 there was scarcely a whisper about drought.

Now, in the first half of August, there is wall-to-wall coverage of ‘The Big Dry’.

How did this happen? What role did farmers, politicians and the media play in getting support for drought assistance measures this time around? Are things being learned for future management of dry conditions? Has the situation been reflected accurately or has there been exaggeration?

First, some history

On Thursday 14 February 1991, Toowoomba’s City Hall was the venue for day one of the first National Rural Health Conference. What began there on that day has resulted in Toowoomba being seen by many people as the spiritual home of Australia’s rural and remote health sector.

Coincidentally, almost exactly 27 years later, on 1 February 2018, Prime Minister Malcolm Turnbull gave his first major speech of the year in Toowoomba’s Empire Theatre Hall.

Described as a Keynote Address, the Prime Minister talked about Australian values, Government achievements, the economy, innovation, infrastructure, energy prices, health and education funding, free trade agreements, Enterprise Tax Plan, income tax, wages growth and the Budget.

The Prime Minister’s speech was setting the agenda for the new calendar year.

It made no reference to drought or rainfall.

It is often said that, at any given moment, there is a drought somewhere in Australia. The (happy) corollary of this is that it is very rare for the whole country to be in drought at the same time.

There have been numerous reviews and inquiries into drought policy and how it should be handled by Commonwealth and State/Territory Governments: from John Lovett’s of 1973; to James Balderstone’s of 1982; Peter McInnes’s of 1990; that of Linda Botterill and Melanie Fisher of 2003; and the Productivity Commission’s of 2009.

The overall conclusion of the McInnes Report was timeless and typical:

– the Commonwealth Government, in conjunction with State and Territory Governments, should implement a national drought policy as a matter of urgency.”

Why has this not happened?

The challenge for a potential National Drought Policy was, and remains, to balance production efficiency and welfare. It is almost impossible to separate the two. The very existence of drought support, or the mere expectation of it, affects farmers’ planning decisions before, during and after droughts.

Drought policies need to be consistent with national rural adjustment and environmental objectives. Ideally they need to give consideration to issues as diverse as social welfare, maintenance of the livestock gene pool, land management, animal welfare and infrastructure planning.

The situation has become even more difficult because of the greater dynamism and uncertainty given to rainfall patterns by global changes in climate.

From 1971-1989 drought support was provided under the Natural Disaster Relief Arrangements (NDRA). Sometimes Nature liked to highlight the irony of the different purposes of the NDRA, as in April 1988 when the Commonwealth was funding 75 percent of both drought and flood relief for Queensland!

In their (Constitutionally-given) drought declaration duties, each State has had its own criteria. But given the arrangement for the Commonwealth to start funding support once the State has reached a specified level of expenditure, there is always a financial incentive for the States “to declare quickly and revoke slowly”.

The general approach has been to declare the existence of drought in a particular area on the basis of an assessment that there is insufficient grazing or water available to sustain sheep or cattle and that stock therefore have to be moved, hand fed and/or watered.

These judgments are easier to make with reference to pastoral industries than to cropping. With the latter, judgments are even more difficult because of the impact of future rainfall on what might be seeded and what might in future be produced and harvested.

In NSW and Queensland, drought declarations have been made on the basis of local government areas or, in NSW, by Pastures Protection Board districts. This ‘lines on the map’ approach is the basis for statements such as “60 per cent of Queensland was drought-declared in 2013”. However, as with all such geographic matters, boundary issues arise, with some adjoining properties bound to be treated differently.

Politics at play

The inherently political nature of drought declaration runs counter to a rational approach. It has long been recognised that drought policy should include measures to encourage preparation by individual farmers, catchment authorities, and governments – in the case of the last, if for nothing else, for the planning and management of water infrastructure.

In his definitive record of his time as Minister for Primary Industries and Energy, John Kerin has written:

… no rigorous economic approach, based on risk management, could ever be politically maintained, once intense and long droughts started to bite and once the media highlighted dead and starving stock, withered crops, rural unemployment, bankrupt farmers and graziers and destitute families… droughts highlight the problem of trying to reconcile efficiency and welfare considerations, which inevitably becomes a political question.”

The current drought’s emergence into the public consciousness and the consequent actions by Commonwealth and State Governments have again illustrated the political aspects of the issue.

There are regular ‘hand on heart’ agreements that rationalist or ‘strategic’ approaches need to be taken to planning for dry times and treating drought as a manageable risk, and plenty of valuable but underutilised intellectual capital has been invested in the matter (as per this article, Using adaptive governance to rethink the way science supports Australian drought policy).

But then, at a certain point in the cycle, comes the emotion and the related politics. And because the Commonwealth has a long history of coming to the party to back up the States, it is impossible for them to resist the option of such things as interest rate subsidies, carry-on loans and support for freighting feed, water and stock.

A related and recurring issue is whether there should be support for the small businesses, economies and employment of country towns affected by drought and, if so, the means by which it should be provided. Usually this has been put in the too-hard basket until the drought is over; when it is no longer seen as an issue.

(The impact of drought on rural communities was described in a 2004 report, Social Impacts of Drought, while mental health, drought and climate change are discussed in The Climate Institute’s 2011 report (pictured below), A Climate of Suffering: the real cost of living with inaction on climate change).

There have nevertheless been some tangible improvements to the system. The severity of the 1980-83 drought was one of the drivers for John Kerin to establish the Rural Financial Counselling Service, the services of which have been lauded by the Prime Minister and his Ministers over the past few weeks.

Only in ‘Exceptional Circumstances’

From 1997 to 2012 the key term used was not “declaration of drought” but ‘Exceptional Circumstances’ (EC). This was generally described as (but not universally accepted as) “rare and severe events that farmers cannot be expected to manage for longer than 12 months, and which only happen every 20-25 years”.

Apart from anything else, this definition failed to allow for the fact that global climate change has altered rainfall and heat patterns and thus the frequency and severity of droughts.

Responsibility for declaration of Exceptional Circumstances fell to the Federal Agriculture Minister, but with the States retaining their own measures such as transport and fodder subsidies. Family support payments and interest rate subsidy schemes were re-birthed as the EC Relief Payment.

The cycle of policy review/dry times/political response continued.

2001 saw the beginning of a run of dry years, seen retrospectively as the Millennium Drought – “the longest uninterrupted series of years with below median rainfall in southeast Australia since at least 1900”.

The Coalition Government held firm for some time on the grounds that payments to farmers constituted ‘middle class welfare’.

The farm lobby led a successful public relations campaign and some $900 million was allocated to the EC program and household support was made more readily available. The Commonwealth spent $2.6 billion on interest-rate subsidies between mid-2001 and the end of 2011.

During this period the EC arrangements gained a poor reputation, with anecdotal evidence that many farmers who needed support couldn’t get it, some who got it really didn’t need it, and that poor farming and management practices were being propped up by government money.

Further reviews

There were further reviews of drought policy in 2008-09, with an Expert Social Panel calling for an increased focus on people, on preparing for drought, and for greater government support of community, health and mental health programs in drought-affected areas. The Panel also commented on the negative effects of a continual focus in the media on the existence of ‘drought’.

In 2009 the Productivity Commission again recommended the abolition of interest rate subsidies and of EC declarations.

The Millennium Drought started breaking across the country from 2009, before major floods arrived in the summer of 2011.

The EC system came to an end in 2012, with interest rate subsidies replaced by the Transitional Farm Family Payment (TFFP), paid at the Newstart rate and initially subject to an assets test threshold of $1.5 million.

The Labor Government introduced the Farm Finance Scheme (FFS), conceived as a rural debt relief package but increasingly used as a delivery mechanism for concessional loans to drought-affected farmers. It included $420 million over two years for concessional loans, funding for additional Rural Financial Counsellors, and changes to make it easier for farmers to access the Farm Management Deposit scheme.

After the 2013 Federal Election the Coalition directed funds from the FFS to the drought-hit states of Queensland, NSW and Victoria.

In January 2016 NSW’s Independent Pricing and Regulatory Tribunal reported as follows:

In July 2014, the Intergovernmental Agreement on National Drought Program Reform (the IGA) came into effect. This agreement between the Commonwealth and state and territory governments aims to ensure that government-funded drought programs not only support farmers in times of hardship, but also help them adapt to and prepare for the impacts of increased climate variability and adopt self-reliant approaches to managing their business risks. (IPART, NSW Drought Program Evaluation Framework – Other Industries — Final Report January 2016).

Plus ça change. Linda Botterill, an authority on drought policy, has observed that the intergovernmental agreement on drought policy reform signed by all governments in May 2013 looks very much like the one agreed in 1992 in terms of both content and underpinning principles.

But the names continued to change. The TFFP became the Farm Household Assistance program (FHA) in 2014 – which brings us to the events of 2018…

• Gordon Gregory is a former CEO of the National Rural Health Alliance. Read his previous articles at Croakey. His next article will examine how today’s drought came rapidly to be a high profile public issue that governments could not ignore.

Today’s drought gets on the agenda

Note: This piece was first published by Croakey on 21 August 2018. Thanks to Jennifer Doggett who edited it for Croakey.

When politicians start wearing Akubras, you know that a rural issue has hit the political agenda.  But long before the Prime Minister donned his hat and moleskins to stand ‘shoulder to shoulder’ with Australian farmers, rural communities in drought-affected areas were speaking out about the difficulties they faced and calling for support.

So how did this drought progress from these local advocacy efforts to a high-profile, headline-dominating national issue that has attracted over half a billion dollars in aid for affected areas from the federal government?

In Part 1 of the ABC of Drought Gordon Gregory described the history of drought policy since 1971, and argued that “a rigorous and rational approach to national drought policy” remains illusory.

In Part 2 he examines how the current drought came rapidly to be a high profile public issue that governments could not ignore.  He explains that short-term expenditures of public monies to mitigate the effects of drought are unavoidable once the hardship being experienced by farmers, livestock and the land resource are on the public consciousness.

By analysing media coverage of the drought and in particular coverage by regional ABC radio stations, Gregory describes how, after many months of below-average rainfall, the current drought rapidly became a high profile concern.

This analysis may be instructive for any entities working to have their particular ’cause’ treated considerately by governments.

Gordon Gregory writes:

Sometimes the impact of drought is seen and felt in the major cities, as was the case when, on 8 February 1983, a dust storm spread over Melbourne. The Ash Wednesday fires in Victoria and South Australia soon followed, killing 75 and injuring 2600 people, destroying 9,000  homes, and killing 300,000 head of stock, including 250,000 sheep.

More often, however, drought is slow and creeping until it crosses some invisible line and takes off like an emergency flair to become a staple diet for a short time for most media outlets, as has happened in the past two months. Presumably someone is considering how social media, the new force in the fourth estate, has contributed to the existence, understanding and management of the current drought.

What got the current drought over that line?

On 28 March 2018 the Senate Select Committee on Regional Development held a public hearing in Canberra. Its witnesses that day included USQ’s Institute for Resilient Regions and the University of Western Australia’s Centre for Regional Development. There was no reference to drought or rainfall.

On 29 March the Prime Minister was interviewed by Rebekah Lowe on ABC radio Broken Hill. He had just been at the Royal Flying Doctor Service base to confirm the allocation of $84 million extra for the RFDS’s mental health and dental work.

What transpired in that interview was what might be termed a strategic discussion of water management in a dry continent: balancing environmental and irrigation flows, managing the Murray-Darling Basin, ‘water theft’ and management of water storages. Having previously been Minister for Water Resources the Prime Minister was well-equipped for such a discussion.

The interview then went on to discuss the Menindee Lakes and building water infrastructure such as the pipeline from Wentworth to Broken Hill.

“Wherever we can what we need to do in managing water in a hot, dry continent, is where we can possibly do it, we should pipe it rather than running it in open channels. Where we can configure storages so that they are deeper, then you have less evaporation. I mean we live in a big flat – by and large – dry, hot country. So we have got to be smart about the way we use water.”

This is the strategic, planned, cool debate about Australia and water: unemotional, devoid of very much focus on short-term human consequences.

It was the calm before the storm.

The drought gets personal – a chronology

9 April 2018

A NSW Government announcement was covered online on 8 April by ABC Upper Hunter’s Cecilia Connell. It referred to a new scheme to assist drought-affected families in New South Wales “as more than a quarter of the state deals with worsening dry conditions”.

11 April 2018

ABC online ran a story from the Central West of NSW by Tim Fookes.  This story described how farmers across New South Wales’ central-west were battling the driest period in at least a decade, along with temperatures up to 10 degrees above average.   

19 April 2018

Michael McCormack, Deputy Prime Minister and Leader of the National Party, addressed the National Press Club and announced additional funding for Rookwood Weir, making the following comments:

“Water infrastructure and security is vital – vital for the livelihoods of not only agriculture but people in so many regional communities.  It is vital to the success of our farmers, our small businesses, and for local jobs in the region. Water infrastructure is vital for drought-proofing communities and flood mitigation, and there’s no greater example of this than Rockhampton and Rookwood.

Australia is home to the world’s best farmers; the most innovative, practical and most resilient on our planet, and they are the best environmentalists.  Without water, our communities cannot grow the food and fibre that our nation needs and the world demands. Let me tell you: we grow the very best food, the very best fibre in the world, especially our irrigators.”

8 May 2018

ABC Illawarra ran an online item from Picton, near Sydney, by Gavin Coote and Nick Rheinberger on a farming family on the outskirts of Sydney which had put the call out for people to adopt its cattle in a last-ditch bid to remain afloat during a historic drought.  The dairy farm at Picton in Sydney’s south-west has been in the Fairley family since the 1850s and is in the grip of unprecedented dry conditions.  Sixth-generation farmer John Fairley said he had never seen it this bad.

4-5 June 2018

Prime Minister Malcolm Turnbull, accompanied by Deputy Prime Minister (Michael McCormack), Minister for Rural Health (Bridget McKenzie), Minister for Agriculture and Water Resources (David Littleproud), Minister for Regional Development, Territories and Local Government (John McVeigh), and Assistant Minister for Trade, Tourism and Investment (Mark Coulton,) visited Trangie, Charleville and Blackall.  They held doorstops and did radio interviews.

Shadow Minister Joel Fitzgibbon noted that the Prime Minister acknowledged that the climate is changing in a way which is challenging our farmers and our agriculture sector. “After five years in government the Prime Minister is using his drought tour to ‘listen and learn’. It’s as if drought only just emerged.”

5 June 2018

ABC television’s 7.30 Report aired the ‘Adopt a cow’ story from Picton.

7 June 2018

That invisible line has still not been crossed. On Sky TV Peta Credlin and Bridget McKenzie first discuss Barnaby Joyce, then the ice epidemic, and then the shortage of doctors. Then Senator McKenzie stated:  “We know we’re the most arid country in the world. We’ve got a $62 billion agricultural industry which really drives our national economy in so many ways. So we’re good at it. But we do know that we have these periods of drought and we have to have a sustainable model to deliver it.”

7 June 2018

The Minister for Agriculture and Water Resources, the Hon. David Littleproud, released a statement announcing an additional $20 million in funding for farmer support services.

28 June 2018

The Farm Household Allowance extension legislation was passed by the Senate.  This legislation enabled farmers in drought to access a fourth year of the Allowance.

9 July

The Minister for Agriculture and Water Resources released a statement reporting that the government had held “Constructive discussions at drought round table“.  These resulted in an agreement to use the National Farmers’ Federation drought policy as a framework to move forward and to further discussions with the banks on Farm Management Deposit offsets

10 July

Grant Maudsley, AgForce General President, commented on the Drought Roundtable.  He stated that “collaboration between governments at all levels, the financial sector and primary producers will be the key to developing an enduring drought policy.”

29 July 2018

ABC Rural ran a story The big dry: ‘See us, hear us, help us’ reporting that farmers across New South Wales and Queensland are calling it the worst drought in living memory, with many facing ruin.

30 July 2018

The NSW Government announced an extra $500m in drought assistance for struggling farmers.  This brought the New South Wales Government’s drought assistance package to over $1 billion.

5 August 2018

The Prime Minister urged almost 20,000 farmers eligible for drought relief who are yet to claim welfare payments to contact a financial counsellor. The Prime Minister appealed to farmers to use the federal government’s Rural Financial Counselling Service to check whether they were eligible for the Farm Household Allowance.

6 August 2018

The ABC’s Chart of the day asked whether the current drought is the most severe in history.  It found that while this drought is severe it has not been as prolonged as the millennium drought — the longest dry spell in history, which saw nine consecutive years of low autumn rains, crucial for the southern cropping season.

Conclusion

“We’re another day closer to rain” said a grazier interviewed for ABC TV News at the Louth Races in Cobar Shire (11 August).

One can’t argue with his logic. And his attitude typifies the accepting, resilient and normally cheerful approach of farming and grazing people to the uncontrollable climatic situation they face.

Another common view of those who bear the brunt of dry times is: “We do not want handouts.” Short-term help will always be needed in dire situations but rural people, including farmers, do understand the vagaries of nature they face. This should embolden farm leaders, politicians, the public and the media to have the discussions and then put in place a national water management policy of which short-term emergency drought assistance is but a small part.

Where so many areas of policy are concerned, including health care, aged care, industrial change and the environment, we must continue to insist on approaches that are both rational and compassionate.

But a holistic approach is required and a balance must be retained. If  the management of drought is separated from other aspects of natural resource management, the challenge is made worse.

In short, there is currently too much consideration of ‘drought’ and not enough of ‘water management’. At every moment,  including in dry times, public policy should be dealing with water management in all its aspects.
In Part 3 of this series – Too much ‘drought’, not enough ‘water management’ – Gregory will argue that the problem begins with the separation of drought from other aspects of the management of Australia’s natural resources.

An “ambitious” call for a national rural health strategy

Note: This piece was published in Croakey, 13 July 2018. My thanks to Melissa Sweet, Croakey Editor.

In his recent article kicking off the series, Gregory critiqued what the Federal Government is calling its Stronger Rural Health Strategy, describing it as a package of rural medical workforce programs.

In this second piece he makes the case for development of a real National Rural Health Strategy – a document about the principles to be agreed and adhered to by governments at all levels (from all sides of politics) and by the rural health sector itself.

Considerable effort will be needed to put such a document in place, and there needs to be a clear distinction between such a Strategy and Federal/State/Territory rural health plans or road maps. But with an over-arching Strategy in place, rural health can be given the national focus and prominence it deserves.

The ‘Stronger Rural Health Strategy’ announced in the May Budget has none of the characteristics of a real national rural health strategy. It is not bipartisan. And in a sector in which the States and Territories do so much, not to mention local government, it is not cross-jurisdictional.

Nor does it involve or commit the rural health sector itself, or make reference to all of the non-health sectors involved with the social and economic determinants of health.

The Budget’s co-option of the term ‘rural health strategy’ muddies the waters and makes it more important to distinguish a strategy from a plan or road map, and all of those from a bundle of programs.

There are several precedents for production of, and adherence to, a true National Rural Health Strategy.

The most recent was the second iteration of Healthy Horizons, endorsed by Health Ministers and the sector for the period 2003-2007. That document was described as “a framework for improving the health of rural, regional and remote Australians”.

It was approved by the Australian Health Ministers’ Advisory Council (AHMAC) and endorsed by Australian Health Ministers. Accountability was built into the framework, with a requirement for progress reports to AHMAC from all jurisdictions and from the sector itself (through the National Rural Health Alliance (NRHA).

In some quarters it is thought to be ambitious, at a time when rural and remote health is said “not be on the agenda”, to conceive of a national strategic document to which all jurisdictions have agreed.

The counter-argument is that when rural health is not a priority is precisely the time when stronger focus and greater commitment from governments should be sought.

Bipartisan support

There are a number of reasons why it is desirable to have bipartisan support for a high level national document on rural and remote health.

  1. The existence of such a document would proclaim that the health and well-being of the one-third of Australia’s population who live in rural areas is a matter of importance.
  2. An agreed national strategy would ensure that, irrespective of which party is in power, there would be a consistent approach to the management and prioritisation of rural health.
  3. An ongoing, settled, national approach to rural health would be a fixed context in which the States and Territories determine their own plans for rural health. This would reduce variability between jurisdictions in the way rural and remote health is treated, and facilitate work to achieve a uniform national approach in related areas such as professional registration and accreditation, and the setting of occupational terms and conditions.
  4. A consistent, documented bipartisan approach to rural health provides the policy context in which national organisations concerned with health and well-being (including but not exclusively those in the health sector) can prosper and optimise their contribution to good health.
  5. Such an approach provides certainty about the basic principles and approaches to be taken to rural health, which can be used to keep governments, businesses, researchers and health service providers publicly accountable for what they do and what they may fail to do.

Context

The notion of a National Rural Health Strategy needs to be seen in the context of planning arrangements made at other levels. Each State and Territory health jurisdiction produces, from time to time, its own jurisdiction-wide or rural health plan.

Given the disparate electoral and policy cycles in each jurisdiction, these plans have a variety of timelines so that it is not possible to mandate in a national plan that such-and-such an activity will be achieved by such-and-such a date.

The hierarchy of arrangements sees plans for individual jurisdictions, including potentially a federal rural health plan, sitting at a level below the national strategy. Programs, in turn, sit below the plans. (Some people have a preference for the term ‘road map’ instead of ‘plan’.)

The third piece in this series will attempt to embolden the faint-hearted by detailing the style and content of a new, real National Rural Health Strategy.

Do the Government’s claims about its rural health strategy stack up?

Note: This piece was first published in Croakey, 9 July 2018.

In the Federal Budget in May, the Government announced what it called a Stronger Rural Health Strategy.

It would be very useful to have a national strategy to guide and inform governments and other agencies concerned with the status of health and health services in rural and remote areas.

But this Budget document is not it.

It is a package of programs for rural medical education, many of them reshaped versions of programs that already exist – and with some questions needing to be clarified about exactly what is intended (for instance, how much money will be allocated).

A Federal Budget program cannot, by definition, be a longer-term, national strategic document: the Budget looks forward over only four years; is about the allocation of funds rather than goals and principles; and is not something that can be endorsed by States/Territories and by both sides of politics.

For much of the period between 1991 and 2007, there was a real National Rural Health Strategy, issued by the Health Ministers’ Conference and jointly approved by all health jurisdictions and the sector itself, represented by the National Rural Health Alliance. The most comprehensive and longest-lasting of these was called Healthy Horizons and was in place from 1999 until 2007.

In the first of three pieces for Croakey, I unpack the current Stronger Rural Health Strategy package, make the case for a new bipartisan National Rural Health Strategy, describe its place vis-a-vis health sector ‘road maps’, ‘plans’ and programs, and illustrate what such a document would contain.

Unpacking the Stronger Rural Health Strategy

Senator Bridget McKenzie, Minister for Rural Health, has described the Stronger Rural Health Strategy announced in the May Budget as “the most comprehensive workforce reform package ever produced in Australia” and as “a comprehensive and transformational rural health package over the next 10 years”.

She continued by saying that The Stronger Rural Health Strategy “resets 29 years of incremental regulatory build-up at every stage of the medical workforce supply, including teaching, training and retention”.

Are these claims reasonable, or is the lily being somewhat gilded?

Close scrutiny of publicly available materials about that Strategy suggests that these claims may be exaggerated.

The first thing to say is that where rural and remote health issues are concerned, the Stronger Rural Health Strategy (hereafter SRHS) is not comprehensive. It concerns only health workforce issues. And in almost all respects it concerns medical workforce issues only.

The fact that all of the Department of Health’s workforce programs now fall under the aegis of the Chief Medical Officer is significant. There are now only vague but fond recollections of the time when there was an Office of Rural Health.

In what way the SRHS is ‘transformational’ is not clear to me. The Minister’s emphasis in her Senate speech on the “resetting” of regulation or red tape is curious. The medical workforce is one of the most heavily regulated there is, and neither the profession itself nor the general public seem to have any objection.

The centrepiece of Australia’s medical system for years has been a regulated market and price for the services of GPs. Through the Medicare Benefits Schedule (Medicare, essentially) a floor price is set for their services, irrespective of clinical need, effectiveness or general quality. Competition between increased numbers of vocationally registered GPs does not reduce the price they charge below the level set by the Schedule.

And the public have a strong interest in regulation. Without it there would be no Medicare.

Let’s not forget too that it is the regulation of overseas trained doctors that prevents them for a period from competing with Australian trained clinicians in the cities, and which provides the mainstay (40-60%) of GP services in many rural and remote areas.

Regulation also plays a critical role in establishing and preserving specific rural programs such as those funded through the universities and the Rural (Health) Workforce Agencies.

The next thing to note is that a Budget commitment over 10 years is meaningless given the uncertainties about who will be in government in that period, what their view will be about the importance of rural health, and what their capacity will be to fund essential services like health. Governments will always face the trap of spending too many of the fruits of economic growth for political purposes, mainly through unwise tax cuts.

The Government’s consistent messaging about the SRHS is that it is “a $550 million investment to support improved rural health services”.

Questions abound

Where the $550m comes from is a mystery – and is likely to remain so, given that the Budget papers only deal with the period until 2021-22.

One thing that can be said is that, over 10 years, that’s an average of $55m a year. Given that the primary health care deficit with which people in rural and remote areas have to live has been estimated at over $2 billion each and every year, $55m a year is really not a lot.

It is to be hoped that current and future Australian Governments give more priority to rural and remote health workforce issues than is indicated by $55m a year.

The Budget papers show that the SRHS will be provided with $83.3 million over the five years 2017-18 to 2021-22. The funding over those five years is concentrated in the second and third years (2018-19 and 2019-20) and valued at $150m. In the other three years there are savings against the program, valued in total at about $70m. This surely needs explaining. It would be good to know which of the programs will have reduced funding in the fourth and fifth years.

Of the $150m allocated in total for 2018-19 and 2019-20, only $122m is current expenditure for the Department of Health.

Several elements of the package are augmentations or re-arrangements of existing programs, such as extension of the Rural Health Multidisciplinary Training Program, updating the geographic eligibility criteria for rural bulk billing incentives, amending return of service obligations under bonded medical training programs, and streamlining the GP training arrangements provided through the two Colleges.

From 1 July 2019 the General Practice Rural Incentives Program and the Practice Nurse Incentive Program will be combined and re-named the Workforce Incentive Program. This is just the latest iteration of general practice incentive programs that have existed for at least 25 years. Extension of the program to support nurses, Aboriginal and Torres Strait Islander health professionals and allied health workers is welcome.

Incrementalism

One of the higher profile initiatives in the package is establishment of the Murray-Darling Medical Schools Network, credited with “creating end-to-end medical school programs that take school leavers straight to rural medical schools”.

This is an incremental addition to what has been happening in medical education and training for twenty years, but is not ‘transformational’. The Integrated Rural Training Pipeline for medicine (IRTP) was announced in December 2015.

The Murray-Darling Medical Schools Network will receive $95.4 million over a period not specified in the Budget papers. There will be no additional medical Commonwealth Supported Places (CSPs) in the universities. Rather, 2 percent of the existing CSPs (up to 60) will be subject to competition between university providers, including the new Murray-Darling Network.

The amount allocated to the SRHS includes an extra $84.1m for the Royal Flying Doctor Service, bringing total Commonwealth funding of the RFDS to $327 million over the next four years. (Inclusion of this $84.1 and its extrapolation through to year ten may help explain the difference between the Budget paper’s five-year $83.3m and the headline $550m over ten.)

The continued seriousness of the bottleneck at the Registrar stage of training for general practice is recognised by a couple of means.

From 2021 there will be an additional 100 places for junior doctors in training for rural generalist practice. To provide more registrar positions away from the metropolitan hospitals, the pathways through the RACGP and ACRRM will be ‘rationalised’. There will be a Rural Primary Care Stream and a Private Hospital Stream. Both will be very welcome, with the latter providing salary support for junior doctors working in private hospitals.

Further additions to the number of doctors working in rural areas will come from encouragement to those who currently do not have Vocational Registration (VR) to obtain it by enabling them to directly bill Medicare if they work in a place classified 2-7 in the Modified Monash Model.

Moves are foreshadowed towards the situation in which all bonded medical students will have a three-year bonding period, and there will be some changes to the regulation of their return of service obligation.

Presumably the key selling point of the SRHS – that it “will deliver 3,000 specialist GPs to the regions over the next 10 years” – is based on an estimate of the extra number who will adopt rural practice in order to obtain VR, to acquit return of service obligations, to train in the Rural Generalist Pathway, and/or in response to more closely targeted place-based incentives.

Partly as a response to Health Workforce Australia’s 2014 report that projected health workforce supply and demand through to 2025, there will be a new planning tool for health workforce and services data. It will help the Department to anticipate workforce shortages among professions registered with the Australian Health Practitioner Regulation Agency and tweak incentives and training funding as appropriate.

Overall the SRHS continues the Australian Government’s positive engagement with an issue that is top of the mind for many people: having access to a doctor. It includes some incremental moves down a familiar track but is no more than a partial treatment for the ills of people and communities in rural and remote Australia.

Further explanation needed

However, some of its elements warrant further explanation. For example, one of the SRHS Fact Sheets informs readers that there is to be continued funding for the Australian Primary Health Care Nurses Association and “an independent review of nursing preparation and education”.

Both of these initiatives are welcome but the particular Fact Sheet includes no mention of the words ‘rural’ or ‘remote’ so that inclusion of these elements in the SRHS may be bogus.

Medicine is still front and centre where the Federal Government’s consideration of rural health is concerned, and strong advocacy must continue to try to extend its role to other disciplines, health care settings and health-related sectors, and to topics other than the workforce.

A centrepiece of this advocacy should be work on a new, real National Rural Health Strategy that would be approved by both sides of politics, governments at all levels, and the rural and remote health sector itself.

 

123 years of argument for primary prevention in healthcare

Here’s a new take on the better sense of trying to prevent ill health rather than merely treating it. It’s from a speech last week by a Conservative member of the House of Lords, Lord Prior of Brampton, a former UK Minister for NHS Productivity:

“Simply putting more money into the NHS and hoping for the best will not work. With funding must come radical reform. We need a shift from ‘diagnose and treat’ to ‘predict and prevent’. Care must be joined up around - and tailored to - the patient.”

And here’s the take on the issue from 1895 – 123 years ago – with which everyone is familiar.

The Fence or The Ambulance
by Joseph Malines, "an American physician"

‘Twas a dangerous cliff, as they freely confessed,
 Though to walk near its crest was so pleasant:
 But over its terrible edge there had slipped
 A duke and many a peasant;
 So the people said something would have to be done.
 But their projects did not at all tally:
 Some said, “Put a fence around the edge of the cliff”
 Some, “An ambulance down in the valley.”

But the cry for the ambulance carried the day.
 For it spread to the neighbouring city:
 A fence may be useful or not, it is true,
 But each heart became brimful of pity
 For those who had slipped o’er that dangerous cliff,
 And the dwellers in highway and alley
 Gave pounds or gave pence, not to put up a fence,
 But an ambulance down in the valley.

“For the cliff is alright if your careful,” they said,
 “And if folks even slip or are dropping,
 It isn’t the slipping that hurts them so much
 As the shock down below - when they’re stopping,”
 So day after day when these mishaps occurred,
 Quick forth would the rescuers sally
 To pick up the victims who fell off the cliff,
 With their ambulance down in the valley.

Then an old man remarked, “It’s a marvel to me
 That people give far more attention
 To repairing results than to stopping the cause,
 When they’d much better aim at prevention.
 Let us stop at its source all this mischief, cried he.
 “Come neighbours and friends, let us rally :
 If the cliff we will fence, we might almost dispense
 With the ambulance down in the valley.

“Oh, he’s a fanatic.” the others rejoined:
 “Dispense with the ambulance Never!
 He’d dispense with all charities, too, if he could:
 No, no! We’ll support them forever.
 Aren’t we picking up folks just as fast as they fall?
 And shall this man dictate to us? Shall he?
 Why would people of sense stop to put up a fence?
 While their ambulance works in the valley?”

But a sensible few who are practical too,
 Will not bear with such nonsense much longer
 They believe that prevention is better than cure
 And their party will soon be the stronger
 Encourage them, then with your purse, voice and pen
 And (while other philanthropists dally)
 They will scorn all pretence, and put up a stout fence
 On the cliff that hangs over the valley.

PPS (Post Poem Script): When Bruce Harris sent me a copy of this poem in 1997 as part of my training for work in the health sector he commented – with his usual wit and wisdom – as follows:

“From the parable:

– choose to live in a place with no cliffs – ideal but unlikely;
– don’t go near the cliff – education, expects too much;
– build a fence – authoritarian, expensive.

Until these happen, some of us have to man the ambulances!”