Doctors take heartless NHS to court

A group representing nearly 1,000 doctors is preparing to mount a legal action against the health service to stop care being withdrawn from patients who want to pay for their own cancer medicines. It is seeking a judicial review of the Department of Health policy that forces patients to pay for all their treatment if they buy any additional medicine.

Many patients would like to buy extra drugs that are not offered as part of their treatment because the National Health Service has ruled that the benefits do not justify the costs. The government fears that if patients make the purchases, called co-payments, it will lead to a “two-tier” NHS.

Doctors for Reform believes patients should be given the freedom to choose. Its intervention follows a campaign by The Sunday Times highlighting the plight of breast cancer sufferers denied the opportunity to improve their chances by paying privately for drugs.

Last December we reported the case of Colette Mills, a breast cancer sufferer from Stokesley in North Yorkshire, who was told that if she topped up her medication with privately bought drugs she would have to pay for her entire treatment – about £10,000 a month. The Department of Health has issued guidance to health trusts warning them that co-payments are not allowed. In December Alan Johnson, the health secretary, reiterated the rules.

Doctors for Reform has teamed up with Halliwells, the law firm, to challenge the ruling. Halliwells is offering its services free as the doctors are trying to raise £35,000 in donations towards government legal fees if they lose. The doctors point out that examples of co-payments already exist in the NHS, for instance in dental care.

Dr Christoph Lees, a steering group member, said: “Doctors are caught in a terrible dilemma: do you tell a patient about a drug that could improve their quality of life, or do you pretend it doesn’t exist?”

Another cancer patient, Debbie Hirst, 56, from St Ives, Cornwall, began legal action against her local NHS trust to win the right to pay for the drug Avastin. Legal judgment was averted when the trust decided to treat Hirst as a special case and paid for the medicine.

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Australia: The government can't fix black health, either

By Christopher Pearson

LATE last year Kevin Rudd, along with the premiers and chief ministers, announced they were committed to the target of closing the 17-year gap in life expectancy between indigenous Australians and the rest of the population. That resolution was formalised last week in a statement of intent, signed by Rudd and Opposition Leader Brendan Nelson and various health organisations, during a health equality summit in Canberra. The plan is that the gap is to be bridged within 22 years, in 2030.

There's something inescapably Mickey Mouse about an in-principle commitment to an outcome at a distant date with a suspiciously round number. By that time, of course, the main signatories and all their front bench colleagues will be long gone from parliament and in many cases from public life altogether. Still, that doesn't mean the undertaking won't keep coming back to haunt them, like Bob Hawke's line about no child left in poverty.

The level of seriousness with which the federal Government is approaching the issue can be judged by its programs and its rhetoric. Last week Rudd claimed that 17 per cent of the life expectancy gap, almost three years, could be attributed to Aborigines smoking at about twice the rate of other Australians. He promised $14.5 million over four years to tackle high smoking rates, which strikes me as no more than a drop in the bucket. Rudd says another seven years of the gap can be accounted for by factors such as alcohol abuse and poor nutrition, which lead to higher than average incidence of diabetes, renal failure and other chronic diseases.

He and Nelson committed to providing healthcare services and facilities that "are capable of bridging the gap in health standards by 2018", a phrase gnomic to the verge of meaninglessness.

Let us take the Prime Minister at his word and, for argument's sake, accept that 10 of the 17 years' gap can be put down to smoking, drinking and poor diet. The first thing to note is that these are all matters of individual choice, rather than anything that could even remotely be considered an occasion of national disgrace. In a pluralist society, the nanny state can deplore people's lifestyle choices but Aborigines are as entitled as the white proletariat to tell nanny to mind her own business. As well, at least in the short term, addictions to nicotine and alcohol are largely unresponsive to health awareness campaigns.

There are other elements of Aboriginal life, especially in remote communities, that are no doubt prejudicial to good health but are nonetheless matters of personal choice. The dogs to be found in rural encampments, for example, carry all sorts of infections and parasites, yet adults and children often curl up with them at night. Likewise, those indigenous mothers whose vestigial education didn't extend to hygiene often choose to steer clear of bush clinics and visiting doctors. In doing so, they leave untreated ear infections that can easily lead to hearing loss or deafness in young children, who are then themselves almost beyond the reach of education. Yet the state cannot and surely should not be in the business of compelling adults, with or without children, to attend a clinic.

In some settlements, betrothed girls as young as 12 and 13 are encouraged or permitted by their parents to have sexual relations with a prospective husband. This often leads to emergency caesarian sections because the girls are too small to bear a baby in the usual way, and it contributes to higher infant mortality rates. These liaisons are legally problematic, of course, but traditional. A government that tried to enforce the law regarding criminal dealings with a minor in cases such as these, regardless of particular circumstances, would be asking for trouble and would be roundly condemned for interfering with time-honoured practices. These are some of the culturally specific reasons for the bleak indigenous morbidity and mortality statistics.

However, there is a school of thought in public health that holds that the meaningful comparison is not with the rest of the population considered as an amorphous mass but with the non-Aboriginal members of the bottom income decile. It's thought to be much more of an apples and apples comparison and more instructive when it comes to gauging the nature and scale of the problems.

Leading British epidemiologist Michael Marmot has shown (in Inequalities of Health) that socioeconomic characteristics of communities, as well as individual characteristics such as income, education and occupation, affect health outcomes. When it comes to across-the-board comparisons in the lowest decile, we can extrapolate from American studies that suggest whites tend to have worse health outcomes than blacks, though on the same income. It also follows from Marmot's findings that for Aborigines to achieve the same health outcomes as the rest of the population they'd have to cover something approaching the same socioeconomic spectrum: a very tall order in only 22 years.

He has another publication, The Status Syndrome; How Your Social Standing Directly Affects Your Health and Life Expectancy, which is worth mentioning here. Its focus is also on the relationship between socioeconomic position and health outcomes. This holds even when you control for the effects of variables such as income and education and risk factors such as smoking. The direct link he identifies concerns the psychic benefits of being in control of your life and having opportunities for the full range of social engagements.

The land rights movement has always maintained that there is a considerable sense of personal and collective empowerment in returning to ancestral territory, more important than easy access to up-to-the-minute facilities. These are considerations that David Scrimgeour, an authority on indigenous epidemiology, points to when trying to explain why health outcomes in recent West Australian research are in some respects better in remote settlements on traditional lands than in cities. He told Michael Duffy, co-host of Radio National's Counterpoint, that rural mortality rates were lower, especially with "the big killers of Aboriginal people: heart disease and diabetes".

Those outcomes also suggest that access to medical facilities may not, of itself, make as much of a difference as is usually assumed. Elsewhere, in The Medical Journal of Australia, Scrimgeour says that indigenous morbidity rates from all causes appear to be the same across the urban-remote continuum, which supports Marmot's view that socioeconomic status is the central issue.

Rather than taking a health-based approach to achieve better health outcomes, there's a compelling case for adopting a wider social policy approach. Its main emphasis is going to have to be on extending the operation of the real economy into as much of rural and remote Australia as possible. If Rudd Labor is serious about Aboriginal health, it will confine itself to tinkering at the margins with the Northern Territory intervention. It should give wholehearted support to 99-year leases, building more privately owned housing in outback communities and generating real jobs. If the ALP is going to address the socioeconomic basis of indigenous morbidity and premature mortality, it is first going to have to take on board Noel Pearson's critique of passive welfare.

A less rhetorically driven and more factually based version of the relative positions of the poor and those in the middle-income deciles would be helpful, too. A recent Household, Income and Labour Dynamics in Australia survey showed that those of the poor who participated in the real economy have been getting better off during the past five years. That means, among other things, that in the lowest income decile the task of catching up -- in terms of income and health -- will be that much harder for Aborigines who've been entirely reliant on benefits.

Tony Abbott, a seasoned health minister whose shadow portfolio includes indigenous affairs, takes a sceptical view of last week's announcement. "There has been no shortage of good intentions in this area but precious few good outcomes," he told The Australian. "I have a deep suspicion of statements of aspiration unless they are backed up by specific measures that can realistically be expected to make a difference. Unfortunately, that's where our modern reluctance to be judgmental about other cultures kicks in. A lifestyle characterised by domestic violence, substance abuse and unemployment is not conducive to good health, regardless of people's ethnicity or culture. There will be little change in Aboriginal health outcomes until the way they live comes more closely to resemble that of other Australians."

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