Now Daphne Havercroft, a Founder Member of an advocacy organisation for patients in the UK, called  Independent Cancer Patients’ Voice (ICPV), offers her perspective, arguing that women should be given balanced, accurate information, and their personal choices about whether to be screened, or not, should be respected.

She writes:

“ICPV doesn’t have a united view on breast screening. Our members have various views.

But  we are united in agreeing that women should have fair and balanced information to make an informed choice about whether or not to be screened. If they choose not to be screened, they should not be made to feel that it is an irresponsible decision, as sometimes seems to be the case.

We welcome the work being done in the UK by Dr Joan Austoker of Oxford University to rewrite the information leaflet sent to women with Breast Screening appointments so that they are told the truth about what is known of the benefits and harms of breast screening. Three of us recently met Dr Austoker and realised what a difficult job she has, because whatever she produces will not please everyone.

It is now well accepted that breast screening will lead to over-treatment for some women. The controversy concerns the statistics about the extent of harms versus benefits.

We hear views from women who have been diagnosed with breast cancer varying from those who are outraged that they may have had unnecessary treatment to those who are convinced their lives were saved by breast screening. The problem is that neither these women nor their doctors can say with absolute certainty whether the treatment was appropriate or whether they were over-treated.

It is unethical for any woman, whether or not she has had breast cancer, to use her views and personal experiences to influence other women as to whether or not to be screened.

That is a decision each woman is entitled to make for herself.

It’s time to move on. ICPV wants to see all women provided with fair and balanced information about breast screening. It must be based on the best available evidence, and be honest about the differing views of experts.

We have a great opportunity to bring a multidisciplinary approach to the future of breast screening by bringing together epidemiologists, breast clinicians, public health experts, researchers, psychologists, cancer patients and women of screening age to understand what we currently know about the biology of breast cancer, what we need to know to better distinguish between disease that will do not harm if left and that which will kill.

Then we must decide on the research priorities that will reduce the incidence of over-treatment, yet not lead to under-treatment. If we make good progress, breast screening information for women will rapidly become out of date and have to be revised every few years as knowledge increases.

Let’s start this work now, for the sake of future generations of women.”

It’s telling that a new report from the NSW Cancer Council called Roadblocks to Radiotherapy is using the power of patients’ stories to raise broader issues of concern about the inequitable access to radiotherapy that have been highlighted in literally dozens of reports and inquiries over the years. It will be interesting to see whether this report has more impact than all those that have gone before.

Radiation oncologist Professor Graeme Morgan has been a tireless advocate over many years for improved access to radiotherapy. Here is his analysis of the report – and a call to action:

“On Friday, NSW Stateline documented the personal traumas of cancer patients attempting to access grossly inadequate radiotherapy services provided by NSW Health.

In NSW, only 36% of cancer patients receive radiotherapy – well short of the benchmark of 52%. In June this year, the NSW Auditor-General criticised the inability of NSW Health to provide enough treatment machines and recommended it develop a 10 year Strategic Plan for Radiotherapy.

Although NSW Health now has a draft Plan, it fails to substantively tackle the lack of access and equity for treatment.

But the rest of Australia is little better with the national radiotherapy treatment rate at 38%, largely unchanged since 1999 – varying from 43% in Victoria to 31% in Western Australia.

How has this been allowed to happen? Well, it’s not due to a lack of reports or inquiries – in the 10 years from 1986 to 1996 over 50 reports had been published – an average of 5 per year.

In 2002, former Senator Peter Baume in “A Vision for Radiotherapy In Australia” recommended the formation of a central body – Radiation Oncology Australia  – for planning, quality and funding, and to overcome the fragmentation between different levels of government – sound familiar?

But after seven years, little has been achieved – still only 38% are being treated, but the number missing out has risen from 7,400 in 1999 to 16,200 in 2008, and as a result 2,500 premature deaths each year due to lack of radiotherapy.

In the last Federal budget, funding was announced for ten regional cancer centres. But this will be to no avail if money is not allocated through a central body for radiotherapy – as occurs with chemotherapy through the PBS.

During the election campaign, Rudd committed to taking over health care from the states if they could not show they were able to improve service delivery within 12 – 18 months. In the case of radiotherapy services, the States have had years to address the problem.

It’s time Rudd took over so that all cancer patients in Australia have equitable access to this essential cancer treatment.”

And now for an anecdote from Croakey:

Last year, when researching an article on cancer care in the bush for Australian Rural Doctor magazine, I heard many distressing stories about what the lack of radiotherapy services in the NT means for cancer patients there, especially for those from remote areas. I tried to imagine what it must be like for Aboriginal people from remote areas having to travel thousands of kilometres to Brisbane or Adelaide when they were unwell.

It became clear that the trauma of a cancer diagnosis, bad enough in the best of circumstances, is  magnified terribly in remote communities. It inevitably means a long, arduous journey into a foreign world far from home and kin. One doctor told me of  an Aboriginal man with a young family, who  had to spend several months living in a hostel in Adelaide while having radiotherapy without the support of a familiar face. It was his first trip outside the NT. He was not the only such patient the doctor had seen develop serious depression.

Others chose to go without treatment. The doctor told me of one such patient who had to be sent back to Darwin, to die without any family around her.

So there are plenty more powerful stories out there, many beyond NSW’s borders.

It’s a question that merits not only the asking, but also some clear-headed attempts at negotiating a way between the vested interests that so often obscure the path to sensible answers in this area.

At least the issue of workforce reform is getting some hearing, with two conferences putting it on the agenda in recent days.

The organisers of this two-day conference that began today in Sydney are optimistic that the COAG driven National Health Workforce Taskforce has made “significant headway” in promoting a nationally coordinated strategy for health workforce planning, and that unified approaches are emerging in professional bodies, training institutions, health services, and regulatory infrastructure.

But they also note some of the problems: “Roles and tasks have remained in silos that have been in place for many decades. The current recruitment, training, and staff management systems are disjointed and health service and clinical management approaches have not readily adapted to changing demand.”

Meanwhile, the ANU last week hosted a forum on health workforce reform last week – you can watch Robert Wells talking about the need to share the evidence with the community here.

Dr Mark Ragg, who facilitated the forum, has written this account for Croakey:

“I was at a forum in Canberra on Thursday on health workforce reform organised by the ANU Primary Health Care Research Institute, and listened to Emil Djakic speak.

Now a bit of background that is bleeding obvious to anyone who’s ever been near workforce reform. To get a better workforce, there needs to be a devolution away from a doctor-centric health system towards one that better uses the skills and abilities of a wider range of players.

There are many discussions around the best way to do that, and to make sure it improves patient safety, but few outside the medical profession believe the current system is the best way. But such a change would involve a slight loss of control for doctors, in some areas. Some doctors are fine with that, others are not. But issues of control are nearly always behind the fiery debates that always take place.

Well, in speaking about the primary health care workforce Emil, who is chair of the Australian General Practice Network, said that he wasn’t convinced that reform was needed, and that he wasn’t sure of the direction any reform should take, and that what was needed was more research. Any changes made had to be based on ‘data, data, data’, he said.

Fine. Surprising, but fine.

After the forum, I spoke to two men from other doctors’ organisations who used similar phrases. ‘Data, data, data’, one said.

Coincidence? Possibly. Or a concerted approach by some doctors’ organisations to try to delay action while ‘more research is need’. Surely not.

We’ll see how effective such an approach would be. Warren Snowdon, who is Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery was pretty positive about the fact that ‘reform is going to happen – we promised it and we’ll deliver it’.

Hope he’s right.”

• Mark Ragg is adjunct senior lecturer at the Sydney School of Public Health, Sydney University, and director of the health and communications consultancy RaggAhmed.

• And on related issues…Does Australian medicine operate a “closed shop” that discriminates against overseas trained doctors? Find out more in this news story for the BMJ.

At the risk of a gratuitous self-plug, the use of these medicines in young children was one of the issues of concern that Ray Moynihan and I highlighted in our book, Ten Questions You Must Ask Your Doctor (Allen & Unwin, 2008). We came across several references raising concerns about these products’ use in children when researching the book back in 2007.

So the TGA is certainly not rushing the jump.

Nonetheless, the move will be such a challenge to accepted practices that it will need to be backed by a long-term educational campaign. So argues Ron Batagol, a Pharmacy and Drug Information Consultant.

He writes:

“In a move that is likely to provoke much spirited debate amongst doctors, pharmacists and, most importantly, the parents and carers who look after the day-to-day health issues of  young children in their care, the Therapeutic Goods Administration (TGA) has given notice that it is intending to  “upschedule” over-the-counter cold and cough products to Prescription Only for children under six years and Pharmacist Only for children aged between six and 12 years.

As part of the upscheduling exercise, the TGA has also recommended cough and cold medicines should not carry dosage instructions for children under six years old. The TGA says that this approach would bring the regulation of cough and cold preparations in Australia into line with measures in place in the UK and Canada.

After extensive  internal and external reviews of the evidence surrounding both  efficacy and safety in use, the proposed changes are stated by TGA to have been made ” in light of the current lack of evidence of efficacy and the historical profile of adverse drug reactions (ADRs) in Australia and overseas”.

It is certainly true, that the  consensus of informed opinion amongst paediatricians about the usefulness and propensity of side-effects of these products is in concurrence with the TGA assessment.

Now I must say that there is a whole fascinating social phenomenon associated with parents and carers buying cough ands cold products for children in their care.

This has, in fact,  been noted in the TGA External Review, where they raise the concept of  “social medication” which researchers have found is, in part, aimed at modifying child behaviour to more acceptable patterns, and in part a ‘coping strategy, and that cough and cold medicines were a common “social medication” in this respect’. Pharmacists at the “coal face” will be very familiar with this belief amongst their clients and the associated behaviour patterns.

Presumably, in recognition of  the social behavioural re-scheduling moves would certainly make them feel to some extent disenfranchised, turning on its head as it does, a long-held, even if erroneous, understanding that recommending a suitable cough and cold product for use by children served both a therapeutic and, as discussed, also a “social” function.

It seems to me that there will need to be long-term educational campaign on this issue, if the  proposed changes are adopted.

Indeed, TGA has said that the changes recommended would need to be widely promoted and explained to medical practitioners, pharmacists, parents and caregivers, and that particular efforts be directed towards educating consumers, medical practitioners and pharmacists that OTC cough and cold medicines have not been shown to be effective, and are potentially harmful in children under 6 years of age.

From recent discussions of this issue, when I raised it on our major pharmacy internet discussion website Auspharmlist, I have no doubt that at all that education and explanation will certainly be needed for many of my pharmacist colleagues, and their professional organizations!  This is, of course, quite understandable.

After all, on the face of it, the proposed issue is somewhat analogous to the lengthy but ultimately quite successful campaign over the past 5-10 years, to “educate” doctors and inform the broader community that antibiotics are not required to treat a whole range of common infections, and may ultimately promote bacterial resistance.

Five to ten years ago, of course, patients virtually demanded an antibiotic from their doctors in such situations.  These days, most patients are aware of this or, at least, do understand the situation when it is explained to them.

But, with TGA inviting responses from  stakeholder organisations, it is going to  require a huge effort to achieve the aims of broader community understanding of the rationale for the move by TGA to restrict availability of this group of widely-used, and generally well-regarded  infant and childrens’ medicines.”

Their investigations raise concerns for the wellbeing of many vulnerable groups – especially in rural Australia – but also show there are many unanswered questions about the relationship between recession and health.

Dr Megan Keaney and Rebecca James from Research Australia, write:

“Amongst the millions of column inches written and hours broadcast about the global financial crisis, very little attention has been given to whether recession is bad for our health. It is not difficult to imagine that becoming unemployed is bad for our mental health but are there wider impacts? If so what will they be, who will bear the burden and is our health and welfare system prepared to meet the challenge?

Mental health professionals are already seeing a steady stream of recession casualties.  “BJ” is one such person. At age 57, he lost his business and savings late in 2008 and by November was severely depressed. He took an overdose of medication that left him with memory problems. When he left hospital, his ex-wife of 10 years took him home to a rural town, thinking that he would recover in a few weeks.  Twelve months later she remains his carer and his brain injury means that he has no prospects of returning to work or living independently.

A report released this week by Research Australia, Australia’s Financial Crisis: Implications for Health and Research reveals that becoming jobless is associated with higher rates of a variety of mental health disorders. Suicide rates in young men track the unemployment rate and even keeping a job in an environment where job insecurity is heightened is associated with higher rates of psychological disturbance.

Although the jury is still out, studies from previous recessions suggest that becoming unemployed is bad for physical health too.  For instance, a  UK study from the 1980s showed that job loss led to a 37% higher chance of dying in the next 10 years.

The good news is that for mental health at least, return to the workforce as the economy recovers, leads to improved mental health. If that was the whole story then health departments might be comfortable that although some extra mental health services might be needed to meet extra need during recession, with economic recovery, the status quo should return. However, as BJ’s case highlights, it may not be that simple. And the difference is that recessions don’t have the same impact for everyone.

It is well accepted that there is a strong correlation between socio economic status and health. In Australia people who live in disadvantaged communities with higher rates of joblessness, lower household incomes, lower levels of education and lower social status have much poorer health outcomes across the board than the well off. In Australia there is a strong link between poverty and unemployment.

The real risk of recession is that it adds to the pool of long term unemployed (those people who are out of a job for 12 months or more). The longer people are out of job, their return to the workforce is less likely. Unemployment impacts on those who can least afford it – people with lower education, fewer skills, and intercurrent health problems. Not surprisingly rising unemployment concentrates disadvantage in already struggling communities on the urban fringe and in rural Australia.

We know that long-term unemployment and poverty is bad for our health. So what will this recession bring and are we well prepared to meet that challenge?

During the early 1990s recession the number of long term unemployed receiving income support increased from 170,000 to a peak of 438,000. Although the percentage of unemployed who are long term unemployed in 2009 is low relative to the early 1990s (about 13%) it is feared that this group will rise by 150% over the next two years.

Treasury’s recently revised forecast that unemployment will peak at 6.7% might appear reassuring given that in the last two recessions unemployment rose to well over 10 percent. However the number of people looking for work is not the whole story.

Over the last 20 years there has been enormous uptake of the Disability Support Pension with the number of recipients increasing from 307,000 in 1989 to 750,000 this year. This recession too is a story of underemployment with the labour under-utilization rate increasing from 9.9% to 13.6 % in the 12 months to August 2009.

In other words, 1.5 million Australians are unemployed and looking for work or would like to work more hours. There is no doubt that for these people and their families, financial stress is real. So how will their health suffer?

Long-term unemployment might mean higher rates of illness and premature death from a wide range of illness including heart disease, cancer, mental illness and even accidental injury. Importantly the impacts are likely to be intergenerational.

Western Australian research shows that children from disadvantaged families start out life behind the eight ball with problems including lower birth weight which are carried through to higher rates of childhood illness such as respiratory and mental illness, and even into adult life with international research suggesting that chronic adult disease has its roots in early childhood and even prenatal factors.

Much of this health disadvantage is mediated through social factors such as lower educational levels, fractured families and communities and in turn higher rates of health risk behaviours including smoking, alcohol use, less physical activity and obesity. A good start counts for a lot when it comes to health.

At the other end of life, research shows that for older workers ill health and unemployment is a two way street. Close to half of Australians aged over 45 who retire early do so because of ill health. Older workers who develop heart disease or mental illness are especially unlikely to re-enter the workforce.

For the health care system, more illness means more demand. Australians enjoy relatively good access to the health care system and long-term data tells us that unemployed people and those who reside in urban disadvantaged communities see their GPs more often and have more hospital visits.

However recent polling by Research Australia and MBF reveal that for many Australians, this recession is already affecting choices we make about our health. For instance, over the last 6 months financial stress has caused close to 20% of people to put off seeing a doctor or dentist and a staggering two million people have gone to work ill, rather than take sick leave, because of concern about job security.

Many questions remain unanswered. Recessions might be bad for our health – particularly if we lose our job and never work again. However, as the economy recovers jobs will be regained and fears about joblessness and financial stress will fade. But are there lingering problems for our health? We really do not now whether cyclical economic downturns impact our health in the long term and well accepted research demonstrating that relative socio- economic status correlates with health outcomes provides only some of the answers.

Most importantly when reflecting on the possible consequences of this downturn for our health, we need to consider whether government policies and programmes designed to limit the economic fall out of this recession are working.

Do we need different strategies that better target social and health impacts? Are we making the right investments now to support vulnerable groups so that we have a healthy and productive workforce as we come out of recession?

What is clear is that we need to better integrate our health, economic and social research effort so that we learn the lessons of this recession. Only then will we be able to deal with the public policy challenges that are the legacy of this recession or accompany the next one.”

• (Declaration: Croakey’s moderator Melissa Sweet had a hand in editing the report)

Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

But Ron Batagol, a pharmacy and drug information consultant, says this will require us to examine some of our somewhat hypocritical attitudes towards breasts.

He writes:

“A meeting of Health Ministers on 13th. November has endorsed the Australian National Breastfeeding Strategy 2010-2015.

The Strategy recognises the biological, health, social, cultural, environmental and economic importance of breastfeeding and provides a framework for priorities and action for Australian governments at all levels to protect, promote, support and monitor breastfeeding throughout Australia.

Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond if both mother and infant wish.

It is concerning that a longitudinal study of Australian children conducted in 2004 found that while 92 per cent of new borns were initially breastfed, by one week, only 80 per cent were fully breastfed. The study also indicated a steady decline each month with only 56 per cent fully breastfed at three months and 14 per cent at six months.

The new federal strategy would include increasing community acceptance of breastfeeding as a cultural and social norm, establishing breastfeeding support networks for pregnant women and improved breastfeeding training for health professionals.

But, since it has been estimated that over a quarter of Australians still think that breastfeeding in public is unacceptable, obviously there is still a long way to go!

And  I have to say that it’s quite paradoxical. In the post-modern world of the 21st century, when the fairer sex “frocks up”, as they call it these days, no one gives a second thought about exposed cleavage.  In fact, the dress designers have lead the charge to make the breasts the focal point of society’s attention when women’s attire is “out there” being critically scrutinised by all and sundry.

On the other hand, as we’ve seen in recent times, with unfortunate regular monotony, the sight of women, anywhere outside the confines of their own homes, trying to nourish their infants with the most natural of all beverages, mother’s milk, provokes an outcry of pompous indignation.

Oh, yes, excuse me, I forgot!  On a plane, with all those complete strangers sitting in close proximity? In the sacrosanct and hallowed corridoors of Parliament of all places!  And for God’s sake, worst of all, in a 5-star restaurant – a place where other people pay good money to sit down, quaff a fine wine or three and gourmandise their way through their mouth-watering degustation.

Suddenly, the notion of these mammary glands doing what they were actually created to do in a “public place” is deemed to be titillating, and breastfeeding is transmogrified into something wicked and evil.

Yet, 28 years ago, a worldwide Marketing Code was established for synthetic milk formulas, because millions of infants died in developing countries where well meaning mothers tried to copy their emancipated, more affluent counterparts by preparing formulas despite lack of clean water, refrigeration or education about how to make up the feeds.

So now, breast-milk  is “in” again- transported in  unbreakable packages, and satisfying consumer demand- all in all, the perfect 21st century product, with breast-fed babies having better immunity, and better long-term medical benefits than their bottle-fed buddies.

One can only live in hope that, as a society we may become a little less hypocritical and to try to remember why these mammary appendages were given to women in the first place.

Surely that’s not too much to ask, is it?”

Some of the most critical comments have come from breast cancer consumer advocates - overtones, perhaps, of how prostate cancer consumer groups have sometimes reacted to evidence about the potential harms of prostate cancer screening.

Now Hazel Thornton, an independent advocate for quality in research and health care in the UK, and an Honorary Visiting Fellow, Department of Health Sciences, University of Leicester, gives us another perspective. Thornton describes herself as having being “given the breast cancer label” as the result of undergoing mammographic screening in 1991.

She writes:

“It is unsurprising that women find it hard to accept the facts from papers such as that by Stephen Morell and colleagues from the University of Sydney, and from robust systematic reviews of screening by mammography, or of breast self-examination.

Twenty years of being told what to do in paternalistic promotional literature extolling the benefits of ‘finding it early’, and being frightened by being told that ‘it could save your life’, are difficult to reverse.

As we see, many women’s support and information groups are still encouraging women to disbelieve good evidence of over-diagnosis and over-treatment. They assert that it is acceptable to accept unnecessary lumpectomies, mastectomies, radiotherapy, chemotherapy and hormonal treatments “just in case”.

Promotion and arguing that this utilitarian ethic is acceptable by those in authority is unethical and harmful: it denies those women who trust them proper respect and the right to be properly helped to make up their own minds by neutral presentation of balanced facts. For more information, see the English version leaflet that can be downloaded here.

For too long ‘The Facts’ that women have been provided, e.g. by the UK NHS Breast Screening Programme, have been short on fact, short on evidence-based data, but full of persuasion, estimates, promise of benefit – but silent about harms.

Until this year, that is, when they at last capitulated to exposure by a letter in The Times 19th February 2009 signed by 23 international experts, stating that their invitation leaflet was short on the truth and totally inadequate for the purpose of enabling women to make an informed decision about whether to attend.

Many women were and still are unaware that they have any choice in the matter – and, as Iona Heath entitled her paper in the BMJ: “It`s not wrong to say no!” (abstract is here)

Strenuous objection had repeatedly been made to informing invited women about pre-invasive cancers such as DCIS.

Yet, in the UK, on Sunday 1st November 2009 it was reported in The Sunday Times that “The Government has been forced to rewrite its advice on breast cancer screening after research showed that thousands of women have been misled into having unnecessary surgery.”

Joan Austoker (who is leading the revision of the invitation leaflet) “had admitted it had been a mistake to withhold information about unnecessary treatment for DCIS”. It was also reported that they “want to make sure that all the risks of breast screening are referred to in appropriate detail.”

Only this week, 17th November 2009, the US Preventive Task Force has published guidelines with the following recommendations: “The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation)” .

Quite a turnaround!

This month in the UK, Sense about Science, addressing poor public understanding about what screening can and cannot do, launched a booklet: “Making Sense of Screening”.

Little by little, reason is beginning to prevail over blind belief!”

Would such a move be useful and welcomed in Australia? Read on…

Associate Professor Tim Gill, Institute of Obesity, Nutrition and Exercise, University of Sydney:

“Requiring calories counts to be placed on menu boards in restaurant chains is a good thing but as Jane Martin points out, it is unlikely to have a profound effect on food choice by itself.

It is akin to putting up speed advisory signs at dangerous bends in the road. They are useful if you understand and are accepting of the benefits of such advice; recognise your own limitations and the need to be cautious of road conditions; are not distracted by other issues and thus fail to acknowledge such advisory signs; or over-ride the advice because of your perceived lack of time to slow down.

Unfortunately with both calorie counts and speed advisory signs they are often ignored.

This is not a reason to avoid instituting such measures because they will be of benefit to those who are in a receptive state and can effectively process and act on the information.

Rather it is a reminder that such measures need to be instituted in combination with a variety of other strategies to encourage and support people to be more receptive to these signals.

Of course the preferred method of dealing with dangerous bends in the road is not to encourage people to slow down but rather to take that responsibility away from them by remaking the road at great expense to remove the bend.

Funny, no one ever suggests that this is a nanny-state approach to road safety.”

***

David Gillespie, author of Sweet Poison, Why Sugar Makes us Fat:

“Would you feed your kids a glass of milk or a glass of Coke for breakfast?  Yep, I’d go with the milk too.

How about if you know that the milk has 168 Calories but the Coke has only 108.  Would you switch to the Coke then?  No? You’ve just explained to yourself why Calorie labelling is a pointless waste of time.

You’ve also explained to yourself why Big Sugar is particularly keen on Calorie labelling.  They know a few things which most nutritionist have either forgotten or didn’t know in the first place.

Fat serves up 9 Calories per gram whereas everything else (including sugar) is only 4 Calories.  Calorie labelling is therefore really just fat labelling by another name.  The reason the milk has more Calories than the coke is because it contains fat and the Coke doesn’t.

The study referred to by Dr Russell tells us that it doesn’t really matter anyway.  Just over a quarter of the respondents noticed the Calorie information and it didn’t influence their choices anyway.

Big Sugar knows that no-one knows or cares what a Calorie label means and even if they did, sugary products would come out looking good by comparison.  Do we really want people being steered towards high sugar, low fat foods by Calorie labels?

Ignorance of the number of Calories in food has nothing to do with why we are all fat. We are fat because our food supply is laced with sugar.  Sugar has been proven to significantly interfere with our body’s internal Calorie counter (by making us resistant to the hormones which tell us when are full).

When our appetite control system is working, we eat exactly the number of Calories we need.  If they come from fat, we eat less of everything else.  If they come from protein or carbohydrate, we eat more.

We are fat because our fuel gauge is broken.  We are not fat because we don’t know how much fat is in what we are eating.  We don’t need Calorie counts on menus, we need our built in Calorie counters to start working again.  And the way to do that is eliminate sugar from the food supply.

But don’t fret too much about lobbying for Calorie counts, Big Sugar will implement them voluntarily soon enough.”

****

Stephen Leeder,  Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy:

“My personal view is that the more nutritional information that consumers can be given access to, the better.  The work that Tom Friedan, former chief health officer of New York City and now boss of CDC, in getting restaurants to label their menus is part of a larger enterprise to raise community and commercial awareness of nutritional responsibility. He did the same with tobacco control to good effect.

People DO take an interest in food labelling. Come with me one weekend to Coles in Katoomba – hardly the socioeconomic pinnacle of NSW society – and observe how often customers stop and read and compare food labels.

Many would argue, with evidence, that colour coding of foods with red, orange and green to indicate the safety levels of key components such as saturated fat, calorie density and whatever else.

The food industry presents elaborate objections to the ‘traffic light’ labelling. But in the meantime, until this is resolved, clear nutritional labelling makes sense. I think one of the craziest moves ever was the move away from the calorie, which many people understood, to kilojoules, which people don’t understand.

Food labelling is very political and much engagement with the food industry by action oriented politicians (and not all are) makes great sense.”

***

Boyd Swinburn, Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention Deakin University:

“I am just travelling at the moment but have discussed this people here in the US.  It started in New York City where to got in regulations to include the calorie content next to the price on the menu boards of chain restaurants.  They also had an anchor that about 2000 kcal is what was needed for a typical day for a typical adult.

Several other cities/states started following suit and expending the provisions. The industry could foresee an escalating situation and called for federal regulations which require the calorie information but prevent local authorities for pushing it further.

I definitely think the Australia should follow suit and all the arguments that it is not possible have evaporated. Our use of kJ will add complexity however.”

That is the suggestion of this very interesting piece below from Patrick Bolton, who has long and diverse experience in the industry.  He has worked as a GP and hospital administrator in urban and rural Australia in several states and territories. He has researched and published in health data, information management and health systems evaluation. He is national vice-president of the Australian Hospitals and Healthcare Association, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of NSW.

Bolton writes:

“When he is not solving the world’s climate and economic problems, I understand that the Prime Minister is touring the nation consulting about the future direction of the healthcare system. I’ve knocked around in, and been an observer of, that system for a while, and I offer the following observations in the hope of informing that debate.

There are always more things that can be done in healthcare than money to do them

As a result, some people miss out on some care some of the time, and this will always be so. This isn’t rationing because there is nothing rational about it.  At present the system responds to this truth by pretending it doesn’t exist. A problem must be acknowledged before it can be addressed.

Some of the people who miss out make a noise – for example by complaining to an MP – and then get what they want. This is unfair on those who don’t complain because it means that limited resources are shifted to the loudest.

It is not irrational for the people who complain to complain. They will benefit, assuming the medical care they receive does more good than harm. It is society as a whole that loses. There is no-one arguing on the side of society as loudly as individuals argue in their own self-interest. The hit the individual faces is large, the personal cost to each individual in society small.

Of greater effect on the system is that healthcare workers make choices for individual patients, not for society. Again this is rational. As a healthcare worker I want to provide the best care for each individual that I look after, and as a patient this is the standard I expect of the healthcare workers who care for me. Even were I prepared to favour the interests of society over the individual, I would have to trust that others in the same position will do the same. If they do not, then my altruism is benefiting them and not me.

This factor creates a difficulty because doctors are arguably best placed to assess which patients will benefit most from which interventions, but any management system that asks them to do this puts them in a position of conflict of interest. This is a source of professional dissatisfaction for healthcare workers

The difference between what people want and what the system can provide is one of the sources of dissatisfaction with the system. It contributes to the perception that reform is required.

The only way to make the health system cheaper is to reduce services

Many of the initiatives proposed by the Hospitals and Healthcare Reform Commission are said to improve health outcomes and so make us live longer and healthier lives. This is desirable if it is correct. Unfortunately, we will all still be dead in the long run, and around 80% of healthcare resources are consumed in the last two years of life, whether we die at 70 or 100. None of the proposed changes are about reducing cost as an end in itself. If the proposed changes work we will live longer – so consuming healthcare resources for a longer period, albeit possibly at a slower rate, then cost the same amount when we finally die.

There a no great savings for the healthcare system in this, although there may be increased  productivity as an offset. Health is a superior good, one on which individuals and communities spend more as they become wealthier, and this may justify additional expenditure.

It is not clear what the objective of the health system is

It is difficult to go somewhere unless one knows where one wants to go. Individual needs, expectations, and capacity to assess outcomes of the healthcare system vary. This means that the perceived purpose of the healthcare system varies depending on who you ask.

It would be surprising if the interests of the most vocal group – healthcare providers – coincided with that of the majority who pay for these services. There are no other areas where the interests of vendors and customers coincide, so why expect this in healthcare?

Healthcare doesn’t seem to make much difference to health

This is well known and such a show-stopper that everybody, me included, seems to acknowledge it and move on. I think it reflects several factors. These are:

a)    There is good evidence that the health of first world societies is closely associated with the level of equality in that society, not to the level of healthcare. If this relationship is causal then it can be argued that one should invest in strategies to promote equality in preference to healthcare.

b)    Individuals are not good at assessing the outcomes of the care they receive and the system is not good at measuring outcomes.

Most people recover from illness, but some do not. The outcome is multi-factorial, so it can be difficult to say which part of an individual’s health outcome is a result of the care that they received and which due to other factors. It is particularly difficult for lay people to judge the quality of the care they receive.

Changes in healthcare tend to be incremental, and so outcomes compare current treatments with alternatives which are likely to be only slightly better at best, as opposed to no treatment. It is generally held to be unethical to compare new treatments against no treatment. One might argue that this is irrational in cases where current therapy has not been shown to be superior to no treatment.

The quality of outcomes measurement of the healthcare system is woeful. Given that much of the money for healthcare comes from the public purse this is a significant failing of accountability.

c)    There is a high error rate in healthcare. International studies repeatedly show that errors in healthcare delivery occur in around 10% of cases. In Australia these errors are associated with about half of all in-hospital deaths. If death is the outcome measure then Australian hospitals may be killing as many people as are killed by the conditions for which they were admitted. The harm that the health system causes may offset any benefit that it delivers.

d)    Estimates are that one-third of what is done in healthcare is unnecessary. Two things follow from this. First, if unnecessary care can be identified and stopped, then the efficiency of the healthcare system can be improved by up to 30%. Second, unnecessary care still causes harm, and this offsets the benefit from effective and necessary care for the system as a whole.

Healthcare in Australia is not a very enjoyable place to work

This has important implications for workforce engagement and sustainability.

Poor work hygiene is bound up in the foregoing issues. It is hard to feel satisfied about what one is creating if the value of the product is at best unclear, and possibly negative.

The response of policy makers to these issues has been to tighten the leash and increasingly micromanage healthcare delivery. Healthcare workers are highly skilled employees, expert at making individualised decisions in complex settings. It is unlikely that directive management can lead to better outcomes that professionals can provide themselves, so micromanagement results in alienation of the work force without improving performance.

Suggested pre-requisites to change

There is nothing new in any of this, but it needs to be said because the healthcare system cannot improve until these factors are addressed. Some suggestions to do this are:

1.    The new health system needs to be as clear as possible about what it is trying to achieve, and collect data which measures performance towards these achievements.

2.    The new healthcare system needs to be able to demonstrate that the things that it does are effective, cost effective and done to people who will benefit, and not those who will not.

3.    The new health system is going to have to allocate resources transparently on the basis of 1 and 2 above. This is so that equity and efficiency are maintained in the face of other interests.

Addressing these factors is necessary but may not be sufficient. If they are addressed, then healthcare will improve under the current governance model. Some other governance model may be preferable for the reasons currently being debated, but we can’t know this until the problems discussed here have been addressed.

No governance model can be properly assessed until these underlying distortions are addressed. Introducing the kinds of major change contemplated is not without risk. It will be impossible to manage and measure the impact of this risk until these factors are addressed.”

There I told you – it was worth taking the time for the read, wasn’t it? Plenty of food for thought there.