Stephen Duckett, Grattan Institute and Anika Stobart, Grattan InstituteThe big investment in aged care announced in last night’s federal budget – an extra A$17.7 billion over five years – is a welcome response to the Royal Commission into Aged Care Quality and Safety. But even an investment of this scale does not meet the level of ambition set by the royal commission.
The government has committed A$6.5 billion for more home-care packages (about A$2.5 billion more for home care per year when fully implemented), and A$7.1 billion for residential-care staffing and services (about $2.4 billion more for residential care per year when fully implemented).
But the government has failed to outline a clear vision of what older Australians should expect of their aged-care system.
The budget includes funding for 80,000 extra home-care packages over two years. The current home-care packages program has numerous problems, including nearly a 100,000-strong waiting list.
But the government has not explicitly promised to clear the waiting list and bring waiting times down to 30 days, as the royal commission called for.
The budget has some good news for people in residential aged care. The Basic Daily Fee (for services including food) will be increased by A$10 per resident per day, as called for by the royal commission.
And there’s more funding for better staffing, with mandates for an average of at least 200 minutes of care for every resident every day (40 minutes of which must be by a nurse) by 2023.
This is a good start, given nearly 60% of residents presently get less than this. But residents will have to wait two years – not one, as recommended by the royal commission – before they get more care hours.
The budget also provides additional funding to improve the aged-care workforce. The government will subsidise the training of new and existing aged-care workers, including 33,800 places to attain Certificate III.
But the government has not gone far enough in supporting the workforce. It stopped short of guaranteeing that every staff member providing care for older Australians will be trained to a minimum Certificate III level, and that all residential aged-care facilities will have a registered nurse on site 24 hours a day.
The budget commitments appear to be a once-off, with workforce funding plummeting to only A$86.5 million in 2024-25, compared to A$293.3 million in 2022-23. And there is no commitment to lift carers’ wages.
Small steps towards a better system
The royal commission made it clear the aged-care system needed to be reformed from top to bottom. The government’s announcements foreshadow a shake-up of the system over five years. But the extent of reform is yet to be determined.
The budget papers show funding will be up by about A$5.5 billion per year once most reforms are in (see the chart below). That’s not enough to create a needs-driven, rights-based system, called for by the royal commission and the Grattan Institute.
The government has committed to a new Aged Care Act, to be legislated by mid-2023, though the details are yet to be filled in. This Act must put the rights of older Australians at its heart.
The government has also committed to designing a new home care program and will provide a single assessment process for both home care and residential care.
A local network of health department staff will be embedded in the regions, and there will be a network of 500 “care finders” to help older Australians get the support they need.
But the biggest risk to achieving real structural change is governance and transparency. Here, the government has fallen short.
The government does not support the establishment of an independent aged care commission. Most disappointingly, it is pumping A$260 million into the Aged Care Quality and Safety Commission, which the royal commission found had demonstrably failed.
While some transparency will be provided through public reporting of staffing hours and star ratings to compare provider performance, clear transparency measures will be needed to ensure the additional billions don’t end up boosting providers’ profits.
The good news from budget 2021 is that the journey has begun. The government has made a substantial down payment to allow development of a new aged-care system. We must hope that more will follow, so the neglect ends and every older Australian can get the care and support they need.
This extra demand will put still more pressure on an already overloaded mental health system.
Digital help is on hand
It’s crucial that public and private mental health services adopt new technologies now to help meet this future demand.
Compelled by the massive health services dislocation accompanying the COVID-19 pandemic, Medicare this year finally moved to support for the most basic form of telehealth, supporting both telephone and video consultations.
That’s 144 years since Alexander Graham Bell produced the first working telephone in 1876. Let’s hope it doesn’t take quite as long for our general health care system, and particularly our mental health system, to incorporate the power of 21st-century digital technologies.
Clearly too many Australians who seek mental health care do not gain the potential benefits of what’s available in telehealth innovation.
This failure is not unique to Australia. Pre-COVID-19, the World Economic Forum highlighted the massive gap in mental health service provision between developed and developing countries. It’s calling for rapid deployment of smarter, digitally enhanced health services.
The World Health Organization and every other major health body is warning of the urgent need to expand mental health services in response to the economic and social dislocation caused by the pandemic.
To prevent this in Australia, we need widespread social and welfare investments and a better mental health system.
Pre-COVID-19, the Productivity Commission in its draft report on Australian mental health care highlighted a lack of sustained investment (relative to the social and economic costs of poor mental health), poor coordination and a fundamental lack of responsiveness to the needs of those most affected.
It also called for more prevention and early intervention measures, particularly for children and young adults.
Australia has two separate mental health systems. State-based systems are highly focused on emergency departments and acute and compulsory care. These benefit principally the smaller number of people with very severe and persisting illnesses.
Private hospitals provide additional hospital beds to people with private health insurance, but also support day programs that cost a lot but provide limited value.
The upshot is that Australia has a missing middle – big service gaps for the people most in need of care.
We need more specialised but outpatient care and multidisciplinary care for those in need. That means GPs, psychiatrists, psychologists, nurses and other skilled health workers, working in coordinated team structures. These services are desperately needed in outer urban, regional and rural communities.
A digital future, now!
A digitally enhanced, 21st century-style mental health service may be the answer.
Smart digital systems, such as smartphone apps and other technologies, can help to assess quickly the level of need and direct people to the best available clinics.
They can help our highly talented mental health professionals provide better care. They also bring the world of other tools, peer support and enhanced social connections to the client, no matter where they are located.
Online or helpline-supported screening tools should be used to guide people along the best, evidence-based treatment path for them.
Primary health networks – the regional health authorities funded by the commonwealth to coordinate primary care – should ensure the services they commission are using digital technology appropriately and tracking the provision of care.
These new forms of digitally enabled care will make the whole mental health system more efficient, freeing up resources to help the backlog of Australians who need more intensive clinical care.
Australia’s governments must seize the opportunity that COVID-19 has created. Digital systems must now be viewed as essential health infrastructure, so that the most disadvantaged Australians move to the front of the queue.
Delaying or avoiding medical care despite health problems is not a new concept. People often downplay the severity of their symptoms, believe they will resolve on their own or perceive they can manage themselves at home.
This reasoning is now compounded by fear of becoming infected with COVID-19 as well as overburdening the health-care system.
Some people living with chronic conditions such as heart failure, lung or kidney disease may be more concerned about contracting COVID-19. This is justified. People with chronic conditions tend to get sicker than the overall population if they catch coronavirus, and are more likely to die.
Concerns about overburdening the health-care system, which people already perceive to be stretched, has been a common reason for delayed care-seeking, even before the current pandemic.
But constant reports of overflowing hospitals and scarce resources during the coronavirus crisis may serve to validate this concern for people who are considering whether or not to seek medical care.
While it’s too early to have definitive statistics, Australian estimates suggest attendance at hospitals and general practices could be down by as much as 50%.
Why it’s important to continue to seek care
People with chronic health conditions may need to seek medical care for a range of reasons. This could be routine care for a chronic disease such as chronic obstructive pulmonary disease (COPD), asthma, diabetes, cancer, bowel or heart disease.
They may need to seek unscheduled care if their condition flares up. For example, for a person with chronic heart failure, it would be important for them to seek timely health care if they were experiencing symptoms such as breathlessness, fatigue, or peripheral oedema (the accumulation of fluid causing swelling, usually in the lower limbs).
Importantly, if people delay seeking care for chronic illnesses, we may see an increase in preventable deaths.
For example, for people with heart disease, untreated symptoms could lead to long-term heart damage, need for intensive care, and death.
It’s also possible if a large number of people avoid seeking treatment now, hospitals will find themselves overwhelmed when the pandemic is over.
You can go out for medical care
While the global public health messaging urges people to stay home to save lives, it’s important to understand one of the key exemptions is medical treatment. And this doesn’t apply only to people with COVID-19 symptoms.
Regular GP or specialist appointments
People with chronic conditions may already be receiving advice from their health professionals about how regular appointments will be conducted.
To minimise risks to staff and patients, many health services are offering telehealth appointments (via phone or video conference). It’s best to contact your GP or specialist by phone prior to your appointment to see whether this service is available and appropriate.
There will be times when a telephone or video-conference is not suitable, such as when your doctor needs to perform a physical examination, administer therapies including medications, or you need tests such as blood tests or x-rays.
If you do need to attend a clinic or hospital in person, you should be assured they’re taking additional precautions to prevent the spread of infection during this time.
If symptoms flare up or in an emergency
If your symptoms get worse, you should still contact your GP or specialist if this is your normal course. This is important even if you don’t think your symptoms are urgent.
And it remains critical that in life-threatening circumstances – like if you believe you’re having a heart attack or stroke – you seek medical attention immediately by calling triple zero (000).
These are medical emergencies and our hospitals are well-equipped to respond, even during COVID-19.
Some practical tips
The Heart Foundation offer the following advice for people living with chronic conditions during COVID-19:
keep looking after your health and stay connected with your doctor
get your annual flu vaccination
practise physical distancing and good hand hygiene
stay active and eat a healthy diet.
And most importantly: don’t ignore a medical emergency.
The coronavirus pandemic is changing the way we access health care, and dental care is no exception.
Dentists are no longer allowed to provide a raft of care, such as regular check-ups and tooth whitening, to minimise the spread of COVID-19. However, if you’re in a lot of pain, your dentist will be able to treat you.
Here’s how the coronavirus is changing the way we look after our teeth.
When dentists work on your teeth, they can produce aerosols – droplets or sprays of saliva or blood – in the air.
This happens routinely when your dentist uses a drill or when scaling and polishing, for instance.
And dentists are used to following stringent infection control precautions under normal circumstances to lower the risk of transmission of infectious diseases, whether they are respiratory diseases or blood-borne.
These precautions help keep both patients and dentists safe because it assumes all patients may have an infection, despite the reality that most won’t.
But with the coronavirus pandemic, there is an increased risk of aerosols carrying the virus either directly infecting dental staff, or landing on surfaces, which staff or the next patient can touch.
This transmission may be possible even if you feel perfectly well, as not everyone with the virus has symptoms.
This is based on level three restrictions, according to guidance from the Australian Dental Association.
Recommendations of what is and isn’t allowed may change over time.
What does it mean for me? Can I still get a filling?
What’s not allowed?
Non-essential dental care is now postponed. This includes routine check-ups and treatment where there is no pain, bleeding or swelling. So treatments such as whitening and most fillings will have to wait.
Other conditions or treatments that will need to be postponed include:
tooth extractions (without accompanied pain or swelling)
broken or chipped teeth
bleeding or sore gums
halitosis (bad breath)
loose teeth (that aren’t a choking hazard)
concerns about dentures
crowns and bridges
clicking/grating jaw joint
scale and polish
What is allowed?
Some patients will need urgent care for acute problems requiring treatments that produce aerosols. So such procedures have a risk of spreading COVID-19.
The global spread of COVID-19 has illuminated the “care crisis” that has been building for decades.
Women, through their unpaid housework, childcare and elder care, have kept families functioning. However, COVID-19 is putting a strain on women’s abilities to keep the cogs of daily life turning. We are now starting to see the impact of what happens when women are unable to do it all.
What is the care crisis?
For decades, scholars have warned that the bulk of the unpaid domestic work carried by women is unsustainable. The ageing of populations across Western nations will add to the burden even more as women care for elderly parents, spouses, friends and family. This will in turn significantly reduce the employment pool and add strain on those providing the care.
Without free childcare or flexible work, families are patching together a tenuous web of caregivers and family members to smooth before- and after-school transitions and to tend to sick children. COVID-19 exposes our care system as being held together by a thread, based on the unpaid and perpetual labour of women.
For decades, researchers have shown women are stressed, pressed and emotionally unwell from the constant struggle to manage these competing demands. The data are clear – women’s larger share of the care is making them sick.
Once COVID-19 started to spread, the world changed dramatically. Now, the invisible unpaid work started to become visible. And someone has to do it.
Worried about childcare? What our searches can teach us
To better understand how childcare during coronavirus is worrying Australian parents, we draw data from Google searches over the past 30 days from the United States and Australia. The US is further along in the coronavirus journey, so can offer some insights into how worry about the virus changes over time.
At first, Americans were more concerned about the economy. But as schools, workplaces and non-essential services start to shut down, the threat of the care crisis has emerged – the concentration of Google searches for coronavirus that include “daycare” and “elderly” intensifies. The work is coming home. Who is now going to do it?
Australia is now preparing more aggressive social-isolation measures to slow the spread of COVID-19, with school and non-essential service closures reported only this week and only in some states.
However, Australia, too, has been slow to respond and the federal government has resisted school closures in part because 30% of healthcare workers in Australia are women. What will happen to this group of workers if they have to look after their children and those affected by COVID-19?
Do all states exhibit the same worry?
Across the US, trends in search terms vary dramatically across states. In the past week, searches in most states have been concentrated on how coronavirus will impact the economy.
But something interesting is happening to the states in the middle of the country – Nebraska, Kansas, Iowa and Minnesota. In these states, searches for daycare and coronavirus are more common than searches related to coronavirus and the economy, grocery stores and the elderly.
Our research shows mothers in these states have access to better childcare resources – more affordable childcare, longer school days and more expansive after-school care. A forthcoming book, Motherlands, shows mothers in these states are more likely to work full-time, including right before and right after childbirth. These states are exemplars, offering parents the best childcare resources.
But what happens for families in these states when everything shuts down?
When we dig a little deeper, we see searches for daycare centres being open during coronavirus soared by 100%. Questions about whether those centres will charge fees even while closed increased by 400%. Nebraskans are also worried about their financial futures, but theirs are more tightly linked to daycare.
Over the past week, Australians are increasing their searches of daycare, with some regional variation. People in Australian Capital Territory, New South Wales and Victoria are most likely to ask Google about daycare. Families in these states average 31 hours of weekly childcare, or equivalent to another full-time job – time that families will have to fill.
What is the future of care?
COVID-19 will be devastating in its effect on our health, families and economy. But, as we face this new brave world together, it is important to understand the role of caregiving and the importance of carers in this crisis.
To date, women have done this work freely for families. But now the burden is too big and we need to see this work for what it is – important, essential and of great economic value. Individuals can use this as an opportunity to try something new, but also take stock of what we value as a society.
It is an opportunity to realise that the unpaid labour of grandparents and women is not enough – we need real solutions for a problem that, until now, has remained invisible.
The devastation wrought by the Australian bushfires has been immense and, as the fires continue to burn, the final loss won’t be known for many months. While the impact on the environment, human and animal life is overwhelming, for many individuals the loss of personal items such as photographs, documents, artwork and personal treasures is significant.
Heirlooms and artworks are often cherished for the people, events and experiences they represent rather than their monetary value or cultural importance. They can be integral to understanding our personal history, culture and identity.
While damage to them can be heartbreaking, even a badly damaged family treasure may hold immeasurable personal significance.
For those threatened by bushfire, planning for the preservation of your treasured items can start now. Planning resources are available online. For those who have been affected by fire damage, you may still be able to salvage items.
There are three main factors to consider when thinking about the impact of bushfires on your personal treasures – smoke, heat, and water.
The most obvious damage from smoke is soiling. Soot, ash and other particulate matter are usually dark and greasy. When deposited on the surface of an object, colour and detail are obscured. Damage from high heat exposure can result in blistering, melting, warping, charring and partial or complete loss.
If water has been used to put out the fire, water related damage can be an issue. Water can cause shrinkage, distortion, discolouration, mould and partial or complete loss of original material.
The possible damage to your items will depend on the material types. Here are some tips for handling them.
Paintings can be affected by all three factors.
• If an artwork is framed, it is recommended that you leave the frame in place. Exposure to high heat can soften the paint layer, which may cause it to stick to the frame. A specialist should remove the work from the frame.
• The particulate nature of smoke means that it can cause abrasion as the soot is wiped away. Get advice before undertaking any cleaning. Do not use water.
• Assess the surface for loose material (lifting paint, blistering). Take care when handling to ensure no loss of fragile material. Retain any loose elements in a Ziplock bag. These can be reattached later.
Paper documents, prints and photographs
Though potentially affected by all three factors, water damage can be the most severe for these items, with the risk of mould.
• Allow wet items to slowly air dry, indoors if possible. Increase indoor airflow with fans, open windows, air conditioners, and dehumidifiers. Do not use hair dryers, ovens, irons.
• Photo albums can stick together. Do not try to open them. Ask a conservator for advice.
• Dry paper documents and photos can be cleaned of soot with a vacuum and dry sponge.
Textiles (i.e. sporting memorabilia)
Textiles can be affected by all three factors.
• Handle with care, as they may be fragile.
• Low powered vacuum removal of soot may be possible if fabric is not weak (shedding).
Glass, metal and ceramic objects
These items can be affected by high temperatures and smoke. Heat can distort shape (melting) or alter surface finishes (i.e. glaze on pottery). Such damage is usually irreversible. Smoke damage can leave a darkened layer of soot on the surface.
• Care is need when removing soot to ensure abrasion of the surface doesn’t occur.
• Heat can make these objects brittle. Care is needed when handling.
• Use gloves when handling. Skin oils can damage the surface.
What else can you do
You may not be able to save everything, so focus on prioritising what is most important to you. Personal safety is the highest priority when entering damaged buildings. Wear protective clothing, footwear, goggles, gloves and masks to protect from hazardous material and possible mould spores.
Items may be more fragile than they look, so consider using something rigid to support them when lifting and transporting such as a piece of tray, pieces of cardboard, box, a plastic container or lid.
Retain any items that are recognisable, it may be possible to restore them.
Details for accredited conservators can also be found through the AICCM website. A conservator will be able to provide advice on how to best approach the recovery and ongoing preservation of your heirlooms and artworks.
Smoke haze from Australia’s catastrophic bushfires is continuing to affect many parts of the country.
Although there’s no safe level of air pollution, the health hazards tend to be greatest for vulnerable groups. Alongside people with pre-existing conditions, smoke exposure presents unique risks for pregnant women.
These conditions can have short-term and lifelong effects on a baby’s health, with increased risk of conditions including cerebral palsy and visual or hearing impairment. Even babies born only a few weeks early can experience learning difficulties and behavioural problems, and have an elevated risk of heart disease in later life.
So it’s especially important pregnant women protect themselves from exposure to bushfire smoke.
Pregnant women breathe at an increased rate, and their hearts need to work harder than those of non-pregnant people to transport oxygen to the fetus. This makes them particularly vulnerable to the effects of air pollution, including bushfire smoke.
We often measure poor air quality by the presence of ultra-fine particles called PM2.5 (small particles of less than 2.5 micrometres in size). These particles are concerning because they can penetrate into our lungs, and into blood and tissue to cause inflammation throughout the body.
Importantly in pregnant women, environmental pollutants can cause inflammatory damage to the placenta’s blood supply. This can interfere with the placenta’s development and function, which can in turn compromise the growth of the fetus.
What the evidence says
Many studies have linked poor air quality, particularly high PM2.5 levels, to poor pregnancy outcomes. Data from 183 countries showed in 2010, an estimated 2.7 million premature births, 18% of the total, were associated with PM2.5 pollution.
A 2019 study of more than 500,000 pregnant women from Colorado looked at the effect of bushfire smoke on pregnancy outcomes. The authors analysed data on air quality, fire incidence and pregnancy and birth records from 2007-2015, during which time Colorado was regularly affected by smoke from fires burning in California and the Pacific Northwest.
The study found PM2.5 due to bushfire smoke was linked to spikes in premature birth, especially in women exposed during the second trimester.
The effects were detectable even with low exposure to smoke and small increases in PM2.5. For every 1 microgram/m³ increase in average daily exposure to PM2.5 during the second trimester of pregnancy, the risk of premature birth increased by 13%.
To put this into context, in Canberra in the first week of January, PM2.5 levels averaged more than 200 micrograms/m³, compared with the typical background concentration of 5 micrograms/m³. EPA Victoria classifies PM2.5 levels above 25 micrograms/m³ as unsafe for vulnerable people.
As well as PM2.5, bushfire smoke contains larger PM10 particles, nitric oxides, carbon monoxide and other gases and toxic chemicals. These all have potential to impair lung and heart function in the mother, activate inflammation, and directly affect fetal and placental development.
The best strategy is to reduce smoke exposure as much as possible. Recommendations from NSW Health include staying inside on high-risk days, sealing the house to prevent smoke infiltration and using air conditioning to keep cool.
Avoid creating smoke by cigarette smoking, burning candles, or frying and grilling. Use PM2 (N95) masks and air-filtering devices if possible, and avoid exposure to ash, which contains particulate material you can inhale.
Pregnant women in a fire region should carefully follow emergency services’ direction. It’s better to evacuate early, with an emergency supply kit containing clothes, medications, water and food you don’t need to cook.
Make sure your medication and prenatal vitamins are accessible, continue to take them, and stay well hydrated. Inform authorities and shelters you are pregnant and need to maintain your antenatal care.
Be aware of the signs of premature labour including abdominal cramps or contractions, a heavy vaginal discharge, loss of fluid or vaginal bleeding, pelvic pressure and low backache. Seek help if you think you may be going into labour.
Given what we know about the consequences of poor air quality on pregnancy outcomes, it’s critical pregnant women are given top priority when it comes to bushfire relief and health care support.
As China grows more powerful and influential, our New Superpower series looks at what this means for the world – how China maintains its power, how it wields its power and how its power might be threatened. Read the rest of the series here.
One of the earliest guests I had on The Little Red Podcast, the podcast I co-host with former China correspondent Louisa Lim, said something that stuck with me about the view of China in the rest of the world. John Fitzgerald, a well-known historian of China’s diaspora, confidently declared that the Chinese Communist Party (CCP) “couldn’t care less” about what non-Chinese Australians thought of it and its actions.
Looking through the results of the recent Lowy Institute Poll on Australians’ attitudes toward China, this is probably a good thing for the party.
The Australian public’s confidence in China’s ability to act as a responsible power has fallen off a cliff. In just one year, it dropped from more than half of Australians to just 32%. That’s a dire number.
That wasn’t the only surprise in the poll. Four-fifths of respondents agreed with the proposition “China’s infrastructure investment projects across Asia are part of China’s plans for regional domination”, and 73% believed Australia should try to prevent China from expanding its influence in the Pacific.
The poll was released in late June, at a time when China’s image was taking a hit internationally. Millions of people took to the streets in Hong Kong to protest a now-defeated extradition bill that could have seen Hong Kong residents sent to China on suspicion of crimes.
Then came news in Australia that the wife of an Australian writer who has been detained since January was herself interrogated by Chinese officials and blocked from leaving the country.
Even for a country that purportedly doesn’t care what the rest of the world thinks, trust is hard to come by these days.
A matter of trust
It’s not entirely clear why so many Australians now distrust the Chinese state to the point where they believe our government should actively counter it (although perhaps not go to war with it).
There’s little evidence to suggest that one issue alone has caused this sharp decline in trust. For instance, the Communist Party’s most egregious recent violation of human rights, the detention of up to 1.5 million Uyghurs simply for being, well, Uyghurs has touched relatively few Australians.
Rather, the decline in trust seems to be the result of an accumulation of negative news on China — some well-informed, some half-baked (such as the 60 Minutes expose on a Chinese “military base” in Vanuatu). And for some, it’s based on personal experiences.
Last month, for instance, Australian National University revealed a massive data breach in the school’s computer system, including tax file numbers, bank accounts and passport details. The sophistication of the attack, which came after multiple attempts, meant there was only possible one suspect, according to senior intelligence officials: China.
Stealing people’s bank details might be profitable for the hacking team, but it doesn’t win hearts and minds for the Chinese state. Actions like this do more to damage China’s image than the words of noted China critics Clive Hamilton and Clive Palmer.
This sort of intimidation has been on the rise under Xi’s leadership in recent years. Academics who are critical of China now expect to be targeted by the CCP.
A podcast like mine, banned in China, doesn’t help. In the wake of an episode about China’s real-time censorship of its own historical record, I was hit by a denial-of-service attack that our university’s IT service struggled to fix. I gave up doing research inside China a while ago, after it became clear that my former colleagues and friends in rural China were increasingly at risk.
Even colleagues who have signed petitions calling on the Australian government take an evidence-based approach to China policy have been warned off continuing their in-country research by their Chinese research partners, ending collaborations which often stretched back decades.
To the outside world, this obsession with control looks like weakness rather than strength. A sanitised image of life inside China will do nothing to build trust in China as a responsible power.
Misplaced attempts at soft power
So how does China go about winning back a 20-point drop in trust?
To answer this question, I have to borrow a famous line from the film, The Princess Bride:
You keep using that word. I do not think it means what you think it means.
When it comes to the concept of soft power, the Chinese state misses the basic point that it doesn’t work particularly well. Money can’t buy you love, or in Joseph Nye’s terms, if your ideology and your culture have no appeal, cash won’t fix that.
Yet, the Communist Party is now a firm believer in soft power, built around its confidence that China’s ancient culture can return it to its legitimate status as the preeminent civilisation in the world. This confidence may be misplaced, as anyone who sat through the ponderous, state-backed, blockbuster film The Great Wall can testify.
This officially approved cultural soft power package might not sell to non-Chinese audiences in Australia or, well, anywhere. But China has recently been trying another tactic – economic soft power. This is specifically aimed at the developing world: China positions itself as a nation that overcame colonial oppression to emerge from grinding poverty and become an economic powerhouse.
Under former President Hu Jintao, the party tiptoed away from the notion that China would pursue a “peaceful rise”, because they worried the word “rise” sounded threatening, even preceded by “peaceful.”
Now, under Xi’s watch, there is a new catchphrase to describe China’s rise. Anchors on CGTN happily ask European and African interlocutors about the merits of “the China model” for economic development, in which the state acts as chess master, guiding the economy and society at every turn.
Some nations are buying into this. Last weekend, a taskforce of Solomon Islands MPs and bureaucrats presented their recommendation to parliament over whether to switch diplomatic recognition from Taiwan to China. While many Solomon Islanders, including Prime Minister Manasseh Sogavare, are reluctant to switch, the country’s close economic ties with China make such a move feel inevitable.
A Chinese development model that promises an escape from poverty has appeal across the Pacific – and beyond.
Trust on both sides of the wall
Whether Beijing is able to turn around this trust problem depends, in part, on how much China begins to trust itself in the rest of the world.
Forthcoming research my ANU colleagues and I are conducting with Hong Kong-based researchers examines attempts by Chinese state actors to influence the 2019 Australian federal election.
Preliminary results indicate that the Communist Party didn’t give a hoot which party won. The goal of Chinese propaganda during the election, rather, was to create a sense of distrust among Australian-Chinese communities by depicting Australia as a racist, unwelcoming place.
We should be mindful of attempts by elements of the Communist Party to influence our political processes. Yet it’s crucial to remember the CCP targets many groups in Australia, including private businesses run by former Chinese citizens, religious groups and student organisations, not because they are all loyal party stooges, but because the party does not trust them.
The challenge for China, if it wants to be trusted by the rest of the world, is how to move beyond Mao Zedong’s famous dictum:
Who are our enemies? Who are our friends? This is a question of the utmost importance for the revolution.
This thinking should have no place in a globalised world, but in CCP circles, it’s back in vogue.
The challenge for Australia’s leaders is to recognise China’s current political reality, but not be drawn into the same binary, simplistic thinking. There’s enough of that going around.
The Opposition’s A$2.3 billion cancer care plan – announced in Bill Shorten’s budget reply speech on Thursday night – aims to ensure cancer treatment costs for scans, specialists and drugs are bulk billed or subsidised under the Pharmaceutical Benefits Scheme (PBS). It would be a hard heart indeed that did not welcome such a move.
Maybe even better than avoiding the out-of-pocket costs of treatment is preventing future cases of cancer. Around one-third of all cancers are preventable by not smoking, staying at a healthy weight, eating healthy food, being physically active, minimising alcohol consumption, and avoiding excessive sun exposure.
But apart from a small commitment to tobacco control in the 2019 budget, neither the government or opposition has made even the vaguest commitment to, or investment in, cancer prevention.
So far we have heard virtually nothing from either party on efforts to tackle obesity, promote healthy eating, encourage more physical activity, reduce alcohol consumption, promote sun protection, or boost efforts to increase participation in cancer screening and vaccination programs.
The government currently spends around A$2 billion a year on “public health”, which includes monitoring, regulation, as well as prevention and vaccination. This amounts to less than 2% of the nation’s total health expenditure of A$170 billion. That is about half of what we spend on patient transport.
A boost to 5% – or closer to A$8.5 billion – could make enormous strides in better prevention programs, driven by high-quality research.
Poor track record
When it comes to investment in disease prevention, the story is not strong for the Coalition.
The Rudd Labor government established the Australian National Preventive Health Agency (ANPHA) in 2009, with funding of around A$60 million a year. The agency ran national programs focusing on tobacco, alcohol, healthy eating and reducing alcohol consumption.
But the new Abbott government axed the agency in 2014, after drafting legislation to expunge it from the books.
Programs such as Live Lighter and Foodcents, for example, provided evidenced-based and practical help for people to live healthy lives. Other programs improved the availability of nutritious foods, and ensured walking and cycling were safe and viable components of transport planning.
In 2012, the then Labor government committed to the continuation of the NPAPH to 2018, but it was axed by the Abbott government in the 2014 federal budget.
This took hundreds of millions of dollars otherwise committed to prevention efforts out of the federal budget calculations.
All of these discontinued efforts were likely to have had a major effect on reducing future generations of Australians from hearing those awful words: you have cancer.
Like any human endeavour that aims for big changes in systems and behaviours, stopping and starting the programs that lead these changes diminishes the prospect of success.
So why is it hard to get governments to invest in prevention?
Strong and influential industries consistently lobby governments to protect their commercial interests. That’s what happens in a market economy democracy. The alcohol, processed food and even tobacco industries continue to exercise an influential voice in the halls of power.
Unsurprisingly, industry aggressively opposes higher taxes on these products (“sin taxes”) and programs discouraging their use.
It is common to hear politicians tell stories of individuals, “real people” who benefit from a new treatment or access to new life-saving medical care or drugs. We all connect with these heart-warming stories and they illustrate the importance of the public funding investment.
Such stories are harder to tell in prevention. How do we find the 64-year-old enjoying his granddaughter’s first day at school, largely because he did not die of a smoking-related disease in his 50s because tobacco control efforts in his youth meant he did not take up smoking?
Effective prevention policies, such as putting a minimum floor price on alcohol, work to reduce alcohol-related harm. But making it more difficult to reduce the price of alcohol is politically unpopular.
Finally, the benefits of prevention often take many years, even decades, to arrive. Political timeframes are often linked to election cycles of three or four years.
A long-term view is vital. Each dollar invested in skin cancer prevention, for example, returns about A$2.20 in cost saving in avoiding cost of treating the disease. But there are decades between reducing kids’ sun exposure and avoiding treatment when those kids reach their 50s and 60s.
As the election campaign unfolds, let’s hope both aspiring Australian governments continue to show a genuine interest in the health of Australians and commit to preventing disease. Is 5% of the health budget too much to ask for that?
Labor’s big-ticket election promise is a A$2.3 billion package to provide free medical scans and specialist consultations for cancer patients, plus automatic listing of new cancer therapies on the Pharmaceutical Benefits Scheme (PBS) once they’re recommended by the nation’s expert advisory panel.
One in two Australians will be diagnosed with cancer by the age of 85, and around 145,000 new diagnoses are made each year. So most of us have a close relative or friend who will be affected by the policy.
But there are some important policy considerations a Shorten government would need to plan for to ensure the package provides optimal care, improves patient outcomes, and does actually reduce out-of-pocket costs.
New therapies for cancer are rapidly evolving, and are often extremely expensive. Seeking treatment involves navigating a complex array of public and private providers across multiple health care sectors, often leaving patients with high out-of-pocket costs.
These costs are highly dependent on which providers the patients choose (and the fees they charge), the level of private insurance cover, and the volume of services used.
A recent Queensland study found the median out-of-pocket expenses for a breast cancer patient, for example, was A$4,192.
It’s possible but very time-consuming for patients to “shop around” to reduce costs. But this is an unreasonable burden to place on patients.
The Labor proposal provides an opportunity to develop a comprehensive cancer control program that encompasses prevention, early diagnosis, treatment and follow-up – at a reasonable cost.
Cancer treatment is well researched; there are clear evidence-based guidelines that establish clinical pathways for the best treatment.
Nevertheless, there is substantial variation in treatments given to cancer patients. This difference cannot always be explained by their clinical conditions, and sometimes the care is not evidence-based.
It’s important that the proposed reforms do not just fund more care, but support more of the best care.
The approach that has shown promise in other countries is known as “bundled payments”.
Under bundled payments, a series of health care services – that can span over time and across multiple health care sectors and providers – are bundled together for funding purposes. This gives providers or institutions greater flexibility in how they spend money delivering care to the patient.
There is a danger that bundling can provide incentives to skimp on care, because the provider receives the same amount of funding no matter how much care is provided. But this can be addressed by monitoring the quality of care and the patients’ outcomes.
Ensuring the financial benefits flow to patients
Australian governments have made several attempts to provide better safety nets that cushion patients from extra charges.
Study after study shows that, in these circumstances, providers are likely to raise their fees. So while patients get some financial benefit, the doctors benefit also.
Under current Medicare rules, the Australian government does not and cannot determine doctors’ fees. It can only determine the amount of the Medicare benefit.
In general practice, most consultations are bulk-billed implying that the fee the doctor charges is equivalent to the Medicare benefit.
Only 31% of specialist consultations are bulk-billed, leaving more patients with an out-of-pocket payment.
What can government do to encourage cancer care providers to bulk-bill?
Labor has announced they will add a bulk-billing incentive payment, as occurs in primary care. Specialists will receive an additional payment if they bulk-bill a cancer-related service.
This will not guarantee that every patient will not incur any out-of-pocket costs – although it should increase the likelihood that they will. Indeed, the Labor target is that 80% of patients will be bulk-billed.
However, previous research has shown that while the GP bulk-billing incentive led to a reduction in costs for those eligible (concession card holders), it also increased costs for those not eligible.
Careful monitoring is required to ensure the volume of services – and their fees for non-cancer patients – do not go up.
A further unprecedented complication is that for some services, it will be necessary to differentiate Medicare payments on the basis of the patient’s cancer status.
To guarantee patients face no out-of-pocket costs would require more radical reform. Again, the bundled payment system could be a vehicle for such reforms whereby payments are conditional on all the patient’s service providers agreeing to deliver care with no additional fee to the patient.
Depending on whether a patient is privately insured, the bundled payment could be financed by private health funds and Medicare.