Federal Budget submission from The Cancer Council Australia

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1 Federal Budget submission from The Cancer Council Australia Overview The Cancer Council Australia calls on the Rudd Government to fund five critical initiatives in the Federal Budget: Recurrent commitment to the National Bowel Cancer Screening Program (election commitment, including $25 million to extend target age group) Revival of the National Tobacco Campaign ($15 million election commitment) Abolition of duty-free tobacco product sales ($25 million p.a. budget gain) Improved travel and accommodation assistance for remote cancer patients (Senate recommendation) Recurrent commitment to the National Skin Cancer Awareness Campaign. All five priorities are either directly aligned with a 2007 Labor election commitment or reflect Labor s general policy on health funding and inter-governmental cooperation. Four of the five would deliver direct savings to government, including an annual budget gain of $25 million from abolishing duty-free cigarette sales; potential 3:1 and 5:1 returns on tobacco and skin cancer control investments respectively; and major public hospital savings on bowel cancer treatment through early detection. Improved assistance for remote patients would boost the viability of regional communities, which generate more than double the exports produced in cities. Fully implemented, the initiatives would save tens of thousands of lives more than 1500 deaths prevented each year through the National Bowel Cancer Screening Program alone, with substantial ongoing reductions in mortality through reduced smoking, greater skin cancer awareness and improved cancer treatment outcomes for Australians in rural and remote areas. Following is an outline or each priority, including estimated costs, benefits, funding breakdown and revenue source; timetable, rationale and detailed relevance to Rudd Government commitments and policies. The Cancer Council Australia is Australia s peak non-government national cancer control organisation. Its member bodies are the eight state and territory Cancer Councils, whose views and priorities it represents on a national level. Responsibility for content is taken by Professor Ian Olver, Chief Executive Officer, The Cancer Council Australia. Correspondence to Paul Grogan, Director, Advocacy, The Cancer Council Australia, c/o or (02)

2 Priority 1: Recurrent commitment to National Bowel Cancer Screening Program Cost: To be determined with state and territory governments, according to medical evidence, quality assurance requirements and evaluation of current program. 1,2 With the five-year Australian Health Care Agreements renewable in , it is time-critical for the Rudd Government to permanently fund the National Bowel Cancer Screening Program from the Federal Budget, drawing on Labor s $2 billion health reform fund and its three-year, $25 million election commitment to screen 50-year-olds as an extension of the current program. Estimated benefits: More than 30 Australian lives saved per week. 1,3 Substantial longterm health system cost savings through both prevention (polyp removal) and detection (successful treatment of early-stage cancer). Funding breakdown: Overall program administration funded by the Australian Government; public hospital colonoscopy services jointly funded by Australian and state/territory governments through a quality assurance framework built into the 2008 Australian Health Care Agreements. Funding source: Majority of funds to be derived from Labor's $2 billion National Health and Hospitals Reform Plan, in addition to $25 million committed by Labor for extending the National Bowel Cancer Screening Program to people aged 50. Timetable: Incremental intake of all Australians aged 50 and over onto the program, with a target of full implementation by Biennial screening. Relevance to Rudd Government agenda: Building on election commitments ($2 billion health reform fund; screening 50-year-olds as a down-payment on targeting the full clinically recommended age cohort of all people aged 50 and over); Labor will work with state and territory governments to set up a national framework for ongoing implementation of the National Bowel Cancer Screening Program, including a structure for workforce planning, training and support; and ensuring sufficient follow-up services and quality assurance mechanisms are in place 4 ; consistent with two major Federal Labor policy statements, Future ideas, future economy: preventative health care for our families and our future economies and New directions for Australian health; consistent with Labor policy to work co-operatively with states and territories for better health (and health economy) outcomes. Rationale: Every week that full implementation of bowel cancer screening is delayed, large numbers of Australians die unnecessarily. Level 1 (the highest available) evidence has for more than 12 years shown that bowel cancer screening saves significant numbers of lives, 1 yet Australia is well short of reaching its enormous potential to reduce bowel cancer mortality, morbidity and treatment costs through population-based screening with faecal occult blood testing. The phase-in of a bowel cancer screening program was first announced as an election commitment by the ALP Opposition in 2004, with a commitment from the then Howard Government two weeks later. More than three years later, only people turning 55 and 65 2

3 in a calendar year are targeted for screening around 15% of people who should be targeted for screening. 1 Moreover, there has been no progress on an integrated federal/state framework to ensure effective, efficient and quality-assured program delivery and maximum participation along the lines of Australia s world-leading breast and cervical cancer screening programs. With the Australian Health Care Agreements due for renewal this year, the Rudd Government has a unique opportunity to move beyond a piecemeal, time-tied approach to bowel cancer screening and announce a permanent, recurrently funded commitment to the program. The Bowel Cancer Screening Program is directly aligned with the principles of the new, co-operative approach to health funding announced by Labor in the election campaign, as well as the Prime Minister s commitment to improve cancer prevention and early detection. 5 Bowel cancer claims more than 80 Australian lives each week 6 and its impact will increase significantly as our population ages. 7 As well as having the potential to prevent more than 30 Australian deaths per week, bowel cancer screening can significantly reduce hospital expenditure. For example, removing a precancerous polyp detected through screening costs around $1250, while treatment at a public hospital for cancers that develop from polyps can cost more than $23,000 per case. 8 While capacity for colonoscopy will need to increase to accommodate population-based screening, colonoscopy demand in Australia could be more effectively managed with a faecal occult blood test program. State hospital research shows that up to a quarter of colonoscopies currently performed at a taxpayer cost of $120 million per annum do not follow evidence-based NHMRC guidelines. With sufficient commitment and a co-operative approach across jurisdictions, it is feasible to build full capacity for the National Bowel Cancer Screening Program within four years of the next budget, given that program implementation began in It took only five years for the establishment of the National Breast Screening Program, once federal and state/territory health ministers had made a joint commitment. In the first Budget of a new Australian Government committed to disease prevention, inter-jurisdictional co-operation and investing for Australia s future, there is a critical opportunity to commit to permanent funding of a critical and long-overdue public health initiative. Priority 2: Re-initiate the National Tobacco Campaign Cost: $15 million ALP election commitment. Estimated benefits: $48 million to the Australian economy, or a 3:1 return on investment, within three years; $30 million in direct savings to the Australian Government within one year. (Source: Extrapolation of independent analysis of National Tobacco Campaign ) Significant contribution to reduced preventable death and disease through predicted further drop in smoking prevalence. 3

4 Funding breakdown: $15 million for television advertising. May include the development of some new materials, pending market testing. Funding source: $15 million committed by Labor in November 2007 for the implementation of the National Tobacco Strategy, potentially augmented by new revenue raised by the abolition of duty-free cigarette sales (see Priority 3). Timetable: Targeted television campaign run during the financial year, with advertising schedule segmented to expose the general population to a minimum 400 target audience rating points (TARPs) per month. Relevance to Rudd Government agenda: 2007 election commitment (the National Tobacco Campaign is the key federal component of the National Tobacco Strategy; cooperative federalism (e.g. integrating the media campaign with state-based activities such as Quitlines, state-funded tobacco control advertising); consistent with two major Federal Labor policy statements, Future ideas, future economy: preventative health care for our families and our future economies and New directions for Australian health; consistent with Labor policy to reduce social disadvantage. Supporting policy: Transfer inter-jurisdictional tobacco control policy and programs from the Ministerial Council on Drug Strategy (MCDS) to the Rudd Government s Preventative Health Task Force and build tobacco control into the Australian Health Care Agreements. The enormous cost of smoking to public hospitals, and smoking s accumulated impact on mortality and morbidity, mean tobacco presents a clearly different challenge to government from other licit and illicit drugs. Rationale in summary: Each year more Australians are killed by tobacco than by breast cancer, AIDS, traffic and other accidents, murders and suicides combined. Smoking is responsible for 15,500 deaths each year and 7.8% of the total burden of disease in Australia. 10 The total social cost of smoking in Australia has been estimated at $21 billion a year. 11 In , smoking accounted for more than 291,000 hospital episodes per year, at a cost of $682 million. 12 Smoking is by far the leading preventable cause of cancer in Australia. 13 Australia has a comparatively strong record in tobacco control, with an estimated $8.6 billion and 17,000 lives saved from reduced smoking over the past 30 years. It is estimated that $2 has been saved on health care for each $1 spent on tobacco control programs to date, with total economic benefits exceeding expenditure by at least 50 to 1. 1 Yet despite the enormous and incontrovertible returns, Australian governments continue to under-invest in tobacco control. A recent comprehensive evaluation of tobacco control strategies over the past decade has reaffirmed the effectiveness of television advertising in measurably reducing smoking prevalence. The study also shows that a relatively intensive advertising campaign (400 TARPs per month) over one year is significantly more effective in reducing smoking prevalence than the same investment spread over three years. 14 Opportunity: While $15 million over one year would buy the minimum level advertising (400 TARPs per month), increasing the media investment to around $25 million would buy 700 TARPs per month. A recent (unpublished) US study found that 700 TARPs per 4

5 month over two years provided better returns on investment in terms of smokers quitting than 400 TARPs per month. A cost-free revenue source for this significantly cost-beneficial opportunity would be the abolition of duty-free tobacco sales at Australian airports, which would provide an estimated $25 million per annum (see Priority 3). Priority 3: Abolish duty-free tobacco sales Cost: No significant budget outlay required. Estimated benefits: $25 million per annum in new federal revenue (based on estimates 15 ). Funding breakdown: $11 million to increase National Tobacco Campaign spend for maximum return on investment (see Priority 2). $14 million for additional tobacco control programs for socially disadvantaged groups, who bear an unacceptably high proportion of tobacco burden. 16 Initiatives for funding would include state/territory Quit programs, targeted media campaigns and tailored supporting programs (e.g. telephone counselling), which are focus-tested for low-income, Indigenous and/or other socially disadvantaged groups. Funding source: Self-funding through removal of duty-free, with significant net benefits. Timetable: Recurrent allocation to reduce smoking rates among socially disadvantaged groups; one-off allocation to television campaign in Relevance to Rudd Government agenda: Provided associated new revenue contributes to additional tobacco control measures, abolishing duty-free tobacco sales at airports is consistent with the disease-prevention focus of two major Federal Labor policy statements, Future ideas, future economy: preventative health care for our families and our future economies and New directions for Australian health; consistent with Labor policy on reducing social disadvantage and improving Indigenous health; proposal is cost-neutral, but delivers additional revenue stream in line with expected budget policy of fiscal restraint; consistent with Labor ideal of building health economics into mainstream economic policy, given substantial returns available and exponential effect of reinvesting back into reduced smoking prevalence. Rational in summary: As summarised in Priority 2, smoking imposes an enormous, unacceptable, yet preventable burden on Australia s social and economic wellbeing. Duty-free sales allow smokers to bulk-purchase a product likely to cause death and disease. Consumption driven by bulk sales imposes an added cost on the health system. In 2005, Australia demonstrated its commitment to global tobacco control by ratifying the WHO Framework Convention on Tobacco Control (FCTC), an international treaty designed to reduce smoking-caused death and disease worldwide. The FCTC calls on Parties to the Convention to prohibit the sale of duty-free tobacco products. 17 As a recognised regional and international leader in tobacco control, Australia must set an example by banning the sale of duty-free tobacco products. 5

6 The Australian Government is well-placed to abolish the incongruous duty-free sale of tobacco products and invest the estimated net $25 million in new annual revenue over the medium term into tobacco control measures shown to deliver major economic and social returns. Priority 4: Whole-of-government response to funding Senate recommendations on Patient Assisted Travel Schemes Cost: To be negotiated with state and territory governments. Current subsidies for patient travel and accommodation in most jurisdictional schemes have received little or no CPI increase since being devolved by the Commonwealth in Subsidies are on average ¼ the recommended Australian Taxation Office rate for commercial and government travel and accommodation. 18 Estimated benefits: Measurable improvements in rural and remote patient outcomes. It is estimated that remote patient assistance expenditure is less than 2% of overall cancer treatment costs in Australia, yet 30% of cancer patients live outside major metropolitan centres. 19 Funding breakdown: To be negotiated with the states/territories. National leadership is integral to ensuring the Senate s recommendations are delivered through the Australian Health Ministers Advisory Council. Funding source: Funding increase derived from Labor s National Health Reform Plan (option may include reformed Rural Medical Infrastructure Fund); negotiated with the states and territories and factored into the Australian Health Care Agreements. Timetable: Recurrent commitment built into Australian Health Care Agreements. Relevance to Rudd Government agenda: Bi-partisan Senate recommendations; priority aligned with four Labor election commitments: 1) Upfront investments made under Federal Labor's National Health Reform Plan will be targeted at areas where need is high, particularly including rural and regional areas; 2) Federal Labor's National Health and Hospitals Reform Commission will be asked to explicitly identify a long-term plan for improving rural health services; 3) Federal Labor will reform the Rural Medical Infrastructure Fund to make more communities eligible for assistance and to make it easier to apply for funding; 4) Federal Labor is strongly committed to improving Indigenous health. 20 Rational in summary: The case for significantly improving the effectiveness and accessibility of cancer patient travel and accommodation assistance schemes, as backed by the Senate, 21 is reflected in key statistics: Approximately 30% of Australian cancer patients are estimated to live outside a major population centre where tertiary care is available; 22 Evidence shows that those who live furthest from a large treatment centre are at the highest risk of a comparatively poor cancer treatment outcome; 23 6

7 A report published in the Medical Journal of Australia in 2004 showed that people with cancer in regional NSW were 35% more likely to die within five years of diagnosis than patients in cities. Mortality rates increased with remoteness. For some cancers, remote patients were up to 300% more likely to die within five years of diagnosis. 24 Moreover, as the barriers to care associated with distance widen the gap in cancer treatment outcomes between rural and metropolitan Australia, paradoxically the regions continue to make a disproportionately high contribution to the economy that sustains the public health system nationally. For example, exporter numbers in regional areas are growing at 18% per annum compared with only 6% in cities. 25 Meanwhile, poor health outcomes and reduced access to healthcare services threaten the viability of rural and remote communities. Providing real increases in financial assistance for cancer patients in the bush and streamlining the complex, inequitable systems that process such payments would be a responsible, measurable and much needed use of taxpayer dollars. Substantial improvements to remote travel and accommodation assistance as recommended by the Senate would also assist Indigenous people in particular, a comparatively far higher proportion of whom live in remote or very remote communities. 26 A co-operative, inter-governmental approach to significantly improving rural and remote patient travel assistance based on national leadership could also help facilitate the establishment of regional cancer centres of excellence. The eventual roll-out of multidisciplinary cancer services in large regional centres would dramatically reduce the distances remote patients must travel for adequate treatment. Priority 5: Recurrent commitment to national skin cancer awareness campaign Cost: $5.7 million per annum Estimated benefits: Government investment in skin cancer prevention returns up to $5 for every $1 spent. 27 Preliminary research shows existing campaign has potential to significantly reduce skin cancer costs. 28 Funding breakdown: $5.7 million per annum over four years. Funding source: allocation already funded from federal budget. 29 Additional recurrent allocation drawn from preventative health fund, allocated through Department of Health and Ageing Population Health budget. Timetable: Recurrent commitment, with campaign to run over successive summers during peak skin cancer risk periods. Relevance to Rudd Government agenda: Continuation of current Rudd Government program (2008 skin cancer awareness campaign); importance of skin cancer protection cited in Future ideas, future economy: preventative health care for our families and our future economies; strong return on investment consistent with policy of economic responsibility. 7

8 Rationale: Skin cancer is Australia s most economically expensive cancer, costing the health system almost $300 million per annum to treat. 30 Skin cancer also claims more than 1600 Australian lives each year. 31 Latest research shows that government investment in skin cancer prevention returns up to $5 for every dollar spent; preliminary research on the current Australian Government National Skin Cancer Awareness Campaign indicates it is effective in influencing 27, 28 behaviour to reduce the economic and social costs of skin cancer. Evidence clearly shows that an ongoing commitment to a national skin cancer awareness campaign would deliver substantial economic and social benefits to Australia 32 and help shake our nation s unwanted mantle as the world s skin cancer capital. References 1 Clinical practice guidelines for the prevention, early detection and management of colorectal cancer, National Health and Medical Research Council, The Cancer Council Australia, Moving forward on bowel cancer screening: report of a discussion forum, 2006; Australian Institute of Health and Welfare, Cancer in Australia 2001; Federal Labor media statement, 11 October 2007, 5 Australian Labor Party, Future ideas, future economy: preventative health care for our families and our future economies. 6 Australian Institute of Health and Welfare, Cancer in Australia: an overview, Australian Institute of Health and Welfare, Cancer incidence projections Australia , Corporate Value Associates, CRC Screening Strategy: Governing committee cancer control network presentation, Commonwealth Department of Health and Aged Care Australia s National Tobacco Campaign evaluation report: volume three. Accessed 31 August Begg S, Vos T, Goss J, Barker B, Stevenson C, Stanley L & Lopez AD (2007, in press). The burden of disease and injury in Australia Canberra: AIHW & Brisbane: University of Queensland. 11 Collins D & Lapsley H National Drug Strategy monograph series: Counting the cost: estimates of the social costs of drug abuse in Australia in No. 49. Canberra: Australian Government Department of Health and Ageing. 12 Hurley SF Hospitalisation and costs attributable to tobacco smoking in Australia: Med J Aust 184(1): Australian Institute of Health and Welfare (AIHW) Australia s health AIHW cat. no. AUS 73. Canberra: AIHW. 8

9 14 Wakefield M. et al, Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence: time series analysis, American Journal of Public Health (in press). 15 Tobacco Control: A Blue Chip Investment in Public Health, VicHealth Centre for Tobacco Control, Siahpush M. Smoking and social inequality. Australian and New Zealand Journal of Public Health. 2004; 28:(3): World Health Organisation, Framework convention on tobacco control, Australian Taxation Office, Taxation Determination TD 2006/43 Income tax: what are the reasonable travel and meal allowance expense amounts for ? 19 National Health Priority Action Council, National Service Improvement Framework for Cancer, Federal Labor media statement, 18 November 2007, 21 Parliament of Australia: Senate, Highway to health: better access for rural, regional and remote patients, Commonwealth of Australia 2007, ISBN National Health Priority Action Council, National Service Improvement Framework for Cancer, Australian Institute of Health and Welfare and Australasian Association of Cancer Registries. Cancer survival in Australia : geographic categories and socioeconomic status. Canberra: AIHW, (Cancer Series No. 22. AIHW Catalogue No. CAN 17.) 24 Jong KE, Smith DP, Yu XQ, et al. Remoteness of residence and survival from cancer in New South Wales. Med J Aust 2004; 180: Harcourt,T, Export Growth and Job Creation in Regional Australia, Australian Trade Commission, Australian Institute of Health and Welfare, Recent developments in the collection of Aboriginal and Torres Strait Islander health and welfare statistics 2005, Shih STF, Carter R, Economic Evaluation of a National SunSmart Program, Health Economics Unit, School of Health and Social Development, Deakin University, in press 28 Dobbinson, S, Jamsen K, Francis K, Dunlop S and Wakefield M, , National Sun Protection Survey, Department of Health and Ageing, Portfolio Budget Statements, May Australian Institute of Health and Welfare (AIHW), Health system expenditures on cancer and other neoplasms in Australia, , Canberra, AIHW (Health and Welfare Expenditure Series no.22). 31 Australian Institute of Health and Welfare, Cancer in Australia: an overview, 2006, Carter, R., R. Marks, and D. Hill, Could a national skin cancer primary prevention campaign in Australia be worthwhile?: an economic perspective. Health Promotion International, (1): p

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