Anne Deveson’ s media presence spearheaded the media’s involvement in public health and mental health. She contributed at so many levels – social commentaries and documentaries -which challenged our sensibilities. (more…)
Ian Webster
-
IAN WEBSTER. Protecting young people from our ‘favourite drug’ – alcohol.
Marketing of alcohol is out of control. 20% of those watching major sporting events on TV are under the age of 18 years.
(more…) -
IAN WEBSTER. Standing up for Medicare.
Fair access to health care is in the zeitgeist of European countries and Australia. The political sensitivities of this issue were demonstrated in the last election with the angst generated by the Labor Party’s “Mediscare” campaign. (more…)
-
IAN WEBSTER. Amid chaos, ethics.
Speaking particularly of the treatment people in Manus and Nauru, Professor Ian Webster argues that in this secular and chaotic world, the values and principles of the professional codes of health workers could be used to frame their future contributions to a civil and humane society. (more…)
-
IAN WEBSTER. Malcolm Turnbull and homelessness – reaching mentally ill people
This week our PM, Malcolm Turnbull, was admonished when he gave $5 to a homeless man in Melbourne. He was sorry if people thought he should not have done this. He said, “I felt sorry for the guy”….”there but for the grace of God go I.”
George Orwell wrote after being ‘down and out’ in Paris and London, “Still I can point to one or two things. I have definitely learned by being hard up. I shall never again think that all tramps are drunken scoundrels, nor expect a beggar to be grateful when I give him a penny, nor be surprised if men out of work lack energy, nor subscribe to the Salvation Army, nor pawn my clothes, nor refuse a handbill, nor enjoy a meal at a smart restaurant. That is a beginning.” (more…)
-
IAN WEBSTER. Health care for aged people is increasingly complex.
From his experience in intensive care in one of Australia’s busiest intensive care units at Liverpool Hospital in Southwest Sydney, Professor Ken Hillman describes the failure of specialised, super-specialised, medicine to deal appropriately and humanely with seriously ill aged persons and those whose life has run its course. (Ageing and end-of-life issues, posted 9/7/2016 in Pearls and Irritations)
Ockham’s Razor (1) is wielded inappropriately when there is not a single biological breakdown but many breakdowns. Ageing causes progressive erosion of the reserve capacity in all body systems; and chronic disease impairs the function of many organs. The aims in preventive medicine and successful ageing are to protect and preserve the function of body systems with advancing age and to prevent the onset and progression of chronic disease. (more…)
-
IAN WEBSTER. Bulk-billing rates are not what they seem.
A categorical mistake: Is bulk-billing a reliable indicator of access to GPs?
Where I work in regional NSW, patients have difficulty finding a GP who is prepared to bulk-bill them for their medical care. The phone call to the practice receptionist ends, so often, with, “The doctor’s books are full”. At the same time we’re told that 83% of Medical Benefits Schedule (MBS) services are “bulk-billed”. Like everyone else, I thought this fact would mean increased access and affordability for patients to a local GP.
Had I thought more thoroughly about the problem and scrutinised the MBS data, the penny would have dropped. (more…)
-
Ian Webster. Is community medicine dead?
John Menadue said in the NSW Health Council Report of 2000, “Services should be based where patients and consumers live. The autonomy and dignity of each patient is best serviced by providing services wherever possible outside hospital. So a shift to community multi-disciplinary health teams is a major issue still ahead of us.” He returned to this theme in a recent blog, “A major aim of good health policy for Australia must be to keep people out of expensive hospitals.”
Two South African physicians, Sidney and Emily Kark, working in poor communities started community-based primary health care – community medicine – in 1940. In each community their approach started with community diagnosis, working out the health needs in the community.
In 1973 the Whitlam Government set up the Community Health Program for Australia. It was led by an ex-South African, Dr Sidney Sax, who knew the Kark’s approach very well. His committee recommended that the community health program should be based on primary health care. (1)
One aim was to influence the doctors of the future and so, for the first time, chairs of community practice were funded by the Government in all medical schools. At the time, medical schools were narrowly focused on biomedicine and disciplines concerned with the body’s organ systems. Every medical student could tell you about Virchow’s contribution to pathology in the 19th century, but few knew anything about his statement about the social causes of disease, “Medicine is a social science, and politics nothing but medicine on a grand scale.” (2)
Outside the medical school, the general public were becoming more interested in the way doctors were trained. They were concerned about the neglect of disability, chronic diseases, mental health, addiction, Aboriginal health and other troubling health problems. And preventive medicine was missing from the GP’s repertoire.
I came to community medicine at the UNSW after working in Whyalla, South Australia and Sheffield, England. Sheffield was once the “blackest city” in Europe. Coal dust, smog, untreated childhood infections and tobacco smoking caused the lung diseases I treated at the city’s only respiratory clinic. And the impoverished and dank suburbs where I worked as a GP showed me how the social world played out in people’s health. This convinced me of the importance of social medicine.
These problems of health in the community were seen as lost causes in the medical schools of the day but over time, and to a varying extent, they have been picked up in contemporary undergraduate teaching.
Public health was a Cinderella discipline. It was regarded by most medical students as boring stuff about drains, sewerage, unimaginative health promotion interspersed with dry statistics. But with the capacity to collect large datasets and the increasing power of commuters to analyse and interrogate data there was an explosion in enthusiasm for public health. Important questions could now be answered and integrated into the guidelines for medical practice. Epidemiology now makes enormous contributions to the thinking and practice of day-to-day medicine.
But these technical developments – seeing the world through a computer screen – marginalised the messy business of dealing with the day-to-day lives of troubled people, working alongside others to deal at the grass roots with their predicaments.
In the recommendations of the Community Health Program for Australia was the central role of the GP in multidisciplinary community health teams. And progressively, but slowly, medical schools have come to accept general practice as a legitimate academic discipline and area for postgraduate training and specialisation.
In parallel with the academy, the Commonwealth aimed to support general practice through creating networks of GPs. These were known as Divisions of General Practice during the Howard government. They were renamed Medicare Locals in the health reforms of the Rudd government, giving them increased responsibilities and funding.
The current government is funding Primary Health Networks across Australia.
“Primary Health Networks (PHNs) have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time.” (3)
PHNs will have increased responsibilities for the populations in their geographical footprints. For example, in meeting local and regional needs for mental health and drug and alcohol problems, and managing the burgeoning problems of chronic disease as well as preventing and treating the common illnesses and injuries seen by GPs.
Community medicine is not dead, it is there in the principles which will inform the new PHNs with their defined responsibilities for communities and “community diagnosis” in their localities.
References:
- A Community Health Program for Australia, Report from the National hospitals and Health Services Commission: Interim Committee, June 1973. Australian government publishing service, 1973
- Anderson MR, Smith L and Sidel V W What is Social Medicine? Monthly Review, vol. 56, No. 8, January 2005. The authors said, “Rudolf Virchow is considered by many to be the founder of social medicine.”
- http://www.health.gov.au/internet/main/publishing.nsf/Content/primary_Health_Networks
Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales.
-
Ian Webster. Drugs and the problem of pain
At the centre of the drug problem is the problem of psychic and physical pain
People with mental illness turn to alcohol and drugs to lessen their distress. When adolescents and young adults use a substance to ameliorate their social anxieties a pattern of lifelong alcohol and drug misuse can be set in train. People managing to live in the community with psychosis have high life-time rates of alcohol and cannabis/illicit drug abuse/dependence – 40% to 60% – with males at the top level.
About one in five people experience continuing pain. Access to a specialised pain clinic is virtually impossible for large segments of the population. Where a public clinic exists, waiting lists are 5 to 6 months before an initial assessment can be made. Who then can blame a person turning to a drug to manage their unremitting pain?
The common image of homelessness is the “derelict alcoholic”. Think for a moment of how a street-living person has to survive the problems of rough sleeping, pain and mental illness. Legal and illegal drugs, especially cannabis and alcohol, become the way poor people and homeless people manage their lives as they have few other options. Crystalline methamphetamine “ICE” is often used to deal with physical pain as well as mental pain.
This area is complex for clinicians. It is not helped by the way pain-relieving drugs are classified and controlled. Opioid analgesics are on the Poisons List of governments; the emphasis is on harms and penalties not therapeutic value. Unfortunately, legislation of this kind frames the clinician’s approach to managing patients experiencing chronic pain.
A recent global study of the barriers to accessing opioid analgesics sponsored by the UN and International Narcotics Control Board described the impediments to access, some of which are relevant to Australia – inadequate health professional training, fear of dependence, fear of diversion to others and onerous regulation.
Contrary to common belief, patients taking opioids to control pain would prefer not to be taking these drugs and resent being labelled as addicts, as they commonly are. On the contrary, the level of addictive behaviour in these patients is relatively low – of the order of 5 to 10% – and very few of these patients divert their medications to others in Australia.
Drug problems should not be seen as issues of pharmacology, or the legal status of a substance, but as inherently people problems and the problem of suffering. Our response should be shaped by pragmatic humanistic principles not by heavy-handed legislation. In doing so, much of the unintended consequences, the harms, which typify our current approaches to pain, drug regulation and mental health should be reduced.
Ian Webster is Emeritus professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide prevention Advisory Council.
-
Ian Webster. Alcohol and Sport.
The facts about alcohol should stop politicians in their tracks. But they are unmoved.
A quarter to a third of the work of a general hospital is alcohol-related. On Australia Day one in seven ED attendances were caused by alcohol; in some EDs it was one in three. The Senior Australian of the Year, Gordian Fulde, time and time again, has described the carnage at St Vincent’s Hospital’s ED late on Thursday, Friday and Saturday nights; as many as 70 percent of cases at peak periods are intoxicated.
That’s only part of the medical story. The alcohol load is massive in the trauma, orthopaedic and burns units and manifestly over-represented in suicide attempts, mental health, brain injury and in the general medical and surgical wards. Twenty to 40 percent of patients in general practice have had a serious alcohol problem at some time in their life. Globally, alcohol is the third most modifiable risk factor to prevent disability and death. Alcohol overshadows most contemporary public health problems.
In the social story, alcohol outstrips the impact of other substances. One third of child protection cases, 40+ percent of domestic violence, 40+ percent of homicides, 45 percent of assaults attended by police and up to 60 percent of suicides – the list could go on. The police, courts and welfare agencies are tied up dealing with the consequences. Alcohol’s social impact dwarfs the anxieties about ICE and cannabis.
It’s not that we can’t tackle alcohol; it’s the countervailing forces which stop us. Dealing with the health and social harms of alcohol is not straightforward public health as the strategies to reduce harm competes with commercial interests and politics.
In the recent holiday period, the cricket season was awash with alcohol advertising, for all to see. Loopholes in legislation allowed alcohol advertising to subvert the measures designed to protect young minds. When alcohol is linked so convincingly to sporting success and peer-acceptance, young minds are too easily persuaded that being a drinker is OK.
Since ancient Greece, sporting activities have celebrated athleticism, skills, teamwork and playing by the rules. Sporting heroes have been role models for youth. But the role models of today are seduced into colluding with the alcohol industry – for celebrity, money and power. The once noble traditions have been corrupted by the dollar.
This collusion is not for the common good. With apologies to former US President Dwight Eisenhower, the alcohol industry and organised sport have established a powerful ‘industrial complex’ along with their bedfellows – the gaming and PR industries. The asymmetry of power and political influence, compared with the proponents for public health means that effective strategies such as reduced late-night trading hours for alcohol-outlets and evidence-based alcohol taxes struggle for a place in government policy.
Michael Thorn, referring to the alcohol industry, wrote last week (Pearls and Irritations, 23/01/2016), “It’s an industry built on identifying, targeting and exploiting its best customers, and ensuring they continue to misuse and abuse alcohol.” He observed that 20 percent of Australians aged 14 years and above consume 74.2 percent of all the alcohol consumed in a year. As far back as 2006, a US study showed the alcohol industry’s revenue in that country was dependent on heavy and disordered drinkers (‘sick’ drinkers) and underage drinkers. (1) A degree of exploitation redolent of the gaming industry’s dependence on problem and addicted gamblers.
Professor Robin Room and Dr Michael Livingstone, internationally recognised alcohol policy researchers from Latrobe University, and Michael Thorn, CEO, Foundation for Alcohol Research and Education, have said recently, that the alcohol industry’s interests run in the opposite direction to public health and effective alcohol policy and the industry should be excluded from alcohol policy decision-making. On the evidence, who can disagree?
It is also in the community’s interest to warn sporting organisations, that partnership with the alcohol industry undermines sporting values and risks the health of future generations.
___________
- Foster SE, Vaughan RD, Foster WH and Califano JA Jr. Estimate of the commercial value of underage drinking and adult abusive and dependent drinking to the alcohol industry. Archives of Pediatric and Adolescent Medicine. 2006 May; 160(5): 473-8.
Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.
-
Ian Webster. On thin “ICE”.
“If we wish to annihilate the junk pyramid, we must start at the bottom of the pyramid: the addict in the street, and stop tilting quixotically for the higher-ups so-called, all of whom are immediately replaceable. The addict in the street who must have junk to live is the one irreplaceable factor in the junk equation. When there are no more addicts to buy junk there will be no junk traffic. As long as the junk need exists, someone will service it.”
(William S Burroughs, Naked Lunch, 1959)
Are we in the midst of an “ICE” epidemic? Was the PM correct to say methamphetamine (“ICE”) is our “worst drug problem”, it is a “pernicious and evil” drug, it is “far more addictive than any other illicit drug”? Mr Abbott was launching the national task on “ICE”.
Or is this another cycle of drug alarm and groupthink? Recall, “reefer madness”, the “killer weed”, “the next crack cocaine”, “the meth mouth”, “the faces of meth” and “hashish assassins” ad infinitum.
On 8th April Leigh Sales introduced the ABC 7.30 Report, “Revelations of ice use and suicide in the Australian Navy have shocked the Defence establishment and Australia’s political leaders.” This followed the previous night’s tragic report by Louise Milligan of nine suicides in young sailors at the West Australian naval base, HMAS Stirling. These perplexing and disturbing events demand reflection on the underlying causes of mental distress and suicide. But these important questions were conflated with “ICE”, a spin-off from the PM’s announcement of the task force. Next day, on Radio National’s AM program, Green Senator Peter Whish-Wilson, himself a military veteran, was interviewed about the parliamentary inquiry he had instigated into mental health in the military community. Again “ICE” was dragged to centre stage, not by the Senator but by Fran Kelly, the interviewer. Other media have been even more caught up in the “ICE” frenzy.
Addiction is not a switch to be turned off and on. Addiction takes time, months, sometimes years, to develop. Methamphetamine use over a long period becomes the substrate for addiction. The majority of long-term users have already well-established dependence on other drugs – polydrug users. They are drug tolerant and in drug-seeking overdrive; they seek more potent drugs.
Simple exposure does not cause addiction. Think for a moment of the hundreds of hospital patients receiving pain relief, virtually none will become “addicted”. The same drug, morphine, injected in the ‘street’ carries a high risk of addiction. Addiction (drug dependence) arises from an interaction between a vulnerable person (nature and nurture), the social environment (attitudes, norms of peers) and a drug.
Medicine is long familiar with amphetamines. They are not new. They have been used in asthma, depression (even anxiety), for appetite suppression and now may be prescribed for narcolepsy and attention deficit hyperactivity disorder. University students take the stuff to cram for exams and US pilots are kept alert by amphetamines during combat missions. Their stimulant effects are understood and the potential harms to the cardiovascular system are known.
Where do the amphetamines, methamphetamine, stand in relation to other substances?
The population prevalence rate of methamphetamine use in 12 months is 2 – 3 per cent compared with the 83 per cent for alcohol. Alcohol use disorders occur at 15 – 20 times the rate of methamphetamine disorders. For every methamphetamine-related death there are 65 alcohol-related deaths; for every emergency presentation there are 30 alcohol-related presentations; for every ambulance emergency call-out there are 25 alcohol-related call-outs.
Many suicides are underpinned by illicit drug use, including methamphetamine, but alcohol intoxication and dependence is a far more potent factor in suicide worldwide; of attempted suicides presenting to hospitals, 50 to 80% had been drinking heavily or were intoxicated at the time and at post mortem alcohol is the drug most commonly found.
The amphetamine drugs are harmful. They can cause psychotic disturbances; about one in seven admissions for schizophrenia have a concurrent stimulant disorder. They cause anxiety, aggression and depression, on withdrawal, as well as affecting the cardiovascular system. These are features too of alcohol intoxication and dependence as well as there being a veritable textbook of alcohol-caused mental and physical conditions and harm to others.
Policing and law enforcement are important especially to prevent the exploitation of vulnerable people. They can’t solve the “ICE epidemic despite the current wave of interdictions and arrests. Community-based solutions are needed – supports for families and children, educational and work opportunities for young people, early intervention and prevention, access to primary care interventions and to treatment and rehabilitation services; none of which are given priority compared with resources devoted to law enforcement.
As William Burroughs said,
“When there are no more addicts to buy junk there will be no junk traffic. As long as the junk need exists, someone will service it.”
And he should know.
Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.
-
Ian Webster. Alcohol-drenched cricket.
Michael Thorn is right; the ICC Cricket World Cup was an alcohol-drenched event (SMH Tuesday, 31st March 2015).
Cricketers were once models of sportsmanship. There was even altruism and some became statesmen. Recall, “That’s simply not cricket.” No longer, as the game is subverted by money and alcohol. As I write, the ABC is broadcasting the “performance-enhancing” drug scandals in the AFL. Just as scandalous, more scandalous, is that sport is a vehicle for promoting our most socially damaging drug, alcohol.
To adolescent binge drinking, we respond – they should be taught at school; the drinking age should be raised; they need other outlets and activities; they should be disciplined and so on. But in this hand-wringing adults are forgotten. It is the behaviour of adults that the young seek to emulate. They aim to become like us.
In becoming adults, young people test limits and learn social skills for the future. They want to be acknowledged, to fit in, to be one of the group. Herein lies the problem. Skilled marketers can exploit these vulnerabilities and link sporting achievements, heroic performances, glamour and attractiveness to the brands of alcohol; welding loyalty to a brand.
There are physiological and psychological reasons for concern about drinking in adolescence. A lifetime pattern of heavy drinking is more likely to be established if drinking starts at a young age and the developing brain is at risk. Governments know this and restrict alcohol ads during TV viewing times of young people. But sport gets around it.
That advertising alcohol creates problems is accepted, but not by all. The alcohol industry in 1998 set up a voluntary Alcohol Beverages Advertising Code to adjudicate complaints about alcohol advertising. The code covers – the responsible and moderate portrayal of alcohol, responsibility towards minors, responsible depiction of the effects of alcohol and safety. It is hardly surprising that independent evaluations have shown its determinations generally favour the advertisers. And it has been criticised for lack of transparency and inability to cover ‘new media’. Also there are other advertising codes for television, radio, outdoor and publishers’ which include alcohol in their codes of practice.
An alternative and independent body was set up in 2012 by the McCusker Centre for Action on Alcohol and Youth and the Cancer Council of Western Australia– the Alcohol Advertising Review Board. It has 122 independent panel members. The Board’s chair, Professor Fiona Stanley AC, said in the 2014 Annual Report that many of the complaints were about sport and alcohol. The Board has recommended that,
“…the loophole in the Commercial Television Industry Code of Practice should be closed as part of a comprehensive strategy to reduce young people’s exposure to alcohol promotion. This should be accompanied by measures to remove advertising and promotion related to alcohol company sponsorship of sporting associations, teams and events where children and young people may be exposed.”
Australia has tinkered around the edges of controlling the promotion of alcohol and balks at going as far as countries like France and New Zealand. France, a country with a passion for alcohol, has banned alcohol sponsorship, advertising in cinemas and television and targeting young people.
Alcohol is not ice cream or cornflakes. It has toxic effects on the mind and body with manifold social consequences. Yet worldwide it is one of the most heavily advertised products. More than 94% of Australian students aged 12 to 17 have seen alcohol advertising on television as well as in magazines, billboards and a myriad of other locations. Current industry self-regulation is an abject failure.
If there is any good news out of the World Cup ‘booze up’ it is that the cricketers’ behaviour has offended the sensibilities of many Australians. Time then, to break the nexus between sport and alcohol.
Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.
-
Ian Webster. Suicide prevention.
September 10th was World Suicide Prevention Day – Suicide Prevention – One World Connected and from the 5th to the 12th October Mental Health Week ran in Australia. The week’s highlight was the ABC’s “Mental as” which ran through the whole week. Over three nights “Changing Minds – the inside story” on ABC TV involved us with the staff and patients of Liverpool Hospital’s in-patient mental health unit. It was riveting television. The program portrayed the relationships between staff and patients with disordered minds as they slowly regained their sanity. There was much humanity.
A constant thread during Mental Health Week was the risk of suicide, but mental illness is not the only pathway to suicide.
In September, Dr. Margaret Chan, Director-General, World Health Organisation said in launching the first WHO report on suicide prevention, “Preventing Suicide: A global imperative”:
“The burden of suicide does not weigh solely on the health sector; it has multiple impacts on many sectors and on society as a whole. Thus, to start a successful journey towards the prevention of suicide, countries should employ a multisectoral approach that addresses suicide in a comprehensive manner, bringing together the different sectors and stakeholders most relevant to each context”.
Suicide exacts an unacceptable toll of more than 2200 lives each year in Australia. Three quarters are men in the prime period of their lives. From the 1990s to 2010 suicide rates declined by 17 per cent, mainly from reduced suicides in young males. But the decline has stalled and Australia must look to new approaches at national and local community levels.
Suicide is not an act which occurs in isolation. It arises out of interactions between long-term vulnerabilities, trigger events and accumulating adverse factors in a person’s life. Disadvantaged communities are the hardest hit.
Sadness and ‘sorry business’ pervade too many Aboriginal and Torres Strait Islander communities leading to an inexorable downward spiral in community spirit and well-being. Between 15 and 19 years of age Aboriginal and Torres Strait Islander young people die from suicide four to six times the rate of other young Australians. Urgent action is needed in these communities.
People with continuing mental illness; those with distressing physical illnesses, disability and pain; people who identify as lesbian, gay, bisexual, transgender or intersex; armed service veterans; and those living in rural or remote areas have high risks of suicide. The Northern Territory and Tasmania have higher rates than the rest of Australia. Each community, region or group poses special challenges for actions to prevent suicide.
Not only are families and friends devastated by suicide and left with unanswered questions and bewilderment as workplaces, schools, clubs, emergency services and whole communities can be affected.
We know that 75% of people who take their lives will have attended a general practitioner or hospital in the three months before they died. And many of the 65,000 people who attempt suicide each year will also have been in contact with homeless shelters, schools and colleges, workplaces, Centrelink, police and courts.
Herein lies a key piece in the jigsaw. These points of early contact are opportunities to connect a person to on-going follow-up and support to enable them to re-establish meaningful relationships and community involvement. But this ‘chain of care’ can only be as strong as each link in the chain.
There are hopeful signs that this is happening in different parts of Australia as communities galvanise around the issue of suicide. These local suicide prevention networks aim to build connections to prevent suicides and to support those who have been bereaved. It is a paradox that it takes such tragic events to re-kindle relationships which have been lost.
There is no single strategy which can reduce the rates of suicide as the pathways to risk in childhood and adolescence, young adults, middle age and in later life, involve different vulnerabilities, exposures and experiences. But community connectedness and resilience are relevant at every step along these paths.
As the WHO says this is where our efforts can be most effective. In other words governments and service providers have to understand that suicide prevention can’t be left to mental health services alone; it must involve all emergency service personnel, health and social services, local communities and especially primary health care.
Ian W Webster, National Mental Health Commissioner, 2012-2014, Chair, Australian Suicide Prevention Advisory Council, 1998 – 2014.
-
Ian Webster. Cutting waste and costs in health
Waste in health care conjures up several pictures.
One picture is of community nurses, psychologists and Aboriginal health workers in the community centre I visit anchored to their computer screens, endlessly it seems, trying to fulfil the demands of data entry. They are obviously frustrated by the lack of relevance this has for solving the problems of their patients. It takes time away and it is disempowering. About one third of each day is lost in this way.
While not so apparent, there is a certain cynicism amongst the local hospital’s specialists about ‘gaming’ to preserve the local hospital’s funding and the administrative demands made on their time. The Garling Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals in 2008 highlighted how non-clinical workload takes time away from clinicians who should be able to dedicate this time to clinical tasks. And the Greater Metropolitan Clinical Taskforce in 2004 reported on the conflicts between the information needed for clinical decisions and the data used by the administrators and funders. John Menadue, in his speeches on health care reform, has described the mismatch between vertical bureaucratic accountability and reporting and the horizontal and shared communication and working relationships of health professionals.
There is much disillusionment in the current health care system where there should be enthusiasm and pride. Not only is time wasted in an atmosphere of excessive checking, rechecking and codification – to protect the Minister and the system – but good people and good-will are being wasted. Despite the demands and impediments on their time and commitment there are still front-line heroes who “go well beyond the call of duty” to pick up the pieces left undone by others. These people are the pivots around which the services revolve and they should be celebrated and encouraged.
To prevent waste, data collection and information technology must be ‘practice-worthy’; they must help solve clinical problems and assess the progress of patients if they are to contribute to effective and efficient patient care.
The second picture is of the waste of misdirected efforts.
In the National Report Card on Mental Health and Suicide Prevention of 2012 the National Mental Health Commission, on behalf of the mental health community, expressed disquiet about the Activity Based Funding (ABF) being developed for the National Hospital Pricing Authority. The Commission said, “The new ABF system should be designed to meet the needs of people with mental health difficulties regardless of whether services are provided in hospitals, in the community or elsewhere. Alternatives to hospitals must be a priority.” The fear is that ABF will inevitably suck funding for mental health back to hospital activities rather than support and care in the community. If any part of ‘health’ demands a community-based approach, mental health does.
The Commission’s view is that people should be supported to have contributing lives where they live and work and not be dependent on hospital-based services, necessary as this may be at critical times. Exactly the same can be said in the prevention and management of physical health generally – especially in the management of chronic disease and the intractable complexities of the increasingly prevalent multiple conditions. For people with these conditions hospital admissions are but punctuated interludes along pathways lived out in the community.
Waste will mount inexorably so long as we neglect to invest in primary health care and community health.
Professor Ian Webster is Emeritus Professor of Community Health at the University of New South Wales.