John Dwyer

  • JOHN DWYER. Health care reform – Part 2.

    Without acceptance of a ten year plan and the creation of an instrument to implement that plan we will not be able to engineer the evidence based structural reforms to our health care system that will improve quality, equity and cost effectiveness. (more…)

  • JOHN DWYER. Health care reform – Part 1.

    Without acceptance of a ten year plan and the creation of an instrument to implement that plan, we will not be able to engineer the evidence-based structural reforms to our health care system that will improve quality, equity and cost effectiveness.  (more…)

  • JOHN DWYER. “Health Care Homes”, set up to fail and doing so spectacularly.

    Touted by Minister Hunt as the biggest health care reform initiative since the introduction of Medicare, the “Health Care Home” model for the better management of patients with two or more chronic diseases is floundering, beset with predictable organisational and resource inadequacies. As is so often (too often) the case with health policy initiatives, a laudable concept collapses at the implementation phase (e.g. Primary Health Networks). The boldness of the plan is not matched by the necessary resource boldness.   (more…)

  • Profit trumping professionalism! All too often the case in Australian pharmacies

    On May 3, Health Minister Greg Hunt spoke at a conference organised by the Pharmacy Guild of Australia. This is the pharmacy owners association (all pharmacists) which in 2011, notoriously, entered into a deal with the vitamin and supplement provider, Blackmores, to have 5000 pharmacies try and sell a Blackmores’ product to clients picking up prescription medicines. Once revealed the subsequent opprobrium, of course, resulted in the deal being cancelled. (more…)

  • JOHN DWYER. Poor oral health in Australia; a costly chronic problem getting worse and which current strategies have no chance of resolving.

    Australia’s health “system”, such as it is has two “Achilles’ Heels”. The left one is our lack of emphasis on the prevention of disease while the right one concerns our incompetence in integrating health services in a patient-focused way. Both were on vivid display recently with the release of a new report by the  “Australia’s Oral Health Tracker”. (more…)

  • JOHN DWYER. The curse of political mediocrity; The informed, bold, courageous policies that Australia needs in health are nowhere to be seen. (Part 3 of 3)

    This “fair go mate” country of ours is wealthy but in reality ever less egalitarian. Increasing Inequity is palpable and most notable in the problems we have with housing, education and health. Health outcomes for Individuals are increasingly dependent on personal financial wellbeing. Australians are spending about 30 billion dollars a year to supplement the care available from our universal health care system. Many, of course, do not have the resources to to cover “out of pocket” expenses. Many of these problems have become chronic as political intransigence inhibits the development of bold, informed and even courageous policies. Policy development, such as it is, is often insular, ignoring the successful tactics of other countries in addressing similar problems. The Commonwealth Fund, which compares the worlds health systems for quality, is critical of our efforts to swing our health system around to focus on the prevention of disease. Eleven other OECD countries are currently doing a better job than we are.How can we change this unsatisfactory situation? PART 3. (more…)

  • The curse of political mediocrity; The informed, bold, courageous policies that Australia needs in health are nowhere to be seen. (Part 2 of 3)

    This “fair go mate” country of ours is wealthy but in reality ever less egalitarian. Increasing Inequity is palpable and most notable in the problems we have with housing, education and health. Health outcomes for Individuals are increasingly dependent on personal financial wellbeing. Australians are spending about 30 billion dollars a year to supplement the care available from our universal health care system. Many, of course, do not have the resources to cover “out of pocket” expenses. Many of these problems have become chronic as political intransigence inhibits the development of bold, informed and even courageous policies. Policy development, such as it is, is often insular, ignoring the successful tactics of other countries in addressing similar problems. The Commonwealth Fund, which compares the world’s health systems for quality, is critical of our efforts to swing our health system around to focus on the prevention of disease. Eleven other OECD countries are currently doing a better job than we are. How can we change this unsatisfactory situation? PART 2 of 3. (more…)

  • The curse of political mediocrity; the informed, bold, courageous policies that Australia needs in health are nowhere to be seen (Part 1 of 3).

    This “fair go mate” country of ours is wealthy but in reality ever less egalitarian. Increasing Inequity is palpable and most notable in the problems we have with housing, education and health. Health outcomes for Individuals are increasingly dependent on personal financial wellbeing. Australians are spending about 30 billion dollars a year to supplement the care available from our universal health care system. Many, of course, do not have the resources to to cover “out of pocket” expenses. Many of these problems have become chronic as political intransigence inhibits the development of bold, informed and even courageous policies. Policy development, such as it is, is often insular, ignoring the successful tactics of other countries in addressing similar problems. The Commonwealth Fund, which compares the worlds health systems for quality, is critical of our efforts to swing our health system around to focus on the prevention of disease. Eleven other OECD countries are currently doing a better job than we are.How can we change this unsatisfactory situation? PART 1 of 3.

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  • JOHN DWYER. The devastating effects of Trumpism on science and medicine.

    While the “Fire and the Fury” surrounding  the chaos at the White House dominates media reporting on the Trump presidency, the power of the office is being utilised to implement a myriad of bad decisions that will have very long-lasting effects. Nowhere is this more obvious than in the plans Trump has to slash funding for science and medicine. (more…)

  • JOHN DWYER: When will we seriously tackle the Inequity associated with the delivery of health services to rural and remote Australians? Part 2 of 2.

    Health outcomes for Australians living in rural or what are characterised as “remote” areas are far inferior to those of their city cousins. If you don’t live in metropolitan Australia your life expectancy is reduced by about four years. You are four times more likely to die of a stroke. Rates of obesity, infant mortality, mental health disorders, and diabetes are all much higher than is the case for our urban population. There is nothing new here, we have known about these realities for decades as well as the strategies needed to address the  problem. At least five major enquires have reached similar conclusions over the last decade yet hardly any of the recommendations have been implemented as needed policies are stymied by political wrangling and incompetence.This is particularly true for attempts to solve the biggest problem of all; the shortage of Australian trained doctors in the “bush”. (Part two)   (more…)

  • JOHN DWYER: When will we seriously tackle the Inequity associated with the delivery of health services to rural and remote Australians? Part 1 of 2.

    Health outcomes for Australians living in rural or what are characterised as “remote” areas are far inferior to those of their city cousins. If you don’t live in metropolitan Australia your life expectancy is reduced by about four years. You are four times more likely to die of a stroke. Rates of obesity, infant mortality, mental health disorders, and diabetes are all much higher than is the case for our urban population. There is nothing new here, we have known about these realities for decades as well as the strategies needed to address the  problem. At least five major enquires have reached similar conclusions over the last decade yet hardly any of the recommendations have been implemented as needed policies are stymied by political wrangling and incompetence.This is particularly true for attempts to solve the biggest problem of all; the shortage of Australian trained doctors in the “bush”. (Part one of two contributions)   (more…)

  • JOHN DWYER. The folly of looking at private health insurance as a single issue . Part 2 of2

    So “Private Health insurance is in the DNA” of the Coalition government we hear from Minister Hunt. That may well be the case but there is no evidence to suggest that the delivery of equitable, quality health care to all Australians is so programmed. Indeed many have commented that the recent focus on private health insurance and the need for younger Australians to embrace a very poor deal is couched in rhetoric which suggests that Private Hospital care is better than Public Hospital care and, in any case, the public hospital system may not be there for you when you need it. (more…)

  • JOHN DWYER. The folly of looking at private health insurance as a single issue rather than a policy failure .Part 1 of 2

    So “private health insurance is in the DNA” of the Coalition government, we hear from Minister Hunt. That may well be the case but there is no evidence to suggest that the delivery of equitable, quality health care to all Australians is so programmed. Indeed many have commented that the recent focus on private health insurance and the need for younger Australians to embrace a very poor deal is couched in rhetoric which suggests that private hospital care is better than public hospital care and, in any case, the public hospital system may not be there for you when you need it. (more…)

  • JOHN DWYER. Punishing and jailing the mentally ill.

    A 37-year-old Sudanese woman has been sentenced to 26 years in jail for murdering three of her children by deliberately driving her car into a lake. The story is a tragic one and has nothing to do with criminal behaviour. It raises, yet again, the appalling way in which we treat those with a seriously mental illness who, while ill, break our laws.  (more…)

  • JOHN DWYER. Policy mayhem is stifling efforts to have more Australian doctors “in the bush” – part one

    In this two part article, I am reviewing the basis for the serious problem we have in providing adequate health care for Australians who live in rural, and particularly, remote areas. Good intentions are, as ever, intertwined with political machinations which make policies for solutions harder to implement. Currently, yet another government review is soon to be released. Here is the background needed for judging the results.  (more…)

  • JOHN DWYER. Policy mayhem is stifling efforts to have more Australian doctors “in the bush” – part two

    In this two part article, I am reviewing the basis for the serious problem we have in providing adequate health care for Australians who live in rural, and particularly, remote areas. Good intentions are, as ever, intertwined with political machinations which make policies for solutions harder to implement. Currently, yet another government review is soon to be released. Here is the background needed for judging the results.   (more…)

  • JOHN DWYER. The parlous state of strategies to protect consumers from health care fraud. Part 3 of 3.

    Credible scientific evidence of clinical effectiveness should underpin the delivery of health care. Satisfactory health outcomes and cost effectiveness require this approach. In Australia however pseudoscience flourishes as regulatory bodies fail to protect consumers from health care fraud.  (more…)

  • JOHN DWYER. The parlous state of strategies to protect consumers from health care fraud. Part 2 of 3.

    Credible scientific evidence of clinical effectiveness should underpin the delivery of health care. Satisfactory health outcomes and cost effectiveness require this approach. In Australia however pseudoscience flourishes as regulatory bodies fail to protect consumers from health care fraud and a massive industry prospers as it convinces consumers to use expensive supplements they do not need. In this three part examination of the issue the extent of the problem is examined, as are the changes that would better protect consumers.   (more…)

  • JOHN DWYER. The parlous state of strategies to protect consumers from health care fraud. Part 1 of 3

    Credible scientific evidence of clinical effectiveness should underpin the delivery of health care. Satisfactory health outcomes and cost effectiveness require this approach. In Australia however pseudoscience flourishes as regulatory bodies fail to protect consumers from health care fraud and a massive industry prospers as it convinces consumers to use expensive supplements they do not need. In this three part examination of the issue the extent of the problem is examined, as are the changes that would better protect consumers.   (more…)

  • JOHN DWYER. A shared vision for restructuring primary care in Australia.

     

    At last the clouds are dispersing, the sun is shining through and one can see a splendid vision of a restructured primary health system that meets the needs of contemporary Australia. For the first time that I can remember, there is a consensus among informed consumers and health professionals that enthusiastically supports the introduction of “Patient-Centred Healthcare Homes” as the primary care model we need to deliver cost effective and equitable integrated primary care. The model has been or is being implemented in eleven OECD countries and the results are most encouraging. Just published is a position paper from a “roundtable” exercise involving The Consumers Health Forum, the George Institute, the Royal Australian College of General Practice, the Menzies Centre for Health Policy, Sydney University and the Australian National University. Their support for the model echoes that of the AMA and the Royal Australasian College of Physicians. I am providing this impressive list of supporters, as consensus on healthcare reform in Australia has been held captive by vested interests for so long. (more…)

  • JOHN DWYER. Medicare and the 45th Parliament.

     

    Clearly the future of Medicare was the election issue of greatest importance for most Australians. Community concern was focussed on the possibility that the primary care they receive from their general practitioner might be privatised such that a superior service would be available to those who paid more, either directly or though the extension of private hospital insurance to allow for coverage of GP services. This was never going to happen but its important to understand what it was that had stimulated discussion of the possibility. Private health insurers, who are not permitted to cover services provided with Medicare dollars, are frustrated as community health services are not reducing the number of their insured who need hospital care. Many insurers see 60-70% of their costs generated by 5-10% of their insured who need frequent stays in hospital. As there is much evidence that primary care systems elsewhere are better than us at reducing the incidence of hospital care, they would like to provide these superior services to those they insure. To do so would cost a fraction of the expense needed for hospital care. (more…)

  • JOHN DWYER. Restructuring the governance of health care in Australia. Part 1

    Part One. Structural reforms for better health outcomes from a redesigned more cost-effective health care system.

    The most important pre-election health care initiative has received very little publicity. Labor has committed to establishing a “Healthcare Reform Commission” if elected. While not likely to generate much discussion in one’s local pub it represents an acceptance by a major political party that we do need to explore structural changes to the way we deliver health to achieve better outcomes and fiscal sustainability. What follows is an evidence based scenario for the evolution of major structural reforms, many of which are currently being pursued internationally. (more…)

  • JOHN DWYER. Restructuring the governance of health care in Australia. Part 2

    Part Two.  Structural reforms for better health outcomes from a redesigned more cost-effective health care system. 

    There is broad agreement that in the near future our General Practitioners and their teams will earn the majority of their income from capitation payments that will require, for the first time in our Primary Care system, the documentation of health outcomes. Many doctors are concerned about this direction and argue that they may have neither the time nor the necessary kills to fulfil such requirements. International experience informs us that these doubts can be reversed with the creation of Primary Health Care Organisations to assist with these and many other issues.  (more…)

  • John Dwyer. Structural reforms to healthcare – two major reforms.

    Does the government understand the structural reforms to health care needed by modern Australia?

     Political pre-election posturing at the moment has involved many debating the question that asks ’Do we have a spending or a revenue problem in Australia?” Certainly when it comes to our health system we should first be asking what structural reforms would make that question less important. 

    While the idea that States could tax their citizens to pay for hospital care vanished in a flash, there is a distressing significance to the idea ever having been floated in the first place. It means that the Coalition still does not understand the components of the structural reforms needed to improve both the health outcomes and cost effectiveness of our health system. Implemented, the proposal would have further entrenched the inefficiencies in a fractured health system.

    Equitable, cost-effective health care in modern Australia requires two major reforms.

    Informed opinion, generated by world-wide evidence, suggests that the first major reform requires us to appreciate that the funding for the total spectrum of health care, which includes hospital, community and the primary care funded by Medicare, needs to be pooled so that these services can be integrated. Funding flexibility is a crucial issue, as this would allow differential spending on various components of the system depending on regional need. For example, rural primary care is more problematic than rural hospital care. Sadly this imperative is obviously not in the conscious mind of a government that would enshrine a separation of hospital and primary care funding as demonstrated by their State tax proposal.

    The concept of regional funding is very important as different regions with very variable demographics and health priorities are readily demonstrated in our huge country. In our present system we have Local Hospital Districts and Primary Health Networks (PHNs) within a State boundary. While the latter are meant to improve the quality of Primary Care and better integrate individuals care and provider availability there geographical boundaries make this impossible. There is only one PHN for Tasmania and only one for the whole of Western Australia outside of Perth! New Zealand has 80 such organisations.

    If one agency held all the health dollars available for health care and logical health districts were established without reference to State boundaries a resource distribution based on local needs not just population density would markedly improve health outcomes and cost-effectiveness. Regional fund holding in the UK sees “Commissioning Agents” able to seek providers for that regions health needs. This was to be the approach taken by the short-lived “Health Care Commission”, established by the Whitlam government.

    Federation has failed our health system as it has prevented it being operated as one system in which three components are fully integrated (Primary, Community and Hospital care). This is our unique disadvantage within the OECD. Now, 40 years after the idea was first suggested there remains an urgent need for COAG to pool all our health dollars and establish a State/Federal “Health Commission” to disperse the funds. The COAG meeting of health ministers later this week should commit to a reform journey with this initiative as the destination.

    Currently our States are responsible for funding our public hospitals with a variable, oft insecure, contribution from Canberra. Hospital admissions continue to increase steadily and the growth in hospital spending far exceeds any increase in Medicare spending. Because of the responsibility/funding divide, States are at the mercy of the success or otherwise of Primary/Community care to reduce the number of people requiring hospital care. They have no levers to pull to control demand. Figures from the Australian Institute of Health and Welfare suggest that 600.000 admissions to public hospitals each year could be avoided by a better-resourced Primary Care system. It is clear that a future featuring affordable and excellent hospital care is dependent on reducing the demand for hospital care.

    So a second major reform is long overdue. We need a major structural reform to change our outdated hospital, doctor and sickness centric system to one that focuses on the prevention of chronic illness, the reduction of hospital admissions and “team medicine”. A multidisciplinary team working in the one practice integrating all the care needed by enrolled patients. In much of the world this proven approach to better health care is referred to as the “Medical Home” model. It provides the needed components for modern primary care. Patients enrol in a practice populated by a team of health professionals from different disciplines to Improve patient’s health literacy and maintenance of a healthy lifestyle. Continuity of care allows for early recognition of problems that if not treated could become serious and chronic. The range of services needed by patients with established chronic diseases are provided in their “one stop shop” and the practice is resourced to extend care into the home/community to minimise the need for hospital admission.

    Such a model necessarily increases practice expenses, as the multidisciplinary team the patient needs has to be funded. However, doing so will reduce hospital admissions and so for the whole system is cost effective. The program will need more commonwealth expenditure and that should also include funding for prevention strategies. Having more water bombers available for the fire season would be welcomed but their availability should not mean that hazard reduction during winter is not prioritised. We can do a better job of coordinating care for patients with advanced, incurable chronic diseases but in focussing almost entirely on this priority we are doing little to turn off the tsunami of Australians who continue down the path to chronic avoidable illness.

    The tentative step towards introducing the “Medical Home “ model into Australia announced last week is welcomed conceptually but it is focussed entirely on the management of established disease not strategies for minimising the current flood of Australians developing chronic disease and the “Healthcare Home” as envisaged is a pale reflection of the fully developed model described earlier. A detailed plan needs to be presented before any judgement can be made on the likely success of this first step. The plan, as announced, would aim to provide patients with “multiple chronic illnesses”, who stick with one GP for their care, benefit from better-integrated care. A participating GP practice would receive fixed amounts quarterly for providing the enhanced care. While moving away from a fee for service model for the care of chronic illness and appreciation of the need to integrate a range of needed services is welcomed it is not clear how the GP conducting the orchestra will be able to fund the additional players needed. For a scheme said to involve 200 GP practices and 65,000 patients the suggested cost of $21 million seems totally inadequate and anyway, what does it mean when we hear the scheme is to be cost neutral?

    As usual, the devil is in the detail. How much will the practices be paid for the integrated service? Will this payment (capitation) vary depending on the number of chronic problems suffered by a patient? What level of morbidity will set the threshold for entrance into the scheme? How will the trial’s outcomes be measured? Who will determine the additional staff requirements and the skills they need as well as the financial compensation they will be offered in the scheme? Etc.

    All these questions can be addressed and have been elsewhere, but how much better would be this initiative be if it were to establish thirty or more fully resourced Medical Homes to prove their worth in the Australian context? We need to continue to advocate for that suggestion.

    John Dwyer is Emeritus Professor of Medicine at the UNSW.

  • John Dwyer. ‘Health’ products and treatments that are often unproven and sometimes dangerous.

                      Health Care Advertising and Consumer Protection

    There are far more irritations than pearls available currently to those of us trying to champion the importance of having our health care underpinned by credible scientific evidence of clinical effectiveness. Though we live in the most scientific of all ages it is cause for concern that practices based on “pseudoscience” remain so entrenched in our community. Consumer protection from misleading often-fraudulent advertising and unscientific ineffective practices is distressingly inadequate.

    For those concerned about this situation, the pleasure from watching the Australian Open Tennis championship on TV is diminished by the plethora of advertisements telling Australians that better health is available from vitamins and “supplements” that in fact offer no benefit to the average citizen. Swisse and Blackmores make a fortune selling a promise of a healthier you if you regularly consume their products. To prove this is so they have the likes of Lleyton Hewitt and Ricky Ponting telling you how they have benefitted from such consumption. I doubt that either of these fine athletes have independently pursued evidence to make sure what they are saying is true. What about all those fraudulent advertisements for painless quick weight loss products? You cannot watch the Sky News channel for very long before you are asked if you have had your “Inner Health” today! While there are definite indications for treatment with probiotics (“good bacteria”) to suggest that everyday everyone needs these good guys is indefensible.

    The truth is that with health literacy in short supply for many of us it is easy and convenient to believe that an unhealthy life style can be neutralised by pills from a bottle. Of course there are people in the community who do need vitamins and supplements for various conditions but such use should be planned and supervised by doctors and nutritionists. There has been much quality research that confirms the lack of benefit and occasional harm associated with excessive vitamin and “supplement” intake. Although companies marketing products for which they make a therapeutic claim are meant to hold evidence that their claim is supported by credible evidence, many just label their product with an “as traditionally used” label even when scientific studies have contradicted those traditional claims. This is big business with Australian’s spending at least three billion dollars a year on products that for the majority provide no benefit.

    Our universities are not doing enough to make sure that they do not give undeserved credibility to pseudoscience. Courses in Chiropractic, Osteopathy and Traditional Chinese medicine often include concepts that could be considered to represent pre-scientific beliefs. At a recent Open Day for a major university’s Traditional Chinese Medicine program, participants had the ancient art of “cupping” demonstrated and touted as a technique for countering lung disease and all who attended left with a artefact to place on a specific spot behind the ear to prevent depression.

    Two related matters received much mainstream publicity recently. The first involved the extraordinary decision of the University of Wollongong to award a PhD to a candidate who for the last decade or so had been a very public spokesperson for the anti-vaccination movement. She enrolled in a higher degree program in the Humanities and Social Science faculty with a supervisor who, as a champion of free speech, courted controversial students who had been criticised for their publicised opinions. The “research” for the thesis would focus on the safety or otherwise of our current vaccination policies.

    The candidate concluded that vaccines did far more harm than good, were not necessary and would not be forced upon an ignorant community if an international conglomeration of companies with a vested interest in the vaccine industry had not coerced the WHO into lying to the public about vaccine safety. Many with the appropriate expertise examined the thesis and found it to be riddled with errors particularly when discussing immunology and epidemiology. The official reviewers of the thesis were social not biological scientists. There has been a major effort both inside and outside of the University to have the thesis re-examined but to date the University maintains it is comfortable with the decision to grant the PhD. Meanwhile the supervisor has labelled criticisms as an attack on free speech seemingly dismissive of the fact that a PhD thesis is not a vehicle for opinion but rather a vigorous search for and presentation of verifiable facts.

    The second issue which provoked Editorials in the Fairfax and Murdoch media concerned reports that hundreds of Chiropractors across the nation were claiming to be able to assist patients with numerous problems beyond their traditional focus on musculoskeletal problems with one’s back and neck. Particularly objectionable is the targeting of care for neonates, children and pregnant women. Involved chiropractors support the totally discredited suggestion of their 19th century founder, that there is associated with the spinal column an invisible but potent energy force (“innate energy”) the integrity of which is essential for whole of body health. Even slight distortions of the bony spinal column (“subluxation”) can interfere with this energy flow and cause problems remote from the spine. Chiropractors can make “adjustments” to the spine to correct the defects. Some of the problems that can be addressed in this way include Autism, Asthma, bed-wetting, developmental delay and colic. Parents are advised to have all neonates see a chiropractor soon after birth so that any distortions that occurred during the birthing process and that could cause long-term problems are addressed. Some chiropractors claim that their pregnancy care can prevent the need for Caesarean births, others say they can cure cancer.. This in 2016!

    How can this be I hear many of you thinking? The previous government decided that consumers would be better protected if chiropractors, osteopaths and traditional Chinese Medicine practitioners were required to seek national registration and have their professional activities monitored by a federal Board for their specialty under the auspices of the Australian Health Professional Registration Agency (AHPRA). This organisation reports to the COAG Health Council set up Australia’s Health Ministers who appoint Board members. AHPRA and the Chiropractic Board of Australia have been totally ineffective in protecting consumers from fraudulent activities described above. The Board has even been populated with members who practiced subluxation chiropractic. It has taken up to two years to investigate complaints made to the Board and AHPRA claims they do not have the legislative power to limit the scope of practice of the profession. AHPRA claims that only a few chiropractors fail to modify their advertising and practises after a warning. This is not true and this week the Friends of Science in Medicine sent images from 400 chiropractic websites targeting children to the CBA, AHPRA and Minister Jack Snelling who heads the COAG Health council. I should emphasise that the chiropractic profession is polarised with many chiropractors that stick to an evidence based form of practice distressed by the behaviour of colleagues who bring the profession into disrepute.

    The government is not helping. When our NH&MRC concluded that homeopathy and 18 other “Alternative” practices (Iridology, Reflexology, Reiki etc.) were not supported by any evidence of effectiveness one would have expected the government to stop allowing tax-payer dollars to be used to subsidise such treatments. Not so! While Homeopathy has been declared to be of no value, despite protests, students studying Homeopathy at colleges of Natural Medicine receive an annual $6000 handout from the government.

    There are many other anomalies that compromise consumer protection in this area that we could discuss and in so doing acknowledge that there are some medical doctors who engage in health care fraud, but to summarise, our approach has been and continues to be one where the emphasis is on having after the fact complaints dealt with rather than legislating and organising to prevent the incidents that generate so many complaints from happening in the first place. True consumer protection must be based on the primacy of such a strategy.

    John Dwyer is Emeritus Professor of Medicine, UNSW.

  • Why we don’t want private health insurance for primary care

    The worst possible outcome from the current review of Private Health Insurance would be changes that resulted in the best-resourced Primary Care being only available to those who have such insurance.

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  • John Dwyer. Wasting precious health dollars.

     

    In the last eighteen months our coalition government has repeatedly warned that the rate at which we are increasing health related expenditure is unsustainable. The attempt to extract a co-payment from Australians visiting their GP was justified using this concern. However it is the better use of the currently available health dollars that should be given priority rather than asking Australians pay more for a health system that no longer adequately meets contemporary need. It is true that a considerable amount of the cost ineffective expenditure on health is generated by members of my profession with low value and sometimes no value tests and procedures wasting at least 10 billion dollar a year. While there are vested interests hampering necessary reforms, progress is being made as critical pathways, generated from the best available evidence by independent and expert clinicians, are developed centrally for application locally. The Institute for Clinical Excellence in NSW is one organisation facilitating this type of reform which should improve the standardization of evidence based clinical decision making.

    Looking more broadly at the inefficient use of precious health dollars we could discuss the 600,000 or so avoidable and expensive admissions to public hospitals each year and the billions of dollars wasted as 24 million people are served by nine Departments of Health. However there are two other examples of cost ineffective expenditure that are in the news and worthy of further comment; the Private Health Insurance rebate and the subsidy tax-payers pay to the private heath industry as they pay for a raft of useless pseudo-scientific modalities. Both of these have been addressed recently and unsatisfactorily by health minister Sussan Lay.

    Interviewed on the 7.30 report Minister Lay defended the need for government to use six billion dollars of our money to reduce the cost of Private Health Insurance claiming it was needed to relieve the pressure on the demand for public hospital services. She has no doubt been told and believes that this is so. It is not.

    The Howard government introduced the taxpayer-funded rebate at a time when private health insurance rates were falling. In the ensuing twelve months private health insurance rates increased by only 2% and there was an almost negligible decrease in admission to public hospitals. After that year there was no noticeable effect even though additional strategies did significantly increase the uptake of private insurance. Making insurance more expensive as one aged and demanding a significant levy be paid by wealthier Australians who did not have private insurance, did have the desired effect on participation rates but not on helping public hospitals.

    Private and public hospitals operate in different health care universes. Both by and large offer excellent services but one has a fixed budget and an average annual increase of 3% in the demand for admission that is fiscally intolerable. The other makes more money when more patients are admitted. More than 70 % of the patients in public hospitals have serious and often chronic medical conditions while more than 70% of patients seeking private hospital care need day only procedures or surgery. As cash strapped public hospitals were forced to close beds without being able to escape the demands from sick medical patients, elective surgery became increasingly difficult to deliver in a reliable and timely matter and much surgery (and the surgeons needed for that surgery) moved to the private sector.

    Had the six billion dollars worth of subsidies been available to public hospitals many could have continued to offer more of the surgery required by patients who reluctantly paid for private insurance to get their operations in a timely manner. With the public sector increasingly unable to compete, volume wise, with the private sector surgical fees have skyrocketed contributing significantly to the 29 billion dollars of out-of-pocket expenses Australians fork out each year for their health care.

    A number of health insurers, responding, they say, to consumer demand, will pay for treatment from a range of “Alternative” practitioners. The Labor government concerned, at the growth in such payments, asked the Chief Health Officer and the NH&MRC to examine some 18 modalities to see if there was “credible scientific evidence for their clinical effectiveness”. The committee assembled looked at practices such as Iridology, Reflexology, Homeopathy, Reiki etc. and reported to the current government that there was no evidence that any of them offered clinical benefit. The government was urged to stop public subsidies for these pseudo-sciences and, in so doing send a message to the public emphasising the need to enquire about the evidence base for any care they receive. The report is “lying on the Minister’s table”. For decades I have been depressed by the influence the “Alternative” industry has on governments so I was not that surprised at the response when, at her Press Club presentation, reporter Sue Dunleavy asked her the following question.

    “Every year health insurers are paying $180 million for natural therapies for which there is no evidence,” she said.

    “You already have the review of the worth of those therapies conducted by the chief medical officer on your desk.

    Can you tell us what that report said and what you are doing about it?”

    The nonsensical and depressing response was “…the issue of complementary therapies is an issue of great interest to Australian patients and certainly to private health insurers and those concerns about the budgetary implications of which you speak.

    But I don’t propose to take any piece in isolation out of the complex mix of interests, stakeholders (for want of a better word) and, of course patients and taxpayers, when we look at the important issue of private health insurance.

    To pick up one report commissioned by a previous government (not that necessarily has to be an issue in itself) and make it something that this government has to respond to almost at the micro level, without regard to the intersecting policies issues and interests, I don’t believe is sensible public policy.”

    Many contributors to “Pearls and Irritations” have noted that for a cost effective sustainable health system providing better health care, we, as is the case in much of the developed world, must invest in Primary care that emphasises prevention, in house team management of chronic diseases and the ability to care for many in the community currently sent to hospital. Quality hospital care is totally dependent on our reducing the need for so much hospital care. The currently wasted dollars, if applied to fund needed reforms could provide us with the excellence we need without increasing the % of GDP we spend on health. Such reforms should be a major issue for the coming election.

     

     

  • John Dwyer. An increase in the GST or efficiency gains to fund our hospitals. Which would you prefer?

    Premier Baird has announced that he will require a 15% GST to fund our public hospital system in the coming years. It is certainly true that with present policies, revenue won’t match the cost of the anticipated future demand for hospital care. Hospital admissions climb steadily each year (average increase 3%) and the additional patients tend to be sicker and older. Our current health system puts pressure on our State and Territory governments to constantly find more beds and provide new hospital stock. Without financial restructuring his government will not be able to provide us with the quality service we need and expect. The better targeted suggestion from Victoria that we increase the Medicare levy won’t provide the money needed. The current levy only covers about 50% of the cost of Medicare.

    However financial restructuring can involve two, not necessarily mutually exclusive tactics. In the policy vacuum that has absorbed Australian politics like a black hole, the easy tactic is for government to ask Australians for more money. A far better approach would see us at last addressing the structural inefficiencies in our health system that would provide savings that at least for health care, would make this huge increase in a regressive tax unnecessary.

    Premier Baird’s problem is that the structural levers that need to be pulled to improve the health of the nation and its budget are in Canberra. It’s the Federal government that funds the majority of our primary (GP) and community care and it’s the inability of both, as currently structured, to reduce the demand for hospital care that so frustrates State and Territory governments. Any review of the benefits or otherwise of our federal system will reveal that it has created rather than solved many problems for cost-effective, equitable delivery of health care.

    Our taxpayer funded public health system spends more than 55 billion dollars a year on hospital care but only 19 billion dollars a year on primary care. However, wearing federal blinkers, the federal government looks at Medicare as if it was a stand-alone health system and State and Territory governments are forced to focus on hospital care. Health economics 101 and much reliable international evidence tells us that if we spend more money on a structurally reformed primary care system we would save far more than these reforms would cost by significantly reducing the demand for hospital services. This is the “win, win” path we should be taking, not an increase in the GST.

    Premier Baird and his fellow Premiers are looking at escalating fiscal problems for hospital funding over the next ten years. What we need is to take a reform journey through that decade that would see us still spending about 10% of our GDP on health but having a healthier population requiring far fewer trips to hospital. At least eight OECD countries are well advanced on that journey and many have evidence of reductions in hospital admission rates of 20-35%.

    Available evidence tells us that the most important change our health system needs would see us introduce a model of primary care known as “Integrated Primary Care”. This model places an emphasis on prevention of disease (only 2% of our current health budget is spent on prevention), early detection of changes that could develop into chronic conditions if not treated in time, in house “team management” of all the health needs of those who have an established illness and outreach services from the practice into the community to treat individuals who otherwise might need hospital care. Research reveals that more than 600,000 admissions to our public hospitals each year could have been avoided with an appropriate community intervention. Around the world the model is increasingly referred to as a “Medical Home”. One enrols in this entity wherein multidisciplinary teams of health professionals can provide the above services. International experience shows us that patients and health professionals enthusiastically embrace the model.

    As our federation is reviewed and our health care costs are wrestled with, consider the following inefficiencies that should also be addressed before considering an increase in the GST. We have nine departments of health for 23 million people. Duplication costs us 2-3 billion dollars a year. We spend over 6 billion dollars a year subsidising private health insurance using the false argument that such spending will see private hospital care reducing the demand for public hospital services. It doesn’t. The money would be much better spent on improving primary care and reducing admission to both public and private hospitals. My profession is steadily tackling the very unprofessional expenditure of up to 10 billion dollars a year on low value or no value procedures and tests. Australians spend 3 billion dollars a year buying vitamins and “supplements”, not needed by the vast majority of us, as they are led to believe you can neutralise an unhealthy lifestyle with something out of a bottle.

    Tackling these problems as we progress along our health reform journey will provide us with a health system for the future that is second to none, equitable and cost effective. Even if we could afford a massive increase in the GST it would be money poorly spent on a health system calling out for reform. Now where oh where is the political leadership to take us on this productive journey?

     

    John Dwyer is Emeritus Professor of Medicine at UNSW.

  • John Dwyer. Pseudoscience and health care.

    Current Affairs 

    The catalyst for my need to share with you frustrations associated with the penetration of pseudoscience into Australian health care and the poor protection of consumers from same, was generated by the release of the details of the long awaited Free Trade agreement between Australia and China.

    We now know that Chinese medicine was the subject of a side letter from Australia’s Trade Minister, Andrew Robb, to the Chinese government, which outlined plans to strengthen cooperation on traditional medicine, which among other things, could open the door for hundreds of contractual service providers from China to be officially registered to work here. The CEO of the Acupuncture and Chinese Medicine Association was delighted by the news, “We do know that the Chinese government has set globalisation of traditional Chinese medicine as a major priority and they’ve invested a lot of funding into this process”. Minister Robb also noted the opportunities that would be available for Australian manufacturers of supplements and “Complementary” medicines to penetrate the huge Chinese market.

    The above association has dismissed concerns raised by this policy noting that practitioners of Traditional Chinese Medicine (TCM) in Australia must be registered by the Australian Health Practitioners Regulatory Agency (AHPRA) which has established a TCM board to protect consumers from inadequate practitioners. AHPRA has, however, been distressingly unsuccessful in protecting consumer from pseudoscience. What do I mean by “pseudoscience”? Concepts that, in reality, are pre-scientific “belief” systems. They are not supported and could never be supported by any credible scientific evidence. Such concepts are an affront to our understanding of physiology and pathology. Homeopathy is a good example.

    The previous federal government made a big mistake in deciding that practitioners of Chiropractic, Osteopathy and Traditional Chinese Medicine should be nationally registered as was required of many other health professionals. Intense lobbying saw Tanya Plibersek agree that chiropractors could call themselves doctors. Hard to believe but as constituted neither AHPRA nor its subspecialty boards have any authority to limit the scope of practice of registrants. They can only respond to complaints about individuals and even that takes many months to resolve. This is a major problem as pseudoscientific beliefs and practices dominate all three of these newly registered professions.

    The chiropractic profession is polarised. About 30% of chiropractors limit their care to evidence based treatments for definite muscle and bone problems particularly those effecting the back and neck. However recent research found that 70% of chiropractitioners’ websites claim to be able to help patients with many conditions not associated with any discernible musculo-skeletal problems. They make these claims based on their acceptance of the reality of “subluxation” theory as espoused by their founder in 1895. The belief is that there is associated with the spinal cord an invisible but vital energy the integrity of which is essential to health and the functioning of body systems remote from the spinal area. Minor, indeed undetectable, distortions of the normal spinal cord anatomy, (”subluxation”) interfere with this innate energy causing disease. Subtle “adjustments” of the spinal cord anatomy by chiropractors can correct the flow and restore health. The executive of the professions peak body, the Chiropractic Association of Australia, supports this concept. There is no credible scientific evidence to support this theory.

    Particularly disturbing is the harnessing of this theory and its implications to bring chiropractic into paediatrics. Hundreds of registered chiropractors claim to be able to assist children with Autism, Asthma, bed-wetting, developmental disorders, colic, fever and over 60 other conditions. Many chiropractors combine their adjustments with a range of naturopathic treatments such as homeopathy and a nonsense called “Applied Kinesiology” wherein palpation of muscles can allow one to diagnose a range of diseases. One feels sorry for the chiropractors trying to stick to evidence based care.

    There are also major concerns regarding the practices of many registered Osteopaths. Many osteopath’s websites talk about “Osteopathy of the Cranial Field” and the wonders of “Visceral Manipulation”. The former involves feeling for pulsations in the head associated with the propulsion of cerebro-spinal fluid around the brain, the nature of which diagnoses a disease process and subsequent cranial manipulation is used to fix the problem. The latter involves pushing around the contents of one’s abdomen to set up a chain reaction of pulsations that corrects remote, disease producing distortions.

    The “Friends of Science in Medicine”, of which I am the current president, has been established to fight this penetration of pseudoscience into our health care delivery system. More than a thousand leaders in science and clinical medicine in this country support us. We have had a voluminous correspondence with the AHPRA executive team and the appropriate Boards in an attempt to have these regulatory authorities protect the public from such misleading claims and practices, which is their statutory obligation one would have thought. The task is that much more difficult as many members of the regulatory boards actually practice such pseudoscience. We have made no progress as AHPRA does not have the authority, (or the in house expertise), to issue directives re the acceptable scope of practice for its registrants.

    Which brings us to TCM, a tradition founded on pseudoscientific principles. The theoretical basis of acupuncture for example, is pre-scientific and involves imaginary structures and vitalistic forces. An undetectable, immaterial life force, “qi”, is said to flow through channels (meridians) on the body. Disease occurs when the flow of qi becomes blocked. Inserting needles at specific acupoints on those meridians somehow restores the flow of qi. No such structures and forces have ever been identified by anatomists or physiologists. The World Health Organisation has recently taken down its Acupuncture website for revision after intensive analysis of all the credible research on the subject concluded that Acupuncture was no more than a superb placebo. Interestingly the number of TCM practitioners in China has plummeted in recent decades while the number of doctors trained in the “Western” tradition has soared.

    Recently the National Health and Medical Research Council, our peak clinical science body, working with a committee set up, on government instructions, by the Chief Medical Officer, analysed the scientific data available for 18 popular “Alternative” practices (Homeopathy, Reflexology, Iridology, Applied Kinesiology Reiki etc.) The investigation found no credible scientific evidence that any of them were effective. Unfortunately the equally implausible antiscientific practices described above for Chiropractic, Osteopathy and TCM were excluded from the review because their practitioners now had national registration and therefore must be practising evidence based care!

    Apart from pseudoscience, Australian health consumers are disadvantaged by misinformation from the very profitable Complementary and Alternative Medicine (CAM) industry. The vast majority of Australians get no benefit from taking vitamin supplements, probiotics, detoxification regimens etc. The impression given by advertising is that you can neutralise an unhealthy lifestyle with something out of a bottle. We spend three billion dollars a year as a result of this misleading urging. Now we will see those marketing these supplements urge middle class Chinese to use products that most will not need. In return our government will actively support the further penetration of TCM into our health system.

    None of the above implies that we should not subject strong anecdotal and plausible evidence of a possible beneficial effect of a traditional herb or concoction to rigorous scientific evaluation. After all that is how much of our modern drug repertoire was developed. Research dollars and health care dollars are precious and in short supply so despite the cries of the alternative industry that their practices would be found to be beneficial after more research, not a further penny should be spent on the pseudosciences. In fact billions of dollars have been spent because of the widespread use of CAM justified attempts at validation.. The National Institutes of Health in the USA has spent more than 2 billion dollars on CAM in recent years and found very little that was useful.

    There are many barriers to further protecting consumers from fraudulent and misleading health care claims and practices. General health literacy is inadequate for a modern society, the Therapeutic Goods Authority is a “toothless tiger” and lacks the authority, resources and political support to adequately protect the public and our pharmacists, men and women trained in, and promising to adhere to, evidence based medicine have stores full of products that they know lure buyers with false or exaggerated claims. A number of our universities give undeserved credibility to pseudoscience. At a recent open day for the TCM course at one university, visitors were shown by faculty how “Cupping” could be used to treat disease and all who attended went on their way with a clip to put on a certain spot on their ears to prevent depression!

    Sharing my frustrations has been cathartic but there is one more I will document before stopping. After the NH&MRC report on the uselessness of Homeopathy the government announced that it would no longer allow taxpayers dollars to be used to supplement private health insurers coverage for homeopathy. FSM wrote to Christopher Pyne requesting that the more than $6000 subsidy paid to students studying to be Homeopaths in tertiary colleges should be withdrawn. After all how can you justify taxpayers supporting students training to implement treatments you accept are worthless? Minister Pyne replied that he was confident the homeopathy course met required academic standards.

    Why is it that governments of all persuasions will not give regulatory agencies the resources and authority to better protect the public and contribute to efforts to insure that our health care is cost effective? The only evidence-based conclusion is that the political power of vested interests is outweighing the imperatives provided by modern science.

    John Dwyer is Emeritus Professor of Medicine, UNSW.

     

     

     

     

  • John Dwyer. Politics trumps health policy yet again.

    Current Affairs.  Health.

    A new medical school in Perth will create more problems than it will solve.

     As must also be true for many colleagues who have been focussed on evidence based solutions to the serious shortage of Australian trained doctors working in rural communities, I am frustrated and annoyed by the Prime Minister’s capricious decision to fund a new medical school in Perth. In an attempt to solve the maldistribution of Australian trained doctors that has resulted in almost 50% of the General Practitioners available to people in rural and remote communities having been trained overseas, governments have applied a “market place” philosophy to the problem. This logic suggested that if we doubled the number of Australian trained doctors there would inevitably be competition for rural careers, as metropolitan opportunities would all be taken! In 2016 our intake of Australian students into medical schools will peak and many readers will know that (a) we are already having difficulty in finding quality clinical placements to maintain educational standards and (b) the flood of new graduates has done nothing to ease the shortage of Australian doctors working in “the bush”. This continuing problem is responsible for much unacceptable inequity with health outcomes in all categories being less satisfactory for rural Australians. Were rural patients able to access medical services as readily as their city cousins it would increase Medicare payments by two billion dollars a year!

    Here is the irony. To solve this problem we do need new medical schools but not schools situated in metropolitan areas providing a standard metropolitan centric curriculum. Here is the major cause of frustration. At least three thorough enquiries seeking evidence-based strategies to address the above inequity have been conducted in the last four years and all have agreed on the major initiatives required. These have been presented to government and as far as I know only one of the suggestions has been accepted (but not implemented).

    There is abundant national and international experience that tells us that medical students who will actually want and pursue a rural career are students who are emotionally, intellectually and even financially wedded to a preference for rural life and hence a rural career. The closest we have come to applying this knowledge involves all medical school having a quota for 25% of their students to be “rural”. The definition of what constitutes “rural” is ridiculous. You are so designated if you have spent five years of your life in a rural postcode. You could have been born in Broken Hill, moved to Melbourne when you were five and not laid eyes on a cow since then but still qualify as “rural” student. The accepted suggestion referred to above would see medical schools fined if they did not achieve their 25% quota.

    At least five universities have been lobbying government for funds for rural based medical school.  In general these would involve expansion of excellent existing rural clinical schools into rural medical schools. I have been heavily involved in developing an evidence-based initiative proposed by a Charles Sturt/ Latrobe partnership for the Murray Darling basin. As had been true for other universities both the Gillard and Abbott governments have said they were attracted to the models but there was no money available. In the background many existing medical schools, concerned that such developments might require them to reduce the number of students they admit, have argued against the establishment of rural schools. Now to have the Abbott government, without consultation with key players, announce a Perth based medical school is nothing short of disgraceful; a “keep WA happy” imperative trumps any need to improve the health of rural Australians.

    What are the key recommendations that we must continue to pursue despite the damaging political intransigence so far on display? Space will only permit a summary.

    Create opportunities for whole of medical education requirements to be fulfilled in the country, too many medical graduates dependent on city placements for vocational training will not return to a rural community. For this reason rural medical schools should be based on undergraduate programs. Admission to a rural based medical school will involve “affirmative action” philosophies to provide for example, the flexibility to overcome rural high school educational disadvantage and an interview to assess genuine “rurality”. Students will enjoy a rural specific curriculum with an emphasis on early development of procedural skills and a focus on indigenous health issues. The medical course will have strong inter-professional learning modules that will involve shared learning with other health related students. Team learning to prepare for team medicine is an imperative for the best use of a scare workforce in the country. Graduates will be guaranteed an internship in a rural based hospital. It is worth debating the merits of redistribution of existing medical school placements rather than increasing further the number of enrolled students.

    A lot of work by dedicated knowledgeable professionals from a number of universities, rural community advocates, the now defunct Health Workforce Australia and numerous rural health organisations has generated the above suggestions and all would have expected that a rural based medical school with the above features would be the “next cab of the rank”.  ‘How naïve’ says Mr. Abbott.

    John Dwyer is Emeritus Professor of Medicine at UNSW.