A new report comparing health systems in eleven countries gives Australia a pat on the back but not for equity. What’s going on? (more…)
Stephen Leeder
-
STEPHEN LEEDER. Review of the Medicare Benefits Schedule.
The Medicare Benefits Schedule, or MBS, is the basis for Medicare payments made for medical care in the community. It runs to over 900 pages and contains 5,700 items. Well over $2Ob pass through its ledger each year. It includes long and short clinical consultations and surgical procedures ($17b), pathology tests ($2.65b) and x-ray and other imaging ($3.2b) that form the bulk of out-of-hospital care, mostly but not entirely ($1b not) provided by doctors. (more…)
-
STEVE LEEDER. Health care: getting it right the first time
Ronald Reagan once famously quipped that the nine most terrifying words in the English language are ‘I’m from the government, and I’m here to help’. But that doesn’t, for one moment, stop Michael Horrocks, Professor of Postgraduate Surgery at the University of Bath and a former President of the Vascular Society of Great Britain and Ireland, relaying precisely that message to a room full of vascular surgeons and interventional radiologists. ‘We are here to help,’ he says. ‘We are not the Care Quality Commission. We are here to serve. …There will be plenty of chance to comment as we go through,’ he says as the team [of clinicians and managers] wants to provide answers to what they can see are their less-good figures. ‘We are not here to catch you out. We are here to help.’
-
STEVE LEEDER. A welcome review of the Medicare Benefits Schedule
In 2015 Sussan Ley, then the Minister for Health, established a review of the schedule of fees for medical benefits. The review of the schedule’s 5700 items, involving a rigorous evidence-based process, is now around half way through. When completed it will provide an opportunity for more cost-effective health care and a saving of public revenue. (more…)
-
STEPHEN LEEDER. Over-servicing in health.
Abuse of Medicare or other reimbursement schemes is much easier if the regulations surrounding it are lax. That is what makes the current review of Medicare so important so that the rules are clear and make the best match possible between cost and benefit. This will result in less temptation to overuse useless procedures that might make the clinician rich but do nothing – and perhaps even harm – the patient.
(more…) -
STEPHEN LEEDER. Looking forward to a national health policy and not ignoring the community.
Health policies presented as part of the election campaign should address our expectations for prompt, courteous and effective high-quality care when we need it and not be a random collection of thought balloons – from a child’s birthday? – about waiting lists and co-payments .
Health care is essential to achieving goals for more jobs and a brighter budget. Its availability to all is a fundamental of fairness. Labor or Coalition, health policy is critical to what they hope to achieve for us. Here is why we should be hearing a national health policy from the contestants. (more…)
-
STEPHEN LEEDER. Alcohol and sport.
Queensland’s victory over NSW in the June 1 game was reported as the highest rating State of Origin match ever and ‘the top TV event of 2016.’ Both teams carried alcohol advertising on their clothing into the match.
The association of alcohol with sport is deep, complex and profitable. Sport provides a lucrative vehicle for advertising and in turn many codes have come to depend heavily on the support of alcohol sponsors. The relationship is one of co-dependency. (more…)
-
Stephen Leeder. The takeover of the Medical Journal of Australia.
A quick glance at the last page of the most recent issue of the MJA reveals that there is as yet no replacement editor-in-chief and that two of the most senior medical editors – Janusic and Armstrong – are missing in action, as is the Editorial Advisory Committee. There is an interim editor. Many of the assistant editors have gone as well – replaced in the AMA president’s memorable words on ABC Radio because all they did was move words around on the page. This they had been doing, together with checking facts, assertions, arithmetic, grammar, syntax, clarity and originality of submitted papers and keeping the faith in the MJA community some for 20 years. This activity was now to be done by anonymous staff employed often overseas by the publishing giant Elsevier.
How this role for Elsevier allows them to claim copyright if all that they are doing is moving words around on the page as you will find they do in the fine print at the bottom of the back page of the MJA describing the editorial staff, I do not know. I assume that it is part of the commercial deal done by the Australasian Publishing Company, AMPCo that used to be the sole publisher of the MJA on behalf of the Australian Medical Association. If you publish in the MJA now, copyright over your paper is held in part by Elsevier.
The large publishing companies that have scooped up and repackaged knowledge and science are like giant fishing trawlers. I leave it to you to contemplate the similarities.
When I took on the job as editor-in-chief a little over two years ago I did so understanding the risks because AMPCo has a grim reputation as an employer and because the AMA and I are not natural bedfellows, but those risks did not extend to working with or for Elsevier. I do not propose to rehearse today the many reasons why I consider Elsevier to be an untrustworthy company – you can read about the rebellion of the Dutch and French governments over their pricing policy in selling subscriptions to their journals on the Web site friendsofmja.net and a Google and Wikipedia search will lead you down into the dangerous and murky canyons of their dealings with research workers, pharmaceutical companies, universities and libraries. They are not the kind of organisation that you would consider taking home to meet mother, assuming that you get on well with your mother.
Few academics know the details of what the big publishers have been up to for the past 20 years and anyway many scholars have vested interests in not rocking the boat because they need to publish to progress. I am 73 and at a point in my career where these things no longer matter. But this aside, what does matter is what happens to a journal, 101 years old that has belonged to the premier medical association in Australia. Despite lots of ups and downs and complex dealings with advertisers and its owner it has been a good custodian of professional values, committed as promised in its first issue, to the publication of research and policy. What happens when it becomes part of the Elsevier stable?
A quotation to outsource production of the MJA was obtained from three companies of which Elsevier was one and presented to the AMPCo board in November last year after I had left the meeting and without my knowledge. The bid had been prepared with no consultation with me or the editorial staff but with the AMPCo management staff. I disagreed with the generous estimates the bid contained of how much could be saved and my colleagues and I offered detailed alternatives. These were not accepted.
On April 28, without discussion of alternatives, I was summonsed to meet the chairman of the AMPCo board at midday who issued me with a letter of termination. I was then accompanied to my office by the HR manager to identify my goods that were to be packed and sent to me. The shocked editorial staff who had gathered outside my office and I repaired at 1 pm to a local coffee shop for an hour. This event was described by the AMA president at the AMA Conference in Brisbane recently as the staff taking the afternoon off to go to the pub with me and that AMPCo paid. AMPCO indeed DID pay (I had offered), all of $100 but for coffee. The receipt is on file. A PR company was hired, I assume at a generous rate, to handle this debacle, all remaining staff being prevented from public comment. AMPCo’s second sacking of an editor-in-chief in the past four years – there have been several before us as well – proceeded with surgical precision and the guillotine blade did not squeak through disuse as it fell. I was not warned about dismissal or given a chance to resign. All these details and more can be read in full detail on our Web site friendsofmja.net You will be relieved to know it is open access.
Like my predecessor, whatever our faults, I was passionately committed to the future of the Journal and all the editorial staff – not just the medical editors. These people were my professional colleagues who participated in planning substantial changes to the journal following reader consultation. We were doing well. But the bottom line is what matters. What lessons can be drawn from this?
First, corporate values rule in publishing at present. Others will speak about this. The effects of the commodification of knowledge – where a publisher asks to be paid to publish your paper, keeps the copyright, limits access to the paper and charges libraries a king’s ransom for bundled subscriptions, is scandalous. Universities pressed on all sides to conform to bureaucratic and mangerialist principles to maintain their funding base, judge the performance of their academics by publication citations and indices of unproven validity about research productivity, provided by the publishers.
Second, academics have let this happen under their noses and I do not believe that the indifference to what has been happening in libraries and journals has been ethical or impressive. Colin Steele, a research fellow at ANU who has taken a detailed and long-standing interest in this process, has written:
There are two competing, and at the moment, irreconcilable forces operating in scholarly communication. On the one hand [there is] the recognised need for scholarly exchange and, on the other, the increasingly embedded publishing system, and the rewards enshrined in the dominant Thomson and Elsevier article metrics used for research assessment and University league tables.
Specialty journals have profited from aligning with big publishers every bit similar to the snouts-in-the-trough behaviour involved in accepting sponsorship for conferences and travel from the pharmaceutical industry. We academics and universities are far from blameless.
Third, information technology is transforming the collection, collation and dissemination of knowledge. This offers hope. Knowledge has been commodified in recent decades but this will not last. The big publishers had best make their bucks during the remaining fat years because the lean years are coming when now forms of information dissemination out will displace them. Neoliberal managerialism and commercialisation will pass as surely as older faded ideologies have done. Think of open access and new forms of electronic information management as being like a vaccine against polio. When we have it we will not need the iron lung corporations with metal pumps to help us breathe.
Stephen Leeder is the immediate past Editor-in-Chief of the MJA. He is Emeritus Professor of Medicine at Sydney University. Professor Leeder presented the above speech at a recent symposium ‘Reclaiming the Knowledge Commons: The Ethics of Academic Publishing and the Futures of Research”. The speech was published in the Weekly Report Issue 15 of the ‘Friends of the MJA‘.
-
Stephen Leeder. Telling the story of mental health.
It is unusual for Foreign Affairs, a magazine published by the United States Council on Foreign Relations in New York, to contain articles on health, but the first issue of 2015 carries an essay (Darkness invisible: the hidden global costs of mental illness) by three distinguished scientists from the National Institute of Mental Health about the hidden costs of mental health.1 Based on evidence from a 2010 Harvard University study on the current and future burden of disease,2 they state that “the direct economic effects of mental illness (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy around $2.5 trillion a year”, an amount projected to rise by 2030 “to around $6 trillion, in constant dollars — more than heart disease and more than cancer, diabetes, and respiratory diseases combined”.1
The World Health Organization estimated in 2012 that about a quarter of all time lost to disability is due to mental illness, putting it at the top of the league chart.3 Unlike many other chronic illnesses, mental illness frequently strikes the young. Further, of the 800 000 people who commit suicide each year, 75% are in low-income and middle-income countries.4
Extraordinary failure
Yet, the authors of “Darkness invisible” say, the 2010 Harvard report had no impact. In wealthy countries, mental illness is still perceived as an individual or family problem rather than “as a policy challenge with significant economic and political implications”. In many low-income and middle-income countries mental care for the mentally ill is seen as an unaffordable luxury.1 The authors also point to breakthroughs in therapy, especially new medications and the capacity to communicate using mobile phones, that are now more affordable, yet are frequently overlooked.1
So what are we doing? Globally we are spending around $2 a year per individual on mental health, averaging about 25 cents per person in low-income countries. In Australia in 2004–2005 the average national per capita expenditure on mental health services was $117.5 As we have seen in Australia, the advantages of dismantling mental hospitals that “once oversaw care for the mentally ill”,1 especially those with long-standing severe illness, are accompanied by failures to provide community care for these people. The criminal justice system comes into play by default, in both the acute and long-term management of people with mental illness. In the United States, “30 percent of the country’s chronically homeless and more than 20 percent of the people incarcerated … suffer from a mental disorder”.1 The scene is dismal in Australia as well.
Darkness invisible explores new technologies including using the Internet and mobile devices to provide psychotherapeutic interventions supported by inexpensive generic medications that could be administered by health workers in the vast tracts of the earth where there are very few medical practitioners and no psychiatrists. The authors may well have wondered about the lethargy among the medical profession worldwide in creating opportunities for the training and deployment of more psychiatrists. We don’t look good as we pass this mirror. There is no substance to our defence when wealthy communities are well supplied with psychiatrists and psychologists.
A call for better advocacy
Darkness invisible concludes with a call for mental health advocates to multiply their efforts and “do a better job of explaining to officials and the public the true costs of mental illness”, and “win more allies within the medical profession by drawing attention to the fact that improved mental health leads to better overall health”.1
This call will resonate with those who perceive the lamentable consequences of unexplained political propositions and proposals: bankrupt policy replaced by sound bites and slogans. There’s a powerful story to be told about mental health, with chapters on the consequences of inadequate care on individual wellbeing and the national economy.
As a senior business executive put it to me recently, “To succeed, first you must have a convincing story, then good leadership, then the metrics”. More light, more storytelling please.
Stephen Leeder is Editor in Chief of the Medical Journal of Australia. This article appears in the current issue of the journal.
-
Stephen Leeder. Electronic medical records for patients!
Australia embarked on an ambitious journey when it committed to developing a medical record that would go with each patient to whatever health care provider they consulted. “The eHealth record system — launched in June 2012 — is an electronic record for a patient that contains a summary of their health information.” http://www.nehta.gov.au/our-work/pcehr
This personally-controlled version, known as PCEHR, was rather akin to establishing a colony on Mars – maybe best to get to the moon first. The enterprise was reviewed in depth last year after faltering.
The new federal government maintains a modest investment in the project. According to ITNews : http://www.itnews.com.au/News/385351,budget-2014-what-is-funded-and-what-is-cut.aspx#ixzz33B822dHE “$140.6 million in 2014-15 has been allocated in the federal budget for the continued operation of the PCEHR system [now to be known as MyHR], while the Government finalises its response to the review of the system.”
As Sally Glass, a leading health and IT expert describes in eHealthSpace, a Website devoted to health-related IT, http://ehealthspace.org/news/pcehr-review-recommends-opt-out the review contains 38 recommendations. These proposals illustrate the complexity of the personal electronic record initiative. There is no low-hanging fruit. The previous governing agency for the personal record is to be replaced by the Australian Commission for Electronic Health (ACeH) that would answer directly to the Standing Council on Health (SCoH).
In describing Minister Dutton’s comments about IT and health at a recent conference, Glass writes that “The Minister referred to … strengthened governance of eHealth including “crystal clear” accountabilities; [an] opt-out model (which the Minister personally supports); improving clinical usability of the record to increase clinician acceptance and adoption; and how the [MyHR] is structured to hold personal, sensitive information.”
That is all good but the impeding complexities remain daunting. Consider, for example, the need for MyHR to use a nationally-uniform set of names for medications. That may sound easy, but given the vast array of prescription and non-prescription drugs, it isn’t. And then there is the question of incentives to use MyHealth. How much will doctors be paid to use it and what happens if they don’t?
No-one should ever have imagined that introducing a personally-controlled electronic medical record would be simple. So many jurisdictions have an interest in being part of the action. So many different health service providers – hospital doctors, allied health professionals, community based practitioners to name several – would reasonably expect to have access to such a record and to be able to add to it details of their care. The IT environment of each provider at present is different and MyHealth must interface with each. The ‘personally-controlled’ aspect means that concerns about privacy and confidentiality – what a person may wish to have in his or her record and what differential access the or she may wish to extend to different providers – are all legitimate and must be built into the functionality of the record.
The personally-controlled record could even be a health hazard. Trisha Greenhalgh, a professor of primary health care interested in the sociology of health system changes and who works at Barts and the London School of Medicine and Dentistry, comments:
“Failed” electronic personal record programs are common and even “successful” initiatives are typically plagued by delays, escalation of costs, scope creep, and technical glitches, including catastrophic system crashes. [By] distracting staff into data entry and standardized protocols, computerized records jeopardize the human side of medicine and nursing and distributed record systems bring unanticipated hazards, including (but not limited to) the insidious growth of the surveillance society.”
There are simpler models of electronic records that we might turn to first, the equivalent of putting a man on the moon rather than a family on Mars. The personally-controlled version contrasts with much simpler electronic records that are held by, say, a hospital or a general practitioner, for patients who consult them. In both places there will be an institutional IT system into which the record is automatically integrated. The patient does not control or own that record and does not determine which health professional ads what or sees what is in it. The safety of confidentiality, long practised for paper-based institutional paper records, can be readily extended to electronic records.
The logic of starting not with the entire population but inside systems of health of a much smaller size, where managerial control is feasible and electronic records are part of an institutional IT system, such as in the Kaiser Permanente managed care system in California, suggests an alternate pathway. These have not proved easy or cheap to establish, but now, in the case of Kaiser, all six million enrolled members have a record that enables coordinated care, from general practice through the hospital and back into the community, includes drugs and tests and enables prevention. Enhanced communications using secure messaging allow community members rapid and effective access to carers. The medical centres are paperless. We are about 20 years behind such achievements.
In pursuing the highly desirable goal of everyone having an electronic medical record we may need to proceed bit by bit (or byte by byte). If investment in IT systems for hospitals progressed effectively, that would be an excellent beginning. Much is happening there, as in general practice, and efforts to bring these different systems together may well be rewarded with the achievement of personal medical records almost as a spin-off. That may be the best investment proposition.
Stephen Leeder is a professor of public health and community medicine at the University of Sydney.
-
Facing the future. Guest blogger: Prof. Stephen Leeder
Facing the future in a world where black swan events change everything.
When considering what we may be facing with a new federal government in Australia, a wise starting point would be a conversation with Nassim Nicholas Taleb, he of the Black Swan theory.
Taleb has written extensively, using the discovery of black swans in a world that did not believe they existed as his metaphor, about the impact of unpredictable game-changing events. Such events (9/11, the tsunami that led to the Fukushima catastrophe, the internet) change the course of history but we do not see them coming.
According to Wikipedia, Black Swan events have the following characteristics:
- The event is a surprise (to the observer).
- The event has a major effect.
- After the first recorded instance of the event, it is rationalized by hindsight, as if it could have been expected; that is, the relevant data were available but [not processed in a way that enabled us to prevent it].
So perhaps the best that we can do in thinking about what we are facing is to acknowledge that the big things that will shape our history over the next 3-6 years are not predictable. An epidemic, an earthquake, a nuclear war, a tipping point in climate change that kills all the fish, a crazy person on a rampage with a gun, the discovery of a cure for cancer or dementia – no-one can say.
In the meantime of course there is a high measure of predictability about our daily lives. Tony Abbott will continue to conduct his business with intelligence, discipline, an ascetic athleticism, a trenchant debater’s criticism of opponents and a demand for loyalty in his ranks. He may well manifest a religious concern for the plight of the poor. Think three years in a seminary and then think three years as prime minister. The differences are unlikely to be profound. None of us really change much over time.
Tony Abbott is on record as having little sympathy for those with mental illness, questioning whether what is commonly called mental illness is not a cute name for weakness of character. He may have moved beyond this caricature: we shall see.
Stopping the boats and abolishing the carbon tax are core promises. The first will only be achieved by a more sophisticated and nuanced approach than having the Australian navy intervene. Settling the xenophobic paranoia whipped up over this matter will take time. Carbon has a bad history in Australia. Maybe a Black Swan event is necessary for our nation to address climate change seriously.
In relation to health care, little has been said to indicate what the new national policies will be. The challenges – older people, more chronic disease, more technology, more need for national prevention programs, and more resources for general practice – are mainly managerial and only secondarily political, though of course the capacity for faulty politics to stuff things up in health care is substantial.
The previous government embarked upon a program of change to the health care system as described recently in a blog by John Dwyer. As he argued, however, much remains to be done to better align the provision of care with the health needs of Australians. This is especially so in relation to the care of those who have serious and continuing illness who require care from hospitals, general practitioners, community health staff, specialists in the community and home care. The joining up of these care modalities is best done from a community base and while progress has been made, we lag far behind international best practice.
The preventive agenda, never enthusiastically endorsed by the conservative side of politics, has much work to do with the disastrous epidemic of obesity, diabetes and cardiovascular disease. To address this effectively will require the engagement of the food industry, curbs on our alcohol consumption, revised plans for urban design and much more. A retreat into assigning responsibility entirely to the individual for lifestyle behaviour and food and beverage choices is unacceptable and silly. We have done well with a long struggle over tobacco, especially during the past six years, and much more needs to be done across portfolios to address the huge health problems associated with over- and inappropriate consumption of processed foods. Tony, are you listening please?
We can only wait and see what Mr. Abbott et al. have in mind. Black Swan events can change everything in a trice.
In summary, the predictable aspects of the future can be discerned in the character of the principal players and the political context in which they are operating. But it is the big, unpredictable events that will shape our history. Let’s hope they are good ones that create new opportunities!