The recent report of the Inquiry into Chronic Disease Prevention and Management in Primary Health Care by the House of Representatives Standing Committee on Health has been somewhat overshadowed by the current election campaign.
One of the terms of reference of the Inquiry required the Committee to consider the role of private health insurers in chronic disease prevention and management. (more…)
It’s half way through the election campaign and both major parties have made some significant health policy announcements with Labor outspending the Coalition on health by over $2 billion (over four years).
However, despite the fact that health consistently rates as the number one issue for voters, neither major party has satisfactorily addressed the key issues essential to ensuring that our health system is fair, efficient and equipped to meet future challenges. (more…)
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…)
It is timely as the federal election approaches to consider whether all Australians are getting the healthcare they need. Approximately 30 per cent of Australians live in rural and remote areas.
Arguably they do not get a ‘fair go’ in relation to their healthcare compared to the rest of us.
Rural and remote Australians are disadvantaged by social circumstances that influence their health status and ripen them for avoidable chronic disease when compared to counterparts in Australia’s major cities. (more…)
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…)
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…)
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 Thompson reminds us of the total lack of transparency in fees charged by doctors in Australia. Surgeon’s report shows the ineffectiveness of private health insurers to control health costs Posted on 07/05/2016 by John Menadue
So can we dissect this further. What is in a medical fee – well may you ask. When you go to your doctor you may see a fees schedule on the reception desk – or you may have received a letter from the receptionist / practice manager indicating that you will be responsible for certain fees over and above what you will get back from Medicare and ( possibily ) your Private Health Scheme . It is not unusual to be asked to pay something in advance before an appointment ( usually for a procedure – endoscopy ) is even made . Even lawyers don’t make you do that- do they . So there are at least three fees- what the Government pays the doctor – the Medicare fee , then there is the AMA rate – why this is different does not seem to be based on any scientific evidence , and then there is what the doctor actually charges you . Again not based on anything but what the doctor feels the market will support – and it usually does because effectively you have no choice .Do you ask for a second opinion ? do you have a discussion about the fee and why it is so much higher than the Medicare rebate or the AMA fee- when this person is going to put a new hip into you next week or open up your belly – I don’t think so . (more…)
2016 marks seven years for the Foundation for Alcohol Research and Education’s (FARE) Annual Alcohol Poll (conducted by Galaxy Research), and we continue to see Australia’s concern about the negative impacts alcohol has on the community. (more…)
The National Foundation for Australian Women has prepared an analysis of the Budget 2016-17 with what it calls a ‘gender lens’. An executive summary of this analysis follows. A link to the full document can be found on ‘the budget’ button: www.nfaw.org.
Budget 2016-17 fails to bring Australian women into the centre of the economy and pushes many further into poverty. Cuts to overseas aid hurt vulnerable women in our region.
The budget is far from fair, with just a touch of the white picket fence. It provides tax breaks for the wealthy, while low to middle income families are hit by ‘zombie’ savings from the Abbott-Hockey horror budgets. It is lacking in investments in education and training reforms which might drive innovation and jobs. (more…)
Thanks to Medicare introduced over 40 years ago, despite bitter conservative opposition, we have one of the best health systems in the world. It is sustainable but we waste over $20 b per annum. There are threats and problems that we must face.
What are they? (more…)
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:
Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales.
Private health insurer Medibank has worked with the Royal Australasian College of Surgeons to produce a report that shows enormous variation in fees charged by surgeons for similar procedures.
The Surgical Variance Report for General Surgery reviewed thousands of procedures performed on Medibank members in eight common operations – gallbladder removal, gastric band procedures, bowel resection procedures, hernia procedures, gastroscopy and colonoscopy.
The data shows that some surgeons working in private hospitals are charging 15 times the amount charged by their peers for the same procedure. For example, surgeons performing gastric sleeve operations for weight loss charged average private fees (in addition to what the insurer and Medicare covered) ranging from $231 in South Australia to $3593 in Queensland. The average fee in NSW was $3160 and in Victoria it was $1874. For gall bladder removals, fees charged ranged from $369 in Tasmania to $1166 in NSW. In Victoria, the average fee was $387.
It is important to emphasise that fees in the Medibank/College report are those charged privately to patients after Medicare and Medibank have made their contribution to the cost of the patient’s treatment.
The report also provided information on complication rates for these operations. These rates also varied very substantially. For example, complication rates for bowel resection procedures varied from 0 per 1,000 procedures for some surgeons, to 571 per 1,000 for others.
President of the College, Professor David Watters said, “These reports will provide surgeons with information that may help them gain a better understanding of, and learn from, variations, for the benefit of the service they provide to their patients and the community,” he said.
There are two important conclusions that arise from this work. First, it emphasises the lack of financial control on health costs when there is a reliance on private health insurance. In Australia, there are 33 private health insurers registered under the Private Health Insurance (Prudential Supervision) Act 2015. While Medibank’s initiative is to be welcomed, it illustrates the problem of a crowded and fragmented market where the numerous competing insurers are unable to act collectively to influence the suppliers of health services. A single insurer provides the opportunity to develop the necessary financial control on ever increasing costs of health services. As a national insurer, Medicare, is also a far more efficient and equitable operation than the 33 disparate insurers competing with each other, all with their substantial administrative and marketing costs. As Ian McAuley (University of Canberra) wrote in 2014, “Norway and Sweden remind us of a vision we have lost: the economic benefit of a strong, single national health insurer.
The second conclusion from the report is derived from Professor Waters’ comment above. This report, Professor Waters states, is aimed at providing information to the supplier of the service, not the purchaser. For more effective financial control of these important services, the client should have the information on costs and performance of surgeons so that he/she can make a rational consumer’s decision on price and quality. As Medibank’s Chief Medical Officer Dr Linda Swan said at the release of the report: “Information sharing is key to improving the delivery of healthcare, and ultimately to improving patient outcomes.” Agreed, but it is important that the patient also shares the information. A single insurer could also perform this function more efficiently.
John Thompson is an economist with experience in primary health.
Here is my proposal for a Dictionary definition of Synergy:
the interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects.
“the synergy between artist and record company” or disability support workers and people with disabilities with high support needs.
In some of my writings I have referred to what I call the “synergistic” outcomes that result from the interaction of people with disabilities and their support workers. These effective working relationships should be given the respect that is their due since they make an indispensable contribution to ongoing efforts to devise effective models of leadership in such workplaces.
But then I ask: Why are these highly successful working relationships so often below the radar when it comes to forming social welfare policies for the disabled? Could it be that these highly efficient working relationships are simply out of sight and out of mind? Is that why they seem to be ignored when it comes to the discussion of how to make improvements in the disability workforce? Maybe we need to look again at the manuals that are written for workers and develop a distinctively new theory of management. And why not? The synergistic approach I advocate might best be seen as an “inside out” approach to the management and organisation of the disability workforce. It will demonstrate public confidence in the abilities of the people who are served to exercise control over their own lives. Let me try and explain this “synergistic” model of work-place leadership in more detail. In order to make sure that this kind of model is flexible enough to allow change, even if complete change does not take place, the aim is to avoid an approach which sees the disabled person as a problem and instead reckon with such a person as a “problem-solver”, just like anyone else, and just like the support worker as well. In this a “synergistic” model develops a distinctive understanding of societal inclusion.
In this context, an emphasis upon synergy for the disability workforce aims to provide a corrective to the guidance that is often put to people with these “different abilities” and their support workers. To have an “inside out” approach is about reckoning with life chances and the creation of opportunities. Therefore, by initiating such an approach we confront the support worker who sometimes sees him/herself as a person languishing at the lowest, grass roots level who then needs the disability sector for employment. We need to turn this around. In my view a synergistic approach to the disability sector is not just about better help for the disabled person – it is about raising the status of all involved, and ascribing due respect.
It may be highly contentious to say outright that disabled people are second-rate citizens but if so much of our social value is measured by income then maybe “2nd rate citizen” is exactly what the income disparity tells us.
In the disability field, does love conquer all?
The best form of care is, of course, supplied by family members or close friends. These are those whose support is supplied by love. They are living testimony that love conquers all. Love is mighty and powerful and particularly when administered with compassion, empathy and patience.
Wherever we may be located by the flow-charts of such organisations, we are all human with our own individual pursuits of happiness. When it comes to high support needs for people with disabilities, love is something that is beyond the control of the “medical model’s” contribution to meeting the needs of disability. But hopefully it will be there as the indispensable motor of any positive medical contribution. A person with a disability at times will require more than just physical support in medical, dietary and psychological terms. That is, we need to promote communities of people who consciously function in ways that humanise the clinical methodology of the medical model, and this can be done by giving greater attention to what I would thereby call “the social model”. Society is a network of coinciding and interdependent responsibilities. An emphasis upon a “social model” of disability support will find it is necessary to emphasize this again and again.
Let me give an example that has stuck in my mind. Some time ago, around 1987, a friend of mine with Friedreich’s Ataxia (the same disease I have) was to be married to the guy of her dreams (an able-bodied individual). But as she signed the register, she became so excited that she suffered a heart attack and died. In hindsight, the wedding was a beautiful moment, and the embodiment of the social model. But now I am wondering: what should have been done to prevent the heart attack? Perhaps those enthused by the prospects of her wedding had under-estimated the impact of their own advice upon those with “medical model” responsibilities. In other words, we need to find the wisdom to enhance the interaction, the synergy, between the medical and social models of disability. That synergy is important. It is so important.
I have come, much to my own surprise, to another related conundrum: how can the medical model be modified to avoid a standardised approach to disability care that simply confirms mythic stereotypes about seriously disabled people. I struggle daily with the way the facility where I live in shared support accommodation is managed. I am therefore wondering whether at a deep, cultural level its modus operandi presupposes the medical model. I’m wondering: is the organisation somehow stuck in a rut assuming that we residents are actually “sick”, that our lives are basically structured by illness?
I’m not saying that the residents are free of physiological problems that require special care. I am not even thinking here primarily about physiology; I am thinking about the way in which our “roles” are understood by the prevailing management. Are we, in effect, occupying the role bundle of the person who is sick, who is subject to medical care?
It is perhaps somewhat dangerous (it might seem that I am tooting my own trumpet) but consider my own case. Before coming to live in this place, I lived for 21 years(1990-2011), on my own and during those 21 years I completed a double degree in Arts and Accounting at Monash University, a Master of Arts at Monash University and finally a PhD at the University of Melbourne. This is not to say those years were easy; of course I had added pressure upon me in my studying because of the physiological complexities that had to be addressed by medical means since the onset of Friedreich’s Ataxia at 14(1976). University started when I lived on my own at 28, and graduating with my PhD at 43(1991-2006)). Over the 21 years of living on my own I had two long stays in hospital, but all in all my educational conquests far outweigh any medical complications. This all has me thinking: I’m living as part of a situation in which I have been confronted by nothing less than the reality of what I have referred to above as “the social model”. This is a situation that will be endorsed by most people who have physical disabilities without any intellectual impairment.
To conclude this reflection about synergy – love and the management of the disability sector, leads me to encourage us all, particularly public policy researchers, senior management in “not for profit” organisations and elsewhere, to think carefully about the “who?” question when dealing with the severely disabled people they are committed to serving. This certainly means that an ethos of equity is needed along with the legislated provision of further assistance. It will require political courage to ensure that an ethical culture is developed in which people with disabilities who have high support needs are cared for individually and effectively.
I prefer the term “resident” to the current lingo that wants to view me as a “customer”, which can be used in stereotypical ways to standardise care and thus give rise to stereotyped opinions in public discourse.
My desire to rise above the privations of this shared support accommodation fuels my motivation for this and also many of my previous articles. Thanks for reading.
A special thank you to Bruce Wearne for his editing and helping to tweak this piece and Christina Irugalbandara for her excellence and academic support work.
Dr Peter Gibilisco is an Honorary Fellow, University of Melbourne. He has published a book ‘The Politics of Disability’.
“A spoonful of sugar helps the medicine go down”, according to Mary Poppins. Many more spoonfuls of sugar currently pervade our lifestyles and unconscious food choices. The recent media focus on sugar has been remarkable, but the media frenzy has sought a single solution, a quick fix, to what is in reality a complex problem: childhood and adult obesity. Rapid increases in obesity rates have occurred since the late 1980s in Australia and in many other countries, and even if starting to plateau, still leaves 63% of adult Australians overweight or obese.
Sugar is pervasive, not only (as we might expect) in fizzy drinks and sport drinks, but also added to a surprisingly wide range of foods. These include tomato or chilli sauces, muesli bars, as well as many “low fat” marketed foods (some yoghurts for example) which are high in added sugar. But is sugar the culprit? or is it just a marker of a trend towards increased processed food, increased consumption of convenience foods, and acculturation of our taste towards increased salt, increased sugar and increased fat ? All of these contribute to the “wicked problem” of weight gain, exacerbated by decreased physical activity at work and play, and through increased car use to get to or from places.
But how does all this relate to sugar? A recent commentary in the Sydney Morning Herald (Peter Martin, April 2) called for soft drink taxes to be introduced [i]. The idea is that we all have to eat something, but some foods contain almost exclusively sugar, and soft drinks and so-called sport drinks contain almost nothing else (what nutritionists call “empty calories” as they lack any of the nutrients, vitamins or fibre that other high sugar foods, such as fruit may offer). High levels of consumption of empty calories from sugar sweetened beverages is a clear and independent contributor to weight gain in many epidemiological studies[ii].
Many arguments are raised against efforts to curb sugar consumption. Firstly beverage manufacturers assure us it is part of a healthy and “balanced” diet. It seems un-balanced if it’s just adding to our total energy intake, and yet corporate marketing portray empty calories as contributors to a glowing lifestyle image and as a metaphor of well-being. One must be cautious of the motivations of the food industry according to Dr Margaret Chan, Director-General of the World Health Organisation. At the 8th Global Cnference of Health Promotion in Helsinki (2013)[iii] she said “it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics (of) lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt”. They also contribute to the polarised argument between individual choice to consume unhealthy foods, compared to structural, societal and cultural factors that contribute to us doing so. If we accept that we are mired in advertising and cultural depictions promoting unhealthy foods, in sponsorships of major sporting events and of the Olympics, then our cultural milieu is defined by these products. Governments that choose to address the problem this way are accused of “nanny state interventionism”, but it does require complex counter marketing against unhealthy products, facilitating access to affordable healthy choices, and mandating external industry regulation (as the food industry does not self-regulate well, as demonstrated when self-regulation was tried in restricting advertising of unhealthy foods to young children).
One strategy, suggested by Peter Martin is the introduction of a sugar tax. This will be a differential tax, with the greatest impost on food items with the most sugar, and lesser taxation imposed on foods with less added sugar. This approach has been implemented in Mexico where a 10% tax has resulted in a 12% decline in the consumption of sugar[iv] sweetened beverages. Such taxes have community support and are evidence based[v]. Free-market advocates claim this is unfairly “taxing the poor”, but from a public health perspective targeting those at social disadvantage and targeting children and adolescents are exactly the groups who consume the most sugar sweetened beverages. An even stronger rationale for a sugar tax is that it will generate revenue, just as tobacco taxation has done for several decades. This can fund the substantial government investment required for comprehensive obesity prevention, extending well beyond simply reducing sugar. This could be used to support comprehensive obesity prevention efforts, and are supported by the majority in the community. This is our only chance to build the infrastructure for a healthier community and a healthier food environment in Australia. Thus preventing obesity just won’t happen with any single strategy, and a sugar tax is but one financial mechanism for funding the complex solutions required.
Finally the problem is not only sugar. The Hippocratic maxim of exercise and diet in moderation still holds, and while the media in faddist fashions present us with new single solutions and quick fixes, a prudent approach would be to eat less overall, eat less fat and less sugar, consume mainly fresh produce and mostly plant-based foods. Diets like the Mediterranean diet show such balance, and combined with more active daily lifestyles (and non-smoking) are the only way to make real improvements to population health.
Adrian Bauman, School of Public Health and Charles Perkins Centre, Sydney University
William Bellew is Adjunct Professor, School of Public Health, Sydney University.
[i] http://www.smh.com.au/comment/obesity-its-time-to-tax-soft-drinks-20160330-gnum4b.html
[ii] Malik VS et al. American Journal of Clinical Nutrition. 2013;1;98(4):1084-102
[iii] http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/
[iv] Colchero MA et al British Medical Journal 2016 Jan 6;352:h6704.
[v] Escobar MA et al. BMC Public Health. 2013 Nov 13;13(1):1.
Getting Australian Health Services right depends on delivering both Aged Care & Health Care effectively for frail ‘high risk’ older-old people. Reducing inappropriate hospital admissions, shortening length of stay, returning frail people to their homes rather than Residential Care, all depend on accessible, locally based, Community Aged Care assessment support and management systems. For around 30 years a simple, geographically based, Australian system – State Geriatric Medicine Teams with Commonwealth Aged Care Assessment Teams (ACATs) – provided local access for many frail older people and up-to-date information on the complexities of local Aged Care services. This system is being dismantled – but what is replacing it?
The History:
In 1982 the Commonwealth put out the persuasive McLeay Report “In a Home or At Home”. From the mid-1980s Commonwealth Health, together with State based Geriatric Services, set up local district Aged Care Teams (combining state funded Geriatric Services with Commonwealth funded ACATs) working with Community Services (HACC), Residential Care and GPs on common local boundaries. In NSW 22 District Geriatric Teams were developed for metropolitan populations of ~250,000 (18 in Sydney, 2 in Illawarra, 2 in Newcastle); 9 Regional Teams served variable rural populations. This process was duplicated across all States with ~170 local ACATs covering Australia (~66% being funded to provide ‘extended’ care)*. ACATs & Geriatric Teams were famed world-wide as an inclusive, equitable, innovative approach to Aged Care & Health Care for frail older-old people. It was far from perfect; had variable penetration; was variably effective for local reasons (e.g., Queensland Health was then un-regionalised) – but generally worked at a local level.
In April 2012 a new 10 year Commonwealth aged care reform program “Living Longer Living Better” was released, with its emphasis on “consumer-directed care”. Stated aims included: more support at home; better access to residential care; increased recognition of carers; more support for people with dementia; better access to information; utilising the market; encouraging businesses to invest and grow*. The changes commenced in 2013-2014 with: new Home Care Packages; My Aged Care – a centralised entry point contactable only by phone or internet; then a tender process for new Regional Assessment Services. The final implementation phase of a new system was set for 2017 to 2022.
The Issues:
In terms of access equity & coordination, the pre-existing Aged Care system has been fragmented & not effectively remodelled for the future. Components are put to three year tender for multiple operators to pursue on fragmented and changing geographic bases. Replacing the 1980s models would not be a problem if alternate solutions were effective, or more equitable, or financially intelligible, or even easier to access & use for less advantaged older-old Australians and their family carers. They are not.
The new system fails the vulnerable older-old in most need – the ‘cognitively frail’ with less capacity for self-management, less computer literate, less well off. It is devised for ‘young-old’ people & more switched on carers, but even they are finding it difficult to access & understand the complexities and interfaces. Individual local services (Community Nursing, Home Care, Transitional Care, Hospital-in-the-Home, Ambulatory Care) are intact, even proliferating, but form a fractured uncoordinated mess for the ‘at risk’ old. Assessment – by Regional Assessment Services (valuable but locally divided); ‘My Aged Care’ (centralised, internet and phone accessible); residual ACATs; private or not-for-profit Assessment Services – is not reasonably accessible for older-old people in most need. Communication is poor across fragmented assessment services for those whose job it is to assist at a local level – family carers, community nurses, social workers, GPs, Geriatric Teams, or discharge planners.
The motivation was good – equity, innovation, flexibility of access for “person-centred care”. However, the new system embodies unproven or dated concepts of ageing: a mistaken belief that ageing per se causes disability; a belief that public aged care systems are less efficient or innovative than private systems – hence weakening public responsibility for Aged Care; three yearly tender, on theoretical grounds of the value of competition over continuity of care; an acceptance of “market forces” (which do not operate effectively or efficiently in Aged Care) hence privatising without clear evidence of benefit. The result is a growing but fractured system, good for healthy competent older people – but increasingly inoperable for frail ‘older-old’ and disadvantaged carers, resulting in a poorly accessible, complex, headless beast of a system.
Steps to Solutions?
“You should turn the clock back if it is telling the wrong time” John Kay Economist – ‘Other Peoples’ Money’ 2015.
We may not need to turn the clock back; but – to mix metaphors – we should not throw the babies out with the bathwater.
Professor Tony Broe AM, BA, MB;BS (Hons), FRACP, FACRM
UNSW Conjoint Professor of Geriatric Medicine
Obesity rates are increasing in the Australian population (Figure 1). There is a widening socioeconomic gap with low socioeconomic groups having the highest rates. There is some evidence that obesity rates in children may be levelling off but not in low socioeconomic status children. Overweight and obesity contributes significantly to the burden of disease (about 9% in Australia at present), loss of quality of life and premature mortality (death before completing expected life span) in Australia.
Obesity is a complex problem requiring complex solutions. There is no magic bullet. Ultimately obesity occurs because of an imbalance in the amount of energy consumed and absorbed in the gut and the amount used up as part of metabolism as well as through physical activity. There are many complex factors influencing this imbalance across the lifecycle (Figure 2). These are in turn influenced by many factors in the social and economic environment. It is easy to think that it is all just too hard at one extreme or that it can be simply address by individual will power at the other extreme.
At a population level, there are a number of strategies that can achieve improvements. These involve changes in the way we live. While on their own any one strategy is unlikely to solve the problem of obesity, collectively they may contribute to further slowing or reversing the rise in the prevalence of obesity in the Australian community. One such strategy is to reduce sugar sweetened beverages (SSB). In the UK government will apply a levy on SSBs from 2018 joining a number of other countries including France, Belgium, Norway and Sweden.
There are three main reasons for focusing on on SSBs:
How can a reducing in SSB consumption be achieved? It is not easy. SSB are ubiquitous in the Australian environment. Dispensing machines are located almost everywhere in addition to availability through supermarkets, cafes and restaurants. A number of strategies have been proposed and attempted:
What are the possible unintended consequences of these actions? It is possible that a tax may economically disadvantage the poor who have higher SSB consumption. This can be partly addressed by education about use of water and could be offset by reduced tax on healthy alternatives such as fresh fruit and vegetables. These efforts may displace consumption onto other energy dense drinks without added sugar (fruit juices, milk drinks). This may have already occurred with fruit juice but there is no evidence for other drinks.
So what is the way forward? A range of health groups have recommended social marketing campaigns, restrictions of children’s exposure through marketing and in schools and sporting facilities, reduced availability it workplaces, government institutions, health care facilities and public places and exploration of tax increases. All these are likely to be necessary to reduce SSB consumption sufficiently to reduce obesity rates.
These measures are, of course, likely to meet resistance from industry groups. They argue that this is a matter for individual choice and not for government regulation. However the socioeconomic gradient in SSB consumption and its effects on weight and the burden of disease both for individuals and the whole community suggest that public health action is warranted. With its high impact on children, the consequences of inaction are likely to be significant across generations.
References
Australian Bureau of Statistics: 4364.0.55.007 – Australian Health Survey: Nutrition First Results – Foods and Nutrients, 2011-12
Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006 Aug;84(2):274-88
Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature 2012; 482: 27-29
Re-think sugary drink. Consensus Statement on sugar-sweetened beverages. Cancer Council Australia, National Heart Foundation, Diabetes Australia, Nutrition Australia, YMCA, Australian Dental Association, Dental Health Services Victoria, Obesity Policy Coalition. http://www.rethinksugarydrink.org.au/downloads/Consensus_position_statement.pdf
Figure 1: Overweight or obese, persons aged 18 and over, 1995, 2007–08 and 2011–12
Notes:
Source: AIHW 2012, ABS 2013.
Figure 2: Some of the causal factors involved in weight gain.
Professor Mark Harris is from the Centre for Primary Health Care and Equity, UNSW.
In response to one element of a 2005 Productivity Commission report , the Council of Australian Governments (COAG) decided that the state and territory systems of registration of health professionals, some in existence for over 150 years, would be replaced by a single national scheme . The new scheme, based on a “national law” adopted by all jurisdictions, is run by the Australian Health Practitioners Regulation Authority (AHPRA) which commenced operation in July 2010. It now covers 14 health professions and 600,000 health professionals. By the end of 2016, AHPRA will have been subject to two federal parliamentary inquiries (see here and here), one state parliamentary inquiry and an independent inquiry commissioned by the COAG Health Council. Such a record must lead to the question as to what is wrong with the scheme.
First, it is not truly a “national” scheme as NSW declined to join in, other than to participate in the national register. This has been euphemistically deemed a form of “co-regulation”. Three years later Queensland also opted to become “co-regulated”. The 2012 Victorian Parliamentary inquiry recommended that Victoria follow the same path.
The interim agency that designed and built the national scheme informed the health professions that the new scheme would bring efficiencies with cost savings and also claimed that the scheme would adopt best practices from the existing state and territory systems. Neither proved to be true as the annual renewal of registration fees for doctors rose by approximately 50% in Victoria in the first year of the system. In its first iteration, the draft national law omitted mention of funding for doctors health programs, an omission only amended after vigorous lobbying. Even now, nearly six years later, AHPRA’s allocation is inadequate to fund the best practice example of the comprehensive Victorian program for distressed doctors.
A recurring theme behind the four inquiries has been dissatisfaction from complainants, state health complaints commissioners and health professionals over the timeliness and fairness of the handling of complaints against health professionals. To quote from the most recent inquiry conducted for the COAG Health Council by Mr Kym Snowball :
“It was apparent from the outset of the Review that there is widespread concern about the manner in which notifications have been managed under the National Registration and Accreditation Scheme (the National Scheme). These views were repeatedly raised with the Independent Reviewer by members of the public, health practitioners, ombudsmen, jurisdictions and professions.”
The report then itemised nine separate concerns including:
“• delays in the preliminary assessment or investigation of concerns raised by notifiers
It is noteworthy that the CEO of AHPRA has downplayed this strong criticism, as is exemplified in this exchange on Radio National in March this year. The Snowball report also identified the national scheme’s lack of accountability to individual health ministers in the respective states and territories.
In the absence of any detailed analysis as to why the scheme should be so strongly criticised, I offer the following possible explanations, together with suggestions for improvement. I believe that there are both structural flaws and legislative flaws in the scheme. The key structural flaws are the size of the bureaucracy that has been created and its consequent remoteness from the people it serves, its expensiveness (for little or no additional return) and the lack of direct responsibility to each state and territory health minister. The legislative flaws have been discussed elsewhere and, as they are only peripherally related to the overall problems with the national scheme, they are not detailed here.
The larger a bureaucracy, the more difficulty the general public and each health professional group will have in accessing its services and in obtaining information. Five years of experience of the mega bureaucracy that is AHPRA bears this out.
The lack of direct responsibility of each health minister is very evident when one compares the new national scheme with the system it replaced. Under the national scheme, any health minister with concerns must work through the COAG Health Council and AHPRA and then eventually the relevant national board (for doctors it is the Medical Board of Australia) and finally his or her relevant state board. Under the previous system, each state or territory medical board, nursing board and the like reported directly to the local health minister.
Similarly under the previous system (and focussing now just on medical practitioners), the state medical board employed its own staff to handle the receipt and preliminary assessment of complaints. Those staff, their necessary skills and the quality and timeliness of their work were all directly under the control of the state medical board. Under the national scheme, each state board has no such responsibility and must simply accept whatever staff AHPRA provides. Medical complaints can be sensitive and complex to handle and a high degree of knowledge, experience and skill is required if the system is to work efficiently and sensitively. In my time as President of the Medical Practitioners Board of Victoria, the Board employed both legally qualified and medically qualified investigating officers. While salaries were necessarily higher, the benefits of their skill and knowledge made this a sensible use of resources.
By comparison, there is a sense that the new system seems to be back to front in the following way. Section 25 of the national law states that a key function of AHPRA is ‘to provide administrative assistance and support to the National Boards and the Boards’ committees in exercising their functions’. In practice, it appears that AHPRA, via its administrative staff, dictates to the Medical Board and its state Medical Board branches (committees) the work flows and the quality and timeliness of the work done on behalf of the Boards. To gain access to this “administrative assistance and support”, the Medical Board of Australia has to spend resources each year negotiating a “health profession agreement” with AHPRA.
Fortunately, built into the national scheme is a solution to these structural flaws, namely the New South Wales model of “co-regulation”. Under co-regulation, NSW kept its previous Medical Board, renaming it the Medical Council of NSW. The Council (working in close cooperation with the NSW Health Care Complaints Commission) handles complaints, performance and health/impairment issues, leaving registration and the maintenance of the national register in the hands of AHPRA. Although there would be some short term additional costs, it would be relatively simple for all states and territories to copy NSW and become “co-regulated”. If this were to happen, it is envisaged that the national law would remain in place and with it, the powers for the health ministers as a group to control workforce issues would also remain.
The experimental national scheme can rightfully claim that it has successfully established a single national register and with it, ready portability of registration across Australia. These key elements must be retained. As NSW has 30% of Australia’s 103,000 doctors and 27% of Australia’s 370,000 nurses, the NSW experience demonstrates that a national register can readily coexist with co-regulation.
Dr Kerry Breen is a past president of the Medical Council of Australia, a past president of the Medical Practitioners Board of Victoria and a past chair of the Australian Health Ethics Committee of the NHMRC.
In part 1 of this series, I set out why I was attracted to the development of an option set out in a COAG paper on health reform which suggested the establishment of a commonwealth hospital benefit which would replace the PHI subsidy.
Regional Purchasing Agencies to address the’ blame game’ in health.
In part 2, I examine another option in the federalism discussion paper which is for ‘The commonwealth and the states and territories to share responsibility for all health care through Regional Purchasing Agencies.’
The discussion paper outlines the proposal as follows:
Option 4: The Commonwealth and the States and Territories share responsibility for all health care through Regional Purchasing Agencies
The Commonwealth and the States and Territories would jointly establish regional purchasing agencies. These agencies would purchase a range of health services for individuals in their catchment, defined by a minimum service obligation including primary and specialist care, hospital (both public and private), and allied health services. Agencies could be accountable to the Commonwealth and the State and Territories, or just one level of government.
The Commonwealth and the States and Territories would pool funding to make payments to the purchasing agencies based on demographic and health characteristics of catchment populations and the mix of services covered by the minimum service obligation. Agencies would then be responsible for managing the purchase of health services from within this fixed budget.
Catchments for regional purchasing agencies could be based on existing structures, such as Primary Health Networks and Local Hospital Networks, or their equivalent State or Territory health service authorities.
High level health policy, including setting minimum standards of care and quality, and funding roles would be shared between the Commonwealth and the States and Territories. Regional purchasing agencies would be responsible for funding and commissioning primary care and the MBS would no longer operate in the same way—for example, it could be cashed out to help fund the regional purchasing agencies. The impact on other roles would need to be considered.
Various options could be considered for the establishment of regional purchasing agencies. They could be government or semi-autonomous government bodies, they could be managed by private organisations, selected through a competitive tender process, or there could be a mixture of different approaches. One option would be for the role of the Commonwealth to be limited to funding and setting minimum standards of care and quality, with the States and Territories taking responsibility for governance and system management.
The Commonwealth and the States and Territories would agree to jointly fund regional purchasing agencies from existing health funding.
This option would increase areas of shared responsibility between the Commonwealth and the States and Territories. It could seek to build on existing governance arrangements.
Responsibility for service delivery and the commissioning of services would lie with the purchasing agencies. This would allow for greater competition in the market for services.
This option would address system fragmentation and may also better respond to local circumstances. This is consistent with the principle of subsidiarity and should result in better services for patients, so long as adequate arrangements are in place to ensure provision of quality services in remote and disadvantaged regions.
Pooled funding arrangements would need to be established in a way that would reduce incentives for cost shifting between governments. This approach should also increase incentives for investment in prevention and early intervention. There would be an incentive to ensure services were provided cost-effectively within allocated funding to avoid unnecessary (and costly) hospitalisations.
This option would include many of the benefits of individualised care packages … It would need to be supported by well-designed and clearly defined roles to minimise the risk of blurred accountability and blame-shifting, resulting in service gaps.
This option involves large-scale reform. It would present particular challenges for rural and remote areas where there are fewer existing services. Consideration would need to be given to the size of purchasing agency regions, to ensure they cover a large enough population to manage risk, realise economies of scale, and ensure availability of suitably skilled staff. This could be an issue for smaller States and Territories.
Consideration would also need to be given to the role of private health insurers.
Once implemented, this option would be durable as the health system would contain incentives to provide people with the care they need in a cost-effective manner as agencies operate from a fixed budget. It would take some time to implement and would require a significant up-front investment, in addition to ongoing operational costs.
This option is a variation of a proposal I have been making for some time, that the commonwealth and the states establish a Joint Commonwealth State Health Commission in any state that would agree. In effect the Commission suggested would be a joint state wide purchasing agency. See link https://publish.pearlsandirritations.com/blog/?p=3810.
This commission that I have proposed would pool all commonwealth and state health funds in that state, develop an agreed health plan in that state and purchase services from existing agencies, both public and private. The Regional Purchasing Agencies proposal in the draft federalism paper is a more modest approach, being regional and not state-wide, but it may be a more practical way to proceed. Perhaps establishing regional pilots would be a useful first step. A pilot project involving the whole of Tasmania would also be a useful first step given the small size of Tasmania.
To address the blame game and improve health efficiency and equity, it is necessary that there is effective coordination of all health services, particularly those delivered by hospitals and non-hospital agencies. The great inefficiency in our present health arrangements stems from the fact that the commonwealth government has responsibility for primary care but the states operate the hospitals. A Regional Purchasing Agency could be a very useful way to start resolving the blame game.
A major aim of a good health policy for Australia must be to keep people out of expensive hospitals. The division of responsibilities between the commonwealth and the states makes that very difficult.
For many years, Ian McAuley and I have been highlighting the damage to our health system and the Australian economy as a result of the $11 b. p.a. subsidy to the private health insurance industry. We have highlighted the following and never has there been a rebuttal by these vested interests.
Despite what I think is an overwhelming case against taxpayer funding of PHI I have not seen a serious response from the PHI industry…ever. I can only conclude that it has no confidence to defend its position, and if it attempted to do so it would open up a debate that it wants to avoid at all costs.
Instead of joining in a public debate to justify $11 b. p.a. government subsidy, it relies on lobbying directly and secretly on the federal government, both ministers and officials.
In 2007 Kevin Rudd made a secret deal with the PHI industry that a Rudd Government would maintain the taxpayer subsidy. We only learnt about it years later.
Now CEDA’s Balanced Budget Commission has suggested revenue measures which the government should consider to achieve a balanced budget. One revenue measure it suggests is ‘removing the private health insurance rebate exemption’. The CEDA Commission also suggests ‘cutting the private health insurance rebate’. This CEDA report is professional and supported by a cross-section of very senior academics and public officials including four former heads of PM & C. But once again I expect the PHI lobbyists will try to close down the ‘debate’ as quickly as they can.
In so many areas of public life in Australia, vested interests are abusing their power and influence on government. It is a public scandal what the PHI industry has been doing at the expense of the Australian taxpayer and good health policy. But it is not just health policy that is being corrupted; it is our democracy where vested interests exercise enormous and secret power.
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.
Malcolm Turnbull’s ruse is obvious. He wants us to forget all about deficits and debt and the need for budget repair. To avoid these issues, he now tells us that if we want improved health and education services, we cannot have them because the states have refused his offer on state taxes and he will not increase commonwealth taxes.
But we know that large increases in commonwealth government revenue are possible without any increase in income tax rates.
There are numerous proposals on ways to increase revenue without increasing tax rates. The most recent was from the Committee for Economic Development of Australia (CEDA). That Committee suggested various ways in which revenue could be increased without increasing income tax rates.
The other obvious way to increase revenue is to ensure that large multinational companies, private companies in Australia and trusts pay their fair share of tax. Many don’t pay any tax at all.
None of this involves increasing tax rates. But these proposals would not be welcomed by the wealthy vested interests that support the Liberal Party.
There is probably $20 b. to $30 b. of increased revenue per annum by addressing the issues above.
All public surveys that I have seen suggest that Australians are prepared to pay increased tax, even increased rates of tax, if they believe that the tax system is fair and the money is spent efficiently.
I have posted blogs earlier about the remarkable successes of the Nordic countries – Denmark, Sweden and Norway. These countries have some of the most successful economies and societies in the world yet they have very high rates of taxation. The Nordic countries have a basic trust in government. They broadly believe that the tax system is fair and services are efficiently delivered.
It is something badly lacking in Australia.
See links to two earlier articles on the Nordic successes – Postcard from Denmark on the Nordic success (17/1/2015); Why are the Nordics so successful? (18/1/2015).
Before Malcolm Turnbull and the states start haggling over hospital funding, it’s worth looking at why the system costs so much to run. Maybe it’s not just cash, but waste and inefficiencies that need addressing, writes Mike Steketee.
Why do our hospitals cost so much to run? Like$55 billion a year and rising rapidly?
It is the question worth asking before Malcolm Turnbull and the premiers start haggling at today’s COAG meeting over how best to pour more money into hospitals. Yes we are an ageing population and the health system is devising ever more clever ways to treat us.
But that is not all that is going on. If you are 55 or over living in Fairfield in western Sydney, your chances of having knee arthroscopic surgery were 185 per 100,000 people in 2012-13. In Bunbury in Western Australia, the chances were more than seven times greater – 1319 in 100,000.
Are there that many more dicky knees in Bunbury or at least ones that require hospital surgery? Or is it that many older people in Fairfield have been denied necessary surgery?
Not likely on either front, according to the Australian Commission on Safety and Quality in Health Care, funded by federal and state governments. As it said in November:
Despite the evidence that knee arthroscopy is of limited value for people with osteoarthritis and may cause harm, more than 33,000 operations were performed on this age group during 2012-13. Many of these people will have degenerative disease in their knees and will not benefit from this intervention.
It added that, even if you argue the extremes distort the picture and take out the areas with the highest and lowest rates, hospital admission rates for arthroscopy still varied more than four times between local areas.
The Commission found an overall variation of more than seven times for cataract surgery, which was performed 160,489 times on those 40 or over in 2012-13. Age differences between areas do not come anywhere near explaining variations of this size.
For lumbar spine surgery for those 18 and older, the variation was 4.8 times. This included spinal fusion procedures, for which the Commission said there was limited evidence of its effectiveness for painful degenerative back conditions.
And so on. Carried across a hospital system which saw 9.7 million admissions in 2013-14, this suggests that a great deal of money is spent unnecessarily.
John Dwyer, emeritus professor of medicine at the University of NSW, has had a stab at estimating the waste generated by doctors across the whole health system and comes up with a figure of at least $10 billion a year. As they say, a billion here and a billion there and soon you’re talking serious money.
A Productivity Commission research paper last year made a similar point:
Governments and patients spend a considerable amount of money on health interventions that are irrelevant, duplicative or excessive; provide very low or no benefits; or, in some cases, cause harm.
Despite all this, the Australian health system delivers some of the best outcomes in the world, other than for Indigenous people. But costs are rising rapidly, in part because of too little control over waste and too much emphasis on hospital treatment.
Knees seem to be one particular problem. Knee replacement surgery was performed at the rate of 191 per 100,000 population in Australia in 2013-14 – 61 per cent higher than the average in 30 OECD countries.
Overall, admissions for longer than day surgery in Australian hospitals are lower than some countries such as Germany but higher than those with which we often like to compare ourselves, such as New Zealand, the UK, the US and Canada. The last of these had a rate of admissions half of that in Australia.
The Productivity Commission paper canvasses some of the weaknesses that apply across the whole health system but often culminate in expensive hospital treatment. It says governments subsidise many health treatments that have not been assessed for clinical and cost effectiveness.
Often clinicians do not realise they are over-diagnosing patients, providing superfluous or harmful treatments or applying valuable treatments in the wrong way. Clinical guidelines … can be an effective way to promote high value medicine but they are often too complex, out of date, lack credibility or poorly implemented.
Doctors are often resistant to change, including in acting on the findings of evidence-based medicine, arguing that their training equips them to know best the needs of individual patients. The way they charge – on a fee-for-service basis – is an incentive to provide more services than are necessary.
The initiative announced by Malcolm Turnbull and Health Minister Sussan Ley on Wednesday to trial a different way of treating chronically ill patients, who often have multiple conditions, is an attempt to address some of these problems. At the moment, they said, such high users of the health system saw up to five different GPs a year, making it more likely they would fall through the cracks and end up in hospital.
“Half of all potentially avoidable hospital admissions in 2013-14 were attributed to chronic conditions,” they added. Under the two year trial, one GP practice will co-ordinate the care of these patients and receive quarterly payments. This shifts the emphasis to improving the overall health of the patient, rather than charging for individual treatments.
Turnbull and Ley hailed this as “one of the biggest health system reforms since the introduction of Medicare 30 years ago.” However, we shouldn’t get too carried away: various forms of co-ordinated care, including for chronic illnesses, have been tried for at least the last 20 years, with mixed results. Nevertheless, an increased emphasis on primary care – that is through GPs and including prevention programs – is crucial to keeping people out of hospital.
These potential savings are before we even start talking about inefficiencies in administering the health system. With both the federal and state governments putting money into public hospitals, there is bureaucratic duplication on a large scale.
Each level of government blames the other for deficiencies in hospitals. As well as blame shifting, each is constantly manoeuvring to shift costs on to the other. For example, hospitals, which are run by the states, are forced to keep elderly patients in beds costing $1200 a day because there are not enough places costing only $200 a day in nursing homes, which are funded by the federal government.
Turnbull is right in suggesting this week that if the states raised more of their own revenue – for example, through his proposal to let them levy income tax – it would make them look more carefully at how money was spent. At the moment, it is much easier to beg Canberra for more money than to make voters cough up through taxes.
It is just that experience suggests that the main effect of Turnbull’s idea would be to put even more pressure on hospitals. In most areas where they already have the power to raise taxes, the states have competed with each other to bid them down, such as through ever more generous exemptions for payroll tax and land tax.
Of course, if Canberra stood firm on the states solving their own problems, it would force them to tackle some of the waste and inefficiency in their spending – either that or allow hospital and other services to run down and cop the wrath of voters. But then the states would just try to blame it on Canberra.
Mike Steketee is a freelance journalist. He was formerly a columnist and national affairs editor for The Australian. This article was first published in The Drum 1 April 2016.
Prime Minister Turnbull says his proposal for the States to levy their own income tax ‘is the most fundamental reform to the Federation in generations’. Well maybe. It certainly would be a significant change, but reform? Furthermore, even if this proposal were ever implemented, it is hardly new. For example, the Fraser Government actually legislated to allow the States to raise their own income taxes, but none took up the opportunity.
In principal I agree that governments would be more accountable, and possibly more responsible, if they raised all or most of the revenue needed to fund their expenditures. Consequently, I accept that a move towards reducing the present degree of vertical fiscal imbalance and better match revenue and expenditure responsibilities should be seriously considered.
At this stage, however, Prime Minster Turnbull is only proposing to transfer 2 percentage points of the income tax rate to the States; effectively an annual transfer between the Commonwealth and the States of about $14 billion. This compares with the $8 billion a year that the Abbott Government took away in the notorious 2014 Budget, and if nothing else changed this extra $14 billion would be quite a carrot to induce the States to agree.
The Turnbull Government, however, is indicating that it is prepared to restore around $3 billion of these cuts to State payments, and so allowing the States to raise $14 billion in income tax revenue would leave the Australian Government Budget a net $9 billion down. Further savings would therefore be necessary, either from the Commonwealth’s own programs or from payments to the States. In this context it is not surprising that the Treasurer has floated the idea that another $6 billion could be clawed back by the Commonwealth ceasing its funding of State schools as part of the $14 billion package.
But apart from this fiscal problem, realistically much more would be needed to realise the Prime Minister’s vision of the States taking over full responsibility for a variety of functions and thus ending the ‘blame game’. Indeed, the $14 billion a year that has so far been floated would not even cover the cost of the Commonwealth contribution to hospitals as well as schools.
Most importantly, in this context, is that $14 billion is well short of the total of $50 billion paid each year to the States to cover all presently tied grants. For the States to be fully responsible for funding all their services would therefore require a far larger share of the income tax than has so far been mentioned, or alternatively allowing them much more freedom and capacity to increase income tax rates.
But until the States get the taxable capacity to raise all or most of this annual $50 billion does anyone seriously believe that this relatively small change to give them a 2 percentage point income tax rate would make the States much more accountable and responsible?
In my opinion there is some further scope to rationalise the respective roles and responsibilities of the Commonwealth and the States. For example, if Mr. Turnbull is fair dinkum why doesn’t he offer to return to the arrangements established by the Keating Government under which the Commonwealth was totally responsible for funding national highways, while the States and local government had total responsibility for all other roads. This arrangement was a sensible separation of responsibilities, but it fell foul of the pork-barrelling National Party, and so the Howard Government reversed it.
As both John Menadue and I have emphasised, however, for many joint government programs there are good reasons why we have adopted our present shared funding arrangements (see my earlier article on Federalism, reposted on 31 March, and John Menadue’s post on the same day).
Most importantly, in many cases the Australian Government has responsibilities that cannot be separated from those of the States. For example, education and training is vital for the future of innovation, productivity, employment participation, and economic growth, all of which are key Commonwealth responsibilities. While health necessarily involves both levels of government, as the Australian Government responsibilities for Medicare and aged care necessarily interact with the State Government responsibilities for hospital care.
Indeed, the Turnbull Government seems to be prepared to acknowledge that separating the roles and responsibilities of the two levels of government presents a particular problem. According to some media reports the Australian Government may not withdraw from health funding, but it could withdraw totally from having any responsibility for Schools. Certainly the Australian Government has less at stake in schools, where its intervention has never achieved a great deal in the past. But in that case, maybe the Australian Government should take over total funding responsibility for vocational education and training which is necessarily closely related to the needs of industry, and where most of the funding is increasingly being provided to both private and public providers using a competitive model.
Perhaps the most important Australian Government responsibility that would be compromised by the States setting their own tax rates would be the potential impact on fiscal policy. In the immediate future this is not expected to be a problem as the proposal envisages that the States would initially only be getting what would effectively be a share of the income tax, and the change would be revenue neutral. But once the States start setting their own income tax rates then this would compromise the necessary independence of the Australian Government to determine fiscal policy for the nation. Indeed, time is of the essence with fiscal policy and we cannot afford to have it run by some sort of Federal-State Committee. While on the other hand if governments set tax rates independently of one another, there is a risk that any time the Australian Government lowers its tax rates, then the States would seize the opportunity to take advantage of the extra taxation capacity available, and raise their own State income tax rates.
In addition, although the Australian Tax Office would continue to be responsible for administering the tax system, and each taxpayer would continue to file only a single return, there would be a number of administrative problems with the Prime Ministers’ proposal that would not be easy to resolve. Thus, unlike the GST revenue, which has a common tax rate and can therefore be distributed on a per capita basis, this per capita distribution makes no sense for income tax revenue if rates of taxation differ among States. Accordingly, companies are already demanding that the states should not have a share of company tax because of this sort of complication. Many individuals, however, also derive income in more than one state, and it still remains to be worked out how their income tax payments can be distributed between two or more States where the rates of taxation vary.
As John Menadue points out in his accompanying post, given its many problems and lack of clarity, this proposal by the Prime Minister is essentially a diversion from what is or should be the major concern of the Council of Australian Governments (COAG). The most critical challenge, which all Australian governments are facing, is first to repair the substantial Budget deficit, and in the longer-run to reconcile the demands for public services that are presently projected to run well ahead of likely government revenues.
What COAG should therefore be discussing is how to raise more revenue and/or reduce the demand for services or improve their efficiency. Personally, and as I have argued in other postings, I think it will prove to be impossible to meet reasonable demands for future services without at least some increase in overall taxation in the decades ahead (see, for example, my recent article posted 28 March).
In this regard the response by the Labor leader, Bill Shorten, to any suggestion that income tax might rise sometime in the future was most unhelpful. Mr. Shorten has already ensured that the possibility of raising the necessary extra revenue by increasing the GST was taken off the table, and now he seems to be intent on doing the same to any possible increase in the income tax in the decades ahead. One wonders how Labor could deliver its vision of society, and what it has supported, without increasing the overall tax take in the future – certainly Mr. Shorten has so far not told us.
By contrast, allowing the States to determine their own tax rates raises the risk that at worst the States may enter a new race to the bottom. This is what happened after payroll tax was handed over to them by the McMahon Government in 1971. The States have since dropped the payroll tax rate and increased the tax threshold and exemptions. Ostensibly this was in response to tax competition generated by a perceived need to attract new firms, but most of the changes did little to attract industry because they mainly helped small business which is not geographically mobile.
On the other hand, this time the Australian Government may force States to raise taxes by further squeezing their remaining tied grants. In that case the Australian Government would continue to solve its own fiscal problems by short-changing the States so that they are forced to raise taxes and thus take the blame for solving a problem of the Australian Government’s own making.
A better alternative would be to adopt the proposal by SA and NSW that the States all get a fixed share of the income tax. This hypothecated share of the income tax could then be increased if all governments agreed to raise the rates for this purpose. Furthermore, by thus achieving an agreed increase in the overall level of taxation nationally, it would help to resolve Australia’s most important longer-run fiscal problem.
Malcolm Turnbull’s suggestion of states entering the income tax field may please ‘state rightists’ in the Liberal party, but it will damage our national aspirations and our national society and economy.
In the repost below, Michael Keating, almost two years ago emphasised the importance of the commonwealth government’s domination of income taxes since 1942. This commonwealth government supremacy has been a key factor in building our successful national economy and society. Or as Paul Keating has said, the commonwealth’s income tax monopoly ‘is the glue that holds us together’.
We federated to overcome the confusion of six different state tariff regimes. Do we now want eight different incomes tax regimes?
The commonwealth’s supremacy in income tax is critical for economic management across the country. Do we want to weaken that national leadership and responsibility?
We have national markets in every field and with a very mobile workforce. Do we now want to put up state barriers to this?
Malcolm Turnbull’s proposal would put pressure on the states to reduce their own tax rates. Perhaps this is what his ‘state rightist’ supporters would like. We saw that in the 1970s when Queensland reduced state taxes and abolished death duties. All other states followed and we are now much worse off as a result. If states decided to introduce their own income taxes, we could see another race to the bottom.
What Malcolm Turnbull is trying to do was tried forty years ago by Malcolm Fraser. The details may be different, but the Fraser proposal went nowhere.
The Turnbull government has become very agile in diversionary tactics. The Abbott government spoke of a debt and deficit disaster but the Turnbull government wants to divert attention elsewhere. A GST was deliberately floated but then our attention was directed elsewhere. One critical issue above all else is budget repair. The Committee for Economic Development in Australia (CEDA) and others have suggested options for overcoming our persistent budget deficit, including increases in revenue. But the government doesn’t want to hear about that, so our attention is diverted to state income tax.
I believe that strong national economic and social leadership is essential for the commonwealth government in the 21st Century, particularly in the global world economy in which we live. That globalisation will continue to grow. Why should we handicap ourselves in meeting such a challenge?
I have always believed that ‘cooperative federalism’ although less sexy and requiring hard work, is the much better way to proceed. In the health field where states spend up to 30%of their budgets, I have proposed for many years a joint commonwealth-state health commission in any state that will agree. Perhaps a joint commonwealth-state health purchasing agency in regions would be a more practical way to start. I will be writing more about cooperative federalism in the health field.
Tony Abbott has left us with many unfortunate legacies. He abolished the COAG Reform Council which had been trying to lead an informed debate on ways that the commonwealth, state and territory governments could cooperate to harmonise their responsibilities. One task of that Reform Council was to build a ‘seamless national economy’.
Malcolm Turnbull seems to want to pull the seams apart.
Michael Keating will be writing further on this subject.
Readers of this blog will be aware that I have been expressing concern about the serious consequences of the government subsidy costing $11 b. p.a. for the private health insurance industry. This subsidy has serious budget consequences: it is skewed in favour of high income earners; it has not taken pressure off public hospitals; it has underwritten a dramatic increase in private specialist fees; it penalises country people who have very limited access to private hospitals; it weakens Medicare’s ability to control prices; it’s premium increases for over a decade have been at three times the rate of CPI increase and steadily takes us down the disastrous US health path.
Yesterday, the Balanced Budget Commission of the Committee for Economic Development of Australia (CEDA), outlined various options to increase revenue and to reduce outlays
. In its options, CEDA suggested ‘removing the private health insurance rebate exemption’. In my blog of 19 November, I estimated that the government loses about $3 b. p.a. as a result of the revenue foregone through exemption from the Medicare levy surcharge.
CEDA also suggested ‘cutting the private health insurance rebate’. In my blog, I estimated that the cost of that rebate in the last budget was $6.3 b.
The CEDA Balanced Budget Commission which made these recommendations includes Paul McClintock, former Howard government Secretary of Cabinet; John Edwards, Reserve Bank of Australia board member; Professor Rodney Maddock from Victoria University; Michael Keating, former Secretary, Prime Minister and Cabinet and Finance; Terry Moran former Secretary Prime Minister and Cabinet,Ian Watt,former Secretary Prime Minister and Cabinet and John Langoulant, former WA Under-Treasurer.
In 2013-14, Australian governments spent A$105 billion on health; A$44 billion of that was on public hospitals.
The Commonwealth government is increasingly concerned with the size of the health budget and has acted to reduce the inappropriate use of Medicare benefits. But the Commonwealth government has less influence on public hospitals because the state and territory governments control their expenditure.
State governments are facing tighter budgets as demand for heath care increases due to an ageing population, greater rates of chronic disease and more service use generally.
The collection and analysis of data on the performance of our health-care system can be used to improve the quality of health services and maybe also reduce costs.
At a national level, the clinician-led Choosing Wisely campaign is developing lists of specific tests, treatments and procedures that may be unnecessary and sometimes harmful for individual patients. Recommendations include reducing use of CT scans in the emergency department and not ordering x-rays for patients with uncomplicated acute bronchitis.
But while improving the decisions made by individual doctors is important, there remain other causes of substantial variation in the safety and quality of care provided in Australian hospitals. This needs to be addressed.
Efforts to improve the quality of care in hospitals have traditionally been left to individual hospitals and their managers. But we now have the data to compare different hospitals. We can identify the best and worst performers and, most importantly, determine how to boost the performance of the stragglers.
Identifying and intervening to improve low-quality care requires financial investment. But there are significant potential long-term savings, due to improved efficiency and better patient outcomes.
In New South Wales, the Bureau of Health Information has developed and tested methods for comparing the death rates within 30 days of treatment for heart attacks, strokes, pneumonia and hip fracture surgery.
For stroke patients, ten hospitals had noticeably higher-than-expected death rates for these conditions. An additional 16 deaths were observed in every 100 patients treated at a low-performing hospital compared to a high-performing hospital.
Clinical auditors and review panels should investigate differences in the care provided at the high- and low-performing hospitals and approaches to improve care quality.
Other data show the costs of treating similar conditions varies dramatically. A Grattan Institute analysis shows the average cost of performing a hip replacement at different hospitals ranges from under A$10,000 to more than A$30,000.
Further investigation may find the higher costs are due to the use of more expensive prostheses and to keeping patients in hospital for longer after surgery. Assessments can then be made about whether more expensive prostheses or extended lengths of stay produce better patient outcomes, which justify the additional costs.
We have analysed hospital data to compare costs, outcomes and the care pathways of patients treated for similar conditions at the main public hospitals in South Australia.
After adjusting for differences in the types of patients presenting at emergency departments with chest pain, seven in every 100 patients presenting at a particular hospital were readmitted or died within 12 months. This compared to four to five patients at the other hospitals.
The same hospital spent up to A$669 more on each patient than the other hospitals. Over one year, these additional costs amount to almost A$1 million.
Analysis of the care pathways showed that the hospital with the highest rates of re-admission, premature death and costs, discharged more patients from the emergency department. This hospital also kept patients who were admitted to an inpatient bed in hospital for longer than the other hospitals.
This suggests some patients may have been inappropriately discharged home from the emergency department, while other patients could have been discharged earlier.
Further investigation might look more closely at how and why decisions are made to admit patients from the emergency department and at what might be causing admitted patients to stay longer in hospital.
State governments are increasingly interested in improving quality. The Queensland government has set up an Integrated Care Innovation Fund to invest in initiatives to improve efficiency and value. NSW set up a similar Translational Research Grants Scheme. In South Australia, the Transforming Health initiative aims to improve the quality and consistency of health care across all metropolitan public hospitals.
But while individual efforts to improve quality may have some effect, it is more likely that co-ordinated, systematic approaches will have a greater impact.
Data should be analysed across hospitals on an ongoing basis to identify areas of clinical activity with the greatest potential for improvement, such as the examples above. Findings that quality could be improved should be fed back directly to hospitals.
Specialist teams should be set up to work with hospitals to further investigate areas of concern and to develop and implement improvement strategies.
Rather than going back to the drawing board on health reform, governments need to improve what we’ve already got and bring the poor performing hospitals and departments in line with their better performing peers.
Jonathan Karnon is Professor of Health Economics, University of Adelaide. This article first appeared in the Conversation on 21 March 2016.
Let me be frank. There are many stringencies that have to be faced in the provision of disability support services. We all know this whether we are recipients of in-home one-on-one support, residents, workers or management of disability support services, or even as officials of the Department of Health and Human Services (DHHS). We all are under the pump in an economic climate where there is widespread political anxiety about budget blow-outs and a possible collapse of our financial and economic system. We all know this. So when I make my professional contribution, as a resident of such a health-care facility, my recommendations and pleas are complex.
Many of the problems in the disability support services arise because it seems that efficiency demands a certain generalized procedure. In this case “efficient” means something like: (a person) working in a well-organized and competent way.
And when dealing with disability support, effectiveness is also a crucial characteristic to be balanced against any “efficiency”. This is the meaning of “effectiveness”: the degree to which something is successful in producing a desired result; success.
I would ask that readers appreciate that I too am a citizen, a member of this polity, one who has paid my taxes, one who has worked persistently to promote the common good. Yes, what I am about to say is framed in my own interest but it is not only that. I am just as much concerned morally as any other non-disabled professional person about the serious state of our disability support services. Unless that is understood then my point will not be appreciated.
There have been developments at the level of Federal and State Government funding – negotiated through the Council of Australian Governments (COAG) – that have brought about significant changes to the delivery of human services more generally and disability support services in particular. I do not have access to a research facility to adequately assess and evaluate all of these. I regularly seek advice from those who may know but I do not want readers to presume that I have mastered all the details of all the complex agreements, contracts and policies that are now in place.
In all this, within the political sphere dominated by neoliberalism comes the mechanism that can negatively impact on social decisions, and that is the way in which policies are freighted with a seeming over-riding criteria introduced by this question: but what is this efficient and effective procedure doing to enhance individual profit?
Some social decisions, concerned with human-related social services are, and should be, unrelated to efficiency.
But there are some gross inefficiencies, I believe, that are part of the disability support sector that have very little, if anything to do, with disability support. More likely is it the support of the organisational and managerial structure that claims to be supportive of disabled people that is benefiting. The management of service providers are required by their own charters to turn a positive result in their financial returns . There are some unscrupulous service providers in the not-for-profit disability sector, like my own, who charging me $647.54 per fortnight in rent, including some shared transport – if it be available – and for food. The provision of food money is allocated to certain support workers at approximately $14 per day for residents in this facility, even though in recent times, I have complained to management about their failure to disclose provision money in their accounts.
Such not-for-profit enterprise will follow the model of service provision that I would call the neoliberal streamline model: to put it simply it interprets organisational and managerial reality in terms that instinctively require financial profit to have precedence over people’s welfare.
One will ask, bewildered, why should a not-for-profit organization need to show a profit? We are a shared supported accommodation residence and we are said to be in the not-for-profit disability sector. Are we simply to roll over and allow an abstract efficiency with little or no room for effectiveness, to prevail? Are we really wanting a neoliberal perspective that affirms that efficiency means money saved, while effectiveness means costs and hence a challenge to ongoing future viability?
This state of affairs prods me to drive home an ethical perspective about residents in shared supportive accommodation. In this house we have 9 individuals with high support needs. In other words what is required for residents in shared supportive accommodation are processes and resources that overcome a lack of human support. There are a lot of funds paid and even more is required for unmet needs of disability support. But I have come to my matured and well educated perspective, having developed it over many years living in the face of a progressive disability for over forty years.
My conclusion is this: the disability sector has lost its way being caught up in the self-interest of an overloaded pool of management. Instead of alleviating the need for support such a sector is in danger of exacerbating the need for greater assistance!
But all is not doom and gloom. There is a plausible and workable solution within reach to many of the failures to provide efficient and effective disability support. Through the attainable cost savings people with disabilities can actually be empowered. This is evident from schemes of direct employment techniques that have been widely used to positive effect by both DHHS and the National Disability Insurance Scheme (NDIS).
Direct Employment has just been formally introduced into Victoria. I was involved in the initial pilot program. This is a key reform with the Disability Services that many Individual Support Package (ISP) users should consider due to its numerous benefits. It is a person-centred approach to disability, being more positive in allowing one to contribute to the community, enhancing community inclusion.
In July 2013, I was keynote speaker at the Disabilities Support Professionals Conference at the University of Sydney. There I spoke with my computer voice about; Cindy, a 46 year old lady with a severe intellectual disability. She is involved with Direct Employment, her self-planning carried out by family members. As a result Cindy lives a more inclusive life. She is supported by three workers whose rosters, pay, training and other work conditions are managed by the O’Loughlin family, with sister-in-law Christine and brother Darren managing the accounts and finances. Cindy, and her mother Lesley, take responsibility for the recruitment, training and day-to-day management of Cindy’s workers. Thanks to Direct Employment, Cindy is receiving the support she needs, she is happier and is living as an individual in the community the way she chooses to live. Cindy’s family are the professionals involved in her support.
The encouragement of such forms of disability support derived from their logic with a focus upon social coherence. It is important to ensure that this kind of arrangement is flexible enough to allow some changes in a day-to-day sense, even if complete change does not take place. The aim is to re-build trust and flexibility in disability supports, thereby creating both community inter-dependence and independence.
Direct Employment offers flexibility, allowing people with disabilities to choose the support staff they prefer, helping them lead their own lives and make decisions for themselves. Direct Employment is better suited to cater for individual needs and lifestyles: it is, after all, an important concern for people with disabilities. Hence it allows for a more personalised approach that is better suited to meet individual support needs than the efficiency-driven of not-for-profit organisations constrained to make a profit. As a person-centred approach, I believe Direct Employment is an important reform that will be the key to the future lives of many disabled people and their families!
Let’s hope so.
Special thanks to, Christina Irugalbandara, Bruce Wearne and Cunxia Li
Peter Gibilisco, B Bus (Acc) Ph.D. (Melb), Honorary Fellow University of Melbourne.
New Book: The Politics of Disability
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.
Five years ago, when I started this project of building large water tanks to collect water during the rainy season in the Dry Zone of Central Myanmar I had no idea how many lives would be changed because of this simple concept. To date 114 water tanks have been built for villages and schools due to the generosity of so many donors in Australia, the USA and the UK.
As the Australian coordinator, I have given talks and shown a Powerpoint presentation to many groups in order to raise funds, while Saya Toe, the coordinator in Myanmar, organises the team of builders who go from village to village building the tanks with help from the local people. Each time I visit there are requests for tanks from the village headmen or head teachers of schools and seeing the poverty and great need, it is hard to refuse. There are over 650 villages in the Dry Zone and the government has done nothing over the last sixty years to alleviate the situation.
In January, 2015 I visited a school and the head teacher showed me a small concrete container filled with brown water from the local dam (there were even leaves floating in it) It was the drinking water for the schoolchildren. She said simply: “Please help us – we are so thirsty!” When I returned in October, 2015, I was shown the same concrete container filled with sparkling, clear water which had been piped from the large tank built several months previously. It was a moving moment watching the children come and drink there.
So once again I am making an appeal for these children and their families in one of the most impoverished parts of our world (a country which has been shut away from the rest of the world by its repressive military regime for many years) Any donation, however small, would be gratefully received and a tax-deductible receipt given.
Living Water Myanmar partners with Global Development Group for Project J812N Living Water Myanmar. Donations can be made online (simply google Global Development Group) but it is really important to put the project name and number.
Cheques can also be sent to GDG,
56, Goorari St, Eight Mile Plain, Qld 4113 (with the project number and name on back of cheque.
It is a great help if donors could also email me (rosemary.breen6@bigpond.com)
Saya Toe has recently set up a Facebook page (Living Water Myanmar) for anyone interested to see some of the recent work. Each village or school which receives a tank is committed to planting ten trees to help the environment.
Each time we have a drink of water, take a shower, flush the toilet, water the garden, turn on the washing machine or dishwasher, may we remember our brothers and sisters for whom clean water is a luxury and may it remind us to share generously with them.
In gratitude,
Rosemary Breen