Category: Health

  • David Isaacs. As bad as Guantanamo

    If I liken the immigration detention centres on Nauru and Manus Island to the US facility on Guantanamo Bay, even passionate advocates for those seeking asylum such as human rights lawyer Julian Burnside dismiss my concerns: “Oh we’re not as bad as that.” I will argue that we are indeed as bad as that, possibly worse.

    Many people fleeing persecution to seek asylum have been subjected to psychological trauma in the countries they are fleeing and in the often highly traumatic journeys they take to reach ‘freedom’. However, people seeking asylum who are subjected to prolonged immigration detention are significantly more likely to suffer severe mental health problems than people seeking asylum who are not detained. Furthermore, the incidence of mental health problems increases with duration of incarceration. The United Nations defines torture as “…any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions”. Since prolonged detention without trial is unlawful under international law, Australia’s immigration detention policy clearly fulfils the key elements of the UN definition.

    Arguably what makes Guantanamo so bad is four things: lack of due process for imprisoning people there, lack of accountability (limited information, no transparency), indefinite imprisonment without due process (seemingly arbitrary legal processing, lack of clear end-point to imprisonment); and severe physical and mental maltreatment. Nauru and Manus share the first three characteristics with Guantanamo. Nauru and Manus, like Guantanamo, are ‘black sites’, out of sight and mind of the public, shrouded in secrecy, with severe restrictions on reporters. The Australian Border Force Act means employees including doctors, lawyers, teachers and guards who report the truth face two years imprisonment. Yet, for an Australian offshore detention policy to be successful in deterring people-smuggling, the stated intention, none of these four things are necessary. Therefore, even if you accept the Government justification for the Australian asylum seeker policy, the current treatment is unethical.

    Guantanamo is arguably worse in one respect: we know men are systematically tortured physically using techniques like water-boarding. However, Nauru is worse than Guantanamo in one hugely important respect: it includes children. When we surveyed Australian paediatricians, over 80% said immigration detention of children is child abuse. Successive Australian Governments have outdone the US Government in cruelty by torturing and abusing innocent children, all with the immoral aim of deterring other innocents.

    Furthermore, those imprisoned on Manus and Nauru are not terrorists; indeed, they are not guilty of any criminal offence, since seeking asylum is not a crime. Although the occasional innocent man was interned on Guantanamo, most knew what to expect when they went to war. In their autobiographies, Primo Levi and Nelson Mandela both astonishingly attempted without rancour to understand the motives of their captors; when they took up arms to fight injustice, they both knew the consequences if caught. On Nauru and Manus Island, in contrast, the injustice is being perpetrated against the very people seeking asylum. There can be few worse things than to be imprisoned unjustly and kept there indefinitely without right of appeal. Australia tortures innocent men, women and children who come begging for mercy. No wonder we are reviled internationally.

    When I worked on Nauru in December 2014, the predominant emotion was of utter despair and hopelessness. What would you do if you were imprisoned unjustly and indefinitely without right of appeal? In the current culture of victim-blaming, if you get depressed and self-harm or attempt suicide, you are accused by the Government of seeking preferential treatment. If you subsequently kill yourself, you had pre-existing mental health problems. If you get angry enough to riot, you are accused of violent ingratitude, with no mention of the extreme provocation that causes normally placid people to get angry enough to resort to violent protest.

    Gillian Triggs and the Australian Human Rights Commission have tirelessly and courageously exposed the harms done to children in immigration detention. The harm is also to adults, of course. But the very term ‘human rights’ implies an obligation, which risks being somewhat confrontational. Australia’s reprehensible treatment of people seeking asylum is as much a question of human decency as human rights. No civilised country should behave like this to fellow human beings. We treat refugees with respect and generosity. We treat people seeking asylum with contempt and cruelty. We talk of showing compassion, and in the same breath tell the meek to go back to where they came from. Australia is traditionally the land of the fair go, but in the words of president of the Australian Medical Association, Brian Owler, current asylum seeker policy is tearing at the moral fabric of our society. We, the public, need to prevail on all our politicians to listen to our pleas to find a new moral direction. Please help us re-discover our soul.

     

    David Isaacs is a consultant paediatrician in a University teaching hospital in Sydney, where he has run a Refugee Clinic since 2005, and is Clinical Professor at the University of Sydney

     

     

     

     

  • Kerry Goulston. Postcard from Vietnam. Health and medical cooperation with Vietnamese doctors and nurses.

    In 1998, Dr Phillip Yuile visited Professor Ton That Bach, Rector of Ha Noi Medical University, with a letter of introduction from Professor Kerry Goulston, Associate Dean of Medicine at the University of Sydney who had been appointed by the then Dean, Professor John Young, to explore possible links between the two universities. Subsequently Professor Ton That Bach invited Professor Goulston to Ha Noi to discuss a collaborative association between Sydney University and Ha Noi Medical University which had been established by the French in 1902..

    Professor Ton That Bach was highly respected by colleagues and beloved by his students, all of whom he knew individually by name. After he died suddenly in 2004 at Lao Cai he was given a state funeral and thousands paid their respects in the streets of Ha Noi.

    A meeting was held in Ha Noi in November 1998 between Professor Ton That Bach and Professors Kerry Goulston, Professor Bruce Robinson and Associate Professor Phillip Yuile from Sydney University. The purpose of the meeting was to formalize ties between the two institutions and to begin planning future activities. At an inter-country level this process was facilitated by the Australian Ambassador to Vietnam at the time, Mr Michael Mann. A warm relationship quickly developed with Professor Ton That Bach who stressed that he foresaw a continuing association centred on young doctors and nurses between the two Universities. He said that, although traditionally there had been medical linkages with France, he would like to see new links develop with Australia.

    Subsequently, in December 1998, an exchange program commenced with five students from the Sydney University Northern Clinical School spending an elective term in Ha Noi. Sponsorships were provided by the Sydney University Northern Clinical School, Ramsay Health Care, the Australian Returned Services League and private individuals.   In February 1999 the exchange relationship between the two countries commenced with Vietnamese doctors visiting Sydney hospitals under the auspices of the Sydney University Faculty of Medicine .

    In December 2001, Professor Ton That Bach, his wife Dr Nguyen Thi Nga, Head of the Blood Transfusion Service in Ha Noi and Dr Dang Van Duong visited the Northern Clinical School and the University of Sydney where Professor Ton That Bach was made an Honorary Fellow of the Faculty of Medicine and met with many academics and clinicians and signed a Memorandum of Understanding between the two Universities.

    Also in 2001, Hoc Mai, The Australia Vietnam Medical Foundation was established as a non-profit Foundation of the University of Sydney with Professor Marie Bashir, Governor of New South Wales, as Patron. The name “Hoc Mai”, meaning “forever learning”, was proposed by three young Vietnamese doctors, Trinh Binh Giang, Nguyen Van Bay and Ha Phan Hai An.

    Since 2001, over 300 Vietnamese doctors and students have spent time in Australia under the sponsorship of Hoc Mai. These have included postgraduate degree students, participants in short formal courses and doctors on short clinical placements.  In turn, over 200 Sydney University medical students have carried out their Elective Term in Vietnam under the supervision of Professor Dang Van Duong. There have also been numerous visits by individuals and teams of Sydney University academic clinicians who have lectured and taught short courses on a wide variety of topics in Ha Noi and at other centres in Vietnam.

    Further Memoranda of Understanding between Ha Noi Medical University and Sydney Medical School have been signed by Professor Nguyen Lan Viet as Rector of Ha Noi Medical University in 2005 and by Professor Nguyen Duc Hinh who was appointed Rector of Ha Noi Medical University in 2008. Professor Nguyen Duc Hinh has visited Sydney a number of times and has been made an Adjunct Professor of the University of Sydney.   He has cemented the longstanding close relationship between the two universities.

     Medical English

    In 2007 the first of many short courses in medical English was held at Bach Mai Hospital in Ha Noi. The aim of these free courses is to give Vietnamese healthcare workers who have basic English language competence the opportunity to hear conversational English spoken in a medical context and to assist them in speaking English. These interactive small group courses are intended to help with grammar, pronunciation, syntax, expression and medical vocabulary. Since 2007 many hundreds of Vietnamese doctors, nurses and other health care professionals have participated in these courses which have been held at several hospitals in Ha Noi. In 2011 this English language program was extended to include nursing students in the Ha Noi Medical University Advanced Nursing Program. These courses are held over four days in February and in September and are taught by Australian volunteer doctors, nurses and others who travel to and stay in Ha Noi at their own expense.

    New methods of medical teaching

    A one-day workshop was held  at Ha Noi Medical University in December 2009, attended by the Rector of Ha Noi Medical University, senior academic staff, clinicians and educators with the aim of determining educational priorities to which Hoc Mai could contribute. Four areas were identified: (a) teaching medicine and medical skills in English (b) defining learning objectives (c) introducing new teaching methods (d) introducing new methods of assessment. Subsequently, visits by Sydney Medical School academics helped to introduce new methods of assessment such as Scorpio and Mini-Cex for students and young doctors at Ha Noi Medical University and Ha Noi Hospitals.

    Advanced Course in medical teaching and research for talented Ha Noi Medical University graduates

    This course, which is conducted in English, is intended to provide a select group of outstanding recent Ha Noi Medical University graduates with ideas and tools to enable them to introduce and lead change in medicine and health care in Vietnam in the future. The course, which has been held yearly since 2010, was originally funded by Atlantic Philanthropy but in the past five years has been supported by competitive grants from AusAid and the Australian Department of Foreign Affairs and Trade and through the generosity of several private individuals.

    The course  has three components: (a) periodic four-day visits to Ha Noi Medical University by small teams of Australian clinical academics from a wide variety of specialties  (b) on-line interactive tutorials held approximately every 3 weeks (c) a four-week visit to Sydney involving two weeks of intensive tutorials and a two-week  clinical placement in Sydney hospitals.

    Each year, around 60 potential participants are chosen by Professor Nguyen Duc  Hinh, Associate Professor Ha Phan Hai An and Associate Professor Van Dang Duong on the basis of their academic record. All are then interviewed in Ha Noi by Australian Hoc Mai members using a structured interview to assess their ability to understand and speak English. Applicant’s curricula vitae and referees’ reports are also taken into account. Through this process around 20-25 are selected to attend the four-week immersion course in Sydney.

    The curriculum of the entire Advanced Course covers topics which are essential for future health care in Vietnam but which are not widely taught at present. These include but are not limited to: evidence-based medicine, communication skills, patient management plans, assessing clinical skills, effective clinical handover, medical ethics, professionalism, disability , leadership management, clinical errors and patient safety, child protection, pain management, hospital infections and hygiene, smoking cessation, health workforce, research methods, medical statistics, using the internet for clinical purposes, presentation skills, publishing a research paper and preparing a curriculum vitae.  Individual course components and the program as a whole are evaluated anonymously by the participants and reported to the teachers. At the end of the course, depending on the availability of funding, a number of participants are selected for an intensive four-week program of further teaching and supervised placements at Sydney Medical School and associated hospitals in Sydney. In addition to this program, Professor Owen Dent has conducted three day-long workshops on the use of the SPSS statistical computing package in clinical research and in February 2016 year a workshop on hospital management and leadership was held in conjunction with the February session of the Advanced Course in Medical Teaching and Research and the Medical English program. This was organised by Professor Huong and was attended by 140 participants.

    Kerry Goulston is Emeritus Professor of Medicine, University of Sydney.

  • Renee Bittoun. Postcard from Hanoi. Smoking in Vietnam

    Unlike Australia today where the prevalence of smoking is about 15%, Vietnam remains a country where smoking is widespread. About 60% of the men smoke and about 5% of women. The burden of diseases related to smoking is therefore extremely high. On visiting a Hanoi hospital respiratory ward last week, most of the 100s of inpatients were patients with acute exacerbations of COPD (Chronic Obstructive Pulmonary Disease), and visiting the cancer hospital also showed that most of the cancers were also smoking related. There are efforts to reduce uptake of smoking however there is little supporting funding.

    Vietnam_SmokingMy role in the short week of visiting these sites was to teach the staff about smoking cessation. The medical and allied health staff were very keen and eager to learn about our approaches. However there was a great deal more to address. Cigarettes are very very cheap and readily available. The tobacco industry is local and tobacco is grown in Vietnam, with probable conflicts of interest for the government. The math has been done however that shows the enormous loss in health costs versus the gain in income.

    There are particular goals that might make a difference relatively quickly. Increasing the cost of tobacco and hypothecating the income to smoking related tobacco control and treatment services is known to have a significant effect on prevalence. Improving the awareness of health workers of the huge financial and health burden that smoking has on the well-being of the population would commence a trickle-down effect to the community. This along with a multifaceted intensive and prolonged anti-smoking media campaign would be very cost beneficial.

    There are things, however, we may learn from the prevalence of smoking in Vietnam. Most intriguingly it would be helpful to understand why so few women and girls smoke. It is highly inappropriate for Vietnamese women to smoke. A study of the cultural and environmental influences may show results that might be translated to other nation’s groups in order to reduce the prevalence of smoking elsewhere, and not just in women and girls.

    Renee Bittoun is Adjunct Associate Professor, Clinical School, Smoking Research Unit, Faculty of Medicine, Brain and Mind Centre, Sydney Medical School, University of Sydney.

  • Stephen Duckett. Blood money: pathology cuts can reduce spending without compromising health

    The Mid-Year Economic and Fiscal Outlook (MYEFO) set the cat among the pathology pigeons late last year. One of the government’s flagged changes, estimated to save around A$100 million a year, was to abolish the bulk-billing incentive Labor introduced in 2009.

    The industry mobilised, threatening to charge consumers significant out-of-pocket co-payments for pathology tests for blood, tissue and other bodily fluids. The threatened increases were well in excess of the A$1.40 to A$3.40 cut to the bulk-billing incentive, which companies received for not charging patients out-of-pocket charges.

    A campaign was organised, focusing on the increased cost of pap smears. It included apetition supported by more than 200,000 people.

    Health Minister Sussan Ley escalated her rhetoric, pointing out that Medicare was notdesigned to be a guaranteed bankable revenue for corporations, nor a taxpayer-funded payment to cross-subsidise pathology companies for other costs of doing business.

    The minister noted:

    … complaints from stock exchange-listed pathology companies about this MYEFO decision have revolved around impacts on ‘shareholders’ – not patients – exposing what is really motivating these criticisms.

    The MYEFO-induced furore about bulk billing provides context for a wider “root and branch” review of pathology payments. As the Grattan Institute’s report, Blood Money, published today, shows, there is money to be saved in pathology. This can be done in ways that don’t affect patient access to needed tests.

    Industry profit

    The Blood Money report addresses several questions. First, why is bulk billing on the agenda for pathology tests at all? All out-of-hospital pathology tests should be bulk-billed.

    There should be no “incentive” for pathology corporations to bulk-bill. Rather, bulk-billing should be a requirement to participate in this market.

    The place of co-payments in health care is highly contested. Those who argue for co-payments say they help to reduce demand, particularly for frivolous use of health care.

    But consumers almost never initiate pathology services. Professionals order tests to assist them to make a diagnosis or to track a patient’s condition. In those circumstances, there is no theoretical argument to use financial disincentives for consumers, in the form of co-payments, to limit demand.

    Industry consolidation and technological advances have completely reshaped the pathology industry over recent decades. But the way governments pay for pathology services hasn’t kept up.

    Fee-for-service was originally a way for individual consumers to pay their medical practitioner for professional services. Health insurance then evolved to provide insurance for those costs. Medicare, when it was introduced, followed the same model.

    But what was suitable for cottage-industry medical practice is not necessarily appropriate as a payment system for big corporations. More than three in every four Medicare-billed pathology tests are analysed by one of two big corporations: Sonic Healthcare and Primary Health Care. Both companies suffered a share price drop when the MYEFO cuts were announced.

    Many parts of the pathology schedule are now highly automated. The large corporations benefit from economies of scale as the costs of an additional test to run through an analyser are trivial. But Medicare pays the same for the tests processed by the machine for the thousandth patient as it does for the first.

    Same service, lower costs

    A 2011 discussion paper on pathology funding proposed that Medicare negotiate with providers to share the benefits of technological change by discounting the schedule for high volumes by, say, 5%. The Commonwealth Department of Health should dust off this paper and use it as a basis for proper commercial negotiations with the big pathology corporations.

    The bulk-billing incentives should be in the mix as well. Serious negotiations of that kind would save taxpayers about A$175 million per year; A$100 million from bulk-billing incentives, the balance from a 5% trim.

    The government should also consider going to tender for the right to bill Medicare for out-of-hospital pathology. In other words, companies would bid to be involved in the out-of-hospital pathology market by offering to provide tests at particular prices.

    The tender specification might incorporate provisions that the price to be paid by government goes down after a particular number of tests is performed.

    A pilot scheme of tendering should be established in Victoria for 2017, with the scheme allowing for multiple successful winning bids to ensure continued competition in the pathology marketplace. Tenders could be rolled out in other states after an evaluation of the Victorian experience.

    Tendering should generate greater savings than the 5% trim.

    Tendering introduces price competition into the pathology market. Rather than companies responding to a government-regulated price, they would have to specify the prices at which they think they can operate. If a company bids at too high a price, they may not be among the group of successful tenderers.

    The 2011 pathology discussion paper notes strong savings from other departments tendering pathology services:

    • Victoria has tendered out most of its regional
      public pathology services for more than 20 years. Negotiated prices are 65-75% of Medicare fees, equating to a 10-20% saving.
    • Defence tendered pathology services for military personnel. It settled at 80% of Medicare fees, without patient initiation fees. This was equivalent to a 5% discount.

    Neither paid the equivalent of a bulk-billing incentive. Further savings, on top of a negotiated trim, could therefore be achievable.

    There are savings to be made in pathology payments and they should come from narrowing the margins of profitable corporations, not from cutting services to the ill and vulnerable.

    In a time of increasing deficits, the government must prioritise reforms that reduce spending without compromising the health of Australians. Pathology payment reform provides an opportunity to do this – an opportunity that should not be missed.The Conversation

    Stephen Duckett is Director of the Grattan Institute‘s Health Program. 

    This article was originally published on The Conversation. Read the original article.

  • Which country has the world’s best healthcare system?

    On 9 February, the Guardian published a report on health systems around the world. It drew particularly on analysis of ratings by the Commonwealth Fund and its correspondents around the world. The UK’s national health service was ranked number one in the world. Australia was ranked number four.

    For Guardian article, see link below:

    http://gu.com/p/4f6vb/sbl

  • John Menadue. Making the Federation work better.

    The Abbott Government decided that over the next decade commencing in 2017 the Commonwealth Government would reduce grants to the states for education and health by $80 b. This is likely to produce a major and concerted campaign by the states to protect their hospitals and schools. It does provide an opportunity for more effective cooperation between the Commonwealth and the States in the health sector. I have reproduced below an article on this subject which was posted in May last year as part of the policy series co-edited with Michael Keating. I argue for the establishment of a joint Commonwealth State Health Commission in any state that will cooperate. In addition to this state by state approach, it might also be possible to build cooperation on a region by region basis. I do not think that a major change in constitutional arrangements is possible or that the Commonwealth will concede completely to the States or vice versa. But I believe that a pragmatic and step-by-step approach could be successful.  See repost of article below.

    Repost

    State governments spend about 25% of their budgets on health and another 25% on education. A cooperative arrangement between the commonwealth and state governments in one of these areas would greatly improve the operation of our federation. This article will focus on possible cooperation in health.

    A State handover of health services to the Commonwealth, as suggested by Tony Abbott many years ago, would be one way to overcome the waste and buck-passing between the Commonwealth and State governments in health. Kevin Rudd suggested that his government might take over state hospitals. Opinion polls suggested that the public would support this approach. But Kevin Rudd backed away. In passing it should be noted that the Commonwealth has no recent experience in running hospitals. It is not an easy task.

    But as a Commonwealth takeover is most unlikely, an alternative would be to establish a Joint Commonwealth/State Health Commission (Joint Health Commission) in any State where the Commonwealth and a State government can agree – a coalition of the willing, a Commonwealth/state partnership on a state by state basis.

    It is envisaged that the joint commission, with shared Commonwealth/State governance would be responsible for funding, planning and integrating all health services in that State. Consistent with an agreed plan, the Commission would then buy health services from existing providers – Commonwealth, State, local, NGO and private.

    A political agreement between the Commonwealth and any State is essential. If this political agreement is achieved, we would see a more cohesive and integrated health service, delivered much more efficiently. Once the benefit was clear in one State, hopefully other States would follow.

    I believe that this proposal would have strong public support. We are tired of the blame game.

    Either the Commonwealth government or any State government could initiate the breaking of the impasse.

    Background

    The Commonwealth Government provides about 43% of national health funding and the State Governments and territories 26 %. Another 31% of funding is from non-government sources (mainly individual users of health services).

    In both the NSW and SA health reviews that I chaired some years ago, a view was widely expressed that it’s all very well for State governments to review their health systems, but a major problem is the inefficiency, fragmentation, gaps, cost and blame shifting which results from the different roles of the Commonwealth and State governments in health’. This view was expressed, not only by those working in the health system, but also by the community generally. It was also frequently expressed by the media. The problem of divided responsibilities is well understood. The public doesn’t really give a hoot who plans and delivers health services. The public’s real concern is that the services are provided efficiently and equitably.

    Integration of commonwealth and state health functions are essential. Professor John Dwyer, in this blog, estimated   that more than 600,000 state hospital admissions per year could be saved if there was more timely community intervention which is funded by the Commonwealth.

    A solution requires a political agreement between the Commonwealth government and at least one State. The political issue cannot be avoided and attempts to get around this issue are likely to be unsuccessful, time-consuming and cumbersome. A bureaucratic or organisational response to a political problem will be unsatisfactory. The issue must be addressed politically. If there is political agreement, governance, financial, administrative and other issues could be successfully managed.

    Such an approach would not produce a unified national health system, but six (excluding the territories for the moment) joint health systems which are State-based. Nonetheless, this would be superior to the present division and fragmentation. The six State-based joint commissions may also better reflect the different history and needs of respective States. One size doesn’t necessarily fit all.

    The states may also be now more interested in what is proposed here because the 2014 budget suggests that over the next 10 years the Commonwealth will contribute $ 50 b less to state hospitals than the outgoing Labor government proposed. There was no certainty that this 10 year funding would have remained in place but I don’t think there is any doubt however that the Abbott government will attempt to shift more responsibility to the states for hospitals and schools.

    A Joint Health Commission in any State where the Commonwealth and the State could agree would have the following characteristics.

    1. Coverage of Joint Health Commission

    The wider the coverage the better to ensure real and comprehensive resource allocation and integration of services across the full continuum of care. The following programs should be included as the planning responsibility of the Joint Health Commission.

    • State Health (including Health Care Agreement)
    • High level residential aged care
    • Department of Veterans’ Affairs (DVA)
    • Home and Community Care (HACC)
    • Commonwealth Regional Health Services in rural and remote areas.
    • Medical Benefits Scheme (MBS)
    • Pharmaceutical Benefit Scheme (PBS)
    • Aboriginal Health
    • Local Government health
    • NGOs (e.g. nursing services)
    • Public health

    State Health, HACC, etc. would tender for the provision of services to the Joint Health Commission. Similarly, local government and NGOs would tender, although allocations to them would probably need to be made through the State Health department.

    Private hospitals could probably be excluded from this coverage, as they depend on private contributions rather than direct government funding – except for occasional seed money. But provision should be made for private hospitals, along with local government and NGOs, to tender for supply of services to a Joint Health Commission, (see 3 below). The private delivery of health services should be encouraged where it is consistent with the state-wide plan and is delivered efficiently.

    Importantly, existing providers would continue to operate and provide services, and where appropriate, ministers – both Commonwealth and State – would continue to be responsible for their own services. But those services would be purchased by the Joint Health Commission as part of a state-wide plan, which I refer to under ‘functions’ below.

    2. Pooled Funding of Joint Health Commission

    The Joint Health Commission would receive a negotiated pooled allocation of funds from the Commonwealth and the State government. which reflected the coverage of programs for which it would be responsible (see 1 above), with appropriate population growth and cost indexation add-ons. As a starting point the shares of the two governments would reflect their current funding shares. Changes in the shares and total funding would be subject to the advice of the National Health Performance Authority (NHPA). That Authority would provide public advice to the two governments. The two governments would need to agree on annual funding arrangements.

    Whilst confidence in the funding formula is developed, it might be useful to consider shadow funding in the first 3 years and move to actual pooling of funds thereafter.

    3. Functions of Joint Health Commission

    1. a) Shared Resource Allocation through the purchase of various services from providers – Commonwealth, State and local government, and NGOs as part of a joint strategic plan.
    • In this case, shared resource allocation can be achieved through the establishment of a minimum set of Commonwealth and State programs.
    • The major changes associated with the JHC would provide an opportunity to move from producer dominated health care delivery to an output/patient focussed delivery system. So many of our health programs reflect provider interests; the MBS reflecting the interests of doctors and the AMA, the MBS reflecting the interests of the Pharmacy Guild and Big Pharma and public hospitals reflecting the interests of their providers, state governments. Patients are a secondary concern. We need to shift to a patient focussed health system in such key areas as chronic, acute and occasional care.
    • Funding would be allocated with agreed short and long term integrated outcomes, rather than siloed program outcomes, with specified standards and levels of performance.
    1. b) Shared Performance Management

    Oversee continuous improvement of the health system, monitor progress and establish reform targets and timelines:

    • Development of standard measurement
    • Benchmarking
    • Patient-centred best practices

    The NHPA provides an excellent opportunity for the establishment of a system that can meet the needs of consumers, community and health services. The NHPA can provide an approach that examines health status and outcomes, determinants of health, and health system performance.

    The NHPA should facilitate the mapping of progress for the population of a State, region or service. It could also be used to examine progress in tackling a particular health problem (e.g. aboriginal health), and to take a wider look at the interface between health and other government departments, the private sector and non-government organisations.

    4. Joint Health Commission Governance

    The following features could be included, and would ensure full Commonwealth and State government input into the state-wide plan:

    • Membership of the board should be high level to enable strategic decision-making on broad and longer-term issues.
    • Maximum transparency and disclosure of the Joint Commission’s work and final recommendations in order to neutralise special pleading and vested interests and to ensure public understanding and support.
    • The board of directors must have clear ‘governance’ responsibility and not a junior role. They should reflect the broad interests of the whole community and not be seen as representative of the Commonwealth or State or ‘insider interests’ that so dominate health systems in Australia.
    • Independent chair appointed by the two Ministers from a short list provided by the respective Commonwealth and State Health CEOs. It might be useful to have the chair from another State.
    • Apart from the chair, no jurisdiction to have more than 50% representation.
    • Representation could include other Commonwealth and State jurisdictions (e.g. Indigenous Affaires) and people having experience in the private sector.
    • The board would appoint the CEO who would be responsible to the board and not the two jurisdictions.
    • The board would approve the strategic plan and budget.
    • A constitution may be useful to provide more user-friendly objects, role, function and operating procedures, including engaging the private sector.
    • Subsidiarity should be an important principle for governors in developing the state-wide plan. Management and service delivery should be driven down to the lowest and most local level possible, consistent with state and nation-wide standards.
    • The Board should have a small secretariat, but rely on Joint Health Commission for planning etc. It must avoid a new level of bureaucracy.
    • Board costs would be shared by Commonwealth and State.
    • The Commonwealth and State minister would be responsible for negotiating high-level policy principles, including overall funding on the advice of the board. This would help reduce the risk of the board dividing on Commonwealth/State lines. Ministers must reach broad agreement if the Joint Health Commission is to work.
    • The board should be responsible to the Commonwealth and State minister, with one financial report to both. If there is not agreement between the two ministers, there would be a public dispute resolution procedure which would encourage cooperation and dialogue between the two ministers. This would encourage public trust in the integrity of the process. I would expect that this would produce an agreement in almost all cases. If resolution is not possible, the Commonwealth minister would prevail; given the need for a stronger national role and that the Commonwealth Government provides 43 % of national health funds compared with 26 % by the states.

    These governance arrangements could be reviewed in 5 years.

    Summary   

    A Joint Health Commission established upon agreement of any State with the Commonwealth would be a substantial improvement on the present arrangements. It would help break the impasse on federalism and better integrate health services. It requires a political decision between the Prime Minister and premier.

    The public is tired of the blame shifting and fragmentation in health and would respond to a sea change such as this. Such a joint health commission in any State that agreed would help achieve what both of them are seeking in health – a better integrated health system and a favourable community response, A committed Commonwealth government could use its financial leverage to make such an offer attractive to the states.

    A Joint Health Commission in any one State could begin to address the ‘big ticket’ problems in health delivery – the Commonwealth/State fragmentation, an eroding primary health care system, an antiquated workforce structure and obvious system failures in safety and quality.

    Of course, the fragmentation in health is not just caused by Commonwealth-State fragmentation. The two big Commonwealth programs – MBS and PBS – are not effectively integrated.

    All these big-ticket issues are lost sight of in the argy-bargy of Commonwealth/State blame and cost shifting.

    Not only would a Joint Health Commission in one State be a substantial improvement, it would also be very symbolic, demonstrating that governments can address hard political issues in a cooperative way.

    We must stop asking continually for more money or tweaking the health dollars, when many problems are structural. A lot of health spending is counter-productive – throwing money at problems to get them out of the media or for short-term political gain, rather than solving systemic problems. Any increase in health dollars must be accompanied by system change. A Joint Health Commission starting in one State is a sound way to begin breaking the impasse.

    The key is political will by ministers. If there is the political will, the governance problems can be resolved.

    There is no reason that the principles proposed above in health could not be applied in other fields such as education.

    John Menadue AO was formerly Secretary Department of Prime Minister and Cabinet, Secretary Department of Trade, Ambassador to Japan and CEO of Qantas.

  • Alex Wodak. Endgame in the protracted drug policy debate: are we there yet?

    The long running debate about illicit drugs policy has moved a great deal in the last five years. But social policy reform is a different matter from a debate. Actual reform usually takes many decades.

    The recent growing consensus regarding the abject failure of a criminal justice dominated approach to drugs is very encouraging. Retired and even serving police commissioners have been lining up before the microphones to acknowledge the comprehensive failure of efforts to date. The seizure announced 16 February of 720 litres liquid methamphetamine, said to be worth $1.2 billion, represents the largest drug bust in Australia’s history. But there was little optimism that even a seizure of this size would make a difference to the market. In 2014, 91% of Australian drug users surveyed reported that ice was ‘easy’ or ‘very easy’ to obtain.

    In 1994, I went with Ms Ann Symonds, a (then) member of the NSW parliament, to see the (then) Minister for Health, Senator Graham Richardson. My message was that the drug policy he was responsible for could never be effective. I showed him a report written by a US coast guard operator who had estimated the numbers of pedestrians, cars, trucks, buses, containers, ships and planes entering the USA every year. The official had also estimated the volume of cannabis, heroin and cocaine entering the US every year. He showed that US authorities had a better chance of finding a needle in a haystack than finding most, let alone all, of the drugs entering his country.

    Seventeen million passengers and several million containers arrive in Australia every year. Only three in every 1,000 containers are searched. Containers carrying frozen food have to be thawed out before they can be searched and this involves potentially considerable financial loss and inconvenience as the once frozen food has to then be discarded. Somehow Australia’s 27 thousand km coast line has to be watched 24 hours a day, 365 days a year.

    Senator Richardson seemed to accept the logic of the presentation. As he showed us out, he suggested that Australia could not move faster than the international community would allow us to do, that the attitude of leaders of the medical profession to any change in drug policy would be critical and that change would also not be possible without widespread community support.

    Twenty-two years later, the shape of future global drug policy is becoming clearer. The international drug policy consensus is now irrevocably broken. Consequently, countries now have much more freedom to design a drug policy that the community and its politicians believe is appropriate for its circumstances rather than accept the one size fits all approach required till now.

    The threshold step required is to redefine drugs as primarily a health and social issue. Several steps then follow. First, criminal sanctions for the production, sale and use of drugs will have to be reduced and, where possible, eliminated. Second, drug treatment will have to be expanded and improved to reach the same level as other health services. Third, as much of the drug market as possible will have to be regulated. Parts of the drug market are already regulated including methadone treatment for heroin users, the needle and syringe program and Sydney’s Medically Supervised Injecting Centre. Fourth, the community will have to ensure that life for young people should not require intoxication to be bearable. This means reducing poverty and improving the housing, education and employment conditions for our young people, especially our disadvantaged youth. When life is bleak and without hope, a few hours of chemical vacation becomes quite attractive. Policy change should occur in small increments with rigorous evaluation of policy effectiveness and adverse effects.

    It is easy to dismiss the complexities of a political resolution of our current drug policy mess. But our politicians have at times achieved wonders. In the 1980s, politicians from all the major parties put aside their differences and worked together to prevent Australia being over run by HIV. Australian politicians also excelled themselves in tobacco control. These were world-class achievements against huge obstacles. Australians owe our politicians a debt of gratitude. The introduction of heroin-assisted treatment in Denmark was brought about by all the country’s political parties agreeing privately to jointly support the decision. The political gridlock of recent years in Australia is not encouraging but that will eventually pass.

    The costs of political action on drug policy are falling while the costs of inaction are rising. The time for ever-more gesture politics on drug policy is slowly coming to an end. When dealing with communities locked into dysfunctional policies, just as when dealing with alcohol or drug dependent patients or loved ones, it is critical to retain a sense of hope.

    It is important to remember our history. Australia permitted medicinal use of heroin until importation and production was banned in 1953. Edible opium was taxed and regulated in Australia until 1906. Medicinal cannabis was used lawfully in Australia until the 1970s. In the US, Coca Cola contained cocaine until 1903.

    The required changes in drug policy are substantial. But we and other countries have made equally substantial changes before. Faced with such momentous change it is easy to convince ourselves prospectively that the reforms required are unachievable but we may end up reflecting in retrospect that change was inevitable.

    In a recent Essential poll (16 February), 68% thought the ‘Federal Government should do more’ about illicit drugs followed by obesity (57%), food safety (50%), smoking (46%), Zika virus (36%), HIV (34%) and Ebola (27%).

    Respondents also rated illicit drugs (44%) as their most serious concern followed by food safety (26%), obesity (25%), smoking (23%), Zika virus (16%), HIV (14%) and Ebola (12%). This suggests that voters expect Australian governments to act effectively on illicit drugs sooner rather than later.

    Dr Alex Wodak AM is President of the Australian Drug Law Reform Foundation

     

  • Peter Gibilisco. Neoliberalism and its Perceptions

    Politics has changed so much over the years; our political climate is unstable, since 2007 we have had five different prime ministers. A person in my position would ask how does this affect people with severe physical disabilities?

    Neoliberalism has its aim to put into question all collective structures capable of obstructing the logic of the pure market. Such a belief allows one to question the ideology behind the welfare state, progressive taxation and other social policies that can lead to an egalitarian society. Their ideology harvests the sentiment that many welfare recipients are lazy and should do more to help grow the economy. But rather neoliberals are persistently oriented towards supporting a society in which self interest prevails and that is why they give all their energy to policies that claim to further the individual pursuit of wealth. That is, the individual pursuits that are deemed worthy of government support are those that are beyond those living on the “other side” of the great divide between the rich and the poor.

    I am lucky enough to live in Australia but even with my poor eyesight I am still able to witness the degradation of impoverishment upon ordinary people whenever I visit my local community, Noble Park.

    Individual pursuits, whether of the rich or the poor are always, at least to some extent, justified in terms of one’s self-interest. And this goes a long way to explaining the powerful and dogmatic reasoning behind the powerful ideology as it is supported by those who are very rich. And that is confirmed by the equally dogmatic phrase: ‘power is money’.

    Liberal political and economic policies are dominated by this ideological viewpoint. Such policies have been integral to political economies all over the world, in both developed and developing countries. The re-birth of Liberalism as Neoliberalism was seen as the answer to the western world problem of stagflation, which reared its head in mid 1970s. Hugh Stretton put it well:

    Alternative strategies for dealing with the offending stagflation would advantage different classes, parties, industries. Economic reform was as usual a political task. Other interests saw opportunities to change the direction of development to improve the mixed economies’ efficiency by means which would incidentally make the rich richer, business freer, welfare cheaper and the poor more self reliant. Those means were described as de-regulating, privatising, restoring competition, cutting welfare, “rolling back the boundaries of government” (Stretton, 1986:7).

    Neoliberalism is a political economic theory and practice that has emerged with greater and greater appeal since the 1960s, and since the 1980s it has increased in prominence at the level of public policy formulation. The neoliberal approach rejects social democratic doctrines. Neoliberalism focuses politically on the establishment of a stable medium of exchange, the reduction of localised rules, regulations and barriers to free-ranging commerce, and the privatisation of state-run enterprises. This contemporary and dominant economic ideology of most western countries is referred to with a “neo-“ prefix because it is a latter-day version of the classical liberalism that initially arose in the 18th century. Moreover, neoliberalism claims to be a political system designed to highlight both the political limitations of the market economy in the nation-state, and the economic efficiency and effectiveness of the market economy when it is freed to operate on a global scale.

    Classical liberal economics was developed by Adam Smith, and we can sense its appeal at what we now say was the beginning of the industrial revolution. Smith argued that government intervention disrupted the natural order of society. According to Smith, the natural order of society can be defined as a society left to its own devices. Smith based his economic beliefs on the argument that most economic self-interest is altruistic. This can be noted in his famous quote from The Wealth of Nations:

    ‘It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest. We address ourselves. Not to their humanity but to their self-love, and never talk to them of our own necessities but of their advantages.’

    Now, after thinking about this for some years, I come to the view that something like this principle is working itself out in my own relationship with what is now referred to as the “disability sector”.

    As it is commonly understood altruism is about selflessness, it is a principle or practice of concern for the welfare of others. But my situation seems to be endorsed by Smith in the above quote. In the social service delivery to which I am a recipient, involving a personal care attendant, the “altruistic effects” that actually work themselves out in the workplace becomes a friendship circle – workers and clients are mates. This workplace is actually our home in which the residents are actively welcoming the visitors to their “space”, under their private “roof”. It is not only those paid for their work in this workplace who have an interest, a general self-interest, in forming what takes place. After all it is also a place sustained by the friendships that are generated.

    According to Smith, this classical liberal system would provide for an economic infrastructure that could not only provide economic benefits, but also help promote a proud, virtuous and motivated society (Gibilisco). Amartya Sen portrays the mixed emotions of self-interest:

    ‘Can you direct me to the Railway Station?’ asks the stranger. ‘Certainly,’ says the local, pointing in the opposite direction to the post office, ‘and would you post this letter for me on your way?’ ‘Certainly,’ says the stranger, resolving to open it to see if it contains anything worth stealing (Sen, cited in Stretton and Orchard, 1994:51).

    During an interview with me, Hugh Stretton explained his dissent from this ideological interpretation of Adam Smith. He pointed out that Smith never said that the interests which prompted people’s economic decisions and behaviour were all selfish. Smith’s first book The Theory of Moral Sentiments was about our feelings, and concerns about other people’s needs, safety and happiness, as well as our own. When he said, in The Wealth of Nations, that he owed his breakfast to his baker’s self-interest, there is good reason to think that Smith meant the baker’s joy in his skills and work, and pride in the quality of his bread and the pleasure it could give his bread’s consumers, as well as the money it earned him.

    Smith certainly believed that people’s generous feelings, and concern for others’ safety and prosperity, as well as their own, could join in determining their market choices and their social and political values and behaviour. Because it comes from the neoliberal ‘bible’ (i.e. Smith’s The Wealth of Nations) I think this observation must play a vital part of any effective attack on the neoliberals’ assumption that material self-interest is the sufficient cause of market efficiency, which in turn, they then suggest, is a necessary condition – many even think of it as a sufficient condition – of a good society.

    Meritocracy

    Meritocracy is defined by government policies promoting the principles of merit. The actions pursued by advocates of meritocracy are fundamental to the belief that people get out of the system what they put into it based on what they deserve according to market based principles – i.e. what they produce and how what they produce performs in the market. It is a political vision for the future based on merit, and opposed to the traditionally conservative theories of the aristocracy. However, Michael Young a well-known writer on the subject has argued that “meritocracy is even worse than aristocracy because it attempts to acquire plus points because it connotes power and privilege as merited rather than born with”. He further argues that meritocracy is detrimental to those with disabilities. Young in his 1998 article titled: “Meritocracy revisited: assessing the social implications of meritocracy” puts it like this:

    … showing how sad, and fragile, a meritocratic society could be. If the rich and powerful were encouraged by the general culture to believe that they fully deserved all they had, how arrogant they could become, and, if they were convinced it was all for the common good, how ruthless in pursuing their own advantage.

    As a result, today we may have the worst of both worlds. Social reality, as portrayed by today’s media, tells us that the rich are getting richer, while the poor are getting poorer. In the case of people with disabilities, their capacities, under such a system, are rarely deemed meritorious or worthy of reward.

    Moreover, this brings into question, possible deplorable links between meritocracy and equal opportunity.

    However, we need to keep in mind that the concept of individual merit had been introduced as far back as Michael Young’s 1956 book The Rise of Meritocracy. In a more recent article, he has suggested that:

    [a] line of argument that is also made much of in the book is that a meritocracy can only exist in a full form if there is such a narrowing down of values that people can be put into rank order of their worth.

    This connects with a political insistence on the rise of a new form of meritocracy, which can also be prejudicial and ultimately discriminatory against those with socially defined lesser abilities or different abilities. Young argues that what one is born with, or without, is not of one’s own doing. To put it in a more crude form of discourse, being a member of the “lucky sperm club” confers no moral right to advantage. But such a view of “luck” does seem to align with the political-economic doctrines of some advocates of neoliberalism

    This article is dedicated to the memory of my friend and mentor, Hugh Stretton.

    I would like to thank Bruce Wearne and Christina Irugalbandara.

    I would like to promote this worthy new organisation http://www.uvpd.org.au/index.html

  • Jonathan Page. The Inspiration of Vietnam

    Postcard from Hanoi:

    I have been an oncologist for some 35 years, treating adults with advanced cancer. Despite a far greater understanding of the disease, with the discovery of quite remarkable “targeted” therapies, most patients still die of this disease. Many are not suitable for these treatments, many don’t respond or respond poorly and briefly, and of course many simply present very late in the course of the cancer.

    As an oncologist I am thus confronted by uncertainty, sadness, despair and grief on a regular basis, as are all the members of the oncology team, but at times leavened by the joy of success, the gratitude of families and the deep insights into the human “soul”.

    Through my own adult life I have had a mixed relationship with death, particularly my own, beginning with a simple non-acknowledgment, then noticing an increasingly intrusive terror, with quite visceral reactions to certain patients as they moved towards their own demise under my care. I was in my forties at that time and would experience profuse sweating, tremors, nausea and a curious clouding of consciousness. I thought I may have malaria (a noble affliction) but to whom should I go for wise counsel? There was little wisdom to be found. Over time my symptoms evolved into a depression, but this only became clear to me years later, in retrospect.

    Technically I had been suffering “thanatophobia”, that is “fear of death”. A common complaint, but rarely considered (in our society) since we prefer a “cultural denial”. Thus, more recently, over 15 years or so I have pursued a deeper understanding of death, my own and that of others. This universal phenomenon unites us all. As John Donne reminds us: “any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls: it tolls for thee”.

    I have learnt much from Joan Halifax who wrote “Being with Dying: Cultivating Compassion and Fearlessness in the Presence of Death” and the late Stephen Levine who wrote both “Who Dies? An Investigation into Conscious Living and Conscious Dying” and also “A Year to Live: How to Live this Year as if it were your Last”. I have completed a one year course based on this latter book.

    Death has now become less fearsome to me and more interesting! As Buddhism has told us for 2,600 years, a regular meditation on one’s own death will invigorate one’s life and shed some light on the true nature of the world and the meaning of our own experience.

    The complete practice of oncology requires some exploration of one’s own mortality, to more deeply understand the experience of each patient, to be of service and, importantly, to learn. There is a long history in most cultures of a specific “companion to the dying”. Medical practitioners including oncologists are ideally placed to occupy this role.

    Over the years I have been greatly supported by a mindfulness practice including regular meditation. Again, this cultivation of mindfulness, bringing one’s mind into the present moment with awareness and “heartfulness”, is an ancient Buddhist practice, taught also in other spiritual traditions and in more modern secular environments. This practice enables a deeper understanding of one’s inner emotional life, allowing one to be more “available” for patients, rather than locked within a defensive carapace. The risk of “burnout” and depression is far less.

    Strangely (or perhaps not) these skills have never been a substantial part of medical education or the oncology specialty, with some notable exceptions such as the programme at Monash University in Melbourne and the long-running “The Healer’s Art” course developed by Dr Rachel Naomi Remen at University of California, San Francisco School of Medicine.

    What about Vietnam?

    I have had the privilege of visiting this astonishing country many times, firstly as a medical student in 1974, then more recently with colleagues, supported by the Hoc Mai Foundation, travelling to Hanoi to teach Medical English, oncology and other specialty topics. However, at a deeper level, I (and I suspect my colleagues also) travel to Vietnam to learn from this resilient, gracious and warm-hearted people. I feel there is a spiritual nature to the Vietnamese society, reflecting elements of Buddhism, Confucianism and Taoism.

    It is helpful to leave one’s ‘ego” or one’s “sense of an important self” at home and thereby immerse oneself in this enriching and restorative culture. The Vietnamese (to my eye) seem to embody a friendly mindfulness, a universal respect, remarkable patience and lack the reactivity so often seen in more “Western” cultures.

    I am looking forward to a further visit to Hanoi, to renew friendships and, importantly, to imbibe the pervasive spiritual vitality in that city that now has a direct positive impact on my work.

     

    Jonathan Page, Medical Oncologist, Manly and The Mater Hospitals, Sydney, NSW.

  • John Menadue. Postcards from Hanoi.

    I will be in Hanoi from February 17-26, attending a Hoc Mai Foundation workshop on learning from each other about health issues in Vietnam and Australia, and assisting in the learning of English in the health field. Hoc Mai means ‘forever learning’.

    The foundation was established in the late 1990s. University of Sydney was a very active partner.  Over 30 groups of Australian clinicians and others interested in Vietnam have travelled to Vietnam since the late 1990s. 29 Australians will be in our group in Hanoi.

    Emeritus Professor Kerry Goulston will be leading our group. He has made almost 30 visits to Vietnam as part of the Hoc Mai Foundation.

    During this February visit, a few of us will be sending ‘postcards’ from Hanoi. The first postcard  from Jonathan Page, a medical oncologist, follows.

  • John Menadue. Hoist with their own petard

    Private health insurance funds like NIB are complaining about high specialist fees. But these very same funds are major contributors to the problem. And it is a problem. In the last 30 years we have seen a dramatic increase in specialist fees.

    A major contributor to this increase in specialist fees is the ‘gap insurance’ that private health insurance firms offer. Gap insurance effectively underwrites specialist’s ability to increase fees and weakens Medicare’s ability to cap fees. In the AFR today, NIB gives two examples of how this is done. For prostatectomy (surgical removal of prostate) the Medicare Benefit Schedule Price is $1,939, but with gap insurance NIB offers to cover this up to $2,941. For knee replacements, the Medicare Benefit Schedule Price is $1,318, but with gap insurance NIB offers to cover this up to $2,014.

    But that is not the end of the story by any means.

    The growth of private health insurance makes it more difficult for Medicare to control fees. Instead of the Medicare Benefit Schedule Price capping fees, the Medicare price is just the first stepping stone to higher fees. Whilst NIB will pay up to $2,941 for a prostatectomy, compared with the $1,935 in the Medicare Benefit Schedule, the AMA has a recommended fee of $4,465. And on top of that AMA recommended price, NIB tells us that some surgeons are charging another $6,000. Yet we have a Royal Commission on Trade Union behaviour!

    NIB reveals the same pattern for knee reconstructions. The Medicare Benefit Schedule Price is $1,318 but that is ratcheted up to $2,014 through NIB gap insurance. And then it goes up to $3,960 to the AMA recommended fee. To top this off, NIB advises that some surgeons are charging between $4,500 and $5,500.

    There are many reasons why health costs are rising. Private health insurance companies like NIB and specialists are major contributors.

    The ‘market’ that economists talk about does not work in the health sector. Providers, doctors and hospitals, have the power to set prices as the above figures show.

    With the ‘market’ not working there are really only two ways for governments to avoid price and fee gouging. The first is through price control. That is largely the way that Japan keeps its healthcare costs down. But that approach is unlikely in Australia given our constitution and political situation.

    The second is to have a single public payer to counter the power of providers. That is generally what countries with successful health schemes do.

    Medicare was designed as a single payer. But its power has been diluted by the growth of private health insurance with gap insurance. We are steadily moving down the disastrous US path. And the Australian taxpayer is paying $11 b. p.a. to subsidise these destructive private health insurance funds.

    We should have no sympathy for NIB, BUPA and Medibank Pte about rising costs. They are major contributors to the problem. And they get bundles of money from taxpayers despite the damage they do.

  • John Menadue. Part 2. How we deliver healthcare is as important as the funding of healthcare. Medicare has degenerated into a payments system.

    In Part 1 I focussed on the importance of improving the delivery of health care and not just funding.

    In Part 2 I will focus on specific areas where costs should be reduced.

     

    Part 2

    Getting costs down

    • The government should abolish the subsidy for private health insurance which costs all up about $11 billion p.a. This welfare subsidy is one of the fastest growing areas of Commonwealth government health expenditure. We have never had high income welfare recipients on such a scale before .PHI is the Damocles sword hanging over our health system. PHI is the reason for the disastrous American health system. High levels of private health coverage in Australia are achieved not through the attractiveness of the products on offer but mainly through the carrot of the tax subsidy and through the stick of penalising the uninsured. The subsidy favours the wealthy, is inefficient, has underwritten rising specialist fees through gap insurance, has not taken the pressure off public hospitals and has weakened Medicare’s ability to control costs. PHI discriminates against country people where there are few private hospitals. The immediate abolition of this subsidy would do more to improve our health system than anything else. This is welfare big time- far more than the welfare we used to pay to the motor industry. The abolition of the $11 b. subsidy would more than fund a universal dental scheme. Alternatively, say $5 b. of the saving by abolishing the subsidy could be paid directly to private hospitals through an activity based funding arrangement. It is absurd that public funds should be churned through high cost private health insurance rather than being paid directly to hospitals. Before the Howard government, Commonwealth government funds were paid directly to private hospitals, but this was discontinued. Direct Commonwealth funding for both public and private hospitals would also substantially improve the integration of hospital care. But private hospitals would oppose this because they find it much easier to twist the arms of private health insurance companies. And some of the major hospital groups, particularly Ramsay, are generous donors to the Liberal Party.
    • We need a more productive workforce. Health is the largest and fastest growing sector in the Australian economy. Despite all the talk of improving productivity in Australia no-one has been game to take on the entrenched privileges in the health workforce.Where is the honesty and consistency here? The blue collar workforce is fair game but not doctors and lawyers. We need expanded roles across the board particularly for nurses, pharmacists, allied health workers and ambulance officers. The Productivity Commission in its February 2007 report estimated that a 5% improvement in the productivity of health services would deliver savings of about $3 billion p.a. This is a very conservative estimate. The health sector in Australia is rife with demarcations and restrictive work practices. eg 5 % of normal births in Australia are delivered by mid wives. In the Netherlands it is 70%, in the UK 50% and in NZ 95%. We have a few hundred nurse practitioners when there should be thousands. The work practices in most industries are light years ahead of the work practices in the health sector.
    • Fifteen years ago 45% of doctors were GP’s. It has fallen to about 35% yet we know that care is most equitably and efficiently delivered by GP’s. Specialists are reactive and we all know they have become very expensive thanks to gap insurance provided by private insurance companies.
    • We could save about $2 billion p.a. in drug costs if we paid drug suppliers the same prices that are paid in NZ. We also pay a high price for the protection of pharmacists through the 5000 limit on the number of community pharmacies and the restrictions on where new pharmacies can be located. Pharmacies cannot be established in supermarkets.
    • We need to raise productivity in our hospitals. The Productivity Commission suggests that the productivity gap in best practice in public hospitals ranges from 3% to 89%. In private hospitals the range is 22% to 37%. There are major governance problems in many hospitals with a dis- connect between management and clinical functions. Running hospitals is very difficult with clinicians coming and going from private practise like the cottage industries of old.
    • The Commonwealth/State fragmentation in healthcare results in blame-shifting, the evasion of responsibility and higher costs. If for example the Commonwealth Government or a joint Commonwealth/State body had responsibility for all health care funding in a state or region, there would be a clear incentive to focus on treatment in the community and in homes to ensure that the high cost hospitals are really a last resort. The National Health Performance Authority found that in 2013/14 over 600,000 hospital admissions for 22 conditions could have been avoided with timely interventions in the community, mainly by GP’s. But the problem in doing this is that the Commonwealth government funds general practice and state governments operate hospitals.
    • The real elephant in the room in health care cost reduction is avoidable mistakes, including deaths. They are euphemistically called “adverse events”. But Ministers, clinicians and managers do their best to avoid the issue. Based on earlier surveys in NSW and SA I estimated, very conservatively the cost of avoidable mistakes in our health sector at $5b pa (see my blog of June14, 2013). Despite a great deal of money and effort there is no sign of improvement. Insiders won’t solve the problem Good people are caught in a bad system.
    • Only last week, Medibank Private said that $800 m. p.a. could be saved if a reference pricing system with Australian and global benchmarks was introduced for prostheses such as for hip and knee replacements, plates and pacemakers. Medibank Private said that prices for identical products could be 45% lower in the public system compared with the private system. With differentials like that it is no surprise that private health insurance premiums have increased at three times the rate of inflation.

    The quality of our health care is generally good but waste and inefficiency is deep and widespread.

    We need to address waste and costs in a measured way. We should not panic, but we should get it done. Australian healthcare costs are 9-10% of GDP. This is not high by world standards. It is below the OECD average. A major reason why we have been able to do better than others is that we have Medicare as a public insurer. One lesson is clear all around the world. The countries that have high levels of private health insurance, like the US, have high costs.

    A fundamental problem in the health sector is the way we deliver healthcare. But we keep focusing only on funding. We have a horse and buggy health delivery system that is unfit for the 21st Century. Medicare takes that horse and buggy delivery system as a given.

    I have almost given up hope that the ALP will restore Medicare to what was intended, a single payer and a strong public insurer.

    The vested interests don’t want change in the way we deliver health care. They must be delighted to see how gutless the ALP is.

    More and more money will not necessarily improve the delivery of health care and neither should we expect it to. It will mainly entrench a lot of bad habits and the position of vested interests.

     

  • John Menadue. Privatising Medicare’s payments system and the erosion of Commonwealth Public Service capability.

    The government has apparently accepted the advice of the Commission of Audit that Medicare’s payments system should be reviewed with the possibility of privatisation. The payments system includes Medicare, the Pharmaceutical Benefits Scheme, Aged Care Services and Veterans’ Affairs.

    It sounds like another expression of neo liberalism, that only the private sector can be efficient and cost-effective.Let us see whether that is so through market testing. I remain sceptical.

    As a regular user of Medicare services and payments, I am not aware of problems in the payments system. But if there are problems, the government should fix them.’.

    This proposal on privatizing Medicare payments is part of the continuing trend to degrade government capability in both policy and administration of programs. The Australian Public Service is becoming short of senior people who understand the complex world of business strategy and those things required in commissioning the delivery of services or planning infrastructure investments and their delivery. In social policy it is not at all clear that the Commonwealth now has the people who understand the big systems that are so essential to a large part of what the public sector does.

    In between jobs, the new Secretary of PM & C put the problem this way in an interview with Laura Tingle in the AFR in May 2015. He said:

    ‘I think our institutions are being eroded in their capability and eroded in public trust. … Over time large parts of the public service have lost their policy development edge.’

    He has been replaced in Treasury by John Fraser, most recently a banker. Yet much of the governments’ deficits around the world have occurred as a result of governments having to bale out the banks for poor decisions and poor risk management.

    The problems that we apparently have with Medicare are common to many agencies. Good accounting in government has been abandoned and replaced with narrow financial metrics. Outside a few agencies, there just isn’t the capacity to do proper cost/benefit analysis. Many decisions are made on the run on the basis of cash outlays over four years.

    This failure of government administration suits private providers who exploit ministers’ and bureaucrats’ lack of analysis capacity and the domination of short-term cash outlays in the public presentation of the budget.

    It also suits neoliberals to get as much off the budget as possible even if the community is worse off. This is happening in the health sector. Some government expenditure is relieved by pushing business towards private health insurance, but we know that administrative costs of private health insurance are three times higher than Medicare. Furthermore we know that the growth of private health insurance makes it harder for Medicare to control fees. So whilst the budget may look a little better, the community is much worse off.

    We have had glaring examples of how government policy, capability and operations have been run down to the benefit of accounting and consulting firms who come and go with projects and their ‘economic models’, but there is little building of intellectual capital in the process.

    Staff numbers in the Australian Taxation Office have been cut back at a time when we have record tax avoidance and hundreds of our major companies paying no tax at all.

    I have rarely seen a root-and-branch criticism of a department as we saw with the Australian Public Service Commission Capability Review of the Department of Health and Ageing last year. The Secretary of the Health and Ageing at the time is now Secretary of Finance.

    The Department of Immigration and Border Protection has become securitized with a focus on border protection and control at the expense of nation-building and humanitarian programs. Senior and competent people with knowledge in nation-building and refugee programs have left the department. We see the result most graphically in the snail-pace response to settling 12,000 refugees from Syria. Less than 10 have arrived! Canada has put us to shame.

    The Attorney General’s Department failed to tell security agencies about the risk of Mann Haron Monis weeks before he entered the Lindt Café. The Attorney General’s Department has carriage of the policy and implementation of ‘meta data’ through the Data Retention Act. We were told at the time it was urgent because of the terrorist threat. But the policy cannot be introduced until the end of 2017at the earliest because of flawed implementation. AG’s department has just not been up to the job.

    One reason for the pink batts problem was the loss of  implementation capability in the Department of the Environment. That same department has bungled the approval of the Carmichael mine.

    The Department of Defence is subject to very little effective checking of its very expensive capital projects. It keeps making the same mistakes. As John Stanford put it in this blog on 11 December last year

    ‘Our defence acquisitions keep repeating the mistakes of the past, from mixing and matching systems inappropriately and accepting excessive risks, to allowing political judgements to override efficiency considerations and the proper regard for the public purse. In the new submarine acquisition, we seem to have learned nothing from the Collins Class procurement’.

    When the new submarines are delivered China and India will have nuclear submarines.

    The Department of Defence has a one-line budget appropriation which effectively denies rigorous examination of mega-dollar projects by the Department of Finance and others.

    The sorry story continues with the mega funding of roads. As Mike Keating and Lucas Fraser pointed out in the policy series in last year’s blog

    ‘A reasonable projection of planned road expenditures indicates that the accumulated stock of debt to FY 2023-24 could be of the order of $114 b. When added to the already accumulated debt, this amounts to a total accumulated road-derived public sector debt of $140 b. within a decade, a matter than until now has been entirely unreported’. Where is the Department of Transport or Infrastructure Australia when we have such gigantic and wasteful expenditures on roads”?

    There is a dismal and concerning story about how the capital of government is being deliberately eroded.

    We are paying a very heavy price for neoliberalism and the down-sizing of government that goes with it. The selling of Medicare’s payments system may be another step along this path.

    The coinage of the Australian Public Service is being seriously devalued. Can the threads of good policy development and administration be recovered? It is getting late.

  • John Menadue. Part 1. How we deliver health care is as important as the funding of health care. Medicare has degenerated into a payments system

    Part 1 of these articles will focus on the inefficient way we deliver health care, the many perverse incentives and the power of vested interests to resist reform in health care delivery.

    Part 2 will focus more particularly on examples of waste and inefficiency in health care delivery

    Part 1

    We have been told many times that our health system is unsustainable.

    To justify its case for an increase in the GST, the government was telling us that an increase was necessary because of rising costs in health and education. Now the GST is apparently off the table as Malcolm Turnbull retreats on yet another issue.

    Some premiers and commentators suggested that an increase in the Medicare levy was best because it was fairer than an increase in the GST. And we will hear a lot more from the premiers about health because the Abbott Government said it would cut $ 80 b from grants to the states for education and health over the next decade commencing in 2017

    But what is being avoided in all this confusion about budget repair and health costs is that there is no real discussion about the waste, inefficiency and low productivity in our health sector. We continue to focus on the funding of our health sector, but refuse to debate how the delivery of care – its cost and safety – can be improved. Medicare is overwhelmingly discussed in terms of funding only. It should also be about how those funds are spent to improve the delivery of health services. Basically Medicare funds an existing system of health care delivery. That needs to change.

    There are three main reasons for our failure to address the delivery problems in health care.

    The first is the power of the vested interests. These vested interests fight doggedly and selfishly to maintain their privileged position in health delivery. The principle vested interests in health are the AMA, the Pharmacy Guild of Australia, Medicines Australia and the private health insurance sector. In an earlier blog I said that the Health Ministers may be in office, but they are seldom in power. The vested interests –the providers- are really in power.

    A second reason for the failure to focus on delivery of health services is that politicians are afraid of the vested interests – doctors, pharmacists, pharmaceutical manufacturers and suppliers, and the private health insurance sector.

    The third reason is the failure of economists and other commentators to consider efficiency in the delivery of health services. These economists talk continuously about the need for appropriate incentives, but in the health sector many of the incentives are quite perverse – such as fee for service.

    As Ross Gittins put it in a recent SMH article, ‘Like so many of the interest groups, econocrats are obsessed with funding education and health rather than ensuring both systems are working in ways that have found a good trade-off between fairness and efficiency, and effectiveness.’ … See link to article.

    These economists that we hear and see so often in the media are mainly employed by the banks. They have little or no knowledge or interest in health economics. They tie themselves in knots over the need for IR reform and improvements in productivity in the workforce generally. But over the years I have never heard any of them address the appalling work practices and demarcations in our health sector which really go back to the 19th Century. Yet our health and welfare sectors employ 13% of our workforce, the largest sector by far. It is also the fastest growing. At its worst, our waterfront never had the appalling work practices and demarcations that still persist across our whole health sector. Clinicians justify our archaic work practices on the grounds of safety when it is really territory they are defending.

    Economists are yet to grasp that health consumers have little power over prices or quality of care. Power is with the providers-doctors, pharmacists, drug distributors and private hospitals. That is why a strong public insurer is essential to counter the power of providers. If there is not a strong public insurer we will follow the disastrous path of the US that has the most expensive and unfair health system in the world. But our economists who say they believe in markets will not recognise the failure of the health ‘market’.

    On 4 Corners several months back, Norman Swann suggested that waste in health expenditures could be as high as 30% of our total health expenditures. I think that estimate may be on the high side, but it is clear that there are excessive costs. – see link to article ‘Four Corners: No wonder we’re wasting money in health care – we got the incentives wrong’ by Jennifer Doggett, Ian McAuley and John Menadue.

    In a paper in July 2007 I estimated that there was at least $10 billion in possible savings and productivity improvements in health. That represented about 10% of our total health costs in that year. I think it would be nearer 20 % or $ 30 b per annum. I have spoken and written extensively on this matter.

    The lack of accountability in health

    Despite the rapid increases in costs and escalating demand in the healthcare industry, there is no accountability in any meaningful way for what the health industry delivers. Doctors are accountable for malpractice but not for their overall performance particularly in general practise. Accountability is patchy in many private hospitals. Taxpayers have a legitimate reason to ask – ‘Are we getting value for money particularly when we pay 80 % of doctor’s incomes.’ In a survey several years ago by the Health Council of Canada, 97% of over 1,800 senior respondents said that healthcare providers should be required by law to reach certain service benchmarks in such areas as patient outcomes , the use of preventive strategies like screening and waiting times. There is the same lack of accountability in Australia.

    The Council also asked the group ‘Do you believe healthcare in Canada will improve if the government spends more money on healthcare?’ 58% said ‘no’.

    Managing the demand for health services

    The demand for health services is increasing rapidly across all age groups and not just among the old. We are over-diagnosed and over-treated. In 1984-85, medical services per head were 7.1 per annum. In 2007-08 they were 13.1 per annum – about double. The trend continues.

    • We must accept that we cannot have all that we want in health and that governments, in consultation with the community, have to set priorities. Can we afford continuing existing levels of funding for IVF and end-of-life treatments at the expense of funding for mental health and indigenous health?
    • We need to rationalise our co-payments to make them efficient and equitable. We all should take more responsibility for the way we use health services, particularly as we are now much wealthier than we were 30 years ago when Medicare was introduced. A universal health scheme does not have to be free. But it must be fair and efficient. But co-payments are a dog’s breakfast! We pay about 18% of health costs out of our own pockets, but there is very little rhyme or reason in how this is done.
    • The best way to curb the long-term growth in health spending is through prevention in such areas as alcohol, smoking, junk food and obesity. Our sporting, alcohol and junk food sectors are in a joint enterprise to promote poor health. But the first action of the Abbott Government in its first budget was to abolish the Australian National Preventive Health Agency which was focussing on lifestyle risk factors.
    • We need to change the perverse incentives, such as fee-for-service, which is associated with bulk-billing. Clinicians are rewarded by the number of transactions rather than health outcomes. It promotes what is called ‘turn style medicine’ FFS is particularly inappropriate for chronic care, mental health and services with high fixed costs and low variable costs, such as imaging. The government should move away from fee for service and set budgets for general practitioners when they prescribe drugs, order pathology tests or imaging services. We need more doctors on salaries and capitation payments for caring for patients-not on a service by service basis. Hopefully, the Medicare review will grasp this nettle.
    • We need to tackle the wide variations in the incidence of clinical practice across the country, e.g. caesarean sections and cataracts. In the Australian Atlas of Health Care Variations the Australian Commission on Safety and Quality in Health Care found ‘substantial variations in health care use in areas such as antibiotic prescribing, surgical, mental health and diagnostic services’ Medicare should be much more proactive in exposing and limiting very expensive and inexplicable variations in clinical practice. .It also needs to publish the enormous variations in doctors fees and particularly the fees of specialists. Better public data for greater transparency is essential.

     

     

     

  • John Thompson. Fiona Nash and private health insurance for rural Australians

    Screen Shot 2016-02-11 at 4.04.29 PM

    A few nights ago on Q&A, the Minister for Rural Health, Fiona Nash, undertook to drop out of private health insurance while she was in office. Ms Nash lives in Crowther, a small town about midway between Wagga Wagga and Bathurst. Foregoing private health insurance makes a lot of sense for her because, like most rural and regional people, she pays a large amount to private insurers and has very limited access to private hospitals and related private services in her area.

    The map above shows why rural people are especially short changed with the private health system. The brown markers indicate public hospitals and the private hospitals are shown by purple markers. Crowther is almost in the middle of the map – 180 kms from Wagga Wagga and 141 kms from Bathurst.  There is one private hospital in Wagga Wagga and one in Bathurst, and neither has an emergency department. [On my count, there are about 30 public hospitals in this area. JM]

    The private health system is one of the most expensive Commonwealth Government programs.  In 2016/16 direct outlays by the Commonwealth Government will be $6.3 billion and income tax foregone will amount to $4.2 billion, a total of $10.5 billion for the year.

    Ms Nash, as a Nationals Party representative, should recognise that the private health system is particularly costly for her rural constituents because they are getting such a very raw deal. They are paying large sums directly to the private insurers and similarly large sums in taxation to support those insurers.  And they are getting very little in return.

    Rural Australians should ask themselves what they are getting for the large sums they are paying, both directly and through their taxes, to private insurance companies, and perhaps follow the lead of their elected representative, the Minister for Rural Health.

    John Thompson is an economist with an interest in health policy.

  • Michael Gracey AO. Grappling with the Indigenous health gap.

     

    By most recognised markers of socio-economic status, Indigenous Australians fare badly compared with their non-Indigenous counterparts. This is certainly the case where health standards are concerned. For example, rates of infections and hospitalisation for these and many other illnesses are much higher; chronic diseases like heart disease, stroke and diabetes are more prevalent; and hearing loss and blindness rates are increased as are a multitude of other disabilities. Illnesses and deaths linked to alcohol and drug abuse, and accidents and violence are more frequent, as are disorders associated with psychosocial stress. Death rates are increased across the life span and Indigenous people tend to die younger and have a life expectancy which is somewhere between 10 and 17 years shorter than that of other Australians. The statistics are stark and this situation represents one of Australia’s worst embarrassments internationally.

    But we need to understand how this situation evolved, what has and is being done about it, and whether these inequities in health and wellbeing are being corrected. It may come as a surprise to readers aged below 50 to realise that the divide between health standards among Indigenous and other Australians became generally recognised and acknowledged only within their lifetimes. The earliest reliable reports about poor Aboriginal health appeared in the mid-1960s after it was recognised that Aboriginal infants had very high rates of gastroenteritis, malnutrition and high death rates and that the life expectancy of Aboriginal people was much shorter than for other Australians. When the media reported these findings there was a public outcry and a quick but poorly organised political response was provoked to try to fix the problem. By then this was labelled the “Aboriginal Health Problem”.

    The late 1960s and early 70s brought many rapid changes into the lives of Indigenous Australians. These included: the 1967 Referendum which allowed the federal parliament to enact laws relating to Indigenous people and to include them, for the first time, in the national census; the federal court decision to grant “equal pay for equal work” for Indigenous workers; the establishment in Sydney of Australia’s first Aboriginal Medical Service in 1971; the gradual relaxation of restrictions on access to alcohol by Indigenous adults; and a rapid shift of Aboriginal people in rural and remote areas into towns and their fringes. In 1979 a federal parliamentary committee acknowledged the poor standards of Indigenous health and identified their root causes as being in deprived socio-economic circumstances and sub-standard living conditions. By that stage almost two centuries of marginalised living and social exclusion had reduced the original inhabitants to being an under-class in Australian society; the late Professor Rowley called them “Outcasts in White Australia”. This group of people by then had an entrenched core of ill-health, chronic disease and premature deaths which would be extremely difficult to correct.

    The social determinants underlying the patterns of ill health that affect Indigenous Australians must be addressed before significant and sustained improvements in health and wellbeing will occur. These contributing factors include poverty, overcrowding, unhygienic living conditions, low education standards, under-employment, social stigmatisation and marginalisation, disengagement from mainstream society, and their inadequate participation in decision-making processes which affect health and wellbeing. It must be appreciated, also, that some of the factors which have strong negative impacts on Indigenous health are trans-generational. For example, prenatal under-nutrition and impaired growth can adversely affect pregnancy outcomes over multiple generations; this means that those negative effects may take 50 years or more to be eliminated.

    In 2005 Tom Calma, then Aboriginal and Torres Strait Islander Social Justice Commissioner, released a report which called on Australian governments to commit to achieving equality for Indigenous Australians in health and life expectancy within 25 years. The Federal Government then made a formal Statement of Intent in 2008 to ensure that Indigenous people would have ”equal life choices”. The target date of 2030 was set for the various goals to be reached. This ambitious strategy and program was warmly received but within a year it was being questioned whether the targets were achievable in the time allotted; in particular, the goal of removing the life expectancy gap between Indigenous and non-Indigenous people was considered to be “probably unattainable” (https://www.mja.com.au/system/files/issues/190_10_180509/hoy11300_fm.pdf . These reservations were soundly based. By then there were many thousands of Indigenous people with long-standing chronic diseases like diabetes, chronic respiratory and cardiovascular diseases, late-stage kidney failure, irreversible visual and hearing loss and a range of other permanent disabilities. Added to that formidable burden was the increasingly heavy load of illnesses, social and stress-related disorders, and premature deaths associated with cigarette smoking, alcohol and drug abuse, in Indigenous people as well as those linked to accidents and violence. Quite clearly this wide-ranging and massive range of illnesses, disabilities and premature deaths would have no simple, single solution as, for example, could be applied to successfully control or prevent an infectious disease outbreak by a community-wide immunisation program.

    Yet, despite the timely and nationally published cautionary advice cited above, the Close the Gap Strategy and program continued. Each year a formal report has been released in parliament outlining progress towards the stated targets. There have been some improvements in Indigenous health over the past decade or so but it is difficult to attribute them to this strategy alone. For example, improved pregnancy outcomes such as heavier birth weights, suppression of childhood infections by immunisation, and lowered infant and maternal mortality, were achieved largely by other programs based on sound public health principles; that work began well before the Close the Gap initiative began. Annual report cards have mostly shown what is often officially called “mixed outcomes” – this usually means that the reporting agencies and their bureaucrats could find little that would attract a favourable headline in the press. This is disappointing because most Australians, black and white, want to see Indigenous people share the high levels of health which most of us take for granted. These mixed results in health, wellbeing, living standards, education, employment and productivity among Indigenous people have left them feeling let down. When the seventh annual Close the Gap report was presented by Prime Minister Abbott in February 2015 he acknowledged that the results were “bitterly disappointing”. Why didn’t he grab the nettle then, acknowledge that the strategy was failing, indicate that it had been introduced by former Prime Minister Rudd, and then ditch the policy and start again? That opportunity was lost and yet another year passed until the next Prime Minister, Turnbull, reported this month that the results of the eighth annual report were “mixed”.

    One of the key targets of the Close the Gap program all along has been to equalise the life expectancy of Indigenous and other Australians. However, the 2016 report acknowledged that the improvements that have occurred so far are not happening fast enough for that target to be reached within the next 20 years. Even in some instances where improvements seem to have been encouraging, closer scrutiny of the details exposes otherwise hidden obstructions. Take infant mortality rates for example. While the rates of Indigenous children dying in their first 12 months of life have dropped substantially over the past 15 years, the rates among non-Indigenous infants have also been dropping. When the relative rates, that is Indigenous compared with non-Indigenous rates, are examined it is evident that Indigenous infants are dying at about double the rate of other infants before their first birthday. Prime Minister Turnbull conceded that achieving the target to close the life expectancy gap by 2030 remains “a significant challenge” (ABC News item, 10 February 2016). Regrettably, other aspects of the 2016 Close the Gap report which have significant impacts on health were also disappointing; they include educational attainments, employment rates and housing standards.

    Repeated and protracted disappointments like these leave people feeling angry and frustrated, particularly the Indigenous community who have so much at stake for themselves and their future generations. Nationally prominent Indigenous leaders like Patrick Dodson have said recently that the Closing the Gap initiative is doomed to failure unless it is radically reformed. He added that the Prime Minister has not yet put his stamp on Indigenous affairs and has not paid sufficient attention to these issues.

    Resolving the inequities in health between Indigenous and other citizens must be done with an all-inclusive approach to all of the inter-related issues that are involved. Providing better and more accessible and appropriate health and disease care can only be part of the solution. Strategies and programs that are aimed at promoting and improving wellness as well as treating illness must be given more prominence in the clinical approaches towards better Indigenous health outcomes. A crushing disappointment for clinical carers of all types who work in this field has been to see the substantial improvements in health which have occurred over recent years, much of it in children, be undermined by high-risk attitudes and behaviours in later life which result in preventable premature deaths. Examples are the serious illnesses and deaths due to tobacco smoking, physical and mental damage and deaths from alcohol abuse and other addictive drugs, vehicle accidents and other forms of violence, and the long-term consequences of overweight and obesity including diabetes and cardiovascular disease. The gains that have been made in reducing infant and young child deaths should lead to improved life expectancy but this is being thwarted by the continuing wastage of lives in adolescence and early and mid-adult life. Much of this wastage is preventable. This is where responsibility for personal, family and community-based health must become part of the equation. Indigenous acceptance of responsibility and participation must become an essential element of this process in order for real progress to occur.

    A recurring theme in the continuing debate about trying to achieve equity in health and wellbeing between Indigenous and other Australians is the need for increased participation of Indigenous people in the activities and social circumstances which affect them. Not only is there a place for enhanced Indigenous involvement in these issues, there is a real need for this to happen. Examining the way health and clinical services are currently provided to Indigenous people shows that three main sectors are involved:

    • federal and state government services
    • the specially developed and independently-run Indigenous Medical or Health Services, and
    • private or other non-government providers of clinical and related services

    If these three sectors had been working cooperatively and effectively over the past thirty or more years, Indigenous health should not be in its present sorry state. Despite past failures there is still goodwill among the wider Australian community to see that this situation is corrected. I have previously called for a fourth sector to be organised to help bring this about (Refer to earlier Gracey blog on ‘What is need to fix Aboriginal health?’ here). This new sector would be established as a community-based organisation representing ‘grass roots’ Indigenous people who are currently sidelined from the process of policy development and making decisions about running programs at the community level to suit their own needs and aspirations. Adding this new dimension would show at last that local Indigenous communities have a real contribution to make in the health improvement process. This is not being achieved by regional Indigenous Medical or Health services although they claim to be ‘community-controlled’. In fact, members of local Indigenous communities have very little or no say in the selection of such regional bodies; in effect they are voiceless. The emergence of this fourth dimension would demonstrate that local communities and their members are prepared to accept this responsibility to contribute to planning and delivering health care for their own people. Such a development should help answer the repeated calls by Indigenous leaders from different parts of Australia for their people to play a bigger role in improving health and wellbeing of the Indigenous population.

    It is time for the issues surrounding Indigenous health to be thoroughly and objectively reviewed. This would help to ensure that the mistakes of the past are not repeated and perpetuated. Australia must be able to do better. The health needs of Indigenous people are, indeed, more demanding than for other Australians. But more funds, more doctors, nurses, clinics, hospitals, and related services cannot alone provide the solution. There must be a wide-ranging approach to all of the infrastructure services and other factors which influence the determinants of wellness and illness. Education, employment, housing, hygiene, access to affordable nutritious food as well as avoidance of unhealthy lifestyles must all be part of the equation towards better health. The media often sensationalise negative factors in society that contribute to the continuing poor state of Indigenous health. While many mistakes have occurred in the past and marginalisation of Indigenous people has had serious negative impacts on their wellbeing, it is time to look to the future and take a more positive outlook. Present problems should be seen as opportunities or challenges to put things right. To focus repeatedly on racism or negative stereotyping as the root cause of this continuing dilemma could be counter-productive and tend to separate Indigenous and other Australians even further. Instead, we should try to reach a situation where Indigenous people are given better chances to accept responsibility for their own health. Encouragement and cooperation will foster trust between them and the wider society and its representatives, namely governments and their agencies and bureaucrats. But all sides must accept this will be a “two-way street” where flexibility and patience will be keys to ultimate success.

    Michael Gracey AO is a paediatrician who has worked with Indigenous children, their families and communities for more than forty years. He was Australia’s first Professor of Aboriginal Health and for many years was Principal Medical Adviser on Aboriginal Health in the Western Australian Department of Health. He is a former President of the International Paediatric Association.

  • David Isaacs. Secrets and lies and bad morality: Australia’s policy on people seeking asylum

    The latest episode in the long, sorry saga of how badly we can treat people seeking asylum was played out in the High Court in February 2016. Long because the story started in 1992 when the Paul Keating Labor government introduced mandatory detention ‘as a temporary measure’ in reaction to a handful of people arriving in leaky boats from Cambodia. And I use the term ‘people seeking asylum’ advisedly, because the term ‘asylum seekers’ dehumanises the people and has been shown to cause Australians to switch off. The High Court found it is legal for the Government to send babies born in Australia and children and adults transferred to Australia for mental health and other problems back to Nauru. This decision was predictable because the Government passed retrospective legislation making it legal. As the human rights lawyer Daniel Webb put it so eloquently, the law is complex but the morality is simple. Bad Governments pass bad laws to allow them to do things that are morally wrong. I am a doctor not a lawyer, so I am not qualified to say at what point the High Court has a duty to make sure our Government does not exact really heinous legislation, but this is pretty bad. Excising Christmas Island from the mainland and sending people into detention centres on Nauru and Manus Island is our Guantanamo. These are ‘black sites’ where people can be severely mistreated under a veil of secrecy: out of sight and out of mind.

    To argue that people are now free to come and go from the detention centre on Nauru is disingenuous. They are not safe if they leave the detention centre and they are not safe in the detention centre. Their visas to stay on Nauru are restricted to 5 years, so their future is as uncertain as ever. Nauru is their prison. Mr Dutton has stated that the hospital on Nauru is comparable to Australian hospitals. I did a clinic at the Republic of Nauru (RON) Hospital in December 2015 and it is far, far worse than any Australian hospital I ever visited. Furthermore, the staffing is as important as the facilities and the RON Hospital struggles for qualified staff. Of course, Mr Dutton will argue things have changed in the last year. Verifying the truth is impossible when the only journalist allowed in for years was a single Murdoch Press Government sympathiser and doctors who speak out risk two years in prison.

    Ethics can be defined as ‘how we ought to behave’ and medical ethics as how health professionals ought to behave. I recently published a paper (available on request) in the Journal of Medical Ethics (http://jme.bmj.com/content/early/2015/12/20/medethics-2015-103066.abstract) in which I argue that prolonged immigration detention fulfils all the criteria for torture. I then argue that doctors and other health care professionals are conflicted: they have a duty to their patients to help them but they also have a duty not to condone torture. The US Central Intelligence Agency (CIA) argues to this day that water-boarding prisoners in Guantanamo and Abu Ghraib was not torture because the technique was devised by psychologists and supervised by doctors. The doctors would presumably argue that the water-boarding was going to happen anyway and they were ensuring the prisoners did not drown. Highly respected colleagues and lawyers have said to me “Nauru is not as bad as Guantanamo”. Is it not? Are we to have degrees of torture? There have been unconfirmed (probably unconfirmable) reports by a guard of water-boarding and ‘zipping’ being inflicted on people in immigration detention in Nauru (http://www.abc.net.au/news/2015-08-14/guard-tells-parliamentary-inquiry-asylum-seekers-tortured-nauru/6699162). Why would the guard lie? Mr Dutton denied it, but he would wouldn’t he.

    The harms we are inflicting on adults to punish them for having the temerity to flee persecution in their homelands are immoral. We treat innocent adults worse than we do convicted criminals. But the public are more likely to sympathise with the argument that children are innocent victims. Gillian Triggs realised this, which is why her Forgotten Children enquiry is so powerful. Alison Light, in her wonderful book “Common people”, describes how the 19th century English workhouses were intended to punish men who did not want to work, but the biggest victims were women and children. I was struck by the parallels with immigration detention centres. I am proud that increasing numbers of paediatricians and paediatric nurses have decided to speak out against what is being done to children by our Government in our name. Alanna Maycock, Hasantha Gunasekera, Karen Zwi and Josh Francis have all risked imprisonment for telling the truth.

    What should happen? The Government mantra, ‘We’ve stopped the boats’, means the immigration detention centres are redundant. Keeping people imprisoned can only be to deter other desperate people from seeking asylum. Europe, struggling with a far bigger immigrant problem, has not resorted to such vulgar deterrent policies, although extreme right wing European groups cite Australia as an example to follow. We should allow the derisory number of children to remain in Australia with their parents. We should close the detention centres on Nauru and Manus, which are not only immoral but hugely expensive (it costs over half a million dollars per year for each person kept on Nauru). Mr Turnbull committed his Government to a tough stance on border control. If that stance includes continuing to torture innocent people we should hang our heads in shame.

    Professor David Isaacs is Senior Staff Specialist, Department of Infectious Diseases and Microbiology and Clinical Professor of Paediatric Infectious Diseases at the University of Sydney. He works at the Children’s Hospital at Westmead.

     

  • Stephen Duckett. Health in 2016: a cheat sheet on hospitals, Medicare and private health insurance.

    We start 2016 as we started 2015 – with big challenges for the health system and uncertainty as to how governments will meet them.

    The health care headaches in 2016 are, in fact, the same ones we faced a decade ago, albeit different in severity and symptoms. They include population growth, ageing and the rise of chronic disease; inequality in access to care and health outcomes; technological change (the good, the bad and the expensive) and the seemingly inexorable rise in health costs.

    Circling for landing are three major reviews on private health insurance, primary care, and low-value care. Their recommendations, and the government’s response to them, are very much up in the air.

    Adding to the uncertainty is the broader review of federalism and its consequences for public hospital funding, along with speculation around the 2016 federal election date and what each party’s Santa sack of election promises might contain.

    Private health insurance

    The number of people with private health insurance continues to creep up but the market is not in good shape.

    The rebate is one of the fastest growing areas of government health expenditure and complaints about the product abound. High levels of coverage are being achieved throughcarrots (the rebate) and sticks (penalties for the uninsured) rather than genuine consumer appeal.

    One solution being floated is for the whole subsidy framework to be thrown out. Instead of subsidising private insurers, which pay private hospitals, the government could subsidise private hospitals directly.

    Government advisers are impressed by the efficiency gains that activity-based funding (paying hospitals per procedure rather than a lump sum) brought to public hospitals and believe similar improvement can be brought to the private sector.

    The mechanism to achieve this could be a Hospital Benefits Schedule which, like the Medicare Benefits Schedule, would prescribe a schedule fee for private hospital care, based on existing Commonwealth payments for public hospital services under activity-based funding. The same schedule may later be used for public hospitals, replacing grants to the states.

    However, it will only be politically palatable if it is cost neutral for consumers or comes with reduced private health insurance sticks.

    The devil is in the detail of a new policy such as this. Will payment be to the hospital or surgeon? Will it cover the surgeon’s fee, as in public hospitals? Will it cover diagnostics? Without this information it is impossible to forecast the impact of the shift.

    Public hospitals

    This will be a challenging year for public hospitals. Major reductions in Commonwealth funding for hospital admissions – which continue to grow – will kick in from 2017, and states are likely to start the belt-tightening early.

    The cuts far exceed the productivity gains that can be made, so a reduction in services is certainly possible. Efficiency may be improved somewhat by the ongoing expansion of activity-based funding to mental health and “sub-acute” care such as rehabilitation and palliative care.

    The possible changes to private health insurance and a Hospital Benefits Schedule may be one way to put money from the federal government back into the system, but there is no sign that Treasurer Scott Morrison is keen to loosen the purse strings.

    Hospitals will also be under pressure to lift quality. Hospitals face increasingly stringent “quality standards” with tougher monitoring covering a broader scope of issues, including access and timeliness.

    Meanwhile, the increasing array of publicly available data is putting variation in hospital performance under the spotlight more and more, with commensurate calls for greater accountability.

    Medicare

    Two independent reviews of Medicare are expected to land sometime in 2016.

    The first examines primary care. It could address any number of challenges, including chronic disease management, “six-minute medicine”, co-payments, frozen rebates, and the growing corporatisation of general practice.

    Management of chronic diseases such as diabetes, heart disease and cancer poses the main challenge. The rise of chronic disease is imposing big costs on a system that wasn’t designed to provide the complex, continuous and coordinated care now needed.

    The government will have to consider far-reaching reform with only limited and equivocal evidence to draw on. Options on the table include a shift in the balance of payments to practices, with less emphasis on payment for attendances (fee-for-service) and more emphasis on payment for care over the episode of illness or year (capitation payments).

    There may be other changes in payment structures. The government’s long-standing desire to reduce perceived incentives for six-minute medicine may see a minimum consultation time imposed on the standard (level B) fee.

    If sense prevails we won’t see a resurrection of the GP co-payment policy zombie. We should, however, see an end to the freeze on medical rebates; the only question being when and with what trade-offs.

    A further issue to be addressed is the shift toward practices owned by corporate chains that profit from referrals to and provision of diagnostic services, such as blood tests and X-rays. The implications of changed ownership structures for practice are not at the forefront of practice payment redesign but should be.

    The second review looks at quality and cost-effectiveness of items on the Medicare schedule. The review got off to a rocky start with wild claims about 30% waste in the system, and release of its first list of items targeted for delisting in the sleepy period between Christmas and New Year.

    The work on modernising the schedule will come to fruition in 2016. There will be individual and group losers in this process who undoubtedly will scream loudly with varying levels of effectiveness.

    What should you expect?

    It isn’t yet clear whether Health Minister Sussan Ley’s appetite for reviews portends massive reform to the sector, or simply a politically judicious preference for treading water in a portfolio still reeling from tumultuous management by her predecessor. However, the auguries are good for the former.

    The scene for change has been set, at least with the medical profession. Respectable leaders are engaged and leading some of the review processes. Hopefully this will be the year the health system rises to meet the big challenges of 21st-century health care.

     

    Stephen Duckett, Director, Health Program, Grattan Institute.  This article first appeared in The Conversation on February 1, 2016.

     

  • Ian McPhee. Let’s talk about dying.

    What does it mean to die well?

    We must acknowledge divergent views on assisted dying and start framing laws that will enable it, writes Ian McPhee.

    I am a medical specialist with advanced cancer. In a career begun more than 35 years ago, I have seen death in all its guises: in homes, at the roadside, in the emergency department, intensive care, operating theatres and on hospital wards. There has been no age limit on these experiences.

    I have gently taken a dead child from a mother after she travelled for an hour with him cradled in her arms following a farm accident. I have watched the slow, inexorable deterioration of ICU patients with multiple organ failure because of myriad causes.

    Inevitably, because it is the lot of a doctor whose practice has been predominantly hospital-based, I have also been present at countless attempts at resuscitation from cardiac arrest, the vast preponderance of which were unsuccessful – perhaps surprising news for regular viewers of medi-drama.

    The cult of survival, however, is extant and is sadly a feature of 21st century, Western medicine. Only a short while ago an intensive care colleague related the story of a call, generated by a senior doctor, to assist in the resuscitation and ICU admission of a patient whom he assessed on review as cadaveric, or dead.

    How can a system have evolved to deal so inhumanely with an individual at the end of life? How is it possible that doctors continue to administer futile care as if a “last right” for their patients, when for themselves they wish for no such thing. As recently as this month, in the Journal of the American Medical Association, this fact was again highlighted.

    The cult of survival, however, is extant and is sadly a feature of 21st century, Western medicine.

    Dr Ian McPhee

    The limitations of intervention are understood but this is not translated into the treatments administered to patients. In a 2014 paper, researchers from Stanford University reported that 88 per cent of more than 1000 US doctors surveyed indicated they would forgo high-intensity care for themselves at the end of life.

    To bring focus here, my colleague Peter Saul said recently that we are facing “a perfect storm of ageing and expanding population with a higher burden of chronic disease”. His call to us as a society has been: “Let’s talk about dying.” It is no less directed at health professionals as it is to the public at large.

    For me, the recent, wide public consideration and debate of end-of-life issues has taken on special significance. Eighteen months ago, at the age of 59, I was diagnosed with a rare, aggressive T-cell lymphoma. In the interim, multiple attempts to achieve remission have failed.

    At the time of original diagnosis I was reading Atul Gawande’s book Being Mortal. Gawande is an American surgeon, author and staff writer for The New Yorker. For those unfamiliar with this work, he has made the case for a patient’s wellbeing to be at the forefront of care considerations, for their wishes to be actively sought, and for medicine to move to helping them to not just live but also die with a sense of control.

    Within his narrative there was for me a special anecdote. Gawande’s father, himself a surgeon, developed a spinal-cord tumour. Treatment options were investigated, discussed openly, and evaluated for their potential impact on those things that held meaning within what had been a truly full and fulfilling life.

    Importantly, he made informed choices, not least among them to enter into the care of a neurosurgeon who took time to answer even the “annoying” questions.

    Their relationship became “informative”, as opposed to paternalistic. There was later surgery, and, beyond that, symptom management. And when a long-considered point was reached at which going on would have provided no benefit, treatment was ceased. Ultimately death was at home, surrounded by family.

    I too have actively sought an informative relationship with my own treating clinicians and given similar consideration to what I might expect from my treatment.

    Yet, while now inhabiting my end of life, do I wish to consider foreshortening it? And if not immediately, are there ever likely to be circumstances that are no longer tolerable in my view; according to my values, and determined by my own informed assessment of my situation?

    Intolerable enough, that is, to mean, in the absence of medically assisted dying, suicide.

    The counter argument to those in favour of assisted dying has tended in large part to be based on the notion that palliative care is the answer; that it is accessible to all, universally effective and, by implication, restorative. Of course, it may not be any of these.

    In my own border community of almost 200,000, there are no palliative-care specialist doctors in the public sector. The same is true for many non-metropolitan centres.

    The palliative-care clinician’s pharmacopoeia in many ways matches those that I have drawn on during a 30-year career in anaesthesia and acute pain. There are no magic bullets. I cannot accept that it might be otherwise.

    Palliative medicine is, however, a vital part of a “system” of care. I acknowledge that for many it is the difference between last months of extreme suffering, and the achieving of some respite.

    And while it might herald for some a meaningful end, and even approach the Gawande notion of a “good death”, there remain others, and I number among them, whose sense of what is meaningful carries with it vastly different connotations.

    It is past time to acknowledge the existence of such divergent views, accept that there is scope for regulation to reflect this, and move toward establishing the framework to enact it.

    To not do so will mean only a slow but steady growth in the number of people such as Peter and Pat Shaw, who determine that their last day will involve final, furtive visits to garden sheds. Most sadly of all, however, such passing will of necessity continue to mean the exclusion of immediate family, lest they should be seen as having acted criminally in assisting at a loved one’s entry to the Big Sleep.

    Dr Ian McPhee is a clinical senior lecturer at Sydney Medical School and an anaesthetist in provincial practice in NSW. This article was published by Sydney University.

  • Ian McAuley Private health insurance – does the lady protest too much?

    Sussan Ley, the Commonwealth Health Minister, has hit out at private health insurers’ bid for a six per cent price increase.

    In view of the strong support the Coalition has always given private health insurers, such public criticism from a Liberal Party minister may surprise us. As one-time Prime Minister Tony Abbott said “private health insurance is in our DNA”.

    It would be reassuring to believe that the Sussan Ley has come to recognise private health insurance (PHI) for what it is – a high-cost financial intermediary that does nothing to take pressure off public hospitals and that has been largely responsible for diverting scarce health care resources away from areas of need.

    As John Menadue, Jennifer Doggett and I have pointed out in conference papers, submissions to enquiries and a major study published by the Centre for Policy Development, PHI is an expensive, inequitable and inefficient way to share health costs. It does at high cost what Medicare and the Australian Tax Office (collecting taxes to fund Medicare) can do far better.

    Its bureaucratic overheads are high: only 86 cents in the dollar of insurers’ premiums are returned as benefits, compared with 95 cents for Medicare.

    It fails in its main avowed purpose to relieve pressure off public hospitals, because in channelling funds to private hospitals it has attracted resources – nurses and specialists – away from public hospitals. All it has done is to shuffle queues for access to limited resources, bringing insured patients to the front of the queue and pushing everyone else back.

    It fails to keep providers’ costs and patients’ usage under control. That’s because of what economists know as “moral hazard” – the tendency for people to over-use a service when it is free at the point of delivery. A single funder such as Medicare can control moral hazard through use of well-structured co-payments to impose some pricing discipline and through hospital staff allocating services on the basis of need. By contrast, when there are multiple insurers they necessarily have to be permissive in meeting the demands of service providers, particularly highly-paid medical specialists.

    That’s why PHI premiums have been rising at an average of 5.5 per cent a year since 2000, while general inflation has averaged only 2.9 per cent. Insurers claim that they are simply passing on costs incurred in hospitals, without acknowledging their own role in driving price inflation and over-usage in health care.

    Insurers may claim that in marshalling private funds for health care they have kept demands on the Commonwealth budget and therefore taxes in check, but even if this is the case, there is no virtue by any economic criterion, “right” or “left”, in substituting what is essentially a privatised tax (PHI) for an official tax. It’s a weird ideology that would find benefit in saving taxpayers $1.00 in official tax at the cost of their having to pay $1.10 or even $1.50 for the same or inferior service, because for most people the incentives for holding PHI come near to compulsion.

    Young people are cajoled into PHI through the penalties in “lifetime community rating”, and people with moderate and higher incomes are cajoled into PHI through exemption from the Medicare Levy Surcharge. While official taxes can incorporate progressivity, PHI, in its regulations designed to achieve “community rating”, builds in many injustices. For example, those who rely on PHI for private hospitalisation or dentistry are subsidised by the taxpayer up to 40 per cent, while those who pay from their own resources get no support.

    We don’t know the reasons for Susan Ley’s criticism of health insurers. Maybe it’s just clever politics, to distance herself and the government from another round of premium increases. Maybe it’s about her own constrained budget: because of the direct subsidies to PHI every one per cent premium rise means there is $60 million less for other health priorities. (In fact the total fiscal cost of supporting PHI, often reported at $6 billion a year, is more like $11 billion a year once tax expenditures (revenue forgone) are taken into account.)

    Or perhaps she realises that there are better ways to support private hospitals than channelling funds through PHI, and that scarce funds for health care are best directed at primary care and prevention, rather than subsidising the lifestyles of medical specialists and the well-off to jump the queue.

    (On my website are several papers on PHI. Those wishing to go further into the issues, or to find sources for the points covered in this article, will find a major study John Menadue and I conducted for the Centre for Policy Development in 2012. Late last year Jennifer Doggett and I made a submission, incorporating updated costing and other data, to a Departmental inquiry into health insurance.)

     

  • Ian Webster. Alcohol and Sport.

    The facts about alcohol should stop politicians in their tracks. But they are unmoved.

    A quarter to a third of the work of a general hospital is alcohol-related. On Australia Day one in seven ED attendances were caused by alcohol; in some EDs it was one in three. The Senior Australian of the Year, Gordian Fulde, time and time again, has described the carnage at St Vincent’s Hospital’s ED late on Thursday, Friday and Saturday nights; as many as 70 percent of cases at peak periods are intoxicated.

    That’s only part of the medical story. The alcohol load is massive in the trauma, orthopaedic and burns units and manifestly over-represented in suicide attempts, mental health, brain injury and in the general medical and surgical wards. Twenty to 40 percent of patients in general practice have had a serious alcohol problem at some time in their life. Globally, alcohol is the third most modifiable risk factor to prevent disability and death. Alcohol overshadows most contemporary public health problems.

    In the social story, alcohol outstrips the impact of other substances. One third of child protection cases, 40+ percent of domestic violence, 40+ percent of homicides, 45 percent of assaults attended by police and up to 60 percent of suicides – the list could go on. The police, courts and welfare agencies are tied up dealing with the consequences. Alcohol’s social impact dwarfs the anxieties about ICE and cannabis.

    It’s not that we can’t tackle alcohol; it’s the countervailing forces which stop us. Dealing with the health and social harms of alcohol is not straightforward public health as the strategies to reduce harm competes with commercial interests and politics.

    In the recent holiday period, the cricket season was awash with alcohol advertising, for all to see. Loopholes in legislation allowed alcohol advertising to subvert the measures designed to protect young minds. When alcohol is linked so convincingly to sporting success and peer-acceptance, young minds are too easily persuaded that being a drinker is OK.

    Since ancient Greece, sporting activities have celebrated athleticism, skills, teamwork and playing by the rules. Sporting heroes have been role models for youth. But the role models of today are seduced into colluding with the alcohol industry – for celebrity, money and power. The once noble traditions have been corrupted by the dollar.

    This collusion is not for the common good. With apologies to former US President Dwight Eisenhower, the alcohol industry and organised sport have established a powerful ‘industrial complex’ along with their bedfellows – the gaming and PR industries. The asymmetry of power and political influence, compared with the proponents for public health means that effective strategies such as reduced late-night trading hours for alcohol-outlets and evidence-based alcohol taxes struggle for a place in government policy.

    Michael Thorn, referring to the alcohol industry, wrote last week (Pearls and Irritations, 23/01/2016), “It’s an industry built on identifying, targeting and exploiting its best customers, and ensuring they continue to misuse and abuse alcohol.” He observed that 20 percent of Australians aged 14 years and above consume 74.2 percent of all the alcohol consumed in a year. As far back as 2006, a US study showed the alcohol industry’s revenue in that country was dependent on heavy and disordered drinkers (‘sick’ drinkers) and underage drinkers. (1) A degree of exploitation redolent of the gaming industry’s dependence on problem and addicted gamblers.

    Professor Robin Room and Dr Michael Livingstone, internationally recognised alcohol policy researchers from Latrobe University, and Michael Thorn, CEO, Foundation for Alcohol Research and Education, have said recently, that the alcohol industry’s interests run in the opposite direction to public health and effective alcohol policy and the industry should be excluded from alcohol policy decision-making. On the evidence, who can disagree?

    It is also in the community’s interest to warn sporting organisations, that partnership with the alcohol industry undermines sporting values and risks the health of future generations.

    ___________

    1. Foster SE, Vaughan RD, Foster WH and Califano JA Jr. Estimate of the commercial value of underage drinking and adult abusive and dependent drinking to the alcohol industry. Archives of Pediatric and Adolescent Medicine. 2006 May; 160(5): 473-8.

    Ian Webster is Emeritus Professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia. He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide Prevention Advisory Council.

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

                      Health Care Advertising and Consumer Protection

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

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

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

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

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

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

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

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

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

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

    John Dwyer is Emeritus Professor of Medicine, UNSW.

  • Brad Chilcott. I donated a kidney to my son. Don’t tell me not to make it ‘political’.

    In early December, I went into surgery to give my eight-year-old son Harrison my left kidney. He heard me groaning in recovery as the anaesthetist put him to sleep a few hours later so that he could receive it. The operation was the first of my life and Harrison’s 13th. He’d experience his 14th general anaesthetic two weeks later when surgeons removed the vascular catheter that had been used to connect the dialysis machine into his heart three times a week for the five months leading up to the transplant.

    After a successful surgery, Harrison had a number of complications that meant an eight-day stay in the intensive care unit of the Women’s and Children’s Hospital in Adelaide, followed by another six days in the surgical ward. Daily blood tests, a Christmas Day virus that precipitated an extra five days of hospital hospitality, and then on Sunday, 3 January, our family enjoyed our first hospital-free day in well over a month.

    As is my wont, I covered the process extensively via my social media outlets, interspersed with the occasional comment on the social and political issues of the period – a Myefo update committed to balancing the budget on the backs of the poor here and abroad; welcoming refugees and asylum seekers; supporting my brilliant friend Wawira Njiru’s work in Kenya making sure kids don’t have to go to school on an empty stomach; protecting penalty rates from being cut by people wealthy enough not to be forced to rely on them.

    On Christmas Day, before the infection set in that evening, I took Harrison into hospital for an 8am blood test wearing the full Santa suit I’d donned to give our three children their presents early that morning. I figured if we had to be in hospital on such a day, we should at least make it memorable. We handed out candy canes to taxi drivers waiting at the rank outside, orderlies cleaning the halls and other families having a similar experience to our own. Driving home, I filled the car with petrol in full costume while commuters took photos and small children gawked in confusion. Harrison loved every moment.

    On Christmas Day, before the infection set in that evening, I took Harrison into hospital for an 8am blood test wearing the full Santa suit. That afternoon, resting after a hearty Christmas lunch with the in-laws, I posted on social media: “Trip to hospital – saw Drs, nurses, cleaners, servo staff, RAA and more helping folks enjoy Christmas. Of course they deserve penalty rates” to which one person responded, “Enough politics for the day”.

    It’s easy to understand the sentiment – why sully the joy of Christmas with “politics” when there’s backyard cricket to play and pudding to consume? But if you’re any kind of activist or political advocate, it’s a familiar response.

    Children spending their third Christmas in immigration prisons; Australian Aid set at the lowest level in Australia’s history; health and education budgets being slashed by billions of dollars; one in three Australian pensioners living below the poverty line; climate change; sexism; racism; recognition of Australia’s Indigenous people … the easiest way to avoid thinking too deeply about any issue that arises around the barbecue on the beach is to dismiss it as “politics”.

    This is nothing new – people have always employed the word “politics” in the work of absolving themselves of personal responsibility for addressing inequality, injustice and the exploitation of the earth and its people.

    For our family, however, there’s no amount of using the word “politics” that can distance us from the truth that government-funded healthcare has not only kept Harrison alive for eight-and-a-half years but has also enabled him to thrive despite a range of other physical challenges.

    He’s required a huge volume of medical supplies and medication that have been provided free of charge or heavily subsidised; publicly-funded in-school support services have allowed him to keep up with his peers educationally; 14 operations and more-than-regular appointments with physicians since birth would’ve attracted a financial cost I can’t even comprehend, entirely borne by the public purse.

    So, while it might be easy to dismiss $15bn of cuts to the annual health budget as “politics” when you read it as a headline in the paper, the reality is that those are dollars that may have been spent on a child like Harrison. Forcing people to pay for pap smears and other preventative procedures is either “politics” or it’s a change that will mean some people won’t have their illness diagnosed early or accurately enough with huge impact on them and their families.

    Similarly, cuts to the education budget and the cancellation of the Gonski funding model are either an ideological minefield to be avoided in polite conversation – or it’s $196m that won’t be spent in my electorate alone on making sure that every Australia child receives a quality education . It’s either “politics” or it’s some children missing out on the opportunity to achieve their full potential because of the economic circumstance of the family they were born into.

    For the nurses, service station staff, cleaners and other workers that helped millions of Australians, including Harrison and I, have a good Christmas, penalty rates can’t be dismissed as mere “politics”. They’re students, single parents, new Australians and more who rely on every dollar to make ends meet.

    Children in immigration prisons, women enduring the violence of men, pensioners below the poverty line, parents who can’t afford child care, Muslim Australians being vilified by politicians and abused in our streets, Aboriginal people being forced from their communities – while others treat their experiences as abstract, impersonal political concepts, these people have no such convenience. That which is derided as a topic that should not interrupt the Christmas cheer invades their lives without their consent.

    Harrison and I went back in to hospital last week for blood tests. He’s on a huge amount of anti-rejection medication. We’re in the hands of the best medical practitioners in the field, the nursing and other support staff at the hospital are wonderful and Harrison has all the social scaffolding he needs to thrive. But this situation didn’t happen by chance – throughout Australia’s history progressive people fought for this outcome, so successfully that it would be culturally unacceptable for us to be paying for this level of care. Australians naturally assume it’s what sick children deserve.

    We are living, and grateful, beneficiaries of those who valued other people enough to make politics personal.

    Brad Chilcott is the Founder of Welcome to Australia. This article was first published in The Guardian on 16 January 2016.

  • Robin Room and Michael Livingston. Alcohol companies target the 20% of Australians who drink 75% of the alcohol.

    Researchers have known for a long time that alcohol consumption is quite concentrated in a small part of the population. They argue about the exact distribution, but there is substantial agreement that, so long as alcohol sales are not heavily restricted, consumption is distributed in a quite predictable way. That is, there are many light and moderate consumers, along with a long tail of those drinking at heavier levels.

    In Australia, the top 20% of the drinking-age population in 2013 consumed around three-quarters of all the alcohol consumed. The top 5% consumed more than a third.

    The concentration of alcohol consumption among the heaviest drinkers has actually increased in recent years. The top 10% of consumers accounted for 49% of the consumption in 2001, and this had increased to 53% in 2013.

    The heaviest-drinking 20% of the population reported consuming a daily average equivalent to 43 grams of pure alcohol – a bit over four standard drinks. This is a substantial underestimate of their actual drinking.

    The total amount of drinking reported in such surveys is calculated to be about 55% of the alcohol sold in Australia, so their actual daily average is likely to be about 7.8 drinks. This is nearly four times the low-risk limit of two standard drinks per day recommended by the National Health and Medical Research Council.

    The dangers of alcohol

    If you drink enough alcohol, you get intoxicated, making you unfit for a lot of everyday activities. This includes, for instance, driving a car, most kinds of work or looking after children. Apart from these issues of injury and social functioning, alcohol also carries longer-term health risks.

    At an average of four drinks per day, the chances of dying of an alcohol-related cancer or other chronic disease are two in 100 for men and 2.5 in 100 for women. At 7.8 drinks a day, the chances are about five in 100 for men and eight in 100 for women.

    Adding in risks of dying from alcohol-related injuries more than doubles the risk for men, and increases the risk for women by more than 50%. Just considering the risks of health and injury harms, alcohol is by far the riskiest commodity that a majority of us regularly consume.

    The current guidelines “to reduce health risks from drinking alcohol” set upper limits calculated on lifetime death risks from drinking. These are around four times the rate National Road Safety Strategy aims for as an upper limit of lifetime rate of deaths from traffic collisions. They contrast, for instance, with the National Health and Medical Research Council (NHMRC) guidelines on water safety, which aim to keep the risk of death from contaminated drinking water below one in a million.

    Alcohol marketing

    Those in the business of selling alcohol have long known about the skewed distribution of alcohol consumption in the population. In meetings among people in the industry, those at the top end of the distribution are called the “super consumers“, and they are vital to maintaining or increasing sales.

    If all the “super consumers” reduced their drinking to the two-drinks-a-day average recommended by the NHMRC as an upper limit, it has been calculated, based on self-reported consumption, that alcohol sales would fall by 39%.

    In its public face, the alcohol industry takes the line that it is only seeking to protect and promote “responsible drinking”: how to “drink properly”, minimising risks of harm.

    But, in its internal discussions of the need for retailers to “identify and target super consumers”, the industry is acknowledging a large part of its sales are to drinkers who are taking substantial risks with their own lives and the lives of those around them. If all drinkers in Australia were to drink within the government guidelines for low-risk drinking, the alcohol market would shrink substantially.

    If governments want to reduce alcohol-related harms, they can’t rely on the industry’s commitment to responsible drinking. It’s directly against the industry’s interests for the heaviest drinkers (who make up the majority of their sales) to drink less.

    Given this inherent conflict, policymakers should focus on well-evaluated policies such as reduced late-night trading hours for pubs and nightclubs and smarter taxation of alcoholic products. Most importantly, governments should be sceptical of working in partnership with an industry whose interests are diametrically opposed to public health.

    Robin Room is Professor and Director, Centre for Alcohol Policy Research, Latrobe University.  Michael Livingston is Post-Doctoral Research Fellow at the Centre for Alcohol Policy Research, Latrobe University. This article was first published in The Conversation on January 20,2016.

  • Michael Thorn. Caught Out: How Cricket Australia maintains Aussies high drinking average.

     

    The runs are coming thick and fast in the current Victoria Bitter One Day International Series between Australia and India, bested only by the onslaught of alcohol advertising both on and off the pitch as well as in the commercial breaks in between the on field action.

    That barrage of alcohol ads on the telly are the result of an egregious loophole in Australia’s legislation that allows for alcohol advertising to be broadcast on television before 8:30pm during sporting broadcasts on weekends and public holidays.

    So while the Australian cricket team deservedly basks in the glow of its 4-0 series lead with only the fifth and final game of the series to be played; Cricket Australia and the alcohol companies that advertise during sporting events deserve only our disdain.

    Of course we know why the alcohol industry does it.

    Alcohol companies know only too well that the earlier children are exposed to alcohol branding, the more likely they are to commence drinking earlier and the more likely they are to drink to excess.

    And make no mistake. The Australian alcohol industry is absolutely dependent on not simply recruiting new drinkers but ensuring that its customers drink at levels harmful to their health.

    A new video produced by my organisation, the Foundation for Alcohol Research and Education (FARE), earlier this week exposed the Australian alcohol industry’s heavy reliance on risky drinkers, with over 3.8 million Aussies averaging more than four standard drinks of alcohol a day, twice the recommended health guidelines.

    Targeted by the alcohol industry and branded as ‘super consumers’, the industry’s best customers represent just 20 per cent of Australians aged 14 and above, yet they account for a staggering 74.2 per cent all the alcohol consumed as a nation each year.

    This is the alcohol industry’s dirty little secret. It’s an industry built on identifying, targeting and exploiting its best customers, and ensuring that they continue to misuse and abuse alcohol.

    So much so, that if the industry’s best customers were to drink within the guidelines, the total alcohol consumed as a nation would be reduced by a staggering 39 per cent or more than 38 million litres of pure alcohol.

    Unfortunately, we will all grow old waiting for the alcohol industry to ever agree to effective measures that would save lives and reduce harm, and to willingly stop exploiting these opportunities to link alcohol products with sport.

    It is government that must accept the ultimate responsibility to ensure that vested interests do not trump the health and welfare of our children, our families and our communities.

    The price we pay as a society is already too high; a heavy burden that extends beyond the 5,500 deaths and the 157,000 hospitalisations every year.

    It’s been almost ten months since Australia’s one-day cricket team won the 2015 ICC World Cup. Thanks to a series of unfortunate and embarrassing post-game interviews by Channel Nine’s Shane Warne and members of the cricket team, it was not the sporting victory that held the nation’s attention in the days to follow, but rather the communities building disappointment and outrage that alcohol and a culture of drinking to excess had literally drowned out and overwhelmed the sporting achievement.

    I said then that I hoped the strong reaction would make clear to sports administrators and those responsible in government that it was time for action.

    To date those calls have fallen on deaf ears.

    Today Cricket Australia still worships at the feet of Big Alcohol. Still accepts millions of dollars for the honour of a logo on a shirt and the naming rights to its contests. Still works hand-in-cricket glove with the alcohol industry with the knowledge that by doing so Cricket Australia is complicit in recruiting the risky drinkers so crucial to the alcohol industry’s bottom line and normalising the alcohol-drenched culture.

    Far from strengthening its code during its recent review, Free TV Australia failed to remove the sports loophole and relaxed its code even further.

    And while we can take comfort in changing community attitudes that recognise it is not acceptable that our children be exposed to a sporting code inextricably linked to big alcohol and a culture of risky drinking, it seems that Free TV Australia, Cricket Australia and our governments remain two steps behind and alarmingly out of touch.

    Michael Thorn is Chief Executive of the Foundation for Alcohol and Education Research.

     

     

     

     

     

     

  • Kim Oates. Excuse me doctor, have you washed your hands?

    Imagine you are a patient in hospital. The doctor draws back the bed sheet to examine your abdomen. Before you are touched, you say “Excuse me doctor, have you washed your hands?”

    Would you dare? Would you be too embarrassed, awkward or even afraid to ask? Would you worry that it would be rude to ask, or that it could undermine the doctor’s authority? Would you risk upsetting the person taking care of you if it led to your doctor taking offence? Or you might think it’s just not your role to ask this type of question.

    Hospitals can be dangerous places. Sometimes things go wrong and patients suffer. Dr Don Berwick from the Institute for Healthcare Improvement in Boston showed that the risk of death from hospital admission was the same as the risk of death from mountain climbing or bungy jumping. But of course, because hospital admissions are far more common than these sports, the actual number of deaths is far higher.

    One reason for this is that people admitted to hospital are often unhealthy to start with. They may have multiple health problems. Some have supressed immune systems, making them more susceptible to infection. They may undergo complex procedures where there are small margins for error.

    Another less apparent reason is that not all health professionals practise hand hygiene as well as they should.

    According to the Australian Commission on Safety and Quality in Healthcare, each year approximately 200,000 patients acquire an infection while they are in hospital, making hospital acquired infection the most common complication for hospitalised patients.

    Sometimes these infections can enter the blood stream, with the potential to cause death, particularly when the infection is from an organism resistant to most antibiotics. And hospitals are places where antibiotic resistant bacteria are more commonly found.

    Hand hygiene is probably the most important thing health workers can do to protect their patients from infection.

    But what can patients do to protect themselves? Asking health professionals if they have washed their hands is a good start.

    Studies show that a substantial minority of health professionals don’t wash their hands as often as they should, although concerted campaigns, coupled with surveillance, by Hand Hygiene Australia and other patient safety bodies show that compliance with hand washing is increasing.

    In 2010, 70% of nurses complied with hand washing regimes, the highest of all health professional groups surveyed. By 2105, their rate had risen to 86%. But would you rest easy if you knew that there was a 14% chance that your nurse was one of those who had not performed correct hand hygiene?

    Doctors comply less often. In 2010 the hand hygiene rate for doctors was just under half, a worrying 49%. By 2015 their rate had risen to 71%. It’s a big improvement but doesn’t help if you are the patient of one of the 29% who has not complied.

    What can you, the patient, do about this? The answer is simple in theory, but difficult in practice. Just ask: “Have you washed your hands?”

    However, studies show that 77% of patients would feel uncomfortable asking their doctors if they have washed their hands before examining them. Fifty seven per cent said that they would not ask, assuming the doctor had already washed. Twenty per cent worried that asking could be construed as questioning the doctor’s professionalism.

    Contrast this information with what health professionals think about being asked this question by patients. Twenty nine per cent said they would not like to be asked. Twenty seven per cent said they would find it humiliating if they were asked.

    This essential question is not the responsibility of the patient or of the health professional alone. The best health care occurs when there is a partnership between the patient and the health professional.

    Patients need to know it’s OK to ask the question. Health professionals need to encourage them to ask. Ninety two per cent of patients said they would be more likely to ask the question if the health professional invited them to ask the question, such as by wearing a badge saying “Ask me if I’ve washed my hands.”

    Patients need to be encouraged to ask and health professionals need to become more comfortable with patients who ask the question. If the aim of health care is to improve the health of the patient, rather than make it worse, it’s pretty obvious.

    Kim Oates is an Emeritus Professor at Sydney University and a clinical advisor to the Clinical Excellence Commission

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  • The policy scandal of a $11b taxpayer subsidy to private health insurance.

    I don’t think that I can recall a domestic policy that is so outrageous as the $11 b. annual cost to the taxpayer of the subsidy to private health insurance (PHI) companies. The subsidy is paid to policy holders, but it really means that PHI companies receive the benefit of the subsidy. For further explanation of the $11b figure see link to submission below. Repost from 08/12/2013

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  • John Duggan. Advice from expert clinicians or the AMA

    For those interested in the cost of health care the recently released interim report by the Medical Benefits Schedule (MBS) Review “obsolete MBS items track one” demonstrates the dawning recognition that there are procedures and tests that do not justify their existence or federal funding.

    The story begins with the decision of Ms Sussan Ley, Minister for Health to form the Medical Benefits Schedule Review taskforce, with a mandate to review the schedule in its entirety. The Task Force is ‘an expert clinician led Medicare Benefit Schedule (MBS) review … established to lead an accelerated program of MBS reviews to align MBS funding services with contemporary clinical evidence and improve health outcomes for patients’.

    The taskforce, chaired by Professor Bruce Robinson, Dean of the Sydney University Medical School, is an expert clinician-led group whose main duty is to align MBS funded services with contemporary clinical evidence and improve outcomes.

    One role of the taskforce of 13 members is to appoint chairs and members of working groups to progress the work using evidence based reviews and data and assessment of literature. Priority areas will include safety, clinically unnecessary service provision and accepted clinical guidelines. It also has the power to recommend adding new services to the MBS.

    Of the host of clinical committees created several have already reported on obsolete items – an interesting group. The strictures about kidney x-rays (MBS item number 58705) illustrate the problem and variety of obsolete and useless procedures recommended for abolition. The gastroenterology group reviewed the practice of treating gastric bleeding by infusing refrigerant fluid into the stomach, discarded soon after its initiation about 60 years ago and which was only used eight times in the last 11 years.

    It is evident to any medical scientist that the review is overdue and can only benefit both patients and the budget.

    Whether the AMA feels happy about the review will be reflected in its attitude to the recommendations of the Task Force.

    John Duggan is Conjoint Professor, School of Medicine and Public Health, University of Newcastle.

  • Ian McAuley, Jennifer Doggett, John Menadue. Private Health Insurance companies are price takers. Prices are set by doctors and hospitals.

    Repost from 22/10/2015

    On Tuesday the Australian Competition and Consumer Commission (ACCC) released its  report on private health insurance.

    Private health insurance (PHI) was also in the news a day later with the standing down of the CEO of Medibank Pte, the largest PHI company.

    The ACCC report has been a regular report since 1999, when the Howard Government introduced a swag of subsidies for private health insurance. It covers specific “consumer” issues, such as possible false or misleading representation of products, anti-competitive behaviour, and the incidence of unexpected out-of-pocket expenses.

    Because government policy is taken as a given condition, its recommendations are confined to administrative matters. In this year’s report they are largely about the need for insurers to use standardised terminology and clearer information on restrictions, exclusions and out-of-pocket costs.

    Although not explicitly stated, its concern seems to be to help consumers to make a choice within the range of products (more than 20 000 on offer) from 34 private insurers, rather than helping consumers make a choice whether to hold private insurance or not.

    Unsurprisingly, the report finds that consumers are faced with what the cartoonist Scott Adams (creator of the Dilbert character) calls “confusopoly”. The range of products is bewildering, different insurers use different language to describe similar products, and there  are subtle definitions in policy exclusions (who knows the difference between “obstetrics” and “gynaecology”, for instance?).

    Its most telling findings are that complaints are on the rise, and that the main concerns of complainants are the unpleasant surprises they get (exclusions, co-payments, restrictions on choice of providers) when they come to claim on a policy. The price of private insurance is only of minor concern, even though its price, in real (inflation-adjusted) terms has risen by 54 per cent since 2000.

    We don’t find that at all surprising.  Since the Howard Government introduced generous subsidies for private insurance in 1999, six million more people have taken some form of hospital cover. Many of these have been virtually forced into private insurance by the Medicare Levy Surcharge applying to those with high incomes, and many others were  enticed by the 1999 “Run for cover” scare campaign.

    Research in behavioral economics shows that people don’t make careful, rational choices about insurance. People tend to over-insure for small risks, while leaving themselves inadequately covered in other areas. People buy insurance because they believe it is a prudent thing to have, without giving it much consideration.

    This is confirmed by the ABS in its survey of reasons why people hold private health insurance. It has found that financial considerations hardly count, but that “security, protection, peace of mind” is the overwhelming reason for people to hold private insurance.

    It’s only when people come to make a significant claim, which can be many years down the track, that they realise that they have bought a dud product. Or, perhaps, after outlaying thousands of dollars for private insurance over many years, they have a medical emergency and discover, for the first time, that there is an efficient and responsive public hospital system covering their needs.

    What comes through in the ACCC’s report is a level of frustration. This is a body with a strong faith in the benefits of competition. It says “as a starting point, competition should be relied upon to drive efficient outcomes wherever possible”, but finds that even though there are plenty of players in the market the industry is not providing what consumers want.

    The problem the ACCC faces is that in private health insurance competition doesn’t work, mainly because the insurers are simply a financial intermediary between consumers and well-organised suppliers, as we have pointed our in our work on private insurance for the Centre for Policy Development. Insurers, are essentially price-takers in a market dominated by powerful suppliers.

    That power asymmetry was illustrated earlier this year in the dispute between Medibank Private, Australia’s largest health insurer and Canberra’s Calvary Hospital. The fact that MBF had to back down in this dispute may explain the standing down of the CEO of Medibank Private, George Savvides. He understood the power of providers, but his board didn’t.

    As we point out in our research, it takes the power of a single insurer, such as Medicare and similar bodies in other countries, to ensure that costs are controlled and to see that scarce resources are put to their best use. A case study in resource misallocation (the economists’ term for “waste”) driven by the perverse incentives in private insurance was provided by a recent ABC Four Corners program on over-servicing in private hospitals.

    While the ACCC is critical of some insurers’ practices, particularly some potentially misleading product descriptions, it does not claim that this industry is engaged in collusion or other systemic anti-consumer behaviour. It seems to be annoyed by consumers who do not do their homework and shop around for the best deal – this is a common grizzle by competition regulators, who seem to believe that we all have unlimited time to devote to comparison shopping.

    But even if we were all well-informed and diligent consumers, shopping around for the best products, this would still be a market subject to fundamental market failures that go well beyond the usual scope of competition regulators. Private health insurance is simply a high-cost financial intermediary that takes 14 cents in the dollar for management and profits, without adding any consumer value.

    The fundamental problem is that insurance of any form, be it public or private, by its very nature suppresses price signals – the very mechanism that makes markets work. When a service is free at the point of delivery the discipline of markets does not operate. Economists know this problem by the quaint term “moral hazard”.

    The ACCC acknowledges the existence of moral hazard in private insurance, but there is no way it can resolve the fundamental conflict: that is seeking to use market mechanisms to regulate an industry whose very raison d’etre is to allow people to buy out of the discipline of markets.

    Of course there is still moral hazard in single insurer systems, but a single national insurer can use its power as a strong purchaser to make sure suppliers operate efficiently. There are plenty of successful overseas models of single national insurers, particularly in Canada and the Nordic countries, but, closer to home state governments, particularly in Victoria, and the Commonwealth Department of Veterans’ Affairs, act as single purchasers of hospital services. And moral hazard on the part of consumers can be held in check by the use of judicious co-payments set at such a level to provide some market discipline but not so as to discourage those with limited means from seeking necessary care.

    Perhaps, when the ACCC produces its 2014-15 report for release this time next year, it could remember that competition is not the answer to all market failures. Competition is not an end in itself – it is one way, in some markets, whereby efficient and fair outcomes can be achieved. In some markets it doesn’t work.

     

     

  • Jennifer Doggett, Ian McAuley, John Menadue. Four Corners: No wonder we’re wasting money in health care – we got the incentives wrong

    Repost from 06/10/2015.

    A recently-aired ABC Four Corners program aptly titled “Wasted” exposed three areas of unnecessary, ineffective and outright dangerous health interventions, in knee, spinal and heart surgery.

    The show’s host, Norman Swan, presumably extrapolating from the findings in those three areas, claimed that waste could be as high as 30 percent of all health care expenditure.

    Perhaps that’s an overstatement, but the point made by Swan and by most of the ten other clinical experts who appeared on the program is that we just don’t know how much waste there is in health care because we lack the processes for evaluating the effectiveness of various interventions.

    We know what we pay for a knee replacement or a cardiac stent, but we do not systematically evaluate the outcomes of these procedures.

    Identifying and reducing or eliminating funding for low value services would save our health system billions every year.

    However, this would only address one area of waste and inefficiency within our health system. A less obvious but potentially more significant source of waste lies in the way in which health care is funded in Australia, in particular via fee-for-service payment mechanisms and private health insurance.

    These funding processes are driving unsustainable growth in health services consumption without meeting the needs of the community for efficient, preventative and coordinated care.

    Unless Australia’s health funding system is fundamentally reformed to discourage inefficient and provider-driven health expenditure, efforts to increase the efficiency and targeting of Medicare expenditure will be dwarfed by the growing waste associated with our current funding systems.

    The big picture

    Every year we spend around $160 billion on health care – two thirds through our taxes, and one third through private sources.

    At a macro level we can claim we spend that money well. At around ten per cent of GDP it’s in line with expenditure in similar countries, and by gross indicators such as infant mortality and life expectancy we’re among the high achievers.

    But within our health care arrangements – a complex mix of private and public funding and provision – there are areas of poor outcomes, such as indigenous health, youth suicide, and obesity, and there is evidence of resource misallocation, such as long waiting times for elective surgery in public hospitals while there are government subsidies encouraging queue-jumping for those with lesser needs to use private hospitals.

    The role of data

    It’s not that we fail to collect data in many areas of health care, but as Adam Elshaug, Associate Professor of Health Care Policy at Sydney University points out, all the data is kept in separate silos – some relating to the Pharmaceutical Benefits Scheme, some relating to the Medical Benefits Scheme (MBS), and some in state public hospitals just to name three of the non-interlinked sources.

    While we lack a systematic method of data analysis and feedback (which was one of the original purposes of Medicare), there are a some studies of cost effectiveness in specific areas of health care, upon which the experts were able to draw. In these three areas of health care, that make up a large proportion of surgical admissions in private hospitals, all the experts were able to identify evidence of ineffective treatment and over-servicing and where resources could be put to better use. As an example Swan pointed out:

    At least half of all back scans and X rays are of no value, and to put that into perspective, that’s at least half a billion dollars over ten years. Now that would buy you a regionally delivered national suicide prevention program that would save 1000 lives a year.

    The experts offered a number of explanations for this waste. One strong message was that the vast majority of the 5700 items on the MBS schedule had never been subject to any rigorous cost-effectiveness evaluation. As Elshaug reminded us, the MBS schedule dates back to the 1960s (when it had only 300 items), when the idea of “evidence based policy” as a standard was still some decades off. It has been easy for advocates, mainly in the medical profession, to add new items to the schedule, but it is very hard to have any removed. Professor Rachelle Buchbinder, Director of the Department of Clinical Epidemiology at Monash University, recounted the great difficulty she had experienced in having just one item removed from the MBS. She was confronted by well-funded corporate interests, and was subject to ad hominem vilification. (We wish Minister Ley the best of luck in her taking on the MBS schedule.)

    Drivers of growth

    Many referred to the availability of imaging technology, referring, for example, to the fact that GPs can now order knee MRIs without going through a specialist. Often discussions about technology in health care degenerate into a romantic and unrealistic call for the clock of technological advancement to be turned back. But Paul Glasziou, Director of the Centre for Research and Evidence Based Practice at Bond University pointed out that imaging and other diagnostic technology is here to stay and is becoming more widely available (have you noticed that “health” app on your smartphone?). As the Productivity Commission pointed out in its 2005 report on medical technology, IT-based technologies in most industries have reduced unit costs, and there is no reason why it should not do so in health care if used properly.

    The problem that Glasziou and others pointed out is that diagnostic technology has given us much more capacity to detect what is “abnormal” or supposedly “wrong” in our bodies. We misinterpret the normal changes associated with ageing, and, as a result otherwise healthy people are turned into “patients”. Our expectations and anxieties as consumers have interacted with GPs’ fear of missing a diagnosis and desire to do something tangible, in the form of delivering a “product” to the patient, leading to a detected abnormality and on to surgery, with all the attendant costs and the possibility of infection and other iatrogenic risks. (A similar motivation to provide some tangible product has been found to be a driver of pharmaceutical over-prescribing.) Doctors are generally dedicated professionals motivated by a strong desire to “do something” for those who turn up in their surgeries.

    But as Robyn Ward, Chair of the Medical Services Advisory Committee said, “often the best medicine is no medicine at all, often the best intervention is no intervention at all”.

    She said that if GPs could explain how certain procedures are ineffective, patients may make better decisions. And if GPs or other health professionals could help people understand that adopting a healthy lifestyle may be more effective (and certainly less costly) than going down the diagnosis-surgery path, there would be better outcomes all around.

    The problem with our current funding system

    But that’s not where the incentives lie in a fee-for-service system. Swan summarised the problem when he said “the way we pay for health services in Australia does not encourage good practice”. We pay for throughput, not for outcomes.

    One perverse consequence of these incentives for over-servicing is that early intervention at the primary care level, which is supposed to result in better health outcomes and financial savings, can actually worsen outcomes and cost money when the incentives are wrong.

    Cardiologists Richard Harper (of Monash University) and Andrew Macisaac (of St Vincent’s Hospital) noted that there was excessive use of angiograms (Harper suggested that up to 43 percent of invasive angiograms were unnecessary), and that these were most likely to occur in private hospitals. There is a confirmation of published findings by Monash University researchers that observed “startling variation” in the use of well-known procedures in Victorian hospitals. They found “in the 14 days following a heart attack, men and women admitted to a private hospital were 2.20 and 2.27 times more likely to receive angiography than their counter-parts in public hospitals”. They were 3.43 and 3.86 times more likely, respectively, “‘to undergo revascularisation” (coronary by-pass surgery, angioplasty and stent).

    That study was published in 2000, around the same time the Commonwealth was strengthening subsidies for private health insurance, in a set of arrangements that de facto linked funding of private hospitals to private insurance. At no time has the Commonwealth evaluated that policy, but independent research suggests that while it has injected a large amount of new money into private hospitals, and into the incomes of medical specialists, it has done nothing to achieve its avowed objective of “taking pressure off public hospitals”, because where the funds have gone, so too have the specialists. If anything the subsidies have sucked resources out of public hospitals and have put pressure on public hospitals to try to match the incomes specialist can enjoy when they work in private hospitals.

    If people who present to private hospitals get more treatment than those with similar conditions who present to public hospitals, then there is certainly some resource misallocation. Either public patients are being under-serviced, or private patients are being over-serviced. The Four Corners program strongly suggests the latter.

    The funding honeypot – private health insurance

    While there were frequent reference to the problems of fee-for-service medicine, the program only touched on the interaction of private health insurance and fee-for-service remuneration, which is where the root of the problem lies. Private health insurance is a major driver of resource misallocation and waste. But since 1997 the Commonwealth has had a policy of supporting private insurance, almost as an end in its own right.

    It is notable that not since 1969 – when the Nimmo Report paved the way for universal public health insurance – have governments subjected private health insurance to policy scrutiny. The principle of evidence-based medicine, and the general bipartisan disdain for industry subsidies, do not seem to apply to private health insurance.

    Although unquestioned support for private health insurance is normally associated with Coalition governments (“Private health insurance is in our DNA was Prime Minister Abbott’s justification), it has become bipartisan. When the Rudd Government set up the National Health and Hospitals Reform Commission it specifically ruled out any scrutiny of private health insurance. The Gillard Government strengthened the Medicare Levy Surcharge penalties for those higher income people without private insurance, and removed the 20 per cent tax offset for those who incur expenses not covered by private health insurance. Only the Greens seem to be committed to the original principles of Medicare as a single national insurer.

    Thanks to the Medicare Levy Surcharge, people on higher incomes (individuals with an income above $90 000 and families with an income above $180 000) are virtually conscripted into private insurance. Quite apart from the problem of promoting a two-tier health system, with the public system reduced to a residual “charity” system, the surcharge has strong incentives for people to use private insurance, and for opting out of sharing his or her health expenses with other Australians. Someone with an income of $150 000 can either buy top hospital cover for around $1300 or pay an extra $2250 in taxes, for example.

    The subsidy to private health insurance comes to more than $8 billion a year according to Commonwealth Budget papers, and is growing strongly. That figure does not include the effect of the Surcharge, which, if it is re-framed as a subsidy for having private insurance (rather than as a penalty for not having it), results in revenue forgone of around $3 billion a year, or a total subsidy of around 11 billion dollars a year. As Jeff Richardson of Monash University once said, not even in the days of high support of manufacturing were the rich actually provided with a taxpayer-funded Holden with change left over.

    With governments ready to provide such permissive access to public money to support private insurance, it is hardly surprising that private health insurance premiums have risen so strongly. Since 2000, while general prices (as measured by the CPI) have risen by 54 per cent, private health insurance premiums have risen by 133 percent – a 50 per cent real increase. As a source of ever-growing funds private insurance has been a honeypot for private hospitals and those who work in them (as well as directing public money that taxpayers may have believed were for health expenditure, to flybuy cards and Coles gift vouchers).

    So long as we have a highly-subsidised private health insurance industry, fee-for-service medicine, and a private hospital system with its own privileged source of funding, these problems will remain. In time we could head to the US system, where private health insurance has resulted in health costs approaching 20 per cent of GDP, and with only mediocre outcomes by the standards of most prosperous countries. (“Obamacare” will solve some coverage problems, but it will not solve the cost problem.)

    The real cost of private health insurance

    There are several independent analyses of the costs of private health insurance – Jeff Richardson’s “Private Health Insurance and the PBS: How effective has recent government policy been?”, an analysis by Don Hindle and Ian McAuley “The effects of increased private health insurance: a review of the evidence”, a Centre for Policy Development paper“Private health insurance: High in cost, and low in equity”, an article for The Conversation by Terence Cheung of the University of Adelaide “Why it’s time to remove private health insurance rebates”, and a chapter in the recently-published book Governomics: can we afford small government?

    A common theme of these works is that measures such as private health insurance, designed to shift costs off-budget, generally result in the public paying more for the same or worse services, with far less accountability or equity, and with much higher administrative costs as slimmed down public agencies (such as Medicare) are replaced by corporate bureaucracies duplicating competitors’ corporate bureaucracies.

    In fact, in the USA, reliance on private health insurance, far from saving public money, has resulted in a blowout in public expenditure. Because health costs are set in an undisciplined market between powerful service providers and comparatively weak health insurers, even the publicly-funded programs (Medicare and Medicaid) are now costing more than the comprehensive single insurer models in place in Canada, the UK and the Scandinavian countries.

    Outcomes, not volume

    In the Four Corners program Robyn Ward called for a system that pays for value and outcomes rather than activity or volume. It’s a view shared by many others.

    It is hard to see how such a system based on outcomes rather than outputs could be developed through any monetary incentive system. One basic problem is that in very few cases is it possible to link any specific health interventions unambiguously to outcomes. There are too many other variables leading to people’s health outcomes, and there is often a very large time lag between interventions and outcomes. When it comes to non-interventions (e,g, the decision not to have a knee reconstruction) the measurement and time lags are even more problematic.

    It is even harder to see how any private insurance-based system can deliver satisfactory consumer outcomes or any significant degree of cost control. The economics textbooks claim that businesses seek profit, while the business textbooks, based on empirical studies of organizational behaviour, see growth and expansion as the prime objective of firms (with profit as a constraint to be satisfied). That growth objective would surely dominate in any scheme relying on financial incentives, leading to over-servicing. The Four Corners program is an excellent exposition of the way private sector incentives lead to such poor outcomes. If costs rise because of over-servicing, the insurers can simply jack up their premiums.

    The benefit of a single public insurer is that Commonwealth Treasurers will always sustain pressure to keep expenditure in control and to achieve value for money. It’s easier for insurers to raise premiums than for governments to raise taxes.

    Public insurance, private and public delivery

    That is not to say the private sector should not be involved. It is simply to point out that private insurance should have no role in funding health care.

    There is clearly a role for personal out-of-pocket (i.e. uninsured) contributions to health care. In fact, such contributions are a feature even of the most generous single insurer models as operate in the Scandinavian countries, and, in a wealthy country such as Australia they should clearly pay their part. When Medicare was first designed we were much less prosperous, but now, on average, households now have around $300 000 in financial assets, a figure that has grown, in real terms, more than 60 per cent this century.

    While we all need to be covered for high health care expenses, we don’t need the “first dollar cover” provided by so many private insurers – the cover that drives us to over-use of health services. Both public and public insurance comes with the same incentive for over-use (“moral hazard” in the quaint language of economics) – there is no difference in the notion “Medicare will pay for it” and “BUPA/Medibank Private/HCF will pay for it”, but, as pointed out above, Medicare comes with the discipline and accountability of public finance, and it is easy for governments to build in compulsory out-of-pocket contributions to lessen moral hazard.

    Out-of-pocket payments provide some price signals to consumers, and they can be designed in such a way that most people who make light use of health services in any one year can be independent of any public funding support, so that public funding can be directed to serious acute and chronic conditions. We already spend around $27 billion a year in out-of-pocket contributions, but, as Jennifer Doggett points out, their incidence is haphazard, and do not adhere to good insurance principles: some health care programs are free at the point of service, while for some others the patient is left bearing open-ended risk. Ham-fisted ideas to bring in open-ended MBS co-payments, as proposed by the Abbott Government, understandably meet with community resistance.

    In the delivery of services the private sector has always played a central role, and will go on doing so. Alarmists often interpret any criticism of private health insurance as an attack on the “private system”, but that’s bunkum. There is no reason why private hospitals cannot be involved in delivering publicly-funded services.

    That model is already operating in Australia through the Department of Veterans’ Affairs, which acts as a single insurer for war veterans, while purchasing most services, including hospitalisation, from the private sector. At a state level there have been initiatives to break this dependence. Victoria, under the leadership of Premier Jeff Kennett first made the offer to private hospitals in the 1990s and the Tasmanian Government has recently offered $25 million of elective surgery cases to private providers. There’s nothing radical about such measures – in fact they are in line with national competition policy that calls for competitive neutrality between private and public sector providers.

    Future dangers – Medicare Select

    The Four Corners program has been a useful reminder of the problems we face in health care, particularly (but not only) the perverse outcomes when private insurance, fee-for-service payment, and a private hospital system separated from public hospitals interact. No doubt private insurers, who will be well aware of these perverse outcomes, will be presenting to government schemes which they claim will solve these problems. For example, arising out of the Health and Hospital Reform Commission’s work, the insurers put forward an idea called Medicare Select, which made great claims about consumer choice and cost control, but which was simply a way of churning even more public funds through health insurers, adding private sector administrative costs to public sector administrative costs, without demonstrating any value-added, other than offering consumers some “choice” of care plans – as if people are in a position to know their future health care needs.

    We could well see the private insurers offer Medicare Select, or some similar proposal, as a “solution” to our problems. Even if such schemes are put forward in good faith, we should heed the lessons from the USA, however, where private health insurers have been quite unable to contain health costs – or perhaps unwilling.

    There are too many parties – medical specialists, private hospital companies, appliance manufacturers, pharmaceutical firms – who would see cost containment as quite inimical to their interests. And there is the whole investment community – superannuation funds, banks stockbrokers, financial advisors – looking for a new growth industry, as profits in traditional industries such as airlines, newspapers and retailing are squeezed.

    Only a strong government can protect us from the economic and health costs of health care becoming a growth industry.

    Jenniffer Doggett is a consultant in the health sector. Ian McAuley is a Adjunct Lecturer, Canberra University. John Menadue chaired Health Enquiries in NSW and SA and was involved with Gough Whitlam in the creation of Medicare.  All three are Fellows of the Centre for Policy Development. 

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    John Menadue posted three articles on health reform as part of the Policy Series ‘Fairness, Opportunity and Security’ which he edited with Michael Keating. Links to those three articles follow.

    Health Policy Reform: Part 1 – Why reform is needed.

    Health Policy Reform Part 2 – Why reform is difficult.Health ministers are in office but not in power.

    Health Policy Reform: Part 3 – Principles for reform.