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Does Australia need a version of the Institute of Medicine?

Croakey has often been grateful for the work done by the Institute of Medicine (IOM) in the US.

The IOM, established in 1970 as the health arm of the National Academy of Sciences, aims to provide unbiased and authoritative advice to decision makers and the public, and “asks and answers the nation’s most pressing questions about health and health care.”

Two of its reports spring to mind, in particular. The 1999 To Err is Human: Building A Safer Health System and the 2009 Conflict of Interest in Medical Research, Education, and Practice.

The most recent IOM publication (released overnight) is a report on a workshop aimed at improving the quality of oncology care via patient-centred cancer treatment planning.

Public health policy consultant Margo Saunders has been investigating gaps in the provision of relevant and useful health policy advice in Australia, and whether we could benefit from an organisation like the IOM.

***


Australia needs better mechanisms for developing timely health policy advice

Margo Saunders writes:

Recent discussions about whether Australia needs a national Centre for Disease Control reflect legitimate concerns about complacency regarding disease surveillance and communicable disease.

At the same time, increasing attention is turning to the burden of non-communicable diseases, as highlighted by the World Health Organization and NCD Action Group and the NCD Alliance.

In Australia, numerous government and non-government agencies focus on a disparate range of health issues, but progress is invariably slow and some issues receive little or no attention. 

Despite the work of agencies such as the National Health & Medical Research Council in developing guidelines and supporting collaborative research, and of the intentions of the newly-created Australian National Preventive Health Agency to provide greater focus on prevention initiatives, there is no mechanism for marshalling expertise in order to progress issues that are either stuck at the bottom of the agenda or struggle to even make an appearance. Many of these are issues which lack an organized, vocal constituency; involve messy, cross-portfolio matters; or are simply beyond the intellectual or financial capacity of the relevant organisations.

Unlike Canada, we cannot expect public health matters to be addressed and coordinated by a national Public Health Agency and a Chief Public Health Officer.  Unlike Britain, we cannot refer responsibility for treatment and prevention guidance to a National Institute for Health and Clinical Excellence.

Unlike the USA, we have neither a massive national infrastructure like the Centers for Disease Control and Prevention, with more than 14 000 staff, nor high-profile health advocates and communicators like the Surgeon-General and CNN’s Dr Sanjay Gupta.

And, when it comes to addressing Peter Shergold’s recent plea for stronger bridges between the worlds of research and policy, it becomes clear that we have nothing like the US Institute of Medicine (IOM).

Established in 1970 as the health arm of the National Academy of Science (NAS), now known as the National Academies, the Washington, DC-based IOM is an independent, nonprofit organisation whose members donate their knowledge and expertise to hundreds of committees convened to answer specific sets of questions – without pay.

The Academies as a whole, which also include the National Academy of Sciences, the National Academy of Engineering and the National Research Council, provide independent and authoritative analyses and advice, often on controversial or under-researched issues, which bridge the gaps between researchers, decision makers and the public.  Linkages between Academies have produced initiatives such as the IOM – National Academy of Engineering challenge to students to create interactive ‘apps’ and other tools to improve health.

Some of the IOM’s studies began as specific mandates from Congress, while others are requested by federal agencies and independent organisations.  Federal agencies are the primary source of financial support, with studies also funded by state agencies, foundations, other private sponsors, and the National Academies endowment.

In addition to the work of its expert committees, the IOM organises activities such as forums and roundtable meetings to facilitate discussion and cross-disciplinary thinking.  Many of the IOM’s reports have been influential in guiding decisions on policies, programs and research directions.

The recent decision to allow unrestricted online access to all National Academies publications means that all IOM publications are freely available.

One issue recently investigated by the IOM was Conflicts of Interest in Medical Research, Education, and Practice.  The two-year project resulted in a report and recommendations issued in 2009 which have had a significant impact.

In Australia, the NHMRC, which has also been looking at this issue, held a workshop on Transparency and Conflict of Interest in June 2009.  The conclusion of a leading participant in the workshop was: “I think there was agreement that it’s a difficult area.”  A set of draft principles was to be considered at the NHMRC’s December 2009 meeting; 18 months later, nothing more has emerged.

It is also interesting to compare the IOM’s publication topics with those of the NHMRC.  Public Health and Select Populations & Health Disparities appear as IOM topics; there are no comparable areas on the NHMRC’s publications list.

While the NHMRC has been active in publishing clinical guidelines and has addressed important issues such as alcohol guidelines, its online publications list suggests that numerous areas have received little attention. For example, according to the NHMRC’s website, there have been no publications on men’s or women’s health for 5 years or more, nothing on rural health for 9 years, and nothing on cancer for 3 years. No reports on environmental health were produced between 2006 and 2009, and the most recent publication on antibiotic resistance appeared in 1996.

It cannot simply be assumed that responsibility for these issues has been taken up by other organisations.  Professor Thomas Gottlieb, President of the Australasian Society for Infectious Diseases, and Professor Graeme Nimmo, President of the Australian Society for Antimicrobials, have argued that the problem of multiresistant bacteria as a public health threat has increased over the last decade and there is a crucial need for action on national control and surveillance strategies.

This is a classic example of an issue which requires contributions from a wide range of stakeholders and cuts across academic disciplines and government policy silos.  It was professional bodies, not the NHMRC, who hosted a summit conference earlier this year to bring together an interdisciplinary group of experts to establish priorities and a joint plan for action.

As Gottlieb and Nimmo point out, ‘While basic science research on microbiology is currently adequately funded by the [NHMRC] and the Australian Research Council, a number of essential aspects required to combat antibiotic resistance do not find a ready place in existing project grant structures.’

The IOM has been instrumental in addressing complex, cross-cutting issues such as health literacy, an issue which has lacked serious and coordinated attention in Australia despite indications that levels of health literacy in Australia are problematic.

While the importance of health literacy has been acknowledged in a string of strategic and health reform frameworks, there have been no apparent moves within Australia to take the crucial first step of assigning ‘ownership’ of the issue to any agency or organisation.

In the USA, the IOM was asked to define the scope of the problem, identify obstacles to improving health literacy, assess current approaches, and identify goals and strategies for future efforts.  The IOM’s report, published in 2004, had a major impact throughout the public and private health sectors and prompted a program of much-needed research.

The Institute’s continued involvement has ensured that the issue has not faded from view.  In early 2006, the IOM held its first Roundtable on Health Literacy and reviewed responses to the recommendations of the 2004 report.  Subsequent meetings have brought together a wide range of stakeholders for continuing dialogue and discussion, with publicly-available summary reports.

Following the 2010 launch of the National Action Plan to Improve Health Literacy, the IOM held a public workshop to consider opportunities for health literacy in the context of the Obama Administration’s health reforms.  The IOM’s 2011 publication, Leading Health Indicators for Healthy People 2020, produced at the request of the US Department of Health and Human Services, lists health literacy as a social and economic health determinant and health outcome.

The continued absence of a coordinated effort to assess, analyse and improve health literacy in Australia serves as one example of a complex — and ‘homeless’ — health issue failing to gain traction.

Additional examples can be seen in the subjects of other recent IOM initiatives: integrating primary care and public health; the public use of data and innovation to improve health; assessing the value of community-based, non-clinical prevention policy and wellness strategies; effects of climate change on indoor air and public health; advancing oral health; the relationship between hunger and obesity; substance use prevention, diagnosis, treatment and management for members of the Armed Forces; the mental and behavioural health care needs of the geriatric population; and the health of lesbian, gay, bisexual and transgender people.

Indeed, Australia’s National LGBTI Health Alliance heralded this last report as a document which ‘provides recognition at the US federal level for LGBT health research and issues’ and which should be ‘a great tool for leveraging change in our own work in Australia.’

The need to rescue messy, long-term issues from the ‘too hard’ basket dovetails nicely with the need to more effectively engage outside expertise in government policy — in systematic and constructive ways rather than simply relying on ad hoc, voluntary submissions in the course of public consultations.

If publicly-funded academic research is, as Cabinet Secretary Terry Moran AO has suggested, ‘inaccessible, indigestible and obscure’ and often of limited relevance to public policy needs, are we being short-changed?

If Peter Shergold’s assessment is correct in that Australia’s public investment in research and development ‘contributes little to addressing the political response to the nation’s economic and social challenges,’ are we content to leave it at that?

And what do we make of federal public servants who are reluctant to include more than one academic expert in a ‘reference group’ on the grounds that having two or more might lead to disagreements?

Encouragingly, Shergold believes that calls are emerging in Australia for ‘an invigoration of knowledge transfer activity’.

The IOM provides one model of successful and systematic knowledge transfer.  Whether Australia adopts it, or develops others, we cannot escape the fact that the ability to meet key health challenges will only be improved if the best use is made of available resources.

As the National Academy of Sciences approaches its 150th birthday in 2013, perhaps this is an appropriate time for Australia to start thinking about how we, too, can generate the sorts of informed and purposeful deliberations which will inspire significant and lasting efforts to improve the health and welfare of the population.