In this latest edition of The Health Wrap, Associate Professor Lesley Russell reviews the latest news in aged care, digs into Aboriginal and Torres Strait Islander health workforce issues, shares some useful new resources on tackling the social determinants of health, and pays tribute to former Health Minister Nicola Roxon.
Push for action on aged care
The ongoing work of the Royal Commission into Aged Care Quality and Safety continues to deliver horror stories about the poor care in residential aged care facilities (RACFs). The extent of the problem is such that in September the Government agreed to grant the Royal Commission another commissioner and an extra six months to complete its work.
An interim report is due at the end of October, and the final report, originally due in April 2020, is now due by 12 November 2020.
However, it seems unwise and even dangerous that essential reforms should wait until then for action, and so there has been a recent push to see them delivered earlier – and for funding to be included in the next Budget for such reforms.
Plenty of recommendations about what must happen are already emerging from the Royal Commission, and there is also the report on the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia, released in October 2018 by the Senate Standing Committee on Health, Aged Care and Sport.
The Australian Medical Association (AMA) and the Australian Nursing and Midwifery Federation (ANMF) have launched a campaign calling for more funding and more staff in RACFs, saying they “can no longer wait and watch the aged-care system in Australia deteriorate”.
Their list of demands includes home-care packages, 24-hour on-site nurses, staff-to-patient ratios and increased incentives for GPs to visit aged care patients.
A particular issue is the time that many people wait for home care packages, which can defer and prevent the need for more complex care in RACFs and hospital.
As of June 2019, there were 119,524 older people waiting for their assessed home care package. The Royal Commission has reported that 16,000 people died waiting for a home care package.
A key issue for both home care and RACFs will be staffing levels and expertise, and that is intrinsically linked to pay rates and training.
The ANMF have a webpage that is focussed on making staff ratios for RACFs law (after all, there are such requirements for child care).
You can also read their National Aged Care Survey 2019 – it’s very sobering and cogently makes the case that continued, systemic failure in Australia’s aged care sector and inaction by governments and providers have resulted in widespread failure to ensure safe, quality care to the residents of these facilities.
The Government does have an Aged Care Workforce Strategy (released in September 2018) which was developed by a specific Taskforce.
It’s pretty hard to see what this has achieved, probably because the fourteen points of the Strategy are very general and bland (for example: Creation of a social change campaign to reframe caring and promote the workforce) and it proposed a voluntary code of conduct for the industry. The Department of Health’s Aged Care Workforce Strategy resources page is here.
I found this article on lobby groups in the aged care sector quite depressing. It makes the case that the 1997 Aged Care Act, with its focus on financial incentives for providers, is what takes the “care” out of “aged care”.
Workforce matters
Late last month the Australian Institute of Health and Welfare released a web report on Medicare-subsidised GP, allied health and specialist health care across local areas: 2013-14 to 2017-18. The major take-out from this report is that use of these services varies considerably depending on where people live.
The AIHW says that “This variation may reflect differences in patients’ health and health care preferences, population growth and accessibility of services (availability, costs and service options)”.
I would push back on that and argue that the key issue here is the availability of services and that goes to workforce planning.
Increasingly we are seeing that, at the local level, Australia does not have the right workforce in the right places enabled to deliver needed services and to work at the full scope of practice. And I attribute that directly to the fact that there is no longer a national independent health workforce agency.
As an example, let’s look at just one small but very important sector of the health workforce – Aboriginal Health Workers (AHWs) (note that this term also includes Torres Strait Islander Health Workers).
This AIHW report is short on information on this issue. It states that in 2017–18, 1.6 million Australians (6.3% of the population; up from 725,000 people in 2013–14 or 3.1% of Australians) received a Medicare-subsidised service provided by a nurse practitioner, practice nurse, midwife or Aboriginal Health Worker.
This growth has been largely driven by increases in regional PHN areas, with Northern Territory PHN area experiencing the highest increase in service use, up from 16 services per 100 people in 2013–14, to 47 per 100 people in 2017–18.
As the National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) celebrates its tenth anniversary conference in Alice Springs this week, it’s timely to note that Aboriginal and Torres Strait Islander Health Workers play a vital role in delivering health services to Indigenous Australians, particularly in enhancing the amount and quality of clinical services provided and facilitating communication with people and communities.
The 2018 Annual Report from NATSIHWA has an analysis of census data that shows a 33 percent increase in the number of AHWs nationally over the 10 year period 2006 to 2016 (from 1009 to 1347 IHWs). However, this increase has not been enough to keep up with Aboriginal and Torres Strait Islander population growth (221 AHWs per 100,000 people in 2006 to 207 AHWs per 100,000 people in 2016).
Moreover, the small increase in the number AHWs from 2006 to 2016 masks substantial issues in workforce growth, retention and recruitment.
While Queensland and NSW saw substantial increases in AHW numbers over the decade, numbers were stagnant or declined in other states, with the loss of AHWs particularly marked in the Northern Territory. There are nearly three times as many female as male AHWs, and this gap widened between 2006 and 2016.
As the NATSIHWA report notes: “This data adds weight to the call for a National Indigenous Health Workforce Strategy and the need to address critical recommendations in the Australian Government’s Growing our Future report.”
I looked at the use over time of the Medicare Benefit Schedule items that can be used for AHWs’ services. (I’m not sure if this is the same data the AIHW was looking at and it’s important to point out that many of the tasks undertaken by AHWs are not billable to Medicare.)
There are currently five such items: 10950 (for provision of allied health services under a Chronic Disease Management Plan); 81300 (for follow-up of allied health services); 10983 (assistance with telehealth services) and 10984 (assistance with telehealth services at a residential aged care facility); and 13105 (haemodialysis management for patients in very remote areas).
Item 10950 was introduced in 2006 and item 81300 was introduced in 2008. Uptake of these items has never been substantial and, as Figure 1 shows, it is disturbing to see that it is decreasing over the past three financial years.
Is this due to fewer AHWs or to some inherent problem with the MBS item? These are issues that need further study.
Items 10983 and 10984 were introduced in 2011-12. It is encouraging to see that increasingly AHWs are involved in telehealth consultations – it’s easy to imagine how helpful that could be for clinicians and reassuring for patients.
It’s regrettable but no surprise that use of teleservices for Indigenous patients in RACFs is so low.
Item 13105 was only introduced in 2018 and so there are no trends over time. In 2018-19 4185 services were billed, of which the majority (3925) were in the Northern Territory.
Meanwhile, the Australian Indigenous Doctors’ Association conference recently put the spotlight on the important work of AHWs (and follow @WePublicHealth this week for news from the NATSIHWA conference).
Tackling social determinants
It seems that everyone – except perhaps those in government – know we should be doing more to tackle the social determinants of health (SDOH).
Yet another report, Action Required: the urgency of addressing social determinants of health, this one from the US-based PwC Health Research Institute, makes the case that unless urgent action is taken to address SDOH, governments and health systems will not see the kinds of improvements they might expect given the level of expenditures they are making.
The report highlights the major problems and costs posed by growing rates of obesity and resultant chronic health conditions.
The report takes a different approach and outlines “five steps for bold action”:
- Build the collective will
- Develop standard but adaptable frameworks
- Generate data insights to inform decision making
- Engage and reflect the community
- Measure and redeploy.
A number of interesting international case studies are provided, including, under “Using Data to Inform Design”, the Western Sydney Diabetes Study. (Read more about the study here). The PwC report highlights the study’s “honest assessments of where participation or funding has been disappointing and places ripe for future opportunity”.
This report may or may not have the right approach, but it has value because it highlights how these things can be done by a coalition of partners, of which government is only one.
And it makes the case that the primary responsibility for addressing SDOH may not lie with healthcare insurers and providers.
#PreventiveHealthStrategy
Sadly, in setting out the work of the Steering Committee for the new National Preventive Health Strategy, it appears that Health Minister Greg Hunt has not considered the SDOH.
The approach, in terms of both the four areas of focus – cancer and chronic disease population screening (current and emerging opportunities); immunisation; nutrition and obesity; public education and research) – and the groups represented on the committee, is very clinical.
And note that it says nothing about wellbeing and the prevention of mental health disorders – key aspects of health.
My colleague, Jennifer Doggett, recently wrote in Croakey about stakeholder concerns – you can read her article here – and Dr Tim Senior this week tweeted a very on-target analysis of the problems with this narrow and short-sighted approach.
Please note that the Croakey team is encouraging readers and followers to use the hashtag #PreventiveHealthStrategy when sharing relevant articles/commentary/resources that might help broaden the focus of the strategy.
Croakey has previously highlighted the need for the National Preventive Health Strategy to address poverty, to look at people’s health and wellbeing holistically, and to include the impact of climate change on health.
As a related matter, it was good to see ABC TV’s The Drum recently tackle hate as a public health issue, including comments from Banok Rind. If you missed the program, watch it here.
Integrating social care
I’ve just made the case about why the SDOH are so important in preventive health, but they are also important in clinical care.
The case is made in a new report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, from the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine (what used to be the Institute of Medicine).
This report was the subject of an editorial No Health Care Without Social Care in the most recent edition of The Lancet.
The report outlines five types of healthcare activities that can enable healthcare systems to better integrate social care into health care delivery:
- Awareness activities identify the social risks and assets of defined patients and populations
- Adjustment activities alter clinical care to accommodate identified social barriers
- Assistance activities reduce social risk by connecting patients with social care resources
- Alignment activities enable health care systems to understand their communities’ existing social care assets, facilitate synergies, and invest in and deploy them to positively affect health outcomes
- Advocacy activities bring together as partners health care and social care organizations to promote policies that facilitate the creation and redeployment of resources to address health and social needs.
Here’s how this could work when it comes to patients’ transportation needs:
Awareness: Ask people about their access to transportation.
Adjustment: Reduce the need for in-person healthcare appointments by using other options such as tele-health appointments.
Assistance: Provide transportation vouchers so that patients can travel to health care appointments. Vouchers can be used for ridesharing services or public transit
Alignment: Invest in community ride-sharing or time-bank programs.
Advocacy: Work to promote policies that fundamentally change the transportation infrastructure within the community.
The report also discusses how integrating social care into healthcare delivery requires an appropriately staffed and trained workforce, health information technology innovations, and new financing models.
The Interprofessional health care team should include social workers, community health workers, social service navigators, trained volunteers, family caregivers, and lawyers (and of course in the Australian situation I would add Aboriginal Health Workers).
So suddenly we are back to health/healthcare workforce needs and planning and the need for a national health workforce agency to oversee this!
The good news – honouring a prevention hero
This week the University of Sydney honoured Nicola Roxon, former Labor Minister for Health and Attorney General, with a Doctor of Laws (Honoris Causa) for her global leadership on tobacco plain packs.
I was present at a reception organised by Professor Simon Chapman that feted her courage and global leadership, not just on plain packs, but on prevention and health reforms.
She has previously been praised as “Australia’s best minister for prevention” and speakers at the reception echoed that praise, with overtones of how much we all miss those “good old days” when there was a National Preventative Health Agency, National Partnership Agreements with the states and territories, and $825 million in prevention funding (sigh!).
As a reminder of what Roxon kick-started, see these milestones shared by Professor Simon Chapman:
And more good news…
I am recently returned from walking in Portugal; and, yes, I will write it up for #CroakeyEXPLORE. 
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
