In this latest edition of The Health Wrap, Associate Professor Lesley Russell argues the need for immediate action in response to critical reports on mental health and aged care, digs into the buzz around “value-based healthcare”, and reports on some research involving a group of Indigenous Bolivians, the Tsimane’ people.
She also shakes her head at the ongoing saga of Brexit and UK politics, and ends with a performance to bring “beauty and joy”.
Lesley Russell writes:
As Croakey readers will appreciate, two very important interim reports have been released in critical areas where health and social welfare overlap – mental health and aged care.
How will government, healthcare organisations and individual healthcare professionals, patients and consumers respond?
I would argue that the problems in these two areas are already so bad and so costly that we should be pushing government to begin to respond now, ahead of the final reports and in time for some necessary funding (because additional funding is certainly needed) to be included in the 2020 Budget.
After all, in both these areas, there are already stacks of previous reports, reviews and inquiries sufficient to offer broad guidance (see Mining the Archives on Aged Care below – and it’s even worse in mental health where I once counted 30 major reports since the Burdekin Report in 1993).
And the reports themselves outline areas where immediate actions are needed.
Because the needed reforms to aged care and mental health must be sustained well into the future and through several election cycles, the responses must have bipartisan agreement.
Moreover, given that the solutions to the issues in aged care and mental health extend well beyond healthcare into a range of bureaucratic areas and professional skills, how will the responses to recommendations be coordinated?
A start to addressing these problems and more can be – in fact, must be – made now.
I worry that despite effective media coverage, we are about to enter the holiday season and momentum for action will dissipate. Then by February, when everyone is back on deck, there will be a new set of problems to be confronted.
Public interest journalism and advocacy groups must not let that happen.
Royal Commission into Aged Care Quality and Safety
The interim report is available here, along with an overview of public hearings and summaries of community forums.
The report is confrontingly and aptly titled Neglect – it could just as aptly be called National Shame or Never Again or even Enough. It is written in clear, stark prose to effectively convey the dreadful and damning information it contains. Croakey has published some extracts at length to highlight this.
It finds that the aged care system is “cruel and discriminatory”, and a “sad and shocking system that diminishes Australia as a nation”. In part this is attributed to the fact that “as a nation, Australia has drifted into an ageist mindset that undervalues older people and limits their possibilities”.
The interim report outlines three areas for immediate action:
- More Home Care packages to reduce the waiting list which is currently around 150,000 (I heard that at Senate Estimates it was said it would cos $3 billion to completely eliminate the waiting list).
- An effective response to the over-reliance on chemical restraints. The Royal Commission recommends that this is done in part through the next Community Pharmacy Agreement.
- Stopping the flow of younger people with disabilities into residential aged care and expediting getting those already in aged care out into more suitable accommodation.
It will be much harder to ignore this report than has been the case with all those that came before.
However, I am not encouraged by the tone of the media release from the Health Minister Greg Hunt and the Minister for Aged Care Richard Colbeck (along the lines of: we are shocked but look at all we are doing and spending), which was also reflected in their media conference.
Colbeck said: “The Commission makes … some comment about what’s required in that space. I will use the imprimatur of the Royal Commission to carry all of those things forward with my colleagues.”
There is so much to absorb and analyse here. In the first instance I would direct you to the excellent and timely Twitter analysis from Rick Morton (@SquigglyRick), as well as his article in The Saturday Paper.
Ahead of the report’s release, and in response to concerns about the need for better information and transparency about aged care providers, advocates for older Australians are pushing to allow consumers to post public comments and reviews on the Internet.
While the Aged Care Quality and Safety Commission has a search function where people can find accreditation reports on aged care providers and read consumers’ reports for specific homes, this information needs to be easier to find.
After all, as the Royal Commission highlights, 80 percent of nursing home funding comes from government and taxpayers are entitled to know how this money is spent.
Also see this wrap of reaction, compiled for Croakey by Jennifer Doggett.
Mining the archives on aged care
As a reminder that there is really nothing new here, and that we have been horrified and insisted on reforms and regulations before…
If you read my writings and pontifications on a regular basis, you will know that a recurrent theme is that we never mine the archives, learn from previous work, take note of endless reports, reviews and evaluations.
Instead the solution to the long-standing, most difficult problems is always hailed as a new report or review or advisory group. You see that played out in mental health (Sebastian Rosenberg is an excellent ally here), we are seeing it with Health Minister Greg Hunt’s new efforts on prevention and primary care, and we see it most egregiously in aged care.
The Aged Care Royal Commission has shown this very pointedly with the release of a new background paper A History of Aged Care Reviews. This includes an overview of 18 major public reports and inquiries related to publicly-funded aged care in Australia since 1997 (12 of them in the lifetime of this Government) and looks at government responses to each of these.
The reviews and inquiries have consistently highlighted recurring issues within the aged care system, including:
- Difficulties in navigating the disjointed system and getting needed services
- Quality and safety and adequacy of care, linked to staffing issues
- The need for additional support for those with dementia, mental illness, disability, and at the end of their life
- Weaknesses in delivery of services to maintain healthy functioning and wellbeing and lack of integration with the broader healthcare system, and
- Ineffective oversight and complaints mechanisms.
The background paper finds that government responses to the various reports and reviews often come years afterwards, if at all. Sadly, the Royal Commission is being confronted with virtually all of the issues listed above.
The conclusion of this paper states what is all too apparent in the interim report from the Royal Commission:
Despite all of these reviews, and all of the Government responses, the underlying problems remain.
The overarching question that arises is why, after all these reviews, the aged care system still fails to support an appropriate quality life for the most frail and vulnerable members of our community.”
As we read the interim report and all the previous reports, we must develop a clear answer – accepted by all stakeholders – to the question posed in Croakey by Dr Joyce Siette from the Australian Institute of Health Innovation: How will we know when Australia’s aged care system is fixed?
Productivity Commission on mental health
The draft report is available here.
I recommend that you also open up the link on this page to “Statistics” and take in the cost of mental illness and suicide ($500 million a day) to see the magnitude of the problem – or check this extract.
This report is wide-ranging and substantive but lacks the punch and impact of the aged care report. The language is much more muted. As an example: “It is not clear that the Mental Health Treatment Plans and the review are working as well as they could to encourage best practice” – when it is very clear that these plans are not working and they are costing Government $22.5 million/week; plus some $6 million in patients’ out-of-pocket costs.
It does cover to some extent the social determinants of mental health such as poverty and racism (but no mention of climate change) and it deals with the full range of workforce issues (somewhat controversially, I suspect, by talking about “shifting to a more efficient allocation of skills”).
The point is also made that mental health reforms must reach well beyond the remit of the Department of Health.
Here’s how I summarise the broad recommendations from the draft report:
1. A generational shift is needed.
- Ensure people who need care get it.
- Facilitate recovery and active participation in community, education and workplaces.
- Identify risk factors and then access to early treatment.
- Clear gateways into mental healthcare and help with navigation.
- Key roles for psychosocial supports, housing services, justice system, workplaces, social security.
2. Treatment of mental illness is tacked on to a healthcare system that is largely designed around physical illness.
- Need culture, structures, workforce that address this disconnect.
3. Need a path for maintainable long-term reform.
- Closing critical gaps in services.
- Investments in services beyond health.
- Addressing work-related mental health issues.
- Reforms to care coordination, governance, funding arrangements.
Also see Dr Melissa Sweet’s analysis of the report and call to action for health equity responses, as well as this 58-page compilation of the Croakey team’s Twitter summary.
This highlighted for me just how effectively Twitter can be used to share insights and information.
Here’s some of the commentary on the draft report:
NSW Council of Social Service NCOSS welcomes draft Productivity Commission report. NCOSS has undertaken grassroots consultation across 24 communities in metropolitan and regional NSW to inform its submission to the Productivity Commission. You can read the recommendation it made in this media release.
Mental Health Australia Mental Health Australia welcomes Productivity Commission Report and push for a national agreement. MHA is pushing Charter 2020: Time To Fix Mental Health, now co-signed by more than 110 mental health and suicide prevention organisations nationally. Charter 2020 calls for an agreement that delivers integration and coordination of mental health services, including agreed objectives, indicators, monitoring arrangements and funding between all levels of government.
The National Rural Health Alliance media release Draft PC report highlights need to improve rural mental health services highlighted the report’s findings that although the prevalence of mental illness is relatively similar across Australia, people in capital cities are much more likely to access services and that regional communities have a 54 percent higher rate of suicide than capital cities. In addition, Aboriginal and Torres Strait Islander people are twice as likely as non-Indigenous people to die by suicide and twice as likely to be hospitalised due to mental illness.
Other related Croakey articles:
- Mental health consumers present a “collective dream” for a wonderful future
- As the Productivity Commission report puts the focus on mental health reform – what do young people want?
- Mental health reform – what does the sector want?
- Productivity Commission Inquiry into Mental Health Draft Report – responses from the sector.
- Responses to the PC Draft Report on Mental Health – Dr Sebastian Rosenberg.
As I write this, I have yet to see any formal response from the Minister for Health.
We need to know how (or even if) he plans to integrate the recommendations from the Productivity Commission into the work of the proposed (yet to be developed) blueprint for the future of mental health care, to be part of the Long-Term National Health Plan. When this was announced at the National Press Club in August, the work of the Productivity Commission was not mentioned.
An announcement from the COAG meeting last week has Hunt pushing the states for more hospital (acute) beds for young people – but these alone will be ineffective unless accompanied by more prevention and early intervention and better step-down (sub-acute) care and follow-up.
The States and Territories want increased numbers of psychology services available under Medicare – but this alone will be ineffective unless they are properly targeted based on need and out-of-pocket costs are not limiting.
There is also an announcement from Hunt about aftercare funding for people who have attempted suicide. But then, in the same media article, the Prime Minister’s national suicide prevention adviser Christine Morgan says that only a proportion of people who die by suicide in Australia had contact with the health system, so there was a “need to consolidate as well as broaden our approach”.
She added: “.. aftercare is just one part of a suicide prevention response, and that I remain focused on developing advice about what more we can do to identify and assist people in distress and crisis before they make an attempt on their life as well.”
None of this ad hoc stuff is encouraging.
Value in healthcare
Value in healthcare has become something of a buzzword, but what does it mean?
In practice, it depends on whose point of view is being considered. In light of the Long Term National Health Plan – under which the Morrison Government says it is committed to reforming the health system to be “more person-centred, integrated, efficient and equitable” – I looked to explore some of the recent work done in Australia and overseas on value-based care.
How to define value in healthcare?
The World Economic Forum, in collaboration with The Boston Consulting Group, launched the Value in Healthcare project in July 2016. The first report from this group, Value in Healthcare: Laying the Foundation for Health System Transformation (April 2017), synthesises the project’s preliminary findings, with a focus on defining the problem, developing a comprehensive framework for a value-based health system and proposing a high-level roadmap for system transformation.
It defines value in healthcare in a patient-centred way. “The fundamental principle of value in healthcare is, first, to align industry stakeholders around the shared objective of improving health outcomes delivered to patients for a given cost, and then to give stakeholders the autonomy, the right tools and the accountability to pursue the most rational ways of delivering value to patients.”
This concept of value is not a simple equation because the health outcomes that matter to patients are multi-dimensional. Patients are not only concerned with traditional clinical indicators and outcomes, but also with broader factors such as quality of life. To be truly indicative of what matters to patients, they must be involved in the design and development of value measures.
Additionally, in assessing the resources and expenditures involved, it is important these reflect the actual costs to a patient over a full cycle of care, which may involve many parts of the healthcare system/s and include many providers.
Recent Australian work
1. Last week the Deeble Institute released Issue Brief No 33 Reforming for value: opportunities for outcome-focused national health policy. This builds on previous work in Issues Brief No 31 Value-based healthcare: setting the scene for Australia.
This most recent Issues Brief makes the case that:
- Health policy reform must draw upon concerted policy mechanisms to redirect systems toward delivering meaningful improvements in health outcomes, especially for populations who stand to derive the greatest benefits from care.
- To do this, health data collections must be put to better use. Accountability for improving Australia’s health must be driven by purposeful collection of information about health outcomes of care.
- Outcome metrics (rather than activity metrics) for policy objectives must be developed and embedded in performance and accountability frameworks across national health funding agreements.
- Tools such as Clinical Quality Registries and Patient Reported Indicator Surveys can be used to ensure that health outcome metrics are standardised, related to individuals’ care needs and measured across complete cycles of care.
2. NSW Health has a Leading Better Value Care program – the website is here. A recent webchat on Organising Care for Better Value, run jointly by NSW Health and the NSW Agency for Clinical Innovation can be found by following the hashtag #LBVCChat.
See also Deeble Institute Issues Brief No 32. Re-orienting funding from volume to value in public dental services.
Recent international work
1. European Union. Defining Value in “Value-Based Healthcare”.
Defines value-based healthcare more broadly, as “a comprehensive concept built on four value-pillars: appropriate care to achieve patients’ personal goals (personal value), achievement of best possible outcomes with available resources (technical value), equitable resource distribution across all patient groups (allocative value) and contribution of healthcare to social participation and connectedness (societal value).”
2. Enhancing Value in European Health Systems. The role of outcomes measurement. A consensus document.
“Measuring outcomes is close to a change of paradigm; it will require time and dedication, and a common effort by all players in this field.”
3. Some useful material is on the website of the Value Based HealthCare Centre, Europe.
4. A broader report from Nesta Innovation Foundation (UK) Public Value: How can it be measured, managed and grown? looks at finding better ways of mapping and measuring public and social value – outcomes, institutions and services that are valued by the public but whose monetary value is not easy to count.
5. In the United Kingdom the Social Value Act (2013) explicitly encourages broader notions of value, as have recent revisions of the Treasury Green Book used to assess public spending choices.
Patient co-design as an essential corollary of value-based healthcare
The Consumers Health Forum and the Australian Healthcare and Hospitals Association have been working together for some years now to improve experience-based co-design involving patients and carers.
The AHHA toolkit is here.
The NSW ACI also has a guide for building co-design capability here.
What makes a good life?
This is an existential question we all ask. A recent study asked the question of a group of Indigenous Bolivians, the Tsimane’ people, who are known for their incredible cardiovascular health.
The Tsimane’ are one of the most isolated of 36 Bolivian Indigenous groups, and it is interesting to note that their population has grown rapidly, from an estimated 6,000 people in the late 1990s to about 16,000 in 2015.
They are traditionally farmer-foragers. The Tsimane’ diet has largely consisted of rice, plantain, cassava root, corn, nuts and fruits, with protein, mostly from animal meat, accounting for 14 percent of their diet, with and fat accounting for the same proportion. In 2014-15 it was estimated that members of the group are inactive for only 10 percent of the day.
But as migrants and ranchers have moved into their area, the Tsimane’ have more opportunities to make occasional income from contract and day labour. That money is spent on things like medical care and tools but also on processed foods.
Their integration is not limited to purchasing market items but extends to other aspects of lifestyle, such as: entertainment (listening to outside music over traditional flute music); health care (using biomedicine vs. forest medicine); and seeking out Western education, rather than staying in one’s birth community.
How have these changes to the Tsimane’ lifestyle affected their health and wellbeing? This has been under study for several decades.
Predictably, it has been found that even small increases in access to market-based foods and cooking oils that are high in calories have contributed to fat gain and obesity in this population.
The most recent study, published in PLOS ONE, rated lifestyle issues that included 38 wide-ranging items, among them child care, education, listening to radio news, electronics, gas stoves, home-brewed beer, cultural ceremonies, and traditional flute music. It looked at the type of wealth people found essential for a good life.
The study found that:
- Women tended to have more accurate knowledge of market lifestyle ideals but were more likely to reject aspects of social life that promote market integration such as getting help from people outside of the family or being friends with outsiders who may know how to help find paid work.
- Forty percent of the top-rated lifestyle items were market-related, including manufactured tools, purchased livestock and education. When there was overlap with traditional approaches and customs, market alternatives typically were rated higher: for example, rifle hunting over bow hunting and Western education over staying in one’s own community. Only traditional food items like crops, wild game and fish were consistently valued over market alternatives.
- Forms of non-monetary wealth that rated highly (especially by those living furthest from market towns) included social wealth (larger families, helpful neighbours) and embodied wealth (medicinal knowledge and spiritual knowledge and practices).
While the Tsimane’ are one of the most intensively surveyed small-scale societies of the past two decades – with more than 400 peer-reviewed articles published during that time – very little of that work has focused on insider perspectives from the Tsimane’.
This study shows how, for small-scale societies, transitions from self-sufficiency to cash-based labour in market economies are associated with the exacerbation of existing and the emergence of new social incongruities.
And it posits the question: can the Tsimane’ maintain their health and wellbeing if their lifestyle ideals change substantially?
Taking action against clinician burnout
Last month the US National Academy of Medicine released a new report Taking Action Against Clinician Burnout: A systems approach to professional well-being.
It outlines six goals that stakeholders should pursue to prevent and mitigate clinician burnout and foster professional well-being.
Simply put, these are:
- Create positive work environments
- Address burnout in training and at the early career stage
- Reduce tasks that do not improve patient care
- Improve usability and relevance of health IT
- Reduce stigma and improve burnout recovery services
- Create a national research agenda on clinician wellbeing.
This report adds to the resources available on the NAM Clinician Wellbeing Knowledge Hub.
Burnout among healthcare professionals is also a serious, endemic issue here in Australia (and incidentally one that must be addressed if real reforms are to be made in areas like those we have been discussing – mental health and aged care).
See this latest article at Croakey, published as part of a series exposing the traumas of Emergency Departments, for patients and clinicians. The evidence seems clear that burnout is linked to poorer patient outcomes.
Impact of Brexit on health and health care
I defy anyone to understand what is going on with Brexit and politics in the United Kingdom, but one thing is certain – there will be consequences.
What will it mean for the National Health Service and health and social care more generally, at a time when life expectancy is already flat-lining and health inequalities are growing?
Here is a recently updated report from the Kings Fund which attempts to outline the issues, including the implications for staff, regulations, access to treatments and financing.
However, there have been further political developments since it was last updated – so stay tuned.
The good news story
I always end The Health Wrap with a good news story; sometimes it is really needed after I have analysed and criticised my way through my take on health news.
This week it’s something to bring beauty and joy – Yo Yo Ma playing Bach cello suites.
If you’re not lucky enough to get to hear him live on his current Australian tour, listen to and watch this video.
The video is a part of Ma’s Bach Project in which the cellist will perform Bach’s six suites for solo cello in one sitting, in 36 locations worldwide. Each concert is paired with a day of action.
According to the Bach Project website, the days of action are “a series of conversations and collaborations that explore how culture can help us imagine and build a better future”.
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.
