Introduction by Croakey: Is Australia on the verge of a long-awaited and sorely needed move towards cooperative federalism to drive health reform? Encouraging noises to this effect emerged today from the first National Cabinet meeting since the Federal election.
The Prime Minister later told journalists that there had been “a very good spirit, a spirit of engagement, one that recognised our common interests and our common purpose”.
The NSW Premier said “what is incredibly pleasing is a real focus of working with the States and Territories in relation to substantive health reform going forward. This is something that has been in the too-hard basket for too long”.
The Queensland Premier said it had been “a refreshing change to be able to discuss health. Previously, we have tried to get this on the agenda. We’ve got a Prime Minister who listens and understands that health is a big issue and it is a national issue that’s affecting everybody across our nation”.
The Victorian Premier said: “…on behalf of every nurse, every ambo, every doctor, every patient in Victorian public hospitals I want to thank the Prime Minister. Politics was put aside at this meeting and we’ve put patients first and that is the most important thing. Now, the test for all of us will be to work hard in the weeks and months to come, to come up with practical ways in which we can make the system work as a true system”
A statement issued after the meeting said:
• The Federal Government agreed to extend the National Partnership on COVID-19 Response for a further three months to 31 December 2022, at a cost of approximately $760 million.
• There was a commitment to work together to identify practical improvements to the health system and specifically the connections between GPs and hospitals, and “practical ways to get aged care residents and NDIS participants out of hospital and into a more appropriate setting”.
• The Federal Government will work with the states and territories, drawing on local knowledge, to determine locations for Medicare Urgent Care Clinics.
• The First Secretaries Group, chaired by Professor Glyn Davis, has been tasked with developing health system improvements and reporting back to National Cabinet.
• States and Territories expressed their support for the Commonwealth’s commitment to progress a referendum to constitutionally enshrine a Voice to Parliament in the Constitution as a matter of priority.
• The Council on Federal Financial Relations, chaired by Treasurer Dr Jim Chalmers, will provide advice within three months to National Cabinet on pressures on Commonwealth and State and Territory budgets, including anticipated fiscal pressures with a focus on areas of joint funding responsibility.
National Cabinet will next meet before the Commonwealth Budget in October to discuss these reforms.
In The Health Wrap, Associate Professor Lesley Russell delves into more detail about many of the key issues on reform agendas.
Lesley Russell writes:
A key focus for Croakey Health Media and policy wonks in the weeks and months ahead will be the efforts of the Albanese Government to deliver on their election commitments in health, healthcare, Indigenous health and climate change (and in fact any issue that improves the health status and reduces the health disparities of Australians).
I will do my best to keep track of what is happening and report it in The Health Wrap. As part of that effort, there will be a regular segment on the work that the previous Morrison Government left undone in health – an ongoing update to The Accountability Report.
Here are some recent post-election reports on what experts and key stakeholder groups want to see done.
Reform of hospital funding
Professor John Dwyer in Pearls and Irritations: Desperate Premiers call for radical redesign for health care funding.
As the national ambulance/Emergency Department/hospital/workforce crisis grows, it is clear that the current National Health Reform Agreements (NHRAs) between the Federal and State and Territory governments must be reworked or the public hospital system will collapse.
Recent State Budgets have shown the Premiers and First Ministers are (finally) willing to put more resources into acute care – Victoria; South Australia; Western Australia; Tasmania; Northern Territory; the NSW and Queensland 2022 Budgets are due this month, although NSW has already announced a $4.5 billion healthcare package ahead of the Budget; the ACT Budget is due in October.
At the same time the States and Territories have called for the Federal Government to abandon a 6.5 percent cap on the growth in NHRA funding and they want total hospital costs, including those incurred as a result of the pandemic, split 50-50 with the Commonwealth (currently the Federal Government contributes only 45 percent of hospital funding).
The current situation is a crisis that daily borders on being unsafe for patients and healthcare workers, but it offers a unique opportunity to address the Federal/State and Territory divides in financing and the disconnects between community-based care, aged care, and acute and sub-acute care.
NSW has already indicated its interest in such an approach (see comments by Premier Dominic Perrottet here and comments by Regional Health Minister Bronnie Taylor here). Medical Republic reports that Perrottet and Victorian Premier Dan Andrews will push for the new National Cabinet to address how hospitals and GPs might work more closely.
More recently South Australian Premier Peter Malinauskus has also chimed in with his support for primary care reforms.
There was a refreshing level of comity at the first meeting of the Council on Friday June 17. Albanese has offered the States and Territories a $760 million extension to the additional funds provided for COVID-19 costs ($934.1 million in 2022-23). For the moment at least he has rejected demands for an extra $5 billion annually into public hospitals, citing the need for budget repair.
That State and Territory leaders leave the meeting apparently satisfied with this is a certain indication they have been promised further considerations of their requests for healthcare reforms in the near future.
The NHRAs commit all governments to explore better ways to pay for healthcare and small budgets are provided for pilot programs of integrated care. It seems that the various initiatives that have been undertaken with this funding take a rather loose definition of integrated care. This work, yet to be evaluated, is described in more detail here.
When was the last time we saw a smiling group of government leaders?
Mental health reforms
Professor Stephen Duckett and Professor Graham Meadows in The Conversation: Mental distress is rising, especially for low-income middle-aged women. Medicare needs a major shakeup to match need.
Work is this area could begin immediately, following the short-term and medium-term recommendations of the Sydney Mental Health Policy Forum (April 2022). Dr Sebastian Rosenberg and Professor Ian Hickie have written about these in Croakey Health Media: A federal election manifesto: options for strategic mental health reform in Australia.
This work outlines reforms that would end the fragmentation which characterises current mental health services, boost accountability, and establish effective, regional control over planning, funding and implementation of community-focused mental healthcare.
Two other aspects of mental health should accompany this work. The first is ensuring that there is an appropriate mental health workforce (see the paper by Rosenberg and Hickie in Australasian Psychiatry (2020): W(h)ither psychiatry? Contemporary challenges in Australian mental health workforce design ).
Secondly, this work should be accompanied by implementation of the National Mental Health Research Strategy, released in April by the National Mental Health Commission.
New models of primary care
Dawda et al in Medical Journal of Australia: Value-based primary care in Australia: how far have we travelled?
True et al in Medical Journal of Australia: Lessons from the implementation of the Health Care Homes program
There is general agreement that general practice/primary care needs not just more funding but also reforms to ensure it is fit for purpose and addresses patients’ needs.
The recent paper from Dawda et al makes the case that the primary care sector should be more focused on value-based care, something that is missing in the 10-Year Primary Health Care Plan which was released alongside the 2022-2023 Budget.
A key focus of this paper is on pilot programs (most relatively small in scale and short-term) that have been implemented by both Federal and State Governments and how little we have learned from them, both in terms of what works and what does not.
The list of such projects includes:
- Collaborative commissioning by Local Health Districts and Primary Health Networks
- Evidence-based pathways of care
- Health Care Homes (the interim evaluation reports are here, but apparently the final report was not received or not released by the Morrison Government)
- Coordinated Care Trials (the evaluation of the second round of trials is here)
- Diabetes Care Project
- The NSW Health value-based healthcare initiative which has been implemented across the state.
The paper by True et al uses information from the interim evaluations to extract three lessons learned from the Health Care Homes initiative. These are relevant to efforts to change the model of care in general practice.
Health Care Homes is a preferred model of care for healthcare professionals and patients, but it was difficult to demonstrate clinical health benefits due to the short implementation time.
Changing the model of care in general practice is complex. It demands changes in workforce, care processes, and patient expectations. Practice facilitators can help with implementing and retaining fidelity to the new model of care.
System enablers such as workforce development, digital technologies, integrated information systems, quality data and alternative payment mechanisms are prerequisites to delivering value-based health care.
Both these papers highlight that new models of primary care require a coordinated team-based approach. A national medical workforce strategy has been developed but a comprehensive health workforce strategy is lacking and workforce issues specific for rural and regional areas are yet to be addressed.
An Australian Centre for Disease Control
The new Labor Government has committed to the establishment of an Australian Centre for Disease Control (CDC), but without any detail as to the scope of this agency.
The ongoing COVID-19 pandemic (and the possibility of new threats from new BA.4 and BA.5 variants) highlights the need for a rapidly responsive national mechanism for disease surveillance, the national coordination of responses, and assessment of the effectiveness of these responses. There are many other prevention and public health tasks that could be assigned to such an agency.
The States and Territories currently have the legal responsibility for public health protection, so a national CDC will need their cooperation. The work of the CDC will also require an experienced and well-trained workforce and a pipeline to ensure its continued availability.
The establishment of a CDC will require legislation: when this happens, expect lots of experts looking to be heard.
See also these recent articles:
Alison Barrett writing in Croakey: Will Australia finally get a Centre for Disease Control? If so, how might it work?
PHAA webinar held in April: Design principles for an Australian CDC.
How well are the Primary Health Networks working?
As we think about the needed reforms in primary care and mental health and the need for better access to medical services in aged care, it’s timely to ask about the current roles of the Primary Health Networks (PHNs) and how well these are servicing the needs of their communities.
In early 2019, Dr Paresh Dawda and I published a paper which interrogated the role of PHNs in primary care reform and asked if they were fit for purpose to drive and foster needed reforms. We also offered suggestions for improving this capability.
Interestingly (frustratingly?) the 10-Year Primary Health Care Plan 2022-2032 barely mentions PHNs outside of their role in commissioning.
There was an evaluation of the PHNs released in 2018 which asked all the right questions:
- Are PHNs fit for purpose?
- Have PHNs improved the coordination of care?
- Have PHNs increased the efficiency and effectiveness of medical services for patients?
- How effective has the Department of Health been in providing necessary support?
But basically the answer to all those questions was “it’s too early to tell”.
Four years later, we still don’t have the answer to those questions.
The Department of Health website provides access to the performance and quality framework against which the performance of the PHNs is measured and indicates that this is done annually. But these annual reports are not publicly available.
With respect to the question about the DoH management of PHNs, it’s worth noting that the Australian National Audit Office website states that an evaluation of the Department’s performance management of PHNs was proposed for 2021-2022 but there is no indication that this is underway.
Some information about the roles and functioning of the PHNs can be found in published papers and with some judicious googling.
PHNs are funded to ensure the availability of after-hours care through the PHN After Hours Program.
An evaluation of this program, published in May 2021, found that it has not enabled PHNs to effectively address the root causes that limit after-hours service delivery. The report recommended continuation of the program but with a review to refine its focus.
This review has not been done. The 10-Year Primary Care Plan states that “The Government will consider future policy for after-hours services in the context of this plan, the impacts of MBS telehealth and the 2020-21 evaluation of the PHN After-Hours program.”
Chronic disease priorities
A paper published late in 2021 highlights the need for a greater focus by PHNs on chronic pain and coronary vascular disease issues (two leading causes of disease burden).
The role of PHNs in implementing chronic disease prevention activities in general practice is unclear. An article published in Croakey in August 2021 found that PHNs have an informal role to play in prevention but their activities are constrained by financial incentives and competing priorities.
There are very few published papers that utilise the data collected by PHNs. Some of this data is collated by the Primary Heath Insights development project (this involves 27 of the 31 PHNs) but this is not publicly available.
Other sources of PHN data include the Australian Institute of Health and Welfare here and the DoH. Some aspects of DoH reporting include data from PHNs; for example childhood immunisation data is reported by PHN here and the Primary Mental Health Care Minimum Data Set has data from PHNs here.
What is happening with My Health Record?
A recent article in The Guardian highlights that it is now 12 years since patients’ electronic health records were introduced and more than $2 billion has been spent. But hardly anyone – healthcare professionals or patients – are using them.
When was the last time your My Health Record (MHR) was updated? As a healthcare professional, when was the last time you asked about a patient’s MHR? Do you actually have a MHR?
A study undertaken by NPS MedicineWise and the University of Melbourne in 2018 found less than 10 percent of patients had MHR activity recorded in their general practice record, and an even lower proportion recorded an upload or download of health information.
More recent research shows that less than 2 percent of patients who present to Emergency Departments have their MHR accessed by a doctor or nurse.
Less than 50 percent of Australians have opted into the system (just 12.9 million records have any data in them) and the latest annual report from the Australian Digital Health Agency shows that just 2.69 million people accessed their MHR in 2020-2021. This was an increase of 14 percent from the previous year, but the increase was largely driven by people accessing COVID-19 vaccination records and COVID-19 test results.
Let’s not talk about replacing MHRs with something new. We tried that when My Health Record replaced the Personally Controlled Electronic Health Record and that cost nearly half a billion dollars, most of which went to consultants.
But we do need to make MHR more user-friendly, more trusted with respect to management of privacy and cyber security risks, and to increase uptake. As the work to date on Health Care Homes demonstrates, new models of primary care and better integration of primary, aged and acute care services will demand better information systems.
The Medical Journal of Australia recently published an analysis of research on Aboriginal and Torres Strait Islander health done since the introduction of Closing the Gap in 2008.
This is important because – as the authors point out – to date, no review of Indigenous health research outputs has described the scope and characteristics of the research, the extent to which it is focused in the burden of disease, or the research designs being implemented. This is essential knowledge needed to ensure research informs practice, policies and programs.
The research found 2,150 original research articles published over the 12-year period (from 2008 to 2020). Of these, 58 percent used descriptive designs and only 2.6 percent were randomised controlled trials.
There were few national studies. Studies were most commonly conducted in remote settings (28.8 percent) and focused on specific burdens of disease prevalent in remote areas, such as infectious disease, hearing and vision.
The largest number of publications focused on mental and substance use disorders (20.5 percent); infectious diseases (14.1 percent); health services planning, delivery and improvement (33.5 percent); and health and wellbeing (29.5 percent).
The paper is headed with this quote from Professor Tom Calma from 2009:
It is not credible to suggest that one of the wealthiest nations in the world cannot solve a health crisis affecting less than three percent of its citizens.”
It also reminds us that 17 years ago, in his 2005 Social Justice Report, Professor Calma made three recommendations to address equality in life expectancy between Indigenous and non-Indigenous Australians:
- A government commitment to achieving equality in health status in 25 years.
- Equality in access to primary care and health infrastructure.
- Bipartisan support for this commitment.
Those needs have yet to be fully addressed.
Earlier this month, Croakey Health Media published an article with a title that caught my eye: “Health Journey Mapping: having a yarn about health”. It outlines the Health Journey Mapping tools and resources that help improve the quality and cultural safety of the healthcare journey for Aboriginal and Torres Strait Islander people.
That sent me on a journey to investigate the “clinical yarning” approach to improving clinician – patient communication in Indigenous healthcare. This approach has been around for some time, but hopefully is finally gaining currency.
As outlined by Lin et al, clinical yarning consists of three inter-related areas: the social yarn, where the healthcare worker aims to find common ground and develop an interpersonal relationship; the diagnostic yarn, where the healthcare worker facilitates the patient’s health story while interpreting it through a biomedical or scientific lens; and the management yarn, that employs stories and metaphors as tools for patients to help them understand a health issue so a collaborative management approach can be adopted.
These researchers now run the Clinical Yarning Education Project at the University of Western Australia.
Access to healthcare in prisons
A recent Viewpoint in The Lancet Public Health looks at access to healthcare for people in custodial settings.
Australia’s situation is summarised succinctly as: “Access to weekly nurse visits, little access to specialised care; exclusion from universal health insurance scheme; some reports of increased access to facilities for physical activity.”
Australia is specifically noted as a country where the exclusion of people in prison from Medicare is an “important and avoidable impediment to continuity of care and transfer of health information.”
Another notable consequence of prison healthcare that is disconnected from community systems is the challenges it creates for managing the spread of infectious disease. Rates of tuberculosis, viral hepatitis, HIV, and most recently COVID-19, are markedly higher among individuals in prisons than in the general population.
This exclusion from community systems is counter to the United Nation’s Mandela Rules which stipulate that prison healthcare services should be organised in close collaboration with to the general public health administration.
Furthermore, people released from custody with multiple and complex health needs are rarely connected with healthcare in the community upon release, and consequently their health outcomes are predictably poor.
The most recent Australian report on prison health is from the Australian Institute of Health and Welfare as part of Australia’s Health 2020 (most of the data are from 2018).
It is introduced thus: “People in prison are a particularly vulnerable population. They are generally more disadvantaged, with higher health care needs than the wider Australian population. Most people in prison are there for relatively short periods, which means that the health issues of people in prison become health issues for the whole community. These factors suggest that people in prison need a high level of health care and continued health care and support in the community following their release.”
It should also be noted that Aboriginal and Torres Strait Islander people are vastly over-represented in the prison population.
On entering prison, Indigenous people lose access not only to Medicare but also to health services modelled on Aboriginal concepts of culturally safe healthcare. Research has highlighted the multiple barriers to accessing culturally safe healthcare that are experienced by Indigenous women in prison.
An article in The Conversation in 2021 from Professor Megan Williams outlines what is needed to deliver on the recommendations around improving Indigenous health made 30 years earlier in the report from the Royal Commission into Aboriginal Deaths in Custody.
She concludes that a nationally coordinated scheme is required that funds prisons to work with Aboriginal and Torres Strait Islander community-controlled health services.
In case you missed it …
Below is a random collection of interesting and/or important issues.
Science must overcome its racist legacy
Nature’s guest editors speak out about leading Nature on a journey to help decolonise research and forge a path towards restorative justice and reconciliation.
The guest editorial states: “The journey to recognising and removing racism will take time, because meaningful change does not happen quickly. It will be difficult, because it will require powerful institutions to accept that they need to be accountable to those with less power. It will be rewarding because it will enrich science. It is essential because it is about truth, justice and reconciliation – tenets on which all societies must be founded. As scientists, we know that where there are problems in the historical record, scientific rigour and scientific integrity demand that they be acknowledged, and, if necessary, corrected.”
Hate – motivated behaviour as a public health threat
I was recently alerted to this article, ‘Hate-Motivated Behavior: Impacts, Risk Factors, And Interventions’, in Health Affairs, from 2020. It looks at hate as a social determinant of health inequalities and hate-motivated behaviour as a public health threat. Hate-motivated behaviour poses a threat to the population’s well-being, especially for vulnerable populations targeted on the basis of race, ethnicity, sexual orientation, religion and disability.
COVID-19 vaccine issues
A group of civil society organisations, including Médecins Sans Frontières Australia, the Public Health Association of Australia, and Oxfam Australia, is calling on the Albanese Government to support a TRIPs waiver to help improve COVID-19 vaccinations in low-income countries, where less than 18 percent of people have had at least one dose.
I have previously written about efforts to establish a m-RNA vaccine manufacturing capability in South Africa to help get affordable vaccines to African countries. Now it appears that vaccine production has been halted due to a collapse in demand.
The Financial Times reports (paywalled) that African leaders have called the COVAX vaccine sharing scheme to commit to buying at least 30 percent of all COVID-19 jabs from Africa as the future of Africa’s biggest manufacturing facility in Port Elizabeth, South Africa, hangs in the balance.
See also this recent article published in Croakey Health Media: Australia urged to support an injection of equity on global COVID responses.
Meanwhile, civil society organisations warned in a news release (17 June) that the World Trade Organisation (WTO) Ministerial Conference has produced a weak decision on COVID-19 medicine monopolies which covers only vaccines, excludes non-patent intellectual property barriers, and contains restrictions which are more onerous than some existing WTO rules.
“This condemns the world’s most vulnerable people to inequitable access to vaccines and treatments. They will continue to die in greater numbers than those lucky enough to live in high income countries,” said the statement.
Advocates say the decision reflects watered-down amendments put forward by the EU, UK and Switzerland, lobbied by their pharmaceutical companies, and that the outcome will not address inequitable access to vaccines and treatments in low-income countries, and sets a bad precedent for future pandemics. Almost 300 global public health, human rights and union organisations have criticised the decision and called for stronger government action.
Labor’s plans to tackle NDIS reforms
In a speech delivered on June 15 to the Where To From Here conference, Bill Shorten, the Minister for the National Disability Insurance Scheme, outlined the focus of his work.
His speech makes the key point that, if run effectively, the NDIS can deliver a huge return on the investment.
Shorten also flags the need for greater co-operation between the three layers of government – Commonwealth, State and Territory and local – and for the health, education, care and support, and infrastructure sectors to work together to drive improvements for people with disability.
“If the NDIS is effective, there’s a huge return on our investment in years to come. Not only does this return include stronger meaningful social and economic connections for people with disabilities, there’s also a financial return to governments … including reducing health, employment, social security, housing and justice costs.”
Croakey Health Media recently published an article by Dr Nicola Fortune (Some urgent advice for the new Government on reducing inequities for Australians with disability) exploring the issues outlined in the April 2022 report from the Centre of Excellence in Disability and Health.
Co-creation, co-design and co-production in public health
Community participation is now seen as an essential part of the design, implementation and evaluation of public health initiatives. The terms “co-creation”, “co-design” and “co-production” are used interchangeably to describe these processes, but they have essential distinctions.
A paper just published in Public Health Research & Practice looks at the definitions and distinguishing characteristics of these terms. It’s a useful resource to ensure the correct terminology is applied.
Work left undone by the previous Minister for Health
I keep finding things I missed when compiling The Accountability Report as part of my weekly Election Wraps for Croakey. Some of these have already been alluded to in this edition of The Health Wrap.
Here are two more:
I always wondered what happened to the funds provided in the 2018–19 Budget ($82.5 million over 4 years) to improve access to psychological services in residential aged care facilities. This initiative was to be delivered via the PHNs.
Australian Healthcare Associates was engaged to undertake an evaluation to commence in June 2021, with the final report due to be submitted to the Department of Health in March 2022.
As far as I can determine this evaluation report has not been made public.
Last November the DoH released a consultation paper on a National Medicines Traceability Framework from prescription medicines. The consultation paper isn’t actually publicly available – you have to apply to get a copy – so presumably DoH didn’t want too much consultation!
I believe that this Framework is part of the effort to ensure the sustainable supply of PBS medicines – something that appears to be increasingly important. The number of medicine shortages in Australia reportedly rose by 300 percent between 2019 and 2020.
There is no evidence that this work has proceeded further.
The only commentary on the consultation paper is found in online newsletters aimed at the pharmaceutical industry, which require subscriptions to access. I’ve seen some of this commentary which describes the proposed track and trace model, with a central data repository operated by the federal government, as complex and costly. Apparently it has little support from the key stakeholders (presumably manufacturers and wholesalers).
It is not possible to know the extent to which the proposed framework reflects the World Health Organization recommendations for the traceability of medicines.
The best of Croakey
Don’t miss this recent report from the Royal Australian and New Zealand College of Psychiatrists Congress, by Dr Amy Coopes: First Nations’ healing practices critical for cultural safety in mental healthcare.
The good news story
Why do cats love catnip? They seem to get high on the stuff. Now it turns out that this is not just another cat-related enigma.
Japanese researchers have found that the amount of iridoids released by catnip plants is increased by more than 2,000 percent when the plant is damaged by cats. So perhaps cats’ love of catnip confers an evolutionary advantage: keeping bloodsucking insects at bay.
(It’s not clear if iridoids would make a better insect repellent for humans.)
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.