Whatever happens at the United Kingdom general election on 4 July, one thing is clear: the next Government has a mountain of work to do in improving health and healthcare, reports Dr Lesley Russell.
The latest edition of The Health Wrap also brings encouraging results from a basic income project, news on efforts to improve cardiac care for Aboriginal and Torres Strait Islander people, yet more research on the benefits of exercise, and a stack of public health news from the United States, including the devastating impacts of restrictions on abortions there.
Russell also reports on an “amazing story…that should be required reading for everyone who works at the intersections of public health, policy making and politics”.
It’s about how Indiana, a Republican state, increased public health spending by 1,500 percent.
And the quotable?
We were careful to avoid terms we know that just turn our legislators’ hearts and minds off… One of them, to be honest, was ‘public health’.”
Lesley Russell writes:
It’s cold and wet in Sydney (at least by Sydneysiders’ standards) and the political news from the United States, the United Kingdom and France – all with elections on the horizon – is looking increasingly grim for democracy and for needed investments in health and healthcare systems.
So this week’s photo is meant to bring some joy.
This young kookaburra (blue wing feathers indicate it’s a male) and his family/friends hang out in our very urban neighbourhood, greeting each morning and signalling each sunset with raucous cackles.
They all enjoy visiting our birdbath and exploring my untidy garden for worms and small skinks.
Privatisation of healthcare services costs
Here’s a selection of recent media articles on problems with private health insurance and the private healthcare system:
- The private health procedures where out-of-pocket costs have jumped most (paywall)
Australians’ out-of-pocket payments for common medical procedures in the private system have increased by as much as 300 percent in five years. - Out-of-pocket medical costs soar, health insurance premiums set to rise (paywall)
Out-of-pocket expenses for private medical services have increased by 38 percent in the past three years as health insurance premiums (which have increased 45 percent over the past 10 years) increase at their highest level in five years. - Private health sector on life support as patients’ care delayed (paywall)
As concern grows over the shaky viability of the private health system, some privately insured patients are being left in pain and uncertainty as specialists’ theatre lists are cancelled or hospitals abandon completely certain surgeries deemed too unprofitable.
Many other consumers who have taken out top cover are finding they can’t obtain private maternity care or mental health inpatient care amid multiple systemic pressures on the private system. - Call for independent body to set insurance premium rises (paywall)
Catholic hospitals are calling for a fundamental overhaul of the way private health insurance premium rises are calculated and approved, with the costs pressures faced by hospitals taken into account in yearly increases that should be decided through an independent process.
It’s clear that the economic viability of private hospitals is under threat (I don’t think anyone can claim that the economic viability of the private health funds is under threat!).
There seem to be two main reasons for this:
- In recent years the hospital sector has encountered sharp cost increases, well in excess of the indexation offered by private health insurers.
- The way in which the private health insurance funds reimburse costs in both the private and public systems is not transparent and is increasingly dependent on agreements between the funds and private facilities and practitioners.
We don’t know why some private hospitals are struggling and others are thriving and expanding.
The Albanese Government inherited from the Morrison Government a series of lapsed reviews of the private health insurance system. I wrote about this in August 2023, describing it as Labor “quietly tinkering “, but at this time I am unable to determine what is happening with these reviews.
However, there is a rapid review of the financial viability of private hospitals currently underway within the Department of Health and Aged Care. This apparently started in May and is due to report in August.
Reforms are also needed to the way premiums are set and premium increases are approved. Last year, insurers returned, on average, just 83 percent premiums to members, with some major funds returning less than 80 percent.
As cost of living pressures bite, no wonder Australians are increasingly querying the cost and value of private health cover.
Many would argue that bold consideration should be given to the effectiveness of the private health insurance rebate, which cost the Government (ie taxpayers) $7.325 billion in 2023-2024; this will rise to $8.095 billion in 2027-2028 (See Table 6.8.1. in 2024 Budget Paper #1).
This money, invested in the public system, could relieve the current pressures and address inequalities inherent on the current public/private divide.
A recent paper from Professor Fran Baum and colleagues highlights that there is little evidence for the benefits of privatisation of public services and it likely has an adverse impact on population health and contributes to the increase in inequities.
This work was well summarised for Croakey by Marie McInerney in an article here.
In April 2023, the Consumers’ Health Forum released a media statement calling out the increasing privatisation of primary care.
“Increasingly, we are seeing private profit-driven companies move into primary health to provide these services – whether that is corporate-style GP chains replacing the traditional local GP, or even retailers like Woolies who are now promoting telehealth services.
“We are moving towards an American-style two-tier system where only the rich can pay for fast care and we’re moving away from the basics of universal healthcare which Australians really value.”
A paper published in March in The Lancet Public Health analyses the impacts of healthcare privatisation on the quality of care, taking an international view. It found that the majority of studies reviewed “suggest that privatisation reduces the quality of care and worsens the health outcomes of patients treated in privatised health-care settings”.
I commend to you the 2020 paper from Professor Stephen Duckett that presents an excellent (and still topical) analysis of why no Australian government has been brave enough to tackle the Private Health Insurance Rebate or even to clearly define the role of the private system within the national healthcare system.
The paper makes two salient points:
“The Australian experience is that a large private sector changes the dynamics of public policy. Rather than pursuing policies to ensure that the public system can meet demand, alternative policies to subsidise the private sector come to the fore and become entrenched and difficult to unwind.
“The overwhelming academic evidence is that Australia’s annual subsidy to private health insurance subsidies is not value for money. If this annual subsidy is abolished, the cost of additional demand in the public sector would be less than the current subsidies. Despite this, no major political party will challenge the industry.”
More on the benefits of exercise
I’m always looking for justifications for my obsession with hiking and to persuade me that my time at the gym is well-spent. Recent days have seen plenty of these.
A recent paper in BMJ Sport and Exercise Medicine finds that one year of heavy resistance training at around 65 years of age has long-lasting benefits for leg muscle strength. Leg strength is a critical indicator of health and mobility in older people.
The training involved three gym visits a week for twelve months and repeated lifting what was considered a heavy load: 70 to 85 percent of the maximum weight a person can physically lift at one time.
These findings add to the growing body of evidence suggesting that weightlifting can help older people stave off frailty and stay healthy as they age.
Other studies show that even people in their 80s and 90s who have never lifted weights before can make significant gains and build muscle.
On a slightly different topic, a paper from Australian researchers published in The Lancet shows that walking three to five times a week is an effective way to reduce back pain.
“Walking is a low-cost, widely accessible and simple exercise that almost anyone can engage in, regardless of geographic location, age or socioeconomic status,” said Professor Mark Hancock, the study’s senior author.
The researchers postulate that the benefits of walking on back pain likely include the combination of the gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and release of ‘feel-good’ endorphins.
“And of course we also know that walking comes with many other health benefits, including cardiovascular health, bone density, healthy weight, and improved mental health.”
CSIRO to dismantle clinical research units
It’s always disconcerting when you read headlines like that in a recent edition of The Saturday Paper: CSIRO dismantles clinical research units.
In an exclusive reveal, based on information from Senate Estimates, Rick Morton reported that job cuts at the CSIRO will see the agency close two clinical research units and shelve a plan to establish a food research centre in Victoria.
CSIRO heads are looking to cut labour and operational costs by at least 25 percent over the next year. At least 400 jobs are expected to be cut.
Like Morton, I went looking for answers to what this means for health and biomedical research.
As reported in The Guardian, the 2024-2025 Federal Budget papers show that CSIRO will receive $916.5 million in funding for 2024-25, a $92 million decrease in funding from 2023-2024. The agency will also need to raise an additional $66 million in revenue across the financial year, which it primarily does through joint research projects.
It has been confirmed that 73 jobs will be cut from research roles in the health and biosecurity unit (now headed by Professor Brett Sutton) and the agriculture and food division.
The main details of the proposed cuts to human health research include:
- Reduce or exit research into nutrition capabilities, agriculture and food relates pre-clinical analytical studies, biomarker and molecular diagnostics.
- Exit from clinical trial services. This will mean the loss of 14 staff from the clinical research trial incubator program at the purpose-built clinical research facility at the South Australian Health and Medical Research Institute (SAMHRI) and at the new medical research clinic at the Westmead health and innovation precinct in Sydney.
- Slash the human health research program workforce by nearly 30 percent (up to 43 jobs, almost all of them ongoing positions).
It also means that CSIRO will no longer be a partner with La Trobe University in the Australian Food Innovation Centre.
As outlined by Morton, the CSIRO had planned to move its Food Innovation Centre from Werribee to La Trobe University, where it would create the Australian Food Innovation Centre.
It won a competitive tender process to be the university’s partner in the centre, but now, after an $860,000 co-contribution, has shelved those plans.
In 2023, La Trobe University told the Inquiry into Developing Advanced Manufacturing in Australia, held by the Senate Standing Committee on Industry, Science and Resources, that Food Innovation Centre was critical to securing the future of Australia’s food industry: “Currently in the agri-food sector, there exists no single solution to address the long-term challenges such as climate change and weather volatility, food security, supply chain resilience and associated health and nutrition outcomes.”
“We look to refine the capability that we have in those units,” Professor Doug Hilton, CSIRO Chief Executive Officer, told Senate estimates on June 5, while refusing to speculate on the total number of job losses.
“As you would understand, science priorities change and national priorities change, and not all scientists have exactly the same skills, and it’s important to be able to refine the capabilities that we can deploy to the most important problems that the nation faces. There will always be a case for doing that in an ongoing manner.”
You look at the claims made about the importance of the research CSIRO leads and partners – especially that around nutrition and diet – and you wonder at the logic of the decisions that have led to this situation.
Where is the Albanese Government’s commitment to making Australia a centre for innovation?
Who else can take over these important areas of research? As the impacts of climate change grow, the ability to feed the world will be critical.
Who is exploring the long term consequences of these decisions for Australian research?
Health and the UK elections
It can hardly have escaped your attention that the United Kingdom is heading for an election on July 4. Likely by the time you read this, the results – presumed to be a landslide against the current Conservative Government – will already be known.
But with national health status fraying, the National Health Service (NHS) in crisis and people struggling to get the care they need, it seems imperative that I summarise – if briefly – some of the health and healthcare issues the new government must address.
Many of the current problems can be sheeted home to austerity policies over the past decade and a half: the UK government must simply spend more on health and social welfare.
A study from the Institute of Health Equity at University College London, led by Sir Michael Marmot, found that, in the decade after 2011, more than one million people in England died prematurely due to a combination of poverty, austerity and COVID-19.
An editorial in The Lancet calling for a “healthy change” says this: “Political, financial, and public health crises have taken devastating tolls on communities where progress towards good health and prosperity was already stagnating or deteriorating, and without decisive and focused interventions, these trends are projected to accelerate. It is no surprise that most voters rank health, and specifically the beloved but beleaguered National Health Service (NHS), as the most important issue in this election.”
Here’s a short list of what some are analysing as the parties’ policies (manifestos) and putting forward as solutions to the current crises:
- The King’s Fund. General Election 2024: the health and care manifesto pledges.
- The Lancet. A programme for greater health equity for the next UK government.
- APCO. Health at the Ballot Box: How to Influence UK Health Policy After the General Election.
The Health Foundation has a series of papers that analyse the parties’ manifestos, outline priorities for action, and look at increased funding needs.
There’s a Twitter/X thread from The King’s Fund that looks at party policies on prevention, public health and inequities here:
There are critiques of the party manifestos here:
BBC. NHS election plans unconvincing – health experts
Reuters. UK election pledges fall short of $48 billion health funding gap, think tank says
News from the United States
A raft of American news on health and healthcare is summarised below.
US Surgeon General declares firearm violence a public health crisis
Dr Vivek Murthy, the US Surgeon General and head of the US Public Health Service Commission Corps, has issued a landmark Surgeon General’s Advisory on Firearm Violence, declaring firearm violence in America to be a public health crisis.
The advisory outlines the devastating and far-reaching consequences that firearm violence poses to the health and well-being of the country.
It calls on the nation to address gun violence with the vigour used to reduce deaths and injuries from tobacco and motor vehicle crashes.
Gun violence deaths are a uniquely American phenomenon – and an issue that medical groups and public health advocates have sought to address with limited success.
The scourge of gun violence is not shared equally. A 2022 study highlights that firearm homicides and poverty are intertwined.
Data from the Centers for Disease Control and Prevention show:
- Black Americans face the highest risk of gun-related deaths at a rate of 27 per 100,000 compared with 6.2 for all other racial and ethnic groups combined.
- White Americans aged 45 and older have the highest rates of gun suicide at 14.8 per 100,000
- For those under age 45, American Indians and Alaska Natives have the highest rates of gun suicide at 12.3 per 100,000.
- Veterans also have significantly increased rates of suicide by gun.
Continuing impact of the US Supreme Court decision on abortion
June 24 marked two years since the US Supreme Court handed down the Dobbs v. Jackson Women’s Health Organization decision, overturning the 1973 Roe v. Wade decision that recognised a woman’s right to terminate a pregnancy.
Since then, about half of the 50 states have banned or severely restricted abortions.
In many parts of the United States this has had harsh consequences for women’s reproductive health and their ability to access abortion.
Since 2022, the number of women who live more than 300 miles from the nearest abortion clinic has increased almost 900 times to 16 million.
A recent report from the Guttmacher Institute shows that in 2023, more than 171,000 women travelled from their home state to get an abortion.
The New York Times has an interesting graphic that shows where these women went (mostly from Republican-controlled states to Democrat-controlled states).
The saddest of these recent reports is a study that found the recent surge in infant deaths in Texas, where the rate is 12.9 percent compared with 1.8 percent for the rest of the country) is linked to the state’s strict abortion ban, with no exceptions for birth defects.
The research, published in JAMA Pediatrics, found that the most significant driver of the increase in infant deaths was babies who died of congenital abnormalities.
The Texas law blocks abortions after the detection of cardiac activity, usually five or six weeks into pregnancy, well before tests are done to detect foetal abnormalities.
Hair stylists have a role in public health
I don’t usually quote beauty magazines in The Health Wrap, but there’s a first time for everything!
An article in Allure magazine outlines how hair stylists can use the trust they have with their regular clients and lean in to their long-held role as “unofficial therapists” to provide mental health information.
The article outlines how hairdressers and barbers in both the United States and the United Kingdom, particularly those in Black communities, are being trained to recognise mental health issues and suggest referrals.
None of these training programs are meant to replace professional mental health services. “We don’t want to turn [stylists] into doctors or therapists — far from it,” says British barber Tom Chapman, who founded the Lions Barber Collective, which helps raise awareness for the prevention of suicide.
“The idea is that we can bridge the gap between the communities we serve and the resources available.”
The idea of using hair stylists as a source of trusted public health information is not new.
As far back as 2010, Cut for Life: Hairstylists and barbers against AIDS was set up in the Unted States under the auspices of the Centers for Disease Control and Prevention.
More recently, there have been trials using hairstylists for Black women as messengers about preexposure prophylaxis (PrEP) for protection against HIV infection (see this article in The New England Journal of Medicine).
Training and encouraging barbers and hair stylists to convey public healthcare messages and encourage their customers to take preventive health measures is now a well-researched strategy Programs targeting hypertension in the Black community have been launched and studied in New Orleans, Dallas and Los Angeles.
When I worked for Dr Regina Benjamin, the US Surgeon General, I came to understand how African Americans, too often discriminated against in the healthcare system, really trusted their hair stylist and the community they find in the hair salon.
Dr Benjamin knew that many Black women limited their exercise because the were worried about undoing their expensive (and often time consuming) hair styles. She spoke to a convention of 10,000 Black hair stylists and ran a competition for “exercise proof” hair styles. You can read more about this effort here.
And there’s an interesting article about how Black women have adapted their hairstyles and care to their exercise regimes here.
The Denver Basic Income Project
Homelessness has been a growing problem in Denver. Denver mayor Mike Johnston, who was elected in July 2023, pledged to address this issue and on his first day in office signed an emergency declaration to help 1,000 people experiencing homelessness find permanent shelter.
Since then 1,150 people have been moved indoors, but there is more work to be done.
One innovative approach is the Denver Basic Income Project – a program that provides unconditional cash to the homeless. The aim of the project, overseen by the University of Denver’s Center for Housing and Homelessness Research, is to test the feasibility and impact of guaranteed income for unhoused people.
Homeless people are given US$1,000 a month, no strings attached.
The preliminary results are encouraging. A year later 45 percent had secured housing and mental health had improved. People used the money on groceries, rent, hygiene, clothes and transportation.
Taxpayers saved US$590,000 because there were fewer visits to the hospital, jail and shelters.
Research reports on the project, which has been extended for a further six months, are here.
Indiana’s public health investment
There’s an amazing story published in Health Affairs that should be required reading for everyone who works at the intersections of public health, policy making and politics.
It’s about Indiana, a state with a Republican governor and where Republicans hold supermajorities in both chambers of the state’s General Assembly. In 2023 – when trust in governmental public health was strained nationwide – Indiana increased public health spending by 1,500 percent.
Specifically, the Indiana Republican legislature appropriated $225 million in new public health funding for fiscal years 2024 and 2025, up from $7 million a year.
The article explains how this unprecedented legislative victory for public health was achieved.
Indiana has consistently ranked among the bottom states for public health outcomes. The COVID-19 pandemic sounded the alarm and highlighted the historical under-investment in public health.
The effort was prompted by a report, Indiana Public Health System Review, from researchers at the Indiana University Fairbanks School of Public Health that caught the Governor’s attention (yes, academics can drive healthcare reform!).
He established the Governor’s Public Health Commission, which included locally elected officials and leaders from business, health and academia. The Commission’s report recommended the expansion of public health services across the state.
The effort to then get these recommendations funded involved tried-and-true public health methods including multisectoral coalitions, business and civic government partnerships, and coordinated communication with policy makers.
Advocates wooed reluctant conservative lawmakers, not with promises of addressing systemic racism, ending gun violence or mitigating climate change, but with messages around healthy babies, clean water and economically vibrant communities. (It did help that the state had significant funding reserves available for spending.)
There’s a good description of how this was done here.
“One of our major goals was that no matter where you lived in the state of Indiana, you would have the same access to the same public health services that any other county does,” said Kristina Box, who recently retired as Indiana’s health commissioner.
“We were careful to avoid terms we know that just turn our legislators’ hearts and minds off… One of them, to be honest, was ‘public health’.”
Good news on Indigenous health
A study recently published in The Lancet Global Health shows how a culturally informed model of cardiac care developed at the University of Queensland can help eliminate the gap between First Nations patients and non-Indigenous patients in terms of heart health outcomes.
There was also a significant reduction in unplanned cardiac readmission among Indigenous patients after the model of care was implemented.
The model of care was developed under the governance and guidance of local Aboriginal and Torres Strait Islander stakeholders. The steering committee provided feedback throughout implementation, and informal feedback from Aboriginal community health organisations and consumer groups was ongoing.
An article in The Conversation outlines how the model of care works.
The authors attributed the success to a variety of factors, including nurse-led care coordination, multidisciplinary care-coordination teams involving Aboriginal and Torres Strait Islander Hospital Liaison Officers, personalised and culturally informed education, a focus on the needs of patients and their families, and the fact that patients could confidently ask questions and yarn about their diagnosis and treatment in their own words without feelings of shame or embarrassment.
Best of Croakey
Croakey recently hosted an informative #CroakeyLIVE webinar on the national Scope of Practice Review – Unleashing the Potential of our Workforce – that is currently underway.
You can read Marie McInerney’s summary of the webinar and the discussion it generated, here.
Also see this summary via X/Twitter.
The good news story
Some weeks I struggle to find a good news story (a sign of the times?) and other weeks there’s a surfeit.
I couldn’t choose between these two…
A community’s nude calendar helps Bombala’s aged care centre re-open.
The take-out from this lovely story, presented by ABC News here, is that communities can make things happen – and sometimes you just have to be bold!
It’s clear everyone enjoyed getting their gear off for a good cause.
I note, however, a caution by my Croakey colleague Charles Maskell-Knight in the latest edition of The Zap, that while this is a good news story of a sort, it highlights the problems in delivering aged care in small rural communities.
“Providing high quality residential aged care is an expensive business and requires a pool of skilled staff, which can be hard to source in many areas,” he wrote. “The workaround in Bombala is unlikely to provide the high levels of care that some residents require, and they will still be forced to relocate out of their community.”
On a slightly more serious note, there’s this story about how Australian researchers are working to reduce sleep disturbances during hospital stays.
Hospitals are notorious for their noisy environments, impacted by various sources such as alarms, paging systems, and pinging medical equipment.
These excessive sound levels not only negatively affect patients’ experiences in hospitals but also contribute to annoyance, stress, and potential burnout among hospital staff.
The study on which this work is based can be accessed here.
And in Perth an effort is underway to address the noise levels in Intensive Care Units.
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.
