In her final edition of The Health Wrap for 2018, Dr Lesley Russell reports on the latest news in healthcare quality and safety, mental health, human rights, as well as recommendations addressing obesity and stillbirth.
The 2018 version of the Australian Atlas of Healthcare Variation looks at healthcare use in four selected clinical areas: paediatric and neonatal health; cardiac tests; thyroid investigations and treatments; gastrointestinal investigations and treatment. Specific recommendations for improvements are made. There are interactive features available.
The report, covered for Croakey by Marie McInerney, highlights how much work there is to be done in ensuring best practice, better access and implementing the principles of Choosing Wisely. Some examples:
- In 2015, 42 – 60 percent of planned caesarean sections performed before 39 weeks did not have a medical or obstetric indication. The highest rates were in private hospitals.
- Antibiotic use in Australian children is three times higher than for children in Norway and the Netherlands.
- There is significant prescribing of proton pump inhibitor drugs to treat colic in infants despite the fact that there is no evidence they are effective and they increase the risk of gastroenteritis and pneumonia. These drugs are also used inappropriately for long periods by adults.
- Patterns of use for colonoscopy and gastroscopy suggest over-use in some areas and populations groups and under-use by others (Indigenous Australians, people living in outer regional and remote areas, and people living in low socio-economic status areas) due to limited access.
- There is evidence to suggest over-testing for thyroid functioning. Disease patterns do not explain the variations seen in neck ultrasounds and thyroidectomies.
- Variations in cardiac testing indicate both over-use in some areas and lack of ready access in others. There needs to be a clinical care standard on diagnosis, investigation and management of ischaemic heart disease.
A separate section examines national patterns in medicines use over time (for 2013-14 and 2016-17) for four common groups of medicines: antipsychotics, opioids, antimicrobials and medications for attention deficit hyperactivity disorder (ADHD).
A detailed publication showing variation at a local level will be available in 2019 for this work. The current report does include recommendations for the appropriate use of antipsychotic medicines in people aged 65 years and over.
Taken together these represent some key areas for reforms in health policy and financing and in ensuring best practice in clinical areas. The recommendations are summarised here:
- The need to reduce harm in the provision of healthcare (eg too many early, planned C-sections).
- The ability of well-informed consumers to be powerful agents for improving the appropriateness of care (eg over-prescribing of antibiotics).
- Disturbing patterns of inequity (eg despite higher rates of bowel cancer, poorer Australians have less access to colonoscopy).
- Markedly higher healthcare use in some areas with no clear clinical indication (eg rate of prescribing of medicines for ADHD in 75 times higher in the local area with the highest rates than in the local area with the lowest rate).
- System factors can influence the use of particular treatments (eg. prescribing of anti-depressants is high in Tasmania because availability of mental health services is limited).
- There is a need for regular public reporting, access to more complete and informative data, quality improvement strategies for the use of tests, and better information for consumers to allow informed decision‑making.
The right to health
December 10 was Human Rights Day, and this year was the 70th anniversary of the adoption by the UN General Assembly of the Universal Declaration of Human Rights.
In an essay published in The Lancet (available free but you do have to set up an account), Professor Lawrence Gostin and colleagues, including the director-general of WHO, looked back at the evolution of human rights in global health over the past 70 years and outlined key messages for the future of health as a human right.
They see a crucial role for health practitioners in the sustained political engagement that is needed to realise the right to health.
Refugee and asylum seeker health
The health of asylum seekers and refugees in off-shore detention remains an issue of political contention in Australia.
Two class actions launched this week allege that the Australian government has subjected asylum seekers and refugees to torture, crimes against humanity and the intentional infliction of harm in the operation of its offshore processing system. It does seem that the Australian public, if not the Government, is having a moral awakening on refugee policy.
It will be interesting to see how these issues are addressed at the upcoming Labor Party national conference. There will be a push from activists for radical changes, while more pragmatic Labor members are hopeful of a peaceful transition to a more progressive asylum seeker policy in line with the recent shift in public sentiment. Labor leaders will look to temper the political risks, knowing that the Coalition will run dog-whistle scare tactics on any changes.
Manager of Opposition Business in the House, Tony Burke, has said that there will be no radical changes to current policy (read it here); Deputy Labor Leader, Tanya Plibersek, says that the party’s official position on asylum seeker policy should be amended to reflect the legislation that was recently put forward in the parliament and that turnbacks and other issues that have long been Labor policy will be debated.
Including health in migration policies and migration in health policies
As I’ve been thinking about these issues, recent articles on migration and health in The Lancet caught my eye (again, these are freely available but you do have to set up an account to access them – worth the small effort).
These papers result from the UCL-Lancet Commission on Migration and Health and they look at the health of a world on the move.
Of these, Advancing health in migration governance, and migration in health governance, seemed to me to have particular resonance for Australia.
This paper looks at how health is an essential factor to enable orderly, safe, regular, and humane migration. Yet it remains at the margins of decision-making on migration governance, which is usually made within the ministries of interior, foreign policy, and immigration.
Many countries have explicitly stated before international human rights bodies that they cannot, or do not wish to, ensure health protection, including the provision of essential health services to migrants, and especially to irregular migrants.
Australia does not ensure that refugees and asylum seekers here have appropriate access to needed health services and does not do enough to help improve the health of refugees living in the most tenuous and health-threatening conditions around the world (think Yemen and the Rohingya).
A way out of the politicking on refugees
This from the wonderful and wise John Menadue will give you pause for thought over the holiday period and as we head into elections. He writes in his blog Pearls and Irritations:
We can be proud of what we have done for refugees in the past but like many others I am ashamed that we have now had a succession of ‘leaders’ who have appealed to our most selfish instincts.
When I feel discouraged about our national failure, I am reminded of Graham Greene’s challenge that ‘the only unforgivable sin is despair’.”
Read the rest of his post here.
Senate report on obesity epidemic
The recommendations are not unexpected, and include:
- A National Obesity Strategy, a separate National Childhood Obesity Strategy, and the establishment of a National Obesity Taskforce.
- Improved food labelling
- Reformulation of some foods
- A tax on sugar-sweetened beverages (SSBs)
- Greater restrictions of food advertising
- Education campaigns
- Health interventions for those living with obesity
- Attention to stigmatising language around obesity.
It is perhaps more interesting to read the dissenting reports as an indication of where the election policies of the major parties might be headed.
A joint dissenting report from Liberal Party and PHON Senators was mostly about opposition to the recommendations (surprise!). The senators opposed the establishment of a National Obesity Taskforce (citing COAG work in this area), the recommendations about changes to the Health Star Rating system (stating that a review of the system is already underway and it should not be mandatory), a tax on sugar sweetened beverages or SSBs (arguing that it is not effecting and citing data from McKinsey & Company, Overcoming obesity: An initial economic analysis, 2014), and the recommended restrictions on food and drink advertising.
A dissenting report from Labor Senators opposed a tax on SSBs citing a lack of evidence of effectiveness and a concern it would be regressive. They also disagreed with the recommendations on food advertising, saying that these would be an impost on media and advertising businesses.
As an alternative, they recommended that the National Obesity Taskforce conducts a comprehensive review of the current regulatory framework for food and drink advertising and marketing to children, and that a food identification standard (ie what is “discretionary food”) be agreed to inform such a review and facilitate uniform implementation.
Two points to note in regard to these dissenting reports:
- At the 12 October COAG meeting, the development of a National Obesity Strategy through the Australian Health Ministers’ Advisory Council (AHMAC) was agreed, together with a proposal that an Obesity Summit be held as the first phase of its development.
- Food advertising in Australia is regulated under a complex mix of statutory regulations and self-regulatory codes. There are many problems, as outlined by the Obesity Policy Coalition.
As Jane Martin, Executive Manager of the Obesity Policy Coalition, wrote for Croakey on November 5, powerful strategies to reduce obesity rates in Australia already exist. They just need to be implemented.
A National Obesity Strategy has the potential to be effective when it ensures that the right tools are employed by all sectors, and at all levels of government.
Just this week, as a follow-up to the Senate report, Martin wrote:
We have to stop seeing obesity as a problem without a solution. We know what needs to be done. We have a strong consensus from around 40 public health, community and academic groups who identified eight policy priorities in Tipping the Scales.
Tired of waiting for governments to act, we joined together to provide a policy blueprint to stem the tide of obesity – a ‘how to guide’ if you will.”
She’s right – it is a problem worth fighting. We just need a government willing to join the battle.
And to add to the urgency, data released this week by the Australian Bureau of Statistics as part of the 2017-18 National Health Survey show that two-thirds of Australians are overweight or obese. This is up from 63 percent three years ago and 56 percent in 1995.
Poor diet and inactivity are undermining the long-term, hard-earned benefits of fewer people smoking or drinking to excess.
You should also read an article this week in The Conversation which makes the case that increasing the price of alcohol is the most value for money policy option to prevent obesity in Australia.
This is based on work recently published in the Assessing Cost-effectiveness of Obesity Prevention Policies in Australia (ACE-Obesity Policy) report. This research shows that policies aimed at reducing alcohol consumption would not only reduce the well documented health and social harms associated with drinking too much but would also have significant impacts on body weight. (BTW it would also improve dental health!)
Senate report on stillbirths
The Select Committee on Stillbirth Research and Education, an initiative driven by Senator Kristina Kenneally and chaired by Senator Malarndirri McCarthy, released its report on December 4. You can read the recommendations of the report here.
The report found that stillbirth affected more than 2,000 Australian families every year. Its recommendations included more research, improved data collection, better clinical support for families, and protection and support for employees who have experienced stillbirth. You can read a summary here.
Unlike comparable countries around the world, Australia’s stillbirth rate has not changed in more than 20 years, and the rate among Aboriginal mothers is twice as high. Data from a recent report from the Australian Institute of Health and Welfare shows that the stillbirth rate is around 7 deaths per 1000 births.
The Centre for Research Excellence in Stillbirth (Stillbirth CRE) summarised the case for making stillbirth research and education a national priority:
Many stillbirths are preventable, and Australia is underperforming in the challenge to reduce deaths and improve care and support for those who experience stillbirth…
Stillbirth is an issue of national significance that requires coordinated leadership and action across all levels of Australian government to improve the current and future wellbeing of Australian women, their families and our wider society.”
Currently AHMAC is working on a National Strategic Approach to Maternity Services which is due for completion by July 2019. It will replace the National Maternity Services Plan 2010−2015, which concluded June 2016. (As an aside – how can such a gap on such an important health issue be allowed?). As an overarching national approach to a high-quality maternity care system, there is room here to include strategies to reduce the rates of stillbirth.
In response to the Senate report, the Health Minister Greg Hunt, announced a national roundtable to address the rate of stillbirth in Australia, and $7.2m for medical research and education programs.
In October Labor announced that in government it would provide $5 million to reduce stillbirths.
Doing mental health better
This week’s best read in mental health (and a contender for best read of 2018 in this category) is the piece my colleague Jennifer Doggett wrote for Inside Story and cross-published at Croakey: Doing it Better or Doing it Differently?
Incredibly well researched and thoughtful, it’s a must-read for everyone, especially (we hope) politicians and policy makers. I commend it to you.
Towards the integration of mental and physical health
This is a constant theme of mine – and others. I was alerted to a report Filling the chasm from the UK Centre for Mental Health and the University of Birmingham by a colleague who works in this area in the US. He had tweeted:
#Primarycare has a pivotal role in supporting and promoting our mental and physical health.
Yet national policy has left this to chance: #mentalhealth has been on the margins of primary care policy, and primary care has likewise been marginal to mental health policy.” @miller7
The report explores a number of promising local initiatives in the NHS which are bridging the gap between primary care and secondary care services, supporting people who fall into this ‘grey area’ due to having more complex needs, not meeting secondary care thresholds, or presenting with multiple or medically unexplained symptoms.
It identifies these key elements for future primary care developments and for bridging the gap between primary and secondary care.
If you’re into data….
The AIHW this week released an interactive data tool that enables comparison of the most recent data from 36 OECD member countries across a range of health and healthcare indicators, with a focus on Australia’s international performance.
I couldn’t determine whether the waiting times for elective surgery for Australia (which are mostly better then the OECD average) were for public or private hospitals or both.
Peterson-Kaiser Health System Tracker
The Peterson Center on Healthcare and the Kaiser Family Foundation have set up a Health System Dashboard. The brief – outlined here – was to look at the value of US healthcare and whether this has improved over the past 25 years.
While the focus is on how the US is performing, the international scope makes it possible to see how Australia is doing too.
One (bad) stand-out for Australia is the very high rate of caesarean sections. (It’s not clear if the hospital costs provided for Australia are public, private or both.)
This is the last edition of The Health Wrap for 2018. It will be back after Australia Day – refreshed, well-exercised, well-fed and well-read.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow Lesley on Twitter at @LRussellWolpe
Previous editions of The Health Wrap can be read here.