The Health Wrap by Associate Professor Lesley Russell returns for 2021 with a big review of 2020 and the lessons to be learnt from the coronavirus pandemic, plus a close look at vaccines and a range of urgent health reforms that remain unaddressed, including for aged care, mental health, and more.
Lesley Russell writes:
In the first edition of The Health Wrap for this new year, I look back at 2020 and ponder what it presages for 2021. The key issue was — and will continue to be for the foreseeable future — coronavirus and its ramifications.
But aside from coronavirus overlaying everything, the sad fact is that my review of 2019 and predictions for the year ahead in The Health Wrap in January 2020 is still largely current.
The same big issues and wicked problems still loom in health and healthcare with virtually nothing done to address them in the past 12 months. So apologies in advance for what must inevitably be a pretty depressing assessment.
Will vaccines help control the coronavirus pandemic?
2021 will be the year of vaccine rollouts, but will this mean the pandemic is brought under control, especially in those countries like the United States and the United Kingdom where community control efforts to date have failed miserably?
So much is written on this every day – it’s a major task to keep up with everything. Despite the amazing growth in our understanding of this infection, there is still much that remains unknown. The ABC asked Australian experts what we can expect from the pandemic in 2021. You can read their responses here.
If you are interested in the Biden Administration’s efforts to overcome the failures of the Trump Administration in the US, I have been writing regularly on these issues and you can find most of my work at the US Studies Centre.
When you look around the world, Australia is truly fortunate in where we find ourselves, although there have been many missteps and much pain for this gain.
In a recent analysis of international responses to the pandemic, Australia ranked highly. I give most of the credit to the states and territories (whose leaders were too often maligned) and the Indigenous community leaders and Aboriginal Community Controlled Health Organisations.
I am less generous about the Morrison Government’s efforts.
In November, in a response to Katharine Murphy’s Quarterly Essay “The End of Certainty: Scott Morrison and Pandemic Politics”, I wrote: “Morrison gets a pass grade for the initial months of the pandemic response, but he has failed to sustain this and has reverted to his true form – more partisan, more narrowly focussed and much less visionary than the country needs or deserves.”
The vaccine rollout will provide yet another test of the Morrison Government’s commitment to public health resources, health equity and transparency about decision-making.
Just this past week, the Therapeutic Good Administration has announced the “provisional approval” of the Pfizer mRNA vaccine for Australia, and so we await details of the roll-out and who will be first in line to receive this.
There are some 700,000 people (quarantine and border workers, frontline healthcare workers, aged care and disability staff and residents) in the first priority category but Australia will only receive 80,000 doses initially (and the Pfizer vaccine is already in short supply overseas).
Who will be at the front of the priority line? Will the Government choose to give 80,000 people a single dose, or keep half the allocation for second doses? What happens if further supplies of the vaccine are restricted as the European Union moves to limit the export of vaccines?
The situation will improve somewhat when the Astra Zeneca/Oxford vaccine gains approval – but the supply situation here is also unclear.
The first 3.9 million doses have been bought from overseas, then CSL will begin making monthly batches – the government says 50 million doses; CSL says up to 30 million doses.
Awareness and education
Transparency is essential for public trust in vaccines, so too is public education and awareness.
Research shows there is hesitancy about coronavirus vaccines even among healthcare workers. The Consumers Health Forum has called for Federal and State Governments to urgently step-up comprehensive communications to ensure the best possible outcome of the vaccine rollout for everyone.
This past week has seen the first evidence of the Federal Government’s $23.9 million education campaign – you can see the ad here. I’m not sure how persuasive this will be for many people, especially sceptics and those whose first language is not English.
It is important too that people understand that vaccines alone will not end the pandemic; this is particularly the case in countries like the US, but even in Australia it will take a considerable time for life to return to a post-COVID-19 “normal”.
However, there are some encouraging results from vaccination, even in these early days.
In Israel, which is currently leading the global vaccination drive with around 30 percent of its citizens having had at least a single dose so far, there are reports that coronavirus infections and hospitalisations have plunged among the age groups that have been vaccinated.
What have we learned from coronavirus?
If epidemics are mirrors of society and quickly expose the flaws the health and welfare safety nets, what has the pandemic revealed about Australia?
It has certainly tested our public health, healthcare, aged care systems (and our prison systems) and the people who work in them.
I think we have failed to truly appreciate the extent to which the systems and workers have responded and consequently I am concerned that there will not be sufficient efforts to reform and better support these in the future.
In March my Croakey colleague Jennifer Doggett wrote on “COVID-9’s Six Lessons for Australian Healthcare” for Inside Story. Her points were:
- Health isn’t a solo event – need to focus on communities and health disparities.
- Fragmentation of healthcare responsibilities creates confusion.
- Coordinated primary care must be a priority.
- Effective communication is vital.
- Health literacy matters.
- The public system will always bear the burden.
Everything on her list remains valid, but I wonder what else she would add today?
Certainly we are learning (not fast enough) the importance of effective communication and health literacy – issues complicated by the astounding level of misinformation that is circulating.
Marie McInerney, in a piece last week at Croakey, tells that a newly formed coalition of health and technology experts has warned of the risks of “rampant misinformation on social media” for Australia’s COVID-19 efforts and widespread take-up of vaccinations.
The coalition has called on Federal MPs to force Big Tech companies to reveal the true extent of COVID-19 “deadly and hidden” misinformation.
In the same article McInerney also reports that research from the Edith Cowan University in Western Australia has found issues with official COVID-19 online communications in Australia and internationally, which have failed to meet readability standards and therefore put their populations at risk. These researchers summarised their work in an article for The Conversation.
Professor Raina MacIntyre, in a recent article re-published in Croakey, made some salient points about what we have learnt that include:
- The state of the pandemic in the US, UK and Europe shows that money, technical know-how and scientific knowledge do not guarantee good pandemic control.
- Culture (civic mindedness and trust in government), leadership, appropriate experts informing policy decisions and the willingness of the public to follow expert advice are as important as sophisticated healthcare systems and technology, research and scientific knowledge. Compare Australia and New Zealand to the US and UK as evidence of this.
- Public health’s role has been invisible compared to that of clinical medicine and consequently political leaders may fail to appreciate the importance of getting proper expert advice. Clinician advisors who do not understand non-pharmaceutical epidemic control measures turn to medical technology as the only familiar solution. Many politicians and the public do not understand “public health” and the need to have built in public health surge capacity.
- There has been a pandemic of “experts” commenting in the media and providing the public with garbled and misleading messages.
Impact on mental health
We know that the pandemic has had a significant impact on mental health of the population at large and especially among those who are already vulnerable and healthcare workers.
A study from the Black Dog Institute published in July highlights how, during the peak of the outbreak in Australia, the rates of psychological distress, anxiety, and depression symptoms rose among adults and looked at some of the factors associated with this.
The 2020 National Youth Mental Health Survey conducted by headspace in the same time period also shows high levels of psychological distress among young people.
A national survey of more than 10,000 healthcare workers that was reported in October found more than half reported burnout and 28 percent said they had suffered from depression. Some respondents said they plan to leave their healthcare jobs due to mental health concerns. The survey report says it is “difficult to know” whether authorities were listening to concerns about anxiety, depression and burnout among healthcare workers.
These issues and recommended strategies for dealing with them, in both the short and long term, are summarised in a report from the Black Dog Institute. Many of the long-term mental health impacts of the pandemic are unknown and there are calls for more research in this area.
The pandemic has meant that many people have been forced to confront the reality of death and the suddenness with which COVID-19 can become life-threatening – and often the inability of family and carers to be present – has highlighted the importance of having Advanced Care Directives.
More than 85 percent of Australians are without an Advance Care Directive, and only 30 percent of older Australians (people aged 65 and over) have one, yet nearly 50 percent of people will not be able to make their own end of life medical decisions.
A paper published in August makes the case that advanced care planning is an urgent priority and should form a part of the health system’s COVID‐19 response strategy.
Palliative Care Australia has released a Palliative care and COVID-19: Grief, bereavement and mental health outcomes paper with recommendations for policy makers, health and aged care leaders and professionals, and consumers and carers to meet the mental health, grief and bereavement needs of Australians during the pandemic.
Finally, statistics from the Australian Institute of Health and Welfare highlight how Australians have used healthcare services differently during the pandemic. There is also a detailed study from New South Wales on the impact of coronavirus on healthcare activity.
Telehealth and digital technology have emerged as both facilitating and disrupting healthcare although the benefits, disadvantages and challenges of virtual care have yet to be fully evaluated. The longer-term impact of the pandemic on two other areas of healthcare – workforce and reductions in low value care – also needs evaluation.
Reforms delayed are reforms forgone
If you are a regular reader of The Health Wrap, then you will know that I am often driven to despair by the inability and/or unwillingness of the current Federal Government to tackle the needed reforms in health and healthcare.
All we get are tinkerings at the margins, with the hard issues sent off to advisory groups, committees and commissions — the reports then received are then largely ignored. The coronavirus pandemic has served only to reinforce these inclinations.
It’s interesting to read Croakey editor Jennifer Doggett’s summary of the issues that were examined in last October’s Senate Estimates hearings – it gives some idea of what is happening and what is not.
I’m strongly aligned with the authors of a recent article in the Medical Journal of Australia who see “crisis as opportunity” and in this light look at how the pandemic could reshape and reform the health system.
You can tell how difficult an issue is, and how reluctant governments are to tackle them by looking at the pile of reports, reviews, commissions, committees and advisory groups.
Mental health and aged care are the standouts here. The urgent need for reform in both these areas is highlighted in the latest edition of the Australian Health Review.
But we have heard nothing over the past 12 months about addressing workforce planning, boosting primary care, improving access to allied health and dental care, prevention and tackling obesity. The Government is more focussed on improving the profitability of private health funds than on addressing the growth in patients’ out-of-pocket costs.
The Government hews to an out-dated approach that focuses on healthcare (illness, hospitals, prescriptions) – rather than health and wellbeing, addressing health disparities and the social determinants of health and ensuring cultural safety.
Despite 20 reviews in 20 years, aged care was in a terrible mess long before coronavirus arrived on the scene to further highlight the failures.
In September Croakey published an excellent article by Jan Donovan on “COVID lessons for the future of aged care.” The first report of the Senate Select Committee on COVID-19 , tabled in December, found the Morrison government responsible for “significant failings in the aged care sector prior to, and during, the pandemic” and states that it “failed to properly prepare the aged care and disability sectors for the pandemic”.
The final report of the Aged Care Royal Commission is due on 26 February, but the interim reports already make clear what the essential reforms are. To quote the Grattan Institute: “The question looming over Australia’s aged care system is whether, in real estate parlance, it’s a renovator’s opportunity, or whether a complete rebuild is required.”
The Grattan Institute has outlined possible approaches to restructure and reforms in aged care in two recent papers: Rethinking aged care: emphasising the rights of older Australians; and Reforming aged care: a practical plan for a rights-based system.
It’s impossible to accurately count how many inquiries, commissions and investigations there have been into mental health over the years. But despite “report after report”, most of the recommendations remain un-implemented and the Morrison Government is yet to act.
In December, after releasing the Productivity Commission report and the National Mental Health Commission’s interim report on suicide prevention (the final report is due in February), the Prime Minister gave officials another 12 months in which to develop further recommendations for potential adoption by the National Cabinet.
When they do, it’s not always based on the evidence: the 2020 Budget provided increased services under the Better Access program despite the fact that the Productivity Commission called this program unaccountable, maldistributed, of dubious quality and in dire need of evaluation.
Frustrated, mental health experts have put forward their own recommendations:
- Sebastian Rosenberg: Combatting Commission fatigue: what does real reform in mental health look like?
- Brain and Mind Institute: Rethinking mental health in Australia.
The National Preventive Health Strategy promised by Health Minister Greg Hunt in June 2019 is yet to be delivered. The consultation paper, released in August, drew strong criticism for the failure to address critical issues such as poverty, climate change, cultural competency, cultural bias, discrimination and racism – core components of any prevention agenda for Aboriginal and Torres Strait Islander people, and mental health.
In particular, recent research has highlighted how vulnerable Australia is to the impacts of climate change on health and indicated that policy inaction threatens Australian lives. Just this past week, an opinion piece in the Medical Journal of Australia calls climate change “the greatest preventive health challenge.”
The work of the MBS Review, which has been underway, with multiple committees and extensive analysis and consultation (see here) since 2015, should be a major point of reform, revitalisation and modernisation of Medicare.
Sadly, the inherent possibilities in this work have been undermined by self-interest from organised medicine and it is not clear if this work will be continued into the future.
In the five years of its existence, the Review has issued some 60 reports and made more than 1,400 recommendations for changes in the MBS. This has involved more than 100 clinical committees and working groups, which engaged with more than 700 clinicians, health sector experts and consumer representatives. All the reports, findings and resources from the Review are available here.
The MBS Review Task Force’s final report was quietly released in December. And if there were any doubts that that there would be no immediate action on the recommendations put forward by the Task Force, Hunt put those to rest by saying, “This is a report to government and not of government, and we will now consider, consult and respond as we have done throughout the course of the review in relation to all previous proposals.”
In 2019 I wrote about the need to consider and implement the recommended reforms in primary care – something that remains undone. And in December I wrote about the fate of the final report and its recommendations – including that this work must continue.
It is undisputed that primary care is one of the essential foundations of an effective and efficient healthcare system. Sadly, the current Government pays only lip service to that, and to date has made a little more than a paltry push to move Medicare services beyond general practice to primary care.
In October 2019, Hunt announced the Primary Health Reform Steering Group – touted as the first step in the development of a Primary Health Care Ten-Year Plan (as part of the Long Term National Health Plan – when was the last time you heard reference to that?)
The media release announcing the Steering Group and its membership stated that its first business would be the provision of advice about the implementation of the $448.5 million provided in the 2019-20 Budget to support doctors to provide more flexible care to Australians aged 70 years and over. But to date there has been silence about this (due to be implemented in July 2020) and the establishment of a broad-based Consultation Group.
The Health Care Homes initiative, once touted as a new approach, is no longer on the Minister’s radar. The program has some 10,000 people enrolled (considerably less than the 12,000 target) and will continue until June 2021.
The regulation of medical devices is poor and stands in stark contrast to the regulatory controls that are applied to pharmaceutical problems. There have been catastrophic failures in medical device regulation with breast implants, surgical mesh, hip implants and heart valves, and these are worsened because there is currently no ability to trace defective devices that are implanted in patients.
Regulatory reforms that were due to be introduced this year have now been delayed until November 2021, with the pandemic given as the rationale.
Much of the hard work in thinking through needed reforms to health and healthcare has been done by groups and experts outside of government (see, for example, Blueprint for Health Reform from the Australian Healthcare and Hospitals Association). In the absence of active and engaged leadership from government on these issues, we must hope these continue to be the needed drivers of consensus and pressure for action.
The concern for many now is that the Government will use the exigencies of the coronavirus pandemic as an excuse to cut back spending in healthcare and other sectors like housing, education, unemployment support and domestic violence that impact on health.
A recent letter in the Medical Journal of Australia warns of the dangers of recent calls to enact austerity policies and to prioritise rapid reductions in government debt through cuts to health and social services.
The authors argue that Government spending on health, education, and social supports has the potential to increase economic growth and that “taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.”
The best of Croakey
The latest in a series on #CommunityControl by Croakey Professional Services, created in collaboration with the Aboriginal Health and Medical Research Council (AH&MRC) of NSW.
The good news story
After four long years, a good news story, succinctly put by the newly installed 46th president of the United States:
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.