The emergence of the Omicron variant of concern underscores the need for urgent action to address vaccine inequities and to enhance global cooperation in public health, according to Associate Professor Lesley Russell.
In her packed final edition of The Health Wrap for this year, Russell also reports on the state of the Australian Public Service, and other workforce matters, ranging from nurse practitioners to “the unicorns” of mental health.
Lesley Russell writes:
This is the last issue of The Health Wrap for 2021 and it’s an eclectic mix of some of the issues that have fascinated me and sent me chasing for further information, both recently and over the past few months.
I hope you enjoy reading about them.
My best wishes for the holiday season and for a peaceful, happy and COVID-19 free new year with lots of good health policies and a civil election campaign (I’m an optimist!) and of course lots of great reading at Croakey Health Media.
The big story in health is the emergence of the Omicron variant of SARS-CoV-2 and what this means for the developed world’s opening up plans and for the control of the pandemic in developing countries, especially in Africa.
Here’s are some useful references on Omicron.
- The New York Times: Three questions we must answer about the Omicron variant.
- The New York Times: Tracking Omicron and other coronavirus variants.
- Sydney Morning Herald: What is the end-game of COVID-19?
- Sydney Morning Herald: Is Omicron more dangerous? Will vaccines work? Here’s what we know so far.
- Ozsage advice on Omicron is available here.
The emergence of this new SARS-CoV-2 variant of concern has reignited global discussions of vaccine distribution, virus mutation, and immunity against new virus strains.
A key question is around the effectiveness of current vaccines against this variant. The vaccines may well continue to ward off severe illness and death, although booster doses may be needed to protect most people. Pfizer-BioNTech and Moderna are already preparing to reformulate their vaccines and are promising early roll-outs if necessary.
Meanwhile, there is the great news that the Victorian Government’s investment in mRNA vaccine development is paying off with a candidate coronavirus vaccine ready for clinical testing early in 2022.
Another issue is the role that vaccination (or lack therof) plays in the emergence of variants. This is discussed in an article in The Conversation.
The new variant has served to highlight the appalling low rates of vaccination in Africa. I recently wrote about this in an article for Inside Story.
Since I wrote that article, more information has emerged about the progress that is being made towards an African centre for mRNA vaccine research, development and manufacture. You can read about Afrigen efforts to replicate the Moderna vaccine here (paywall) and here.
It is incredibly timely that, in a special session from 29 November to 1 December, the World Health Assembly was debating the merits of a WHO pandemic convention, which could set in place “an overarching framework … needed for strengthening global health security”.
Reports from that meeting are that there was agreement to begin negotiating a potential pandemic treaty to govern and coordinate a global response next time there is a pandemic. But there are concerns about the lack of urgency.
Melissa Sweet has written more about this for Croakey.
In a paper just published in Africa Health, Professor Larry Gostin and his colleagues at O’Neill Institute for National and Global Health Law at Georgetown University outline the issues that must be considered and make the point that global mechanisms for health security should complement not undermine, effective regional, national, and sub-national approaches.
Further advice in this area comes from the report from Independent Panel for Pandemic Preparedness and Response which was co-chaired by Ellen Johnson Sirleaf and Helen Clark. In a paper just published in the BMJ, Johnson Sirleaf, Clark and colleagues outline their recommendations, including the establishment of a Global Health Threats Council.
Other articles in the BMJ series consider the findings of the Independent Panel in more detail.
On a related issue, what scientists in South Africa did in terms of alerting the world to the Omicron variant is to deliver a glimpse of future needs: a global early-warning system, using genomic surveillance, to spot and track the changes and spread of pathogens based on whole-genome sequencing. The data must then be shared rapidly and can be used to develop therapies and vaccines.
Global cooperation in public health has often been hampered by nations’ refusal to share samples and data, by patchwork funding for surveillance, and by scattered epidemiological and clinical information that is disconnected from genomics. The Rockefeller Foundation has announced it will invest part of a recent $1 billion commitment to help establish a broad platform to overcome these hurdles.
Pandemic’s impacts on people’s views about science
The Wellcome Global Monitor 2020: COVID-19 report, which explores how the pandemic has affected the lives of people around the world and influenced their perceptions of science, healthcare systems and governments, has just been released.
I was especially interested in the findings about how perceived knowledge of science and confidence in government influences trust in science.
Globally, only 25 percent of the public said that their government values the opinions and expertise of scientists ‘a lot’, though an additional 35 percent said government leaders place ‘some’ value on them; 28 percent felt their government does not place much or any value on scientists’ opinions.
The following figures from the report explore these findings in more detail. While Australia looks good in comparison to some other countries and regions, there is clearly more work to be done. In my opinion “more work” means more and better science education for all Australians.
It’s time for the psychiatry profession to step up
Last week frustrated and brave psychiatry trainees did something quite shocking – they publicly released a letter to the President and Board of the Royal Australian and New Zealand College of Psychiatry (RANZCP) in which they resigned as members of the Trainee Representative Committee and outlined their ongoing grievances.
The letter points to “glaring deficiencies” in the RANZCP training program and examinations and a “culture of disregard for trainee welfare and feedback”.
An article from Dr Ben Veness for MJA Insight details the devastating failure of the electronic examination system. (Such failures have also been reported for other colleges.) He sees that excessive hierarchy in medicine harms both doctors in training and patients.
Most powerfully, Dr Helen Schultz, a RANZCP Fellow, has spoken out in a piece published in The Medical Republic, saying “something is rotten in our training colleges”.
It’s worth noting that there is serious money involved. Collectively, the membership fees of associate members contribute about $2.4–$3.4 million to the operating revenue of the RANZCP, which is an astonishing $42 million a year.
In addition, trainees are charged joining ($702) and examination fees ($425–$2,658 for each of six assessments). The most recent (failed) examination had 248 candidates who paid the college $659,000.
These public disclosures are very disconcerting, coming at a time when there is a growing awareness of bullying and pressure for junior doctors (increased by working through the pandemic). Likely trainees in other medical colleges are thinking they could write a similar letter.
It is particularly problematic for psychiatry which is facing a serious and growing workforce shortage that is already impacting on the ability of patients to access specialist care.
The most recent federal analysis of the psychiatric health workforce dates from March 2016 (here’s yet another opportunity for me to bemoan the absence of a national health workforce planning agency).
It projected a future undersupply of 125 by 2030 for the psychiatry workforce, despite the high reliance on overseas trained doctors, projected at 55 new fellows per year. The shortage of psychiatrists is particularly acute in the public sector and outside metropolitan areas.
The development of a 10-year National Mental Health Workforce Strategy has been underway for some time (comments on the draft closed in September) but it seems unlikely that this will be released and endorsed by the states and territories by the end of 2021 as planned.
The mental health stresses delivered by the pandemic, and the hope that there will soon be some major mental health reforms in response to recent reports, serve to highlight the consequences of shortages in the psychiatry workforce.
In the October 27 edition of The Health Wrap, I reported on data in the General Practice: The Health of the Nation 2021 report from the RACGP. This, together with reports from the Australian Institute of Health and Welfare, show that increasingly GPs are bearing most of the mental health workload in terms of Medicare-subsidised services.
The proportion of Australians accessing psychiatric services subsidised by Medicare has barely changed over the decade 2009-10 to 2019-20 (from 1.3 percent to 1.7 percent) (see figure below).
I have done my own analysis of Medicare data for psychiatry services to see how they changed since the pandemic began (see figure below). Basically, access to services declined.
There was little or no observable change in referrals by GPs for opinion and report (MBS item 291) or for an initial 45-minute consult with a new patient (MBS item 296).
The number of services billed as follow-up consultations (MBS items 304 and 306) declined dramatically in the second quarter of 2020 and the third quarter of 2021, coincident with pandemic lockdowns in New South Wales and Victoria.
This decline in face-to-face consultations for ongoing patients was not replaced by the use of telehealth (MBS item 288). Telehealth services from the third quarter 2019 to the third quarter 2021 increased by some 60 percent, that that represented only 12,047 additional services.
The explanation appears to be that psychiatrists in private practice (who predominantly work in the better-off metropolitan areas of the major cities) are as busy as they want to be, are not taking on new patients, and have not stepped up to address the increased need for mental health services during the pandemic.
An article by Melissa Davey in The Guardian last April highlighted the high out-of-pocket costs involved.
And she reported one person as saying: “Finding a good psychologist or psychiatrist who bulk-bills and has appointments available is like hunting for unicorns while blindfolded.”
Operating on the wrong body part
It’s a shocking fact that surgeons sometimes operate on the wrong body part.
In 2006 it was estimated that each year there were 1,300 to 2,700 wrong-side/wrong-site, wrong-procedure, and wrong-patient events in the United States. The researchers found that reports of these instances were more common in the mainstream media than in the medical literature.
I could not find any national data for Australia, despite long-standing guidelines from the Australian Commission on Safety and Quality in Health Care.
The 2018-19 annual report on sentinel events from Safer Care Victoria shows that most years one event is reported as “procedure involving the wrong patient or body part resulting in death or major permanent loss of function”.
There have been many efforts over the years to tackle these dreadful errors.
A paper published last year looked at how sophisticated innovative technology could address this. But more recently a suggestion has come forward for an easy fix, using a much simpler approach.
It has long been recommended that doctors “mark the procedure site” before surgery, effectively labelling the correct location. This seems reasonable.
But an opinion piece by a clinician in the Washington Post argues this is the wrong strategy, Instead, doctors should label the wrong site whenever there is a risk of left/right confusion.
Zimmerman report finally released
In the past few issues of The Health Wrap I have been tracking what is happening in terms of the Morrison Government’s efforts to reform Health Technology Assessment (HTA) and other aspects of the regulation of medicines and devices and the review of the National Medicines Policy (see here and here and here).
In particular, I am concerned that the voices of Big Pharma, device manufacturers and clinical experts will be privileged over those of consumers. This concern is aggravated because the Department of Health (DoH) appears reluctant to share information, submissions and progress reports.
The (retiring) Health Minister Greg Hunt has indicated that a review conducted by the parliamentary Standing Committee on Health, Aged Care and Sport would be central to this work. That review, often referred to as the Zimmerman report, has finally been made public.
The report, “The New Frontier – Delivering better health for all Australians” (I love how these titles seem to indicate a focus on consumers/patients that is so often belied by the content), focuses on innovations in medicine such as genomics and personalised or precision medicine.
The report discusses issues under the headings of Therapeutic Good Administration, HTA and the Pharmaceutical Benefits Advisory Committee, Medical Services Advisory Committee, Rare Diseases, Clinical Trials, Research and Development and also considers the patient voice in each of these issues.
It makes 31 recommendations to reform the current system for regulation and reimbursement. Many of these – around timelines for review and fees and cost recovery – clearly respond to industry needs.
There are calls for a renewed commitment to clinical trials, for a national approach to newborn screening to replace the current patchwork of state and territory programs, and for a national genomics testing program.
There are also calls for new bureaucracies inside the Department of Health: a Centre for Precision Medicine and Rare Diseases and an Office of Clinical Evaluation. But it is not clear how these would interact with the independent regulatory agencies.
A number of the areas targeted for more attention (genomics, clinical trials, repurposing of drugs) are already a focus of initiatives funded by the Medical Research Future Fund.
Only one of the 31 recommendations is about “The Patient Voice”. It would have the Department of Health do the following :
- Integrate the patient voice upfront into the HTA system.
- Implement a notification system for all HTA bodies and the TGA to advise relevant patient groups of the receipt of an application.
- Provide patients and stakeholders with a concise sponsor’s submission summary to help facilitate their own involvement in the HTA process.
- Consider making patient evidence compulsory for certain applications and consider the role of patient evidence in the decisions of the TGA .
- Notify relevant patient groups of thI e outcome of the assessment process by all HTA bodies.
- Be funded to implement these recommendations.
It is also recommended that federal funding be provided for organisations to support participation in the HTA process.
The report has been largely applauded by the pharmaceutical industry.
I came across this statement from one major company in an on-line newsletter targeted at the industry (paywalled). It sums up their general approach:
The recommendations made by the Committee reinforce the need for change to Health Technology Assessment (HTA) in Australia and highlights the importance of the National Medicines Policy (NMP) review and the Strategic Agreement in helping achieve much-needed reform in a timely manner.”
That anodyne statement essentially reflects the report. Many of the recommendations lack clarity and some requirements (like a mechanism to ensure ongoing supply of high-need medicines) already exist.
The state of the Australian Public Service
A number of recent reports have examined the functioning and effectiveness of the Australian Public Service (APS).
The APS has a key role to play in the development, implementation and oversight of legislation and regulations and in providing advice to government around this. Is it fit for purpose?
Last week saw the tabling in the federal parliament of the 24th report on the state of the Australian Public Service. It has generated a series of articles in The Mandarin.
This article – State of the service report offers APS snapshot for 2021 – offers a good overview. There are some fairly shocking revelations about the increasing levels of sexual harassment and bullying reported.
Women in the APS workforce reached and, in most cases, exceeded parity with men at every level up to and including the collective senior executive cohort.
However, the employment rates for people living with a disability, public servants with an Aboriginal or Torres Strait Island background, and employees from non-English speaking backgrounds have remained flat in the past few years
The Mandarin has an interview with APS Commissioner Peter Woolcott, in which he rejects concerns that the APS is no longer providing frank and fearless advice to government, but acknowledges the APS no longer has a monopoly over advice, with ministers’ offices, consultancies, social media, stakeholders and interest groups also playing a role.
Another article in The Mandarin exploring APS employment data finds that temporary jobs are now 13 percent of all the workforce — the highest portion in the APS since at least 2002 when online records start.
It’s no surprise then that government spending on consultancies is rising, and is now estimated to cost taxpayers more than one billion dollars a year (an Australian National Audit Office report found last year the total value for consultants reached $1.2 billion in 2018-19).
A recent report from the Senate Select Committee on Job Security reported evidence that labour hire and consultants are being utilised to undertake core public sector work and not just to address fluctuations in workforce needs (such as those generated by the pandemic).
The Australian National Audit Office has just released a report on the APS workforce response to COVID-19.
The most outstanding finding was that a whole-of-government risk assessment for managing the APS workforce in a crisis was not in place prior to the pandemic and consequently key workforce risks were managed reactively. Despite this, no work yet has been conducted to improve APS workforce risk management.
If you join the dots from these information sources, it’s pretty easy to understand the erosion of the capabilities and status of the APS – and the subsequent adverse impacts on health and healthcare policies and initiatives that emanate (or should emanate) from the federal government.
In case you missed it
A new Grattan Institute paper makes the case for a $20 billion federal government Social Housing Future Fund which would make regular capital grants to state governments and community housing providers.
You can read more in this article in The Conversation by Brendan Coates, the report’s author.
The Nurse Practitioner 10-Year Plan
The Department of Health is developing a 10-year plan for nurse practitioners. This is apparently being done concurrently with development of the National Nursing Strategy – except I can’t find any information about the development of such a strategy apart from this reference on the DoH website.
The consultation paper for the Nurse Practitioner Plan is a