Introduction by Croakey: The year has begun with a bang. Many people are telling us about how busy they are, already.
Perhaps that’s a consequence of a Federal Government with a determined reform agenda that is inviting consultations, submissions and engagement. Not to mention the ongoing impacts of COVID on people, systems and workplaces. And no doubt it’s also a consequence of an increasingly complex and challenging world, where so much is both important and urgent.
As The Health Wrap launches into 2023, Adjunct Associate Professor Lesley Russell provides an overview of key issues and concerns, from national health reform to COVID, the arts, breastfeeding, food deserts, oral health and more.
Lesley Russell writes:
This is the first edition of The Health Wrap for 2023; it’s still a surprise to me that we are already well through February and a sure sign that this year will go quickly.
From the health policy wonk point of view, there is so much that we wish to see happen this year and I, for one, am anxious that the reforms in health and healthcare that are so badly needed will be slow to arrive, if indeed they arrive at all.
A lot has happened over the holiday break, so I’ve done my best to catch you up to date with all the news and views.
Primary care reforms
I think it’s fair to say that the Strengthening Medicare Taskforce report offered no surprises – except that it was so very predictable, offered no detail, and had no outlines of priorities and plans for action. As such, it could be seen taking up time that could have been spent on implementation.
At least now the Albanese Government (and hopefully all members of National Cabinet) own the issues, meaning they don’t have to rely on reports and recommendations from the Coalition Governments – although, as Jennifer Doggett and I point out, they could have used the 2009 recommendations from the National Health and Hospitals Reform Commission, which are as applicable now as they were when released more than a decade ago.
Ian McAuley, writing for Pearls and Irritations, also expresses a sense of déjà vu about the Strengthening Medicare Taskforce report.
Martyn Goddard, in his pithy Policy Post article, is even more caustic, writing:
The proposals in the remarkably slender Strengthening Medicare Taskforce report are old ideas rehashed which, even if they finally happen, will take many years and will have limited impact. The Government is either ruling out the most effective and urgent reforms or ignoring them altogether.
There’s nothing on the Medicare rebate, very little of substance on increasing GP numbers, nothing on hospitals, ambulances, nurses, allied health, or the funding split between the Commonwealth (which can raise the money) and the states (which can’t).”
I think most stakeholders are a bit more optimistic and willing to say, like Peter Breadon and Lachlan Fox from the Grattan Institute, writing for The Conversation, that Medicare reform is off to a good start and now the hard work must begin.
The not-quite-explicit promise is that there will be more money for primary care reform (and for hospitals and prevention?) in the May Budget. The election commitment towards this work – $750 million over three years – does not begin to flow until 1 July 2023.
The Albanese Government has not outlined next steps, so it is not clear how and when the changes to Medicare structure and financing that Minister Butler has said must precede any new spending will be developed, and by whom.
While I see general agreement that reforms are needed, I don’t see much consensus about what the detail of those reforms should look like, and I don’t see the main players (political parties, professional organisations, business groups, clinical providers and medical manufacturers) paying enough attention to the needs and interests of the key stakeholders in reforms – the public, patients and their carers.
You can bet that the usual loud voices are lobbying strongly and they will be hard to budge from their ongoing, outdated turf fights.
As part of his recent speech at the National Press Club (reported at Croakey together with this analysis by Jennifer Doggett, Professor Stephen Duckett offered some suggestions for how the Albanese Government should tackle the tasks now confronting them.
On top of the work to develop and implement a roadmap to Medicare reform, the Government faces three additional tasks with critical timeframes: first, to assuage doctors’ anger and their concerns over workloads and income; second, to address the expansion and better integration of the primary healthcare workforce; and third, to respond to patients’ concerns about access and affordability.
The quick, Band-Aid fix for both of these involves more money; if the Government is not going to simply add more MBS items and increase MBS rebates (and I hope they don’t), then there must be some consultation and straight talking to convince both healthcare professionals and the Australian public that we are headed down a reform path that will improve the healthcare system and benefit all stakeholders.
Here you can see all of Croakey’s articles to date on the Strengthening Medicare Taskforce.
And the bigger, health reform archives.
Exploring issues for Medicare reform
Here’s some interesting information from Goddard’s paper (referenced above) about how MBS Item 23 (GP short consult) payment would have moved under different indexation rates – CPI, economy-wide labour costs, and labour costs in the health and human services sector.
Had indexation been sustained, the Item 23 payment, now just on $40, would be between $45 and $48, depending on which index is used. Note that pay in the health and human care sector generally has risen more slowly than pay in the economy as a whole.
Having presented this, I must add that I feel it would be a retrograde step for Medicare reforms to focus on these sorts of numbers for time-limited consultations.
The case for why reforms must focus on addressing improvements in the care of those with chronic and complex conditions and health disparities and inequalities is well made in a recent article in The Medical Republic and in an accompanying opinion piece from Dr Tim Senior, aptly entitled ‘Support for GPs working at the deep end’.
Professor Mary Chiarella, writing for Pearls and Irritations, sends a strong reminder that the reform of primary care is not just about doctors:
… the resistance of the medical profession to the concept of multidisciplinary PHC (unless the remuneration and control rests with a GP) is both Luddite and discourteous to other equally well educated, equally well-regulated health professionals.”
A recent paper in the Australian Journal of Primary Health highlights that there is a need for new roles in the healthcare system. This paper reports on the successful pilot of a nurse-led, general practice co-locate healthcare coordination service for patients from culturally and linguistically diverse (CALD) backgrounds.
Under the previous Coalition Government much was made of the ability of telehealth to improve healthcare access. I have written previously (The Health Wrap, 1 May 2021) about how simply expanding telehealth services is only a small piece in the much larger puzzle of healthcare reform and that better targeting and evaluation is needed.
A recent paper from Australian researchers published in the BMJ looks at telehealth use (the majority of this was telephone) in primary care during COVID-19. It finds that telehealth was perceived to improve access to healthcare for some vulnerable groups and those living in rural settings, but reduced access for people from non-English-speaking backgrounds.
Last month the Australian National Audit Office (ANAO) released a report on the expansion of telehealth services. It found that the Department of Health did not plan for performance monitoring or evaluation of temporary or permanent telehealth (although I note that evaluation of permanent telehealth items is now under development).
The current crisis in primary care is not just an Australian phenomenon. The 2022 Commonwealth Fund International Health Policy Survey of Primary Care Physicians analyses the effects of the pandemic on the primary care workforce across 10 high-income countries, including Australia.
In nearly all countries, a third or more of younger primary care physicians were experiencing burnout, at significantly higher rates compared to older physicians (those aged over 35). In Australia, 44 percent of younger GPs and 29 percent of older GPs reported burnout at the time of the survey.
Regardless of age, these doctors rarely sought professional help for their mental health. Only 17 percent of younger GPs and eight percent of older GPs in Australia did so.
Older primary care physicians in all surveyed countries were significantly more likely than their younger peers to report they plan to stop seeing patients within the next three years (37 percent of older Australian GPs said this).
As Professor Anthony Scott wrote in The Conversation back in May last year, Labor’s plan to strengthen Medicare won’t work unless it addresses the GP shortage.
The arts and public health
A recent article in The Lancet Public Health looks at the growing body of evidence indicating the arts have a role to play in promoting good health and preventing and managing illness.
This builds on a scoping review of over 3,000 research studies from the World Health Organization’s Health Evidence Network that explore the effect of the arts (including participating in performing arts, visual arts, literature, engaging with culture and heritage) on health and wellbeing.
The review concluded that the arts could key roles to play in the prevention of ill health, the promotion of good health, and the management and treatment of a range of different conditions, including loneliness, mental illness, neurological disorders, and end-of-life care.
In a brief from the WHO regional office for Europe that looked at supporting health through the arts, the arts are described as “often low-risk, highly cost-effective, integrated and holistic treatment options for complex health challenges”.
The article in The Lancet concludes that taking advantage of these findings will not be easy because the area is not in the usual scope of either arts of health policy makers. This means that finding mechanisms both within and across traditional policy jurisdictions will be necessary to support initiatives in this area.
The point is also made that arts and cultural policy makers must do more to ensure equal, accessible arts engagement opportunities for all their citizens.
It’s timely to think about this in light of the newly released National Cultural Policy.
The Lancet provides some examples Australia might emulate, such as Singapore’s Arts Strategy for 2018–2022 that pledges to “bring the arts to under-reached communities in places such as hospitals and nursing homes”.
Costs of CPR
Out-of-hospital cardiac arrest (OHCA) – when a person’s heart suddenly stops pumping blood around the body, caused by an abnormal heart rhythm – remains a leading cause of death in Australia. Each year there are some 30,000 OHCAs across the nation. Unfortunately, the death rate remains at 90 percent, cementing OHCA as one of the leading causes of death in Australia.
There is a need to improve the community’s understanding of cardiac arrest, and to increase awareness and training in cardio-pulmonary resuscitation (CPR). CPR training rates have not changed over the past decades.
Australian research in adjusted models published last year shows that people were more likely to receive CPR from a bystander if they were of a younger age, if a bystander witnessed their collapse, if they arrested in a public location, and if this was in an urban location.
Bystander CPR is a crucial component of the ‘chain of survival’; patients who receive bystander CPR are more than two times more likely to survive than those who do not receive bystander CPR.
However, the failure rate is high; only around 10 percent of cardiac arrest patients survive.
A 2018 study to investigate regional variation in the characteristics, incidence and outcomes of OHCAs in Australia and New Zealand found bystander CPR was commenced in 41 percent of cases and 28 percent of these cases survived the event and 12 percent survived to hospital discharge.
Even for cardiac events in hospital, the success rate for CPR is still low, and does not reflect the magical recoveries portrayed in TV medical dramas.
I know from personal experience that it helps to be able to do something useful in these situations, even if it is only to call emergency ambulance services or find the nearest defibrillator.I recently found a study that looks at the psychological cost of performing CPR.
It argues that is we are to encourage people to learn CPR and how use automated external defibrillators (AEDs) and then to be prepared to use these when needed, then we must also address the “collateral damage” – the psychological and emotional consequences of carrying out the procedure.
These are brutal procedures, especially if delivered to a loved one and if efforts weren’t able to reverse the sudden cardiac arrest. For those with clinical qualifications, giving up on CPR can be traumatic.
If you follow either @DGlaucomflecken or his wife @LGlaucomflecken on Twitter, then you will know how well they have conveyed the shock and trauma of resuscitation for an OHCA, made no easier by the fact that they are a medical couple.
Some notes from a talk @LGlaucomflecken gave earlier this month on this topic are here.
It should be impossible to talk about so many aspects of health – the importance of the first 1000 days, maternal health and wellbeing, obesity, dental health, prevention, and even issues such as women’s workforce participation – without talking about breastfeeding.
Breastfeeding has proven health benefits for both mothers and babies in high-income and low-income settings alike. Yet, less than 50 percent of babies worldwide are breastfed according to WHO recommendations.
In Australia, as at 2017-18, it was estimated that 93 percent of mothers initiate breastfeeding at birth; however, only 29 percent continue breastfeeding exclusively until six months of age.
A recent series of papers in The Lancet looks at the dubious (but very effective) marketing practices of the commercial milk formula industry, using strategies designed to prey on parents’ fears and concern, to turn the feeding of infants and young children into a multibillion-dollar business—generating revenues of about $55 billion each year.
These papers are well summarised here and you can watch the Australasia and Pacific launch of the papers here.
Australia contributes to this problem: Australian milk companies have a significant share of the lucrative Chinese import market. While Ausaid’s Asia Pacific policy states Australia’s responsibilities in providing development assistance and emergency aid should not create new markets for breast milk substitutes in the region, Australia’s unregulated formula trade contradicts this.
The marketing of infant formula in Australia is a voluntary and self-regulated code.
An international survey just published in BMJ finds that most health and nutrition claims on infant formula products seem to be backed by little or no high quality scientific evidence.
Professor Julie Smith at the Australian National University has done amazing work over many years raising public awareness around the need for breast feeding supports and also about the exploitative marketing of breast milk substitutes.
Food poverty and food deserts
In January, The Conversation ran an article about mapping food deserts in Australia, which was also republished by Croakey Health Media.
The article makes sobering reading: how can this happen in a country like Australia?
But then, even in the richest parts of Australia, we are all noticing the soaring, sometimes ridiculous cost of fruits and vegetables (I paid $3 last week for a small knuckle of ginger).
Food poverty and food deserts are healthcare issues. Poor diet quality is a major contributor to the burden of chronic conditions and is a key modifiable risk factor for the progression and management of coronary heart disease and type 2 diabetes.
As an aside, a recent publication from Australian researchers looks at how siloing the work of dieticians and doctors means that dietary management of these conditions is sub-optimal.
An American study published in Health Affairs finds that food-insecure families spend thousands of dollars more on healthcare than food-secure families.
The floods in the Kimberley and New South Wales have further served to worsen food insecurity for many Australian families.
Last October, the Minister for Agriculture, Fisheries and Forestry, Senator Murray Watt, asked the House Standing Committee on Agriculture to undertake an inquiry into food security in Australia. You can track hearings (most recently on 15 February) and submissions here.
Here are links to other recent Croakey articles on this topic:
- Highlighting on-going food security issues for Indigenous Australians during COVID-19. 29 September 2021
- As we face a “perfect storm” for food security, here are some solutions. 6 April 2022
- Bridging the gap in food security and equity – a call for action. 10 May 2022
- As household food costs spiral, is children’s health being undermined? 7 September 2022
- Inquiry makes wide-ranging recommendations to address food security and related concerns. 2 November 2022
Where is the response to the Halton Report?
You might recall that one of the first things Health Minister Mark Butler did when appointed was to commission a review of Australia’s response to the pandemic from the former Secretary of the Department of Health, Jane Halton.
A summarised version of the report and its recommendations was released in September 2022, when it was characterised as addressing vaccine and treatment procurement.
Now The Saturday Paper, using FOI, has obtained a copy of the report, although sections were heavily redacted and some pages were missing. Journalist Karen Middleton has done an excellent job of writing about what the report says – and what the Albanese Government is yet to do to protect Australia from the ongoing ravages of the current pandemic and any future pandemics.
Sadly these articles are not publicly available – but if you are interested in this area of health policy, do try to get access to them.
In the January 7-13 edition of The Saturday Paper, in an article entitled ‘Exclusive: Halton report warns of repeating Morrison Errors‘, Middleton outlines how the Government’s strategy on vaccines and antivirals has not been updated since the beginning of the pandemic and this must change to prepare for worse variants of COVID-19.
In a further article ‘Exclusive: 26.8 million doses of Covid-19 vaccine wasted‘ in the February 11-17 edition, Middleton reveals that Australia has wasted 26.8 million doses of COVID-19 vaccines (given that this report was written in the third quarter of 2022, that figure is likely higher now).
Worse, Halton has warned that, even after a change in Federal Government: “There is no clear mechanism nor mandate across these [government and advisory] structures to ensure all sources of input are integrated as a basis for decision-making, distribution, education and delivery.”
The Government has accepted all of Halton’s recommendations “in principle” but we are yet to see a formal government response.
Like many, I have been critical of Labor’s failure to effectively manage the pandemic and its consequences: the slowness in responding to the recommendations from this report does nothing to blunt my critiques.
In case you missed it
Report from the Royal Flying Doctor Service “Best for the Bush: rural and remote health baseline 2022”
This report notes that the pursuit of solutions and actions to address the health disparities between urban and rural communities requires a sound understanding of the health issues impacting rural and remote Australia and the specific gaps in service provision that need to be addressed as the highest priority.
It defines reasonable access to primary healthcare for people in rural and remote areas as having, at a minimum, general practitioner, nursing, oral health, mental health and Indigenous health services within a 60-minute drive time. This could include through permanent services, visiting or ‘fly-in fly-out’ services, and having timely access to telehealth services as part of an integrated suite of services.
There is a lot of work to be done here (all independent of primary care reform). As a recent report on ABC TV’s 7:30 program highlighted, many regional areas don’t have this level of access. For example, there are not hospital maternity services available in Gladstone, a town of 60,000 people. Women must travel at least an hour to give birth.
Healthcare spending for value
A report from the Health Affairs Council on Health Care Spending and Value, “’A Road Map for Action: Recommendations of the Health Affairs Council on Health Care Spending and Value’, has two broad foci:
(1) A synthesises of the literature on how much the United States spends on healthcare, the value achieved from that spending, and the potential impact of interventions to reduce spending (see report appendices and supporting briefs).
(2) Recommendations on how to achieve higher value health care spending and growth in the nation.
Only some of the recommendations (which are rated on the basis of the likelihood of producing savings or slowing growth) are applicable in Australia, but the consistent focus on reducing low-value care will be of interest.
March 9 is Social Prescribing Day in the United Kingdom. The UK based National Academy for Social Prescribing has a terrific series of evidence briefing papers on the value of social prescribing in areas such as:
- Arts, culture and creativity (this harks back to the earlier discussion on arts and public health)
- Physical activity
- Financial , social welfare and legal advice
- There are also briefing papers on:
- Measuring outcomes
- Funding models
- The economic impact of social prescribing
- The accessibility of social prescribing.
A recent article in The Guardian discusses what is being done in Australia in terms of piloting “green prescribing” (so far just a few small efforts).
A national survey conducted during the pandemic found that 82 percent of Australian adults would be interested in receiving a nature prescription and that appetite was still high (76 percent) among those who were spending the least amount of time – less than two hours a week – in nature.
Funding for oral health research
An examination of Australian research funding of major diseases (‘Oral health research funding in relation to disease burden in Australia’) has revealed it is not keeping up with the burden of disease in the country – with investment in oral health particularly under-funded.
The study investigated major government funding schemes, which included the Australian Research Council (ARC), the National Health and Medical Research Council (NHMRC), and Medical Research Future Funds grants (MRFF).
The analysis found oral health sciences to have the lowest and most inequitable level of support, when compared with other research fields on burden of disease.
Reforming US Centers for Disease Control and Prevention
In the wake of a report “Moving Forward” commissioned by the Director of the CDC, Dr Rochelle Walensky, the agency is now on a mission to reorganise and modernise itself, so that the missteps during the pandemic (not helped by interference from the Trump White House) will not happen again.
Key findings and recommendations from the CDC review:
- It takes too long for the CDC to publish its data and science for decision making
- The agency’s turnover of staff during the COVID-19 response created gaps and other challenges for partners
- The agency’s guidance documents are confusing and overwhelming, and the website is not easy to navigate
- COVID-19 uncovered the need for flexibilities that do not exist today at the CDC.
The report is well summarised in this article in The Lancet.
In a separate report, “Building the CDC the Country Needs”, the Center for Strategic and International Studies takes a focus on the role of the CDC in protecting US national and global health security.
There are lessons here for Australia as work to set up a Centre for Disease Control (and chronic disease?).
Comprehensive review on Long COVID
Last month Nature Reviews Microbiology published a seminal paper on Long COVID from Dr Eric Topol et al.
The review explores what is known about Long COVID, the overlap with other conditions, the variable onset of symptoms, Long COVID in children and the impact of vaccinations.
It finds that current diagnostic and treatment options are insufficient, and urges the prioritisation of clinical trials that address leading hypotheses. Future studies must be inclusive of marginalised populations and meaningfully engage patients throughout the research process.
The best of Croakey
What are the key health issues facing NSW voters? Croakey has begun a series of articles addressing this question, with more to come.