In her latest column, Adjunct Associate Professor Lesley Russell reviews the political determinants of COVID, makes some predictions about where the Strengthening Medicare Taskforce is headed, and shares some must-watch clips from the World Health Summit.
Don’t miss the good news story from Every Street.
Lesley Russell writes:
The unacknowledged deaths due to COVID-19 in Australia is an issue regularly addressed in The Health Wrap. The official death toll is now well over 15,000 people (tellingly, I could not find an official Australian Government number that was current, the Our Word in Data website gives the total number of deaths on 14 October as 15,475). The vast majority of these occurred in 2022 (the Australian Bureau of Statistics says 11,441 deaths to 31 August).
In the first two years of the pandemic, it seemed that Australia avoided the “excess deaths” seen particularly in the United States, the United Kingdom and Europe, but recent data indicate that the impact of Omicron in 2022 has been substantial.
The Actuaries Institute has produced an analysis showing that for the first five months of 2022, there were 12 percent more deaths overall (8,500 more) than predicted. COVID-19 accounted for more than half of these and may well be linked to the remainder (mainly heart disease, diabetes and dementia).
As the Institute’s CEO stated: “Non-COVID-19 excess deaths are occurring around the world, with experts suggesting reasons including post-COVID-19 sequelae (conditions arising from COVID) or interactions with other causes of death, delayed deaths from other causes, delays in emergency care, delays in routine care, increased use of drugs and alcohol, and undiagnosed COVID-19 deaths.”
COVID-19 is now expected to be the third-leading cause of death in Australia in 2022. Compare this to 2020 when COVID-19 was the 38th leading cause of death, with 895 deaths.
There are warnings of worse possibilities ahead unless effective action is taken to increase the rate of uptake of COVID-19 booster shots, encourage mask-wearing and better ventilation in enclosed spaces, improve access to healthcare services, address the burden of Long COVID and the other physical and mental health consequences of infection, and tackle the social determinants of health (many of which have been undermined by the dreadful floods in eastern Australian states).
A recently published study found more than 330,000 excess deaths in Great Britain in recent years can be attributed to spending cuts to public services and benefits introduced by a UK government intent on pursuing austerity policies. The situation has been worsened by the pandemic.
Excess deaths due to the coronavirus pandemic contributed to life expectancy in England falling in 2020 to its lowest level in almost a decade. Public Health England said this was due to the “very high level” of excess deaths.
These findings come as the current Conservative Government, beset by leadership woes, has signalled a fresh round of major public spending reductions after the financial crisis precipitated by its proposed mini-budget. You can read more in a summary article in The Guardian UK here.
In the United States the COVID-19 pandemic has made the link between politics and health glaringly obvious. Democrat-leaning “blue” states were more likely to enact mask requirements and vaccine and social distancing mandates. Republican-leaning “red” states were much more resistant to health measures.
A study using data from 2020 shows that people living in counties with higher levels of Trump support were less likely to comply with social isolation requirements and these counties had higher rates of hospitalisation and death from COVID-19.
That divergence continued through 2021, when vaccines became widely available. A recent paper links political party affiliation and vaccination views with mortality data. It found substantially higher excess death rates for registered Republicans when compared to registered Democrats, with almost all of the difference concentrated in the period after vaccines were widely available.
And although the arrival of the highly transmissible Omicron variant narrowed the gap in infection rates, hospitalisation and death rates – which are dramatically reduced by vaccines – remain higher in Republican-leaning parts of the country.
It should be noted that there is also a strong association between voting patterns and obesity – and obesity and its consequences are risk factors for the severity of COVID-19 infection.
In Australia, we saw a similar politics reflected in mask-wearing practices in the Parliament.
I wondered if there were any Australian studies that linked demographics (aside from age and certain pre-existing conditions) to COVID-19 mortality. I found a recent paper in The Medical Journal of Australia which looks at the demographics and clinical features of people in intensive care during the first three waves of the pandemic (ie to November 2021, before the arrival of the Omicron strain).
The researchers found that in-hospital mortality among patients with COVID-19 admitted to ICUs was higher during the third wave than earlier in the pandemic (and that the median age of these patients was younger). This was attributed to: changes in the epidemiology of the pandemic; differences between states in non-pharmaceutical interventions; and incomplete population vaccination that left some groups at greater risk of infection and severe disease.
That last point may reflect the impact of vaccine hesitancy in some population groups.
Australian governments have shown little interest in exploring the demographics that underpin the morbidity and mortality association with the pandemic and linking this to resistance to public health advice and vaccination. While there are obviously some sensitivities involved in collecting the data, I would argue it is essential to know more about these issues if programs and communications are to be effectively targeted.
Perhaps these issues will be explored as part of the Parliamentary inquiry into Long COVID and repeated COVID infections?
(BTW, submissions to this inquiry close on November 18. It is so important that the Parliamentary committee hears from people living with the sequelae of SARS-CoV-2 infection.)
Make sure you read Alison Barrett’s article for Croakey Health Media – As the World Health Organization chief calls for action on Long COVID, what is Australia doing?
What is the Strengthening Medicare Taskforce doing?
The Strengthening Medicare Taskforce was set up in July aims to deliver “concrete recommendations” to the Albanese Government by the end of 2022. The website says: “The Australian Government will consider the recommendations from the taskforce and deliver the highest priority improvements to Medicare through the $750 million Strengthening Medicare Fund.”
Given the huge scope of focus for the taskforce (you can read the areas for focus here), the large and growing gaps in availability and affordability of services, the dire healthcare workforce situation, and the endless harping by organised medicine about doctors’ financial needs – that $750 million will be stretched to deliver meaningful reforms.
As far as I can tell, only three meetings (held monthly) have been held to date and it does not appear that there are any working parties; if the task is to set priorities among what we already recognise as the key issues, perhaps these are not needed?
To date three communiques have been issued:
29 July 2022: A pro-forma statement of purpose and the membership of the taskforce. It states that taskforce members “had the opportunity to discuss the reform journey to date with the co-chairs of the former Primary Health Care Reform Steering Group, who guided the development of the Primary Health Care 10 Year Plan 2022-2032” – without mentioning that these members (Dr Steve Hambleton and Dr Walid Jammal) are also members of this taskforce – as were three other members of the taskforce.
[The draft recommendations from the Primary Health Reform Steering Group were published in August 2021. The Primary Health Care 10 Year Plan 2022-2032 was issued in March 2022.]
26 August 2022: A one page statement. The Taskforce discussed international research and evaluations around voluntary patient registration with primary care providers. There was also a presentation from the Primary Care Business Council on “the challenges and opportunities in relation to the business operations of general practice from the perspective of some of Australia’s largest corporate providers”.
29 September 2022: Members considered “opportunities to modernise primary care and improve patient outcomes through digital and data reform”. It states that 23 million Australians have a My Health Record (hopefully taskforce members know that most of these MHRs are not used, either by patients or healthcare workers). The taskforce discussed what needs to be done to make health data systems work.
In one sense these communiques are not very informative, but there are strong hints of what we are likely to see from the taskforce’s report.
Here are my best bets – I don’t necessarily support any or all of them:
- A campaign to drive patient enrolment, most likely with financial incentives to GPs. How much will this cost?
- A trial of some new bundled payment approach to financing primary care services (GPs and allied health) for selected patients with chronic and complex conditions. Hopefully this will build on what was learned from the Health Care Homes trial.
- Increased MBS rebates for certain primary care services but targeted to rural and remote areas. I expect this to be minimal, so doctors will remain unhappy.
- A continuing push for expansion of digital health services (sadly this will mean mostly the subsidising of phone call services) and a new campaign to get people to use My Health Record. Lots more) money could be wasted here.
And just like that – in a flash – $750 million is spent (in one year or four?).
Professor Mary Chiarella and Ken Griffin have written a series of articles for Pearls and Irritations, providing a nursing perspective on the work of the taskforce:
- What the Strengthening Medicare Taskforce must do to modernise the primary health care workforce.
- The Strengthening Medicare Taskforce: All healthcare workers are on the front line. Let’s get them on the front foot.
- The Strengthening Medicare Taskforce: Commonwealth must resist lobbyists and embed team-based care.
Croakey Health Media has published a number of articles on the work of the Strengthening Medicare Traskforce:
- Amid competing agendas and priorities, some suggestions for ways forward for meaningful health reform.
- Advice for the Strengthening Medicare Taskforce from health groups and experts.
- Bold and brave: Government urged to embrace GP reform.
A collection of related Croakey articles is available here.
Trialling bundled payments in the US
Regular readers of The Health Wrap will know that I keep an eye on what the Innovation Center at the US Centers for Medicare and Medicaid Services is doing.
The biggest lesson from their work is that innovation is not easy: it takes constant tweaking and a lot of time to get the outcomes that are meaningful and improvements over the status quo, and doing this in a way that saves money is even harder.
The Innovation Center recently announced that the Bundles Payments for Care Improvement Advanced Model (BPCI Advanced), which was launched in October 2018, will be extended, with some changes, for two further years, through until December 31, 2025.
BPCI Advanced is an alternative payment model that tests whether linking payments for an episode of specialist care across hospital/outpatient/community services (such as joint replacement) will incentivise healthcare providers to invest in practice innovation and care redesign to improve coordination, reduce costs, and maintain or improve quality of care for Medicare beneficiaries (Americans aged 65 and over).
A BPCI Advanced clinical episode begins either at the start of an inpatient admission to an acute care hospital or the start of an outpatient procedure. A goal of the BPCI Advanced Model is to promote seamless, patient-centred care throughout each Clinical Episode, regardless of who is responsible for a specific element of that care.
As of December 31, 2021, more than 1.2 million Medicare beneficiaries have received care from participants in the BPCI Advanced Model, with the involvement pf more than 1,800 hospitals in coordination with 69,867 doctors.
There’s a succinct summary of the findings to date – although I warn that it is full of US healthcare acronyms and jargon.
In brief, it says that an independent evaluation indicates that for surgical episodes, BPCI Advanced achieved net savings to Medicare and possibly improved quality of care, driven mostly by orthopaedic procedures. The savings were small – 3.6 percent of what payments would have been absent the model. However, savings from surgical episodes, were fully offset by losses from medical episodes, with the largest net losses occurring in congestive heart failure and sepsis.
As I have often written, this long-term, consistent approach, with examination of outcomes and rejigging of criteria along the way, is the sort of approach to innovation we should be implementing in Australia.
To date we have seen only stop-start, endless pilots which produce lessons and information that are rarely utilised.
What should doctors wear?
The BMJ recently published an interesting article on patient preferences for doctors’ attire.
The clothing worn by a doctor is a form of nonverbal communication that may influence the patient–physician relationship. It’s an important element in establishing patient confidence and trust, enhancing patient comfort when discussing personal problems and shaping patients’ perceptions of professionalism, intelligence and empathy.
This study used patient survey data from hospitals and healthcare practices in Italy, Japan, Switzerland and the United States (interestingly the data were from 2015–2017). It did not compare or contrast patients’ expectations of dress for male vs female doctors, although it did assess the expectations of male vs female patients.
The study highlights that patients’ expectations of how their doctors dress depend on cultural norms, the medical setting, and patient factors such as sex and age. In some clinical care contexts, preferences vary substantially, in others, they are nearly universal such as those for emergency department doctors and surgeons wearing scrubs. With some exceptions, patients tended to dislike extremes in attire such as casual or business suit.
It was very common for patients in the countries studied to prefer their doctors wear a white coat, a historically traditional aspect of the doctor’s uniform, often considered a symbol of the profession. The white coat thing is very American.
I wrote about doctors’ dress (Do Clothes Maketh the Doctor?) for Inside Story back in 2017. I outlined the relatively recent history of the white coat as a potent symbol of medical expertise and authority (back in the 19th century doctors wore black to hide the blood stains).
It’s rare these days to see an Australian doctor sporting this universally recognised uniform. It is increasingly seen as an outdated – and some say potentially dangerous – symbol of the medical hierarchy and a poor substitute for good hygiene and infection control.
Ending discrimination in mental health
The 9 October edition of The Lancet has the report from The Lancet Commission on Ending Stigma and Discrimination in Mental Health.
It is introduced thus:
“It is time to end all forms of stigma and discrimination against people with mental health conditions, for whom there is a double jeopardy: the impact of the primary condition itself and the severe consequences of stigma. Many people describe stigma as ‘worse than the condition itself’.
“This Commission report is the result of a collaboration of more than 50 people globally. It brings together evidence and experience on the impact of stigma and discrimination and successful interventions for stigma reduction. The report is co-produced by people who have lived experience of mental health conditions and includes material to bring alive the voices of people with lived experience.
The voices whisper or speak or shout in the poems, testimonies and the quotations that are featured.”
I think it’s essential reading.Some work in this regard is underway in Australia. The previous Coalition Government tasked the National Mental Health Commission (NMHC) with developing a National Stigma and Discrimination Reduction Strategy. Work on this began in 2021. More information is available here.
The NMHC website states that “A public and interjurisdictional consultation period will be held in mid-2022 before the Strategy is delivered to Government by the end of the year”.
There are links to the resources used in the work of the NHMC here, with an impressive compilation of background briefs, workshop reports and evidence reviews. However although I found a link to enable stakeholders to provide feedback on the draft strategy (here), I could not find a copy of this draft.
A 2021 review of Australian initiatives to reduce stigma towards people with mental illness looked at what exists and what works.
It found that most programs have significant input from people with lived experience, and programs involving education and contact with a person with mental illness are a particular strength. But best-practice programs are not widely implemented and there were few programs for culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander communities and LGBTIQ people.
Hopefully the forthcoming strategy will build on the existing strengths and address the current weaknesses.
As the Croakey #SpeakingOurMinds series shows, the voices of those living with mental illness and their families and carers should be privileged in the development of the strategy. (The #SpeakingOurMinds series is highlighted as The Best of Croakey in this edition of The Health Wrap.)
Tackling domestic violence
This week saw the launch of the National Plan to Eliminate Violence Against Women and Children 2022 – 2023. Domestic violence has reached epidemic proportions in Australia, with one women killed every ten days at the hands of a partner or ex-partner.
The national plan aims to end this violence in a generation; it sets the priorities for continued action and investment to address gender-based violence. However, to date there is no new funding to help implement it.
The Minister for Social Services, Amanda Rishworth, describes the 144-page document as a “blueprint” and acknowledges there is more work to be done. It needs two five-year action plans to implement the National Plan and a stand-alone National Plan for Aboriginal and Torres Strait Islander women and children.
The new plan calls for improved prevention and responses, for better crisis housing and assisting boys and men to develop “healthy masculinities”. The Guardian calls it “world leading” – although the proof of that will be in the implementation.
An article in The Conversation is a good summary of the National Plan’s strengths and weaknesses.
World Health Summit
The World Health Summit was held 16-18 October in Berlin. You can access videos of many of the program events here and media releases from the Summit are here.
Watch the video with Helen Clark.
Watch the video with Dr Mike Ryan.
The best of Croakey
My Croakey colleague Dr Ruth Armstrong did an excellent job editing contributions to the Croakey #SpeakingOurMinds series featured during Mental Health Week, with wonderful insights from the series creator Simon Katterl and others with lived experience of mental illness.
All contributions to the series are gathered here.
The good news story
This story, about a blind woman in New Zealand who shares her joy of “micro-adventures” walking in her home city of Dunedin – “finding joy in our own backyard” – struck the perfect note for me, and acknowledges my recent hiking trip in the Queenstown area of the South Island.
Since the pandemic began, Julie Woods, along with her husband and a friend, have walked the streets of Dunedin, and on 15 October this year (International White Cane Day) they completed the 1003rd street. That’s every street in the very hilly inner city.
I loved that Julie says her favourite suburb is South Dunedin – “because it was flat!” and her favourite street is Emily Siedeberg Pl, named after the country’s first female medical graduate.
You can read more here, including about how her challenge ended with walking up Every Street.And finally, a photo from me to highlight the glories of hiking in New Zealand – this is on the famous Routeburn Track.
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.