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The Health Wrap: walking as medicine, rural mental health and multi-morbidities in Closing the Gap

We could walk ourselves into better health, but would the system value our efforts, or recognise that, for some of us, the gradient grows ever more steep? Join The Health Wrap‘s Lesley Russell for a brisk constitutional through the latest public health headlines.


Lesley Russell writes:

Everything you wanted to know about walking – and more

“Walking is a man’s best medicine”, said Hippocrates over 2,000 years ago – and it seems he was right.

The June issue of the British Journal of Sports Medicine is devoted to walking and health. It marks the 21st anniversary of the publication of the seminal review paper Walking to Health, published in 1997 by Morris and Hardman, which first presented a synthesis of the health benefits of walking. The editors include Professor Emmanuel Stamatakis, from the Charles Perkins Centre at the University of Sydney.

The whole issue is a great read and provides me with plenty of justification for my walking addiction. I’ve yet to write up my most recent walk in Burgundy in June, but you can find my other walks, including Cornwall in April, at #CroakeyGO. You can also read about the various #CroakeyGO walking journalism events.

Four take-outs:

  • Walking is a best buy for public and planetary health.
  • Walking briskly for your health means taking about 100 steps a minute. Vigorous walking requires about 130 steps per minute, while jogging starts at about 140.** This issue is summarised nicely in a New York Times article.
  • The evidence base that suggests walking benefits mental health is growing, but remains fragmented and incomplete, with more research needed.
  • Walking, as a social behaviour, is influenced by our social networks and social norms. Promoting walking to individuals without considering these social constructs – inherent in social settings such as schools, workplaces, parks, neighbourhoods, streets and public spaces – means missed opportunities to more effectively produce and maintain behaviour change.

** My average (over my almost daily 10 km walk) is 125 steps / minute. But it slows when I’m walking around built-up areas thanks to traffic lights (which I try to obey). A great recent article here on how traffic signals favour cars and discourage walking.

In a piece published simultaneously in The Conversation, Stamatakis wrote about the finding that those who walk faster have a lower risk of premature death. Compared to slow walkers, average pace walkers had a 20 percent lower risk of early death from any cause, and a 24 percent lower risk of death from heart disease or stroke. The beneficial effects of fast walking were more pronounced in older age groups: average pace walkers aged 60 years or over experienced a 46 percent reduction in risk of death from cardiovascular causes, and fast walkers experienced a 53 percent reduction.

The difficult push to provide (and fund) the care patients need: it’s about more than medicine

The past weeks have seen a rash of interesting papers and commentary that highlight the international struggle to deliver the healthcare services that are needed for the 21st century.

It seems to me that in Australia we are really at a crossroads on this – there is general recognition that to effectively prevent, treat and ameliorate the growing burden of chronic conditions we need a multidisciplinary approach that integrates physical and mental health and recognises the contributions of the social determinants of health.

But there is currently a policy and political impasse, with key power brokers and politicians unwilling to cede professional turf and shibboleths and be brave and bold enough to take the first needed steps towards reform of service structure, delivery and financing.

How to pay for care that requires a social intervention?

An opinion piece in the New York Times looks at the role social factors play in health outcomes, especially for poor patients, and asks how we could support and pay doctors to address these. In the US, there have been steps towards value-based payment models, with attempts to measure quality, outcomes and costs and reward or penalise providers based on their performance.

But while these models generally adjust for patients’ medical problems, they do not look at their risks based on their social disadvantage. Yet we know patients with more social risk factors have worse outcomes.

The author writes: “If I’m paid for how many stents I put in or how many patients I see, it doesn’t really matter if my patients live on the street or can’t read the instructions on a pill bottle. But if I’m paid based on how well their blood pressure is controlled and how frequently they’re admitted to the hospital, those things start to matter quite a bit.”

Under this approach, the practice of healthcare looks a lot broader than the practice of medicine and it follows that the multidisciplinary care team must include people who work in social welfare.

Recent reports and efforts that address the impact of social risk factors on patients and healthcare providers:

Continuity of care is also important

There has been good publicity for a recent meta-analysis showing that continuity of care is associated not just with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services but also (no surprise) – lower mortality rates. Given the benefits, continuity of care from both GPs and specialists needs to be given greater priority in healthcare planning and funding.

This is an area where a financial incentive to the patient might work well as an encouragement to have a regular GP. Although 75 percent of Australians say they have a preferred or regular GP, in practice many people use the first general practice where they can get an appointment – or the Emergency Department.

Stephen Leeder’s acerbic insights on MBS reform

In a piece posted on both John Menadue’s blog and Croakey, Professor Stephen Leeder likens the Medicare Benefits Schedule (MBS) to a book of rules that is Australia’s secular response to the Book of Kells – a bible for the right way to do things.

The problem is, the MBS is produced by the policy equivalent of monks – people kept apart from the exigencies and pressures of the real world. The assumption on which the MBS is built is that health care is best paid by raising a separate fee for each service.

Leeder’s key question is this: are individual fees for individual services the way to fund the healthcare needs of people with several chronic diseases that require long-term, multidisciplinary care that extends beyond the traditional reach of medicine in the doctor’s office or the hospital? There are better ways of paying for these services than raising a bill from every healthcare provider every time such a patient needs attention – although these are not elucidated in this article.

Leeder refers admiringly to the work of Prof Bruce Robinson and the MBS Review committee in updating the MBS “Book of Kells”. He didn’t say this, but I suspect he might also feel that this is updating a gospel for the last century, not this one.

This week we read of concerns that bulk billing clinics are turning away patients with chronic and complex conditions who need longer consults because the Medicare reimbursement is insufficient for the time involved. The Royal Australian College of General Practitioners is calling for all Medicare rebates for GP consults to be increased by 18.5 percent and for a new payment of $163 for consultations lasting an hour or more.

Indigenous health: the impact of multi-morbidity

A study published this week in the Medical Journal of Australia highlights multi-morbidity as a significant driver of higher mortality rates in the Indigenous population. After adjusting for age, sex and socio-economic status, the rate of multi-morbidity (defined as two or more chronic conditions) in Indigenous Australians is more than 2.5 times that of the non-Indigenous population. In younger populations this is largely driven by mental health disorders; in those aged 60 and over, it is mostly due to physical conditions.

In an accompanying editorial, Dr Tony Broe says this study shows that Australia is not managing multi-morbidity and chronic disease very well in the population as a whole and in the Indigenous population specifically. A large part of the solution is non-medical, he says, and requires a major cultural change.

So we are back to the points made above about the need for reform in how healthcare is delivered and funded. The current fragmented approach to multi-morbidity has an adverse impact on outcomes and contributes to patients’ out-of-pocket costs. I wrote about this in an earlier edition of The HealthWrap.

Broe also stresses the importance of the Uluru Statement for Indigenous health:

A lot of the comorbidities of younger Aboriginal people relate to mental health issues, driven by stress and trauma. In fact, a study we’ve just published shows that even the high rates of late-life dementia in Aboriginal people are associated with childhood stress and adversity. Aboriginal people are under stress and we need to take some of that away by recognising their existence and their self-determination. The Uluru Statement is a good place to start.”

Closing the Gap in cardiovascular risk

In the same issue of the MJA there is an article and an editorial on the high cardiovascular risk facing Indigenous Australians, especially those in younger age groups. Ischaemic heart disease is the leading cause of death among Indigenous Australians – the population rate is 1.8 times that for non-Indigenous Australians. This research finds the mortality rate is even higher in young people, with 12.0 percent of deaths in 30–39-year-old Indigenous Australians caused by heart disease, compared with 3.8 percent for non-Indigenous people in this age group. Yet less than half the affected population is receiving lipid-lowering therapy.

This research is seminal not just because of its findings but because of how it was conducted. It addresses the importance of addressing prevention and the underlying social determinants of health and, critically, was overseen by an Aboriginal Reference Group and undertaken in cooperation with Aboriginal co-authors.

ANAO on primary health care grants provided through the IAHP

The case has been made that it should be GPs who are running Indigenous chronic disease programs. I would modify that statement – it should be the responsibility of primary health care services (ie Aboriginal Community Controlled Health Organisations). In that light, the recent report from the Australian National Audit Office (ANAO) that looks at how funds under the Indigenous Australians’ Health Plan (IAHP) are provided is important reading.

The IAHP, which is overseen by the Department of Health, was established in 2014 at the time of then Prime Minister Tony Abbott’s notorious reorganisation of Indigenous Affairs, which was accompanied by budget cuts of over $500 million over four years, with some $166 million of that coming from health. Those funding cuts have never been restored.

The bulk of IAHP expenditure is via grants, with 85 percent of this funding going to ACCHOs. Since 2015, a total of $1.44 billion in grants has been awarded. In 2016-17, IAHP grants funded services to an estimated 352,000 Indigenous Australians (54.2 percent of the Indigenous population).

This is not a report DoH can be proud of, especially in light of the continuing failure to Close the Gap on Indigenous health disparities. Frankly, I read the ANAO findings as a polite way of saying the Department has no idea what the funds it provides through IAHP grants are achieving.

The chief findings include:

  • The original objectives in establishing the IAHP will not be achieved until 2019-20, four years later than planned.
  • DoH has not yet implemented the planned need-based funding allocation model and there are shortcomings with the performance monitoring and reporting arrangements.
  • DoH has not established service-related performance benchmarks for funded organisations so has no way to measure how grants provide value for money.
  • Because reporting under the performance framework includes organisations not funded under the IAHP, it is not specific enough to measure the extent to which IAHP-funded services are contributing to achieving program outcomes.
  • Issues with performance data collection limit its usefulness for longitudinal analysis and continuous quality improvement.

The 2018-19 Budget stated that a new funding model for ACCHOs would be implemented from July 2019. Some (effective and efficient providers) will get five-year funding contracts; however, no new funds are provided. This proposal has been well received but there are concerns that more consultation is needed.

Mental health care and services in rural Australia

Australia’s efforts to bring attention to the importance of mental health and wellbeing are undermined by the failure to ensure that funding and services are sufficient and appropriate to meet the needs. In particular, certain segments of the population, including groups with a high burden of mental health disorders, are missing out.

Nowhere is that more obvious than in rural and remote areas. Earlier this year, the Royal Flying Doctor Service warned of a mental health crisis in rural and remote areas. parts of the country.

As a consequence, funding was provided to the RFDs in the 2018-19 Budget for a “new national mental health program” to be up and running by 2019. This will involve outreach, inclusion of mental health professionals in the primary care clinics, and telehealth services, although to date, details have been few. Even the funding levels are uncertain.

Parliamentary inquiry

There is a parliamentary inquiry underway into the accessibility and quality of mental health services in rural and remote Australia. To date there are some 70 submissions, and hearings are being held this month in outback Western Australia.

The National Rural Health Alliance says that the current dire workforce shortage demands a “complete rethink”. Their submission makes seven recommendations including:

  • Overhaul the way mental health professionals are trained to both attract and retain them in country areas.
  • Ensure they have additional generalist skills needed to address the unique needs of rural and remote Australia.
  • Ensure rural and remote areas receive the same mental health funding per capita as major cities.
  • Evaluate the effectiveness of current federal and state mental health programs.
  • Ensure guidelines are used to decide whether or not telehealth services are appropriate.

An urgent need for mental health services for young people

A recent report which will be of interest to the inquiry looks at the urgent need for better services to tackle young people’s mental health needs. Lifting the Weight: Understanding young people’s mental health and service needs in regional and remote Australia was produced by Reach Out and Mission Australia.

It is based on the Mission Australia Youth Survey 2016 which found almost one in four young people in rural and remote Australia have a probable serious mental illness.

But 52 percent of young people who indicated they had a problem for which they needed professional help did not seek this, because of cost, lack of availability, or fear of discrimination. This in part explains why the risk of suicide rises as distance from major cities increases.

Workforce shortages in rural and remote areas

The NRHA data show shocking disparities in the distribution of the mental health workforce (see figure, from SARRAH).  Australians living in cities receive on average 40 percent more mental health services than those in rural and remote areas.

The current situation is aggravated because outside of the Better Access program, a Chronic Disease Plan or a Mental Health Plan, all of which cap services, there is no funding model for the use of allied health services like psychology in rural areas.

Will telehealth services and new technologies help?

As a lack of access and cost puts traditional mental health treatment beyond the reach of many, the breach is being filled with telehealth services (which have been around for several decades) and newer mental-health technologies like apps.

New online telehealth psychological service items have been provided under the Better Access program from November 2017. Will these make a difference?

A 2016 paper ‘Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability’ found that despite the obvious benefits of telehealth, its uptake and integration into mainstream practice has been slow and fragmented. Factors influencing success and sustainability of services were identified and grouped into six categories: vision, ownership, adaptability, economics, efficiency and equipment.

Many pilot programs have not migrated into sustained services.  The barriers and challenges associated with telehealth in Australia include clinician preference for face-to-face consultations, ethico-legal concerns, change management practices, resources (including time), funding models, service coordination and administration personnel.

Better targeting of funding and services to areas of need

A recent article by Sebastian Rosenberg et al in The Conversation (re-run in Croakey) uses just three graphs to succinctly summarise the issues and highlight the inherent inequity in how Medicare-funded mental health services are delivered. It’s the epitome of the inverse care law.

Time for action!

Where is the National Rural Health Commissioner on this issue?


  • Previous editions of The Health Wrap can be read here.
  • Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe

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