Hope exists beyond the government's Medimuddle

The start of a new year, in conjunction with the appointment of a new federal health minister, raises hope. An agenda of important health matters awaits her attention.
Incoming Health Minister Sussan Ley takes up her portfolio with strong professional experience in guiding education policy through community consultation in city and country. These skills should serve her well in the health portfolio.

Related News: 6 questions for the new health minister 
First, however, the ground must be cleared of the wreckage of the co-payment proposal.
Driven by ideology, uninformed by policy or accurate analysis of the health system, it was always going to be a debacle. In its latest manifestation, the co-payment plan, which will see doctors forego income, is festooned with a host of confusing exceptions.

It looks like a Scandinavian assemble-it-yourself gazebo built without instructions or an allen key.

But unfortunately it is no joke. Were it to quietly disappear, a sigh of relief would be heard across the land. However, it is proceeding amid a storm of justifiable anger from GPs.
Beyond this ‘Medimuddle', there are actions of far greater substance needed to help secure the future of healthcare in Australia.

Related News: The new co-pay plan: full details
First, energy should be applied to clarifying for all the purpose of the health system and explaining how it has come to be. We need a narrative about why we invest public money in healthcare. We pay for Medicare to meet the needs of all Australians.

The equity thing — a ‘fair go' — is an honoured Australian value. When it comes to healthcare, those who can pay more do so already. We recognise that much illness can strike anyone, and we seek to help those who get sick or injured. That's the story of us, but we need to hear it retold quite often.
Chatter about the necessity for an additional price signal for healthcare, on top of the ones we have already, has never made sense.

We aim for a universally accessible system because as a society we care about the health of all our citizens. We care and value equity.

We are a remarkably altruistic community and we do not neglect those who need care simply because they are poor. We placed many wreaths recently because we care. This narrative needs to be clarified, corrected and repeated.

Second, because money does matter in health, waste should be rooted out. The principal areas of waste in healthcare are attributable to archaic management, most notably failure to apply IT where we can. Yes, we have done well in bringing the computer into the surgery and ward, and into pathology and radiology services. But there is so much more we can do to unite the fragments of healthcare by wiring them together.

Then there is the matter of lots of medical and hospital care provided in the face of evidence that it does no good or is unnecessary. The unnecessary parts should not be confused with humane care or time spent in doctor—patient communication, and in showing concern and compassion. That's quite different.

Waste is not simply a matter of too much hi-tech machinery, but as was shown decades ago, the accumulated waste of doing and repeating far too many small-ticket investigations and prescribing little dollops of unnecessary medication (and this still includes unneeded antibiotics).
Waste is also to be found in the overpricing of generic pharmaceuticals where we continue to pay considerably more for many generics than is the case in, say, Canada.

To tackle this waste will require political skill in negotiating and implementing policy, because professional groups often become vigilant and aggressive custodians of the waste product and the income it generates.

Third, repair work is needed in general practice, especially where the co-payment train wreck blocks the tracks.

There is an urgent need to reduce red tape and improve quality of care in general practice, and to increase its availability in rural and regional Australia and on the edges of our cities.
Most economically advanced countries now recognise the critical importance of general practice in providing co-ordinated care and a medical home for the growing number of people with chronic health problems.

Damage to primary care harms both patients and the bottom line of the national health budget.
Health has many determinants — education, income, environment, diet, genes — and the healthcare system is complex. But these features are no excuse for the substitution of ideology and thought bubbles for a careful and steady approach to the changes needed to secure quality healthcare for all Australians.

Let 2015 be the year when health policy that enables this to occur reappears and is implemented.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy in the University of Sydney.

Published in Australian Doctor 19 January 2015 http://bit.ly/1J1CHeH

The year that reminded us about public health

2014, from the perspective of public health, was the year of Ebola. 

The Red Cross website states that, “The current Ebola outbreak is the worst in history. More than 7000 people have died from Ebola and over 17,200 cases have been reported [since the epidemic began in May 2014 in Sierra Leone]. Sierra Leone, Liberia and Guinea are the hardest-hit countries”.
There are over 10,000 volunteers, many from the affected countries, working with the Red Cross on Ebola. Christmas and New Year celebrations have been cancelled in the ironically-named capital, Freetown, in Sierra Leone.  Palo Conteh, head of the Ebola response unit, said, "We will ensure that everybody remains at home to reflect on Ebola”.

But Ebola is there and not here and, barring serious mutation, it is unlikely to come. The reasons for this are clear and have to do with the poverty and lack of health services in the affected countries. Sierra Leone is tropical and small with a population of about six million people, 70 per cent of whom are in poverty despite the country’s deep harbour, its diamonds and gold, rutile and bauxite exports.
Civil war between 1991 and 2002 left the country in a shambles, its infrastructure smashed, with 50,000 dead and millions displaced. Only half the population has reliable access to clean drinking water and so diarrhoeal diseases are common and kill children.

In 2012, according to the WHO, the Government spent $15 per person on health.  Each year in Sierra Leone 220,000 children are born. The infant mortality rate of 73 deaths per 1000 births puts the country near the top of that league. There is one doctor per 50,000 of the population, and 70,000 children younger than five years die each year, the highest rate in the world.

Maternal mortality is also high, at eight per 1000 births. As humanitarian organisation Amnesty International puts it, one in eight women risk dying during pregnancy or childbirth. “Thousands of women bleed to death after giving birth. Most die in their homes. Some die on the way to hospital; in taxis, on motorbikes or on foot. In Sierra Leone, less than half of deliveries are attended by a skilled birth attendant, and less than one in five are carried out in health facilities.” Female circumcision is rife.

So, while 6000 deaths from Ebola are tragic, the underlying social conditions in Sierra Leone enable this to occur, and many times that number of children and women die of conditions also attributable to the environment. That is the central message of public health.

To achieve good levels of public health and avoid death from childbirth, diarrhea, malaria and Ebola, we must go back to basics. You can’t contain or prevent Ebola without clean water and cups to drink the rehydrating fluids, and without basic medical amenities. If you can’t stop a hemorrhaging mother bleeding to death you can’t treat Ebola.  

You cannot do these things without improving the environment.

Clinical teams can be rushed in to help Ebola victims – a thoroughly worthy response. But the longer term requires action that addresses poverty, provides aid, and costs money. Serious money. That’s what Ebola reminded us about this past year.

The second environmental lesson 2014 has taught us is that our fantasy, created as though we were turtles lolling in the warm waters of the Galapagos Islands remote from the mainland of reality that global warming either doesn’t happen or doesn’t matter, is that there is no protection against the serious health problems arising from it in future. This is something we need to learn and act upon despite the bipartisan chaos that surrounds the Australian politics of climate change.

Time to get serious, time to stop pretending that the carnival that is life in Australia is free and instead see that the environment – physical, human and global – will set the agenda for our future health. 

Published in Australian Medicine, Opinion, 23 Dec 2014.  http://bit.ly/1xORSzt