The difficult challenge of medical indemnity

Published in Australian Medicine 18 November 2019 https://bit.ly/2Dg9ZeL

Healthcare is in danger of becoming humanless

Two communication challenges that have hit the media recently should act as a warning for the increasing automation of communication for GPs.

First, there’s the mandatory new rules for referring patients to public hospital clinics in Victoria; and second, the ineffective management of patients supported by the National Disability Insurance Scheme (NDIS), which sees GPs’ involvement relegated to a form-filling exercise.

Australian Doctor reported last month that Victoria Health had introduced more formality in GPs’ referrals to specialist clinics, including vascular surgery, urology and adult ENT. Patients referred without ‘complete’ information — and the information required is extensive — will no longer be accepted, nor will patients whose referrals do not satisfy specific criteria.

For example, a patient referred for an aortic aneurysm requires radiological evidence that it is at least 4cm in diameter or is growing more than 1cm a year. And a patient for prostate cancer assessment must have a PSA level according to certain age criteria, a palpable prostatic abnormality or bone pain.

These stipulations for referral aim to make the best use of expensive medical care facilities. Sloppy referrals of patients probably not needing specialist attention should be reduced. But care is needed, as with any guideline, to allow clinical judgement to be the final arbiter. No guideline based on statistically grouped data can fit each case.

While guidelines for referral concentrate the mind, they should allow for exceptions based on clinical assessment that need human communication and interaction.

Do we really want to get to a situation where healthcare is as humanless as the likes of border control and modern retail?

Recently in the US, I was impressed (and greatly relieved) to discover that the previous immigration procedures on entry were now paperless, depending instead on facial recognition and fingerprints. But the humans, generally friendly, who had staffed the stalls were also gone.

Arriving at Atlanta, one of the biggest terminals in the country, we also found the coffee shop ominously quiet: orders were placed via an iPad at one’s seat and customers silently consumed refreshments while watching television.

Communications were once based on people speaking to one another rather than completing forms. In US medical circles, there is currently lively controversy and debate about what has been lost with the almost universal move to electronic medical records.

There is evidence of benefit in reducing medication errors, but it is sparse beyond that. Experienced clinicians complain about the opportunity cost of the time spent entering data and the subsequent loss of time for direct patient interaction.

Author John Banville recently reviewed the wide-ranging book The Unnamable Present by Roberto Calosso, an Italian polymath. Writing in the New York Review of Books, Banville quotes Calosso’s concern that, in the brave new world of the web, “information tends to replace not only knowledge, but thought in general”.

The internet leads to “disintermediation” — a loss of connection with others who can help and guide us — and becomes instead a place where “a man can entangle himself in a series of algorithms and imagine he is thinking”. Calosso hopes our preoccupation with digital data “may come to be regarded one day as an instance of mass delirium”.

Why not build into the stylised referral a two-minute (or maybe five-minute) phone conversation between the GP and the clinic to ensure everyone is in sync? This suggestion may provoke mirth because it is naive, but it could be done.

In the case of the NDIS, as with any new system, there will be discomfort. Management of the program in its early years has been unimpressive.

Although GPs fill out a bundle of forms to ensure patients can access the scheme, they’re not deeply involved in the planning of services and have no direct communication with the NDIS when they should have. The issue is now concerning both the AMA and the RACGP.

The tendency of communication based on templates, and information technology, is to reduce the human element and human interaction. This may be vital to the mechanised production of goods, but in the provision of collaborative medical services, it utterly misses the point.

More information: The Unnamable Present by Roberto Calasso, reviewed by John Banville

Published in the Medical Observer 4 November 2019 https://bit.ly/33oXkS4

Healthcare costs increasingly shifting to patients, study shows

13 September 2019

Out-of-pocket spending on health by households in Australia is rising faster than overall household spending on goods and services—and taking an increasingly bigger slice of the household budget, according to a research study published today in Australian Health Review, the journal of the Australian Healthcare and Hospitals Association (AHHA).

The study, by Sydney University researchers Professor Farhat Yusuf and Professor Stephen Leeder, uses consumer-reported data gathered by the Australian Bureau of Statistics Household Expenditure Survey.

Household out-of-pocket (OOP) spending on healthcare rose by more than 25% over a recent 6-year period while overall household spending on goods and services rose by 15%.

In 2015–16, the mean amount spent by households on healthcare out of their own pockets was $4,290, or 5.8% of total household expenditure.

The most expensive OOP item was private health insurance ($1,744), followed by non-PBS medicines ($585), specialists ($438) and dentists ($396). Spending on GPs was $96.

The biggest percentage rises in out-of-pocket healthcare costs between 2009–10 and 2015–16 were for health insurance (51% rise), co-payments to ‘other health professionals’ (42% rise), and co-payments to specialists (35% rise).

‘Out-of-pocket expenses on healthcare as a proportion of the total household budget has been rising in real terms since 1984’, said AHHA Chief Executive Alison Verhoeven.

‘This study notes that the progressive movement of healthcare costs “from public to person” has occurred “without policy debate, slowly and steadily, with small steps such as freezing Medicare rebates”.

‘Other more recent data suggest that OOP costs have continued rising right to the present day.’ The situation was brought to a head earlier this year with media reports of huge five-figure co-payments for some types of medical and surgical care, particularly cancer care, with dire financial consequences for individuals as a result.

‘Yet, there is no evidence that higher OOP costs are related to better quality of care or increased access to care.

‘This creeping burden on individuals challenges our notions of universal healthcare, a fair go, and care based on medical need rather than the depth of your pockets’, Ms Verhoeven said.

The study found that OOP costs were highest among affluent households, especially those holding private health insurance.

Correspondingly, OOP costs were lowest in low-income households, but no data were available on to what extent care was skipped because of the cost. Other studies show, however, that OOP costs weigh most heavily on individuals with low incomes and multiple health problems.

‘This individual upward drift in out-of-pocket health expenses deserves very serious policy attention before our nation’s health starts to drift downwards’, Ms Verhoeven said.

Recent estimates of out-of-pocket expenditure on health care in Australia is available at http://www.publish.csiro.au/ah/Fulltext/AH18191. This release is also available online.

The Australian Healthcare and Hospitals Association is the national peak body for public and not-for-profit hospitals, Primary Health Networks, and community and primary healthcare services.

A child shall lead them

Published in Australian Medicine 21 October 2019 https://bit.ly/2NhDL7B

Confronting the problem of suicide

Published in Australian Medicine 16 September 2019 http://bit.ly/2kGGqNR

Fifty years of the Public Health Association of Australia

Published in Australian Medicine August 19, 2019 http://bit.ly/2ZslZHH

Reducing the burden of death and disability in Australia

Published in Australian Medicine July 15 2019 http://bit.ly/2GoRxCu

I'm calling for the PM to lead from the front on prevention

With a new government in Canberra and good prospects of stability for the next three years, it is the perfect time to consider what could be done to develop and advance an agenda for prevention.

The Public Health Prevention Conference held in Melbourne earlier this month canvassed a host of possibilities.

Prevention is rarely achieved quickly, and a three-year time period allows for plans to be developed thoughtfully, coalitions built, and resources allocated carefully and without haste.

There are two principal channels for prevention that could be used to good effect.

First, we should accept that prevention can be highly effective when applied in hospital, the GP surgery and the home.

Read more: I'm your new health minister - cough, cough - and here's my plan

This variety of prevention concentrates on the individual; ensuring that they are immunised and encouraged (where possible) to live in a way that reduces their risk of chronic illness by not smoking, having their blood pressure checked regularly and taking part in screening programs.

As a nation, we are doing reasonably well with this kind of prevention, something Minister for Health Greg Hunt concentrated on in his video speech to the Melbourne conference.

He challenged the audience to come forward with “your advice, your comments, frank and fearless as always”.

He concentrated on immunisation and cancer prevention such as cervical and bowel cancer programs.

But treatments can be preventive, too. A senior cardiologist friend of mine who works in New York said to me recently: “I used to see lots of patients turning up in the ED with malignant hypertension. These days I see virtually none.”

He credits this to the widespread use of antihypertensives.

Read more: Cutting cancer costs is a worthy policy, but we must try to prevent it too

He accepts that these drugs are used irregularly by many patients, but the cumulative effect of their widespread prescription, he believes, has been to reduce the incidence of malignant hypertension. Maybe he’s right.

The effective treatment for HIV prevents transmission from affected people to their negative partners is another good example.

Certainly, there are many opportunities for prevention in clinical medicine, but time and financial pressures make it easy for the busy practitioner to pass these over.

In view of this, it would be beneficial on a national level if government and its departments worked with specialist colleges, pharmaceutical companies and patients to set an agenda to make the most of these ‘golden moments’.

Another kind of prevention

The second variety of prevention is much more difficult and lies largely outside the purview of medicine: it received extensive coverage at the Melbourne conference.

Six years ago, I attended a one-day meeting at Parliament House convened by Senator Guy Barnett, who was concerned about the rising rate of diabetes.

He gathered physicians, diabetes educators, representatives of the food and advertising industries, patients, and several politicians.

I chaired a working group of industry representatives. We had a congenial conversation and agreed that we would need to work together to create a healthier food environment.

Towards the end of the day, one member interrupted. “Professor,” he said. “You’ve got the wrong people in the room today. You need the CEOs. We can’t make decisions to change the composition of our products. They can. And, by the way, you’re the wrong person, too.”

I accepted his criticism: it made sense. But who would he suggest take my place?

“The Prime Minister,” he replied. “Only he would have the authority to mix it with the CEOs.”

Read more: Thanks but no thanks: PM's health handout is bad policy

Perhaps this is logistically impossible, but only something like it will enable the beginning of an agenda for prevention in our communities.

Agendas that are set by top-level people, be they politicians or business managers, have a better chance of changing things than ones that come from people lower down the organisation — like my friends at the diabetes workshop.

Such agendas do not require the ‘top dogs’ to do all the barking but the top men and women need to endorse and value the development of a strategy.

This is not for a moment to suggest that grassroots-level efforts are out of place. Far from it. They can serve to sensitise the people at the top to the need for change and suggest ways forward.

But we do need top-level support to succeed. It will take time to transact, but like concerns with the climate, the sooner we start the better.

Published in the Medical Observer 24 June 2019 http://bit.ly/2WZEzAM

The morning after the night before

Published in Australian Medicine 17 June 2019 http://bit.ly/2XtT4RK

Demolish, rebuild: How I'd fix our health system

We now have a health system resembling an old cottage, with so many renovations and add-ons, especially in relation to payment, that it would be reasonable to ask whether we should demolish and rebuild.

The multiplication of bureaucratic complexity and endless tinkering with fees and reimbursements may provide employment for those who enjoy that sort of thing.

And it is time that compromises can be found that work for a bit. But it is a stupendous waste of resources.

To contemplate a complete rebuild of our health system is frightening, I admit.

Several years ago, I was addressing a parliamentary committee exploring health and Malcolm Turnbull, a member of the committee, asked me what I would do if tomorrow on waking I was to discover I had been made minister for health.

I replied that I would go back to bed and pull the doona over my head hoping that the nightmarish prospect would pass with a little more sleep.

But these days I would answer differently. Three aspects of a new system commend themselves.

First, there would be a new system of paying for healthcare. Moving towards a system that is genuinely understood by all to be for all, and paid for through progressive taxation in which remuneration is fair and generous, would be desirable.

We would seize opportunities to develop policies and reorient investment that would better serve our purposes.

A new system that promoted integrated care would be welcome. Primary care and general practice would be front and centre.

Second, I would invest in developing strategies that took prevention seriously at the level of the social determinants.

This would require activity beyond the boundaries of the existing health system. It would be expensive, tedious and demanding.

But it could lead to new ‘sanitary reform’ of our society and a new era of prevention. These reforms would be an essential step in preparing to meet the health challenges of the now inevitable climate change.

The great contemporary epidemics (or syndemics as they have come to be called because they travel together) of obesity and diabetes also demand a preventative approach.

The new system would seek active involvement with industry on urban design, transport and food.

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Finally, I’d take a long look at what people want from healthcare in the same vein as the late Professor Ed Pellegrino, a US renal physician who was renowned for his work in medical ethics.

His survey of cab drivers identified three priorities: a doctor to be there to transfer the anxiety for patients taking the next step when confronted with a health challenge, for example finding a breast lump; a health system capable of saving life from trauma or infection; and a system able to provide cure where possible, and relieve pain and suffering.

Let’s examine what we would need in an ideal health system, built from scratch, to meet these three goals.

The first would require high-quality primary care available 24/7 face-to-face and online for remote settings.

For the second, emergency ambulances and EDs are required. But at present these are encumbered by huge inpatient loads with patients stuck in wards when many could be managed in the community with integrated services.

There is plenty of room for a radical rebuild here.

Third, curative and caring services, currently the source of out-of-pocket payment chaos, also deserve a radical rethink and reorganisation.

Hospital beds still dominate and limit the exploration of effective reform options. Outpatients might be reinvigorated with benefit.

In all of this rethinking and redesign, we should remember the huge variety of expectations people have of healthcare.

In 1976, Newcastle medical school, where I worked for a decade, sought to put the patient at the centre of the curriculum.

To find out what the community wanted from our graduates, we visited several community groups, including a nursing home and a school to meet young parents.

Expectations varied widely and wildly. A father insisted he wanted a doctor who didn’t keep him waiting. A grandmother wanted a doctor who listened. A senior nurse who had had aortic aneurysm surgery simply wanted a competent surgeon even “if he (sic) had no bedside manner”.

My guesses in this article are only that. To successfully rebuild our health system, a lot of architectural inquiry across society would be the first, and most essential, step.

But we should not baulk at the idea of radical change. Good health demands it.

Published in Medical Observer 20 May 2019 https://bit.ly/2Jxltj0

It’s the economy, but not just jobs and growth

Published in Australia Medicine 20 May 2019 https://bit.ly/2W06QeZ

What do we really want from health funding?

Even in this golden  age of medical and surgical wizardry and developing gene science, all wrapped and ribboned in IT, we owe our health to things which won’t appear in budgets or election platforms in the ‘health’ category.

Although our relatively clean air, potable water, dependable quality food supply, education and low levels of poverty matter intensely in keeping us healthy, you will not find a line for them in the spreadsheets of those seeking our vote – at least not in the section labelled ‘health’.  True, The Climate and Health Alliance has welcomed the recent commitment by the federal ALP to a National Strategy on Climate, Health and Well-being, but this is unusual and there’s many a slip ‘twixt strategy and action. 

The recent federal budget reversed the perverse freeze on rebates for general practice, thank goodness. But with the medical literature revealing growing scepticism about ‘pay for performance’, more money into PIPs seems odd.  Medical research through the future fund fared well.

But more generally we are treated to the spectacle of goodies falling out of Santa’s Christmas sack – a few hundred thousand for each of two dozen clinics, scanners, screening programs, special allowances and other items designed to be enjoyed even as the dollars are quickly consumed. 

The days of big projects in health – like Medicare – the equivalent of Snowy Mountains II, appear to be over, yet integrated care and the new data technologies call for such responses. 

With rising numbers of people needing care for multiple chronic diseases, questions are being asked – not about the amount we spend on health care, but about where the money is going, and whether we citizens are getting value, in terms of quality of life, for our taxes.

There must be a limit to spending on health care or it could swallow the entire budget. Both as individuals and as a nation, we have many calls on our treasury, of which health care is just one.  Other countries roll spending on health and social welfare into one budget, and you can see why. In the US, the Department of Health, Education and Welfare was formed in 1953 and operated until 1980. 

But whatever the administrative architecture, spending on health – public and individual – competes with defence, education, and many other warranted demands of a civil society.

Given our specific interest in funding for health care, just how crucial is money to good health care?  Would more money improve life expectancy?  Would it improve quality of life? 

International experience demonstrates that there is an upper limit to the amount a country can spend on health care leading to improvements in life expectancy.  The US overspends wildly. If you imagine a graph that plots expenditure against life expectancy, you will see that big gains occur in health in poorer countries once they increase expenditure from low levels.  Little dollops, big gains.  The assumption here is that, if a country can afford to increase spending on health care, it will also have invested in other features of prosperity, such as better food, clean water, sanitation and immunisation.

But the graph does not continue upward for ever.  A limit is reached where increasing investment does not achieve further gains in life expectancy.

While life expectancy is a robust proxy measure for health, it does not measure quality of life, a health marker for which we have scant data. But it is the best available globally so we use it.  Comparisons of life expectancy show that:

“in 1800 no country had a life expectancy above 40 [Shakespeare was an ‘old man’ in his 40s when he wrote Lear] In the UK life expectancy before 1800 was very low, but since then it has increased drastically.

“In less than 200 years the UK doubled life expectancy at birth, and similar remarkable improvements also took place in other European countries during the same period.… People in some sub-Saharan African countries still have a life expectancy of less than 50 years, compared to 80 years in countries such as Japan …

“A century ago life expectancy in India and South Korea was as low as 23 years – and a century later, life expectancy in India almost tripled, and in South Korea almost quadrupled.“

These gains in longevity run in parallel not only with increasing prosperity, but with ever more years of age-related disability and chronic illness.  For relatively small investments huge dividends can be reaped

https://ourworldindata.org/health-meta

In Australia, we have reached the top part of the graph where greater expenditure in health care is not likely to increase life expectancy.  Our life expectancies are among the best in the world. This is not to deny the value in the incredibly expensive therapies which can help treat some patients with cancer and other precision targets, but they are exceptions.

There’s a billboard on a nearby church that asks, “What do you really want?”  This is a fair question to ask of our health care system.  As a society we can, and already do, spend more on health care because of its value in achieving improved quality of life. 

A desperate and expensively acquired few more days or weeks of life, or a better life-long quality of life?  The answer might well guide our health investment differently.  It may require quite different budgetary commitments to the ones we usually make when we think of ‘funding health’  Worth considering when Santa comes our way.

Published in he Medical Observer 16 April 2019 https://bit.ly/2GrF2GT

Still grinning and bearing the cost of dental care

Published Australian Medicine 15 April 2019 https://bit.ly/2V6oGLP

Politicians must grasp and act

Published in Australian Medicine 18 March 2019 https://bit.ly/2uinPIS

The cracking tale of two 'murders' by a bum that I know

I killed two chairs at Christmas. Not intentionally and not the leaders of my two least favourite committees. Both were made of wood.

The first murder occurred in a playground in our neighbourhood where, with friends from our street, we were enjoying a happy Christmas afternoon catch-up.

The chair was a wooden folder, in its senior years, and gave up when I went to sit on it. Fortunately, my landing strip was designed for falling children and with help I tottered to my feet, none the worse for wear save for the sad loss of a slice of delicious pavlova I had been cradling at the time of the crash.

The second chair murder occurred in the sitting room of a holiday rental in January by the sea. I attempted to stand up after watching too much wonderful tennis and the chair gave way, the rear legs splaying with a puff of bamboo dry rot, tipping me on to the floor and landing on the point of my right shoulder.

You can guess the rest; and now my infra and supraspinatus muscles are resting, with their tendons snapped, with nothing to do.

What to make of these ‘tragedies’?

First, they both happened extremely quickly. One moment I was okay and within a nanosecond I was sprawled. I suppose that is no surprise but, rather as with sudden cardiac death, the message is with falls that unless you prevent them well ahead of the provocative trigger, you have no hope.

Get rid of unsafe chairs, engineer hotspots out of our roads, and encourage smokers to quit.

But second, I wondered what kind of prevention algorithm I would need to avoid future chair murders. Should I check all wooden chairs that I encounter, test their legs and if they are folding chairs make sure the mechanism is clicking closed correctly? Rather boring and probably not practical.

And if I extended this principle to things other than chairs, would I have time in the day to do things other than all the preventive surveillance required?

Third, and a derivative of the second point, these two falls made me stop and consider what we might call the time-economics of prevention more generally.

I recall decades ago a conversation with a single mother from western Sydney who told me just how scarce her time was for anything beyond survival.

An early start to the day to get children fed and to school, then to work a full day to pay bills, home in the early evening to handle kids and household chores.

The attraction of takeaway food was overwhelming and there was no time for exercise. By dinner she was exhausted. Cigarettes provided comfort.

Time is at the heart of it all

Time — whether there is so little of it you can’t prevent a fall or a crash or a heart attack, or enough of it to satisfy so many competing demands on it — is a dimension of prevention.

For both reasons — at times too little, at times too heavy the competing demands — we should be sensitive to this ‘social determinant’ of health in our communications and plans for prevention.

It’s wise and humane not to ask people to do what’s impossible.

Oh, and don’t be like me: keep in mind the well-being of old chairs!

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

https://bit.ly/2tEjj7r

Drug testing - the decision is political

Published in Australian Medicine 18 February 2019 https://bit.ly/2GAgAUL

Preventing heart disease - a continuing story

Published in Australian Medicine 21 December 2018 https://bit.ly/2C9G6eV