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