An age-old debate*

World Health Day is celebrated on 7 April to mark the anniversary of the founding of WHO in 1948.  It is not a day that stops the nation – no sweeps and no light switched off, especially this year.

What is it?  The WHO web site states that: ‘World Health Day is a global campaign, inviting everyone – from global leaders to the public in all countries – to start collective action to protect people's health and well-being.’ 

This year the topic was Ageing and health with the theme "Good health adds life to years". Noting the theme of World Health Day this year, a recent Lancet editorial http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960518-2/fulltext points out that while the biggest causes of years of life lost among people aged 60+ years are ischaemic heart disease and stroke, only between 4-14% of older people in less- and least-developed settings are receiving antihypertensive treatment.

April 7 received zero media coverage.  Old age is boring.  It is not news.

Shortly after World Health Day, in Australia, $3.7 billion of reforms to aged care over five years were announced by the federal government. http://www.theaustralian.com.au/national-affairs/at-a-glance-aged-care-reforms/story-fn59niix-1226334312515

• $1.2 billion to strengthen the aged-care workforce.
• $268.4 million for dementia.
• $54.8 million to support carers.

These proposals are linked to existing aged care support and include $880.1 million over next five years to expand home care with 80,000 new home-care packages by 2012.  The ageing of the world’s population is a special challenge for nations still undergoing economic growth such as China and India. The population aged 65+ years in those countries will, according to UN projections, double between 2000 and 2020 and quadruple — to 900 million people — by 2040. The number of older citizens in more-developed countries by 2040 will be only one-third that of those in the less-developed countries. The economically-advanced world thus holds no monopoly on old age.

In China where a one-child-per-family has operated since 1978 and applies to 40% of families, family for older parents will be very challenging, especially if the one child lives in a city and the parents live rurally.  Whereas now there are 10 million people in China aged 80 or over, by 2050 there will be, according to current estimates, 100 million.

In old age, as the WHO theme suggests, it is the disease burden rather than age itself that is the biggest problem. 

It is also among older people that attention should be lavished on the modifiable factors that multiply absolute risk of death and disability. Treating blood pressure, for instance, is more, not less, important in the individual older patient than it is in a younger person in the prevention of stroke and heart disease, as the Lancet implies.

The policy challenges for an ageing world, especially one that seeks to sustain health in old age, concern the context, content and cost of services.

The context is not a straightforward policy component because social attitudes towards older people vary widely. Oriental concepts of filial duty will confront the practicalities of distance, time, and new lifestyles.  In some cultures, the wisdom of the elders is prized while in others it is ignored. In multicultural Australia, sensitivity to cultural variations is critical to the effective provision of support for older people. Different cultural attitudes to institutional, home and respite care all need to be respected.

The content of care includes the technicalities and includes decisions about how resources for aged care will be used to best effect.  That is true at the macro level but closer to the people we are aiming to help, end-of-life discussions are a valuable part of a patient-centred aged care policy.

When it comes to cost, we must ask if the welfare model of health service provision that we follow at present is sustainable in the light of population ageing, and if it needs modification. How will this be achieved without doing violence to notions of equity and bankrupting the nation? Questions such as these have been addressed partially in the financial arrangements in the new federal aged care proposals.

As grey demand increases, the attitude of younger taxpayers cannot be assumed to one of selfless generosity towards meeting the costs of care and support of ever more older people. This makes the development and protection of superannuation and personal savings a huge political priority right now.

Ageing is not like HIV or bird flu — it is entirely predictable and susceptible to rational examination, prediction and policy formation. The Productivity Commission http://www.pc.gov.au/projects/inquiry/aged-care/report and groups such as Alzheimer’s Australia http://www.fightdementia.org.au/dementia-an-economic-and-fiscal-disaster-waiting-to-happen.aspx are urging us to think, discuss and debate seriously the major policy elements within ageing.

*Published in MJA Insight Magazine

THE SERIOUS CONTINUING ILLNESS POLICY AND PRACTICE STUDY

A UNIQUE COLLABORATION between The University of Sydney and the Australian National University – mediated by the Menzies Centre for Health Policy – is undertaking far-reaching investigations into chronic illnesses in Australian urban communities. It is a partnership that focuses in on the performance of integration and coordination of health services for those with chronic illnesses. The main outcome of the collaboration is the Serious and Continuing Illness Policy and Practice Study (SCIPPS), which aims to address issues of healthcare integration and coordination at a local level as expressed by patients and their carers.

Click here to view the brochure

THE LINKS, NOT VOLTS OR THE BYTES, ARE WHAT MATTER*

Among the career achievements of the British physician Sir Donald Acheson (1926-2010) were his contributions as chief medical officer of the UK (1983-1991), to clinical epidemiology and medical education reform when as professor and dean at Southampton University (1963-1978), assessing and redressing the effects of social inequalities on health and especially his pioneering work at Oxford (1957-1968) on the linkage of medical records with other health data. He was a gracious humanitarian and his contributions were made with modesty and effectiveness.

Record linkage, pursued with great energy and creativity in Western Australia by Michael Hobbs (an Acheson protégé) and his colleagues over several decades especially in their monitoring trends in cardiovascular disease in Australia, provides us with an understanding of what happens to patients as they traverse episodes of illness and care, whether in hospital or in the community.  This enables patient-centred care, so extolled by quality gurus such as American Don Berwick.  We know so much more from a longitudinal record of a patient than we can gather by cutting and pasting the records of unconnected episodes of care. 

So whereas we often have separate medical records for inpatients and outpatients in our hospitals, and indeed separate systems for recording their data from pathology, imaging, the ED and the ward, a linked record enables us to see what has been done with and for a patient in all these settings and assess the value of the interventions.  Recently, in an attempt to assess what happens to patients with severe chronic problems managed using coordinated care in a NSW hospital, we had to figure out their use of services both within and out of hospital from eight unrelated electronic data files. Electronics are not enough.

The achievement of the linked medical record should be understood as the fundamental reason for the current interest and investment in electronic health records.  We have immense data processing and transmitting advantages over those that Acheson, Hobbs and others had available to them when they started their linkage projects. ‘Electronic’ the record will be, but that simply describes one of its qualities, not what it is for.

By using the word ‘linked’ we put right up front the purpose for the construction of these records.  We want the advanced orders, discussed sensitively and carefully in the general practice, to be there when the ambulance responds to an emergency call and the patient is seen in ED by a team to whom he or she is not known. 

We want linkage so that the general practitioner can see, even without asking or having to dither around changing portals, logins and passwords to access another web site, what went on with a patient during his or her recent sojourn in hospital.

The literature about electronic records is immense and there is recognition in parts of it of the value of having the patient involved in the construction, quality surveillance and oversight of the information it contains.  While privacy issues tend often to be overstated, a patient surely should be able to determine whether elements of their health journey are not to be made freely available through this medium.

A managerial appreciation of the value of a linked record derives from what information collated from hundreds or thousands of patients treated for a condition about their fate and experience especially when treated with different modalities for different conditions achieves and at what cost. Outcomes can be factored into the assessment, something that cannot be done at present with unlinked hospital data as are used to determine activity-based funding.  

The recent upsurge of interest in electronic records, so essential if we are rationally to order our investment in health services, has come to be called ‘effectiveness research’ now espoused in several places in Australia. The Scots, who by national persuasion are interested in wise use of money, define it thus: ‘Clinical effectiveness is the extent to which specific clinical interventions do what they are intended to do, i.e., maintain and improve the health of patients securing the greatest possible health gain from the available resources.’

A completely linked data system is a wonder to behold. The agencies for the care of veterans in Australia and (especially) the US have such systems and use them to advantage.  Managed care organisations such as Kaiser Permanente have ‘cradle to grave’ linked record systems.  In such an environment preventive programs can be targeted to those most likely to benefit at times such as pregnancy, post-operatively or upon diagnosis of diabetes when they are searching for preventive help.  Instant understanding is available for clinical managers about length-of-stay, complication rates, medication errors, diagnostic results, and anything you as a clinician or manager of clinical service may wish to know about both the well-being of your patient, the performance of yourself and your fellow clinicians and the performance of the system. 

So why are we stuck with paper?  The problem that seems to defy us is making the change from charts and an independent electronic data system to a linked system is management.  These changes can only be effected by attending at the micro level to processes of getting the system running in the clinical setting and then helping the clinician to adapt.  Medicine, for excellent reasons, is conservative: clinicians will change if convinced of the value of the change and if supported in making the change. Hectoring, incentivising with little dobs of money, or otherwise ignoring the magnitude of the reordering needed to move to a linked record have no evidence in their favour.

Kaiser, for example, in its multibillion dollar switch to electronic systems, spent HALF that investment on change management. I am deeply puzzled when I see how little we invest in managing the necessary changes and how little we understand how critical change management is in achieving a fully functional linked, patient-controlled electronic record. 

The history of IT in health care led Donald Acheson to say about 30 years ago, “The electronic medical record is today exactly where it was 20 years ago: just around the corner.”  I do not think that things are quite that desperate today.  It is not the electronics that are holding us up, not the volts or the bytes, but change management.


*Published in Aus Doc

TIME TO GET SMART ABOUT PHONES*

I own a smart phone.  I am generally regarded as an un-smart owner, especially by my younger generation. This may be rampant ageism but it is also correct. My iPhone is largely wasted on me, the youngsters say. At least I can phone, send and receive text messages, send and receive email and on rare occasions, when need overtakes concerns about cost, I access Google, Wikipedia and other brain aids for the feeble and dementing. Hey, guys, I am not that bad.

Not so many years ago I recall a debate in The Economist about the future of the mobile phone. If I recall correctly that paper thought (though as usual it hedged its bets) that the search for a phone that would have computer-like features was an aberration. Too much complexity.  People would not fiddle around with tiny keyboards and fiddly screens. Bad investment. Well: welcome to 2012. 

When in India last year, I met with an executive of one of the Scandinavian mobile phone companies that are finding their fortunes in that highly electronically-literate country. Pyramid Research estimated that the addition of 125 million net new phones each year between 2010 and 2015 will ‘bring the total number of mobile subscribers to 1.2 billion in 2015’. 


The Pyramid report on India continues: ‘The exponential mobile subscription rates are driven primarily by the increasing adoption of 3G and mobile services such as music, video and broadband access,’ and mobile data services revenue is predicted to grow [by] 27.3 percent. No wonder the woman from Scandinavia was smiling.


I was in India helping review a program focussed on maternal and child survival a principal component of which was the deployment of may hundreds of thousands of minimally-trained women to assist other women during their pregnancy, encouraging them to give birth near or in a facility that could managed haemorrhage and basic neonatal support. They were paid virtually nothing, but what they were paid came to them through their phone accounts.  They were able to cash in the credit at a store.  No bank was necessary, which was lucky because in remote regions there were none.


The mobile phone put these support women in immediate touch with specialists for advice, transport and help. They were also given bicycles.


It is easy now to imagine or indeed, see, how smart phones could hold personal medical records, monitor basic physiological functions in those say with a cardiac pacemaker, calling for appropriate help automatically in a crisis, and remind owners about medications and clinic appointments. Photos taken with a phone camera can be transmitted to physicians and used diagnostically. Kaiser Permanente in California makes extensive use of mobile telephony among its millions of subscribers and their carers. A pesky rash can be photographed by the patient at home and emailed to the primary care physician who may diagnose directly or seek the advice of a dermatologist.

When I visited, an orthopaedic surgeon asked my group how much we thought it cost to review a patient six months after hip surgery.  We offered a comment based on an x-ray and a consultation – let’s say $500-$800.

“Well,” he asked us, “How much does it cost the patient – half a day’s work to get to the appointment, wait for the consultant, see him or her for five minutes and then probably not go back to work that day. That all adds up – for someone.  And while the consultant is seeing the patient and telling them all is well, they are not doing something else that matters.” 

He then told us what happens at Kaiser. Near the six-month mark, the patient receives an SMS text gently reminding them to get an x-ray.  The radiology services (they have no appointments – just turn up) closest to where they live and work would be identified for them. A questionnaire is emailed to the patient seeking information about pain, mobility and other concerns. 

The x-ray image is emailed to the surgeon who reviews it with the questionnaire responses on line.  If all is well the surgeon texts the patient giving them an encouraging report. No-one has wasted time on things that do not need to be done, especially inefficiently. But notice this: the physician is central to this process and all the electronics do nothing but enhance the importance of his or her role in the care of the patient.

The use of smart phone applications is increasing daily and can be used preventively .  Bruce Neal and colleagues  at the University of Sydney’s George Institute for Global Health have developed a really tricky app with BUPA called FoodSwitch http://www.bupa.com.au/health-and-wellness/tools-and-apps/mobile-apps/foodswitch-app that enables the food-wise purchaser to see exactly what they are buying. By pointing the phone camera at the bar code of a can of beans or whatever, immediate information about fat, salt and sugar content, and alternative choices, shows up on the screen.
Bruce Neal was quoted as saying, "FoodSwitch's three-step approach marries the latest technology with cutting edge research. Australians can now scan barcodes, see what's in a food, and switch to a healthier choice in an instant. The application makes recommendations based on the nutritional value of more than 20,000 packaged food products found in Australian supermarkets.”


My health, and the health of billions, is coming to depend on smart phones. 


*Published in Aus Med

Australia can lead the fight against Asia’s lifestyle disease epidemic*

Think Asia and we think millions – or billions when you combine the populations of both India and China.

Unfortunately, millions is also an appropriate unit with which to measure the number of people in Asia who suffer from chronic illnesses such as heart disease, stroke, cancer, ongoing respiratory disease (like asthma and emphysema) and diabetes.

The causes often spin out of rising affluence, shifts from traditional to processed diets, decreased physical activity – as people move from rural to city employment and living – and the pervasive, rising influence of tobacco smoke.

Snapshot of China

In China, around 80% of deaths and considerable disability are now attributable to chronic disease; this percentage is set to grow as the population ages and these conditions become more prevalent.

Around 300 million Chinese men smoke, but rates are much lower among women (it’s less socially acceptable for women to smoke). Sample surveys conducted among about 20,000 people living in nine counties suggest that around half of China’s smokers have high blood pressure and are missing out on treatment. This means they’re at heightened risk of heart disease and stroke.

For a health-care system committed to reform but struggling to come to terms with contemporary expectations of rural and urban populations, this is the stuff of nightmares.

Snapshot of India

The scene isn’t any happier in India. Around half of all deaths – around five million each year – are now due to chronic illness.

In 2004, my colleagues and I published a study which estimated that India was losing more than nine million years of productive life each year from heart-disease deaths in people aged under 65 years. On current projections, this would double by 2030.

Comparable figures for China were six million years of lost life in 2004, which could rise to 11 million years by 2030.

Snapshot of Thailand

Similarly to India, chronic illness accounts for around half of all deaths in Thailand.

But there are some positives to report. The World Health Organization (WHO) estimates that the proportion of men who are overweight is likely to remain steady, at around 35%.

Rates of excess weight among women, however, are expected to rise from 47% in 2005, to 57% in 2015, which reflects local cultural norms. These cultural factors alert us to the power of the environment in setting the range of individual behaviours, which can be as strong as conventional risk factors such as high blood pressure.

Efforts to reduce tobacco consumption in Thailand have been successful, with ratesdeclining over the past two decades. Unsurprisingly, this has raised the ire of the tobacco industry, which sees its market shrinking.

But other parts of Asia haven’t done so well in reducing rates of smoking. In fact, as the tobacco trade journal, Tobacco Reporter, noted in 2009, Asia is one of the world’s most promising cigarette markets, with Indonesia (southeast Asia’s largest market) selling 231 billion cigarettes in 2007 alone.

Health promotion

So, what can Australia do to improve our neighbours' health? There are several compelling options.

First, we can provide an encouraging example of successful health promotion initiatives, particularly in tobacco control.

Thankfully, this has already been happening. Australia was a major advocate for the WHO’s Framework Convention on Tobacco Control, which aims to eliminate trade in illicit tobacco products. Now we should push for its full implementation among all signatory countries, including those in Asia.

Likewise, Australia’s approach to the detection and management of patients with elevated blood pressure has paid dividends, with an 83% drop in rates of death due to heart disease since 1968. This, too, can serve as a model that other nations can study and possibly adopt.

The commitment of the current federal government to health prevention is unusual and exemplary. Of note is the recently established Australian National Health Preventive Agency, which other nations may wish to emulate.

Managing trade

Second, we should consider reviewing our trade relations with Asia so that our exports, especially for food, don’t compound the disease risk profile of Asian countries.

We can learn from the Pacific, where an aggressive trade push (not so much from Australia but other big economies) allowed multinational food companies and food producers to push their high-fat products to a new market. Small, relatively powerless countries fought hard to keep these companies out but, in the end, were defeated by edicts promoting commerce through the World Trade Organisation.

So, a thoughtful “health ethics” review of our trading relations with Asia may be possible. We could, at the very least, articulate a set of national expectations of our corporations in their dealings with Asia, in the form of a health “bottom line”. While these expectations may need the support of law, first we need a discussion about corporations' ethical obligations.

People power

We should think carefully about the role we can play in helping our Asian neighbours develop effective, relevant health workforces.

Our obsession with recruiting overseas students to fuel our tertiary education institutions should be abandoned and replaced with a more responsive approach to assisting other countries appropriately develop their workforces.

This could include increased funding for the Colombo Plan, where Asian students are sponsored to study in Australia and, on completion, return home. The Plan operates on a shoestring budget but has provided 16,082 scholarships to 23 member countries in its lifetime.

Much else could be written about health in the Asian Century, including the need to implement a sophisticated surveillance and control system for emerging infectious diseases. Maternal and child health, and mental health, remain challenges for poorer countries and the disadvantaged in nations such as India.

But in priority order, we must focus on controlling chronic diseases, through heavy investment in prevention programs and effective, affordable health systems to treat existing patients. Australia can – and must – help.

*Published in The Conversation 18 April 2012

Can we stand for this?*

SITTING is not good for us. We should be up and about.

In a recent Australian-based study, published in the Archives of Internal Medicine, hours spent sitting was shown to confer a small increase in the risk of death from all causes.

Is the chair the problem? Historically, “chair” suggested power and authority, not vulnerability and death.

Chair comes from the Greek cathedra and cathedrals were places with chairs on which men of power sat. The occupant of a chair would expect us to take notice, whether a bishop, king or a professor. But the privilege of being seated and treated as a power-person may come at a price.

In fact, doctors who sit 10 hours a day, advising their patients to exercise more, may be in strife themselves.

Sixty years ago a study showed that conductors aged less than 50 years who worked on London double-decker buses had sudden death rates one-third those of bus drivers. Presumably this contrast had something to do with sitting versus standing.

The authors of the paper back then found that the variations in sudden death rates could not be explained by the drivers wearing bigger trousers than the conductors — because they didn’t. “The difference between conductors and drivers in the sudden death rates cannot be explained by differences between the two occupations in physique as measured by uniform size”, they wrote.

The latest study by Australian researchers strengthens growing concern that sitting in and of itself may contribute to all-cause mortality.

So what would be an appropriate public health policy response to this observation?

First, it would be prudent to draw the finding to public attention so that when options present for choosing sitting or standing, people are encouraged to stand (and move).

This has salience when considering ergonomic arrangements in the workplace, where opportunities for working at a computer console might include adjustable desk heights that permit the user to stand rather than sit. Presumably, this would make the temptation to occasionally walk about stronger.

Second, we might encourage doctors and others to consult on our feet as managers who wish to keep meetings short do. Walking clubs organised by several private health insurance funds and the Heart Foundation could be publicised through doctors’ practices. These groups blend physical activity with socialising and chat.

Perhaps a Medicare Local could pilot the value and cost of a walking group for doctors and other health professionals, organised to fit easily into their schedules. This may also save money otherwise set aside for those excruciating team-building and networking retreats.

Third, the Australian National Preventive Health Agency, with the expectation that it will engage in heavy-duty evidence assessment on which prevention programs work best and in what context, may wish to review reportedly successful nationwide activity programs such as Agita São Paulo Program in Brazil.

“The verb ‘agita’ means to move the body, but the term also suggests changing the way of thinking and becoming a more active citizen”, write the program’s protagonists Sandra Matsudo and colleagues.

Launched in 1996 among the 37 million citizens of the state of São Paulo, Agita is now widely adopted by the rest of Brazil and endorsed by WHO. Its message is to encourage people to adopt an active lifestyle by accumulating at least 30 minutes of moderate physical activity per day, on most days of the week.

Following widespread community application, 7% of citizens exposed to the program remained sedentary compared with 14% of those who had not been exposed.

And finally, we should attend to the way we design, build or renovate our urban spaces. In the world’s great cities such as Manhattan, public commuter transport encourages regular incidental walking as well as relieving road traffic obesity and thrombosis.

Time for me to get up from this chair and go for a walk, I think!

*Published in MJA Insight Magazine

What experience teaches

I have been chair of the board of the Western Sydney Local Health District (WSLHD) for twelve months.  As part of the agreements struck between the Commonwealth and the states and territories, NSW’s large area health services were split into 17 much smaller entities.

These networks or districts are based on public hospital services and their community outreach programs and community health services more generally. They are responsible for a goodly portion of preventive and health promotion services and mental health.

Giving clinicians a stronger voice in the running of the services was a central plank of the new structure as was a clearer consumer voice and connection to the new Medicare Locals.

WSLHD is one of these new entities encompassing a population of about 800,00o people living in Blacktown, Parramatta, Auburn, Mt Druitt and related suburbs, including about 10,000 people who identify as Indigenous.

The board’s brief is to assist in the development of policies and strategies to guide the work of the LHD, to co-operate with the minister and the Ministry of Health, and the related Medicare Local and private agencies to help the district achieve the best levels of health possible. This cannot be done by the health system alone, quite obviously, and we are expected to hear what the community has to say and to relate to other agencies and local government in the pursuit of common goals.

I was asked to write about what I have learned as a result of that year in the chair.

First, I have learned the solid truth behind the aphorism, “The board governs but does not manage.  The managers manage, but do not govern.”  When as a board member of another agency I dabbled in management previously, I made a major error, and nothing in the past year has diminished my acceptance of the wisdom of that division of labour.

The second thing I have learned, or relearned, is that the public health system is populated with people of strong humane concern and altruism. When fire struck a nursing home in western Sydney, off-duty staff from Blacktown Hospital phoned in to see if they could help the hospital cope with the load. I am constantly regaled with stories of people throughout the organisation (and there are thousands of them) doing more than they are asked, connecting to patients and families.

The third thing I have learned is that there is a lot of ‘in spite of’ high quality care. In spite of not engaging in best practice health IT support, financial management systems, and building design, an amazing amount of good work gets done. Somehow we muddle through.

It was Andrew Podger, an outstanding secretary of the Commonwealth health department, who introduced me to the management literature on ‘muddling through’ (See George Maddox 1971 paper in Medical Care Vol 9 No.5  Muddling Through: Planning for Health Care in England).

Muddling isn’t as bad as it may first appear and in fact may be the only way through a contentious, politicised health care problem.

The fourth thing I have had reinforced is the importance of starting where staff – clinical, managerial and support – are in their personal career development.  If we set a goal for more coordinated care in hospitals, or activity-based funding, or patient-centredness in our transactions, then the managers will need to manage that with clinicians and others who are in the thick of service delivery.  If there is to be change, then that change needs careful and often sensitive management.

Fifth, I have learned again just how expensive organisational restructuring is. To make it worthwhile you have to be very clear about what you are trying to achieve, and that the likely benefits outweigh the estimated costs.

Don Berwick, in his birthday advice to the UK NHS, offered ten rules to assure its future health, one of which was ‘Do not restructure.’ His advice was a little more nuanced than the heading, but he recognised the cost.

In this case I do think the restructure into more workable entities was desirable, especially if they change the participation of clinicians and the community.  They also reduce the size of the administrative unity to one that is big enough for a full spectrum of hospital services to be sustained, but not so big that people completely lose touch with one another in the organisation.

The health ministry has coped with stupendous changes with admirable calm and professionalism. Our board itself is a band of splendid people that I am enjoying getting to know.

I do find the work emotionally stressful – the sheer scope of the enterprise is daunting.  I have not had the experience of working in an organisation as complex and huge as this before.  I find my control-freakery and pushiness for practical results needs to be tempered.

In addition, the clinician in me frequently gets upset when I see conditions that do not give patients the best chance of dignified care or optimal outcome. This is one reason why doctors generally do not make good managers – and I guess do not make great board chairs, either.

After one year I find myself wondering whether we have really turned our attention to the big picture quite enough, whether we have done the hard yards of sorting through with managers, clinicians and community where we think it reasonable to expect the LHD to be in five or ten years, delivering what services, to whom, and how? Are we thinking innovatively enough about new models of care?

So we have lots left to do and I feel very privileged indeed to be in the position of chair and to be working with the thousands of dedicated staff in our LHD.

Also posted on Croakey