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

Doctors notching wins in a war that can't be won

It is incumbent upon us to promote the desirability of alternative solutions to conflict

At the recent Armistice Day centenary commemorations, I had the privilege of attending a splendid rendition of the concert An Australian War Requiem in Sydney’s Town Hall.

The requiem to the nation’s fallen soldiers in World War I is in three tableaux; the first concerns the horror of war, the second focuses on sons and mothers, and the third — and most dramatic — is a reflection on loss.

The event led me to reflect on the far-reaching role ­doctors have played throughout history in times of war, and continue to play when it comes to human horrors.

Our role is multifaceted and spans the breadth of war.

Our first contribution, of course, is to do our best to heal those who are physically and mentally injured by war, and to understand, as best we can, the awful circumstances they have endured.

One such doctor was New Zealand ENT surgeon Sir Harold Gillies. Working on the Great War’s Western Front, he witnessed attempts to repair the ravages of facial injuries and, as a result, became a pioneer in plastic surgery.¹

A plaque honours Sir Harold Gillies. Photo: Simon Harriyott/Wikimedia Commons. https://bit.ly/2TBAgLu

He opened a hospital in the UK after the Battle of the Somme in 1916, where he treated thousands of cases of jaw and facial mutilation.

In World War II, Australian surgeon Sir Ernest Edward ‘Weary’ Dunlop was renowned for his leadership while being held prisoner by the Japanese.

He was hailed by other POWs in the prison camps and jungle hospitals on the Burma-Thailand railway for being “a lighthouse of sanity in a universe of madness and suffering”.²

Kanchanaburi war cemetery, where thousands of Allied POWs who died on the notorious Thailand to Burma death railway are buried.

Our second contribution comes in the aftermath of war when we look at the reasons for negative behaviour in affected servicemen and women and try to assist them if they emerge shell-shocked or, in modern parlance, with PTSD.

Research suggests that even medieval soldiers suffered from the psychological impact of war despite their training from a young age and being surrounded by death.

In 15th-century France, people believed that warfare caused a kind of madness and soldiers who went “berserk” were celebrated. However, non-combatants who were traumatised by war were pitied or ridiculed.³

Today PTSD remains a major therapeutic challenge, and not only for war veterans. A Google search of the phrase ‘Australian doctors treating PTSD’ yields a vast number of entries concerning psychiatric treatment, medication, lifestyle and other treatments.

Finally, we are bound to share our medical insight into the real cost of war with our communities.

Doctors in the US recently engaged in the modern-day version of this duty of care when, just a few days before the Armistice Day centenary, they took to Twitter to reveal the day-to-day horror of the country’s gun crime.⁴

Fuelled by the US gun lobby’s call for doctors to “stay in their lane” on the country’s gun control debate, dozens of emergency care medics posted photos of themselves working while covered in patients’ blood as a visual reminder of the human cost of America’s shooting epidemic.

Away from the front-line, numerous doctors have also been honoured for championing a reduction in the engines of war.

SA palliative care physician Professor Ian Maddocks was president of the Medical Association for Prevention of War when it received an Australian Peace Medal, and vice-president of the International Physicians for the Prevention of Nuclear War when it received the Nobel Peace Prize in 1985.⁵

And, more recently, Professor Tilman Ruff, an infectious disease and public health doctor from the University of Melbourne, was chair of the International Campaign to Abolish Nuclear Weapons — the recipient of the 2017 Nobel Peace Prize.⁶

It is important for doctors, who see the damage, to make clear to our communities and their political representatives the absolute desirability of finding alternative solutions to conflict.

But the reality is that in a world of scarce resources, war will likely remain part of the human condition, and will not, unfortunately, be going away. We must therefore remain ready to meet its challenges.

Requiescat in pace.

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. 

Published in Medical Observer 26 November 2018

https://www.medicalobserver.com.au/views/doctors-notching-wins-war-cant-be-won