THE HEALTH OF NATIONS*

Gavin Mooney’s book launch

May 7^th 2012

It is my personal and professional pleasure to launch Gavin Mooney’s new book The Health of Nations this evening. Personal, because my friendship with Gavin extends over 20 years and I have benefitted as many here this evening have from his loyalty and support and his commitment to notions of social justice, a commitment that inspires and energises and shakes us up, moves us along, and reminds us repeatedly and firmly of the higher purposes of our work. 

It is also a professional pleasure because Gavin is a leading contributor to the debate about the social significance of economic and political positions and how these contribute to, or perturb, human flourishing including health. He is especially concerned about policies that make worse the extent and effects of poverty and inequality and is a trenchant critic of political, economic and social movements and forces that overlook the serious and damaging side-effects of their pursuit of the neoliberal agenda. ‘To me,’ Gavin writes, ‘social justice is central to public health.’ That is the nub of his argument, his values and his professional life.

It is fortunate that Gavin does not hide his light under a bushel, because if he did the bushel would quickly erupt in flames. There is chutzpah in his naming his new book The Health of Nations in line with Adam Smith’s The Wealth of Nations published in 1776. Smith, of course, was also a Scot and I can imagine that conversations between Mooney and Smith would be lively, especially if lubricated by an ale or two.

For example, while Mooney and Smith may well have joined voices to attack groups – the factions as they were called – of politically aligned individuals who attempt to use their collective influence to manipulate the government into doing their bidding, including bankers and other commercial conglomerates, and today pharmaceutical companies and the AMA, they may have parted company over Smith’s distaste for guilds, forerunners of unions, that brought together workers. Smith wrote:

"People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices. It is impossible indeed to prevent such meetings, by any law which either could be executed, or would be consistent with liberty and justice. But though the law cannot hinder people of the same trade from sometimes assembling together, it ought to do nothing to facilitate such assemblies; much less to render them necessary." 

Yet this is the same Smith who wrote in The Theory of Moral Sentiments: “How selfish soever man may be supposed, there are evidently some principles in his nature which interest him in the fortune of others and render their happiness necessary to him though he derives nothing from it except the pleasure of seeing it.” Indeed, as the Concise Encyclopaedia of Economics tells us: “In fact, while chair at the University of Glasgow, Smith’s lecture subjects, in order of preference, were natural theology, ethics, jurisprudence, and economics, according to John Millar, Smith’s pupil at the time.” Indeed, Smith was painfully aware of global inequalities and looked forward to a day when an "equality of courage and force" would lead all nations into a "respect for the rights of one another."

So Smith’s statement would not have finished the debate. Mooney would have responded to Smith’s notions of capitalism with a clear and strong exposition as in his book of deliberative democracy. And so the dialectic among these two Scots would have flowed – energetic, constructive, and fierce – in pursuit of social betterment but just maybe they would not have come to blows.

There is more to the comparison of Smith’s and Mooney’s work, though. Think of the context for Smith’s book. When Smith wrote he attacked the contemporary Feudalist bureaucracy and philosophy, convinced that Feudalism’s controls over the European economies was stifling and that capitalism might offer a new path forward not only for the creation of wealth for a few but also for those many trapped in serfdom. In other words, his was a critique of a prevailing political economy that held people and nations in an exploitative thrall. This has strong parallels with Gavin’s trenchant attack on contemporary neoliberalism.

Gavin’s book concentrates its criticism of macroeconomic and global economic systems on the political economy of neoliberalism, a form of economic thinking and acting that reifies the individual and the market and “breeds inequality and individualism and discourages a sense of community and feelings of compassion.” It is the expression of neoliberalism in case studies of countries, corporations, governments and professions that is the major work of Gavin’s book. Nothing much escapes his criticism and none of us gets away – to coin a phrase – Scot free.

To balance this critique, in examining countries and states including Cuba, Kerala and especially Venezuela, Gavin explores positive alternatives to the prevailing neoliberal political economy where health and health systems thrive. I am not sure that I would have chosen Venezuela as a good example, even less claim for it as Gavin does that it is “the closest model that I can find to a working example of what my paradigm would point towards.” Its IMR of 17 or 20, depending on whose stats you read, puts it alongside Libya and Uzbekistan and interestingly has been declining smoothly since 1960 when it was 60, without the slightest ripple attributable to oil crises, coups, dictatorships, Charvez’ thumbing his nose at the US and at organised medicine or any other notable political or social event. Closer to home, examples of constructive deliberative democracy including citizens’ juries are also explored in Gavin’s book.

Fundamentally, however, this is a pathology text, indicating to us where things have gone wrong and what the nature and mechanism of disordered politics and economics really are and what distress they cause. We do not look to textbooks of pathology for therapeutic solutions, and it would be inappropriate to expect that political remedies to the problems of neoliberalism should abound in a book such as The Health of Nations. We are left needing to work out what if anything can be done.

We need greater clarity about the way in which, through political action, we can move our society more toward a communitarian future. The strategy should include what needs to be done through advocacy, what needs to be done by new institutional instruments such as new political parties, what needs to be done to garner grass roots support and where we might find the money necessary to make this all happen. All this we may hope to find in Gavin's next book. We need to know what we, as individuals, can do.

Is there a historical inevitability about neoliberalism that is beyond the capacity of international institutions, nations and individuals to solve? Do we just need to sit and wait until disaster strikes?

Perhaps not. Gavin adduces the example of the breadth and depth of community concern over climate change, another consequence of the same political economy in Gavin’s estimate, to argue that all is not necessarily lost or inevitable, that ordinary people, once energised and informed, can push for local, national and global change, even though the effort takes much energy and time. We can occupy Wall Street.

Jeffrey Sachs, from the Earth Institute at Columbia University and another economist and grand campaigner against global poverty and ill health although not of the Mooney stripe, ended his 2007 Reith Lectures that were an exposition of the crises of global poverty, inequality and unsustainability with a call to his audience to abandon cynicism in favour of engagement.

“You must be the peacemakers, development specialists, ecologists, all.” He said. “Do not lose heart. Remember, as John Kennedy told us, "our problems are manmade - therefore they can be solved by men [and women]." And remember what his brother Robert Kennedy reminded us.

“It is from numberless diverse acts of courage and belief that human history is shaped. Each time a person stands up for an ideal, or acts to improve the lot of others, or strikes out against an injustice, he [or she] sends forward a tiny ripple of hope, and crossing each other from a million different centres of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression and resistance.”

Grand speaking indeed, envisioning a collage of individual commitment, a new painting of community action. Gavin Mooney has urged us to return the formation and oversight of health policy to our communities and the citizens that comprise them realising that they – the communities and their citizens – are the ones we serve in health care when we do it best. That is a challenge indeed, but one that can be met, perhaps more easily and effectively in Australia than in many other countries.

Gavin, we are grateful to you for you scholarship, courage, insight, challenge and wisdom manifest in The Health of Nations and I am pleased to launch it on its journey.

*Speech from Gavin Mooney's book launch

PUBLIC-PRIVATE PARTNERSHIPS AND GOOD HEALTH*

This month a privately-funded Dragon reusable spacecraft aboard a privately-funded Falcoln 9 rocket launched from Cape Canaveral is scheduled to dock with the publicly-funded International Space Station. The Dragon is a potential replacement vehicle for the now-retired shuttle.  We are seeing similar public-private partnerships more frequently in the health sector.

Private-public partnerships (PPPs) in health are a form of procurement where private investment substitutes for public money when building and occasionally providing services in public hospitals or clinics.

The principal reason for considering a PPP is when cash for buildings and other capital works is scarce.  PPPs bring private investment into the project even though it is government-owned and the core services are usually, although not invariably, provided by government. The building is built sooner than if we had to wait for the money as part of the government’s budgetary cycle.

PPPs have an extensive and complex history.  The Council of Australia Governments (COAG) endorsed a National Public Private Partnership Policy and Guidelines in November 2008. There is an assumption in these detailed documents that PPPs are long-term contracts between government and the private sector ‘to deliver infrastructure and related services on behalf of, or in support of, government’s broader service responsibilities. They typically include both a capital component and an on-going service delivery component of non-core services.’

The best example in Australia at present is in the northern suburbs of Perth, the 500 bed Joondalup Health Campus and specialist medical centre, operated by Ramsay providing both public and private care. Its web site, http://www.joondaluphealthcampus.com.au/, describes a $393 million redevelopment ‘to enable us to continue to accommodate local needs [that has] already delivered a new Emergency Department, expanded Special Care Nursery with 16 neonatal cots and an upgraded Mental Health Unit with 42 beds.’

The COAG Guidelines argue that the central feature of a PPP is the government purchase of a private service that is delivered within a specified time. Service quality is central to the contract.  If this is inferior not only in quality but in quality, cost and timeliness to that specified in the contract, the government does not pay.  Government usually maintains direct control and liability for the provision of core services. 

Conversations with people who have had experience with PPPs in health convey two emphases. First, there is a massive amount of heavy lifting to be done in drawing up the initial contracts, both in writing them and reading them. The differences in values between the profit-oriented private partner and the welfare-model public provider must be described with crystal clarity and in excruciating detail.

The comprehension of both parties to what it is that they are signing up to must be assayed repeatedly.  Ambiguities left in contracts are like faulty tiles on a space shuttle.  It is later in the flight that the heat is on and explosions follow. Rush leads to botch to disaster.  Ideological glints in the eye, especially of neoliberal zealots on one hand and hungry bureaucrats on the other, indicate dangerous intoxication. Plasma ideology levels should be measured before any contracts are finalised.

Second, a highly expert degree of ‘contract surveillance’ and monitoring is essential throughout the life of the PPP to avoid little wobbles that turn into serious deviations from course.  Minor changes to the contracts, or minor defaults, can easily grow into huge problems.  Air New Zealand Flight TE 901 crashed into Mt Eerebus in 1979 because subtle changes made to the navigational computer by others went undetected by the pilots and 300 lives were lost. Absolute transparency in the management of the PPP contracts is essential.

When expectations do not mesh – as has happened at Sydney’s Royal North Shore Hospital where services to be provided in a new building do not work easily in the old – problems follow.  As reported by Channel 7, “Infrashore - the consortium responsible for the $1.1 billion public private partnership running the hospital - cleaning services subcontractor ISS Health Services and government body Health Infrastructure have been at odds over whether a significant increase in staff is needed and who should pay for it.” http://au.news.yahoo.com/local/nsw/a/-/local/13599557/commissioner-to-inspect-disgusting-rnsh/

So handle PPPs with care.  However much one may tut-tut about not having sufficient public money, especially capital, for public services, the fact is we don’t.  PPPs are among the less risky ways of continuing to run the services we wish to provide to the public while building new buildings. But, like nuclear reactors, beware meltdowns and tsunamis.

*Published in MJA Insight

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