Summit a chance to end nation's decades-long drinking binge

Published in Australian Medicine 25 November 2014

Ebola demands our full attention

The cheery and intelligent man who operates our local dry cleaning agency and I often chat. He has a son doing medicine, and last week, he was worried about Ebola.

He feared that casual contact in his shop or, in the case of his son, on the wards might lead to the disease.  

It made me realise that it is easy to overestimate community understanding of the basic facts about Ebola.

Not that as health professionals we know all there is to know about it - even the precise details of its transmission are uncertain - but sharing what we do know can help the public manage its anxiety.

And quality vigilance depends on good intelligence. So what do we know? The first good thing - and there are not many - is that over half the people who contract it recover.

It is less certain how recovery occurs and whether classic principles of immunity apply, but a 50% recovery rate is a lot better than we saw with HIV in the early years.

Medical care also helps. Fluid replacement and intensive care make a difference to survival chances.

Second, the disease thus far appears to spread through blood, sweat and other body fluids, especially the excreta of infected people, to those who touch them during life or death.  Airborne transmission has not been documented.

In theory, this means that enhanced infection control procedures can protect family and health professionals.

However, as of the end of October, about 500 healthcare workers had contracted Ebola and half of them had died, so protection as practised at present is far from perfect.

Third, we live in an age of brilliant technological possibility, so the search for a drug to treat Ebola or a vaccine to prevent it is likely to yield dividends quickly.

The most likely limits, with so few cases, will be political and economic, as the cost of developing a drug or vaccine may not be a good commercial deal. But the accolades that would come to the inventor of a drug or vaccine would be great.

Furthermore, technological fixes are not always expensive. As reported in the 27 October issue of the New Yorker, a recent competition run by Columbia University yielded several inexpensive innovations designed to assist in managing Ebola.

The competition, auspiced by the schools of public health, and engineering and applied sciences, was open to all students and faculty. Among them was an inexpensive hose that sprayed bleach foam rather than a solution, because unlike a bleach solution, with foam you can see where it has been sprayed. 

But there are significant endemic barriers to combating the virus in West Africa.

The impoverishment of the countries where Ebola has become an epidemic is a major limitation, both in the treatment of those with the disease and the control of its spread. 

Poverty means fewer healthcare facilities and medical supplies, which is why the military support offered by the US, with its sophisticated logistic capability, will make a huge contribution.

Last month, 4000 US troops with cargo planes stuffed with all necessary equipment and transport were deployed to Monrovia in Liberia as part of Operation United Assistance.

With that as a background, groups such as Médecins Sans Frontières and other NGOs' efforts will be enhanced by field hospitals and supply lines for IV fluids and material needed to care for Ebola patients.

Medical volunteers from Australia are also contributing to the Ebola effort ­- including supporting diagnostic laboratories that are hard-pressed to keep up in the affected countries, and are working with MSF and the Red Cross on the front line. 

This month, the Federal Government pledged $20 million in funds for the private healthcare company Aspen Medical to operate a 100-bed hospital in Sierra Leone that will be run by 240 healthcare staff, some of whom will be Australian.

The move came after weeks of public accusations by the AMA and NGOs that the government was not doing enough. 

However, until effective treatment and infection control measures are more widely implemented in Africa, the course of the epidemic is hard to predict.

I understand that the mutagenic potential of the Ebola virus is no match for influenza, but if its mode of transmission does expand to include airborne routes, the challenge of the epidemic would grow enormously.  

Figures published by the US Centers for Disease Control and Prevention say almost 5000 people in West Africa have died from the virus, with the number of cases in Sierra Leone and Liberia said to be doubling every 20 days, which means that by year's end, those affected will be approaching 1.4 million.

It is clear Ebola deserves our serious attention: just as we view the extremist Islamic State as a distant threat to Australian security, so too we should view Ebola.  

As for my friend the dry cleaner, when he asked if he should wash his hands after handling unfamiliar garments, my cautious (but not entirely rational) answer was, yes.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 17 November, 2014 http://bit.ly/16p4FTz

H2O: putting health on the global agenda

Published in Australian Medicine 28 October 2014
 

Stronger focus on drug side effects needed

Randomised controlled trials are the supreme method for determining whether a new treatment, frequently a new pharmaceutical, is superior to current best practice.

They were originally used in agriculture to assess the added value of a new plant or soil additive, but are now firmly ingrained in medical practice.

I recall 30 years ago, an eminent professor of surgery railing against randomised controlled trials, which he considered utterly inappropriate to determine the value of surgical interventions.

He wrote a scathing article in which he referred repeatedly and disparagingly to such trials as "agricultural statistics".

While the randomised controlled trial has given us the best possible evidence about the effects of new therapies for a range of conditions, especially cancer and cardiovascular disease, and have underpinned the evidence-based medicine movement, they do not cover the entire treatment waterfront. This is especially so in relation to side effects.

The way randomised controlled trials work is that they aim to find out how many patients need to be treated — either with the new therapy or the old — to determine if the new drug is better.

The expected improvement in cancer trials is small, usually less than 10%, and so these studies require larger numbers of patients to be sure that even the slightest difference in outcome can be seen.

Sample size calculations, therefore, are based on the detection of relatively rare events, such as a gain in life expectancy or quality of life.

But side effects are another matter. They often fall beyond the vision of the trial, or out of focus of its carefully calculated sample size.

Side effects may not occur for months or years after a trial has finished, or they may be so rare that the randomised controlled trial's sample size is insufficient to detect them, even if they occur during the trial.

With some medications, side effects are of huge importance — for example, if the trial is testing a preventive intervention such as immunisation, rather than a treatment for a serious illness where side effects may be tolerated.

Nobody wants to enter a trial feeling whole and well and leave it with a nasty side effect.

Publicity around claims of side effects from immunisation illustrate this point, and show how critical it is to be secure about the proposed preventive interventions.

Similar concerns surround trials of cholesterol-lowering drugs in very low-risk populations. Side effects can be hard to detect, and if the treated trial subjects are at low risk of the disease (such as an MI) that the drug is intended to reduce but then develop problems with, for example, muscle power, a hard-to-resolve problem arises. Witness the controversy around the Catalyst TV programs on exactly this topic.

So there is a sizeable challenge to be sure that we know what side effects occur, and brilliant randomised controlled trials will not necessarily tell us about rare and distant ones.

Currently, especially in the case of new drugs, the pharmaceutical company sponsoring the trial will have given serious thought to this matter and have in place systems to collect information about side effects.

Of course, it is not only in the context of randomised controlled trials that side effects occur and old remedies, especially in specific genetic subsets of the population, may cause rare problems. Often more information, especially long-term data, is needed.

An intelligence system to learn about possible side effects is far more feasible today than even 10 years ago.

The high degree of electronic connectivity that we all enjoy (and sometimes loathe) can put us in touch with agencies, such as the TGA, to report possible side effects at the click of a mouse.

Now the TGA has come up with an online reporting system for patients as it's concerned that the vast majority of side effects go unreported. Doctors report some and drug companies others, but for over-the-counter and alternative medicines, there have been no formal reporting pathways.

The TGA may easily be overwhelmed with side effect noise and it will need a good filtering system to detect the signals. But this is surely a move in the right direction; another step to ensure medication safety as well as efficacy as we continue to advance our capacity to prevent and to treat.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 8 October 2014 http://bit.ly/1BRzk91

 

Coming to terms with Ebola

Published in Australian Medicine, 30 September 2014

Stepping outside of health to be healthy

Published in  Australian Medicine, 2 September 2014.

How should we respond to the Ebola virus threat?

We Australians live in an exceptionally safe country compared with many others today (and compared with our own in times gone by) when it comes to serious infectious diseases.

Our immunisation programs have succeeded brilliantly against whooping cough, polio and the other diseases of childhood.

The basics of public health -- clean water and waste disposal -- are secure in urban and much of rural Australia. Huge gains in life expectancy have followed.

We no longer need the rituals and beliefs to comfort us as did families in Victorian England when the death of children from infections was commonplace. We are not a society facing the loss of 16 million deaths of combatants and civilians as happened in World War I, followed by about 50 million more who lost their lives from the larger scourge of H1N1 influenza in 1918.

Being unaccustomed to catastrophe, especially those due to infections, it is understandable that we are shocked and frightened by the current outbreak of Ebola virus in West Africa.

Well, even if we aren't ourselves, then at least a friend of mine is. This man, a retired, successful and highly intelligent businessman living in the north-east of the US, recently cancelled his summer holiday in the south of France.

You can read about the fascinating history and virology of Ebola on Wikipedia. The virus was named after the river in the Democratic Republic of the Congo (then Zaire) where it was first isolated in 1976. The current outbreak in West Africa is the first recorded for that area.

On 8 August, the WHO declared the outbreak to be an international public health emergency.

As of 21 August, the WHO reported there had been 2473 cases of Ebola virus in places such as Guinea, Liberia, Nigeria, and Sierra Leone, and 1350 people had died from the disease.

Infectious agents can kill in epidemics by being highly lethal and highly contagious. Highly lethal infections that are not contagious do not create epidemics.

Viruses that spread by airborne droplets such as influenza are highly contagious, but many forms of flu are benign because their pathogenicity is low.

It is only when a strain of influenza that has high lethality and is highly contagious -- such as the H1N1 influenza that followed World War I -- is circulating abroad that serious flu epidemics occur.

In the case of Ebola, there is high lethality associated with human infection. About half of the reported cases see the patient die due to massive cytokine disruptions to the vascular tree. But bodily contact, or contact with bodily fluids, is necessary for infection.

The Ebola virus does not mutate rapidly -- it's 100 times slower than influenza A and about the same as hepatitis B. If we could develop a vaccine, it would not be quickly out-of-date.

So what should we, in Australia, do? First, we need to ensure our surveillance strategies are sound and in place, concentrating especially on plane arrivals of people from West Africa.

Second, we need quarantined treatment facilities available to effectively manage cases.

Two US medical attendants, Kent Brantly and Nancy Writebol, who were exposed to Ebola while treating patients in Liberia were repatriated by air on 2 August to a special facility at Emory Hospital in Atlanta, built with the Centers for Disease Control. The US is thus taking seriously the possibility of treating patients with Ebola on its shores. So should we.

Third, we should, as a nation, contribute what we can to the advancement of scientific understanding of this threat, with an eye on antiviral therapy and vaccine development.

Australia's response has been appropriate to date, but we still do not have a national centre for disease control.

The surveillance networks that we have are generally adequate, but relatively informal and for a nation of our wealth, aspiring to international leadership, 'adequate' is not the word that comes to mind as an expression of appropriate ambition or responsiveness.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board, and editor-in-chief of the Medical Journal of Australia.

Published in Australian Doctor 26 July 2014 http://bit.ly/ZEx5FW

WHY CO-PAYMENTS ARE NOT ALL GOOD

In celebrating the one-year survival of the Abbott government former prime minister John Howard was reported to have asked why, if we have co-payments on pharmaceuticals, we should not have one on general practice. Five reasons stand out.  

First, the co-pays on prescription drugs stop poorer people from accessing to them. Ask general practitioners. Extending co-pays to general practice compounds rather than solves this problem.  

Second, seeing a doctor for a health worry is different to filling a script. A consultation with a doctor may dissipate the worry without further cost or action.

Third, a timely, uninhibited consultation for the first symptom – chest pain, let’s say – of a serious problem may save a life and nip the progress of a disabling illness. Co-payments diminish easy access for less affluent Australians to general practice

Fourth, a consultation may lead to preventive changes – quitting smoking, behaviour modification, stopping unnecessary medications – that are positive investments, not sunk costs.  Co-pays that inhibit preventive consultations diminish the chance of a healthy life.

Fifth, many general practitioners in poorer parts of the country who entirely bulk-bill do not have the financial systems to raise fees.  The logistics of collecting and remitting a co-payment could drive them out of business.

Maybe the co-pays on pharmaceuticals are a public policy error that permits gouging of pharmaceutical prices and diminishes the search for efficiency in drug supply. Rather than asking where else we can impose a co-payment, the question should be, “We don’t have co-payments on general practitioner bulk-billed consultations, so why should we have them on prescribed pharmaceuticals?’

By way of postscript, the current debate about how much the Medicare levy contributes to health care costs is informed by figures from the federal minister that are all wrong.

ASSESSING VALUE BEFORE DEMOLISHING

In the current confusion in health that has followed from a swath of defunding, abolitions, co-payments and diminished Commonwealth funding, it is easy to lose sight of the needs of the individual patient. 

Typically and increasingly, the people who need our health care have a combination of problems such as diabetes and heart disease requiring concerted attention from hospitals, community nurses, general practitioners and community-based specialists. We do not have the firm evidence to say how best to do this, and hence in NSW the state minister for health, Jillian Skinner, has allocated $130m over 3 years to test out alternate ways of achieving this end.  Recently Medibank Private and other private insurers have expressed interest in testing strategies using community nurses to achieve the best alignment of care for our typical patient.

One of the casualties of the federal slashing has been what was called a Medicare Local, an organisation established by the previous government to create an environment of support for general practitioners and the long-term care of patients with chronic problems.  Their function was patchy, as expected from new entities, but where they worked they worked well. But the decision was taken recently to scrap all 61 and start again, with different, fewer entities called primary health networks.  Demolition and rebuilding is an expensive hobby.

In NSW, where we have 17 hospital districts or networks, there were 16 Medicare Locals.  While the match was imperfect, you get the drift.  In places such as western Sydney, fortune favoured us and the Medicare Local and the hospital district covered the same geographic area – from Mt Druitt to the Hills to Parramatta and Auburn.  Good things followed in coordinating care and hospitals and community practitioners learning to work together – for the good of the patient.

The document that evaluates the Medicare Locals concedes the value of a one-on-one relationship but envisions larger organisations combining the roles of smaller Medicare Locals.  What a pity. We know from past experience that the size of the NSW health districts is just about optimal – make them bigger and they are a managerial nightmare; make them smaller and you lose economy of scale.  Each has a degree of local identity and that identity is reflected in the Medicare Locals that serve the community especially when the overlap is complete.

If the federal minister wishes to experiment with how to meet the needs of the patient with chronic problems, why not leave NSW as it is and try out different models in other states such as Victoria that has no fewer than 90 hospital networks.  Or Queensland.  He has encouraged private insurers to experiment so why not his own ministry? 

Tearing up the crop before it has had a chance to bear fruit is expensive and wasteful.  Even more so with Medicare Locals.  Of course many of them can benefit from more energetic and focussed management, but there is no monopoly on that.  Let the plants grow.  We’ll find out soon enough whether the NSW model – one Medicare Local per hospital network – is the best way to go or whether we have been trumped by the Victorians again. 

Anyone seen general practice?

 Published in Australian Doctor 5 August 2014 Pages 22-23.  http://bit.ly/1ltc3nw



THE FUTURE OF MEDICARE AND MEDICARE LOCALS

The Conversation Conference

August 13^th 2014

Recently-announced proposed budget changes bear heavily on the future of Medicare and Medicare Locals (MLs).

 

The element in the budget that I wish to concentrate upon today is what’s happening with the 61 Medicare Locals.  I have been asked to address three questions:

• The argument for ML reform - what has and hasn’t worked and what changes are needed?
• Will the reform of MLs work or will abolition be the only answer? 
• What do we see internationally that could be applied within Australia to alleviate the problems with MLs?

The argument for reform of Medicare Locals

MLs have been reviewed both with regard to their function by John Horvath and specifically with regard to financial management by Deloitte.

As one might predict, the financial management of these entities was found to be immature and often below par. As well, much diversity of competence and performance was found in function among the MLs. General practitioners complained about being excluded from MLs.  Some feared that they will take over their work.

 

In any case the reviews proposed abolishing MLs and replacing them with Primary Health Networks – PHNs – that have rather similar functions.  Although the reviews proposed there should be fewer PHNs than MLs, it emphasised the value of having MLs and Local Health Districts – LHDs – or Local Hospital Networks – LHNs – relate closely to one another.  Contiguity was seen as a virtue.  How this will happen is not clear.  In NSW we have at present 17 MLs and 17 LHDs. As John Horvath observed in his review “to be effective, boundary alignment with Local Hospital Networks (LHNs) is critical for engagement” but of course this will not be possible at the PHN level unless there are more, not fewer, PHNs than there were MLs.

Perhaps to overcome the mismatch between PHN and LHNs, each PHN will have a board, informed by a Clinical Council and a Community Committee for each LHN.  These committees will oversee the functions that MLs provide at present though it is clear that PHNs will not have a service role other than exceptionally.  The Clinical Council is intended to give strong voice to general practitioners who reportedly have felt excluded from many MLs.

 A transition to PHNs may not involve much change providing they remain the same size as the MLs.  In Victoria where there are 90 or so LHNs, things are not clear. In any case funding to MLs will cease next year.  As John Horvath says in his report,  “The role of the PHN is to work with general practitioners, private specialists, LHNs/LHDs, private hospitals, aged care facilities, Indigenous health services, NGOs and other providers to establish clinical pathways of care that arise from the needs of patients (not organisations) that will necessarily cross over sectors to improve patient outcomes.”

 

The argument for a name change is quite acceptable.  ML is confusing.  The argument for abolition and then reconstruction rather than managing the process of development of laggard MLs and learning from the ones that are going well is less obvious.  There is no contestable policy visible, just a budget statement. 

What has worked?  In western Sydney the Western Sydney Local Health District (LHD) whose board I chair has worked with the ML on six projects and has another important one under way. The ML does not itself provide the service.  Rather, it coordinates and manages the players.

Indeed, the function that the ML has proved most useful in managing in partnership with the LHD is the increasing load of people with multiple serious and continuing illnesses has been to link their care between hospital and community.

Our district encompasses a population of nearly one million people, 40% of whom were born overseas.  We include Parramatta, Auburn, and Westmead, Blacktown and Mt Druitt and all places in between.  We have our share of older people and those living with economic disadvantage.  There are three major hospitals – Blacktown Mt Druitt – BMDH – Auburn and Westmead (WH), WH being the largest and BMDH being redeveloped to become a major tertiary centre.  Lots of hospital admissions are of people in crisis with their chronic illnesses.

With special sponsorship from NSW Health we are currently constructing integrated care programs for people with a chronic health problem – heart failure, chronic emphysema or diabetes.  We are doing this in partnership with our ML.  We are devising ways to centre care on the patient by brining into formal relationship general practice, community health services, hospital out-patient and community specialist acre and hospital inpatient services.

This is aided by limited use of electronic records.  It depends on good will and negotiation.  It also depends on formal affiliations between the ML and LHD because our sources of funding are different.

   

These projects do not account for all that the ML does.  For example it has also helped organise out of hours general practice services in western Sydney and has partnered several prevention programs. It is active as a provider of continuing education for general practitioners and those in training.  

Is abolition of the MLs essential?

There has been no recent suggestion to reform MLs, just abolish them.  Any restructuring in the health service comes at a huge cost and serious disruption and that should be factored into the argument for it.

 

I am not as familiar with all aspects of the performance of MLs as the review committees, but I am surprised that the proposal for abolition and then construction of a group of organisations of roughly the same function was not available for contest before it became an edict in the budget.  I personally don’t think that the function of the MLs warranted wholesale abolition. They were young and we had hardly a chance to establish them. That is my point of view.  I could be wrong, of course.

 

But the move to PHNs will be expensive and now we have private health insurers wishing to contract with the federal government to provide PHN services.  How this will serve public patients is unclear.  It is true that in the US managed care transacted by private insurers has often achieved good outcomes for integrated service delivery. But I cannot see how that could be provided in Australia with its divided financial arrangements between states and commonwealth, public and private patients.

So, to western Sydney.  Our district encompasses a population of nearly one million people, 40% of whom were born overseas.  We include Parramatta, Auburn, and Westmead, Blacktown and Mt Druitt and all places in between.  We have our share of older people and those living with economic disadvantage.  There are three major hospitals – BMD, Auburn and Westmead, WH being the largest and BMDH being redeveloped to become a major tertiary centre.  Lots of hospital admissions are of people in crisis with their chronic illness.  Before the ML there were active Divisions of General Practice.

With special sponsorship from NSW Health we are currently constructing integrated care programs for people with a chronic health problem – heart failure, chronic emphysema or diabetes.  We are doing this in partnership with our ML.  We are devising ways to centre care on the patient by brining into formal relationship general practice, community health services, hospital out-patient and community specialist 

acre and hospital inpatient services.

This is aided by limited use of electronic records.  It depends on good will and negotiation.  It also depends on formal affiliations between the ML and LHD because our sources of funding are different. The features of this relationship that have meant it is a success so far as it has developed that I can identify include: 

1.  Managerial commitment and compatible, mature personalities of the executives of both LHD and ML – both share a belief that collaboration is feasible and desirable and a common goal of contributing to the health of the district.    

2.  Overlapping geography.  This is important in preventing dual loyalties and administrative confusion.  There is no space for playing one master LHD or ML off against another.  Although successes have been achieved in some MLs where there are more than one per LHD, reports of conflicts and sub-optimal performance are common.  We lobbied hard to have the ML boundaries set to be the same as those of the LHD and have never regretted it. 

3.  A common foe – the rising tide of chronic illness. 

Has this arrangement been optimal? When it comes to integrated care the answer is no, because factors we know to be critical in the achievement of integrated care are missing. But whether this is ground enough for abolition – especially when the proposed replacement does not, it seems to me, promise more that would enable truly integrated care to be provided – is extremely thin.

International models of relevance to MLs and PHNs.

If we take the fundamental task of MLs or PHNs to be to integrate care for patients with chronic illnesses, then we should look at overseas models.  Where integrated care works to reduce inappropriate use of hospitals there is one payer as at Kaiser Permanente’s managed care for six million Californians, and many of the McKinsey-supported projects in the US and the UK. Complete electronic data systems are used to assess clinical performance and health outcomes, guidelines and a keen interest is expressed in professional standards for all practitioners, with rewards and sanctions for achievement or non-compliance. The Veterans Affairs services in Australia bear close scrutiny as a model in this regard.  Pull any of these pieces out of the integrated care structure and the whole thing collapses.  I know of no examples of successful 

integrated care that have been unmanaged.

We have none of these necessary arrangements.  These qualities of successful integrated care are not within the power of general practice or a ML or PHN to achieve whether embedded in a Commonwealth-funded arrangement or a private insurance set-up given the way Australia funds health care though separate silos.  The initiatives needed to change this belong with the major state and federal health bureaucracies.

 

It is true that growing interest has been expressed by private health insurers in the PHNs and where they might play a role.  For example, Medibank and the WA and Victorian governments have proposed a trial of intensive care coordination 3000 patients with complex and chronic health problems. 2000 of the patients would be covered by Medicare and 1000 would in addition be privately insured.  Community nurses would ensure all patients are seen by their general practitioner within seven days of hospital discharge.  The interventions proposed have elements found in most efforts to integrate care and are not dissimilar to those found partially in many MLs. It is not clear whether the proposals can extent to what is successful in Australia through the VA or in the US through managed care.

So we have the foundations through the LHD-ML liaison to provide more appropriate care for people with chronic illnesses but no superstructure.  To drive towards optimality requires a common funding stream, tighter management of the process and a set of quality performance goals that carry incentives and sanctions.

These features are recurrent in the successful models of integrated care with which McKinsey and Co, a consultancy, have established in the US, England and Europe.  They are similar to what the King’s Fund, a health service think tank, in London also articulate, though in the NHS integrated care has not worked as well as hoped.  Tough, but if you want it to work, observe what the ingredients are where it does work.

The way forward

Integrated care is a necessary revision to the current model of disjointed care because chronic illness is coming to dominate our health care agenda and this cannot be done with optimal success when components of care are disconnected.

 

In moving to PHNs to replace Medicare Locals we can expect a year or more of disruption due to transitions and it remains to be seen what management assistance will be provided to the agencies, presumably including private insurers and existing successful MLs and maybe even LHDs/LHNs that contest to provide the services of a PHN.

 

The positive thing is that the need for integration is clearly recognised as is the role of the general practitioner.  These are good omens.  I do not know what process the federal government proposes to use to implement its approach to PHNs – we can only wait and see.  This is not an era in our political history where policy – either its formation or action that might be based on it – is obvious or strong.  But we can hope that gains made by many fledgling MLs will not be lost.

 

A call to action in the July 26 edition of the Lancet is especially apposite.  “Primary care needs to be reshaped to truly function as the most important pillar for people-centred health and well-being in the 21^st century. Primary care leadership needs to wake up and start a revolution.”

Is an annual GP fee the answer to paying for healthcare?

The uproar over the proposed $7 co-payment for bulk-billed general practice visits and pathology services raises questions about how we pay for healthcare more generally.

But serious discussion is urgently needed in regard to the billions that comprise the cake, rather than the thin icing of the new impost.

While I do it frequently, in my heart I know that there is little point in lamenting that Australia does not have a unified health financing system. It simply doesn't.

With the UK's NHS and managed care systems in the US such as Kaiser Permanente, the entire health budget is managed by a single health authority that can move money to where it is most effectively employed: hospital or community, prevention or care, private or public.

Instead, we in Australia have these compartments that each have their own lives to live, more or less independently. While that's not quite true, it is close enough.

Given the improbability of Australia shifting within the foreseeable future to a unified system of healthcare financing, we need to find small, doable things that achieve efficiencies (which, when defined properly mean effectiveness gains as well) where we can act.

A decade ago, I heard senior health service manager Dr Katherine McGrath, now consultant at KM Health Consulting Services, suggest that, given the rising tide of chronic illnesses that require continuing community-based care, it would be wise to consider a better way of funding services for these patients in general practice.

She suggested that an annual fee could be struck that would cover all the services provided by a GP.

Average fees are exactly that -- patients may require more or less service than the fee would cover but the end result should be even.

Of course, payment on this basis could be gamed, at least in theory, but there is hardly anything unique about that.

More positively, an annual fee might help those GPs who wish to develop and implement a preventive plan with their patients experiencing serious and continuing problems to do so.

Such a system could give more clinical freedom for the GP.

Dr McGrath made a second point: episodic, acute care is demonstrably well-managed within a fee-for-service system.

Occasional use of general practice would not need a system of payment based on repeated visits. Immunisation, common infections, even minor psychological upsets do not need continuing care.

"An annual fee might help those GPs who wish to develop and implement a preventive plan with their patients experiencing serious and continuing problems to do so."

The fee-for-service element of Medicare would remain unchanged.

This hybrid arrangement may be politically workable. A change to annual fee-for-service for chronically ill patients would need careful scrutiny to ensure that unforeseen side effects don't mean that it is more trouble than it is worth.

Such a proposal was advanced three years ago for the management of patients with diabetes in Australia and the results of pilot testing have not yet appeared.

The development of this method of payment would need careful handling and would be unlikely to succeed if imposed from above.

But it might enable the development of different ways of caring for these people, based more on their needs than now, with flexible arrangements about how they could be seen and when.

For example, a special channel for patients with chronic problems might be opened in a general practice where they simply turn up if they need help or reassurance.

It is possible that practice nurses and others could play an expanded role in their care. Recent US studies on the medical home -- a form of patient-centred general practice -- have been encouraging.

The debate about how much a patient pays at the time of receiving care vs how much they pay through their taxes when they are well will not solve our current set of healthcare financing challenges.

The current administration of Medicare is already dauntingly complex and the co-payment will add to that complexity.

We need to test new ways of paying for care in the community for patients with serious and continuing illness.

These forms of payment will serve patients and the profession best if they stimulate improved ways of providing care in continuity, new ways that come from imaginative thinking by the doctors who provide this care.

Their leadership is essential.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.
 

Published Australian Doctor, 23 July 2014.

 

MJA CENTENARY – OPENING ADDRESS

Stephen R. Leeder

Editor-in-Chief

July 4^th 2014

The University of Sydney Great Hall

Welcome

This is a grand day and one to be savoured.  I am delighted to welcome you to the University of Sydney for this centenary celebration. I thank deputy vice-chancellor Professor Shane Houston for his warm and dignified welcome on behalf of the original custodians of this land, the Gadigal people of the Eora nation.

I also welcome Associate Professor Brian Owler, national president of the AMA, his predescessor Dr Steve Hambleton, Ms Anne Trimmer, secretary-general of the AMA and Ms Jae Redden, general manager of AMPCo. I also want to acknowledge  my editorial, journalist and production colleagues from the Journal and from MJAInSight, and our support staff in commercial development, human resources, finance, business development and information technology who work together to make the Journal a success.

I acknowledge members of our Editorial Advisory Committee who give us strong and careful guidance and to our many colleagues who send material to us, our reviewers and our commercial sponsors.  I also thank our splendid array of distinguished presenters.

I am immensely grateful to Dr Richard Smith, a former editor of the British Medical Journal who has demonstrated in his subsequent global health career that there really is life after being an editor, who comes as our master of ceremonies for today’s symposium and this evening’s dinner.  Richard will shortly describe to us the order of proceedings.

The organisation of today has involved a joint effort by many members of our MJA team, especially Zane Colling and Mel Livingstone. Denise Broeren of Think Business Events, Laissez-faire Catering and DJW Projects for AV also deserve great appreciation.  And finally I want to acknowledge and thank our sponsors who have been generous in their support.

Origins

I want first to speak briefly about our origins as a journal then mention several high impact papers that the Journal has published, then consider what one hundred years of Journal publication means beyond the effects of individual papers.  I will conclude with a glimpse of where I believe the Journal is headed.

When I was approached about the editorship of the Journal 18 months ago, Steve Hambleton, who was then national president of the AMA and chair of the board of the publishing company, talked with me about an event to mark the one hundredth birthday of the Journal. 

I have wondered whether in approaching me Steve had in mind that I was of an age where I had a natural empathy for older things. Indeed I can boast of having read and contributed to the MJA for half its one hundred years – admittedly the latter half – so it’s true that I know a bit about it.   

The Medical Journal of Australia emerged in 1914. We can thank Dr Cumpston, the father of public health in Australia, whose achievements are celebrated in a wonderful book by Milton Lewis, the editor of our centenary supplement, for providing a short history of the ten principal forerunners of the MJA between 1846 and 1914. These were attempts to foster communication among the medical profession in the colonies. The Australian Medical Journal, the MJA’s immediate forerunner, operated impressively from 1856 to 1914.

Cumpston notes that in the absence of a medical Journal, medicos had to resort to newspapers to publish their views. He refers to an article published 110 years before the first issue of the MJA in the October 14, 1804 edition of, The Sydney Gazette and New South Wales Advertiser Australia’s first newspaper.

The article was by one Dr Thomas Jamison and was the first on a medical subject published in the public press of Australia.  Dr Jamison had a lot to say about smallpox vaccination in Australia.  He admonished parents who mistook chickenpox for smallpox.  “There is no smallpox here”, he said, “save for few cases spread among the natives by French ships anchored in Botany Bay”.

But he warned that it could come and ‘carry off nine-tenths of those affected’. “Look at the Cape of Good Hope”, he said, “on the same latitude as Australia, where smallpox is rife.”  He urged parents to have their children vaccinated because “the preventive qualities of the Cow Pock are incontrovertibly established; [and] it is attended by no sort of danger or external blemish.”   

”Therefore,” he thundered, (quote) “should parents delay to embrace the salutary benefit now tendered gratuitously and the vaccine be lost, the most distressing reprehensibility may accrue to them for their remissness in the preservation of their offspring, whose destruction heretofore may be reasonably apprehended to ensue from the smallpox should it ever visit this colony in a natural state.” This is a style cultivated by relative few contributors to the MJA today.  Jamison’s letter is able to be viewed in the University of Sydney Fisher Library archives.

Editors

I stand before you, the 16^th regeneration not of Dr Who but of the editor of the Medical Journal of Australia. The first three Doctors occupied 63 years of editorship. and passed the torch to the 13 of us who have followed.  But the 13 who followed, rather like the Australian cricket team often is in India, have not lasted long save for Martyn Van Der Weyden, who was a wag in the tail of the team, so to speak, for 15 years.  My immediate predescessor Annette Katelaris was editor for eleven months. Her contribution was both controversial and transformative.

High-impact publications

How should we judge the effect of the Journal? The social media savvy amongst us will know that clout is measured by clicks. For example MJA.com.au averages 400,000 clicks per month and nearly 200,000 from clickers who click and stick to read.

But citations remain the royal currency in Journals. In our centenary issue of the MJA, Dr Diana McKay, one of our medical editors, used the Web of Science citation analysis tool to examine popularity of articles published in the MJA from 1949 to 2014 by citation.

Safety

First ranked is the 1995 Quality in Australian Health Care Study by Ross Wilson, Bill Runciman, Bob Gibberd, Bernie Towler and John Hamilton, a reprint of which you will find in your symposium satchel. I am delighted that Bill and John are with us today.  I have heard them both lecturing recently and twenty years has only improved their vintage. 

Their paper demonstrated the shocking potential and moral imperative to improve the quality and safety of hospital care. It prompted the Australian Government to form the Australian Commission on Safety and Quality in Health Care launched in 2006. The Commission’s recommendations were written into legislation with the National Health Reform Act 2011. The paper also ignited international interest with replications of the study internationally, including by the WHO in developing countries.

Ulcers

Ranked 2^nd and 3^rd are two papers by Barry Marshall, a Nobel Prize-winner, on pyloric Campylobacter.

In our Centenary issue, Barry Marshall reflects on his work in an article titled “What does H pylori taste like?” He describes “the deliberate self-administration of Helicobacter pylori and the observation that it caused an acute upper gastrointestinal illness with vomiting, halitosis and an underlying achlorhydria.” 

He remembers the audacity of my predecessor as editor, Alistair Brass, and being (quote) “impressed by how far the MJA Editor was ‘sticking his neck out’ in allowing me to publish a hypothesis as to the cause of peptic ulcer”. Both of them lauded and lamented the beating the paper took from reviewers to get it into its final published form.

Lithium

The next most popular paper is probably the most widely recognised, described once as a “jewel in the crown” of the MJA. Professor John Cade’s article “Lithium salts in the treatment of psychotic excitement”, published in 1949, held the Journal’s most-cited paper position for decades. To this day, lithium retains “its royal status in clinical practice guidelines”. Gin Mahli, a Sydney psychiatrist, writes. “Lithium is arguably the best agent for the most critical phase of bipolar disorder, long term prophylaxis and as such it is the only true mood stabiliser. Put bluntly, it works”

These papers and many more have had good and immediate effects.  Some take a while.  Recently I read a paper written 60 years ago on drink-driving.  The writer, Dr F S Hansman who had an interest in the biochemistry of alcohol, had asked doctor-colleagues at what level of alcohol consumption did they consider their driving to be impaired.  “After two whiskies or less”, 90% of them said.  Dr Hansman found that this corresponded to a blood alcohol of 0.04.  It took 23 years before random breath testings using a standard of 0.05 became law.

Going deep, beyond the published papers

Beside recording scientific advances for immediate or deferred application, the MJA serves another splendid function.  The one hundred years of the Journal comprise a superb record or memory of medical achievement and of the people who made it happen. 

Hilton Als, an American novelist, theatre critic and staff writer at The New Yorker, gave a commencement address at Columbia University in NYC on May 21 this year to the graduating class of the School of the Arts. Als called his address Ghosts in Sunlight. You will find it in the July 10 issue of the New York Review of Books. 

Als’ address takes its title from an essay by Truman Capote published when he was 43.  Capote’s essay, Als told the graduating students, describes Capote’s experience on the set of the first film adaptation of his 1966 best-seller In Cold Blood. This was a non-fiction novel about the 1959 murders of Herbert Clutter, a farmer from Holcomb, Kansas, his wife, and two of their four children and the murderers.  Some of you may have seen the recent version of the film.

Ghosts in sunlight

Capote found his encounter with actors who were developing and forcefully portraying real characters from his book – victims and murderers – deeply disturbing.  Capote described how he felt he was watching ‘ghosts in sunlight,’ as the characters he had written about had come back to life.  

I doubt that we will find anything quite as exciting as In Cold Blood when we thumb through the archives of the Journal, but we can easily become absorbed reading the stories of the science and clinical practice and health policy of past years and as the characters come back to life in our imagination.

It can be disconcerting to revisit those memories, to revive the ghosts in the sunlight of our moment.  It can be disconcerting to read reviews of the science of ailments such as obesity that have hardly changed in fifty years and of other conditions, such as heart attack, that have changed radically.  Stories of sepsis in the pre-antibiotic era are frightening.  Yet understanding what progress we have made or failed to make can change us, change our views, and stimulate our imagination.

I hesitate to answer questions from well-intentioned inquirers when they ask which papers in the Journal changed medical practice.  It is a perfectly proper question, and I have referred already to a list in the centenary issue of the Journal of the ten most cited papers. 

But above and beyond those papers with their tangible achievements and changes to how we do things, though, is the marvellous artistic process, the alchemy, by which the stories and memories and encounters contained in those hundreds of thousands of pages came about.  This is the story behind the story, if you will.

The hard work of science

Scientific achievement as recorded in the MJA is always hard won. I spent 1963 working with John Pollard on a neuroscience research project at this university in the pharmacology department as part of a BSc(Med). We were in search of the elusive transmitter substance between the optic nerve and the lateral geniculate body in cats.

We did not find it. Indeed when we presented our finding of a stimulant in extracts of sheep optic nerves that made smooth muscles twitch and which we could not characterise and wondered if this was the transmitter it didn’t work. 

When we presented our findings at a neuroscience conference, Sir John Eccles chaired our session and told the audience that a colleague had found a similar substance in extracts from his socks after a brisk game of tennis.

In returning to complete my medical degree I recall opening Cecil’s textbook of medicine and thinking “Every line in this book represents a research worker’s life.”  The ghosts were clear in the sunlight. 

In the commencement address I have been referring to, Hilton Als quotes Caribbean-born writer Jean Rhys who said that: “she considered her writing to be the tiniest stream. But without those streams, there would be no ocean, and if there is no ocean there is no shore, and if there is no shore there is no place for our ghosts to gather in the sunlight, those artistic forebears who wave us back to dry land when a project seems beyond us and we lose our way, which is at least half the time.”

Neils deGrasse Tyson,

an astrophysicist and science communicator at the Hayden Planetarium at the American Museum of Natural History in NYC, in his TV series Cosmos puts it another way: “Science is a cooperative enterprise, spanning the generations. It's the passing of a torch from teacher, to student, to teacher; a community of minds reaching back to antiquity and forward to the stars.” It is the background culture and society of medicine and medical research that you will find in the MJA that can be as informative and stimulating as individual papers and articles.

Lessons from the ghosts

The ghosts of the practitioners and scientists can change us, too, even now, even when we know that past proposals were often wrong, that many of the lines of inquiry led nowhere really.  They can help us toward humility; they can help us see how we, too, like the authors of the pages that we turn, are creatures of our time. 

They can make us tolerant of the false starts, of the well intentioned failures, even of the pomposity of our colleagues.  (‘What’s good for doctors’, opined the first editorial in the MJA, ‘is good for the community!’ Ahem!)  Ghosts can also frighten us: Capote writes about having to take a bottle of scotch to bed to obliterate the ghosts of the characters of his book from his consciousness.

When all of the issues from 1914 the MJA are digitised, as we plan them to be when we have raised the $70K for that purpose (hint, hint), exploration of the past and encounters with its ghosts in the sunlight will be a possibility for all, anytime, anywhere. 

Glimpsing the future

Today we celebrate a unique record of medical memory in Australia that stretches back 100 years.  This can be a day to renew our quest for sounder medicine, for safer and better patient care, for new insights into preventive possibilities and indeed to recognise and manage our own humanity and frailty and proneness to error with gentle acceptance.  The ghostly values can warm and correct us and set our hearts racing.

The MJA has a bright future if we maintain our deep respect for science, for imagination and humane concern for our patients, the profession, and society and indeed for everyone in the organisation that contributes to the Journal.  As we look to possible futures of the Medical Journal of Australia, we need to be open to the unbidden, the unplanned, and the serendipitous that is never completely captured in a strategic plan. 

We are in the middle of the most exciting explosion of knowledge in human history, with multiple media to communicate and sift it. These dynamics will affect the form and style of the Journal and even its ethics. The format of the Journal will need to become more attuned to contemporary ways of communicating, the content more flexibly responsive to the needs of our diverse readership through electronic tailoring and streaming of content to them where and when they need it.  Already we have a substantial presence in the social media and this will grow.

To remain a trusted instrument of record, where contemporary medical knowledge and reflection is written carefully and history is recorded, that will require all our skill and imagination about new and efficient ways of communicating through multiple media. 

That is what we at the Journal are committed to doing and we thank all of you for your continuing support as we move into our next century.