We can't afford to ignore the need for efficiency

Archie Cochrane (1909-1988) was a Scottish doctor with a mischievous twinkle who turned his quantitative skills as an epidemiologist to the assessment of medical care, not simply to public health.  

He was a strong advocate for randomised trials.

There is now a Cochrane Library of critical reviews of published medical papers and a Cochrane Centre in Oxford that stand as a tribute to his efforts to sort wheat from chaff when it comes to medical practice. And there is a lot of sorting to do.

I recall hearing Dr Cochrane present doctor numbers and infant mortality data from Africa at a conference in London about 35 years ago.

The presentation noted a direct relation between mortality and the number of doctors in African countries: the more doctors, the higher the mortality.

His presentation caused an uproar. His interpretation was that in resource-poor settings, doctors suck up the resources for healthcare and practise specialised medicine in the big cities with nothing left for primary care in the rural setting.  

In a recent WHO report on the relation of workforce to health, it was said that, "Only 5 of the 49 countries categorised as low-income economies by the World Bank meet the minimum threshold of 23 doctors, nurses and midwives per 10,000 population that was established by WHO as necessary to deliver essential maternal and child health services."

It continued: "Some pregnancy-related services can be delivered by mid-level health workers. Community-based health workers can provide a number of life-saving child health services, such as immunisations and the management of non-severe pneumonia."¹

In Australia, questions can and should be raised about the effectiveness of what we as doctors are doing

This is not easily done. An awkward roundtable conversation between the high-profile Harvard surgeon and author Atul Gawande and three other senior clinicians about low-value care, posted online by the New England Journal of Medicine recently revealed the mixed feelings of clinicians.²  

MRI for back pain may be low value, but occasionally an unexpected spinal abscess will show up.

The roundtable acknowledged the Choose Wisely campaign from the American Board of Internal Medicine that has collated 60 lists of 300 recommendations from specialty groups about procedures in common use not judged to be of great value and even harmful.

The clinical ambivalence remained at Dr Gawande's meeting. However, there was acceptance at the close that services harming people need to be identified and their use eliminated.

There is an urgent need for each of us to move into critical appraisal mode about what we are doing.

There may well remain a lot of procedures where value is debatable but we should be able to identify the nonsensical things we do and stop, or be rationed with regard to the full spectrum of our activities, effective and otherwise.

Options? Our colleges and associations should convene working groups to address the question of efficiency in their own backyards, not their neighbours'.

A debate should be stimulated by Federal Health Minister Peter Dutton about efficiency goals in the health system - root and branch.  

Among 10 steps toward a sustainable, effective health system suggested by Steven Lewis, a health policy and research consultant from Saskatoon, at the Canadian Institutes of Health Research, is the following: 

"We must root out useless, burdensome and harmful service use ... The world's best systems ask not just whether something can be done, but whether it should be done. They get to the heart of why intervention rates inexplicably vary, and they clamp down on ineffective diagnostic or therapeutic procedures. 

"All financial incentives that reward both individuals and organisations for inappropriate and unnecessary care should be eliminated. Organisations that prevent health breakdown should be rewarded more handsomely than those that unleash the medical juggernaut to address avoidable failures. 

"It is preposterous to pay physicians more for scheduling multiple appointments to deal with a patient's needs than for addressing them all at once.

Likewise, turn off the tap that excessively rewards the routine use of expensive diagnostic technologies that have a low probability of changing diagnosis, management or outcome."³

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.

References
1. WHO: Achieving the health-related MDGs. It takes a workforce!
2. New England Journal of Medicine 2014.
3. IRPP Insight 2013. How to bend the cost curve in health care.

 

 

Leeder honoured for life of achievement

Published in Australian Medicine, 13 May 2014 https://ama.com.au/ausmed/australian-medicine-13-may-2014

The Budget War

Published in Australian Medicine, 10 June 2014 https://ama.com.au/ausmed/australian-medicine-10-june-2014

Budget deals massive blow to preventive health

The Australian National Preventive Health Agency has slipped into Hades as the tectonic plates of the National Commission of Audit's report and Treasurer Joe Hockey's budget shift and grind.

What a pity.

The agency was established in 2011. Let's be clear why it was a good idea, so that we can mourn its passing properly.

The major afflictions of our community are conditions such as heart disease, stroke, cancer, depression, and problems of bones and joints. None of these things are as preventable as whooping cough or polio, but the decline in heart disease in Australia in the past 50 years is deeply encouraging.

Through a combination of better treatment, less smoking and dietary change, we've more than halved death rates attributed to heart disease. Lung cancer death rates among men are falling. Lessening the effects of these disorders has a major preventive element in it.

The risks for heart disease relate closely to what we eat, how much we drink, our physical activity and more. Yes, these behaviours are ultimately matters of choice: we are, as George W Bush would say, the deciders.

But we're not really. The shopping environment influences what we buy. The advertising environment influences our purchases of alcohol. The economic environment determines where we can afford to live. Let's get real.

These are the shapers, the causes behind the causes. And we must attend to these things if prevention is to work.

Without legislation, we can kiss goodbye to tobacco control. Other countries label foods so people can work out which are the healthiest. New York City has legislatively eliminated trans fats from all prepared food.

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Set yourself a preventive agenda that seeks to achieve these lifestyle opportunity-promoters and you need strength, including at a national level. Individuals struggle to win these battles.

Groups such as the National Heart Foundation, cancer societies and others have been zealous. But the thought behind ANPHA was that it could become a counterweight to the big-time, burly avarice that drives health-destroying profiteering.

No wonder the alcohol industry will declare drinks all round in celebration when the bulldozers demolish ANPHA. Bewdy mate, drink up!

Most of the prevention that leads to a decrease in non-communicable disease is big picture, usually nationally. Unless the national goals are declared, states and territories are not able to prevent. Immunisation and epidemic control are similar. The track record of states acting without national leadership in relation to Indigenous health is not good.

The federal budget has purged the nation of several preventive mechanisms. The wiping out of ANPHA is the most visible. Second, the Preventive Health National Partnership Agreements have been broken.

These agreements included programs working with the states and territories to encourage better health at work.

But it is the politics of prevention that made ANPHA so important to our health future and so hated by those who wanted free rein to push their wares, no matter the health costs. "Get rid of food labelling," they beseech the government. "It infringes upon our liberty to sell what we want. Make health a matter of choice but diminish the consumer's capacity to choose intelligently."

Yes, ANPHA could support more research in prevention. From the perspective of big business, research is pretty innocent stuff and usually has little commercial impact. It's safe.

But when research becomes advocacy, that's when trouble starts. That's when those driven by profit start worrying, and when the political tectonic plates start grinding in response. Take tobacco as your example. Advocacy is what a national agency with muscle could do.

So, when ANPHA goes, that is what goes with it: the ability for an agency with clout to argue for changes that will help ensure a future in which it would be easier to choose to be healthy.

Instead, we are offered a research entity -- the Medical Research Future Fund -- that will search for cures in the future for illnesses that could be prevented today. What a weird business model.

Preventive opportunities in general practice will lessen as the specialty is hit with co-payments. We have no health policy from the Federal Government, so we are in the dark as to what they hope for the nation's health, what it believes its health state to be or where investment should be made.

So the Prime Minister is right in his assertion that prevention is a personal matter. Gone is the interest of the state in societal matters. Prevention as a national project is dead.

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 MJA.