Evidence alone won't change what doctors do

Published in Australian Medicine 11 November 2015 http://bit.ly/1XtfkFt

Good for the economy while good for your health

Published in Australian Medicine 19 October 2015 http://bit.ly/1TphwIm

Academics must cut the tentacles that threaten to strangle them

Mark Robertson’s reassurance that all is well in the world of academic publishing save for the occasional misunderstanding (HES, October 7) takes no account of widespread dissatisfaction within the research community, universities and academic libraries.

Robertson asserts that Wiley, an international publisher for which he works, reported a profit of only 11 per cent most recently. Like any international company it is difficult to know from financial statements pertaining to activities in Australia what the overall profit was. For example, based on research for her PhD, Canadian academic Heather Morrison provided details of the enormous profits of several large scientific, technical and medical scholarly publishers.

She quotes profits as a percentage of revenue for commercial STM publishers in 2010 or early 2011. These include Elsevier with profits of $1.5 billion on revenue of $3.4bn, or 36 per cent; Springer Science+Business Media, $636 million on revenue of $1.9bn (34 per cent); John Wiley & Sons, $106m on revenue of $253m (42 per cent); and the academic division of Informa with profits of $100m on revenues of $313m (32.4 per cent).

Profits from academic publishing are immense, provoking widespread anger in universities, their libraries and research organisations. The Dutch government is in heavy conflict with Elsevier, a Dutch company, because of the huge payouts demanded for subscriptions to journals that it publishes. These are not minor misunderstandings but serious battles.

The business strategy adopted by the major publishers of scientific and scholarly writing is brilliant.

New knowledge generated from research is paid for from the public purse through research grants and academic salaries. ­Academics then give away their ­intellectual property to the publishers of their papers instead of licensing it. They then provide free peer review.

While a portion of intellectual property could justifiably be assigned to publishers, new knowledge should quickly become available to the sponsoring public and it doesn’t. Instead, much essential free scientific water is bottled by publishers, then sold without compensation to the digger of the new well.

Simple diagnostics, however, do not apply. The publishing companies have found in universities a hunger for numerical data to measure performance.

The metrics of publication — how many times your paper has been cited and the prestige or impact factor of the journal you publish in — are used to judge you as an academic. Aggregated, the same metrics measure the performance of your institution.

High-ranking universities attract more international fee-paying students. Academics acclaimed on these metrics gain promotion and preferred employment. Governments with no incentive to comprehend the complex social mission of universities beyond the publication metrics use them by default to determine university support. The system is closed and incestuous — and who can blame the publishers for making money from it?

The plot thickens. Online publication has displaced print and accelerates the dissemination of new knowledge. Academic publishing has seen its share of shonky start-ups that have crashed and burned. The large established publishers have done deals with small academic associations and specialist journals that have kept their parents alive. The associations have found these arrangements to be financial havens and bless the publishers for their good fortune.

The medical profession has passed this way before where the largesse of pharmaceutical companies has supported research and paid for conference travel. Publishers claim that when they take over the production of a journal they assure editorial independence. It is true that they take no interest in the content of the journal, and why should they? But independence of research workers suffers when their intellectual produce is commodified and ­sold as part of a commercial ­enterprise.

The unfettered quest for new knowledge is crucial for innovation and progress. But academe and the research community have willingly embraced the octopus whose metric tentacles now threaten to strangle them.

Assuming that Malcolm Turnbull is serious about innovation, which depends critically on new knowledge, the Prime Minister would do well to inquire into how new knowledge is made, or not made, freely available.

Australia could lead the world by insisting on open access and the decommodification of all new knowledge.

Now that would be innovative.

Stephen Leeder is emeritus professor of public health and community medicine at the University of Sydney.

Published in The Australian November 4 2015
http://bit.ly/1MgQB01

Western Sydney is an amazing place with truly remarkable people providing health care.

WSLHD – ANNUAL PUBLIC MEETING – 2015

WESTERN SYDNEY – AMAZING PLACE!

Stephen Leeder

Chair of the WSLHD Board

I add my acknowledgment to those already expressed of the original custodians of the land and their elders past and present and I welcome people who identify as Aboriginal people here today.

If western Sydney issued its own number plates, what might be the motto?  South Australia has The Festival State.

 

But look where that led.  The grand prix used to be held in Adelaide but was moved to Melbourne because in Adelaide the drivers kept falling asleep.

No risk of that here!  The growth of western Sydney is amazing!  The increase in population is amazing!  The diversity of our population is amazing – so many cultures to guide us and enrich our life if we open to them and embrace difference!  The bonds among our citizens to one another area amazing as we see in our hospitals and schools and sporting organisations, in social clubs and religious groups! So how about Western Sydney: Amazing Place!?

 
 


Just look around – this amazing building that enables Western Sydney University to train doctors and nurses was not here a decade ago.  The new hospital building is amazing.  Mt Druitt is changing and developing rehabilitation services in amazing ways. The Millennium Research Institute’s new building at Westmead won the Sulman prize for architecture this year.  Pretty amazing!  Auburn Hospital and its community services have developed amazingly with the stimulus of the University of Notre Dame Australia.  Community health services are adapting to the needs of people with chronic problems to provide care and support.  The development of the Primary Health Network, building on years of work with our general practitioners and WentWest, has been critically important and amazing. 

Our biggest challenge at Westmead is to ensure that the hundreds of millions of dollars invested in the upcoming Westmead Precinct inspire our services to match their efforts to the health needs of western Sydney in ten to 20 years’ time. 

We have had amazing support from our state politicians, especially Premier Mike Baird and Minister Jillian Skinner. We have enjoyed steady backing from our local politicians – federal, state and local government – as well.  We now also have a federal minister for health and a prime minister committed to innovation and growth.  The ministry of health headquarters at North Sydney, especially Health Infrastructure, have been a huge help on this campus, Mt Druitt and at Westmead as has the secretary, Dr Mary Foley.

None of this would have been possible without the leadership from Danny O’Connor and his amazing executive team.

Now all of these amazing things will help make western Sydney an Australian leader in health care.  I’m also happy that we are helping the Australian economy to grow.  I hope Mr Turnbull notices! 

As you can’t improve productivity without bright new ideas about better ways of doing things, so research and education, which is where these ideas often originate, are critical.  We invest in both alongside clinical care.  We are members of a new partnership with Children’s Hospital, our research institutes, the local health districts of Sydney and North Sydney and the University of Sydney to ensure that what comes out of research is rapidly applied to clinical problems and that the research agenda makes sense to clinicians and the community.

Sometimes we’re told that we are a huge cost, but we could say that in fact we are a really big investment. Think of the thousands of jobs we create. We are already amazingly productive, especially when you see how we apply new technologies and perform so much additional work each year at a highly efficient price.

But our primary function is to care for people in need and to find practical and feasible ways to assist our citizens to experience the best possible health. This requires us to take hold of the hands of other social agencies such as education, community services, transport, and planning to advocate for better and safer environments, more walkways and parks in our suburbs, more community interaction, fewer liquor outlets and easier access to fresh food.  No other way exists to deal definitively with the massive problem of diabetes.

We have the motivation – it is one of our most impressive qualities – and it never ceases to amaze me how dedicated and committed our staff is to our central purpose of helping people who are sick and searching for preventive opportunities. 

Yes, we have challenges.  We have a long way to go in meeting the mental health needs of our population. Recent turmoil at our Aboriginal Medical Service needs steady hands, cool minds, compassionate hearts and deep involvement from our Aboriginal community to set straight. We are working on bringing together all the care needed by people with multiple chronic illnesses.

We are humans, not robots or automatons, and so we make mistakes – occasionally devastating – through ignorance or insensitivity or inattention or overload or prejudice. These mistakes damage our patients and our staff.  As a healing, caring organisation we do two things in relation to those mistakes. First, to those we have hurt we seek to offer support and our apology.  Second, then we set about to learn from our mistakes.  We seek constantly to improve the quality and safety of our organisation. Our quality awards recognise people in our organisation who have excelled in this pursuit.  

Although torn by events such as the recent Friday shooting in Parramatta and the persistent problems that lie beneath the surface of that event, there is much about the steady, humane concern of our district that heartens us.  This is Carers’ Week throughout Australia.  Think of all the care given by families and individuals in our community to the thousands of people with disabling chronic illness and frail older people and young people with disabilities.  As I found in a research study in which we interviewed people with chronic illness in western Sydney, family, neighbours and friends provide most of the care and support these people receive. 

Take the response of our community to the possibility that additional refugees from Syria may soon be offered a home with us.  Think of the community groups Professor Zelas has identified that have quietly set about planning how they will help and what they will provide for these weary people.  Western Sydney – amazing place?  It can also be a place of amazing grace.

There are many items on our agenda for the coming year.  With so much on we can easily lose sight of our central function – helping those who are sick to get back to the maximum level of health within their limits and helping shape the environment so that is easier for all our citizens to make healthy choices.

Today I am speaking on behalf of your board.  We are all immensely proud of our workforce – managers, maintenance crews, volunteers, medical, and nursing, research, education and support staff.  We admire your commitment, your humanity, your proficiency, your professional investment in making our district such an amazing place.  The board knows also how much we depend on the support of this fabulous community.  In turn, we want to support you as best we can. 

So on behalf of your board I say thank you for all you do with us, for us and for the community of this amazing place called western Sydney.

General practice and the rise of chronic illness

Published in Australian Medicine 21 September 2015

Home is where the chart is

I thought molecular biology was complex until I recently ventured into the world of etymology in search of the origin of the word ‘home’.

If you share my interest in this topic, then please take a look at the Oxford University Press blog by Anatoly Lieberman¹, a multilingual 78-year-old teacher of etymology, linguistics and folklore at the University of Minnesota.

He begins with a scholarly and intricate exploration of the words ‘house’ and ‘home’ by writing: “When it comes to origins, we know as little about home as we do about house.”

Perhaps because of the mystery surrounding the origin of the word home, it is powerful, and we need to be careful how we use it.

So, what does it mean?

As Verlyn Klinkenborg, an Iowan non-fiction writer of rural literary meditations, wrote in the Smithsonian magazine in 2012:

“Our psychological habitat is shaped by … the magnetic property of home: the way it aligns everything around us. Perhaps you remember a moment, coming home from a trip, when the house you call home looked, for a moment, like just another house on a street full of houses. For a fraction of a second, you could see your home as a stranger might see it. But then the illusion faded, and your house became home again. That, I think, is one of the most basic meanings of home — a place we can never see with a stranger’s eyes for more than a moment.”²

Despite the word having such an uncertain origin and complex meaning, there’s currently much discussion within general practice about the idea of the ‘medical home’, which is portrayed as an attractive place, not to be confused with a nursing home or an institution for the residential care of people with severe disabilities. But not everyone with whom I have spoken likes the concept.

One such person said to me: “Frankly, I find the idea creepy. It seems to be appropriating an idea (home) that implies warmth and comfort and security to refer to a place where you go when you are ill, insecure and frightened.”

Related News:

• CDM items tied to 'medical home' under RACGP plan
• Primary embraces 'medical home' model
• Govt launches discussion on future of general practice

Where has the medical home concept come from? According to Wikipedia, it was first articulated by the American Academy of Pediatrics in 1967 to offer co-ordinated care for children and their families, especially those with special needs.

The idea has since gathered support.

Now there is a list of qualities that medical home practices must demonstrate in order to be accredited. According to the rules, they must be places where each patient has their own doctor who leads a multidisciplinary team that can meet the individual needs of the patient.

High standards of quality and safety must be adhered to, and performance is formally assessed against these standards. Payment “appropriately recognises the added value provided to patients who have a patient-centred medical home”.

Put simply, the medical home is a place where a patient is known personally by name and history and where a team of health professionals, generally led by a GP, arranges and provides the patient with the care they need.

Related Opinion:

• There's no place like (a medical) home
• Home is where the heart is

At its best, it is about knowing the patient, honouring their identity and knowing their unique health and illness profile and then building on that knowledge whenever a medical transaction takes place.

Going beyond the group practice, the medical home is designed to bring together professionals from different disciplines.

Yet, where a group practice adds in a nurse and other health professionals to meet patients’ needs, in a medical home (at least as formally defined and not as an indefinite and warmly fuzzy idea), these services are more formally organised and paid for.

This has special salience for people with multiple long-term problems, who make up around 30% of the general practice patient population. But we need to be careful because attractive concepts — such as co-ordinated care, which has been trialled here over recent decades — can be disappointing.

There are other issues too, such as the successful co-ordination of carer services, both in hospital and at home. This is a serious management task, and not many doctors have undergone the necessary training to take on this role.

Hospitals are in a relatively strong position because of their infrastructure and range of specialties. For a GP, matching this level of service is going to be extremely challenging, unless he or she has a back-up organisation, such as a group practice.

So by all means, let’s discuss the medical home as a way to provide better personalised, stitched-up care. But let’s be careful: powerful words misused have a habit of coming back to bite you. Beware of overpromising and trampling on sacred ground.

Professor Leeder is Emeritus Professor at the Menzies Centre for Health Policy at the University of Sydney.

References:

1. Oxford University Press blog 2015; Our habitat: one more etymology brought “home”; Anatoly Liberman.
2. Smithsonian magazine 2012; The definition of home; Verlyn Klinkenborg.

Published in Australian Doctor 28 September 2015

Dreaming of how things might be

Published in Australian Medicine 27 August 2015 http://bit.ly/1O4QDGR

Recent interview with ANU students about medical publishing.

Here is an interview with ANU students about medical publishing that may be of interest.
http://bit.ly/1EMOfz5

Gilead's Greed that Kills - Jeffrey Sachs - July 27 2015

Gilead's Greed that Kills

 Jeffrey Sachs

 

July, 27, 2015.

Gilead Sciences is an American pharmaceutical company driven by unquenchable greed. The company is causing hundreds of thousands of Americans with Hepatitis C to suffer unnecessarily and many of them to die as the result of its monopolistic practices, while public health programs face bankruptcy. Gilead CEO John C. Martin took home a reported $19 million last year in compensation--the spoils of untrammeled greed.

Hepatitis C is a global public health crisis, called a "viral time bomb" by the World Health Organization. 150 million people or more worldwide are estimated to be living with the disease. Untreated Hepatitis C can progress to cirrhosis, liver failure, and liver cancer. Every year, at least 700,000 people die from these complications--although HCV can be easily cured with just 12 weeks of medicines being sold by Gilead.

Gilead insists it is saving lives. It claims that it is a hero of innovation, bringing new wonder drugs to the market to cure Hepatitis C, an often-lethal disease that infects almost three million Americans and perhaps 80 million or more people worldwide. The company certainly could be a hero, but is the opposite today. Gilead is the main obstacle between tens of millions of very sick individuals and the medicine that could end their suffering and save their lives.

Gilead owns the monopoly patents on two life-saving Hepatitis C drugs, Solvadi and Harvoni. Gilead did not discover or develop these drugs, except for a brief and modest role at the end of the drug-approval process. Gilead bought these drugs from their discoverers and developers in 2011, after a decade-long discovery and development process, and just before the FDA licensed the drugs in 2013. It bought them with the knowledge that it would use its greed and lobbying power to rip off the American people and deprive people around the world of the benefits of these wonder drugs.

Gilead's gambit worked like this. The US Government funded most of the basic research for Sofosbuvir, the scientific name of the drug that underpins Gilead's two brand name drugs. Yet despite Sofosbuvir being discovered, developed, and tested through phase 2 clinical trials mainly with US Government funds, the government-funded scientist and some early investors took the patent rights. Their private company, Pharmasett, had invested less than $200 million in R&D. In truth, the US Government should own most of the intellectual property on Sofosbuvir, but under U.S. law and practices it is private investors who reap the rewards and taxpayers who bear the burden and the consequences.

Gilead paid Pharmasett $11 billion because it knew very well that it was about to rip off the American people and quickly recoup this sum and much more. Gilead announced that it would use its newly acquired monopoly rights to charge a whopping $84,000 per treatment for Solvadi (and $96,000 for Harvoni, a slightly different formulation), even though the actual production costs are estimated to be somewhere around $68 - $136. Gilead's markup over costs may be close to 1,000-to-1, probably a world record.

How did Gilead choose the price? It chose it for one reason: because it could get away with it. Washington allows this kind of abuse to occur, indeed insists upon it. Medicare is obliged -- in one of the most absurd policies of our era -- to accept whatever price a pharmaceutical company asks for its patent-protected medicines! The result is a level of drug prices that bear no resemblance whatsoever to the costs of production (including the R&D), or to the socially optimal drug pricing that would enable sick people to be cured of their illness.

Gilead says that $84,000 approximates the current last-ditch alternative (a liver transplant) but this is a ridiculous comparison; the new drug indeed allows people to be cured at a very low cost, so there is no reason to hark back to an out-of-date, ineffective approach that is too expensive for the vast majority of people suffering from the disease. Indeed, the taxpayers pay twice: first to fund the innovation, and second to feed a monopoly. From the company's point of view, soaking the taxpayer is the strategy; curing people is a sideshow at best.

By setting an outrageous retail price, Gilead tapped into federal spending on drugs under Medicare and Medicaid, and billed the US and the states for around $6 billion last year, something like $4 billion paid by Medicare and $2 billion paid by Medicaid, according to recent estimates. The federal and state governments therefore probably paid for more than half of the $10 billion that Gilead collected in revenues in the first year of sales, basically enough to recoup the purchase price in less than two years.

Given the monopoly price, tens of thousands of Americans and millions of people around the world infected with Hepatitis C are being told by their doctors, their health insurers, or Medicaid, that they don't "yet" qualify for Sofosbuvir because they are not yet sick enough. Their livers are not yet scarred enough. They are not yet dead enough. They should come back when they are nearly dead, if it's not too late.

Sofosbuvir could reach tens of millions of people worldwide if the drug were available at its true production cost (inclusive of R&D). At $500 per treatment, or even $1,000, millions of people around the world would be able to access this cure. But today, only a tiny fraction do, those who are covered by Medicare, Medicaid, or private insurance to pay $84,000 or some other astronomical price set by Gilead, or a sliver of people abroad who are lucky recipients of some specialized access program. Outside of the US, countries and patients must jump through so many burning hoops that access is fatally compromised, and the human right to health is fundamentally violated.

The end result is a continuing epidemic of Hepatitis C at the very moment that the disease could actually be eliminated or at least close to it. The New York Times has recently reported a new mass outbreak among IV-drug users, who are not able to gain access to treatment. These people are being left to die.

America has handed life and death decisions to corporate greed. Gilead is indeed the death panel that we were once warned about. Yet the Gilead death panel rations a life-saving cure not because it is too expensive to provide, but because it serves the interest of a patent-protected corporate monopoly. It is time for the US citizens to demand the intellectual property rights that US Government-backed science should give them; and for the Government to use rational price-setting to tame untrammeled corporate greed and the monopoly power created by a highly inefficient and unfair patent system.

 

Non-communicable disease: will we rise to the global challenge?



Published in Australian Medicine 6 July 2015 http://bit.ly/1J1Gma6

Taking stock of progress in public health

Published in Australian Medicine 27 June 2015 http://bit.ly/1FltyZY

The Future of MJA

The MJA has served for 100 years as the major means of formal communication between the Australian Medical Association and its membership. It has done this by reporting research and providing guidance that is grounded in science for clinical practice and the formation of health policy. This was enunciated as its purpose and this is what it has done.

In line with its original purpose, the current editorial team, endorsed in this action by the AMPCo board, have begun to revise and reformat the MJA in the light of informed comment from its Editorial Advisory Committee and a formal inquiry into readers opinions and attitudes, likes and dislikes, conducted in 2014. A project planning process has been established and six teams have been formed to explore, discuss and decide on revised format, document processing, etc.

Because the MJA was fractured and traumatised by the events surrounding the dismissal of the previous editor in chief, I have invested energy in seeking to restore respect and good humour among the group. This has taken me 18 months. I have deliberated brought all members of the editorial team into the review project in part to use their considerable intelligence, qualification, dedication and experience, and in part as an expression of my desire to rebuild a team. There is no distinction made in this process among staff: ideas and critique is judged on its value, not who produced it. For example, many staff members contributed to the new cover design, the format of the revised table of contents and the decision and detail about moving research papers from print onto online save for a one-page summary for each paper. In other words, the production and editorial staff have worked in an interdependent mode in pursuit of optimal revision. 

This may seem odd, but there is nothing inconsistent here with the way that I have worked in previous settings as a cursory glance at my academic or business CVs would show. I favour using all talent available to me and I dislike distinctions and layering within the workplace, especially when working in relatively small teams - which the MJA team is.

If we are to preserve the MJA as a journal responsive both to the expectations of the AMA, to the Australian medical research community and health policy makers it will be important to maintain our capacity to change and to move relatively quickly. In the 18 months that I have worked with the MJA I have seen how much effort is required to maintain an active communication network with readers, authors, reviewers and policy makers. To produce a journal that responds in a timely and reflective approach - to the G20 and climate change and the Martin Place siege to name two - to current events requires coordination and integration of editorial and production actions at a high level.

I do not believe that it is easy to separate the medical judgement, editorial processes and production of an association-based journal for the reasons just given. The Canadian, American and British Medical Associations believe similarly and have retained integrated in-house editorial and production functions. So has the Massachusetts Medical Society that produces the New England Journal of Medicine.

Journals that have outsourced their production are very different in style to Association- Based journals. Specialty journals tend to have small voluntary editorial teams. They manage largely research-related content that is easily reviewed and then sent for publication. Many are now wholly on line and meet the comparatively narrow needs of specialties, not general medical audiences. It is easy to see how common templates can be constructed to serve the needs of many of these journals because they are variations on a theme. Those served in this way by Elsevier report high levels of satisfaction, as does the editorial staff at the Lancet, a prestigious journal by any reckoning essentially owned by Elsevier.

The Lancet, unlike the MJA, is a premier research journal but with excellent entrepreneurial flare and public profile as well. It is unique. The resources it commands, both financial and intellectual, enable it to achieve excellence. I gather that Elsevier, as one might expect, participate in the selection of the editor-in-chief, and the symbiosis between Elsevier and the Lancet is generally strong and mutually beneficial. It is possible that if the production of the MJA were outsourced to Elsevier a similar relationship could develop with time.

In brief, prominent international medical association journals that serve the needs of the entire medical profession and not specialties, that provide informed commentary and critique as well as research, are produced in an integrated way in-house. The advantages of interaction of the production team with the editorial side of the team, as we have seen in our redesign process, are substantial.

Now, my comments about the cost of outsourcing the MJA. The dismissal of the production team, most of whom hold university degrees and many of whom have years of experience (a few have been with the MJA for 20 years), would be a big wrench. The transaction costs of moving to a new and unfamiliar production team, located off site and often overseas, would be substantial. It is good to hears said that Scholar 1, our document management system would be able to 'shake hands' with the Elsevier system - an image of US and Russian Soyuz spacecraft docking in orbit comes to mind) but my belief is that it would be a managerial nightmare. Maybe I'm wrong.

As part of the economy of scale that underpins the Elsevier bid, it is likely that the format of the MJA would change to fit the templates that Elsevier applies to its other journals. Whether readers would appreciate a move toward such uniformity I do not know. Many may not care or notice, but some might and wonder whether 'their' journal had been sold off to an international agency as yet another manifestation of economic fundamentalism. These are not idle thoughts: professional associations such as the AMA (and to my certain knowledge the RACP) face major challenges in retaining the loyalty and interest of the foot-soldiers at the same time as moving more in the direction of corporatisation. What do AMA members think about outsourcing? It would be wise (for the sake of the AMA as well as the MJA) to find out.

If the production of the MJA were outsourced, then there would be no point, and no capacity, in pursuing the program of reform that we are half way through. The distraction of negotiating redundancies and the massive amount of transactional activity required to switch systems would soak up everyone's time and energy. I don't want anyone telling me that I don't know this: having overseen the transition from one medical curriculum to another when dean at the University of Sydney I have serious relevant experience.

I fully understand the desire of the AMPCo board to save money, especially with declining revenue from advertising and data bases that have degraded and need urgent repair. The enthusiasm for DoctorPortal will require resources. I am aware that the operation of the MJA is not optimally efficient. I can see ways in which we can effect savings. Once the review process is complete I have in mind to work with the whole team to determine where we can make savings and then, over the next two years, make them. This will be done firmly, humanely and visibly.

The responsiveness of the MJA to member needs could be improved by better communication with the AMA. This needs rehabilitation: we need to get into discussion with the AMA State Branches as well as Federal AMA.

In summary, I freely accept that the board has a choice to make. If the journal production is outsourced then much of its distinctive flavour may suffer and there will be a complex and expensive period of transition. Savings may accrue in two or three years. If the decision is taken to retain production in-house then we will pursue our program of reform and then go in search of efficiency savings. This is NOT unfamiliar territory to me - I have managed effective budgetary savings in several other organisations in which I have worked while being true to humane values and honouring the purpose of the entity.

 

A nail in the heart of the MJA

Efforts to cut the cost of producing the Medical Journal of Australia have driven a nail into its heart.  

An obsession with the bottom line, a failure to understand how the journal is produced, a failure to comprehend its content, nature and purpose, an ignorance of the immense social network of people of goodwill who have supported the Journal by providing articles and reviews over its 101 years, a predominant financially-dominated management approach, an absence of clarity regarding future managerial (as opposed to editorial) direction, have caused this calamity.  

I have received hundreds of emails, text messages and phone calls from doctors, research workers, managers and readers of every stripe, aghast at what is happening with the Journal. 

As the old adage goes, if all you have is a hammer, everything looks like a nail.  Financial challenge for every newspaper, magazine and journal is not in dispute.  Economies are needed.  But these must be carefully tailored to publication in question, not bought off the shelf.

Here is an analogy for what has happened at the MJA. 
Suppose a health service board took the view that the cardiac surgery unit was costing too much and, without telling the surgeon, asked for bids from cheaper, external providers of dubious repute and questionable practices to provide the by-pass pump service.  This false economy would catastrophically mistake the nature of the integrated surgical team.  Quality would be threatened. A Mid Staffordshire Hospital-style catastrophe, http://qualitysafety.bmj.com/content/23/9/706.extract. where the board did not regard clinicians as colleagues, never ventured into the wards and had no idea of what was going on, would be in the making.

Take an economic fundamentalist approach if you wish, and say that voluntarism is out of date, but the MJA has always run and depended on a community – yes, a community – of scholars.  

More than 900 research workers, scientists, clinicians and other scholars provide peer assessment of research papers,  write critical reviews, editorials, perspectives, eulogies, letters (and even the occasional poem) at no charge.  

The unpaid Editorial Advisory Committee helps guide decisions about the form, content and style of the Journal. They do so because of their love of Medicine, the value they attach to collegiality, the value they attach to science, to evidence, to education and to understanding in research, clinical practice, public health and health policy, the pleasure they get from communication, the rewards that come from seeing their ideas, critically refined by review, appear in print.  

You will never understand how the MJA or any other respected scientific journal works by staring at its bottom line, however long you look.

Now acknowledging the true nature of the MJA community affects how you view its economy.  The view that I have provided does not prevent careful quest for efficiency and indeed encourages the search for new outlets and revenue lines.

It encourages the exploration of new media and new communication platforms, and it does not entrench antiquated, paper-based production.  

It takes account of the editorial team in its entirety – the medical editors, the associate editors, the members of the production team – and does not categorise them as those who do the thinking and the others who just ‘move words around on the page’ as the AMA president put it recently, ‘and make the Journal look pretty’. 

What I call the MJA community can be the dynamo for genuine innovation and reform that has a better chance of sustainability than simply outsourcing part of the operation – the equivalent to the pump team – to an outside agency, especially one that causes academics, librarians, students and research managers to express horror at the prospect, based on their experience.

Professor Leeder is former editor of the MJA and emeritus professor at the Menzies Centre for Health Policy at the University of Sydney.

Published in Australian Doctor 8 May 2015.  http://bit.ly/1L5wCPb

Limiting the availability of essential medicines for all

Published in Australian Medicine, 20 April 2015. http://bit.ly/1OxPFXS

 

Designing hospitals to meet new needs

Published in Australian Medicine 16 March 2015 http://bit.ly/1ILl2ra

Tobacco threat still smokes like a dormant volcano

In 2006, I found myself caught within a crowd of 267,153 fellow New South Welshmen. No, it was not at a one-day cricket match or even a State of Origin rugby league clash.

All of us were aged 45 years or above — considerably above in my case. We comprised the subjects for a long-term survey from the Sax Institute, a public health research agency in Sydney, known as the 45 and Up Study.

It is technically described as a “cohort study randomly sampled from the general population of NSW”.

We all completed a health questionnaire and gave our consent to be followed by repeat surveys and linkage of our health databases. 

We were asked if we had ever been a regular smoker, at what age we started (if we had), when we quit (if we had) and how much we had smoked. At baseline, 7.7% of respondents (aged 38.5 years on average) said they were current smokers and 34.1% were past smokers. 

With a mean follow-up time of 4.3 years, there had been 5593 deaths. This was a frightening intimation of mortality for those of us in the study.  

When adjusted for other risk factors, current smokers vs never-smokers had about three times the risk of dying — a risk that increased with the heaviness of the smoking habit. “Smokers were estimated to have the same risks of death [about 10] years earlier than 75-year-old nonsmokers,” the study found.

The good news was that “for those smokers who quit before age 45, the death rates were similar to those seen in never-smokers. Mortality diminished progressively with increasing time since cessation of smoking”.

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The research team was led by Professor Emily Banks from the National Centre for Epidemiology and Population Health in Canberra and the Sax Institute. Renowned Australian epidemiologist Dame Valerie Beral from the Cancer Epidemiology at the University of Oxford was also part of the research group. The results were recently published in the journal BioMed Central.¹ 

"A mature epidemic of tobacco use is not a picnic ground any more than the side of a seemingly quiescent volcano. People who live near tobacco still die."

Dame Valerie has a serious track record for studying the health of women, especially using cohort studies similar to this one. The idea of such a study is to begin tracking people while they are well. Then when an illness befalls them, it’s easy to compare their prior history with that of a person who has remained well, looking for subtle differences in lifestyle, medications, occupation and so forth.  

The great virtue of cohort studies is the absence of bias in the selection of the study subjects. This makes the comparison of individuals years down the track easier: the researcher and the subject are blind at the start to the possible outcomes.

Related Opinion:

• Health risks of nicotine cast doubt on ‘safer’ e-cigarette
• Should Australia lift its ban on e-cigarettes?
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The Sax team concluded that “up to two-thirds of deaths in current smokers can be attributed to smoking. Cessation reduces mortality …the earlier in life [the] greater [the] reduction”.

For those with an epidemiological bent, the study authors argue that smoking in Australia manifests characteristics of a mature epidemic. 

A mature epidemic is rather like a volcano on heavy doses of diazepam: low rate of current smoking; long duration and stable intensity of smoking among those who smoke; young and stable age of commencement; high prevalence of past smoking; and similar levels of relative risk from smoking in successive birth cohorts.

A mature epidemic of tobacco use is not a picnic ground any more than the side of a seemingly quiescent volcano. People who live near tobacco still die. And don’t kid yourself that it will never blow.

Related Feature:

• What if nobody smoked?
•  Clearing the air the air on e-cigarettes

Yes, we have made immense gains in tobacco control. Most people who quit smoking we know do so on their own — impressed, I imagine, by the overwhelming evidence about its harm. But quitting becomes easier if society does not tell people attractive lies about tobacco. Thank goodness we no longer advertise tobacco and so diminish the risk of seduction and deception.

But every smoker who can be urged and helped to quit smoking, when seen in general practice for example, is potentially a life saved.  

They are saved not only from death but also from a huge amount of suffering, and studies such as 45 and Up confirm that if you quit, the results are good.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy at the University of Sydney. He is also editor-in-chief of the Medical Journal of Australia.

 

Published in Australian Doctor 11th March 2015

 

Are we closing the gap?

Published in Australian Medicine 16th February, 2015 http://bit.ly/1OSLIKT

Hope exists beyond the government's Medimuddle

The start of a new year, in conjunction with the appointment of a new federal health minister, raises hope. An agenda of important health matters awaits her attention.
Incoming Health Minister Sussan Ley takes up her portfolio with strong professional experience in guiding education policy through community consultation in city and country. These skills should serve her well in the health portfolio.

Related News: 6 questions for the new health minister 
First, however, the ground must be cleared of the wreckage of the co-payment proposal.
Driven by ideology, uninformed by policy or accurate analysis of the health system, it was always going to be a debacle. In its latest manifestation, the co-payment plan, which will see doctors forego income, is festooned with a host of confusing exceptions.

It looks like a Scandinavian assemble-it-yourself gazebo built without instructions or an allen key.

But unfortunately it is no joke. Were it to quietly disappear, a sigh of relief would be heard across the land. However, it is proceeding amid a storm of justifiable anger from GPs.
Beyond this ‘Medimuddle', there are actions of far greater substance needed to help secure the future of healthcare in Australia.

Related News: The new co-pay plan: full details
First, energy should be applied to clarifying for all the purpose of the health system and explaining how it has come to be. We need a narrative about why we invest public money in healthcare. We pay for Medicare to meet the needs of all Australians.

The equity thing — a ‘fair go' — is an honoured Australian value. When it comes to healthcare, those who can pay more do so already. We recognise that much illness can strike anyone, and we seek to help those who get sick or injured. That's the story of us, but we need to hear it retold quite often.
Chatter about the necessity for an additional price signal for healthcare, on top of the ones we have already, has never made sense.

We aim for a universally accessible system because as a society we care about the health of all our citizens. We care and value equity.

We are a remarkably altruistic community and we do not neglect those who need care simply because they are poor. We placed many wreaths recently because we care. This narrative needs to be clarified, corrected and repeated.

Second, because money does matter in health, waste should be rooted out. The principal areas of waste in healthcare are attributable to archaic management, most notably failure to apply IT where we can. Yes, we have done well in bringing the computer into the surgery and ward, and into pathology and radiology services. But there is so much more we can do to unite the fragments of healthcare by wiring them together.

Then there is the matter of lots of medical and hospital care provided in the face of evidence that it does no good or is unnecessary. The unnecessary parts should not be confused with humane care or time spent in doctor—patient communication, and in showing concern and compassion. That's quite different.

Waste is not simply a matter of too much hi-tech machinery, but as was shown decades ago, the accumulated waste of doing and repeating far too many small-ticket investigations and prescribing little dollops of unnecessary medication (and this still includes unneeded antibiotics).
Waste is also to be found in the overpricing of generic pharmaceuticals where we continue to pay considerably more for many generics than is the case in, say, Canada.

To tackle this waste will require political skill in negotiating and implementing policy, because professional groups often become vigilant and aggressive custodians of the waste product and the income it generates.

Third, repair work is needed in general practice, especially where the co-payment train wreck blocks the tracks.

There is an urgent need to reduce red tape and improve quality of care in general practice, and to increase its availability in rural and regional Australia and on the edges of our cities.
Most economically advanced countries now recognise the critical importance of general practice in providing co-ordinated care and a medical home for the growing number of people with chronic health problems.

Damage to primary care harms both patients and the bottom line of the national health budget.
Health has many determinants — education, income, environment, diet, genes — and the healthcare system is complex. But these features are no excuse for the substitution of ideology and thought bubbles for a careful and steady approach to the changes needed to secure quality healthcare for all Australians.

Let 2015 be the year when health policy that enables this to occur reappears and is implemented.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy in the University of Sydney.

Published in Australian Doctor 19 January 2015 http://bit.ly/1J1CHeH