Tuesday, May 29, 2012

4th International Primary Health Care Reform Conference

In March this year, HCCA consumer representative Joanne Baumgartner attended the 4th International Primary Health Care ReformConference in Brisbane.  The conference had an array of interesting speakers, including Professor Martin Roland from the University of Cambridge; Dr Paul Grundy of IBM; and Rosie Rowe from the Western District Health Service in Victoria. 

Professor Roland discussed the financial incentives for clinician performance in the United Kingdom, comparing this to the Australian model, which he felt was superior.  He concluded that appropriate salaries and training for the medical workforce has a positive impact in terms of addressing gaps in quality of care.  

Dr Grundy heads up IBM’s Global Well Being Services and Health Benefits system.  IBM’s system was first implemented in 1999, and centrally links the company's occupational medicine, safety, industrial hygiene, wellness and health benefits strategic initiatives.  As part of its work, the IBM service lobbies government for the construction of community health facilities in areas where the company operates.  Dr Grundy identified Denmark as the exemplar of global primary care, as each patient has an ongoing GP.  The importance of continuity of care was a theme echoed throughout the conference. 

Rosie Rowe presented a paper entitled “System integration to enhance coordination of care for people with chronic and complex needs”, which examined consumer involvement by those with chronic conditions in the operations of health services in the Grampians region of Victoria.  The results presented aligned well with the ACT experience of consumer involvement and improving the quality of care provided to patients.

Other international speakers hailed from Hong Kong and Singapore.  The research presented by these speakers focussed on consumer involvement in primary care practices, and while the results were interesting, it was clear that consumers are not engaged in the process to the same extent as they are in Australia.  Consumers are not active participants in these kinds of quality improvement or research initiatives in Singapore and Hong Kong.

Another theme addressed during the conference was the role of Practice Nurses.  Presenting clinicians generally believed that Practice Nurses were an asset to primary care, but conceded that because many medical practitioners were unused to utilising nurses to their full capacity, they were being given only simple tasks to perform.  Some practitioners were identified as reluctant to relinquish tasks such as taking blood pressure to Practice Nurses.  However, on the whole clinicians were positive about the prospects of multidisciplinary teams including nurses, physiotherapists and social workers, to provide the best treatment.

Adapted from Joanne Baumgartner's report to HCCA.

Forum on Men's Health

On Thursday last week, HCCA consumer representatives Roger Killeen, Russell McGowan and Bill Heins attended a forum on men’s health convened by Jeremy Hanson of the ACT Liberals.  There were around 30 participants from a range of community groups within the ACT, including the Mental Health Consumer’s Network, YMCA and Woden Community Services.  There did not appear to be any doctors at the meeting.

The meeting was centred on Jeremy Hanson’s health discussion paper, “The State of Our Health”, and complemented the women’s health forum organised by the ACT Liberals and held earlier this year.  Hanson stressed his support for community-led men’s health initiatives and the proposed development of a new sub-acute health facility in the ACT.

Community and consumer participants also contributed to the discussion, with the Public Health Association of Australia’s Michael Moore suggesting the adoption of a root cause analysis approach to men’s health issues, highlighting the need for research into the social determinants of men’s health.  Moore suggested that this research could be conducted by a purpose-funded centre at the University ofCanberra.  Russell also indicated his support for community led approaches to men’s health issues, such as the proposed Canberra Health Alliance.  Based on the Oxford HealthAlliance model, a Canberra Health Alliance would facilitate exchange between experts and consumers to raise awareness about health issues and assist in the implementation of effective community interventions for health.  Russell also noted the need to focus on prevention and self-management as much as on services provided directly by health professionals.

Some particularly useful comments about the difficulty in getting men to access health services in a timely way came from the St Vincent de Paul representative who pointed out that men do not like to cede power and control over their lives to health professionals, and that men of the lowest socio-economic status were even less likely to present for assessment and treatment than other men.  Several worthwhile ideas were put forward by Jenny Miragaya from the Australian Nursing Federation (among others) on how these trends might be addressed, including the targeting of clinics especially to men, and the use of male nurse practitioners as a bridge into accessing healthcare.

A way forward may be the formulation of a Men’s Health Action Plan for the ACT as proposed by Margo Saunders, a freelance health policy researcher.  Bemoaning the lack of action on the national Men’s Health Strategy put forward by the Commonwealth several years ago, she pointed to actions in some of the other jurisdictions like Victoria and South Australia and recommended that the ACT consider a similar approach.

The convening of this forum highlights that men often have very specific health needs and issues. Willingness to access services and the availability of appropriate or targeted care are factors in the health of men across Australia and indeed the world.  A recent study, funded by the Agency for Healthcare Research and Quality and conducted by researchers from the Boston University School of Medicine, has found that men in the USA are more likely than women to be readmitted to hospital within 30 days of discharge.  The risk factors for readmission include retirement, single marital status, depression and absence of primary care follow up post-discharge.

In order to effectively address men’s health issues, it is imperative that coordinated and targeted programs are introduced and promoted to the male population.  Health policy planners must listen to the needs of men and find ways to reduce the social, cultural and economic barriers that discourage men from accessing health care services.

Heather McGowan
Policy and Research

Thursday, May 17, 2012

What's in a name?

I recently read an article based on online-discussions regarding terminology in the health care sector which has given me food for thought.  The discussion was prompted by a post from Stephen McMahon, the CEO of the Irish Patients Association, where he expressed his concern with the use of the word “consumer” instead of “patient”.  McMahon’s argument hinged on the fact that the term “patient” has immediately recognisable connotations of identity, and thus it cannot be dispensed with.  What followed was a flurry of responses, supporting the use of the terms “consumer” or “patient” or suggesting an alternative term.

Those in support of the term “patient” were confident of its ability to demonstrate the service nature of health care.  “Consumer”, its detractors felt, made the focus too corporate.  Another facet of the pro-“patient” argument was that patients, unlike consumers, lack the freedom to change services if it does not meet their needs or expectations.  Those in favour of “consumer” asserted that a consumer by definition is active, and is in possession of the power to make decisions.  Other respondents rejected both of these terms as inadequate and instead proposed alternatives, such as “principal stakeholder”, “health service user” or “customer”.

I found the discussion around the alternative terms to be quite thought-provoking, as I had previously only assessed the debate in terms of the patient/consumer dichotomy.  The argument for the use of “principal stakeholder” was compelling, as it highlighted the central role of consumers in the provision of services, and the duty of governments to remember their obligation to the people.  “Health service user” is a term that has risen in popularity in Europe as an alternative to patient and consumer.  This suggestion emphasised just how much the wider debate about terminology focuses on the English language, with little regard for diverse cultures and languages. In Greece, for example, the term “consumer” is linguistically incompatible with the provision of health services, thus prompting the rise of user-based expressions.  

Proponents of “customer” identified it as the appropriate term because it denotes greater empowerment than either patient or consumer. However, it still runs into the issue of the lack of freedom of movement regarding health services.  While not widespread internationally, the term of preference in France is “ill person” (personne malade), as it first recognises the patient/consumer as a person, with the psychological, social and economic factors this entails.  However, this term is not necessarily applicable across the board, especially for those who do not see themselves as “ill:, i.e. those living with chronic conditions. 

The only conclusion I can definitely draw regarding this debate is that there is no simple answer.  Terminology is important, and those that bemoan its futility, because it achieves no “concrete” improvements, are missing the point.  Language shapes the way in which we understand the world, and the words we use in the context of health care impact on the mindsets of clinicians and consumers/patients.  From my perspective, the term patient is too narrow as it fails to encompass those who are not “ill”, such as people living with chronic conditions, and it denotes a sense of passivity to those it labels.  “Consumer” may not be the perfect term, as it implies the power to change services which we may not possess, but at least it signifies the ability to be considered as engaged, educated and empowered partners in the delivery of health care services.

Heather McGowan
Consumer Representatives Program

Depression in Australia

Recently, the Canberra Times published an article by Julieanne Strachan describing the increasing burden of depression in Australian society. For instance, Australian taxpayers spent over $333 million subsidising antidepressant medication in 2011. The use of antidepressants has increased substantially since 2007, with 13.6 million scripts written by doctors in 2010-2011. In the ACT, doctors issued 169,228 new scripts for antidepressants in 2010-2011, equating to 0.46 scripts per person (keeping in mind that one person can receive multiple scripts). From these figures, it is clear that depression represents a significant mental health issue in our community.

Antidepressants come in many different forms, though generally speaking they work by changing the level of neurotransmitters such as serotonin in the brain. While clinical studies have indicated that many antidepressants can be quite effective at reducing the symptoms of depression in the short term, it is important to consider that the same neurotransmitters have multiple effects on brain functioning, meaning that side effects can occur frequently. Furthermore, most antidepressants only have an effect while they are being taken. As such, it is worth considering additional means of addressing depression, such as cognitive behaviour therapy (CBT) and other forms of psychological treatments. Approaches such as these help us to develop better coping and problem-solving skills and can help to improve our mental health in the long term.

According to the article, this increase in antidepressant use is largely due to increasing stress and pressure at work. Clinical psychologist Darryl Cross argued that people are being required to take on a greater amount of responsibilities at work as businesses and government departments are required to operate with fewer personnel. As health consumers, we need to recognise the impact that stress at work can have on our health and find ways to either reduce the levels of stress we experience or cope with them more effectively. This applies to our overall physical health as well as our mental well-being.
In the past, females were considered to suffer from depression and anxiety to a much greater extent than men, for reasons such as their tendency towards greater emotionality and stress. However, while women are often encouraged to express their emotions, men are encouraged to ‘toughen up’ and move on. As a result, it is likely that many men suffering from depression would not seek help, often turning to alcohol and other drugs as a means of self-medication. It is also thought that men tend to focus more on the physical symptoms of depression, making it unlikely that they will attribute their problems to an underlying mental illness. Fortunately, programs such as Mensheds and MensLine have promoted a greater awareness of this problem while providing nonjudgmental support networks to help men improve their mental wellbeing.

The article listed the “decline of the traditional family unit” as one of the causes of increasing depression rates in the younger generations. However, the factors influencing the support children receive are likely to be far more complex than their basic family structure. Children can experience loving and supportive relationships from a variety of different family members in different situations. Children can also receive support from many sources outside of the home. Darryl Cross suggested that a decline in attendance at religious institutions has also reduced the support that children receive from their community. If this is the case, it will be important that efforts are made to provide children with adequate support from other institutions, such as schools and community groups.

Another area of concern for younger generations has been increasing internet access, which the article suggested may expose children to ‘adult issues’ a lot earlier in life than previously. Indeed, we now have access to more information than ever before, and can form broader social networks that stretch across the globe. Online social media also means that these networks are being created with fewer parental controls, which may be seen as potentially dangerous. However, the internet can also provide an alternative support for consumers concerned about mental health issues. Organisations and services such as Beyond Blue, Lifeline, Headspace and MensLine are able to use websites to  provide consumers with access to information about particular mental health issues, offer basic advice and provide links to various support networks and counselling. This approach is often a less daunting option for consumers, as it enables us to explore our options anonymously from the safety of our own home.

Nicole Moyle
Research Assistant

Friday, May 4, 2012

200 Years of the New England Journal of Medicine

If you have a spare 45 minutes, you should check out this online documentary put together by the New England Journal of Medicine, which charts some of the significant advances made in health care over the past 200 years and demonstrates how information reported in journals can translate into progress.

At the time of the publication of the Journal’s first issue in 1812, medical knowledge was limited.  There was no understanding of infectious disease and infant and maternal mortality was high.  Surgery was performed without anaesthetic and was thus a bloody and brutal affair, with half of all surgery patients dying from complications.  In 1846, a Boston-born dentist named William Morton began experimenting with ether as an anaesthetic tool and its benefits were demonstrated by Dr John Collins Warren, who painlessly removed a tumour from the neck of Edward Abbott,.  Today, anaesthesia is far less dangerous and is more effective than ever before, with less than one in 200 000 patients dying from anaesthesia-related complications.  While today’s medical professionals have a good understanding of hygiene and its role in patient safety, the patients of the mid-19th Century were not so fortunate.  Puerperal fever, or childbed fever, was a major cause of death for women.  In 1847, Ignaz Semmelweiss noted a decrease in the incidence of puerperal fever when physicians washed their hands in an antiseptic solution before performing gynaecological exams.  Ten years later, Louis Pasteur pioneered the theory of bacteriology and proved the existence of micro-organisms which could be responsible for causing infection.   

In the 19th Century, life expectancy was so low that cancer was quite rare, not having sufficient time to develop in the body of the patient.  As the 20th Century advanced, cancer diagnosis and treatment came to the fore of medical science.  In the 1930s, cancer was treated with crude radiation therapy and there was no treatment for blood-related cancers like leukaemia.  On the back of research about anaemia, Sidney Farber used folate as a potential treatment for acute lymphoblastic leukaemia (ALL).  This backfired, however, as the folate actually stimulated the growth of cancer cells.  Undeterred, Farber investigated “anti-folates” or folate antagonists as a means of countering cancerous cell production.  Farber’s patients went into remission, but unfortunately all relapsed within a few years.  In addition, this treatment killed healthy cells along with the corrupted cells, causing adverse side-effects.  By 1971, however, treatments had advanced so much that half of all ALL patients could be cured.  Adult leukaemia types, like chronic myelogenous leukemia (CML), presented differently from juvenile types.  Research into cancer genetics revealed the chromosomal abnormality of the Philadelphia chromosome as the cause of CML.  The discovery of this genetic component led to the creation of imatinib, a CML treatment which inhibits enzyme production instead of simply destroying all rapidly dividing cells.  The hope for the future is that cancer will become a chronic but treatable disease.

The 1980s saw the beginnings of the horrifying HIV/AIDS epidemic.  In the early days of the disease, a diagnosis of HIV was tantamount to a death sentence.  The disease spread through both the Western and developing worlds.  When the first treatment, called AZT, was developed in 1987, interest groups lobbied passionately for access to the drug.  New antiretroviral therapies (ARTs) were developed during the 1990s, and treatment for HIV now costs less than $100 per patient per year.  However, there are still issues with access to ART.

It was fascinating to see how far we’ve come, and how far we can still go!

Heather McGowan
Consumer Representatives Program