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Public health: the gaping hole in the McKeon Review of Health and Medical Research

Public health experts are deeply disappointed by the consultation paper recently released by the McKeon Review of health and medical research.

Find out why in the article below from Jon Wardle, Chancellor’s PD Research Fellow at the University of Technology Sydney, and a member of The Public Health Research Advisory Group (PHRAG) of the Public Health Association of Australia.

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What is missing from the McKeon Review? Let me count the omissions, and the missed opportunities…

Jon Wardle writes:

The McKeon Review into health and medical research recently published its draft paper for consultation (the Review), the eminent panel’s vision and recommendations for the future of health and medical research in Australia.

The Public Health Research Advisory Group (PHRAG) of the Public Health Association of Australia was one group that made comments on the Review’s draft consultation paper.

As a member of PHRAG, I’ll lay out a brief synopsis of the points made in the submission, peppered with some personal flair (i.e. all opinions my own, please see full submission for PHRAG viewpoint).

The full submission will be made available in due course, but in summary, it is fair to surmise that the public health community has been thoroughly underwhelmed by the review’s conclusions and suggestions.

Key to this concern was the Review’s definition of public health, which seemed at odds with the definition embraced by public health community itself.

The Review focused much more on medical research than it did on health, and consequently it viewed that the public health research it thought was most worthy of funding was medical research in public health priority areas, and not the research that Australia’s public health experts highlighted in their previous submission to the Review:

“Public health research is quite different from bio-medical research.

It focuses on the health of whole populations and is concerned with documenting the incidence of disease, understanding the origins of disease, determining what factors make for healthy populations and evaluating the impact of measures (including policies, programs and social changes) that keep populations healthy and free from disease.

Public health research is multi-disciplinary and includes epidemiology and the full range of social sciences (including sociology, psychology, economics, and anthropology). Public health research focuses on how social, economic, physical and natural environments shape health and health-related behaviours. It also includes much health services research, especially that which monitors the effects on whole populations.

Public health research addresses upstream structural drivers of health inequities (such as trade, macroeconomic policy, labour markets, environmental change etc) and conditions of daily living that affect health (health care, urban environment, working conditions and social relations). Public health research also covers evaluation of interventions, so as to determine what works in improving population health.”

Although all of the ‘high value’ interventions (those that achieve the most bang for their buck) in the Review’s Exhibit 2 fall within the remit of public health interventions, the accompanying paragraph makes no mention of using public health as a lever to improve health outcomes.

In fact, each of the three levers suggested focus solely on the delivery of clinical services – either by developing new interventions, making current interventions safer or translating clinical research into clinical service delivery.

The Review makes virtually no mention of public health at all. There is a mention, by default on page 25 (when the report discusses what public health research the NHMRC has already funded).

Public health research only gets a mention later under the vague heading “enhance the non-commercial pathway to impact”. Even then, the report defines public health through this clinical prism – it is interventions such as vaccination, safe sex programs and stop smoking programs.

These are undoubtedly important interventions, yet public health encompasses more than just interventions or monitoring and evaluating clinical service delivery.

It also focuses on the impact of the social and environmental determinants of health, and on the development of social, policy and other environments that support good population health outcomes.

The necessity for a stronger focus on social determinants is particularly evident in priority areas such as indigenous health, migrant health and mental health. The need for further understanding of these determinants is acknowledged internationally through initiatives such as the World Health Organization’s Commission on Social Determinants of Health or the Marmot Review, as well as numerous national initiatives.

Even the federal Senate has seen fit to draft a response to the World Health Organization’s Commission on Social Determinants, yet the concept has been missed entirely by Australia’s major review into health and medical research.

Other public health areas have also been neglected by the Review. Issues such as climate change are likely to affect Australia’s health outcomes yet, as it does not occur in a hospital or consulting room, such research would not seem to fit within the Review’s definition of public health research.

Initiatives such as the South Australian Health in All Policies initiative offer enormous potential to make significant public health contribution to Australia yet would fall well outside the clinically-focused definition of public health used in the review.

This oversight extended to methodologies as well – the value of social sciences to medical and health research was ignored completely – perhaps the panel truly believes they have no value?

But even though it focused on clinical and biomedical research, the Review still managed to gloss over areas in which the greatest gains can be made. Primary care and preventive health don’t even make it on to Exhibit 2, and primary care isn’t mentioned in the report at all.

This is despite, at a population health level, primary care is the most clinically and cost effective method of improving health outcomes (even though more expensive specialist care attracts more research funding).

The Review’s recommendation to establish “Integrated Health Research Centres” is laudable, yet it focuses only on combining the hospital and medical research institute sectors – hardly true integration. Without the inclusion of primary health care and public health networks they leave the majority of the health system disengaged.

Similarly the Review recommends health sector re-alignment and leadership, yet suggests agencies such as the Independent Hospital Pricing Authority and Local Hospital Networks as the driver of these reforms.

This is despite hospitals being downstream of where the greatest gains in population health outcomes can be made (Exhibit 2 actually refers to most hospital interventions as ‘low-value’ or worse), and the fact that many hospital admissions can be directly attributed to poor management of upstream factors.

Primary health care oriented agencies such as Medicare Locals and the Australian National Preventive Health Agency should be pivotal in this process. These areas have been under-researched compared to the hospital system.

The current review’s approach to public health focuses on improving the health of the population though improving the health system. Yet the evidence is increasingly clear that factors beyond improvements in medical care are primarily responsible for the gains made in life expectancy made over the previous decades.

Research and strategies targeting individual behavioural change must be complemented by strategies to develop health-promoting environments. With the increasing burden of disease attributable to non-communicable diseases, these factors are only going to be increasingly important.

There are numerous other areas of the Review’s draft paper that have concerned the public health community.

The rationalisation of health ethics committees sounds great on paper, but may end up simply creating new bottlenecks, and as ‘expert’ committees may change the nature of these committees from reflecting community values to improving processes for researchers.

The recommendation of establishing expert committees for each recommended priority area sounds great, but would they be truly multi-disciplinary?

There is no indication of how the Review panel even came up with the current priorities – what were the criteria and how will future priorities be determined?

At the moment the priorities seem rather arbitrary, and more than a little reflective of the research interests of the panel members. Streamlining of the grants processes would be a welcome change to most researchers – but do the current recommendations disadvantage smaller projects and early career researchers? These are covered in more detail in PHRAG’s full submission, which will be made public in due course.

Ignoring public health research does not seem to be new. The NHMRC did actually take the initiative and commissioned its own report into public health research (the Nutbeam report), but despite supporting all but one of the report’s recommendations is yet to adopt any of them (it should be noted the McKeon review didn’t mention the Nutbeam report at all either).

However, the McKeon Review is narrowly focused and unlikely to support good public health outcomes.

It is hard not to concur with previous Croakey commentator views on the draft – dismal but predictable, more ‘medical’ than ‘health’ and thoroughly underwhelming

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Related reading

• Croakey:  A call for research that makes a difference

• The Conversation: McKeon Review should consider wellbeing of the health system 

• Croakey: Professor Tony McMichael’s critique of the review

• Croakey: Lamenting the missing consumer and community perspective 

 

 

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