He writes:

“There are two outstanding books which I can highly recommend.

First, “Direct Red” by Gabriel Weston, who is a young Scottish Surgeon and a gifted narrator.  She describes openly her travails as a young doctor and why she put her family first.  It is beautifully written.

Secondly,  “Vital Signs” by Ken Hillman. Ken is Chief Intensivist at Liverpool Hospital in Sydney. Probably best known for his pioneering of Medical Emergency Teams. He has put together reflective vignettes from his own experience. Again extremely well written and provocative.

Both these books epitomise the Art of Medicine – caring for and with the patient. In these bureacratic days, we need this reminder.  Too often we lose sight of what Medicine is really about.

Both authors tell us through their own experiences and with great writing skills that the patient is what it is about -  not length of stay, not efficiency, not budget – but about interaction between doctor and patient.

We can all do better.  We can and should reflect on that. Not for the sake of Quality and Safety but because we want to serve our individual patients better.

These books are well crafted  and they remind us what it is all about – the need to look after ourselves as as well as  our patients.

Lord Darzi in the UK realised this. We need similar leading clinicians here to do likewise.

Let the Government, let the bureaucrats know – it is about the  Patient-Doctor relationship. That is what is important – send them these books too!!

If you know  a medical student or young doctor, it’s worth buying both for them—but read them first yourself.”

The doctors say that the appointment of Yoram Blachar, president of the Israeli Medical Association since 1995, as president of the World Medical Association last November is “a matter of grave concern”.

They say it “makes a mockery of the principles on which the WMA was founded in 1947, which was a response to egregious abuses by Germany and Japan in World War Two.”

In a letter, the doctors list numerous reports highlighting the use of torture by doctors in Israel and occasions when the Israeli Medical Association has failed to respond to the charges.

In 1996 a report from Amnesty International concluded that Israeli doctors working with security services “formed part of a system in which detainees are tortured, ill treated, and humiliated in ways that place prison medical practice in conflict with medical ethics.”

At the time Dr Blachar “took no action,” says the letter. It adds that Dr Blachar had justified, in a letter to the Lancet in 1997, the use in Israel of “moderate physical pressure”.

However, a World Medical Association spokesman said that this statement was not Dr Blachar’s opinion but a reference to Israeli guidelines and that it has been widely misquoted. The spokesman said: “Dr Blachar did not then endorse the use of torture and has not done so since. Indeed he has repeatedly supported WMA policy statements and documents that condemn all use of torture, whether by physicians or others.”

The British Medical Association said: “On the basis of imperfect and contested information, although Dr Blachar’s position as joint president of the World Medical Association and the Israeli Medical Association is a difficult one, in our view he has made authoritative statements, as president of both organisations, calling on the Israeli Defense Forces (IDF) and any doctors operating under the IDF’s remit to respect international ethical standards.”

Dr Blachar did not respond to a BMJ request for comment. In previous correspondence in the BMJ, he has several times denounced the use of torture by Israeli doctors.

I suffered an adverse reaction at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) conference in Adelaide this week. It happened when one speaker casually referred to “heart sink patients”.

It’s not as if I hadn’t heard the term before. Anyone who regularly reads the medical mags will know that doctors often use this term to refer to patients who make their hearts sink. There are even guides to help doctors deal with heart sink patients.

Sadly, I am not the sort of person who can quickly unpick my reactions on the spot and provide immediate, useful analysis. So I went away and brooded: why do I find this term, and its casual use, so grating?

Here are a few thoughts:

• It’s generally used to refer to patients that doctors regard as “difficult”, whether because of their health problems (think mental health, drug and alcohol, complex or insoluble) or their personalities (think demanding, complaining or – another medical term I detest – “non compliant”).

• Yet these patients are among those most in need of compassion and care that is sensitive to their needs and situations. Framing them as undesirable patients only helps to reinforce the inverse care law so wisely described by Julian Tudor Hart some decades ago. This law holds that “the availability of good medical care tends to vary inversely with the need of the population served”.

When heart sink patients is a term so widely used, it’s not surprising that it is so difficult to recruit doctors and other health professionals to work in demanding but needy areas like mental health, Indigenous health, and the poorer parts of the country/health system.

So here starts my campaign to find another term for “heart sink” patients. “Needy” perhaps, or what about “deserving”?

Would health professionals and services feel more motivated to try to help patients if they thought of them as “deserving” rather than “heart sink” types?

I somehow doubt this little campaign will find wings, but if it makes even one or two people stop and think about the words they use, it will be worth it. Words are so powerful, after all, in influencing how we perceive others and engage with them.

The doctor writes:

It’s not about ‘goodies and baddies’
Some pharmaceutical companies operate for profit, including in some jurisdictions where company directors have a statutory responsibility and perhaps a fiduciary duty to shareholders to enhance the fortunes of the business by any legal means, including having their employees and contractors do whatever they can to sell drugs.

In the same environment those who care for patients have a professional duty to exercise their clinical judgement in the interests of their patients.  Not always will the interests of the company and of the patients be aligned; in those situations shouldn’t the health carers act with as little influence as possible from the competing interest of profit?

Conflict of interest, and influence by association
When guideline writers or prescribers are in particular relationships with profit seeking pharmaceutical companies conflicts of interest can arise, perhaps on both sides.  The resulting concern for those concerned about the public interest is that bias in doctors may compromise patient care.  Two issues seem relevant: competing interests are ubiquitous and can’t realistically be eliminated; and bias might result even without conflicts of interest.

Firstly, if I drive a bus but feel I am losing my concentration and putting pedestrians and passengers at risk, to keep driving is not in the public interest.  We can’t expect people not to have conflicts of interest, nor to themselves resolve these in the public interest always.

Secondly, ‘A conflict of interest occurs when a public official is in a position to be influenced, or appear to be influenced, by private interests when discharging their public sector duties and responsibilities.’ says ICAC.

Thus, someone who has a relationship described as travel funding (assume ‘no frills’ travel) may not have a conflict of interest.  But such a person may still have been influenced by the travel funding, by processes described by Robert Cialdini, and categorised by Libby Roughead with general practitioners.

These influences include:
1.    Friendship and liking: it’s harder to deny requests made by friends and those we like.
2.    Gifts and reciprocation: we learn early on that receiving a gift means we should reciprocate.

Perhaps these processes explain the relationship between the ‘closeness’ of doctors to drug companies, and those doctors’ usually poorer clinical competence with drug use. See Wazana.

Hence, disclosure
The shortcomings of disclosure of conflicts of interest, or of association, are that the ‘discloser’ may feel she has a moral licence to say anything biased she wishes because the audience has been warned to be wary; or she may feel she has to be so scrupulously cautious that her bias turns the other way, or the influence may not cause bias.

But the audience doesn’t know how much or which way, if at all, to adjust for her conflict of interest or association.

With those nine possible combinations, only one of which must be ‘neutral’, disclosure alone seems unsatisfactory.  A social science experiment has shown that disclosure detracts from the ‘audience’s’ ability to detect the ‘truth’.  Cain D, Loewenstein G, Moore DA. (The dirt on coming clean: perverse effects of disclosing conflicts of interest. J Legal Stud 2005;34:1–25).

The ‘regulator’ may feel satisfied the disclosure is made; the ‘discloser’ may feel she’s been open; and the audience may feel they’ve been respected.  But in the end the burden of the conflict of interest has been shifted to those least deserving of that burden – the audience, or worse still, their patients.  If we need to go further than disclosure, should those with avoidable conflicts be excluded from decision making roles?  See : Moore DA, Cain DM, Loewenstein G, Bazerman M, eds. Conflicts of Interest: Problems and Solutions from Law, Medicine and Organizational Settings. London: Cambridge University Press, 2005

Way forward?
In view of those considerations, the ball would seem to be in the court of the health care providers and regulators, not the pharmaceutical companies; and self-regulation by the pharmaceutical industry to not act contrary to the public interest would seem contradictory because of the competing interest of profit.

Sounds like a case of excessive modesty – even a quick scan of the Crikey Register of Influence shows that many medicos are very willing and able when it comes to marketing. Looking at the bigger picture, there’s a strong argument that modern medicine has done such a good job of marketing itself that we as a society are now paying far more than we ought to be for many treatments and procedures whose benefits have been oversold.

But I digress. The point of this post is to alert you to an interesting story at this science blog. Someone enterprising there has done some digging post the Federal Court revelations about  industry-funding of journals.

The story begins: “Scientific publishing giant Elsevier put out a total of six publications between 2000 and 2005 that were sponsored by unnamed pharmaceutical companies and looked like peer reviewed medical journals, but did not disclose sponsorship, the company has admitted. Elsevier is conducting an “internal review” of its publishing practices after allegations came to light that the company produced a pharmaceutical company-funded publication in the early 2000s without disclosing that the “journal” was corporate sponsored”.”

It’s definitely worth reading the entire post, and there are quite a few interesting comments as well. The credibility of scientific publishing has taken a hit.

Really?

For another perspective, have a read of this Crikey article in which three academics (with midwifery backgrounds) outline how Federal Government policies, including the Safety Net, have had the unintended side effect of driving up obstetricians’ incomes (at huge cost to the public purse), and promoting a problematic model of care.

For those cynics who might wish to dismiss these concerns on the grounds they were put forward by representatives of a discipline known for contesting the obstetricians’ view of the world, here is an extract from a submission to the Federal Government’s recent maternity services review.

It is by David Ellwood, professor of obstetrics and gynaecology at the ANU. I hope he doesn’t mind but I’m quoting it at length because it is so pertinent to the current debate.

Extract of letter:

1. The current rate of intervention in childbirth

The inexorable rise in the caesarean section rate is something which needs to be addressed as a matter of some urgency.  We don’t know the current rate in 2008, although the last figures published by AIHW (2005) show that the caesarean section rate has risen to above 30%.  I suspect when the latest issue of Australia’s Mothers and Babies for 2006 comes out next month the rate will have climbed again.  I’ve been concerned for a number of years that once we reach a rate of somewhere between 35% – 40% we could reach a tipping point from which the rate will accelerate more rapidly.
Indeed this has been the experience in some overseas countries and there are some  notable examples where the caesarean section rnotable examples where the caesarean section rates have rapidly accelerated to 70% or 80%.

There is now a body of scientific evidence in the literature, much of which has been published over the last few years, to suggest that caesarean section does increase the risks to both mother and baby in the index pregnancy, and also increases significantly the risks in subsequent pregnancies.  Although the absolute risks are still relatively low, the relative risk when compared to vaginal birth is significant for a number of adverse outcomes.

I believe that there are a number of strategies that could be used to reverse this undesirable trend, but there are two which are worth bringing to the attention of the Review.  Firstly, there is a significantly higher rate of caesarean section in the private sector than in the public sector.  Whilst some of this is to do with differences in the population of birthing women who use the private sector there is ample evidence that the rates are inappropriately high, even when corrected for some degree of selection bias.  It does seem to be an odd situation, (as was pointed out during one of the workshops) that a women can choose to have an elective caesarean section in the private sector and be financially supported to make this choice, whilst an indigenous women is unable to choose to birth naturally ‘on country’.  The second area in which I believe there could be a major impact is to increase the midwifery input into natural childbirth.  There is a lot of low risk obstetrics which is practiced in the private sector with minimal midwifery input during the ante-natal period.  A move to midwifery models of care, either in the public sector, or encouraging the use of midwives in the private sector should have a significant impact on reducing the rate of inappropriate caesarean sections.

2. The unexpected impact on the public sector of supporting private obstetrics
About seven or eight years ago it would be fair to say that private obstetrics in this country was under significant threat.  The medico-legal and indemnity insurance crisis at that time was leading to a significant number of obstetricians choosing not to practice
private obstetrics.  Indeed, in 2001 the future looked bleak.  There have been three significant policy initiatives which have gone a long way to reversing this trend.  These  have been, in no particular order, subsidies for medical indemnity insurance premiums, tax benefits for those who take out private health insurance (as well as the 30% rebate), and most recently the use of the Medicare safety net to support private obstetric fees.  Whilst this has lead to a very positive change in the number of obstetricians choosing to work in the private sector, I believe this has had an  unexpected adverse impact on the public sector.  As you would be aware, a lot of high risk obstetrics is practiced in the public sector and this is where there is perhaps the greatest potential for skilled obstetricians to make a significant difference.

The current climate is so favourable that it is now possible for newly graduating obstetricians to choose to work exclusively in the private sector.  The incomes which are possible, as well as the fact that it may be easier to obtain a degree of work / life balance from this choice, has meant that many new graduates choose to work exclusively in the private sector.  It is possible to work effectively part time and limit the number of births to ensure a reasonable income without putting in the long hours which are often required in the public system.  As someone who has worked in the public system for all of his professional life, it now appears that the competition between the two sectors is such that it’s becoming almost non-competitive for the public sector.  It has always been difficult to recruit to full time salaried positions within the public sector but it is now becoming almost impossible.

I have major concerns for my own sub- speciality of maternal/fetal medicine as we are now seeing a significant drift to the private sector, even from those who have chosen to work full time in tertiary high risk obstetrics.  I believe that something has to be done to reverse this trend and to put some balance back into this situation so that full time employment in the public system is much more competitive with the kinds of incomes which are now possible in the private sector.

This trend is also having an impact on academic O & G. The increasingly small pool of full-time salaried specialists, who often have an academic role as well, are becoming the ‘work-horses’ for the public system. Thus, their ability to carve out an academic career is very limited.  If this continues, we can predict the demise of academic O & G in a short time.

You can read the rest of the letter here.

.

“Agreements between not for profit research institutes and the pharmaceutical industry can be fraught with conflict, even if an iron clad contract is in place to ensure the independence of the parties involved.  The recent case of Sanofi-Aventis contributing 25cents per pack of Plavix sold in Australia to the Baker Institute is an interesting case in point.  Both parties are publically adamant that the funds are entirely ‘without strings’ and this is most probably true in the legal and contractual sense.  However, it speaks volumes that the 25 cents per pack is derived from the Plavix marketing budget.

Pharmaceutical companies are past masters at managing and manipulating social obligations and reciprocity for their marketing benefit.  Gifts engender a feeling of indebtedness on the recipient and a social obligation to reciprocate in some way to the giver of the gift.  In this way, the phrase “much obliged” has become synonymous with “thank you”.  Marketing expenditure in any industry is always associated with a quid pro quo for the ‘investing’ organisation – increased sales, as Ken Harvey highlights in his response.

In the case of the Baker Institute, this arrangement provides a guaranteed income stream, so the Institute would be commercially ‘mad’ to conduct any research that could jeapordise this arrangement.  While the Institute, according to public statements, legally retains its right to research whatever it likes, conducting research that may be unpalatable to Sanofi may jeapordise renewal of this agreement or the development of future agreements (with Sanofi or other companies).  Sanofi is a large pharmaceutical company with many commercially successful drugs, so the agreement using a ‘royalty’ from Plavix could provide leverage to reduce research in other areas such as diabetes that may adversely affect other drugs in its current portfolio or development pipeline.

Accountability would also be more complex with a corporation than the more well studied individual practitioner.  A practitioner will face clients and may be asked awkward questions in a one to one situation which may reflect on the trust of a patient in their practitioner.

Corporations are faceless entities which are also charged with a different charter – looking after the corporate bottom line (and shareholders, if applicable).  Therefore there is a different sense of public accountability for their actions.

In this case, it can be argued (and probably will be) that the Baker Institute was doing the best deal it could to generate research funds to improve medical research for the greater good of society.  One wonders if the contract will be released publicly to demonstrate the transparent nature of the agreement?”

Michael Moore, CEO, Public Health Association of Australia

In the initial budget for this government was a huge effort on hospital waiting lists and $$$ through to the States for improvements at the tertiary level.

I suspect that this time around there will be an emphasis on workforce development (or there should be).  Primary care is regularly in the Minister’s speeches as another possibility.

Among bureaucrats is a fair bit of talk coming out of the Discussion Papers of the Preventative Health Taskforce and the Health and Hospitals Reform Commission about the possibility of a National Body to look after prevention, health promotion, research – perhaps to do the sort of things that are set out in the goals of VicHealth.  Plans for the National Prevention Agency are already on the public record through the COAG papers.

**

Professor Mike Daube, president, Public Health Association

I would hope to see significant changes to the way tobacco and alcohol are taxed.

It’s hard to think of any reason why a government wouldn’t put up tobacco tax. It’s popular – even among smokers if some of the revenue goes back to education and treatment. It’s long overdue – nearly ten years since the last real increase. It’s in line with international trends – Australia is one of the lower tobacco-taxing countries in the OECD. It stops adults and kids from smoking – more than any other single measure. It brings in much-needed revenue. And just as a bonus, it will save lives.

The alcohol tax system has been a mess for many years. The Henry Review is looking at this, but the present Budget would be a great opportunity to start the move towards volumetric taxation, with a special emphasis on the products that are targeted to kids an at-risk drinkers.

Any increase in tobacco or alcohol tax should be accompanied by a significant further allocation to prevention so that it receives more than the current less than 2% of national health spend. We know that there is overwhelming public support for this approach.

**

Professor Peter Brooks, executive dean, health sciences, University of Queensland

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Funding for telehealth consultations; increased tax on alcohol, cigarettes and junk food; increased funding for prevention

Q. What do you expect will be the big health announcements in the budget?

A. Some infrastructure projects, funding for Indigenous health projects – long overdue.

Q. What areas in health do you expect will be the losers in the budget?

A. Hopefully pathology and imaging services, and procedural fees.

***

Health economist Professor Gavin Mooney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. A costed long term strategy for CTG in Aboirginal health. What has been anounced so far is pathetic.
Revamp of Medicare primary care with increase in capitation for GPs and reductions in ffs. Also more targeted payments for prevention services in primary care.
Program (or clinical) budgeting within tertiary hosoitals to control costs and increase efficiency.
Increased spending generally in keeping people out of hospital
Outside the health portfolio – increased and more progressive income taxation; increased corporation taxes; increased spending on housing for the poor; and increase in salaries for the state sector teachers and other boosts to state education.

Q. What do you expect will be the big health announcements in the budget?

A. More money for hospitals but with attempts to tie to performance indicators (but this will not work)  Increase in charges for PBS items.

Q. Who or what areas in health should be the losers in the budget?

A. Private health insurance premium payers who should have their subsidy withdrawn.
Tertiary hospitals.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Community care
***

Mr Robert Wells, Director Menzies Centre for Health Policy, ANU

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A.No further cuts in primary care or prevention.
Some provision to progress the reform process, eg an independent ‘reform commission’.
An attempt to rationalise the private health insurance rebate to get some value for the investment or to reduce outlays for this.

Q. What do you expect will be the big health announcements in the budget?
A. Very few – the timing of the various reports lets them off the hook for this budget.

Q. Who or what areas in health should be the losers in the budget?
A. Private health insurers
Drug companies – more could be done re pricing, esp in the light of the GFC
Pharmacists – either they should be paid less for prescriptions dispensing or do more in primary care
Doctors- there could be some attempt to limit the amount doctors can charge for a service & still claim from Medicare (ie limit the copayment)- courageous stuff but these are hard times & even banking execs are expected to reduce their incomes

Q. Who or what areas in health do you expect will be the losers in the budget?
Probably consumers – there could be savings in the PBS which ultimately will raise prices for consumers
People who need expensive support aids etc to  supplement their medical care are unlikely to see any relief

***

Prue Power, Executive Director, Australian Healthcare & Hospitals Association

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. The single most important outcome in this Budget is the allocation of the remaining $5 billion to the Health Infrastructure Fund.   The initial $5 billion of the promised $10 billion was provided in last year’s Budget and the health sector is relying on receiving the full amount promised to fund essential infrastructure projects.  Australia’s health infrastructure is in desperate need of upgrading and revitalising to ensure that our health system can continue to deliver high quality care to the community.  If this funding is not delivered, Australians can expect our health system to become increasingly less able to maintain high standards of quality and safety and to keep up with new developments in health care internationally.

Other initiatives that AHHA would like to see in this Budget include: increased efforts to engage consumers in the planning and delivery of health care; a national approach to data and benchmarking within the health system to improve quality of care across the sector; a range of health information technology and management projects to support better delivery of health care; national leadership on oral and dental health; and  improved service integration, including adapting the innovative “Map of Medicine” to the Australian context.

Q. What do you expect will be the big health announcements in the budget?

A. AHHA is hopeful that the Government will fully meet its commitment of $10 billion in new funding for the Health Infrastructure Fund.  We also hope that the Government will understand the long term economic benefits of investing in evidence-based health care and will allocate funding to the other proposals outlined above.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If the Government takes a short sighted view in this Budget and does not allocate the promised funding to the Health Infrastructure Fund and other initiatives in order to increase its bottom line, the Australian community will ultimately be the losers.  In particular, the next generation of Australians will suffer the consequences of inheriting a health system that is not equipped to meet the needs of the community and lags behind that of other countries.

**

Health policy expert Dr Yvonne Luxford

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Clear dedicated funds to further the campaign to Close the Gap in Indigenous life expectancy, including funds to address the social determinants of health
The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Funding for school based health literacy programs with regular testing
A scheme to enable salaried GP positions in Superclinics along with salaried allied health workers and salaried public health physicians
Full Commonwealth funding for the Public Health Medicine training program
Funded support for all health professionals to improve their engagement with eHealth
Increase in access and level of funding for students, sole parents, the aged, unemployed and carers.

Q. What do you expect will be the big health announcements in the budget?
A. The creation of a National Prevention/Public Health Agency
A comprehensive suite of alcohol tax policies  with a percentage of income hypothecated to prevention and treatment programs
Restructuring of funding for the GP Divisions

Q. Who or what areas in health should be the losers in the budget?
A. Drinkwise and any similar industry controlled body

Q. Who or what areas in health do you expect will be the losers in the budget?
A. I don’t have a good feel on who will miss out this budget.

***

Fran Baum, professor of public health, Flinders University

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. More sustainable long term (10 years) funding for health promotion through a national healthy and sustainable communities project to be led by local government and  local health services – multi-sectoral and community driven
Capital and recurrent funding for multi-disciplinary community health centres with salaried medical and other health professional staff (instead of super clinics) focus on chronic care and health promotion – with local boards of management – supported by training program so these centres can take students from all health disciplines on multi-disciplinary placements
Serious funding for research program on the social determinants of health all aimed at answering question “What creates and sustains health and equity” explicitly not focused on diseases
Scrap private health insurance rebate
Regulate alcohol advertising – i.e. scrap industry self-regulation
Ban fast food advertising

Q. What do you expect will be the big health announcements in the budget?

A. More $$ for hospital waiting lists and treatment of diseases and medical research

Q. Who or what areas in health should be the losers in the budget?
A. Hospital intensive care units
End stage treatment for diseases where there is little hope of recovery and not really in the interests of the patient or society

****

Professor Glenn Salkeld, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. I would love to see a national centre for disease prevention and healthy living funded by Treasury and run through the office of PM&C.
I would love to see Education fund a school based program on healthy eating, cooking and physical activity. Get parents involved too.
I would love to see Health and Education get together and come up with real plans for training the next generation of health professionals
in Australia, in our region and in those low and middle income countries that need our help.
I would love to see Sport fund a national insurance scheme which covered the cost of liability and health insurance for all children playing sport.
The cost of club sport is becoming an unnecessary barrier to kids participating in multiple weekend sports.
I would love to see a greater willingness in Health to promote good health – to counter the supply side forces that promote bad health.

Q. What do you expect will be the big health announcements in the budget?

A. Hmmmmm. Given that most of the Health budget is committed to keeping the status quo (to fund recurrent expenditure) I wonder how much
room is left for big announcements in a climate of financial gloom. Any big announcements would have to follow Labor Party commitments
on reform in primary health care, child and maternal services, and the usual technology stuff (like the bionic eye). I’d like to think that
prevention will get a guernsey in the budget but maybe its too early in the life cycle of the Preventative Health Task Force to expect too much
right now.

Q. Who or what areas in health should be the losers in the budget?

A. My son tells me that the TV show ‘The Biggest Loser’ is an essential topic of conversation at school. Overweight and obesity are bound to get
some attention. The real ‘biggest losers’ should be services/procedures/drugs that
provide no gain (health) for a lot of pain (cost).

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Ironically and perhaps sadly I think the losers will be average folk trying to cope with chronic disease, and/or who have a family member
with a disability and/or who live in wrong post code that find access to help, services and support so hard to find. In hard financial times it is so often those who have the least who are asked to sacrifice so much. On this I would be delighted to be proved completely wrong!

**

Health policy analyst Jennifer Doggett

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Whether or not the government allocates the remaining money for the infrastructure fund, as promised, has to be the main health-related issue in this budget.  any other small buckets of money thrown around will be insignificant if they effectively cut $5b from what has been promised for health infrastructure.

Q. What do you expect will be the big health announcements in the budget?

A. No idea – heard the rumours about the Medicare safety-net but not sure how reliable they are. Cutting the safety-net would make sense and probably not alienate much of the government’s core constituency so it’s a fair bet.

Q. Who or what areas in health should be the losers in the budget?

A. As always, stopping inefficient and regressive practice of subsidising PHI through the rebate.  The saved $ could be much better used elsewhere in the health system or simply handed back to consumers.

Q. Who or what areas in health do you expect will be the losers in the budget?

A. If they cut the Medicare safety-net, some of the medical specialists will be the losers, particularly obstetricians and those who have the capacity to move their care from the hospital to community setting.

***
Dr Lesley Russell, Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. That there has been no diversion from or  dimunition in the commitments made on health care reform and closing the gap
on Indigenous health. As President Barack Obama has clearly demonstrated, health care reform is an essential part of the armament needed to tackle the impact of the global economic crisis, and we cannot resile from the timely implementation of commitments to our Indigenous peoples.

Q. What do you expect will be the big health announcements in the budget?
A. No big announcements. Expect lots of small program cuts as the ERC goes looking for savings and everything else on hold, pending reports.

Q. Who or what areas in health should be the losers in the budget?
A. It should not be about who loses but about making policy changes that will ensure some areas and programs work more effectively and equitably. Is there the will and the policy grunt to do this?

Q. Who or what areas in health do you expect will be the losers in the budget?

A. Publicly funded community health care

Public health, especially programs to tackle obesity/nutrition/urban environment/physical activity

Transition, step down care for the mentally ill and their carers

And some concern about funding for rural health programs, which have apparently been reviewed by DOHA, but no publicly available report of this review.

Real and realistic efforts to coordinate health care and associated needs (travel, medical aids, oxygen etc) and ease out-of-pocket costs for the chronically ill.
***

Boyd Swinburn, professor of population health, Deakin University
The government should be recouping its lost reserves by significantly increasing the taxes on alcohol, tobacco and junk food with a significant proportion of them allocated for prevention and the promotion of healthy patterns of consumption – as suggested as the top priority in the 2020 forum more than a year ago I think.

**

Dr James Gillespie, Deputy Director, Menzies Centre for Health Policy, University of Sydney

Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?
A. Nothing earth shattering. It would be nice if a government waited to see what its inquiries into the system report before making major changes.

Q. What do you expect will be the big health announcements in the budget?
A. Very little. Continue the drift  of risk from government and insurance onto out-of-pocket by fiddling with co-payments to save a bit of money and, less likely, cutting the PHI rebate. More likely they’ll freeze this as it means (technically) no broken promises.

Q. Who or what areas in health should be the losers in the budget?
A. Higher income earners’ rebates.

Q. Who or what areas in health do you expect will be the losers in the budget?
A. Some of the higher cost diagnostic areas – imaging etc…. where there is a fair suspicion that corporate business plans are gaming Medicare.

**

Consumers Health Forum

Our budget wish list: We see these will continue the momentum from the reform process and the 2020 summit with practical, implementable changes that will lead to better health outcomes for consumers.  Funding these items will see Govt rhetoric turned into reality.

• E-health – national electronic health records and e-initiatives to bring equity of health care to rural and remote area
• Implementation of the reform process – particularly in relation to the primary health care strategy, preventative health taskforce and the health and hospitals reform commission.
• Funding to resource consumer representatives to take part in the reform process and other committees that make decisions about health care in Australia.
• National Registration and Accreditation Scheme – including resourcing for the community representatives to have effective input
• Taxes (preferably increased) on alcohol and cigarettes to be channelled directly into health services and prevention/wellness campaigns
• Safety and Quality Commission – to implement the S&Q recommendations, including the hospital reporting

What do we expect?

• Beyond the Swine Flu, we have no confirmed expectations. However, we hope the budget will focus on the above.

What should lose?

• Systems that don’t work for consumers.

What do we expect will lose?

• Given the rumours, we expect that – unfortunately – radiology, pathology and IVF will lose

**

Other comments from sources who did not want to be identified:

Anon 1: “I don’t expect much in the way of new initiatives as the big reform agendas are some way off and hard for the government to make commitments at this point. Maybe the Preventative Health Agency but not an expectation I have. Maybe some increases in taxes on alcohol and tobacco. Mental health ??? I do expect more reforms of disability employment which will continue to improve prospects for those with mental illness. But this is against a very different employment context.
Losers we need to see – I hope we see the end of the safety net and some winding back of the Private Health Insurance – but the latter is unlikely. They will have plenty of other areas of middle and upper class welfare to cut before going to this almost sacred cow. I would like to see changes to Better Access (cut the GP mental health plan rubbish) and curtail the growth in psychologists (the common garden variety who represent the least trained and charging the highest OOP expenses). Like to see much more incentives toward collaborative PHC practice,
Losers I expect – safety net, not much else, maybe PBS will have some further limitations.
I think in health we are waiting for regime change.
Indications are that they will take major reforms from the papers under development to the next election and continue to try and hold the current arrangements up for the time being.
I hope I am wrong.”

Anon 2:
Q. What would you like to see come out of the Budget with regards to health (whether from the health portfolio or elsewhere)?

A. Some more MBS and non-MBS money for primary health  care, skewed to low spending areas, but also allowing GPs to be fundholders  for more allied health care for chronic ill people; agreement in principle to  Commonwealth Indigenous health services purchasing organisation; also some  extra for AIHW for regional health information including health status,  spending and services

Q. What do you expect will be the big health announcements in the budget?

A. Not much, essentially a ‘let’s wait on the NHHRC  final report and the COAG working parties’

Q. Who or what areas in health should be the losers in the budget?

A.  Extension of cost-effectiveness application, resulting in higher co-payments for less effective and less important  pharmaceuticals and services (eg drug-inducing stents, in vitro  fertilisation); abolition of the Human Services portfolio and re-allocation of Medicare Australia to the health portfolio and Centrelink to the FACSIA  portfolio; increase in MBS safety nets; changed bond arrangements for  residential aged care; sale of Medibank Private

Q. Who or what areas in health do you expect will be the losers in the budget?

A.    Not much if anything.

***

Anon 3:
“The abolition of  the $6 bn private health insurance subsidy would be a major contribution to  budget savings. This is not a health program. It is a subsidy to financial  intermediaries like Merrill Lynch.  PHI is grossly inefficient (double the cost of  Medicare administration) inequitable and weakens Medicare’s position as the  major purchaser of services. The alleged claims to take pressure off public  hospitals is misplaced. It has just not happened.

The government and the  private health insurance industry claim that the subsidy is only $3.8 b. In  addition to that sum, there is almost another billion dollars in tax concessions for those who take private insurance. Further, government and PHI estimates of the subsidy have been consistently understated. If the  government is prepared to introduce a cap or a means testing of the subsidy,  it would be a useful start.

Be careful about the argument that the minister  and PHI executives use about choice. The principle of a single payer can  promote choice. There is no reason why Medicare or as in the case of  Veterans’ Health, the single public insurer cannot pay money direct to  private hospitals probably through a DRG formula.

Other proposals – for introducing the second stage of increased generic prescribing  for pharmaceuticals and rigorous regulation of radiology and pathology – would all be very welcome.

A major problem with government health policy  is that it is so piecemeal. There is no ‘health system’. There is focus on  the cost of particular services, eg pharmaceuticals, radiology, etc, but  health care in general is not held accountable for what it produces. I  suggest that the Productivity Commission be tasked to advise the government  on ways to improve the efficiency and productivity of the health sector.

For example, there are variations in the pattern of clinical practice right across the country. These variations are never examined and very little  action is taken on them. I would suggest there are very substantial savings  to be made in this area. The variations in the incidence of caesarean  sections across Australia are an example of the sorts of variations that  need addressing.

Over-utilisation is widespread and unchecked. It is also likely that there is under-utilisation by the poor, indigenous and people  living in remote areas.

The government-appointed commission to review health  services has produced a very timid report. There is also an obvious conflict  of interest because of its relationship with the private health insurance  funds. How else could one explain its draft recommendation to fund dental  care through a tax levy which would then be churned through private health  insurance funds? It is just a crazy idea. The rigour and professionalism of  the Productivity Commission is essential if we are to reduce costs and  improve productivity.

One area which I hope the government will address  in the budget is to commence a rationalisation of co-payments.  The co-payments lack logic and  consistency between programs. Australians are much more wealthy than they  were over 30 years ago when Medicare was introduced. Most of us can afford  to pay more. A good co-payments scheme would ensure that individuals take  more responsibility for their health decisions.

If the government wants  to save money in health, it should offer to establish a joint health service commission with any state that will agree.This is the most useful way forward on both  policy and political grounds to resolve the waste and inefficiency of the  Commonwealth/State divide.

The Commonwealth government has pledged  substantial increases in funds to state public hospitals. I am not sure that  it has insisted on increased productivity on the way these funds are spent.  The government had previously highlighted the importance of activity or  episode funding  being made available on the basis of output) rather  than grants to the states to enable them to continue in their inefficient  ways.

If the government wants to get more efficiency in the  health sector and contain escalating costs, it must address some of the  issues mentioned above.”

“We thank everyone for their comments. This is an innovative donation arrangement so we are not surprised at the range of responses.

Some raised concerns, some were based on misunderstanding or preconceptions and others were very supportive of the initiative.

The issues raised in the correspondence, and many more, are dealt with in detail here.

From the outset we have been determined that this should be an open and transparent arrangement, and we are comfortable that important questions of independence and influence are well covered.”

It will be interesting to see whether this response allays or inflames concerns. To my mind, it raises some questions for the Heart Foundation, given the disclosure that Prof Jennings is Chair of the Foundation’s National Cardiovascular Health Advisory Committee.

Meanwhile, here are some other comments on the deal:

Dr Stacy Carter, Senior Lecturer, Qualitative Research in Health, Centre for Values, Ethics & the Law in Medicine and the School of Public Health, University of Sydney:

The naivety – or wilful ignorance – that Melissa describes is both critical and incredible. Doctors and research institutes entering into such deals with pharmaceutical companies are like pantomime characters: the wolf is approaching, the audience is shouting ‘look behind you’, they keep eating their ice-cream.

My colleagues and I have been engaged in some qualitative research around these issues for a while. Get a group of consumers into a room and ask them about drug marketing, and they will soon begin trading stories from their own experience that demonstrate how susceptible to influence many doctors are. Consumers are also under no misapprehensions about the power of corporate profit motives.

Meanwhile, one of the most consistent patterns in research is this area is that most doctors think they (and presumably their reputations) are impervious to influence. I suspect this is the same for many medical researchers.

Consumers look for independence in their medical practitioners and in research: they want to be able to trust. But trust demands trustworthiness, and ties to industry inevitably undermine this trustworthiness. One has to wonder why some doctors and researchers refuse to look up from their ice-cream and face the wolf.

***

Michele Kosky, Health Consumers Council WA:

Some health consumers will feel a real sense of disappointment that a distinguished research institute like the Baker has to engage in this kind of fundraising venture which appears to potentially compromise the independence of the research and influence medical practitioners’ prescribing habits once again.

***

Dr Alasdair Millar, physician:

I worked at the BMRI for 6 months in the late eighties and support its work.  Your article and the one in The Australian do make it clear that the funding to the BMRI is unconditional, and if that is true it is an important fact: the BMRI can do what it likes and no doubt good research will be done with it, and that could benefit medical practice.

Any dubiousness in the arrangement is in the link with prescription volume, in other words the involvement of the BMRI in a marketing effort of a single pharmaceutical company.  The marketing aspect is doubtless the reason Sanofi did not just give a grant of $500,000 to the BMRI.

I presume that the 25c gift will be conditional on prescribing clopidogrel as Plavix, rather than Iscover or simply as clopidogrel, and that in future, when the patents for clopidogrel run out, the BMRI funding will fall unless the trade-name prescribing continues; so in the long run it will have problems.  However, by then a generation of doctors will be used to prescribing clopidogrel as Plavix and the impact of loss of patent protection to the company will be blunted.  Perhaps this is the strategic objective.

It’s also worth pointing out that the 25c per script to be paid to the BMRI will in fact be paid for by Australian taxpayers directly, because clopidogrel is subsidised by the PBS.  The cost of clopidogrel to government via the PBS is substantial and is a legitimate source of concern.

One could make the case that more public good would be gained if the company simply cut the cost of Plavix by 25c per prescription, and that given the subsidy, the Australian government might feel it should have been consulted, especially given that it probably provides substantial funds to the BMRI through the NH&MRC.

**

Dr Ian Haines, Melbourne cancer specialist:

I basically agree with Ken Harvey that the fundamental problems are:
1. The Baker Institute lending its logo to the sanofi advertisements which is indefensible and appears intended to deceive people that the Baker endorses the product Plavix.
2. Donations from Sanofi to the Baker being tied directly to scripts written.

Most health professionals would strongly endorse philanthropic donations from pharmaceutical companies to our leading research institutions which are fully transparent. However, do highly respected and prominent key opinion leaders such as Gary Jennings expect us to seriously believe that next time they are giving a major presentation to doctors, or involved in writing clinical guidelines related to these agents or reviewing journal articles that may be critical of or negative about Plavix or reviewing research grants looking at questions that may favour a rival product that they will be able to be totally disinterested and dispassionate?

If so, their behaviour would be almost unique in human history and they would be potentially reducing their own research funding.

Even if they are truly unique in human history, the perceptions of doctors at their presentations or doctors whose grants are turned down or researchers whose manuscripts are declined will still range from significant scepticism to profound cynicism to outright anger.

The only proper course of action now is for any researcher associated with the Baker to decline to do any presentation, manuscript review, review article or guideline that was in any way related to Plavix or any competitor product. There is no alternative action that would preserve the perceived credibility or integrity of the Baker in the public mind.

Alternative means of funding our major research institutes are urgently needed.
***

Dr Jon Juredini, Healthy Skepticism:

The dangerous thing about this piece of marketing is its plausibility. Most readers will see it as an act of philanthropy, albeit one carried out in a way that will enhance the image of the company. Until I read Ken Harvey’s posting, I didn’t see all the dangers.