That is the suggestion of this very interesting piece below from Patrick Bolton, who has long and diverse experience in the industry.  He has worked as a GP and hospital administrator in urban and rural Australia in several states and territories. He has researched and published in health data, information management and health systems evaluation. He is national vice-president of the Australian Hospitals and Healthcare Association, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of NSW.

Bolton writes:

“When he is not solving the world’s climate and economic problems, I understand that the Prime Minister is touring the nation consulting about the future direction of the healthcare system. I’ve knocked around in, and been an observer of, that system for a while, and I offer the following observations in the hope of informing that debate.

There are always more things that can be done in healthcare than money to do them

As a result, some people miss out on some care some of the time, and this will always be so. This isn’t rationing because there is nothing rational about it.  At present the system responds to this truth by pretending it doesn’t exist. A problem must be acknowledged before it can be addressed.

Some of the people who miss out make a noise – for example by complaining to an MP – and then get what they want. This is unfair on those who don’t complain because it means that limited resources are shifted to the loudest.

It is not irrational for the people who complain to complain. They will benefit, assuming the medical care they receive does more good than harm. It is society as a whole that loses. There is no-one arguing on the side of society as loudly as individuals argue in their own self-interest. The hit the individual faces is large, the personal cost to each individual in society small.

Of greater effect on the system is that healthcare workers make choices for individual patients, not for society. Again this is rational. As a healthcare worker I want to provide the best care for each individual that I look after, and as a patient this is the standard I expect of the healthcare workers who care for me. Even were I prepared to favour the interests of society over the individual, I would have to trust that others in the same position will do the same. If they do not, then my altruism is benefiting them and not me.

This factor creates a difficulty because doctors are arguably best placed to assess which patients will benefit most from which interventions, but any management system that asks them to do this puts them in a position of conflict of interest. This is a source of professional dissatisfaction for healthcare workers

The difference between what people want and what the system can provide is one of the sources of dissatisfaction with the system. It contributes to the perception that reform is required.

The only way to make the health system cheaper is to reduce services

Many of the initiatives proposed by the Hospitals and Healthcare Reform Commission are said to improve health outcomes and so make us live longer and healthier lives. This is desirable if it is correct. Unfortunately, we will all still be dead in the long run, and around 80% of healthcare resources are consumed in the last two years of life, whether we die at 70 or 100. None of the proposed changes are about reducing cost as an end in itself. If the proposed changes work we will live longer – so consuming healthcare resources for a longer period, albeit possibly at a slower rate, then cost the same amount when we finally die.

There a no great savings for the healthcare system in this, although there may be increased  productivity as an offset. Health is a superior good, one on which individuals and communities spend more as they become wealthier, and this may justify additional expenditure.

It is not clear what the objective of the health system is

It is difficult to go somewhere unless one knows where one wants to go. Individual needs, expectations, and capacity to assess outcomes of the healthcare system vary. This means that the perceived purpose of the healthcare system varies depending on who you ask.

It would be surprising if the interests of the most vocal group – healthcare providers – coincided with that of the majority who pay for these services. There are no other areas where the interests of vendors and customers coincide, so why expect this in healthcare?

Healthcare doesn’t seem to make much difference to health

This is well known and such a show-stopper that everybody, me included, seems to acknowledge it and move on. I think it reflects several factors. These are:

a)    There is good evidence that the health of first world societies is closely associated with the level of equality in that society, not to the level of healthcare. If this relationship is causal then it can be argued that one should invest in strategies to promote equality in preference to healthcare.

b)    Individuals are not good at assessing the outcomes of the care they receive and the system is not good at measuring outcomes.

Most people recover from illness, but some do not. The outcome is multi-factorial, so it can be difficult to say which part of an individual’s health outcome is a result of the care that they received and which due to other factors. It is particularly difficult for lay people to judge the quality of the care they receive.

Changes in healthcare tend to be incremental, and so outcomes compare current treatments with alternatives which are likely to be only slightly better at best, as opposed to no treatment. It is generally held to be unethical to compare new treatments against no treatment. One might argue that this is irrational in cases where current therapy has not been shown to be superior to no treatment.

The quality of outcomes measurement of the healthcare system is woeful. Given that much of the money for healthcare comes from the public purse this is a significant failing of accountability.

c)    There is a high error rate in healthcare. International studies repeatedly show that errors in healthcare delivery occur in around 10% of cases. In Australia these errors are associated with about half of all in-hospital deaths. If death is the outcome measure then Australian hospitals may be killing as many people as are killed by the conditions for which they were admitted. The harm that the health system causes may offset any benefit that it delivers.

d)    Estimates are that one-third of what is done in healthcare is unnecessary. Two things follow from this. First, if unnecessary care can be identified and stopped, then the efficiency of the healthcare system can be improved by up to 30%. Second, unnecessary care still causes harm, and this offsets the benefit from effective and necessary care for the system as a whole.

Healthcare in Australia is not a very enjoyable place to work

This has important implications for workforce engagement and sustainability.

Poor work hygiene is bound up in the foregoing issues. It is hard to feel satisfied about what one is creating if the value of the product is at best unclear, and possibly negative.

The response of policy makers to these issues has been to tighten the leash and increasingly micromanage healthcare delivery. Healthcare workers are highly skilled employees, expert at making individualised decisions in complex settings. It is unlikely that directive management can lead to better outcomes that professionals can provide themselves, so micromanagement results in alienation of the work force without improving performance.

Suggested pre-requisites to change

There is nothing new in any of this, but it needs to be said because the healthcare system cannot improve until these factors are addressed. Some suggestions to do this are:

1.    The new health system needs to be as clear as possible about what it is trying to achieve, and collect data which measures performance towards these achievements.

2.    The new healthcare system needs to be able to demonstrate that the things that it does are effective, cost effective and done to people who will benefit, and not those who will not.

3.    The new health system is going to have to allocate resources transparently on the basis of 1 and 2 above. This is so that equity and efficiency are maintained in the face of other interests.

Addressing these factors is necessary but may not be sufficient. If they are addressed, then healthcare will improve under the current governance model. Some other governance model may be preferable for the reasons currently being debated, but we can’t know this until the problems discussed here have been addressed.

No governance model can be properly assessed until these underlying distortions are addressed. Introducing the kinds of major change contemplated is not without risk. It will be impossible to manage and measure the impact of this risk until these factors are addressed.”

There I told you – it was worth taking the time for the read, wasn’t it? Plenty of food for thought there.

This is the statement:

AMSANT has written to the Northern Territory Health Minister with a potential solution to needless deaths among central Australian renal dialysis patients, AMSANT Chairperson Stephanie Bell said today.

“The current policy of refusing to treat Aboriginal patients in Alice Springs is contributing to early deaths for Aboriginal people,” Ms Bell said.

“Sending people from remote communities to Perth or Adelaide is creating enormous psycho-social impacts on individuals, their families and their communities.

“Some people are opting to refuse or withdraw from treatment so they can go back to their country to die: it is an intolerable situation.

“The patients concerned live on or close to their ancestral estates—and didn’t “ask” for those estates to be alienated from their kin and country by the arbitrary imposition of state and territory border lines.

“We have suggested to Minister Vatskalis that a short term solution is available—nocturnal dialysis—and that AMSANT would back the Territory Government in seeking proper recompense from the South and Western Australian governments, as well as Commonwealth support.

“The demand that they move many thousands of kilometres to distant capital cities is irrational and—in the long term—far more expensive than treatment closer to home in a regional centre such as Alice Springs.

“The tri-state committee dealing with these issues for 18 months and has done little more than sit on its hands.”

Ms Bell said that AMSANT realises that the Northern Territory is in an invidious position in being asked to take on patients that don’t “belong” to the Territory in a jurisdictional sense. She said the costs of introducing night dialysis at the Alice Springs Hospital, along with social and housing support, should be met by interstate governments.

“This is clearly a short to medium term solution, one that will be relieved to an extent with the new satellite facility opening in April next year,” said Ms Bell.

“Beyond that, of course, we must work towards peritoneal and haemodialysis being made available in the regions to reduce the load on facilities in Alice Springs.”

Croakey suspects that this is just one slice of a much bigger story about how Indigenous patients with kidney disease miss out on all sorts of potentially life-saving interventions – including measures that might help prevent the need for dialysis in the first place.

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.”

They write:

“John Graham’s suggestion for saving NSW hospitals, as outlined in his recent Centre for Independent Studies monologue, dreams of hospitals managing their own affairs unfettered by outside interference. His piece is called ‘The past is the future for public hospitals’.

He argues in essence: just let us (primarily doctors) get on with it – as we used to do – and all will be well.

The arrogance and lack of ‘back-sight’ in learning from the past are stunning.

We are not going to speculate on how to address the problems of NSW hospitals beyond arguing that Graham’s suggestion is not the way to go.

What is at stake is the question of who has the power to decide how resources in hospitals and health services more generally are used.

Do we want another Bristol or another King Edward Memorial Hospital?  Are doctors to be left in charge? They are trained in medicine but not hospital management which is a major and important discipline in its own rights. We risk producing a culture of ‘medocrats’ and that as the Bristol Inquiry indicated is to be avoided.

The logic of Area Health Services is to address the health of a population not just the patients of a hospital. So what is the role of the hospital in the community under this view from the past? How are questions of equity to be addressed?

Central to any recommendation on governance of our public hospitals must be a recognition of three things.

First hospitals are responsible for allocating resources – for example, setting priorities within the funds available for example – as well as treating patients. Second there needs to be some clear explicit mechanism for ensuring that the culture of hospitals is genuinely conducive to good patient care. And three, hospitals are about power, both power within the hospital and power in the health service more widely.

Whatever else we can learn from Bristol and King Edward’s – and surely from these there must be a learning process – it is that ‘internal’ auditing of hospitals is simply not good enough.

There needs to be openness in all aspects of both patient safety and resource management. Ideally if hospitals  are to serve communities, there needs to be accountability to the citizens in the community they serve such as through citizens’ juries as one of us (MM) organised in the south west of WA [This book has more details].

Graham bemoans the advent of Medicare: “The ideologically driven decision to allow all comers to be treated free regardless of means fundamentally changed the dynamic that underpinned the successful operation of the public hospital system.”

It certainly did. But unlike Graham we welcomed Medicare and want to defend it particularly given the current attempt to undermine it in the floating of Medicare Select by the NHHRC.

Given the ideologically driven ideas in proposing a return to the past in Graham’s CIS paper, it is superfluous to ask what concerns he might have in his proposal for equity (which interestingly was given a big tick in that WA citizens’ jury).”

Not surprisingly, the heavies are cracking down. Here is a brief report from the “who will speak for us” group:

“Things have gone insane here with computer access records of all staff being checked! Management is determined to find out who is involved and are using fear to control people.”

Well, the Australian Healthcare & Hospitals Association has had a read and gives the draft paper a generally positive review, and argues that its findings should be seen as an endorsement of the performance of public hospitals.

Which puts an interesting slant on the timing of the AMA release of its public hospital report card, which resulted in plenty of damning headlines around the place.

The AHHA’s executive director, Prue Power, writes:

“Australians should be reassured that their public hospital system is performing efficiently and delivering good value to the community.

The Productivity Commission draft discussion paper on public and private hospitals, released yesterday, found that on the basis of available data, the costs of providing care in the public and private systems were almost the same.

In its own words “The Commission’s experimental cost estimates suggest that, at a national level, public and private hospitals had a broadly similar cost per casemix-adjusted separation in 2007-08″

The Commission acknowledges the difficulties involved in comparing the two sectors, given their very different patient populations and mix of services provided.

It has done a good job in accounting for these differences, although admits that it is almost impossible to adjust for many factors, such as the lower socio-economic status of patients in public hospitals. Other differences, such as the fact that about half of admissions to a public hospitals occur through emergency departments whereas private hospital admissions are almost all planned, are noted but their impact on overall costs is not assessed.

Given this, it is likely that the cost of public hospital treatment is even lower than that of private hospitals, when all the differences in patient populations are taken into account.

Where there are cost differences identified between the two sectors, the Commission has found that these are probably accounted for by their different roles or are due to inconsistencies in data collection.  For example, general hospital costs were found to be about 30% higher in the public hospital system due to the higher expenditure on ward nursing. This would be expected given the higher rates of complex and critical conditions treated in public hospitals.

Similarly, the higher medical and diagnostic costs in private hospitals are attributed to higher fees being charged by doctors in the private system as well as possible data gaps in the public system where some medical and diagnostics costs may be recorded elsewhere in the system (for example included in operating theatre costs, where they occur in the context of a surgical procedure).

The two major areas where the Commission found that costs cannot be meaningfully compared between the two sectors are medicines and capital costs where funding and data collection practices differ so widely (and in some cases are internally inconsistent) as to make comparisons pointless.

In relation to safety and quality indicators, the Report includes an important discussion about why comparisons between sectors (and also between individual hospitals) are so difficult. For example, in relation to hospital-acquired infection rates it is important to adjust for the relative risk of patients.  In practice, this can be extremely difficult as patient risk is dependent on a wide range of factors, often not recorded in hospital data.

However, the Commission makes some useful recommendation to move towards a more robust and nationally-consistent data collection on hospital-acquired infections, such as including private hospitals in national reporting arrangements.

Overall, the report gives an honest account of the limitations of comparing public and private hospital sectors and does a creditable job of meeting its terms or reference with the limited data available.

It might not contain any surprises for those working in the public and private hospital sectors, but it should reassure governments and the community that public hospitals deliver excellent value for money.”

Professor Bruce Robinson, dean of medicine at the University of Sydney, thinks one solution may be to broaden the range of services involved in providing postgraduate medical education. There are, of course, many reasons why this might be useful – especially if it means more graduates wanting to work in general practice or in disadvantaged areas.

He writes:

“The recent difficulties for international medical students, who after as many as seven years of study have found themselves scrambling to secure postgraduate training positions, have been stressful for all concerned and not helpful to this country’s reputation for education.

The students’ much publicised problems, though, have served one useful purpose. They have been a wake-up call for state and commonwealth governments, medical schools and the profession on the need to overhaul postgraduate medical training.

Without reform we are destined to see the events of the past months – students graduating but not sure they will be able to secure an internship – repeated with increasing severity in the years ahead.

With the number of medical graduates due to more than double in the next two years, local as well as international students will soon struggle to secure postgraduate training positions. Within three years, the numbers of young graduates without internships could be in the hundreds.

Just as important, without reform of postgraduate education and training, we will not be preparing young doctors well for the realities of modern health care and for the medicine most will eventually deliver.

Postgraduate medical training has traditionally taken place in the country’s public hospitals. There is absolutely no way that under-resourced public hospitals can accommodate the increasing numbers of graduates looking for internships in the years ahead. Nor should they.

Changes to the way medicine is practised, the growth in the private hospital sector, and the shift from people being treated in hospitals into ambulatory care settings all necessitate rethinking the intern role.

Patients today spend shorter periods in hospitals, they are increasingly diagnosed and treated in general practices and specialist rooms. When students and young doctors see patients in hospitals for short periods but are then not involved in continuity of their care, they are missing a fundamental part of good medical practice. Without spending some of their training in community settings, in general practice and with specialists, trainees risk not seeing the full range of health delivery.

Changing patient management strategies, which are now more likely to include other health professionals such as physiotherapists and nurses, are also not well reflected in the public hospital-based postgraduate training we now provide.

One of the factors that has restricted change to postgraduate training has been an overly bureaucratic and traditionalist approach by governments and some in the medical profession. But if we are serious about providing better education experiences for our young doctors, we need to think more broadly and develop programs that more fully reflect modern medicine.

Instead of focusing all postgraduate training efforts in public hospitals, we need to be looking at options in the public and private systems, in general practices, specialist rooms and health centres, including Aboriginal medical centres.

Private hospitals now play only a minor role in medical education and training, but in our discussions we have found highly experienced members of the profession working in the private sector who are happy to engage in training young doctors.

We should also consider international opportunities. International training, especially in countries in our region, offers invaluable new perspectives and cultural experiences that foster more enlightened practical doctors. Many Australian health professionals work internationally and are willing to assist in training young doctors.

The Health and Hospitals Reform Commission, in its recent report, made a number of recommendations on postgraduate training, including the development of a new framework with clinical training available across all health settings, both public and private, and involving hospitals, primary health care and community settings.

With the new graduates emerging, there is real urgency to this endeavour.

To take the brightest students, ask them to commit to at least seven years (in the case of Sydney Medical School) of intensive study but then not provide them with the postgraduate opportunities they need to become the doctors they have the potential to be – and that the community needs – is wasteful and unacceptable.

It is imperative that we review and moderate the clinical training we provide, so we can accommodate the higher numbers of graduates but also allow it to occur in settings that make our young doctors ready and relevant to contemporary medical practice.”

• This article first appeared in The Australian’s Higher Education Supplement of 14 Oct. It is reproduced with the author’s permission.

That’s the warning from Dr Peter Short, a health industry worker with extensive background in clinical work and health professional education, who has provided this review of Allyson Pollock’s book, NHS plc – The privatisation of our health care.

He writes:

“Australia’s universal health care system is under threat by the ideologies and ideologues of the neo-liberal market economy. The United Kingdom’s National Health Service (NHS), a beacon of universality since 1948, has been taken over by these market forces and it is this process that is the subject of the book NHS plc – The privatisation of our health care, by Allyson Pollock.

Pollock, an experienced public health medical practitioner and Director of the Centre for International Public Policy at the University of Edinburgh, is a controversial figure in health policy in the UK due to her opposition to health policies that fail to demonstrate value for money for the public services. Furthermore, she argues, these policies have led to an increasing role for private-for-profit providers, effectively privatising the NHS.

NHS plc is divided into eight chapters that fall roughly into three parts: the new ideology (Market Prescriptions, The Real Cost of Market Prescriptions and Privatising the NHS: An Overview); the effects (Hospitals, Primary Care and Long-Term Care for Older People) and the future (Overcoming Opposition and The Emerging Health Care Market).

In the first section Pollock argues that changes in health system thinking have increasingly privileged knowledge of business management principles re-conceptualising health care as similar to factory production lines, with the automobile factory a favourite model.

Pollock analyses a number of private finance initiative projects in the UK that, prima facie, appeared like good value for money although the actual cost was rarely revealed remaining ‘commercial-in-confidence’. One hospital was supposed to cost 94 million pounds but had to repay 115 million pounds after costs for fees and finance was added. (p28)  Inevitably, cost over-runs mean reduced public services when services are closed or are taken up by private service providers.

The middle section of NHS plc is where the ideological rubber hits the health system road. In these three chapters the effects of the privatisation process are detailed. Patients have been relegated to products whose prime function is to cause no impediments to their discharge. Those who require more care than their clinical pathway allows (for example, people with chronic illnesses, the elderly with complex needs or patients requiring rehabilitation) have become bed blockers and slow down the speed of the hospital assembly-line, blocking entry. A growing waiting list is more evidence of the absolute requirement and necessity to ‘improve’ the hospital.

The third section analyses how opposition was overcome. Like in Australia, the UK government: ignored its chronic underfunding and privatisation program; cast its health system as on its knees because of its staff; used catastrophic demography (the ageing population) as a spur to act quickly; imposed endless auditing; began caring more for the organisation and its performance rather than the population’s health needs; reduced the power of clinicians and closed beds and services.

Little evidence was ever produced for these initiatives and evidence was replaced by slogan and ‘common sense’ arguments’. Ironically, the privatised US health system was held up as a desirable model.

Probably the most distressing aspect is that health care clinicians have become, as Pollock puts it, ‘care deniers’ rather than care givers. Care is denied in the public sector when: staff are asked to justify why certain patients are still in hospital beyond their anticipated date of discharge; patients are discharged earlier; patient care is outsourced to families when patients reach the end of their clinical pathway and public sector services are closed. An audit denial culture has replaced a caring accountable culture.

Pollock’s arguments are clearly and generously supported with an impressive gathering of statistics, health service memorandums, parliamentary papers, newspapers and her team’s own academic research. This is in disturbing contrast to the paucity of critical thinking and uncritical acceptance and promotion of the ideology by politicians.

Consider the response of Gordon Brown when asked the rationale of using more expensive private sector funding for public investment – he repeated that the public sector is bad at management and only the private sector is efficient and can manage services well. (p3) Would anything different be said in Australia by a local premier or health minister?

In Pollock’s book, I have seen the future. And I don’t like what I see.

If one was to simply replace the acronyms UK with New South Wales and localise the names and places it would tell the same story.

Pollock’s description and analysis of the NHS may appear far-fetched until Australians connect the changes in local rhetoric and policies, the service closures, the hand-on-heart expressions of political support, the introduction of factory-like management principles and the hundreds of other small, apparently insignificant, changes.

Most clinical workers are encouraged to develop critical thinking during their preparation for practice, and now is the time for them to use that faculty, resisting systems of thought that, on the one hand, speak of modernisation, renewal and patient centred-ness while, on the other hand, promote care denial, car factory principles of care and the destruction of our universal health system.

For Australian voters and patients, Pollock’s book can explain what is being done to our health system in our name, but not with our consent.”

• NHS plc – The privatisation of our health care. By Allyson Pollock, London: Verso, 2004

You can read the article in full here – or skip straight to the conclusion that: …”research suggests that simply reducing noses through the ER door and introducing more primary care physicians alone will not resolve the backlog. ER overcrowding is a symptom of a larger set of issues that cannot be addressed by the emergency department – or even hospitals – alone. As a recent report on improving access to emergency care states:

A system wide problem cannot be remedied by selecting only portions of a system wide solution.”

The article introduced me to a term I hadn’t met before: “orphan patients” – those who have no primary care provider and see the hospital emergency department as their only source for medical attention.

Katoomba Hospital staff - new media activists

You could see it as a measure of the anger and frustration that many doctors, nurses and other health professionals feel about the NSW health system and those charged with running it – including the managers, bureaucrats and State Government.

And you could also see it as a fascinating example of the potential offered by new media for breaking down some of the political and bureaucratic barriers that inhibit open public discussion about the health system. This problem is, of course, not only an issue in NSW. All health departments – federal, state and territory – do an excellent job of keeping the clamps on tight – threatening staff who speak out publicly with sanctions.

It may seem a bit over the top for the Katoomba staffers to be comparing themselves to those who confronted the tanks in Tiananmen Square 20 years ago. No doubt this reflects both the sense of fear and solidarity that the staffers are experiencing. No doubt as well that the Ministerial and bureaucratic tanks will be on their way west soon, if they’re not already.

I asked the bloggers if I could interview someone about the campaign. But they declined, saying they had to remain anonymous, and sent this email:

“As you no doubt will appreciate, the key to our survival is anonymity. Basically, the role of our blog “Who Will Speak For Us?” is to leak information out to the community which they can verify themselves. We have a strong community based lobby group here in the Blue Mountains (HEAL- The Health Equity Access Lobby) whose work has saved Maternity Services at the Hospital.

Because of the gagging of staff, we were unable to let them know what was going on in the Mental Health Unit, Rehab Unit, Theatres, and Kiosk. Some of the staff got together and came up with the idea of an anonymous blog in order to leak information so that the Community knows what questions to ask.

For instance, five beds were closed in the Mental Health Unit since May this year, but the Community did not know until August when we posted it on our blog. They were able to verify these facts by asking the Hospital and Area Health Services.

If we break the anonymity, the staff who have come forward will stop coming forward. You have to realise that everyone in the Executive of the Sydney West Area Health Service who has said “trust me” and has betrayed that trust, so we have to operate the way partisans do.”

It will be interesting to watch the impact of this campaign; will it make any difference; will it galvanise community activism; will we see some copycats springing up; will there be new clauses in employment contracts banning the use of online media?

PostScript:  The bloggers are claiming credit for this local headline in the Blue Mountains Gazette.