The omission has been somewhat rectified by today’s announcement of the Council’s committees, particularly with the newly established prevention and community health committee, and the newly established health care committee.

But primary care remains a minority player on the powerful research committee, which advises and makes recommendations on research grant applications and funding.

Meanwhile, the recent Croakey post prompted Rebecca James, CEO at Research Australia, to offer another interpretation of the new Council’s membership. She writes:

“The bureaucratization of the NHMRC is surprising given the newly legislated independence of the NHMRC.

Perhaps it could be interpreted as a renewed commitment by state governments to reform and embed a “learning” health system.  On the other hand, on matters of basic science, innovation, commercialization, technology, and knowledge transfer (particularly through primary care), there are likely to be a few lone voices on the Council  who may struggle to be heard.

Research Australia’s community surveys show the Australian public considers “improving hospitals and the health system” is the highest priority for the nation, ahead of keeping the economy strong and improving national infrastructure.

Research on prevention, treatment and cures for illnesses and diseases will play an important role in Australia’s future.  Let’s hope the Council can bring together the knowledge, experience, wisdom, and visionary thinking to work out practical ways to meet the public’s expectations.”

Post Script: Hilary Russell, Deputy Head and General Manager, Research Strategy, at the NHMRC, has sent in this response to the recent Croakey posts:

“The National Health and Medical Research Council is appointed under the NHMRC Act 1992.  The Act stipulates that the membership include the Chief Medical Officers for the Commonwealth, States and Territories (nine people).  It also requires the appointment a person with expertise in the health needs of Aboriginal persons and Torres Strait Islanders; in consumer issues; expertise in business, as well as 6 – 11 people with expertise in a range of other health, research and ethics areas.

The newly appointed Council includes experts with a wide diversity of knowledge from their current and previous roles across the continuum of health services, research and biotechnology.

The knowledge and skills of Council members are complemented by the members of the five NHMRC Principal Committees.”

• Declaration: Melissa Sweet, the Croakey moderator, is currently doing some editing work for Research Australia

You can see the new Council’s members here. To question the composition of the Council is in no way intended to cast aspersions on the individual appointees.  I have no doubt that they are quality people with eminent and well-deserved reputations.

My back-of-the-envelope analysis is that the Council has:

•  10 Federal or State government employees (Rosemary Bryant, James Bishop, Kerry Chant, John Carnie, Jeanette Young, Paddy Phillips, Simon Towler, Craig White, Charles Guest, Barbara Paterson)

• 4 medical specialists (James Best, Sandra Hacker, Ron Trent, John Horvath, although perhaps John Horvath should have been counted as a Government employee as he is listed as Principal Medical Consultant for the Australian Department of Health and Ageing)

• 3 scientists/academics (Michael Good,  Kerin O’Dea, Cindy Shannon)

• 1 consumer (Anne Cahill Lambert)

• 1 business rep (Andrew Cuthbertson,  R&D Director and Chief Scientific Officer of biopharmaceutical company CSL Limited)

To be fair, many of the members have experience across diverse fields – Barbara Paterson, the chief health officer for the NT, has a background in general practice.

But the omission of explicit primary health care expertise seems rather strange, especially at a time when it seems there may finally be some action to match the longstanding rhetoric about the importance of primary health care in improving both quality and equity in health care.

If the community and primary health care is where it’s all meant to be at, why isn’t the NHMRC there as well?

I will see if NHMRC ceo Warwick Anderson wants to comment, and let you know…

In the meantime, here are some other peoples’ thoughts on the appointments:

Professor Mark Harris, Professor of General Practice, University of NSW:

“It was disappointing that there was not more representation from primary health care given its importance in the health reforms and need for research especially health services research.  Barbara Patterson is on Council as CHO for NT and on the NHMRC and has a background in GP.  However it would have been useful to have representation from PHC to inform NHMRC’s contributions to the new PHC.”

***

Robert Wells, Director Menzies Centre for Health Policy at the ANU (and formerly a secretary of the NHMRC):

“It is is now a very narrow Council dominated by doctors and government employees. They have appointed 19 people of whom 14 are medical doctors (all of whom are either specialists or public health physicians). The government appointments (Cwlth & states) dominate (11 of 19), esp as Rosemary Bryant the Cwlth Chief Nurse has been appointed & Prof Horvath the  immediate past CMO & still holding some official advisory role for DoHA. There is no primary care physician or other health professional from primary care in an era where primary care is one of the Government’s principal areas for health reform. I think there is no allied health professional person (have not checked the c-vs). As I read it, they could have appointed another 5 or so people to broaden the membership had they wanted.

None of this reflects on the qualities of the appointees. However the opportunity to broaden the membership of the Council to reflect better the realities of 21st century health care  and research needs seems to have been missed.

The members of principal committees has not been announced and these might provide broader membership and more balance.

The other point to note is that under the Act the Council is essentially advisory to the CEO only and its role as a council is perhaps not as crucial as in previous eras.”

***

Dr Chris Mitchell, president, Royal Australian College of GPs:

“Regional and primary care research needs a better focus.

From an AMA policy paper: A survey of public expenditure on primary care research in Australia, New Zealand, the United Kingdom and the Netherlands, found that the average was less than $1.50 per capita per annum, in contrast to the international average expenditure on health and medical research of $28 per capita per annum.

Primary health care research — essential but disadvantaged. Julie J Yallop, Brian R McAvoy, Joanne L Croucher, Andrew Tonkin and Leon Piterman on behalf of the CHAT Study Group. Medical Journal of Australia 2006; 185 (2): 118-120

Australia needs to lift its expenditure on primary health care research progressively over time. More research will help improve clinical practice and provide an evidence base to improve the delivery of primary care services.”

***

Associate Professor Simon Willcock, Head, Discipline of General Practice, Northern Clinical School
University of Sydney:

As per the issue that you raise, there was certainly some concern that there were no GPs represented on the overarching NHMRC, although over the subsequent week or so several “panels” were announced including the “primary care” and “preventive care” panels of the NHMRC, on both of which GPs were well represented.

I think in many ways the larger issue is that medicine and patient care are increasingly seen in “silos”  of care, despite the evidence that a generalist approach to health care s much more effective in improving outcomes.

The NHHRC Report  and Primary Health Care Strategy both recognised this, but are both long on rhetoric and short on detail. Garling’s report in NSW last year was really all about this – patient’s falling between the silos within the public hospital system.

I haven’t seen much evidence so far that “Caring Together” is changing this – to the contrary, the stressed state of our public hospitals seems to relate in fragmented care of patients more than ever.

It also includes many revealing anecdotes and observations about key events in the health portfolio – and more than a few entertaining vignettes. It’s also worth noting that it includes quite a deal of self-critical reflection.

Some quick snippets:

• There is quite a bit of discussion about the pressures created by the 24/7 media cycle and how it has made it more difficult for departmental chiefs “to devote personal time and departmental resources to longer-term policy research and analysis”.

• Perhaps Tony Abbott was not the obstacle to health reform that he is so often portrayed as having been:  “Abbott also was more willing than his colleagues to address structural reform in health when I was advising the Prime Minister on health services delivery in 2005”.

• Former Health Minister Dr Michael Wooldridge gets many favourable mentions (and a few not so favourable), including “Minister Wooldridge should be given great credit for successfully addressing the alarming drop in child immunisation rates in the period to 1996. Through careful highlighting of individual cases of deaths from failure to immunise children against measles in particular, he turned our bland statistics of falling immunisation rates into headline stories of personal tragedies and a sense of crisis that had to be addressed…The political crisis fostered by Wooldridge made the Prime Minister and other ministers sympathetic to the measures proposed, which were agreed to by cabinet in early 1997.”

• We also learn that Wooldridge tried hard to win extra funding for Indigenous health “but his attempts to lock in more substantial increases every year for 10 years received no support from his ministerial colleagues”.  And while Wooldridge had Prime Minister Howard’s “full confidence” in many areas of his portfolio, this was not so much the case in public health policy, such as illicit drugs, and in the relationship between private health insurance and Medicare (”it was widely known within the government that the department had not supported the 30 per cent rebate initiative at the time”).

• The federal health department can’t claim that it hasn’t had plenty of time to prepare for some of the recommendations in the National Health and Hospitals Reform Commission report, many of which were being discussed by senior departmental officers while Wooldridge was Minister. Options they canvassed included “increasing Commonwealth leadership in health, including possible full financial takeover, restructuring the regulation of private health insurance, broadening the base of primary health care and strengthening cost-effectiveness criteria for government health benefits”.

• The NHMRC cops a caning:  “In Health, the National Health and Medical Research Council (NHMRC) ostensibly provided the umbrella for linking with the research community, but its emphasis was on medical research and I struggled for six years to get the council to focus seriously on public health, health services delivery or health economics (despite two review reports, endorsed by the government, giving them extra resources precisely for these purposes). I tended to look elsewhere, attending seminars and conferences of experts from various universities. Professor Stephen Leeder at Sydney University was particularly helpful in the early days, hosting a regular private forum attended mostly by NSW health officials and Sydney University academics, which I participated in whenever I could.”

Some of the more humorous/revealing anecdotes

• “Twice during the kerosene baths crisis, while in difficult meetings with Bishop and her advisers, I was called away to answer an urgent phone call from the portfolio minister, Wooldridge. While each time there was some point of substance to the call, the main purpose was: ‘I thought you might need a break, Andrew.’”

• Any tips on who this could be, Croakey readers? “At one state dinner, my wife and I were seated at a table with a prominent shadow minister, who proceeded to lead the conversation in berating the Public Service. I tried to respond diplomatically. It was to no avail. Moreover, I felt we were being treated as ‘servants’ rather than as fellow guests (and fellow hosts) at the dinner. This became particularly clear at the end of the evening when the MP asked my wife and me to arrange more red wine; when I explained that the wine service had stopped, she readily accepted my wife’s offer of her full glass! It was a useful tip for when the MP later became a senior minister.

• And who was this Minister, doodling during Senate hearings? “To the occasional chagrin of the minister sitting beside me, I did not always stick to the rule of answering only the question asked, even if that rule is generally a good one…I can recall on one occasion a minister doodling rather ostentatiously and constantly on a pad beside me as my officers and Health Insurance Commission officers answered questions on Medicare, the doodling being in the form of a schoolchild’s 50 lines, each stating something like ‘Why don’t they just answer the question. Why don’t they just answer the question’.

• And this quite astounding account of a retreat for senior departmental executives after the 1996 election “There was unease about the new government, particularly after the dismissal of a number of secretaries (including the husband of one of my division heads), the culture among senior executives was more akin to that of robber barons than united leadership and there was unease about me as the new secretary. I engaged one of the best facilitators in Canberra, Lynette Glendinning,  to assist me. She has told me often in the years since that it was the toughest assignment she ever faced. One division head sat in the centre, arms folded and legs outstretched, making it abundantly clear he was there under sufferance….Two other division heads sat to one side, crocheting a tea cosy…”

Podger’s book will be useful for many – gossips, students of history, political science and policy, scriptwriters for The Hollowmen, and also for researchers wanting to understand or influence the policy process.

This may be particularly relevant for the latter: “Much has been written about ‘policy cycles’, from decisions to implementation to evaluation and advice, contributing to new decisions. That is a useful normative approach emphasising the importance of systematic review and evaluation, but it is not an accurate description of real practice. Political decisions are taken when opportunities arise. Departments and secretaries need to have a store of good policy ideas to put to ministers at opportune times.”

It is clear from Podger’s book that governments and bureaucracies these days put much more effort and resources into “media management”, making it very difficult for journalists to gain useful information from insiders. We rely instead on people like Podger keeping detailed diaries.  Will we be reading Jane Halton’s one day?

“The Croakey posting on Conflict of Interest points to both the diversity of views and the complex nature of this issue and Baker IDI welcomes a healthy and well informed debate by way of contributing to industry best practice in this area.

Baker IDI takes its ethical commitments very seriously. We are fully compliant with The Australian Code for the Responsible Conduct of Research and, of course all our research is approved by independent ethics committees.

Much of our work is at the forefront of medical research, and is affected by constantly changing scientific and communication technologies. Codes of conduct can not stand still. They should constantly evolve to respond to the changing needs of society and the challenge of innovation -  an opportunity we should not shy away from.

In the instance of our collaboration with Astra Zeneca, it is worth noting that the particular contract governing the Total Cholesterol Study, was the result of an agreement entered into more than four years ago. The study was independently designed and conducted by Baker IDI and was compliant with the Medicines Australia Code of Conduct for clinical trials with full transparency around the funding body. The content of the publication was entirely educational and no products were mentioned.

The Institute is constantly reviewing its policies and procedures to reflect the changing environment within which we operate. As a result, we have changed our organisational policy on staff involvement in industry-sponsored advertorials.

We are fully supportive of the establishment of a conflict of interest committee as well as national guidelines in this area.  Moreover, we welcome the NHMRC’s consideration that researchers publicly declare conflicts of interest online.

Our recommendation is that the most effective forum for declaring conflicts of interest is a national, non-partisan registry that takes account of the full spectrum of activity rather than the specific contracts of a single organisation in isolation.

The challenges outlined are shared by the medical research community at large and deserve industry-wide attention to ensure effective design and implementation of reflective national guidelines. We embrace the opportunity to contribute to this important process.”

No word yet from the Baker, but Professor Warwick Anderson, ceo of the NHMRC, sent this comment:

“The Australian Code for the Responsible Conduct of Research (issued jointly by NHMRC, the Australian Research Council and Universities Australia) applies to all institutions receiving NHMRC funding, and includes a chapter on conflict of interest, aimed at all disciplines (not just health research).

As far as relationships between clinical researchers and the biotech and pharmaceutical industries are concerned, NHMRC Council’s advice will be sought in September on the ideas that arose at the NHMRC workshop on conflicts of interest, held in June. This will include advice on the need for national principles to help guide ethical relationships between clinical researchers and private sector organisations, such as biotech and pharmaceutical companies.”

For those interested in knowing more about the NHMRC workshop, held in Canberra last month, here is a short report I filed for the British Medical Journal about it.

Australian researchers, universities and other research institutions are likely to face new measures aimed at ensuring conflicts of interest are managed more effectively.

The National Health and Medical Research Council (NHMRC) will consider recommendations that it require researchers to publicly declare conflicts of interest on university and other institutional websites.

The Council has also been asked to consider establishing its own conflict of interest committee to provide advice internally and to act as a reference for other bodies, and to require research institutions to establish similar committees.

The suggestions were made by senior researchers and NHMRC members attending a “transparency and conflict of interest” workshop convened by the Council in Canberra on June 3.

“The ideas that came up are all worth consideration and we will take those ideas to our Council over the next six months, “ the NHMRC CEO Professor Warwick Anderson told the BMJ after the workshop.

The Council is also developing new standards for management of competing interests in clinical practice guideline development, and has evidence these are poorly managed at present.

A broad-ranging survey of clinical practice guidelines, involving 313 produced in Australia between 2003 and 2007, found 79 per cent did not mention whether the authors had competing interests.

None of those declaring conflicts gave information about how these were managed or the dollar-value of the financial relationship.

Dr Heather Buchan, an NHMRC advisor who conducted the survey, said a US study had found most guideline authors had competing interests, and that the new standard was likely to require documentation of how conflicts were declared and managed.

Professor James Best, chair of the NHMRC research committee, said many of the arrangements binding researchers and industry – such as industry-funded trials, education, advisory boards and guidelines – were marketing tools.

“Today’s meeting is an example of NHMRC’s commitment to good practice in this area,” he said.

Professor Bruce Neal, a Senior Director at The George Institute for International Health, which receives significant industry funding, said the issue was bigger than simply researchers’ previous conflicts of interest.

Researchers’ chances of obtaining future industry funding could be influenced by how they reported the results of their independent, investigator-driven research, he said.

Professor John Hopper, of the University of Melbourne, said measures to address conflicts also needed to consider issues such as professional patch protection by authors and reviewers.

An independent nutritionist, Dr Rosemary Stanton, said effective management of conflicts of interest was essential for food and nutrition research and guidelines as this was an area rife with conflicts.

Dr Agnes Vitry, a Senior Research Fellow from the University of SA and a member of Healthy Skepticism, said she was concerned the NHMRC had not committed to implementing the recent Institute of Medicine’s report on conflicts of interest. “Compared to the relevant IOM proposals for institutions such as NHMRC, we are far behind,” she said.

The workshop follows recent controversies in Australia over commercially-funded clinical practice guidelines for venous thromboembolism prevention, and a sponsorship deal between Sanofi-Aventis and the Baker IDI Heart and Diabetes Institute which was in breach of the Medicines Australia code of conduct.

The NHMRC is seeking comment on its strategic plan,  and has also released a review conducted in October 2007 and chaired by Professor Alan Bernstein, the then President of the Canadian Institutes of Health Research, as well as a review conducted in January 2008 and chaired by Dr Elias Zerhouni, Director of the United States National Institutes of Health (both available here).

In the article below, Professor Glenn Salkeld, head of the School of Public Health at the University of Sydney, gives an overview of the Nutbeam review and urges colleagues to “get active”:

“We should all get behind the recommendations of Nutbeam Report of the Review of Public Health Research Funding in Australia. If I had to pick one sentence that captures the spirit of the report it is this:

“High quality public health research that leads to improved health outcomes is most likely to emerge from a thriving public health research community conducting a combination of investigator driven and strategic research.”

This report is all about what it will take to truly deliver the promise that public health research will improve population health. Yes, it will take additional investment by NHMRC in public health research but the message here is not simply to ‘splash the cash’. Rather, a far more strategic and crafted approach to how the investment is made and how it links to policy and practice is required.

The Report contains 14 recommendations that call on NHMRC to take a greater role in leadership in public health research and in improving the processes and coordination of research, policy and practice in Australia.

The report delivers the recommendations in 3 sections: strategic leadership and co-ordination (aligning to the Government’s preventative health strategy), changes to funding strategies and mechanisms and improvement’s to NHMRC application and assessment processes.

The sentiments behind the recommendations are forward thinking and collaborative. Strategic thinking, priority driven research, innovation, flexibility and responsiveness, transparency, infrastructure and workforce capacity building are needed.

The Report calls for NHMRC to move beyond descriptive research and fund more intervention research.

There is a separate and comprehensive set of recommendations relating to Indigenous Public Health Research. Again the call is to move beyond further descriptive studies and focus on intervention research and on rigorous evaluation of interventions in priority research areas.

The deployment of these ideas and improvements will take strong leadership and political commitment by NHMRC. We are not off to a good start.

Recommendation 3 calls on DoHA to further develop the Public Health Education and Research Program (PHERP) to support national Centres of Excellence in key public health priority areas. So what does DoHA do? Abolish PHERP.

PHERP has delivered generalist public health education to the masses but we need to move on and develop specialist training and workforce capacity building.

As the Nutbeam Report observes, we have spread our public health research talent too thin in the application of PHERP funds. What we need is a smaller number of world-class groupings in Australia.

The recent call for NHMRC Centres of Research Excellence in Public Health and Health Services Research are an important step towards that objective.

Imagine what could be achieved if that was matched with a DoHA initiative to fund a national Public Health Office Training Program that took our best and brightest MPH graduates and delivered specialty training ‘in the field’.

While we’re at it, what are we doing to support the next generation of health policy makers?

Then there is the all important track record in public health research funding. In the last decade the NHMRC research funding pie has grown substantially yet the success rate for Public Health for project grants, research fellowship and program grants has been poor. There is a dearth of NHMRC Senior Research Fellows in Public Health.

Many countries have faced the same problems, how to build public health workforce capacity, focus on strategic research (whilst maintaining important investigator driven research) and how best to transfer results into policy and practice. Canada leads the way with the establishment of a Public Health Research Canada Strategic Plan which includes start-up funding grants, rapid response intervention program, infrastructure grants and support for 14 Chairs at mid-career (Associate Professor) level. All great ideas – good enough to borrow for ourselves.

For a relatively modest investment in money, infrastructure and improved processes NHMRC has an opportunity reap great rewards from their investment in Public Health.

We have a unique opportunity with the Government’s commitment to preventative health to do just that. Write to Warwick Anderson, the CEO of NHRMC, and tell him you back the Nutbeam Report recommendations. The sooner the better.”

(Ironically enough, one of the review’s recommendations was the establishment of a national public health research register to improve transparency around research funded by governments.)

Professor Don Nutbeam, who chaired the group that produced the review, said he assumed the delay was due to delays in final sign-off from Health Minister Nicola Roxon’s office. He thought this was more likely to be “cock-up than conspiracy”, reflecting the “inefficiencies and the bureaucratic nightmare that’s been created around the NHMRC and its relationship with the Government.”

I tried to find out more from Roxon’s office but my phone calls weren’t returned (perhaps not surprising, given this was in the midst of the swine flu frenzy). I also was unsuccessful in obtaining comment from the NHMRC ceo Professor Warwick Anderson.

But yesterday, we were both attending an NHMRC workshop in Canberra, and he finally was ready to talk. He put up his hand, saying the delay could not be blamed on the Minister’s office. It was the result of an administrative decision within the NHMRC to release the review, together with two other reviews, as part of a document outlining the Council’s strategy for the future.

He said the review, which was forwarded to the Minister’s office last week, would be released “shortly”.

Nutbeam has been hearing similar promises for some months now. We will keep you posted…