It’s a question that merits not only the asking, but also some clear-headed attempts at negotiating a way between the vested interests that so often obscure the path to sensible answers in this area.

At least the issue of workforce reform is getting some hearing, with two conferences putting it on the agenda in recent days.

The organisers of this two-day conference that began today in Sydney are optimistic that the COAG driven National Health Workforce Taskforce has made “significant headway” in promoting a nationally coordinated strategy for health workforce planning, and that unified approaches are emerging in professional bodies, training institutions, health services, and regulatory infrastructure.

But they also note some of the problems: “Roles and tasks have remained in silos that have been in place for many decades. The current recruitment, training, and staff management systems are disjointed and health service and clinical management approaches have not readily adapted to changing demand.”

Meanwhile, the ANU last week hosted a forum on health workforce reform last week – you can watch Robert Wells talking about the need to share the evidence with the community here.

Dr Mark Ragg, who facilitated the forum, has written this account for Croakey:

“I was at a forum in Canberra on Thursday on health workforce reform organised by the ANU Primary Health Care Research Institute, and listened to Emil Djakic speak.

Now a bit of background that is bleeding obvious to anyone who’s ever been near workforce reform. To get a better workforce, there needs to be a devolution away from a doctor-centric health system towards one that better uses the skills and abilities of a wider range of players.

There are many discussions around the best way to do that, and to make sure it improves patient safety, but few outside the medical profession believe the current system is the best way. But such a change would involve a slight loss of control for doctors, in some areas. Some doctors are fine with that, others are not. But issues of control are nearly always behind the fiery debates that always take place.

Well, in speaking about the primary health care workforce Emil, who is chair of the Australian General Practice Network, said that he wasn’t convinced that reform was needed, and that he wasn’t sure of the direction any reform should take, and that what was needed was more research. Any changes made had to be based on ‘data, data, data’, he said.

Fine. Surprising, but fine.

After the forum, I spoke to two men from other doctors’ organisations who used similar phrases. ‘Data, data, data’, one said.

Coincidence? Possibly. Or a concerted approach by some doctors’ organisations to try to delay action while ‘more research is need’. Surely not.

We’ll see how effective such an approach would be. Warren Snowdon, who is Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery was pretty positive about the fact that ‘reform is going to happen – we promised it and we’ll deliver it’.

Hope he’s right.”

• Mark Ragg is adjunct senior lecturer at the Sydney School of Public Health, Sydney University, and director of the health and communications consultancy RaggAhmed.

• And on related issues…Does Australian medicine operate a “closed shop” that discriminates against overseas trained doctors? Find out more in this news story for the BMJ.

This, however, is something else. In case it’s been a long week….

Click here to view the embedded video.

I will spare you the colorectal surgeon song.

Well, maybe not.

Click here to view the embedded video.

There is plenty more where they came from, but I will stop now…

One problem with this view is that is inhibits a discussion that we need to have about the potential costs and benefits of the planned pandemic influenza vaccine roll-out. One infectious diseases specialist told me recently that it felt like the roll-out was something of a juggernaut – relentlessly proceeding in the face of quite widespread concerns about its merits.

The Australian Infection Control Association – critical players in any vaccine roll out, not least because of their role in encouraging vaccination of health care workers – has today come out opposing the vaccination plans because of the potential risks of multidose vials. Their concerns are reported in the Crikey bulletin.

Meanwhile, Professor Peter Collignon, from the ANU Medical School, has written this analysis for Croakey.

He writes:

“A pandemic H1N1 09 (swine flu) vaccine will be rolled out here very soon as the start of a mass vaccination campaign. However, this will be in multi-dose vials made by CSL. Spokespeople from Federal Health and CSL have all been reassuring that this will be safe and that the manufacturing and safety checking processes will be no different to what happens with seasonal flu.

These reassurances fly in the face of reality. Multi-dose vials have transmitted infectious organisms, resulting in deaths and serious illnesses, repeatedly over decades.

In Australia we had the Bundaberg Disaster in 1928. Diphtheria vaccine contaminated with Staphylococcus aureus from multi-dose vials caused the deaths of 12 children and resulted in a Royal Commission.

In Geelong in the late 1960’s, two factory workers died from Streptococcus pyogenes following workplace flu vaccinations from multi-dose vial. The coroner subsequently recommended against the use of multi dose vials. In NSW a multi-use vial was suspected as the cause for HIV transmission in a surgeon’s office.

Infection Control guidelines and multiple international agencies such as the World Health Organization (WHO), recommend as best practice that single-dose vials be used where possible. Preservatives added to multi-dose vials (such as thiomersal – a mercury containing compound) reduce the survival of bacteria, but as WHO notes, they still remain prone to bacterial contamination. Preservatives don’t kill viral contaminants.

Multi-dose vials have frequently been the likely source of outbreaks and some other examples are hepatitis B, hepatitis C and Pseudomonas aeruginosa.

In a WHO document on best infection control practices for needle injections, it noted that each year worldwide, poor injection practices (that includes a contribution from contaminated multi-use vials) cause millions of blood borne viral infections especially with hepatitis B virus.

In Australia by August 28th there were 150 reported deaths associated with H1N1 and 4,398 hospitalizations. Four deaths have been in pregnant women.

NSW Health has the best updated and detailed data available. By August 26th in NSW there had been 1,164 hospitalizations, 181 ICU admissions and 41 deaths. Infections peaked in mid July and now flu is at low seasonal levels of activity. Only 2 deaths (12%) were in those below the age of 40 years.

Surprisingly the age of the groups with the highest admission rates to ICU were in 50 to 60 year olds. Of note the overall rate of hospital admissions was 16.5 per 100,000 people compared with the rate in Australia for seasonal flu of 15.3 per 100,000 (2003 to 2005).

The very young and those over 60 years have had fewer admissions to hospital than normally seen.

We don’t know how many people have been infected in Australia, but in NZ it was estimated to be 10% of the population (similar to most winters with seasonal flu). The overall case fatality rate is less than 0.005% and thus may be lower than what is usually seen in seasonal influenza for most people.

In Australia each year we vaccinate about 8 million people against seasonal flu with mainly single-dose pre-loaded syringes. It is thus hard to see therefore why we should have to take this retrograde infection control step given the obvious unnecessary hazards associated with the use of multi-dose vials.

The only reasons to use multi-dose vials is to save money or else because there is a rapidly evolving emergency with a high death rate (as it is the easiest way to deliver a vaccine rapidly to a population).

Neither of these conditions are currently present in Australia. CSL expects to make $300 million from sales of the swine flu vaccine this financial year. Thus cost cutting should not be a factor.

We passed the peak of this epidemic in most states in Australia in mid July. While some groups are over-represented with higher than expected morbidity (pregnant women and Indigenous groups), overall this epidemic has not been much worse as judged by overall hospital admissions and deaths in comparison to seasonal flu over the last 10 years.

Even if we had to rush vaccine production, why not deliver them in single use ampoules?

We are also very unlikely to see any second waves here till next winter. Thus we have time here to do any vaccination program properly and learn from what happens in the Northern hemisphere in their upcoming winter.

We should not proceed in haste with a mass vaccination campaign using multi-dose vials. We need to ensure all the appropriate and usual steps associated with vaccine licensure have been followed. We know that basic infection-control procedures are not always followed in hospitals, clinics and general practice units in the community.

Although the risk may be judged to be slight, any failures will be disastrous for any individuals infected and if linked back to the vaccine roll out may also undermine confidence in the ongoing implementation of Australian vaccination programmes in general.

In summary, we need careful reconsideration of the implementation of this vaccination strategy.
•    Multi-dose vials have a potential to transmit infectious organisms and should not be used in a mass vaccination campaign.
•    The proposed mass vaccination campaign should be delayed until a safe formulation of the vaccine supplied in single dose vials becomes available.
•    All appropriate processes involved with vaccine licensure need to be followed.
•    We need to have an appropriate surveillance system in place that can quickly detect any increase in rare or unexpected side effects from the vaccine (eg Guillain-Barré syndrome – ascending paralysis, that occurred in about 1 per 100,000 people in the US in 1970’s with the last Swine flu mass vaccination program roll out).

References and further reading

1. Kellaway C, H., McCallum P, Tebbutta H. The fatalities at Bundaberg. Report of the Royal Commission. Med J Aust 1928;ii(2):38.

2. Hutin Y, Hauri A, Chiarello L, et al. Best infection control practices for intradermal, subcutaneous,and intramuscular needle injections. Bulletin of the World Health Organization 2003;81(7):491-500.

3. Katzenstein TL, Jorgensen LB, Permin H, et al. Nosocomial HIV-transmission in an outpatientclinic detected by epidemiological and phylogenetic analyses. AIDS 1999;13(13):1737-1744.

4. Samandari T, Malakmadze N, Balter S, et al. A large outbreak of hepatitis B virus infections associated with frequent injections at a physician’s office. Infection Control & Hospital Epidemiology 2005;26(9):745-750.

5. Dumpis U, Kovalova Z, Jansons J, et al. An outbreak of HBV and HCV infection in a paediatric oncology ward: epidemiological investigations and prevention of further spread. Journal of Medical Virology 2003;69(3):331-338.

6. Hutin YJ, Goldstein ST, Varma JK, et al. An outbreak of hospital-acquired hepatitis B virus infection among patients receiving chronic hemodialysis. Infection Control & Hospital Epidemiology 1999;20(11):731-735.

7. Verbaan H, Molnegren V, Pentmo I, et al. Prospective study of nosocomial transmission of hepatitis C in a Swedish gastroenterology unit. Infection Control & Hospital Epidemiology 2008;29(1):83-85.

8. Germain JM, Carbonne A, Thiers V, et al. Patient-to-patient transmission of hepatitis C virus through the use of multidose vials during general anesthesia. Infection Control & Hospital Epidemiology 2005;26(9):789-792.

9. Kokubo S, Horii T, Yonekawa O, et al. A phylogenetic-tree analysis elucidating nosocomial transmission of hepatitis C virus in a haemodialysis unit. Journal of Viral Hepatitis 2002;9(6):450-454.

10. Silini E, Locasciulli A, Santoleri L, et al. Hepatitis C virus infection in a hematology ward: evidence for nosocomial transmission and impact on hematologic disease outcome. Haematologica 2002;87(11):1200-1208.

11. Trasancos CC, Kainer MA, Desmond PV, Kelly H. Investigation of potential iatrogenic transmission of hepatitis C in Victoria, Australia. Australian & New Zealand Journal of Public Health 2001;25(3):241-244.

12. Massari M, Petrosillo N, Ippolito G, et al. Transmission of hepatitis C virus in a gynecological surgery setting. Journal of Clinical Microbiology 2001;39(8):2860-2863.

13. Widell A, Christensson B, Wiebe T, et al. Epidemiologic and molecular investigation of outbreaks of hepatitis C virus infection on a pediatric oncology service. Annals of Internal Medicine 1999;130(2):130-134.

14. Stetler HC, Garbe PL, Dwyer DM, et al. Outbreaks of group A streptococcal abscesses following diphtheria-tetanus toxoid-pertussis vaccination. Pediatrics 1985;75(2):299-303.

15. Olson RK, Voorhees RE, Eitzen HE, et al. Cluster of postinjection abscesses related to corticosteroid injections and use of benzalkonium chloride. Western Journal of Medicine 1999;170(3):143-147.

16 Chant K. Lowe D, Rubin G, et al. (1993). Patient-to-patient transmission of HIV in private surgical consulting rooms. Lancet. 342:1548-1549.

17 NSW Health. Weekly Influenza Epidemiology Report, NSW. Including H1N1 influenza 09. [Internet]. 2009. [Accessed 30/08/2009, 2009]. Available from:
http://www.emergency.health.nsw.gov.au/swineflu/resources/pdf/case_statistics_270809.pdf

18. M G Baker, N Wilson, Q S Huang, S Paine et al. Pandemic influenza A(H1N1)v in New Zealand: the experience from April to August 2009
Eurosurveillance, Volume 14, Issue 34, 27 August 2009. Rapid communications
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19319

19. Plueckhahn VD, Banks J. Fatal haemolytic streptococcasepticaemia following mass inoculation with influenza vacine. Med J Aust. 1970 Feb 28;1(9):405-11.

20. The Geelong disaster. Med J Aust. 1970 Feb 28;1(9):401-2.

21. Lexi Metherell. CSL ‘maxed out’ on swine flu vaccine production
http://www.abc.net.au/news/stories/2009/08/19/2660597.htm?section=australia
August 19th 2009

22. Letter from Australasian Society of Infectious Diseases to Professor Jim Bishop (Chief Health officer). Use of multi-dose vials for H1N1 09 (“swine flu”) immunization. August 19th 2009.

23. Collignon P. Patient-to-patient transmission of HIV. Lancet. 1994 Feb 12;343(8894):415; author reply 415-6.

Out of all that input, it might be interesting to look at whose views really counted, when it came to developing one of the most contentious recommendations, for Medicare Select.

The Commissioners noted that those who particularly “influenced and contributed to our thinking on this issue” included:

• Mary Foley – who wrote an NHHRC discussion paper, ‘A Mixed Public-Private System for 2020′, available here. Foley has a background in the corporate health sphere as well as government and the not-for-profit sector.

• Judith Dwyer and Kathy Eagar (health policy academics) who wrote an NHHRC discussion paper ‘Options for reform of Commonwealth and State governance responsibilities for the Australian health system’. Mary Foley also had input into this paper.

• Health economist Richard Scotton (2002), ‘Managed Competition in Health Care: workshop. Canberra

• Just Stoelwinder (a health services academic, also a director of Medibank Private). (2009), ‘Sustaining Medicare – lessons from the Netherlands’, public lecture at Menzies Centre for Health Policy, Canberra

• Health economists James Butler and Alexandra Sidorenko (2007), ‘Coping with the challenges of population ageing: Policy considerations for private sector involvement in aprivate health security pillar in a universal health system in APEC economies, Australian Centre for Economic Research on Health, Research Report No.2.

• Helen Owens, whose submission can be accessed here (it’s number 250).

Just for the record, the Commisioners noted that these people may not necessarily agree with the report’s views.

He has filed this report for Croakey:

“Yesterday was a noteworthy day in Australian health politics, for various reasons.

First, we were presented by the National Health and Hospitals Reform Commission with the most comprehensive analysis of the entire health system we have ever had. Certainly we may not all have agreed with every recommendation, but few would have argued with this analysis of the flaws in our current system. Indeed much was culled from the words of the system’s myriad critics over the last ten years. Announced significantly by the Prime Minister, this analysis is now very much the core currency of the coming health debate, with recognition from the top.

Second it is the most coherent, legitimate and (because of its source) powerful call for a national health system and the end to the Blame Game. We have known this for 20 years but it is now mainstream, not whispered about in corners at health events as necessary but really a political impossibility.

For that change we have to thank many, but two people especially. Professor John Dwyer’s persistent advocacy and naming of the Emperor’s clothes led to the formation of the Australian Health Care Reform Alliance and ultimately the ALP policy to establish the Commission. But we also need to recognise the courage of Nicola Roxon for having the nerve to set up the ALP policy for reform in the face of many doomsayers.

Of course despite the call for the Commonwealth to run all of the primary health system, the proposals do not yet add up to a national health system (and some including no doubt John and many of AHCRA’s members) will be disappointed by that.

However, few will doubt the wisdom of a system where GPs, community health services and other allied health practitioners are all funded under the one set of policies and funding. And there is much to be said for the Commonwealth having a transparent stake in hospital funding (40%), giving it an incentive to maximise prevention.

But the final decisions have yet to be made – there is a consultation to be had – although the political boundaries of change are fairly easy to discern in Rudd and Roxon’s comments.

Third, the report represents both the broadest set of recommendations for change we have seen for decades, and also a set based on some commonly held values. For example, even if not all of the 123 proposals are perfect and some are missing, many of the report’s recommendations represent valuable pieces of the jigsaw towards a more equitable health system including multidisciplinary primary health care services, equitable funding for rural areas, greater investment in Indigenous health, a universal dental scheme (albeit with some reservations about the model), and a network of youth mental health services.

AHCRA also welcomes the proposals to make the health system more person-centred. These include offering aged care service recipients choices about whether to receive home of residential care, stronger indigenous control over health services, better quality information for consumers and stronger voices in their own health care, and more community engagement around policy and resource allocation decisions.

Of course the government’s blind spot is around private health insurance and the wasteful rebate. Yet even there some movement has been visible in the last Budget.

In my opinion this report offers the best opportunity for significant improvements in the way our health system is run for decades. Not perfect for sure, but streets ahead of anything we have seen for decades. Yet it will have many critics.

We need to make sure that we both keep the pressure on the government to improve this suite, but also provide vocal support and encouragement so they don’t end up seeing it as to hard. Lastly we need to ensure the final detail mirrors the Commission’s valuable core principles, not its more satanic counterparts.”

The report, whose publication is required under the Australian Health Care Agreements, inevitably leads to media reports comparing and contrasting the performance of the various states and territories, especially around elective surgery waiting  times.

In the piece below, health policy analyst Jennifer Doggett argues that Minister Roxon needs to refocus the public debate on more important issues:

” If you’re wondering why the Government’s $600 million funding boost for public hospitals failed to reduce elective surgery waiting times. a trip to the local supermarket will help explain this.

When announcing the plan prior to Labor’s 2007 election, the (then) Shadow Minister for Health, Nicola Roxon said “our $600 million elective surgery plan will reduce waiting times, state by state and hospital by hospital”.

However, the State of our Public Hospitals report – which should be available here sometime today – shows that the average waiting time for treatment has increased from 32 days in 2006-07 to 34 days in 2007-08. Almost a third of people presenting to emergency departments were not seen within the recommended time, an increase on the previous year.

Given that the government’s additional funding enabled hospitals to treat more patients, why did waiting times increase?

The reason lies in a basic economic principle – that as the price of most goods and services drops, the demand for them will increase.

Of course public hospital services are free to consumers at the point of service, but it would be a mistake to think that this means that they cost nothing.  As Adam Smith famously wrote, “The real price of everything, what everything really costs to the man who wants to acquire it, is the toil and trouble of acquiring it.”

One of the costs of public hospital treatment to patients is the time spent waiting for treatment.   So if consumers believe that waiting times – and therefore the cost – of public hospital services will decrease, their demand for these services will increase.

This will result in an increase in waiting lists, despite the fact that more services are being provided.

A similar effect can be observed in supermarket queues. The reason that supermarket queues are all about the same length is that people will adjust their behaviour to minimise waiting times.  If one queue suddenly gets shorter, people will quickly move from a longer queue to even up the difference.

If a supermarket decided to increase the output at one checkout – for example by putting in another operator so two people could be served at once – this queue would not be half as long as the others.

As customers became aware that one queue was moving more quickly than the others, enough of them would move to ensure that the waiting times at all check-outs were about the same.

A similar effect has occurred in the public hospital system.  As hospitals have increased the numbers of elective procedures they perform, demand for their services has risen.

This increase is likely to have come from at least three sources:

•    a shift from the private sector as people re-evaluate whether or not it is worth paying the additional cost of private hospital treatment to avoid waiting times (even with private health insurance this can often involve substantial co-payments);

•    a re-evaluation of treatment options from people who have the choice of or an alternative treatment for their condition – such as someone with a sports injury who has the option of surgery or an extended course of physiotherapy; and

•    a return to waiting lists from people who had ‘given up’ seeking treatment due to the long waiting times.

Of course, the fact that more people have received public hospital treatment is a good outcome.  Despite the media and political focus on waiting times and waiting lists, they are not good measures of hospital performance when looked at in isolation.

A reduction in waiting list numbers simply measures the increase in output of a hospital relative to its increase in demand.  By this criterion, a hospital which is not popular with consumers would score better than one with a higher demand for its services (even if they have both increased their output by the same degree).

Better outcome measures are the overall increase in numbers of patients receiving treatment and their level of clinical need.

If the Government wants to claim its $600 million funding boost as a success, it needs to stop talking about waiting list reductions and start focussing on the outcomes that really matter.”

• Know what you stand for. Be clear on your messages and tailor them to “the man on the street”. Don’t speak with 20 tongues.

• Be realistic and know what your bottom line is when lobbying for a particular outcome. Any lobbyist who pushes for 100 per cent success is going to fail.

• Understand your target and what they want. Put yourself in the Minister’s shoes and aim for a win-win.

• A good lobbying campaign is as disciplined and strategic as an effective political campaign.

• Know when to be proactive and when to be reactive – when to use the media and when to work covertly.

• Don’t bring problems to the Minister or bureaucrat, bring solutions. Know the difference between being a successful lobbyist and a nuisance.

• If representing multiple, competing interests, make sure you have a consensus position before your meeting.

• Don’t be the boy who cries wolf. If you are always crying catastrophe, it will be difficult to make an impact when the big catastrophe strikes.

• It’s been said that the definition of a successful  lobbyist is someone who can get their piece of paper on top of the target’s in tray without annoying anyone.

• Identify champions within government who can lobby on your behalf.

• Aim to capture the advisory channels as well as the political channels. Know who are the relevant officers in the relevant departments and how they are briefing on your issue.

• External endorsements can be very effective.

• The Opposition can be used to raise your issue.

• Build up an evidence base, eg through putting reports to Government.

• Know the timing of the decision-making processes for eg when Ministers consider budget and when the Expenditure Review Committee meets.

• When Governments don’t provide much detail, as happened with some of the recent Federal Budget announcements, this is an opportunity for lobby groups to fill in the gaps, to their advantage.

The Sun-Herald this weekend reported on a Deloitte  study commissioned by  the Australian Association of Convenience Stores, which claimed that the NSW’s government’s 2008 decision to require all retail displays of tobacco to be covered-up would cost “$127 million across the state, would cause job losses and even the closure of shops.”

The cover-up alterations are said to cost between $6000-$10,000 for each shop and the Convenience Stores Association is trying to spin it that corner store owners will foot the bill themselves.

But every shopkeeper knows that the shelves are paid for by tobacco manufacturers who climb over themselves to sign up shops to their mode of display which often highlight particular brands at critical eye-lines.

The argument now being run is that if no packs can be displayed, no tobacco company is going to shell out for shelving that won’t optimise their own brands. So we are being asked to believe that the sales forces at British American Tobacco, Philip Morris and Imperial have therefore decided it is now game over in their efforts to have shopkeepers push particular brands  and that the companies would  all be delighted  if shops moving lots of tobacco decided to permanently stop selling, rather than shell out  a few grand for shelving that covers the displays.

Tobacco retail displays have been banned  in most provinces of Canada, Iceland and Thailand (see this picture) for years, and tobacco companies there rushed to ensure that as many retailers as possible continued to stock tobacco. On a recent trip to Bangkok I saw even small food carts displaying professional signage that they sold cigarettes – kept out of sight inside the carts.

Banning display brings tobacco a step closer to the way that governments treat scheduled drugs, which save lives.  Every pharmacy is full of prescribed drugs that cannot be displayed or handled by customers.

Imagine the Pharmacy Guild commissioning Deloitte to allow them to scream about the terrible burden on pharmacists in having to build dispensaries and install safes for heavily restricted drugs. Pharmaceuticals  are also packed in plain, dull boxes, not in state-of-the-art designer livery designed to complement every conceivable smoker demographic. We don’t pull out our anti-hypertension medication and proudly leave the box on display.  To get  your  antibiotic, cholesterol lowering  or anti-malaria supplies, you have to go to a doctor, pay for a consultation, trek to the pharmacy, get a limited supply, obtain it from a person with a four year university degree, pay often big money for it,  and then start all over again when your script expires.

With tobacco, which will kill one in two long terms users when used as intended, you can get unlimited supplies from virtually any shop, sold in a beautiful box.

The out of sight tobacco retail laws, now passed in four states,  have just passed the tobacco industry’s scream test with flying colours. Their only economic impact is likely to be reduced tobacco sales  … which  is exactly why they have been introduced.