The problem with Queensland's Local Health and Hospital Networks

I was saddened to hear today about the death of a man I met only once but have known about for a long time. Before I was headed to Roma a couple of years ago, a friend from IBM days told me I simply had to meet his cousin. His cousin was a named John Young who my friend told me was involved in the Roma airport and later the hospital and health system.

By the time I got to Roma,his cousin had mostly retreated (retired is not the right word) to his property some 50km south of Roma where he worked the land. It was well over a year before I got to meet him and this fact was always discussed whenever I met his cousin in Brisbane. I finally got to meet John Young at a meeting of the local Health Community Council

HCCs were a sort of half way health house set up by State Labor in 1991. For 20 years, HCCs operated geographically at just-above-local council level (there were 36 in Queensland) dealing on the ground with patients and their hospitals. They were the eyes and ears of the health system becoming aware of, and fixing local problems. They talked to the patients and they talked to the staff but relied on their soft power with authorities to get things done rather than any legislation.

Last year the Queensland Government disbanded HCCs in a major revamp of Queensland Health. From 1 July 2012 they will be replaced by 17 Local Health and Hospital Networks (with the unfriendly acronym of LHHNs). These new agencies will be responsible for bigger areas and will have more powers.

The old Roma HCC represented the views of the communities of the Maranoa and Balonne regional councils. They also monitor the performance and quality of public health services in these regions. John was the chair of the Roma HCC and I finally met him at a public meeting at Wallumbilla Hospital in February 2011. Only one couple showed up from the general public, the rest were there from the general hospital but John showed no disappointment with the small turn-out. He diligently explained what their role was and what assistance he could provide. He carefully listened to the couple’s issues with the health system and gave them options on what they could do to improve their situation.

He also talked logistics with the hospital staff. He made whoever he spoke to feel important and he gave suggestions to solve issues. Everything was important and surmountable. At the end of the meeting, he and I shared a joke or two about our mutual friend/cousin before going our separate ways. I never saw him again.

The HCCs were disbanded in June 2011. By June 2012 the will be replaced by 17 Local Health and Hospital Networks (LHHNs) which will have a strong local decision-making and accountability function. There is a 12-month gap while Queensland Health rolls them out with five already established including ones in Brisbane and the Gold Coast. The Government said this was a major reform with profound implications for the quality of health care in Queensland.

The LHHNs will be statutory bodies with Governing Councils, accountable to the local community and Queensland Parliament. In August 2011, I editorialised in my paper the changes were good ones with more money, more beds, more doctors and nurses available at a local level to support an overburdened system. But I said finding the right local people to go on these volunteer boards would be tough. The board members will have the huge responsibility for managing the operation and performance of the hospitals within the network. While I didn’t mention him by name, I thought John Young would have been ideal for the local board.

It will never happen now. This morning I found out he had died of a heart attack in his paddock yesterday. I was shocked and immediately texted his cousin to offer my condolences. He rang back within minutes. I was worried he had not heard the news prior to my text but he had almost found out in real time. John’s wife had relayed the terrible news on the phone to the wider family in updates. John had a fall and it doesn’t look good, she reported. Then a few minutes later, “he’s gone”. He was just 59 years old.

John’s death was a tragedy for the family but it was also bad news for the wider community. I don’t know if he nominated to be part of the local LHHN, but they need people like him if they are going to work. I don't blame him if he didn't nominate. The LHHNs are a far bigger ask than the HCCs, they cover a wider area and have greater powers. Members need skills in business, finance, legal and human resources expertise wanted as well as the delivery of clinical services. All this in volunteer and most unpaid work. Reform is needed, but for these new LHHNs to work, we need people like John on them - people with knowledge, understanding and the ability to listen to and act on problems, in short, people with a vocation for health. Our wellbeing depends on it.

Hans Rosling's Gapminder shows world's health trends over 200 years

It’s early days but it is encouraging to see ABC use the crowd sourcing platform Ushahidi to map the Queensland floods from the perspective of its audience. Ushahidi means testimony in Kiswahili and works best when there are lots of people witnessing the same large event. It was developed to allow people to map incidents when ethnic violence erupted in Kenya in late 2007 and proved influential in exposing fraud in the 2009 Namibian election.

It is great to see innovative tools used here and it reminds me of my favourite thing on the Internet right now. It is a four minute video by Swedish doctor and professor of statistics Hans Rosling produced by the BBC. Rosling has also developed remarkable statistics software called Gapminder which has a dazzlingly brilliant way of interpreting statistics in a way that is informative and compelling.

In this BBC video he shovels 120,000 sets of numbers through his program from world census surveys for two hundred years. He plots the data by countries of the world since 1810 on a graph where the x-axis is income per person and the y-axis is life expectancy in years. Near coordinates 0,0 are the sick and poor, and near n,n are the very healthy and wealthy. In fast forward, we can see 200 years of trends flashing in front of our eyes as two centuries of data is plotted on the graph.

In 1810 all the countries of the world are clustered in the lowest quadrant. The UK and the Netherlands were clearly better than every other country on both indicators, though they were still low with life expectancy around 40 years and average per capita income less than $3,000. By 1860 the Nordic countries Norway, Sweden and Denmark were leading the way with remarkable improvements in life expectancy by up to ten years. The UK was still the wealthiest in the world as it was about to enter Pax Britannica and its new colonies in Australia and New Zealand weren’t far behind though life expectancy was low. The US was also catching up fast.

Fast forward another 50 years and Scandinavia was still the healthiest part of the world with average life expectancy pushing 60 years. New Zealand and Australia were finally seeing the benefits of their remarkable riches (second and third wealthiest in the world behind the US) to push life expectancy above 50. With the exception of colonial countries Canada and Argentina, the European countries were next highest on both indicators, though Japan was rising quickly. At the bottom, average life expectancy was just 22 years in the area now called Bangladesh and 23 in India.

By 1960, the discrepancy between rich and poor were quite pronounced. Most of Europe, North America, the colonial countries and Japan were achieving life expectancy of up to 70 years. The US and Switzerland were pulling away with average incomes up to $20,000. Small oil-rich states such as Brunei and Qatar were averaging over $40,000 though life expectancy was lower. China had slumped to the bottom as it suffered through the famine trauma of the Great Leap Forward. Yet the Chinese were still living ten years longer than they did in 1910. African countries were the poorest but surprisingly healthy with Lesotho people living to 47 years on just $365 (literally a dollar a day).

In 1985 Brunei and Qatar were still the wealthiest countries in the world and their citizens were living longer too. The Japanese were living an average 78 years making them the healthiest in the world. All the First World countries were clustered close behind. The developing nations were catching up quickly. Countries (or soon to be countries) such as Mexico, Latvia, Ukraine, Albania and even North Korea were averaging over 70 year lifespans. The five biggest Asian nations (China, India, Pakistan, Indonesia and Bangladesh) were still poor but beginning to make a charge. Post-colonial Africa was bringing up the rear. Yet even in the poorest country, Mozambique on just $366, the average lifespan was three years higher than Britain in 1810.

In 2009, Japan is still the long-living nation in the world, now averaging 83 years. Its ageing population is presenting new challenges for economists as well as demographers. But most of the West is now averaging 80 years of lifespan with an average wage clustered around $30,000. Qatar remains the richest country in the world (a clue to why a country of 1.1 million has won the right to stage the World Cup in 2022). Most of Middle East, North Africa, East Asia and the Pacific were also living longer than 70 years. There were improvements at the bottom end too. War-torn Afghanistan was the least healthiest country in the world, living just 44 years even there both indicators have remarkably been improving since 1994. The equally war-torn DRC (Congo) is now the poorest country with an average salary of just $359 (less than the poorest in 1960) but the Congolese still live to 48 years.

Rosling notes that within countries there are massive discrepancies. If Shanghai was removed from China it would be in the top 1 percentile. Similarly Australians live for 82 years and enjoy an average wage of $34,327 but if the Indigenous population was measured alone, it would be much worse. Yet despite the wider discrepancies across the world that now exist, Rosling’s imaginative graph makes a powerful point: the trend is worldwide for higher earnings and longer lifespans. Projecting out to 2060, it is clear all countries are pushing towards the mythical “n,n”. Feeding all these long-living people in a world of catastrophic climate change is beyond the powers of this data, but it is certainly engrossing food for thought.

Making Health better: Bennett’s call to arms

(Photo "Health Dept" by Kate in Sydney)

Prime Minister Kevin Rudd put off the decision today for six months whether to implement a $16b public health revamp suggested by the National Health and Hospitals Reform Commission. Rudd says he is not frightened to tackle the issue but will consult with the public and health professionals before taking recommendations to the COAG meeting at a date to be announced late this year.

The revamp was outlined in a report released today by commission chair and BUPA Australia chief medical officer Dr Christine Bennett. The executive summary is available here in in PDF format. The report had five recommendations across the areas of indigenous health, mental illness, rural issues, dental care and access to public hospitals and suggested moving full funding of the system transfer from the states to the Commonwealth.

Though the additional funding required is problematic, the transfer of powers is not as big a deal as it sounds. The federal government already runs the health system at a macro level. As Medicare Australia says, Canberra has the primary role of developing broad national policies, regulation and funding for the industry.

It also does much of the spending. The department’s 2007 factbook (pdf) revealed that Canberra spent 46 percent of the total health budget with states responsible for another 22 percent (individuals spend 19 percent with “other private” bodies on 13). But it is the states that have primarily responsible to deliver and manage public health services. It is NSW, Victoria and the rest that also maintain direct relationships with most health care providers, including regulation of health professionals and private hospitals.

Bennett is not so much interested in taking power away from the states as giving individuals more power. Her stated motto is “wellness begins with you” and the aim of the document released today is to ensure the Department of Health lives up to its name rather than being a Department of Sickness, Injury and Death. This is reflected in the name of the report released today: “A healthier future for all Australians”.

The report had five major recommendations. The first was improving health outcomes for Aboriginals and Torres Strait Islanders (ATSI). It recommends a new authority to run ATSI health. The new body will be better funded, target nutrition, and train up an indigenous workforce. All this are good ambitions but a holistic health plan must take into accoun the impact the appalling imprisonment rates are having on ATSI life expectancy.

The second priority is improved care for the mentally ill. It wants more “sub-acute” (which defines a stage of illness between acute and chronic) services in the community with 7 x 24 “rapid response outreach” teams to provide alternative to hospital treatment. The third priority was support for people in remote and rural areas. This concept of universal service obligation (USO) is borrowed from telecommunications and insists that rural and remote citizens get treated the same as urban citizens. This is admirable but often impractical in a country the size of Australia. To address the shortage of doctors, nurses and facilities in remote and rural areas, the report suggests top-up funding to match communities who have better access medical, pharmaceutical and other primary health care services.

(Photo: 7 Day Dental by flickr_b3rn)

The fourth key recommendation is improved access to dental care. One in three Australians put off dental visits due to costs and there are 650,000 people (3 percent of the total population) on the public waiting list. The report recommends education of dentists and schools and a new universal scheme called Denticare Australia where basic services can be paid by private health insurance or the public purse.

The fifth and final recommendation is improving timely access to public hospitals. It says large public hospitals should have emergency beds available at all times, as well extra funding to reduce waiting lists beyond the budget moneys allocated to 2010-2011 (Health's $52b annual budget is scheduled to be slashed in half for 2011-2012). It suggests a national access target to measure whether people are getting access to health services when they need it.

The report is talking about fundamental re-design. Bennett wants to embed prevention and early intervention, connect and integrate health services, and move to what it calls the "next generation of Medicare" to review comprehensiveness, the USO and safety nets. Crucially it will also examine what pharmaceuticals and services get onto the lucrative Medicare benefits schedule which is five percent of the total health spend.

The report says COAG needs to agree on a Healthy Australia Accord to realign roles and responsibilities for health. This talks for the need for “one health system” under full Commonwealth funding control of primary health care, as well as dental, aged and ATSI care. The Commonwealth would pay the states “activity-based benefits” for public hospital care to share the risk caused by increased demand and provide an incentive for better care. It will start at 40 percent of cost of every public hospital admission and will eventually rise to 100 percent at which time the federal government will be in de facto control of Australian public health.

It suggests a timetable for the Accord to be 2010 and says the reform plan will cost between $2.8b and $5.7b with a further $4.3b to $7.3b in infrastructure. The Denticare plan will cost an additional $3.6b which could be offset by a 0.75 percent increase in the Medicare levy. This taxation hit will be difficult to sell. But as Bennett says in the report “[governments], the community, health professionals and health services are…ready to embrace reform”. Let’s hope COAG sees it that way.

NIDAC report shows Aboriginals are still filling Australian jails

A damning new report by the National Indigenous Drug and Alcohol Committee (NIDAC) has revealed that Indigenous people are filling Australian prisons at alarmingly disproportionate rates. Indigenous people are 13 times more likely to end up in prison than other Australians. Western Australia was the worst place for Indigenous people who were 21 times more likely to be in prison than non-Indigenous West Australians. In total, 31 percent of all Australian prisoners are Indigenous (despite making up just 2 percent of the population), and that figures rises to half of all juvenile offenders in detention. The report also noted that there are now three times more Indigenous women in prison since the supposedly ground-breaking 1991 Royal Commission into Aboriginal Deaths in Custody. It makes a mockery of that report’s recommendation that “imprisonment should be utilised only as a sanction of last resort”.

This latest report (pdf) says the issues involved are significant and complex but says there are strong links between substance abuse and incarceration levels. The report applauds the Council of Australian Governments (COAG) announcement that the 2 July federal, states, and territories meeting in Darwin will give special consideration to Indigenous Closing the Gap matters. But NIDAC says any initiative to improve Aboriginal health issues will not work unless it addresses Indigenous imprisonment rates.

The incarceration problem is partially caused by trauma and suffering that Indigenous people have experienced over generations. NIDAC says that Indigenous Australians in prison are themselves victims of substance abuse or violent crime and have the right to access appropriate treatment and rehabilitation to address these underlying issues. The report says this problem will not be fixed unless there is a national program to tackle health inequalities in the prison system and also strengthens the health and cultural wellbeing of all Indigenous people.

NIDAC says health issues are usually made worse by incarceration. Prisoners are more likely to suffer serious mental health problems, as well as blood-borne virus (BBV) transmission, violence, sexual assault and isolation. People suffering from mental illness are often consigned to incarceration, rather than treatment, because of the lack of appropriate facilities. Meanwhile BBV transmission is caused by high risk behaviour such as injecting drug use, tattooing, physical violence, body piercing and unprotected sex. The Australian Government National Drug Strategy estimated that the level of Hepatitis C among adult offenders in custody is 17 times greater than in the general community and prisoners are 31 times more like to have contracted HIV than non-prisoners.

NIDAC says there are numerous social and economic factors causing these problems. Indigenous Australians remain seriously disadvantaged compared with other Australians and suffer more ill-health, die at much younger ages, have lower levels of educational attainment and income, higher rates of unemployment and poorer housing conditions. Aboriginals most in jeopardy had a depressing list of socio-economic characteristics. These were the lack of schooling, unemployment, financial stress, crowded living conditions, association with the stolen generation, remote location and drug and alcohol abuse. Alcohol in particular is the cause of 90 percent of all Aboriginal offences.

(Photo by Pierre Pouliquin).The report offered a number of short and long term recommendations to solve the problem. The short term items include education support, jail diversion programs, re-integration of offenders, health care performance indicators, health screening, health research, leadership forums and partnerships with Indigenous services. The longer term goals would be funding youth networks, Indigenous drugs and alcohol campaigns, collaborative management plans, best-practice Indigenous-specific programs, working partnerships with law enforcement agencies, rehabilitation centres, consistent national legal approach and employment health training strategies.

All of these goals are laudable and the report deservedly criticises Australia’s shameful approach to Indigenous incarceration. Though it is debatable whether some of the short term goals are a bit optimistic, the real problem with this report (and many other similar ones over the years) is that the recommendations are uncosted. In the recent federal budget the Government announced a spending of $805 million on Indigenous health over four years. But will this spending address the underlying causes? NIDAC Chair Ted Wilkes doubts it. “It is clear current initiatives simply aren’t enough," he said. "It is widely known that there is a strong link between harmful alcohol and drug use, offending rates and poor health. A major rethink is needed and unless we address these issues, a lifecycle of offending can perpetuate and span across generations.”

Cuba announces world's first lung cancer vaccine

Yesterday Cuban scientists announced a vaccine to extend the lives of lung cancer sufferers would be made available to the Cuban Health Service. Speaking in Havana, Gisela Gonzalez said the product, called CimaVax EGF, is the first registered vaccine in the world designed to battle lung cancer. The drug could add five months to a lung cancer sufferer’s life. Gonzales, who heads the medical team that developed the compound, said the vaccine is based on proteins that trigger an immune response from the patient's body and has few side effects compared to chemotherapy because it's a modified protein that attacks only cancer cells.

The CimaVax EGF vaccine is available in Cuba, and will be commercialised in Latin America, starting in Peru. Advanced clinical tests are happening at 18 Cuban hospitals on 579 lung cancer victims. Other tests were carried out in Canada and Britain, while tests are scheduled in Malaysia, Peru, and China. The EGF in the name stands for Epidermal Growth Factor (EGF) which is a protein capable of stimulating cellular proliferation but is also a cancer risk. The vaccine links it to another protein that helps the immune system to create the desired immune response against the EGF. The effect is a decrease in tumour growth.

The vaccine has been developed by Havana’s Centre of Molecular Immunology (CIM). The centre’s mission is to produce biopharmaceuticals products to be used in cancer treatments in the Cuban Public Healthcare System. Its products include antibodies for use in organ transplant rejection, treatments for anemia, the blood disorder neutropenia, and tumour imaging as well as antibodies that recognise growth factor receptors for cancer treatment. The centre is part of Cuba's thriving state-run biotechnology sector which includes 50 research and development centres and is one of the most advanced in the developing world.

People from outside Cuba are welcome to come to the island to seek the treatment. The center’s director of clinical investigations, Tania Crombet, said "it's possible to provide this vaccine to any patient, because it's available in Cuba, it's approved by the Cuban drug agency so we can market the vaccine in Cuba and we can receive patients from outside," she said. However she said that the US would be the exception as Americans are restricted from travelling to Cuba travel by the US trade embargo against Cuba in place since 1962. "Even though there is a new therapeutic tool approved in Cuba they probably wouldn't be able to come to Cuba to receive it because of the embargo," Crombet said.

The drug has been approved for clinical trial in the US, but its possible use there is at least two to three years away. In the meantime 160,000 Americans will die of lung cancer annually. Lung cancer is a malignant tumour in the tissue of one or both lungs and is primarily a disease of older people. It is unusual in people under 40 and the risk increases substantially after the age of 50. Smoking causes 90 percent of all known cases. Currently the main treatments are surgery if detected early, or otherwise radiotherapy and chemotherapy. The new vaccine does not prevent cancer but is therapeutic and consolidates the effect of radiotherapy and chemotherapy. Doctor Elia Neninger, oncologist participating in the project, said its benefit was that it lacked any side effects and also contributes to reduce the prevailing symptoms of the ailment. That will be good news for the cancer’s million sufferers worldwide.