In the latest edition of The Health Wrap, Associate Professor Lesley Russell reviews an important new publication on multi-morbidity, and also reports on discussions on multi-morbidity, prevention and mental health from the recent Public Health Prevention Conference 2018.
Beneath her column are links to some recommended new reading and “tweets of note”, sharing resources on tobacco control and the social determinants of health.
Multi-morbidity – an emerging global priority
There’s a new buzz word in health policy: multi-morbidity. The term is certainly not new – it’s been in use for at least a decade – but there is growing recognition that patients with multi-morbidity are the norm rather than the exception.
Multi-morbidity is sometimes seen as distinct from co-morbidity in that there is no primary or index condition, although more work needs to be done on this definition. Frailty is a related concept in ageing populations.
The UK Academy of Medical Sciences recently published a seminal report Multimorbidity: a priority for global health research, which addresses the growing issue of multi-morbidity as a global health challenge. The report highlights key evidence gaps, calls for standardised definitions and reporting systems, and recommends a series of research priorities.
The Lancet editorial in response highlights the need to update healthcare systems to cope with the increasing burden of multi-morbidity. The changes must include:
- A shift from a specialised to a generalised healthcare workforce
- Changing payment models
- Technologies to support patients’ self-management
- Integrating care both virtually and physically.
In a February 2018 blog, Greg Fell, who is Director of Public Health at Sheffield in the UK (well worthwhile following him on twitter @felly500), lays out, in a fairly cryptic way, what he thinks needs to be done to address this in the NHS.
There are some lessons here for Australia too; in particular, the importance of not ignoring mental health. Fell also details the research that has been done to date on identifying clinically relevant multi-morbidity clusters. Some of this work on understanding patterns and identifying common clusters of chronic diseases has been done in Australia.
The real problem is that most research and treatment is focused on the prevention and management of chronic conditions in isolation. That doesn’t represent reality.
Professor Andrew Wilson, in his presentation at last week’s Public Health Prevention Conference, made the point that risk factors for chronic disease travel together, and this calls a more coordinated approach to prevention. He said:
It’s no longer about single diseases or single risk factors, yet the prevention community is increasingly siloed into people who work in specific areas, such as smoking prevention, physical activity or diet.
But we have got to recognise that these things travel together – they are not independent associations. We have to start to think about these things as collective issues rather than individual problems.”
Writing at Croakey, Professor Stephen MacMahon and Dr Brendon Neuen, from The George Institute for Global Health, also highlighted the need to develope a better understanding of “the causes and consequences of the tidal wave of multimorbidity” in order to respond effectively and transition to more people-centred health systems, characterised by high-value, integrated, and generalist care.
Patients with multi-morbidity present a challenge to the healthcare workforce as it is currently educated and constructed.
The conundrum is best summed up by Richard Smith, former editor of the British Medical Journal: “Doctors and patients are heading in opposite directions… Patients increasingly have multiple conditions, while doctors are specialising in not just organ systems but in parts of organs.”
Former PM Julia Gillard speaks out on prevention and mental health
Former Prime Minister Julia Gillard, in her role as Chair of the board of beyondblue, was a keynote speaker at the Public Health Prevention conference. She talked about the “alarming gap” in access to services, with around half of Australians with a mental health condition not getting access to support or treatment.
She made the point that multi-morbidity – the fact that people with mental illness are more likely to have other chronic physical conditions, leading to reduced life expectancy – makes the need to “bridge the gap” even more urgent.
She highlighted the need to think about the whole-of-life needs of people and not to wait until things go wrong. Under the current fragmented and under-resourced mental health system/s too often help is not available until a crisis point is reached. This highlights the need for a better focus on prevention and the involvement of workplaces, schools and families.
In particular, Gillard highlighted the work beyondblue has been doing with two initiatives. The organisation has designed, trialled and evaluated New Access – a program that provides early intervention support for people with mild to moderate anxiety and depression. This approach is now being commissioned by a number of Primary Health Networks. She also talked about the Way Back Support Service, which provides psychosocial support to people who have attempted suicide (who are at highest risk of later dying by suicide) and their families.
Gillard’s focus on prevention and mental health echoes that in a report Investing to Save: The economic benefits for Australia of investment in mental health reform, which was released this month by Mental Health Australia and KPMG. The report highlights three core areas for action:
- Support for individuals with mental health issues to gain and maintain employment, and to maintain the mental health and wellbeing of the workforce.
- Minimise avoidable emergency department presentations and hospitalisations.
- Invest in promotion, prevention and early intervention.
I noted that in his weekly Update, MHA CEO Frank Quinlan chose to highlight Recommendation 2.1 of this report (Housing First for 15-24 year olds) which found that “For every $1 spent on Housing First models, $3 is generated in the short term (1-2yrs) and $6.70 is generated in the longer term (3+yrs) – this is supported by a strong evidence base that Housing First models work.”
(Note: Julia Gillard’s speech does not appear to be publicly available).
More recommendations from Medicare Benefits Schedule Review
An announcement on April 29 indicated that the Minister for Health has accepted 38 new recommendations from the work of the MBS Review. They include a new item to support the delivery of dialysis in very remote areas to improve access for Aboriginal and Torres Strait Islander people with kidney disease.
This move has been welcomed as a lifeline for the growing health crisis of Indigenous kidney disease. Rates of end-stage kidney disease are astronomically higher among Indigenous people, up to 50 times that for non-Indigenous people. Many of these people must move from their communities in order to receive needed dialysis treatment with devastating impacts on health and wellbeing, survival rates and culture. Such community-based services that exist have had to rely on private donations and fundraising to provide care because of inadequate government funding.
Now Medicare will cover some of the costs of dialysis delivered by nurses, Indigenous practitioners and Indigenous health workers in remote areas, “in a primary care setting”.
However, the accompanying fact sheet provides no details about this new item, which will be introduced by November 1. The effectiveness of this item in overcoming current barriers to accessing community-based services will depend on the details of its implementation and applicability. It is estimated that this item will initially cover 470 patients.
A California push for cancer warning labels on coffee
My Croakey colleague Dr Ruth Armstrong has been travelling in the United States, and she tweeted some travel and public health commentaries and some great photos for @WePublicHealth.
Her tweets included a photo of a warning about the cancer risks of coffee from a California chain diner. This raised considerable interest – after all, Aussies in the US are always on the hunt for a decent cup of coffee, regardless of the hazards involved.
I have no legal training, so I hope my explanation of this lawsuit is accurate. Here’s how I see it.
At the end of March, a judge of the California Superior Court in Los Angeles issued a preliminary decision in a case first filed in 2010 by the non-profit, little known Council for Education and Research on Toxics (try Googling it – nothing comes up!) against some ninety companies that make or sell coffee.
The case was brought under the California Safe Drinking Water and Toxic Enforcement Act of 1986 (known as Proposition 65) and asked for warning labels about the dangers of acrylamide in coffee and damages for the harms done in the failure to provide these warnings.
California has a list of chemicals that are possible causes of cancer – one of them is acrylamide, which is created when coffee beans are roasted. It is also found in potatoes, baked goods, burnt toast and tobacco smoke. Under Proposition 65, businesses must give customers “clear and reasonable warning” about the presence of high levels of cancer-causing chemicals.
The preliminary decision found that companies like Starbucks, 7-Eleven and gas stations had failed to meet the burden of proof that the levels of acrylamide in coffee are safe and that the heath benefits of coffee outweigh any risks.
The defendants have until April 10 to file objections to the proposed decision. The cost implications could be substantial; the law allows for fines of US$ 2,500 for each time a consumer is exposed to a chemical without warning.
No wonder then that some companies affected have already simply agreed to provide warning notices like the one Ruth saw. And earlier, in 2008, companies like Heinz, Frito-Lay and Kettle Foods had agreed to reduce levels of acrylamide in their potato chips and French fries. But the fact is that this decision puts public health experts and Proposition 65 – both aimed at safeguarding the health of Californians – at odds. And it is confusing to the public.
Studies have linked acrylamide at high doses to cancers in rats and mice, but a 2014 research review found “no statistically significant association between dietary acrylamide intake and various cancers”. On the other hand, there is considerable consensus about the health benefits associated with drinking moderate amounts of black coffee.
The real problem with coffee (so-called) is that something like a Starbucks venti white chocolate mocha has 580 calories, 22 grams of fat and 79 grams of carbohydrate (mostly sugar).
The perfect segue into the next issue…
Obesity and a sugar tax
Lots on this issue recently – perhaps there’s hope that, finally, the Turnbull Government will be brave enough to include something on tackling this important and costly public health issue in the upcoming Budget? (Not holding my breath, not taking bets.)
Last week’s Four Corners’ episode (described as a stunning expose of food, nutrition and health politics in Australia) highlighted the clear need for a national, comprehensive strategy to reduce obesity, including a sugar-sweetened beverage (SSB) tax.
There is evidence that the political and economic power of Big Food can be overcome with the right approaches. A recently published evaluation of the impact of the LiveLighter ‘Sugary Drinks’ campaign in Victoria showed reduced consumption of SSBs among adults in the target age range. A sugar tax is a good start for tackling the obesity problem. Some 28 jurisdictions have such a tax already in place and Australia is sadly lagging in its implementation.
As Rosemary Stanton said in a recent tweet: “Campaign against sugary drinks works and adding a sugar tax would make it even more effective. Why don’t we do it? The fact that the drinks industry doesn’t want it is good enough reason to know it would be effective.”
The issues are bigger than the sugar tax, however, as Dr Phillip Baker and Professor Mark Lawrence wrote for The Conversation, and republished at Croakey:
What the program highlighted was as important as what it did not. It showed a clear need for a sugar-sweetened beverage tax and a national strategy with a comprehensive package of measures to reduce obesity.
What we also urgently need (and which wasn’t noted in the program) is a national nutrition policy, based on the Australian Dietary Guidelines, to promote healthy diets and good nutrition more broadly. It is long overdue – we haven’t had one since 1992.”
What to expect in the 2018-19 federal budget?
We are in countdown mode to the release of the 2018-19 Budget at 7:30pm on Tuesday 8 May.
The Treasury called for pre-budget submissions from interested parties late last year. They can be accessed on the Treasury website – there are hundreds of them. An unexpected improvement in the budget position means that everyone is optimistic that their key issue will get the funding required. Almost certainly the Government will choose to use this windfall to shore up their position in the polls and win votes. It will be interesting to see how – or even if – this plays out in health.
To date, in contrast to previous years, there has not been a rash of early announcements. The one exception is that the Treasurer has indicated the Government will abandon last year’s proposal to increase Medicare Levy to raise $8.2 billion to fund the National Disability Insurance Scheme, saying there would be enough money without a tax rise. We can only hope this means the NDIS will be adequately funded to address the needs as stories grow about rationing of services and significant numbers of people are unhappy with their services.
There are expectations that the Budget will fund more intermediate and high-level home-care packages to help reduce current waiting lists for older Australians needing aged care in their own homes.
I think we can be fairly certain there will be little or nothing in the budget to address the biggest issues for health and healthcare: I see these as the issues around community-based prevention initiatives (especially those to reduce obesity and the harms caused by alcohol); better integration of community-based and acute care for both physical and mental health (at the very least this could include a substantial expansion of the pilot program for Health Care Homes); and some sort of kick start to a culture of sustained and sustainable innovation in the planning, development, implementation, financing and evaluation of healthcare programs and associated workforce requirements that will meet the needs of Australians in the 21st century.
I have some hope that there might be some provisions in the Budget to better address the housing needs of those who are homeless or at risk of homelessness and Indigenous Australians.
Homelessness is a national obscenity. It is increasingly apparent that growing health disparities in Australia cannot be reduced simply by providing healthcare services; everyone needs the protection, security and hygiene that come with safe housing. The work being undertaken to reduce trachoma, otitis media, rheumatic fever and scabies in Indigenous populations will be wasted unless housing problems – especially but not solely in remote communities – are addressed. A recent review of the National Partnership Agreement on Remote Indigenous Housing and the Remote Housing Strategy bluntly highlights the problems that must be addressed.
A survey taken for the Australia Institute in April found that almost two-thirds of voters want the government to tax more, spend more and reduce inequality. An Ipsos survey released last week found that 90 percent of voters think there should be universal free access to education and health services and 8 percent agree the rich should be “taxed more” to support the less well off. Somehow I don’t think the Budget will reflect these values.
Don’t miss this excellent preview of #HealthBudget18 for Croakey by Jennifer Doggett, identifying six key areas for action:
- Establish a National Preventive Health Body (although this could be slightly awkward for the Government, given it abolished a similar body, the Australian National Preventive Health Agency in 2014)
- Announce a national obesity strategy
- Set up a Productivity Commission review of private health insurance
- Increase funding for the community-controlled Indigenous health sector
- Increase funding for public dental services
- Take action on mental health.
- Previous editions of The Health Wrap can be read here.
- Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow on Twitter: @LRussellWolpe
ICYMI: Reading and resources recommended by Croakey team
Professor Mike Daube writes for MJA Insight – Tobacco in Australia: time to get back to basics:
For those who worked long and hard to make Australia a world leader in tobacco control, it is deeply disappointing that political complacency in recent years has both led to lack of action and allowed distractions to dominate the public and policy arenas.”
Dr David Thomas and Dr Michelle Scollo write in The Australian and New Zealand Journal of Public Health – Should a smoking question be added to the Australian 2021 census?
Australia is committed to monitoring trends in smoking as part of its obligations as a signatory to the Framework Convention on Tobacco Control. A census question would enable more accurate measures of smoking prevalence for increasingly small geographic areas and population subgroups.”