In this latest edition of The Health Wrap, Associate Professor Lesley Russell looks at the intangible costs (especially mental health costs) of bush fires. She discusses how the drought and bush fires are adding to the problems many rural communities face in accessing health care and asks some probing questions about doctor numbers and the need for an adequate health workforce to support health system reform.
She also reports on some recent findings on growing antibiotic resistance in Australia, to highlight Antibiotic Awareness Week, and ends with some good news about therapy dogs in hospitals and schools.
Lesley Russell writes:
For too many Australians threatened and overcome by bushfires, the past week has been horrendous. And sadly, it’s predicted that many more people will face the bushfire threat before summer is over. We must hope that they receive all they need to help offset their traumas and losses. These needs are not always immediately obvious.
A report from the Australian Business Roundtable for Disaster Resilience and Safer Communities shows that although the tangible costs (damage to property and infrastructure and business and network disruptions) of natural disaster like bushfires are high, the intangible costs (death and injury, impacts on health and wellbeing and community connectedness) are almost always higher. For example, for the 2009 Victorian Black Saturday fires, the tangible costs were $3.1 billion but the intangible costs were $3.9 billion. Of these latter costs, the largest was mental health care, estimated at $1 billion.
There’s an interesting series of articles published on the Northern California Public Media website that explores the impact of the 2017 fires in the communities of Santa Rosa and Paradise in Northern California on youth health. We know that adverse childhood experiences can lead to poor health outcomes later in life (the US Centers for Disease Control calls childhood trauma a public health issue).
Research shows that somewhere between 7 percent and 45 percent of children suffer depression after experiencing a natural disaster. Children more at risk of depression include those who were trapped during the event; experienced injury, fear, or bereavement; witnessed injury or death; and had poor social support. The Conversation published a good article on helping kids cope with bushfires, based on work commission by the Victorian Department of Education after the 2009 fires.
There’s currently an undignified and unjustified stance by the Morrison Government about the links between bushfires and climate change. On multiple occasions this past week senior ministers have pointedly refused to discuss this and have reportedly banned bureaucrats from doing so. This disdain has been compounded by their dreadful comments about those who want to see more done to address this link – and even those who died in the fires.
But, as Dr Sarah Perkins-Kirkwood from the UNSW Climate Change Research Centre writes, there can be no doubt that climate change is part of the bushfire / wildfire landscape, not just in Australia but around the world (as we have seen recently in California and Brazil).
In the face of government denial and intransigence, it’s encouraging to see so may organisations in health speaking out with a concerted voice and pushing for action. See, for example, the article by my colleague Amy Coopes about how climate change and its impact on health and health systems will be front and centre of this year’s annual summit of Australian and New Zealand emergency doctors in nipaluna/Hobart.
The 2019 report of the MJA – Lancet Countdown on health and climate change – just out – describes this as “a turbulent year with mixed progress”. A number of new indicators are introduced this year, including one focused on wildfire exposure. The report finds that, while there has been some progress at state and local government level, there continues to be no engagement on health and climate change in the Australian federal Parliament.
It also found significantly increasing exposure of Australians to heatwaves and, in most states and territories, continuing elevated suicide rates at higher temperatures. There is little evidence to suggest Australia is acting effectively to mitigate the multiple heat-related risks for physical and mental health.
The authors conclude that “Australia remains at significant risk of declines in health due to climate change, and that substantial and sustained national action is urgently required in order to prevent this.”
The substance of this report has been well covered in these two media articles:
Rural health – where are the needed reforms?
The drought and the bushfire crisis have served to highlight the importance of healthcare services in rural Australia. For some time now I’ve been writing about the huge unmet need for healthcare services in rural areas.
Earlier this month the Government’s own Rural Health Commissioner, Professor Paul Worley, was quoted as “slamming inaction on rural health reforms”. He talked particularly about “bandaid solutions”, saying “We find out many years later that these solutions work for the crisis, but the problems still persist.”
Professor Worley said three main areas needed drastic attention to sustain equity in primary care: training; workplace conditions (general practice has failed to provide part-time training, maternity leave and annual leave, which has made it a less attractive training pathway); and funding models for the future.
Of course he’s right – and we could all add to his list of three areas for reform. But who in government is listening? And who in government cares that the drought and the bushfire crisis is adding to the health woes of Australians in the bush?
More on workforce
Another topic I seem to be consistently discussing is workforce. Why? Because I believe no reforms – big or small – can happen without the appropriate workforce.
On the need (or not?) for more doctors and more training places
I’ve never been able to understand the disconnect between health workforce numbers (for example, the claims that we have more doctors than needed) and pressures because of staff shortages and required work hours.
Yes, I know there are issues like the maldistribution of the workforce, salaries, flexibility to cater for family needs, and the inherent need to help out when things get frantic – but it seems to me that training more doctors provides an opportunity to provide each doctor with more time to address patients’ needs (including care coordination) and to look after their own health and wellbeing.
I’m sure governments have arguments about more doctors driving costs and unnecessary care and I suspect the medical colleges will vehemently defend their rights to limit numbers and safeguard their incomes.
The general approach to this issue goes like this (from recent ANZ- Melbourne Institute report The Future of the Medical Workforce):
- The number of medical graduates has more than doubled from around 1400 in 2000 to 3500 now.
- As a result, the number of junior doctors has increased by an average of 8.9 percent per year since 2005, and the total number of doctors is growing at 5.3 percent per year.
- This is creating a much more competitive career ladder for doctors. There is increased competition for coveted specialty training places and increased competition for jobs once they’re qualified.
- And this is why junior doctors are increasingly reporting stress and burnout, mental health problems, bullying and gender discrimination, while female doctors have a higher rate of suicide compared to the general population.
Even though time is consistently reported as a key issue in doctors’ lives and in their ability to effectively communicate with and manage their patients, I rarely see a discussion around what if there were more training places and more medical positions for both GPs and specialists. Would that provide more time and better patient care? Is this just a marketplace issue or something more complex?
There is good evidence on nurse staffing levels and outcomes but the association between doctor numbers and patient outcomes is relatively under-researched. Higher professional / patient ratios have been shown to be associated with a reduction in mortality, failure-to-rescue events, infections, readmissions and complications. Higher GP / population ratios have been associated with lower infant mortality, all-cause mortality and mortality from acute myocardial infarction.
While changes in medical culture are clearly needed, they will be insufficient to improve doctors’ workplace conditions if there are too few medical personnel to provide care.
A report this week of a survey of junior doctors conducted by the Australian Medical Association NSW and Australian Salaried Medical Officers’ Federation NSW Alliance supports my case. More than 61 percent of doctors in training were concerned they would make a clinical error due to fatigue caused by the hours they worked. A culture of intimidation still pervades NSW hospitals with almost 40 percent of junior doctors targeted by bullying, harassment or discrimination from other hospital staff members.
It is predicted that there will be a shortfall of 1000 specialty training places by 2030. Increasing training places requires increasing the numbers of senior medical personnel to oversee these. Yes, there’s a cost involved, but it’s much cheaper than the costs involved in medical errors, young doctors leaving medical training and doctor suicides.
In conclusion: There are many situations in the provision of health and healthcare services where a doctor is not needed and may not even be the best health professional to provide that service. So I certainly don’t see more doctors as a sole solution to the healthcare workforce problem. That’s a major reason why I worry about the number and status of Aboriginal and Torres Strait Islander Health Workers (see this piece in a recent edition of The Health Wrap).
Aboriginal and Torres Strait Islander Health Workers
I commend to you a paper by Dr Chelsea Bond and colleagues in a recent issue of the Australian Journal of Primary Health that looks at a central issue in addressing the health inequality faced by Aboriginal and Torres Strait Islander people – ensuring the provision of an appropriate health workforce. This paper looks “beyond the pipeline”, arguing that focusing merely on workforce numbers is insufficient and that issues around how empowerment and racism are embedded in healthcare systems must be considered.
In particular it examines the discourse concerning Aboriginal Health Workers, where, they write “questions concerning the legitimacy of the role continue to abound within a workforce hierarchy where community knowledge, though shown to be crucial to culturally safe health service provision, is trumped by the other health professions whose knowledges and legitimacy are not in question.”
November 12 – 18 is Antibiotic Awareness Week. Two years ago, my husband had an extended hospital stay as a result of sepsis, and I currently have another family member in hospital battling the same life-threatening infection. It gives you a renewed appreciation for the value of antibiotics and the threats that are posed by growing levels of antibiotic resistance.
To mark Antibiotic Awareness Week and to highlight the need for the human and animal health sectors to work together on reducing antibiotic resistance, the Chief Medical Officer and the Chief Veterinary Officer had a joint media release.
The Third Australian Report on Antimicrobial Use and Resistance in Human Health (AURA 2019), issued in May 2019 by the Australian Commission on Quality and Safety in Health Care (ACQSHC), found that antimicrobial use in the community is falling (the first decline seen in 20 years) but that antibiotics continue to be overprescribed and some dangerous bacteria are growing increasingly resistant to common antibiotics.
The report’s findings are nicely summarised in non-scientific language in this article on the ABC News website.
For the microbiologists, this summary from me:
- The report warns of an ongoing risk to patient safety from common pathogens such as E coli, Salmonella, Neisseria gonorrhoeae and Neisseria meningitidis becoming increasingly resistant to major drug classes, and some organisms resistant to last-resort treatments.
- Almost half the samples of enterococci (gram positive bacteria that are part of the normal intestinal flora of humans and animals) tested across Australia were resistant to the antibiotic vancomycin – a level higher than seen in any European country.
- Community-associated methicillin-resistant Staphylococcus aureus (MRSA or golden staph) has become the most common type of MRSA infection, particularly in aged care homes and remote regions.
- There is clearly more that can be done around antibiotic prescribing. In 2017, more than 10 million Australians had a least one antibiotic dispensed in the community and more than 26.5 million prescriptions for antimicrobials were dispensed. That puts Australia in the top 10 percent for per-capita antibiotic consumption in the world.
Recent research findings
The Medical Journal of Australia looked at these issues in August. It is estimated that Australian hospitals spend $11.3 million annually treating just two of the many antibiotic resistance (AMR) threats (ceftriaxone-resistant E coli and methicillin-resistant MRSA) and Australia has one of the highest rates of vancomycin-resistant enterococci in the world.
The extent of work to be done in this area is highlighted by the results of a paper just published by Journal of American Medical Association which found high rates of surgical antibiotic prophylaxis in Australian hospitals. Survey data show 40.3 percent of surgical prophylaxis prescriptions were classified as inappropriate and 45.2 percent as noncompliant with Australian national Therapeutic Guidelines.
The inappropriate use of antibiotics and the consequences are international problems. International travel contributes substantially to the global spread of intestinal multidrug-resistant gram-negative bacteria.
I thought this paper on real-time sampling of travellers was interesting and just a little scary. Certainly enough to worry Australians who visit developing countries. Some 70 percent of the travellers in the study (Europeans visiting Laos) were colonised by multi-drug resistant bacteria by the end of a three week stay, and all the visitors acquired these bacteria for some period of the stay.
By the way, it isn’t just human travellers we must worry about bringing home drug-resistant bacteria. Australian research shows that 20 percent of silver gulls in Australia are carrying superbugs resistant to antibiotics, raising fears that these disease-causing bacteria may spread from the birds to humans, livestock and pets.
The Australian Government’s Antimicrobial Resistance website has information on managing the threats to human and animal health. The first National Antimicrobial Resistance Strategy was released in 2015, but both it and the associated Implementation Plan are up for renewal this year.
A Progress Report for the Strategy was released in November 2017. It states:
“Significant progress has been made over the last few years. However, there is still a long way to go. We must continue to identify and fill gaps, test and refine existing systems, and frequently review what works to ensure that optimal arrangements are in place to ensure antimicrobials are preserved for future treatments. This Progress Report not only highlights the progress that has been made in Australia in the past two years, but also recognises challenges and gaps that need to be addressed.”
A consultation paper was released earlier this year asking for input to inform both the preparation of a final progress report under the first Strategy, and the drafting of Australia’s next AMR Strategy for 2020 and beyond.
How patients view their medications – and how this can affect medication-related problems
International estimates indicate that a shocking number of patients experience at least one medical error post-discharge from hospital, the most common of which is a medication error. These can have a significant effect on patient safety. In Australia, the incidence of rehospitalisation due to medication-related problems (MRPs) ranges from 1.3 to 38 percent – so improving medication safety during the transition of care should be a priority.
A 2016 paper looked at Australian consumer perspectives of MRPs following discharge from hospital. It found four significant risk factors: health literacy; health status; consumer engagement and cost of medicines. The authors particularly highlighted the importance of consumer engagement.
A new study from the US looks at how older adults view MRPs. This population takes multiple medications that can lead to a myriad of MRPs. Patients identified a variety of problems that could be classified into four broad categories:
(1) obtaining medications (eg. problems with cost and insurance coverage);
(2) taking medications (eg. organisation and remembering to take pills);
(3) medication effects, including side effects and concerns over lack of effectiveness; and
(4) communication and care coordination, including information related to medications.
The paper highlights how differently patients and their doctors think about MRPs. Patients perceive and describe MRPs as inseparable from their financial, social and emotional context. This included the impact of medications on interpersonal relationships, emotional wellbeing, and activities that add meaning and quality to life. In contrast, the doctors surveyed focused on discrete medication issues and – sadly – expressed little interest in learning more about their patients’ perspectives.
If this is an area that interests you, you might appreciate the insights in this paper (and its novel research approach) on Challenges to physician–patient communication about medication use: a window into the skeptical patient’s world.
The good news – especially for dog lovers
At a medical school in America
The newest faculty member at the Uniformed Services University of the Health Sciences in Bethesda, Maryland (where I once taught before I got seduced by politics) is Shetland the dog, who is a lieutenant commander in the US Navy.
He lifts students’ spirits (he sometimes carries around a small basket filled with candy) but he is also there to teach the medical students the value of animal-assisted therapy for their patients.
There are seven therapy dogs at the nearby Walter Reed National Military Medical Center who are involved in patient care of the military personnel and veterans treated there. Two of these, including Hospital Corpsman 2nd Class Sully (the former service dog for President George HW Bush) attended Shetland’s formal commissioning ceremony in September as guests.
You can read more here.
At a primary school in Australia
There’s also a new staff member at Melrose Primary School on Wodonga, Victoria.
Daisy the school dog (she’s a breed that doesn’t shed hair and so can be around children with allergy issues) is have a positive effect on students’ emotional wellbeing and school attendance.
You can read more here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.