In this edition of The Health Wrap, Associate Professor Lesley Russell shares some of the latest news in mental health and oral health, amongst other things.
Lesley Russell writes:
In the past few weeks, important issues of The Lancet have focused on the physical health needs of people with mental illness (an issue that Croakey has also covered extensively via the Equally Well Symposium) and oral health.
The July 16 issue of The Lancet Psychiatry is an important read for governments, health policy makers, providers of clinical services and researchers.
It proposes a blueprint for protecting physical health in people with mental illness and, in doing so, calls this “an international priority for reducing the personal, social and economic burden of mental health conditions”.
The Lancet Psychiatry Commission on the physical health needs of people living with mental health problems presents clear directions for health promotion, clinical care, and future research. It aims to:
- Establish the most pertinent aspects of physical health-related morbidity and mortality
- Highlight the common modifiable factors that drive disparities in physical health
- Present actions and initiatives for health policy and clinical services to address these issues
- Identify promising areas for future research that could identify novel solutions.
The report says the burden of obesity, diabetes and cardiovascular diseases is up to two times higher in people with mental illness. Key modifiable risk factors are smoking, excessive alcohol consumption, sleep disturbance, physical inactivity and poor diet.
But there is also an interplay with the drugs used to treat mental health disorders that is not well understood. More research is needed to understand these side effects and to manage them better.
The Commission states that multidisciplinary lifestyle intervention should be the core principle of care, and should be available from the first presentation of illness. The Diabetes Prevention Program is seen as a gold standard here.
National strategies are urgently needed to address the current inequalities in physical care for people with mental illness.
A number of Australian experts are on this Commission, so we must hope that they are able to raise these important issues with the key policy makers in Australia. It is estimated that people with severe mental illness die up to 20 years earlier than those without, and this gap is widening. You can read a good summary of The Lancet Commission’s work here on ABC News.
Some valuable accompanying articles cover:
- The need for integrating the treatment of mind and body
- Smoking cessation for people with severe mental illness
- The association between physical exercise and mental health
- The effectiveness of a primary care intervention to reduce cardiovascular risk in people with severe mental illness.
(Note that not all of these are open access).
Oral health at a tipping point
A new series in the July 20 edition of The Lancet lays out why oral health has been neglected and argues that radical public health action is needed. The general focus of the case made – putting the mouth back into healthcare and making dentistry a mainstream part of healthcare practice and policy – is one that has been continually advocated in Australia.
But The Lancet series takes some new approaches too. One with particular resonance is that modern dentistry has failed to combat the global challenge of oral diseases.
The argument is made that, in countries like Australia, dental care is increasingly treatment-dominated, high-technology, and focused on providing aesthetic treatments driven by profit motives and consumerism. That has led to stark inequalities in oral health status and access to care. What is needs is a public health refashioning of oral healthcare services.
Oral diseases share the main risk factors of other non-communicable diseases – sugar consumption, tobacco use, and harmful alcohol use, so oral health should have a stronger place on the global NCDs agenda.
This paper was summarised in an article in The Sydney Morning Herald where Australian experts called for action on sugar and especially sugary drinks.
In other related news, a recent cross-disciplinary paper from University of Sydney researchers (so good to see this sort of cooperation) presents the findings of a systematic review of the role of oral health care professionals in obesity prevention and management.
Given the strong links between diet (especially the consumption of sugary beverages) and dental decay and oral health, this makes eminent sense.
The review found that oral health care professionals (at least theoretically) are well positioned to undertake healthy weight interventions in their clinical practice.
In reality, there are significant barriers, including time, lack of training, patients’ unwillingness to listen to advice, and the lack of suitable specialists to refer patients to. Unmentioned was the increasing unaffordability for many of dental care.
More on mental health
Several other recent mental health issues are of note.
A recent meta‐analysis of longitudinal studies of mortality among patients discharged from inpatient psychiatric facilities (who are known to have highly elevated rates of suicide) found that within five years, cardiovascular deaths exceed suicide mortality. This critical new data further shows the need to protect physical health in mental illness.
- AIHW web report update Mental health services in Australia
- National summit puts spotlight on the mental health of older Australians.
- The very personal cost of Australia’s severely lacking mental health services and policies was highlighted on ABC TV Q&A program.
Julia Gillard’s oration
Former Prime Minister Julia Gillard, now Chair of BeyondBlue, recently gave the 2019 Diego De Leo Oration. She named suicide as one of the greatest public health challenges of our time, and called for it to be treated as such.
Her speech highlighted:
- The need to recognise and address the post-colonial, intergenerational determinants of Indigenous mental health in order to effectively address the high rates of suicide in Indigenous communities
- The importance of listening to and learning from the people who have the real expertise in what must be done for suicide prevention – those who live with suicidal thoughts, those who have attempted suicide and those who have been bereaved by it
- The demand for more community-based services and after care for those who have attempted suicide
- The hopes for real outcomes from the findings of the Royal Commission into the Victorian Mental Health System and the Productivity Commission’s inquiry.
If you or someone you know needs help or support, call Lifeline on 13 11 14 (24 hours-a-day), contact your local Aboriginal Community-Controlled Organisation, call Beyondblue on 1300 22 4636 or call Q Life: 1800 184 527.
AMA President’s National Press Club speech
In his recent speech at the National Press Club, AMA President Dr Tony Bartone also demanded more action on mental health issues. Specifically, he called for:
- Government funding and resourcing of a properly skilled mental health workforce.
- Recognition of the important role of GPs
- Work to ensure the NDIS better caters for the needs of people with severe mental illness
- Use of integrated, inter-disciplinary care.
On this last point, I suspect that the AMA has a way to go before it will agree to the necessary pre-requisites for such an approach (bundled payments, team leaders that are not necessarily doctors, 24/7 access). Also I heard nothing about the needed integration of physical and mental health.
But, in fairness to Bartone, it was great to see him use his NPC speech to call for:
- A national obesity strategy
- Sugary drinks tax
- Restrictions on junk marketing to kids
- A Preventive Health Promotion Agency
- Volumetric tax on alcohol
- Warning labels on alcohol.
Read more in this report by Amy Coopes.
Why do patients go to the Emergency Department for care?
The Australian Institute of Health and Welfare recently updated its web report on The use of emergency departments (EDs) for lower urgency care 2015-16 to 2017-18.
Lower urgency care is defined as:
- Patient did not arrive by ambulance
- Patient was assessed as semi-urgent / non-urgent
- Patient was discharged without referral to another hospital.
These are the patients who (notoriously) are often described as “could have been treated by a GP”. And indeed, the AIHW says that “most likely” three million of the eight million annual presentations to EDs could have been treated by a GP at a fraction of the cost. Each non-urgent presentation is estimated to cost around $533.
These findings are similar to those of a study from Western Australia that estimated 20 to 40 percent of ED presentations could be treated by a GP.
Given that these presentations are regarded as a major cause of over-crowding and delay in EDs, some deeper exploration of why people go to the ED is justified.
A 2011 paper that included Australian authors looked at the trends and underlying drivers associated with the increase in ED presentations in developed countries. It proposed that this was due to changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations regarding access to emergency care in acute hospitals.
The recent AIHW data show that rates of ED presentation are markedly higher in regional areas and that children are more likely to come with lower urgency presentations. Over the three years considered, in-hours lower urgency presentations increased while after hours presentation fell. This may reflect the increasing out-of-pocket costs to see a GP.
A South Australian study found that vulnerable groups (Indigenous Australians, refugees, elderly people) had excess ED presentation for a range of issues potentially better addressed through primary and community healthcare. This may also suggest inequities in the uptake of effective primary and community care.
A 2015 study looked at the Australian public’s preferences for emergency care alternatives and the influence of the presenting context. Their results indicated a preference for treatment by an emergency physician in hospital for possible concussion and treatment by a doctor in ambulatory settings for rash/asthma-related and anxiety-related problems. But participants were consistently willing to wait longer in EDs if the rash/asthma-related scenario affected their child.
In my Sydney suburb of Balmain, we are lucky enough to have a GP Casualty service at the local hospital. I’ve been there to have a cut on my head glued up, and my husband had a badly smashed finger tended to. It’s such a great idea I wonder why there aren’t more such units.
Quality and safety in Australian hospitals
The Australian Commission on Safety and Quality in Health Care has just released its 2019 report on The state of patient safety and quality in Australian hospitals. It is a wide-ranging report and I commend it to you.
The report finds that the personal and financial impacts of failures in patient safety are high. In 2017-18, hospital acquired complications were estimated to cost the public sector $4.1 billion (8.9 percent of total hospital expenditure). The most burdensome events are hospital-acquired infections (HAIs), medication complications, delirium, and cardiac complications.
Some figures provided highlights the extent of the problem:
- If the level of HAIs in all public hospitals was reduced to that of the top 25 percent, there would be 11,142 fewer HAIs per year, saving 229,992 bed days and an estimated $460 million.
- If the incidence of delirium was reduced to that of the top 25 percent of hospitals, there would be 5,795 fewer episodes, savings 101,410 fewer bed days and $203 million.
The report details the history of national efforts to address safety and quality in Australia and some of the successes – a good summary, especially if you are new to this area.
It highlights the following as areas needing more attention:
- Open disclosure of safety and quality issues
- Adequate surveillance to recognise major safety lapses and risks
- Implementation of corrective actions
- Establishment of complaint management systems that include a partnership with patients and carers
- Better informed patient consent
- Ensuring a positive and robust safety culture
- Clear understanding of the roles and responsibilities of all stakeholders, both organisations and individuals.
Although I didn’t find this mentioned in the report, one must wonder what the effect of bullying in the clinical setting has on quality and safety and efforts to improve these factors.
The report also discusses the efforts the ACSQHC has underway to move towards value-based care and an increased focus on patient-centred care.
It is time to expand the focus of the safety and quality lens beyond the acute care setting to community-based clinical services – currently we know so little about this. In 2015, Paresh Dawda and I wrote an article for The Medical Journal of Australia that made the case for more data and more action around patient safety in primary care. The situation today is little changed.
The good news
A young, deaf, life scientist in Scotland struggled to understand his university lectures and grew frustrated with finger spelling, so he has taken matters into his own hands (literally) and invented over one hundred new signs – for things like DNA and RNA – which are now recognised by British Sign Language and used across the country.
Meanwhile, this edition of The Health Wrap comes to you from my US home in the mountains of Colorado where we are enjoying wonderful summer weather and lots of hiking (you can follow my walks on Twitter at @LRussellWolpe).
My Croakey colleague Ruth Armstrong first introduced me to the Japanese idea of “forest bathing” (I wrote about it in The Health Wrap last July) – and now it seems to have caught on here in the Rocky Mountains. I especially enjoy walking in the aspens with their straight white trunks and leaves that flutter green and silver in the breeze.
The 2018-19 winter here brought some of the best snow falls in years – and that meant lots of avalanches.
So I was interested to read that Colorado scientists are taking advantage of the stunning destruction from the avalanche season (over 300 were recorded) to explore how the growth rings in the millions of felled trees reveal the relationship between climate and avalanche cycles.
At present there is still lots of snow on the high peaks and the streams and rivers are roaring with melt-off. We have had to curtail some hiking on the higher trails, but the lower trails have provided masses of wildflowers, later than usual.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.