24 November 2017 Dr Ayman Shenouda Who’s looking after the doctor? Federal Health Minister Greg Hunt made a commitment in May to reduce suicide and improve mental health among doctors. This commitment came following the tragic loss of NSW junior doctor Dr Chloe Abbott with Minister Hunt admitting that ‘too often the care is not there for the carers’.[1] We’re now starting to see some action around this issue. The progress on the mandatory reporting issue for one. It is clear that medical professionals need to seek mental health treatment without fear of retribution. Fixing the mandatory reporting laws is the first key step in supporting doctor health. A nationally consistent proposal was to be considered this month by COAG Health Council. Minister Hunt has since made assurances following this meeting that work is now being progressed towards a standard by the end of the year. More discussion through COAG will follow to secure agreement but we’re getting closer.[2] 2013 beyondblue study As in the general population, depression doesn’t discriminate and this was made evidently clear through work led by beyondblue. Beyondblue’s National Mental Health Survey of Doctors and Medical Students revealed for the first time the true extent of the problem. This major study, undertaken in 2013, surveyed more than 12,000 doctors and around 1,900 medical students. [3] The stats that emerged from this were alarming. It confirmed high general and specific levels of distress, and high levels of burnout among doctors and medical students. Substantially higher rates of psychological distress and suicide attempts were found than in the general community. Around 10% of doctors reported suicidal ideation in the previous year and one in four reported suicidal thoughts prior to the previous year. [4] The study also confirmed that medical students and young or female doctors were most at risk and identified significant levels of stigma towards people with mental health problems. Not surprisingly some experienced bullying and racism as well. [5] This is just the start Despite this major study confirming what we already knew about higher rates of psychological distress among medical students and doctors, there’s still slow policy action around this issue. At the time, there were calls for urgent action to improve the mental health and save the lives of Australian doctors and medical students.[6] But progress has been slow – very slow. Four years later and we’re still working through one of the key barriers to getting help – which is mandatory reporting. Minister Hunt is the first federal health minister to acknowledge that mental health issues are tormenting our sector. [7] Acknowledging the problem is a good start but there is much more to be done. And it’s not all up to government either. We all have a role here and it starts with how we look after each other as doctors. A much broader conversation now needs to occur and it will take all of us to make this happen. Let’s start with taking our own advice It’s clear that work-related stressors impact particularly those at the earlier learning or career stage. We’d all be familiar with the risk factors in the workplace – high-intensity work, long hours, conflicting time demands with a heavy professional responsibility. For some, there is bullying and harassment in the workplace. Broader issues like those stigmatising attitudes which persist despite us coming so far in terms of destigmatising mental health issues in the general community need attention. The advice we’d offer to our patients around the importance of maintaining work-life balance to counter these issues should also apply to us. The work we’ve all done to destigmatise mental health issues in the community and the shifts achieved here need to be reflected in our own workplaces too. In achieving a better balance, the answer lies in ‘restoring the pleasure of work – the satisfaction inherent in meaningful work done well’. Working towards ‘addressing the imbalance between excessive demand and perceived low control, and between effort and insufficient extrinsic reward’. This was the advice of Geoffrey J Riley in what remains one of the best pieces written on the subject: ‘Understanding the stresses and strains of being a doctor’ (MJA, 2004). There’s a link as it is a must-read. Driving toxic culture out Leadership in terms of dealing with discrimination, bullying and sexual harassment (DBSH) is required. The extent and impact of workplace bullying and harassment has been exposed in recent years through the press. Reports in 2015 of sexual harassment and ‘toxic culture’ among surgeons led to a public apology to victims from the Royal Australasian College of Surgeons. The apology came after a survey found nearly half of all surgeons had experienced discrimination, bullying or sexual harassment.[8] A Senate Inquiry into bullying and harassment in the medical profession followed. During hearings in November last year, senators were told of an ingrained culture of harassment and bullying of medical students.[9] There were reports of endemic bullying and underreporting of abuse due to fear of consequence. Gender discrimination and ‘teaching by humiliation’ was also exposed. AMSA evidence stated that up to half of all medical students believing this mistreatment necessary and beneficial for learning.[10] . Positive policy responses include those from the Victorian Government in its work to eliminate bullying and harassment in healthcare. Their strategy focuses on strengthening leadership and accountability; building the capability within the health sector to act and respond appropriately and creating a positive environment that promotes and supports both staff and patient safety.[11] We need to see more strategies like these. We know that medical students, interns, IMGs and female colleagues have been identified as most at risk. These are issues we need to tackle within our own disciplines and collectively as a medical profession. We also need more focus on self-care Self-care has the potential not only to minimise the harm from burnout, compassion fatigue, and moral distress but to promote personal and professional well-being.[12] Developing a self-care plan is important. We all need strategies to mitigate stress and burnout and promote well-being. More focus on the importance of self-care in the training to develop early those required coping skills is also important. The RACGP in the White Book, Chapter 14, The doctor and the importance of self-care provide comprehensive guidelines encouraging self-reflection, peer support and working as a team within the practice to protect against stress. It provides some practical strategies which are worth pursuing at an individual and practice level. Responding as a profession Mentoring is also a key part of remaining resilient as creating (and maintaining) a network of peers is so vitally important. It still is for me. I think we all need to check in with each other regularly. But what more can we do to ensure we are active as a profession to support and mentor our young doctors? Collegiality matters here. Our strength is in our membership and we need to value and nurture our next generation. It is clear that we need more action on bullying and doctor burnout and mental health issues. I think part of the solution is through formalising a mentoring role in the training system. It provides that safe place to solve problems. But it is currently an add-on for many of us and hard to sustain in terms of an ongoing commitment. It usually comes down to one individual and relies on altruism (alongside so many unfunded parts of our profession). There are formalised scholarship programs but only for a select few. We are relying on a limited pool of mentors which undermines the effectiveness and funding this important role forms part of the solution towards ensuring a more resilient workforce. [1]The Daily Telegraph. Minister commits funding to address issues crippling young doctors’ mental health. 27 May 2017. Available at: https://www.dailytelegraph.com.au/news/nsw/minister-commits-funding-to-address-issues-crippling-young-doctors-mental-health/news-story/ed7f7871fef2eec8f1d3766b62200854 [2] AMA. Health COAG progresses approach on mandatory reporting. 13 November 2017. Available at: https://ama.com.au/ausmed/health-coag-progresses-approach-mandatory-reporting [3] Beyondblue. National Mental Health Survey of Doctors and Medical Students. October 2013. Available at: https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report---nmhdmss-full-report_web.pdf?sfvrsn=845cb8e9_4 [4] Ibid. [5] Ibid. [6] Beyondblue. Media releases. Urgent action needed to improve the mental health and save the lives of Australian doctors and medical students. 7 October 2013. Available at: https://www.beyondblue.org.au/media/media-releases/media-releases/action-to-improve-the-mental-health-of-australian-doctors-and-medical-students [7] Op. cit. The Daily Telegraph. [8] ABC News. Culture of bullying, sexual harassment widespread among surgeons, report reveals. 10 September 2015. Available at: http://www.abc.net.au/news/2015-09-10/damning-report-reveals-bullying-harassment-among-surgeons/6763490 [9] The Sydney Morning Herald. 'Ingrained culture' of harassment and bullying of medical students, inquiry told. 1 November 2016. Available at: http://www.smh.com.au/national/health/ingrained-culture-of-harassment-and-bullying-of-medical-students-inquiry-told-20161101-gsfbuu.html [10] Ibid. [11] State Government of Victoria. Policy Summary. Eliminating bullying and harassment in healthcare. Available at:https://www2.health.vic.gov.au/about/publications/policiesandguidelines/eliminating-bullying-harassment-healthcare [12] Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care for others: physicians and their self-care. The journal of supportive oncology. 2013;11(2):75-81.
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The lack of focus on general practice in national aged care review is a missed opportunity18/11/2017 24 November 2017 Dr Ayman Shenouda National Aged Care Quality Regulatory Processes Review The recent Review of National Aged Care Quality Regulatory Processes was released on 25 October. The review looked at past failures in terms of the limitations of the regulatory controls to recognise abuse and care issues. It’s emphasis, therefore, was on improved regulatory measures to improve national monitoring arrangements. Aged Care Minister Ken Wyatt, in his announcement on releasing the report, stated that the majority of facilities provide excellent care and are working to continually improve services. Some might argue that media reports of endemic abuse in nursing homes paint a very different picture. That aside, the Minister stated that focus was on seeing improvements to the system that can address those not delivering quality care. Aged care safety and quality It is appropriate for the review to have a core focus on safety and quality. The capacity of the current regulatory environment to protect residents from ‘restrictive practices’ is of course appropriate. A key recommendation was the use of unannounced audits across Australia’s residential aged care facilities (RACF). This is a positive outcome and the commitment by the government to implement this recommendation quickly is also positive news. There were 10 recommendations in total to improve aged care resident protections through more transparent compliance and monitoring. Other key recommendations included establishing an independent Aged Care Quality Commission with provision for a quality commissioner, complaints commissioner, consumer commissioner as well as a chief clinical advisor. This new commission would develop and maintain a centralised database with the view of creating a star-rated system on provider performance. In addition, there would be more protections to curb abuse which would see a recommendation from the Australian Law Reform Commission for a new independent serious incident response scheme (SIRS). On accreditation and compliance, the unannounced visits were the major recommendation with more public disclosure on matters of non-compliance. In addition, if supported, there would be strengthened controls around medication reviews and compliance. Medication reviews were recommended on admission, after hospitalisation, upon deterioration or when changing medication regimes. Where’s the focus on general practice? This is an important body of work but again we see a lack of insight into the key role of general practice in aged care service provision. This is another example of a review which has missed an opportunity to ensure a stronger role for GPs. There should have been scope to work through key issues including those areas of clinical governance as a key quality enhancement measure. It’s all very well to make sure that there are controls to pick up those not doing the right thing. But doesn’t it make better policy sense to place an equal emphasis on why the issues are there in the first place? It is very disappointing that this review did not extend to service solutions through general practice. This oversight being on the back of the recent Productivity Commission’s 5-year productivity review – Shifting the Dial - which also underplayed the role of general practice in a discussion which focussed on prevention and primary care. To a certain extent, even the changes in Victoria with the voluntary assisted dying legislation seem to lack a focus on service capability. Palliative care is one area which lacks clarity in terms of roles and most certainly there is a lack of data, fed by physician only item numbers, which can only constrain services and planning. GPs too do a lot in this area but this mostly goes unnoticed and underfunded. Ensuring there are funding levels to enabling access to palliative care services should be a priority moving forward. Valuing general practice Why is there a lack of focus on general practice? It’s clear that success in terms of prevention makes us far less visible. Such is our role that if we do it well then it goes unnoticed. Best practice interventions for heart disease and stroke, for example, will translate over time through improvements in data. But there’s a very limited audience with not many from outside of the profession interested in this level of detail. The RACGP has made strong investments in recent years to lift our profile. However, the lack of focus is still a key problem. This is evident in this latest report where glaring service solutions – solutions to lift quality - have been again overlooked. The missing GP perspective In a recent Medical Observer article by Professor Leanne Rowe, ‘Why are GPs missing for the national aged care review?’, this lack of focus was also seen as a key issue which limited the report’s findings. The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities. Those obvious service issues, central to ensuring quality, were ignored. A focus on quality needs to also look at ways to make improvements including through stronger staffing and appropriate skill mix levels. The role of the GP is clearly limited due to low rates of reimbursement through the MBS. Optimal models of care cannot work in an underfunded service environment. GP-led care or collaborative care solutions are relevant to achieving those safeguards for residents sought through this review. Stronger integration of GPs and improved collaboration with aged care staff and formalising these models of care would assure safe and high quality coordinated care for residents. More broadly, variable skillsets are important factors that impact on quality of care standards in these facilities. Inadequate staffing levels including the need for more skilled nursing staff is central to many of the quality and compliance issues central to this review. The recent Senate community affairs committee report made specific recommendations in this regard and again it is very relevant to a review focused on quality. Conclusion Ensuring there are transparent and workable processes in place to uphold standards and community expectations in terms of care is very important. The recommendations offered through this review will go a long way towards strengthening these. But a great deal of the issues relates to the corporate ownership structure of the RACFs. More specifically, the limitations that brings in terms of ensuring quality service provision. Improving the lives of older Australians needs a firm policy focus and we’re starting to see that through this Minister. There is an opportunity to build off this review to fix some of those glaring issues limiting the quality of care. I’d like to see a stronger role prioritised for general practice and formalised in national policy. Limitations in terms of remuneration which also fail to capture the complexity of this care needs addressing. Valuing the role of the aged care workforce more broadly is central to ensuring quality outcomes. There’s so much more to be done here to ensure older Australians receive the care they deserve and we cannot afford to drop the focus on GP-led care solutions 10 November 2017 Dr Ayman Shenouda PC Report: We can do better in health The recently tabled Productivity Commission Report ‘Shifting the Dial: 5 year productivity review’ takes a broad policy lens on only on a few key areas which it states are likely to impact overall economic performance over the medium term. Health, of course, made it into this five-year review of the nation’s productivity alongside education and cities. Overall the report turns to technology as an enabler for change and in parts more government control. The report suggests some major policy shifts to achieve a number of efficiency measures. Applying automation to healthcare as a cost reduction strategy specifically to achieve a smaller pharmacy workforce is one such shift. There are some familiar ideas floated throughout with many not pursued in the past for good reason. There is a lack of emphasis on the role of general practice in the health discussion which in turn weakens the piece. A quick snapshot While there are a number of recommendations for health against Healthier Australians many seem short on detail (and evidence). The sharpest shifts are pointed at education system reform, while health seems a little less disruptive. This is, of course, other than the recommendation for pharmacies to be turned into automatic dispensing outlets! In terms of the rest, well tackling those low-value healthcare procedures is really already in train and an important efficiency measure. Creating scorecards for the performance of providers to enable patients to compare outcomes is another idea which has merit but there are many higher priorities to pursue first. There’s certainly a push to utilise more both the PHNs and LHNs to help overcome the federal and state funding standoff and related care gaps. This is both positive and problematic in terms of enabling integration. On one hand it will force more joining up through a funding means but on the other it will be reliant on forging strong relationships with general practice. The latter is not made a priority in this paper and instead implies more control (of general practice). The paper states the need for a new funding pool for the PHNs and LHNs towards population health activities including some commissioning of GP services.There is certainly a need to create better structures and incentives to realign toward prevent and chronic disease management and localised solutions makes the most sense. However, the commissioning approach to procuring medical and health care services is still a work in progress in my view and much much more effort is required to engage general practice. That is the only way to establish trust and work through to those new ways of working in partnership with general practice. Health scorecard The positives … The overall positives of our healthcare system in terms of outcomes are at least acknowledged. We’re living longer, with less disability. Against OECD countries we have high overall health outcomes with the greatest life expectancy at birth. The third greatest life expectancy at birth in fact at 82.8 years (2015). On prevention and injury, we’re seeing a reduction in smoking rates and few deaths on our roads. And perhaps most importantly for a report focussed on fiscal pressures we’re spending less on health when compared to the other OECD countries. And the negatives … But holding us back, according to the report, noting this is from a perspective of lost productivity, are the 27.5% of adults who are obese and the 11 years spent in ill health which is the highest in the OECD. The last being despite having the third-highest life expectancy in the developed world. It doesn’t hold back … There are some scathing comments around some of the broader perceived negatives driving costs up. The comment in setting up the need to defund low-value healthcare procedures is both harsh and without (strong) cited evidence: “Unjustified clinical variations, including the use of practices and medicines contraindicated by evidence, remain excessive, an indicator of inadequate diffusion of best practice, insufficient accountability by practitioners, and a permissive funding system that pays for low-value services.” The example used here is knee arthroscopy which again is something we all knew about. The new Australian Commission on Safety and Quality in Health Care Standards developed to discourage the use of arthroscopy for patients with knee osteoarthritis is mentioned, yet criticised as it is an advisory and able to be ignored. The report cites some other examples to illustrate their concerns around quality: 75% of bronchitis treated with antibiotics, against best practice; and 27,500 hysterectomies without a diagnosis of cancer. Finding efficiencies In finding efficiencies in health the report states: “Doing better with our health resources can act as a safety valve for mounting fiscal pressures.” This, of course, is quite obvious and not without (current) policy focus as finding healthcare efficiencies have really dominated the policy debate for nearly a decade. The report states that ‘some suggest that approximately 10 to 15 percent of health spending is used inefficiency due to poor quality care’. That last statement is (again) not referenced but let’s assume ‘some’ have stated it. We all know that the system is far from perfect but there are also many parts worth protecting including the gains realised in primary care. In this report, the efficiency measures are embedded in the detail, not necessarily making it to the recommendations and worth noting. Observations on the detail The report states that the patient experience of care receives little focus as a goal of the system. It accurately picks up some failures in terms of enabling choice – palliative care being one. But, it is in primary care where patient centred care remains core and where stronger gains have been realised. Particularly in terms of patient empowerment and ensuring prevention is prioritised and this is not really highlighted here. I really don’t think the review has reached out much at all to general practice, otherwise we would see this reflected more in the solutions. I think the piece gets to the real issue where it states the current system encourages activity, not outcomes. It includes one of the strongest statements in this report: “Australia’s messy suite of payments are largely accomplices of illness rather than wellness, only countered by the ingenuity and ethical beliefs of providers to swim against the current.” From a primary care perspective, I agree that those limited MBS payments oriented towards preventative health and chronic disease are too narrow and inflexible limiting both outcomes and reach. But when considering other payment options, it worth remembering that general practice is a private business model and needs to remain as such. Whether that be maintaining fee-for-service combined with risk-adjusted capitation payments but particularly for pay-for-performance initiatives – ensuring continued practice viability must factor strongly. For this to work, pay-for-performance should only be used to drive quality improvement in certain priority areas – similarly to how the PIP currently operates - and be part of a mix of payment arrangements, not the sole driver. The focus on enabling stronger integration is of course key and the stumbling blocks preventing more of it is put down to system deficiencies in the structure of our healthcare system – funding governance, linkages, and attitudes. More linking between PHNs and LHNs – fusing those government layers - at the regional level will achieve more integration. It’s about partnerships or more specifically, cultivating relationships between hospitals and GPs that will create these formal linkages to bring about stronger prevention, early intervention, and chronic disease management. The word partnership is key here and for this to work we would need to see a genuine partnership with general practice, not seek to control it (as the earlier commentary suggests in imposing new funding models). This emphasis really highlights the greenness of this policy piece as it is general practice where the opportunities lie, yet so many opportunities have not been pursued here. Reassuringly, this report also states that the solution is not to destroy the current system which it states would result in a policy adventure with many risks and uncertain outcomes. Instead, we should focus on those parts of the system already making that required shift towards a more integrated patient-centered system. Some might still say that this report takes us on a journey of (policy) misadventure. This might be true (in parts) but there are some areas worth testing. Here's a short synopsis on the key recommendations Key recommendations There are six key recommendations arranged against five identified problem areas – integrated care, patient-centered care, funding for health, quality of health and using information effectively. The recommendations: 2.1 Implement nimble funding arrangements at the regional level 2.2 Eliminate low-value health interventions 2.3 Make the patient the centre of care 2.4 Use information better 2.5 Embrace technology to change the pharmacy model 2.6 Amend alcohol taxation arrangements I’ve hand-picked a few areas here. Recommendation 2.1 The first recommendation (2.1), to implement nimble funding arrangements at the regional level, calls on all governments to allocation (modest) funding pools to PHNs and LHNs for improving population health, managing chronic conditions and reducing hospitalisation (at the regional level). This recommendation would provide a flexible fund to PHNs and LHNs to work through more localised solutions. It is the type of flexible funding solution we’ve called for in primary care for years but the enclosed word ‘modest’ is interesting. This initiative builds on the PHN/LHN partnership discussion throughout the chapter and would help address some of the key barriers to integration. But, in my view, this would also require significant, not modest, funding levels to make a real difference and address current gaps impeding integration. There are some real opportunities to pursue through general practice in order to address some of the clear service gaps or policy failures identified. Palliative care in the home being one of them. Building capacity of general practice in population health to invest in those preventive measures is another. The PHNs were sees an opportunity to enable more GP-led care particularly in preventive care and integration with the LHNs were already part of their remit. Therefore, this specific initiative is almost wholly reliant on general practice and it is disappointing not to see that emphasis made. Recommendation 2.2 Eliminating low-value health interventions (2.2) states that progress to limit low or no-value services has been slow. There remain too many unjustified medical procedures (some we covered off earlier). The report also highlights that Australian procedure rates are markedly higher than other comparable OECD countries. There is also some discussion around patient expectations contributing and more broadly health literacy and the need for improvements there. Broader solutions include the faster development of clinical standards and ‘do not do lists’ by the ACSQHC. The report states that Medical Colleges should also disseminate best practice (which already occurs in general practice). De-funding (interventions) mechanisms as well as removing the tax rebate for private health insurance ancillaries is also discussed. Recommendation 2.3 A key recommendation (2.3) to make the patient the centre of care is of course welcome. It is already a core value in general practice and expansion is really key to fixing our healthcare system. Empowerment measures including improving patient literacy and embedding patient-centered care in training all very important and picked up in this report. The report highlights that ‘the OECD has characterised Australia as relatively poor in its capacity to collect and link health data’. As part of the solution, the PC suggests a new role for the ACSQHC in placing the patient front and centre. This would involve developing well-defined measures of patient experience of care. It would capture outcomes from a patient perspective to help build a picture of how the system is working at the grassroots level. I agree patient-reported outcomes measures or PROMs is important but this should only be used as a balance measure. Outcomes measures (high-level clinical), as well as process measures (evidence-based best practice in driving improvements), must continue to be prioritised if we have any chance of realising our health gains or goals over time. Recommendation 2.4 (and 2.5) Recommendation 2.4 picks up on this broader theme around data capture and related shifts in the previous recommendation. It calls for the establishment of the Office of the National Data Custodian. This change would help to ‘remove the current messy, partial and duplicated presentation of information and data, and provide easy access to health care data for providers, researchers, and consumers’. Much of the remaining parts to this recommendation sets up the requirement for a new model of pharmacy. The next recommendation (2.5) of course deals with the shift to pharmacy automation and The Pharmacy Guild of Australia’s response to it is worth reading. Recommendation 2.6 The final recommendation (2.6) has a focus on public health initiatives and recommends moves towards an alcohol tax system. Interestingly, it falls short on measures to curb sugar intake despite the strong obesity emphasis throughout. Market control through voluntary reductions in sugar content (by major manufacturers of SSBs) is instead floated. This perhaps was one of the key areas worth exploring in enabling a more productive workforce and alleviating those 11 years spent in ill health. The report falls short here. I would welcome an expanded discussion including a stronger focus on physical activity as a key prevention measure. For more information: Inquiry Report No. 84. Shifting the Dial: 5-year Productivity Review 3 August 2017 Sustainable healthcare: A shift to a proactive, preventive approach with increased engagement2/11/2017 30 October 2017 Dr Ayman Shenouda Investing in health A greater investment in health requires a strong focus on patient-centred care prioritising both prevention and primary care. In progressing these shifts we’re currently locked within the constraints of our reactive healthcare system. Despite significant levels of funding, we’re just feeding a sick system here. This is less about payment reform or performance-based models but more one of prioritising and getting that focus right. In making that shift towards a healthier population and sustainable healthcare system it comes down to priorities, not just savings. Removing waste including through the removal of obsolete, redundant or unsafe treatments from the MBS item numbers is important. But so is ensuring we transition from our episodic, acute care or reactive model towards a more proactive one. Preventive care solutions To shift health outcomes then we need to address those causal factors. It’s not just medical care alone that influences health with social factors known powerful determinants of health.[1] Those causal factors affecting health status must be also be tackled. Socioeconomic factors – income, wealth and education – all impact. Those “upstream” factors which include social disadvantage, risk exposure and social inequities that play a fundamental causal role in poor health outcomes and must be addressed.[2] These are issues which play out over long periods and much longer than electoral cycles. But stopping the onset of illness is the only way to contain our rising disease burden.[3] Therefore, it is those emerging preventive care solutions, which fall as either proactive or predictive care, where we now need to focus.[4] A prescription for health This prescription for health is very different to the one we currently have and involves a Proactive, Preventive Approach with Increased Engagement. The shift is something we’ve been trying to do in primary care for some time but barriers from without our framework are limiting a full transition. The policy response involves a mix of proactive and predictive care solutions. For proactive care solutions, this involves improving treatment outcomes through stratifying at-risk individuals based on known algorithms ensuring preventive action is taken well before the onset of symptoms. [5] We know that certain behavioural risk factors - tobacco use, alcohol consumption, physical inactivity and unhealthy eating - are most amenable to change. We can do more to modify these behaviours as part of proactive care through stratifying individuals based on key risk factors for chronic disease.[6] While predictive care is about leveraging emerging technologies and using big data to not only stratify risk but predict risk and intervene even further upstream.[7] More predictive care, through improved analytics, genetic risk testing and technological developments build an even clearer picture. These early insights will help us anticipate issues pinpointing those behaviours to avoid and actions to take much earlier than before and before risk factors arise. [8] Risk and protective factors In transforming our health system, it is a focus on those risk and protective factors over time that really holds the answers. The Life Course Health Development (LCHD) framework offers a new approach to health measurement, health system design, and long-term investment in health development.[9] It takes into account those risk and protective factors and early-life experiences in determining long-term health and disease outcomes. [10] More understanding of how these health trajectories develop over a lifetime helps us influence change for optimal health development through more effective preventive strategies and interventions. [11]
2. Then an equal focus on protective factors –These are those protective or health-promoting factors which are of course broader than health but have a positive influence on our lives and are health affirming. From the best start through breastfeeding, positive educational influences or being more physically active throughout through to access to quality healthcare and strong social capital are just some examples. 3. Finally, increased engagement in striving for our own good health –Population health management really offers the collaborative approach required to empower patients and patient centred care. Informed and involved patients who are active participants in setting their own goals for wellness are central.[15] Those social factors and the government’s part in that to ensure we all have the best start and life possible is really key. Strategies for intervention It is these focus areas which hold promising strategies for intervention. Still, we see very few health dollars being prioritised for prevention. To fully support a stronger focus on prevention we need to pursue new data on risk and protective factors, investigating how and when they develop across the life course.[16] Through these key learnings, new proactive and predictive care solutions will need to be developed and prioritised in our healthcare system. This is not a new concept; many general practices already do this – identify and stratify patients according to risk – but it our current payment system really restricts us here in limiting to diagnoses. It is really just the difference between disease focus care and actually enabling more patient centred care. More incentives around prevention and in reducing risk are required to make this work particularly in general practice for an optimal business model. More broadly, this requires a whole of government shift, not just from within the health budget but towards a Health in All Policies (HiAP) approach. This will help redress inequities and give everyone a fair chance for health. The policy remit extends well beyond health and also beyond any discussions occurring right now around fee-for-service and performance-based models. If the government is really serious about shifting health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. [1] Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/ [2] Bharmal N, Pitkin Derose K, Felician M, and Weden, M. Working Paper: Understanding the Upstream Social Determinants of Health. RAND Health. Prepared for the RAND Social Determinants of Health Interest Group. WR-1096-RCMay 2015. Available at: https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf [3] MacIntosh E, Rajakulendran N, Khayat Z, Wise A. Transforming health: Shifting from reactive to proactive and predictive care. MaRS. 29 Mar 16. Part of the Transforming Health Market Insights Series. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [4] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [5] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [6] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [7] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [8] Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/ [9] Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. The MilbankQuarterly.2002;80(3):433-479. doi:10.1111/1468-0009.00019. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [10] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [11] Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/ [12] Halfon N, Larson K, Russ S. Theories And Consequences. Why Social Determinants? Healthcare Quarterly, 14(Sp) October 2010: 8-20.doi:10.12927/hcq.2010.21979. Available at: http://www.longwoods.com/content/21979 [13] Tasmanian Government. Determinants of Health. Department of Health and Human Services. Available at: http://www.dhhs.tas.gov.au/wihpw/principles/determinants_of_health [14] Op. cit. Halfon et al. Available at: . http://www.longwoods.com/content/21979 [15] Ernst & Young. Population Health Management. EY Health Industry Post. News and analysis of current issues affecting health care providersandpayers.2014.Availableat: http://www.ey.com/Publication/vwLUAssets/Health_Industry_Post_population_health_management/$FILE/Health_Industry_post.pdf [16] Public Health Agency of Canada. Strategic Plan 2016-19. Improving Health Outcomes. A Paradigm Shift. Publication date: December 2015. Cat.: HP35-39/2015E-PDF ISBN: 978-0-660-03990-9 Pub.: 150173. Available at: http://www.phac-aspc.gc.ca/cd-mc/assets/pdf/ccdp-strategic-plan-2016-2019-plan-strategique-cpmc-eng.pdf |
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