Greater needs, but poorer access to services: why COVID mental health measures must target disadvantaged areas



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Graham Meadows, Monash University; Brett Inder; Frances Shawyer, Monash University, and Joanne Enticott, Monash University

COVID-19 outbreaks and the resulting lockdowns, particularly in Victoria, have adversely affected many people’s mental health.

Social isolation, financial stress, and anxiety about contracting COVID-19 can all contribute to psychological distress. For some people, these experiences may trigger mental disorders, such as depression.

People in lower socioeconomic groups are likely to be in particular need of mental health support in the face of the pandemic.

While federal and state governments have rightly boosted mental health services, we need to ensure these services reach those who need them most.

‘Better Access’ doesn’t guarantee access for all

The “Better Access” scheme entitles people to Medicare-subsidised sessions with a psychologist, occupational therapist or social worker, including via telehealth.

Recognising the mental health consequences of the pandemic, the federal government has increased the number of psychological therapy sessions subsidised under Better Access from ten to 20 sessions per year.

Well before COVID-19, we knew socioeconomic disadvantage was associated with poorer mental health. Our earlier research has shown very high psychological distress is much more common in the most disadvantaged fifth of Australian areas than in the most affluent fifth.

But for reasons including out-of-pocket costs and service locations, we’ve found people in poorer areas receive fewer Better Access treatments.

A female doctor speaks to someone on her laptop computer.
Better Access sessions can be delivered via telehealth.
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In Victoria, as in other parts of the world, COVID-19 has taken a higher toll on people in disadvantaged areas.

Not only have poorer areas suffered disproportionate numbers of COVID-19 infections, but they also seem to be enduring greater associated social and economic hardships such as job losses.

And if people in these areas need extra mental health support, they may find they’re under-served by the existing system.




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Three concerns

The expansion of Better Access may in fact deepen the inequity around access to these services.

1. Access to providers

The supply of therapists has not suddenly increased, so neither has the availability of treatment sessions. The increased number of allowable sessions will largely benefit people who already have access to treatment — and who are less likely to come from disadvantaged areas.

With scarce provider time, this potentially means fewer available sessions for those in disadvantaged areas.

2. Gap fees

Telehealth items continue to allow uncapped co-payments (gap fees). Whatever principled commitments practitioners may have to bulk billing, it makes financial sense to want to attract clients who can afford to pay.

So there may be better access for people with greater financial resources.




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3. A digital divide

Telehealth items, including video mental health consultations, may be less accessible in disadvantaged areas because of poorer access to technology, including reliable internet connections.

Those in disadvantaged areas may also be living in overcrowded conditions, and therefore have less privacy to use telehealth.

Where is the need greatest?

The Index of Relative Socioeconomic Disadvantage (IRSD) summarises a range of information about the economic and social conditions of people and households in Australia.

It can help planners direct resources to more disadvantaged areas — which, as we’ve shown, is particularly important for mental health services.

Our new paper offers a model for policy-makers to apply what we know about the IRSD and poorer mental health to planning and monitoring mental health services.

We created a spreadsheet using area IRSD scores to estimate mental health resource needs for different areas.

In Melbourne, for example, we estimated more disadvantaged parts of the western suburbs have a need around 2.5 times greater than parts of the eastern suburbs.

We used Victoria as an example, but this model could easily be adapted for use elsewhere.

How can we make services in Australia more equitable?

We hope our research will complement other Australian tools so the influence of disadvantage on mental health-care needs can be more consistently and transparently taken into account when designing mental health services.

State-based mental health services are often funded by areas, such as those for adults with serious mental illnesses in Victoria. So getting the funds to where they’re most needed is possible for state and territory governments.

But with services such as Better Access, which are funded by Medicare item rather than by geographic area, we will need new ways to ensure they’re distributed equitably.

A young woman has her head in her hands.
COVID-19 has taken a toll on Australians’ mental health.
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A thought experiment

The government could encourage a practitioner using telehealth to ensure 40% of these services get to people living in areas in the lowest 40% according to the IRSD.

The government could also implement an overall bulk-billing target of, say, 50%. Disincentives could follow if the provider falls short of these targets.

For example, a provider would receive commonwealth funding for all services provided if they achieved the 50% target. If not, they would receive funding for all bulk-billed consultations, plus the same number of co-payment services.

So, if a provider only bulk bills 40% of their clients, 80% of their services would receive funding. Similar mechanisms may operate for IRSD targets.

Such a move would likely face opposition, including from practitioners who might find it difficult to change their referral and charging practices. For some, at least initially, their income would suffer. So it could be challenging to introduce.




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This is just a draft proposal and the details, including specific targets, could be refined in discussion with professional bodies. The model in our paper could be used to assess if changes succeed in improving equity.

But something like this could see people with the greatest mental health needs, particularly those in the most socioeconomically disadvantaged areas, better able to access services.The Conversation

Graham Meadows, Professor of Adult Psychiatry, Monash University; Brett Inder, University Professor; Frances Shawyer, Research Fellow, Monash University, and Joanne Enticott, Senior Research Fellow, Monash Centre for Health Research and Implementation (MCHRI), Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Mathias Cormann wants to lead the OECD. The choice it makes will be pivotal


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Adrian Blundell-Wignall, University of Sydney

My old OECD boss Secretary General (SG) Angel Gurria’s third term is coming to an end and the race is on to replace him.

Australia’s departing finance minister Mathias Cormann will face off against likely candidates from Canada, Estonia, Sweden and the United States and others yet to declare their hands.

Nominations are made by member countries and close on November 1.

The successful candidate will be announced by March 1. The next SG will begin the five-year term on June 1, 2021.

The person chosen will be remembered either as the SG who saw the OECD lose relevance in the face of pressure from large countries to cut its budget and marginalise it or, alternatively, as the person who kept alive the importance of the collective interest in holding governments to account, in a lobby-free zone.

The OECD has come a long way

The OECD began as the Organisation of European Economic Cooperation in the ruins of the second world war. Its brief was cooperation in the post-war reconstruction of Europe. It was about getting old foes to bury the hatchet and focus on common needs as US loans and technology were passed to Europe.

Its flagship activities were economic forecasting and country surveys.

As the formation of the European Economic Community in the late 1950s rendered some of its original role redundant, the United States and Canada joined, and in 1960 it was rechristened the OECD.




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Japan joined later in 1964 and Australia much later in 1970. Today it has 37 member countries, all of them upper or middle income democracies, including Mexico, Korea, Chile and Israel.

Brazil, India, China, Indonesia and South Africa are official partners (although not members), meaning the OECD is able to address challenges facing countries that account for 80% of world trade.

From tax to bribery, its work is important

At first it too focused on forecasting and country surveys, but then the International Monetary Fund moved into that role after its original raison d’être of exchange rate stability was taken away as the world moved to floating exchange rates in the wake of massive spending by the US to sustain the Vietnam War and the mid-1970s oil crisis.

Under the its second SG, Emiel van Lennep, the OECD developed new rules, facilitating cooperation on, among other things, financial regulation, tax policy, competition policy, corporate governance, multi-national enterprises, science and technology, environment, bribery and corruption, pensions, social policy, employment and (often forgotten) data consistency and the manuals used by statistical agencies and researchers all over the world.




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It’s Programme for International Student Assessment (PISA) is the gold standard for assessing the performance of students worldwide.

The way it works was well suited to these roles and could not be duplicated by other international organisations. Its agenda is driven by committees made up of representatives of member governments rather than its permanent staff.

In these committees, more than 300 including expert and working groups, representatives come together to discuss problems and how cooperation can help sort them out.




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The expansion has been demand-driven, with member countries, companies and other institutions often providing voluntary financing to make them work (OECD budgets are always under pressure). Today roughly one third of the OECD is funded this way.

It requires a special type of leader.

What’s needed to run the Paris-based organisation is someone who is credible, experienced in international affairs, has presence and gravitas, is a linguist (English and French), a fund raiser, energetic, ready to spend months travelling, thick skinned and has vision and courage.

It needs a leader who’s unafraid

Above all, it has to be someone who believes in the idea of the OECD and wants it to make a difference.

The present SG, Mexico’s Angel Gurria has been perfect, pulling it out of a lull and raising its profile.

Australia’s candidate Mathias Cormann.

Unfortunately, after 15 years with Gurria at the helm, some governments are looking for a more of a consensus-seeker.

“Consensus” means moving to the lowest common denominator, and not rocking the boat by using the full power the SG has to publish under his or her authority whenever consensus cannot be reached, as is often the case.

How will the new SG be chosen? The OECD Council doesn’t have the seniority and independence to decide. The appointment will be approved back in the capitals after lobbying by politicians and trading of favours, just as these things are decided for all heads of international organisations.

The best hope for an inspiring choice will be the smaller countries.

We can be grateful there’s one vote per country and no veto held by major powers as is so often the case in other international organisations.


Adrian Blundell-Wignall is a former director of the OECDThe Conversation

Adrian Blundell-Wignall, Adjunct Professor, School of Economics, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Despite more than 30 major inquiries, governments still haven’t fixed aged care. Why are they getting away with it?


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Eileen Webb, University of South Australia; Christie M. Gardiner, University of Newcastle, and Teresa Somes, Macquarie University

This article is part of our series on aged care. You can read the other articles in the series here.


Australia’s aged care sector has been the subject of more than 30 major inquiries and reviews since 1997.

It is fair to say the findings have been highly critical of the way aged care is run in this country. Many of these concerns have been brought to light again — along with new issues raised — in the ongoing Royal Commission into Aged Care Quality and Safety.

Yet, as the royal commission has noted, successive Australian governments have shown a “lack of willingness to commit to change”.

Responses often come years after the review and recount what has been done in an almost tangential way.

Even the establishment of the royal commission was not based on previous inquiries or recommendations, but in response to media exposés of the appalling conditions in some aged care facilities.




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From these dysfunctional circumstances, three questions arise.

First, what are the ongoing issues with aged care in Australia?

Second, why have successive governments been comfortable making do with piecemeal solutions rather than truly “fixing” aged care, once and for all?

Finally, and most perplexingly, why have Australian voters let them get away with it?

What’s the problem?

It is important to emphasise that aged care is predominantly a federal government responsibility. The 1997 Aged Care Act is the main law covering government-funded aged care. This includes rules for funding, regulation, approval of providers, quality of care and the rights of those in care.

Elderly woman looking out a window.
The Royal Commission released a damning interim report into aged care in October 2019.
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Since 2019, the federal Aged Care Quality and Safety Commission Act regulates complaints, sanctions and enforcement, but has been criticised for lacking teeth.

The 1997 act diluted many preexisting regulatory protections, such as strict financial accreditation and staffing requirements, and opened the sector up to privatisation. At the time, concerns were raised the new regime could compromise standards of care in aged care facilities and disadvantage older people on lower incomes.

The concerns were raised again and amplified in subsequent years. For example, in 2011, a Productivity Commission report noted Australia’s aged care system needed a “fundamental redesign”.

Here is a brief summary of the recurring issues raised in multiple reports:

  • the huge difficulty people have navigating the aged care system, including finding accurate information about facilities

  • failure to meet the needs of vulnerable older people

  • poor quality care, especially for those with dementia and other disabilities

  • the use of chemical or physical restraints

  • inappropriate staff ratios and poor training

  • the rising cost of care, especially in light of an ageing population

  • adherence to accreditation standards

  • ineffective complaints mechanisms.

Why haven’t these problems been fixed?

One of the major hurdles to real reform is the relationship between the aged care industry and the federal government.

The government funds the sector and provides a relatively “light-touch” oversight, while the providers attend to the day-to-day running of the facilities.




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However, there is concern this alignment has meant successive governments are not as involved as they should be and proposals for change are diluted by the influence of industry lobbyists.

Another reason for governments’ reluctance to intervene is many of the providers are “too big to fail”. A facility’s licence and government funding can be withdrawn if standards are not met. Yet this rarely happens.

Why? Because if a licence is revoked, residents need somewhere to go. The issues here can be seen in the closure of the Earle Haven nursing home in July 2019. Here, 68 elderly people were left homeless and had to be moved to hospitals and other aged care facilities.

As a further example, Bupa, one of Australia’s largest providers, continues to operate, despite sanctions or failing fundamental assessments.

Why isn’t aged care a vote winner?

After so many inquiries and so many horror headlines, the problems in aged care are well and truly common knowledge. But do Australians care enough about aged care for it to influence their vote — and so, influence the way governments respond?

If we cast our minds back to the 2019 federal election campaign, the hot button issue concerning older people was the potential demise of franking credits and negative gearing.

Australians voting at a polling booth.
Aged care issues did not feature prominently in the 2019 federal election.
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In-home and residential aged care barely rated a mention in the campaigns of the major parties.

Even now, despite the publicity surrounding the royal commission, if an election was held today, would this issue actually influence voting intentions? Sadly, it seems unlikely.

During the July 2020 Eden-Monaro byelection, a survey of nearly 700 voters showed while 84% believed the aged care system was “in crisis”, this influenced the vote of less than 4% of respondents. It also ranked last in a list of seven issues of importance.

When heartfelt concern does not translate to winning votes, there is little incentive for the federal government to provide meaningful solutions to well-documented problems.




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We only need to look to the record spending in the 2020 Budget, which provided only 23,000 extra home care packages and deferred consideration of funding for residential aged care until the royal commission’s final report next year.

It comes back to voters

Why does concern for the plight of people in aged care fail to generate public action?

We suggest it is because many Australians consciously or unconsciously have ageist attitudes — that older people are inherently not important. On this front, look no further than arguments made by prominent commentators about the fate of older people during COVID-19.

Yes, most fair-thinking Australians care about our older citizens, yet until either we or our family members are directly impacted, we do not prioritise it.

If we don’t care enough or care about other things more, nothing will change. And, while this remains the case, the government will have no reason to do more than just tinker with an unsatisfactory status quo.




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The Conversation


Eileen Webb, Professor of Law and Ageing, UniSA: Justice and Society, University of South Australia; Christie M. Gardiner, Associate Lecturer of Law, University of Newcastle, and Teresa Somes, Associate Lecturer, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Melburnians will soon be able to have 2 visitors per day. It’s far riskier than an exclusive bubble



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Mary-Louise McLaws, UNSW

Victorian Premier Daniel Andrews announced on Sunday a further easing of coronavirus restrictions, as Victoria’s 14-day average of new daily cases continues to trend downwards.

Among the changes, Melburnians were told that from November 2 they can have two visitors at home per day, plus any dependants. Regional Victorians can already enjoy this rule, as their 14-day rolling case average is much lower at 0.4, compared with Melbourne’s 6.4.

This new rule replaces the “bubble” concept featured in the original roadmap. Under the previous plan in Melbourne, “step 3” of easing restrictions included a household bubble, whereby residents could nominate one other household with whom to socialise exclusively at home.

I understand the lifting of restrictions must be done compassionately with an eye on collective mental health. But from an outbreak-management perspective we must be very careful about indoor gatherings. The two people per day rule seems to be riskier than an exclusive bubble.

The bubble contains the infection risk

The risk of indoor spread is often greater because of poor ventilation, which might add to the risk of airborne spread. Further, people can unmask and fail to maintain physical distancing, which are more likely to happen indoors.

Close indoor contact poses the highest risk of transmission of SARS-CoV-2, the virus that causes COVID-19. Victorian Chief Health Officer Brett Sutton reminds us indoor contact is about “20 times more dangerous than outdoors”. This is reflected in one study from Japan, which is yet to be peer-reviewed, and estimates “the odds that a primary case transmitted COVID-19 in a closed environment was 18.7 times greater compared to an open-air environment”.

Transmission still does occur outdoors, but the risk is lower.

The practice of exclusive social bubbles likely makes outbreaks easier to contain. The only people an infected person would have close indoor contact with would be their own household and their bubble household. In this scenario, contact tracers would know exactly whom to contact for isolation, testing and interviewing.

Here’s why the new lifting of the social rule is riskier

The proposed new rule could make timely contact tracing more difficult. With Melburnians allowed to have two adults over per day, they could have up to 14 contacts per week who don’t come from the same household.

Let’s go through a hypothetical example.

Say you are exposed to the virus unknowingly, on day zero. Over the next few days you start having visitors to your house. You can become infectious up to three days before showing symptoms. When COVID-19 cases have been diagnosed while asymptomatic (symptom-free but infectious) and followed up for at least seven days, up to 20% remain asymptomatic but infectious to others. Half of all people infected will develop symptoms around day five and day six and 97% will develop symptoms within 11 days.

So, you could be infectious to your visitors between day three and day five after being exposed while asymptomatic. That leaves three days when you could be contagious without knowing. We think people are more contagious when showing symptoms, but it’s widely accepted now that people can, and do, transmit the virus while asymptomatic.

Under the upcoming rule, during this three-day window, you could theoretically pass the virus to six adults from six different households (assuming you’re an extrovert who has lots of friends round for dinner). They can then transmit it to their households and friends in three days’ time to 18 people while they are asymptomatic. If your friends also brought their children or other dependants, who then got infected and went to school, the number could be even higher. Under the exclusive bubble, the problem would have been confined to just two households.

Then, after your final two guests leave on the evening of day five post-infection, you develop symptoms. You get tested on day six because your cough or sore throat did not go away. Your positive result is returned on day seven and a contact tracer interviews you within 24 hours. On day eight your visitors will start to be interviewed. If they don’t get interviewed immediately, your friends infected on day three have now already infected two others. Over the next two days your other four friends also became infected and passed it onto their friends.

Obviously this is a worse case scenario. But you can see how the chain of transmission can easily get out of control. That’s why being tested as soon as you have symptoms is so important. It speeds up the tracing of every contact you had over the 72 hours prior to your symptoms.

Four people gathering indoors
Indoor close contact is a much higher coronavirus risk than outdoor contact with masks.
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If we added to our scenario continuous asymptomatic transmission (where you never developed symptoms) it becomes even more concerning. This is because your infected friends could go on to infect many others before someone becomes sick and alerts contact tracers. Even more concerning is when you delay testing, which makes it even harder for you to recall who your contacts where and when your day zero was.

This is just a hypothetical situation. But it illustrates why I’m concerned about allowing widespread indoor close contact.

The hope is that new daily case numbers, by the time this rule is implemented, are so low the risk of new chains of transmission is very low too. Meanwhile, Victoria’s contact-tracing team is more robust than ever before.




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The other relaxed restrictions are less concerning

The other relaxed restrictions are of little concern. Allowing ten people to gather outdoors, from only two households, poses a negligible risk.

The extension of the 5km travel radius to 25km makes epidemiological sense. The risk increases when you allow people from high-risk areas into low-risk areas, so maintaining the “ring of steel” between metropolitan Melbourne and regional Victoria is logical. This approach of “ring-fencing” is a well-established tool and is why Wuhan, the city where the pandemic began, controlled the outbreak early and is now welcoming millions of tourists.

The next step, planned for November 2, also sees the return of retail shopping. This poses negligible risk as long as shoppers wear masks, maintain hand hygiene, and use QR codes on entry. In my view, the risk of transmission from wandering through shops is much lower than having people over to your house.The Conversation

Mary-Louise McLaws, Professor of Epidemiology Healthcare Infection and Infectious Diseases Control, UNSW

This article is republished from The Conversation under a Creative Commons license. Read the original article.

As the Queensland campaign passes the halfway mark, the election is still Labor’s to lose



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Paul Williams, Griffith University

We’re at the mid-point of the Queensland election campaign.

Pre-polling opened on Monday, with about two million Queenslanders expected to vote before election day on October 31.

But with just 12 days to go, despite the Liberal-National Party (LNP) opposition stumbling a little more often than the Labor government, neither side has emerged as a clear front-runner. However, the ALP has its nose in front.

Pandemic conditions favour incumbents

Unusually, for a state that produced the likes of Bob Katter, Pauline Hanson and Clive Palmer, the campaign’s first two weeks have been notable only for a low-energy blandness. COVID-19 conditions and too few federal leaders appearing on the hustings have only added to a quiet air of sober austerity.

Fortunately for the Palaszczuk government, flavourless campaigns very often play into the hands of incumbents.

For example, the March 2020 election for the Brisbane City Council saw LNP Lord Mayor Adrian Schrinner easily re-elected after a colourless campaign, despite early pandemic fears.

Indeed, it appears the pandemic has been a boon for incumbents everywhere. Between August and last weekend, Labor/Labour governments have been easily re-elected in the Northern Territory, Australian Capital Territory and New Zealand.

Voters, at least for now, appear to view leaders, parties and issues through a unique COVID-19 lens, and give governments free passes on such traditional vote-killers as debt, deficit and unemployment.




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Put simply, opposition parties are getting little traction when making the case for change. This phenomenon will not have escaped the attention of federal Opposition Leader Anthony Albanese.

Newspoll puts Labor ahead

The Queensland opposition’s own lack of traction was confirmed in a weekend Newspoll.

LNP leader Deb Frecklington at a press conference.
The Liberal National Party is trailing Labor, according to the latest Newspoll.
Cameron Laird/ AAP

Currently, Labor and the LNP are evenly pegged in their primary vote at 37%, with Labor enjoying a narrow lead, after preferences, of 52 to 48%. That’s a swing to Labor of about one percentage point since the 2017 state election. If uniform, that swing could see Labor seize three additional LNP seats.

Newspoll also revealed a slightly higher Greens vote, with One Nation’s vote down by about five points since 2017.

Role reversal

That lack of appetite for change has seen something of a role reversal between the major parties.

Where the LNP is spruiking a “vision” via costly infrastructure projects — a $15 billion “New Bradfield” irrigation scheme and a $33 billion Bruce Highway upgrade — Labor is painting itself as the party of steady growth and public safety amid the greatest health crisis in a century.




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Even so, the campaign is firmly aligned with the traditional pillars of Queensland political culture. In the words of political scientist Colin Hughes, this means it is about “things and places rather than people and ideas”.

It’s therefore hardly surprising that jobs, infrastructure, crime and frontline public service delivery are dominating.

But a theme of political stability also emerged during the first week. After eight decades of majority government, since the mid-1990s, Queensland has seen three hung parliaments.

Both Premier Annastacia Palaszczuk and LNP leader Deb Frecklington warned of instability being brought about by a vote for minor parties, then pledged “no deals” with crossbench members. Few believed either leader.

Integrity issues distract second week

The campaign’s second week turned to integrity when the ABC reported Frecklington had been referred by her own party to the Electoral Commission of Queensland after attending a dinner in August hosted by a property developer.

Under 2018 legislation, political donations from property developers are illegal.




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Frecklington denied any wrongdoing. The LNP also denied reporting Frecklington, noting it “regularly communicates with the ECQ to ensure that [they] comply with the act.”

This came as the state’s Crime and Misconduct Commission (CCC) took the unprecedented step of writing to every candidate with a stark warning,

[…] the lines between government and the private sector are blurring, with overlapping networks of association involving consultants, influencers, lobbyists and executives.

Labor briefly played up integrity questions last week, but the Frecklington story soon faded.

Even so, the issue robbed the opposition of a valuable campaign oxygen and made Prime Minister Scott Morrison’s (probably only) visit to Queensland something of a non-event.

Economic issues still dominate

Indeed, the fact that Morrison’s intervention caused few local ripples underscores the fact this campaign is very clearly about Queensland affairs.

That’s why Palaszczuk and Frecklington spent about half of their first two weeks in the regions, where economic pain is so often felt hardest.

LNP leader Deb Frecklington elbow bumps Prime Minister Scott Morrison.
Prime Minister Scott Morrison visited Queensland last week.
Cameron Laird/AAP

It’s also why the LNP is pledging an unemployment rate of 5% (down from the current 7.7%) and why Labor talked up its enthusiasm for coal mining via the approval of a $1 billion Olive Downs mine near Mackay.

Moreover, while Treasurer Cameron Dick insists Queensland must “borrow to build”, the LNP promises it could balance the budget by by 2024 without new taxes, asset sales or forced redundancies.

Last week, Labor jumped on Frecklington’s refusal to rule out “natural attrition” in the public service as a cost-saving measure — drawing comparisons with former LNP Premier Campbell Newman’s unpopular cuts. This is despite Labor’s own public service hiring freeze sounding remarkably similar.

Campaigns already ‘launched’

In a campaign already marred by vandalised corflutes and nasty tweets, the LNP has pledged to put Labor last on how-to-vote cards.

Queensland Premier Annastacia Palaszczuk.
Labor and the LNP both had their campaign launches over the weekend.
Glenn Hunt/AAP

It’s a curious strategy that will have an effect only in a small number of seats where the LNP finishes third behind Labor and a minor party or independent. Later, the LNP said it would put the Informed Medical Options Party — an anti-fluoridation, anti-“forced” vaccinations group — last in the 31 seats the IMOP is contesting.

Will pre-poll voting beginning this week, up to 70% of electors could vote before October 31, when postal votes are also considered. This pressure to “front-end” their campaigns saw the major parties bring forward their campaign launches to Sunday, October 18.

Few surprises were offered, although Labor’s long-pledged euthanasia legislation and free TAFE for students under 25 years have generated headlines. The LNP’s $300 car registration rebate and plans for cheaper electricity for 16,000 manufacturing businesses will also provoke interest.

This election is still Labor’s to lose.The Conversation

Paul Williams, Senior Lecturer, School of Humanities, Griffith University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

When and how should the Victoria-NSW border reopen? Is fishing allowed in Victoria? When can I travel between Melbourne and regional Victoria? Your COVID-19 questions answered


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Hassan Vally, La Trobe University

Victoria recorded one new case of COVID-19 on Monday, another fantastic result that suggests the coronavirus outbreak there is now being well controlled. Premier Daniel Andrews said on Tuesday the state was “well placed this weekend to be able to make very significant announcements about a further step to opening”.

It’s worth acknowledging what a fantastic job everyone has done in Victoria. Huge sacrifices have been made, people have done the hard yards in difficult circumstances, and now it’s time to step our way out.

Here are answers to common questions about emerging from lockdown and how to make sure you’re doing it safely.




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When and how should the Victoria-NSW border reopen?

The Sydney Morning Herald reports the NSW-Victoria border could reopen within a month (and Andrews said he would like to see NSW reopen to regional Victoria as early as this week).

The Herald quoted NSW Premier Gladys Berejiklian saying:

We are very keen to see what happens in Victoria once further restrictions are eased because that’s the real test […] And if Victoria demonstrates that they’ve […] upped their contact-tracing capacity, that they’re able to demonstrate they’re not going to have uncontrolled outbreaks while they’re easing restrictions, well that will give us confidence to open the borders.

So there’s a bit of guesswork here but if you match her comments up with the current roadmap to ease restrictions, it sounds like there’s a chance the border could be reopening some time in the first half of November.

There will be a period of watching closely how well Victoria does as restrictions ease; this will be the real test of where Victoria is at in terms of suppressing transmission.

But once you have confirmation NSW and Victoria are pretty much tracking the same way, there’s no reason to keep the border closed. There are plenty of good economic and social reasons to have it open.

Even though the numbers look fairly similar between Victoria and NSW, the shape of the two outbreaks has been and remains slightly different. In NSW, most new cases are from overseas arrivals and the number of mystery cases is lower, as shown in this excellent breakdown published by the Sydney Morning Herald and The Age.

So, quite reasonably, there’s a bit of caution about letting Victorians into NSW; there’s more uncertainty around exactly where Victoria sits in terms of controlling the spread of the virus. But as long as things continue to go well in Victoria as it opens up, NSW can have greater confidence it’s safe to reopen the border.

How should the opening of the border be managed? Well, I don’t think you can attempt a staged opening of a border. The whole point of a border reopening is to allow free movement between the two states. Either you wait until you’re confident and then open the border, or you don’t do it at all. You can’t half open it.

Is fishing allowed in Victoria?

For Melburnians, the answer is basically yes, assuming there’s a fishing spot within your 25km radius and you’re sensible about it. As with all activities, it’s important to stick to the restriction changes announced this week and follow hygiene and distancing rules. (Use this ABC tool to find out what’s within 25km of your Melbourne home.)

For regional Victorians, you can go fishing as long as you’re being COVID-safe and following the restrictions (outlined in the Instagram post embedded above).

The Victorian Fishing Authority says:

When fishing or boating you must keep a 1.5m distance from other participants, wear a fitted face covering at all times (except for children under 12 or where an exemption applies), practice good hygiene and not share equipment.

I’m not much of a fisherman myself but, as an epidemiologist, I think fishing sounds like a lovely, low-risk, relaxing outdoor activity — if you don’t mind dealing with the fish.

When can Melbourne people travel to regional Victoria?

According to the Department of Health and Human Services, for Melburnians:

Travel to regional Victoria is still only allowed for permitted purposes even if this is within 25km. This means you cannot travel into regional Victoria for exercise or recreation.

This is the “ring of steel” you have heard so much about, the aim of which is to protect regional Victoria from the virus in metropolitan Melbourne.

The government’s Roadmap for reopening currently says when there have been zero new cases in the community for more than 14 days, the state can move to the roadmap’s final step. Then, travel within Victoria will be allowed (but you can’t enter any restricted area).




Read more:
As holidaymakers arrive, what does COVID-19 mean for rural health services?


Can regional Victorians visit Melbourne?

According to the third step in the roadmap, regional Victorians:

…must not travel into metropolitan Melbourne under current restrictions, except to buy necessary goods and services, for care and compassionate reasons or permitted work or education. While in metropolitan Melbourne you must comply with the metropolitan Melbourne restrictions.

A man fishes in Melbourne.
Fishing is a low-risk, relaxing outdoor activity.
Shutterstock

You can travel through metropolitan Melbourne on your way to a holiday in regional Victoria but shouldn’t stop unless it is for one of the three permitted reasons.

Being smart about it

As the pendulum shifts away from the government telling us what we can do, to us making our own decisions, it’s important to be COVID-safe in the way we navigate this new normal.

That means limiting your contact with people, wearing a mask, practising social distancing and hand hygiene, staying home when sick, and getting tested if you have symptoms.




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WHO is right: lockdowns should be short and sharp. Here are 4 other essential COVID-19 strategies


The Conversation


Hassan Vally, Associate Professor, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Beyond the police state to COVID-safe: life after lockdown will need a novel approach


Meg Elkins, RMIT University and Robert Hoffmann, RMIT University

As second-wave outbreaks of COVID-19 around the world demonstrate, it’s a tricky transition from hard lockdowns to more relaxed, but still effective, measures.

The responses of different nations (Sweden and Taiwan, for example) have their champions, but the truth is there no shining example to follow on how to keep the coronavirus in check while returning, as much as possible, to living life as before.

Right now the government of Victoria, Australia’s second most populous state, is involved in just such an experiment. Its success in moving beyond lockdown to a sustainable “COVID-normal” will hold lessons for nations still on the upward curve of their own second waves (such as Austria, France, Germany, Italy and Britain).

There are also lessons for other Australian states, which have relied (perhaps too much) on hard borders to keep the virus out rather than new social norms to manage the virus.

The Victorian response will prove to be a template to emulate. Or dissected for pitfalls to avoid.




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As behavioural economists, we’re interested in what drives cooperative, and non-cooperative behaviour. We’re particularly interested in how rules, and law enforcement, shape social norms, as well how they can inadvertently lead to greater resistance and rule-breaking.

One clear point evident from the Victorian experience is how blunt the tools of lockdown and law enforcement are to achieve social conformity to new behavioural norms. Moving to “COVID-normal” will require looking for other, less punitive ways to get people to do the right thing.

Policing the rules

Till now the approach of the Victorian government has been very blunt indeed. Its stage 4 rules have been among the more severe imposed in any democracy in the world. These rules have been criticised as excessive or unnecessary, but they have been simple and straightforward. Both to follow and to enforce.

This the Victorian police force has done with zeal, empowered by harsh fines for breaches of public health directives. Though their job has undoubtedly been made harder by rule breakers emboldened by conspiracy theories, videos of police forcefully arresting resisters have both confirmed protesters’ paranoia about living in a police state, and eroded community support.

Polling by Roy Morgan in mid-September showed just 11% of Victorians now rate the Victorian police very highly for honesty and ethical standards, compared to 37% in 2017. Overall approval has fallen from 76% to 42%.

This loss of trust reflects scandals such the Lawyer X case (which led to a royal commission). But “heavy-handedness” enforcing COVID-19 rules was the next most cited concern, with the poll taken after the circulation of videos including police forcibly removing a woman from her car and arresting a pregnant woman in her home for promoting protests on social media. Community support for restrictions is also fraying.




Read more:
WHO is right: lockdowns should be short and sharp. Here are 4 other essential COVID-19 strategies


Deterrence, permission, resistance

Laws are necessary, but philosophers since Plato have told us that societies only function when people comply with social norms when no one is looking. It is impossible to maintain social order solely through the deterrent effect, by detecting and punishing wrongdoers.

Gary Becker, winner of the Nobel prize for economics in 1992, was the first to apply economic theory to why people obey or break laws. In his seminal 1968 paper Crime and Punishment: An Economic Approach, he explained how a “rational” individual weighs up the expected gains or losses from committing a crime and compares them to gains or losses of not committing a crime. That calculation includes judging the probability of being caught.

This framework assumes most people have an aversion to risk and that penalties (such as a large fine) therefore have a deterrent effect.

The problem is humans aren’t necessarily rational. Driven by feelings rather than cognitive assessments, most of us inaccurately assess probabilities. Behavioural research suggests 80% of us are prone to optimism bias when assessing personal risk. We tend to underestimate the likelihood of experiencing bad events such as divorce, being in a car accident, contracting a disease or getting caught breaking the rules.

While it’s impossible to know the motivations of the more than 20,000 Victorians so far fined for breaking lockdown rules, the anecdotal evidence suggests most have simply underestimated the chance of being caught, such as breaking the 5 km travel limit to buy a PlayStation controller, or curfew to buy cigarettes.

The limits of perception

Yet as the Victorian government moves to relax its restrictions, its main solution to ensuring adherence to the more complicated rules for “COVID-normal” social interactions appears to be increasing penalties for breaches. The fine for breaching social gathering restrictions, for example, has been increased from A$1,652 to A$4,957.

While these will have some effect, research suggests “deterrence perceptions” depend on an individual’s pre-existing “crime propensity”. That is, most people have no inclination to commit crimes like theft, vandalism and assault, so “deterrence perceptions are largely irrelevant”.

This make Victoria’s next stage of norm-enforcement highly problematic, given behaviour now outlawed isn’t criminal per se, but what used to be normal socialising. As questions asked at Victorian premier Danial Andrew’s press conference on Sunday indicate, there’s a much greater likelihood of confusion about rules – and therefore breaches.

Encouraging intrinsic motivation

The big question is how to move beyond external (or extrinsic) incentives and encourage intrinsic motivations. According to psychologists Richard Ryan and Edward Deci, who studied extrinsic and intrinsic motivations in school students:

Because extrinsically motivated behaviours are not inherently interesting and thus must initially be externally prompted, the primary reason people are likely to be willing to do the behaviours is that they are valued by significant others to whom they feel (or would like to feel) connected, whether that be a family, a peer group, or a society.

Economists Raymond Fisman and Edwards Miguel illustrate the power of non-punitive “nudges” to encourage these motivators in their book Economic Gangsters (2010). A classic example comes from Bogota, the capital of Columbia, where in the 1990s new mayor Antanas Mockus decided to tackle crime and problems such as traffic fatalities using “cultural persuasion” rather than more law enforcement.

Rather than employing more police to patrol the roads, the city instead employed hundreds of mime artists to mimick and ridicule drivers and pedestrians doing the wrong thing. As Mockus explained:

The idea was that instead of cops handing out tickets and pocketing fines, these performers would “police” drivers’ behaviour by communicating with mime – for instance, pretending to be hurt or offended when a vehicle ignored the pedestrian right of way in a crosswalk. Could this system, which boiled down to publicly signalled approval or disapproval, really work?

The evidence is it did. Within a decade traffic deaths were halved. Other novel strategies helped cut Bogota’s homicide rate by 70%.

Finding a new normal

These are obviously long-term results. They don’t provide a perfect template for governments seeking immediate society-wide adherence to new COVID-safe behavioural norms. There are no easy solutions, particularly given a small segment of the population is convinced flouting the rules is a noble stand against tyranny.




Read more:
Melbourne is almost out of lockdown. It’s time to trust Melburnians to make their own COVID-safe decisions


But with Victorian courts already facing a huge backlog of unpaid or contested fines, and the high likelihood we will need to practice “COVID-safe” behavioural norms for at least a year, it’s time to start thinking about other ways to promote social cooperation other than the long arm of the law.The Conversation

Meg Elkins, Senior Lecturer with School of Economics, Finance and Marketing, RMIT University and Robert Hoffmann, Professor of Economics and Chair of Behavioural Business Lab, RMIT University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

As holidaymakers arrive, what does COVID-19 mean for rural health services?


Timothy Baker, Deakin University and Cameron Knott, University of Melbourne

At the start of the pandemic, health services in regional cities and small towns braced for a tsunami of cases. Many worried the patient transport system between hospitals would fail, and each hospital would be left to fend for itself. Small hospitals planned makeshift intensive care departments with improvised long-term ventilators. And health-care teams drilled themselves in how they would manage a COVID-positive patient who was deteriorating.

Fortunately, in Australia, these dire predictions were wrong (at least for now). But they could have been right. Rural areas are not immune to COVID-19. In the United States, the current rural infection rate is higher than has ever been recorded in metropolitan areas. A Louisiana hospital described exactly the makeshift intensive care scenario we feared in Australia. Rural patients are more vulnerable too, as the community is older with more chronic health problems.




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Rural America is more vulnerable to COVID-19 than cities are, and it’s starting to show


In rural Australia, dealing with the pandemic has been more like whack-a-mole than an overwhelming wave. Outbreaks occurred around meatworks, local hospitals, and super-spreaders travelling from hotspots.

So, what have we learned so far about the impact of COVID-19 on rural health, and how can we maintain effective rural health care as tourism ramps up?

We must work together

A pandemic lays bare pre-existing structural problems. It exposes the lack of formal channels for rural clinicians to communicate across disciplines and across regions. It reveals the barriers between clinicians in the hospitals and bureaucrats in regional and city offices.

But it also provides an opportunity to connect these groups. During the pandemic, health services across different regions and states shared local solutions. Public health, hospital, community care and inter-hospital services created joint protocols. New communication channels must be maintained and ready for activation if cases increase.

Local knowledge remains important. Embedding local health workers in contact-tracing teams is a strength of NSW’s pandemic defences.

As the Victorian town of Shepparton discovered last week, local outbreaks cause an immediate and massive demand for testing. Using local media to keep rural communities up to date enhances the remarkable support already shown for quarantine measures.

Teleconferencing between clinicians has expanded, as it has between clinicians and patients. It is best and most geographically equitable when it adds to face-to-face local care.

But it may also detract from enabling the best care when it replaces clinicians on the ground. One possible example is that of a woman who died in the emergency department of a regional NSW hospital in September. No doctors were present in person, having been replaced by telehealth treatment outside business hours.




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Where did Victoria go so wrong with contact tracing and have they fixed it?


Self-reliance and silent hypoxia are a bad combination

Identifying patients before they become critically ill is crucial to rural acute care. This is true for COVID-19. The disease has a reasonably predictable path of early fever, improvement, and then a sometimes rapid deterioration in the second week. For all but large regional centres, this means COVID-19 is managed in the community. Deteriorating patients need to be transferred early.

Unfortunately, COVID-19 has a horrible trick. It can cause extremely low levels of blood oxygen without a patient feeling unwell or breathless, or realising their oxygen levels are critically low. This is called silent hypoxia.

A person with a pulse oximeter on their finger, measuring their blood oxygen levels
Many rural health services have used remote oxygen monitoring tools so clinicians can check in on patients recovering at home.
Shutterstock

It’s a problem everywhere, but it may be worse in rural areas. Patients often visit regional hospitals at a later stage of their illness due to self-reliance, distance to care, and a poorer understanding of the health system. By the time a rural COVID-19 patient thinks they are unwell enough to attend, they may already be close to dying.

Rural health services have had to adopt policies of regular local and remote checking-in for COVID-19 patients, especially in the second week. Telephone and internet connections are not always enough, so many hospitals have bought oxygen-monitoring tools for patients to use at home.

Maintaining normal services is difficult

COVID-19 need only infect a few staff at regional hospitals to make service delivery impossible. In northwest Tasmania, Australian Defence Force members had to replace infected and quarantining staff in mid-April.

Even without an outbreak, COVID makes it difficult to maintain normal operations. Health services relying on fly-in fly-out staff have struggled when staff can no longer travel freely across quarantine lines from the city or across state borders. Exemptions were given but the approval process was slow and many staff still had to do periods of self-quarantine, meaning many staff found it too difficult. Mechanisms to replace or increase staff may still be needed for regions with outbreaks.

Although rural hospitals have been spared the overwhelming numbers of COVID-19 seen in Melbourne hospitals, the extra precautions required to manage patients who could potentially have COVID-19 are draining. Maintaining services reliant on supplies at the end of the supply and logistics chain is slower and challenging. Like metropolitan staff, rural staff are feeling fatigued and requiring extra mental health support.

This is a problem as people move to rural areas for holidays and business. Even in normal years, health services in coastal and other tourist towns are busiest when the population swells in summer. With bookings of holiday accommodation booming in many areas, rural health services may be facing their busiest and most tiring part of the pandemic. If holidaymakers feel leaving the city means leaving behind the risk of infection and the need to socially distance, the results in some rural towns may be catastrophic.The Conversation

Timothy Baker, Associate Professor and Director, Centre for Rural Emergency Medicine, Deakin University and Cameron Knott, Honorary Clinical Lecturer, Department of Critical Care & Rural Clinical School, University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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