The devastation wrought by the Australian bushfires has been immense and, as the fires continue to burn, the final loss won’t be known for many months. While the impact on the environment, human and animal life is overwhelming, for many individuals the loss of personal items such as photographs, documents, artwork and personal treasures is significant.
Heirlooms and artworks are often cherished for the people, events and experiences they represent rather than their monetary value or cultural importance. They can be integral to understanding our personal history, culture and identity.
While damage to them can be heartbreaking, even a badly damaged family treasure may hold immeasurable personal significance.
For those threatened by bushfire, planning for the preservation of your treasured items can start now. Planning resources are available online. For those who have been affected by fire damage, you may still be able to salvage items.
There are three main factors to consider when thinking about the impact of bushfires on your personal treasures – smoke, heat, and water.
The most obvious damage from smoke is soiling. Soot, ash and other particulate matter are usually dark and greasy. When deposited on the surface of an object, colour and detail are obscured. Damage from high heat exposure can result in blistering, melting, warping, charring and partial or complete loss.
If water has been used to put out the fire, water related damage can be an issue. Water can cause shrinkage, distortion, discolouration, mould and partial or complete loss of original material.
The possible damage to your items will depend on the material types. Here are some tips for handling them.
Paintings can be affected by all three factors.
• If an artwork is framed, it is recommended that you leave the frame in place. Exposure to high heat can soften the paint layer, which may cause it to stick to the frame. A specialist should remove the work from the frame.
• The particulate nature of smoke means that it can cause abrasion as the soot is wiped away. Get advice before undertaking any cleaning. Do not use water.
• Assess the surface for loose material (lifting paint, blistering). Take care when handling to ensure no loss of fragile material. Retain any loose elements in a Ziplock bag. These can be reattached later.
Paper documents, prints and photographs
Though potentially affected by all three factors, water damage can be the most severe for these items, with the risk of mould.
• Allow wet items to slowly air dry, indoors if possible. Increase indoor airflow with fans, open windows, air conditioners, and dehumidifiers. Do not use hair dryers, ovens, irons.
• Photo albums can stick together. Do not try to open them. Ask a conservator for advice.
• Dry paper documents and photos can be cleaned of soot with a vacuum and dry sponge.
Textiles (i.e. sporting memorabilia)
Textiles can be affected by all three factors.
• Handle with care, as they may be fragile.
• Low powered vacuum removal of soot may be possible if fabric is not weak (shedding).
Glass, metal and ceramic objects
These items can be affected by high temperatures and smoke. Heat can distort shape (melting) or alter surface finishes (i.e. glaze on pottery). Such damage is usually irreversible. Smoke damage can leave a darkened layer of soot on the surface.
• Care is need when removing soot to ensure abrasion of the surface doesn’t occur.
• Heat can make these objects brittle. Care is needed when handling.
• Use gloves when handling. Skin oils can damage the surface.
What else can you do
You may not be able to save everything, so focus on prioritising what is most important to you. Personal safety is the highest priority when entering damaged buildings. Wear protective clothing, footwear, goggles, gloves and masks to protect from hazardous material and possible mould spores.
Items may be more fragile than they look, so consider using something rigid to support them when lifting and transporting such as a piece of tray, pieces of cardboard, box, a plastic container or lid.
Retain any items that are recognisable, it may be possible to restore them.
Details for accredited conservators can also be found through the AICCM website. A conservator will be able to provide advice on how to best approach the recovery and ongoing preservation of your heirlooms and artworks.
Smoke haze from Australia’s catastrophic bushfires is continuing to affect many parts of the country.
Although there’s no safe level of air pollution, the health hazards tend to be greatest for vulnerable groups. Alongside people with pre-existing conditions, smoke exposure presents unique risks for pregnant women.
These conditions can have short-term and lifelong effects on a baby’s health, with increased risk of conditions including cerebral palsy and visual or hearing impairment. Even babies born only a few weeks early can experience learning difficulties and behavioural problems, and have an elevated risk of heart disease in later life.
So it’s especially important pregnant women protect themselves from exposure to bushfire smoke.
Pregnant women breathe at an increased rate, and their hearts need to work harder than those of non-pregnant people to transport oxygen to the fetus. This makes them particularly vulnerable to the effects of air pollution, including bushfire smoke.
We often measure poor air quality by the presence of ultra-fine particles called PM2.5 (small particles of less than 2.5 micrometres in size). These particles are concerning because they can penetrate into our lungs, and into blood and tissue to cause inflammation throughout the body.
Importantly in pregnant women, environmental pollutants can cause inflammatory damage to the placenta’s blood supply. This can interfere with the placenta’s development and function, which can in turn compromise the growth of the fetus.
What the evidence says
Many studies have linked poor air quality, particularly high PM2.5 levels, to poor pregnancy outcomes. Data from 183 countries showed in 2010, an estimated 2.7 million premature births, 18% of the total, were associated with PM2.5 pollution.
A 2019 study of more than 500,000 pregnant women from Colorado looked at the effect of bushfire smoke on pregnancy outcomes. The authors analysed data on air quality, fire incidence and pregnancy and birth records from 2007-2015, during which time Colorado was regularly affected by smoke from fires burning in California and the Pacific Northwest.
The study found PM2.5 due to bushfire smoke was linked to spikes in premature birth, especially in women exposed during the second trimester.
The effects were detectable even with low exposure to smoke and small increases in PM2.5. For every 1 microgram/m³ increase in average daily exposure to PM2.5 during the second trimester of pregnancy, the risk of premature birth increased by 13%.
To put this into context, in Canberra in the first week of January, PM2.5 levels averaged more than 200 micrograms/m³, compared with the typical background concentration of 5 micrograms/m³. EPA Victoria classifies PM2.5 levels above 25 micrograms/m³ as unsafe for vulnerable people.
As well as PM2.5, bushfire smoke contains larger PM10 particles, nitric oxides, carbon monoxide and other gases and toxic chemicals. These all have potential to impair lung and heart function in the mother, activate inflammation, and directly affect fetal and placental development.
The best strategy is to reduce smoke exposure as much as possible. Recommendations from NSW Health include staying inside on high-risk days, sealing the house to prevent smoke infiltration and using air conditioning to keep cool.
Avoid creating smoke by cigarette smoking, burning candles, or frying and grilling. Use PM2 (N95) masks and air-filtering devices if possible, and avoid exposure to ash, which contains particulate material you can inhale.
Pregnant women in a fire region should carefully follow emergency services’ direction. It’s better to evacuate early, with an emergency supply kit containing clothes, medications, water and food you don’t need to cook.
Make sure your medication and prenatal vitamins are accessible, continue to take them, and stay well hydrated. Inform authorities and shelters you are pregnant and need to maintain your antenatal care.
Be aware of the signs of premature labour including abdominal cramps or contractions, a heavy vaginal discharge, loss of fluid or vaginal bleeding, pelvic pressure and low backache. Seek help if you think you may be going into labour.
Given what we know about the consequences of poor air quality on pregnancy outcomes, it’s critical pregnant women are given top priority when it comes to bushfire relief and health care support.
As China grows more powerful and influential, our New Superpower series looks at what this means for the world – how China maintains its power, how it wields its power and how its power might be threatened. Read the rest of the series here.
One of the earliest guests I had on The Little Red Podcast, the podcast I co-host with former China correspondent Louisa Lim, said something that stuck with me about the view of China in the rest of the world. John Fitzgerald, a well-known historian of China’s diaspora, confidently declared that the Chinese Communist Party (CCP) “couldn’t care less” about what non-Chinese Australians thought of it and its actions.
Looking through the results of the recent Lowy Institute Poll on Australians’ attitudes toward China, this is probably a good thing for the party.
The Australian public’s confidence in China’s ability to act as a responsible power has fallen off a cliff. In just one year, it dropped from more than half of Australians to just 32%. That’s a dire number.
That wasn’t the only surprise in the poll. Four-fifths of respondents agreed with the proposition “China’s infrastructure investment projects across Asia are part of China’s plans for regional domination”, and 73% believed Australia should try to prevent China from expanding its influence in the Pacific.
The poll was released in late June, at a time when China’s image was taking a hit internationally. Millions of people took to the streets in Hong Kong to protest a now-defeated extradition bill that could have seen Hong Kong residents sent to China on suspicion of crimes.
Then came news in Australia that the wife of an Australian writer who has been detained since January was herself interrogated by Chinese officials and blocked from leaving the country.
Even for a country that purportedly doesn’t care what the rest of the world thinks, trust is hard to come by these days.
A matter of trust
It’s not entirely clear why so many Australians now distrust the Chinese state to the point where they believe our government should actively counter it (although perhaps not go to war with it).
There’s little evidence to suggest that one issue alone has caused this sharp decline in trust. For instance, the Communist Party’s most egregious recent violation of human rights, the detention of up to 1.5 million Uyghurs simply for being, well, Uyghurs has touched relatively few Australians.
Rather, the decline in trust seems to be the result of an accumulation of negative news on China — some well-informed, some half-baked (such as the 60 Minutes expose on a Chinese “military base” in Vanuatu). And for some, it’s based on personal experiences.
Last month, for instance, Australian National University revealed a massive data breach in the school’s computer system, including tax file numbers, bank accounts and passport details. The sophistication of the attack, which came after multiple attempts, meant there was only possible one suspect, according to senior intelligence officials: China.
Stealing people’s bank details might be profitable for the hacking team, but it doesn’t win hearts and minds for the Chinese state. Actions like this do more to damage China’s image than the words of noted China critics Clive Hamilton and Clive Palmer.
This sort of intimidation has been on the rise under Xi’s leadership in recent years. Academics who are critical of China now expect to be targeted by the CCP.
A podcast like mine, banned in China, doesn’t help. In the wake of an episode about China’s real-time censorship of its own historical record, I was hit by a denial-of-service attack that our university’s IT service struggled to fix. I gave up doing research inside China a while ago, after it became clear that my former colleagues and friends in rural China were increasingly at risk.
Even colleagues who have signed petitions calling on the Australian government take an evidence-based approach to China policy have been warned off continuing their in-country research by their Chinese research partners, ending collaborations which often stretched back decades.
To the outside world, this obsession with control looks like weakness rather than strength. A sanitised image of life inside China will do nothing to build trust in China as a responsible power.
Misplaced attempts at soft power
So how does China go about winning back a 20-point drop in trust?
To answer this question, I have to borrow a famous line from the film, The Princess Bride:
You keep using that word. I do not think it means what you think it means.
When it comes to the concept of soft power, the Chinese state misses the basic point that it doesn’t work particularly well. Money can’t buy you love, or in Joseph Nye’s terms, if your ideology and your culture have no appeal, cash won’t fix that.
Yet, the Communist Party is now a firm believer in soft power, built around its confidence that China’s ancient culture can return it to its legitimate status as the preeminent civilisation in the world. This confidence may be misplaced, as anyone who sat through the ponderous, state-backed, blockbuster film The Great Wall can testify.
This officially approved cultural soft power package might not sell to non-Chinese audiences in Australia or, well, anywhere. But China has recently been trying another tactic – economic soft power. This is specifically aimed at the developing world: China positions itself as a nation that overcame colonial oppression to emerge from grinding poverty and become an economic powerhouse.
Under former President Hu Jintao, the party tiptoed away from the notion that China would pursue a “peaceful rise”, because they worried the word “rise” sounded threatening, even preceded by “peaceful.”
Now, under Xi’s watch, there is a new catchphrase to describe China’s rise. Anchors on CGTN happily ask European and African interlocutors about the merits of “the China model” for economic development, in which the state acts as chess master, guiding the economy and society at every turn.
Some nations are buying into this. Last weekend, a taskforce of Solomon Islands MPs and bureaucrats presented their recommendation to parliament over whether to switch diplomatic recognition from Taiwan to China. While many Solomon Islanders, including Prime Minister Manasseh Sogavare, are reluctant to switch, the country’s close economic ties with China make such a move feel inevitable.
A Chinese development model that promises an escape from poverty has appeal across the Pacific – and beyond.
Trust on both sides of the wall
Whether Beijing is able to turn around this trust problem depends, in part, on how much China begins to trust itself in the rest of the world.
Forthcoming research my ANU colleagues and I are conducting with Hong Kong-based researchers examines attempts by Chinese state actors to influence the 2019 Australian federal election.
Preliminary results indicate that the Communist Party didn’t give a hoot which party won. The goal of Chinese propaganda during the election, rather, was to create a sense of distrust among Australian-Chinese communities by depicting Australia as a racist, unwelcoming place.
We should be mindful of attempts by elements of the Communist Party to influence our political processes. Yet it’s crucial to remember the CCP targets many groups in Australia, including private businesses run by former Chinese citizens, religious groups and student organisations, not because they are all loyal party stooges, but because the party does not trust them.
The challenge for China, if it wants to be trusted by the rest of the world, is how to move beyond Mao Zedong’s famous dictum:
Who are our enemies? Who are our friends? This is a question of the utmost importance for the revolution.
This thinking should have no place in a globalised world, but in CCP circles, it’s back in vogue.
The challenge for Australia’s leaders is to recognise China’s current political reality, but not be drawn into the same binary, simplistic thinking. There’s enough of that going around.
The Opposition’s A$2.3 billion cancer care plan – announced in Bill Shorten’s budget reply speech on Thursday night – aims to ensure cancer treatment costs for scans, specialists and drugs are bulk billed or subsidised under the Pharmaceutical Benefits Scheme (PBS). It would be a hard heart indeed that did not welcome such a move.
Maybe even better than avoiding the out-of-pocket costs of treatment is preventing future cases of cancer. Around one-third of all cancers are preventable by not smoking, staying at a healthy weight, eating healthy food, being physically active, minimising alcohol consumption, and avoiding excessive sun exposure.
But apart from a small commitment to tobacco control in the 2019 budget, neither the government or opposition has made even the vaguest commitment to, or investment in, cancer prevention.
So far we have heard virtually nothing from either party on efforts to tackle obesity, promote healthy eating, encourage more physical activity, reduce alcohol consumption, promote sun protection, or boost efforts to increase participation in cancer screening and vaccination programs.
The government currently spends around A$2 billion a year on “public health”, which includes monitoring, regulation, as well as prevention and vaccination. This amounts to less than 2% of the nation’s total health expenditure of A$170 billion. That is about half of what we spend on patient transport.
A boost to 5% – or closer to A$8.5 billion – could make enormous strides in better prevention programs, driven by high-quality research.
Poor track record
When it comes to investment in disease prevention, the story is not strong for the Coalition.
The Rudd Labor government established the Australian National Preventive Health Agency (ANPHA) in 2009, with funding of around A$60 million a year. The agency ran national programs focusing on tobacco, alcohol, healthy eating and reducing alcohol consumption.
But the new Abbott government axed the agency in 2014, after drafting legislation to expunge it from the books.
Programs such as Live Lighter and Foodcents, for example, provided evidenced-based and practical help for people to live healthy lives. Other programs improved the availability of nutritious foods, and ensured walking and cycling were safe and viable components of transport planning.
In 2012, the then Labor government committed to the continuation of the NPAPH to 2018, but it was axed by the Abbott government in the 2014 federal budget.
This took hundreds of millions of dollars otherwise committed to prevention efforts out of the federal budget calculations.
All of these discontinued efforts were likely to have had a major effect on reducing future generations of Australians from hearing those awful words: you have cancer.
Like any human endeavour that aims for big changes in systems and behaviours, stopping and starting the programs that lead these changes diminishes the prospect of success.
So why is it hard to get governments to invest in prevention?
Strong and influential industries consistently lobby governments to protect their commercial interests. That’s what happens in a market economy democracy. The alcohol, processed food and even tobacco industries continue to exercise an influential voice in the halls of power.
Unsurprisingly, industry aggressively opposes higher taxes on these products (“sin taxes”) and programs discouraging their use.
It is common to hear politicians tell stories of individuals, “real people” who benefit from a new treatment or access to new life-saving medical care or drugs. We all connect with these heart-warming stories and they illustrate the importance of the public funding investment.
Such stories are harder to tell in prevention. How do we find the 64-year-old enjoying his granddaughter’s first day at school, largely because he did not die of a smoking-related disease in his 50s because tobacco control efforts in his youth meant he did not take up smoking?
Effective prevention policies, such as putting a minimum floor price on alcohol, work to reduce alcohol-related harm. But making it more difficult to reduce the price of alcohol is politically unpopular.
Finally, the benefits of prevention often take many years, even decades, to arrive. Political timeframes are often linked to election cycles of three or four years.
A long-term view is vital. Each dollar invested in skin cancer prevention, for example, returns about A$2.20 in cost saving in avoiding cost of treating the disease. But there are decades between reducing kids’ sun exposure and avoiding treatment when those kids reach their 50s and 60s.
As the election campaign unfolds, let’s hope both aspiring Australian governments continue to show a genuine interest in the health of Australians and commit to preventing disease. Is 5% of the health budget too much to ask for that?
Labor’s big-ticket election promise is a A$2.3 billion package to provide free medical scans and specialist consultations for cancer patients, plus automatic listing of new cancer therapies on the Pharmaceutical Benefits Scheme (PBS) once they’re recommended by the nation’s expert advisory panel.
One in two Australians will be diagnosed with cancer by the age of 85, and around 145,000 new diagnoses are made each year. So most of us have a close relative or friend who will be affected by the policy.
But there are some important policy considerations a Shorten government would need to plan for to ensure the package provides optimal care, improves patient outcomes, and does actually reduce out-of-pocket costs.
New therapies for cancer are rapidly evolving, and are often extremely expensive. Seeking treatment involves navigating a complex array of public and private providers across multiple health care sectors, often leaving patients with high out-of-pocket costs.
These costs are highly dependent on which providers the patients choose (and the fees they charge), the level of private insurance cover, and the volume of services used.
A recent Queensland study found the median out-of-pocket expenses for a breast cancer patient, for example, was A$4,192.
It’s possible but very time-consuming for patients to “shop around” to reduce costs. But this is an unreasonable burden to place on patients.
The Labor proposal provides an opportunity to develop a comprehensive cancer control program that encompasses prevention, early diagnosis, treatment and follow-up – at a reasonable cost.
Cancer treatment is well researched; there are clear evidence-based guidelines that establish clinical pathways for the best treatment.
Nevertheless, there is substantial variation in treatments given to cancer patients. This difference cannot always be explained by their clinical conditions, and sometimes the care is not evidence-based.
It’s important that the proposed reforms do not just fund more care, but support more of the best care.
The approach that has shown promise in other countries is known as “bundled payments”.
Under bundled payments, a series of health care services – that can span over time and across multiple health care sectors and providers – are bundled together for funding purposes. This gives providers or institutions greater flexibility in how they spend money delivering care to the patient.
There is a danger that bundling can provide incentives to skimp on care, because the provider receives the same amount of funding no matter how much care is provided. But this can be addressed by monitoring the quality of care and the patients’ outcomes.
Ensuring the financial benefits flow to patients
Australian governments have made several attempts to provide better safety nets that cushion patients from extra charges.
Study after study shows that, in these circumstances, providers are likely to raise their fees. So while patients get some financial benefit, the doctors benefit also.
Under current Medicare rules, the Australian government does not and cannot determine doctors’ fees. It can only determine the amount of the Medicare benefit.
In general practice, most consultations are bulk-billed implying that the fee the doctor charges is equivalent to the Medicare benefit.
Only 31% of specialist consultations are bulk-billed, leaving more patients with an out-of-pocket payment.
What can government do to encourage cancer care providers to bulk-bill?
Labor has announced they will add a bulk-billing incentive payment, as occurs in primary care. Specialists will receive an additional payment if they bulk-bill a cancer-related service.
This will not guarantee that every patient will not incur any out-of-pocket costs – although it should increase the likelihood that they will. Indeed, the Labor target is that 80% of patients will be bulk-billed.
However, previous research has shown that while the GP bulk-billing incentive led to a reduction in costs for those eligible (concession card holders), it also increased costs for those not eligible.
Careful monitoring is required to ensure the volume of services – and their fees for non-cancer patients – do not go up.
A further unprecedented complication is that for some services, it will be necessary to differentiate Medicare payments on the basis of the patient’s cancer status.
To guarantee patients face no out-of-pocket costs would require more radical reform. Again, the bundled payment system could be a vehicle for such reforms whereby payments are conditional on all the patient’s service providers agreeing to deliver care with no additional fee to the patient.
Depending on whether a patient is privately insured, the bundled payment could be financed by private health funds and Medicare.
This is part of a major series called Advancing Australia, in which leading academics examine the key issues facing Australia in the lead-up to the 2019 federal election and beyond. Read the other pieces in the series here.
Over the last 35 years, Medicare has given Australians access to high-quality health care at a reasonable cost. But, despite our justifiable pride in Medicare, it’s time to reconsider the way we pay for health care.
Australia’s Medicare system is a A$20 billion-a-year program. It subsidises most of our out-of-hospital doctor consultations, blood tests, X-rays and scans, physio appointments, eye tests and many other health services. It’s based on a long list of items and each time an item is provided, Medicare pays a benefit.
But paying doctors and other health providers a set fee for each service they deliver is not delivering optimal value for the health dollar. There are two reasons for this.
First, it encourages a higher volume of services, but not necessarily better-value services.
Second, it constrains doctors into delivering the care based on the items in the schedule, which often don’t meet the needs of complex patients.
One promising alternative is “bundled payments”. Rather than paying doctors a “fee for service”, they would be paid a prospective lump sum to care for the patient’s medical problem, over a specified period.
The lump sum would be a pooled payment for all services provided to treat the condition. The provider’s role would be to coordinate the patient’s care across different parts of the health system and work with a range of health professionals to deliver high-quality care.
This would give doctors greater flexibility to manage the care patients need. At the same time, doctors would be held accountable via measurements of the quality of their care.
Importantly, this would give patients greater access to a broader range of services and make it easier to navigate our complicated health system.
Why health costs are rising
Between 1984 and 2018, Australian government spending on services outside of hospitals has increased from A$426 to A$818 per person, after adjusting for inflation.
This increase is almost entirely due to service volume. Back in 1984, the average Australian made 7.25 out-of-hospital Medicare claims a year. By 2018, this had escalated to 15.34; a doubling in the average number of claims.
The biggest growth has been in the number of pathology claims for blood and tissue tests (1.4 in 1984 to 5.2 in 2018), followed by GP consultations (4.2 compared to 6.3) and diagnostic imaging, including X-rays and other types of scans (0.3 versus 1.0).
This is not just the result of population ageing. At every age, we are making more Medicare claims. In 1985, people aged between 75 and 84 made 16.1 Medicare claims per year. In 2018, this number had grown to 44.6 claims per person per year.
Medicare prices have been very steady. For GP consultations, for example, the benefit paid per service has increased by 72% over the 35-year period, and mostly as a direct result of policy initiatives such as the Strengthening Medicare reforms introduced in 2004-05.
In fact, since 2005, the benefit per service has declined by 6% in real terms. This is a result, in part, of the Medicare freeze imposed by government between 2012 and 2018.
So price control is only one part of constraining expenditure growth. The other is the volume of services.
The medical care market has undergone considerable corporatisation. Corporate entities now own around 10% to 15% of all GP practices in Australia.
Corporate entities can own and run primary care practices as well as pathology laboratories, diagnostic imaging services and even pharmacies. This creates more incentive to refer patients to their own businesses for blood tests and imaging to increase the volume of claims, and therefore increase profits.
Greater spending doesn’t mean better care
The second critique of Medicare is that current funding arrangements create disincentives for delivering optimum care over a longer period, particularly for complex patients who require multiple services from multiple providers. They might have cancer, for instance, or multiple chronic diseases such as heart disease and diabetes or dementia.
Currently, Medicare makes a payment for every claim made within what we call an “episode of care” – a set of services to treat a condition, or a procedure. Each provider in that episode has an incentive to increase their own volume of care, but there are virtually no incentives to coordinate or deliver an optimum pathway of care for the patient.
Further, there are too few opportunities and rewards in this system to give doctors flexibility to offer different types of care for patients. This includes care provided by nurses, physiotherapists or dietitians; email or telephone consultations; patient education; and coordination services.
Instead, pay doctors a lump sum
The main feature of a good payment system is that it creates the right incentives for providers and patients to use health care resources effectively, efficiently and equitably.
Bundling payment involves working out the best care pathways for each condition. Cancer, for example, is a complex disease that requires ongoing care from primary, specialist and hospital services.
Under a bundled payment, the patient’s GP clinic would be paid a lump sum to ensure the patient receives all the services they need. This includes consultations, health checks, blood tests, physiotherapy, dietetics, patient education, and so on. The GP would have more control over how each of those services is delivered.
If viable, the GP could bring some of these services into their practice, or they could subcontract them to other organisations.
The practice would be held accountable for providing high-quality care through various performance measures. These could range from patient satisfaction measures to objective measures such as timeliness of care or fewer avoidable complications. Payments could, in part, be made conditional on meeting performance targets.
Ultimately, because we are giving the provider more say over how care is delivered, the model of care can be more easily adapted to the needs of the patient.
Health reform must be based on evidence
In the small number of countries where bundled payments have been piloted, they are associated with improved quality, financial savings and increased patient satisfaction.
Although these studies show promise, the evidence base is still in its infancy.
Successful reform in this area will require careful design of the bundles, the payment levels and patient selection process, as well as how best to monitor quality care. In particular it requires robust evidence to determine:
what constitutes an optimal bundle of care for a particular condition
the cost of delivering those services
how the payment should be adjusted for the specific characteristics of a patient
the role performance targets may play in motivating health providers to deliver high-quality care.
You’re a lucky survivor. You’ve received high-quality care from nurses and doctors whilst in hospital and you’re now preparing to go home with the support of your family.
The doctors have made it clear that the situation is grim. It’s a case of: change your lifestyle or die. You’ve got to stop smoking, increase your physical activity, eat a healthy balanced diet (whilst reducing your salt), and make sure you take all your medicine as prescribed.
But before you leave the hospital, the cardiology nurse wants to talk to you. There are a few apps you can download on your smartphone that will help you manage your recovery, including the transition from hospital to home and all the health-related behavioural changes necessary to reduce the risk of another heart attack.
Rapid advancements in digital technologies are revolutionising healthcare. The benefits are numerous, but the rate of development is difficult to keep up with. And that’s creating challenges for both healthcare professionals and patients.
What are digital therapeutics?
Digital therapeutics can be defined as any intervention that is digitally delivered and has a therapeutic effect on a patient. They can be used to treat medical conditions in a similar way to drugs or surgery.
Paper-based letters, health records, prescription charts and education pamphlets are outdated. We can now send emails, enter information into electronic databases and access electronic medication charts.
And patient education is no longer a static, one-way communication. The digital revolution facilitates dynamic and personalised education, and a two-way interaction between patient and therapist.
Take diabetes for example. This condition affects 1.7 million Australians. It’s a major risk factor for developing cardiovascular disease and stroke. So it’s important that people with diabetes manage their condition to reduce their risk.
A recent study evaluated a team-based online game, which was delivered by an app to provide diabetes self-management education. The participants who received the app in this trial had meaningful and sustained improvements in their diabetes, as measured by their HbA1c (blood glucose levels).
App based games of this kind hold promise to improve chronic disease outcomes at scale.
New electronic devices are also being used by people of all ages to track activity, measure sleep and record nutrition. This information provides instant and accurate feedback to individuals and their therapists, allowing for adjustments where necessary. The logged information can also be combined into large data sets to reveal patterns over time and inform future treatments.
Digital therapeutics are spawning a new language within the healthcare industry. “Connected health” reflects the increasingly digital ways clinicians and patients communicate. A few examples include text messaging, telehealth, and video consultations with health professionals.
There is increasing evidence that digitally delivered care (including apps and text message based interventions) can be good for your health and can help you manage chronic conditions, such as diabetes and cardiovascular disease.
But not all health apps are the same
Whilst the digital health revolution is exciting, results of research studies should be carefully interpreted by patients and providers.
Innovation has led to 325,000 mobile health apps available in 2017. This raises significant governance issues relating to patient safety (including data protection) when using digital therapeutics.
A recent review identified that most studies have a relatively short duration of intervention and only reflect short-term follow up with participants. The long-term effect of these new therapeutic interventions remains largely unknown.
The current speed of technological development means the usual safety mechanisms face new ethical and regulatory challenges. Who is doing the prescribing? Who is responsible for the efficacy, storage and accuracy of data? How are these technologies being integrated into existing care systems?
Digital health needs a collaborative approach
Digital health presents seismic disruption to patient care, particularly when new technologies are cheap and readily accessible to patients who might lack the insight required to recognise normality or cause for alarm. Technology can be enabling and empowering for self management, however there’s a lot more needs to be done to link these new technologies into the current health system.
Take the new Apple Watch functionality of heart rate notifications for example. Research like the Apple Heart Study suggests this exciting innovation could lead to significantly improved detection rates of heart rhythm disorders, and enhanced stroke prevention efforts.
But when a patient receives a high heart rate notification, what should they do? Ignore it? Go to a GP? Head straight to the emergency department? And, what is the flow on impact on the health system?
Many of these questions remain unanswered suggesting there is an urgent need for research that examines how technology is implemented into existing healthcare systems.
If we are to produce useful digital therapeutics for real-world problems, then it is critical that the end-users are engaged in the process. Patients and healthcare professionals will need to work with software developers to design applications that meet the complex healthcare needs of patients.
Teens weren’t marching in the streets calling for gun control after the Columbine High School massacre in 1999. So why are today’s teens and young adults – whom I’ve dubbed “iGen” in my recent book on this generation – speaking out and taking action?
With mass shootings piling up one after another, this is a unique historical moment. But research shows that iGen is also a unique generation – one that may be especially sensitive to gun violence.
Keep me safe
People usually don’t think of teenagers as risk-averse. But for iGen, it’s been a central tenant of their upbringing and outlook.
Their behavior has followed suit. For my book, I conducted analyses of large, multi-decade surveys. I found that today’s teens are less likely to get into physical fights and less likely to get into car accidents than teens just 10 years ago. They’re less likely to say they like doing dangerous things and aren’t as interested in taking risks. Meanwhile, since 2000, rates of teen binge drinking have fallen by half.
With the culture so focused on keeping children safe, many teens seem incredulous that extreme forms of violence against kids can still happen – and yet so many adults are unwilling to address the issue.
“We call on our national and state legislatures to finally act responsibly and reduce the number of these tragic incidents,” said Eleanor Nuechterlein and Whitney Bowen, the teen organizers of the D.C. lie-in. “It’s essential that we all feel safe in our classrooms.”
Treated with kid gloves
In a recent analysis of survey data from 8 million teens since the 1970s, I also found that today’s teens tend to delay a number of “adult” milestones. They’re less likely than their predecessors to have a driver’s license, go out without their parents, date, have sex, and drink alcohol by age 18.
This could mean that, compared to previous generations, they’re more likely to think of themselves as children well into their teen years.
As 17-year-old Stoneman Douglas High School student David Hogg put it, “We’re children. You guys are the adults. You need to take some action.”
Furthermore, as this generation has matured, they’ve witnessed stricter age regulations for young people on everything from buying cigarettes (with the age minimum raised to 21 in several states) to driving (with graduated driving laws).
Politicians and parents have been eager to regulate what young people can and can’t do. And that’s one reason some of the survivors find it difficult to understand why gun purchases aren’t as regulated.
“If people can’t purchase marijuana or alcohol at the age of 18, why should they be given access to guns?” asked Stoneman Douglas High School junior Lyliah Skinner.
She has a point: The shooter, Nikolas Cruz, is 19. Under Florida’s laws, he could legally possess a firearm at age 18. But – because he’s under 21 – he couldn’t buy alcohol.
Libertarianism – with limits
At the same time, iGen teens – like their millennial predecessors – are highly individualistic. They believe the rights of the individual should trump traditional social rules. For example, I found that they’re more supportive of same-sex marriage and legalized marijuana than previous generations were at the same age.
Their political beliefs tend to lean toward libertarianism, a philosophy that favors individual rights over government regulations, including gun regulation. Sure enough, support for protecting gun rights increased among millennials and iGen between 2007 and 2016.
But even a libertarian ideologue would never argue that individual freedom extends to killing others. So perhaps today’s teens are realizing that one person’s loosely regulated gun rights can lead to another person’s death – or the death of 17 of their teachers and classmates.
The teens’ demands could be seen as walking this line: They’re not asking for wholesale prohibitions on all guns. Instead, they’re hoping for reforms supported by most Americans such as restricting the sale of assault weapons and more stringent background checks.
In the wake of the Stoneman Douglas High School shooting, the teens’ approach to activism – peaceful protest, a focus on safety and calls for incremental gun regulation – are fitting for this generation.
New South Wales senator Sam Dastyari has been appropriately disciplined by Labor leader Bill Shorten for exercising poor judgement in his interactions with a Chinese businessman who is not an Australian citizen.
Dastyari has been sacked from his position as deputy Senate whip. This is his second demotion in little more than a year after having fallen foul of acceptable standards of political conduct.
On that first occasion – confirmed by the release this week of a tape recording – Dastyari contradicted his own party’s policy that is critical of China’s activities in the South China Sea.
Compounding his difficulties, he had also accepted a A$5,000 donation from the Chinese businessman mentioned above to meet personal legal obligations.
On this latest occasion, it’s alleged that Dastyari went to the businessman’s house and advised him that conversations between the two needed to be conducted beyond the range of their mobile phones so as to avoid eavesdropping by Australia’s intelligence services.
Dastyari insists that he was not passing on classified information, but the very fact he was alerting a foreign businessman to the possibility of his phone being tapped by the security agencies justifies his sacking.
This was an act of stupidity, if not disloyalty, for an elected representative who claims he has nothing to hide.
The episode also calls Shorten’s management into question. Dastyari should not have been returned to a leadership role so quickly after his first display of poor judgement.
After his earlier demotion he spent just five months on the backbench. He should now remain there for a long time.
Need for clarity
In all of this there is a much bigger issue, and one that requires urgent attention. This is especially so given China’s continued rise, and its persistent efforts to influence politics among its neighbours.
As an important regional player, Australia is far from immune from Chinese “money” politics.
What is required as a matter of urgency is legislation that bans all foreign political donations, along with a separate register of lobbyists who are operating on behalf of foreign entities.
The Dastyari episode should have brought home to the government of the day the need for clear-cut protocols to preclude the possibility of foreign money tainting the political process.
Labor and the Greens have proposed legislation that would ban all foreign political donations. The government is now saying – belatedly – that it will advance legislation in the new year to bring this about. No reasonable argument exists to delay this process.
At the same time, government and opposition should prioritise the establishment of a National Integrity Commission – similar to state-based independent commissions against corruption – to bolster public confidence in the political process, now at a low ebb.
In a research paper, the Parliamentary Library points out that Australia is “one of the few countries where donations from foreign interest political parties or candidates is not prohibited”.
In defining “foreign interests”, the International Institute for Democracy and Electoral Assistance includes entities that “contribute directly or indirectly [and who] are governments, corporations, organisations or individuals who are not citizens; that do not reside in the country or have a large share of foreign ownership”.
That wording would seem to be a reasonable model for Australian legislation.
Of English-speaking democracies, only New Zealand allows overseas donations to parties, but these are capped at NZ$1,500.
The Dastyari episode underscores the need for clear-cut rules to prevent those with links to foreign governments from using money to influence the political process.
The billionaire Huang, whose applications for Australian citizenship have been blocked by the Australian Security Intelligence Organisation, has deep connections in China’s ruling Communist Party.
None of this should be viewed as surprising, or necessarily cause for alarm, but what should be regarded as completely unacceptable is the use of money by foreign donors to influence policy in the service of a foreign government.
In Huang’s case, he withdrew a $400,000 funding pledge after Labor’s then-defence spokesman Stephen Conroy sharply criticised China’s territorial encroachments in the South China Sea.
What is required is clarity around foreign political donations. Politics and self-interest should not be allowed to stand in the way of reasonable steps to put in place regulations that ban all such donations.
In the Senate today, in several personal explanations, Dastyari insisted that he had not passed classified information to Huang, and that indeed he had never received briefings about relations with China that would have enabled him to do so.
That may well be the case, but perceptions in this case are fairly devastating.
Questions remain, such as:
Why did Dastyari need to go to the Chinese businessman’s house in the first place?
What did he need to tell Huang out of range of their mobile phones?
Who leaked the information about the encounter to Fairfax Media?
Was it leaked by a government agency for political purposes?
The point is this story has, potentially, some way to run, and may yet result in unexpected further developments.
What the whole unfortunate episode demonstrates is that public officials need to avoid carelessness in their interactions with anyone who might represent a foreign government. This is especially so in the case of a country whose methods of doing business politically are not aligned with those of Australia.
Finally, in his interactions with Huang, Dastyari may have served his interests better if he had familiarised himself with the example of the former Labor national secretary during the Gough Whitlam era.
David Combe served in the contentious period between 1973 and 1981, during which, it is alleged, he had sought financial assistance from Iraq for Labor’s losing 1975 election campaign. That support did not materialise, but revelations that it had been canvassed at all severely embarrassed Labor.
After he relinquished his role as national secretary, Combe developed a lobbying business and in the process was befriended by a Soviet embassy official in Canberra whom it later emerged was a KGB agent.
In 1983, Prime Minister Bob Hawke expelled the Soviet official. A cloud descended on Combe, who was later found by the Hope royal xommission not to have compromised Australia’s security.
However, if there is a lesson in the Combe and Dastyari episodes it is that those in positions of public trust cannot be too careful in the company they keep.
Australia’s productivity growth has been stagnant for over a decade and, according to a new report, our health policies and programs could be partly to blame. Released today, the Productivity Commission report also highlights how the health-care sector (among others) could play a starring role in improving productivity.
The commission has offered a short list of thematic directions for reform. In health these include eliminating low-value services that have uncertain clinical impacts, changing the way services are delivered to focus more on the patient, and moving away from a community pharmacy model to more automatic dispensing in a greater range of more convenient locations.
The underlying message is that productivity growth is essential if Australia is to expand its economy, generate opportunities for real income growth and raise community living standards.
But as a Productivity Commission discussion paper released last November noted, there is a justified global anxiety that growth in productivity — and in income and well-being, which are inextricably linked to it over the longer term — has slowed or stopped. Across the OECD, growth in GDP per hour worked was lower in the decade to 2016 than in any decade from 1950.
The commission notes that labour productivity has been rising, but that has more to do with greater capital investment than more efficient workforce practices.
The report also highlights a change in thought about productivity. The emphasis has shifted from the need to produce goods more cheaply to improving our human capital – the knowledge, skills and work practices of our community – and delivering more efficient and effective health, education and related services.
The change recognises that Australia is now predominantly a service economy, that health care is a significant economic service, and that the productivity of our workforce, including its health, needs to underpin our economic growth.
This is similar to that of New Zealand and the United Kingdom, less than Canada and far less than the United States – which is an international outlier at over 17% of its total domestic output. Add aged care and disability services, and the commission puts the figure at 13% of Australia’s GDP.
We continue to spend ever more on health, in real (inflation-adjusted) terms, both as taxpayers and as consumers. But are we getting good value for our money? An inefficient health system, wrongly priced services and poorly designed system incentives all drag on the cost of health care and on the productivity of a very large sector of the economy.
A decade ago, the health-care and social-assistance sector employed nearly 1.07 million people. This was a little less than retailing (1.21 million) and a little more than manufacturing (1.03 million). The health sector employed 10.3% of the Australian workforce.
Fast forward to 2017 and retail employment has stayed relatively stable at 1.26 million and manufacturing has declined to 0.9 million. In contrast, health care and social assistance has risen to 1.64 million – 13.3% of total employment.
Any opportunity to increase the efficiency of the health workforce will translate directly to greater labour productivity for the economy as a whole. And its effectiveness can be improved, in part by education and training, which improves the skills of our doctors, nurses, allied health workers and others to work collaboratively to deliver patient-centred care. This is the subject of an independent review for the COAG Health Council by this article’s author.
The actual productivity of the health workforce, unfortunately, is notoriously hard to measure. This is due in no small part to the lack of market forces and to wage costs that are often negotiated between unions and their employers – the governments.
The Productivity Commission’s forthcoming report on improving markets and competition in health and other human services will hopefully offer useful guidance on what reforms are needed in some of these sectors.
Workforce health is an important part of our human capital
A third role for a more efficient and effective health sector is to contribute to improving the health of the workforce overall. Education and health are recognised as the two most significant building blocks of human capital. Making the most of our human capital is a central message of the OECD’s research on productivity.
There is also ample evidence, including in the new Productivity Commission report, that poor health leads to poor labour market outcomes. A 2013 study into disadvantage in Australia concluded that people with long-term health conditions are likely to experience deep and persistent disadvantage, but, equally, disadvantage can lead to poor health.
Back to the future
The challenge remains to reform the health system, and its workforce in particular, so that practitioners, administrators and others have the skills, knowledge and professional attributes to meet the emerging health-care needs of our community.
As the Australian Institute of Health and Welfare points out in its latest review of Australia’s health, the community’s burden of disease is changing. There is now a greater need for longer-term integrated care to deliver services for those with chronic diseases, the elderly, those with dementia, disability and poor mental health, and to provide services to those in rural areas and remote communities.
The message in this latest report is welcome, but unfortunately it is not entirely new. A Productivity Commission report over a decade ago made the point that Australia’s growth potential will depend increasingly on making the best use of our human capital.
One of the aspirations at that time was for an agreed agenda of integrated health services reform within a national framework. It was seen as a way of adding much-needed impetus to overcoming long-standing structural problems that prevented the health-care system from performing to its potential.
Little progress has been made since then. Hence this report is important in reinforcing the message that the next big gains in productivity will need to come from reforming the delivery of health and education. Let’s hope the call for a shared agenda of reforms is taken up more actively than experience to date might suggest.