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Category: Health

17/03/2024

The Australia Card and Data

16 March 2024

The Australia Card debate, which was from 1985-7 was whether we should all carry a card that would link all the information about us.

I was in favour of it because my concerns at that time in occupational health and safety was as to whether exposure to various workplace chemicals had an adverse effect on health.

The best data came from Sweden, where people’s occupation was on a database and their mortalities could be compared. Nowhere else had comparable data.

It seemed to me that the data was going to be collected inevitably and we should have a debate then and there as to who would collect it and what could be done with it.

I was in the Australian Democrats, who were usually quite sensible and given to rational argument, but the view was that people would be safer if the data was not collected at all so they opposed the card and the naysayers won the day in the Party and the nation.

The Credit Reference Association was already collecting data about unpaid bills and there was a debate as to whether the subject of the data, (who was usually only alerted to its existence when they could not get a loan), could have access to their own record to respond with reasons for whatever was on it.

Naturally financial data was of use to the tax office and now buying habits, web-search histories and emails result in changes to the feed of ads on social media.

Now that financial data is collected, the discussion can move on to more socially helpful data. Apparently Facebook can announce a flu epidemic earlier than the public register of viral tests or hospital admissions just from reading the frequency of the words ‘flu or sick’ on the posts.

In life I have progressed from dealing with acute diseases in heroic medicine and intensive care settings to looking at how to do prevention. Prevention is always the poor cousin, because if you spend money on it is hard to show results in the short time frame that accountants and politicians want.

As I moved from medicine to social policy and tried to advocate for ‘preventive social policy’ the situation became even more difficult, despite the well known fact that increasingly social disadvantage gives rise to poorer health outcomes. This is acknowledged with lip service, but the late-stage capitalist growth in inequality powers on regardless.

In 2001 as a NSW MLC I initiated an inquiry into DoCS (Dept of Community Services), which was then called FACS (Family and Community Services), and is now called DCJ (Dept of Communities and Justice). My inquiry showed that the Dept was dysfunctional, which we knew already, and the changes since have not helped much. Initially the problem was that they wanted to concentrate on the children most at risk, which meant still minimal supportive prevention for cases that were not at risk yet. Then the Department became even more defensive and privatised cases, so the kids became a commodity with NGO and ‘for profit’ corporations getting packages to look after kids with problems and then giving them to carer families for about a third of the money that they were given. ‘Management’, it seems, is a very expensive and lucrative business.

Obviously looking after kids whose parents are dysfunctional is a very difficult undertaking. Does one take the child and give it a good foster care family? What is a good foster care family? How much do you support dysfunctional parents? Are the grandparents, who presumably brought up the dysfunctional parents a good bet? Who makes the decision and what appeal mechanisms are there? Presumably all this is rendered ever more difficult by the fact that the gap between rich and poor is rising, there is no longer anywhere near enough public housing, and welfare payments are not really enough to live on.

It seems that the best way to see what policy works is to follow the kids in a lifetime study and see how they turn out. The criticism is that the OOHC (Out of Home Care) system has a hugely higher percentage of kids graduating to juvenile justice and then adult prisons. But data is hard to get as the Department, despite its numerous renamings, will not release the information as it is politically embarrassing. Naturally the privacy of the children is cited, but the data could easily be de-identified as much epidemiological data is.

We need to get data to make better decisions, ones based on facts as far as possible, with transparent assessment procedures with honest assessments of what is happening and a minimum of political or bureaucratic interference. With ‘issues management’ aka PR BS getting more sophisticated all the time, it will be an increasing struggle. The Aust Bureau of Statistics, which tries to produce facts, but can only work with the data it is given and presumably cannot be political in trying to get better data, was significantly defunded by Tony Abbott as part of his war on facts. Meanwhile the private sector hoovers up personal data and a few diehards try to keep using cash.

Ross Gittins, the SMH Economic Editor who generally writes good commonsense in a digestible form and has recently been recognised for his good work, has penned the article below in today’s SMH.

Australia Card anyone?

How the digital world is getting better at measuring us up

Ross Gittins, Economics Editor

SMH March 15, 2024

These days we hear incessantly about “data”. The media is full of reports of new data about this or that, and there’s a new and growing occupation of data analysts and even data scientists. So, what is data, where does it come from, what are people doing with it, and why should I care?

Google “data” and you find it’s “facts and statistics collected together for reference or analysis”. The advent of computers has allowed businesses and governments to record, calculate, play with and store huge amounts of data.

Businesses have data about what goods and services they’re making, buying and selling, importing or exporting, and paying their workers, going back for 30 or 40 years.

Our banks have data about what we earn and what we spend it on, especially when we use a credit or debit card – or our phone – to pay for something.

Much of this data is required to be supplied to government agencies. If you ever go onto the Australia Taxation Office’s website to do your annual tax return, it will offer to “pre-fill” your return with stuff it already knows about your income from wages, bank interest and dividends.

Try it sometime. You’ll be amazed by how much the taxman knows and how accurate his data are.

Another dimension of the “information revolution” is how advances in international telecommunications – including via satellites – have allowed us to be in touch with people and institutions around the world in real-time via email and the web – news, entertainment, social media, whatever.

Last month, the Australian Statistician – aka the boss of the Australian Bureau of Statistics – Dr David Gruen, gave a speech outlining some of the ways these huge banks of “big data” about the economic activities of the nation’s businesses, workers, consumers and governments can be used to improve the way we measure the economy in all its aspects: employment, inflation, gross domestic product and the rest.

We’re getting more information and more accurate information, and we’re getting it much sooner than we used to. But we’re still in the early days of exploiting this opportunity to be better informed about what’s happening in the economy and to have better information to guide the government’s decisions about its policies to improve the economy’s performance.

Gruen starts by describing the Tax Office’s “single-touch” payroll system, software that automatically receives information about employees’ payments every time an employer runs its payroll program.

Not all employers have the software, but those who do account for more than 10 million of our 14 million employees.

Gruen says the arrival of the pandemic in early 2020 made access to this “rich vein of near real-time information” an urgent priority. The taxman pulled out the stops, and the stats bureau began receiving these data in early April 2020.

With a virus spreading through the land and governments ordering lockdowns and border closures, they couldn’t afford to wait a month or more to find out what was happening in the economy. Thus, the whole project of using big data to help measure the economy received an enormous kick along – here and in all the other rich economies.

So, in addition to the longstanding monthly sample survey of the labour force, we now have a new publication: Weekly Payroll Jobs and Wages Australia. These data allowed the “econocrats”—and the rest of us—to chart the dramatic collapse in jobs across the economy over the three weeks from mid-March 2020.

They show employment in the accommodation and food services industry falling by more than a quarter in just three weeks. Employment in the arts and recreation services industry fell by almost 20 per cent. By contrast, falls in utilities and education and training were minor.

The monthly labour force survey has a sample size of about 50,000 people, compared with the payroll program’s 10 million-plus people, meaning it provides information on far more dimensions of the workforce than the old way does.

So, the bureau’s access to payroll data taught it new ways of doing things. And the pandemic increased econocrats’ appetite for more info about the economy that was available in real-time.

With household consumption – consumer spending – accounting for about half of gross domestic product, improving the timeliness and detail of the data was a great idea.

So, in February 2022, the bureau released the first monthly household spending indicator using (note this) aggregated and de-identified data on credit and debit card transactions supplied by the major banks. This indicator provides two-thirds coverage of household consumption, compared with the less than one-third coverage provided by the usual survey of retail trade.

The bureau has also begun publishing a monthly consumer price index in addition to the usual quarterly index. This is possible because big data – in the form of data from scanners at checkout counters and data scraped from the websites of supermarket chains – is much cheaper to gather than the old way.

The bureau has also started integrating different but related sets of big data from several sources, so analysts can study the behaviour of individual consumers or businesses. It has developed two large integrated data assets.

The one for individuals links families and households with data sets on income and taxation, social support, education, health, migrants and disability.

The one for businesses links them with a host of surveys of aspects of business activity, income and taxation, overseas trade, intellectual property and insolvency.

The purpose is to allow analysts from government departments, universities or think tanks to shed light on policy problems from multiple dimensions.

For instance, one study showed that people over 65 who’d had their third COVID vaccination within the previous three months were 93 per cent less likely to die from the virus than an unvaccinated person. But that’s just the tiniest example of what we’ll be able to find out.

16/02/2024

‘Health Policy’

Chesterfield-Evans, A. (2024)

Journal of Australian Political Economy No. 92, pp. 98-105.

HEALTH POLICY
Arthur Chesterfield-Evans

Just before the 2022 federal election, Mark Butler, now the Minister for
Health in the Albanese government, spoke to the National Press Club,
praising the courage of the Hawke government in creating Medicare in
1984. His speech also set modest priorities for a prospective Labor
government, committing to (1) improve the digital health record and make
the MyHealth record actually useful; (2) develop multidisciplinary care;
(3) establish a new funding model for ‘MyMedicare’; and (4) grow the
medical workforce, with special mention of nurses and pharmacists (Butler
2022). Significantly, Butler did not commit afresh to Medicare as a
universal health scheme free at the point of delivery, the key element of
the original 1984 scheme that he praised. In an environment where,
politically, it seems that taxes cannot be increased, perhaps this ideal may
be an impossibility, but it is surely significant that it is no longer stated as
an aspiration.
Currently, Medicare is quietly dying as the low rebates cause doctors to
abandon it. Australia is moving to a US-type private system by
default. This has resulted in large amounts of hand-wringing rhetoric, but
so far little action. This short article comments on the changes initiated by
the current Labor government during its first year and a half, contrasting
these with the deep-seated problems needing to be addressed if better
health outcomes are to be achieved.
Labor’s reforms
The government has made some minor changes to Medicare which came
in with great fanfare on November 1, 2023. There were new item numbers

for new specialist technologies or treatments and an increased Medicare
rebate for GPs, up to $41.40 for a standard visit for a RACGP member,
which is 40.6% of the AMA fee. Doctors without the RACGP qualification
still get $21, which is 20.6% of the $102 AMA fee.
When Medicare was born, the Medicare rebate was 85% of the AMA fee.
The rebate has risen at half the inflation rate for 39 years, so doctors now
feel ripped off every time they see a Medicare patient. Labor blames the
disparity on the rebate freezes of the previous LNP Coalition governments,
but its own record is poor. Successive governments of all types have
deferred to the private health lobby and are starving Medicare, slowly
defaulting towards a principally private system, as in the USA. This is a
deeply-troubling prospect because the US health system has been
recurrently criticised (Commonwealth Fund 2021) – and rightly so –
because it makes access to health care dependent on ability to pay. Notably,
however, it is the world’s best system at turning sickness into money.
The other recent Labor ‘reform’ was to allow pharmacists to process
prescribed medications to cover patients’ requirements for 60 days, rather
than 30 days, thereby halving the costs of prescribing and dispensing.
While this may seem helpful, patients are often confused by complicated
generic names and generic brands; and compliance or discontinuation of
medicines is a largely unquantified problem. These are existing problems
with the current arrangements for dispensing medications: the recent
policy change, while well-intentioned, does not redress them. It transfers
resources from professional staff to the pharmaceutical industry.
The ‘Strengthening Medicare Taskforce’ had good medical and allied
health representatives and support. Its December 2022 report defined the
problems but, trying to avoid controversy, positive suggestions were thin
on the ground. A deeper analysis and more comprehensive approach to the
redress of health issues is needed.
Basic problems in the health system
Diverse funding sources causes cost-shifting
Fundamentally, no-one is in overall control of the health system. It has a
number of different funding sources: the Federal and State governments,
the Private Health Insurance industry (PHI), Medicare and individuals

themselves. Workers Compensation (WC) and Compulsory Third Party
(CTP) insurers also put in a bit. These arrangements lead to a situation
where each funding entity attempts to shift costs without any real care for
the overall cost of the system. Private entities such as pathology and
radiology also have an interest in providing more services, whether they
are needed or not.
The broad division of the health system is that public hospitals and
emergency departments (EDs) are State-funded, and non-hospital services
are Federally, PHI or self (patient) funded. There is some overlap,
however, because the State’s provision of some community-based services
allows them to save on hospital-bed days; and private funds paid to State
hospital in-patients are eagerly sought. The starvation of Medicare (which
reduces the Federal government’s spending) has resulted in more patients
going to EDs at higher (State) cost, as well as increasing PHI and patient
costs.
This cost-shifting has evident implications for the affordability of health
care: notably, a recent study showed that Australia, when compared to 10
other countries, scored poorly on its measure of affordability
(Commonwealth Fund 2021).

A new health paradigm is needed
Yet more fundamentally, there is a huge problem with the conceptual
model of the health system. In common parlance, the ‘health system’ is the
‘paying to treat illness’ system. Paying doctors to see and treat patients is
seen as the major cost and is the most politically fraught element in the
system.
Historically, everyone was assumed to be healthy and had episodes of
either infectious diseases or surgical problems. They went into a hospital
for a brief period and either recovered or died. The legacy of this is that
heroic interventions are over-resourced and the more cost-effective early
interventions are under-resourced.
Infectious disease is now relatively uncommon, notwithstanding the recent
and ongoing coronavirus concerns. Most disease is chronic; and the
objective is to maintain health for as long as possible and to support those
who need support in the community rather than in institutions. ‘Health’
must be re-defined as a state of physical and mental wellbeing; and
maintaining it as ‘demand management’ for the treatment system.

Life-style diseases of diet, obesity, smoking, vaping, alcohol, drug-use and
lack of exercise need attention. It might be commented that these habits
are more determined by the political economy of the products than by any
health considerations; and the government should intervene to re-balance
this market failure.

Hierarchies, cartels and corporatisation
The medical system is hierarchical with specialists at the top and GPs at
the bottom. The specialist colleges have produced less practitioners than
would have been optimal. The starvation of General Practice has led to
increasing specialist referrals for simple procedures. Most patients are
happy to go along with this, though often much less happy about the rising
costs. Practitioners tend to work down to their station rather than up to
their capacity. GPs, if given the appropriate additional education and
empowered to act, could do what quite a lot of specialists do now, while
nurses could take the load from GPs; and, in terms of home support, a more
comprehensive and flexible workforce needs to be developed.
Private medical insurance systems are a further source of problems. They
have marketing, churn, profits, liability and fraud issues; and they make it
necessary to account for every item of every procedure. While the
corporations watch every cost, the regulator cannot. Corporations buy
medical practices and take up to 55% of the gross revenue. Smaller
radiology practices are being gobbled up as investments (Cranston 2020).
If overheads are defined as the amount of money put in compared to the
amount paid for treatments, Medicare costs about 5% and PHIs, as they
are regulated in Australia, about 12%. In the USA, the private health funds
take up to 35%, and Australia’s CTP system got close to 50%. A universal
health insurance system could avoid many of these costs and would be far
superior from a social equity point of view.
Similar problems are evident in the provision of care for people with
disabilities. Labor pioneered the NDIS when last in office a decade ago,
and rightly claims this as evidence of its commitment to redress the
previous neglect. However, the NDIS can be considered as a privatisation
of the welfare system. It overlaps medical system functions and is poorly
regulated. If its efficiency is judged by the percentage of money put in that
is paid to the actual workers delivering the service, care is not very

efficient. There have also been significant criminal rip-offs (Galloway
2023).
Retirement care arrangements have major flaws too. Aged-care
accommodation is largely driven by the real estate industry; and access to
continuing care is an add-on of often dubious quality.

What should the government do?
The problems described above are diverse, deep-seated and not easily
rectified. However, a government intent on staying in office for a series of
terms could heed the call for some big thinking, drawing on the experience
of health practitioners themselves. Here is a list of what might be done,
becoming more medical and more politically difficult as it progresses:
• Keep people healthy with education, clean water, sanitation, housing,
good food, regular exercise, high vaccination rates, road safety,
universal swimming lessons, CPR and first aid training and the active
discouragement of smoking, vaping, alcohol and drug use, junk food
and gambling.
• Provide housing with graded community support options for those
people with disadvantage or impairment. Create a registration and
insurance system for home and community support services, so that
individuals can buy standardised services from other individuals.
• Maintain fixed staff-patient ratios related to the disability
classification of residents in institutional care.
• Make maximum use of community and school interventions and
support services such as District and Community nurses and School
nurses, mental health support networks, Aged Care Assessment
Teams, Hospitals in the Home etc.
• Address health problems as early and as low down the support and
treatment hierarchy as possible, by empowering those who provide
the services.
• Create a meaningful regulatory, inspection and enforcement system
for support services, both community and residential, and for
workplaces and recreational facilities.
• Use the medical information system to research drug and treatment
effectiveness.

• Support General Practitioners and try to increase their ability to solve
problems without referral. Have GPs work in Health Centres with
community support workers as far as possible; and improve
communication with data collection a by-product of normal work, not
an additional imposition.
• Have independent evaluation of the numbers needed in the specialties
and pressure the colleges to provide these numbers. Use waiting times
as an initial index.
• Initiate either university-based or college-based continuing medical or
professional education, with mandatory refresher exams every
decade.
• Have universal professional indemnity insurance, with doctors and
other health professionals unable to be sued if they report all incidents
of sub-optimal outcomes within 48 hours of becoming aware of them,
and participate in regular quality control meetings.
• Publicise and promote organ donation, end of life plans, wills and
enduring powers of attorney as sensible steps in life-management.
• Evaluate Intensive Care interventions in QALY (Quality-Adjusted
Life Years) terms, researching their outcomes and comparing them to
earlier intervention initiatives.
• Change the composition of the Pharmaceutical Benefits Advisory
Committee so that it has no pharmaceutical industry representative on
it; and remove ministerial discretion from its decisions. The previous
system evaluated new drug listing approvals with a cost-benefit
analysis (Doran et al. 2008), but the Howard reforms of 2007,
following the Australia-US Free Trade Agreement and lobbying by
Pfizer, put a drug industry representative on this committee, making
its negotiations more transparent and thus more difficult for the PBS
to negotiate prices (Access to Medicine Working Group 2007).
• Work towards replacing Workers Compensation and CTP insurance
schemes with income guarantee schemes (this will only be possible
when Medicare allows timely treatment).
• Create a credible and indexed scheme for paying medical
professionals which does not have KPIs that distort performance.

• Make Medicare a universal taxpayer funded health system that is free
at the point of delivery and stop subsidising PHI. It might be noted
that the Government currently quotes Medicare and PHI costs
together as a sum rather than itemising the two, which serves to
disguise the subsidy to PHI (Parliament of Australia 2022).

Conclusion
The current federal Labor government has made statements about health
policy reform and done minor tinkering during the first year and a half in
office. Based on this start, it is doubtful that it will have the courage to
make the necessary major changes, addressing the systemic problems.
Fine rhetoric is unlikely to achieve much. That makes it doubly important
to develop proposals for more fundamental reform. Written with this
intention, the suggestions made in this article could be the basis for
tackling the fundamental institutional and political economic issues
problems associated with personal and societal ill-health.
Dr Arthur Chesterfield-Evans trained as a surgeon in Sydney and the UK
and is a Fellow of the Royal College of Surgeons. He currently works as a
GP with interests in workers’ compensation and third-party injury. He has
been a tobacco activist and an elected member of the upper house of the
NSW Parliament. He has Master’s degrees in Occupational Health and in
Political Economy.
chesterfieldevans@gmail.com

References
Butler, M. (2022) ‘Address to National Press Club, 2 May,’ available:
www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-
care-speech-national-press-club-2-may-2023.
Commonwealth Fund (2021) US Report, available:
www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-
reflecting-poorly.
Cranston, M. (2020) ‘Radiology enjoys a post-virus buying boom’, Australian Financial
Review, available: www.afr.com/policy/economy/radiology-enjoys-a-post-virus-buying-
boom-20201106-p56c7k.

Doran, E., Henry, D., Faunce, T.A. and Searles, A. (2008) ‘Australian pharmaceuticals policy
and the idea of innovation’, Journal of Australian Political Economy, 62, pp. 39-60.
Galloway, A. (2023) ‘Federal crime syndicates using cash vouchers and gifts to steal NDIS
funds’, The Sydney Morning Herald, available: www.smh.com.au/politics/federal/criminal-
syndicates-using-cash-vouchers-and-gifts-to-steal-ndis-funds-20230414-p5d0ma.html.
Parliamentary Library (2022) Health overview, available:
www.aph.gov.au/About_Parliament/Parliamentary_departments/Parliamentary_Library/p
ubs/rp/BudgetReview202223/HealthOverview.
PBS (2007) ‘Access to medicines working group’, available: www.pbs.gov.au/info Access to
Medicines /general/working-groups/amwg/amwg-jul-2007.
Sax, S. (1984) A Strife of Interests: Politics and Policies in Australian Health Services,
Sydney: George Allen and Unwin.
Searles, A., Jefferys, S., Doran, E. and Henry D.A. (2007) ‘Reference pricing, generic drugs
and proposed changes to the Pharmaceutical Benefits Scheme’, Medical Journal of Australia,
187(4), pp. 236-39.
Strengthening Medicare Taskforce (2022) Taskforce Report, Commonwealth Department of
Health, available: www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf.

07/12/2023

Hospital Crisis is just part of the story.

6 November 2023

The hospital crisis is partly because General Practice has been so downgraded that more cases go to hospital than need to. The Federal government starving Medicare has a number of consequences:
Many GPs are simply retiring and there are no enough new ones taking their place, so we are getting towards a serious shortage
GPs cannot survive on the Medicare rebate, so now charge a co-payment.
Since Emergency departments are free, people wait until the situation gets worse then go there.
Emergency Depts are about 6 times the cost of GP visits, so the total cost of the Health Care system rises.
The other part of the Federal government starving Medicare is that the State governments pay for the emergency departments, so it is a case of the Federal government saving money by making it a lot more difficult for the States.
But an overriding fact is that Australia has been convinced by the neo-liberals that tax is a bad thing and government spending must be a small percentage of GDP. Currently this is about 38.4% of GDP, slightly less than the USA, which has very poor welfare and health systems. This means that the governments cannot actually afford to do anything, and behave like a corporation, cutting employee wages and making cuts wherever it thinks no one will notice, or it has the power to do so. Now if Labor ever tries to raise taxes, the Liberals, who are great exponents of small government accuse Labor of being ‘tax and spend’, and Labor, rather than have a serious debate merely retreats. The fact that he Scandinavian countries have government as close to half of GDP and have their citizens much better off never gets mentioned. Denmark is at 49.9%, Germany 49%, Finland 54% and France at 54%. The UK is at 45%.
We now have a failing GP sector, a problem in aged care, a shortage of nurses, paramedics on strike, a hollowed out public service that merely awards its former tasks to private sector operators that it cannot even monitor and Australia falling down the World educational standards table is not a coincidence. The governments have a virtual monopoly of these jobs. They have deliberately let wages fall, so that now people simply will not do them.
We need to stop privatising, rebuild that public sector so that it can deliver services that we need. Profit is merely another unnecessary overhead. We need to decide what needs to be done, and raise enough tax to pay the people to stay in their public service jobs. Education, health and aged care do not need a ‘market’ to function/. If one exists for comparison purposes, that is fine, but there is no actual virtue in having most of the services delivered by corporations that have the choice of good service or good profits. It is a con, and it is time we forced the government to give us Medicare and a health system that actually works for all, and education for all.
Here is a letter from my Medical partner in today’s Sydney Morning Herald.

The horror stories now emerging about overloaded public hospitals, ambulances and emergency departments comes as no surprise to anyone following the downgrading of Medicare to a ‘‘mixed billing’’ system. This has made it unaffordable for many people to see a GP. But the real cost of turning Medicare into a two-tier system has been to the public hospital system. The only winners are private corporations, private hospitals, private health insurance funds and their many lobbyists in Canberra. We are going the way of the US, and if people don’t fight for Medicare, we are all doomed.
Con Costa, Hurlstone Park:

Here is today’s Herald Editorial

Health system needs its own emergency care
The state of health of the health system has dominated the lives of Australians for four years, but it has never been in such need of urgent care. Indicative of how working conditions for frontline healthcare workers have deteriorated, people now spend a median of three hours and 36 minutes in NSW hospital emergency departments, the longest wait ever. It’s little wonder that health workers are suffering burnout, stress and bullying and are leaving the industry in record numbers.
The COVID-19 pandemic sharpened awareness of our vulnerabilities and forced extra spending on hospitals, clinical responses, vaccinations and prevention measures.
And when we emerged from the pandemic’s worst days it became evident the health system too was experiencing difficulty recovering from years of stress. It had been deteriorating for a long time already, but post-pandemic we became uncomfortably aware that ambulances were queueing for hours to offload emergency patients and hospitals were under enormous pressure with lengthy wait times in emergency and admission.
GPs bumped up fees, forcing people who could not afford the $11-a-visit hike into hospital emergency departments. The industry is being further destabilised by the exodus of 6500 nurses and midwives a year.
If anything, the situation is worse outside the big cities. Last year, for instance, five deaths in regional hospitals could potentially have been prevented, but not in an overworked hospital system with staff shortages that make mistakes even more likely. The NSW parliament’s health portfolio committee report on rural, regional and remote health 18 months ago found a ‘‘culture of fear’’ which did not encourage or value feedback and complaints. Some workers say they were even punished for making complaints.
Now an investigation by the Herald has revealed a health system sinking further into crisis. Eight nurses and midwives have taken their lives in the past three years, while nearly 2000 NSW Health workers have lodged compensation claims for psychological injuries over the past two years. More than 33,500 NSW Health employees have also claimed they are burnt out, while 21,000 workers say they have witnessed bullying in the workplace. One in 12 ambulance employees hold a compensation claim for a psychological injury.
Experts and unions warn that the data, drawn from documents obtained exclusively under freedom of information laws and the state government’s recently released annual employee survey, People Matter, shows a workplace struggling with staff mental health concerns.
Further illustrating the stress, NSW Ambulance fielded a record 363,251 calls and fired up the lights and sirens for more than 181,000 emergency call-outs between July and September, the most of any three-month period since the Bureau of Health Information began taking records in 2010.
Money seems to be the root cause of health’s problems. Today’s national cabinet meeting will address the rampant cost blowouts in the NDIS and Canberra wants the states to take responsibility for funding treatments. On Friday, Premier Chris Minns and Treasurer Daniel Mookhey meet the Health Services Union over a protracted pay dispute threatening to collapse the NSW triple zero call system on New Year’s Eve. Minns said the money is not available.
The future funding and structure of our health systems concerns us all. It is an area where the federal and state governments share responsibility. The solution to the healthcare crisis is complex and will take time, but it is an area where increased funding must be found.
That clearly calls for a better national approach and the states responding with an end to parochial wheelbarrowpushing and finger-pointing.

23/11/2023

Apartheid Education Buses

23 November 2023

I live near a turning circle in a good area of Sydney. There is a Bus Stop there and the government bus there has an ad with a picture of a forlorn looking schoolgirl saying that she cannot have a decent education, so would I donate to The Smith Family so she can.

As the ad displays there, 8 shiny new buses take private school children from the turning circle to 8 different private schools.

It seems that our governments are happy to subsidise ‘choice’ so that they do not have to fund a fair go and we are happy to tolerate an apartheid education system.

www.theguardian.com/australia-news/2023/nov/23/australia-100-wealthiest-schools-earnings-income-data-education-department?utm_term=655e79e42ab1fedfc11542549409ff2e&utm_campaign=AustralianPolitics&utm_source=esp&utm_medium=Email&CMP=aupolitics_email

18/11/2023

How Much Exercise Should You Do?

17 November 2023

It has been shown that exercise lessens mortality and lengthens life by lessening the chance of cancer and cardiovascular diseases like heart attacks and strokes.

So the question has become ’How much exercise do you have to do; how long and how hard?’

New research has been done in 2 major studies, and an editorial that evaluates them.

In a study by Stamatakis in the European Heart Journal, the amount of Vigorous Physical Activity (VPA) was measured for a week in 71,893 UK Biobank middle-aged adults using a wrist-worn accelerometer. Their mortality was compared after 5 years and was:

No exercise 4.2%,

1-10 mins of exercise/week 2.1%

10-30 mins 1.8%

30-60 mins 1.5%

over 60 mins 1.1%

What is remarkable about this is how little vigorous physical activity is needed to halve mortality!

There was also a linear relationship between the frequency of exercise and mortality.

In other words, the more often you exercise the better, with 27 times a week having the lowest mortality, but only short bursts are needed.

A similar study by Demsey on 88,412 middle aged UK Biobank adults showed that a higher amount of Physical Activity Energy Expended (PAEE) was associated with a lower mortality after 6.8 years.

If this energy expenditure was made up of more Moderate to Vigorous Physical Activity (MVPA) there was an additional benefit. Cardiovascular disease rates were 14% lower when MVRA was 10-20% of PAEE.

The bottom line is that exercise is good and incorporating a little in your day will benefit you.

Vigorous exercise can probably be equated with being short of breath, so walking up a hill or steps briskly rather than strolling is better. Obviously any sort of sport that involves some period of exertion is good if you are able to do it. If you have done no exercise for a while or have very poor fitness, just increase it slowly – walk a bit faster initially and build up from there.

It is good to know that every bit helps!

Here are the studies:

https://academic.oup.com/eurheartj/article/43/46/4801/6771381

https://academic.oup.com/eurheartj/article/43/46/4789/6770665

https://academic.oup.com/eurheartj/article/43/46/4815/6774597

17/11/2023

Loneliness is a Major Public Health Issue

17 November 2023

The World Health Organisation (WHO) has declared that loneliness is a major public health issue. The COVID isolation worsened the situation, but at least drew attention to it. Declining family size, the stress on the individual, and the ability to live alone have worsened the long-term trend to loneliness.

The Japanese have recognised this for some time, but have not mastered the problem. In Australia it seems only to get attention when some old person is discovered dead for months when the smell emanates from their flat or their electricity is cut off. In the younger age groups, suicide may be the first and last sign.

From a medical point of view, I have quite a lot of patients that have long-term painful problems that cannot be resolved and render them unable to work. They are often financially embarrassed also, a fact that they often try to hide. They are recognised as depressed but people are reluctant to acknowledge that medications do not help much. This week I had a patient who asked if the insurer would pay for a companion dog, as he could not really afford to feed it. We discussed dog sources and sizes. My guess is that workers compensation insurers will be willing to pay for tablets that don’t work as they are a ‘medical expense’, but not a little dog that may be a more practical solution.

An article in the Guardian surprised me that loneliness is a bigger problem in Africa than in Western countries. I had assumed that the strong family ties and interdependency would make it a worse problem in Western rather than African societies.

What is needed is governments to recognise that there is a value in the relationships between people. It used to be called ‘social capital’, but the term seems to have fallen out of favour. We could encourage ‘Meet Your Neighbour Day’, street Christmas parties and other activities that encourage interpersonal contact beyond the social media apps. Both civic and domestic architecture could give more thought to encouraging human to human contact.

www.theguardian.com/global-development/2023/nov/16/who-declares-loneliness-a-global-public-health-concern

18/10/2023

Advocacy to Delay the Silica Benchtops Ban

18 October 2023

I wondered why the NSW Government was delaying the ban on silica-containing benchtops until July 2024. Infectious diseases have no political friends, but industrial diseases do. Below is a full page ad in today’s Sydney Morning Herald advocating a delay on the ban and some regulations about how to cut the benchtops with no dust. They also point out correctly that other benchtop materials have some hazards, and there are a lot of other products that produce silica dust when cut or dug. And they point out that a lot of people are involved in installing benchtops.

It is true about other products being harmful. But it is also true that there are readily available non-toxic alternatives that could be used. It is a bit rich for an industry that did precious little to stop the development of silicosis now to ask to be regulated. The obvious solution is to minimise the harm from all sources of silica including cutting concrete and digging sandstone foundations. That requires regulations that often actually exist, but Safework does few site inspections and relies on ‘self regulation’ and a ‘notify us’ system of light regulation, based on a fundamental contempt for OHS as soon as it inconveniences business.

The government must be forced by publix pressure to ban silica benchtops, which are basically all silica except for a bit of binder chemical, and to enforce other regulations with filtered air and barriers with PPE (personal protective equipment) as a last resort. Concrete or sandstone must be cut with water on the saw so that there is minimal dust.

It is depressing, but not surprising that those who have created so much of a problem by setting up an import system for this toxic product now have the gall to lobby against effective government action.

C:\Users\chest\OneDrive\Pictures\SMH Silicosis Ad 231018.jpg

12/09/2023

Smoker with Lung Cancer Sues Crown Casino

I thought that this sort of stuff only happened last century, but the gambling lobby has not changed. I guess it will be cheaper for them to pay the people who get cancer than to go smoke-free.

https://www.theguardian.com/…/crown-casino-melbourne…#

04/04/2023

Classification of Impairment

4 April 2023

I was lucky enough in my surgical training years to have most of a year working as neurosurgical registrar for Dr John Grant. He set up the 1st spinal Injuries Unit in Australia saying that while everyone was looking for a miracle cure that would allow injured spinal tissue to repair, most paraplegics were dying of bedsores or infections coming up their urinary catheters and much better practices and training was needed.

He went to England in 1960 and with Sir Ludwig Guttman started the Stoke Mandeville games, the precursor of the Paralympics. He developed the Paralympic Games to help his patients, who were mostly young men whose lives had been shattered after a catastrophic injury, often after doing something daring or unwise. Wheelchair athletics was a major part of this, as it gave the young paraplegic people something to strive for. John Grant became head of the Australian Paralympic movement and Chair of the Organising Committee of the Sydney 2000 Paralympic Games. My part was merely to help treat the spinal patients.

Later I moved into occupational medicine so as to fund my work in the anti-tobacco movement. There I found impairment from workplace injury and had to decide who could work and who could not. This got a nasty edge to it as insurers wanted people classified as fit, so that if they would not work their pay could be suspended. The Courts argued about this until the legal process was deemed so expensive that the American Medical Association worked with the insurance industry to devise a complicated medical examination which measured ‘Whole Body Impairment’ as a percentage. This was not supposed to simply translate simply into how much money an injured person was awarded, but of course that is exactly what happened. Since pain cannot be measured it had to be left out of the calculation, so you can have terrible pain, but if you have only lost a few measurable degrees of back movement, your percentage impairment may be minimal. The system also makes no distinction between an impairment and a disability. If you are a labourer and have a lower body injury and cannot work at all or are someone who works at a desk and can maintain their previous income, the impairment is the same. I have never learned the details of the system, as I think it a bad farce, but it is used to assess impairment in Australia, makes a lot of money for the doctors who do the medicals, and saves the insurers a fortune. Of course there are few who try to fake injury, but in my experience this is fairly rare, far rarer than insurance companies would have you believe.

But making an objective assessment of what a person can and cannot do is not easy, and so one is to pity the classifiers who want a level playing field by classifying people for the Paralympic Games. Given that each country wants to pick a team of winners and they classify their own athletes, it is little wonder that in some countries ‘intellectually disabled’ are as smart as anyone else, or that you cannot even notice a limp in some of the runners.

The 4 corners of Monday 2 April looked at the whole Paralympic Classification system and produced damning figures that 10 of 12 of the gold medal winning Spanish basketball were not disabled at all, and that in some areas 69% of the winners had minimal disability.

As this sad farce continues there is a huge kerfuffle lest the tiny number of trans athletes with the genetic advantage of having had male hormones might get an advantage over females.

John Grant must be turning in his grave.

15/03/2023

Fracking for Gas Destroys Farmland

15 March 2023

Some years ago, I was a farmer in New Zealand. I met a cashed-up American who was in NZ trying to buy farmland. I asked him why he was NZ rather than Australia. He said, ‘Australia is fuc*ed , mate. The governments have let them frack it all, and soon they won’t be able to farm’.

He was from the US and had seen it happen there. The problem is that politicians are mostly lawyers and accountants and do not know what they do not know. Perhaps they are easily conned by lobbyists in suits. The fact is that the surface of the earth is like a layered cake with rock strata that stop water simply going to the lowest level. If an underlying impermeable level is broken, the water which may have been kept in the overlying soil drains to a deeper level. So big mines or fracking, which means fracturing and cracking the stratum, allows gas to be released upwards, but also allows the water to flow downwards. This leaves the topsoil without water, which eventually will turn it to sand as the organic matter dies.

The nett effect is that the gas is released once, but the water escapes forever. The gas company makes its money and moves on- the yield of the land is forever damaged. The farmer is the first economic casualty, national production notices it more slowly. The chemicals used in fracking also pollute the groundwater, so bores used for stock produce undrinkable water. There is no method for removing these chemicals from the groundwater.

The advocacy group, ‘Lock the Gate’, are doing their best but are still losing the political battle and the gas companies are still expanding activities. Some of the best agricultural land is the Darling Downs in Queensland and the Liverpool Plains in NSW, which are both under threat. What is also likely to happen is that they will frack near the Great Artesian Basin, which is a huge water body under a third of Australia. It is currently unpolluted by fracking chemicals, but if it becomes polluted, which seems inevitable, there will no usable water in huge areas of arid Australia. It will be a national ecological disaster.

The words of the American entrepreneur are ringing in my ears.

Farmers betrayed by government, Shell, PetroChina “fairytales” as prime land damaged by gas fracking