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Health – Page 2 – Dr Arthur Chesterfield-Evans

Doctor and activist


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Category: Health

‘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.
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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.

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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

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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

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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

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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

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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.

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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.

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The Silicosis Epidemic- A Symptom of Wider Regulatory Failure

Dr Arthur Chesterfield-Evans 28 February 2023

The epidemic of silicosis amongst tradespeople working with manufactured stone was predictable, preventable, and an illustration of a broken OHS system across NSW and the rest of Australia.

Until 2011, NSW had a workplace health and safety regulator whose statutory role was to “promote the prevention of injuries and diseases at the workplace and the development of healthy and safe workplaces”. The WorkCover Authority of NSW included specialist sentinel groups that researched, monitored, inspected and educated workplaces for dust diseases, farm and rural health (including pesticides) and noise, amongst other matters. Crucially, WorkCover also employed industrial hygienists and an occupational medicine group. These groups enabled the agency to anticipate many problems before they manifested in the state. The current furore over manufactured stone using powdered crystalline silica would probably have been averted if the dust diseases group were still in place.

For example, manufactured stone was previously produced in NSW, but made with powdered talc or limestone in a fibreglass matrix. The Dust Disease group discovered an employer using the cheaper silica flour and immediately put a stop to that. Similar proactive actions by this group halted the importation of mineral-bearing products adulterated by asbestos, such as brake shoes and gaskets, before they became a problem. Issues raised by the increasing use of carbon fibre and nano particulates would also have been within the purview of the Dust Disease group.

However, following the election of the coalition in 2011, the NSW government’s focus shifted to the financial losses of the workers compensation scheme. The insurance and workers compensation schemes were split from WorkCover with the creation of iCare and the State Insurance Regulatory Authority (SIRA).  Workcover also lost its independent source of premium income.

Limited funding for the remaining inspectorate and other functions such as promoting workplace injury prevention now came from Consolidated Revenue, set by NSW Treasury. Over the next few years WorkCover’s management under John Watson (the generic manager, not the Labor politician) shed many of its professionally qualified staff. New inspectors were less qualified than previously, a rule book replaced comprehensive understanding of occupational health and safety, workplace inspections decreased and in-depth investigations virtually vanished.

WorkCover’s system of Authorised Medical Practitioners, which trained GPs in occupational medicine across the state, was completely abolished. The excellent training manual for AMP’s, better than most textbooks, was written and maintained by Dr Kelvin Wooller at WorkCover. When he left, the regulator would not allow Dr Wooller to continue using the manual to train NSW medical practitioners but did nothing with it. Expertise in occupational medicine has consequently decreased in the wider medical community, making it difficult for many employers to find “a registered medical practitioner with experience in health monitoring”, as specified by the Work Health and Safety Regulation, and for workers to get a definitive diagnosis and compensation for workplace illnesses and diseases.

WorkCover was abolished in 2015, replaced by SafeWork NSW, which is now part of the Department of Customer Service, the department that is all things to all people.  The government seems not to understand what its function should be.

The regulation of workplace health and safety in NSW should be handled by vigilant sentinel occupational disease groups to provide workers with proactive protection and help keep workplaces safe. A core group of government-employed professionals is necessary as a repository for learnings and information that would otherwise be lost. This is the OH&S philosophy that drives other countries.

NSW has few workplace inspections, almost no penalties for appalling workplace practices and a cost-minimisation approach to the treatment of injured workers as the government reduces the premiums of workers compensation to make NSW ‘business-friendly’ at the cost of workers’ lives. There are currently a lot of inspections of benchtop manufacturers and suggested and overdue bans of manufactured stone with silica, but reactive activity in response to a significant epidemic has not fixed the systemic problem.

This needs to be an election issue in NSW. It should also be noted that John Howard’s similar 2007 changes to the Federal government regulator –the National Occupational Health and Safety Commission, (WorkSafe Australia), now Safe Work Australia –meant that that policy/advisory body also has far fewer personnel, less expertise and a less pro-active approach.  The perception of OHS as merely slowing industry’s “progress” has damaged the process nationally in a similar way to that of NSW.  The Federal government also needs to act in this area.

This article was published in John Menadue’s Pearls and Irritations 28 February 2023

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