While Australia already conducts world-class research, future global leadership requires a major funding investment

The Medical Research Future Fund (MRFF) announced as part of the 2014–15 federal Budget1 will be an integral factor in Australia’s ability to continue delivering among the best health and medical research in the world. If we look beyond the political rhetoric and debate, the MRFF offers substantial value to Australia. Yet very few commentators, including those in the medical and health sectors, have acknowledged this to the degree it deserves.

Presently the Australian Government spends 0.075% of gross domestic product on health and medical research — only 64% of the Organisation for Economic Co-operation and Development (OECD) average of 0.118%.2 The MRFF, as proposed, will build to a $20 billion perpetual fund over the next decade, ultimately providing $1 billion in funding annually for health and medical research. It is vital that this size and pace of funding be achieved to bring Australia back to an internationally comparable level of government research support.

Benefits of research to health care

There is international evidence that hospitals and health care facilities that do research deliver higher-quality care, have better patient outcomes and are more efficient. In its 2009 final report, A healthier future for all Australians, the National Health and Hospitals Reform Commission presented recommendations for creating an agile, responsive and self-improving health system.3 Central to these recommendations was embedding research in clinical and health services settings, and fostering a culture of improvement.

More recently, a key theme in the Strategic Review of Health and Medical Research (the McKeon Review), presented to the federal government in 2013, was that the best performing health systems are those that embed research in health delivery, leading to better health outcomes.4 This belies the proposition that it makes more sense to spend our limited public funds on health care, especially when it comes to the vulnerable groups in our community.

It is not true to say that almost all the medical research discoveries and cures of the future will come from beyond our shores. Australian discoveries, such as the cochlear implant and the recombinant human papillomavirus vaccine against cervical cancer, show that Australia is well and truly capable of health and medical research that has a transformational effect on the health of our community and around the world. Furthermore, a strong medical research culture is required to evaluate and selectively import the fruits of the 97% of medical research performed outside Australia that is relevant to our health system.4

Research in many fields, including that on the human brain, genomics, genetic discovery for diseases such as melanoma and multiple sclerosis, and bionics, is increasingly undertaken through international collaborations. The MRFF investment will position Australia as a valuable collaborator and contributor to such global efforts. Having local scientific and public health expertise is vital for our national biosecurity and for taking urgent, effective local action to protect the Australian community against pandemics such as influenza A(H1N1)pdm09, Ebola virus and severe acute respiratory syndrome, or other worldwide health threats.

The benefits of research are also finally becoming visible among our Indigenous communities, where infant mortality is falling, life expectancy is improving and, for the first time, hope is emerging that we can “close the gap” over the coming decades.5 The health needs of Australian Aboriginal and Torres Strait Islander people are unique and will not be addressed by research conducted in Europe or the United States.

Economic effects of health research

Medicines and health products now make up one of Australia’s most valuable high-technology export industries, at almost $4 billion per year.4 Many discoveries and inventions currently underway have the potential to create high-value jobs and strengthen the economy. For example, innovations such as the continuous automatic positive airways pressure kit, to prevent the upper airways of people with sleep apnoea from closing, generate tremendous export dollars.4 Funding the “gap” in the research pathway to such innovations becoming commercially ready will benefit Australia’s health and the economy.

However, health and medical research requires substantial investment that is not driven by profit. Much early-stage discovery work is considered too immature for commercial investment and will not occur if left to the private sector. Further, much valuable medical research does not lead to marketable discoveries. The Australian research by Professor Terence Dwyer and colleagues that established the link between prone sleeping and sudden infant death syndrome is just one example.6 Thousands of infants’ lives have been saved by this important discovery and its successful translation into effective health promotion, but by its nature it could never result in commercial success.

One of the world’s largest longitudinal population-based health studies was conducted over 12 years by Melbourne’s Baker IDI Heart and Diabetes Institute, to examine the health of Australians with regards to heart and kidney disease, diabetes and obesity. This research is critical in guiding how to best spend our health dollars, where to invest in treatment, and how Australians can play an important role in improving their own health.7 This work also informs what clinicians should be talking about with their patients and which tests they should be doing to prevent complications and disability. This is not pie-in-the-sky research, but work that has a direct bearing on people’s health today.

Filling the gaps in health research

While we can be proud of the contribution Australian health and medical research makes to our nation and the world, there are gaps and weaknesses. The McKeon Review identified that we are failing to make the most of our research discoveries.4 We have a great health system, but the failure to more completely and quickly adopt our research discoveries means that we miss opportunities to improve the quality of care and the efficiency of our health care system.

We need to do more to embed research into our health system and to improve the interaction between the health sector and researchers. In this way, we can undertake research that is relevant to our health needs and ensure evidence-based improvements in health care are implemented more quickly and effectively. To reduce costs, existing practices should be examined to ensure that they are evidence-based. We also need to do more to ensure that our research discoveries translate into new drugs, medical devices and diagnostic tools that are the basis for progress in health care. This has the potential to deliver not only improvements in health, but new jobs and business opportunities for Australians.

The potential of the MRFF to support these endeavours is enormous. While there are questions to be answered, including what the MRFF will fund and how it will operate, we should not lose sight of the bigger picture. Australia has one of the best and most efficient health care systems in the world, underpinned by past and current research, and the potential to do much more is exciting. The MRFF offers us a way to achieve this potential, and the evidence shows that all Australians stand to benefit.

A better understanding of patient safety threats and incidents is needed to inform preventive action

Although most health care services are delivered in the community-based primary care sector, little is known about medical errors and near misses (here referred to as patient safety threats) and the consequent adverse events and harms (here referred to as patient safety incidents) in primary care. In Australia, research and data on patient safety comes almost exclusively from the hospital sector. The common assumption is that the problem is at least as common in primary care as in other areas of medical practice, but there is currently no mechanism to capture and analyse national data. A better understanding of patient safety threats and incidents in primary care is needed, along with resources to enable preventive action.

In Australia, little is known of patient risks of harm in primary care, and the few studies that have been done in this area are dated. Given the size of the sector, the diversity of providers, the frequency with which people access services, and the central role of primary care in the system, it is essential that the quality and safety of primary care are continuously improved and efforts made to prevent patient safety incidents. However, there is currently no mechanism to capture and analyse national data, and there is no agreed taxonomy to underpin effective incident monitoring; although as far back as 1997, Britt and colleagues developed a taxonomy and showed that an incident monitoring process could be successfully applied in general practice.1

Most research is based on surveys and questionnaires of general practitioners. The overall incidence of GP-reported errors has been estimated at about one per 1000 Medicare services and two for every 1000 patients seen by a GP.2 In 1998, Bhasale and colleagues used an incident monitoring approach to show that 76% of GP errors were preventable and 27% had the potential for severe harm.3 Fifty-one per cent of incidents related to pharmacological management, and the biggest contributory factor was poor communication. Despite the fact that diagnostic uncertainty is a key feature of general practice, most of the errors reported in this study were generated by basic oversights rather than uncertainty: failure to review the patient’s history, or abnormal test results missed or not acted on.

A literature review prepared in 2009 for the Australian Commission on Safety and Quality in Health Care (ACSQHC)4 showed numerous and substantial gaps in current knowledge about threats and incidents that present a risk to patients in primary care, with most of this information relating to general practice and pharmacy. The gaps are even more serious when it comes to knowledge of interventions and strategies to improve patient safety in primary care, and the review found a lack of rigour in the research in this field.

The three most common factors thought to contribute to harm in primary care are clinical complexity, human factors and systems causes;5 and they are not mutually exclusive.

Human factors in the clinical setting are about “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge”.6 Put another way, “human factors are all the things that make us different from logical, completely predictable machines. In simple terms they are all those things that enhance or reduce human performance in the workplace”.6 Understanding human factors is an important aspect of understanding the causes of patient safety threats and incidents and preventing them.

Challenges related to clinical complexity include managing multiple conditions and multiple medications. As the prevalence of multimorbidity is high and increases with age, this is a growing problem for primary care.7 Studies to improve the management of these patients have focused on quality of care rather than safety and error prevention. Calls have been made to adapt guidelines to take account of multimorbidity8 and to make better use of electronic prescribing and medication reviews when multiple medications are involved.5

System causes that contribute to patient safety threats and incidents include a lack of coordination, including between primary and secondary and tertiary care sectors; cost-cutting measures; and environmental and design factors. For example, the transition from community to hospital and back into the community has been associated with duplications and omissions of tests and treatments, prescribing errors and adverse events.9

Adverse drug events (ADEs) constitute the most important subset of patient safety incidents in general practice, and one study has shown that 7.6% of ADEs result in hospitalisation.10 In older patients, ADEs resulting from commonly prescribed drugs at therapeutic dosages are frequent and are associated with morbidity.11 In Australia, it is not mandatory to report adverse drug events, so the true size of the problem remains unknown. The Royal Australasian College of Physicians, in its 2013–14 Budget submission, has called for making reporting of ADEs compulsory, but at the same time has requested reimbursement for physicians doing this.

Despite the potential size and impact of this problem, there is a conspicuous lack of information about what works in this area. A comprehensive review undertaken in 2009 found that neither community-based, pharmacist-led interventions (including medication reviews) nor primary care physician education programs were effective in reducing hospitalisation for ADEs.12 Another article concluded that “deprescribing in older persons likely results in reduced medication usage and cost and is unlikely to cause harm to patients”, but there is a “lack of high-quality, long-term, prospective evidence to show that deprescribing results in clinically meaningful outcomes”.13

These complex patient safety problems require solutions across the whole health care system and not just a focus on acute care or general practice. In particular, there must be a greater focus on patient safety in allied health areas.

The one constant in all of these patient safety concerns is the patient. Putting patients at the centre of health care also means putting them — and their carers — at the centre of questions around quality and safety, reporting and management. Patients have a key role to play in helping to identify safety incidents and taking appropriate action to prevent them,14 but this is rarely done. Where such work has been undertaken, it shows divergences in views about what is important.

Interviews with primary care patients suggest that breakdowns in access to and relationships with clinicians may be more substantial than technical errors in diagnosis and treatment.15 Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities. Problems such as failure to get a timely appointment, a busy doctor who does not take the time to adequately explain and educate, even perceived racism, can have harmful consequences and show that patient dissatisfaction and poor-quality care share common origins. They also highlight that a focus on technical errors is insufficient to ensure patient safety.

The goal of quality and safety initiatives is to reduce harm, and the stories that patients tell of their view of deficiencies in the system highlight system design flaws that are amenable to analysis and change. Harmful adverse events have consequences that linger. One study found that nearly a third of patients who reported adverse events causing harm also reported long-term or permanent emotional effects, and over 20% described long-term physical consequences.16

This poses an awkward problem for GPs: the high levels of trust that Australians have in their GPs are translated into their positive attitudes to GPs’ role in patient safety. When adverse events occur, especially if the incident is not managed well, patients may experience considerable psychological trauma. Unintended adverse events can be confronting, even for experienced and skilled GPs, and patients who are harmed often experience the incident as a violation of trust and lose confidence in their GP and practice.

For now, Australia’s lack of system-wide reporting on patient safety is a black hole that means there are no data and no contextual information for patient safety improvements. The work done in this regard by the ACSQHC in 2009–2011 appears to have ceased with the publication of the Patient Safety in Primary Health Care — Consultation Report July 2011.17 This report called for work to be undertaken to ensure the development of a nationally coordinated, systematic and effective means of reporting errors and near misses in primary health care, based on an agreed set of safety measures. But it also chose to highlight the Australian Medical Association’s contrarian view, “‘Our view is that the organisation of primary care in Australia is in for such a shake up over the next two or three years that it is the worst time to be contemplating some sort of safety intervention or initiative”.17

That was a very prescient statement, given the changes proposed by the Australian Government with respect to the replacement of Medicare Locals with Primary Health Networks (PHNs). But quality and safety are too important to put aside any longer, and efforts must be made to advance the admirable but false start made in primary care. Quality and safety must be an integral aspect of the new PHNs and they can be further advanced by practice-based research networks and a primary care patient safety collaborative.

If Australia is to regain the momentum to improve patient safety in primary care, there needs to be:

• recognition that patient safety incidents in primary care matter;
• national data collection to evaluate the full extent of the harms caused;
• a concerted research effort to better understand the problems and their causes; and
• collaboration across jurisdictional and professional boundaries to implement improvements.

There needs to be action at every level of the health system and policy initiatives and resources to drive this. The role of the patient needs to be central and that of general practice paramount, and an opportunity needs to be provided for primary care networks to take the lead.

To the Editor: Our hospitals and hospital-based colleagues provide wonderful care and, unfortunately, most of us will require inpatient care at some stage in our lives: we are all aware of increasingly complex comorbidity and polypharmacy problems as we age.

An apparent impasse between community care and hospital discharges and admissions remains, even though information technology in the 21st century should make life easier. This has fiscal, medical and social sequelae.

Finding a solution to this requires a complex debate, which should remain focused on the best outcomes for our patients.

Who looks after the patient in hospital? There is naturally a team of doctors and allied health personnel. The team leader is usually a consultant whose name is listed at the head of the patient’s bed.

The Academy of Medical Royal Colleges in the United Kingdom recently endorsed this concept, ensuring that patients, their relatives and carers will know “which doctor is ultimately responsible for all aspects of their care”.1

So where do community physicians fit into all of this? Because real life does happen outside hospitals, and patients actually return to their communities!

My patients, especially those with complex problems, complain recurrently about a loss of continuity between their hospital and their general practitioner.

A critical innovation could be that the patient’s GP is listed alongside the name of the relevant specialist colleague at the head of the bed.

The patient would then be reassured that their prime medical carer has close alignment with the hospital staff, and junior hospital staff would know who to contact on admission and discharge, ensuring a smoother transition and reducing fragmentation.

This would be a win-win situation for all concerned!

Being involved in politics during the Whitlam era was exhilarating

I have met every Prime Minister since Gorton, save Rudd. Most of these encounters have been fleeting and now, as those who were the young Ottomans of the seventies approach the age where they put their 70-year-old feet on the ottomans, it is interesting to reflect on Gough Whitlam, whose memorial service echoes in my ears as I write.

Everybody has an anecdote about Gough. Mine is about a night in 1973 when I was leaving Parliament House with John Knight, who later became Senator for the Australian Capital Territory before tragically dying in 1981 at the age of only 37. On the steps of Parliament House, we encountered Graham Freudenberg, who was working for Gough at the time. Both John Knight and I were on opposition leader Bill Snedden’s staff. However, staffers, irrespective of party affiliation, were generally on good terms, and Graham — Freudy, as he was known when we were all in a bibulous frame of mind — in the ecumenical spirit of the times, invited us both to a party.

We got lost going to the party in John Knight’s Datsun, but, spying a phone box, Freudenberg suggested we call for reinforcements. Five minutes later, after a brief phone conversation, around the corner came nothing other than C1, the Prime Minister’s car. I said to Freudenberg, “Not every day of the year that the principal private secretary of the leader of the opposition has the opportunity to ride in C1. You go with Knighty and follow us.” Freudenberg agreed; Gough’s driver, whom I also knew, agreed — and for about 5 minutes of borrowed splendour, I did what no other opposition staffer had, to my knowledge, ever done — ride in solitude in the back seat of the Prime Minister’s car, chatting with the PM’s driver.

It was a bloody good party. I never knew why the car was there. Gough was not. After this escapade, there were apparently some murmurings, but nothing of any moment until, one day some weeks later, I met the Prime Minister coming up the stairs of Parliament House. He half turned and, with that Gough smile, boomed: “I hope you enjoyed the ride the other night, Jack.” And that was that. Generosity, wit, tolerance. That was 1973. Kerr and Fraser with their “genius” Barwick were yet to come.

Gough was one of those figures who, in a short time, oversaw long overdue social changes. Even working on the opposite side of the House, it was an exhilarating period in Canberra. Gough with all his expansionary vision for his Australia, however, was “easy meat” in the first Budget, when the worldwide recession hit with the collapse of the Bretton Woods agreement, coupled with the oil crisis when petrol prices soared. His lack of economic savvy was at the heart of Gough’s ultimate failure, and, although his oratory has not lasted down the ages, Bill Snedden made a very good speech in reply to this first Budget.

The pathway Whitlam strode along was littered with an array of beautiful bulbs, some of which germinated into delightful blooms. Others (such as Salvado in Western Australia, one of a number of projected growth centres) barely germinated.

I remember the battle over the introduction of Medibank, and the calm, logical manner with which Bill Hayden confronted his adversaries. He was well briefed by John Deeble and Dick Scotton, Medibank’s architects, with the ubiquitous man in black, Paddy McGuinness, Hayden’s then economic adviser, lurking in the background. That Medibank involved changes to the payment systems to both doctors and hospitals was perceived as a direct challenge to the private health funds and the Australian Medical Association (as if fee-for-service medicine was ever at risk and hospital funds would be run out of business).

Much of the political noise was about disturbing the sanctity of the doctor–patient relationship and subjecting doctors to compulsion. Abortion and the rights of the woman versus those of the unborn child were debated as a form of subplot, a surrogate for Whitlam wickedness. There was talk about socialised medicine and dark forebodings about the consequences if Medibank came to fruition. There was the Hospitals and Health Services Commission, which fitted more to the grand Whitlam design because it spread the federal umbrella of centralised control. That exercise ultimately failed, existing only from 1972 till 1978, but the Hayden Medicare plan did succeed after the double dissolution election of 1974 resulted in Whitlam being re-elected.

To Whitlam’s credit, the legislation was passed by a joint sitting of the two houses of federal parliament, although he was never as sure-footed with this as he was with other of his proposals because it needed the detailed financial attention that Hayden could provide in ensuring it ultimately came into being in 1975.1 However, Whitlam was the chief steward, and if he had not supported it as he did, then even with Hayden and the myriad Labor doctors such as Moss Cass, they would never have seen it through.

At the heart of the Medibank system was community rating and a sense of equity in that everybody was entitled to both a government-paid hospital bed and treatment as a public patient. The government pricing system in what is now Medicare has been more or less successful. It is long overdue for review — but that is another tale.

It is interesting that the United States is experiencing similar hysteria about Obamacare, which, although untidy, is attempting to do what has long been accomplished in Australia — make reasonable health care available to the whole population.2 There are elements of compulsion in the provisions of the Affordable Care Act, just as there were in Australia’s original Medibank proposal. A taxation levy was designed to pay for Medibank. This provision was resisted longest by the conservative forces.

The other provisions that send the reactionary teabag wavers into a political spin is the centralisation of power, whether this be in Washington or Canberra. Most of the debate then degenerates into power struggles. The US Republican states call the current White House the bastion of socialised medicine. So long as the matters of compulsion and federal–state imbroglio are allowed to fester, any national health scheme is at risk. In the US, the threat is to repeal — but to what?

I pondered as I listened to the Whitlam memorial service and the litany of achievements that Gough promoted. Had those eulogists not missed one very significant achievement — the 1974 passage at a joint session of the federal parliament, the enabling legislation? The health debate after 1974 was reduced to skirmishes which, at times, became personal and ugly, but the integrity of Medibank, transmuted into Medicare, has remained. Not a bad achievement and, for a period, I was there.

Thanks Gough. I enjoyed the ride.