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Financial penalties for avoidable hospitalisations.

Published by Anonymous (not verified) on Thu, 24/06/2021 - 4:56am in

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Health

The 2020-25 Commonwealth-state hospital funding agreement requires the Independent Hospital Pricing Authority to consider penalties for excessive rates of potentially preventable hospitalisations. The new penalty would sit alongside existing penalties on states with higher-than-expected rates of ‘adverse events’ in hospitals.

Potentially preventable hospitalisations are defined as those that can either be avoided or their rate reduced with good primary health care.

One category of potentially preventable hospitalisations is admissions for vaccine-preventable diseases such as measles, and this category should probably now be updated and expanded to include COVID-related admissions. Potentially preventable hospitalisations also include admissions for heart disease and other chronic conditions where a higher rate of admission is an indicator of weaknesses in primary care.

The definition is still somewhat crude – could a hospital admission that is so serious it leads to a 10-day stay really have been prevented with good primary care? However, since first proposed in Australia more than a quarter of a century ago, the rate of potentially preventable hospitalisations has become established as a widely used indicator of health system performance.

In 2017-18 there were about 750,000 potentially preventable hospitalisations, including 85,000 that were vaccine-preventable (mostly pneumonia and flu), 330,000 potentially preventable acute admissions (including dental conditions and cellulitis), and 345,000 potentially preventable admissions for chronic diseases such as asthma and chronic obstructive pulmonary disease.

Potentially preventable hospitalisations occupied almost 3 million bed-days in 2017-18 and occurred at a rate of about 3,000 per 100,000 population. Some parts of Australia have much higher rates of potentially preventable hospitalisations than others (as shown on the graph below).

Australian Institute for Health and Welfare

Who should be penalised for poor performance?

The task for the Independent Hospital Pricing Authority is a complex one. Potentially preventable hospitalisations are a measure of failures in primary care rather than hospital care, because by definition if the admission had been prevented the patient would not have gone to hospital.

The Commonwealth government is responsible for the ‘system management and support, policy, and funding for GP and primary health care services’, so any penalty for excess rates of potentially preventable hospitalisations should logically fall on the Commonwealth. But designing a penalty that falls on the Commonwealth without creating perverse incentives for the state will be tricky.

One approach could be for the Commonwealth to pay states for excess potentially preventable hospitalisations. This would require the Independent Hospital Pricing Authority calculating an expected rate of potentially preventable hospitalisation for each diagnosis on the potentially preventable hospitalisations list, adjusted for the factors that are known to lead to higher rates of admissions. The Commonwealth would then pay states the full costs of these higher-than-expected admissions in each diagnosis cluster.

But if this new higher payment for potentially preventable hospitalisations were passed on to hospitals, it would create a perverse incentive for hospitals to admit these patients inappropriately. Introduction of the new penalty should therefore be accompanied by an agreement with the states that they would not incorporate it into payments to hospitals. The states might also be invited to agree that any additional funding which flows to them should be used for state-wide programs to reduce potentially preventable hospitalisations or in areas with high rates of those admissions.

A new, reciprocal, and two-way penalty regime could also be used in other areas where failures in Commonwealth policy lead to higher costs in state hospital systems. New penalties on the Commonwealth might be for the costs of patients who have to remain in hospital after their acute care has been completed, because of long waits for aged care or appropriate accommodation under the National Disability Insurance Scheme.

Currently, the only penalties in Commonwealth-state agreements are for safety and quality of care breaches, and these fall on the states. Broadening penalties, so that some fall on the Commonwealth, would reflect more accurately the ‘marble-cake’ nature of responsibility for healthcare in Australia.

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Australia’s Covid vaccine rollout, Part 4. A good outcome by Christmas is possible

Published by Anonymous (not verified) on Thu, 24/06/2021 - 4:51am in

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Health, Politics

A move away from AstraZeneca is inevitable in Australia’s vaccine rollout, brought on by the need to reach herd immunity and to resolve the blood clot concerns. We forecast plenty of Pfizer arriving from after September, and the possibility of completing a high efficacy vaccine rollout by December. For the coming months, though, the rollout will inevitably be slowed at which time all Pfizer doses should go to those remaining in the most at-risk groups.

The government has announced frequent revisions and changes to targets, all of which provide little improvement in our confidence that they know what they are doing. We show below that they are now in a vicious circle that will only be resolved by strong decision making and unnerving patience by the community. The problem has been worsened now that Pfizer is advised for everyone under 60 years.

One suspects that, in hindsight, if our health experts and politicians had the chance to start again with one vaccine, it would have been with shored up orders of the 95%-efficacy-Pfizer. Most of the government’s problems would not exist had that happened.

The chance to rectify that early mistake has come. We predict delivery of 31 million doses of Pfizer in the last four months of the year, enough for everyone who wants it (or the high efficacy Novavax and Moderna vaccines).

In theory, we could reach herd immunity by Christmas, and consider opening our international borders. However, there will not be enough Pfizer to meet the demand for the next few months.

Waiting until Pfizer doses arrive on stream in large batches means we need to be patient with the vaccine rollout and hold our nerves with our quarantining and contact tracing systems.

It also requires a complete turnaround in how the program is managed.

We can predict the number of doses of vaccine to arrive in Australia

We explained in Part 2 how the Vaccine Roadmap of 14 March, and later data, enable us to predict the delivery of vaccine doses month by month for 2021. Our predictions are shown below in table and graph form.

Vaccinations supply

More AstraZeneca would be delivered from September but we have excluded numbers (*) from the table as the vaccine would be surplus to Australia’s requirements – it would not make sense to have the high efficacy Pfizer doses arriving by the millions and not use them (We have not included Moderna and Novavax deliveries due to uncertain delivery dates.)

Thus, it is estimated that up to the end of August, 26 million doses of the two vaccines combined would be delivered (though not necessarily injected), with another 31 million doses of Pfizer arriving from September to December. It is expected that the number of AstraZeneca doses injected will be significantly below the predicted number of doses delivered.

Vaccinating 25 million Australian

In summary, there will be plenty of Pfizer for those Australians who want it in the last quarter of 2021.

The vicious circle confronting our decision-makers

There are two forces at work throwing the government’s rollout into chaos.

First, the Delta Covid variant which appeared in early June in Victoria is quoted as up to 70% more transmissible than the Alpha variant. It means that – all else being equal – the risk of being infected is somewhat greater for everyone, even for many of those who are fully vaccinated. Anecdotal evidence indicates other concerns with the Delta variant, including more likelihood of hospitalisation.

With the appearance of this strain, there seemed to have been a significant shift in the Commonwealth government’s and National Cabinet’s objectives. Originally the main priority of the vaccination campaign was to prevent serious illness and deaths in groups 1a and 1b, including those 70 or older.

However, with concerns about Delta transmissions, the push began to vaccinate the young, group 2b. To increase uptake, Pfizer, which is recommended for that group, was opened up to those aged from 40 (or 30) to 49. The governments might have intended to open it up to other age groups.

This creates supply problems for vaccinating all 7.0 million in the 2b cohort. For them, 14 million doses of Pfizer will be required. We forecast only 9 million doses to be delivered up to the end of September. The shortfall is about 5 million. Already in mid-June, we hear of supply shortfalls for Pfizer as those aged 40-49 roll up. Only 1 million doses were delivered in June.

The young are said to transmit the virus more widely and rapidly than older people. If they are allowed to ‘run loose’ there may be collateral damage for the most vulnerable from an outbreak, in the form of more hospitalisations and deaths and more who suffer from long Covid. We estimate that up to 3 million young Australians cannot be properly vaccinated until October.

The other force affecting the rollout is the policy regarding the risk of blood clots from the use of AstraZeneca.

Messages have become confused. On the one hand, it seems the condition is now much more treatable, meaning the policy for the under 50s possibly could have been withdrawn and AstraZeneca used for them.

On the other hand, there have been two deaths from the syndrome in Australia, a 48-year-old and a 52-year-old. Experts were debating whether to extend the age range to the under 60s. As I write, this decision has been made: Pfizer will now be preferred for the 50-59 age group as well. The AstraZeneca vaccine will now only be recommended for use in people aged 60 and over.

This change suddenly means we will need about 3 million extra doses of Pfizer, and need that many fewer of AstraZeneca.

Conservatively, for the age range 16 to 59, we estimate a shortfall of Pfizer of about 8 million doses until October. This extra demand equates to an extra 8 million doses of AstraZeneca produced by CSL that will not be required; 2 to 3 million doses per month could be added to all the others sitting on the shelves (or donated to needy countries).

In summary, the intention to vaccinate the young because of their higher transmission propensity, combined with the blood clot restrictions, have increased the demand for Pfizer to the end of September by about 17 million doses, yet with only 9 million coming!

But with the blood clot genie out of the bottle, surely there will be even greater resistance to AstraZeneca amongst those who are 60 or older. Expect the daily vaccine numbers to plummet across all age groups.

Hence the government is in a bind. Those aged under 60 are restricted to the Pfizer vaccine for which we don’t have sufficient supply. Yet, we do have millions of spare AstraZeneca which would make them and the community more Covid-safe if it were recommended for them.

Confoundingly, we hear that a major advertising campaign will be launched in July to encourage under 40s to get vaccinated. We need to ask, vaccinated with what?

While the young are beseeched to have a vaccine which we don’t have enough of, older Australians, even those who have been vaccinated with AstraZeneca, might have to remain indoors in order to avoid infection from the highly mobile youngsters.

Hence, the decision needs to be made to prioritise Pfizer for the most at-risk still to be vaccinated.

We could have herd immunity and open our borders by Christmas – But will it happen?

AstraZeneca will be quickly phased out: it is now no longer advised for anyone under 60, and herd immunity seems impossible with it as a primary vaccine.

This means the rollout will have to be much slower until Pfizer arrives in large numbers in October. (Unless some can be fast-tracked.)

The aim of vaccinating the young should be dropped for the time being. If the supplies of Pfizer are limited until the end of September it should be used to vaccinate those remaining frontline workers and those remaining in the most at-risk groups, which includes those 70 or older and those with severe medical conditions.

There will be many in the 70 and over age group holding off because they perceive Pfizer to be more effective against long Covid and provides higher personal immunity. It would be unconscionable to save the lives of those under 60 by not recommending AstraZeneca for them due to blood clot risk, yet risk the lives of those over 60 by not offering an alternative to AstraZeneca.

However, once supplies ramp up, a complete rollout of Pfizer or equivalent can be completed by December, given the tens of millions of doses on order.

Until then our current nationwide strategy of maintaining zero community cases must continue, via hotel or remote quarantining and through contract tracing. All Australians, including the young ones, will have to continue safe-Covid practices until we achieve a satisfactory rollout and immunity level.

Occasional community outbreaks may occur, but since October last year, we have shown that they can be doused quickly. Thus, we will need to hold our nerves for some months yet.

A successful vaccine rollout will open up society again, returning us to close to our normal pre-Covid lifestyle and economy and open up our international borders, allowing Australians to travel overseas and for us to accept visitors.

But we aren’t there yet. It is one thing to have the doses, but it is another matter to inspire people to want them. We have to increase the community uptake of vaccines, well above the 70% that surveys are predicting at the moment. It is hoped that people will react positively to being offered the best vaccines available. The government also needs to advise whether mixes of vaccines will be permitted, with boosters available using a different vaccine to the first one.

The loss of confidence in our decision-makers needs to be restored. The politicians and health officials need to be more transparent, provide us with more data and drop the politics.

Most importantly we need a federal government that is up to the task. They will need to gear up for four full-on months, preparing vaccination hubs and other outlets to reach the finish line.

Our best vaccination day so far was 11 June when 153,338 doses were given. From the beginning of September, we might still need to inject 24 million doses of Pfizer. For the four months to December, that means 200,000 a day. This is achievable!

The federal government has said they would like to complete the full rollout of two doses to all Australians who want to be vaccinated by the end of October, perhaps by the end of December 2021.

The challenge for a good outcome for Australia by Christmas is there for them. Are they up to it?

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Dissecting the controversy around Medicare reform and a disappointing response from the ALP

Published by Anonymous (not verified) on Thu, 24/06/2021 - 4:06am in

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Health

Any plan to change Medicare — especially if it comes from a Coalition government — is bound to attract controversy. So when health minister Greg Hunt announced a fortnight ago that more than 900 items on the Medicare benefits schedule would be changed with just a month’s notice, the reaction was immediate.

The changes mean that the Medicare reimbursements for a large number of surgical procedures — orthopaedic, heart and other general surgery — will fall. The aim is to encourage modern clinical practices by shifting funding from lower-value to higher-value healthcare.

Doctors’ groups, private health insurance funds and private hospitals have called for the changes to be delayed to allow them time to adjust their internal processes and charging. The Australian Medical Association says that the changes, if rushed, could result in unexpected out-of-pocket costs for patients. Other industry and consumer groups, along with the Grattan Institute’s Stephen Duckett and UNSW’s John Dwyer, have supported the call for a delay.

Despite the lengthy process of expert deliberation leading up to the changes, Labor has called for them to be scrapped altogether, adding more confusion to an already complex issue.

The review of the schedule, which began in 2015, was a massive undertaking. Supported by a consumer panel and a public consultation process, a network of committees and working groups examined 5700 items listed on the schedule, producing more than sixty reports and 1400 recommendations.

As well as recommending changes to Medicare, the review proposed measures to increase the quality and safety of treatments and to make access to medical services more equitable.

The review of ophthalmology, for example, recommended increasing rebates in rural and remote areas to tackle current shortages. Some services that GPs are currently allowed to provide should, it recommended, be limited to specialists with the training that enables them to deliver a higher-quality result.

It’s hard to argue against recommendations like this that are based on evidence and developed collaboratively by clinicians, health economists and other experts, and consumers. And the sheer number of recommended changes highlights how overdue the review of the schedule was.

That shouldn’t be any surprise. Medicare was designed more than a generation ago, and since then our health needs have changed. Advances in medical and pharmaceutical research and technological innovations have driven changes in clinical practice.

In some areas, these have been dramatic. A procedure that was once time-consuming and demanded a high level of skill might now, with the assistance of technology, be performed much more quickly by a clinician with less training. Other services that were once common should no longer be performed because the alternatives are more effective and safer.

Implementing the changes may be complex, and arguments about the detail are inevitable, but the review was necessary and had wide support across the health sector. In fact, many Australians might be surprised to learn that this type of review doesn’t occur as a matter of course.

That’s why the controversy is more about the implementation than the changes themselves, though we’re also seeing the politicisation that inevitably accompanies any debate about Medicare.

Of course, the major professional groups can’t help protecting their own interests. The AMA, for example, is being disingenuous when it claims that concern about out-of-pocket costs is motivating its desire to delay the changes. It’s had plenty of time to act on this longstanding problem by doing more to tackle fee variations, particularly by reining in specialists who charge significantly above the recommended fees.

But the changes are administratively complex, and the short timeline does put unnecessary stress on hospitals, health funds and doctors. And it’s hard to see how delaying them for a few weeks or even months would cause any major problems; it would certainly buy the government some valuable goodwill across the sector.

Particularly at the moment, when the government is struggling with its own challenges in implementing the Covid-19 vaccine rollout, it should be sympathetic to organisations with fewer resources trying to grapple with changes to the Medicare schedule.

Labor’s blanket opposition — clearly motivated by the hope of a Mediscare-type campaign at the next election — isn’t helping. It may be understandable, but it’s a disappointing response from a party that should have a sophisticated understanding of the need to keep Medicare up to date. That’s not to say there’s no truth in Labor’s claims about the lack of underlying support for Medicare within Coalition ranks. But the Medicare schedule review is not the best target for trying to make this point.

Labor’s commitment to Medicare shouldn’t mean allowing it to ossify in the 1980s. If Medicare is to continue serving the needs of the Australian community, it needs to evolve. A sustainable and robust Medicare can’t continue to subsidise low-value care with outdated and non-evidence-based rebates.

What’s important at this point, though, is to make sure these administrative hiccups and attempts to politicise the review don’t derail longer-term improvements. So far the focus has been on changes to individual Medicare items, but the review also dealt with the need for system-wide reform.

A continuous review mechanism is needed, it said, to ensure that Medicare can evolve with changing clinical practices and community needs. The government and the AMA support that recommendation, but its success will depend on collaboration between the major interest groups. The government’s recent willingness to work with the AMA on implementing future review recommendations is a positive sign.

Also urgent is action on out-of-pocket costs, which make up 17 per cent of total health funding, or around double the contribution of private health insurance. Despite these costs’ impact on access and choice, the government shows little interest in how much consumers pay for medicines, health and medical services, and devices. Limited safety nets provide little protection for people with chronic, complex conditions who must pay a large number of relatively small amounts for medicines, supplements, dental services, allied health, medical gap payments, aids and appliances.

People who are charged unfairly by health professionals have little recourse, and the government’s half-hearted attempts to help them avoid these charges — via the medical costs website, for instance — don’t appear to have had any impact. Meanwhile, an entire branch of the health department deals with private health insurance, which is used by less than half the population and contributes only 9 per cent of health funding.

Medicare is a blunt instrument for tackling many of these issues. Changing rebates often has a limited impact, is complex to enforce and can result in perverse incentives. But it is often the only tool the federal government has to drive changes and therefore should be used to its full potential. Allowing the sector some latitude in implementing the current changes will help create a climate in which longer-term improvements can be made.

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Australia’s Covid vaccine rollout, Part 3. In June 2021 we are at the crossroads

Published by Anonymous (not verified) on Wed, 23/06/2021 - 4:51am in

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Health, Politics

The first week of June will be significant in Australia’s Covid story. Victoria had entered lockdown on Thursday 27 May after a case of community infection arrived via Adelaide. Another more dangerous variant would also appear. Australians would react with more heading out to get a jab, but not in sufficiently large enough numbers. Pressures were building for the government to dramatically change its vaccine strategy.

Here we explain why a move to high efficacy vaccines is necessary. While embarrassing for the government, it might be the good news amongst the bad (as explained in Part 4).

Change is being forced onto our decision-makers!

The ABC has an excellent webpage called Untangling Australia’s vaccine rollout timetable.

At the very beginning the link includes:

“We don’t want to make promises that we can’t keep. That is incredibly important,” Prime Minister Scott Morrison assured Australians in January.

The webpage notes that in the three months since the official launch of the vaccine campaign on February 22, the government has announced more than a dozen targets, revisions or updates to the rollout plan. The webpage has excellent graphics displaying how the rollout changed over those months. (The graphics are best viewed on a large screen.)

It was last updated on 30 May. It ends with:

As June approaches, the nation stands poised to pass the government’s 4-million-dose milestone — two months later than originally planned.

The vaccination rate has climbed to a record 535,000 doses a week.

At this pace, Australia can expect to reach the 40 million doses needed to fully vaccinate the adult population in September 2022.

On 15 June, the total number of doses administered had reached 5,888,718, an increase of 684,741 for that week, an improvement on May, but only 100,000 per day. Despite worrying developments about the Victorian outbreak and a new variant, the increase is not nearly enough: if it continued at this weekly rate until 40 million doses were delivered it would take 48 weeks, up to May 2022!

The daily rate might increase as second doses occur, but the finish line is not close. If we want to vaccinate our 5.5 million children as well (as some countries are starting to do), add a few more months.

The pointers are that Australia will have to switch to relying on Pfizer (and the higher efficacy Moderna and Novavax vaccines) due later in the year.

Because it has higher efficacy, has a space of only three weeks between doses and can be more readily upgraded for new variants, it makes sense that if more Pfizer were available there would be a jump in the uptake rate. An early indication is WA authorities being “bowled over” by the massive interest from West Australians aged between 30 and 49 in getting the Pfizer once it was opened to them.

The major reason for prioritising Pfizer though is because we need to cope with the Delta (Indian) variant, now the dominant strain in some countries. We are seeing headlines such as Why the Delta covid variant strain is terrifying experts and warnings that it spreads more easily, is more severe, and is more resistant to vaccines.

The strain is quoted as up to 70% more transmissible than the Alpha variant, and a major driver of infections in the young. With the strain apparently now in Australia, there was a significant shift in the federal government and National Cabinet’s objectives with now a push to vaccinate the young, group 2b, using the stronger Pfizer. The aim – to minimise transmissions.

This change in strategy is taken up in Part 4, where we demonstrate that it creates further problems, a vicious circle that can only be broken with a shift in vaccine strategy.

The problem of reaching herd immunity and opening our borders

The overall sum of these issues is that under current plans Australia will not reach herd immunity. The more virulent strains now seem to make it impossible to get there without switching to high efficacy vaccines.

This informative article was published in The Conversation on 15 February: Herd immunity is the end game for the pandemic.

The article explained the role of the basic reproduction number, R₀, a measure of the contagiousness of the virus which causes Covid. The R₀ for the original Covid strain was thought to be 2.5. That meant, on average, a person with Covid-19 would infect 2.5 people. The article explained how it was possible to use the factor to predict the level of coverage (vaccine uptake) required to reach herd immunity. The lower the efficacy of the vaccine the higher the uptake required to reach herd immunity as some people who are vaccinated can still become infectious and ill from Covid and some can also be asymptomatic, potentially spreading the disease.

Thus it concluded that to reach herd immunity with the original variant we’d perhaps only need to vaccinate 63% of the population with the Pfizer with its efficacy of 95%, or 67% if we used the Novavax with its efficacy of 89%. However, we would need to vaccinate almost 100% of Australians to achieve herd immunity with the AstraZeneca vaccine, with its efficacy of 62%. With a combination of the three vaccines it would still have been difficult.

With the Delta variant detected in Victoria’s outbreak, we learn that the R₀ for the Delta variant is thought to be 5.0.

The aforementioned article includes a very useful graph which we reproduce below. Note the curves for three different levels of efficacy. A dotted line is drawn up from the horizontal axis at the R₀ = 2.5 mark. The vaccination uptake levels required are shown on the vertical axis across from where the dotted line cuts the curves.

Covid contagiousness

We have taken the liberty of adding a solid blue line to the graph at R₀ = 5.0. With a ruler you can draw your own conclusions.

Assuming the theory behind this graph is correct, it shows that to reach herd immunity Australia would need to switch to Pfizer (or equivalent) and achieve a vaccine uptake of close to 85%.

It is likely the government will move its focus to Pfizer (or equivalent)

Our decision makers will soon have to face up to whether or not to continue with AstraZeneca as our main weapon against Covid.

Various experts are expressing doubt about our current strategy and have indicated the need to switch to high efficacy vaccines (see the transcript of 7.30 on the ABC on the 10 June).

To add to the concerns, the ABC included this online article on what we know about the Indian Delta COVID-19 variant detected in Victoria’s outbreak. It indicated that AstraZeneca effectiveness against the Delta variant might be as low as 60 per cent.

Greg Hunt has been ‘all over everywhere’ on the matter of the Covid rollout. However, perhaps on 23 May he indicated the way forward when he announced that from the beginning of October we should have two million Pfizer doses a week, raising the possibility of vaccination by Christmas for those who want it. A few days earlier he had stated: “Right now, we want to encourage everybody over 50 to be vaccinated as early as possible … But we’ve been very clear that, as supply increases later on in the year, there will be enough mRNA vaccines for every Australian.”

In other words, he was telling Australians that if they had concerns about AstraZeneca, they could wait for a few months for the Pfizer or equivalent. (Of course, those who were happy to act earlier could still have AstraZeneca.)

The Minister was reprimanded by some fellow decision-makers for undermining the rollout with these statements, but it seems inevitable that the government will change its strategy. That is made even more possible as we hear that cold storage problems with Pfizer are being overcome making it more transportable with a longer shelf life, meaning it can be used in remote communities and be given in less sophisticated clinics, such as pharmacies.

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Australia’s Covid vaccine rollout, Part 2. What we’ve been delivered

Published by Anonymous (not verified) on Tue, 22/06/2021 - 4:55am in

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Health, Politics

At a press conference about the vaccine rollout in December, Health Minister Greg Hunt said, “our goal is to under-promise and over-deliver”. Over January and February, the rollout was mapped out for us. However, the problems that soon developed were not a case of ‘the best-laid plans’ going awry but more like a case of ‘no plans at all’! It was inevitable that what was promised would not be delivered.

Supplies were barely dribbling in

Despite the lauded contracts, the government eventually realised delivery dates and quantities of both vaccines were either not known or were not guaranteed. With Pfizer we learnt – after it seems the government had learnt to its surprise – that the doses would not be arriving in a few large batches (e.g. millions), but rather in regular relatively small shipments of about 100,000 doses a week.

The good news is that at least it seems these small batches have been arriving in Australia on a reliable basis since the end of February. The bad news is that with this slow delivery rate there could not Pfizer vaccines soon enough to vaccinate those in groups 1a and 1b, as we thought we were promised (see Part 1).

The priority table given in Part 1 shows over 16 million doses were needed for the 1a and 1b groups. At 100,000 doses delivered a week, it would be almost six months, to the end of August, before that many Pfizer would have arrived.

For group 1a alone, 1.4 million doses, or 14 weeks’ worth of Pfizer were needed.

The government thus had to transition to using AstraZeneca for the bulk of the vaccine rollout for the top priority groups. Many of the frontline workers, together with the elderly, the sick and indigenous who were at most risk, would miss out on Pfizer and be switched to the lower efficacy AstraZeneca and its 12 weeks between doses. The risk of outbreaks from quarantine and in aged care increased as a result.

As it was, the transition to AstraZeneca wasn’t easily achieved.

At the end of February the government was banking on delivery of a big order of AstraZeneca from Europe as well as the millions of doses – up to 50 million – soon to be bursting out of the CSL laboratory in Melbourne.

In the meantime, vaccination hubs and centres were being set up around the country to receive the copious quantities of doses from the government for injecting into the waiting arms of the public. Some GPs and clinics spent tens of thousands of dollars getting ready to vaccinate hundreds, if not thousands, of people per week.

The latest plan for Australia that we know of is the Vaccine Roadmap dated 14 March 2021 from the Department of Health. It includes a very useful graph, not picked up by the mainstream media, which shows what the government had planned for 2021 i.e. the rollout ending in December.

Revised Covid Vaccine Supply

In the graph, cumulative data for the vaccine doses to be delivered are stacked on top of each other for each month. The heights of the bars can be unstacked and used to estimate the number of new doses expected to be available each month for each vaccine. Following is a graph of these predicted monthly deliveries. (Novavax data are not included, pending its approval for use.)

Vaccination roadmap

From the March roadmap, we see that AstraZeneca was to become the main vaccine for the most at-risk groups. It was estimated there would be enough doses of the AstraZeneca, and Pfizer if used, for 1a by end of March and 1b by end of May. The roadmap showed that AstraZeneca would continue to be used for group 2a until July-August, meaning everyone aged 50 and over would have been vaccinated, mainly using AstraZeneca. From then, while there was predicted to be plenty of AstraZeneca continuing, there was also plenty of Pfizer becoming available too, but after most of those aged 50 or more had been vaccinated!

Importantly, this graph clearly shows that at mid-March, under the government’s plan well before the blood clot scare, Pfizer was already destined for the arms of the young and healthy, albeit in the last third of the year. However, much of the roadmap would soon be outdated in regard to AstraZeneca.

Delivery issues soon appeared. About 3 million doses from Europe would not be arriving, while the local AstraZeneca production in Melbourne, that the PM announced would be available “within weeks”, was nowhere in sight.

Heads were scratched about the CSL doses – “where the hell were they?”.

The clear indication that usable deliveries from CSL were weeks behind schedule materialised on 7 April when the PM called on the EU to supply the outstanding 3 million doses. Clearly, the government was panicking because it was well behind in the rollout and anxious to obtain more vaccine doses quickly, albeit from the unhelpful Europeans.

Thus, during March the government did not have nearly as much of the AstraZeneca as they had anticipated. Deliveries could not be made to vaccination centres in sufficient quantities. It was reported in the media that many clinics were only receiving 50 doses a week.

The following table illustrates the shortfall. It is based on two sets of data. The “expected” doses are from the government’s roadmap published on 14 March. The “supplied” is from the COVID-19 in Australia statistical website.

Vaccination supply chart

Sources: Expected. Supplied.

By the end of May, the Pfizer deliveries were matching expectations, once it was announced the doses would arrive in weekly batches; the shortfall by end of May was only 0.1 million doses. However, AstraZeneca deliveries, mainly to be produced locally by CSL, were estimated to be 6.6 million doses behind as we headed into June.

The following graph clearly shows how the actual supplies fell well below expectations for AstraZeneca.

Vaccines expected vs supplied

Priority groups were reprioritised

The federal government’s forecasting, project management and understanding of contracts proved to be deplorable.

By the end of March, they had hoped to have administered 4 million doses. However, only 2.3 million were received from producers. Worse still, only 0.7 million of those doses had been administered. In theory, given the actual supply, the government could have vaccinated most group 1a members with two doses of Pfizer by the end of April. But that certainly did not happen.

The federal government made the bizarre decision of not giving the most critical group the best vaccine first. There is only one source of the virus – overseas arrivals, thus the high efficacy Pfizer, with just three weeks between doses, should have gone to frontline quarantine and healthcare workers first. If they get infected, the virus can end up in the community, with an outbreak on our hands. Yet we heard that many had not been vaccinated or were being ‘forced’ to accept the AstraZeneca option, which requires a 12-week waiting period for the second critical dose.

It seemed no longer important to give the better vaccine to the top priority groups, that the elderly, the chronically ill and the indigenous communities were no longer deemed to be critical cohorts, nor the disabled. We learned about shocking rollout problems with aged care residents and staff.

Even before the blood clot issue surfaced in early April, the government was flustered. There were two conflicting problems. Demand problems in the overall community were uneven and showed that uptake was very sluggish, meaning herd immunity targets were looking problematic. Supply problems meant that with pockets of high demand around the country there were not enough doses available to be sent to those clinics that had patients lining up.

Here we note how the blood clot decision in April led the PM to dramatically announce a recalibration of the rollout. The New Daily reported: “Completing a major backflip from the initial rollout, the Pfizer vaccine will now be almost entirely restricted to those under 50, with older people to only receive AstraZeneca.”

However, the 14 March roadmap indicates that the urgent recalibration had already been in place, well before the PM’s ‘remorseful’ announcement!

As the plan changed so did the language used by our decision-makers.

As far back as February, there were indications the government was aware of resistance to AstraZeneca. Statements like “both vaccines are equally effective in preventing hospitalisation and death” were shortened to “all of the vaccines are equally effective.” An example of the Health Minister using this misleading shortened statement can be found here.

Based on originally published efficacy rates, everything else being equal in infectious situations, AstraZeneca is not as effective as Pfizer in preventing mild to moderately severe Covid illness, including long Covid (which might affect up to one-third of victims). And many people wanted to have their vaccination completed within three weeks, not three months.

Our senior health officials could have corrected the Minister’s statement, but maybe they too had started to believe that to encourage people to accept AstraZeneca it is acceptable to make statements such as “there is no evidence of a material difference between these two vaccines”.

Had our politicians and health officials become so desperate that they needed to use the tactic of tweaking accuracy in order to get people lining up at vaccination centres so that the looming fiasco would not be as bad?

Many Australians understand efficacy and risk, and that long Covid is something they want to avoid. People realise that if ‘community immunity’ is low then it is imperative that one’s ‘personal immunity’ needs to be as high as possible. Inaccurate statements and claims make many lose confidence in the messages sent. We don’t know of any survey data, but even before the blood clot announcement, the proportion of Australians who only wanted Pfizer would have been significant, and a major reason for apparent vaccine hesitancy and the lower-than-hoped-for uptake.

The government continued to battle the ever-growing embarrassment of the rollout.

While the PM blamed the EU for shortages, predictably federal ministers turned to blaming the states for the slow rollout.

Meanwhile, the emerging blood clot problems with AstraZeneca reached a tipping point. By early April the decision was made not to recommend the AstraZeneca for under 50s. The fit and healthy young would be offered Pfizer. The blood clot risk is small, even for those under 50, but was high enough for the science to indicate the recommendation.

The government and health officials thus presented us with the mystery then as to why Pfizer is best for those aged under 50 and is (or was) best for those aged over 80 but is not best (or at least not preferred) for those aged in between, 50 to 80 years! And from June 17, make that 60 to 80 years.

This came about, though, because the government had not ordered enough Pfizer, so what supplies it was to receive now had to be “quarantined” for those under 50, meaning anyone older had to have AstraZeneca or nothing.

With insufficient uptake from groups 1b, vaccinations were opened up for group 2a in order to have more throughput at the vaccine centres. The blood clot problem issue with AstraZeneca, though, meant vaccine hesitancy had inevitably grown with those 50 and over, although they were now eligible to be vaccinated.

Not being honest and transparent with the public is not the way to achieve a high uptake.

For a vaccine described as “entirely voluntary” by the Health Minister, the language to have more people queuing up for vaccines became more persuasive, if not more coercive and threatening. For example, those who want to hold off for Pfizer might hear the blunt news (or threat) that if they don’t want AstraZeneca now they might have to wait until 2022 to be vaccinated.

The Covid hotline and vaccine booking service are far from helpful. Ask a question about the two vaccines on offer and you are told bluntly “the vaccines are safe”. Ask anything else such as what they mean by “safe” or any difference in their safety or effectiveness and you get the same four-word answer. They emphatically declare that anyone 50 or over without a special exemption can only have AstraZeneca. They advise you to speak with your GP, but we hear that many GPs do not provide the vaccine and are no better informed than the media.

Four Corners summarised the vaccination problems on 24 May in an episode entitled Australia’s COVID vaccine rollout: What went wrong?

In Part 3 we look at the vaccination numbers in early June, the time of an outbreak in Victoria and the appearance of a new variant, both of which would severely question the way the rollout is heading.

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Should procedural specialists be the highest earning doctors in the nation?

Published by Anonymous (not verified) on Mon, 21/06/2021 - 4:56am in

Tags 

Health

Data shows that procedural specialist doctors earn more per year than many other professionals in Australia and that the highest earning doctors in Australia are surgeons and anaesthetists, earning almost twice what general practitioners (GPs) earn. Why is this so and can it be justified?

Increasing disparity in the earnings of specialists and GPs is reducing recruitment of doctors into general practice. A recent release by the Australian Tax Office highlighted concerning aspects about the funding of Australia’s health care system

Some procedural specialists may argue that their high incomes are justified by their long years of training on low pay, their level of skill, their level of responsibility and the hours worked. Some of these factors may have a degree of validity but they don’t tell the whole story.

While it is true that their training is long, medical and surgical specialist trainees are well paid nowadays. Interns (first year medical graduates) start at an average annual salary across Australia of $76,500, supplemented by payment for overtime. Thereafter salaries rise sharply as the average annual salary for registrars (trainees) is said to be $173,771.

Neither do specialist doctors work especially long hours. Data from 2018 showed that average hours worked per week by specialists was 42 hours and by GPs was 37 hours while registrars worked the most hours at an average of 46 hours per week. The lower average hours worked by GPs almost certainly reflects the part-time work of women GPs with children to care for.

In addition it should be noted that general practice is now a specialty with similar training and examination requirements to other fields of medical practice and that GPs need to have a broader range of diagnostic and patient management skills than do most specialists. GPs too carry serious responsibilities. For GPs working in rural or remote areas, many have to have a range of procedural skills.

None of the above factors seem to explain why general practitioners earn on average about half what procedural specialist doctors earn. The explanation lies within our Medicare system which brings us to the second recent news item: the announcement by the Federal Government of changes to Medicare resulting from a five year study called the Medicare Benefits Schedule Review.

The report received some favourable comment but it is not yet clear how much of this far-reaching report will be acted upon by Government. Already there has been a report suggesting that Government is ignoring some recommendations.  While the MBS Review contains recommendations in regard to block funding of some services and in regard to out-of-pocket expenses, the Review was not directed towards remedying the problems discussed here.

A generation or two ago GPs earned at least as much and generally more than did specialists. What happened to change this balance? The answer lies in the original Medibank and its successor Medicare and the formula (the concept of the most common fee) used to decide what rebate would be paid for the fee that any doctor charged, based on surveys of actual fees at that time. The original schedule favoured procedural work and this discrepancy has increased over time, especially where technical improvements have allowed many procedures to be done more efficiently.

Medicare in our view is the most vital component of Australia’s mixed public/private health care system and must be preserved – but it also needs to be reformed in a manner that seeks to correct the distortions that have crept in. To date any attempt to rebalance the inequities inherent now in Medicare has failed. Thus GPs who are the backbone of Australia’s good health care system remain undervalued while many but not all specialist services are overvalued.

There is evidence that these distortions are changing the career choices of new medical graduates such that there are too many graduates applying for the high income specialties and too few wishing to become general practitioners, leading to shortages beyond the major metropolitan areas. While there are many personal factors that may influence a doctor’s career path, there is good reason to believe that potential earning is a dominant one and that this can be fixed.

The distortions in favour of procedural medicine based on Medicare rebates have been recognised for nearly two decades.

One of the recommendations of the 2005 Productivity Commission report on Australia’s Health Workforce was that ‘the Department of Health and Ageing should investigate the extent of the bias in the Medical Benefits Schedule in favour of procedures over consultations and how any significant bias should be addressed.’

The real need is for Medicare rebates to be higher for GPs and lower for procedural specialists, but introduced in a manner that will not lead to higher out-of-pocket costs for patients.

The task given to the Productivity Commission in 2005 was huge and the time it was given to prepare its report was rushed. With the exception of the national scheme for the registration of health professionals, few if any of its recommendations have been acted upon.

It is time to give the Productivity Commission a new referral to take on the task that it asked of the then Department of Health and Ageing; i.e. to ‘investigate the extent of the bias in the Medical Benefits Schedule in favour of procedures over consultations and how any significant bias should be addressed.’

Such a study should also be invited to examine whether the earning differentials between various groups of doctors are justifiable and are in the best interests of the health care system and patients.

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Australia’s Covid vaccine rollout: what we were promised

Published by Anonymous (not verified) on Mon, 21/06/2021 - 4:55am in

Tags 

Health, Politics

How does the original Covid rollout compare with what we are experiencing right now and what we are likely to end up with? In Part 1 we look at what we were promised. In Part 2 we examine how the rollout collapsed. In Part 3 we find that at mid-year, significant changes to our rollout strategies are inevitable. In Part 4 we show that a successful Pfizer rollout completed by December is possible if the federal government is up to it.

What we know already is that the final rollout will contrast markedly with the original promises and plans. (And the outlook changes as we write – Parts 1, 2 and 3 were written before the announcement on 17 June about extending Pfizer to the 50-59 year-olds.)

To understand where we are headed, our starting point is what the vaccination rollout was meant to achieve: from the outset it seems that the main priority of Australia’s Covid vaccine campaign was to prevent serious illness, resulting in hospitalisation or death.

It is not clear whether there was any consideration or weighting given to minimising mild to moderately severe Covid illness, including long Covid. It seems long covid affects up to one-third of those who catch it, leaving them with debilitating long term issues, including breathing problems and chronic fatigue.

What we do know is that since January 2020, right from the start of the pandemic, we have been constantly warned that some groups are at much higher risk of hospitalisation and death from Covid than others, in particular, those aged 70 and over, those with severe medical conditions and our indigenous populations. It can also be assumed they can suffer from long Covid.

Now, in June 2021, those warnings seem to have little currency in our ever-evolving rollout situation. The most at-risk groups are no longer given priority for the best vaccine.

Leading up to the start of the vaccine rollout

There have been many vaccine announcements since August 2020. The Department of Health website has a summary of Australia’s vaccine agreements. There you can also find links to various government publications and ministerial statements.

By November 2020, the Australian Government announced an agreement to secure 10 million doses of the Pfizer vaccine. That built on already existing commitments to purchase the AstraZeneca vaccine. (Orders would also eventually be made for millions of doses of the high efficacy Novavax and Moderna vaccines.)

On 28 December 2020 the Guardian reported comments made by the Health Minister, Greg Hunt, about Australia’s Covid-19 vaccination rollout:

  • The government’s intention to complete the two-dose vaccination for all Australians who wanted it by the end of October.
  • He indicated that would be ahead of the original schedule of the end of 2021.
  • He affirmed that the vaccine was free, universal and entirely voluntary.
  • He urged as many Australians as possible to be vaccinated, and that he was heartened by reports at the time of an expected uptake of up to 80%.
  • He announced that 3.8 million doses of the AstraZeneca vaccine were expected to be delivered from overseas and ready before the end of February.

At that press conference, the minister said, “our goal is to under-promise and over-deliver”.

What was the original vaccine rollout plan?

Relevant documentation is not easily available from the Department of Health. Some external links to its website no longer work. Some documents and pages are not dated and some might have been updated, with the original deleted or amended, but with no indication of any changes made.

The first evidence we can find of an original rollout plan is this COVID-19 Vaccine Roadmap possibly published as early as 6 January this year.

The plethora of announcements continued over the summer. In early February, The Age ran this feature: Morrison shows again he’s master of spin. It discusses the gushing drip-feed since August about Australia’s access to vaccines. The article notes “the Prime Minister’s talent for making 10 announcements when one might do”.

Another 10 million doses of Pfizer were announced, taking the total on order to 20 million.

On February 12 the PM proudly announced that the AstraZeneca vaccine would be made by CSL in Melbourne, and be available “in a matter of weeks”. The company would supply up to 50 million doses, with more than a million doses manufactured each week, with the bottling of the vaccine planned to start that Monday, 15 February.

Australians had some reason to be optimistic about the vaccination program, based on the frequent upbeat press conferences by ebullient ministers and senior health officials.

But there was also reason to be pessimistic; had we bet too much on the one horse; the AstraZeneca vaccine? The Pfizer vaccine originally purported an efficacy rate of 95%, while the AstraZeneca’s was quoted as low as 62%.

What did we think we were promised?

Common sense tells us that to stop the virus at the entry point it is imperative that frontline quarantine and health workers be vaccinated first. Moreover, that they be given the most efficacious vaccine (Pfizer) which only requires three weeks between doses, rather than 12.

Common sense also says that the most vulnerable members of our community – those more susceptible to hospitalisation or death – should also be given the most effective vaccine, namely Pfizer. In turn, the next most vulnerable groups should also receive the most effective vaccine available, and that the younger members, being fitter and healthier, should be offered the lower efficacy AstraZeneca.

This seemed to be embodied in the government’s early plans.

The government’s priority groups were confirmed in February. Under the section ‘Who will get the COVID-19 vaccine first?’ it notes: “The vaccine is being rolled out in Australia in phases, starting with priority populations — since large volumes of the vaccine aren’t immediately available. Certain groups are prioritised because they would be most affected if infected with COVID-19.”

The priority groups listed are summarised as follows:

Priority group members
People
Million doses

Phase 1a
Including frontline workers and aged-care staff and residents.
678,000
1.4

Phase 1b
Including the elderly (70 or older), Aboriginal and Torres Strait Islander peoples aged 55 and older and those with severe medical conditions.
6,256,000
14.8

Phase 2a
Including those aged 60-69 years, and aged 50-59 years and Aboriginal and Torres Strait Islander people aged 16 to 54 years.
6,558,000
15.8

Phase 2b
Those aged 16 to 49 years.
7,333,000
16.0

Phase 3
Children (under 16 years)
5,090,000
13.6

Total

25,805,000
61.6

 

In total, about 62 million doses were to be allocated, clearly enough for two doses each for the adult population of around 20 million and the whole population of around 25.5 million. With 20 million doses of Pfizer ordered, many of us thought the rollout would follow these common sense protocols.

Others seem to have thought the same, such as the Royal Australian College of General Practitioners, as indicated by this January 8 article on what Australia’s vaccine roadmap meant for GPs.

And so did the Minister for Trade. On 11 February, 9News reported:

“Mr Tehan told Today this morning the formal approval [of Pfizer] was “great news” for Australia. They’ll arrive towards the end of February and we’re absolutely on track to roll our vaccine program out,” he said. Mr Tehan said older Australians and health care workers would be first in line for the jab.

“First it will go to the elderly, those people who are on the front line with our hospital workers and then in the aged-care facilities and then roll out into the community,” he said.

This thinking is confirmed by an article in The Conversation on 15 February:

“Australia has secured access to 20 million doses of the Pfizer/BioNTech vaccine, 53.8 million doses of the Oxford/AstraZeneca vaccine, and 51 million doses of the Novavax vaccine. The federal government plans to begin vaccinating groups at high risk with the Pfizer/BioNTech vaccine, then use the AstraZeneca vaccine for the remainder of the population.”

However, that is not what happened in the following months. Instead from mid-February, the elderly, the sick and older indigenous people would still be listed in the 1a and 1b phases, but lose their priority status of being the first to receive the Pfizer vaccine, even though the Department of Health website told us “they would be most affected if infected with COVID-19”.

The whole rollout would go awry. The government’s process of “laying it on with a trowel” meant they had over-egged the vaccine rollout message.

They had over-promised and would under-deliver.

In Part 2 we examine why and how the government’s plans unravelled.

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Rogue doctors and the good character test

Published by Anonymous (not verified) on Sun, 20/06/2021 - 3:37am in

Tags 

Health

With the death of former medical practitioner, Geoffrey Edelsten, one can predict that there will be commentators and journalists who will seek to laud him. Here is a different view.

When young men and women graduate in medicine and are registered as medical practitioners for the first time, their average age is around 23 to 25 years or older for graduate entrants. Applicants for registration are obliged to reveal any criminal convictions and are expected to meet the requirements of good character. Not surprisingly, at initial registration, these young applicants rarely fall at the hurdle of criminal conviction or bad character.

Those few doctors of bad character are usually only recognised through their unprofessional conduct in the years after graduation. This small group of doctors can create massive problems for society and regulators. Some such as Dr Harold Shipman in the UK and Dr Michael Swango working in the US, and later in Africa, actually murder their patients.

While Australia has been free of murderous doctors, there have been a few who have been involved in criminal activity, or Medicare fraud and over-servicing, or in repeatedly harming patients through poor judgement and lack of skill. They are difficult for medical boards, tribunals and courts of appeal to handle. They usually lack insight into their performance and have little sense of morals. They have a negative effect on the overall reputation of the medical profession. Frequently, they have misused their position to become wealthy and do not hesitate to spend money on prolonged legal actions to avoid deregistration and later to seek re-registration. The legal issue to be determined when such a person is applying to be returned to the register is usually whether to believe their claim to have reformed and to now be of good character.

It is worth emphasising why being of good character is so important for doctors. This was explained clearly by the NSW Medical Tribunal in 2004 when it stated:

“Medical practitioners are in a highly privileged position of trust. They receive confidences not only as to their patients’ physical and mental difficulties, but as to their most personal and private secrets. On occasions they are the recipients of information about a patient’s family affairs, his or her domestic and marital relationship and financial status. Accordingly they must be, and must be seen to be, honest. They must possess not only medical skills but the highest moral and ethical standards. To be persons of probity whose integrity is unquestioned”.

During my 19 years with the Medical Board of Victoria, I was involved in the Board’s efforts to deal with three such troublesome doctors, all of whom became of interest to the media. As a result, their stories are reasonably well known, but for the moment I will focus on the recently deceased Geoffrey Edelsten.

The best account of the less reputable aspects of the medical career of Edelsten is publicly accessible as it was written as the reasons for decision by the NSW Medical Tribunal chaired by Justice McGuire in 2004 when Edelsten’s application for restoration to the NSW medical register was rejected.

Edelsten graduated from the University of Melbourne Medical School and was first registered in Victoria in December 1966. He did his residency at the Royal Melbourne Hospital in 1967 where contemporaries recall that much of his energy went into managing a local pop group. He then worked as a rural general practitioner in NSW and Queensland before moving to Sydney where he established a chain of general practices. It was in this setting that he first ran into difficulties, initially over his billing practices, and was subject to investigation by the Health Insurance Commission (Medicare).

Soon he was in deeper trouble and at an inquiry conducted by the NSW Medical Tribunal in 1988, he was found guilty of allegations including seeking the assistance of a ‘professional hit man’ to deal with a former patient who was said to be harassing him, inducing doctors in his employ to engage in ‘over-servicing’, engaging in improper fee-sharing arrangements (‘kick-backs’), falsely claiming Medicare rebates for treatment given by untrained staff, and allowing an untrained person to undertake laser surgery in his practice. He was deregistered and ordered not to reapply for registration for ten years. Edelsten appealed this decision but the appeal failed.

However, Edelsten was still registered in Victoria and he moved to Melbourne where he remained registered until September 1992. In July 1990 he faced a criminal trial in NSW for allegations of soliciting an assault and conspiring to pervert the course of justice. The latter charge related to his provision of laser treatment to Christopher Dale Flannery and issuing a medical certificate that led to Flannery being able to avoid appearing before a certain judge. Edelsten was found guilty of both charges and as a result, spent twelve months in gaol.

In 1988, the Victorian legislation did not give the Medical Board power to act on his NSW deregistration. In order for this to happen, the legislation needed to be amended, so for the time that Edelsten was in gaol, he was registered in Victoria. Finally, in 1992, the Medical Board of Victoria was able to hold an inquiry into Edelsten’s conduct, directed at his conviction for serious crimes and whether his character was such that he should remain on the Victorian register. The Board found against him and his name was removed from the Victorian register on 4th September 1992. Edelsten appealed this decision to the Supreme Court of Victoria but his appeal was rejected. The next day he applied for re-registration. The application was rejected.

Over the next decade and a half, he repeatedly sought to be restored to the medical register in both NSW and in Victoria. The issue at stake in every application was the question of his character. In applications of this type, the onus of proof is on the applicant; i.e. Edelsten needed to provide evidence that he had learnt the error of his ways, was repentant and had reformed. The hurdle Edelsten faced was succinctly described by the NSW Medical Tribunal in 2004 in the following manner: “Success in this application depends upon the Applicant satisfying this Tribunal on the balance of probabilities that he has overcome the defects in character which led to his professional misconduct and that he is now a fit and proper person to be registered as a medical practitioner.”

The Tribunal then favourably quoted a 1966 opinion of a higher court that:

“Reformations of character and of behaviour can doubtless occur, but their occurrence is not the usual but the exceptional thing. One cannot assume that a change has occurred merely because some years have gone by and it is not proved that anything of a discreditable kind as occurred. If a man has exhibited serious deficiencies in his standards of conduct and his attitudes, it must require clear proof to show that some years later he has established himself as a different man.”

In NSW his first application for restoration to the register was dismissed by the NSW Medical Tribunal in 2001, with a ruling that he not apply again for two years. In 2003, he applied again. His application was denied by the NSW Medical Tribunal in a 54-page decision handed down in January 2004. The grounds for denial included his demonstration of “a lack of frankness and honesty in his evidence; that he has not discharged the onus cast upon him of establishing that he has overcome the defects in his character which led to the dishonest and dishonourable conduct resulting in his removal from the register; and that he has not rehabilitated himself so that he is now a person of good character for the purpose of practising medicine, qualified and entitled to be restored to the register.”

Indeed, the Tribunal stated,the current application is so unmeritorious as to border on the frivolous.” He was ordered not to make any further application for four years.

The Tribunal also recorded:

“It is difficult to conceive of more serious misconduct than the Applicant demonstrated in seeking to obtain the assistance of a man he knew to be a professional stand-over man and murderer to intimidate by threats or violence a former patient. That conduct alone reflected the gravest defects in character. The further matters dealt with by the 1988 Tribunal involved gross dishonesty whereby he sought to unjustly enrich himself. Additionally he demonstrated serious disregard for the physical welfare of his patients by permitting and enabling a person not a registered medical practitioner to perform laser surgery.”

In a summary that cannot do justice to the NSW Tribunal’s meticulous documentation of Edelsten’s “lack of frankness and honesty”, these are the general areas that the Tribunal remarked upon holding himself out to be a doctor when he was deregistered, not being frank with the Tax Office, failure to make reasonable efforts to pay outstanding court fees and fines, failing to fully inform his bankruptcy trustee of his debts, giving misleading information to an earlier hearing by the NSW Medical Tribunal, and giving false and misleading information about a company in which he was the sole director.

Having outlined in some detail Edelsten’s “lack of frankness and honesty”, the Tribunal concluded:

“this Applicant has proffered so many untruths and deliberately misleading statements on so many occasions prior to him coming before this Tribunal and in the proceedings before it, for his application to have any prospects of success. It was incumbent upon him to establish beyond question that he was at last being absolutely frank and honest. He completely failed to do so as this Tribunal has no hesitation in finding that he continued to either deliberately lie or to attempt to seriously mislead it.”

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Book Launch of the Handbook for Wellbeing Policy-Making July 1st

Published by Anonymous (not verified) on Wed, 16/06/2021 - 7:44pm in

Wellbeing & Policy Making Book Launch Event on 1st July 5-6.30pm London Time. Attending the Launch is Free, the book is not!

[blurb from Nancy Hey, director of the WW Centre for Wellbeing]:
The What Works Centre for Wellbeing, and our commissioning partners at the ESRC: Economic and Social Research Council have been working with colleagues at The London School of Economics and Political Science (LSE) for the last four years to bring the science of wellbeing economics into policy making so that it can be used consistently and with confidence. This groundwork is summarised from an academic perspective in a new book from Prof Paul Frijters and Dr Christian Krekel.

Join me on 1st July 5-6.30pm for the launch of their new book and to hear from our superb panel of scholars and practitioners Prof Lord Richard LayardThe Brookings Institution‘s Carol Graham , Government Economic Service‘s Sara MacLennan , Prof Andrew Oswald from University of WarwickMcKinsey & Company‘s Tera Allas Prof Liam Delaney from The London School of Economics and Political Science (LSE) on their perspectives on wellbeing and policy making past, present and future and around the world.

Please register here: https://lnkd.in/dZS3baC

#research #science #future #economics #wellbeing #policy #publicpolicy

#policymaking #WellbeingEconomics #WellbeingEconomy #BookLaunch

 

Propaganda seems to rule our thoughts…

Published by Anonymous (not verified) on Wed, 16/06/2021 - 7:19am in

This is a good piece in the Huffington Post, which concludes: To oversee one Covid wave is a misfortune, to allow two begins to look like carelessness. But to trigger a third wave, squandering all the good work of your own vaccine success story, could be seen as unforgivable by a public which has to... Read more

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