The crux of modern health care challenges

In rock climbing, the crux is the hardest section, or sections, of a particular climbing route. To solve a crux, the climber must draw on their skill and expertise, problem-solving abilities, perseverance and teamwork, before being able to send it — solve the crux and complete the route. This issue of the MJA covers a broad range of subjects that could be considered some of the most critical challenges in modern health and health care.

Over the past 55 years, the proportion of people in Australia who die from cardiovascular diseases has halved (https://www.abs.gov.au/statistics/health/causes-death/changing-patterns-mortality-australia/latest-release). Nonetheless, cardiovascular diseases remain a leading cause of death and morbidity. In this issue of the MJA, Figtree and colleagues (https://doi.org/10.5694/mja2.52482) describe the Cardiovascular Health Leadership Research Forum. Established in 2022, this initiative unites governments, health service providers, and the research workforce to tackle major cardiovascular health challenges. By accelerating the implementation of new preventive and therapeutic strategies, it seeks to enhance patient outcomes and produce economic benefits.

On a broader scale, Jackson (https://doi.org/10.5694/mja2.52476) discusses the National Health Reform Agreement, and the challenges it faces to remain fit-for-purpose for maintaining a high quality equitable health system. Seven policy barriers are identified that have long undermined health system reform, and will need to be addressed for the next agreement to be successful.

Four further articles discuss key aspects of modern socially responsible health care. Rodda and colleagues (https://doi.org/10.5694/mja2.52471) review current approaches to identifying and managing gambling disorder. Formerly known as pathological gambling, gambling disorder is now classified as a behavioural addiction. Gambling disorder affects only 1% of the population; however, gambling is pervasive in Australian culture with significant costs. Approximately three-quarters of the Australian adult population spent money on gambling in 2022, with total losses of $20–25 billion per year (https://www.aihw.gov.au/reports/australias-welfare/gambling). This does not account for the further social costs of gambling, which are extensive. Of those Australian adults who gamble, almost half are classified as being at risk of harm, with the highest rates in young people and men. The evidence base outlined by Rodda and colleagues provides best practices for identifying gambling disorder and risk thereof, and subsequent treatment.

Slape and colleagues (https://doi.org/10.5694/mja2.52475) provide a perspective on the establishment of a First Nations custodial dermatology service. This First Nations-led service, established in New South Wales and now extended to the Northern Territory, reflects a commitment to ethical and socially responsible health care services through timely and high quality health care that is culturally safe and meets the complex health care needs of incarcerated people. More broadly, the foundational principles of this service highlight the promise of First Nations-led specialty care within the prison system.

In their research letter, Nolan and colleagues (https://doi.org/10.5694/mja2.52471) used deidentified dispensing data from the Pharmaceutical Benefits Scheme (PBS) to demonstrate that about one in five PBS-subsidised testosterone prescriptions are for trans individuals, despite there being no specific PBS indication for gender affirmation. In younger people, this figure is as high as four in five. They argue that a specific PBS authority indication for “gender affirmation” would facilitate equitable access and improve quality of care for trans people.

Finally, Fry and colleagues’ medical education article (https://doi.org/10.5694/mja2.52481), which, in their words, “is intended to serve as a beginner's introduction to the environmental footprinting techniques that can be applied to uncover health care's environmental impacts”, with a clear focus on greenhouse gas emissions. They identify five key areas for action, including improving health care environmental footprinting literacy and incorporating environmental footprinting into existing frameworks for quality improvement, procurement and health system performance. These are practical recommendations that have implications for individual health care worker practices, but also, perhaps more importantly, for system change guided by health and medical leadership and management.

These are some of the most challenging aspects of modern health and health care. Much like climbers working through a crux, these challenges will require the collective efforts of the medical and health care community to achieve the best outcomes for patients and the broader community.