Opinion: What things shouldn’t we be wasting this crisis on?

By Nicholas Gruen

Monday March 30, 2020

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The subject of this post has been a theme of some conversations I’ve had with some people in Canberra. What things should we have been doing before the crisis that the crisis concentrates the mind sufficiently to try to do now? And what things should we have been thinking of, but weren’t till the crisis arrived?

Though lots of things need to be done quickly and needn’t have some long-term game plan attached, it’s worth thinking about what long-term benefits might come. Doubling the dole, I’m hoping, will make it more likely that when the payment is ‘normalised’ it goes back to a more humane level than it was at. There will be little need for the government to be stingy with it when it’s trying to engineer a recovery in six or more months time.

The Commonwealth being the government with the big tax base and a central bank sitting behind it should be offering broad underwriting of state schemes of tax relief. It might hopefully use that to bring about some rationalisation of state and federal taxes at the end of the process — and closer cooperation between states and the feds — maybe by allowing the Commonwealth to collect tax for the states to simplify administration for businesses.

Then there’s regulation.

For instance, there’s a venture to develop a coronavirus vaccine at UQ (which, as Paul Frijters can attest, is notorious for its unethical experiments on innocent – but slightly racist – bus drivers). Others will know the details better than me, but I’ve always been struck by the way in which safety and efficacy seem to be far more entangled with each other in regulatory approval of pharmaceuticals than they need to be. I’d expect there are large and now urgently needed and easily understood gains to be made in that regard.

An example of the kind of thing I’m talking about is the taking of Hydroxy Chloroquine. We have decades of experience of this as an anti-malarial drug. In fact, while we were getting the experience, so were the mosquitoes, and they’re pretty much over it by now. There are only a few places where the drug actually works against malaria. But we’ve got lots of experience with it so we can prescribe it and supervise the safety of using it.

If it’s promising, there should be field trials of it right now. We can run a randomised controlled trial inside a hospital, giving the drug to one large group of medical professionals and a placebo to another large group. We’d learn lots and fast. There are lots of other sensible experiments that could be run.

In such circumstances, with proper communication, there should not be strong resistance to any of this — as it will enhance and be seen to enhance safety. There’s the additional issue of the extent to which one should trade off the safety of some treatment — in this case, a vaccine or other treatments of COVID-19 — with the lives that are lost from delay in releasing/adopting it. These decisions are made now. And it’s easy to say that the medical regulators are risk-averse. Generally speaking, they should be. But right now it doesn’t take a genius to work out whose risk they’re minimising. Their own — that’s who.

Regulators have careers, and over an appreciable period of time, their skin in the game gradually comes to dominate that of others. Decisions get made for them and not the people for whose benefit they’re regulating. To get around this, I’d identify a class of medically trained people (specialists, doctors and nurses) and informed people from the community from whom I’d choose at random a board of decision-makers. I’d go with any decision for which there was a strong majority of say two-thirds or more — or perhaps a weaker majority subject to an appeal to another similar body in the event of any strong dissent. Anyway, I’m just sketching things here.

In any event, it seems to me that now might be a time when governments might be prepared to actually try to think about regulating safety from the wider perspective of maximising the lives saved and minimising suffering.

If medical staff become overwhelmed, or even just seriously stretched, there’s a need to consider how to train people to help them out. There are lots of things nurses do that could be done by people quickly trained to do those things — taking temperatures, giving injections. They might also be trained to administer complex machines in fairly routine ways whilst being trained in detecting things that need escalation. Often these things simply go by the board for lack of staff resourcing now.

Those nurses who were up to it could also have expanded duties. There’s been skirmishing between nurses and doctors for decades, with functions kept off nurses for no better reason than to protect the doctors’ union and prop up demand for their services. As I understand it, some mild progress has been made over the past decade or so, but I expect plenty more could be done.

I’d like to take the high ground here. Currently, the rules get haggled over, but there’s not much regard for independent or evidence-based decisions. There could be better and worse ways of operationalising this. As an illustration, I’d suggest this:  For the duration of the crisis, some independent arrangement would be put in place to oversee improvisation at the hospital level. That is, as the need arose, doctors, nurses and hospital administrators could work out any arrangement they considered was appropriate in the circumstances. (One might want a board of the kind I sketched out above).

Legislation would be passed protecting all participants from any negligence claims arising from any changes to the demarcations in the division of medical labour where those changes were agreed in a way that complied with the method that had been agreed upon the accepted way of making them. These changes and how they were made would be registered in some national database to ensure transparency and the ability of different institutions to learn from one another. Efforts should be made to measure the safety of the resulting system.

Something similar should happen regarding the division of labour in nursing homes, not just of the medical staff but also of other staff. Changes should only be made if there is competent monitoring of outcomes and an independent body judges that it is in the interests of the patients all things considered.

Another area in which progress has always been much slower than people expected — like regulation review — has been teleworking. Since the telephone people have predicted a surge in work from home, but it’s amazing how slowly it’s happened. The same is true of distance education — and the replacement of universities by massive open online courses (MOOCs).

If I seem fairly vague about what the answers are here — that’s because I am. But these are areas in which we need to discover more answers than we have. I doubt they can be solved using top-down approaches so we should be funding experiments. Since we don’t have any choice but to ramp up these activities very aggressively, we should be making funding available for a lot of human-centred design activity to try to figure out how we can make these systems more human, improve feedback over them, and community building over them. As with the more streamlined regulation discussed above, having some national clearinghouse of successful and less successful experience in an attempt to seed a national knowledge commons on these things could be helpful. Governments could also negotiate with the providers of software as a service in ways that could improve the power of such a knowledge commons as I sketched out here.

Anyway … In those areas I’ve identified there must be lots of other good ideas. Any ideas? And what other areas should we be looking at?

 

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