Category: Health

  • RAY MOYNIHAN. Drug companies are buying doctors – for as little as a $16 meal.

    An important new study in the United States has found doctors who receive just one cheap meal from a drug company tend to prescribe a lot more of that company’s products. The damming findings demonstrate the value of new transparency laws in the US, and remind Australians we’re still very much in the dark about what our doctors get up to behind closed doors.

    Just published in the leading Journal of the American Medical Association (JAMA) Internal Medicine, this study is well worth a look for anyone interested in the hidden influences on how doctors prescribe.

    Together with a host of other recent work, it adds to the growing mountain of evidence suggesting doctors who expose themselves to marketing strategies – from seeing attractive drug reps to attending sponsored “education” – are doing patients and the wider public a grave disservice.

    Need for transparency

    The new study took advantage of a new government-run and publicly available databasewhich discloses all drug company payments to doctors. Researchers looked at how often doctors prescribed four popular brand-name drugs, and linked prescribing rates to how often those doctors received meals from the drugs’ manufacturer.

    They found that receiving just one company-funded meal was associated with a 20% increase in prescribing of Astra Zeneca’s cholesterol-lowering statin, Crestor, compared to other drugs in the same class.

    For two other heart drugs, the increase was in the order of 50%. For Pfizer’s anti-depressant Pristiq, taking one free meal was linked to a 100% increase, or a doubling of the rate of prescriptions.

    The average cost of the meals drug companies gave these doctors was between US$12 (A$16) and US$18 ($A24).

    And when doctors ate sponsored meals on more than four occasions, their prescribing of the brand-name drugs rose dramatically. Perhaps unsurprisingly, doctors who got more expensive meals tended to have bigger prescribing increases.

    Association not cause and effect

    Perhaps the most important caveat, as the study’s authors stressed, is that “the findings represent an association – not a cause and effect relationship”. Nevertheless, the results reinforce similar findings from recent studies also using the new transparency data in the US.

    In March investigative journalists at ProPublica found doctors who received drug company payments or gifts – mostly free meals – wrote scripts for brand-name drugs at much higher rates compared to doctors who didn’t take industry money.

    In May, in the journal PLOS One, researchers found almost half of the 700,000 doctors in the US had received payments from drug companies. Specialties receiving the highest industry payments had the highest prescribing costs per patient.

    And also in May, the JAMA Internal Medicine published a small study from the state of Massachusetts, similarly uncovering an association between payments from industry and modest increases in rates of prescribing brand-name statins (cholesterol-lowering medication).

    So why does this matter?

    The main concern in all the recent US studies is the unnecessary cost to patients and the health system when brand-name drugs are prescribed instead of cheaper generic alternatives.

    But perhaps the more serious concern is the danger of doctors prescribing under the influence of drug company marketing – which always favours the latest new drug, rather than what’s in the patient’s best interest.

    As The Conversation has covered recently, newer and aggressively promoted drugs can have very limited advantages over older ones, if any, and sometimes carry very serious side effects – particularly for the elderly.

    There is already evidence many older Australians are at risk of harm from taking too many inappropriate medicines – and there is a growing push to promote “de-prescribing”, which means taking people off drugs they don’t need.

    Australia still in dark

    Compared to the new transparency regime in the US, Australia has fallen way behind. Under new rules some payments to some individual doctors will have to be disclosed from this August, but there are too many loopholes.

    As a result of horse trading about the new rules – between the doctors, the drug companies and public authorities – any funding of meals costing less that A$120 will not have to be disclosed. And if doctors who have received payments don’t want their names disclosed in August, they won’t be.

    Also, all of the roughly 25,000 events, including breakfasts, lunches and dinners which doctors and other health professionals regularly attend annually, will from now on remain totally secret – until there is regulatory reform.

    Consumer groups are angry that citizens remain in the dark, and many doctors are horrified by the wining and dining of their colleagues, with some cutting their ties: refusing to see the attractive sales reps and seeking “education” elsewhere.

    Disclosure on its own is no panacea

    As others have pointed out, disclosure on its own is not a panacea, and it’s legitimate to ask why doctors should receive any free gifts or meals at all.

    Already there’s been one legislative attempt to enforce more independence between doctors and drug companies in Australia, and it is likely more will emerge in the future.

    Until then, it might be wise to inquire whether your doctor still takes the free meals – and perhaps seek your care elsewhere if the answer is yes.

    Ray Moynihan is Senior Research Fellow, Bond University.  This article was first published in The Conversation on 23 June 2016.

  • ALEX WODAK. Global drug prohibition and national security

    Buddhists say that everything has a cause and everything has an effect. Violence, oppressed minorities, rampant corruption and failed states are both causes and effects of global drug prohibition. Serious threats to national security are an important but rarely discussed cost of drug prohibition. (more…)

  • DAVID POPE. Medicare – Eaten out from within.

     

    This cartoon by David Pope was published in The Canberra Times.

    I posted this cartoon on social media today, with links to your blog article. The cartoon was, in part, inspired by your posts. Too often, a good thousand words is worth more than any picture. Thank you for them.  David Pope.

    See link to David Pope’s gallery http://www.canberratimes.com.au/photogallery/act-news/david-pope-20120214-1t3j0.html.

    Medicare

     

    Warren Buffett described private health insurance in the US as the ‘tapeworm in the US health system’.

  • ARTHUR CHESTERFIELD-EVANS. Medicare- Did the Liberals try to abolish it?

     

    This is a current question with Shorten claiming that the Liberals are trying to privatise it and Turnbull calling this a Labor lie. What is the truth? The answer is in the history of Medicare funding. Medibank was set up by the Whitlam government and the bulk billing frees were set at 85% of the AMA ‘Most Common Fee’. The 15% was a discount but saved doctors a lot of costs and all their bad debts. They got slightly less, but the clerical and hassles saved by simply sending the paperwork, and later the computer message to the Medicare computer was felt to be a good deal. (more…)

  • Bill Shorten is right: Malcolm Turnbull is a major threat to Medicare

    Labor appears to have rediscovered old values, while the Liberals don’t appear changed one bit. Ian McAuley explains the mire that is the fresh debate on the future of Medicare.

    (more…)

  • JOHN MENADUE. Privatisation and the hollowing out of Medicare

    Malcolm Turnbull says that the Coalition will ‘never, ever, privatise Medicare’. Given the wide public support for Medicare and Malcolm Turnbull’s way with words his attempted rebuttal is not surprising.

    But the Coalition has been eroding Medicare from within for a decade and a half since John Howard. The vehicle for this erosion is private health insurance (PHI) and the government is facilitating this process with the $11 billion p.a. taxpayer funded subsidy to support private health insurance.

    And the ALP does not seem to care. It scarcely ever mentions the damage of PHI. Is it scared of this vested interest?  (more…)

  • JOHN THOMPSON. The regional health “plan”.

    The Minister for Health, Sussan Ley, advises that, as Member for Farrer, she represents some of Australia’s most remote and disadvantaged communities and therefore understands that access to health services, as well as people’s priorities, can differ significantly to those in our capital cities. (more…)

  • PETER GIBILISCO. Friedreich’s Ataxia and my Miraculous Journey with Education

     

    My life to date has been unduly constrained by the enforcement of standardised practices, stereotypes and official policies designed to uphold the primary care of people with Friedreich’s Ataxia. I was diagnosed with onset at 14; now I’m 54. (more…)

  • STEPHEN LEEDER. Looking forward to a national health policy and not ignoring the community.

     

    Health policies presented as part of the election campaign should address our expectations for prompt, courteous and effective high-quality care when we need it and not be a random collection of thought balloons – from a child’s birthday? – about waiting lists and co-payments .

    Health care is essential to achieving goals for more jobs and a brighter budget. Its availability to all is a fundamental of fairness. Labor or Coalition, health policy is critical to what they hope to achieve for us. Here is why we should be hearing a national health policy from the contestants. (more…)

  • BRUCE BAER ARNOLD. How Pathology Australia advocates for ‘patient care’ to achieve big corporate profits.

    Each time we go for a blood test to investigate or keep track of an illness, or have a tissue sample from a Pap test or suspicious mole sent off for analysis, the wheels of the pathology industry are put to work.

    Pathology in Australia is big business. One company draws an annual revenue of almost A$4 billion. And a proportion comes from the public purse, via Medicare rebates.

    The industry features a handful of very large corporations – including giants Sonic and Primary Health Care – that typically use multiple brands, giving a misleading sense of competition.

    Other large groups operate on a commercial basis but have a religious and thus notionally not-for-profit orientation, such as the St John of God group in Western Australia.

    There are also a shrinking number of smaller independent operators trying to occupy market niches or leverage personal relationships.

    The industry doesn’t speak with one voice; different providers have competing interests. The key private sector industry body is Pathology Australia. But it doesn’t representPrimary Health Care or religious entities. (more…)

  • IAN McAULEY. A Royal Commission into banking and the private health insurance industry.

    In this election campaign the issue that triggered a double dissolution – restoration of the Australian Building and Construction Commission – has hardly scored a mention.

    That contrasts with the 1974 double dissolution election, called by the Whitlam Government in response to the Coalition’s use of its Senate power to thwart the government’s most important pieces of legislation.

    The establishment of Medibank – the forerunner of Medicare – was the main issue in that election. Labor’s vision was for a publicly-funded single health insurer, while the Coalition fought tooth and nail to defend the privileged position of private health insurance (PHI).

    The struggle continued in subsequent elections. Between 1975 and 1983 the Fraser Government gutted Medibank, but the Hawke Government resurrected it as Medicare, and over the years of the Hawke-Keating Government, as Medicare grew in popularity, membership of PHI steadily fell to around 30 percent of the population. Then in 1986 the newly-elected Howard Government introduced a set of generous subsidies for PHI, resulting in its coverage rising back to a little over 50 per cent of the population. (more…)

  • MICHAEL GRACEY. The simmering shame of aboriginal ill-health.

    Indigenous people have experienced miserable health outcomes compared with other Australians for decades. Efforts going back to the 1960s brought some improvements but these were not enough to remove the inequalities. The federal government was prompted to try to resolve this impasse by establishing the so-called ‘Close the Gap’ Strategy in 2008. This brought fresh hope that this international embarrassment would be removed from Australia’s report card. Indigenous people welcomed the initiative but medical experts questioned whether the massive changes the Strategy set as targets could be achieved, as planned, within a single generation. It seems that the reservations about the feasibility of the Strategy were well founded. When the seventh annual Close the Gap report appeared in 2015 the then Prime Minister Abbott admitted that progress was “far too slow” and that the findings were “profoundly disappointing”. When the 2016 report was published the situation was still unsatisfactory and Prime Minister Turnbull limply commented that the results were “mixed”. There was no statement of determination from him that his government would do all in its power to put things right. Surely that wasn’t too much to expect. (more…)

  • WARWICK ELSCHE. Shorten should play to Labor’s strength.

     

    For more than 60 years, since opinion polling became important in shaping election strategies, there has been for the Australian Labor Party one awkward but stubborn consistency.

    Rightly or wrongly the Australian Electorate, with very isolated and brief exceptions, has always preferred and trusted the non Labor side of politics, the Liberal-National Party Coalition, as managers of the National economy.

    Incredibly, the present Government, which came to power on the strength of a supposed debt and deficit calamity retains that favoured regard on economic issues despite the fact that it has, in just three years added more than 100 billion to the National debt and trebled the deficit – the two things they claimed were threatening Australia’s future. (more…)

  • JOHN THOMPSON. Private health insurance seek to extend tentacles.

    The recent report of the Inquiry into Chronic Disease Prevention and Management in Primary Health Care by the House of Representatives Standing Committee on Health has been somewhat overshadowed by the current election campaign.

    One of the terms of reference of the Inquiry required the Committee to consider the role of private health insurers in chronic disease prevention and management. (more…)

  • JENNIFER DOGGETT. Midway through the election campaign, how is health travelling?

    It’s half way through the election campaign and both major parties have made some significant health policy announcements with Labor outspending the Coalition on health by over $2 billion (over four years).

    However, despite the fact that health consistently rates as the number one issue for voters, neither major party has satisfactorily addressed the key issues essential to ensuring that our health system is fair, efficient and equipped to meet future challenges. (more…)

  • IAN WEBSTER. Bulk-billing rates are not what they seem.

     

    A categorical mistake: Is bulk-billing a reliable indicator of access to GPs?

    Where I work in regional NSW, patients have difficulty finding a GP who is prepared to bulk-bill them for their medical care. The phone call to the practice receptionist ends, so often, with, “The doctor’s books are full”. At the same time we’re told that 83% of Medical Benefits Schedule (MBS) services are “bulk-billed”. Like everyone else, I thought this fact would mean increased access and affordability for patients to a local GP.

    Had I thought more thoroughly about the problem and scrutinised the MBS data, the penny would have dropped. (more…)

  • LESLEY BARCLAY. Diagnosing rural health gaps in the election.

    It is timely as the federal election approaches to consider whether all Australians are getting the healthcare they need. Approximately 30 per cent of Australians live in rural and remote areas.

    Arguably they do not get a ‘fair go’ in relation to their healthcare compared to the rest of us.

    Rural and remote Australians are disadvantaged by social circumstances that influence their health status and ripen them for avoidable chronic disease when compared to counterparts in Australia’s major cities. (more…)

  • STEPHEN LEEDER. Alcohol and sport.

    Queensland’s victory over NSW in the June 1 game was reported as the highest rating State of Origin match ever and ‘the top TV event of 2016.’ Both teams carried alcohol advertising on their clothing into the match.

    The association of alcohol with sport is deep, complex and profitable. Sport provides a lucrative vehicle for advertising and in turn many codes have come to depend heavily on the support of alcohol sponsors. The relationship is one of co-dependency. (more…)

  • JOHN DWYER. Restructuring the governance of health care in Australia. Part 1

    Part One. Structural reforms for better health outcomes from a redesigned more cost-effective health care system.

    The most important pre-election health care initiative has received very little publicity. Labor has committed to establishing a “Healthcare Reform Commission” if elected. While not likely to generate much discussion in one’s local pub it represents an acceptance by a major political party that we do need to explore structural changes to the way we deliver health to achieve better outcomes and fiscal sustainability. What follows is an evidence based scenario for the evolution of major structural reforms, many of which are currently being pursued internationally. (more…)

  • JOHN DWYER. Restructuring the governance of health care in Australia. Part 2

    Part Two.  Structural reforms for better health outcomes from a redesigned more cost-effective health care system. 

    There is broad agreement that in the near future our General Practitioners and their teams will earn the majority of their income from capitation payments that will require, for the first time in our Primary Care system, the documentation of health outcomes. Many doctors are concerned about this direction and argue that they may have neither the time nor the necessary kills to fulfil such requirements. International experience informs us that these doubts can be reversed with the creation of Primary Health Care Organisations to assist with these and many other issues.  (more…)

  • PETER BROOKS. Mind the gap in doctors’ fees – it is all around us

    John Thompson reminds us of the total lack of transparency in fees charged by doctors in Australia. Surgeon’s report shows the ineffectiveness of private health insurers to control health costs Posted on 07/05/2016 by John Menadue

    So can we dissect this further. What is in a medical fee – well may you ask. When you go to your doctor you may see a fees schedule on the reception desk – or you may have received a letter from the receptionist / practice manager indicating that you will be responsible for certain fees over and above what you will get back from Medicare and ( possibily ) your Private Health Scheme . It is not unusual to be asked to pay something in advance before an appointment ( usually for a procedure – endoscopy ) is even made . Even lawyers don’t make you do that- do they . So there are at least three fees- what the Government pays the doctor – the Medicare fee , then there is the AMA rate – why this is different does not seem to be based on any scientific evidence , and then there is what the doctor actually charges you . Again not based on anything but what the doctor feels the market will support – and it usually does because effectively you have no choice .Do you ask for a second opinion ? do you have a discussion about the fee and why it is so much higher than the Medicare rebate or the AMA fee- when this person is going to put a new hip into you next week or open up your belly – I don’t think so . (more…)

  • MICHELE KOSASIH. Seven years on and still itching for change on the negative impacts of alcohol.

    2016 marks seven years for the Foundation for Alcohol Research and Education’s (FARE) Annual Alcohol Poll (conducted by Galaxy Research), and we continue to see Australia’s concern about the negative impacts alcohol has on the community. (more…)

  • National Foundation for Australian Women. Budget 2016-17: A gender lens.

    The National Foundation for Australian Women has prepared an analysis of the Budget 2016-17 with what it calls a ‘gender lens’. An executive summary of this analysis follows. A link to the full document can be found on ‘the budget’ button: www.nfaw.org.  

    Budget 2016-17 fails to bring Australian women into the centre of the economy and pushes many further into poverty. Cuts to overseas aid hurt vulnerable women in our region.

    The budget is far from fair, with just a touch of the white picket fence. It provides tax breaks for the wealthy, while low to middle income families are hit by ‘zombie’ savings from the Abbott-Hockey horror budgets. It is lacking in investments in education and training reforms which might drive innovation and jobs. (more…)

  • JOHN MENADUE. Health principles and policies for the next parliament.

    Thanks to Medicare introduced over 40 years ago, despite bitter conservative opposition, we have one of the best health systems in the world. It is sustainable but we waste over $20 b per annum. There are threats and problems that we must face.

    What are they? (more…)

  • Ian Webster. Is community medicine dead?

    John Menadue said in the NSW Health Council Report of 2000, “Services should be based where patients and consumers live. The autonomy and dignity of each patient is best serviced by providing services wherever possible outside hospital. So a shift to community multi-disciplinary health teams is a major issue still ahead of us.” He returned to this theme in a recent blog, “A major aim of good health policy for Australia must be to keep people out of expensive hospitals.”

    Two South African physicians, Sidney and Emily Kark, working in poor communities started community-based primary health care – community medicine – in 1940. In each community their approach started with community diagnosis, working out the health needs in the community.

    In 1973 the Whitlam Government set up the Community Health Program for Australia. It was led by an ex-South African, Dr Sidney Sax, who knew the Kark’s approach very well. His committee recommended that the community health program should be based on primary health care. (1)

    One aim was to influence the doctors of the future and so, for the first time, chairs of community practice were funded by the Government in all medical schools. At the time, medical schools were narrowly focused on biomedicine and disciplines concerned with the body’s organ systems. Every medical student could tell you about Virchow’s contribution to pathology in the 19th century, but few knew anything about his statement about the social causes of disease, “Medicine is a social science, and politics nothing but medicine on a grand scale.” (2)

    Outside the medical school, the general public were becoming more interested in the way doctors were trained. They were concerned about the neglect of disability, chronic diseases, mental health, addiction, Aboriginal health and other troubling health problems. And preventive medicine was missing from the GP’s repertoire.

    I came to community medicine at the UNSW after working in Whyalla, South Australia and Sheffield, England. Sheffield was once the “blackest city” in Europe. Coal dust, smog, untreated childhood infections and tobacco smoking caused the lung diseases I treated at the city’s only respiratory clinic. And the impoverished and dank suburbs where I worked as a GP showed me how the social world played out in people’s health. This convinced me of the importance of social medicine.

    These problems of health in the community were seen as lost causes in the medical schools of the day but over time, and to a varying extent, they have been picked up in contemporary undergraduate teaching.

    Public health was a Cinderella discipline. It was regarded by most medical students as boring stuff about drains, sewerage, unimaginative health promotion interspersed with dry statistics. But with the capacity to collect large datasets and the increasing power of commuters to analyse and interrogate data there was an explosion in enthusiasm for public health. Important questions could now be answered and integrated into the guidelines for medical practice. Epidemiology now makes enormous contributions to the thinking and practice of day-to-day medicine.

    But these technical developments – seeing the world through a computer screen – marginalised the messy business of dealing with the day-to-day lives of troubled people, working alongside others to deal at the grass roots with their predicaments.

    In the recommendations of the Community Health Program for Australia was the central role of the GP in multidisciplinary community health teams. And progressively, but slowly, medical schools have come to accept general practice as a legitimate academic discipline and area for postgraduate training and specialisation.

    In parallel with the academy, the Commonwealth aimed to support general practice through creating networks of GPs. These were known as Divisions of General Practice during the Howard government. They were renamed Medicare Locals in the health reforms of the Rudd government, giving them increased responsibilities and funding.

    The current government is funding Primary Health Networks across Australia.

    “Primary Health Networks (PHNs) have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time.” (3)

    PHNs will have increased responsibilities for the populations in their geographical footprints. For example, in meeting local and regional needs for mental health and drug and alcohol problems, and managing the burgeoning problems of chronic disease as well as preventing and treating the common illnesses and injuries seen by GPs.

    Community medicine is not dead, it is there in the principles which will inform the new PHNs with their defined responsibilities for communities and “community diagnosis” in their localities.

    References:

    1. A Community Health Program for Australia, Report from the National hospitals and Health Services Commission: Interim Committee, June 1973. Australian government publishing service, 1973
    2. Anderson MR, Smith L and Sidel V W What is Social Medicine? Monthly Review, vol. 56, No. 8, January 2005. The authors said, “Rudolf Virchow is considered by many to be the founder of social medicine.”
    3. http://www.health.gov.au/internet/main/publishing.nsf/Content/primary_Health_Networks

    Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales. 

     

     

  • John Thompson. Surgeon’s report shows the ineffectiveness of private health insurers to control health costs

    Private health insurer Medibank has worked with the Royal Australasian College of Surgeons to produce a report that shows enormous variation in fees charged by surgeons for similar procedures.

    The Surgical Variance Report for General Surgery reviewed thousands of procedures performed on Medibank members in eight common operations – gallbladder removal, gastric band procedures, bowel resection procedures, hernia procedures, gastroscopy and colonoscopy.

    The data shows that some surgeons working in private hospitals are charging 15 times the amount charged by their peers for the same procedure. For example, surgeons performing gastric sleeve operations for weight loss charged average private fees (in addition to what the insurer and Medicare covered) ranging from $231 in South Australia to $3593 in Queensland. The average fee in NSW was $3160 and in Victoria it was $1874. For gall bladder removals, fees charged ranged from $369 in Tasmania to $1166 in NSW. In Victoria, the average fee was $387.

    It is important to emphasise that fees in the Medibank/College report are those charged privately to patients after Medicare and Medibank have made their contribution to the cost of the patient’s treatment.

    The report also provided information on complication rates for these operations. These rates also varied very substantially. For example, complication rates for bowel resection procedures varied from 0 per 1,000 procedures for some surgeons, to 571 per 1,000 for others.

    President of the College, Professor David Watters said, “These reports will provide surgeons with information that may help them gain a better understanding of, and learn from, variations, for the benefit of the service they provide to their patients and the community,” he said.

    There are two important conclusions that arise from this work. First, it emphasises the lack of financial control on health costs when there is a reliance on private health insurance. In Australia, there are 33 private health insurers registered under the Private Health Insurance (Prudential Supervision) Act 2015. While Medibank’s initiative is to be welcomed, it illustrates the problem of a crowded and fragmented market where the numerous competing insurers are unable to act collectively to influence the suppliers of health services. A single insurer provides the opportunity to develop the necessary financial control on ever increasing costs of health services. As a national insurer, Medicare, is also a far more efficient and equitable operation than the 33 disparate insurers competing with each other, all with their substantial administrative and marketing costs. As Ian McAuley (University of Canberra) wrote in 2014, “Norway and Sweden remind us of a vision we have lost: the economic benefit of a strong, single national health insurer.

    The second conclusion from the report is derived from Professor Waters’ comment above. This report, Professor Waters states, is aimed at providing information to the supplier of the service, not the purchaser. For more effective financial control of these important services, the client should have the information on costs and performance of surgeons so that he/she can make a rational consumer’s decision on price and quality. As Medibank’s Chief Medical Officer Dr Linda Swan said at the release of the report: “Information sharing is key to improving the delivery of healthcare, and ultimately to improving patient outcomes.” Agreed, but it is important that the patient also shares the information. A single insurer could also perform this function more efficiently.

    John Thompson is an economist with experience in primary health.

     

     

     

     

  • Peter Gibilisco. A Synergistic Approach to Disability

    Here is my proposal for a Dictionary definition of Synergy:

    the interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects.

    “the synergy between artist and record company” or disability support workers and people with disabilities with high support needs.

    In some of my writings I have referred to what I call the “synergistic” outcomes that result from the interaction of people with disabilities and their support workers. These effective working relationships should be given the respect that is their due since they make an indispensable contribution to ongoing efforts to devise effective models of leadership in such workplaces.

    But then I ask: Why are these highly successful working relationships so often below the radar when it comes to forming social welfare policies for the disabled? Could it be that these highly efficient working relationships are simply out of sight and out of mind? Is that why they seem to be ignored when it comes to the discussion of how to make improvements in the disability workforce? Maybe we need to look again at the manuals that are written for workers and develop a distinctively new theory of management. And why not? The synergistic approach I advocate might best be seen as an “inside out” approach to the management and organisation of the disability workforce. It will demonstrate public confidence in the abilities of the people who are served to exercise control over their own lives. Let me try and explain this “synergistic” model of work-place leadership in more detail. In order to make sure that this kind of model is flexible enough to allow change, even if complete change does not take place, the aim is to avoid an approach which sees the disabled person as a problem and instead reckon with such a person as a “problem-solver”, just like anyone else, and just like the support worker as well. In this a “synergistic” model develops a distinctive understanding of societal inclusion.

    In this context, an emphasis upon synergy for the disability workforce aims to provide a corrective to the guidance that is often put to people with these “different abilities” and their support workers. To have an “inside out” approach is about reckoning with life chances and the creation of opportunities. Therefore, by initiating such an approach we confront the support worker who sometimes sees him/herself as a person languishing at the lowest, grass roots level who then needs the disability sector for employment. We need to turn this around. In my view a synergistic approach to the disability sector is not just about better help for the disabled person – it is about raising the status of all involved, and ascribing due respect.

    It may be highly contentious to say outright that disabled people are second-rate citizens but if so much of our social value is measured by income then maybe “2nd rate citizen” is exactly what the income disparity tells us.

    In the disability field, does love conquer all?

    The best form of care is, of course, supplied by family members or close friends. These are those whose support is supplied by love. They are living testimony that love conquers all. Love is mighty and powerful and particularly when administered with compassion, empathy and patience.

    Wherever we may be located by the flow-charts of such organisations, we are all human with our own individual pursuits of happiness. When it comes to high support needs for people with disabilities, love is something that is beyond the control of the “medical model’s” contribution to meeting the needs of disability. But hopefully it will be there as the indispensable motor of any positive medical contribution. A person with a disability at times will require more than just physical support in medical, dietary and psychological terms. That is, we need to promote communities of people who consciously function in ways that humanise the clinical methodology of the medical model, and this can be done by giving greater attention to what I would thereby call “the social model”. Society is a network of coinciding and interdependent responsibilities. An emphasis upon a “social model” of disability support will find it is necessary to emphasize this again and again.

    Let me give an example that has stuck in my mind. Some time ago, around 1987, a friend of mine with Friedreich’s Ataxia (the same disease I have) was to be married to the guy of her dreams (an able-bodied individual). But as she signed the register, she became so excited that she suffered a heart attack and died. In hindsight, the wedding was a beautiful moment, and the embodiment of the social model. But now I am wondering: what should have been done to prevent the heart attack? Perhaps those enthused by the prospects of her wedding had under-estimated the impact of their own advice upon those with “medical model” responsibilities. In other words, we need to find the wisdom to enhance the interaction, the synergy, between the medical and social models of disability. That synergy is important. It is so important. 

    I have come, much to my own surprise, to another related conundrum: how can the medical model be modified to avoid a standardised approach to disability care that simply confirms mythic stereotypes about seriously disabled people. I struggle daily with the way the facility where I live in shared support accommodation is managed. I am therefore wondering whether at a deep, cultural level its modus operandi presupposes the medical model. I’m wondering: is the organisation somehow stuck in a rut assuming that we residents are actually “sick”, that our lives are basically structured by illness?

    I’m not saying that the residents are free of physiological problems that require special care. I am not even thinking here primarily about physiology; I am thinking about the way in which our “roles” are understood by the prevailing management. Are we, in effect, occupying the role bundle of the person who is sick, who is subject to medical care?

    It is perhaps somewhat dangerous (it might seem that I am tooting my own trumpet) but consider my own case. Before coming to live in this place, I lived for 21 years(1990-2011), on my own and during those 21 years I completed a double degree in Arts and Accounting at Monash University, a Master of Arts at Monash University and finally a PhD at the University of Melbourne. This is not to say those years were easy; of course I had added pressure upon me in my studying because of the physiological complexities that had to be addressed by medical means since the onset of Friedreich’s Ataxia at 14(1976). University started when I lived on my own at 28, and graduating with my PhD at 43(1991-2006)). Over the 21 years of living on my own I had two long stays in hospital, but all in all my educational conquests far outweigh any medical complications. This all has me thinking: I’m living as part of a situation in which I have been confronted by nothing less than the reality of what I have referred to above as “the social model”. This is a situation that will be endorsed by most people who have physical disabilities without any intellectual impairment.

    To conclude this reflection about synergy – love and the management of the disability sector, leads me to encourage us all, particularly public policy researchers, senior management in “not for profit” organisations and elsewhere, to think carefully about the “who?” question when dealing with the severely disabled people they are committed to serving. This certainly means that an ethos of equity is needed along with the legislated provision of further assistance. It will require political courage to ensure that an ethical culture is developed in which people with disabilities who have high support needs are cared for individually and effectively.

    I prefer the term “resident” to the current lingo that wants to view me as a “customer”, which can be used in stereotypical ways to standardise care and thus give rise to stereotyped opinions in public discourse.

    My desire to rise above the privations of this shared support accommodation fuels my motivation for this and also many of my previous articles. Thanks for reading.

    A special thank you to Bruce Wearne for his editing and helping to tweak this piece and Christina Irugalbandara for her excellence and academic support work.

    Dr Peter Gibilisco is an Honorary Fellow, University of Melbourne. He has published a book ‘The Politics of Disability’. 

     

     

  • Adrian Bauman & William Bellew. Does a spoonful of sugar help the medicine go down?

    “A spoonful of sugar helps the medicine go down”, according to Mary Poppins. Many more spoonfuls of sugar currently pervade our lifestyles and unconscious food choices. The recent media focus on sugar has been remarkable, but the media frenzy has sought a single solution, a quick fix, to what is in reality a complex problem: childhood and adult obesity. Rapid increases in obesity rates have occurred since the late 1980s in Australia and in many other countries, and even if starting to plateau, still leaves 63% of adult Australians overweight or obese.

    Sugar is pervasive, not only (as we might expect) in fizzy drinks and sport drinks, but also added to a surprisingly wide range of foods. These include tomato or chilli sauces, muesli bars, as well as many “low fat” marketed foods (some yoghurts for example) which are high in added sugar. But is sugar the culprit? or is it just a marker of a trend towards increased processed food, increased consumption of convenience foods, and acculturation of our taste towards increased salt, increased sugar and increased fat ? All of these contribute to the “wicked problem” of weight gain, exacerbated by decreased physical activity at work and play, and through increased car use to get to or from places.

    But how does all this relate to sugar? A recent commentary in the Sydney Morning Herald (Peter Martin, April 2) called for soft drink taxes to be introduced [i]. The idea is that we all have to eat something, but some foods contain almost exclusively sugar, and soft drinks and so-called sport drinks contain almost nothing else (what nutritionists call “empty calories” as they lack any of the nutrients, vitamins or fibre that other high sugar foods, such as fruit may offer). High levels of consumption of empty calories from sugar sweetened beverages is a clear and independent contributor to weight gain in many epidemiological studies[ii].

    Many arguments are raised against efforts to curb sugar consumption. Firstly beverage manufacturers assure us it is part of a healthy and “balanced” diet. It seems un-balanced if it’s just adding to our total energy intake, and yet corporate marketing portray empty calories as contributors to a glowing lifestyle image and as a metaphor of well-being. One must be cautious of the motivations of the food industry according to Dr Margaret Chan, Director-General of the World Health Organisation. At the 8th Global Cnference of Health Promotion in Helsinki (2013)[iii] she said “it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics (of) lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt”. They also contribute to the polarised argument between individual choice to consume unhealthy foods, compared to structural, societal and cultural factors that contribute to us doing so. If we accept that we are mired in advertising and cultural depictions promoting unhealthy foods, in sponsorships of major sporting events and of the Olympics, then our cultural milieu is defined by these products. Governments that choose to address the problem this way are accused of “nanny state interventionism”, but it does require complex counter marketing against unhealthy products, facilitating access to affordable healthy choices, and mandating external industry regulation (as the food industry does not self-regulate well, as demonstrated when self-regulation was tried in restricting advertising of unhealthy foods to young children).

    One strategy, suggested by Peter Martin is the introduction of a sugar tax. This will be a differential tax, with the greatest impost on food items with the most sugar, and lesser taxation imposed on foods with less added sugar. This approach has been implemented in Mexico where a 10% tax has resulted in a 12% decline in the consumption of sugar[iv] sweetened beverages. Such taxes have community support and are evidence based[v]. Free-market advocates claim this is unfairly “taxing the poor”, but from a public health perspective targeting those at social disadvantage and targeting children and adolescents are exactly the groups who consume the most sugar sweetened beverages. An even stronger rationale for a sugar tax is that it will generate revenue, just as tobacco taxation has done for several decades. This can fund the substantial government investment required for comprehensive obesity prevention, extending well beyond simply reducing sugar. This could be used to support comprehensive obesity prevention efforts, and are supported by the majority in the community. This is our only chance to build the infrastructure for a healthier community and a healthier food environment in Australia. Thus preventing obesity just won’t happen with any single strategy, and a sugar tax is but one financial mechanism for funding the complex solutions required.

    Finally the problem is not only sugar. The Hippocratic maxim of exercise and diet in moderation still holds, and while the media in faddist fashions present us with new single solutions and quick fixes, a prudent approach would be to eat less overall, eat less fat and less sugar, consume mainly fresh produce and mostly plant-based foods. Diets like the Mediterranean diet show such balance, and combined with more active daily lifestyles (and non-smoking) are the only way to make real improvements to population health.

    Adrian Bauman, School of Public Health and Charles Perkins Centre, Sydney University

    William Bellew is Adjunct Professor, School of Public Health, Sydney University.

    [i] http://www.smh.com.au/comment/obesity-its-time-to-tax-soft-drinks-20160330-gnum4b.html

    [ii] Malik VS et al. American Journal of Clinical Nutrition. 2013;1;98(4):1084-102

    [iii] http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/

    [iv] Colchero MA et al British Medical Journal 2016 Jan 6;352:h6704.

    [v] Escobar MA et al. BMC Public Health. 2013 Nov 13;13(1):1.

     

  • Tony Broe. Coordinating Community Aged Care & Hospital Aged Health Care

    Getting Australian Health Services right depends on delivering both Aged Care & Health Care effectively for frail ‘high risk’ older-old people. Reducing inappropriate hospital admissions, shortening length of stay, returning frail people to their homes rather than Residential Care, all depend on accessible, locally based, Community Aged Care assessment support and management systems. For around 30 years a simple, geographically based, Australian system – State Geriatric Medicine Teams with Commonwealth Aged Care Assessment Teams (ACATs) – provided local access for many frail older people and up-to-date information on the complexities of local Aged Care services. This system is being dismantled – but what is replacing it?

    The History:

    In 1982 the Commonwealth put out the persuasive McLeay Report “In a Home or At Home”. From the mid-1980s Commonwealth Health, together with State based Geriatric Services, set up local district Aged Care Teams (combining state funded Geriatric Services with Commonwealth funded ACATs) working with Community Services (HACC), Residential Care and GPs on common local boundaries. In NSW 22 District Geriatric Teams were developed for metropolitan populations of ~250,000 (18 in Sydney, 2 in Illawarra, 2 in Newcastle); 9 Regional Teams served variable rural populations. This process was duplicated across all States with ~170 local ACATs covering Australia (~66% being funded to provide ‘extended’ care)*. ACATs & Geriatric Teams were famed world-wide as an inclusive, equitable, innovative approach to Aged Care & Health Care for frail older-old people. It was far from perfect; had variable penetration; was variably effective for local reasons (e.g., Queensland Health was then un-regionalised) – but generally worked at a local level.

    In April 2012 a new 10 year Commonwealth aged care reform program “Living Longer Living Better” was released, with its emphasis on “consumer-directed care”. Stated aims included: more support at home; better access to residential care; increased recognition of carers; more support for people with dementia; better access to information; utilising the market; encouraging businesses to invest and grow*. The changes commenced in 2013-2014 with: new Home Care Packages; My Aged Care – a centralised entry point contactable only by phone or internet; then a tender process for new Regional Assessment Services. The final implementation phase of a new system was set for 2017 to 2022.

    The Issues:

    In terms of access equity & coordination, the pre-existing Aged Care system has been fragmented & not effectively remodelled for the future. Components are put to three year tender for multiple operators to pursue on fragmented and changing geographic bases. Replacing the 1980s models would not be a problem if alternate solutions were effective, or more equitable, or financially intelligible, or even easier to access & use for less advantaged older-old Australians and their family carers. They are not.

    The new system fails the vulnerable older-old in most need – the ‘cognitively frail’ with less capacity for self-management, less computer literate, less well off. It is devised for ‘young-old’ people & more switched on carers, but even they are finding it difficult to access & understand the complexities and interfaces. Individual local services (Community Nursing, Home Care, Transitional Care, Hospital-in-the-Home, Ambulatory Care) are intact, even proliferating, but form a fractured uncoordinated mess for the ‘at risk’ old. Assessment – by Regional Assessment Services (valuable but locally divided); ‘My Aged Care’ (centralised, internet and phone accessible); residual ACATs; private or not-for-profit Assessment Services – is not reasonably accessible for older-old people in most need. Communication is poor across fragmented assessment services for those whose job it is to assist at a local level – family carers, community nurses, social workers, GPs, Geriatric Teams, or discharge planners.

    The motivation was good – equity, innovation, flexibility of access for “person-centred care”. However, the new system embodies unproven or dated concepts of ageing: a mistaken belief that ageing per se causes disability; a belief that public aged care systems are less efficient or innovative than private systems – hence weakening public responsibility for Aged Care; three yearly tender, on theoretical grounds of the value of competition over continuity of care; an acceptance of “market forces” (which do not operate effectively or efficiently in Aged Care) hence privatising without clear evidence of benefit. The result is a growing but fractured system, good for healthy competent older people – but increasingly inoperable for frail ‘older-old’ and disadvantaged carers, resulting in a poorly accessible, complex, headless beast of a system.

    Steps to Solutions?

    “You should turn the clock back if it is telling the wrong time”  John Kay Economist – ‘Other Peoples’ Money’ 2015.

    We may not need to turn the clock back; but – to mix metaphors – we should not throw the babies out with the bathwater.

    • Essentially we need to keep the benefits of new approaches to Community Aged Care that are valued by independent older people. At the same time, we need to restructure an accessible local district public interface between Community Aged Care, Primary Care and Hospital Care for the ‘at risk’ older-old. Commonwealth coordination of community Aged Care with State Health Care worked for 30 years. It will be even more essential as the baby boomer population reaches ‘older-old’ ages in the 2020s to 2030s.
    • The ‘young-old’ (60 to 75 years) – 90% active, mobile, cognitively competent –need better chronic disease interventions, but not usually complex Aged Care Systems across local Community and Hospital Interfaces*. Aged Care solutions are mainly for the ‘older-old’ (75 to 100+) who, like old wines, do not travel well. Their rising needs are driven, primarily, by the corollary of current ‘healthy ageing’ and compression of morbidity to late-life – cognitive frailty, cognitive decline, dementia – with reduced capacity for decision making*.
    • Primary care, community aged care, residential care, hospital care – can’t work in isolation or by pushing individual barrows. A combined Commonwealth State approach to coordinating community Aged Care interfaces with Aged Health Care has worked in the past. It will be essential as the baby boomer population reaches ‘older-old’ ages in coming decades.

    Professor Tony Broe AM, BA, MB;BS (Hons), FRACP, FACRM

    UNSW Conjoint Professor of Geriatric Medicine

     

  • Mark Harris. Obesity: it is time to tax sugar sweetened beverages?

    Obesity rates are increasing in the Australian population (Figure 1). There is a widening socioeconomic gap with low socioeconomic groups having the highest rates. There is some evidence that obesity rates in children may be levelling off but not in low socioeconomic status children. Overweight and obesity contributes significantly to the burden of disease (about 9% in Australia at present), loss of quality of life and premature mortality (death before completing expected life span) in Australia.

    Obesity is a complex problem requiring complex solutions. There is no magic bullet. Ultimately obesity occurs because of an imbalance in the amount of energy consumed and absorbed in the gut and the amount used up as part of metabolism as well as through physical activity. There are many complex factors influencing this imbalance across the lifecycle (Figure 2). These are in turn influenced by many factors in the social and economic environment. It is easy to think that it is all just too hard at one extreme or that it can be simply address by individual will power at the other extreme.

    At a population level, there are a number of strategies that can achieve improvements. These involve changes in the way we live. While on their own any one strategy is unlikely to solve the problem of obesity, collectively they may contribute to further slowing or reversing the rise in the prevalence of obesity in the Australian community. One such strategy is to reduce sugar sweetened beverages (SSB). In the UK government will apply a levy on SSBs from 2018 joining a number of other countries including France, Belgium, Norway and Sweden.

    There are three main reasons for focusing on on SSBs:

    1. SSBs contribute significantly to the energy intake of Australians.   The Australian Health Survey in 2011-12 found that the reported consumption of sweetened beverages increased with age across childhood, with 61% of teenagers aged 14-18 years reporting drinking it on the previous day. Overall teenagers consumed 6% of their energy from SSBs. Rates are higher in low SES people.
    2. SSBs have no nutritional value (they are so called “empty calories”). Furthermore they tend not to cause satiety (as does food). There is an association between levels of SSB consumption and weight gain among both adults and children. In Australia water is a plentiful, safe and cheap alternative.
    3. Modelling and some experience from other countries suggests that reducing SSBs would have a significant effect weight gain. For example removing SSB from the diet of teenagers would reduce their energy intake by about 10% thus contributing to reduced rates of overweight and obesity in this age group.

    How can a reducing in SSB consumption be achieved? It is not easy. SSB are ubiquitous in the Australian environment. Dispensing machines are located almost everywhere in addition to availability through supermarkets, cafes and restaurants. A number of strategies have been proposed and attempted:

    • Reduce or ban advertising especially for children. Advertising on SSB exceeds $50m per annum in Australia and children are currently not protected from this advertising.
    • Educate the population about the risks of SSB through media campaigns. There is evidence that consumption of SSB has decreased since 1995 especially in children. However this may also contribute to inequities as the change has been greatest among higher SES groups.
    • Remove SSB from school and health service canteens and dispensers. This may be effective for primary school but is less effective for high school especially as children can access SSB outside the school grounds.
    • Reduce the size of SSB containers (eg new smaller soft drink cans).
    • Increase tax on SSB. This has been successful in tobacco control. Modelling suggests that this would need to increase prices by 20% to be effective.

    What are the possible unintended consequences of these actions? It is possible that a tax may economically disadvantage the poor who have higher SSB consumption. This can be partly addressed by education about use of water and could be offset by reduced tax on healthy alternatives such as fresh fruit and vegetables. These efforts may displace consumption onto other energy dense drinks without added sugar (fruit juices, milk drinks). This may have already occurred with fruit juice but there is no evidence for other drinks.

    So what is the way forward?   A range of health groups have recommended social marketing campaigns, restrictions of children’s exposure through marketing and in schools and sporting facilities, reduced availability it workplaces, government institutions, health care facilities and public places and exploration of tax increases. All these are likely to be necessary to reduce SSB consumption sufficiently to reduce obesity rates.

    These measures are, of course, likely to meet resistance from industry groups. They argue that this is a matter for individual choice and not for government regulation. However the socioeconomic gradient in SSB consumption and its effects on weight and the burden of disease both for individuals and the whole community suggest that public health action is warranted.   With its high impact on children, the consequences of inaction are likely to be significant across generations.

     

     

    References

    Australian Bureau of Statistics: 4364.0.55.007 – Australian Health Survey: Nutrition First Results – Foods and Nutrients, 2011-12

    Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006 Aug;84(2):274-88

    Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature 2012; 482: 27-29

    Re-think sugary drink. Consensus Statement on sugar-sweetened beverages. Cancer Council Australia, National Heart Foundation, Diabetes Australia, Nutrition Australia, YMCA, Australian Dental Association, Dental Health Services Victoria, Obesity Policy Coalition. http://www.rethinksugarydrink.org.au/downloads/Consensus_position_statement.pdf

    Figure 1: Overweight or obese, persons aged 18 and over, 1995, 2007–08 and 2011–12

    Harris1

    Notes:

    1. Age-standardised to the 2001 Australian population.
    2. Overweight and obesity classification based on measured height and weight in all 3 surveys.

     

    Source: AIHW 2012, ABS 2013.

     

    Figure 2: Some of the causal factors involved in weight gain.

    Harris2

     

    Professor Mark Harris is from the Centre for Primary Health Care and Equity, UNSW.