English lessons: can publishing an atlas of variation stimulate the discussion on appropriateness of care?

Health systems around the world are facing the twin pressures of increasing demand for services, caused by the impact of ageing populations and medical science developments, and a lack of resources as a consequence of economic slowdown in many countries.1 In these circumstances, it should not be surprising that there is an increased focus on using available resources to deliver high quality care and addressing variation in the provision, uptake and costs of health care2 with a view to identifying and reducing unwarranted variation.

The ubiquity of recognition of variation3–5 continues to raise the profile of variation, capturing the imagination of researchers and policy makers6 to pose a challenge to those planning and delivering health care. That challenge runs much deeper than the undemanding observation and recording of variation, to one which must stimulate clinicians, managers and patient groups across the health care system into urgent and necessary action to identify and reduce unwarranted variation. That action is essential, not only as a means of enabling the health care systems to close their funding shortfalls, but more importantly to reduce harm to patients, improve the quality of services and increase value from resources. This is the focus of the NHS Right Care initiative (www.rightcare.nhs.uk) and the genesis of the NHS Atlas of Variation series in England.

The NHS Atlas of Variation series

The NHS Atlas series is a comprehensive view of health care from a geographic perspective, principally using formal NHS administrative organisations to measure a range of indicators including spend and outcomes. The work to produce the NHS Atlas series was greatly influenced by the philosophy and experience of Professor John Wennberg of Dartmouth College in the United States, who knew the full impact of publishing variation and the concept of unwarranted variation, which he defined as “variation in the utilization of health care services that cannot be explained by variation in patient illness or patient preferences”.7

The first Atlas was produced in 2010, and was followed by a series of themed Atlases and two other compendium Atlases (Box 1). NHS England is not alone in producing an atlas of variation; a number of other countries are following the lead from America, Canada and Spain, including Australia, Germany, the Netherlands, Norway and New Zealand.

Preparation phase

There are as many lessons to learn from the pre-publication phase of the Atlas series as there are in the post-publication phase. The first lesson is the need for engagement and sponsorship from the very “top of the office”, from both policy makers and senior clinicians. That support is critical to the credibility and sustainability of Atlas production and necessary to mitigate any undue political or managerial interference regarding the main purpose of the Atlases. The Atlas editorial team was convinced that the publication of the Atlas series was much more than just about assisting the NHS deal with the increasing need and demand, which is rising faster than the resources available or the political challenges of the day; namely, meeting targets too frequently designed around organisational objectives not patient need. As important as they may be, it was considered that the publication of the Atlas series is an essential process to jolt the culture of health care away from assuming that existing patterns of care are right and that more resources are always required to improve outcomes. We knew that the culture of the medical and nursing professions, and the behaviours within the NHS, would need to change. The Atlases were designed for emotional impact as well as the transmission of information to prompt all clinicians in primary and secondary care to work together with their population to agree what services should look like, what needs to stop and what services need to start doing to provide higher value health care.

The second lesson from this phase is to remember that the purpose of sharing data on variation is not to claim what is the right or wrong rate of, say, an intervention, but to stimulate the discussion and to prompt the search for unwarranted variation, where resources are being wasted and shift those resources to more appropriate care where patients and the population achieve better outcomes. Indeed, we are reminded that it is not right to use variation data alone to determine which rate is “right” but should acknowledge that the presence of too much variation is a sign of health service delivery problems.8 These are two fundamental concepts and the Atlas production team frequently challenges itself about the use of data, how those data should be presented and to be clear about what it signals.

A way of mitigating that issue introduces the third lesson. It is critical to engage and maintain a constructive relationship with the most senior clinical leaders — in the case of NHS England, the National Clinical Directors (NCDs). This is important when selecting the indicators and agreeing the commentary for the Atlas. The leadership shown from NCDs in NHS England cannot be underestimated and should never be undervalued as an important step in the process of deciding which indicators and which dataset should be applied and what narrative to transmit. This positive relationship also enhances the credibility of the Atlas and increases the focus of attention to those indicators that have been declared as being of such importance by the NCDs, which can also lead to improved uptake and use of the Atlas series through the medium of both the printed versions and the interactive Atlases. These early lessons endorse the notion that stimulating interest and curiosity is the first step toward action and a reduction in unwarranted variation.

Publication phase

It is important to be clear that the publication of the Atlas of Variation is not a blunt performance tool, and the Atlas team is careful not to use any data that the health system does not already have access to. Therefore, available data are always used, in a novel way, to produce commentaries and illustrations, with maps, about the extent of variation for all sorts of provision, spend and outcome. The lesson is that the publication of the maps needs to be both stimulating and dramatic to draw a response from the health care system to investigate the known variation in each area of health care; an objective which appears to be achieved by organisations’ inquisitiveness to understand their position in relation to their peers and then to use that information as formative learning9 for future planning and decision making.

A key message from this phase is the involvement and engagement of other stakeholders, beyond the NCDs, in both the preparation and participation of the launch of the Atlas. It has previously been declared that the engagement of senior clinicians and policy makers is an important part of the whole process, particularly during the publication process. There are other key stakeholders to engage here too; perhaps the most important are patient representative groups and third sector organisations that can create a powerful and positive narrative about what the Atlas is displaying, remembering the message that not all variation is bad — if it were, it would be easier to take action.10 The involvement of patient representatives also helps the shared decision making (SDM) agenda, which is an important part of the transformation process, enabling the active involvement of patients with their clinicians to make the right decision about the choice of treatment.

NHS Right Care has long advocated and continues to promote the use of SDM as a way of empowering patients to become part of the solution to the challenge of delivering high quality care. The transformational program has developed and published 35 patient decision aids (PDAs) to complement the Atlas series. PDAs are specially designed resources to help patients make informed decisions about their care. People who have used the PDAs report that they understand their problem and the choices they have more clearly.

The ambition of NHS Right Care is to use the Atlas of Variation to stimulate a search for unwarranted variation in the NHS and its underlying causes, by providing a tool for learning and exploration of potential deficits in local resource allocation. That ambition is amplified when using the PDAs as a tool to engage and support patients in decision making about what is right and appropriate for them.

Public services, including health services, are under pressure to control increasing costs, and the NHS has been challenged to adapt to evolving demands and “shine a light on variation in care and unacceptable practice”11 to improve the quality and safety of care. A significant lesson is that the production and publication of an atlas of variation is not an end in itself but an essential component of a large scale transformation initiative to increase value, improve quality and reduce harm.

Next phase

The domains of quality and safety have strongly influenced the shape and delivery of the NHS for more than a decade, but is this the right paradigm for the next decade and beyond? We ask this as we are reminded that the issue of variation in health care is not a new phenomenon. Indeed, it could be argued that variation has been met with a level of inertia and confusion for many years and by raising the awareness of variation, through the publication of the NHS Atlas of Variation series, we aim to stimulate the search for unwarranted variation but also to further advance the focus of attention toward value.

If health care systems are to meet rising demand with reducing resources, there needs to be a shift from traditional patterns of planning and contracting around established organisations and clinical processes to one that is focused on “doing the right thing — for the right patient — at the right time”, where we need to think about value. The Right Care initiative has set out to promote value by encouraging organisations to aim for optimal care, declaring that it is not a process that can be done in isolation of other organisations, and to remember that no one professional group has all the necessary information or knowledge to plan and deliver optimal care.

Rather, health care systems need to look at their processes, working with their populations to decide if the balance is right between prevention, screening, diagnosis, intervention and long term care. The search for unwarranted variation plays an important part in that quest and the time has arrived for us to enter the “value era”, in which a population perspective and patient views of value are adopted to improve the health outcomes for both populations and individual patients.

Reducing variation to increase value

Possibly the simplest way to think of value is from an economic perspective. The word “value” is, like many words, slippery to define and can have a range of meanings to different people. In the plural, as in the terms “values”, the word has a moral meaning — for example, “we value diversity and equality.” In the singular, however, the meaning is largely economic.

The Right Care approach identifies three types of value:

Allocative value — to optimise allocative efficiency by taking responsibility for the resources allocated.
Technical value, or efficiency — it is essential that all organisations work across the health care system to maintain a good understanding of what is being delivered, including whether some services are now being delivered at a rate that could be classified as overuse.
Personalised value — determined by the degree to which the outcome relates to the particular problem that the individual brought to the health service, where shared decision making becomes the norm for that population.

The primary focus of the Atlas series has been to create a tool to raise the profile of variation, at a population level, as part of a much bigger transformation initiative. What quickly emerged was the need to think of both population and personalised health care as being two sides of the one coin. The agenda now is to focus on increasing the value of health care to the whole population as well as on the optimal care for the individual patient. This is summarised in the Right Care approach (Box 2), which clearly offers an insight into why atlases of variation are important, but recognises that they cannot be the singular answer to transforming health care.

Conclusion

This article has demonstrated how the production and publication of an atlas of variation can be an important step in the journey toward increasing value in health care — for patients, for populations and by directing resources to higher value health care, for tax payers. The article has described how the preparation stage, which includes many conversations, negotiations and lengthy discussions (eg, deciding the indicators and narrative) leads to improved engagement of all stakeholders. Working hard to build a positive relationship at the preparation stage pays dividends during the publication phase, where all stakeholders can contribute to the overall message and purpose of the Atlas. It is not sufficient, however, to publish an atlas of variation in isolation from other tools (eg, patient decisions aids) and expect it to have remarkable impact. An atlas of variation needs to be an integral part of a larger transformational change program.

Box 1 –
NHS Atlas of Variation series titles

Year	Title

2010	NHS atlas of variation in healthcare
2011	NHS atlas of variation in healthcare 2.0
2012	NHS atlas of variation in healthcare for children and young people
2012	NHS atlas of variation in healthcare for people with diabetes
2012	NHS atlas of variation in healthcare for people with kidney disease
2012	NHS atlas of variation in healthcare for people with respiratory disease
2013	NHS atlas of variation in healthcare for people with liver disease
2013	NHS atlas of variation in diagnostic services
2015	NHS atlas of variation in healthcare 3.0

Box 2 –
NHS Atlas of Variation series illustrated as an essential part of a large scale transformation initiative to increase value and reduce unwarranted variation

CfV = Commissioning for Value. PDAs = Patient Decision Aids. STAR = Socio-Technical Allocation of Resources.

Clinical variation: why it matters

Understanding variation in care is an important step in improving patient health outcomes through appropriate care

Variation in health care usage is a troubling feature of contemporary medicine. For similar populations, usage of medications, interventions and procedures may be very different and lead to variation in outcomes. The following articles discuss why exploring unwarranted variation is a priority for health care systems; how atlases of health care variation act as catalysts of change and what health care systems can do to increase appropriate care. In this context, the Australian health care systems’ response to the problem of unwarranted health care variation is considered.

In November 2015, the Hon Sussan Ley, federal Minister for Health, launched the Australian atlas of healthcare variation.1 The Atlas, the first in a series, looks at variation in health care use at population level for 36 clinical activities including medication dispensing, diagnostic and surgical interventions and interventions for chronic diseases. International data, where available, are included and provide context. For example, Australia’s rate of dispensing of antibiotics is almost double that of Canada. This variation is consistent with a large body of evidence including that from a recent Organisation for Economic Co-operation and Development report, which included Australian data.2,3

In a number of countries, variation is being explored as a way to define and promote appropriate care and thereby value in the health care system. In this Supplement, DaSilva and Gray argue that atlases of clinical variation are catalysts for change by stimulating debate, engaging all participants in the health system so that patient-focused care can be achieved.4 The authors argue that no one group has all the necessary information, knowledge or capacity to plan and deliver appropriate care. For this reason, the Australian Commission on Safety and Quality in Health Care (the Commission) and the National Health Performance Authority developed the Australian atlas with input from the states and territories, and clinician and consumer groups. The Atlas’s recommendations require action from many parts of the health care system.

Variation is not bad per se. As Buchan and colleagues note, some variation in health care delivery is warranted and desirable, such as meeting differences in patients’ health needs or health preferences.2 For example, patients with knee pain from osteoarthritis may choose physiotherapy, knee replacement or lifestyle changes. The focus must be on variation that is inexplicable by either patient need or preference and is therefore unwarranted, such as would occur in the above example if treatment options were not offered. Unwarranted variation means people are exposed to real harm from not receiving care that they need or potential harm from receiving care that they do not need and cannot benefit them.

Atlases as such do not demonstrate the impact of unwarranted variation on patient outcomes. Atlases highlight variation such as, in this case, the seven-fold variation in dispensing rates of antipsychotics in people aged over 65 years. Clinical experts, for example, can analyse the data for unwarranted variation, distil the evidence for change into a clinical care standard and thereby effect widespread reduction in unwarranted variation and increase appropriate care.5

Research literature often focuses on the harms of not receiving evidence-based care. However, there is increasing awareness that people can be harmed from overdiagnosis and overtreatment, an example being antibiotic treatment of all infections.6 “Winding back the harms of too much medicine” (http://www.preventingoverdiagnosis.net) and “choosing wisely” (http://www.choosingwisely.org.au) are two recent catchphrases.

In the era of evidence-based medicine, defining what is right should be easier but remains challenging. Evidence of effectiveness is limited and can change over time, particularly for emerging technology, pharmaceuticals and patients with multiple comorbidities. Where evidence exists, implementation science needs improving. Glasziou, a recognised evidence-based medicine expert, describes a leaking evidence-to-practice pipeline.7 For evidence-based care to occur, evidence needs to be available, applicable and accepted, and able to be implemented, acted upon and agreed to by the patient. Achieving this requires multiple strategies; organisational prioritisation of the issue as important; resources to achieve the objective; systems to support clinician and consumer adoption of best practice; outcome measurement; and feedback for improvement, as Turnidge and colleagues describe in relation to antimicrobial use in Australian hospitals.8 The Commission’s work to support clinician and consumer adoption of best practice includes developing clinical care standards, clinical quality registries and patient-reported outcome measures (PROMs). Articles in this Supplement discuss the emerging evidence for these initiatives.9,10 For example, mechanisms to measure patient outcomes such as PROMs can assess the effectiveness of care.10,11 Clinical quality registries can improve clinical appropriateness and clinical care standards reduce unwarranted variation in treatment, such as for acute coronary syndromes.9,10

There is urgency for improving appropriate care because of increasing demand for services from an ageing population, medical science developments and cost escalators.4 Mechanisms to define, communicate and continually measure value to the patient may improve patient outcomes, and thereby increase the appropriateness of individual care and the sustainability of health care for populations. Future atlases that provide time-trended data will help. Exploring variation is the first step.

[Correspondence] No health without peace: why SDG 16 is essential for health

We live in an increasingly globalised world in which almost 34 000 people a day are forced to flee their homes because of conflict and persecution.1 Refugees are increasingly moving into more traditionally stable countries, often risking their lives in the process, catalysing public health crises anew. As of 2015, more than 65 million people have been forcibly displaced worldwide; more than 20 million of them since 2011.2 The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), established in 1949, provides humanitarian assistance through education, health-care, and relief and social services, to some 5 million Palestine refugees alone in Lebanon, Jordan, Gaza, the West Bank, and Syria.

Bulk billing falls back, patient costs rise

The GP bulk billing rate has fallen back and patient out-of-pocket costs have jumped in what could be an early sign that the Federal Government’s Medicare rebate freeze is forcing general practices to increase patient charges to stay financially viable.

Repeated AMA warnings that medical practices were being driven by the rebate freeze to reduce or abandon bulk billing and hike patient charges have been leant weight by Health Department figures showing the bulk billing rate fell from 85.9 to 85.4 per cent in the September quarter while out-of-pocket costs surged 4.5 per cent to reach an average of $34.61.

While the AMA urged caution in reading too much into one quarter’s figures, the results could be the first confirmation of fears that Government policy is pushing up the cost of seeing a GP, including for vulnerable patients, such as those with chronic illness or on welfare.

“We know that the patient rebate is in many cases inadequate to maintain quality medical practice,” AMA President Dr Michael Gannon said.

In their search for ways to stay afloat, practices appear not only to be cutting back on bulk billing but also looking to charge non-bulk billed patients more.

Government figures show the average patient contribution increased at more than six times the pace of inflation in the September quarter, a heavy financial blow to households already stretched by near-stagnant wage growth, fuelling fears that patients will increasingly defer or forego seeing a doctor.

While decrying the “obsession” of both sides of politics in using the bulk billing rate as a measure of the quality of health care people receive, Dr Gannon said the Medicare figures nonetheless highlighted the importance of the Medicare rebate in funding primary health services, and the consequences when it failed to keep pace with the cost of providing care.

“The statistics show that Australians pay above-average out-of-pocket expenses, which is a sign that patient rebates are inadequate in funding our health system,” he said.

But Health Minister Sussan Ley claimed the latest Medicare data showed GP bulk billing rates remained at record high levels.

Seizing on figures showing the bulk billing rate in the September quarter was almost 1 percentage point higher than the same period last year (84.6 per cent), Ms Ley said the result was an affirmation of the Government’s policies.

“These ongoing increase in bulk billing rates are underpinned by our record investment in Medicare, which is increasing by $4 billion over the next four years,” the Minister said.

But Shadow Health Minister Catherine King said the quarterly result belied the Minister’s claims.

“This is the evidence Malcolm Turnbull didn’t want revealed – bulk billing is dropping and he knows it,” Ms King told reporters. “Australians are already seeing the impact of his six-year Medicare freeze every time they go to the doctor with more and more patients having to pay out of their own pocket.

“On the day before the election Malcolm Turnbull promised that no Australian would pay more to visit the doctor – this was a complete and utter lie.

“The Government needs to pull their head out of the sand and admit that their health policies are hurting Australians.”

AMA President Dr Michael Gannon has directly lobbied Prime Minister Malcolm Turnbull to immediately end the rebate freeze, warning that the increasing financial squeeze on medical practices was forcing many to cut bulk billing and increase patient charges in order to remain financially viable.

Medicare rebates have been frozen since 2014, and under current plans will not be indexed until at least 2020.

Ms Ley has talked down hopes that the policy could be reversed soon, arguing the Government cannot afford to recommence indexation until its finances improve.

The Government is due to release its Budget update next month, but the Parliamentary Budget Office has reported a further deterioration in the Government’s finances, projecting that the deficit will balloon to $105.1 billion by 2018-19 – an $8.9 billion blow out from the Budget.

The latest Medicare statistics show the bulk billing rate for the September quarter ranged from a high of 88.7 per cent in New South Wales to a low of 60.3 per cent in the Australian Capital Territory.

Latest news

[Series] The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services—but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place.

UK’s ‘stunning own goal’ could feed doctor exodus

The British Government has been accused of a “stunning own goal” over its muddled plan to make the country self-sufficient in doctors by the middle of the next decade.

Just days before Prime Minister Theresa May told senior National Health Service officials there would not be any more money for public health services when the Government issues a financial update this month, Health Secretary Jeremy Hunt announced an extra 1500 home-grown doctors would be trained each year from 2018 in order to reduce the nation’s reliance on international medical graduates.

Under the plan, which the Government said would cost £100 million (A$160 million) in its first two years, doctors would be fined £220,000 (A$352,000) if they left the NHS before completing a minimum four years of service.

The goal is to make the country self-sufficient in doctors by 2025.

Mr Hunt outlined the plan as a response to concerns that a shortage of medical practitioners is contributing to overwork and poor morale among NHS doctors.

Ms May also portrayed it as a way to reduce the country’s reliance on practitioners from overseas to help fill workforce gaps – an issue with heightened implications given the UK’s decision to cut ties with the European Union.

But, coming against the backdrop of a bitter dispute over the Government’s attempts to impose new work contracts on junior doctors, the policy has been criticised by some as ham-fisted and ill-conceived.

Harrison Carter, co-Chair of the British Medical Association’s medical students committee, told The Lancet the initiative was poorly directed and failed to address the underlying problems afflicting the UK’s medical workforce.

“It’s a stunning own goal by the Secretary of State [for Health],” Mr Carter said. “[The Government] needs to deal with the underlying issues causing doctors to walk away from the NHS.”

A recent survey of 420 British doctors who have graduated in the past decade found that 42 per cent planned to practise overseas, because their experience of work was worse than they had expected. A further 16 per cent said they had “taken a break” from their medical career.

The results have underlined concerns that the bruising industrial battle over work contracts, which involved unprecedented strikes, has created significant ill-will and disillusionment among junior doctors, encouraging many to look elsewhere to develop their careers.

Dr John Zorbas, Chair of the AMA Council of Doctors in Training, told the Financial Times that there was strong interest among young UK doctors about working in Australia.

“When I speak to my overseas trained colleagues already working here, interest from UK doctors in training about working in Australia is high,” Dr Zorbas said. The AMA has written to the UK Government about the [NHS] dispute, which is no doubt impacting on the morale of doctor sin training in the UK. Unfortunately, it appears the Government’s agenda is more about an attack on working conditions than improving the quality of care for patients.”

Mr Carter said Mr Hunt’s plan to create extra training places and impose a four-year service requirement was no solution.

“This is not the way to address the crisis in morale in the profession,” he said. “What they will be faced with is doctors who are disillusioned, with low morale, and who will be bound to their job, not because of desire but because of an obligation.”

His concerns have been echoed by Royal College of Physicians Registrar, Andrew Goddard, who told The Lancet that although the extra training places was welcome, an extra 1500 graduates a year was not enough.

There is also dismay at the way the Government has sold its policy, particularly remarks by the Prime Minister regarding overseas trained doctors.

In an interview following the announcement, Ms May should doctors from overseas would stay “in the interim period until the further number of British doctors are able to be trained and come on board”.

While the PM later clarified her comments to say that overseas trained doctors did not have to leave, senior figures in the profession said the remarks were damaging.

“I think it is really dangerous to start thinking that all overseas doctors are about to go home,” Medical Schools Council Chief Executive Katie Petty-Saphon told The Lancet. “We really appreciate the work of overseas doctors…and the NHS would fall over without them. They are welcome here and they need to stay here.”

Mr Carter said the Prime Minister’s comment betrayed confused thinking within Government over the push to self-sufficiency in doctors.

He said if the goal was to train local doctors to take over roles currently filled by overseas trained practitioners as well as meeting the growing need for health care, the Government would need to train many more than just 1500 extra a year.

“There is no way that by 2025, with the 1500 who will come in [from] 2018, we will be anywhere near being self-sufficient,” Ms Petty-Saphon said.

Adrian Rollins

Mental health groups urged to boycott new plan

A prominent mental health advocate has blasted the Government’s draft Fifth National Mental Health Plan as “rubbish”, and called on mental health groups to boycott the consultation process.

The plan was released for consultation on 20 October, with Health Minister Sussan Ley describing it as “an important document” that was “focused on actions that will genuinely make a difference for consumers and carers”.

“The Fifth Plan contains seven priority areas, which have been identified for action in close collaboration with the mental health sector,” Ms Ley said in a statement.

But Professor John Mendoza, the former head of the Mental Health Council of Australia, said the plan would simply continue funding late-term intervention at the expense of prevention and early intervention.

Professor Mendoza called on colleagues at an international mental health conference in Brisbane that the consultation process should be boycotted.

“The plan does not reflect the Prime Minister’s commitment at the election ‘to leave no stone unturned when it comes to mental health’,” Professor Mendoza told The Australian, adding that the plan was “mealy-mouthed rubbish” designed by bureaucrats with no institutional knowledge.

“The plan does not take us one step further in relation to the Government’s announcements last November when it responded to the National Mental Health Commission report and it strongly endorsed the national commission’s recommendations.”

Professor Mendoza said that Prime Minister Malcolm Turnbull had used the words “we need to really embrace innovation, we have to focus on the mental wealth of the nation”.

“And he was stating that because it was clear to him that the economic drag on Australia now, through its focus on acute, late-intervention services rather than early intervention and prevention, means that we have hundreds of thousands of Australians who are unable to participate in work, who are unable to complete education, who are unable to sustain and maintain relationships, because they simply can’t get access to the care they need,” Professor Mendoza said.

“The Commission said this isn’t good enough, we need fundamental reform. And the Government said that was what it was going to do.

“Now, the Fifth Plan that’s been released for consultation does nothing of the sort.

“It pays no attention to the Government’s reform agenda, and it certainly doesn’t marry up with what either the Queensland and NSW Governments [are doing] – two different sides of politics, both of them have articulated clear plans.

“This national plan is completely devoid of any specific actions, any measures, any targets.”

The seven priority areas are:

Integrated regional planning and service delivery;
Coordinated treatment and support for people with severe and complex mental illness;
Suicide prevention;
Aboriginal and Torres Strait Islander mental health and suicide prevention;
Physical health of people living with mental health issues;
Stigma and discrimination reduction; and
Safety and quality in mental health care.

The Department of Health and Mental Health Australia will hold consultation meetings in all capital cities, as well as Townsville and Alice Springs, in November and December.

The final plan will be considered by the Australian Health Ministers’ Advisory Council and the COAG Health Ministers’ Council early next year.

Maria Hawthorne

Whooping cough booster faces axe

The Federal Government may axe the whooping cough vaccine booster for first year high school students as it pulls plans for an Australian Schools Vaccination Register.

An immunisation expert group has been asked to review the pertussis vaccine schedule, including the need for a booster currently being administered to children in secondary school.

The Government has announced that the Australian Technical Advisory Group on Immunisation (ATAGI) has been asked to “provide advice on the clinical place and effectiveness of the pertussis vaccine schedule, including the pertussis booster currently given in the first year of high school”.

Currently, it is recommended that infants receive a dose of the diphtheria-tetanus-acellular vaccine at two, four and six months of age, with further boosters at 18 months and four years. An additional booster is given between 12 and 17 years.

The review comes at a time when the number of whooping cough cases is in decline – about 16,000 cases have been notified so far this year, well down from the 22,500 infections reported in 2015.

But the decline has come not long after the country’s largest-ever recorded outbreak of the disease, between 2008 and 2012, including 38,732 notified cases in 2011 alone.

The National Centre for Immunisation Research and Surveillance said whooping cough was a “challenging” disease to control because immunity waned over time, and epidemics occurred every three to four years.

The Centre said declining immunity was a factor in the last major outbreak, during which 4408 people were hospitalised, including 1832 babies. Between 2006 and 2012, 11 died from pertussis, all but one of them infants less than six months of age.

The review of the pertussis vaccination schedule coincides with the decision not to proceed with the creation of the Australian Schools Vaccination Register.

The Health Department said it had discontinued the tender process for the creation of the Register following advice about the review of the pertussis booster vaccine for secondary school students and the end, in 2018, of the catch-up varicella vaccination program for adolescents.

The Register was announced in the 2015-16 Budget as part of the No Jab No Pay policy, and was portrayed as vital in helping to controlling infectious disease outbreaks by identifying areas where vaccination coverage was low.

But Health Minister Sussan Ley said it had now been “put on hold…pending further advice from independent medical experts on the vaccination needs of adolescents”.

The Health Department said it was possible that the Schools Register would only hold data on the human papilloma virus (HPV) if the pertussis booster for adolescents was axed and once the varicella catch-up vaccination program ends.

The Health Department said it was now looking at alternatives to the Schools Register, including the inclusion of such data in the whole-of-life Australian Immunisation Register which began operations on 30 September.

It is also in discussions with the Victorian Cytology Service about continuing the HPV Register in 2017.

Commonwealth Chief Medical Officer Professor Brendan Murphy was keen to assure that these changes would have “no impact on the health of adolescents because the full range of vaccination services are being delivered to the community, and will continue to do so”.

The move to axe the Register has coincided with the release of Government figures showing that almost 200,000 children have had their vaccinations brought up-to-date following the introduction of the No Jab No Pay reforms.

The figures, reported in the Sunday Herald Sun, show that since the reforms were introduced on 1 January, 86,562 families, including 102,993 children, have been denied childcare payments, and $38 million of Family Tax Benefit A benefits have been suspended. Parents of 8896 children are still not meeting vaccination requirements.

But 183,000 children have had their vaccinations brought up-to-date as a result of the program, under which parents face losing Family Tax Benefit A and childcare payments if they let their child’s immunity slip.

Adrian Rollins

Penny pinching threatens chronic care reform

The Federal Government’s landmark Health Care Homes reform is at risk of collapse because of a lack of funding, the AMA has warned.

Health Minister Sussan Ley has announced that $100 million will be provided to support the phase one trial of the reform, involving 65,000 patients and 200 medical practices in 10 regions across the country.

Under the Government’s plans, practices will receive monthly bundled payments worth an average $1795 a year to manage patients with chronic and complex health conditions. Payments will vary from $591 for chronically ill patients who can largely self-manage their condition to $1267 for those who need more intensive care and $1795 for those with the most complex health demands.

The allocations mean that patients on the lowest level of subsidy will be funded for just 16 visits to the doctor a year, rising to 48 visits a year for those deemed of highest need.

Controversially, such patients would only be eligible for five extra Medicare-subsidised visits to the doctor for health issues that lie outside their chronic illness – a major change from the current system under which patients have uncapped access to GP care.

A spokesperson for Ms Ley told Fairfax that five-visit cap was only an “indicative figure for modelling and planning purposes”, and said no patient would have their access to Medicare restricted or capped.

Ms Ley said Health Care Homes allowed for team-based, integrated care and would provide increased flexibility and coordination of services to tailor treatment to individual need.

But the details of the trial have reinforced suspicions that the Government is undertaking Health Care Homes primarily as a cost cutting exercise, and the AMA voiced concerns that if the reform was not adequately funded it could founder.

“The modelling is concerning and potentially leaves the whole program at risk of falling over because of being underfunded from the beginning,” AMA Vice President Dr Tony Bartone told News Corporation.

Dr Bartone, a GP, is the AMA’s representative on the Government’s Health Care Home Implementation Advisory Group, which last met on 30 September.

He said that, if appropriately funded, Health Care Homes could support GPs to keep patients healthier and out of hospital, but added the Government needed the goodwill of general practitioners if its trial was to succeed.

“That goodwill will evaporate significantly if there is not the appropriate funding,” he warned.

Earlier this year, AMA President Dr Michael Gannon warned that appropriate funding would be a “critical test” of the success or otherwise of the reform.

“BEACH data shows that GPs are managing more chronic disease. But they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts,” Dr Gannon said.

“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial and the model will struggle to succeed.”

Adrian Rollins

Australians shedding their hard drinking image

Drinks sales are forecast to decline as growing numbers of Australians cut back on their consumption or quit altogether, in a sign that higher excises and lock-out laws are helping to curb the nation’s drinking problem.

Industry analyst IBISWorld expects per capita alcohol consumption, which has already dropped to a 50-year low, will continue to decline until at least the middle of the next decade as people heed health messages and respond to higher prices, drink-driving laws and other measures by reducing their intake.

The analyst predicts that by 2024 consumption will drop to 8.54 litres per person, a fall of almost 20 per cent from the start of this decade.

“We’re seeing increasing health consciousness among the under 30s, while at the other end of the market people are also drinking less,” IBISWorld senior analyst Andrew Ledovshkik told The Australian Financial Review.

The analysis echoes the findings of an Australian Institute of Health and Welfare report showing that consumption is declining, with 22 per cent reporting they had abstained from drinking in 2013 (up from 17 per cent in 2004), and the proportion who have never had a full drink reaching 14 per cent.

Even rates of risky drinking are declining.

The AIHW reported an 11 per cent drop in the rate of Australians drinking at risky levels on a single occasion (from 2950 to 2640 per 10,000 people), and 13 per cent drop who indulge in risky drinking over a lifetime, from 2080 to 1820 per 10,000.

The declines have paralleled changes to the cost and availability of alcohol.

The excise on beer and spirits is indexed twice a year and for some beverages has reached $81.21 per litre of alcohol. Wine is treated differently and is subject to a so-called equalisation tax currently set at 29 per cent of its wholesale value. Public health advocates are critical of the arrangement and argue that alcohol should be taxed at a minimum unit price that applies regardless of the beverage.

Several State governments, most notably New South Wales and Queensland, have also acted to restrict outlet trading hours and impose lock-outs in response to alcohol-fuelled assaults and murders.

The Institute said the results suggested that strategies including increasing the price of alcohol, restricting trading hours and reducing the density of outlets “can have positive outcomes in reducing the overall consumption levels of alcohol”.

Aside from making alcohol more expensive and difficult to get, there are signs that younger people are less inclined to drink to the same extent as older generations.

In the United States, a survey of 67,000 youths and adults conducted by the Abuse and Mental Health Services Administration found that just 9.6 per cent of adolescents aged between 12 and 17 years reported drinking alcohol in 2015, down from 17.6 per cent in 2002.

The question is whether others drugs are being used as a substitute for alcohol.

In the US, there has been a slight drop in heroin use, but prescription drug use and abuse is high. It is estimated that about 19 million Americans aged 12 years or older misused prescription drugs, mainly painkillers, in the previous year.

In Australia, about 3.3 per cent of those 14 years or older have used analgesics for non-medical purposes in the previous 12 months, 10 per cent have used cannabis, 2.1 per cent have used cocaine and methamphetamine, 2.5 per cent have used ecstasy, 1.3 per cent have used hallucinogens and 0.1 per cent have used heroin.

But even with the decline in its consumption, alcohol remains a major health problem. It was the leading cause of disease burden for the under 45s in 2011, and alcohol use disorders accounted for 1.5 per cent of the total burden of disease that year.

Adrian Rollins