Claims of sub-standard chronic care ‘blatantly wrong’

The AMA has hit back at “blatantly wrong” claims that GPs are failing to adequately care for patients with chronic illnesses.

AMA Council of General Practice Chair Dr Brian Morton said that although there was “no doubt” management of chronic disease could be improved, a Grattan Institute study accusing GPs of serial shortcomings in their care of patients with chronic illnesses including diabetes, asthma, heart disease and mental illness, was flawed.

Using data drawn from 162 medical practices using the Medical Director patient management system, the report, Chronic failure in primary care, claims that just 15 per cent of diabetic patients had their blood glucose, weight and blood pressure checked every year, less than 30 per cent with high blood pressure had it adequately managed and two-thirds of patients with a mental illness missed out on care.

But Dr Morton strongly disputed the findings, which he said did not stand up to scrutiny.

For instance, he said, the proportion of Australians admitted to hospital with uncontrolled diabetes was 7.5 per 100,000 – one of the lowest rates among rich countries and well below the United Kingdom (23.9 per 100,000).

The Grattan Institute report itself admitted the paucity of data available to assess the effectiveness of the primary health system in managing complex and chronic disease, which Dr Morton said meant its analysis and conclusions must be treated with caution.

The report’s author, Professor Hal Swerrison, used the findings of the report to argue that the Government was getting a poor return on the $1 billion a year it provided to GPs to prepare chronic disease plans and conduct health assessments.

To rectify this, Professor Swerrison recommended that Medicare rebates be frozen at current levels and funds currently provided through the Practice Incentives Program, Service Incentive Payments and other sources to support chronic disease management be instead combined into an annual $40,000 payment to practices based on achieving performance targets and health outcomes.

A similar model was considered in the Primary Health Care Advisory Group report presented to Health Minister Sussan Ley late last year, as well as a blended model of fee-for-service and so-called capitation payments. The Minister is yet to formally respond to the report.

In its submission to the Primary Health Care Advisory Group, the AMA expressed support for a blended payment model and reform of Medicare chronic disease items to strengthen the role of a patient’s GP, cut red tape, streamline access to allied health care and reward longitudinal care.

Dr Morton said any changes to the model of care needed to be carefully considered and tested before being introduced, and a much more urgent priority was to lift the freeze on Medicare rebates.

“The burden of complex and chronic disease in this country continues to grow, and the Government needs to take a long-term view if it is to tackle this problem effectively,” he said. “The Government needs to invest significantly in general practice, [including] immediately lifting the current freeze on the indexation of Medicare rebates.”

He said the Grattan Institute report also highlighted the need for much better primary health care data: “There is very little data as to what actually works in Australia in the primary care space. Yes, we need data, and we need to collect it.”

The AMA has proposed a PIP incentive payment to support quality improvement, “informed by better data collection”.

Last month, pharmacists outlined the scope of their ambitions for involvement in the provision of health services, particularly chronic care.

Pharmacy Guild of Australia Executive Director David Quilty told a parliamentary inquiry into chronic disease prevention and management that pharmacies could play an “enhanced role” in a number of areas including: transitional care, continued dispensing and prescription renewal, treatment of minor ailments, vaccination, medicine adherence, point of care testing, risk assessments, early intervention, broader diabetes management, treatment of patients through biologics, asthma support, improved after-hours access to primary health care, illicit drug use and the use of pharmacies as rural health hubs, with a strong focus on triage services.

While the AMA has highlighted the risk to patients of allowing pharmacists to administer vaccines, conduct health tests and provide other services outside their scope of expertise, it has proposed the introduction of non-dispensing pharmacists in general practices as a way to help improve medication management, particularly for the chronically ill.

Adrian Rollins

The sick will pay heavy price for Govt cuts

Patients are likely to face blow outs in emergency care and elective surgery waiting times from next year, and may even miss out on care altogether, unless the Federal Government acts immediately to unwind massive Commonwealth public hospital spending cuts.

AMA analysis shows a huge shortfall in Federal funding for hospitals will rapidly open up from mid-2017 as a lower indexation arrangement kicks in, creating a gap in resourcing that State and Territory governments are unlikely to be able to cover.

AMA President Professor Owler said the states and territories were facing an “economic disaster” unless the Federal Government urgently restored its funding, and warned patients would be forced to wait longer for vital health care and may, in some cases, miss out altogether.

“As hospital capacity shrinks, doctors won’t be able to get their patients into hospital or keep them there to receive the critical care they require,” Professor Owler said. “Doctors will always do the best they can by their patients, but these cuts mean the system as a whole simply won’t be able to meet the demand.”

His warnings came amid mounting speculation the Commonwealth will provide emergency funds to avert a pre-election crunch in public hospital finances – though it is expected to make little dent in the long-term shortfall, which is projected to reach $57 billion by the middle of next decade.

Expectations are increasing that Prime Minister Malcolm Turnbull will use a rare joint meeting with the nation’s premiers and treasurers scheduled for 1 April to clear the decks on a range of contentious issues in the lead-up to the Federal election, not least massive cuts to Commonwealth support for public hospitals unveiled in the Government’s disastrous 2014-15 Budget.

The Prime Minister has reportedly already offered New South Wales Premier Mike Baird an emergency $7 billion cash injection to tide the State’s public hospital and education systems through till after the election, which could come as early as July or as late as November, and other premiers are now lining up to demand similar assistance.

Professor Owler said such handouts would help relieve pressure on hard-pressed public hospitals in the short-term, but if a financial crisis for the nation’s public hospitals was to be averted there needed to be an overhaul of Commonwealth-State arrangements to ensure hospitals were supported by a reliable long-term source of funding that grew in step with the increase in demand for their services.

“It is clear there is a crisis in public hospital funding and an immediate commitment is required, but a quick fix will not solve the long-term capacity problems for public hospitals or ease the economic burden on State budgets,” he said.

There is mounting evidence that the performance of hospitals is already being hurt by a squeeze on their finances, even before massive cuts detailed in the controversial 2014-15 Budget come into effect.

The human cost

The AMA’s annual Public Hospital Report Card, released earlier this year, showed that hospital performance is already beginning to suffer as the flow of Commonwealth funds slows.

In emergency departments, the proportion of urgent Category 3 patients seen within the clinically recommended 30 minutes fell back to 68 per cent in 2014-15 – a two percentage point decline from the previous year, ending four years of unbroken improvement.

Meanwhile, improvements in elective surgery waiting times have stalled – the median delay in 2014-15 was 35 days, six days longer than a decade earlier.

Professor Owler said there was a real human cost to be paid for such a deterioration in performance.

“For a patient requiring urgent attention for abdominal pain, this could mean they are seen one to two hours after they present to the ED,” he said. “Their symptoms could be consistent with indigestion, or could be a perforated bowel. The quicker a doctor can see them and make a diagnosis, then the quicker they can receive relief from their pain, and their condition can be prevented from deteriorating, potentially to a very serious situation.”

In the Budget, the Coalition announced it would renege on hospital funding guarantees to the states, saving $1.8 billion over four years, while a further $57 billion would be would be saved by 2024-25 by downgrading the indexation of Commonwealth hospital funding to inflation plus population growth.

Increasing the squeeze, the Independent Hospital Pricing Authority has set the National Efficient Price – which determines how much the Commonwealth pays for hospital services – at 1.8 per cent lower than the amount that was set last year, locking in hospital underfunding.

States under pressure

The massive Commonwealth cuts have outraged the states, which have warned of a significant reduction in hospital services unless another stream of funding is found.

The savings appeared to be part of a broader Commonwealth strategy to dump most of the funding responsibility for health services onto the states and directly on to patients, and occurred in the context of a renewed debate about taxation and the structure of the Federation.

Two premiers, Mr Baird and South Australia’s Jay Weatherill, had championed changes to the GST and income tax arrangements to give states access to a more robust stream of revenue to fund hospitals and schools, but they were undercut when Mr Turnbull dismissed any talk of changing the consumption tax.

The resistance of Canberra to calls for more funds has been stiffened by the fact that all the states are currently in surplus, while the Commonwealth expects a deficit of $37.4 billion this financial year, and no return to surplus over the next four years.

But, while Treasurer Scott Morrison has continued to talk tough, telling the states to sort out their hospital funding problems themselves, behind the scenes Mr Turnbull has reportedly been approaching some premiers to discuss a possible deal.

Professor Owler discussed the looming crisis in a meeting with Mr Weatherill earlier this month, and the SA Premier echoed his concerns.

Any short-term deal offered by Mr Turnbull would only “kick the can down the road”, he told ABC radio.

But he indicated the states were likely to accept any injection of funds offered.

“Mike Baird and I have been pushing for a much bigger solution – a 15-year solution – but we have to be realistic, we’re on the shadows of an election, and it’s an urgent problem,” Mr Weatherill said.

Adrian Rollins

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations

Alcohol-related presentations are common in emergency departments (EDs) throughout Australia and New Zealand. Two point prevalence surveys indicate that one in eight presentations to EDs are alcohol-related.1,2

ED clinicians are at the forefront of responding to the consequences of alcohol-related harm. Verbal and physical violence and aggression are common in EDs, with adverse effects on staff wellbeing and job satisfaction.3 As little is known about this problem in the local context, our study surveyed perceptions of clinical staff of alcohol-related presentations to Australasian EDs. The study had two main objectives: to quantify the scale of the problem of alcohol-related violence experienced by ED staff, and to assess their perceptions of the effects of alcohol-related presentations on the functioning of the ED.

Methods

A mixed methods, cross-sectional online survey was developed after undertaking a literature search, and refined by the consensus of an expert steering committee. Definitions for verbal and physical aggression were taken from the Medicine in Australia: Balancing Employment and Life (MABEL) Longitudinal Survey (http://mabel.org.au/) (Appendix 1). Free-text items were included for qualitative analysis. The survey was piloted, leading to minor modifications of its wording.

The survey was conducted from 30 May to 7 July 2014. Participation was anonymous, voluntary, and consent implied by completion of the survey. The survey link was distributed by email to 156 directors of emergency medicine at EDs accredited by the Australasian College for Emergency Medicine (ACEM). Directors were asked to forward the survey link to all clinical staff in their ED to encourage participation. The ACEM e-bulletin and social media channels were also used to promote the survey. The College for Emergency Nursing Australasia (CENA) also distributed the survey. These distribution channels ensured the survey was targeted at clinicians working in Australasian EDs. At the time of its distribution, 1575 emergency registrars and 1270 emergency physicians were working in ACEM-accredited EDs, together with an average of eight nurses per physician.

The survey distribution methodology meant that a response rate could not be determined. A small number of responses were received from ED staff who were not doctors or nurses; these were excluded from analysis.

Statistical analysis

Quantitative data was analysed using SPSS Statistics for Windows 22.0 (IBM). Proportions with 95% confidence intervals (CIs) were calculated, cross-tabulated by clinician role, and compared in χ² tests; P < 0.05 was defined as statistically significant. When analysing Likert scale data, “positive” and “very positive” responses were combined, as were “negative” and “very negative” responses. When assessing how frequently alcohol-related aggression was experienced, “frequently” and “often” responses were pooled, as were the responses “occasionally”’ and “infrequently”. Qualitative data were categorised according to thematic keywords derived from the free-text responses, and then analysed by the frequency distribution method.

Ethics approval

Ethics approval was provided by the Monash Health and Monash University Human Research and Ethics Committees (reference, MUHREC-CF14/1691-2014000782).

Results

Responses to the survey were received from 2002 clinicians (emergency physicians, ED registrars, resident medical officers, interns, and ED nurses) working in EDs in Australia and New Zealand (Box 1).

Alcohol-related verbal aggression from a patient had been experienced by 97.9% of respondents (1899 of 1940) in the past year, and physical aggression by 92.2% (1784 of 1935) (Box 2). Appendix 2 breaks downs the frequency of alcohol-related verbal or physical aggression experienced during the past year according to clinician type. Eighty-seven per cent of respondents (1682 of 1929) had felt unsafe in the presence of an alcohol-affected patient. Nursing staff were more likely than other ED staff to have felt unsafe (Box 3).

Sixty-eight per cent of respondents (1311 of 1940) reported having experienced verbal aggression often (a few times per month) or frequently (one or more times a week); 42% (807 of 1935) had often or frequently experienced physical aggression from alcohol-affected patients in the past year. Third party aggression (from patients’ relatives and carers) was also common. Although most staff had experienced alcohol-related verbal and physical aggression from patients and verbal aggression from a relative or carer in the past 12 months, nursing staff were more likely to have experienced this problem than non-nursing staff (χ² test, P < 0.001) (Appendix 2).

Forty-eight per cent of respondents (931 of 1931) reported routine screening for alcohol consumption of patients presenting to their ED, and 44% (850 of 1928) reported screening, brief intervention and referral to treatment for patients at risk of alcohol harm.

Thematic analysis of qualitative responses (selected examples: Box 4) showed that alcohol-related aggression was a daily occurrence, as reflected in 24% of free-text comments on this theme (44 of 186). Respondents also commented that such behaviour should not be acceptable in the workplace.

Men and women reported similar frequencies of verbal and physical aggression from patients, but women were more likely to report verbal or physical aggression from relatives or carers (χ² test, P = 0.01) (Appendix 3).

Alcohol-related presentations were perceived to have a negative impact on waiting times, other patients in the waiting room, and the care of other patients (summary: Box 5; full results: Appendix 4). Alcohol-related presentations were also widely viewed as having a negative or very negative impact on the workload, wellbeing and job satisfaction of ED staff (summary: Box 5; full results: Appendix 5).

Free-text responses about the impact of these presentations on ED functioning confirmed this. Sixty per cent of respondents (1191 of 2002) provided a comment about the effect of alcohol-related presentations on other patients attending the ED. Most described negative effects, with 48% (569 of 1191) commenting that other patients experienced distress and felt unsafe if an alcohol-affected patient displayed loud, aggressive, violent or antisocial behaviour. Seventeen per cent (201 of 1191) commented that this distress was heightened in vulnerable patients, including children, the elderly, and in those who were mentally unwell.

Twenty-three per cent of these respondents (272 of 1191) also commented that alcohol-affected patients caused increased waiting times for other patients because they often were treated as a priority. Alcohol-affected patients were perceived to affect other patients by diverting resources (17% of respondents; 205 of 1191) and clinicians (15%; 182 of 1191), and by generally compromising the quality of care that other ED patients received (16%; 188 of 1191).

Discussion

Our study found that more than 90% of ED clinicians had in the past year experienced physical aggression from a patient affected by alcohol, with 42% experiencing this aggression weekly or monthly. This frequency of physical aggression from a single cause is disturbing, particularly compared with a large survey of Australian general practitioners and hospital doctors in which 32.3% reported experiencing physical aggression in the past year.4

Verbal aggression from patients affected by alcohol was an ever-present part of clinical life for ED staff. This compares with 70.6% of a more general cohort of doctors reporting that they had experienced verbal or physical aggression.4 While all ED clinician types experience violence and aggression, it is more frequently experienced by ED nurses,5 and it has been suggested that nurses see violence and aggression as an inescapable part of their job.6,7

We also found that ED clinicians frequently experience both physical and verbal violence and aggression from alcohol-affected patients’ relatives and carers. While this third party aggression has been reported before, comments made by respondents suggest that accompanying persons were often also affected by alcohol, and this may explain the high rate of aggression. Although there was no difference in their experience of violence and aggression from the patients themselves, female staff were more likely to experience violence and aggression from the carers of alcohol-affected patients. Previous research did not find this gender difference for either doctors or nurses.8,9

Adverse impacts of alcohol-affected patients on other patients and the effective operation of the ED is concerning. The need to divert resources disrupts or delays care for other patients. Effects on the welfare of and care for other patients, particularly vulnerable groups, are further exacerbated by the disruptive and antisocial behaviours of alcohol-affected people in EDs.

Violence and aggression had a negative effect on respondents’ perceptions of their wellbeing and job satisfaction. This has been previously reported,8 and it has been suggested that this affects the quality of care beyond its obvious effects on workload. Patient aggression and violence has a profound impact on patients, clinicians and the therapeutic relationship.10 It can also affect staff retention and recruitment, and this highlights the importance of community education about alcohol-related harms and of changing the culture of unacceptable behaviour.9

The MABEL study found that medical practitioners were less likely to experience aggression in workplaces where strategies to reduce aggression had been implemented.11 Environmental and human factors should be taken into account to reduce the risk of workplace violence, while resources that enable appropriate medical care and access to safe sobering-up facilities will assist EDs to manage alcohol-affected patients.

Study limitations

Selection and non-responder bias inevitably affects voluntary surveys. ED clinicians who have recently experienced aggression and violence from alcohol-affected patients may be more likely to respond. Further, as the survey was anonymous, it was difficult to ensure that respondents did not complete the survey several times. However, our review of respondents’ IP addresses and their demographic data suggests that this was unlikely. More than half the respondents worked in major referral hospitals, suggesting that this group was over-represented. Recall bias was minimised by asking respondents only about the past 12 months. Definitions of violence and aggression were provided in the survey to limit misclassification of events by respondents. Misclassification may, however, have resulted in some respondents confounding alcohol-related presentations with those related to other drug use, or to a combination of alcohol and drug use.

Conclusions

Alcohol-related verbal aggression was commonplace for the clinicians who responded to this survey. Physical violence was experienced by a large majority. This violence and aggression has a negative impact on the care of other patients and on the wellbeing of clinicians. Managers of health services must ensure a safe working environment for staff. More importantly, however, a comprehensive public health approach to changing the prevailing culture that tolerates alcohol-induced unacceptable behaviour is required.

Box 1 –
Workplace characteristics of the 2002 emergency department staff who responded to the survey

	Number	Percentage

Gender
Men	700	35.0%
Women	1285	64.2%
Not stated	17	0.8%
Staff role
ED nurse	904	45.2%
EM physician	507	25.3%
EM registrar	373	18.6%
Medical officer	136	6.8%
Other	67	3.3%
Not stated	15	0.7%
Location
Victoria	408	20.4%
Queensland	367	18.3%
Western Australia	300	15.0%
New South Wales	298	14.9%
South Australia	211	10.5%
Tasmania	46	2.3%
Northern Territory	29	1.4%
Australian Capital Territory	11	0.5%
Australia (total)	1670	83.4%
New Zealand	313	15.6%
Not stated	19	0.9%
Role delineation of ED
Major referral	1035	51.7%
Urban district	566	28.3%
Regional/rural	379	18.9%
Not stated	22	1.1%

ED = emergency department; EM = emergency medicine.

Box 2 –
Frequency of alcohol-related verbal or physical aggression experienced by respondents within the past 12 months (summary)*

Number of responses

Often/frequently

Occasionally/infrequently

Not at all

Verbal aggression from a patient

1940

67.6% (65.5–69.7%)

30.3% (28.3–32.3%)

2.1% (1.6–2.9%)

Physical aggression from a patient

1935

41.7% (39.5–43.9%)

50.5% (48.3–52.7%)

7.8% (6.7–9.1%)

Verbal aggression from a relative or carer

1923

30.8% (28.8–32.9%)

58.7% (56.5–60.9%)

10.5% (9.2–11.9%)

Physical aggression from a relative or carer

1930

18.9% (17.2–20.7%)

58.0% (55.8–60.2%)

23.1% (21.3–25.0%)

Data are presented as the percentage of received responses, with the 95% confidence intervals in parentheses. * For full results and breakdown by clinician group, see Appendix 2.

Box 3 –
Emergency department staff reporting that they have felt unsafe because of the presence of an alcohol-affected patient in their emergency department*

Staff role

Number

% (95% CI)

Emergency department nurses

863

91.8% (89.8–93.4%)

Emergency department registrars

360

88.6% (84.9–91.5%)

Emergency department physicians

499

82.6% (79.0–85.0%)

Emergency department medical officers

133

72.2% (64.0–79.1%)

Other/unknown

85.1% (75.3–91.5%)

* P < 0.001 (χ² test).

Box 4 –
Selected qualitative responses to the survey

Alcohol-related aggression and violence in the emergency department (ED)

Verbal abuse is an hourly occurrence. One or two people removed for physical aggression each shift, a staff member injured severely enough to have days off every few months, patients restrained by security/code black every two to four hours. Serious property damage (window/wall broken) every one or two months. [ED doctor, female]
Staff are regularly faced with physical/verbal aggression due to alcohol presentations; several members of staff have had chairs thrown at them, one underwent a shoulder reconstruction after sustaining a dislocation from a patient and we are constantly abused. [ED nurse, male]
If I am out of uniform I do not have to tolerate these behaviours and have a course of action; if I am in uniform, I am fair game! [ED nurse, female]
I was assaulted and knocked unconscious by a patient. I was put in my own resus[citation] room with concussion and vomiting. I had residual effects for several weeks following. The patient was arrested in the ED. When asked why he hit the doctor, his reply was: “because no-one brought me a **** sandwich.” [ED doctor, male]
I was obviously pregnant and was threatened by a patient (in front of his kids and wife) that he was going to punch me in the stomach. [ED nurse, female]

The impact of alcohol-related presentations on patient care

They can feel threatened and intimidated in an environment where they should feel safe. They are often shocked and offended by what they see or hear. [ED nurse, female]
I always feel terrible when there is a parent with a sick kid and they are exposed to behaviour and language and sometimes violence or even police presence; it’s very unfair towards them. [ED doctor, female]
A woman and her 4-year-old daughter in a cubicle had a drunk man open the curtain and urinate over the bed thinking he was in the toilet. Distressing for mum and child. [ED nurse, female]
Other patients in the ED often have delayed care because of intoxicated patients, and sometimes even important tests or observations are missed or forgotten because the intoxicated patient is taking up so much of our time — either vomiting, abusing staff or other patients, creating a scene, or generally being unsafe. [ED nurse, female]
They use resources that may otherwise go to another case. If you have one remaining bed and two patients, and one of them is highly intoxicated, they will get preference over the patient who may be quite ill but is able to sit in the waiting room. [ED nurse, female]

Box 5 –
The impact of alcohol-related presentations on emergency department function and care of other patients* and on emergency department staff^† (summary)

Number of responses

Positive/very positive

Neutral

Negative/very negative

Don’t know

On patients

On waiting times

1980

0.5% (0.3–0.9%)

13.7% (12.3–15.3%)

85.5% (83.8–86.9%)

0.4% (0.2–0.7%)

On other patients in the waiting room

1980

0.4% (0.2–0.8%)

4.4% (3.6–5.4%)

94.4% (93.3–95.3%)

0.8% (0.5–1.3%)

On the care of other patients

1982

0.6% (0.4–1.1%)

10.9% (9.6–12.4%)

88.3% (86.8–89.6%)

0.2% (0.1–0.5%)

On emergency department staff

On staff workload

1991

0.8% (0.5–1.3%)

4.7% (3.8–5.7%)

94.2% (93.1–95.2%)

0.3% (0.1–0.7%)

On staff wellness

1981

0.7% (0.4–1.2%)

24.6% (22.7–26.5%)

74.1% (72.1–76.0%)

0.6% (0.4–1.1%)

On staff job satisfaction

1983

1.3% (0.9–1.9%)

17.4% (15.8–19.1%)

80.9% (79.2–82.6%)

0.4% (0.2–0.8%)

Data are presented as the percentage of received responses, with the 95% confidence intervals in parentheses. * For full results and breakdown by clinician group, see Appendix 4. † For full results and breakdown by clinician group, see Appendix 5.

Trends in drug use among adolescents admitted to residential treatment in Australia

In Australia, trends in drug use are primarily measured through two population surveys.1,2 These show alcohol, cannabis and tobacco to be the most commonly used drugs among adolescents. The National Drug Strategy Household Survey found that methamphetamine use has remained very low (2%) and stable among 14–19 year olds, with no rise in methamphetamine use overall in the population; however, there was a change in the main form, with crystal (“ice”) replacing powder.2

Population-level surveys are not sensitive to changes in use of drugs, which have a low prevalence in the general population by different age groups. Our report examines trends in reported current drug use and drug of greatest concern among an adolescent population admitted to four residential treatment sites across New South Wales and the Australian Capital Territory from 2009 to 2014. These young people are likely to be excluded from population surveys.3

The study sample included 865 adolescents, aged 14–18 years, admitted to residential treatment between 1 July 2009 and 31 December 2014, representing a large proportion of the adolescent residential treatment population in NSW and the ACT.4 Analyses included log-binomial regression for trends by admission year and multiple log-binomial regression to control for changes over time in sociodemographic characteristics.

The mean age of the study population was 16.6 years and 72.6% were male (Box 1). Over a third (37.2%) were referred by juvenile justice staff or self-reported criminal activity. Methamphetamine was the only drug to show an upward trend in the reporting of drug of greatest concern (Box 2), from 10.8% in 2009 to 48.4% in 2014 (relative risk [RR] per year, 1.37; 95% CI, 1.27–1.47); and in current use of drug at admission, from 28.8% in 2009 to 59.4% in 2014 (RR per year, 1.15; 95% CI, 1.09–1.22). Trends in methamphetamine use remained significant after controlling for sociodemographic characteristics. Alcohol, cannabis and tobacco use remain high, with 64.1% of participants reporting currently using alcohol, 85.2% cannabis and 72.7% tobacco in 2014.

Among 321 participants reporting current methamphetamine use, those reporting inhaling smoke or vapour increased from 12.5% in 2009 to 85.5% in 2014 (RR per year, 1.21; 95% CI, 1.15–1.27). Different forms of methamphetamine were not recorded; however, ice is commonly inhaled, which suggests that the main form used by participants has changed. There were associations between methamphetamine use and number of places lived and enrolment in a special class at school, suggesting that young people who may have learning difficulties or unstable accommodation may be at a higher risk of methamphetamine use or that use may result in learning issues and unstable accommodation.

Although self-reporting is common in behavioural research, there may be some response bias. For example, recent media attention may have increased reporting of methamphetamine as the drug of greatest concern. Under-reporting of methamphetamine use may also have occurred due to stigma. However, we found similar trends on both measures. The questions used were drawn from scales in the Brief Treatment Outcome Measure, which was developed in six phases including testing psychometric properties with treatment clients, a 30-month clinical trial in selected rural and metropolitan health services and clinician feedback.5

In contrast to stable population-level trends, methamphetamine use among this adolescent population has increased substantially. To equitably address methamphetamine-related harms, population surveys and health campaigns should be supplemented by a targeted approach to monitoring, prevention and treatment of at-risk groups.

Box 1 –
Sociodemographic characteristics of participants (n = 865)*

Characteristic	No. of participants

Mean age, years (SD)	16.6 (1.0)
Male	628 (72.6%)
Ever suspended or expelled from school	725 (83.8%)
Ever enrolled in special class at school	340 (39.3%)
Places lived in previous 6 months
1	287 (33.2%)
2	235 (27.2%)
3	160 (18.5%)
≥ 4	183 (21.2%)
Arrests in previous 3 months
0	279 (32.3%)
1	241 (27.9%)
2–3	233 (26.9%)
≥ 4	112 (12.9%)

* Data are number and proportion of participants unless otherwise indicated.

Box 2 –
Trends in drug of greatest concern, by year of admission (n = 865)

Alcohol and other drug treatment policy in Australia

We need more resources that are better spent

Alcohol and other drug (AOD) treatment policy is at a significant point of transition in Australia. The media is replete with examples of people unable to access appropriate AOD treatment — whether it be for detoxification, residential rehabilitation, pharmacotherapy or counselling. Anecdotal reports are backed by evidence of high unmet need and demand for treatment. Fewer than half of those seeking AOD treatment in Australia are currently able to access appropriate treatment.1 This is an appalling situation, but not much different than in most developed countries,2 and all the more concerning because we know treatment works and it reduces the substantial social costs of harmful AOD consumption.3

Good AOD public policy involves a balance between reducing the supply of drugs (through regulation and law enforcement), reducing the demand for drugs (through prevention and treatment) and reducing the harmful consequences of use (through harm reduction interventions). Australian governments currently spend most on law enforcement.4 Yet research shows that law enforcement responses, notably those related to incarceration, are far less cost-effective than treatment.5 Governments need to shift investment away from law enforcement and into treatment, including the resourcing of effective referral and treatment pathways for people who come into contact with the criminal justice systems.

Despite a clear need, finding more funding for AOD treatment and effectively allocating it may be harder than anticipated. There is a complicated array of funding arrangements for AOD treatment in Australia.6 State and territory governments fund most specialist AOD treatment. The federal government funds primary health care and pharmaceuticals (via Medicare and the Pharmaceutical Benefits Scheme) and also contributes a significant share of specialist AOD treatment funding.7 However, there is little planning and coordination between levels of government in Australia.1 The National Drug Strategy 2010–20158 is silent on the division of responsibilities between state and federal governments for AOD policy and practice, which compounds the problem federalism presents for coordinating effective AOD treatment services. It is therefore difficult to hold any one level of government to account. A doubling of current resources would be required to address unmet treatment need, and this will inevitably lead to arguments about who is responsible for this funding and where new funds should be allocated.

Policymakers at both state and federal levels currently operate in a vacuum; there is no Australia-specific research evidence they can bring to bear on decision-making for how to organise and fund AOD treatment. Jurisdictions have developed autonomous and independent treatment service systems. For example, the predominant purchasing mechanism in New South Wales involves block grants, but it is a variant of activity-based funding in Victoria.1 In Western Australia, 88% of AOD treatment episodes are provided by non-government organisations, whereas in NSW this figure is 26%.9 While increased resourcing is the primary priority, concurrent comparative analysis of the impact and cost-effectiveness of AOD treatment funding systems, including purchasing models and provider types, would inform refinements to AOD treatment services in Australia.

Despite the absence of such research, Australian governments must increase their investment in AOD treatment. In this context, it was pleasing to see the federal government apportioning the lion’s share of funds allocated in response to the work of the National Ice Taskforce to new AOD treatment resources.10 This significant investment ($241.5 million and an additional $13 million for new Medicare Benefits Schedule items for addiction medicine specialists) has the potential to reduce some of the unmet demand for AOD treatment. The way in which those resources are distributed will be critical to their success. In particular, we need to understand how funds will be distributed between primary health care and specialist AOD treatment. The greatest need is in specialist treatment services, although there is a risk that new funds will be targeted at primary health care. This would be a wasted opportunity.

For the first time in Australia, we know the extent of unmet AOD treatment need and demand. We also have a good understanding of the complicated funding flows in this area. While more resources for AOD treatment are needed, responses should also include appropriate resourcing of broader social support services. Although local data on the prospective drivers of sustained drug use are scarce, overseas evidence11 and reflections from Australian service providers suggest that social stability factors — such as employment, positive family relationships and stable housing — are crucial determinants of drug use patterns. Alongside AOD treatment, effective responses must appropriately resource integrated services that support people to achieve their AOD treatment goals.

“Ice” (crystal methamphetamine): concerns and responses

There is no cause to feel impotent, despite disturbing media reports about methamphetamine

Methamphetamine has been around for some time. Although it is now available in a crystal form that is more potent and more readily smoked than earlier forms, no-one should feel impotent in the face of widespread alarmist commentary about this drug.

The recent National Ice Taskforce Report1 describes a pattern of increasing use of methamphetamine over the past decade. Compounding the effect of the shift in use from the older amphetamine sulphate to methamphetamine (in powder or crystal form) is the increase in purity of illicit methamphetamine: the purity-adjusted price (the dose obtained for a given price) is now similar for both methamphetamine forms,2 so that users obtain much larger doses. This probably underlies the evidence of more regular and greater levels of dependent use among people who use the drug, and also some of the increases in observed harms.3

The medical profession is pivotal in responding to these changes, and needs to provide clear, evidence-based responses and care for those affected; it is not “someone else’s problem”.

People who use methamphetamine come into contact with the general health care system for a number of reasons, ranging from problems directly related to use (eg, insomnia, acute mental health problems) to complications of use (eg, injuries, infections and cardiovascular problems), some of which may be detected while providing other care (eg, during antenatal care). Some users present when seeking treatment from general practitioners, including some requesting benzodiazepines or other sedatives, but methamphetamine use may not be disclosed or the GP may not have asked about it; sometimes it is other members of the family who seek help.

People who use methamphetamine are generally younger (under 40 years of age); more men than women use these drugs, and users commonly experience mental health and other substance use problems.4 Use is more prevalent among some groups more frequently exposed to health risks, especially Aboriginal and Torres Strait Islander people, and the gay, lesbian, transgender and transsexual communities. Recent use is more common in rural and remote communities. Most people who have used methamphetamine have done so only occasionally; however, the best available data suggest that there are now more regular and dependent users of the drug than at any other time in the past decade.5

What would be an appropriate response? There is a pressing need for a flexible and coordinated treatment system that can respond in a timely manner to people who use amphetamines. We need to develop the skills, confidence and capacity to do so. Drug and alcohol specialists, nurses, psychologists and other allied health practitioners all play key roles in partnership with primary and acute care services, including emergency departments and mental health services. Strategies to engage the broader medical workforce are urgently needed. GPs cite a range of reasons for feeling unskilled or unsupported in managing people with substance misuse problems, so that many are reluctant to do so.6 This situation must be changed if we are to improve our frontline responses to problems linked with methamphetamine use.

Optimal alcohol and drug-specific treatments incorporate multidisciplinary care that also attends to co-occurring substance use (eg, tobacco), as well as to physical, mental health and social problems. Psycho-social treatment approaches include specific drug counselling and support, withdrawal services, day programs and residential treatment for those who require more intensive support. Assertive follow-up and proactive relapse prevention programs are crucial, as the relapse rate among dependent methamphetamine users is high.

More research is needed to develop methods for better attracting methamphetamine users to treatment, to provide brief interventions for those with less severe problems, and to improve treatments for those who need intensive assistance. In addition to ongoing research overseas, a recently announced NHMRC grant to fund research that explores an alternative pharmacotherapeutic approach (application 1109466) and another that will examine the particular needs of Aboriginal communities (application 1100696) are promising starts.7

The alcohol and drug treatment sector needs to grow significantly to allow it to respond to those who need intensive treatment and to be available to support primary care. The announced introduction of Medicare item numbers for addiction medicine specialists8 will facilitate development of the workforce in this area. The use of a national planning model that assesses needs according to population prevalence, estimates the demand for treatment, and calculates the amount of resources required to respond effectively has been used to develop mental health services. A similar plan should be a matter of priority as a blueprint for national drug and alcohol service development.9 Western Australia has used modelling to develop one version of such an approach, focusing on system integration because this “ensures service delivery is comprehensive, cohesive, accessible, responsive, and optimises the use of limited resources”.10

The release of the Final Report of the National Ice Taskforce provides an opportunity for action. However, many key issues raised in the report still require adequately resourced strategies; this applies especially to specific plans for Indigenous communities. Mixed funding by the federal and state governments makes it challenging to achieve the necessary coherence of response. The Primary Health Networks will need to rapidly develop the capacity to engage with GPs, and specialist drug and alcohol services if they are to play a key role. Governments, health services and the general community must seize this opportunity to respond to the problems associated with methamphetamine use.

[Editorial] Health—an explicit human right

“The past year severely tested the international system’s capacity to respond to crises and mass forced displacements of people, and found it woefully inadequate.” So begins Amnesty International’s annual report for 2015, The state of the world’s human rights, published last week. Set against the backdrop of unprecedented and worldwide migration, recurring themes include access to health services, the effects of conflict on health, women and children’s health, sexual rights, and the denial of health care in prisons.

Premium hike could drive cover downgrade

There are fears a surge in private health insurance premiums will drive more patients into downgrading or dumping their policies, leaving many with inadequate cover and increasing the pressure on stretched public hospitals.

The Federal Government has approved an average 5.59 per cent increase in premiums from 1 April – more than double the rate of inflation.

Health Minster Sussan Ley has claimed a victory of sorts after convincing 20 of the nation’s 33 private health funds to resubmit lower increases than originally planned, a move she said had saved consumers $125 million.

But the latest round of premium hikes, which range from 3.76 per cent to 8.95 per cent, are likely to feed mounting consumer dissatisfaction with the value of private health insurance, leading to more downgrading or dumping their insurance.

The AMA has raised the alarm on these and other developments in the private health insurance market that undermine the quality of cover and could disturb the important balance between private and public health systems.

AMA President Professor Brian Owler said in the past six years the proportion of people with policies that had exclusions had jumped from 10 to 35 per cent, often with serious consequences.

The AMA President said it had become virtually a daily occurrence for patients booked in for common treatments to discover upon arrival that they were not covered by their insurance.

He said all too often insurers made changes to a policy after it had been bought without informing policyholders, leaving many unexpectedly stranded.

“People are shocked to make this discovery only when they need a particular treatment, and doctors are seeing this happen on a daily basis,” Professor Owler said.

The AMA’s criticisms were echoed in an Australian Competition and Consumer Commission report highly critical of the quality and accuracy of information provided by the health funds, which the watchdog said served to confuse consumers about what they were covered for and hampered their ability to make informed choices.

Ms Ley has launched a review into the private health insurance industry to examine regulation of the sector, including the setting of premiums, as well as other issues including the industry’s push into primary health care; a possible relaxation of community rating principles; and a proposal to replace health insurance rebates with Medicare-style payments for hospital care.

The Health Minister said the review had received more than 40,000 submissions from the public, and flagged there would be “broader structural overhauls” made to current industry regulation.

Part of the Government’s focus is on the cost of medical devices in the private health sector, and the Minister has launched a separate review of the Prostheses List.

Ms Ley said the process for approving premium increases also need to change.

“The current premium approvals process isn’t providing the right checks and balances to ensure consumers get the best deal every year, and there are clearly significant additional costs and barriers blocking larger premium savings from being passed on,” she said.

But whereas the Health Minister has put the focus on industry regulation as much of the cause of the problem, Professor Owler put much of the blame on the hunger for profit.

Since the privatisation of Medibank Private, the market share of for-profit insurers has surged to 63 per cent, something AMA Medical Practice Committee Chair Professor Robyn Langham said had been a “game-changer”.

“We now have an industry dominated by the interests of for-profit health insurers rather than not-for-profits, with a subsequent shift of focus from providing patient benefits to increasing profits for shareholders,” Professor Langham said.

In its submission to the Government’s review, the AMA warned that industry practices including downgrading existing policies, habitually rejecting claims, lumbering patients with bigger out-of-pocket costs, pressuring policyholders into reducing their cover and selling people cover they don’t need, were badly compromising the value of private health cover and could eventually upset the delicate balance between the public and private health systems.

“On their own, these activities reduce the value of the private health insurance product,” the AMA said in its submission to the Review. “Collectively, they are having a destabilising effect on privately insured in-hospital patient care and treatment.”

Professor Langham said the AMA was planning to produce an annual report card to given consumers clear and simple information regarding the health insurance policies on offer.

She said consumers would be able to check differences in benefits paid for a sample of common procedures, and identify exclusions and restrictions (including junk ‘public hospital-only’ insurance policies). Professor Langham said the report card would also help doctors to compare the gap arrangements of different insurers in order to work out who provided better cover for health costs.

The AMA’s submission to the Government private health insurance review can be viewed at: submission/ama-submission-private-health-insurance-consultations-2015-16

The only way is up

Health fund premium increases to take effect from 1 April

Insurer	Average Increase with rate protection
ACA Health Benefits Fund Ltd	6.19%
Australian Unity Health Ltd	5.05%
BUPA Australia Pty Ltd	5.69%
CBHS Health Fund Ltd	5.92%
Cessnock District Health Benefits Fund Ltd	6.19%
CUA Health Fund Ltd	8.95%
Defence Health Ltd	5.48%
Doctor’s Health Fund Pty Ltd, The	3.76%
GMHBA Ltd	5.44%
Grand United Corporate Health Ltd	4.26%
HBF Health Ltd	4.94%
Health Care Insurance Ltd	6.90%
Health Insurance Fund of Australia Ltd	6.55%
Health Partners Ltd	7.14%
Health.com.au Pty Ltd	8.81%
Hospitals Contribution Fund of Australia Ltd, The	5.42%
Latrobe Health Services Ltd	5.52%
Lysaght Peoplecare Ltd	4.38%
Medibank Private Ltd	5.64%
Mildura District Hospital Fund Ltd	6.74%
National Health Benefits Australia Pty Ltd	5.28%
Navy Health Ltd	5.50%
NIB Health Funds Ltd	5.55%
Phoenix Health Fund Ltd	5.72%
Police Health Ltd	4.81%
Queensland Country Health Fund Ltd	4.91%
Queensland Teachers’ Union Health Fund Ltd	7.15%
Railway & Transport Health Fund Ltd	5.61%
Reserve Bank Health Society Ltd	5.37%
St Luke’s Medical & Hospital Benefits Association Ltd	5.89%
Teachers Federation Health Ltd	4.97%
Transport Health Pty Ltd	6.49%
Westfund Ltd	5.94%
INDUSTRY WEIGHTED AVERAGE	5.59%

Adrian Rollins

[Articles] A comparison of health expectancies over two decades in England: results of the Cognitive Function and Ageing Study I and II

During the past two decades in England, we report an absolute compression (ie, reduction) of cognitive impairment, a relative compression of self-perceived health (ie, proportion of life spent healthy is increasing), and dynamic equilibrium of disability (ie, less severe disability is increasing but more severe disability is not). Reasons for these patterns are unknown but might include increasing obesity during previous decades. Our findings have wide-ranging implications for health services and for extension of working life.

[Correspondence] Implementing health policy and systems research in Myanmar

We agree with Karen Eggleston and colleagues’ (Nov 21, p 2053)1 assertion that one of the greatest challenges facing Myanmar is the optimum allocation of scarce resources, and add that evidence to inform this is needed urgently. We started working to generate such evidence shortly after the move to a nominally civilian government in 2011 opened the country up to more international collaborations. Here, we summarise the insights gained while doing one of the first multidisciplinary research programmes on the health system and tuberculosis control in Myanmar, which included two literature reviews, a mixed-methods situational assessment, a case-control study of risk factors for emergence of drug resistance, a qualitative study of barriers to accessing health services, and an economic analysis of patient costs.