“Sorry, I’m not a dentist”: perspectives of rural GPs on oral health in the bush

Australians living in rural areas have poorer oral health than city residents.1 They experience higher rates of dental caries2 and are more likely than people in city areas to visit dentists for problems other than check-ups.3 Complicating this situation is the inadequate availability of dental care services in rural areas because of the uneven distribution of dental practitioners across Australia; most dentists and other dental practitioners practise in city areas.4,5 Many small rural towns in Australia do not have the population to support a full-time or resident dentist. Dental services in Australia are largely provided by the private sector (85%);6 public oral health services are provided only for those under 18 years of age and for adults who hold health care concession cards.7

People on low incomes who cannot regularly access dental care and who do not have private insurance are more likely to present to general medical practices and hospital emergency departments with oral health problems for immediate treatment and referral.8–13 It is concerning that dental conditions accounted for 63 000 avoidable hospital admissions in Australia during 2012–13.14 The admission rates for these conditions were lowest among city residents (2.6 admissions per 1000 population) and highest for very remote residents (3.7 per 1000),15 although the rates in each category vary between jurisdictions.16

When dental services are not available in remote areas, people visit non-dental health providers, including medical staff, for dental care.12 Although rural general practitioners see patients with dental health problems, there has been limited research into their views about oral health. Our study investigated how rural GPs manage presentations by patients with oral health problems, and their perspectives on strategies to improve oral health in rural areas.

Methods

This study forms part of a broader oral health rural workforce research project that is investigating the relationship between dental practitioners and primary care networks. The chief dental officers of Tasmania, Queensland and South Australia were invited to identify rural and remote communities in which oral health care was a significant problem, and where there was at least one general medical practice, a health care facility and a pharmacy, but no resident dentist. Primary care providers in selected communities who had experience in advising patients with oral health problems were invited to participate in semi-structured interviews. Participants were recruited using both purposive and snowball sampling strategies.17

The interview guide was developed on the basis of our review of the relevant literature, and included questions about each participant’s professional background; the frequency and management of oral health presentations, and the level of confidence with which the practitioners managed these patients; and their views on strategies that could improve rural oral health. The interviews were conducted in the participants’ workplaces by one or more members of the research team between October 2013 and October 2014. Recruitment continued until data saturation18 was attained in the concurrent data analyses. Interviews were audio-recorded and later transcribed.

Interview data were subjected to thematic analysis.19 NVivo version 10.0 (QSR International) was used to organise transcripts and codes. All transcripts were verified against audio recordings by two members of the research team, and interview data coded independently for cross-validation. The coding results were compared and discussed at regular meetings involving all researchers until consensus was reached. The consolidated criteria for reporting qualitative research (COREQ)20 were used as a guide for ensuring quality. Quotes from individual GPs are identified in this article only by number (eg, GP 20).

Ethics approval for the study was granted by the Human Research Ethics Committee (Tasmania) Network (reference H0013217).

Results

Characteristics of study sites and participants

Sixteen communities were identified by state dental officers for inclusion in the investigation: three each in Tasmania and South Australia, and ten in Queensland. All but three Queensland communities were found to satisfy the study inclusion criteria (Box 1). In these communities, 101 primary care providers, including 30 GPs, participated in the study. In this article we report on the perspectives of these 30 GPs (18 from Queensland, nine from Tasmania, three from South Australia). Twenty-two were men, eight were women; 15 were 40 years old or younger, 15 were over 40 years old; the median time that the participants had worked in their current practice was one year (range, 0.04–35 years; interquartile range, 0.11–3.88). Nine GPs participated in two group interviews and 21 in individual interviews. Interviews lasted 30 to 60 minutes.

Four themes emerged from the interviews: rural oral health; managing oral health presentations; barriers to patients seeing a dentist; and improving oral health (Box 2).

Rural oral health

Participants reported seeing between one and 20 patients of various ages with oral health problems each month (mean, 12 per month for each community):

… the guy that just walked out and the one before him just walked out with a dental problem and probably three others came in today … four to five per week, close to 20 a month. (GP 10)

The oral health problems they saw ranged from toothaches, abscesses, oral infections and dentures to trauma:

… mostly what we see is dental abscesses, mouth ulcers, sometimes it is dentures … And, of course, extreme pain and tooth abscesses. (GP 8)

Having seen patients with oral health problems, GPs could observe the oral health status of their communities. Nine of 30 GPs commented that it was “so bad”, “very poor”, “never expected”, or even “shocking”:

I mean this town has shocking, shocking dental care … I’ve never seen teeth so badly decayed. (GP 10)

Managing oral health presentations

Most participants provided prescriptions for antibiotics and short-term pain relief, and advised patients to see dentists:

… if I suspect infection I will give antibiotics … As far as pain goes, I will give them a short-term oral pain relief … but I always give advice to go to the dentist. (GP 13)

Some also reported providing education about oral hygiene and preventive dental care:

I mostly provide pain relief, provide antibiotics, provide advice in personal dental care, I’m very hot on that. (GP 10)

Other treatments include dental block injections and tooth extractions:

Occasionally I pull people’s teeth here, but I’d rather not do it. (GP 19)

Eighteen of the GPs were confident, within their scope of practice, about providing oral health care advice and treatment:

Yes, pretty confident with basic dental emergency relief. (GP 4)

However, some acknowledged that they were not always confident, and that they lacked training in the area:

I start off … “sorry, I’m not a dentist”, and all I know is there are supposed to be 32 teeth in the mouth and that is pretty much all I know. I don’t have the training, absolutely not. (GP 6)

Barriers to patients seeing a dentist

Participants expressed concern that, for a number of reasons, patients would often not visit a dentist as advised. Some believed that this was because oral health was a low priority for these patients and this started with the parents:

Dental care is not a priority in rural people’s lives — at all … There are some quite attractive young men and women who’ve got shocking teeth … so just for lack of care … But again, it’s parental priority. When I was a kid, I come from a large family, my memory of school holidays was twice a year mum driving to a dentist. That was in the day with the old dentist drill with the black rubber bands … drilling … terribly slow … but we still used to go, we didn’t have a choice. But it’s my parents drove that, and they didn’t have a lot of money to spare, but they saw it as a priority. (GP 19)

As a consequence, some patients returned to the GP with even worse problems that required hospitalisation:

… the pain goes away and they don’t go to the dentist, and then they come back with chronic infection, and I say, “but I told you to go to the dentist” … lots of repeat clients. (GP 7)

Dental problems become medical problems if not treated and [we] need to admit them to hospitals. (GP 3)

Participants also noted that those on low incomes who did not have health care cards could often not afford to see a dentist regularly:

… the other thing that really is a big hindrance for oral health is the cost of going to the dentist, so a lot of people aren’t really going … [not] willing or are able to do that. I know I haven’t been to a dentist for a long time. (GP 20)

In the absence of a resident dentist or regular visits by mobile dental services, both public and private patients needed to travel to a larger centre to obtain dental care. This was described as “quite hard” and a “dilemma” for rural residents. A very remote GP reported:

I think the major issue for most of our patients is cost issues [involved in] flying off the island … so it’s the dilemma we face as professionals, as practitioners, as well as our patients. (GP 8)

Improving rural oral health

GPs suggested a number of ways to improve oral health in their rural communities. This included additional training in dental care on topics such as “major trauma interventions”, and more “practical advice”:

… we don’t really learn any dentistry at all … it’s still part of the body and doctors just kind of bypass it. (GP 20)

… I suppose we have to do what is best for our patients, and if we can in any way up-skill, upgrade our scope of practice in terms of dental care delivery, I’m happy to consider that. (GP 8)

Being busy clinicians in a small town, most GPs preferred flexible education and training, such as short online courses and workshops.

… the problem is I went to this course, had a great time, bought the kit, came back, never used it and then I’ll forget it! … it has to be regular, annual or semi-annual. (GP 19)

Spending some time at a dental clinic was also regarded as very beneficial:

I spent a day there [at a dental clinic] to have a look at what they did … It was a really helpful day … And because you have a friendly relationship, I can say OK, I am flicking [patients with dental problems] your way. (GP 15)

Twelve participants described the importance of community- and school-based oral health promotion:

Oral health education for the public should be better. Mum and Dad don’t brush their teeth, so the kids don’t do it either. (GP 2)

I really feel that having someone locally doing preventative health advice, especially with the children, checking that the fluoride is enough, a lot of our patients use tank water and they are not getting possibly the fluoride they need. Getting the paste on their teeth on a regular basis I think would make a big difference; just educate them. (GP 7)

Some saw opportunities to provide preventive advice to patients when they came for medical appointments:

I tell people routinely, but it’s part of the whole general holistic approach in general medicine. (GP 19)

Both public and private visiting oral health services were regarded as valuable for the community. A strategy suggested by 12 participants was to have a resident or visiting dentist or dental practitioner who could serve both public and private patients. This model was described by one GP as “half public and half private”:

We’d like an adult dentist please! On a regular basis and not just from the public system. It would be useful if there was someone out here that did private patients, so that people are not more disadvantaged who can’t get to town, and can’t get in if they don’t have a health care card. (GP 12)

GPs were not well informed about visiting dental services.

The private dentist comes when he comes … I don’t know why the hospital and doctors don’t know when the government dentist is coming. (GP 9)

Some GPs expressed concerns about the lack of a clear referral pathway to dentists, describing the communication as “one-way”; “nothing comes back”, “[we] never get feedback”:

There is no follow-up there, most of the time the dentist does not really send you anything back. Usually when I refer patients, you get more feedback, but I don’t get that from dentists. To be honest, the professional interaction coordination between me and most dentists, as a GP and the dentist, is nothing. (GP 11)

Only one GP reported receiving feedback from a dentist to whom he referred patients:

So if I refer someone to a dentist … I’ll write a letter to them and they’ll write back to me. (GP 19)

Discussion

We found that residents of the communities we sampled presented to GPs with oral health problems. Consistent with other reports,9,12,22 management of these problems by GPs typically included short-term pain relief, prescribing of antibiotics, advice that the patient see a dentist, and, if required, hospitalisation. GPs raised concerns about repeatedly seeing patients who did not visit a dentist as advised, and they referred to the relatively low priority given by many patients to oral health, as well as to cost and travel distances as major barriers to patients visiting a dentist. A number of presentations that required hospitalisation could have been averted by following the GPs’ advice. Participating GPs were therefore conscious of the need in their communities for broader oral health education and for promotion measures that would involve a range of health care professionals linking with other stakeholders. These measures include the delivery of regular oral health promotion programs in schools, reinforcement of good oral hygiene practices by parents, and fluoridation of town (or tank) water supplies where this was not currently undertaken.23 As primary care providers, GPs could play a critical role in providing oral health screening and education during their regular interactions with patients.

The interviewed GPs recognised that building their capacity and confidence could help them better care for patients with oral health problems. This might be achieved through regular short workshops on practical skills, training for dental emergencies,24,25 undertaking training modules, and consulting practice guidelines, including those available from the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the Royal Flying Doctor Service. These could be included in the induction process for GPs working in more isolated practice settings.

Participants expressed concerns about the lack of information about the dental services that visited their towns and the dearth of feedback from dentists about patients they had referred to them. Changes in professional and medical personnel and to visiting dental services, often attributed to funding cuts, compounded this problem. For the communities sampled in this study, there was clearly a need to establish effective communication and referral pathways between GPs and members of the dental teams.

In the absence of a universal dental health insurance scheme, some GPs recognised the opportunity for developing alternative business models for delivering dental services. For example, a mixed public/private funding model could enable dentists to provide services to both public and private patients in smaller communities in a financially viable and ethical manner. The potential of tele-dentistry to connect the GP with a dentist located elsewhere could also improve care for patients26 and help reduce the costs and burdens to patients of travel to regional centres for dental care.

A limitation of our study was the fact that 14 of the 30 GPs interviewed had worked in their communities for less than a year. This may have affected their answers to some questions, including those about communicating with the dental team. However, their responses were consistent with those of participants who had worked in their communities for longer periods, which suggested that this was a common problem, regardless of time in the current location. Further, we did not specifically recruit GPs from Aboriginal health centres, and our data were not verified against the records of dentists who had worked in the region. Finally, although we achieved data saturation, not all problems experienced by GPs may have been identified; different concerns might perhaps have emerged in other settings and in specific population groups.

Nevertheless, this study was unique in that it included a diverse sample of communities across three states and a relatively large number of GPs. This study contributes to our understanding of the experiences of GPs with respect to oral health in rural communities, and canvassed a number of strategies for improving the situation.

Rural oral health could be improved by a number of approaches, including building the capacity of GPs to assist people with dental health problems, strengthening community and individual engagement with oral health promotion and prevention activities, improving visiting dental services for all remote residents, regardless of whether they hold health care cards, and establishing more effective referral and communication pathways between dentists and GPs.

Box 1 –
Characteristics of the communities including in the study

Town

Population

Nearest dental surgery

Visiting dental service

ASGC-RA

< 500

248 km

Public dentist: once every 3 months; school dental van: sporadic visits

RA5

< 1000

70 km

No visiting oral health services

RA4

< 1000

40 km

School dental van: sporadic visits

RA3

< 1000

87 km

Private dentist: once a month

RA4

< 1000

179 km

Public dentist: once a year

RA5

< 1000

210 km

Private and public dentist visits: once every 3 months; mobile Aboriginal dental van: once a year; school dental van: sporadic visits

RA5

> 1000

43 km

No visiting oral health services

RA4

> 1000

40 km

No visiting oral health services

RA3

> 1500

214 km

Private dentist: once a month for 3 days; school dental van: sporadic visits

RA4

> 1500

212 km

Public and private dentists: sporadic visits

RA5

> 1500

200 km

Private dentist visits: once a month; school dental van: sporadic visits

RA5

> 2000

62 km

Private dentist visits: once a year

RA3

> 3000

196 km

Public dentist visits: once a month; mobile Aboriginal van: once a year

RA4

ASGC-RA = Australian Standard Geographical Classification Remoteness Area.21

Box 2 –
Thematic representation of general practitioners’ perspectives on rural oral health

Reporting of health practitioners by their treating practitioner under Australia’s national mandatory reporting law

In 2010, the Australian states and territories adopted a national law requiring health practitioners, employers and education providers to report “notifiable conduct” by health practitioners to the appropriate National Health Practitioner Board through the Australian Health Practitioner Regulation Agency (AHPRA). Notifiable conduct encompasses four behaviours: (1) practising while intoxicated by alcohol or drugs; (2) sexual misconduct during the practice of the profession; (3) placing the public “at risk of substantial harm” because of an impairment; or (3) placing the public at risk because of a “significant departure from accepted professional standards”.1 Details of these rules have been published elsewhere.2,3

The mandatory notification law was received with some concern, particularly by doctors and medical professional bodies.2,4 A particularly controversial aspect was its application to practitioners who, in the course of providing care to another practitioner, form a belief that notifiable conduct has occurred. The versions of the law enacted in Western Australia and Queensland allow certain exemptions for practitioners treating other practitioners, but those in force in the other states do not.3

Critics of extending mandatory reporting to care relationships object to the perceived assault on the time-honoured ethics principle of patient confidentiality; they also worry that it will deter impaired practitioners from seeking assistance.5–7 Defenders of the rule argue that treating practitioners have a valuable vantage point from which to identify impaired colleagues, and that requiring them to do so protects the public and enhances trust in the health system.8

Our earlier study of 816 mandatory reports received by AHPRA over a 14-month period2 found that around 8% were made by treating practitioners. In recognition of the importance of these “treating practitioner reports” for policy and practice, we collected and analysed additional data on this subset of reports, and the outcomes of their investigation by AHPRA.

Methods

As part of a larger study of mandatory notification,2 we reviewed all reports received between 1 November 2011 and 31 January 2013. Access to the reports was subject to strict conditions guaranteeing privacy and confidentiality, and study team members signed non-disclosure agreements. The study was approved by the Human Research Ethics Committee at the University of Melbourne (reference, HREC 1239183.2).

The examined reports were from all states and territories except New South Wales, and had been lodged with AHPRA either in a notification form available on the AHPRA website or in letter form. The layout and content of the reports have been previously described.2 Although health practitioners in NSW are subject to the same reporting requirements as those in other states, AHPRA has a more limited role in relation to notifications made in NSW.2

The reports were reviewed between April and June 2013 at the AHPRA head offices in Melbourne. Three trained reviewers extracted de-identified information about the statutory grounds for notification, the type of problem reported, and practitioner characteristics and demographics. This information was supplemented with data from the national register of health practitioners, including information on sex, age, practice location, profession, and the specialties of both the reporter and the subject of the report.

All reports lodged by a treating practitioner about a practitioner-patient were flagged for more detailed review; they formed the focus of our analysis.

A senior investigator (MB) examined each flagged report to verify that it had been submitted by a treating practitioner. She also extracted any free text that discussed the health condition treated, the nature of the treatment relationship, the perceived risk, and steps the reporter took before lodging their report.

Using a grounded theory approach,9 two investigators (MB, DS) reviewed a subsample of the extracts and developed a coding scheme for deriving information on six variables from the free text: primary health condition for which the patient was being treated; the reporter–patient relationship; the timing of the risk; impediments to risk reduction; advice sought on reporting obligations; and disclosure to the patient of the intent to report. Using the finalised coding scheme, one investigator and a second, legally trained reviewer independently coded the textual extracts for all reports.

Comparison of the data coding by the two coders found inter-rater reliability that ranged from good to very good, depending on the variable. For example, the kappa (κ) score for the variable “impediments to risk reduction”, which probably involved more implicit judgment than the other variables, was 0.77.

In November 2014, the outcomes of the response by AHPRA to each case were obtained and added to the analytic dataset. This allowed 18 to 36 months to elapse after the report lodgement dates.

Statistical analyses were conducted with Stata 13.1 (StataCorp).

Results

Of 846 mandatory reports made to National Boards through AHPRA during the study period, 64 (8%) were lodged by health practitioners who had a treating relationship with the subject of the report. The others were lodged by non-treating practitioners, managers, employers or educators. All results reported here relate to the treating practitioner reports.

Sample characteristics

A large majority of the reporters (57 of 64) were doctors, and most of the practitioner-patients were nurses (41 of 64) (Box 1). Two-thirds of the reports by doctors were made by psychiatrists (26 of 57) or general practitioners (16 of 57).

The most common dyads were doctors reporting nurse-patients (35 of 64 cases) and doctors reporting doctor-patients (15 of 64 cases) (Box 2). Nurse reports about nurse-patients were relatively uncommon (5 of 64 cases), although every nurse report involved a nurse-patient.

Grounds for report

Three-quarters of the reports (47 of 64) indicated that the practitioner-patient had placed the public at risk of substantial harm because of an impairment (Box 3). One-fifth of the reports (14 of 64) indicated that the practitioner had practised while intoxicated. Only three reports were triggered by departures from professional standards or sexual misconduct.

Health condition being treated

Practitioner-patients were primarily being treated for mental illnesses (28 of 64), substance misuse disorders (25 of 64) or neurological conditions (9 of 64) (Box 3). The most common forms of mental illness were psychosis, mania and depression. The most commonly misused substances were opiates, benzodiazepines, alcohol and amphetamines.

Nature of treatment relationship

The reporter for one in five reports (14 of 64) was the patient’s regular care provider (Box 4); the others involved treatment encounters with a non-regular care provider. The most common scenario was that the reporter had assumed the role of treating practitioner in the context of an acute presentation to hospital (38 of 64 cases), usually a psychiatric admission (27 of 38 cases). The other scenarios were that the reporter was seeing the patient for the first time (9 of 64 cases) or that the treatment relationship had been established indirectly through an informal corridor consultation (3 of 64 cases).

Other aspects of reports

In most reports (46 of 64 cases), the reporter mentioned discussing the mandatory notification requirement with the patient before the report was lodged. Most reporters (56 of 64) also mentioned that they had sought advice from an indemnity insurer, lawyer, manager or professional peer before making the report.

Twenty-six of the 47 reports of impairment described a risk of harm to the public; 12 of these reports discussed only future risks, six discussed only past risks, and eight discussed both.

Nearly four in five reports (50 of 64) described an impediment to risk reduction. There were four main types of impediment. The most commonly described was that the practitioner-patient lacked insight into the risks posed to patients by conditions such as mania, psychosis, or dementia (29 of 50 cases). A second impediment was deliberate dishonesty with the treating practitioner; this most commonly arose in cases where a practitioner-patient had an addiction and intentionally provided false information to the treating practitioner in an attempt to obtain drugs of misuse (12 of 50 cases). A third impediment was deliberate disregard for treatment advice or patient safety (5 of 50 cases); for example, when a practitioner would not adhere to prescribed medicines or comply with a plan intended to protect patients during the recovery of the treated practitioner. The final impediment to safe management was an ongoing intention to self-harm with medicines that could be obtained in clinical practice (4 of 50 cases).

The 14 reports that did not describe impediments to risk reduction either contained statements indicating that the practitioner-patient had insight into their health condition and was cooperating with treatment (two of these patients had already notified themselves to AHPRA), or there was no relevant information that enabled coding of this variable.

Reponses of reports

By November 2014, National Boards had made a final decision on 86% of the treating practitioner reports (55 of 64). Boards took immediate action in 19 cases. Immediate action is a formal measure that involves placing interim restrictions on practice; it is imposed when this is considered necessary to protect the public pending further investigation.

The final outcomes were: no further regulatory action by a Board (24 of 55 cases); voluntary agreements with the Board and AHPRA regarding appropriate monitoring, treatment or practice restrictions (16 of 54); imposition of formal conditions on the practitioner’s licence (12 of 55); a fine or formal reprimand (2 of 55); and referral to another body for resolution (1 of 55). Although the most common adjudication was to take no further action, it would be erroneous to infer that reports with this outcome were inappropriate or unfounded; steps may have been taken to redress a legitimate concern after the report had been lodged and before the Board’s final decision.

Discussion

Our study of mandatory reports of notifiable conduct by treating practitioners found that 90% were made by doctors, usually psychiatrists or general practitioners, and were typically related to a practitioner-patient who was experiencing mental illness, substance misuse problems or a neurological condition. Relatively few reports were made by regular care providers. Most reports were linked with situations in which the treating practitioner was struggling to safely manage the risk that the practitioner-patient posed, and reporters usually discussed the report with the patient before submitting it.

Australia’s requirement that treating practitioners notify regulators of practitioner-patients with impairments is not unprecedented. New Zealand has required health practitioners to report impaired peers since 2003,10 and several American states have mandatory reporting obligations that extend to treating practitioners.11 However, the Australian legislation is unusually far-reaching in two respects. First, it imposes a duty to report not only health impairments, but also certain concerns about performance. Second, it does not explicitly shield treating practitioners from the obligation to report if the practitioner-patient is participating in an approved program of treatment.

Opponents of mandatory reporting argued that the new requirements would open the floodgates to over-reporting.2 This has not occurred. Mandatory reports are rare events,2 and mandatory reports by treating practitioners are especially infrequent — so infrequent, in fact, that under-reporting is probably a more justifiable concern.

The prevalence of impairment in the health workforce is unknown, but conservative estimates suggest that at least 1000 doctors (about 1% of Australia’s 90 000 registered medical practitioners) are impaired in their ability to practise at some stage in the course of any given year.12–14 Our 15-month sample contained reports on only 16 doctors, and only 20% of the reports were made by the practitioner-patient’s usual care provider. Previous research in the United States and New Zealand suggests that under-reporting of impaired colleagues is widespread,15 even in the context of mandatory reporting laws. Barriers are likely to include loyalty to colleagues, concerns about over-reacting to a situation, and uncertainty about the reporting obligation.16–18

A second objection to the extension of mandatory reporting into the patient–doctor relationship is that it breaches a cornerstone of medical ethics: patient confidentiality. However, the duty to maintain patient confidentiality is not absolute. It is widely accepted that it should yield to obligations to report serious problems or risks that come to light during treatment, including certain infectious diseases, health conditions that imperil driving, and signs of child abuse.19 Whether impairments that pose risks to safe clinical practice are so different from these accepted forms of reporting is debatable. Addressing this issue is beyond the scope of our study, but several aspects of our findings should inform the debate. In particular, the infrequency of treating practitioner reports and the perceived seriousness of the impairments disclosed make it difficult to distinguish the risks associated with practitioner-patient impairment from those of other accepted categories of mandatory reporting by treating practitioners.

Perhaps the most serious charge levelled at the mandatory reporting of practitioner-patients is that it will discourage medical practitioners from seeking assistance.5 This objection involves an empirical question: do the harms that result from treatment foregone because of the law exceed the harms averted by identifying impaired practitioners who would not otherwise have been recognised? Such counterfactuals are difficult to assess. Anecdotal reports suggest that the Doctors’ Health Advisory Services in some states experienced a decline in referrals after the law was enacted.6 But it is not clear whether there was a net decrease across all relevant health services; the question of causality is even less certain. Further, the deferred treatment argument presumes that impaired practitioners would still seek care in the absence of the possibility that they might be reported, but the available evidence suggests that health practitioners may have been reluctant to do so even before the introduction of the law.17,20

When discussing concerns about seeking help, it is worth noting how the reporting behaviour by treating practitioners observed in our study deviated from the exact requirements of the law. The statutory duty to report refers to a past risk of harm and, unlike mandatory reporting programs elsewhere, there is no safe harbour for cases where a practitioner-patient subsequently seeks care and takes appropriate steps to protect patient safety. The pattern of reporting we observed did not correspond with these legal requirements. When explaining their decision to report, treating practitioners were more likely to refer to a future risk of harm than to a past risk. Further, treating practitioners frequently emphasised factors that reduced their ability to work with the practitioner-patient to mutually manage the risk to the public (eg, the patient’s lack of insight, dishonesty or recklessness). Caution is required when making inferences about notifiable conduct that was not reported on the basis of what was reported, but these aspects of the reports, coupled with the very low overall rate of reporting, clearly suggest that treating practitioners resisted reporting their practitioner-patients in circumstances where their treatment was on an appropriate and promising path.

Our study has three main limitations. First, we were unable to directly measure over- and under-reporting. Second, Australia’s mandatory reporting law was implemented in concert with a variety of other major changes to health practitioner regulation, so it was not feasible to assess changes in the rate or nature of treating practitioner reports before and after the introduction of the new law. Finally, we relied on information provided in the reports for most of the variables of interest. To save time or protect confidentiality, some treating practitioners may have omitted or altered salient details. Consequently, the counts we report, particularly for variables that relied on being mentioned in the reports, should be interpreted as lower bound estimates.

Much of the policy debate on the merits of mandatory reporting by treating practitioners has been based on certain implicit assumptions. The standard narrative involves an impaired patient who recognises their illness and seeks treatment from their usual care provider, who must then reluctantly take the contentious step of reporting their patient. Our findings suggest a different picture. The debate should acknowledge several realities. In particular: treating practitioner reports are rare, very few are made in the context of an established treatment relationship, and they tend to occur in situations where there is an identified impediment to safely managing a future risk of harm within the confines of the treating relationship.

Box 1 –
Characteristics of treating practitioners and practitioner-patients involved in mandatory reports

	Practitioner making the notification (treating practitioner)	Practitioner subject to the notification (practitioner-patient)

Total number	64	64
Profession
Medical practitioner	57	16
Nurse	5	41
Pharmacist	1	2
Psychologist	1	1
Other*	0	4
Status
Practitioner	64	59
Student	0	5
Sex
Male	40	20
Female	23	44
Data missing	1	0
Mean age (range), years	46 (24–62)	41 (20–81)

* Dentist, physiotherapist, medical radiation practitioner.

Box 2 –
Frequency of notifications, by professions of treating practitioner and practitioner-patient

Box 3 –
Statutory grounds for reporting, and health conditions mentioned, for 64 mandatory reports by treating practitioners

Statutory grounds for report	Number of reports

Have an impairment	47
Practised while intoxicated	14
Departure from professional standards	2
Sexual misconduct	1
Health condition being treated

Mental illness	28
Psychosis/mania	16
Depression/attempted suicide	10
Eating disorder	1
Obsessive–compulsive disorder	1
Substance misuse	25
Opiates	8
Benzodiazepines	6
Alcohol	5
Amphetamines	5
Other (cannabis, cocaine or LSD)	3
Neurological condition	9
Dementia/cognitive impairment	7
Seizures	2
Unclear	2

Box 4 –
Relationship between treating practitioner and the practitioner-patient for 64 mandatory reports by treating practitioners

Treating relationship of reporting practitioner to practitioner-patient	Number of reports

Regular care provider	14
General practice	9
Psychiatry practice	4
Infectious disease practice	1
Non-regular care provider	50
Acute care provider	38
Psychiatric admission	27
General medical admission	2
Emergency department admission	9
First assessment	8
Psychiatrist	4
Physician	3
Pharmacist	1
Psychologist	1
Informal consultation with colleague	3

Vitamin D testing: new targeted guidelines stem the overtesting tide

Bilinski and Boyages have previously reported that the frequency of vitamin D testing had risen dramatically in Australia between 2000 and 2010.1,2 Further, testing did not translate to improved health outcomes.3 Since that report,1 Medicare Benefits Schedule (MBS) expenditure on vitamin D testing rose from $109.0 million in the 2009–10 financial year to $151.1 million in 2012–13, falling slightly in 2013–14 to $143.1 million.

An MBS review for vitamin D testing in 2014 recommended targeted testing for high-risk groups only, and against population screening.3 High-risk patients include those with osteoporosis, osteomalacia, disorders of calcium and parathyroid hormone, malabsorption, chronic renal disease, patients with darker pigmented skin or reduced sun exposure, those under 16 years of age and patients taking drugs known to reduce vitamin D levels. Five new Medicare item numbers (66833, 66834, 66835, 66836 and 66837) were introduced in November 2014 to replace the two previous numbers (66608 and 66609) and improve quality use of testing. This report analyses data from the Medicare statistical reporting tool for the first 8 months (November 2014 to June 2015) since the introduction of the new MBS numbers and guidelines.

The present study found that there had been a marked reduction in benefits paid for vitamin D testing (Box). In absolute terms, there was a saving of about $39.46 million (an average fall of 42%) compared with the same time period the year before. The greatest fall occurred in the summer month of February 2015 but the trend continued in the winter months. The number of services for vitamin D per 100 000 population fell from 18 140 in 2013–14 to 14 415 in 2014–15. The savings to the end of the 2014–15 financial year equate to about $42 million and, if the trend continues (ie, a reduction of 42%), the annual savings will be close to $64 million, reducing the annual spend to $60 million.

The new policy has almost halved expenditure in a short period of time and, if sustainable, will result in a large amount of funds to be reinvested. Before this intervention there had been an unsustainable growth in vitamin D testing. This report highlights the impact of various strategies including analysis of general practitioner test-ordering patterns and quality use of pathology testing policy based on good clinical practice and evidence-based medicine. The report highlights the value of regular monitoring and publication of all high-cost and high-volume pathology test item numbers, which will allow professional societies as well as individual clinicians to monitor trend data to look for opportunities to reinvest the scarce health dollar. New real-time business intelligence and Big Data tools have made this task easier.4

The study is limited by the nature of the MBS data, which capture only the number and dollar benefit of service. Further, patient-level data analysis could shed light on appropriateness of testing.

Although a large proportion of Australians (between 31% and 58%) are estimated to have vitamin D deficiency (defined as serum 25-hydroxyvitamin D levels < 50 nmol/L5), according to season, moderate to severe deficiency is uncommon and only present in about 4% of people.2,6 The new testing requirements should allow better targeting of those at greatest risk and those who will benefit most.

Box –
Medicare benefits paid for all vitamin D testing in Australia: July 2013–June 2015

2013–14* ($)

2014–15^† ($m)

Difference ($)

Difference (%)

July

12 772 332

10 901 057

−1 871 275

−14.7

August

11 713 108

10 840 342

−872 766

−7.5

September

12 958 166

14 157 002

1 198 836

9.3

October

12 306 916

11 422 808

−884 108

−7.2

November

11 661 161

9 744 773

−1 916 388

−16.4

December

12 265 479

7 653 015

−4 612 464

−37.6

January

8 276 481

5 133 015

−3 143 466

−38.0

February

13 777 880

6 294 101

−7 483 779

−54.3

March

12 315 477

7 097 905

−5 217 572

−42.4

April

11 416 530

6 301 455

−5 115 075

−44.8

May

12 454 074

5 954 850

−6 499 224

−52.2

June

11 207 630

5 732 827

−5 474 803

−48.8

Total

143 125 234

101 233 150

−41 892 085

−29.3

* MBS item numbers 66608 and 66609. † MBS item numbers 66833, 66834, 66835, 66836 and 66837 for November 2014 to June 2015, and 66608 and 66609 for July 2014 to October 2014, and then drop effectively to zero in the remaining months.

[Correspondence] NHS Forward View: one year on

Recently, the National Health Service (NHS) in England has experienced substantial pressure but also made great progress. A year ago, we launched the NHS Five Year Forward View, our vision for the future of the health system.1 We proposed that to achieve the triple aim of improved population health, quality of care, and cost control, triple integration is needed to dissolve the boundaries between mental and physical health, primary and specialist services, and health and social care. We launched 50 so-called vanguards, localities across the country that are taking the lead on new ways to provide care.

Patients face $100 x-rays

The Federal Government is coming under pressure over concerns its cuts to bulk billing incentives will leave patients needing x-rays, ultrasounds, MRIs and other diagnostic imaging services hundreds of dollars out-of-pocket.

Estimates by the Australian Diagnostic Imaging Association (ADIA) suggest general patients who are currently bulk billed will face significant up-front costs, from up to $101 for an x-ray to as much as $532 for an MRI, if the Government’s plan to wind back bulk billing incentives for diagnostic imaging and axe them for pathology services is approved.

When the changes were unveiled in the Mid-Year Economic and Fiscal Outlook in December, AMA President Professor Brian Owler condemned them as “a co-payment by stealth”.

“Cutting Medicare patient rebates for important pathology and imaging services is another example of putting the Budget bottom line ahead of good health policy,” Professor Owler said. “These services are critical to early diagnosis and management of health conditions to allow people to remain productive in their jobs for the good of the economy.”

His concerns have been borne out by the ADIA’s analysis, which shows the Medicare rebate for an x-ray will be cut by $6 under the changes, while the rebate for an ultrasound will be $12 less, that for a CT scan will be $34 lower, $43 less for a nuclear medicine service and $62 less for an MRI.

The Association said the effect of these cuts would be amplified by the fact that, under Medicare, patients have to pay the full cost of the service upfront before being able to claim the rebate.

In practice, this will mean that a general patient having an x-ray will be required to pay between $54 and $101 before being be able to claim their Medicare rebate.

Patients requiring an MRI will face the biggest upfront charge, ranging from $422 to $532.

Even after receiving their rebate, patients will still be left out-of-pocket. The ADIA calculates that for an x-ray, patients will ultimately lose between $6 and $56, while those needing an MRI will take a financial hit of between $62 and $173.

General patient diagnostic imaging expenses as a result of bulk billing incentive cuts

	X-ray	Ultrasound	CT scan	Nuclear Medicine	MRI
Rebate cut	$6	$12	$34	$43	$62
Upfront costs	$54-101	$117-206	$323-434	$407-463	$422-532
Out-of-pocket costs	$6-56	$12-101	$34-145	$43-99	$62-173

Source: Australian Diagnostic Imaging Association

ADIA President Dr Christian Wriedt said the changes were introduced without consultation and, by potentially deterring people from seeking early diagnosis and treatment, represented “bad policy”.

“This will make it much more difficult for many patients to receive the life-saving level of care they need,” Dr Wriedt said. “We are talking about services that are absolutely essential to diagnosing and treating many conditions, and we’re making it harder for people to get. More people, especially those with chronic, serious conditions, will not be properly assessed.”

Shadow Health Minister Catherine King said patients with serious, ongoing conditions such as cancer and heart complaints would be hardest hit.

“Patients with serious conditions never need just one scan,” Ms King said, citing the example of someone with thyroid cancer.

She said a confirmed diagnosis involved having an ultrasound and thyroid function test, a follow-up ultrasound and pathology tests, and a final round of head or body scans.

“All up, that comes to around $1000 in upfront charges,” Ms King. “Patients will eventually get much of this back from Medicare, but they will still be left with hundreds of dollars in out-of-pocket expenses.”

Health Minister Sussan Ley has so far pushed back against such concerns, pointing out that the Government has not touched Medicare rebates and arguing that bulk billing incentives – introduced by Labor in 2009 – were an unjustified handout to providers.

But Dr Wriedt said Medicare rebates for diagnostic imaging services had not been indexed for 17 years, ratcheting up the financial pressure on providers and leaving them with little choice but to pass the bulk billing incentive cuts through to patients.

He said the Government’s strategy was to push more costs on to consumers.

“Let’s not kid ourselves. This is a cash grab and a co-payment by stealth,” he said. “They [the Government] know that this will hurt people, and particularly the most vulnerable in our communities, and yet they’re pushing ahead.”

But the Government’s plan might yet fall afoul of the Senate, where it will have to rely on the support of cross-bench senators to get the measure passed.

At least one has flagged she will join Labor in opposing the changes.

Independent Tasmanian Senator Jacqui Lambie has threatened to vote against all Government legislation in order to prevent cuts to bulk billing incentives for pathology and diagnostic imaging services.

Realisation that the cuts could result in women being charged for pap smear tests provoked widespread outrage, and almost 190,000 have signed a Change.org petition protesting the measure.

Senator Lambie said it was time the Government stopped its “sneaky attacks on Medicare”.

“Australian women should not have to pay more for vital cancer health checks,” she said. “Over my dead body will I allow the Liberals to try and sneak through more changes and cuts to our Medicare system. I will vote to block all their legislation in the Senate until they stop playing with our Medicare system.”

Adrian Rollins

Thousands of doctors join NHS strike

Around 45,000 junior doctors are estimated to have gone on strike across England as part of a stand-off with the British Government over proposed changes to contracts they believe will lead to unsafe work hours that will compromise patient safety.

Striking doctors established picket lines outside more than 100 National Health Service hospitals and clinics, according to the British Medical Association, in the first such industrial action in more than 40 years.

The NHS reported that 1279 inpatient operations and 2175 outpatient services have been cancelled as a result of the strike, while thousands of junior doctors honoured a commitment to attend work to ensure that accident and emergency departments were not affected by the protest.

NHS England said that 39 per cent of junior doctors had reported for duty – a fact seized on by Health Secretary Jeremy Hunt to imply that the industrial action did not have widespread support.

The NHS said that altogether 71 per cent of rostered staff, including junior doctors, other doctors and consultants, had showed up for work.

NHS England National Incident Director Anne Rainsberry said the strike had nonetheless “caused disruption to patient care, and we apologise to all patients affected. It’s a tough day, but the NHS is pulling out all the stops, with senior doctors and nurses often stepping in to provide cover”.

But the BMA said it was misleading of Mr Hunt to claim the strike was a flop because so many junior doctors had reported for work.

“Since we asked junior doctors who would be covering emergency care to go into work today, it is hardly surprising that they have done so, along with those who are not members of the BMA,” a BMA spokesman told the Daily Mail. “The simple fact is the Government cannot ignore the thousands who have today made it quite clear what they think of the Government’s plans.”

Several hospitals and NHS trusts placed striking doctors on a ‘black alert’, claiming they were operating under emergency conditions because an influx of cases.

Sandwell Hospital in West Bromwich declared a level 4 incident and directed striking junior doctors to return to work.

But the BMA condemned such declarations as a ploy to try to thwart the protest.

BMA Chair Dr Mark Porter said doctors had given the NHS ample warning of the impending strike to ensure hospitals could make adequate preparations and minimise the disruption to patients, such as by deferring scheduled surgery and consultations.

Striking doctors in several locations reported there were no obvious circumstances that warranted emergency declarations by their local NHS, and said that although they were equipped and prepared to abandon the strike at a moment’s notice if their services were required, they would continue to take industrial action until that time.

The doctors are striking over a plan by the Government to force them on to contracts which would increase requirements to work long shifts, including on weekends and out-of-hours. They claim there are inadequate safeguards against unsafe working hours, potentially compromising patient care and safety, while the BMA declared an in-principle objection to the Government’s aim of removing the distinction between weekend and after-hours work and the rest of the working week.

Mr Hunt said numerous studies had shown that people received lesser care on weekends than they did during the week, and “I can’t, in all conscience as Health Secretary, sit and ignore those studies”.

“We have to do something about this. People get ill every day of the week,” the Minister said, and criticised the strike as “wholly unnecessary”.

But one of the striking doctors, emergency medicine consultant Dr Rob Galloway, said the Government had left doctors with no option but to take industrial action.

Writing in the MailOnline, Dr Galloway said there was “no doubt” that junior doctor contracts needed reform, and there needed to be improvements in handling unscheduled care on weekends.

But he said that the Government, through the approach it had taken, had squandered what would have been strong support for reform.

Alongside attacks that called the commitment and integrity of doctors into question, Dr Galloway said the Government’s offer amounted to an effective pay-cut for out-of-hours work, making it even harder for hospitals to recruit and retain staff.

“If you want to improve weekend care, why on earth would you impose a pay cut for staff doing this vital weekend work, pushing them out of the NHS? The new contract as it stands will make things worse, and lead to a recruitment and retention crisis.”

The World Medical Association had thrown its support behind the junior doctors.

WMA President Sir Michael Marmot said the peak international medical organisation recognised the right of doctors to take action to improve working conditions that may also affect patient care.

“In this case, it is clear that patient care would suffer in the long term if the Government’s proposals to change the working hours of junior doctors goes ahead,” Sir Michael said, adding that the doctors had received widespread support from the public and NHS colleagues.

He urged the Government to “establish a new working relationship with junior doctors. It is essential that trust is restored on both sides, for the sake of patient care”.

The 24-hour strike is due to end this evening, Australian Eastern Standard Time.

Unless the dispute is resolved, further strikes are planned for 26 January and 10 February.

Adrian Rollins

Picture credit: William Perugini / Shutterstock.com

Latest news:

Pap smear scare a warning

As the Federal Government embarks on an election year, Health Minister Sussan Ley has had a sobering lesson in the power of social media.

When a story was posted on website Mamamia early on 6 January claiming women would be charged $30 for a pap smear because of the Federal Government’s cuts to pathology and diagnostic imaging bulk billing incentives, it sparked a storm of protest.

A petition on change.org protesting the cuts rapidly gained momentum. By late that morning, it had garnered more than 10,000 signatures.

It was not until almost midday that Ms Ley responded, going on Twitter to argue that there had been “no cut 2 $ value of Medicare Rebate YOU receive 4 pap smear/test or your access to it as falsely claimed 2day”.

But by then the horse had well and truly bolted.

The message that women would for the first time likely to be charged out-of-pocket expenses for a pap smear had spread far and wide through Twitter, Facebook, and other social media, and was being picked up by mainstream news outlets.

As the day wore on, the Minster posted more tweets trying to calm the storm, and her office issued a statement attacking what it said were misleading claims.

In it, her spokesperson said there had been no shift in the cost of having a pap smear or the Medicare rebate.

The sole change, the spokesperson said, was to scrap the incentive paid directly to pathology providers, worth between $1.40 and $3.40 for each pap smear.

“It is therefore not part of the patient’s Medicare rebate, as some have tried to claim,” the spokesperson said, and Ms Ley has insisted that competitive pressures in the pathology industry mean providers will have to absorb the cost rather than pass it on to patients – an assertion the sector disputes.

The Government has struggled to gain traction on the issue.

Its complex and nuanced argument has been drowned out by the simple message being broadcast far and wide on social media that women will be charged for a pap smear.

The scale of the Government’s problem has been laid bare by the fact that, despite numerous media interviews and statements rebutting the $30 pap smear claim, by mid-Friday the petition was closing in on 200,000 signatures.

The episode is a salutary lesson for the Minister and the Government in the perils of blindsiding health groups and the public with unheralded cuts and changes.

There was no consultation prior to the announcement in the Mid Year Economic and Fiscal Outlook on 15 December of $650 million cuts to the bulk billing incentive for pathology and diagnostic imaging services, and little subsequent detail about the measure, leaving a virtual vacuum in which confusion and apprehension could quickly develop.

In the febrile atmosphere of a Federal Election, where the pressure for instant judgement calls and responses is intense, issues can quickly spiral out of any political control.

It could be a very long year for the Government unless it changes tack on how it does business.

Adrian Rollins

Government policy, not consumer behaviour, is driving rising Medicare costs

By Professor Stephen Duckett, Director, Health Program, Grattan Institute

This article first appeared in The Conversation on 2 December, 2015, and can be viewed at: https://theconversation.com/governmentpolicynotconsumerbehaviour…

Announcing the ill-fated 2014 budget initiative to introduce a consumer co-payment for general practice visits, the-then Health Minister, Peter Dutton, lamented that annual Commonwealth health costs had increased from $8 billion to $19 billion over a decade.

He described the increase as “unsustainable”, and used it to justify the Budget’s bitter pill.

The implication of his announcement was that consumers were driving the increase in costs, and that action to change consumer behaviour was necessary to rein them in.

The growth numbers were presented as part of the government’s then mantra of a “debt and deficit disaster”, and massaged to create maximum shock and awe. The minister’s numbers did not adjust either for population growth or inflation.

Nonetheless, a more legitimate set of growth numbers would still show Medicare Benefits Schedule (MBS) payments growing at an annual rate of 2.3 per cent in real per head terms, faster than growth in Government expenditure overall (1.8 per cent).

But this still leaves open the question of whether consumer behaviour is driving rising costs, or whether there may be other causes.

A report released in late November by the Parliamentary Budget Office shows that Government policy has driven a significant proportion of the growth in MBS costs. In fact, of the $325 real increase in MBS spending per head since 1993-94, all but $74 has been the result of explicit government decisions.

MBS spending per head is the product of the rebate for each MBS item and the per head use of those items. Both elements of this calculation have been tinkered with as part of policy change over the last two decades.

A significant proportion of the growth in Medicare costs has been driven by Government policies such as items for new services and larger rebates.

Governments have increased rebates for some items faster than inflation. This has been done, for example, to encourage an increased rate of bulk billing.

New item numbers have also been added as part of major policy reviews. (Each MBS service involves one or more item numbers and an associated description. For example, an ordinary consultation with a general practitioner is item number 24.) The single largest cost impact ($51 per head) came from changes to diagnostic imaging items, including new items for magnetic resonance imaging (MRI).

But implementation of policies to expand magnetic resonance imaging and reform diagnostic imaging items more generally has been poor. It is questionable whether consumers are getting value for money from this investment. Also, some diagnostic imaging tests appear to be overused.

Policies designed to increase bulk billing accounted for an extra $70 per head: increasing the GP rebate from 85 per cent of the schedule fee to 100 per cent accounted for $42 per head; targeted increases in the rebate to increase bulk billing rates accounted for the rest.

When did Medicare spending soar?

In the decade to 2003-044, Medicare spending grew by $53 per head. Just over half of that was attributable to the addition of new diagnostic imaging items to the schedule. In the next decade, spending grew at five times that rate – by $272 per head.

Most of the growth was due to decisions taken when Tony Abbott was Health Minister, between 2003 and 2007. In fact, almost half (47 per cent) of the growth in Medicare spending over the last two decades is the result of policy decisions taken when he was running the health portfolio.

The changes were introduced over the years for a mix of policy and political reasons.

The decline in bulk billing was associated with public dissatisfaction with Medicare and was clearly having political impacts. This led to new bulk billing incentives and increases to the rebates for general practitioner fees.

The increasing prevalence of chronic diseases, such as diabetes and heart disease, led to new assessment and care planning items.

A decline in the proportion of GPs providing after-hours care led to new items to redress that as well.

General practitioners got more rebate income (in real terms) for seeing the same number of patients, so it was actually changes initiated by Government that led to the increase in spending.

What does this mean for Medicare reform?

Two main lessons can be drawn from the Parliamentary Budget Office report.

First, the Government must be clear about what is driving growth in expenditure. The co-payment proposal sank like a lead balloon partly because it was seen as inefficient and unfair, but also because the public didn’t have any ownership of the “problem” the changes sought to address. The way the problem was initially presented was wrong, causing confusion between Medicare services (which include diagnostic tests) and GP visits. The vast majority of the population, who have few visits, refused to accept that per head use was going up.

Second, the report shows how much governments have relied on tinkering with the Medicare Benefits Schedule to drive system change in the last decade. “Here a new item, there a new item, everywhere a new item”, became the Canberra policy song sheet.

Health Minister Sussan Ley wiped the slate clean when she was appointed in December, setting up a raft of reviews to look at everything from primary care to disinvestment.

Importantly, reviews must consider whether the Medicare Schedule is still “fit for purpose” in the context of the increase in chronic disease and the impact this is having on clinical practice.

It must be hoped new policies developed in response will be both more sophisticated and less profligate than we have seen over recent decades.

Pharmaceutical industry exposure in our hospitals: the final frontier

The relationship between the medical profession and the pharmaceutical industry has changed considerably over the last two decades. While the days of expenses-paid overseas conferences and golf trips may be over, pharmaceutical company presence is still felt not only in private practice but also in our hospitals.

Some of these interactions benefit patients; in particular, industry-sponsored clinical trials and research studies in hospitals. Besides generating new evidence and drugs, patients who participate in clinical trials in hospitals appear to have better outcomes and lower mortality.1 However, there is a risk that industry sponsorship may unduly influence clinician researchers or the hospital itself. To reduce (but not eliminate) this risk, hospitals must comply with mandatory national research governance frameworks through the implementation of local policies and procedures, and researcher codes of conduct, overseen by research ethics committees.2

On the other hand, pharmaceutical company-sponsored medical education for doctors and students risks the presentation of biased evidence and subsequent poorer treatment choices for patients. All industry influence in hospitals should be transparently acknowledged and carefully examined in order to minimise potential harms.

Universities and hospitals have a mixed record when it comes to protecting doctors and medical students from making biased decisions by implementing policies to restrict exposure. Across Australia, health services struggle to take the final step to eradicate pharmaceutical company presence. This hesitation may be due to subtle underlying cultural and financial dependence on pharmaceutical company sponsorship, as well as a commonly held belief that small exposures are fairly harmless.

This contrasts with the community sector, where the No Advertising Please campaign launched in 2014 (http://www.noadvertisingplease.org) encouraged doctors to pledge to avoid ever seeing pharmaceutical company representatives, recognising that prescribing decisions are influenced even by these small exposures to marketing.

One of the biggest obstacles to complete eradication of undue influence from advertising is that the medical community continues to hold positive attitudes towards market-oriented activities of the pharmaceutical and medical device industries.3,4 This is often correlated with the belief that the information from pharmaceutical company representatives is trustworthy, and that these interactions are therefore beneficial to patient care.5 Some argue that this commercial promotion is far more effective in conveying essential information to clinicians than publicly funded drug information and, therefore, that we should be prepared to tolerate influence on prescribing behaviour.6

In a 2010 systematic review,7 Spurling and colleagues effectively excluded the existence of any reliable evidence that information sourced from pharmaceutical company representatives improves the prescribing habits of doctors. In the robust debate following the No Advertising Please campaign, the pharmaceutical industry was unable to point to any such evidence.

Despite acknowledgement of study findings to the contrary, doctors commonly state that they are able to effectively manage pharmaceutical company representative interactions such that their own prescribing is not adversely impacted.5 In one study, whereas 51% of surveyed doctors agreed that pharmaceutical company representatives had a large influence on other doctors’ prescribing habits, only 1% believed that this influence applied to themselves.8

Another reason for the loss of momentum is that doctors share a belief that a sponsored lunch at a morbidity and mortality meeting, for example, is harmless; that a small exposure, be it a gift or sponsored lunch, is unlikely to have a significant impact on prescribing practices.7,9 Yet the pharmaceutical industry, which owes it to shareholders to be at the forefront of marketing psychology, continues to spend billions of dollars on this small-scale sponsorship. In a trial involving 352 medical students, exposure to a logo on a notepad or clipboard resulted in more favourable implicit attitudes about that brand-name drug compared with the control group.10

Exposure to pharmaceutical products and branding is likely to affect an individual’s objectivity towards the brand, and his or her prescribing behaviour in relation to associated products. A 2010 systematic review showed that doctors’ exposure to pharmaceutical promotional material was associated with, on average, higher prescribing frequency, higher costs and lower prescribing quality.7 In 2011, a systematic review found that medical students’ exposure to pharmaceutical company marketing increased positive attitudes towards that exposure.11

Change requires a two-pronged approach

First, ongoing education continues to be necessary to inculcate change in the profession regarding pharmaceutical industry interactions.5 Education, particularly of trainees, should be part of this cultural transition,3 as there is some evidence that education is protective; in places of strict pharmaceutical regulation, individuals are less influenced when exposure does occur.10 Education aims to eradicate the belief that an individual is exempt from influence, and to improve reception to organisational change.

Second, specific policies and strategies must be consistently implemented.5 These should address pharmaceutical company relationships specifically, as well as conflicts of interest more generally.11 A united approach would be ideal, with reinforcement and support from colleges and registration boards. All members of health care staff require education and support regarding conflict of interest policies and procedures. These strategies are already being achieved at a medical school level4,11 and need to be effectively implemented at a health service level.

The systems that many public hospitals currently use to promote appropriate prescribing behaviour should be reinforced. These include formulary systems, electronic medical management systems, drug and therapeutic committees, prescribing guidelines, clinical pharmacist input, antimicrobial stewardship programs, and therapeutic equivalence programs. These systems should remain strictly independent of any pharmaceutical industry input, and merely recording conflicts of interest at the start of meetings is an inadequate solution. Pharmaceutical company-sponsored clinical trials are an important component of medical research that occurs in hospitals, and such systems reduce undue influence.

The financial burden associated with this form of divestment is acknowledged, and therefore a gradual transition may be ideal. Various organisations within the medical community have managed to effectively transition away from reliance on pharmaceutical company money, sometimes instead accepting alternative sponsorship, such as from medical defence or medical finance organisations.12

Case study 1: medical students

The Australian Medical Students’ Association (AMSA) was the first Australian medical organisation to completely remove reliance on pharmaceutical company sponsorship. This was later mirrored in America, where the American Medical Students’ Association did the same, as part of a rigorous conflicts of interest reform.13

From 1994 to 2004, the issue of pharmaceutical company sponsorship at AMSA events was hotly and repeatedly contested. At the July 2005 AMSA Council, following an extensive survey of medical students’ attitudes, representatives from each of the Australian medical schools passed the policy. In 2007, a working party examined the research on the influence of pharmaceutical exposure on medical students and eventually drafted the AMSA guidelines governing these interactions.14 Over the next few years, AMSA gradually moved sponsorship opportunities nationally to medical indemnity and financial organisations. As an organisation with an annual turnover of $3.2 million and heavily dependent on sponsorship, this was no small feat. Current AMSA sponsorship guidelines are so rigorous that they preclude companies with a subsidiary that sells pharmaceutical products.12 This case study shows that reliance on pharmaceutical company sponsorship can be removed successfully at an undergraduate level.

Case study 2: public hospital doctors

Monash Health is Victoria’s largest public health service, covering five major hospitals, and the Monash Doctors Workforce and Education units at Monash Health have successfully transitioned financial reliance away from pharmaceutical company sponsorship. While pharmaceutical industry presence in the health service still exists through the sponsorship of clinical trials, these two centralised medical workforce and education departments are now successfully free from pharmaceutical company influence, with any resources or sponsorship required for training events now internally funded by the organisation. In addition, the annual Monash Doctors Careers Expo held at Monash Health is now exclusively sponsored by medical finance and medical insurance organisations, as are the Monash Doctors Education junior doctor tutorials and interprofessional orientations. This case study shows that health services can successfully move away from a dependence on pharmaceutical company sponsorship for their workforce and education events.

Health services must be proactive in shifting cultural and financial reliance away from pharmaceutical company sponsorship. This transition is possible without significant financial detriment and is important for independent prescribing decisions. No justifications for the presence of pharmaceutical industry exposure in our health services remain, aside from sponsored clinical trials. Complete eradication rather than minimisation is an essential goal for appropriate patient care.

[Correspondence] Iran’s health-care system in transition

Iran’s health system has undergone several reforms in the past three decades with many challenges and successes. The most important reform was the establishment of the National Health Network in 1983, which aimed to reduce inequities and expand coverage and access to health care in deprived areas.1 The Iranian Government has since implemented several other reforms, such as the Family Physician Programme, integration of health services and medical education, the hospital autonomy policy, and the Health Sector Evolution Plan, all of which have had benefits and disadvantages.