Improving health literacy in refugee populations

We must ensure that people of refugee background have the confidence, support and resources to manage their health

Health literacy is defined as the degree to which an individual can obtain, communicate, process and understand basic health information and health services to make appropriate decisions about their health.1 Low health literacy is inextricably linked to poor health outcomes. Individuals with limited health literacy have higher rates of illness and more hospitalisations.2 Acquiring good health is a process that requires access to health care and health knowledge to inform positive health behaviour coupled with ongoing access to necessary resources.

The refugee experience is often characterised by displacement with limited access to services and basic necessities. For resettled refugees, low health literacy can be expected as they navigate a new country, language and culture. The stressors of cultural and language differences, and securing housing and employment may exacerbate trauma, leading people to feel isolated and helpless, with attendant symptoms of sleeplessness, poor concentration and emotional issues. The psychological effects of trauma may be long term and experienced intergenerationally.3 Many may have had disrupted education owing to protracted time in precarious living situations, so it cannot be assumed that they have reading ability in their own language. Further, due to displacement and changes in family composition, traditional ways of sharing health information may be fragmented.

Such experiences have a profound impact on the way people engage with health information, health care services and preventive health activities.4 Being clear about the role of health services and health care providers, and explaining the purpose of appointments, benefits of preventive activities and recommended treatment regimens may assist. The situation is complex — a standard knowledge base cannot be assumed, precaution is necessary and the provision of information needs to be modified.5 Clinicians could mindfully adapt their skills to care for this population; however, we recognise that the provision of information is not necessarily straightforward. Our research found little consistency in the approach that maternity care providers take to providing health information.6 Afghan families reported that they mostly received brief verbal information, a few received written information in their own language, and some had seen pictorial information. Many sought information and advice from family members overseas, and several obtained information from the internet.

Providing the best possible standards of professional interpreting requires systems to facilitate access, training and practice.7 Enabling people to communicate freely in their own language supports the development of trust, respect, rapport, cultural safety and relationship-centred care.8 The role of interpreters is to provide a language service with strict parameters with no ongoing relationship. Bicultural workers, however, may assist people to navigate health services, get to appointments and negotiate expectations. They also act as an aid for clinicians to understand differing health beliefs and social circumstances that may affect decision making. Bicultural workers provide a bridge to reduce the social distance that often exists between health professionals and clients.

The health care setting offers a dynamic learning environment in which clinicians are in a key position to improve health literacy.9 A tool that encourages two-way participation is teach-back. Teach-back is an evidence-based communication strategy that requires health professionals to ask the individual to repeat back what they have explained but in their own words. It is not a test of the individual’s memory.10

Some health literacy advocates suggest that assessing health literacy is an important step in addressing health disparities.2 However, this has the potential to create shame and stigma. Many measurement tools do not inquire about the full scope of health literacy and are narrowly focused on reading, writing and numeracy deficits. If applied, assessments need to be completed in the context of relationship-centred care.8

The health system needs to support clinicians to adopt novel ways of responding to low health literacy.11 A health-literate organisation is defined as one that makes it easier for people to navigate, understand and use information and services to take care of their health.12 A health-literate organisation would recognise that refugees may have concerns that are perceived as more immediate than their personal health status.13 People of refugee background are often worried about finances, learning English and family members who remain in dangerous situations. To support clinicians working with diverse communities, health services need to develop stronger local service partnerships that broaden access to existing community and local resources.

We believe that improving health literacy in this population involves much more than access to information — it is about people having the confidence, support and resources to manage their health. Health literacy in refugee populations could be tackled by multifaceted, multidisciplinary interventions and policies that are responsive to these unique circumstances.14

News briefs

Touchbase website for LGBTI health

A new website has been developed to provide targeted information on drugs, alcohol, and mental and sexual health to Australia’s lesbian, gay, bisexual, transgendered and intersex communities, BuzzFeed Australia reports. TouchBase (www.touchbase.org.au) is a joint initiative between the Victorian AIDS Council, the Australian Federation of AIDS Organisations and the Australian Drug Foundation. A unique aspect of TouchBase is its focus on drug interactions with HIV medication and hormones. “We’ve created TouchBase to address gaps in existing information for LGBTI people,” said Victorian AIDS Council CEO Simon Ruth. “It’s a unique website, because LGBTI people have different drug-using norms — we use drugs in different patterns, we have different concerns, people have been dealing with different issues throughout their lives.”

New Surgeon-General for ADF

Air Vice-Marshal Tracy Smart has been named as the new Commander of Joint Health Command and Surgeon-General of the Australian Defence Force (ADF), taking over from Rear-Admiral Robyn Walker, who served in the role from 2011. Air Vice-Marshal Smart became the highest ranked lesbian officer in the ADF in 2009 when she was made Air Commodore in 2009. Her latest promotion will see her responsible for the delivery of health services and medical readiness of all ADF members, and will also provide strategic health advice and technical oversight of operational health services. She has publicly led the ADF contingent at the Sydney Gay and Lesbian Mardi Gras three times since 2008, the Star Observer reports. “One of the things that matter to me is to say gay men and lesbians are in every walk of life, including what in Australia now is a highly respected profession, like medicine and defence. The more people who do it the stronger that message is.”

Google searches track infectious diseases

The United States’ National Public Radio (NPR) reports that researchers from the University of Illinois in Chicago have teamed up with internet search giant Google to track sexually transmitted diseases. Google has given the researchers and the Centers for Disease Control and Prevention access to its search data. “Researchers can mine Google data to identify search terms that spiked during previous upticks in a particular disease. Then, researchers can measure the frequency of those searches in real time to estimate the number of emerging cases. For instance, a jump in gonorrhea might coincide with more people searching ‘painful urination’ or other symptoms. Search trends can be broken down by city and state, weighted by significance and combined with other data to produce a snapshot of where disease is spreading well before public health agencies report the number of verified cases.”

Vaccine for dengue fever approved in Mexico

The New York Times reports that Mexico has become the first country to approve the use of a vaccine to protect people aged 9–45 years against dengue fever. Clinical trials showed the vaccine reduced the risk of developing dengue by about 60%, the NYT reported. There is no treatment for dengue, a viral disease transmitted by mosquitoes. It can cause high temperature and intense joint and muscle pain. In severe cases, it can be fatal. Estimates about the number of people sickened by dengue each year range from 50 million to 400 million. In recent years, the disease has spread out of its traditional location in developing countries in tropical areas.

Almost two-thirds of Aussies overweight or obese

Australian Bureau of Statistics data released in the 2014–15 National Health Survey showed that 63.4% of Australians are classified as overweight or obese, totalling 11.2 million people. A quarter of children aged 5–17 years are overweight or obese. Nevertheless, 56.2% of Australians aged 15 years and over consider themselves to be in excellent or very good health. One in nine adults experienced high or very high levels of psychological stress. “The percentage of adults consuming more alcohol than the recommended guidelines — two standard drinks per day — dropped by 2% from 2011–12 to 17.4%”, the Huffington Post reports. “One in four men exceeded the lifetime risk guidelines compared to one in 10 women. Smoking rates among 18–44 year olds have declined by 12 percent since 2001. Rates of smoking are higher in outer regional and remote areas. Mental and behavioural conditions topped the major long-term health conditions list, with four million sufferers identified in 2014–15.”

Lung cancer screening in Australia: progress or procrastination?

There is progress internationally with lung cancer screening but far slower headway in Australia

Lung cancer is the fourth leading cause of death and kills more Australians than colon and breast cancer combined.1 It has a 14% 5-year survival rate as most patients present with incurable disease. The number of years of potential life lost to lung cancer in Australia is estimated to be 58 450, similar to that of colorectal and breast cancer combined.1 Primary prevention remains crucial and will reduce future lung cancer deaths, but the majority of lung cancer deaths are now occurring in former smokers who remain at elevated lifetime risk of lung cancer.2

Should Australia adopt lung cancer screening?

Screening with low-dose chest computed tomography (CT) scan has been proven to reduce lung cancer mortality by at least 20%, and screening is now being implemented in the United States. There is no new treatment modality that can reduce lung cancer mortality by this amount. The International Association for the Study of Lung Cancer (IASLC) recommends the implementation of feasibility screening programs in countries without ongoing lung cancer screening studies.3 These programs should incorporate smoking cessation initiatives, standardised algorithms for the selection and management of screening participants, and specialist multidisciplinary teams to manage participants with positive screening results.

In Australia, there are about 2 200 000 current or former smokers between the ages of 55 and 74 years who may be eligible for lung cancer screening.1 Lung cancer screening has been clearly shown to be feasible in specialist centres in many countries.4 It shifts lung cancer stage at diagnosis from advanced to early stage (potentially curative) disease.3,4 The cost of such programs, however, remains an important concern.

The incremental cost-effectiveness ratio per quality-adjusted life-year gained of lung cancer screening in Canada, which has a health care structure similar to Australia’s, is about A$10 000.5 This compares favourably with colorectal screening (A$7000, European data)6 and breast screening (A$45 000, United Kingdom data).7 The costs of treating advanced lung cancer are greater than the costs of treating the early stage disease.8 Further, a consequence of rising pharmaceutical costs of cancer treatment is that early detection becomes more desirable both in direct mortality reduction and reduction of downstream treatment costs.5

Concerns with screening implementation in Australia

Vital information that is currently lacking in the Australian health care setting includes: an economic evaluation to assess health care cost utility; definition of a target population; false-positive rates; and best recruitment and uptake strategies.9 The feasibility of chest CT screening in the Australian setting has already been demonstrated with the Queensland Lung Cancer Screening Study10 (long-term follow-up near completion) and the Western Australia-based Asbestos Review Program.11 However, uncertainties remain over the best recruitment strategies, management of pulmonary nodules and most cost-effective approach. A further evaluation study in WA (LungScreen WA Project) will contribute useful data.

Targeted risk-based approach

The risk of lung cancer is heterogeneous and data from the large US-based National Lung Screening Trial demonstrate that the criteria used to identify at-risk individuals included many who were, in fact, at low risk for developing lung cancer.4 Subsequently, logistic regression-based risk prediction models have demonstrated improved sensitivity with less CT scans required to identify more lung cancers.4 This approach has recently been shown to be more cost-effective.5 A similar, risk-based approach to managing indeterminate nodules (majority are false positive) that require follow-up is also likely to reduce unnecessary repeat CT scans and costs.4 The use of validated risk-prediction models to both select and manage participants is likely the most effective method for screening and such an approach has been recommended by IASLC.3

Future structure

Any future lung cancer screening program in Australia faces a unique challenge. Unlike truly population-based Australian screening programs such as BreastScreen, the National Cervical Screening Program, and National Bowel Cancer Screening Program, which screen people without risk stratification for the disease in question, lung cancer screening would screen participants who have been individually assessed as having a higher than average risk. A national program needs to be community based with shared, informed decision-making between clinicians and potential participants, accredited reporting centres and a central data registry for quality control, monitoring and outcome reporting. Crucially, it must have an integrated smoking cessation intervention, with recent international data supporting the cost-effectiveness,5 additional mortality benefit12 and a high sustained quit rate13 with such an approach. It is a teachable moment that should not be missed.

In the absence of a coordinated approach, ad-hoc screening should be strongly discouraged, with no evidence of benefit and the very real risk of harm. The majority of the outstanding questions for lung cancer screening are likely to be answered in the next few years — Australia needs to generate progress now towards a cohesive national approach and avoid procrastination. The challenge facing Australia is the translation of international results into sustainable, cost-effective clinical practice, ensuring that the desired benefit outweighs the known harms, at the same time as enhancing tobacco control policies.

[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

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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.