more_vertChina has an immediate need to address the rapidly growing population with cardiovascular disease events and the increasing number of people living with this illness. Despite progress in increasing access to services, China faces the dual challenge of addressing gaps in quality of care and producing more evidence to support clinical practice. In this Review, we address opportunities to strengthen performance measurement, programmes to improve quality of care, and national capacity to produce high-impact knowledge for clinical practice.
Preference: Administration and Health Services
2
Educational outcomes for children in care: linking 2013 child protection and NAPLAN data
This report presents a snapshot of the academic performance of Australian children in the care of child protection services in 2013. Findings are based on the linkage of data from the Child Protection National Minimum Data Set and the National Assessment Program—Literacy and Numeracy. This report shows that the proportion of children in care meeting the national minimum standards (NMS) for literacy and numeracy varied (ranging from 44% to 83% across assessment domains and year levels).
Good for the economy while good for your health
Prominent among the proposals for the future from Mr Turnbull as he assumes the prime ministership are ones that relate to economic growth. He seeks a more agile economy, one in which innovation is promoted and prized and where the negative forces of debt and deficit are dealt with by increasing productivity and growth. These aspirations are supported by stronger recognition in the new Cabinet of science and innovation.
Recently I have had cause to reflect on the place of health care in one piece of the Australian economy. Specifically, I was considering how much health care for the million citizens in western Sydney actually contributes to the economy. The answer is a lot. So, rather than portraying health care as a terrible drain on the national economy and incessantly saying we should cut our costs, we might express it differently.
We’re an investment, not a cost!
Our health care is based strongly on science and innovation. The revolution that has occurred in diagnostic and therapeutics due to new technology is profound. Procedures that once took days now take minutes. New drugs work wonders. CT and MRI have completely replaced the ghastly contrast-medium angiograms and pneumoencephalograms. The productivity of surgeons and other proceduralists has multiplied many times over.
So, if you are looking to grow an ‘industry’ through science and innovation, you could do no better than to look at health. It leads the way. Great efficiencies and immense amounts of suffering due to dreadful procedures have been banished by science and innovation.
In western Sydney, the health services provide care to nearly a million people. Public hospital and associated community services operate with a recurrent budget of nearly $1.4 billion per annum. That’s a lot of money pumped into the local economy. General practice likewise generates local expenditure in the millions.
Whether all this money is wisely or optimally spent is a separate and (I agree) an important question. But overlaying this concern is the fact that health care is a big contributor to the Australian economy.
What is the goal of the economy, we may ask? Surely it is to support the Australian community and enable us to compete in the world to maintain our prosperity and assist, as we see fit, to bring less-developed nations up to speed. Given that the segment of the global economy in which we compete is highly innovative and science-based, then we need to place emphasis on those attributes here Down Under.
As our future prosperity is unlikely to depend as heavily as it has in recent decades on ripping stuff out of the ground and selling it to China, inventing nothing, doing no innovation, making no scientific progress and then buying in all the creature comforts that we need from the US and Japan (and increasingly form China), we need to achieve self-sufficiency in innovation. That requires investment – in science, technology and education.
While it is hard to see these opportunities through the clouds of day-to-day slog in our hospitals and surgeries, investment in medical technological innovation, the education of smart scientists to develop even more and better equipment and drugs, the support of health research of all sorts – these things make an economy grow. These are the ways in which we develop economic agility and the nimbleness necessary to be able to adapt to change.
Health as a superior good
There is another important fact that tends to get in the way of clear perception of where health fits in the economy, and that is the complex notion that health is a superior good, something that we spend on almost without limit, constrained only by the extent of our discretionary income.
That is what makes trying to keep health costs under control so difficult. As affluence increases, ordinary goods such as food do not attract all that much additional expenditure. But health? We feel we can never get enough of it, and we are prepared as individuals and as a nation to keep on paying!
We have emerged from a period of economic discussion in Australia dominated by what many experts see to be an exaggerated concern for a relatively small deficit. The real economic challenge is the changing base of our revenue, away from minerals and coal toward service industries such as finance, education and health care. We need to be agile; we need to look for ways to increase our productivity through innovation and invention.
Health can help achieve those economic goals for the nation. Rather neatly, this can occur as a secondary outcome of our continued concentration on providing the best possible care for all Australians.
Time to launch NATSIHP
New Prime Minister Malcolm Turnbull has made it clear he wants to reshape the focus and direction of the Coalition Government. He talks of a modern Government with modern approaches. Let’s hope this enthusiasm translates to Indigenous health.
While former PM Tony Abbott made a virtue of his commitment to Indigenous issues – including his pledge to spend a week each year living and working in an Indigenous community – genuine new policy rollout was slow under his leadership.
A prime example of this is the National Aboriginal and Torres Strait Islander Health Plan (NATSIHP).
In July 2013, the former Labor Government launched a new NATSIHP, which set out a 10-year framework for the direction of Government policy to improve the appalling health status of Aboriginal and Torres Strait Islander people. The plan had bipartisan support.
The development of the NATSIHP was a clear example of the Government working in partnership with Aboriginal and Torres Strait Islander people to achieve improved health outcomes for the Aboriginal and Torres Strait Islander community.
But, in the two years since the launch of the NATSIHP, we are yet to see the new Government put its commitment into action.
The Government has developed an Implementation Plan for the NATSIHP, but has not yet launched it.
The Implementation Plan provides the basic architecture for turning the NATSIHP into concrete action. More work on defining service models, workforce requirements, and funding strategies is needed.
Guided by the Implementation Plan, the NATSIHP is capable of driving real progress towards the best possible health outcomes for Aboriginal and Torres Strait Islander people, and could realise health gains in a relatively short period of time.
To achieve these improvements, a key strategy is for the Government to identify areas of poor health and inadequate services for Aboriginal and Torres Strait Islander people, and direct investment accordingly.
This must include increased support for Aboriginal and Torres Strait Islander community controlled health services to enable them to fulfil their pivotal role in improving health outcomes for Aboriginal and Torres Strait Islander people.
The NATSIHP recognises that culture is central to the health and wellbeing of Aboriginal and Torres Strait Islander people, and this must be reflected in practical ways throughout the actions of the NATSIHP Implementation Plan.
The NATSIHP broke new ground with the identification of racism as a key driver of ill-health. The implementation of the NATSIHP must provide a clear focus on strategies to address racism, and strengthen the cultural safety of Australia’s healthcare system.
This includes identifying and eradicating systemic racism within the health system and improving access to, and outcomes across, primary, secondary, and tertiary health care.
While we need to continue to strengthen health care, we also need to enhance our focus on building pathways into the health profession for Aboriginal and Torres Strait Islander people, as well as supporting the existing Indigenous health workforce.
Aboriginal and Torres Strait Islander people are significantly underrepresented across all health professions, particularly medicine, nursing and allied health. This must change.
Aboriginal and Torres Strait Islander health professionals are an important resource to improve Aboriginal and Torres Strait Islander health, as they are able to use their unique cultural and clinical expertise to contribute to greater health outcomes for Indigenous people.
Specific actions to address Indigenous health workforce shortages must be reflected in the actions of the NATSIHP Implementation Plan.
NATSIHP implementation is long overdue. It must occur without further delay.
The initial Implementation Plan was to be developed within 12 months of the NATSIHP’s release. That time is long gone.
At a Senate Estimates hearing in June, Government officials indicated that the Implementation Plan for the NATSIHP was still being developed, and that it would be released soon. That was three months ago, and still no action.
PM Turnbull strengthened and reordered his Health portfolio team upon taking over the leadership, with now Rural Health Minister Senator Fiona Nash retaining responsibility for Indigenous health. I will be discussing the inactivity on NATSIHP with her at the earliest opportunity.
The AMA’s Indigenous Health Taskforce is keen to see the Government make NATSIHP a reality – and a success story.
Medicare review taken off course
The AMA has demanded the Federal Government recast its approach to the Medicare Benefits Schedule Review as medical researchers have distanced themselves from claims doctors are routinely ordering ineffective and potentially harmful tests and procedures that are costing the nation cost the nation hundreds of millions of dollars each year.
The AMA has reasserted its support for the Medicare Benefits Schedule Review (and the accompanying Primary Health Care Review) as long as it not only about removing outdated services and procedures, but replacing them with items that reflect modern practice.
AMA President Professor Brian Owler told The Australian Financial Review the medical profession backed efforts to update the MBS but “we’re not going to have a Review that takes money away and puts it on the bottom line of the Budget, and the [Health] Minister [Sussan Ley] says that’s where it’s going. It takes services away from patients.”
The blame game
There has been mounting disquiet over the Government’s handling of the Review, including the depth of consultation with clinician representatives and claims that the vast majority of items were not backed by evidence, and around 30 per cent of all care was of little worth.
Fears about the direction the Government was taking were crystallised on 27 September when Ms Ley launched public consultations by arguing that only a tiny fraction of the 5769 items on the MBS had been assessed for effectiveness and safety, and “inefficient and unsafe Medicare services…cost the nation dearly”.
Issuing the call for consumers to participate in the Review, Ms Ley said that, “30 per cent of expenditure is not necessary, wasteful, sometimes even harmful for patients”.
Professor Owler said the claim was not only “factually incorrect”, but was being used by the Government and the Review Taskforce Chair Professor Bruce Robinson to try and frame the discussion around the idea that there were massive savings to be made because doctors were milking the system.
The AMA President said the figure had been uncritically imported form the United States and there had been no evidence to support it in the Australian setting.
Instead, he said, the Government’s real intention was to use the Review to make Budget savings.
“They need to be upfront about what this process is and that it’s a budget preparation measure,” he told the AFR. “We’re having this conversation and it’s ‘No, no, this is not a cost saving exercise’. But, ‘Yes, the cost savings are going to the bottom line of the budget’. They say ‘Yes, we will reinvest’, but it’s going to be a very protracted, drawn out process to get any money back into MBS.”
Follow the evidence
A day after the Government launched the consultation process, ABC television’s Four Corners program aired claims that doctors were ordering tests and performing procedures that were of little or no benefit for patients and cost the nation hundreds of millions of dollars each year, including scans for lower back pain, spinal fusion surgery, knee arthroscopies and inserting stents in patients with stable angina.
Ms Ley seized on the program, which she said had exposed “real – not perceived – waste in health spending”, and demonstrated the need for the MBS Review.
The Minister said medical specialists and health researchers appearing on the program had “put their professional reputations on the line to provide important insight into billions of dollars being spent on unnecessary, outdated, inefficient and even potentially harmful procedures”.
But two researchers whose work was drawn on in the Four Corners program to help substantiate claims that doctors used inappropriate and unnecessary tests and procedures said their data had been misinterpreted and taken out of context.
Writing in Medical Observer, Associate Professor Helena Britt and Associate Professor Graeme Miller said that although their research showed GPs ordered imaging in about 25 per cent of new cases of low back pain, “conversely, we could equally state that 75 per cent of new cases were not sent for imaging”.
The researchers said that while they did conclude that the rate of imaging for back problems at the initial encounter was inconsistent with guidelines, this was only the case if there were no ‘red flag’ issues present, such as significant trauma, fever, weight loss, inflammatory conditions or advanced age.
“Unfortunately,” they said, “we cannot identify whether or not patients referred for imaging for back symptoms had any of these red flags, but the guidelines suggest that zero imaging for all cases would not represent best quality care.”
Ms Ley rejected claims the Government had launched an attack on the medical profession, and asserted that 97 per cent of MBS items had never been assessed for their clinical effectiveness or safety.
But Professor Owler said the Minister’s claim was “quite misleading”.
While just 3 per cent of items had been assessed through the Medical Services Advisory Committee process, the AMA President said, “but that doesn’t mean that there’s not evidence behind all of the other things that we do”.
He questioned the need for evidence-based reviews for performing life-saving operations: “I don’t need an evidence-based review to say that I should remove the tumour from a child that presents through the emergency department because I know they’re going to end up dead within the week if I don’t do it.”
“There are some things that, yes, we need to evidence-based review, but there are many on the schedule that don’t, and saying that 97 per cent doesn’t have evidence is quite misleading.”
MBS reviews nothing new
He said the medical profession had to be “vigilant” about the narrative being used to shape debate about the Review.
Professor Owler said the AMA not only supported the MBS reviews, but had been engaged with successive governments in undertaking them since 1990. He said in the last five years alone, the AMA had participated in reviews covering 26 areas of the MBS.
“Can we save money? Yes, and the AMA’s more than happy to engage in that process, but let’s actually go through and do the reviews and come up with the evidence before we actually pre-empt what the outcome is and what procedures might have conditions or be removed from the Schedule,” he said.
“The risks to patient care from an emasculated MBS are too great to allow this Review to go off the rails.”
Adrian Rollins
“What should happen before asymptomatic men decide whether or not to have a PSA test?” A report on three community juries
Prostate-specific antigen (PSA) testing of asymptomatic men remains controversial.1 Testing may improve prostate cancer survival rates,2 but can also lead to harms, such as repeated investigations and the unwanted effects of treatments, including incontinence and impotence.3–5 Evidence regarding benefits and harms alone has not resolved tensions over PSA testing.6 Disagreement among experts and in guidelines has confused public communication in Australia and internationally.7,8
In December 2014, the Prostate Cancer Foundation of Australia (PCFA) and the Cancer Council Australia (CCA) released clinical consensus guidelines for general practitioners for public comment,9 after the National Health and Medical Research Council (NHMRC) had published information on the topic for health practitioners.10 These documents established criteria for identifying men more likely to benefit than to be harmed by PSA testing. However, it remains unclear if and when GPs should introduce the subject of PSA testing in consultations with individual men. The Royal Australian College of General Practitioners (RACGP) advises GPs not to broach the subject of PSA testing, but to provide full information regarding the benefits, risks and uncertainties of testing and treatment if patients specifically ask about it.11
In this article, we report the outcomes of three community juries convened in 2014 to consider the dilemmas associated with PSA testing. A community jury is a group of citizens brought together to receive detailed evidence about a specific problem and to then deliberate on this problem.12 Our aim was not to capture the opinions of the broader community, but to ascertain what a well informed citizenry would accept as legitimate PSA testing policy and practice, and the reasons for their views. Community juries are an established, appropriate method for investigating such questions.12 Community juries have been used in Australia and elsewhere to consider questions related to cancer screening.13,14 Unlike surveys and focus groups, they involve extensive provision of information, constructive and structured dialogue between ordinary members of the public and experts, and adequate time for consideration of the problem. The process is similar to a legal proceeding, but the outputs are not legally binding; they instead provide evidence for policy making.
We consulted major stakeholders (consumer organisations, GPs, epidemiologists, urologists, the CCA) to design the questions that the juries would consider. All agreed that the key issues to be explored were:
-
whether GPs should initiate discussions with asymptomatic men about the PSA test;
-
when men should be given information about the potential benefits and harms of testing, biopsy and treatment.
Valid consent for interventions is integral to an ethical health care system, and providing adequate and timely information is fundamental to valid consent. While this has been noted in relation to PSA testing,15,16 it is not yet clear what should happen before men decide for or against taking a PSA test. Noting the work currently being undertaken by the NHMRC, CCA and PCFA, we sought information on what selected groups of members of the public consider to be the obligations of GPs regarding informing men about PSA testing, and what else might be required before a man could validly consent to a PSA test.
Methods
Community jury research is a deliberative method, with the following general characteristics:
-
a group of citizens is convened for 1 to 3 days;
-
they are asked to consider a specific problem;
-
they hear evidence from (often opposed) experts, and ask the experts questions;
-
they are given time for deliberation and to come to a documented conclusion.
There are two main approaches in community jury research: participants draft open recommendations as a group, or vote on options specified by the researchers.17 We used both approaches in our investigation: Jury 1 tested an open approach, while Juries 2 and 3 were asked to vote on specific options (Box 1).
Recruitment and selection
We recruited three community juries in 2014 — two of mixed gender and ages (Juries 1 and 2), and one of men of PSA screening age (Jury 3) — by placing advertisements and articles in the mass and social media in Sydney. Of 119 respondents, 42 were unavailable on the days scheduled for the juries; 37 with recent personal or close family member experience of prostate cancer treatment, biopsy or active PSA monitoring were also excluded. We sought socioeconomic and cultural diversity for our juries. Juries 1 and 2 were socioculturally diverse but of above-average educational attainment; the all-male Jury 3 was also socioculturally diverse, but its educational attainments broadly matched those of the general Australian population. Forty participants were thus recruited according to their eligibility, sociodemographic characteristics and availability (Box 2).
Each jury commenced with an evening orientation session (Day 0), during which the questions and the jury process were introduced and consent was obtained. Jury Day 1 focused on interrogating the evidence and understanding the ethical, legal and practical aspects of the problem. Testimony on the following themes was prerecorded by selected experts and shown to jurors in a video presentation:
-
basic biology, diagnosis, treatment and prognosis of prostate cancer;
-
qualitative empirical evidence on how Australian GPs manage PSA testing in their practices;
-
ethical and legal aspects of patient consent (in general, and with regard to screening);
-
potential harms of screening asymptomatic men for prostate cancer; and
-
potential benefits of screening asymptomatic men for prostate cancer.
Each presentation lasted about an hour. Prerecording ensured that the evidence presented was standardised, although some experts slightly modified their presentations for Juries 2 and 3 according to the more specific options considered by these juries. The biographical sketches of the experts and the video presentations shown to Juries 2 and 3 are available online.18 Immediately after each video, the relevant expert was available for questions through a conference calling system. Facilitated by a researcher, these question-and-answer sessions allowed jurors to clarify or challenge the arguments presented. Facilitation focused on promoting constructive dialogue and fair interaction between jurors. Our observations of unstructured deliberations and the transcripts indicated that this inclusivity was maintained during non-facilitated periods.
For the first hour of Jury Day 2, jurors reflected on, discussed and debated the evidence, aided by a researcher acting as facilitator. Juries then deliberated for an hour without the researchers, and either reached a set of recommendations (Jury 1) or majority verdicts on the questions posed (Juries 2 and 3). The recommendations or verdicts, the underlying reasoning, and dissenting views were reported to the research team in a final, facilitated feedback session.
Data collection and analysis
The three deliberative groups (juries) were the units of analysis in this study. All jury deliberations (facilitated and non-facilitated) and expert question-and-answer sessions were audio-recorded and transcribed. During the final session, the verdicts and reasons were recorded by a researcher on a flipchart. Each point was reviewed by the jury to ensure accuracy. Transcripts were subsequently reviewed to identify key reasons why jurors supported or rejected the presented options.
Ethics approval
Our study was approved by the Cancer Institute NSW Population and Health Services Research Ethics Committee (HREC/12/CIPHS/46).
Results
Jury 1
In response to the question, “What should happen before men decide whether or not to be tested?”, Jury 1 recommended that:
-
GPs should initiate discussions about PSA testing with 50–70-year-old asymptomatic men, and provide information about the limitations of the test and the potential benefits and harms of biopsy and treatment;
-
these discussions should be encouraged but not mandatory;
-
discussions should inform a man’s decision making rather than be constrained by formal procedures (eg, signing a form);
-
GPs should consider a cooling-off period, so that men need to wait 1 to 2 days after the discussion before being tested; and
-
the community should be informed about expert uncertainty regarding the PSA test, to stimulate discussion between men and their GPs.
Problems discussed by Jury 1 without reaching a consensus were:
-
the appropriate content for a patient information sheet;
-
how to communicate to men that they can opt out of PSA testing; and
-
whether to discourage PSA testing by charging a fee.
Juries 2 and 3, part A
Similar to Jury 1, the majority view of both Juries 2 and 3 was that GPs should introduce the topic of PSA testing to asymptomatic men aged 50–70 years (Box 3). Prostate cancer was seen as a legitimate health concern for older men, so that PSA testing was an appropriate topic for general health discussions. Jury 3 (all males) also argued that GPs were best placed to inform men about PSA testing, as GPs were a more reliable point of access to medical advice; relying on other information sources would be “leaving it to chance”. All men, they said, should have equal access to the same information.
A minority in both Juries 2 and 3 voted that GPs should not raise the topic of PSA testing with asymptomatic men because other, more important health issues should receive priority, and because men might be more inclined to have a PSA test if GPs raised the topic. They were particularly concerned about the unreliability of the test and the risks of unnecessary treatment ensuing.
Juries 2 and 3, part B
Like Jury 1, the majority of Jury 2 (mixed gender) voted that detailed benefit–harm information about PSA testing and prostate biopsy and treatment should be provided in advance to support informed decision making. This was a minority position in the all-male Jury 3 (Box 3).
The reasons given by members of Juries 2 and 3 for their views included:
-
men have a right to know relevant information before making a decision; and
-
after an elevated PSA test result, it might be difficult to refuse subsequent biopsy and treatment, and men may not obtain the information needed to decide about the next steps.
Similar to Jury 1, Juries 2 and 3 supported a cooling-off period so that men could reconsider their decision before testing.
The majority of Jury 2 (13 of 15) supported providing all information before PSA testing. However, 10 of the 13 objected that our wording (especially “should” and “all”) was too prescriptive. They wanted GPs to be free to provide information tailored to an individual’s level of interest and personal requirements.
Two-thirds of the all-male Jury 3 voted that information about the benefits and harms of biopsy and treatment should be provided only after an elevated PSA test result had been received. These jurors argued that the PSA test alone was not intrinsically harmful, and favoured staggering the delivery of information, with written information available to those who wanted it at any particular point. Jury 3 members, in particular, were concerned about “information overload”. They felt that most men would not want to understand the harms and benefits of prostate biopsy and treatment until it was directly relevant to them. They trusted GPs to tell them what they needed to know in a timely manner, avoiding unnecessary anxiety. Notably, some participants argued that details about the risks of biopsies and treatment options should be provided to men by urologists because of their specialist expertise.
Discussion
After two days of deliberation, all three community juries recommended that GPs should discuss the PSA test with asymptomatic men over 50 years of age as part of routine care. Jurors felt GPs were best placed to consistently inform men about PSA testing, rather than relying on their being informed (or not) by other sources. All three juries wanted GPs, if prompted, to provide information about the limitations, benefits and risks of testing, biopsy and treatment, and to offer to provide more details if desired by the patient. The concept of a cooling-off period to allow men to think about whether or not they wanted a PSA test was also highly valued.
All Jury 3 members were men, and many were having, and appeared committed to, routine annual PSA tests. They also reached different conclusions to the other juries about when information should be provided. While Juries 1 and 2 focused on what would be good for men generally, members of Jury 3 often focused on their own personal experiences and preferences, including a shared inclination to rely on a doctor’s assessment of the particular information that was required to inform a patient’s decisions. This suggests that, although an informed public prefers GPs to take an active role in educating men about the PSA test, some men of screening age may not wish to be burdened with uncertain and detailed information about the consequences unless they have received an elevated PSA test result.
There are valid reasons why GPs might resist raising awareness of the PSA test. Simply mentioning it may encourage men to favour being tested; patients differ in their information needs;19 and communicating the potential harms of PSA screening is difficult.20,21 The new consensus recommendations and NHMRC-developed information resources promise to support GPs in the challenging task of discussing the topic. Models for communicating information about screening in a balanced and patient-centred way have also been described in the literature. The “consider an offer” model,19 for example, suggests that GPs help men consider and evaluate recommendations or offers of screening, while explicitly acknowledging that the offer might reasonably be refused. Rather than encouraging screening or expecting people to analyse detailed evidence, whether they felt ready to do so or not, such patient-centred approaches could help individuals decide how much information they wish to receive, and to reflect on their values and preferences regarding benefits and harms when deciding whether or not to be screened.
A limitation to this study is that community juries are comprised of small groups of engaged citizens whose views may not represent those of the general public. However, as all three juries came to similar conclusions, it is likely that our findings are replicable. Our unit of analysis was the deliberative group, but we note that the findings from the all-male jury differed from those of the mixed-gender juries, and that the men in the mixed juries endorsed the final recommendations of the juries in which they participated. This suggests that gender-related factors may influence jury processes.
The juries were clear: GPs should raise the topic of PSA testing and explain the benefits and harms, but tailor their information to the individual patient. Timing of information provision was less clear. PSA testing, the juries concluded, is a health issue that matters to men, and GPs are a reliable, trustworthy source of advice on health issues. These jury outcomes invite critical reflection by professional bodies about how GPs should actively support individual men making decisions about PSA testing.
Box 1 –
The questions addressed to the three juries, and the options available for their verdicts
Jury 1 deliberated and drafted recommendations on the open question:
- Consent and PSA testing for prostate cancer: “What should happen before men decide whether or not to be tested?”
Juries 2 and 3 were asked to vote on two questions:
- Part A. Select 1 or 2:
- Should GPs introduce the topic of PSA testing during appointments with male patients who have no symptoms?
- Should they wait until men ask about it?
OR
- Part B. Which of these options do you endorse? (Please give your reasons):
- Men without symptoms should get all the information about the possible benefits and harms of testing, and biopsy and treatment, before they decide whether or not to have a PSA test.
- Men should not get information about possible benefits and harms of biopsy and treatment before PSA testing. Instead, the doctor should wait until they know the test result. If the test result is raised, then the doctor should give information.
Jurors were asked to endorse either B1 or B2, and to give reasons for their decisions. The juries were repeatedly reminded that the questions were specifically about PSA testing for asymptomatic men.
OR
Box 2 –
Characteristics of the jury participants
|
|
Jury 1 |
Jury 2 |
Jury 3 |
||||||||||||
|
|
|||||||||||||||
|
Number |
13 |
15 |
12 |
||||||||||||
|
Age |
|
|
|
||||||||||||
|
< 40 years |
2 |
5 |
1 |
||||||||||||
|
40–70 years |
10 |
8 |
9 |
||||||||||||
|
> 70 years |
1 |
2 |
2 |
||||||||||||
|
Range, years |
28–70 |
19–75 |
37–74 |
||||||||||||
|
Median, years |
52 |
49 |
57 |
||||||||||||
|
Gender |
|
|
|
||||||||||||
|
Male |
9 |
9 |
12 |
||||||||||||
|
Female |
4 |
6 |
0 |
||||||||||||
|
Highest educational attainment |
|
|
|
||||||||||||
|
High school |
2 |
3 |
1 |
||||||||||||
|
Trade or diploma |
0 |
1 |
7 |
||||||||||||
|
Bachelor degree |
4 |
7 |
3 |
||||||||||||
|
Postgraduate degree |
7 |
4 |
1 |
||||||||||||
|
Cultural background/ethnicity* |
|
|
|
||||||||||||
|
Australian |
11 |
11 |
7 |
||||||||||||
|
Southern/eastern European |
0 |
1 |
0 |
||||||||||||
|
Southeast Asian |
1 |
0 |
1 |
||||||||||||
|
Northeast Asian |
1 |
2 |
2 |
||||||||||||
|
Southern/central Asian |
0 |
1 |
1 |
||||||||||||
|
Northwest European |
0 |
0 |
1 |
||||||||||||
|
Socioeconomic status of suburb† |
|
|
|
||||||||||||
|
Low |
1 |
1 |
2 |
||||||||||||
|
Middle |
1 |
4 |
4 |
||||||||||||
|
High |
11 |
10 |
6 |
||||||||||||
|
|
|||||||||||||||
|
∗Based on the Australian Standard Classification of Cultural and Ethnic Groups (ASCCEG).22 †Based on Socio-Economic Indexes for Areas (SEIFA).23 |
|||||||||||||||
Box 3 –
The outcomes of the deliberations of the three juries
Jury 1 recommendations
- GPs should:
- initiate discussions with 50–70-year-old asymptomatic men about PSA testing;
- be prepared to provide men with information about all the potential harms and benefits;
- consider instituting a cooling-off period so that men need to wait before taking the test.
Juries 2 and 3 verdicts
- Part A
- Should GPs introduce the topic of PSA testing during appointments with male patients who have no symptoms?
- Should they wait until men ask about it?
OR
Jury 2 (mixed gender, n = 15) voted 12–3 for option 1;
Jury 3 (all men, n = 12) voted 10–2 for option 1.
- Part B
- Men without symptoms should get all the information about the possible benefits and harms of testing, and biopsy and treatment, before they decide whether or not to have a PSA test.
- Men should not get information about possible benefits and harms of biopsy and treatment before PSA testing. Instead, the doctor should wait until they know the test result. If the test result is raised, then the doctor should give information.
OR
Jury 2 (mixed gender, n = 15) voted 13–2 for option 1;
Jury 3 (all men, n = 12) voted 8–4 for option 2.
Legal criteria for involuntary mental health admission: clinician performance in recording grounds for decision
In enacting mental health laws, parliaments empower doctors and other health professionals to detain patients and coercively administer treatment in defined circumstances. These laws have been informed by the United Nations Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (1991).1 These principles include requirements that patients be treated in the least restrictive environment (principle 9), and that every effort be made to avoid involuntary admission (principle 15). Laws made in recent years also purport to give effect to the articles in the 2006 United Nations Convention on the Rights of Persons with Disabilities.2 Australia is a signatory to this convention.
Principle 16 of the 1991 UN catalogue requires that, when involuntary admission occurs, the grounds of the admission be communicated to the patient without delay, and the fact of the admission and the grounds for admission be communicated to the patient’s personal representative, the patient’s family (unless the patient objects) and a legal review body.1
In South Australia, the grounds for involuntary admission were previously recorded on the initial detention form, as required by a regulation of the SA Mental Health Act 1993. The form had space for a brief statement of the grounds for detention. It was expected that, if practicable, a psychiatrist would then examine the patient within 24 hours. It was not required that a copy of the form be given to the patient.
In 2010, the Mental Health Act 2009 came into operation. This new Act requires the order for involuntary admission to be given to the patient, together with a statement of their rights. It was expected that by receiving a copy of the order, patients, carers and the tribunal would be informed of the specific grounds for their detention, as this had previously been included in the order. However, the Minister for Mental Health had removed the requirement for grounds to be documented on the form.
In 2014, the SA Office of the Chief Psychiatrist published a review of the operation of the Act in which the requirement for the inclusion of written reasons on orders was reconsidered. It was recommended that reasons for detention not be included in the form.3 The SA Government is currently considering the outcomes of this review.
In the context of the current policy and legal debate about requiring doctors and other medical practitioners to succinctly document grounds for involuntary treatment on a form, our study examined how effectively doctors have complied with this legal requirement in the past. This has been done by rating forms for inpatient detention completed by medical practitioners under the former Mental Health Act 1993 for compliance with legislative criteria.
Methods
We analysed 2491 consecutive forms authorising the initial detention of involuntary patients. These forms had been faxed to the Guardianship Board of South Australia from hospitals that admitted involuntary patients during the period 17 July 2008 – 15 June 2009.
One of us (K R), a legal researcher, reviewed the forms to assess compliance with the requirements of the Mental Health Act 1993. An initial trial rating of 250 forms was completed before undertaking the analysis of all the documents.
The grounds for detention were defined in section 12(1) of the Mental Health Act 1993:
(1) If, after examining a person, a medical practitioner is satisfied—
(a) that the person has a mental illness that requires immediate treatment; and
(b) that such treatment is available in an approved treatment centre; and
(c) that the person should be admitted as a patient and detained in an approved treatment centre in the interests of his or her own health and safety or for the protection of other persons, the medical practitioner may make an order for the immediate admission and detention of the person in an approved treatment centre.
The Mental Health Act 1993 “Order for admission and detention in an approved treatment centre” (Form 1; reproduced in the Appendix) cites these legislative criteria and allows space for the examining physician to enter the reasons for detention.
We adopted a generous rating approach, in that we accepted any evidence that each criterion had been addressed by the practitioner, without seeking to determine whether a threshold level for the criterion had been met (eg, assessment of the degree of risk).We rated a criterion as having been met if it was referred to in writing in the reasons given, or if the criterion printed on the form was clearly marked up (eg, with a circle, underlining or tick) to indicate that the practitioner had considered that criterion.
Mention of a current illness, such as depression, schizophrenia or psychosis, was accepted as the presence of a mental illness.
The Act required that treatment be available in a treatment centre. This criterion was not assessed, as, if a person had been detained, treatment would be made available; if a bed in a ward was not available, a patient would be accommodated in an emergency department.
In assessing the forms, an overall statement of their compliance with legal criteria was made. Forms were assessed as clearly meeting the criteria if they addressed all the criteria required by the legislation (the detainee has a mental illness; is a risk to himself or to others; and requires immediate medical treatment). In some forms, not all criteria were explicitly addressed, but what was written and marked up constituted a justification for detention, and the form was therefore classified as “otherwise meets criteria”.
Ethics approval
The project was undertaken with the approval of the South Australian Department of Health Research Ethics Committee (HREC/14/SAH/129).
Results
Of the 2491 forms reviewed, only 985 (40%) addressed all the necessary legal criteria for detention (Box 1). Specifically, 1471 forms (59%) did not refer to a need for immediate treatment, 540 forms (22%) did not refer to the presence of a mental illness, and in 359 forms (14%) there was no reference to risk to self or to others (Box 2).
With regard to risk, 1247 forms (50%) recorded risk to self but not to others, 718 (29%) risk to both self and to others, and 167 (7%) risk to others but not to self.
On some forms, it was possible to infer that all criteria had been addressed even though this was not explicitly stated. If forms that “otherwise met criteria” in this manner were included, the number of those assessed as addressing the legal criteria increased to 1249 (50%). This group included 193 forms in which the assessor made a note that a need for immediate treatment could be inferred from the other details recorded on the form, although the need for immediate treatment was not specifically mentioned.
As the majority of practitioners did not refer to the need for immediate treatment, a further descriptive analysis was undertaken after removing this element, and this indicated that 1697 forms (68%) explicitly addressed the remaining criteria: the presence of mental illness and risk to self or others (Box 3).
Discussion
In providing written grounds for the detention and involuntary treatment of their patients, medical practitioners addressed all necessary criteria on only 40% of the admission forms. We view this very low completion rate as a significant problem in documenting evidence of compliance with the law and protecting the rights of the affected patient. However, when the criterion that was most poorly addressed (the need for immediate treatment) was removed from analysis, the rate of compliance with the remaining criteria increased from 40% to 68%. This is reassuring.
Nevertheless, these results raise a significant question about the legality of the involuntary admission of those for whom the criteria were not addressed on the form. Does the fact that criteria were not specifically addressed reflect the actual clinical circumstances of the patient, or simply an error of omission by the clinician when completing the form? To answer this question it would be necessary to compare the information on the form with other sources, such as case notes or patient interviews. This was not part of our study.
A strength of our analysis was the large number of forms assessed. In theory, the examined collection should represent every mental health detention in SA between 17 July 2008 and 15 June 2009. We are nevertheless aware that some hospital units may not have complied with the requirement to routinely fax forms to the Guardianship Board. The detaining medical officer was not responsible for faxing forms, however, so we do not believe that lapses in doing so by some units would bias the outcome of our analysis.
Completion of forms
Given that mental health laws seek to limit the use of coercion to defined situations, the requirement to succinctly state the grounds for taking this action should protect the rights of patients if the defined grounds are not present. The discipline of completing the form, a skill that requires the integration of clinical findings with legal requirements, can, arguably, assist with this clinical decision making. The legal requirement to complete the form also accurately reflects the gravity of the loss of liberty for the patient, which is comparable with other forms of custody, including police arrest.
Variability in decision making
It is worrying that decisions to make orders may be made for extra-legislative rather than legal reasons. Variability in decision making about the need for an order can be attributed to the level of training of clinicians and to the individual clinician’s attitude to risk.4 Some extra-legislative factors may be clinically relevant, such as non-compliance of the patient and their lack of insight,5,6 although they ultimately influence the assessment of risk within the context of the defined criteria.
There is also a potential for clinicians to substitute their own moral judgement for what the law requires. This has been discussed in the context of experts who testify in forensic matters “… in accordance with their own self-referential concepts of ‘morality’ and openly subvert statutory and caselaw criteria that impose rigorous behavioral standards as predicates for commitment”.7
A recent report of in-depth interviews with 10 Norwegian psychiatric clinicians about how legal criteria are interpreted suggested that an ideal rational deliberation can lapse into paternalism, with assumptions made about lack of insight and the pointlessness of attempting to provide voluntary care for people with severe mental illness.8 Another author identified the risk of applying a false “ordinary common sense” to decision making in the law; this can nurture irrational, unconscious, bias-driven stereotypes and prejudices.9
Whether a requirement for clinicians to succinctly document grounds for involuntary admissions would rectify the problem of extra-legislative decision making is not known. It is still possible to apply extra-legislative criteria in making a decision, and to then retrospectively justify it by correctly citing the law in recording the decision.
In SA, patients are no longer provided with grounds for their detention. It must now be very difficult to detect whether criteria for detention under the Mental Health Act 2009 have been addressed. Patients would be better protected by a requirement that the grounds be recorded at the time of detention.
Other jurisdictions in Australia have a variety of laws regarding the completion of forms and the notification of involuntary patients. All except the Australian Capital Territory and SA require a form that includes the grounds for detention. New South Wales, the Northern Territory, Queensland, Victoria, Tasmania and Western Australia require that people who are involuntarily detained be informed either of the fact of their detention and their rights, or of the reasons for their detention.10–15 The manner in which they must be informed, however, differs. In the NT, involuntary patients may be informed orally or in writing, although a record of the notification must be made.11 In Queensland,16 Victoria13 and NSW,10 involuntary patients are informed in writing; in Tasmania, the legislation provides a right to be informed, but does not specify how involuntary patients are to be informed.17
We do not have a uniform system of counting and reporting inpatient detention rates.18–20 The Australian Institute of Health and Welfare refers to general trends (eg, 29.0% of public hospital admissions of patients with psychiatric symptoms in Australia during 2011–12 were involuntary), but it cautions that direct comparisons between service settings can be affected by differences in data collection standards and methods.19 In SA, statistics on the number of involuntary orders in emergency departments and wards are now available,21 but there is no usable denominator that would allow the calculation of rates and accurately attribute meaning to yearly fluctuations.
Light and colleagues22 highlighted a similar problem with respect to involuntary community treatment orders, noting the lack of a comprehensive, uniform national dataset and the need for rigorous and publicly accessible policy on their use. The same can be said for the reasons for inpatient compulsion. The collection of this information would allow links between rates of compulsion and the practices and culture related to documenting the grounds for detention to be explored.
Should admission forms include the grounds for involuntary treatment?
On the one hand, the poor performance of medical practitioners in completing legal forms, as described in our article, might support the argument that specifying the grounds for involuntary treatment on such forms should be abandoned. However, we suggest not only that the recording of reasons be required, but also, given the concerns discussed in this article, that the reasoning on the forms be regularly monitored for quality assurance and that clinicians be supported to improve their performance. This would ensure rational deliberative decision making based on law and good practice.
The UN mental health principles stipulate that the grounds for involuntary treatment be communicated to the patient and to a legal review body. Giving a patient a form that includes the reasons for their detention may help them understand what is happening to them, and this transparency will, in itself, provide a quality check on the accuracy of information recorded and on the reasoning on the form. Further, if tribunals routinely received these forms, they would be better able to evaluate the appropriateness of detention and to provide constructive advice to practitioners on best practice.
Box 1 –
Completion of the Mental Health Act 1993 Form 1 by medical practitioners (analysis of 2491 forms)
|
Specific legal criterion |
Addressed on the form |
Not addressed on the form |
|||||||||||||
|
|
|||||||||||||||
|
Mental illness |
1951 (78%) |
540 (22%) |
|||||||||||||
|
Requires immediate treatment |
1020 (41%) |
1471 (59%) |
|||||||||||||
|
Form refers to individual’s health and safety and/or protection of others |
2132 (86%) |
359 (14%) |
|||||||||||||
|
Form overall |
|||||||||||||||
|
All necessary criteria explicitly addressed |
985 (40%) |
1506 (60%) |
|||||||||||||
|
All necessary criteria either explicitly addressed or could be implied from the form (“otherwise meets criteria”) |
1249 (50%) |
1242 (50%) |
|||||||||||||
|
|
|||||||||||||||
Box 2 –
Mental Health Act 1993 s. 12 criteria not addressed (analysis of 2491 forms)
|
Criterion not addressed |
|
||||||||||||||
|
|
|||||||||||||||
|
One or more criteria missing |
1506 (60%) |
||||||||||||||
|
Requirement for immediate treatment missing |
1471 (59%) |
||||||||||||||
|
Statement regarding the presence of mental illness missing |
540 (22%) |
||||||||||||||
|
Statement regarding risk to self or others missing |
359 (14%) |
||||||||||||||
|
|
|||||||||||||||
Box 3 –
Reanalysis of the completion of Mental Health Act 1993 Form 1 by medical practitioners, after removing the criterion “requirement for immediate treatment” (analysis of 2491 forms)
|
|
|||||||||||||||
|
All necessary criteria explicitly considered |
1697 (68%) |
||||||||||||||
|
All necessary criteria either explicitly considered or could be implied from the form |
1725 (69%) |
||||||||||||||
|
|
|||||||||||||||
Is there value in the Relative Value Study? Caution before Australian Medicare reform
In April 2015, the federal Minister for Health, Sussan Ley, announced several initiatives to improve the operation of Medicare. One of these is the formation of a Medicare Benefits Schedule (MBS) Review Taskforce, to align MBS services with “contemporary best clinical practice”.1 The taskforce was allocated $34 million in the 2015 federal Budget, and has been described as the “most comprehensive review of the MBS ever taken”.2
In light of this review (and ongoing federal government determination for health care savings), it is timely to consider the lessons from the failure of the last major collaboration between government and the medical profession to restructure health system funding. The Relative Value Study (RVS) was a 7-year collaboration between the Australian Medical Association (AMA) and the federal health departments in the 1990s. The RVS was a review of the services and fees of the existing MBS, in order to address perceived unfairness. The RVS cost the taxpayer over $7.8 million but was never implemented.
Funding of the Medicare Benefits Schedule
When the Medical (now Medicare) Benefits Schedule was introduced in July 1970, medical fees were set according to an indicative list of AMA-approved “most common fees” charged. Technological advances subsequently reduced time to perform many procedures, but the calculation of payment did not change. By the 1980s, there was growing pressure from general practitioners and public health professionals to reform the MBS to better reward consultation-based medicine and encourage health promotion. There was also discontent from doctors that Medicare rebates were not keeping pace with increasing practice costs or inflation.3 This discontent was heightened by a freeze on indexation of rebates in 1999.4
Further, there was concern (from funders and researchers) that medical costs were increasing and that better value for money was needed for health services.5 The “common fees” origin of the MBS was seen as potentially resulting in doctors being paid what the market would bear or what patients were willing to pay, rather than for the real value of health services.6,7
In response to similar concerns, researchers in the United States developed a method for estimating doctors’ work based on valuing the resources used in the production of their medical services.8 This process allowed production of a relative value scale to rank services according to costs, and formed the basis of Medicare payment reform in the US in 1992.9
By the 1990s, there was sufficient dissatisfaction with the MBS that a similar process was considered for Medicare in Australia by the AMA and the then Minister for Health, Carmen Lawrence.
The Relative Value Study in Australia
The AMA and the Commonwealth Department of Human Services and Health agreed to jointly review the relativities and funding of the MBS. The Medicare Schedule Review Board (MSRB) oversaw this process and comprised three representatives from each organisation. In 1994, a joint discussion paper stated that the “overall objective of the review is to set relativities of fees for private services covered by the MBS on a consistent, fair and workable basis”.6 Further objectives were to encourage a fee level so patients were not unduly out of pocket, and to provide a reliable basis for updating fees.
The RVS was a three-stage process (Box).
Stage 1
Stage 1 comprised a review of consultation item numbers (viewed as needing most urgent change) and proposed the introduction of time-tiered consultations for specialists, and an expansion of GP time tiers, resulting in an eight-tier system of consultation item numbers.5 Stage 1 also developed a costing formula for medical fees (http://www.health.gov.au/internet/main/publishing.nsf/Content/B94757E6DEC62E08CA257BF0001E727E/$File/feesformula.pdf):
Medical fee = [Professional component] + [Practice cost component]
F = [Relative value of service × Doctor earning rate] + [Direct costs + Overheads + Professional indemnity costs + Working capital allowance]
The formula defined medical fees in terms of professional and practice costs. Professional cost was seen as the product of the relative value of a service (itself a combination of time, intensity and risk) and the relative value of the doctor, while practice costs were the sum of direct costs (such as staffing and consumables), general overheads for a reasonably efficient practice, professional indemnity costs and an allowance for working capital.
Stage 2
Stage 2 comprised three large technical studies completed in 2001, providing information for the costing formula.
The Practice Cost Study10 used modelling techniques to estimate practice costs incurred by reasonably efficient private medical providers, to populate the practice cost component of the costing formula.
The Professional Relativities Study11 developed two non-interchangeable scales of relativity: one valuing procedures and one valuing consultation services. The Australian Work Relative Value Unit (RVU) scale valued MBS procedures by assessing the time to complete (including pre- and post-service time) and work intensity (the combination of cognitive skill, technical skill and effort, and stress due to risk to patient or difficulty of procedure), and ranked all item numbers in a specialty in order of their total work value. The Attendance Item Work Relativities scale calculated relativities of consultations based on the eight-tier item number restructure from the Stage 1 report. These relativities considered length, location and intensity of consultation, amount of face-to-face time, and differentiated new and regular patients.
The Remuneration Rates Study12 calculated base GP remuneration rates (from a sample of 60 GPs), and developed career comparisons between GPs and specialists, and then between GPs and other “similar” professions, including lawyers, accountants and geologists.
Reception of the Stage 2 reports
There was criticism of some specifics of the technical reports. The Remuneration Rates Study reported a wide range of values for GP work value points and suggested GP career remuneration should be less than that for an accountant or lawyer but more than that for a geologist. The choice of “other professionals” was criticised as not reflecting the unpredictability or difficulty of GP work. The Practice Cost Study was criticised for including different office and support staff costs for GPs and specialists, not considering locum costs and for large differences in professional developments costs (annual GP allocation of $1256, versus $4394 for specialists).13
Importantly, after the completion of all the Stage 2 reports, there remained a number of assumptions that the technical researchers (and subsequently members of the MSRB) could not agree on. The proportion of appropriate non-face-to-face time for GPs and specialists could not be agreed, and the Professional Relativities Study produced two models of attendance item scales. The size of a reasonably efficient general practice was also not agreed, and therefore multiple costings for different-sized practices were provided in the Practice Cost Study. There was also failure to agree on appropriate continuing medical education costs and on the appropriate payment for an efficient GP — whether this should be the average of other professionals, or more (or less) than for the comparator professions.
Failure to agree on these assumptions meant that the MSRB was not able to agree on the value of the 15-minute GP attendance — the item number against which all other item numbers would be compared. The Department’s preferred value was 1.15 RVUs, whereas that of the GP members of the MSRB was 1.77 RVUs.
Modelling processes
Before the release of the Stage 2 reports, the AMA released modelling which suggested that a 15-minute GP consultation should be valued at $44 (based on 1.77 RVUs), and that full implementation of the RVS would cost an additional $1.5 billion. The Department’s modelling suggested a 15-minute GP consultation fee of $29.30, and predicted increased consultation costs of $154 million and a reduction in procedural costs of $96 million, for a net implementation cost of $58.3 million.
The difference between the two modelling figures was not resolved. As the MSRB was developing its recommendations on the review of fees in March 2001 (after over 70 meetings), the Board was disbanded by the then Minister for Health and Aged Care, Dr Michael Wooldridge.
Stage 3
Stage 3 aimed to link the data from the three technical studies to produce a new schedule of fees. The Department conducted an independent Stage 3 report based on its preferred assumptions, which was tabled to Senate Estimates in May 2001.14
The AMA modelling figures were used to advocate for increased health funding leading into the 2001 election. With the re-election of the Howard Government in November 2001 and the retirement of Dr Wooldridge, the RVS was not further funded in the 2002–03 Budget and implementation did not proceed.
Discussion
One health policy theory suggests that for an issue to get onto the health policy agenda, consideration needs to be given to three streams: problems, policies and politics.15 These three streams usually flow independently but will occasionally come together to create a window of opportunity for health reform.
During the establishment of the RVS, the three streams were seen to converge. There was acknowledgement of a problem: fundamental unfairness of the MBS leading to increased provider and researcher dissatisfaction. From a policy perspective, there was agreement that a review of the system was needed and researchers had shown that an alternative system could be designed. There was also a political will for change, as evidenced by the considerable funding budgeted for the RVS.
Why did the RVS fail and what did we learn?
The fatal flaw in the RVS process was the initial failure to resolve the different objectives of the members of the MSRB. As the RVS progressed, it became apparent that the policy solutions would either decrease income to some procedural medical practitioners (not satisfactory to the AMA) or significantly increase Medicare costs (not satisfactory to the government).
Further, the failure of the AMA and the Department to agree on a number of technical assumptions made modelling difficult and implementation impossible. These disagreements prevented valuation of the base consultation and stopped linkage of the two scales from the Professional Relativities Study. Additionally, failure to agree on the career value of GPs prevented determination of the doctor earning rate for other specialties.
From a technical standpoint, the RVS methodology has been criticised for failing to measure the quality of outputs (such as effect on health outcomes) or the societal benefit of a procedure.6 A resource-based relative value study suggests that two procedures have the same value if they use the same resources. But is providing a hearing aid to an 80-year-old as valuable as removing a melanoma in a 30-year-old?
Also, the RVS formula described values in dollar terms, rather than in terms of pure relativities. If all the RVU activity was added together, and this was divided into the total budget, a value could then have been determined for each RVU. This would have at least allowed implementation of the relativities and recalibration of MBS values, regardless of disagreement about the level of remuneration.
Finally, although the broad objectives of the RVS may have encouraged initial collaboration, they may have contributed to overall failure of implementation. A similar issue lay at the heart of the Medicare Locals program (established with broad objectives to improve the health of the community, but criticised in an external review for lacking clear purpose16) and is also a consideration for the emerging Primary Health Networks.
Where have we come since the failure of the RVS?
Departmental modelling confirmed the view that the MBS better rewarded procedural medicine compared with consultative medicine.16 In response to this, incentives programs were designed to reward consultative medicine (particularly general practice), such as the Enhanced Primary Care (1999) and Strengthening Medicare (2004) programs.17,18
These incentive programs increased funding for general practice and provided a smaller-scale “no loser” policy solution — more acceptable to the AMA and more easily implemented by the government.
Some of the relativities developed in the RVS have been used by the Department when reviewing remuneration of particular specialties to ensure cost-neutral adjustments. In 2005, the then Minister for Health, Tony Abbott, suggested, “I certainly think it would be good if we could look again at the relative value study”.19 This did not occur, and major MBS reform stalled until Minister Ley’s announcement of the current review process.
Conclusion
The collaboration of the RVS failed because of a combination of political, technical and policy disagreements that could not be resolved.
Value remains in the RVS, at a minimum as a lesson about the difficulties of health care reform. The new MBS Review Taskforce can learn from this, and the previous technical work can be built on to develop a sustainable and dynamic MBS. As the MBS approaches 50 years, such a review is hardly overdue.
Box –
Stages of the Relative Value Study in Australia
|
Stage |
Completed |
Output |
Author |
||||||||||||
|
|
|||||||||||||||
|
Scoping |
1994 |
Report: Towards a Relative Value Study |
Department and AMA |
||||||||||||
|
Stage 1 |
1999 |
Relative value costing formula and eight-tier attendance item number restructure |
Department and AMA |
||||||||||||
|
Stage 2: technical reports |
2001 |
Practice Cost Study: costs of running an efficient medical practice |
PricewaterhouseCoopers |
||||||||||||
|
|
2001 |
Practice Relativities Study: relative value scale for procedures; and relative value scale for consultations |
National Centre for Classification in Health |
||||||||||||
|
|
2001 |
Remuneration Rates Study: determination of fair remuneration for GP; comparison between GP and specialist pay; and comparison between GPs and other professionals |
Healthcare Management Advisors |
||||||||||||
|
Stage 3: modelling report |
Not completed |
Medicare Schedule Review Board dissolved in March 2001 (however, the Department conducted its own modelling report in May 2001) |
Department (with some separate modelling by the AMA) |
||||||||||||
|
|
|||||||||||||||
|
Department = federal Department of Health. AMA = Australian Medical Association. |
|||||||||||||||
Using accountability for mental health to drive reform
Across the health care system, accurate measurement and frequent transparent reporting of patient experiences has the capacity to reduce variations in care and increase effective service provision.1 The merit of applying this principle to mental health is well understood.2,3 Over 20 years, four successive national mental health plans have each called for this kind of accountability. Despite the rhetoric, and as we now brace for a fifth plan, Australia still has no agreed set of priority indicators nor any process to enable useful benchmarking.
This is a critical management deficiency recognised by the National Mental Health Commission and the Mental Health Commission of New South Wales, which have both recently (and separately) published sets of preferred key indicators.4,5 Repeated Australian reports and reviews suggest mental health services are still best characterised as fragmented,6 bedevilled by major gaps in provision,7 inequitably distributed,8 increasingly costly (http://mhaustralia.org/submission/mental-health-australia-submission-senate-inquiry-extent-income-inequality-australia) and outcome blind.9
Australia’s current data collection systems focus on activity rather than outcomes and are typically aggregated to state and national levels. Local opportunities for benchmarking are limited to comparing inputs and processes, such as bed numbers and length of stay, and have not evolved to permit comparison of outcomes. Previous attempts to develop nationwide approaches to data definitions and reporting have proven a glacial (and expensive) affair. We propose a new, limited set of indicators for mental health that have the capacity to drive reform.
These should not only be useful nationally but also regionally. Evidence of the utility of such regional comparisons is strong and growing.4,10 There are significant regional differences in relation to issues such as suicide and rates of access to mental health care. Data need to be available at this level, rather than just statewide, to permit useful comparisons and propel reform.
An additional consideration is that the chosen indicators must reflect the broader concerns of the community and the validated experience of consumers, carers and service providers. Current data collections focus on governmental reporting requirements and do not reflect the social priorities that are evident in mental health care, such as in relation to social participation, employment and homelessness.
In proposing specific indicators, we build on our previous proposals on national service priorities.3 We propose 12 indicators across three domains (health, social and system reform), consistent with the core value of the National Mental Health Commission — the right to lead a contributing life.
The indicators emphasise proximal factors (eg, death rates in the 12 months after discharge from a health facility) that can drive reform, rather than distal outcomes that are likely to reflect more complex determinants acting over longer time frames (eg, life expectancy).
The 12 indicators are set out below, with a brief outline of current data and any limitations in relation to their current collection or use.
Health domain indicators
Suicide rate: attempts and completions
These data are already collected and reported, including in relation to the Indigenous community where the problem is acute.11 Data on suicide attempts are not available in Australia, unlike elsewhere.12 Data on completed and attempted suicides are needed at the regional level to support local, tailored prevention activities. In 2003, there were 2214 suicides and in 2013, there were 2522.13 By comparison, a national campaign has seen the road toll decrease from 1621 in 2003 to 1156 in 2014.14
Death rates < 3 and < 12 months after discharge from any mental health facility, including cause of death
These data are not collected, with infrequent exceptions.15 Cause of death permits new, vital linkage of mental and physical illness, critical given the frequency of comorbidities.
Proportion of the population receiving mental health care services — both among the general population and, specifically, the population aged 12–25 years
These data are already collected and reported every decade. There is recent evidence indicating some lift in the rate of overall access to care, mainly due to the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative,16 now costing around $15 million per week.17 However, with 75% of all mental illnesses manifesting before the age of 25 years,18 it is vital also to monitor access by young people,19 including to new e-mental health, early intervention and online services.20 For young men, the access rate is as low as 13%. This indicator would help to track whether services designed to meet the needs of young people were reaching their target audience.
Prevalence of mental illness
Prevalence data are already collected every decade. It would be useful to present these data by region in future iterations, to build understanding of comparative community resilience and vulnerability, and to better target resources where they are needed most.
Social domain indicators
Participation rates by people with a mental illness of working age in employment
Having a job is critical to the health, welfare and dignity of people with a mental illness.21 Addressing unemployment and minimising welfare spending has been a clear social priority for successive governments. Despite this confluence of interests, there is no current specific national data collection. The Organisation for Economic Co-operation and Development ranks Australia lowest in terms of the income of people with a severe mental disorder as a ratio of the average income of the population.22
Participation rates by people with mental illness aged 16–30 years in education and training
When young people are exhorted to “earn or learn”, it is critical to monitor their education outcomes. This is being done elsewhere (eg, the United Kingdom Office for National Statistics) but not in Australia.
People with a mental illness reporting they have stable housing
Each night, 105 000 Australians are homeless.23 It is estimated that more than a third of people who are homeless in inner city areas have severe mental illness.24 There is currently no specific data collection. Discharge into homelessness still occurs. These data would tell us about the impact of housing and supported accommodation services.
Community surveys of attitudes towards mental illness
Recovery is more likely when clinicians and service providers understand the social realities that people with a mental illness face in their daily lives.25 Community education campaigns help to demystify mental illness and counter stereotypes.26 Although some information exists, there is no regular national survey of community (and business) attitudes and stigma towards mental illness.
System domain indicators
Consumer and carer experience of care
Patient satisfaction is one of the core ingredients in making a service system accountable, transparent and responsive.9,27 There are no nationwide validated data collected on the experience of care of mental health consumers and carers.
Readmission rates to hospital or re-presentation to emergency departments within 28 days after discharge
Some readmission data are already reported. In 2010–11, the proportion of admissions to state and territory acute psychiatric inpatient units that were followed by a readmission within 28 days was 15% nationally.28 This figure has been stable since 2005–06. This indicator would enable detailed comparison of the approach taken to arranging community support on discharge from one region to another.
Life expectancy for people with severe and persistent mental illness
This measure has been reported previously, with the life expectancy of this cohort much shorter than that of the general community.29 This indicator would highlight the extent to which the mental health care system is addressing the complex needs of the cohort, managing both physical and mental health issues, housing and other matters.
Number of people accessing specialised programs to enhance economic and social recovery
In the community-managed mental health sector, no service-level data are currently reported. This measure would at least monitor whether the community mental health sector is becoming a more significant player in Australia’s mental health system.
Conclusion
There are clearly other areas of interest beyond the indicators listed here, including smoking rates, comorbidities and cost. There would also be considerable merit in tracking spending on mental health research so as to gauge our capacity to innovate.
There are currently hundreds of mental health indicators and multiple reports. We contend that very little of this information is used or usable at the local level to drive reform, and that much of this data collection should cease. All Australian governments should agree now to refocus their reporting priorities around these 12 indicators. Governance of their collection should reside in a body suitably independent from government which can identify gaps and inequity. This was an essential role played by the New Zealand Mental Health Commission30 but is yet to emerge in Australia.
It is critical that these indicators do not sit apart from a new, system-wide process of continuous quality improvement in mental health care and suicide prevention. No such process currently exists. This focused approach, around 12 agreed indicators, should drive quality improvement by making data available at the regional level for benchmarking by service providers, funders, decision makers and, importantly, consumers and carers. Every community wants to know the extent to which it has a mental health system on which it can rely. Local empowerment is the engine of mental health reform, and timely, useful accountability data are the fuel.
A further step would be to set some targets for these measures that reflect the scope and ambition of mental health reform in Australia. Across a myriad mental health plans and policies, this is yet to be articulated and is now long overdue.
Improving health equity in Australia: practical advice for those ready to act
A personal checklist for the time-poor clinician
In these times of health reform mired in complexity and politics, I found myself recently wondering where physicians with a particular concern about health inequities for rural and remote Australia, especially public health physicians like me dealing daily with their distribution and determinants, might turn for guidance.
Recalling plaudits in a book review in the Journal,1 I retrieved all three editions of the Oxford handbook of public health practice. The first edition in 2001 of the handbook2 was rightly praised for conceptualising public health practice in a fresh and imaginative way. Its second edition appeared in 2006, and was emphatic in admonishing that “people who dislike decisions should not become public health practitioners”.3 The third and current edition implores the reader “to leave the health of the public in a better state than you found it”.4 Each edition has included a chapter on health inequities — those of the first two were written by Anna Donald, the much-revered Australian-born advocate for evidence-based medicine who died before publication of the third edition.5
Framing the practical actions in each edition is the ability to distinguish between the forces beyond the health system that cause inequities and the factors within the health system. Using this distinction, the Box presents a personal checklist for clinicians who are time-poor yet curious, influential yet non-specialist in health inequities and rigorous in their scrutiny of evidence and ready to act when that evidence is sufficient.
Within our sphere of influence, the handbook invites intelligent and effective policies, incentives and regulations to ensure that health professionals and health services are distributed according to need. Another piercingly clear recommendation is to empower underserved groups experiencing unjust outcomes themselves to demand the health services they deserve. This means transparent investment in cost-saving primary health care as a buffer before expensive hospitals which, by default, become the facility of both first and last resort for the underserved when local options are limited by factors beyond individual control.6
Sensitising colleagues in non-health sectors to the relationship between what they do and the detrimental effect on health equity as an agreed outcome for society is argued strongly in each edition of the handbook. As the significantly higher death rates for women living in rural Australia are not explained by their behavioural risk factors,7 a singular policy obsession by governments to promote individualistic clinical preventive services is unlikely to make a difference in the absence of steady and substantive long-term strategies to improve environmental, social and economic conditions for women in the bush. When none of Australia’s 564 local government areas ranked in the lowest decile for socioeconomic advantage are located in either Victoria or the Australian Capital Territory, perhaps the physical location of national institutions developing such policies might be an important modifiable factor.
Action on local inequity needs support. A prototype of system-level standards already exists in the Systems Assessment Tool available as part of every One21seventy audit undertaken by primary health care services seeking to meet the needs of Australia’s most severely disadvantaged group — remote Aboriginal and Torres Strait Islander peoples (http://www.one21seventy.org.au/cqi-information/systems-assessment-tool). Dated 2000, the reference document establishing benchmark ratios for health professionals to community size now needs updating. Whether urban or remote, Primary Health Networks whose boundaries embrace especially disadvantaged populations in low-ranked local government areas need these standards. Armed with contemporary system-level standards to evaluate the quality, composition, interconnection and capacity of primary health care, an evidence-based understanding of local impediments consequent to central policies would follow.
High-impact medical journals could play a pivotal role for time-poor clinicians, publishing trends in key social and economic indicators by region to provide backgrounds for readers who are not expert in public health practice but are eager to join an informed, professional chorus for action on health inequities. As respected channels for credible evidence exchange, such journals might feature annual updates on key health system determinants that we can do something about, including distribution of and support for general practitioners, and the use of pragmatic trackers of health system performance in the critical sector of primary health care (for example, to monitor potentially preventable hospitalisations). Because doctors love to learn, is there a niche for well written primers about macroeconomics, industrial relations reform, social impact investing and community empowerment? Simultaneous publication of companion lay versions might create preconditions beyond medical and policy networks for what the World Bank terms community-based monitoring.8 All of these ideas are entirely compatible with the prescient recommendations for action on health inequities put forward in each edition of the handbook.
Box –
Health equity: a checklist for clinicians
Beyond the health system
- Learn something specific about social and economic conditions:
- inequality of income distribution in Australia (Gini coefficient)
- Indigenous history in our neighbourhood
- number of babies born into poverty every year
- environmental indices such as walkability in urban suburbs or completeness of plumbing repairs in remote communities
- rules for unemployment and disability payment schemes
- relative advantage and disadvantage by geographic area (Socio-Economic Indexes for Areas)
- Develop a personal position on minimum wage policy.
- Examine the relocation of centralised government bureaucracies to regional areas with high unemployment and few private employers in order to create sustainable job opportunities and better inform national policy on geographic inequities.
- Interrogate proposed incentives or changes and any policy “thought bubble”, in line with our better selves and as health professionals who have sworn to the Declaration of Geneva.
- Trace the money flow in every allocation of resources or funding announcement. Who gets a job out of any new government proposal and for how long? Who stays in a tenured position irrespective of policy result? When and how do the disadvantaged themselves take over?
- Challenge every social idea: is this the best we can do?
Within the health system
- Check the facts about the adequacy of primary health care capacity in the immediate work surroundings.
- Critique proposed models of health service delivery in disadvantaged communities by asking whether we would settle for them if they were the options being planned for our children, parents or partner?
- Examine the membership and embedded power relationships of every committee we are asked to join. If it is a committee on Aboriginal health, are most members Aboriginal? If it is about migrant health, does an Anglo-Saxon chair it? If it is about rural health, what are the residential postcodes of everyone around the table?
- Ask whether another epidemiological project or descriptive report is really necessary. Do we already know enough? Can we already track improvements were they to occur?
- Interrogate the role of applied research: should we ever randomise the disadvantaged to interventions already accessible to the affluent?
- Argue a timeline for a change in health outcomes at a population level for a community we care about. Specify the target difference, propose a timeline, be willing to be held to account, and set an example by working diligently to this target in our daily practice.