more_vertIn Europe and the USA, 700 000 people die after out-of-hospital cardiac arrest and unsuccessful cardiopulmonary resuscitation (CPR) every year,1 about 2000 deaths per day. These estimates apply to many other parts of the world. This cause of death is probably the third most common cause of death in developed countries, after all cancers combined and other cardiovascular causes.1 When professional emergency medical services arrive after cardiac arrest—which can be after 8–12 min or more—the brain has already started to die.
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Sky-high Indigenous imprisonment rates a health disaster
Imprisonment is rarely good for health, particularly if you are an Indigenous Australian.
But, tragically, Indigenous people are far more likely to be locked up than other Australians, exacerbating health problems and sending many into a downward spiral of illness and premature death.
The figures are stark.
In 1991, the Royal Commission into Aboriginal Deaths in Custody identified extraordinary rates of incarceration among Indigenous Australians compared with the rest of the community, and established a link with poor general and mental health.
But, despite the Royal Commission’s recommendations, the situation has got significantly worse.
Among Aboriginal and Torres Strait Islanders, the adult imprisonment rate soared 57 per cent between 2000 and 2013, while juvenile detention rates increased sharply between 2000-01 and 2007-08, and have fluctuated ever since at around 24 times the rate for non-Indigenous youth.
Currently, almost a third of all prisoners are Aboriginal, including 48 per cent of juveniles held in custody.
Not only that, but the rate of reoffending is astronomical. In fact, repeat offending and re-incarceration is a large contributor to this high rate of imprisonment.
Shocking though these statistics are, they do not begin to describe the suffering and distress experienced by incarcerated Indigenous people, their families and communities.
Mental illness and mental health problems, including alcohol and drug abuse, contribute significantly to their rates of imprisonment and recidivism.
Being incarcerated, in turn, exacerbates existing conditions in prisoners. And, without appropriate and effective treatment within prison, mental illness and mental health issues are a major factor in poor outcomes for people released from prison, including suicide, death from overdose or injury and reoffending.
Social disadvantage and a history of upheaval culminating in trauma and grief clearly contribute to the high level of imprisonment among Indigenous Australians.
Many studies published since 2000 have highlighted that Aboriginal people already have a higher prevalence of significant psychological distress when compared to the non-Aboriginal population, disrupting social and emotional wellbeing and causing post-traumatic stress disorder, depression and substance abuse.
Alcohol is well-known as a common precursor to offending among Indigenous Australians, with indications that it could be a factor in up to 90 per cent of all Indigenous contacts with the justice system.
Once incarcerated, Aboriginal prisoners are at greater risk of developing or exacerbating a mental illness. Ninety-three per cent of Aboriginal women in jail, and 81 per cent of men, have some form of mental illness. Altogether, 30 per cent of Aboriginal women and 20 per cent of Aboriginal men in jail have attempted suicide, and 33 per cent of Aboriginal women and 12 per cent of Aboriginal men suffer from post-traumatic stress disorder.
It is apparent that there is a complete lack of appropriate services to meet complex social, cultural and health needs.
A clearer understanding of some of the drivers of incarceration of Aboriginal and Torres Strait Islander men and women is needed, as are better interventions through culturally appropriate health and disability services before entering custody, during imprisonment, at the time of release and post-release.
There are several things that can and should be done to end this vicious cycle of illness, abuse and incarceration for Indigenous people, including making it much easier for Indigenous offenders to get into diversion programs for alcohol and drug-related offences; establishing Indigenous-specific diversion programs linked to Aboriginal community controlled services; improving the level of health services for Indigenous prisoners; comprehensive health screening for those entering prison, and channelling them into appropriate treatment; and research and develop performance indicators to guide effective health services for Indigenous offenders.
These matters will be considered in the AMA’s Indigenous Health Report Card, which will be released later this year.
Sickest, smallest to be hit hardest by Commonwealth cuts
The Federal Government has been warned that more people are likely to die because of an increasing shortfall of thousands of doctors, nurses and other health professionals in public hospitals as a result of Commonwealth cutbacks.
AMA President Associate Professor Brian Owler said the Abbott Government’s decision to reduce public hospital by $57 billion over 10 years would have a devastating effect on the State and Territory health systems.
“The AMA has warned of a perfect storm if funding is not increased,” A/Professor Owler said. “We already see hospitals struggling to achieve performance targets. We know that overcrowding, we know that delays in getting into a bed from the emergency department, is not just a matter of the headlines, it is matter of increased morbidity. People have more complications or are more likely to die if they spend more and more time in an emergency department.”
The AMA National Conference was told that in Queensland alone, the Federal Government’s decision to slash growth in public hospital funding from 2017 will rip $11.8 billion out of the State health system over 10 years, resulting in 1503 fewer doctors and 5319 fewer nurses being employed in the time.
A/Professor Owler said the outlook for the smaller states and territories, which had limited revenue-raising capacity, was particularly worrying.
“I really fear for those states, because we know that their economies are quite small. They don’t have the ability to make up the shortfall in revenue, and those states are going to be really badly affected,” he said.
Queensland Health Minister Cameron Dick told the AMA National Conference that the Commonwealth was shoving more of the burden of public hospital funding on to the states.
Mr Dick released modelling by his Department showing that the Commonwealth’s share of national efficient public hospital expenditure would peak at 35.5 per cent in 2016-17 before rapidly falling away to just 32.1 per cent by 2024-25 – virtually 10 percentage points below the level committed to in the 2011 National Health Reform Agreement.
“There will be greater pressure on the hospital system as a result,” the Queensland Minister said. “People will have to wait longer for surgery, people will have to wait longer for patient appointments. We will not be able to deliver the services we need. As the population gets older and costly medical technology increases, there will be a gap.”
AMA Tasmania President Dr Tim Greenaway described to the AMA National Conference how the Commonwealth funding cut would hit his State particularly hard.
Tasmania has the nation’s oldest, fattest, poorest and – by many measures – least healthy population, and Dr Greenaway warned the Federal Government’s policy would only make the situation worse.
Despite having greater health needs than most other states and territories, Tasmania’s spending on health care ($1275 per capita) is below the national average ($1735 per capita), and Dr Greenaway said the Commonwealth’s funding cuts would only “lock in” the State’s inadequate investment in health, “which will inevitably increase health disparity”.
The states and territories are furious the Federal Government has walked away from its commitments under the National Health Reform Agreement, and the issue is set to be near the top of the agenda when Prime Minister Tony Abbott meets with his State and Territory counterparts to discuss reform of the Federation at a leader’s retreat in July.
A/Professor Owler said the Federal Government’s decision was indefensible.
“It’s up to the Commonwealth to live up to its responsibility to make sure that all Australia’s get access to the services they deserve,” he said, adding that the squeeze on hospitals would also have a significant effect on doctor and nurse training.
A video of the Quality public hospital services: funding capacity for performance policy session can be viewed at: media/ama-national-conference-30-may-2015-session-1
Adrian Rollins
Access to health services by Australians with disability 2012
In 2012, 17% of people with disability who needed to see a GP delayed or did not go because of the cost; 20% who needed to see a medical specialist did not go mainly due to the cost; and 67% who needed to see a dentist delayed seeing or did not go because of the cost. Compared with people with disability living in Major cities, people with disability living in Outer regional and Remote areas had lower use rates of services provided by GPs, medical specialists and dentists as well as coordinated care provided by different types of health professionals. They were more likely to visit a hospital emergency department for health issues that could potentially be dealt with by non-hospital services, and to face barriers to accessing health services.
Incentives hold out promise of better after hours care
The Federal Government has promised patients will find it simpler and easier to see a GP at night or on weekends following the reinstatement of incentives for medical practices to provide after hours services.
In a move strongly supported by the AMA, Health Minister Sussan Ley has announced that almost $99 million will be provided next financial year to pay practices that operate extended hours or make arrangements for their patients to receive after hours care.
Ms Ley said access to after hours GP care was an issue that was raised consistently during her consultations with the medical profession and the community since becoming Minister, and the incentive would give “positive support” to practices that ensured their patients had access to after hours care.
The reinstatement of the incentive was a key recommendation of the review of after hours primary health services led by Professor Claire Jackson, and followed widespread dissatisfaction with the arrangement under the previous Labor Government to give Medicare Locals responsibility for co-ordinating and funding after hours services.
AMA President Associate Professor Brian Owler applauded the Minister for moving so swiftly to reinstate the Practice Incentives Program After Hours Incentive.
A/Professor Owler said the AMA had been calling for the return of the PIP funding “for some time” because of the benefit it would provide to both patients and practices.
“The new PIP payment structure will encourage and support general practices to provide after hours coverage for their patients, which will in turn ensure continuity of care,” the AMA President said. “Individual practices will now have greater control over after hours services for their patients, [and] patients will benefit.”
To pay for the reinstatement of the PIP incentive, the Government has scrapped the After Hours GP Helpline and redirected funds freed up by the abandonment of the Medicare Locals network.
Though some complained that the Helpline has provided a vital service, the Jackson review found there was little evidence it had reduced the pressure on rural doctors to attend after hours call-outs or improved continuity of care. It recommended that the service be scrapped and the funds instead directed into GP incentives.
While details of eligibility requirements for the incentives are yet to be released, the scheme –which commences on 1 July – will offer five payment levels depending on the degree of service provided.
They range from the very basic, level 1 service involving “formal” arrangements for patients to seek after hours care at another provider, through to a full service model where a practice has staff rostered on around the clock, seven days a week.
The incentive would rise from $1 for each Standardised Whole Patient Equivalent (an age-weighted measure based on GP and other non-referred consultation items in the MBS) at a level 1 practice, rising to $11 per SWPE at the top end.
The Minister said all practices would be required to inform patients of their after hours arrangements, and to ensure that correct details were provided in the National Health Service Directory.
“Under these new arrangements, patients will be able to easily find out what after-hours services are available, including services provided by arrangement outside of the patient’s usual general practice,” Ms Ley said.
The reintroduction of the after hours PIP has coincided with the Federal Government’s move to scrap Medicare Locals and replace them with larger Primary Health Networks.
Importantly, the Government has specified a different role for PHNs regarding the provision of after hours services than that fulfilled by the Medicare Locals.
Under the new arrangement, PHNs will be required to work with “key local stakeholders” to plan, co-ordinate and support after hours health services, with a particular focus on “addressing gaps in after hours service provision, ‘at risk’ populations and improved service integration”.
A/Professor Owler said the change in focus and function was welcome.
“The Government has listened and responded to AMA concerns about giving responsibility for after hours funding to Medicare Locals, which has proven to largely be a failure and simply increased red tape for practices,” the AMA President said. “While the new Primary Health Networks will still have a role to play in ensuring community access to after hours health services, their focus will be on gaps in service delivery.”
Adrian Rollins
Govt wants kids to have cut-price health checks
The Federal Government wants children to have cut-price health checks after confirming it would rip almost $145 million out of general practice by abolishing a Medicare program that last year provided comprehensive pre-school health assessments for 154,000 children.
But Health Minister Sussan Ley said parents would still be able to get their GP to conduct a similar Medicare-funded health check of their child, though at a fraction of the cost to the taxpayer.
The Minister was forced to make the clarification after an announcement in the Federal Budget that $144.6 million would be taken out of general practice over the next four years by “removing the current duplication” Medicare-funded health checks and child health assessments provided by the states and territories.
AMA President Associate Professor Brian Owler voiced concern about the cut, saying it was “very unclear” whether or not there was duplication occurring.
The measure was also heavily criticised by health groups angered by what appeared to be a decision to axe comprehensive health checks for children aged three to five years, introduced by the former Labor Government in 2008.
But Ms Ley rushed to assure parents that they could still get Medicare-funded health checks for their children.
“Parents needing to access the pre-school health check for their child in order to access income support will still be able to do so through a GP or the various state-based nurse infant and children checks, as is currently the case,” the Minister said. “The only change in the Budget is to the Medicare items GPs can bill taxpayers and patients for undertaking the check.”
The Government has moved to scrap Labor’s “Healthy Kids Check”, which costs Medicare $268.80 per visit, and instead allow GPs to bill for the check as a standard GP item costing $105.55 for an equivalent amount of time.
“Instead of GPs billing a special Medicare item worth hundreds of dollars per visit, they will instead be able to deliver the pre-school health check for three- and four-year-olds through a standard GP item worth about half that,” Ms Ley said.
The Government said an increase in the number of people using the Healthy Kids Check in recent years had sent the cost spiralling.
It reported that the number of assessments had jumped from 40,031 in 2008-09 to 153,725 last financial year, driving the annual cost from $1.8 million to $20 million.
While lamenting the cost of the program, Ms Ley simultaneously criticised it for not being comprehensive enough.
“Currently, only half of Australia’s 300,000-plus four-year-olds have accessed a pre-school health check at the more expensive billing rates,” the Minister said, adding there was no evidence show Labor’s program provided health checks superior to standard GP and state infant check services.
But a study published in the Medical Journal of Australia last year did not support this conclusion.
It found the program was effective in detecting problems with speech, toileting, hearing, vision and behaviour in about 20 per cent of children, and directly led to changes in the clinical management of between 3 and 11 per cent of such children.
The study’s authors said their results suggested “GPs are identifying important child health concerns during the Healthy Kids Checks, using appropriate clinical judgement for the management of some conditions, and referring when concerned”.
They added that GPs were also using the checks as an opportunity to identify other health problems.
The authors admitted to having no knowledge of the cost-effectiveness of the program, “although, given that its timing coincides with vaccination at four years of age, the incremental cost is likely small”.
It followed a study published in the MJA in 2010 which found that although the evidence behind the Healthy Kids Check at that stage was “not compelling”, it had the potential to play an important role in monitoring child development by filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services.
Adrian Rollins
A maple leaf among the gum trees
Longer obstacle courses may not produce better doctors
Intern training is now formally under scrutiny. As part of a review commissioned by the Australian Health Ministers’ Advisory Council (AHMAC) and led by Andrew Wilson and Anne Marie Feyer, a discussion paper was released in February this year that raised a number of questions and made a number of assumptions.1 That paper mentions the Canadian experience, and hence the internship described below is salutary.
One intern’s experience
Last year, one of the interns in my program in rural Victoria2 was a Canadian who had undertaken her undergraduate medical training in Australia. She had done so because, unlike in Canada, here she was not forced to make an irrevocable decision about her future career during her medical school years. She came from the prairie province, Saskatchewan. She had reasoned that early postgraduate years in Australia would give her “the breathing space” to make a more informed decision about the career she wanted to pursue.
However, she did not need the full year to decide. Near the end of her internship she made up her mind — she wanted to become a rural general practitioner in Canada. Complementing her hospital rotations in surgery, medicine and emergency medicine, she had undertaken extensive community practice through the combined 20-week rotation in the Victorian town of Bright and in the nearby Mount Hotham snowfields. This experience had sealed her intention.
In the snowfields, the exposure to medical emergencies and the number of trauma cases provided a busy and intensive learning experience. She was one of only two interns in Victoria licensed to take x-rays. The environment reminded her of Canada, and the experience was so rewarding that she needed no more time to sort out her career. Paradoxically, having such a wide variety of experience enhanced her ability to make a career decision early.
Her experience provided several insights.
First, the surgical, medical and emergency rotations provided worthwhile experience. She did not feel that she was being harnessed as cheap medical labour.
Second, in Canada with only 2 further years of training she will obtain her rural general practitioner certificate. Her intern year in Australia was recognised as part of her Canadian postgraduate training.
Third, one might ask: if the intern year satisfied the requirements for the first year of vocational training in Canada, why then would we encumber her in Australia, had she stayed, with a compulsory 4 years of vocational training before full registration? Turn the question around: does a well constructed intern year mean that vocational training could be shorter in Australia than it is at present?
Should hospital requirements come first?
The problem in Australia with not only the first but often the second postgraduate intern year is that the service requirements of hospitals have traditionally dominated the agenda. But if that service commitment is tempered by clear recognition of the educational value of these years, including community general practice experience as a component of a well constructed training program, then the first 2 intern years could surely contribute to specialty training programs.
The educational aspects of hospital-based programs for interns tend to abide by the requirements of the Australian Curriculum Framework for Junior Doctors (ACFJD). But the quality of an intern program should be defined by many features, including good organisation, innovative content, and the involvement of interested specialists, general practitioners, registrars and teachers who bring a high level of skills.
The Canadian intern appreciated the guidance and variety of experience of our program, which was innovative without infringing the ACFJD liturgy.
Longer is not necessarily better
The time taken to achieve a medical qualification is already long, but this has not stopped educators and others arguing progressively that more time is needed to achieve “full registration”, and then even more to achieve “independent practice”.
This phenomenon, which is as much sociological as economic, has been described in Social limits of growth by Fred Hirsch.3 Increasing the length of required education achieves social scarcity. It does not guarantee more skills and knowledge. Hirsch describes this as “the wasteful lengthening of the obstacle course”.
How might the intern years be made more useful for future practitioners?
The widespread introduction of a 20-week general practice rotation is a proposal worth exploring.2 Where it has been implemented, it has increased the complexity of organising training, but it has been warmly received by interns. They feel value has been added to their internship experience without making it longer. Were this to become more common, the role of directors of clinical training becomes critical in building and maintaining the bridge between community practice and the hospital environment.
The importance or otherwise of directors of clinical training is not canvassed in the AHMAC discussion paper1 — but it needs to be, as does the funding of such positions. Adequate supervision does not automatically follow just because the regulatory agencies deem it should be so. Nailing an Australian Health Practitioner Regulation Agency edict to the hospital board is not the solution. However, directors of clinical training who are appropriately resourced may be able to effectively interpret such edicts.
Nonetheless, innovation goes only so far, and funding is imperative for expanding internships into community practice. However, interns’ patients are ineligible to claim Medicare rebates directly. The Prevocational General Practice Placement Program used to provide funding, but that program has ceased. There has been no replacement.
When I graduated, I was unequivocally registered from Day 1. If translated into today’s world, that would mean eligibility for Medicare rebates for my patients. After all, the current intern already has a provider number; this is restricted to ordering tests, but what is the difference to allowing access to other areas of Medicare? If the government wants interns exposed to general practice then the government must pay for this experience, one way or the other.
In the end, the young Canadian doctor realised that she had had a firm base in generalist training. In Canada, she could progress more swiftly to a program tailored to be complementary. She also knew that it would take less time to complete her training. She has accepted a post in a small city in south-western Saskatchewan called Swift Current, where she will be able to put into practice what she has learned in Australia.
Lengthening time is not necessarily synonymous with acquiring greater expertise. What if one changed the metaphor and said expanding the time spent had a diluting effect? If so, further time spent in acquiring the right to practice independently without evidence as to its value could even have homoeopathic characteristics — perhaps like a drop of maple syrup into a firkin of eucalyptus oil.
Seeking a comprehensive approach to tobacco control for Aboriginal and Torres Strait Islander people
Tobacco smoking among Aboriginal and Torres Strait Islander people (hereafter we use the term “Aboriginal” to refer to both Aboriginal and Torres Strait Islander peoples, but do so with respect for the autonomy of the two peoples) is the leading cause of health inequities in this population, and its control is essential to “closing the gap” in health status between Aboriginal and other Australians.1 Australia, however, currently lacks a comprehensive framework that guides and monitors the effectiveness of tobacco control efforts among Aboriginal people at the local, state and national levels.
In a recent Australian study, the mortality rate for smokers over 45 years of age was three times higher than for non-smokers, and they died about 10 years earlier; two-thirds of deaths among smokers could be attributed to their smoking2 — and smoking accounts for 20% of all Aboriginal mortality.3 While smoking rates among Aboriginal people are decreasing, 42% of those aged 15 years or older reported smoking daily in 2012–2013 — more than 2.6 times the rate for other Australians.3 Of particular concern is that 39% of young Aboriginal people aged 12–24 years reported smoking daily,4 compared with 11% of young non-Aboriginal people.5 These data provide an insight into the substantial health gains that could be achieved were smoking rates among Aboriginal people reduced to the levels for non-Aboriginal Australians.1
“Talking About The Smokes”
The Talking About The Smokes (TATS) project for Aboriginal people complements recent efforts6–8 to tackle the problem of smoking in Aboriginal communities. The TATS project is a national collaborative study involving 34 Aboriginal community-controlled health services (ACCHSs), with over 2500 participants and 645 staff involved in 2012 and 2013. As part of the International Tobacco Control Policy Evaluation Project under the World Health Organization Framework Convention on Tobacco Control (FCTC), the TATS project aims to assess the impact of specific policies on smoking behaviour and attitudes. The TATS project found high levels of local knowledge about the risks of smoking.9 Most Aboriginal people who smoke wanted to quit,10 and about 70% had actually tried to quit. Aboriginal people in disadvantaged areas were less likely than others to want to quit,11 and many disadvantaged smokers who tried relapsed after a short time.12
The TATS project has highlighted the role of stress as a key driver of smoking behaviour among Aboriginal people.10 It led researchers to suggest that anti-tobacco messages be reframed to emphasise protecting others from passive smoke exposure, and that sustained targeted anti-tobacco advertising be ensured to reduce the social acceptability of smoking.13 The study has called attention to the importance of the role played by local community leaders as opinion leaders,14 the commitment of ACCHSs to reducing smoking,15 the role of health professional advice,11 and the need to improve access to nicotine replacement therapies.16 In particular, the TATS project emphasises the importance of broad comprehensive approaches to reducing exposure to passive smoke17 and to fighting causes of stress, such as poverty and racism.12
The TATS project provides important evidence about smoking behaviour and attitudes, and highlights the need for a broad approach to ensure the development of shared and consistent local, statewide and national strategies for reducing the high rates of smoking among Aboriginal people.12 The FCTC, endorsed by the National Preventative Health Taskforce,18accentuates upstream factors, such as regulating the exposure, costs and advertising of tobacco, as well as raising awareness and promoting effective quit programs.
Strategies for tobacco control
The United States Centers for Disease Control (CDC) has provided additional elements that could be adapted to establish a comprehensive framework for Aboriginal people in its Best practices for comprehensive tobacco control programs.19 The CDC guidelines focus on preventing smoking initiation in youths and young adults, promoting quitting, eliminating exposure to second-hand smoke and addressing tobacco-related disparities between different population groups. These aims are to be achieved through five overarching strategies:
- State and community interventions that encourage and support tobacco-free norms, such as restrictions on marketing, smoking and sales, as well as reducing exposure to second-hand smoke by expanding smoke-free public spaces and workplaces.
- Mass-reach health communication interventions that are sustained, targeted and culturally appropriate, and which reduce the number of young people who start smoking. The TATS project suggests these programs could involve community leaders, like programs developed in the Tackling Indigenous Smoking project.
- Cessation interventions that provide culturally appropriate psychological support and take into account the critical role of stress, and which ensure access to effective pharmacological treatments and continuing support to prevent relapse.
- Ongoing surveillance and evaluation, which is vital to ensuring programs are effective and modified as needed.
- Considerable funding for infrastructure administration and management to sustain current successes and to implement further effective interventions. Current financial constraints create challenges for sustaining comprehensive tobacco control programs, with important programs having already lost funding.
A comprehensive framework to guide tobacco control could be used to pinpoint gaps in current and past strategies, as well as to identify areas for future research, policy and program development. This could include 3- to 5-year smoking strategies developed collaboratively with Indigenous leaders, ACCHSs and services at local, state3 and national levels, where efforts will be required over decades to reduce the pernicious impacts of smoking on Aboriginal health.
Changes in psychological distress and psychosocial functioning in young people visiting headspace centres for mental health problems
Improving the mental health and wellbeing of adolescents and young adults is receiving increasing attention throughout the world.1 The Australian Government was the first to invest significant funds in a practical and systematic response to this challenge, initiating a national reform process that created new service platforms for young people through its founding of headspace, the National Youth Mental Health Foundation.2
The initiative commenced in 2006, establishing an initial 10 centres and is set to increase to a network of 100 centres across Australia by 2016. headspace centres are one-stop entry points offering a mix of the services that young people need most. Centres provide early intervention by responding to early presentations of mental health problems and by assisting young people at greater risk of developing mental disorders. Being youth-friendly and non-stigmatising are priorities, and centre activities are founded on youth participation and engagement at all levels.3
From the beginning, the headspace initiative has evaluated its activities, despite the significant challenges inherent in determining the outcomes of such a complex, long-term, real-world, system-wide intervention. A preliminary external evaluation in 2009 showed that young people approved the approach used by the initial centres.4 At that time, however, it was still too early, in terms of implementation of the headspace initiative, to assess outcomes for the clients.
To facilitate investigation of the impact of the headspace centres, an innovative routine data capture system was introduced in 2013. This system collects information each time a young person accesses a headspace centre for service, and attempts to follow them up after they have finished engaging with the centre. Analysis of the dataset has shown that young people presenting to headspace centres have a wide range of mental health concerns, and are typically in the early stages of the development of a mental disorder.5 Further analyses have explored the types of service young people receive at the centres. In the companion paper to this article, we report that most of the young people seeking help at headspace centres present with mental health concerns, that they generally receive a timely response, and receive assessment and mental health care services. We also found that the initiative is primarily supported by funding from the headspace grant and by the Australian Government Medical Benefits Schedule.6
The current study reports the main clinical outcomes for young people who had presented to headspace centres for mental health concerns. The primary aim was to determine the extent to which psychological distress was reduced and psychosocial functioning improved in headspace clients.
Methods
Participants and procedure
Participants were all clients who had commenced an episode of care at a headspace centre for mental health reasons between 1 April 2013 and 31 March 2014. Young people who initially visited headspace for other reasons (situational, physical or sexual health, alcohol or other drug, or vocational reasons) were excluded from analyses. This selection was made because young people presenting with mental health concerns comprise the vast majority of those who seek help at headspace centres and definitely use their mental health care services; young people primarily presenting for other reasons may not have used mental health care services (see the companion paper to this article6). Analyses were limited to a young person’s first episode of care during the 12-month data collection period.
The procedure for the routine collection of data provided by the young people and service providers to the headspace Minimum Data Set is described elsewhere.5 Data related to psychological distress were collected from young people immediately before their first, third, sixth, 10th and 15th visits, as well as at follow-up. Measures of psychosocial functioning were recorded by service providers at each occasion of service.
Young people were invited to consent to being followed up when they first attended headspace. They provided an email address, and data were solicited after a 90-day pause in service provision by sending an email with a link to the follow-up questions. Young people could choose to answer these questions electronically, and responses were uploaded into the headspace data warehouse. Ethics approval for the follow-up was obtained from Melbourne Health Quality Assurance Review.
Measures
- The primary presenting concern was categorised according to the clinical presentation features as determined by clinicians. These did not comprise diagnoses, but were rather the main symptoms evident at the initial presentation that were indicative of mental health problems.
- Treatment services were recorded by clinicians, and were categorised as: cognitive behaviour therapy (CBT), interpersonal therapy, acceptance and commitment therapy, psychoeducation (including skills training and relaxation strategies), general and supportive counselling, mindfulness-based therapies, motivational interviewing, problem-solving therapy, and other interventions.
- Client outcomes that were assessed were:
Appendix 1 presents the number of clients for whom data were available at key time points.
Statistical analyses
IBM SPSS Statistics 21 was used for statistical analyses. Frequencies of each primary presenting concern were calculated, and age group and sex differences were assessed by χ2 analyses with Bonferroni correction for multiple comparisons.
Changes in each of the outcome measures over time were analysed in two ways.9 First, mixed-model repeated measures analysis of variance (ANOVA) was used to assess aggregate changes over time in K10 and SOFAS scores according to time point, number of service sessions, age group and sex. The statistical relationship between K10 and SOFAS scores was expressed as a Pearson product-moment correlation coefficient (r). Differences between the characteristics of clients who provided follow-up data and those who did not were analysed by logistic regression.
Second, significant change, reliable change and clinically significant change scores were calculated for the K10 and SOFAS data, as increasingly conditional indicators of change. The criterion for significant change was a moderate effect size (0.5) or greater for the degree of change.10 The reliable change index (RCI) (indicating reliable improvement or decline) and clinically significant change index (CSI) (cut-off point at which the person is more likely to belong to a non-clinical rather than a clinical population) were determined using Jacobson and Truax’s method.11
For the K10 scores, the RCI was estimated as a 6.73-point change (rounded to 7 points) using reliability coefficients reported for an Australian normative group (age group, 16–24 years) in the 2007 National Survey of Mental Health and Wellbeing.12 Using the same norms, the CSI cut-off was estimated to be 22.56 points (rounded to 23 points). For the SOFAS data, an RCI score of 10 was used; this was based on comparable outpatient psychiatric services data using the Global Assessment of Functioning scale as an equivalent. The CSI for the same comparison group was a score of 69 (Söderberg and Tungström [2006], cited by Falkenström13).
Results
The participants were 24 034 clients from the 55 headspace centres fully operational during the study period. Almost two-thirds of clients were female (62.7%), 36.9% were male and 0.4% were intersex or transgender. The mean age was 17.8 years (SD, 3.3), with 16.7% aged 12–14 years, 35.0% aged 15–17 years, 25.7% aged 18–20 years, and 22.6% aged 21–25 years.
Follow-up data were collected between June 2013 and August 2014. Of the total sample, 20 903 clients (87.0%) were eligible to provide follow-up data; the remaining 13.0% were still receiving headspace services or had not yet had a 90-day service-free period. Only 3.1% of eligible young people (651 clients) responded to the follow-up survey.
Presenting concern and treatment services
The most common mental health problems at initial presentation were depressive symptoms and anxiety, which together accounted for more than two-thirds of presentations. These were the most common presenting reasons for all age/sex groups, with the exception of 12–14-year-old boys, who presented most frequently with anxiety and anger problems and less frequently for depressive symptoms (Appendix 2).
Age and sex differences among those presenting with mental health concerns were indicated by χ2 analysis (χ2 [70] = 3300.57, P < 0.001). The proportions of younger males (12–14 years of age) presenting for anger or behavioural problems was greater than for other age/sex groups. Younger females (12–14 years of age) had higher presentation rates for deliberate self-harm than other groups (Appendix 2).
The most common treatment provided for all primary presenting concerns was CBT; for example, 43.6% of service provided to clients presenting with depressive symptoms involved CBT. A similar pattern of treatments was evident for all primary presenting concerns, with the second most common treatment being supportive counselling (except for borderline personality trait presentations). Psychoeducation was ranked third for most mental health problems (Box 1).
Mean changes in outcomes over time
Changes in the two outcome scores over time are depicted in Box 2 and Box 3. These plot the mean scores at each session that they were recorded, according to the total number of sessions attended. The sample sizes for each point declined as the number of sessions attended increased (Appendix 3). The follow-up data analyses were based on a particularly small sample size; further, no clinician-rated measures were available at this point, as the follow-up was based solely on self-report.
For the change in K10 between initial presentation and last recorded assessment, the factor with the greatest effect size was time, which explained 10.8% of the variance (Appendix 4, ANOVA 1; Box 2). Including the 3-month follow-up in the analysis showed that the time effect remained significant and explained 12.5% of the variance (Appendix 4, ANOVA 2). On average, there was a 3-point improvement in K10 scores from first to last assessment, and a further 3-point improvement from last service to follow-up for the small proportion of young people who provided follow-up data.
It is, however, important to note that the group of clients who provided follow-up data was significantly different from the much larger group of those who did not (χ2 [17] = 153.43, P < 0.001, Nagelkerke R2 = 0.062). Those who provided follow-up data were more likely to be female (odds ratio [OR], 1.63; 95% CI, 1.27–2.11), older (OR, 1.07; 95% CI, 1.04–1.11), have attended a greater number of service sessions (OR, 1.59; 95% CI, 1.39–1.82) and had better psychosocial functioning at exit (OR, 1.03; 95% CI, 1.02–1.05).
For change in SOFAS scores, time was again the strongest factor, but explained only 4.5% of the variance in this outcome measure Appendix 3, ANOVA 3; Box 3).
Significant, reliable and clinically significant change
The percentages of young people showing significant, reliable and clinically significant change between their first and last recorded assessments (not including follow-up) are presented in Box 4. Of the young people for whom data were available, psychological distress was significantly reduced in 36%, was reliably improved in 26%, and clinically significantly improved (by crossing the threshold distinguishing a clinical from a non-clinical population) in 21%. In 13% of clients, K10 scores significantly worsened, and in 8% they reliably deteriorated. According to clinician ratings of psychosocial functioning, significant and clinically significant improvement were each evident for 37% of the assessed clients, while 31% reliably improved. In contrast, function significantly declined in almost a fifth of clients, and reliably declined in 15%.
For 9957 clients, both K10 and SOFAS change data were available. Of these, 59.9% significantly improved and 49.2% reliably improved on at least one of the two scales, while 40.4% of those in the clinical group showed clinically significantly improvement on one or both of the scales.
It is important to note that the K10 and SOFAS scales measure different aspects of mental health, and that psychological distress (K10) was self-reported by young people, while social and occupational functioning (SOFAS) was assessed by a clinician. K10 and SOFAS scores were weakly correlated at presentation (r = − 0.19, P < 0.001) and at final assessment (r = − 0.23, P < 0.001).
There were statistically significant differences between those who improved and those who did not (significant improvement on at least one measure: χ2 [15] = 1168.48, P < 0.001, Nagelkerke R2 = 0.153). Improvement was predicted by greater distress (OR, 1.03; 95% CI, 1.02–1.04) and lower psychosocial functioning (OR, 0.94; 95% CI, 0.94–0.95) at service entry, and by attending a greater number of service sessions (OR, 1.16; 95% CI, 1.10–1.22). Age, sex and primary presenting concern did not predict improvement.
Discussion
This article reports the first outcome data for young people who have accessed the national headspace centre network for mental health problems. The analyses focused on the two key clinical outcomes, psychological distress and psychosocial functioning. The results show that psychological distress was significantly reduced in more than one-third of clients for whom data were available, and psychosocial functioning improved in a similar proportion. If improvement in either measure is considered, 60% of clients experienced significant change. Improvements in young people with greater distress and poorer functioning at service entry were noted in those who engaged well with the service (ie, attended more health care sessions). The findings are consistent with those reported from a single Sydney-based headspace service that found both symptomatic and functional improvements in its clients.14
Comparative data that would help determine whether these outcomes are acceptable are difficult to find. headspace clients present for a wide range of reasons and attend for varying numbers of sessions; although only outcomes for mental health clients were examined here, these young people still constitute a diverse group.6 Comparisons with outcomes from highly controlled clinical studies are therefore inappropriate. A study of psychotherapeutic outcomes in similarly aged young people attending a mental health clinic in the Netherlands, where the clients also presented with a variety of mental health concerns and received varying amounts of service, found that psychosocial functioning reliably improved in 19% of clients.13 This compares with the considerably higher rate of 31% that we have reported.
Comparative Australian data are scarce. Public tertiary mental health services use age bands of 0–17 and 18–64 years in their outcomes reports, and these are not comparable with either the age range of clients in these analyses or with the enhanced primary care service model of headspace. The most recent report from the National Outcomes and Casemix Collection (NOCC), which used the Health of the Nation Outcome Scales (HoNOS) family of outcome measures, showed that 37% of those aged 0–17 years and 24% of those aged 18–64 years using community-based public mental health services reported a significant improvement between the first and last occasions of service.15 The outcomes in young people reported here are similar to the child and adolescent results of the NOCC report, but much better than its findings for adults. However, the degree to which HoNOS outcomes are comparable with K10 and SOFAS scores is unclear, and the lack of directly comparable age groups makes interpretation difficult.
Drawing conclusions from the current study is restricted by several limitations. Primarily, the absence of a control group and other limitations inherent to observational studies means that the changes in scores reported cannot be attributed to headspace care.16 Further, most of the outcome data were derived from the last recorded assessment point for each client, but for many young people this was not at the completion of treatment. Our results are therefore likely to underestimate psychological and psychosocial gains in the course of treatment.
The follow-up rate was disappointing, although wholly expected, and highlights the considerable challenges in persuading young people to provide follow-up information after they have stopped attending for service. Without committing substantial resources to maintaining contact with people after leaving a health service, obtaining longer-term outcomes from real-world interventions will always be a major hurdle. Nevertheless, the headspace initiative has developed a process that attempts to routinely follow up young people after the end of service, and this may be unique in service delivery outside a well resourced prospective clinical trial. Over time, this follow-up database will grow and yield a rich source of information, even though there will be inevitable bias in those who provide follow-up data.
Another limitation is that the data cannot clearly determine the extent to which headspace clients received sufficient and appropriately matched “doses” of evidence-based therapies for different presenting problems and diagnoses, although it is evident that most clients did receive evidence-based therapies. headspace centres differ considerably in both their priorities and their capacity as a result of the diverse community and workforce contexts in which they are embedded,17 although all centres pursue a common vision of youth-focused, evidence-based, early intervention.3 The complexity and severity of young people’s presenting concerns also varies, with a substantial subset of young people who need, but are unable to gain, access to specialised tertiary services,18 which may have an impact on average improvement scores for the total client group.
Nevertheless, this article demonstrates that headspace is committed to examining and reporting outcomes for young people using its services, and that the headspace centre initiative is associated with improved mental health outcomes for a large number of young people assisted by this network across Australia.
1 Most common types of mental health care service received by headspace clients, according to the primary presenting problem*
|
Total sessions |
Treatment services type rank |
||||||||||||||
|
Presenting concern |
1 |
2 |
3 |
4 |
5 |
||||||||||
|
|
|||||||||||||||
|
Depressive symptoms |
25 708 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
Anxiety symptoms |
21 516 |
CBT |
Supportive counselling |
Psycho-education |
ACT |
IPT |
|||||||||
|
Anger problems |
3859 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
Motivational interviewing |
|||||||||
|
Stress related |
3521 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
Suicidal thoughts or behaviour |
2355 |
CBT |
Supportive counselling |
IPT |
Psycho-education |
ACT |
|||||||||
|
Behavioural problems |
1389 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
Deliberate self-harm |
1479 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
Eating disorder related |
1159 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
Psychotic symptoms |
531 |
CBT |
Supportive counselling |
Other |
Psycho-education |
IPT |
|||||||||
|
Borderline personality traits |
523 |
CBT |
Other |
Supportive counselling |
Psycho-education |
IPT |
|||||||||
|
|
|||||||||||||||
|
All presenting concerns |
63 221 |
CBT |
Supportive counselling |
Psycho-education |
IPT |
ACT |
|||||||||
|
|
|||||||||||||||
|
CBT = cognitive behaviour therapy. IPT = interpersonal therapy. ACT = acceptance and commitment therapy. * Percentages refer to proportion of total mental health care sessions received by clients presenting with the respective concern. Percentages in rows do not add to 100% as other treatment modes were possible. |
|||||||||||||||
4 Proportion of young people showing significant, reliable and clinical change in psychological distress and psychosocial functioning between first and last service ratings
|
Measure |
Method |
Number of clients |
Change category |
||||||||||||
|
Improvement |
No change |
Deterioration |
|||||||||||||
|
K10 |
Significant change (effect size ≥ 0.5) |
10 228 |
36.1% |
50.9% |
13.0% |
||||||||||
|
Reliable change |
10 228 |
26.2% |
65.9% |
8.0% |
|||||||||||
|
|
Clinically significant change* |
8205 |
21.1% |
78.9% |
NA |
||||||||||
|
SOFAS |
Significant change |
15 496 |
37.1% |
43.4% |
19.5% |
||||||||||
|
Reliable change |
15 496 |
30.9% |
53.6% |
15.5% |
|||||||||||
|
Clinically significant change* |
9556 |
37.0% |
63.0% |
NA |
|||||||||||
|
|
|||||||||||||||
|
K10 = Kessler Psychological Distress Scale. SOFAS = Social and Occupational Functioning Assessment Scale. NA = not applicable: young people in the clinical population are, by definition, not able to deteriorate, but rather remain in the clinical population. * It was not possible to assess the clinical improvement of young people who were in the non-clinical population at the first time point (19.8% of total sample for K10 and 38.3% of total sample for SOFAS); they were therefore excluded from this analysis. |
|||||||||||||||
Response – The Royal Australasian College of Physicians: a 21st century college
This article is a response by the Royal Australasian College of Physicians (RACP) to an article in this issue of the Journal: Komesaroff PA, Kerridge IA, Isaacs D, Brooks PM. The scourge of managerialism and the Royal Australasian College of Physicians. Med J Aust 2015; 202: 519-521. The RACP was made aware only recently of the article, which was submitted to the Journal some time ago. Due to this unique circumstance, a rapid and simultaneous response to the article is provided in this issue of the MJA. Publication of this response should not be taken as creating a precedent at the MJA.
Editorial Advisory Committee:
Charles Guest MPH, PhD, FAFPHM
Bruce Waxman FRACS, FRCS, MRACMA
Jeffrey Zajac PhD, FRACP
Charles Guest and Jeffrey Zajac declare that they are members of the RACP.
A statement from the Royal Australasian College of Physicians
One of the great lessons of the 20th century was the danger of ideologies that attempted to squeeze the complexity of the world into their frameworks.
The authors of “The scourge of managerialism and the Royal Australasian College of Physicians”1 have fallen into this trap by attempting to portray as a “corporatisation” framework a series of structural changes being undertaken to make the Royal Australasian College of Physicians (RACP) more focused on the needs of its members.
Komesaroff and colleagues argue that the College is victim to a takeover from a faceless class of managers and technocrats. Proposals for a more streamlined Board and a College Council that bring our disparate specialties together are characterised as markers on the road to a neoliberal dystopia.
The fundamental flaw in the article is that it provides little attention to facts that do not fit in with its argument. In portraying the College’s role as “providing a forum for physicians to communicate with each other”, it largely overlooks the objectives of the College that demand it be and remain an outward-looking institution committed to maintaining the highest professional standards, delivering robust training to its 6000 trainees and publicly advocating for the health of the public.
How does the authors’ analysis that the College has been captured by faceless managers account for the Australian Medical Council’s recent decision to award the College 6 years’ accreditation as the sole trainee of specialist physicians in Australia and New Zealand? Why would these supposed disciples of Thatcher and Reagan be allowing such a progressive advocacy agenda? At our recent Congress, the RACP adopted a progressive and controversial policy on asylum seekers; embraced the complexity of medicinal marijuana and end-of-life care; and grappled with confronting issues like gender identity and Indigenous health. The Board recently voted to divest investments identified as being directly and materially involved in fossil fuel activities.
And how does an analysis about managerial control account for the many Fellow committees that directly shape the College, or the current proposal to create an influential and representative College Council that will provide a forum to bring together our disparate specialties to share insights, collaborate and drive our broader agenda? The article’s portrayal of reforms championed by the Board needs to be challenged. While a minority resisted the constitutional changes proposed in 2013, a two-thirds majority supported the proposals.
These facts are paid little attention because they get in the way of what appears to be an ideological critique of the College, its Board and its dedicated and professional staff.
The reality is that this College, far from embracing “corporatism”, is following the lead of member-based non-for-profit associations around the world and rethinking the way it is run — focusing on the needs of our members, especially those entering the profession, harnessing technology, reviewing our committees and services to ensure they remain relevant. We cannot work to a collective vision if we do not empower a democratically elected Board to set a strategy and implement it. Change upsets people, but the risk of not changing is that an organisation will become irrelevant because of pressing external challenges.
If the College were to be accused of pursuing any ideological theory or agenda it would be that of “empowerment”. Empowerment is how we engage our more than 22 000 members to train the next generation of physicians, nurture their careers and make a difference as leaders in our communities. That may not be as dramatic a story as a sinister corporate takeover of the College, but it’s one that the College believes in for the benefit of our current and future Fellows and trainees, and for the communities they serve.