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Preference: Administration and Health Services

2

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:
    • the level of psychological distress, based on self-reports according to the 10-item Kessler Psychological Distress Scale (K10);7 and
    • overall psychosocial functioning, assessed by service providers using the Social and Occupational Functioning Assessment Scale (SOFAS).8

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
(43.6%)

Supportive counselling
(18.6%)

Psycho-education
(8.2%)

IPT
(7.5%)

ACT
(4.8%)

Anxiety symptoms

21 516

CBT
(47.0%)

Supportive counselling
(14.6%)

Psycho-education
(9.7%)

ACT
(7.5%)

IPT
(4.9%)

Anger problems

3859

CBT
(36.7%)

Supportive counselling
(21.3%)

Psycho-education
(16.6%)

IPT
(6.8%)

Motivational interviewing
(3.3%)

Stress related

3521

CBT
(34.0%)

Supportive counselling
(21.9%)

Psycho-education
(12.1%)

IPT
(7.2%)

ACT
(5.5%)

Suicidal thoughts or behaviour

2355

CBT
(36.9%)

Supportive counselling
(19.5%)

IPT
(9.6%)

Psycho-education
(9.2%)

ACT
(5.1%)

Behavioural problems

1389

CBT
(32.1%)

Supportive counselling
(23.3%)

Psycho-education
(18.8%)

IPT
(4.7%)

ACT
(3.6%)

Deliberate self-harm

1479

CBT
(36.3%)

Supportive counselling
(22.4%)

Psycho-education
(11.8%)

IPT
(6.6%)

ACT
(5.8%)

Eating disorder related

1159

CBT
(47.9%)

Supportive counselling
(12.9%)

Psycho-education
(8.4%)

IPT
(7.1%)

ACT
(6.0%)

Psychotic symptoms

531

CBT
(33.5%)

Supportive counselling
(23.0%)

Other
(18.8%)

Psycho-education
(12.2%)

IPT
(7.9%)

Borderline personality traits

523

CBT
(31.4%)

Other
(18.2%)

Supportive counselling
(17.8%)

Psycho-education
(11.1%)

IPT
(7.6%)

All presenting concerns

63 221

CBT
(42.8%)

Supportive counselling
(17.9%)

Psycho-education
(9.9%)

IPT
(6.5%)

ACT
(5.6%)

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.

2 Mean psychological distress scores (K10) at different time points

3 Mean psychosocial functioning scores (SOFAS) at different time points

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
(effect size ≥ 0.5)

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.

The services provided to young people through the headspace centres across Australia

headspace, the National Youth Mental Health Foundation, was initiated by the Australian Government in 2006 because it was recognised that the prevalence of mental disorders and the burden of disease associated with mental health problems was greater for those in their adolescent and early adult years than in older adults, but that young people were less likely to access professional help.1 headspace centres aim to be highly accessible, youth-friendly integrated service hubs that respond to the mental health, general health, alcohol and other drug, and vocational concerns of young people aged 12 to 25 years.2 The main goal is to improve mental health outcomes by reducing help-seeking barriers and facilitating early access to services that meet the holistic needs of young people. Recent data indicate that the initiative is largely achieving its aim to improve access to services early in the development of mental illness.3

As the headspace network has grown, the key components of the model have become clearer.4 At the heart of all headspace services is a youth-friendly, non-stigmatising, inclusive “no wrong door” approach, essential for engaging young people in mental health care.5 This is both a challenge and a major point of difference from other mental health services, which are often highly targeted, with clear exclusion criteria. Consequently, there has been a high level of demand for the services offered by headspace.3Centres have been set up across Australia in highly diverse community settings with a flexible local capacity for service delivery. The variation in focus between centres and in the types of services they offer has been noted as both a strength and a concern.6 Workforce problems are an ongoing challenge for many centres, particularly in rural and remote locations.7

headspace aims to provide a timely and appropriate response to the various problems presented by young people, and to provide a soft entry point to mental health care. In this study we set out to investigate what services headspace centres are providing to young people and how they are being delivered. The proportions of young people who initially presented in each of the main service streams — mental health, situational, physical health, alcohol and other drugs, and vocational health — were determined, as were the numbers of clients who received mental health care at headspace centres after initially presenting to the service for other reasons. We examined the waiting time for services, patterns of service use (number of sessions of each service type attended, types of service mix), as well as the major providers and the funding streams that support service delivery.

Methods

Participants and procedures

All participants had commenced an episode of care at a headspace centre between 1 April 2013 and 31 March 2014.

Data were drawn from the headspace Minimum Data Set,3 which includes the routine data collected from all clients who provide consent, producing a near-complete census of headspace clients. Young people enter data into an electronic form before each service visit, and service providers also submit relevant information about each visit. Data were de-identified by encryption and extracted to the headspace national office data warehouse.

Ethics approval was obtained through internal quality assurance processes; these consent processes were reviewed and endorsed by an independent body, Australasian Human Research Ethics Consultancy Services. Follow-up data collection was approved by Melbourne Health Quality Assurance.

Measures

  • The main presenting problem or concern was categorised by the service provider as: mental health or behavioural (symptoms of a mental health problem); situational (eg, bullying at school, difficulty with personal relationships, grief); physical or sexual health; alcohol or other drugs (AOD); vocational; or other.
  • The service type was categorised as one of the following on each occasion of service: mental health; physical or sexual health; AOD; vocational; or engagement and assessment. The number of sessions of each main service type attended by a young person during the data collection period was calculated.
  • The wait time was measured by asking clients how long they had waited after requesting an appointment for their first service appointment, and whether they thought they had been required to wait too long.
  • Service providers were categorised by profession and role. This included intake and youth workers, psychologists, allied mental health workers (social workers, mental health nurses and occupational therapists), general practitioners, nurses, psychiatrists, AOD workers, vocational workers, clinical leads and administrative staff (including reception staff, managers and practice managers).
  • The funding stream was categorised as: the headspace grant (each centre is funded through a headspace grant); the Medicare Benefits Schedule (MBS); Access to Allied Psychological Services (ATAPS); the Mental Health Nurse Initiative (MHNI); Rural Primary Health Services (RPHS); in-kind contributions by partner organisations; or other.

Results

Data were assessed for 33 038 young people who had commenced an episode of care at one of 55 established headspace centres during the study period; 16.8% were aged 12–14 years, 34.4% aged 15–17 years, 25.8% aged 18–20 years, and 23.0% were 21–25 years of age. Most were female (61.9%); 37.5% were male.

Main presenting problems or concerns

The proportions of young people who attended headspace centres for each category of main presenting problem or concern and the number of service sessions they attended are shown in Box 1. Almost three-quarters of presentations specifically involved mental health and behavioural problems; 13.4% were for situational problems and 7.1% for physical or sexual health concerns. Only a small proportion (3.1%) presented primarily for AOD problems, and very few (1.8%) for vocational reasons.

The vast majority of clients, regardless of their initial problem or concern, attended mental health sessions; this included almost all who presented with situational or AOD problems, and almost 85% of those who presented with a vocational problem. The exception was that less than half of those who presented with physical or sexual health concerns also used mental health services.

Clients who first presented for mental health reasons attended the most service sessions, with an average of 4.4 and a median of 3.0 sessions per person. More than a quarter of these young people attended six or more sessions, and more than 10% attended 10 or more. Less than a third attended only once for mental health consultations.

Those who first presented for a physical or sexual health problem attended the fewest service sessions.

Wait time

Most of the young people reported that they did not wait too long for their first appointment (Box 1).

According to their detailed responses, 38.9% of clients had waited less than one week for their first appointment, 41.2% for 1–2 weeks, 14.6% for 3–4 weeks, and only 5.3% had waited more than 4 weeks. Unsurprisingly, almost half of those who had to wait more than 4 weeks reported that they had waited too long.

Service mix

headspace clients typically attend at least one session of engagement and assessment, except those who present primarily for physical or sexual health problems. The time used for engagement and assessment increased with the total number of sessions attended, regardless of the initial presenting problem (see Appendix).

Box 2 shows the proportions of each type of service provision for each of the core streams accessed by clients with different initial reasons for presenting. These data show the strong similarity in service patterns for those who presented with mental health and situational problems. Young people who first presented with situational concerns received slightly more engagement and assessment, but were otherwise similar to those who presented with mental health problems.

Young people presenting with physical or sexual health problems had quite a different pattern to those presenting with other concerns, although there was still a large component of engagement and assessment and mental health treatment. Young people who presented for AOD problems tended to have a greater need for engagement and assessment.

Service providers and funding streams

The service providers that delivered most of each service type are shown in Box 3A. In line with the headspace service model — young people usually have an engagement and assessment session with an intake or youth worker during their initial appointment to gather information and to determine their needs — intake and youth workers provided almost half of the engagement and assessment service, followed by psychologists, who delivered almost 20%. Other allied mental health workers, including social workers and occupational therapists, provided just over 12%.

Mental health services were mostly delivered by allied mental health professionals (81%), with over half provided by psychologists; only 1.2% was provided by psychiatrists, and just over 10% by general practitioners. Almost all physical or sexual health service was provided by GPs or nurses. Specialist AOD workers undertook a third of AOD service, complemented by contributions from allied mental health workers. The small amount of vocational service was largely provided by specialised vocational workers, although a quarter was undertaken by intake and youth workers.

The provision of headspace services relies on a number of funding streams. The major sources for each service type are compiled in Box 3B. Engagement and assessment services were mostly funded by the headspace grant (71%) or through the MBS (21%). Nearly two-thirds of mental health services were funded by the MBS and a smaller contribution by the ATAPS program, with just under a third funded by the headspace grant. Physical and sexual health services were primarily funded through MBS items, but 22% was supported by headspace grant funds. In contrast, the main funding source for AOD and vocational services was in-kind support by co-located services or consortium partners.

It should be noted that there was variation between headspace centres in each of the parameters discussed here, but space precludes the presentation of detailed analyses. Generally, however, no major differences were associated with the size, age or geographical location of centres. The one exception was waiting too long; significantly fewer young people reported waiting too long at the most recently established centres than at centres established during the first three rounds of the headspace program (7.0% v. 10.6%; P < 0.001). The longest wait times were experienced in one large centre in a major city, where 27% of young people reported they had waited too long, compared with only 2% at each of a small inner regional and a medium-sized outer regional centre. Waiting too long was significantly more common at large centres (12.0%) than at medium (9.6%) and small (9.4%) centres (P < 0.001). It was also significantly more frequent in major cities (11.9%) than at inner regional, outer regional and remote centres (8.3%, 9.2% and 8.1%, respectively; P < 0.001).

Discussion

There is considerable interest in the headspace initiative because it comprises a significant investment by the Australian Government in an innovative approach to youth mental health. The results presented here show that the vast majority of young people specifically attend headspace centres for mental health problems, and that the next most common reason for attendance involves situational problems that affect the wellbeing of the young person, such as bullying at school, difficulty with personal relationships or grief. This is consistent with the general early intervention aim of the headspace initiative, and with the recognition that mental health problems and related risk factors are the primary health concerns for adolescents and young adults.8

A sizeable minority of young people initially attended headspace for physical or sexual health problems. For almost half of these clients, this led to a mental health consultation, supporting the contention that physical and sexual health care can and should be a pathway to mental health care (and vice versa).

The headspace initiative engages young people with a range of health and wellbeing concerns, not just those with mental health problems. Few clients, however, presented primarily for AOD problems and vocational difficulties, suggesting that these are more often accompanying problems than primary concerns for those attending headspace centres, although half of the headspace clients aged 17–25 years are looking for work (compared with less than 10% for this age group in the general population).9 Funding for these two core streams relied primarily on in-kind contributions by headspace service partners, emphasising the value of the local partnership model that underpins service delivery, but also revealing vulnerability in terms of stable funding. Building the capacity of the headspace model to better support young people with vocational needs and secondary AOD problems should be a priority.

As young people are often reluctant to attend mental health services, receiving an appointment promptly after a young person has decided to seek help is crucial. The vast majority of headspace clients waited 2 weeks or less for initial service, a notable achievement. Wait times are a major barrier in traditional mental health services,10 and minimising waiting is a distinguishing focus of headspace. Nevertheless, some clients waited longer, and wait times were longer in more established centres. Minimising wait times must remain a constant focus for headspace services, while continuing to respond to the growing demands of young people with a range of presenting problems. Engagement and assessment are also critical elements.

Australia claims to lead the world in innovative approaches to youth mental health care. Our results confirm patterns that diverge from traditional mental health service delivery, and we argue that these patterns are more appropriate for meeting the social and mental health needs of young people.5

1 Number of headspace service sessions attended (all types) and initial wait time for young people presenting with different categories of problem or concern

       

Main reason for presenting to headspace
     

All clients

Mental health and behaviour

Situational

Physical or sexual health

Alcohol or other drugs

Vocational

Number of presentations (% of all clients)

33 038†

24 034
(72.7%)

4440
(13.4%)

2332
(7.1%)

1030
(3.1%)

583
(1.8%)

Number who received mental health service
(% of presentations for respective reason)*

31 134
(94.2%)

23 738
(98.8%)

4331
(97.5%)

1134
(48.6%)

951
(92.3%)

493
(84.6%)
             

Mean number of sessions attended (SD)

4.1 (4.2)

4.4 (4.4)

3.6 (3.7)

2.5 (2.9)

3.0 (3.4)

3.2 (3.6)

Median number of sessions attended

3.0

3.0

2.0

1.0

2.0

2.0

Number of sessions attended

            

1 session

  

35.4%

32.1%

39.0%

50.8%

45.2%

45.5%

2 sessions

  

14.0%

12.8%

14.8%

22.2%

19.3%

16.1%

3–5 sessions

  

25.6%

26.7%

25.7%

18.7%

21.0%

22.3%

6–9 sessions

  

15.1%

16.9%

13.3%

4.6%

10.0%

9.8%

10 or more sessions

  

10.0%

11.5%

7.2%

3.6%

4.6%

6.3%
             

Client did not wait too long for first service

89.4%

88.7%

91.5%

90.9%

91.4%

92.1%

* Includes engagement and assessment services. † Includes 619 young people (1.9% of sample) who had presented for “other” primary reasons not included in the five major categories, such as attention deficit and developmental disorders.

2 Service mix according to initial presenting problem or concern

3 Main service providers (A) and main funding sources (B) for each headspace service type*

(A)

 

Main types of service providers (rank)

Service type

1

2

3

4

Engagement and assessment

Intake/youth worker
(46.4%)

Psychologist
(18.6%)

Allied mental health
(12.2%)

GP
(7.4%)

Mental health

Psychologist
(50.6%)

Allied mental health
(17.2%)

Intake/youth worker
(13.2%)

GP
(11.5%)

Physical or sexual health

GP
(76.1%)

Nurse
(11.7%)

    

Alcohol or drugs

AOD worker
(31.4%)

Allied mental health
(31.4%)

Intake/youth worker
(13.2%)

Psychologist
(10.3%)

Vocational

Vocational
(38.4%)

Intake/youth worker
(24.7%)

Miscellaneous†
(16.5%)

Psychologist
(8.2%)

(B)

 

Main funding sources (rank)

Service type

1

2

3

Engagement and assessment

headspace
(70.8%)

MBS
(20.9%)

  

Mental health

MBS
(57.4%)

headspace
(29.5%)

ATAPS
(7.8%)

Physical or sexual health

MBS
(69.3%)

headspace
(21.8%)

In-kind
(6.7%)

Alcohol or drugs

In-kind
(50.3%)

headspace
(28.6%)

MBS
(17.8%)

Vocational

In-kind
(46.8%)

headspace
(37.2%)

MBS
(11.7%)

AOD = alcohol or drugs; ATAPS = Access to Allied Psychological Services; GP = general practitioner; MBS = Medical Benefits Scheme.

* A maximum of four service providers and three funding sources are reported here; contributions under 5% are not included. For these reasons, rows do not add to 100%.

† Consisting of various types of provider, mainly interns and placement, community engagement and education officers.

Smoking among a national sample of Aboriginal and Torres Strait Islander health service staff

In 2012–2013, the prevalence of daily smoking among Aboriginal and Torres Strait Islander adults was 42%, although it is falling.1 For many years it has been suggested that the high smoking prevalence of Aboriginal health workers (AHWs) is a barrier to reducing smoking in the communities they serve.2,3 AHWs and other Aboriginal and Torres Strait Islander health service staff are role models and advocates for health in their communities, and there is evidence that AHWs who smoke have been less likely than those who do not to assist or promote smoking cessation.2

The high prevalences of smoking previously reported among AHWs or other Aboriginal and Torres Strait Islander health service staff do not differ greatly from the high prevalences in their communities, but are based on small samples.3 Similarly high smoking prevalence among doctors has been reported in some developing countries, raising the same concerns about their roles in supporting cessation and as opinion leaders.4 In contrast, there has been a steady decline in smoking prevalence among doctors in most developed countries — in Australia, this fell from 27% in 1964 to 3% in 1997, much lower than in the general Australian population.5,6

It has been asserted that smoking prevalence starts to fall earlier among doctors than among the general population as doctors are more likely to recognise the health consequences and change normative beliefs, and also become aware of the contradiction between their smoking and their role in improving health.7 The low smoking prevalence found among doctors is seen as an achievable future for the entire population.8

Here, we compare smoking prevalence, quitting activity and beliefs among a national sample of Aboriginal and Torres Strait Islander staff at Aboriginal community-controlled health services (ACCHSs) and among members of their communities who smoke.

Methods

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people in the communities served by 34 ACCHSs and one community in the Torres Strait between April 2012 and October 2013. At the same time, all staff at 31 of these ACCHSs were invited to complete a self-administered survey. Staff surveys were requested but not completed at four of the 35 project sites, owing to other local priorities.

The TATS project has been described elsewhere.9 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness, using a quota sampling design. At each site, we aimed to survey 50 smokers (or ex-smokers who had quit ≤ 12 months previously) and 25 non-smokers from the community served by the ACCHS, with equal numbers in the smoking and non-smoking samples of men and women, and of those aged 18–34 and ≥ 35 years. In four large city sites and in the Torres Strait community, the sample size was doubled.

Staff surveys were paper-based at 20 ACCHSs and online at seven, with four offering both options. Surveys took 5–10 minutes to complete and included questions from the main community survey about smoking and quitting behaviour and attitudes, exposure to advertising, and use of cessation support. These were supplemented by questions about smoking at work, the respondent’s role at the ACCHS, and smoking and cessation beliefs related to his or her role. The questions used in this article are listed in Appendix 1.

In contrast to the staff surveys, trained local interviewers completed the 30–60-minute survey of community members face to face using a computer tablet. A single survey of health service policy and activities was also completed by key informants at each site.

We compared the smoking status of Aboriginal and Torres Strait Islander staff with data from the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The NATSISS was a national, stratified, multistage, random, face-to-face household survey with 7163 Aboriginal and Torres Strait Islander participants aged 18 years and over conducted by the Australian Bureau of Statistics from August 2008 to April 2009, with an 82% response rate.10

We also compared the responses to questions about smoking and cessation practices and attitudes of Aboriginal and Torres Strait Islander staff who smoked with those of smokers in the community survey. We assessed differences in quitting and use of stop-smoking medications between staff who had active support from the health service to quit and those who did not.

The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.

Statistical analyses

All comparisons of staff responses with the responses in the 2008 NATSISS or in the main community survey were directly standardised to the distribution of the age, sex and remoteness of either smokers or the total Aboriginal and Torres Strait Islander population in the 2008 NATSISS. As it not possible to estimate sampling error in non-probabilistic quota samples, we do not report confidence intervals around our prevalence estimates and only report percentages to the nearest integer.

The association between dichotomous variables within our samples was assessed using simple logistic regression to generate odds ratios (ORs) and P values based on Wald tests, and using χ2 tests for other categorical variables. These results were analysed using Stata 13 (StataCorp) [SVY] commands to adjust for the sampling design (using site clusters in both the staff and community surveys, and age–sex quotas in the community survey as strata). NATSISS data were analysed using replicate and person weights as previously described.11

Except for attitude questions, where “don’t know” responses were combined with “neither agree nor disagree”, reported percentages and frequencies exclude participants not answering, answering “don’t know”, or for whom the question was not applicable. For the question about levels of confidence in talking to others about their smoking, we reported those who answered “don’t know” but excluded 7% who did not answer. Less than 5% of responses were excluded for all other questions analysed in this report, except for those in the staff survey about health service support of quit attempts (7%), whether the last quit attempt was before or after being employed at the health service (8%) and whether a quit attempt had been made in the past year (13%).

Results

Surveys were completed by 645 staff at 31 ACCHSs, covering every state and territory as well as major cities and regional and remote areas (Appendix 2). As it was deemed impractical to precisely estimate total staff numbers, we have no precise response rate. However, it is unlikely to be above 50%, as 215 surveys were completed at 17 services with up to 50 staff (mean, 12.6 surveys per ACCHS) and 430 at 14 services with more than 50 staff (mean, 30.7 per ACCHS).

Fifty-eight per cent of respondents (374/641) were Aboriginal or Torres Strait Islander people (Appendix 2). Of the Aboriginal and Torres Strait Islander staff, 76% (286/374) were women, 48% (173/362) had been at the ACCHS longer than 2 years, 88% (319/362) worked full-time, 49% (181/367) were AHWs or community workers, 5% (18/367) were doctors or nurses, 25% (92/367) were in other roles with direct client contact, 21% (76/367) had no contact with clients, and 17% (63/368) were in managerial roles.

Of the Aboriginal and Torres Strait Islander staff, 146 were smokers. None of those who smoked said they did so indoors at work, and 13% (19/145) said they did not smoke at work. Most (57%, 83/145) said they smoked outside the health service boundary or fence. In the past month, 41% (59/145) had smoked where ACCHS clients could see them. While 77% (111/145) had smoked with co-workers during work hours in the past month, only 28% (40/145) had smoked with clients of the ACCHS. All ACCHSs had a smoke-free policy or rules. Most Aboriginal and Torres Strait Islander staff who smoked (74%, 107/144) agreed that being a non-smoker sets a good example to patients at their health service.

Comparison of Aboriginal and Torres Strait Islander staff with NATSISS participants

Compared with all Aboriginal and Torres Strait Islander adults in the 2008 NATSISS, a lower standardised proportion of Aboriginal and Torres Strait Islander ACCHS staff smoked (38% v 49.8%), with more having never smoked and a similar proportion of ex-smokers (Box 1). The difference in the proportion of smokers was smaller when ACCHS staff were compared only with employed adults in the NATSISS (38% v 44.8%). Staff who had ever smoked were more likely than their NATSISS counterparts to have successfully quit (38% [88/234] v 30.1% [95% CI, 28.0%–32.1%]). Most of the staff ex-smokers (62%, 50/81) had quit before they started working at the health service.

Comparison of Aboriginal and Torres Strait Islander staff with community members

A greater standardised proportion of Aboriginal and Torres Strait Islander smokers among the staff than among other community members had ever made a quit attempt (83% [118/144] v 70% [1143/1631]; OR, 2.1 [95% CI, 1.1–3.7]; P = 0.02). However, the difference in the proportion of smokers who had made a quit attempt in the past year was not statistically significant (staff v community, 58% [67/127] v 50% [796/1609]; OR, 1.4 [95% CI, 0.81–2.4]; P = 0.24).

There were significant differences in how many of the respondent’s five closest family or friends smoked, with staff smokers having lower odds than community smokers of reporting all five were smokers (OR, 0.56; 95% CI, 0.34–0.94; P = 0.03). Staff who smoked had significantly greater odds of having often or very often noticed advertising about the dangers of smoking or that encouraged quitting in the past 6 months, compared with other community members who smoked (OR, 2.8; 95% CI, 1.4–5.6; P = 0.004) (Box 2).

Compared with community smokers, a significantly higher proportion of Aboriginal and Torres Strait Islander staff smokers who had ever made a quit attempt had used nicotine replacement therapy (NRT) or other stop-smoking medications, (OR, 3.0; 95% CI, 1.6–5.7; P = 0.001). Significantly higher proportions of staff reported use of NRT patches (OR, 2.8; 95% CI, 1.5–5.2; P = 0.003), NRT tablets (OR, 3.3; 95% CI, 1.2–9.7; P = 0.03), varenicline (OR, 6.1; 95% CI, 2.9–12.8; P < 0.001) and bupropion (OR, 6.6; 95% CI, 2.5–17.2; P < 0.001) (Box 2).

Nearly half of the staff smokers who had made a quit attempt (47%, 52/111) had at least one of these attempts actively supported by the health service, most commonly through an information session for staff (n = 20) or access to free or subsidised NRT (n = 19). A higher proportion of staff who had health service support in their quit attempts, compared with those who did not, had ever used NRT or other stop-smoking medications (79% [41/52] v 46% [27/59]; OR, 4.4; 95% CI, 1.9–10.4; P = 0.001). However, staff from health services that reported providing additional cessation support for staff did not have significantly greater odds of making a quit attempt in the past year than those whose service did not (56% [46/82] v 47%, [21/45]; OR, 1.5; 95% CI, 0.65–3.3), although statistical power to detect a significant effect was low.

There were significant differences between staff smokers and community smokers in how much they believed they would benefit if they were to quit smoking in the next 6 months (P = 0.03) (Box 3); staff had non-significantly greater odds of reporting they would benefit very much or extremely (OR, 1.95; 95% CI, 0.92–4.2; P = 0.08). Smokers’ risk-minimising beliefs and beliefs about the dangers of second-hand smoke were similar among staff and other community members (Box 3). Most staff smokers (58%, 85/146) agreed that staff and managers of the health service disapproved of smoking, with only 12% (18/146) disagreeing with this.

For Aboriginal and Torres Strait Islander staff who had direct contact with ACCHS clients, there was a significant association (P < 0.001) between their smoking status and whether they felt confident talking to others about smoking and quitting (Box 4). Ex-smokers were significantly more likely than smokers to report being very much or extremely confident (OR, 4.3; 95% CI, 2.2–8.3; P < 0.001).

Discussion

Our results suggest that Aboriginal and Torres Strait Islander staff of ACCHSs have a lower smoking prevalence than other Aboriginal and Torres Strait Islander people. However, our estimate of staff smoking may be falsely low, as our response rate was not high and smokers may have been less likely to complete our survey.

Our national estimate of staff smoking prevalence was at the lower end of previous smaller local and regional studies, and much lower than the largest previous study (51%, n = 85), which also reported the highest (but still a modest) response rate of 63%.3,12 However, these studies concentrated on AHWs (variously defined) rather than all Aboriginal and Torres Strait Islander staff. In spite of the supportive environment at the ACCHSs, Aboriginal and Torres Strait Islander staff in our survey were still much more likely to smoke than either Australian doctors or other health professionals in similar countries.6,13 As in previous research with AHWs, and with other health professionals in other settings, we found that staff who smoked were less confident in talking about quitting. This remains a concern and a rationale for assisting Aboriginal and Torres Strait Islander smokers to quit, and may support preferential employment of non-smokers.5,14

The lower smoking prevalence among Aboriginal and Torres Strait Islander staff of ACCHSs was similar to the lower smoking prevalence among other employed Aboriginal and Torres Strait Islander people surveyed in the NATSISS, and was mainly due to more staff having never smoked (rather than more being ex-smokers).

Most of the ACCHS staff who still smoked agreed that being a non-smoker sets a good example to patients. Fewer Aboriginal and Torres Strait Islander staff reported smoking with patients than with co-workers at work, and most did not smoke where they could be seen by patients, suggesting they accept this responsibility as a role model. In contrast, research conducted in 2009–2010 found AHWs reported that patients liked them smoking with them, facilitating connection and patients opening up.15 The same study reported that an organisational culture that supported smoking undermined quitting. However, we found that smoking was now usually not perceived as acceptable in ACCHSs.

Stress at work and at home has long been reported as the primary obstacle to successful quitting by AHWs.2,16 Research in other populations has shown that smoking for stress release is associated with relapse.17 However, successful quitting, for those who are able to do it, has been reported as being associated with reduced stress and, among Aboriginal people, with a general sense of pride and empowerment.18–20 Therefore, quitting smoking may reduce the stress these staff feel.

It does not appear, as previously reported, that a lack of quit support is a significant cause of relapse.2,16 Many quit attempts by staff received additional support from the health service, and use of stop-smoking medications was higher among staff than among other Aboriginal and Torres Strait Islander smokers. High smoking prevalence among the Aboriginal and Torres Strait Islander community has previously been suggested as a cause of failed quit attempts. We found high numbers of smokers among the close friends and family of both staff and community smokers, which has also been associated with relapse in other settings.17

Strengths and limitations

This is the largest national survey on smoking among ACCHS staff. However, as with our sample of community members, it is not a random sample, with both using similar non-probabilistic quota sampling designs, so caution in interpreting results is required. The staff and other community members in our sample are from the same geographically representative locations, and comparisons are directly standardised to the distribution of the population of smokers in the NATSISS. We have elsewhere shown that the 1643 smokers in our community sample were similar to smokers in the NATSISS, except for some inconsistent socioeconomic differences.9

We can compare our sample with 224 organisations providing primary health care services for Aboriginal and Torres Strait Islander people in 2011–12.21 These organisations included, but were not restricted to, member ACCHSs of the National Aboriginal Community Controlled Health Organisation, and included more services from remote areas (39%) and fewer from major cities (12%) than in our study.9 Similar proportions of staff were reported to be Aboriginal and Torres Strait Islander (57% of 5543 full-time equivalent staff) and to be doctors (6%) and nurses (14%) as in our sample (58%, 8% and 14%, respectively). Based on these criteria, there was limited response bias in our sample.

Unlike most similar previous research, we have chosen to report on all Aboriginal and Torres Strait Islander ACCHS staff, not just AHWs, as all these staff are health role models in their communities, and the distinction between AHWs and other roles at the ACCHS can vary across the country.

1 Comparison of smoking status of Aboriginal and Torres Strait Islander staff at ACCHSs with adults in the 2008 NATSISS

   

NATSISS participants*

ACCHS staff (n = 366)

Employed (n = 3772)

Total (n = 7163)

Status

Standardised % (frequency)†

% (95% CI)

% (95% CI)

Smoker

38% (146)

44.8% (42.1%–47.6%)

49.8% (47.8%–52.5%)

Ex-smoker

24% (88)

22.3% (20.2%–24.4%)

21.4% (19.8%–22.9%)

Never-smoker

38% (132)

32.9% (30.5%–35.5%)

28.8% (26.9%–30.7%)

ACCHS = Aboriginal community-controlled health service. NATSISS = National Aboriginal and Torres Strait Islander Social Survey. * NATSISS results only include those aged ≥ 18 years. † Staff survey percentages are directly standardised to the age, sex and remoteness distribution of smokers in the NATSISS.

2 Comparison of smoking and cessation practices of smokers among Aboriginal and Torres Strait Islander ACCHS staff and community members*

Practice

ACCHS staff,
% (frequency)

Community members,
% (frequency)

P

Smoking banned inside home

    

0.19

Total ban

64% (87)

56% (908)

  

Partial ban

22% (40)

22% (359)

  

No ban

14% (17)

22% (361)

  

Number of five closest family or friends who smoke

   

0.004

None

7% (14)

7% (120)

  

One

8% (14)

7% (119)

  

Two

10% (21)

15% (243)

  

Three

35% (31)

17% (273)

  

Four

12% (23)

12% (204)

  

Five

28% (43)

41% (649)

  

Noticed anti-smoking advertising in past 6 months

   

< 0.001

Often or very often

70% (116)

45% (730)

  

Sometimes

30% (28)

34% (535)

  

Never or almost never

1% (2)

21% (341)

  

Smokers who have ever made a quit attempt and have used NRT or stop-smoking medications

120

1155

  

Any NRT or medications

69% (71)

43% (505)

0.001

NRT patch

54% (48)

30% (362)

0.003

NRT gum

14% (21)

13% (152)

0.77

NRT lozenges

5% (6)

4% (42)

0.67

NRT tablets

5% (7)

2% (18)

0.03

Varenicline

49% (38)

13% (167)

< 0.001

Bupropion

9% (12)

1% (17)

< 0.001

ACCHS = Aboriginal community-controlled health service. NRT = nicotine replacement therapy. * Results for the baseline sample of Aboriginal and Torres Strait Islander ACCHS staff smokers (n = 146) and community smokers (n = 1643) in the Talking About The Smokes project, April 2012 – October 2013. Percentages and frequencies exclude those who did not answer or answered “don’t know”. Percentages are directly standardised to the age, sex and remoteness distribution of smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

3 Comparison of smoking and cessation attitudes of smokers among Aboriginal and Torres Strait Islander ACCHS staff and community members*

Attitude

ACCHS staff,
% (frequency)

Community members, % (frequency)

P

How much do you think you would benefit from better health and other things if you were to quit smoking permanently in the next 6 months?

    

0.03

Very much or extremely

75% (113)

61% (988)

  

Moderately

20% (20)

21% (323)

  

Slightly or not at all

5% (6)

18% (293)

  

Smoking is not very risky when you think about all the other things that people do

    

0.19

Agree

30% (36)

46% (731)

  

Neither or don’t know

24% (32)

17% (282)

  

Disagree

46% (78)

37% (621)

  

Being a non-smoker sets a good example to children

   

0.52

Agree

87% (135)

91% (1482)

  

Neither or don’t know

4% (8)

4% (75)

  

Disagree

9% (3)

5% (77)

  

Cigarette smoke is dangerous to non-smokers

    

0.86

Agree

93% (131)

91% (1489)

  

Neither or don’t know

5% (13)

6% (99)

  

Disagree

2% (2)

3% (46)

  

ACCHS = Aboriginal community-controlled health service. * Results for the baseline sample of Aboriginal and Torres Strait Islander ACCHS staff smokers (n = 146) and community smokers (n = 1643) in the Talking About The Smokes project, April 2012 – October 2013. Percentages and frequencies exclude those who did not answer (all questions) or answered “don’t know” (first question). Percentages are directly standardised to the age, sex and remoteness distribution of smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

4 Confidence in talking with others about smoking and quitting among Aboriginal and Torres Strait Islander staff with client contact, by smoking status*

Confident in talking about smoking and quitting

Smokers
(n = 103)

Ex-smokers
(n = 65)

Never-smokers
(n = 97)

Total
(n = 265)

Very much or extremely

27% (28)

62% (40)

37% (36)

39% (104)

Moderately

25% (26)

26% (17)

30% (29)

27% (72)

Slightly or not at all

38% (39)

6% (4)

27% (26)

26% (69)

Don’t know

10% (10)

6% (4)

6% (6)

8% (20)

* Data are % (frequency) and exclude those not answering. χ2 test of association, P < 0.001.

General practitioner management of notifiable diseases is central to communicable disease control

To the Editor: Public health units routinely carry out investigations into cases of notifiable diseases, specified by state and territory Public Health Acts, because of the potential impact on the health of the public. Investigations involve contacting individuals and their contacts, and providing advice for follow up and treatment. This may include seeing a general practitioner for further testing, treatment, or prophylaxis of contacts.1 To assess the extent of input from GPs in managing notifiable diseases we documented GP encounters related to public health unit communicable disease control activity in inner-western and south-western Sydney.

Data on routine communicable disease activity in Sydney and Sydney South West Local Health Districts were collected over 2 months from 1 June to 31 July 2014. For all investigations into suspected and confirmed cases of notifiable disease, data were collected on the type of condition, visits to GPs and tests specifically requested as part of routine public health follow-up. The study was approved by Sydney Local Health District Ethics Review Committee. There were 220 investigations associated with suspected or confirmed cases of 34 notifiable conditions during the study period, requiring 212 GP visits and 286 tests. The Box lists conditions according to their required level of GP input (those involving GP encounters more than 50% of the time were considered to require high-level GP input). Influenza and gastroenteritis outbreaks, typhoid, rubella, hepatitis E and measles were the conditions requiring the highest level of GP input per investigation. Measles, arbovirus, pertussis and gastroenteritis outbreaks were conditions with the highest frequency of suspected or confirmed cases that also required high-level GP input. Based on population size, we estimated that, if extrapolated to state level, communicable disease control activities would have resulted in about 1047 GP visits across New South Wales in the same time period.

Our findings indicate that GP encounters are central to communicable disease control and shed light on which conditions require the most input from GPs. Influenza outbreaks, measles and gastroenteritis outbreaks are of particular concern. Influenza outbreaks require particularly high-intensity input from GPs, while measles and gastroenteritis outbreaks are frequently investigated conditions that require high-level GP input. Influenza and measles are serious conditions, often involving vulnerable populations (nursing home residents and children).2,3 Our results indicate that primary care plays an important role in protecting the public from conditions with potentially serious consequences. This finding should be considered in policy discussions about access to primary care.

Visits to general practitioners and tests associated with communicable disease investigations

Condition or infection investigated
(suspected and confirmed cases)

No. of investigations

Average no.
of visits per investigation

Average no.
of tests per investigation

High-level GP input

      

Influenza outbreak*

5

14.8

20.2

Typhoid

1

9.0

17.0

Gastroenteritis outbreak†

17

2.1

3.7

Rubella

2

1.5

1.0

Hepatitis E

8

1.4

1.4

Measles

24

1.0

1.6

Varicella

1

1.0

1.0

Arbovirus

19

0.9

0.8

Pertussis

18

0.9

0.7

Legionella

9

0.8

0.9

Intermittent GP input

      

Hepatitis A

4

0.5

0.5

Q fever

2

0.5

1.0

MERS Co-V

2

0.5

1.0

Hepatitis B

7

0.4

0.4

Malaria

3

0.3

0.3

Shigella

11

0.2

0.3

< 16 Chlamydia‡

6

0.2

0.0

Salmonella

9

0.1

0.1

Cryptosporidiosis

11

0.1

0.0

No GP input

      

Rotavirus

5

0.0

0.0

Mumps

5

0.0

0.2

Meningococcal

7

0.0

0.0

Lymphogranuloma venereum

1

0.0

0.0

Invasive pneumoccocal disease

22

0.0

0.0

Hepatitis D

3

0.0

0.0

Hepatitis C

2

0.0

0.0

Haemophilis influenzae B

1

0.0

0.0

Diphtheria

4

0.0

0.5

Creutzfeldt–Jacob disease

1

0.0

0.0

Brucellosis

2

0.0

0.0

< 16 Gonorrhoea‡

1

0.0

0.0

MERS Co V =  Middle East Respiratory syndrome (MERS) coronavirus.
* Three or more epidemiologically linked cases of Influenza-like Illness in residents or staff of child care or aged care facilities within 72 hours PLUS at least one case with a positive laboratory test result OR at least two cases with a positive point-of-care test. † Two or more cases of vomiting or diarrhoea in an institution are followed up as a possible outbreak. ‡ Conditions followed up in children aged under 16 years only to ensure they are not at risk.

[Correspondence] Frailty in sub-Saharan Africa

Most high-income countries are called to urgently adapt their health-care systems to meet the new challenges arising from their ageing populations. Models of health-care services aimed at preventing age-related disabling disorders (including the design of screening and assessment instruments) are largely from high-income countries. Little consideration has been given to ageing and its resulting effects in low-income and middle-income regions. This absence of interest for the effects of ageing in low-income regions is worrying because these areas are not only highly populated (especially in absolute numbers), but also have the same demographic trends that characterise high-income countries.

Doctors get their own dedicated national health service

All doctors and medical students will have access to a health service dedicated to meeting their needs no matter where they live and work following a landmark agreement between the AMA and the Medical Board of Australia.

The Medical Board has contracted the AMA, through its wholly-owned subsidiary Doctors Health Services Pty Ltd (DHS), to ensure specific health services for medical practitioners and students are accessible nationwide.

The deal is the culmination of years of work to provide doctors with nationally consistent health services that cater specifically for their needs amid concerns that often practitioners have gone untreated for significant health problems that not only harm them but may place their patients at risk.

The Medical Board announced last year that it would fully fund a national health program for doctors and medical students, and Chair Dr Joanna Flynn said the contract with the AMA was an important milestone in achieving that goal.

“The Board is committed to supporting the wellbeing of all doctors and medical students in Australia,” Dr Flynn said. “Creating health services that are accessible and fair to everyone – and are targeted to meet doctors’ needs – is a really important contribution we are proud to make.”

The announcement of a dedicated national health program for medical practitioners has come just weeks after the medical community was rocked by the sudden death of four young doctors in Victoria. And a 2013 beyondblue report showed that psychological distress, burnout and suicide were disturbingly common among doctors and medical students.

There are long-standing concerns that many doctors with mental health problems, issues of substance abuse and physical ailments have been reluctant to seek help for fear it will harm their career.

There has been a call to rigorously address the reasons some doctors find it hard to seek and obtain help, including the culture of the profession, the work environment, the training culture, and mandatory reporting.

While there has been a gradual increase in the number of health services specifically for doctors, AMA Vice President Dr Stephen Parnis recently said current arrangements were inadequate, and the AMA had for a long time strongly advocated for a national model to support the work of the services that make up the Australasian Doctors’ Health Network.

AMA President Associate Professor Brian Owler said the establishment of Doctors Health Services would deliver on that goal.

While the Medical Board will fund the program, A/Professor Owler emphasised that it would play no role in its operation or the delivery of services.

“Critically, the services will remain at arm’s length from the Medical Board to ensure that doctors and medical students trust these services and use them at an early stage in their illness,” he said.

Existing doctor health services will be invited to express interest in continuing as a provider. Under the new contract arrangements, they will be required to provide confidential triage and referral services, health advice and education, training for practitioners to treat other doctors and facilitation of support groups.

DHS will have a five-member Board including an AMA representative, a doctor in training representative and a medical practitioners with experience in providing doctor health services. The Board will be supported by an expert advisory committee made up of service providers, medical students, doctors in training and AMA representatives.

Adrian Rollins

Managing the AMA List

The AMA List of Medical Services and Fees (the List) plays a significant role in lobbying Government on what it costs to provide medical care. It also provides an important and valuable tool for doctors to assist us with our fee setting and indexation.

Historically, items in the List have broadly aligned with items on the Medicare Benefits Schedule (MBS) by applying Government decisions for funding of medical services as amendments and additions to the List.

But the Government’s increasing tendency in recent years to look for ways to curb spending on health has changed the nature of its funding decisions. Typically, Government changes are no longer by way of simple amendments and additions, but now involve further restrictions and limits on how items may be used.

Consequently, there has been a need to develop a new approach to managing the AMA List and how it should align with the MBS in the future.

The first significant deviation from the Government’s traditional MBS approach was in 2007 when it introduced a specific age-limited item for the Healthy Kids check on the Medicare schedule.

Since that point, governments of both persuasions have pursued budget and health reform agendas that have severely limited the MBS by not allowing or significantly delaying many clinically appropriate procedures from being included on the Schedule.

A clear example was sacral nerve stimulation for urinary incontinence, which was recommended for MBS funding in 2008 but was not introduced on the Schedule until almost 18 months later.

Governments have also withdrawn MBS funding for clinically relevant services by justifying the measure as a minor procedure that should form part of a standard consultation. We saw this with the removal of joint injections.

In the years since, we have also seen governments include brakes on health spending by imposing further restrictions to item descriptors and placing additional caveats on how services can be delivered. Typically, such restrictions have not been specific recommendations of the Medical Services Advisory Committee, but have been introduced by the Department of Health to limit health expenditure.

As time has passed, it has become more difficult to maintain alignment of the AMA List with the MBS.

To maintain the List as a tool to demonstrate the costs of medical care, and to assist us in our fee setting, there is a need to set key principles for managing the List, rather than just automatically accepting Government policies.

This has included identifying circumstances where the List should no longer automatically align with the MBS because:

  • the Government either delays or withdraws Medicare funding for clinically relevant medical services on the MBS;
  • the medical specialty groups propose changes to MBS items to reflect current clinical practice, and the Government defers implementation of the changes;
  • the service does not reflect appropriate clinical practice or is not listed on the MBS but is considered by the AMA as being a clinically relevant service; or
  • the MBS service:
    • is required to be performed according to specified clinical guidelines;
    • precludes the billing of a consultation on the same day;
    • specifies the training, qualifications and/or competencies of the treating medical practitioner; or
    • is restricted to particular requirements of other Government programs, such as the Pharmaceutical Benefits Schedule.

 

In this regard, the AMA welcomes the Government’s recent announcement of the MBS Review Taskforce and Primary Health Care Advisory Group to consider how services can be aligned with contemporary clinical evidence and improve health outcomes for patients.

We are also pleased that both groups will be led by eminent and highly-regarded clinicians, and will be based on frontline medical evidence and experience. We hope that a positive outcome of these reviews will enable better alignment of the MBS and the AMA List.