Tobacco-free generation legislation

The Tasmanian Public Health Amendment (Tobacco-free Generation) Bill 2014 is vital to improve health in Tasmania

Australia has led many initiatives against tobacco smoking, most recently cigarette plain packaging. Smoking costs this country some 20 000 lives annually, far more than alcohol, illicit drugs and road accidents combined, and indeed almost twice the deaths globally from natural disasters. The need for novel preventive supply-side tobacco legislation is paramount, and such a breakthrough now beckons.

In Golden holocaust, Robert Proctor highlights the insidious psychology used by the tobacco industry of telling adolescents that “kids don’t smoke”, so that they will do exactly that, just to appear adult.1 The tobacco-free generation (TFG) initiative seeks to undermine the rite-of-passage effect by progressively raising the minimum age at which retailers can legally sell people cigarettes.2 Tasmania is the first jurisdiction in the world to craft such mould-breaking legislation, although recent more limited moves in the United States raising the legal age to 21 years have proved highly successful.3

Tasmania’s smoking rates are considerably higher than the national figures, reflecting the state’s low socioeconomic status and historic lack of investment in evidence-based tobacco control strategies.4,5 Tasmania has experienced both the best and the worst of responses to the tobacco epidemic, the latter evident in an industry-orchestrated political corruption scandal in the 1970s, which brought down a government.6 However, more recently, the state has led some notable successes.7

Currently in Tasmania around 40% of younger men smoke, a proportion that has not fallen significantly for 10 years.8 Their outcomes in terms of mental illness, chronic disease and early death are dire, indeed worse than previously thought.9 The smoking burden to health services in economically challenged Tasmania is huge. In 2014, a novel Tasmanian initiative for adults banned tobacco in state prisons, and was introduced almost without incident. Thus, sensible and practical actions are feasible. The Tasmanian Legislative Council (upper house) has been a prime mover toward a smoking end game. Now, independent member of the Legislative Council Ivan Dean has introduced the Public Health Amendment (Tobacco-free Generation) Bill 2014, with strong public support and backing from a wide spectrum of health and professional organisations.

The TFG concept is straightforward. An under-18 law is presently in force; thus, already it is not permitted to sell tobacco to people born this century. That restriction will currently expire on 1 January 2018. However, with TFG legislation, the restriction will simply continue. Thus, retailers will never be allowed to sell cigarettes to anyone born this century, although the law will be reviewed after 3 and 5 years. Cigarettes will become a “so last century” phenomenon. With each passing year, there will be fewer slightly older smokers as role models and providers, and the “badge of coming of age” incentive (in Imperial Tobacco’s revealing phrase) diminishes in potency. Moreover, TFG legislation sends the important message that tobacco is too dangerous at any age; it could never now gain regulatory approval. Yet, because it is so addictive to young people it is not possible to remove tobacco from the market overnight without denying existing smokers. TFG legislation is the sensible and practical solution to this dilemma. Moreover, its thrust is on commercial agents who purvey tobacco, rather than on punishing their victims.

The TFG initiative has drawn intensive political lobbying by Imperial Tobacco, including closed meetings and meals with decisionmakers, in breach of article 5.3 of the World Health Organization Framework Convention on Tobacco Control (FCTC). The FCTC recognises the tobacco industry and its front organisations as “rogue” entities. So the legislation passes the “scream test”; the tobacco industry is really worried about this precedent. Some state politician objectors buy into Big Tobacco’s “nanny state” cliches, while others focus on allowing the disadvantaged to make their “own choices”. Such political correctness ignores the vulnerable young targets of industry marketing of its highly addictive product.

On 24 March 2015, the new legislation was debated in the Tasmanian Parliament. There was strong support, including from Attorney-General Vanessa Goodwin, for its aspiration, with a committee established to address workability. In fact, the proposal ticks all the political boxes: it is finance free; the machinery needed is in place and working well (98% of licensed tobacco retailers obey the law); 69% of the community and 88% of 18–29-year-olds support the TFG initiative;10 it fits Tasmania’s “clean and green” image; it will have some quick wins, especially among young pregnant women and their babies; and the longer-term gains for community health and government finances will be enormous.

The current Tasmanian Government has declared that it wants the state to be the healthiest in Australia in 10 years — to achieve that it needs the TFG legislation enacted. The rest of world will soon follow another bold Australian initiative against the global tobacco nightmare.11

Enabling the success of academic health science centres in Australia: where is the leadership?

To the Editor: In a recent perspective in the Journal, Theile and colleagues called for national leadership in the creation of academic health science centres (AHSCs) through partnerships and collaborations that better link Australian universities, research institutes and health services.1 The mission of one of the most influential AHSCs in the world, the Mayo Clinic, is to “provide the best care to every patient every day through integrated clinical practice, education and research”.2

In Australia, it may be increasingly difficult for AHSCs to reach this ultimate goal as we are losing the clinical academics who integrate the tripartite mission of research, teaching and improving patient care within the public health system. In the United States, clinical academics still lead the best performing AHSCs as chief executives and department heads.3 Here, recruitment in academic medicine is declining,4 the clinical research workforce is ageing,5 and senior academics and mentors are retiring. This loss of clinical academic leadership will be to the detriment of patient care in Australia’s health system.

At times of budgetary restraint, clinical research can be viewed as a non-essential expense by the health system. During periods of financial restraint, hospitals do not have the funds to support the cost of infrastructure and protected time for clinical researchers.5 In reality, funding young clinical researchers is an important contribution to the ongoing improvement of patient care. We hope that the emergence of the AHSCs will provide new impetus to better fund applied clinical research and translational science throughout Australia’s public health system.

Can Australia’s clinical practice guidelines be trusted?

To the Editor: In response to the news article from the National Health and Medical Research Council (NHMRC) published recently in the Journal,1 we would like to highlight a generally neglected facet of the clinical guidelines discussion: acceptability. While it is clearly critical for clinical guidelines development to adopt a thorough and transparent process, it is equally important to focus on the end user.2 Many good quality clinical guidelines lay unused because they ignore practitioner requirements, including practical, design and context-specific needs.3

Remote Primary Health Care Manuals (RPHCM) are clinical guidelines that have been published in Central Australia since 1993. They were originally developed to enable standardised and evidence-based practice in the context of remote Aboriginal health care. Repeat evaluations have confirmed the high acceptability of and compliance with the guidelines.4 The “by the users, for the users” approach to their development contributes significantly to their high acceptability and uptake.

We monitor NHMRC recommendations closely to direct and improve our guideline development, and adopt a vigorous and continuous quality improvement process, including recording details and conflicts of interests of contributors, and publishing the evidence review underlying our protocols.5 However, what distinguishes our clinical guidelines from many others is the degree of involvement of end users, largely remote health care practitioners working in stressful, isolated and resource-poor environments.

The content, layout, format, and illustrations of the RPHCM guidelines are tailored to their users and their context. In combination with a strong evidence base and transparency of process, this focus ensures the development of quality guidelines that are highly useable and acceptable.

Closing the dental divide

To the Editor: Russell noted the importance of oral health to general health and quality of life, and the substantial costs of dental treatment.1 In 2012–13, $8.3 billion was spent on dental treatment in Australia.2

A recently released Health Workforce Australia report3 indicated that Australia has a more than sufficient dental workforce. The dental workforce distribution between remote and metropolitan areas is altering as graduate dentists move to outer regional and remote areas,4 although there are many regional and remote areas that will never be able to support full-time dental services due to low population numbers.4

Unlike medical care, dental care is overwhelmingly supplied in the private sector.5 Russell’s solution is to transfer the costs of dental care from the patient to the government.

The National Oral Health Plan 2004–2013 identified six populations for specific action to improve oral health outcomes: children and adolescents, older people, people with low incomes and with social disadvantage, people with special needs, Aboriginal and Torres Strait Islander peoples, and those living in rural and remote areas.

It would be more practical than integrating dental care into Medicare to incrementally increase the availability of the government’s limited resources to populations who have difficulty accessing dental care. The Australian Dental Association has supported the Child Dental Benefit Schedule and suggested that the next group in the staged implementation of government-assisted dental care should be people aged 65 years and over.6 It makes sense from both a health and an economic perspective for government to prioritise the oral health of older people within a policy of staged improvement in dental care access.

[Perspectives] Fergus Cameron: getting the big picture in childhood diabetes

Fergus Cameron’s father encouraged him to study medicine because he thought “I’d do better in medicine rather than in business”, recalls Cameron. It turned out to be a good call. After decades as a clinician researcher, Cameron finds himself as Head of the Diabetes Services and Deputy Director of the Department of Endocrinology Unit at the Royal Children’s Hospital Melbourne (RCH), as well as a diabetes research group leader at the Murdoch Children’s Research Institute.

Closing the dental divide

In reply: Crocombe rightly points to the findings of the recent Health Workforce Australia report1 that Australia has a “more than sufficient dental workforce” but fails to note that the report states that this does not take account of the considerable unmet demand that exists, particularly in rural and lower socioeconomic areas. The problem of maldistribution remains.2

A careful reading of my article would show that my solution to poor dental health in Australia is not to integrate dental care into Medicare — although I do contend that the separation of oral health from that of the rest of the body is hard to rationalise. But the very pragmatic solutions offered, from fluoridation to investment in a “Dental Health Service Corps”, specifically exclude this possibility, and don’t even entail a significant transfer of costs from patients to the public purse.

Strengthening primary health care: achieving health gains in a remote region of Australia

The health status of rural and remote Australian communities is poorer than that of urban communities. Comprehensive primary health care (PHC) services can reduce these health inequities, which by definition are unfair and remediable,1 through the provision of competent clinical care, population health programs, good access to secondary and tertiary care, and client and community advocacy to address health risk factors and social determinants.2

In rural and especially remote areas, there is strong evidence that poor access to PHC remains a critical barrier, particularly for Aboriginal and Torres Strait Islander people, and this is reflected in the high rate of avoidable hospitalisations.3 However, there is a paucity of rigorous studies showing the nature of the relationship between models of health care in remote areas and health outcomes.4 Given increasingly scarce resources, high costs and workforce shortages in remote areas, understanding how well services are meeting community needs and improving health outcomes is essential.

This study addresses this gap in knowledge by evaluating a health service partnership in the Fitzroy Valley in the remote Kimberley region of north-west Western Australia.5 The Fitzroy Valley covers an area of 30 000 km2, and the population of about 3500 people is dispersed across 44 communities with a stable core population. Services are provided to both Aboriginal (80%) and non-Aboriginal residents. The hospital, main community clinic and Aboriginal community controlled health services are co-located in the town of Fitzroy Crossing. Daily primary care services and occasional specialist services are provided through community health clinics in larger outlying communities and less frequent services to smaller satellite communities.

The aim of the partnership was to reorientate the existing health services from an acute reactive approach to a more comprehensive PHC approach, as recommended in the National Strategies for Improving Indigenous Health and Health Care.6 Before the partnership, care was largely episodic and reactive to patient-initiated presentations. The objective of this article is to examine how changes in the model of service delivery were associated with increased use of primary care and resultant health outcomes for the population.

Methods

In 2011, after the health service reorientation, a WA State Health Research Advisory Council Research Translation Project grant was awarded to the research team to implement a retrospective evaluation to identify the key events leading to change and their impact.

Evaluation framework

A framework for monitoring the impact of changes to PHC services on population outcomes was developed for the Fitzroy Valley to take into account its specific demography and characteristics. Building on a similar framework used for a small rural community in Victoria,7 this framework incorporates the key requirements for high-quality health service performance8 and draws on the links between structure, process and outcomes described by Donabedian.9 The development of this evaluation framework required a targeted literature review and validation workshops with stakeholders and national experts in rural and remote PHC evaluation.

In order to maximise its transferability to other health services, the framework indicators are consistent with the National Health Performance Authority Performance and Accountability Framework10 and the Aboriginal and Torres Strait Islander Health Performance Framework.11 The program logic approach underpinning our framework is recommended by the National Strategies for Improving Indigenous Health and Health Care.6 A program logic model uses change theory to describe and identify relationships, and enables the impact of service inputs to be associated with predetermined output indicators, providing an indication of progress towards long-term health improvements. Key inputs were identified and primary health care activity and usage measures were monitored to assess the impact of changes on quality-of-care indicators, mortality, morbidity and health behaviours.12 Indicators and their relationship to policy and the logic model are shown in the Appendix.

Data collection and analysis

Health service data for all residents in the Fitzroy Valley (defined by postcode) from 1 July 2006 to 30 June 2012 were collected and analysed from the commencement of the formal partnership and reorientation of the service. Input data were collected from annual reports, financial reports, workforce data, formal agreement documents and meeting minutes of the three partner health service organisations responsible for delivering care into the Fitzroy Valley: the Kimberley Population Health Unit (KPHU), Fitzroy Crossing Hospital (FCH) and Nindilingarri Cultural Health Services (NCHS).

Output data relating to PHC activity and service use were accessed directly from health department databases and PHC program implementation from annual reports. Outcome quality-of-care indicators (such as glycated haemoglobin level, blood pressure and receiving antihypertensives) were generated from the electronic patient medical records. The proportion of those eligible who received the service was calculated against individuals enrolled in the health service.

Data were collected by an externally funded research officer. Indicators were extracted electronically from the health department databases and the electronic medical record used by Fitzroy Valley Health Services (Communicare [Communicare Systems]). Quality-of-care indicators were assessed against the National Key Performance Indicators for Aboriginal and Torres Strait Islander for primary health care.13

Data were compared over time to monitor trends in health service usage, activity, quality of care and population health outcomes. Data were analysed using the non-parametric trend command in Stata version 10 (StataCorp), which performs the non-parametric Mann–Kendall test for trend across ordered groups.14 All trend lines with P < 0.05 showed a significant change in values over 2006–2011.

Ethics approval

Ethics approval for this study was provided by the Western Australian Aboriginal Health Ethics Committee and the Western Australian Country Health Service Research Ethics Committee, and was supported by the Kimberley Aboriginal Health Planning Forum Research Subcommittee.

Inputs and intervention

Several key policy events were identified, which together formed the intervention during this natural experiment. Supportive state and Commonwealth primary health care policy was a key fundamental enabler that provided the funding to strengthen primary health care services.

The formal Fitzroy Valley Health Partnership Agreement memorandum of understanding in 2006 between the government health services (comprising a 12-bed hospital [FCH] and community health services [the KPHU and NCHS]) and the community controlled health service facilitated the integration of primary health care services. The formal partnership agreement negotiated over a 1-year period enabled the three organisations to have a single governance structure for allocating funding, sharing a single electronic medical record and delineating areas of responsibility. Responsibility for health promotion, environmental health and cultural safety belonged to the community controlled NCHS; acute inpatient care, primary care clinic and specialist care to the state district hospital (the FCH); and public health, screening and primary care community clinics and programs to the state-operated KPHU.

The partnership accessed Commonwealth funding for PHC programs through Healthy for Life (an Australian Government program to improve chronic disease, men’s health, and maternal and child health primary care services for Aboriginal and Torres Strait Islander peoples), enabling the implementation of a shared electronic medical record with the capacity to collect evaluation data.

Western Australian state health funding (through the Council of Australian Governments Closing the Gap initiative) for chronic disease in 2010 provided funding for additional primary health care positions which were able to be consolidated through the partnership and provided chronic disease management and care planning.

In 2009, an application for a section 19(2) exemption (Health Insurance Act 1973 [Cwlth]) to allow Medicare billing for primary care patient visits was successful.15 This was a significant driver of increased PHC activity by providing additional resources and incentives to commence adult Indigenous health checks and care plans leading to their integration into primary care clinics. Medicare billings by all providers were reinvested in primary health care under the governance of the partnership.

Another key event was the implementation of alcohol restrictions in the Fitzroy Valley in 2008 driven by local community leadership.16 This decreased the acute care workload on health care staff and appeared to increase patient presentation for non-acute care.17

Results

Key policy and structural inputs resulted in an increase in primary care activity (Box 1). There was an overall increase in service activity over the 6-year period, with a relatively constant number of hospitalisations. The increasing trend of emergency department presentations (mostly non-urgent triage category 4 and 5) was reversed, as an increasing number of patients were seen in the PHC clinic (Box 2).

Short-term impact: preventive activity and more equitable access to primary care

Changes in key indicators leading to improved health service performance are summarised in Box 3. There was a significant overall increase in access to PHC services particularly for outlying communities in the Fitzroy Valley. More appropriate service provision led to a large increase in health checks in accordance with national guidelines18 (particularly for males after the commencement of the men’s health program in 2008), and a subsequent increase in the proportion of patients identified with chronic disease or risk factors. Increasing proportional investment in primary health care enabled increased access and appropriateness of services provided.

The NCHS provided regular feedback from the Aboriginal community enabling the health services to provide more culturally appropriate and respectful services. Some of these changes included increased employment of Aboriginal staff and cultural training for all staff, thereby leading to a better understanding of the importance of families and their guardianship roles. In addition, more patient-support people were admitted as boarders, there was increased provision of transport to assist patients to attend appointments and a less structured approach to appointments which enabled patients to attend when it was more convenient. Traditional healers became available on request and smoking of rooms after a death was introduced. These responses to community feedback resulting in more patient centred care were reflected in an increased attendance at follow-up appointments.

Medium-term impact: quality of care

Identifying patients with chronic disease or its risk factors and placing them on care plans with regular interdisciplinary follow-up was prioritised, and resulted in 73% of patients with diabetes having care plans. This systematic approach targeting patients with chronic disease led to an increase in primary health episodes from two to 10 per person per year and a higher proportion of the community attending health services regularly for follow-up and in response to recalls. Despite increasing numbers of patients receiving regular care and completing annual cycles of care for diabetes, there was no statistically significant improvement in glycated haemoglobin levels (< 7%) or in blood pressure levels reaching target values (≤ 130/80 mmHg). (A more detailed study of diabetes management showed improvements in cholesterol levels.)19

Long-term outcomes

There was a decrease in numbers of deaths over the study period, and a decreasing trend in the proportion of hospital admissions requiring emergency evacuation.

There was an increase in screening for alcohol and tobacco use over the 6 years, and a significant increase in the numbers of patients who were ex-smokers, intending to quit and drinking within safe limits (Box 4).

Discussion

Positive changes in health service usage and clinical outcomes were demonstrable despite a number of limitations. Using routine health service data retrospectively reflects the accuracy of individual input and limits data collection to indicators routinely available. The transition from paper-based data recording to dual recording using the electronic patient record between 2006 and 2009 may have contributed to some of the variation in trends before 2009, when the electronic records became largely complete. This may account for small changes in trend in some indicators but not the large increases in key indicators such as increased primary care occasions of service, health assessments and care planning.

These limitations notwithstanding, the partnership between community controlled and government organisations drove a change in philosophy from a reactive acute care system to a more proactive, comprehensive PHC approach. This provided two key elements: population health programs targeting prevention and early intervention for high-risk groups and community advocacy around health risk factors at a population level.

Structural changes led to improvements in performance when compared with mean national key performance indicator data for Aboriginal and Torres Strait Islander people.13 These intermediate outcomes are expected to result in further improvements in health outcomes over time.2 This is important given that two-thirds of the gap in health outcomes is estimated to be due to chronic disease.11 Extant literature shows that, after accounting for burden of illness, remoteness and the increased costs of infrastructure, two to seven times the average per capita funding is required by remote Indigenous populations to maximise effectiveness and equity.20 Our study demonstrates that increased primary care investment where capacity to benefit is high can result in measurable positive outcomes in a relatively short period of time.

While improvements in health outcomes are the ultimate goal, intermediate outcome indicators are the most useful for assessing the contributions of PHC because they are sensitive to PHC interventions, and the long lead time from implementation may preclude direct improvements to health outcomes in the short term.2 However, there was an improvement in mortality in the region. Mortality figures for the Derby–Fitzroy Valley statistical local area are decreasing in contrast to other similar regions.21 While we need to be cautious in interpretation because of the small numbers involved, there was a significant drop in the mortality rate over this period. This decrease may have been due to the effects of the alcohol restrictions and was supported by anecdotal evidence from community leaders: “We don’t go to funerals every month like we used to”.

Despite the poor socioeconomic circumstances of the population, improvements in health behaviours can be credited to the health promotion activities of the NCHS, which implemented a comprehensive health promotion program across the Fitzroy Valley, including a quit smoking program. Not only has health education at the individual and community level been a feature of the service, but the alcohol restrictions brought about by strong community action addressing upstream determinants of health were also significant.16,22

The Aboriginal and Torres Strait Islander PHC sector is leading the way with innovative, integrated PHC delivery models under community governance and research linking health service delivery to intermediate health outcomes.23 Our case study builds on the legacy of outstanding leadership and culture of quality improvement across the Kimberley region.24

This study demonstrates changes that are possible with a comprehensive PHC model focusing on the upstream determinants of health, prevention and improved clinical care to meet community needs, even in a challenging remote context. Strong community leadership can maximise the opportunities provided by policy changes and increases in funding, translating them into improvements in practice and health service delivery. These factors are essential enablers and need to be dealt with concurrently for service sustainability requirements to be met.25 Attending to only one or two of these factors is likely to be ineffective, and it was the systematic approach to all of them simultaneously and comprehensively that enabled sustainable change to occur.

Our study is an example of the potency of research embedded in service delivery26 and demonstrates the importance of monitoring the impact of service delivery on the health outcomes of the population. Linking structure to process and outcomes through key indicators can be used as a planning, monitoring and evaluation tool to measure the impact of national and local policies. Resultant evidence can be used to inform policy direction and translate into service delivery changes consistent with the goals underpinning current national health care reform and Closing the Gap policies.

1 Key inputs strengthening primary health care, and their impact on service outputs, Fitzroy Valley, 2006–07 to 2011–12

Partnership = Fitzroy Valley Health Partnership Agreement. 19.2 = section 19(2) exemption (Health Insurance Act 1973 [Cwlth]). COAG = Council of Australian Governments Closing the Gap initiative.

2 Trends in health service use, Fitzroy Valley, 2006–07 to 2011–12

3 Fitzroy Valley Health Service performance indicators, 2006–07 to 2011–12: trends in primary health care activity

Sentinel indicator	2006–07	2007–08	2008–09	2009–10	2010–11	2011–12	P	Mann–Kendall

Individuals on electronic health record	2160	3147	3573	4176	5626	5410
Occasions of service*
Town	4150	8666	13 433	19 628	27 087	35 940	0.03	< 0.01
Hubs	499	1925	5665	8788	10257	10 147	0.04	0.02
Satellites	364	182	476	693	1205	1191	0.05	0.06
Total	5013	10 773	19 574	29 109	38 549	47 278
No. of health assessments	340	475	525	1080	1617	1789	0.03	< 0.01
No. of male health checks performed	0	0	2	159	268	322	0.03	< 0.01
Immunisation
Children aged 24–36 months, coverage	92%	94%	95%	95%	96%	96%	0.04	0.02
No. of adults immunised against influenza	107	908	1397	996	1310	1405	0.07	0.06
No. of Aboriginal patients aged > 15 years screened for biomedical risk factors
Body mass index	143	199	277	519	760	881	0.03	< 0.01
Alcohol consumption	139	142	49	352	262	489	0.09	0.14
Smoking	184	151	82	468	727	845	0.09	0.14
Mean primary care episodes per individual per year	2	4	5	6	8	10	0.03	<0.01
Primary care investment: proportion of total funding	23%	20%	25%	25%	39%	34%	0.06	0.09
Resident population estimate	2664	2718	2773	2828	2885	2942

* Primary health care occasions of service: Fitzroy Crossing town, daily; hubs (Noonkanbah, Bayulu, Wangkatjungka) — community health clinics, Mon–Thu; satellites — community health clinics, 2–4 weekly.

4 Trends in service quality-of-care outcomes, 2006–07 to 2011–12*

Sentinel indicator	2006–07	2007–08	2008–09	2009–10	2010–11	2011–12	P	Mann–Kendall

All-cause mortality, crude death rates per 1000 population (95% CI)	9.38 (5.71 –13.06)	4.78 (2.18–7.38)	9.01 (5.48–12.80)	3.89 (1.59–6.19)	3.12 (1.08–5.16)	2.72 (0.83–4.60)	0.04	0.02
Diabetes
No. of patients	310	337	347	347	380	419	0.06	0.07
Care plans	0	0	0	18%	7%	78%	0.04	0.03
Team care arrangements	0	0	0	5%	13%	73%	0.04	0.03
No. of annual cycles of care completed	2	1	0	9	27	34	0.09	0.14
ACE inhibitor or ABR	43%	56%	57%	79%	82%	87%	0.03	< 0.01
HbA1c level measured in previous 6 months	51%	53%	45%	69%	72%	71%	0.09	0.14
HbA1c level ≤ 7%†	25%	27%	20%	25%	20%	26%	0.8	1.00
HbA1c level < 8%	39%	19%	39%	48%	41%	43%
HbA1c level > 10%	31%	35%	34%	31%	37%	34%
BP ≤ 130/80 mmHg†	44%	34%	34%	42%	42%	39%	0.9	1.00
Health behaviour
No. of attendees	1290	1568	2015	2164	2327	2504
Regular attendees, > 3 visits over 2 years	49%	68%	77%	78%	82%	79%	0.04	0.02
Smoking
No. of patients screened‡	184	151	82	468	727	845
Ex-smoker	2%	5%	10%	11%	12%	13%	0.03	< 0.01
Intention to quit	10%	24%	24%	26%	32%	34%	0.03	0.01
Alcohol consumption
No. of patients screened‡	139	142	49	352	262	489
Within safe limit	11%	9%	29%	21%	26%	28%	0.2	0.27

ABR = angiotensin-receptor blocker. ACE = angiotensin-converting enzyme. BP = blood pressure. HbA1c = glycated haemoglobin. * Data are proportion of patients unless otherwise indicated. † Reference interval. ‡ Aboriginal patients aged > 15 years.

The use of financial incentives in Australian general practice

There is considerable interest in how to improve the quality and outcomes of health care by providing better incentives, including “pay-for-performance” arrangements.1 In Australia, financial incentives in primary care were first introduced in 1996, through the Better Practice Program, which was superseded by the Practice Incentives Program (PIP) in 1998.2 The PIP offers 10 practice-level incentives, currently for: quality prescribing; early diagnosis and effective management of diabetes; cervical screening of under-screened women; continuing care for patients with asthma; encouraging better health care of Aboriginal and Torres Strait Islander patients; adopting new eHealth technologies; operating after hours; providing teaching sessions for medical students; practising in a rural location; and performing certain non-referred services in rural locations. Within the PIP framework, the Service Incentives Payment (SIP) was introduced in 2001; this is an additional payment that is paid directly to general practitioners for completing cycles of care for patients with diabetes and asthma, as well as for cervical screening of under-screened women.3

Medicare data for 2011 showed that 68% of eligible practices were registered for the PIP. Various factors can influence the response to incentives, including the size of the payment, and the financial and time costs of claiming payments. A survey of 315 GPs in five Divisions of General Practice (DGPs) in metropolitan Sydney found that the perceived administrative burden was a barrier to uptake.4 Findings were similar in a series of semistructured interviews in one DGP in Melbourne, which suggested that any risk that patients might perceive over-servicing discouraged services that required further visits.5 Doctors also argued that they provide “cycles of care” in a range of ways, and that a systematic approach to care was more important to them than government incentives. A study that used a survey of DGPs combined with data on SIP claims by DGP, found that there was higher uptake of incentives in more disadvantaged areas, and that larger practices are associated with a higher SIP coverage (and solo practices with a lower SIP coverage).6

Here, we extend what is known about the use of financial incentives by Australian GPs by analysing a larger, nationally representative survey of GPs. We also investigate changes in use over the 4 years, 2008 to 2011. In addition, we explore the characteristics that predict uptake of incentives among GPs and whether this has changed in the same period.

Methods

We used data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal panel survey of medical practitioners in Australia, which started in 2008. Participants in the survey were drawn from the national database of doctors; all doctors undertaking clinical work were invited to participate. MABEL includes four categories of doctors: GPs and GP registrars, specialists, specialists-in-training, and hospital non-specialists. In this study, we included GPs and GP registrars, as our focus was on primary care. The baseline 2008 cohort included 10 498 doctors, of whom 3906 were GPs; in each subsequent wave of doctors added to the MABEL longitudinal panel, a new cohort was invited to participate, and a top-up sample was added.

In MABEL, respondents were asked: “In the last year, approximately what percentage of your total gross earning did you receive from . . . government incentive schemes and grants?”

As incentive payments are expected to account for a small proportion of total income,3 we treated this as a binary variable (ie, any versus no income from government incentive schemes and grants). The MABEL questionnaire also collects data on practice and GP characteristics; we used the variables that indicate the practice size (the number of GPs and the number of administrative staff in the practice), the GP’s business relationship with the practice, the geographic location of the practice and the sex of the GP.

First, we established the trend in the use of incentive payments, and disaggregated this to show entry to and exit from receiving incentive payment income. To describe the factors that influence incentive use by GPs, we estimated a probit regression model with incentive use as the outcome variable and a number of practice- and GP-level explanatory variables (eg, practice size, relationship with practice, location). We used multivariate methods to control for these multiple factors simultaneously in determining what influences incentive use by GPs. We derived average marginal effects to estimate the difference in probability that a GP with a specific characteristic (eg, inner regional practice location) will participate in the incentive scheme compared with the reference characteristic (city location). We estimated the model in each of the 4 years of the survey, 2008–2011, to determine whether these changed over time. Analyses were conducted with Stata, version 12.0 (StataCorp).

The study was part of a research program approved by the University of Technology Sydney Human Research Ethics Committee (UTS HREC REF NO. 2009-143P).

Results

Almost all GPs (90%) reported receiving 10% or less of their income from government incentive and grant schemes. Around half (47%) reported receiving some incentive or grant income in 2008, and this number fell to 43% by 2011, with most of the decline occurring between 2008 and 2009. This small change does not tell us about stability in the individuals participating in these schemes. Box 1 shows the transitions in participation in grant and incentive programs for each 2-year period. Overall, around a third of doctors changed their participation in any year, but as the rate of exit from the schemes was higher than the rate of entry, overall participation fell.

Box 2 shows the results of the regression models for each of the years. Overall, there was little change in which characteristics were significant from year to year, so we focus here on 2008 and 2011. GPs working in larger practices, particularly those with more than 10 GPs, were more likely to be using incentives. Doctors working in such practices (relative to those in solo practice) were 13.6% (95% CI, 6.9%–20.3%) and 10.8% (95% CI, 3.4%–18.2%) more likely to use incentive schemes in 2008 and 2011, respectively. The number of administrative staff in the practice was another indication of practice size. In 2008, GPs working in a practice with more than 10 administrative staff (relative to practices with no administrative staff) were 10.8% (95% CI, − 0.4%–22.0%) more likely to use incentive schemes. In 2011, this effect was much larger and statistically more significant at 27.1% (95% CI, 15.8%–38.4%) more likely to use incentive schemes.

The GP’s relationship with the practice was also significant. Compared with associates, principals and partners were more likely, and salaried employees, contracted employees and locums were all less likely to be using incentive schemes.

By far the largest predictor of incentive scheme use was the location of the GP’s practice. Relative to GPs in city practices, those in inner regional practices were 20.2% (95% CI, 16.6%–23.7%) and 22.2% (95% CI, 18.6%–25.7%) more likely to be using incentives in 2008 and 2011, respectively. This effect was even larger for GPs in outer regional practices, who (relative to GPs in city practices) were 33.6% (95% CI, 29.4%–37.7%) more likely to use incentive schemes in 2008 and 37.2% (95% CI, 33.2%–41.2%) more likely to do so in 2011. Finally, the sex of GPs does not appear to be a significant predictor of incentive use.

Discussion

Financial incentives other than Medicare Benefits Schedule-based fees for service were first introduced in Australia in 1996. Although the program has undergone many changes since its inception, it has been stable since 2006. Our results confirm previous findings that the proportion of income derived from incentive schemes and grants in Australian primary care has not been large.3 In the MABEL longitudinal sample, less than half of the GPs received any income from incentives in 2008 and, 3 years later, this proportion had decreased by several percentage points. This is consistent with the observed fall in PIP payments3 although we acknowledge that these are paid to practices while our data show use of incentive and grant schemes by individual GPs. More in-depth analysis of changes across the 4 years of our study shows a more surprising trend — that there was a high rate of turnover among GPs who used these schemes, with some starting to use them, but a larger number ceasing to do so. There have been a number of changes to grants and incentives since the introduction of the Better Practice Program in 1996. However, the most recent changes — such as the Enhanced Primary Care Package, the SIPs, the increase in the GP attendance rebate to 100%, higher rebates for after-hours attendances, and new items for mental health services — had been introduced before 2008. Therefore, for the period of this study, entry and exit to the schemes would be expected to be stable.

It is not surprising that GPs’ practice location was associated with incentive use, as a number of additional incentives are available for GPs in rural areas. Two PIPs are aimed exclusively at rural practices; one for practising in a rural location and one for performing certain non-referred services in rural locations. The effect of rural (this includes both inner and outer regional) locations did not change very much over the 4 years, which again is in line with the fact that the relevant policies have largely remained unchanged over this period, but in contrast to the retention of urban GPs.

Practice size, measured both by the number of GPs and the number of administrative staff in the practice, was a significant factor in incentive use in both 2008 and 2011. However, the effect of having more than 10 GPs in the practice diminished in magnitude from 2008 to 2011 while the effect of having a large number of administrative staff increased about 2.5 times in this period. This is consistent with there being a large administrative burden associated with claiming incentives.

The relationship of the GP with the practice was also important. Principals were more likely to claim incentive payments, and this may be due largely to payments being made to the practice. The Australian National Audit Office estimated that about two-thirds of general practices participated in the PIP,3 a somewhat larger proportion than of individual practitioners. The effects of GPs’ different relationships with the practice seemed to increase in magnitude over the 4 years, but the MABEL data had no further information on the conditions of contract and salaried GPs, so we were unable to explore this further. Although these GPs may claim incentives, these may be paid to the practice rather than the individual practitioners, and thus do not affect individual income.

Although the MABEL dataset covers many aspects of medical practice, there is a lack of detail on aspects of employment and income. The data simply do not distinguish different types of payments, such as PIPs, from service-related payments, such as SIPs. A major potential limitation of our study is the representativeness of the MABEL sample. Generalisability in terms of age, sex and location is ensured. However, it is much more difficult to understand and compare sizes and styles of practice (including the effects of increasing corporatisation), which are likely to be relevant in our analysis.

Nonetheless there are several implications for continuing or extending the use of financial incentives in Australian general practice. It is important to consider the administrative cost of claiming any incentive, as well as the cost of providing the service relative to the reward. The decreasing participation of urban GPs may reflect some blunting of the incentive effects of relatively small payments, as they become less effective over time. The higher retention of rural practitioners in claiming incentives may reflect a higher reward relative to effort for rural incentives, or the characteristics of rural practice. The response to incentives depends not just on the design of the incentive, but also on other conditions, such as levels of demand for, or changes in approaches to treatment. For example, faced with increasing demand. it may involve less effort to increase the number of consultations than to claim additional payments. This also applies to disincentives, such as reduced rebates and/or higher patient copayments. For these reasons, financial incentives should be reviewed and evaluated regularly. Finally, this and similar studies only show the use of incentives by providers. The impact on patients, their care and their health also warrants investigation in any evaluation of the role of financial incentives.

1 Transitions in the proportion of doctors receiving payments from government incentive schemes and grants, 2008–2011

	Year 1/Year 2
Payments	2008/2009	2009/2010	2010/2011	2008/2011

Received payments in Year 1	47.7%	43.8%	44.0%	43.8%*
Received payments in Year 1, did not participate in Year 2	38.4%	34.5%	34.7%	41.1%
Did not participate in Year 1, received payments in Year 2	27.5%	25.2%	26.0%	29.4%
Changes in participation as a percentage of total participation	32.7%	29.2%	29.9%	35.0%

* Received payments in 2011.

2 Marginal effects (standard errors and 95% confidence intervals) of factors associated with an increased likelihood of general practitioners claiming any government incentive schemes and grants

Year

Factors

2008

2009

2010

2011

Total observations

3906

3662

3664

3436

No. of GPs in practice
(reference, 1)

2–5

0.061* (SE, 0.028;
95% CI, 0.006 to 0.116)

0.079† (SE, 0.030;
95% CI, 0.020 to 0.138)

0.096† (SE, 0.032;
95% CI, 0.033 to 0.159)

0.086† (SE, 0.032;
95% CI, 0.023 to 0.150)

6–10

0.083† (SE, 0.030;
95% CI, 0.024 to 0.142)

0.038 (SE, 0.033;
95% CI, − 0.026 to 0.102)

0.088* (SE, 0.034;
95% CI, 0.020 to 0.155)

0.053 (SE, 0.034;
95% CI, − 0.014 to 0.121)

> 10

0.136† (SE, 0.034;
95% CI, 0.069 to 0.203)

0.067 (SE, 0.037;
95% CI, − 0.005 to 0.138)

0.093* (SE, 0.038;
95% CI, 0.019 to 0.166)

0.108† (SE, 0.038;
95% CI, 0.034 to 0.182)

No. of administrative staff
in practice (reference, 0)

1–5

0.062 (SE, 0.053;
95% CI, − 0.042 to 0.165)

0.044 (SE, 0.058;
95% CI, − 0.069 to 0.157)

0.042 (SE, 0.058;
95% CI, − 0.073 to 0.156)

0.086 (SE, 0.053;
95% CI, − 0.018 to 0.191)

6–10

0.052 (SE, 0.056;
95% CI, − 0.057 to 0.162)

0.066 (SE, 0.060;
95% CI, − 0.053 to 0.184)

0.064 (SE, 0.061;
95% CI, − 0.055 to 0.184)

0.121* (SE, 0.056;
95% CI, 0.012 to 0.231)

> 10

0.108 (SE, 0.057;
95% CI, − 0.004 to 0.220)

0.144* (SE, 0.062;
95% CI, 0.021 to 0.266)

0.157* (SE, 0.063;
95% CI, 0.035 to 0.280)

0.271† (SE, 0.058;
95% CI, 0.158 to 0.384)

GP’s relationship with practice
(reference, associate)

Principal or partner

0.099† (SE, 0.023;
95% CI, 0.054 to 0.144)

0.058* (SE, 0.023;
95% CI, 0.012 to 0.103)

0.029 (SE, 0.024;
95% CI, − 0.018 to 0.075)

− 0.015 (SE, 0.025;
95% CI, − 0.064 to 0.034)

Salaried employee

− 0.109† (SE, 0.032;
95% CI, − 0.171 to − 0.047)

− 0.164† (SE, 0.031;
95% CI, − 0.225 to − 0.103)

− 0.206† (SE, 0.030;
95% CI, − 0.265 to − 0.147)

− 0.192† (SE, 0.031;
95% CI, − 0.254 to − 0.131)

Contracted employee

− 0.142† (SE, 0.022;
95% CI, − 0.184 to − 0.099)

− 0.188† (SE, 0.020;
95% CI, − 0.228 to − 0.148)

− 0.243† (SE, 0.020;
95% CI, − 0.282 to − 0.203)

− 0.216† (SE, 0.021;
95% CI, − 0.257 to − 0.174)

Locum

− 0.132* (SE, 0.053;
95% CI, − 0.236 to − 0.027)

− 0.215† (SE, 0.059;
95% CI, − 0.330 to − 0.100)

− 0.277† (SE, 0.055;
95% CI, − 0.385 to − 0.168)

− 0.147† (SE, 0.057;
95% CI, − 0.258 to − 0.036)

Practice location
(reference, city)

Inner regional

0.202† (SE, 0.018;
95% CI, 0.166 to 0.237)

0.228† (SE, 0.018;
95% CI, 0.194 to 0.263)

0.161† (SE, 0.018;
95% CI, 0.125 to 0.196)

0.222† (SE, 0.018;
95% CI, 0.186 to 0.257)

Outer regional

0.336† (SE, 0.021;
95% CI, 0.294 to 0.377)

0.288† (SE, 0.021;
95% CI, 0.247 to 0.329)

0.288† (SE, 0.020;
95% CI, 0.247 to 0.328)

0.372† (SE, 0.020;
95% CI, 0.332 to 0.412)

Sex of GP (reference, female)

Male

0.007 (SE, 0.016;
95% CI, − 0.024 to 0.037)

0.015 (SE, 0.016;
95% CI, − 0.016 to − 0.046)

0.005 (SE, 0.016;
95% CI, − 0.025 to 0.036)

0.015 (SE, 0.016;
95% CI, − 0.016 to 0.047)

* Significant at P ≤ 0.05. † Significant at P ≤ 0.01.

$19 billion pharmacy deal sign of skewed health priorities

The AMA has accused the Federal Government of skewed health priorities after it announced it would pay pharmacists an extra $600 million to provide an unspecified range of patient services as part of a push to increase their role in the provision of primary health care.

Health Minister Sussan Ley has announced pharmacists will receive $1.2 billion for programs and services as part of an $18.9 billion five-year in-principle Community Pharmacy Agreement struck with the Pharmacy Guild of Australia.

If ratified, the deal – which delivers the sector an annual 4.54 per cent pay rise – would mark a major advance for the nation’s pharmacists in their campaign for an expanded scope of practice, including the delivery of flu vaccinations and the conduct of patient health checks.

Ms Ley said the deal was “recognition of the increasingly important role pharmacists play in a patient’s ‘medical team’ of health professionals, and further demonstrates the Abbott Government’s commitment to delivering greater integration between health services in Australia’s primary care system”.

But AMA Vice President Dr Stephen Parnis said the Government’s decision to award the pharmacy sector a $3 billion pay rise at the same time as imposing a four-year freeze on funding for medical services showed its priorities were “all wrong”.

“Patients have been hit with a Medicare rebate freeze until 2018. Public hospital funding to the states has been cut dramatically. More health programs and services suffered funding cuts in [the] week’s Budget. But the pharmacy sector gets a huge funding boost with no questions asked,” Dr Parnis said. “The Government has its health priorities all wrong.”

As part of the deal, the Government will pay pharmacists a set fee for dispensing medicines instead the current arrangement under which their fee is a percentage of price. Ms Ley claimed the change would ensure no increase in the average dispensing cost, saving $1.5 billion.

The sector has also reluctantly accepted the introduction of a discount of up to $1 on the PBS patient co-payment, which the Government said would make medicines cheaper. The change would also slow the rate at which patients reach the PBS safety net threshold, cutting costs for the Commonwealth.

Last year, the Government increased the PBS safety net thresholds and the patient co-payment. For concession card holders, who account for 80 per cent of all prescriptions dispensed through the PBS, the co-payment is $6.10 per prescription, but medicines are free once the safety net threshold of $366 or 60 prescriptions is reached. For non-concession patients, the co-payment is $37.70, and once the threshold of $1453.90 is reached, further prescriptions are $6.80 each.

The Pharmacy Guild made it clear it was unhappy with the proposed $1 co-payment discount. President George Tambassis said it supported the savings the Government was seeking to achieve through the agreement, “with the exception of the discounting of the PBS co-payment measure, which is a matter for government”.

The Pharmaceutical Society of Australia said it was concerned about the “health impact” of the discount and other savings measures, including the co-payment increase and the life in safety net thresholds.

But Ms Ley said the discount would give pharmacists flexibility to compete on price and quality while saving taxpayers up to $360 million.

In a warning to the sector, the Minister said the measure was also part of a drive to encourage greater competition in the sector.

Current regulations stifle competition by limiting pharmacy ownership to registered pharmacists and banning outlets from opening within 1.5 kilometres of each other.

A Government-commissioned competition review recommended scrapping these restrictions, and the new Community Pharmacy Agreement includes what Ms Ley said was the “most significant independent and public review of the pharmacy sector ever conducted over the next two years, including consideration of both remuneration and regulation, such as location rules”.

The push for an overhaul of these arrangements was given extra impetus earlier this year when the Commonwealth Auditor-General issued a scathing report on the administration of the current Community Pharmacy Agreement, including savings shortfalls, a $300 million blow-out in pharmacist incentive payments, and the diversion of almost $6 million from professional development programs into a “communications strategy”.

Dr Parnis has raised concerns about the allocation, under the new Agreement, of $1.2 billion to fund what the Government said would be “support programs for patients”.

“This is a lot of money for programs that are yet to be devised. We have seen past proposals and worry about fragmentation of patient care because these pharmacy ‘services’ may not add any value to patient outcomes,” he said.

Mr Tambassis said the funding would include $50 million for a Pharmacy Trial Program and $600 million in a contingency reserve to support new and existing community pharmacy programs and services.

And Ms Ley tried to reassure that the money would be used carefully, insisting that all pharmacy programs would be subject to scrutiny and approval by the Medical Services Advisory Committee.

But Dr Parnis said the current concerted push by pharmacists into new and expanded areas of practice, including vaccinations, skin and health checks, mental health assessments and wound dressing was of great concern.

“The Health Minister said that the Government wants pharmacists to play a greater role in the patient’s ‘medical team’ – but pharmacists are pharmacists, not doctors,” he said. “Pharmacists have real expertise. I consult and work with pharmacists every day I’m in my hospital, and that works extremely well.

“I’m just not sure that – the proposals being put forward in this agreement make sense, particularly when they talk about allocating $1.2 billion for this and then we’ll work out the details later.

“Pharmacists are not medically trained to provide medical services, nor are they indemnified to do so. The best primary care is provided by the local family doctor, the GP – the most cost-efficient part of the health system,” he said.

Adrian Rollins

It is not about savings, honest: Minister reassures AMA on MBS review

Health Minister Sussan Ley has given AMA President Associate Professor Brian Owler her personal assurance that the review of the Medicare Benefits Schedule initiated by the Abbott Government is not being driven by a search for savings.

In a notable intervention just hours after the Budget was released, Ms Ley was forced to reaffirm that the primary purpose of the review, announced by the Government last month, was to modernise the MBS and make sure the services listed on it were best practice.

The AMA had given its support to the review on the grounds that its main focus was on eliminating inefficiencies and reflecting advances in medical practise.

But following the release of the Budget, A/Professor Owler sought urgent reassurances from the Government that that remained the case, and that the review would not be simply a cost-cutting exercise.

“I have sought clarification from the Minister that there is no dollar amount attached to the MBS review, which was one of the conditions on the AMA and the profession supporting this process,” the AMA President said. “So, we remain committed to the process of the MBS review. It is not purely about a savings measure, this must be about making sure that we have a modern MBS that actually reflects modern medical practice, and it actually maintains access for patient services.”

In the Budget, the Government allocated $34.3 million over the next two years to support the work of the Medical Services Advisory Committee and “deliver an expanded process of MBS review overseen by a clinician-led Medicare Benefits Schedule Review Taskforce”.

A/Professor Owler said the AMA accepted that the Government would be looking for savings, but warned the medical profession would not participate in a process that was primarily aimed at achieving a “hit-list of savings”.

Concerns about the overriding purpose of the review were fuelled by a briefing by Health Department Secretary Martin Bowles in which he told the AMA President and other health leaders the MBS review would build on considerable savings already made by MBS review processes.

A/Professor Owler said the comments were inconsistent with previous Government assurances that the MBS review was not about Budget savings, and prompted him to seek urgent clarification from the Minister.

Following his discussions with Ms Ley, the AMA President said he was now satisfied that the Government’s objective for the review, as originally stated, was to update the MBS to reflect modern practice and remove inefficiencies.

The fact the review is to be led by respected clinician, Sydney Medical School Dean Professor Bruce Robinson, and its work is to be complemented by a Primary Health Care Advisory Group chaired by immediate-past AMA President Dr Steve Hambleton, has helped build confidence about the quality of the recommendations that will come from the process.

And Ms Ley has been at pains to emphasise that, although the review may result in savings, that was not its overriding purpose, and it was part of a “balanced” approach to expenditure being taken by the Commonwealth.

“The Abbott Government has announced a balanced approach to health spending focussed on efficient, evidence-based investment and laying the foundations for long-term reform,” the Minister said.

She said the Government’s approach enabled a “sensible” $2.3 billion increase in the health budget to $69.7 billion in 2015-16, “whilst also delivering efficiencies that are evidence-based and ensure the future sustainability of program spending”.

Adrian Rollins