Standing at the crossroads in HIV management: implications for primary care practice from the AIDS 2014 conference

Increase testing, increase treatment, consider prophylaxis, search for a cure and try to eradicate HIV

There has recently been renewed interest in HIV management in Australia. Studies have contributed evidence that effective HIV antiretroviral treatment (ART)1,2 and chemoprophylaxis3 prevent HIV transmission. There is a push to identify people with chronic HIV infection who have not been tested4 and to identify people during the acute phase of infection,5,6 when they are most infectious and most likely to transmit disease7 but unlikely to know they are infected.8 HIV treatment is more effective than it was previously; lower pill burdens cause fewer side effects and less toxicity and are less prone to the development of resistance. When combined with traditional HIV prevention measures, the use of antiretroviral agents as pre-exposure prophylaxis (PrEP) by HIV-negative people at high risk of HIV infection reduces transmission by about 75%. The World Health Organization recently recommended PrEP be integrated into prevention programs.9

The 20th International AIDS Conference was held in Melbourne in July, attracting about 14 000 delegates. The theme, “Stepping up the pace”, characterised the meeting’s aim, which was to explore how all these resources and initiatives can be harnessed to have the greatest effect in the global control and ultimate eradication of HIV. There is rekindled interest in HIV cure research, including the continuing pursuit of a vaccine. Speaking at the opening ceremony, UNAIDS Executive Officer Michel Sidibé espoused 2020 targets of 90–90–90: 90% of people living with HIV knowing their status, 90% of people with HIV receiving ART, and 90% of people receiving ART having an undetectable viral load. The Australasian Society for HIV Medicine (ASHM) held a special session to look at Australia’s past role and its new strategic directions nationally (Baggoley, TUSS04) and internationally (McDonald, TUSS04) in relation to HIV. (All proceedings cited here can be accessed by name or session number at the conference website.10) While attendees were upbeat about the potential for ending HIV, the disparity in opportunities between developed and developing countries was an ever-present reality. How does Australia stack up, and what are the challenges for primary care?

Chronicity and cure

In the developed world, HIV is now a long-term, manageable chronic condition. This is the case in Australia for people who are diagnosed and are eligible for Medicare, but the drugs remain expensive and current treatment needs to be taken for life. Cure research suggests that it might be possible to flush HIV from the system if treated early enough (TUAA01). While this remains an aim, follow-up of the Mississippi baby thought to have been cured of HIV infection found that HIV again became detectable after an extended period of no treatment.11 Nevertheless, cure researchers were excited that HIV viral replication was held at bay as long as it was, and see this as a line of investigation. However, a cure is still elusive. While vaccines may be a long way off, primary care remains the ideal setting for long-term chronic disease management and a central point for identifying HIV infection.

Control

The conference began with an overview of the tools we now have to control HIV and how a combination of treatment and prevention can have a synergistic effect in reducing infections (Abdool Karim, MOPL01). Key in demonstrating the prevention benefits of treatment are PrEP trials, which are beginning to report findings. When taken regularly, ART prevents HIV acquisition, and this protective benefit appears to be holding when condom use is not universal (TUAC01). A combination of PrEP and condom use remains recommended (Bavinton, WEAC01). Challenges and obstacles to PrEP for health care providers were explored (Wright, WESY04) and deserve continued discussion. PrEP is often misunderstood as being “a morning-after pill”, flexible or a short-term commitment, but these studies indicate the need for regular dosing to sustain drug levels sufficient to confer prevention. PrEP works, but it needs to be taken rigorously. The Centers for Disease Control and Prevention in the United States have produced comprehensive guidelines,12 and demonstration studies are currently underway in Australia.

Discussion of the role of HIV testing has become increasingly nuanced. It is not simply about laboratory performance, but also about clinical strategies that identify those living with chronic infection. These strategies include indicator-triggered testing, where the presence of diseases that are common in HIV trigger HIV testing, irrespective of other risk factors;13 normalising voluntary HIV testing, where there is no longer a requirement for detailed pretest counselling, simply a requirement for informed consent;14 making testing available in more settings;15 and simplifying the return of test results.

Simplification of treatment

HIV treatment is much simpler than it used to be. The recommended first-line ART in Australia is a once-daily regimen combining three drugs.16 This commonly results in a rapid decline in HIV viral load to an undetectable level (viral suppression) and a steady increase in CD4+ T cells, indicating restoration of a damaged immune system (Cooper, FRPL01). Monitoring viral suppression and treatment tolerance can then be done routinely in general practice, with intermittent specialist review, and many people can keep taking first-line therapy for years. This makes HIV truly a disease that should be managed as a chronic illness in primary care. Previously, treatment regimens were more prone to failure and the development of resistance. While initiation of HIV therapy is restricted to accredited prescribers, all primary care clinicians can participate in the shared care of patients living with HIV.

Complex management

Management of HIV in the older patient is something of particular interest in Australia, as many of our HIV patients have been living with HIV for decades and, as a consequence, are experiencing illnesses associated with ageing. It appears that HIV directly, or possibly indirectly through the drugs used to treat it, accelerates the ageing process (THBS01). It is hypothesised that this effect may be reduced if treatment is initiated earlier, before inflammation associated with HIV has an impact (Deleage, WEAA01). Preventing the damage caused by inflammation associated with early HIV disease is one of the key principles driving earlier treatment initiation (WEAA01). The pragmatic argument is often put that treatment is not delayed in other diseases, yet in HIV, which is clearly communicable, considerable debate has centred on when to start treatment. Historically, this has been a function of wanting to delay the toxicity and difficulties associated with treatment so as to maximise the duration of impact. However, with safer, easier treatment options, this argument holds less weight. We were reminded at the conference that long-term studies are still needed and that there is variation between guideline approaches and recommendations (Cooper, FRPL01).

Domestic and regional responses

The Australian response to HIV was described in the ASHM special session (Wright, TUSS04) and a satellite symposium held by the New South Wales Ministry of Health (SUSA30). Jurisdictional and national strategies are urging greater testing and greater treatment. Barriers to testing are being removed and access to treatment is being expanded, but many social barriers remain (Altice, FRPL02). Australia reaffirmed its commitment to a regional HIV response through supporting regional capacity development. This stands as a reminder that much of the region is experiencing a significant HIV epidemic (McDonald, TUSS04), which has implications for Australians who travel for work and recreation. Global mobility means that we are seeing a change in the characteristics of HIV presentation in Australia, and while 70% of infections are among men who have sex with men, 30% of infections are not, making the question “Could it be HIV?” all the more important. We are at a crossroads — we have the tools, we have the commitment; now we need to harness these to achieve the aim of ending HIV.

The cost-effectiveness of primary care for Indigenous Australians with diabetes living in remote Northern Territory communities

In reply: I acknowledge that data from community controlled health services were not included in our study.1 The high mobility of this population is well recognised and is most common between related communities.2 The bulk of primary care services in remote Northern Territory communities are provided through the 54 government clinics, and we have captured the movement between those services in our dataset. The lesser degree of movement between government and community controlled clinics3 would not have substantively affected our results or our conclusions.

We used propensity score matching4 to improve comparability of the low, medium or high primary care use groups. As shown in the Box, we adjusted for key confounders (age, sex, number of chronic diseases) and found no statistically significant differences between groups. All communities in this study were geographically classified as remote or very remote5 and were similar in terms of their SEIFA (Socio-Economic Indexes for Areas) score.6 Other factors raised by Whyatt and colleagues, including social acceptability and the behaviour of health care providers, may well have significant influence on decisions to use primary care services and, in part, explain the poorer outcomes among the low primary care users.

We are confident that the evidence generated by this study is of use to policymakers and health planners in their efforts to strengthen primary care in remote areas of Australia.

Proportion of patients in each primary care use group before and after propensity score matching, by age, sex and number of chronic diseases

	Low-use (n = 6987)		Medium-use (n = 5926)		High-use (n = 1271)		χ2 significance (P)
	Before	After	Before	After	Before	After	Before	After

Age (years)
15–29	48%	20%	47%	19%	20%	20%	523.3*	2.04†
30–39	24%	23%	25%	25%	23%	23%
40–49	14%	26%	15%	27%	27%	27%
50–59	7%	18%	8%	17%	17%	17%
60–69	7%	13%	5%	12%	13%	13%
Sex
Male	50%	35%	39%	35%	33%	33%	523.3*	2.07†
Female	50%	65%	61%	65%	67%	67%
Number of chronic diseases
0	63%	10%	43%	10%	10%	10%	2004.8*	11.12†
1	17%	16%	22%	16%	16%	16%
2	9%	22%	17%	23%	23%	23%
3	7%	28%	13%	30%	31%	31%
4	4%	20%	5%	17%	16%	16%
5	1%	4%	1%	5%	5%	5%

* P < 0.01. † P > 0.05.

The hidden issues of anticipatory medications in community palliative care

To the Editor: I support reform for providing anticipatory palliative care medication under Pharmaceutical Benefits Scheme (PBS) arrangements, as identified by O’Connor et al.1 There is merit in providing emergency and anticipatory medications under PBS prescriber bag supply arrangements to community-based palliative care.

There has been a decline in the provision of after-hours care and home visits by general practitioners.2 Many GPs, fearful of assault by drug-dependent individuals, no longer carry potentially dangerous injectable medications such as narcotics and benzodiazepines.3 As it is illegal for unused medications to be returned to pharmacies for resupply, supplies currently provided to terminally ill patients by GPs, to assist community palliative care teams, often remain unused on the patient’s death and must be destroyed.

Prescriber bag supplies allow medical and nurse practitioners to provide essential drugs to patients at public expense.4 However, the current formulary mostly includes injectable drugs and few oral medications.5 Modernising the formulary to include small quantities of oral antibiotics, antipsychotics and benzodiazepines would allow patients access to earlier treatment where emergency pharmacy services are restricted. Currently supplied emergency medications have an excessive pack size and often a short therapeutic life. By using smaller pack sizes, the pharmaceutical industry could help to reduce wastage and the risk of diversion.

By limiting the costs to taxpayers and patients of unused PBS medication while increasing community access, these measures are more likely to deliver savings and appeal to GPs and the community.

Use of advance directives by South Australians: results from the Health Omnibus Survey Spring 2012

Advance directives (ADs) have been championed as a remedy for providing evidence of the medical, financial, health care and lifestyle options a person would choose at a time when they may lack capacity for decision making.1 A review of the literature in this area found that these instruments can be useful, but are not widely used due to a variety of factors which inhibit their effectiveness.1,2 In Australia, barriers to effective completion of ADs include poor understanding and application of the different AD forms.2 There is a lack of actual published data on completion rates of specific types of ADs used in Australia.2 As primary care involves assessing individuals at increased risk of chronic diseases and hospital care, low rates of completion of ADs in particular age or other demographic groups may suggest the potential for AD completion initiatives led by general practitioners. This would, in turn, lead to better outcomes from a primary health care, patient management and family carer perspective.

The aim of this study was to determine the proportion of South Australians who have completed the medical, financial, health care or lifestyle ADs in South Australia and/or a will (an instrument often believed to be an AD2). Demographic variables associated with completion or non-completion of these instruments were also investigated.

Methods

Data were collected through the South Australian Health Omnibus Survey (HOS) from 5200 households selected for interview between 4 September and 12 December (spring) 2012. The HOS included a non-replacement sample of people aged 15 years or older. Participants in the spring 2012 survey had an age range of 15 to 97 years. Complete methods for the HOS have been described in detail elsewhere.3 In brief, a random stratified sampling technique was used, defined by a random starting point with 10 households sampled per collection district using a fixed-skip interval. Data were stratified by sex (male/female), age (18–24, 25–34, 35–44, 45–54, 55–64 and ≥ 65 years) and area of residence (metropolitan/rural/regional). In non-metropolitan locations, samples were self-weighting. A cluster size of 10 households was also used for each of the 130 collection districts. Data were weighted by the inverse of the individual’s probability of selection as well as by the response rate in metropolitan and country regions, then reweighted to benchmarks derived from the 2011 estimated resident population based on the 2011 Census, providing a demographic description of the population by age and sex.

All variables were weighted to better align each individual case with the distributions of age, sex and metropolitan or rural/regional location for the total population.

In this study, we report the findings from one survey question relating to the type of AD completed by respondents. Four legal ADs are recognised in SA — enduring power of attorney (EPA), enduring power of guardianship (EPG), medical power of attorney (MPA) and anticipatory direction.

To clarify the specific documents in question, an introductory statement about ADs in general and a brief definition of each AD was provided to participants at the interview stage (Appendix 1). We used the term “living will” instead of anticipatory direction in this introductory statement as the living will has had more consistent use in the literature and by the public.1,2 However, for the purposes of this report, we use anticipatory direction to mean any type of living will document rather than it being limited to medical decisions about end of life.

The study was approved by the Flinders University Social and Behavioural Research Ethics Committee (Project No. 5748).

Statistical analysis

Data were analysed using SPSS version 19 (IBM SPSS Statistics). All analyses were performed using weighted data, and only weighted results are reported unless otherwise specified. Univariate analysis of individual AD document completion with demographic information was performed using χ2 tests of association. A multivariate binary logistic regression was used to assess the independent associations between non-completion of any of the documents and demographic variables. All demographic variables were included in the multivariate model regardless of their statistical significance. Associations for which a two-tailed P value of < 0.05 were obtained were considered statistically significant.

Results

Frequency of document completion

From the 5063 households contacted, 3055 interviews were completed, representing a 60.3% response rate and a 64.4% participation rate (Appendix 2). Wills were the most commonly reported completed instruments (48%), even though they are not ADs. For the recognised legal ADs in SA, more respondents reported having completed the EPA (22%) than any of the health care-related documents — EPG (13%), MPA (11%), anticipatory direction (12%) (Appendix 3).

Individual document completion

Appendix 3 shows that there was an inverse association between rates of completion of individual documents and age across all documents, with those aged 65 years and older showing a much higher completion rate than those in the youngest age category of 15–24 years. People who were married or widowed were more likely to have completed the financial documents — EPA (29% married and 54% widowed) and a will (65% married and 81% widowed) — compared with those who had never married, or who had separated or divorced (EPA, 4% never married and 10% separated/divorced; will, 11% never married and 27% separated/divorced; P < 0.001 for each). There was no difference between the sexes in completion rates of documents, or between metropolitan and rural/regional respondents, except for the EPA and will where the frequency of rural/regional respondent completion rates was slightly higher than that for metropolitan respondents (EPA, 26% rural/regional v 20% metropolitan; P = 0.002, and will, 53% rural v 47% metropolitan; P = 0.004). Those still studying at school or elsewhere had the lowest percentage of completion of documents compared with those with other education levels. Those in the “never worked, student, home duties” category had the lowest percentage compared with those earning an income (results not shown).

Non-completion of any documents

The Box shows the results of the multivariate binary logistic regression for the reported non-completion of any documents. Non-completion rates for any of the four types of AD documents were significantly and independently associated with age (P < 0.001), area of residence (P = 0.031), country of birth (P < 0.001), marital status (P < 0.001), education level (P = 0.003), occupation (P = 0.001) and annual income (P < 0.001).

Discussion

Our findings show for the first time that, although completion rates remain highest in the 65 years and older age group, there is still a significant proportion of older people not completing health care ADs. Older people may not be aware that these documents exist, may not accept their role and value, or may choose not to complete them. Some older people may assume or prefer that health professionals will initiate discussions around these documents at the appropriate time.5

It is interesting and encouraging that younger people (aged 45–64 years) seem to be completing ADs. GPs and other health care professionals are likely to have increasing and ongoing patient encounters with generational groups like the baby boomers (born 1946–1965) as they age. Providing an opportunity to discuss ADs with those aged 45 years and over can facilitate completion of ADs at a time when patients are in relatively good health, as well as build an understanding of factors that may influence health care decision making for them in the future.

While anyone aged over 18 years can complete an AD in SA, those aged 18 to 45 years are far less likely to complete these documents. Targeted health promotion in this group similar to the recent organ donation campaign could increase awareness and promote the benefits of completed ADs in the event of a health care crisis in the future.

The documents most often reported as completed by the general public were a will and, of the four formal ADs in SA, the EPA, a financial instrument, rather than the health care instruments EPG, MPA and anticipatory direction or living will. The relatively high completion rate of EPAs and wills indicates that taking care of our financial assets is an accepted responsibility for many in the community. This could provide a useful context for encouraging people to complete other life-planning documents when GPs are made aware of life-plan changes for a patient (eg, admission to residential aged care, retirement or travelling overseas or interstate). Being open to discussing ADs at this time may provide future benefits to patients, health care practitioners, and families if a future health care crisis occurs.

Given that rural and regional area of residence and non-married or non-working status were each associated with reduced odds of completing most ADs, GPs working in the country or in areas with a high proportion of non-married and non-working individuals might find it especially useful to promote the role of ADs and the value of identifying a trusted substitute decisionmaker to help with future decisions.

While our study has shown that rates of completion of ADs, especially health care and lifestyle ADs, continue to be low, the use of these documents by younger age groups is encouraging and indicates that broadening GP discussion of ADs to include younger age groups might be important in meeting patient goals of future care. Our findings also indicate that those in lower socioeconomic groups may be vulnerable to having their personal autonomy in health care decision making thwarted unless they are given targeted direction on ADs. Detail about the sociodemographic characteristics of those most likely not to have completed ADs provides a useful framework that could help GPs provide these groups with targeted health promotion using relevant community health services.

Analysis of data from the South Australian Health Omnibus Survey Spring 2012 showing the prevalence and independent odds of the 3055 respondents not completing any advance directive documents*

Demographic characteristic

No. not completing
documents

Percentage of total (95% CI)

Odds ratio (95% CI)

Age (years)

15–24

451

93% (90%–95%)

55.3 (31.3–97.7)

< 0.001

25–44

670

69% (66%–72%)

24.9 (17.3–36.1)

< 0.001

45–64

270

27% (24%–30%)

4.4 (3.2–6.3)

< 0.001

≥ 65

10% (8%–12%)

1.0

Area of residence

Metropolitan

1097

49% (47%–51%)

1.0

Rural/regional

354

43% (40%–47%)

0.8 (0.6–1.0)

0.031

Country of birth

Australia

1055

47% (44%–49%)

1.0

Other

396

50% (47%–54%)

2.0 (1.6–2.4)

< 0.001

Marital status

Married

483

31% (28%–33%)

1.0

De facto

225

68% (63%–73%)

2.8 (2.1–3.8)

< 0.001

Separated/divorced

109

42% (36%–48%)

1.8 (1.3–2.4)

0.001

Widowed

14% (9%–19%)

1 (0.6–1.7)

0.993

Never married

609

86% (83%–88%)

3.1 (2.3–4.2)

< 0.001

Education level

Left school in Year 12 or before

372

40% (37%–43%)

1.5 (1.1–1.9)

0.003

Still studying at school or elsewhere

277

85% (81%–89%)

1.2 (0.7–2.0)

0.574

Trade/apprenticeship, certificate/diploma

467

42% (39%–45%)

1.0

Bachelor degree or higher

335

49% (45%–53%)

1.5 (1.1–2.0)

0.005

Occupation†

Professional

410

43% (40%–46%)

1.0

Clerical and sales

315

38% (35%–42%)

1.02 (0.0.8–1.3)

0.879

Blue collar

446

49% (46%–52%)

1.6 (1.3–2.2)

0.001

Never worked, student, home duties

146

69% (63%–76%)

2.2 (1.4–3.6)

0.001

Annual income

0–$40 000

210

36% (32%–40%)

1.2 (0.9–1.7)

0.208

$40 001–$80 000

294

51% (46%–55%)

1.0

≥ $80 001

397

42% (39%–45%)

0.6 (0.5–0.8)

< 0.001

Not stated

550

58% (55%–61%)

0.8 (0.6–1.1)

0.227

* Multivariate binary logistic regression analysis; numbers and percentages may not add to totals or 100% as data are weighted and rounded to whole decimals. † Australian and New Zealand Standard Classification of Occupations codes.4

Evaluation of legal capacity by doctors and lawyers: the need for collaborative assessment

Legal and medical professionals are increasingly being asked to assess the capacity of individuals to make wills (an individual’s testamentary capacity), enduring powers of attorney (EPAs) and advance health directives (AHDs), as well as other legal instruments. Australian society is ageing and consequently the number, as well as the complexity, of assessments being conducted is increasing.

A range of medical conditions may interfere with, or eliminate, a person’s legal capacity to execute a will, EPA or AHD. Collaboration between legal and medical professionals in the assessment process is therefore particularly important. Miscommunication and misunderstanding occur between legal and medical professionals about the roles and responsibilities of each when conducting such assessments — is it legal or medical capacity being assessed?1 — which can be exacerbated by inadequate professional education. Given that loss of legal capacity has significant consequences, assessment needs to be consistent and transparent. Currently, no nationally recognised system for this process exists in Australia.2 At the moment, there is an unsatisfactory, ad hoc implementation of various methods tailored to suit individual practitioners, be they legal or medical. This is legally, medically and ethically concerning.3

This article considers the challenges in assessing testamentary and decision-making capacity. While flexible assessment processes are clearly needed, there also needs to be consensus over clear and consistent principles and guidelines from which to begin. We suggest how a best-practice approach can be made. For the purposes of this article, mental capacity is the general ability to understand the purpose, aim, significance and consequences of entering into particular transactions; and legal capacity is a person’s ability to enter into such a transaction, or having a particular legally recognised status.

The current assessment environment

Advances in the medical understanding of the range of patterns of cognitive dysfunction in different types of dementia have made assessing testamentary capacity more complex.4 The growing need for assessments, and the anecdotally reported fear of litigation if assessments are not satisfactorily conducted, requires a re-evaluation of existing assessment paradigms.

The jurisdictional medley of state and territory legislative and common law provisions for substitute decision making also exacerbates an already challenging situation. This results in different provisions, either legislative and/or common law, applying in different jurisdictions throughout Australia. New South Wales,5 Queensland,6 Victoria7 and the federal government8 have all conducted reviews in the past 5 years. AHDs have also been the subject of recent interest.9,10 However, no review has suggested or developed national capacity assessment guidelines.

Addressing the challenges of capacity assessment

Legal professionals are not trained to assess the effect of medical conditions, such as different types of dementia, on legal capacity. Medical professionals are not trained to assess the notion of legal capacity. Despite the disconnect from each other as a result, the professions together possess the skills necessary to satisfactorily assess capacity. We offer some suggestions to address the challenges of capacity assessment.

General proposals for a collaborative process

Legal and medical professionals should know what is being assessed, how and by whom. To further this end, clear communication is fundamental.11 In addition, legal and medical professionals need more continuing professional education,12 conducted within and between the professions.

A lack of terminological clarity and communication has made unclear the proper assignment of roles to legal and medical professionals and has increased the lack of clarity of process. There has been discussion regarding the separation of capacity as a medical, and competency as a legal, construct; however, it is unlikely that such an attempted separation would have any practical effect.13 Nevertheless, definitional clarity is needed and clear labelling of terms should be given — for example, legal competency or capacity and medical competency or capacity.

Requesting a medical assessment of capacity

A legal professional should first carefully consider whether medical assessment is necessary, recognising that a decision to seek it could concede that capacity is an issue if a third party contests the validity of a testamentary or enduring document. Assessments can also be undertaken to anticipate future legal proceedings that may question the individual’s capacity.

Members of the legal profession should be responsible for providing to medical professionals situation-specific information about a person’s legal capacity to be assessed.14 The issue of obtaining consent from a person to assess their capacity when they potentially lack the capacity to do so is also of fundamental importance but is outside the scope of this article.

Assessment should consider the individual’s ability to understand, appreciate and communicate the reasons for his or her choices.15 Adequate assessment involves weighing the individual’s ability to receive, understand, retain and recall relevant information; select between options for a course of action; understand the reasons for a decision; apply any information received to the circumstances; evaluate the benefits and risks of the choice; communicate the choice; and then persevere with that choice, at least until the decision is acted on.16 This will take into account the individual’s specific circumstances, including any relevant medical factors, as well as social and cultural factors.17

A three-stage process of assessment

Ideally, there will be three stages of investigation. First, an initial assessment should be undertaken by a legal professional. Second, clinical assessment by a medical professional should be undertaken (if necessary). Third, there should be a final determination of whether the individual has legal capacity for the specific task in question.

In this process, it is fundamental to acknowledge that capacity is task- and time-specific in nature. Thought must also be given to the clinical models available for assessment and the benefits and disadvantages of the model(s) being considered, for example, the limitations of the Mini-Mental State Examination.18 It is also necessary to consider what has triggered questions about an individual’s capacity.19 Care must be taken to avoid setting the bar too high in assessing competency or legal capacity because there is a risk of finding people incompetent who actually do have the capacity necessary at law to undertake the specific task.

Consideration must also be given to who should assess capacity.20 A legal professional can proceed without medical input when there is no or little evidence of diminished legal capacity. If there are mild problems, but their magnitude is insufficient to conclude that the individual cannot make decisions commensurate with adequate legal capacity, the legal professional can proceed but should consider seeking a medical opinion. If there is more pronounced evidence of diminished capacity, the legal professional should proceed cautiously, consulting with an appropriate medical professional.19 Formal medical capacity assessment should be undertaken if the individual clearly lacks legal capacity.19

Requests for medical assessment of capacity

Whenever medical assessment is sought, the referral letter from the lawyer should contain information about the individual’s background, values and preferences, and reasons for contacting the lawyer; the legal capacity being assessed; and any known medical, social or environmental factors affecting capacity.19,20 Medical professionals should feel comfortable in refusing to assess capacity unless there is adequate information.20 The legal and medical professionals involved should discuss whether a written medical report is necessary, whether it would be useful, and what format it should take.19 Consent from the individual in question is imperative before any assessment can occur.20 The expense and disruption for an individual of seeking a medical assessment should also be considered.19

Information gathering by the lawyer or doctor, such as speaking to family members and friends, may also occur. Any circumstances discovered in this process that potentially affect the individual’s capacity,20 such as “stress, grief, depression, reversible medical conditions, hearing or vision loss, or educational, socio-economic, or cultural background”,19 also need to be considered and recorded in the assessment. Building trust with the individual, educating him or her about the process, accommodating any sensory (including hearing) impediments, and accommodating cultural and linguistic differences contribute importantly to a more accurate picture of that person’s capacity and should be taken into account.19,20 The recording of the assessment process is important, through extensive file notes and perhaps video recording.

While national Australian guidelines are lacking, there are invaluable resources, such as the NSW Attorney General’s Capacity Toolkit21 and the six-step capacity-assessment model.16 The handbooks prepared for lawyers,19 judges22 and psychologists18 by the American Bar Association Commission on Law and Aging and the American Psychological Association are also potentially useful. Similarly, the British Medical Association and the Law Society have produced a guide for legal and medical professionals.20

Assessing testamentary capacity

The existence of testamentary capacity is a legal decision. Contemporaneous determinations during the life of a testator (the person making a will) are preferable to retrospective assessments after the testator’s death, which are practically and evidentially problematic.

When assessing specific testamentary capacities, reference must be made to the principles established in the 1870 case of Banks v Goodfellow,23 which sets out that the testator should understand the nature and effect of making a will, have an appreciation of the people who are natural beneficiaries, and understand the obligation to provide for people who are dependent on him or her.20 The testator should realise the effects and consequences of the testamentary provision that he or she is making.20 However, an assessment should go further than merely regurgitating the elements established in Banks. Legal professionals have a responsibility to ensure that medical professionals have adequate information to be able to report on an assessment of an individual’s testamentary capacity. A medical professional should request further information if uncertain.

Assessing decision-making capacity

The legal tests for determining decision-making capacity differ from those for testamentary capacity, especially for EPAs, which require a higher standard. For EPAs, the concept of understanding should also include that the individual comprehends the powers to be given and can state or restrict those powers; the time at which the power given under the enduring document commences; that once the power comes into effect, the attorney will be able to use and have full authority over the powers given; that the individual may revoke the enduring power of attorney at any time, provided he or she is capable of doing so;24 and that an enduring power of attorney continues despite the individual losing capacity and being unable to oversee the attorney or revoke the power. There is currently no accepted clinical model to assess financial capacity.

Professional liability considerations

With testamentary and decision-making capacity assessment becoming more complex, it is possible that a practitioner’s liability and the assessment process itself may be subject to increasing scrutiny, as will any attendant ethical issues. Careful assessment protocols can assist in obviating questions of professional liability.19

Conclusion

There is an increasing acknowledgement of the need for, and movement towards, an interdisciplinary approach to assessing legal capacity in the context of wills, EPAs and AHDs. A focused education campaign among the medical and legal professions, as well as in the general community, will be necessary, and national systems need to be developed. In the absence of these, to satisfactorily assess testamentary and decision-making capacity, medical professionals must be aware of the relevant legal tests that require clearer understanding of the expectations each profession has of the other. It is only through an interdisciplinary approach that satisfactory assessments of capacity in testamentary and decision-making contexts will occur.

Splenic rupture: a rare complication of infectious mononucleosis

A 28-year-old man presented to the emergency department with acute left upper quadrant tenderness and postural hypotension. He reported having had fever and cervical tenderness for 1 week before his presentation.

Blood tests showed an elevated white cell count with reactive lymphocytosis. A test for infectious mononucleosis heterophile antibody was positive, consistent with recent infection.

A contrast scan of the abdomen showed splenomegaly with subcapsular haematoma.

Splenic rupture after infectious mononucleosis is rare (incidence, 0.1%–0.5%), but can have disastrous consequences if overlooked.1,2

A bowel cancer screening plan at last

More lives will be saved by fully implementing the National Bowel Cancer Screening Program in 2020

The 2014–15 federal Budget included an announcement of $95.9 million for the long-awaited full implementation of the National Bowel Cancer Screening Program (NBCSP) by 1 July 2020.1 From that date, all Australians aged 50 to 74 years will finally be invited to screen for bowel cancer every 2 years with a faecal occult blood test (FOBT).

The announcement included a plan to incrementally expand the program, currently offered to people aged 50, 55, 60 and 65 years. The program will include 70-year-olds (through a previous funding commitment in 2012) and 74-year-olds from July 2015; people turning 64 and 72 years from 2016; and those aged 54, 58 and 68 years from 2017. The four remaining age groups (52, 56, 62 and 66 years) will be included from 2018 to 2020.1

The rationale is consistent with results from a study by Cenin and colleagues published in this issue of the Journal, which prioritised age groups according to the mortality-reduction benefit that can be expected from FOBT screening.2 Benefit is derived from prioritising screening according to age-based risk and closing gaps in the existing age cohort to shift from 5-yearly to biennial screening.3

A final implementation plan for the NBCSP has been a long time coming. The program was introduced in August 2006 with the mail-out of FOBT kits to people turning 55 and 65 years. While sporadic funding increases in the interim have been welcomed, there have also been unacceptable delays and ongoing concerns. For example, the 2012–13 Budget provided a much-needed $50 million to expand the NBCSP; however, the final implementation date was set as 2034.4 Cancer Council Australia therefore believed it was critical to provide evidence of the enormous potential benefits of completing the program by an acceptable date of 2020.

Cenin and colleagues used the MISCAN (microsimulation screening analysis)-Colon model to examine mortality gains with full implementation of the NBCSP by 2035 compared with full implementation by 20202 — the year recommended by Cancer Council Australia in its 2013 election priorities. The model estimated that full implementation by 2020 would prevent 35 000 (100% extra) bowel cancer deaths over the following four decades.

Now that the future of the NBCSP is assured, it is essential to engage with general practitioners and other health care professionals to improve participation and facilitate continuous improvement in service delivery.

The most recent data available show that, of people invited to participate in the NBCSP between July 2012 and June 2013, only 33.5% did so.5 This is an unacceptably low rate. However, it was not unexpected, given the low awareness among Australians about bowel cancer,6 the novelty of population screening for men and the lack of targeted communication about the NBCSP. A large-scale communications campaign, during program expansion and after full implementation, will be needed to improve participation rates if the NBCSP is to fulfil its potential to reduce bowel cancer mortality.

Since the inception of the NBCSP, GPs have been identified as critical partners. The government has sought to promote GP involvement in the NBCSP through GP representation on relevant committees, and through engagement with the Royal Australian College of General Practitioners (RACGP). While general practice resources such as the RACGP “red book” recommend FOBT screening for 50–74-year-olds, it will become increasingly important to consult closely with the primary care sector and provide support to GPs to facilitate their role in the expanded NBCSP.

GPs are well placed to promote the use of FOBT as the recommended screening tool for average-risk people currently outside the NBCSP. This would help reduce the strain on colonoscopy services. More than 500 000 colonoscopies are conducted annually in Australia.7 While there is no national dataset on how many of these are performed on asymptomatic, average-risk patients, it is thought that a significant number are done as first-line screening.

Currently, 7.5% of FOBT tests completed through the NBCSP return a positive result.5 Of those patients, around 70% present for colonoscopy. Of these, one in 32 are diagnosed with a confirmed or suspected cancer and one in 17 are diagnosed with advanced adenoma.5 FOBT is therefore a valuable tool for prioritising the use of colonoscopy for patients who are at higher than average bowel cancer risk or are symptomatic.

Throughout the NBCSP’s expansion, there has also been discussion about virtual colonoscopy, flexible sigmoidoscopy and plasma DNA testing as alternative screening tools. There is no evidence to suggest virtual colonoscopy would be a feasible alternative to FOBT.8 Although flexible sigmoidoscopy has been shown to be effective in randomised trials,9 it is significantly more expensive than FOBT and questions remain about its acceptability. DNA biomarker tests using plasma and faecal stool samples are also available; however, they are unsuitable for screening, as they have significantly lower sensitivity than FOBT for advanced adenoma and for stage A cancer.10–12

Importantly, South Australian data have shown that twice the number of stage A cancers were diagnosed in people invited to participate in the NBCSP compared with people who were not and who had presented with a symptom.13

The NBCSP’s potential to prevent a total of 70 000 Australian bowel cancer deaths over the next four decades is compelling.

New TGA warning label for use of NSAIDs in fluid-depleted children

To the Editor: Non-steroidal anti-inflammatory drugs (NSAIDs) have been very widely used for many years in Australia and elsewhere, in both prescription and non-prescription settings.

Although their potential for gastrointestinal side effects is generally well understood within the community, the capacity for NSAIDs to cause renal damage, even after short-term use in susceptible individuals, is less well appreciated.

It has been well documented that the use of NSAIDs in those who are fluid-depleted, including their short-term use in otherwise healthy individuals, can lead to renal failure, albeit reversible.1,2

On 23 May this year, the Therapeutic Goods Administration updated its Medicines Advisory Statements on labels for non-prescription medicines. Included was a warning about paediatric products containing NSAIDs.3 The wording of the advisory statement is “Ask your doctor or pharmacist before use of the medicine in children suffering from dehydration through diarrhoea and/or vomiting”.

As the person who initiated the request to have this warning label added, my intention was to have this warning added to all non-prescription NSAID-containing products for both adults and children, because we know that people who are renally compromised for any reason are at risk of kidney damage from the use of NSAIDs. This, of course, includes those taking some antihypertensive medications containing a diuretic, the well known “triple whammy” effect.4,5

Nevertheless, I hope that the warning label on paediatric products containing NSAIDs will alert parents and carers to be vigilant if giving these medicines to children in their care, and to check with their doctor or pharmacist if the child is fluid-depleted from diarrhoea or vomiting.

Identified health concerns and changes in management resulting from the Healthy Kids Check in two Queensland practices

Population screening of young children has been proposed to detect early developmental delay and behavioural difficulties, enabling early intervention and prevention of long-term physical and mental health problems.1–3 The Healthy Kids Check (HKC) is an Australian Government initiative to assess 4-year-old children for physical developmental concerns, introduced as a one-off Medicare-funded assessment in 2008. Although now rescinded, the National Health and Medical Research Council review of childhood screening and surveillance did not recommend screening, instead proposing surveillance (meaning “following development over time”).4 The HKC is classified as screening rather than surveillance, because it is a one-off check. With over 282 200 4-year-olds in Australia in 2010,5 this represents a significant health investment.

The HKC is usually administered by general practitioners, who are well placed to identify and subsequently manage potential problems. Children with possible problems may be referred to specialists for confirmation and management. Although implementation of the HKC varies from practice to practice, there are six mandatory screening items: height and weight, vision, hearing, oral health, toileting, and notation of allergies.6

Effective strategies to identify and confer benefits to child health outcomes are paramount. However, few screening implementation studies have assessed child health outcomes.7 Rather, many have assessed changes to screening rates, identification of potential problems and referrals.8–10 These are surrogate end points; they do not evaluate the effectiveness of screening intervention outcomes. Ideally, to assess the clinical impact of screening programs on child health, researchers should track developmental and health outcomes of children whose screening test results are positive or negative.

There have been two reviews on the effectiveness of the mandatory screening components of the HKC. They found insufficient evidence for the effectiveness of most components, evidence for some components, and evidence of ineffectiveness for the remainder (Appendix 1).3,11 There were plans to expand the HKC to include social and emotional developmental problems and to reduce the screening age from 4 to 3 years in 2014.12 Since the first announcement of the changes, the reduced age has been maintained, but the composition of the new HKC is now unclear. Policy decisions about the expansion of the HKC, and even its original form, are not well informed by data on its efficacy or efficiency. This may reflect the assumption that early detection leads to early treatment and therefore that screening is beneficial. However, screening can be harmful as well as beneficial.13 Screening is effective if (i) the screening test has good sensitivity and specificity;14 (ii) effective early intervention is equitably available and accessed;15 and (iii) early interventions yield better long-term outcomes than those provided later.16

Our study is the first evaluation of the HKC. We aimed to determine how many children had health problems identified by HKC screening and how many of these had their clinical management changed.

Methods

We conducted a retrospective audit of 557 medical records from two Queensland general practices that provided the HKC to children between January 2010 and May 2013 (Box 1). We identified appropriate records by matching dates of birth and Medicare item numbers 701, 703, 705 and 707 (time-based HKC consultations with GP input). We read relevant files from the date of file commencement until either 9 March (Practice 1) or 2 June (Practice 2) 2013. By reading entire files and extracting data related to all child health problems noted by the GP, we were able to match specific health problems to time of detection in relation to the itemised, one-off HKC. Data extracted included child health problems detected before, during and after the HKC. For some children, some health problems were detected twice. In these cases, we coded the first detection: problems detected before and again during, and those detected before and again after, the HKC appointment were coded as “before”; and problems identified during and again after the HKC were coded as “during”.

We recorded any child health problems described in the consultation notes section of the medical records and matched these to the HKC components. These are described in Appendix 2. In the event of a review scheduled or a referral made as a result of the HKC, outcome data from review notes, letters or referrals were also extracted. Two authors (B R and K V) conducted double data extractions for about 10% of the sample to identify potential discrepancies and to discuss and resolve these before independently extracting and entering the remaining data. Data were entered into Microsoft Excel spreadsheets. Discrepancies (predominantly data entry errors) were reconciled by another author (L M) before analyses. Our a priori setting of clinical significance was a minimum change of 6% in clinical management for the program to be effective. This was arbitrary, and represents about one child per GP per year benefiting from the HKC. Study approval was granted by the Bond University Human Research Ethics Committee (RO1568).

Results

Of the total number of children in our sample, over half (331/557, 59%) had no problems in their health or development noted in the medical record at any stage; 116/557 (21%) had problems identified during the HKC; 107/557 (19%) had problems detected before the HKC; and 23/557 (4%) had problems detected after the HKC (Box 2).

Of the children with problems identified during the HKC, 19/557 (3%) were referred or reviewed and then confirmed with appropriate change in clinical management; 7/557 (1%) were managed or referred, with no problems confirmed; 48/557 (9%) had no action taken; and the remaining 42/557 (8%) had uncertain outcomes (Box 3). Therefore, up to 11% (61/557 [19 children with confirmed problems and 42 children with unclear or missing data]) of children may have had problems identified by the HKC and managed appropriately, but most of these children had unclear file notations.

Child health concerns detected by GPs

Overall, 347 problems were identified in 246 children (Box 2). The three most identified developmental problems were speech and language (77/347, 22%), hearing (51/347, 15%) and anatomical concerns (42/347, 12%).

Of the problems detected before the HKC appointment, the most common were speech and language (41/174, 24%), anatomical concerns (32/174, 18%) and hearing (23/174, 13%). Problems identified during the HKC included mandatory components and other problems detected during the check. Problems from the mandatory components were independent toileting (22/144), hearing (21/144) and vision (21/144) (15%, respectively), oral health concerns (10/144, 7%) and concerns regarding height or weight (4/144, 3%). Other problems commonly identified during the HKC involved speech and language (29/144, 20%), behaviour (13/144, 9%), anatomical concerns (8/144, 6%) and cardiac problems (5/144, 3%). No allergy notations were extracted from the health consultation notes.

Behaviour, hearing, and speech and language each accounted for almost a quarter of the problems detected after the HKC (Box 2).

Child health concerns and the Healthy Kids Check

Twenty-six children had 39 problems identified and were either further managed (scheduled for monitoring or review) or referred to specialist services as a direct result of the HKC. Of these, 19 children (19/557, 3% of the total sample) had their problems confirmed, resulting in a change of management (Box 3) (Appendix 3). The most frequent confirmed problems involved speech and language (9/31), hearing (6/31), behaviour (3/31) and vision (3/31) (Box 3).

No further action was recorded for the problems of 49 children (9% of total sample). For these children, the most common problems detected involved toileting (20/56), speech and language (7/56) and behaviour (6/56). For 42 children (8% of total sample) with health-related concerns detected at the HKC, information about scheduled reviews, referral letters or referral outcomes was either missing or unclear (Box 3).

Discussion

The HKC is administered by GPs, who are well placed to identify and manage potential problems early. That 144 problems were detected in 116 children suggests that GPs are diligent in detecting child health concerns. In our medical records audit of two Queensland general practices, we documented a change in management for 3% (19/557) of children, no change for 1% (7/557), no further action for 9% (48/557) and unclear or missing data for a further 8% (42/557). We conservatively estimate that between 3% (19 children with confirmed problems) and 11% (19 children with confirmed problems and 42 children with unclear outcomes) of children have a change in clinical management resulting from the HKC (based on numbers where change was clear and unclear). Our lower estimate of 3% is similar to a developmental screening study that followed referral pathways of children to early intervention services.17

In our study, for 19 children, we identified 26 problems that resulted in clinically important changes to management. Assuming adequate services and interventions were available, accessed and effective, these children benefited from the HKC. They may also have experienced harms (eg, from overdiagnosis of problems that would never have had a negative impact18), but this cannot be determined from the available data.

A lack of independent toileting was the most detected and least actioned problem. This is appropriate: questioning about independent toileting is a mandatory component of the HKC, but action is not recommended until after 5 years of age because of evidence of ineffectiveness.11 However, discussing with parents what is “normal” and giving practical advice about toileting issues may still be beneficial. Child behaviour concerns can be managed actively or passively. A GP may encourage parents to try several strategies to ameliorate child behaviour problems (active), or consider the child’s behaviour to be probably normal and adopt a “test of time” or “watchful observation” approach (passive). There was often insufficient detail in the medical record to distinguish between active and passive approaches; we were therefore unable to determine whether the outcome was appropriate. Finally, problems detected after the HKC may represent missed or new incident problems (not present at the time of the HKC). For example, several learning problems are unlikely to be detected until a child is of school age. Reasons for our lack of allergy notation data are unclear: allergies may have been recorded elsewhere than in the consultation sections of the medical record; the GP may not have recorded any (perhaps not realising their mandatory reporting status); or there were none.

The study has several strengths. It is the first evaluation of HKC outcomes. We used medical records from two large general practices; two researchers independently extracted data; and all data were double entered as a reliability check (few discrepancies were found).

There were also limitations. First, the study design relied on accurate and detailed documentation of events in medical records. We could not determine the outcome of reviews or referrals for 42 children who had a health problem detected during the HKC. Therefore, our estimation of a positive predictive value of the HKC of 3% is likely to be an underestimation. Second, screening can be harmful as well as beneficial. We could not determine whether children (or their parents) experienced harms (such as anxiety regarding the screening results or overdiagnosis).18 Conversely, reassurance of “normal development” is often suggested as a screening benefit; however, medical record audits do not produce these data. Third, because this was a cross-sectional study, the time between the HKC and the medical record audit varied between subjects. Therefore, some data may be missing because of insufficient time between the HKC and rescheduled or specialist appointments. Some children may have had problems that were missed but insufficient time had elapsed for these problems to be recorded, or children may have moved to a new general practice. Finally, this study design precludes estimating the true negative value for the HKC (which would require an independent examination of every child to determine the false negatives). It is impossible to estimate false negatives without an intervention trial (in which all screened negative children would be subject to a gold-standard assessment).

Our data suggest that GPs are identifying important child health concerns during the HKC, using appropriate clinical judgement for the management of some conditions, and referring when concerned. It also appears that GPs use HKC screening to conduct opportunistic examinations that extend the parameters of the HKC, identifying other clinically meaningful child health concerns. However, they may be hampered by limited means of detection with little evidence of effectiveness. We also have no knowledge of the cost-effectiveness of the HKC, although given that its timing coincides with vaccination at 4 years of age, the incremental cost is likely small. Despite lack of evidence of effectiveness, the HKC is scheduled to be expanded to include social and emotional development and assessment at 3 years of age.

Longitudinal studies of community samples or birth cohorts report that few young children have high internalising (eg, anxiety, depression) and/or externalising behaviours (eg, oppositional behaviour) at any assessment period, and that very few continue these behaviours to school entry.19,20 An Australian prospective cohort study following children to adulthood reported screening children at 5 years of age for behavioural, social and emotional concerns poorly predicted psychopathology at 21 years of age.21 Estimates of the sensitivity and specificity of the age 5 years screening tool were 23% and 82%, respectively, for any diagnosis of psychopathology at 21 years of age. In other words, single screening for behavioural, social and emotional problems does not confer long-term benefits for most children, perhaps because of the rapid developmental changes.21 Given the significant child health concerns detected throughout the medical records and at various time points (including times other than the one-off HKC) in our study, we must consider the value of a single-point assessment, which has components of limited evidence.

Despite interventions to improve the uptake of screening in paediatric primary care, few studies have tracked developmental outcomes of those screened.7 Previous research in child developmental screening and subsequent intervention reported that screening for developmental delays was not effective in changing health outcomes for children, and that harms occurred for some parents.22 A longitudinal, prospective cohort study of children undertaking the HKC is needed to understand the long-term outcomes of children with identified health concerns, and to determine whether interventions help or harm.

1 Medical records audit — flow diagram

HKC = Healthy Kids Check.

2 Number of children, and categories, numbers and proportions of problems detected before, during and after the Healthy Kids Check (HKC)

Problems detected*	Before HKC†	During HKC	After HKC‡	Total

No. of children	107	116	23	557
Mandatory HKC components
Height and weight	14 (8%)	4 (3%)	0	18 (5%)
Vision	8 (5%)	21 (15%)	1 (3%)	30 (9%)
Hearing	23 (13%)	21 (15%)	7 (24%)	51 (15%)
Oral health	0	10 (7%)	0	10 (3%)
Toileting	2 (1%)	22 (15%)	1 (3%)	25 (7%)
Other problems detected
Behaviour	10 (6%)	13 (9%)	7 (24%)	30 (9%)
Eating	3 (2%)	3 (2%)	0	6 (2%)
Anatomical	32 (18%)	8 (6%)	2 (7%)	42 (12%)
Cardiac	9 (5%)	5 (3%)	0	14 (4%)
Motor	8 (5%)	3 (2%)	2 (7%)	13 (4%)
Speech and language	41 (24%)	29 (20%)	7 (24%)	77 (22%)
Head circumference	6 (3%)	0	0	6 (2%)
Psychological disorders	10 (6%)	3 (2%)	0	13 (4%)
Other	8 (5%)	2 (1%)	2 (7%)	12 (3%)
Total no. of problems*	174	144	29	347

* Children could have more than one problem; 311 children did not experience any problem at any time. † Includes 28 children with problems identified before and during HKC. ‡ Does not include six children also identified with different problems before the HKC but with no problems at the HKC.

3 Changes in management resulting from problems detected in the Healthy Kids Check (HKC)

Problems detected*	Managed or referred and problem identified	Managed or referred and no problem identified	No action taken	Unclear or missing data	Total

No. of children	19	7	48	42	116
Mandatory HKC components
Height and weight	1	0	2	1	4 (3%)
Vision	3	0	4	14	21 (15%)
Hearing	6	2	5	8	21 (15%)
Oral health	2	0	3	5	10 (7%)
Toileting	1	0	20	1	22 (15%)
Other problems detected
Behaviour	3	1	6	3	13 (9%)
Eating	0	0	3	0	3 (2%)
Anatomical	1	1	3	3	8 (6%)
Cardiac	2	2	1	0	5 (3%)
Motor	1	0	1	1	3 (2%)
Speech and language	9	1	7	12	29 (20%)
Psychological disorders	2	1	0	0	3 (2%)
Other	0	0	1†	1‡	2 (1%)
Total no. of problems*	31	8	56	49	144

* Children could have more than one problem. † Dyslexia. ‡ Diabetes.

Pathogeni-city

Mornings in cities in Australia and elsewhere are a microcosm of early 21st century urban lifestyle, in the making since at least the 19th century — streetscapes dominated by slow-moving cars and trucks, paths occupied by workers, smokers, snackers and runners, and cyclists negotiating traffic. This consumption-dense, movement-poor environment affects our health and our efforts to prevent and manage smoking, obesity and diabetes.

Smokers these days participate in what is increasingly an activity of the outcast — a far cry from the 1960s and 1970s, when (as recent television series remind us) smoking was integral to working and urban culture. Now, Australia’s plain packaging legislation is forcing out, at an individual level and a community level, an activity that shortens and worsens lives, and costs a great deal of money. In this issue, Daube and Chapman (doi: 10.5694/mja14.01026) spell out the clear downward impact that plain packaging has had on smoking rates. The effect is so obvious that simply presenting the facts and adhering to widely accepted editorial standards is all that is required to get the message out — qualities that The Australian doubtless aspires to as it passes its 50th birthday.

I bought and ate a very nice muffin on my way to work today, even though it was packaged very plainly and was not the product of a multinational muffin company. Tackling unhealthy eating clearly requires very different approaches. Nevertheless, as with smoking, putting primary responsibility on the consumer to “quit” unhealthy consumption is counterproductive. Instead, as suggested by Harris and Spooner (doi: 10.5694/mja14.00922) in their editorial on helping patients manage their weight in general practice, modifying a patient’s social environment is a valuable initial step. This can involve mobilising social support and implementing behavioural interventions. Specific dietary, medical and surgical interventions have a scope of use limited to patients with more severe obesity. Perhaps doctors, as part of their patients’ environment, should consider whether they themselves do what they ask their patients to do.

This environment has deep roots in the economics and organisation of modern society. Leeder and Downs (doi: 10.5694/mja14.00943) argue that many aspects of it are obesogenic — economic and commercial models of food production, a built environment discouraging healthier work and leisure, and a lack of public infrastructure to enable people to get about efficiently. Together, these conspire against weight control and better lives. It is too hard to cycle, walk or run along city streets, and too easy to stop and eat, because communities, cities and their food supply lack human scale and responsiveness to real needs. This makes primary care much harder.

Diabetes is one of the more visible manifestations of our current situation. But the threshold for intervention to reduce its development and complications is contestable, and particularly so for gestational diabetes. In two other articles, the authors argue that the most recent international and Australian guidelines, with lower threshold criteria for diagnosis, may result in overdiagnosis, overtreatment and attendant harms. Kevat and colleagues (doi: 10.5694/mja14.00099) highlight the increased risk of maternal hypoglycaemia from treatment, the potential to overlook other important aspects of maternal and fetal wellbeing, and medicolegal implications. D’Emden (doi: 10.5694/mja14.00277) points out that the additional people captured by the new criteria are women for whom risk of adverse neonatal outcomes has not been established.

But, looking beyond smoking, obesity and diabetes, the medical profession could also have a great impact by supporting people to have better health by advocating for a better environment. Doctors as “environmentalists”, perhaps — an idea that has been around since the time of Rudolf Virchow in the 19th century (J Urban Health 2003; 80: 523-524 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456221/pdf/11524_2006_Article_252.pdf).