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Preference: Government and politics

Obesity Epidemic: Time for a rethink. Time for action. Time for leadership.

BY AMA VICE PRESIDENT DR TONY BARTONE

There is no shortage of axioms we associate with this topic. “Obesity is a life style disease.” “It is a matter of choice.” “It’s a disease of modern society.” “It’s a matter of too much in and not enough out.” Right? If only it was that simple. The only thing we can hand-on-heart truly say is that it is a multifactorial problem that requires a multi-pronged approach.

Recently at the AMA National Conference in Melbourne, I had the pleasure of being part of a panel (https://natcon.ama.com.au/session/tackling-obesity) discussing the multiple facets of what is the obesity epidemic and what needs to happen if  we  are to  curb this rapidly progressing threat to our lifestyle and our health outcomes.

The panel facilitated by Professor Brad Frankum included Professor Stephen Duckett, Professor Steve Allender, Jane Fleming OAM; Mr Ahmad Aly, Dr Geoffrey Annison.

What was clear from the discussion was that the problem is immense. With two-thirds of Australians either overweight and or obese we are under no illusion. Recent Australian Institute of Health and Welfare data shows that it is even greater among men where there appears to be a social acceptance around their significant excess weight.

However, what is clear from the discussion is that we need to start looking at obesity as more than just an individual condition. We need to look at it at various levels, with many different strategic approaches focusing at individual, community and public health levels, as well as at government and regulatory perspectives, if we are going to achieve changes.

We need to seriously consider the evidence emerging that it is a biological disease; one that has its underlying components in genetic predisposition and one that has its expression in an obesogenic environment that is modern society.

Furthermore, this emerging body of opinion makes the point of the existence of a primitive response mechanism of our bodies to maintain and resist attempts at dieting, defending our weight through a raft of physiological and hormonal changes in response to the weight loss and defending the set predetermined weight. Hence, we can understand the resultant yo-yo weight loss/gain our patients report in response to many attempts at losing weight.

Clearly, prevention is extremely crucial but is not the sole solution. However its role cannot be diminished. It is cheaper to prevent a problem than to solve it. Being a GP, this is firmly underpinning all our efforts in lifestyle advice and behaviour modification that we discuss with our patients. GPs are ideally positioned to initiate the conversation with our patients and assists our patients with their journey in dealing with their situation. Furthermore, GPs, I believe, have a unique place in the communities they are part of and need to lead and be a part of the community solution.

The issue of a sugar tax came under the spotlight. Even though evidence was presented by Professors Allender and Duckett that a sugar tax cut directly led to modifying or a change in consumption behaviour and to a lesser extent to a reduction in weight (particularly in the Mexico example), such evidence was ignored by Dr Annison of the Food & Grocery Council who still, along with others, believes that moderation of intake and appropriate lifestyle choice is the sole solution to the problem.

Prof Duckett beautifully made the point that he felt a sugar tax was inevitable. Political overtones from the sugar production electorates would be a significant obstacle in the short term. He did make the point that if the politicians representing these electorates, which also have some of the highest levels of obesity, did not recognise the impacts on the health of their constituents, and did not make the hard decisions, why on earth are we paying them. The importance of top-line government/ industry measures was further emphasised, as was more robust food labelling requirements.

Effort in this space must be proportional to the size of the problem. Prof Allender illustrated the comparison with a viral global epidemic led to two-thirds infection rate with a resulting 20year life expectancy outcome. The border response at our airports in the face of a possible virus would be absolutely enormous and immediate.

Communities need to be empowered to develop solutions to lead the change. Studies are showing that a local community level reduction of 5 per cent in obesity in children, over a two-year timeframe, can lead to immediate health improvements and a reduction in the burden of mental health issues.

The appropriateness of bariatric surgery as an intervention in obesity needs to be well understood and supported by public health and government interventions, especially when it comes to public hospital funding. It is clear that bariatric surgery is not an isolated intervention but part of a suite a measures that is a lifelong contract by the patient.

Physical activity is equally important but the role of gyms as being the sole solution is being beautifully challenged by the work of people like Jane Fleming. Participants aged between 18 and 87 frequenting her community-led physical activity programs, reveal the success of a program deserving closer attention and more support.

Fearless, strong leadership from the very top is required in this space. National governments and authorities can provide the coordination. But there needs to be leadership to facilitate a multi-pronged suite of policy and other interventions focusing at every level in the discussion – from Government right down to the individual choices and response. Our position statement outlines a suite of measures and initiatives at every level and no one, single measure is more important    or acceptable in isolation. It does provide a pathway or a roadmap to guide advocacy and the basis for further engagement. Ultimately, every part of the medical profession has a role to play in leading their community and their profession in the future solution to this epidemic of the 21st century.

AMA’s forward direction examined at National Conference

BY AMA SECRETARY GENERAL ANNE TRIMMER

Another AMA National Conference over with a stimulating and varied program, including appearances from the political leadership. It is rare to have a full hand of senior politicians – the Prime Minister, Health Minister, Minister for Ageing and Indigenous Health, Leader of the Opposition, Shadow Health Minister, and Leader of the Greens. It reinforces the fact that health is front and centre of national politics and will remain there as the next Federal election approaches.

Beyond national politics the Conference considered policy issues as diverse as obesity, organ and tissue donation, and the important topic of doctors’ health. It was pleasing to hear the announcement by Health Minister Greg Hunt that the Government would commit funding to assist in addressing the issue of the mental health of doctors and medical students. This will form part of a larger piece of work that the AMA is embarking on to develop a framework for doctors’ health and wellbeing.

In a year when there is no AMA election (as is the case in the odd-numbered years) delegates have more freedom to consider the policy topics, away from the politics of an election. Delegates have the opportunity to meet informally, as they did over breakfast on Sunday, when groups of members with interests in common came together to share a meal. As one psychiatry delegate commented, it provided a great opportunity to meet with other psychiatry members to realise shared interests and passions.

It was encouraging that members who had never before attended a National Conference were able to participate and see first-hand the work of the AMA. With the move in 2016 to representation from among practice groups, a more diverse representation of members is now supported to participate.

At the Annual General Meeting held during National Conference, the Chair of the Board, Dr Iain Dunlop, and I reflected on the year that was 2016. It was a strong year of medico-political advocacy and member engagement which can be seen in more detail in the Annual Report, available through the website.

I reported on the inaugural Future Leaders program, held in Canberra in early August. Calls for applications are currently open for doctors within the first five years of taking up a leadership position in a State, Territory or Federal AMA. The AMA Board is committed to investing in the development of the next generation of AMA leaders – I encourage you to apply if you qualify. Applications and selection criteria are available through the website.

At the Annual General Meeting the Chair announced to members the decision of the Board, taken after considerable research and reflection, to sell and lease back AMA House in Canberra. The Board took the view that more flexible investment of the capital tied up in the building would provide a better return on members’ funds. The building is fully capitalised following an extensive upgrade to its infrastructure over the past four years. A sale is likely later in 2017 following a marketing campaign.

For those who were not able to attend National Conference, this edition of Australian Medicine provides a good overview.

 

The saga of trying to put Medicare on ice

By Professor Stephen Leeder, Emeritus Professor Public Health, University of Sydney

Frozen indexation has meant effectively a cut in income for general practitioners who bulk bill their patients. Although small, it mounts up when multiplied by the number of patients they see. 

If Medicare rebates on consultations lasting less than 20 minutes (the most common type of consultation) had not been frozen in 2014, instead of being $37 now they would have risen to about $40 this year if indexed to the consumer price index. That is according to a fact sheet produced by the Royal Australian College of General Practitioners.

Bulk-billing is hard to freeze

Although this may be thought to serve as a disincentive to bulk-billing, the Federal Health Minister Greg Hunt is quoted in the March 19th issue of The Australian as “highlighting the record increase in bulk billing rates, which have risen 3.5 per cent since the Coalition won Government”. So it does not seem to have reduced bulk billing?

Mr Hunt went on to say: “In the last half-yearly figures that are just out, we’ve gone from 84.7 per cent, to 85.4 per cent, so in other words, Medicare funding is up and bulk billing rates are at their highest ever on a half-yearly basis.”

Why freeze?

Associate Professor Helen Dickinson, a public service research academic at UNSW, explained the origin of the freeze a year ago in the Conversation and reported on ABC: “Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a $664 million budget savings plan … A continuation of the indexation freeze, initially for four years starting in July 2014, was further extended in the 2016 budget to 2020. It has been estimated this will save $2.6 billion from the health bill over six years.” 

The intention in the proposed 2014 Federal Budget was that the freeze would work alongside a co-payment and reduced reimbursement for short consultations. The continued freeze was the only measure that cleared the Senate.  Although the justification for these proposed imposts on general practice included the absolute costs of primary care, these costs included a lot of activity other than general practice.  According to the Australian Institute of Health and Welfare, health expenditure in Australia in 2014-2105 was $161.6 billion.  

A freeze, or frost bite? 

In 2013-2014 $58.8 billion was spent on hospitals and $54.7 billion on ‘primary care’ but as just said, this includes general practitioner services (about $9 billion), other health practitioners, community health care, dental services and medications.  So with a total annual health budget of $161 billion, general practitioner services amounted to $9 billion or 17 per cent. The predicted savings from the freeze, each year, represent 0.25 per cent of total health expenditure. Has such a small saving been worth it?

If seeking to save money in health care, it is probably best to look first at the big expenditure items.  This is why the review of the Medicare Benefits Schedule makes good sense and why, universally, there is an interest in demanding greater efficiency from our hospitals.

But as those who have had the responsibility for running a big and complex organisation know full well, it is wise to assess the likely flow-on from any cuts. Impositions on primary care are not likely to lead to the political pushback that cuts to high-powered specialty services will elicit.  But if they demoralise this workforce, heaven help you in trying to integrate care for patients with complex chronic problems.  And that will cost you far more in the long term than you will save by freezing general practice rebates.

Is a freeze on Medicare fair?

My final point concerns equity. How come private health insurance premiums rise each year whereas general practice fees do not?  Private insurance premiums are heavily subsidised (30 per cent or $6.5 billion in the 2016 budget) by the federal government.  So the Government does not worry about indexing its contribution to private health insurance but it does for Medicare. Work that one out if you can.

 

[Correspondence] In support of the candidacy of Dr Tedros Adhanom Ghebreyesus for WHO DG

I am dismayed to read the letter by Frank Ashall (May 19)1 on the candidacy of Dr Tedros Adhanom Ghebreyesus for WHO Director-General (DG). In my view, Ashall misconstrued the facts in an attempt to undermine Dr Tedros. I am writing as a former Minister of Health for the Ethiopian Government who succeeded Dr Tedros and who was in office during the period Ashall referred to in his letter.

[Correspondence] Attacks on health facilities and health workers: time for the Security Council to act

May 3, 2017, marked the first anniversary of a UN Security Council resolution that condemned attacks on health facilities and personnel in conflict and the “prevailing impunity” for these atrocities.1 But neither the Security Council nor governments have acted on the resolution. Now, a report by the Safeguarding Health in Conflict Coalition, Impunity Must End,2 shows that in 2016, the number and intensity of attacks on health services in 23 countries continued to be staggeringly high. In ten countries, hospitals were bombed or shelled.

Mandatory reporting: the “low hanging fruit” in doctors’ health

Mandatory reporting came under fire at a panel discussion on doctors’ health at the AMA National Conference held in Melbourne late last month.

Currently all states, with the exception of Western Australia, have regulations which require health practitioners to report colleagues who they feel may be a threat to their patients to AHPRA or the Medical Board of Australia.

Although mandatory reporting requirements are well-intentioned efforts to protect patients, many professionals worry they are a major barrier to doctors seeking help for their mental health issues.

Speaking on the panel, Dr Bav Manoharan, a Queensland-based radiology registrar who has been involved in resilience building projects, said there was confusion around mandatory reporting legislation and what the threshold was for reporting colleagues to AHPRA.

“That is a real concern,” he said. “There’s a stigma around a doctor approaching a health service and asking for help in environments where there is mandatory reporting.”

He said that changes to manadatory reporting requirements and a clearer understanding of them were the “low-hanging fruit” in the debate around doctors’ health.

Dr Janette Randall, a Queensland-based GP who is chair of Doctors Health Services Pty Ltd, noted that the threshold for reporting was actually quite high but there was a lot of subjectivity and doctors were getting inappropriately reported.

“We have a strong sense of fear and reluctance to present for care and this is one of the barriers. I do think the time has come to remove the onus on treating practitioners to report. That’s not to say we don’t all retain an ethical and professional responsibility in that space, but we’ve got to be able to create safe environments for people to seek care.”

Marie Jepson, who has been involved in research into depression in the legal community, said mandatory reporting tended to drive mental health issues underground.

“We found there were lawyers who would deliberately not go to the doctor, even though they were quite ill, so they didn’t have to lie on their application for a practising certificate. It meant that they complied with the regulation, but it was a timebomb waiting to go off.”

The issue of revamping mandatory reporting requirements does seem to be gaining traction, particularly in New South Wales, where Health Minister Brad Hazzard has announced he will review the legislation.

Mr Hazzard met with health stakeholders at a forum this week in Sydney to discuss measures to improve the mental health of doctors, after several high profile cases of doctor suicides in the state.

“It’s really critical for people with mental health issues to be able to talk to someone with absolute confidence and know that person is there to help and not to judge them – that’s the critical problem with mandatory reporting,” Mr Hazzard told the forum.

“Having listened to the young doctors it may be that the mandatory reporting requirements are technically not the problem, but practically they are, because that perception among young doctors is by seeking mental health help they may be damaging their career. It looks to me that mandatory reporting provisions do need changing.”

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

[Comment] Offline: Dear Tedros…

You did it. And when the celebrations began after your election as Director-General of WHO last week, it seemed so obvious that you would. You have high-level political experience, you made major contributions to strengthening Ethiopia’s health system, and you are adept at navigating the treacherous waters of international health politics. The debates you took part in, the public scrutiny of your manifesto, and the transparency of the election process have not only strengthened WHO’s reputation, but also enhanced your legitimacy.

[Editorial] Progress in environmental litigation

Ahead of June 5, which marks World Environment Day, the UN Environment and Colombia Law School’s Sabin Center issued a 40-page report, The Status of Climate Change Litigation—a Global Review, released on May 23, which brings together environmental cases of litigation to date. Effective solutions to combat the effects of climate change have been slow to arise. One of the main barriers to implementation is that holding one government or organisation accountable for a global issue is misaligned with the scale of the problem.

AMA nomination sought for NHMRC committee

Expressions of interest are being sought for an AMA nomination for consideration as a member of the National Health and Medical Research Council’s working committee reviewing its ethical guidelines on organ and tissue donation and transplantation.

The NHMRC has asked the AMA to nominate a member for the committee as it plans to start a review of the following ethical guidelines: 

  • Organ and tissue donation after death, for transplantation – Guidelines for ethical practice for health professionals, 2007;
  • Making a decision about organ and tissue donation after death, 2007;
  • Organ and tissue donation by living donors – Guidelines for ethical practice for health professionals, 2007;
  • Making a decision about living organ and tissue donation, 2007; and
  • Ethical guidelines for organ transplantation from deceased donors, 2016.

An integral part of this process will be the establishment of the Organ and Tissue Working Committee (OTWC) comprised of members who have experience or expertise in one or more of the following:

  • Health ethics;
  • Religion;
  • The donation and transplantation of organs and tissues from living donors;
  • The donation and transplantation of organs and tissues from deceased donors;
  • The coordination of organ and tissue donation and transplantation;
  • Community and consumer issues related to transplantation, donation and/or health ethics;
  • Government policy regarding donation and transplantation of organs and tissues from living and deceased donors; and
  • Aboriginal and Torres Strait Islander health issues.

The NHMRC is currently seeking nominations of persons for appointment to the OTWC for the period to 30 December 2019. The AMA has been asked to provide a nominee with experience or expertise in ‘the donation and transplantation of organs and tissues from living and deceased donors’. 

The NHMRC will consider nominations from a number of organisations and there is no guarantee the AMA’s nominee will be appointed.

The NHMRC will seek formal declarations of interest, following initial consideration of all nominations. The NHMRC’s Policy on the Disclosure of Interests Requirements for Prospective and Appointed NHMRC Committee members. This policy can be found on their website at: https://www.nhmrc.gov.au/_files_nhmrc/file/about/committees/nhmrc_policy_disclosure_of_interests_committee_members_150513.pdf

The OTWC will be effective for the period 1 July 2017 to 30 December 2019.

 Deadline for consideration as AMA nomination

AMA members should send their nomination, along with their Curriculum Vitae, to the Federal AMA Secretariat at ethics@ama.com.au by COB Monday, 12 June. Your personal information will be protected in accordance with the AMA’s privacy policy which can be found on the AMA’s website at privacy-policy.