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Preference: Government and politics

Government policy ambitions trimmed

Health Minister Sussan Ley is talking up the Health Care Homes trial and the MBS review as the Coalition Government recalibrates its policy ambitions following its scarifying Federal election experience.

Trying to prevent her term in office being defined by the widely disliked Medicare rebate freeze, Ms Ley insisted in an interview on ABC radio that her policy program was much broader and encompassed a range of measures to improve the delivery of health care including the modernisation of the Medicare Benefits Schedule, the Health Care Homes model of chronic care, the introduction of an opt-out national e-health record system and mental health reforms.

“That is just for starters,” she said. “We are embracing brave, forward-looking reform.”

But with Prime Minister Malcolm Turnbull virtually declaring Medicare off-limits during the election campaign and Treasurer Scott Morrison demanding that any new expenditure items must be fully offset by savings elsewhere, the Minister is yet to identify any new policy initiatives since being re-elected.

Instead, she has so far had to spend much of her time defending her performance during the election campaign and the Medicare rebate freeze, and re-defining the Government’s approach to upgrading Medicare’s software and payments systems.

“We have made very strong undertakings that the Medicare system will be modernised within Government and by Government, and I am looking forward to that because the existing system is about 30 years old and it is creaking a little and work needs to be done,” Ms Ley said.

Seeking to move the discussion of health policy beyond a focus on the Medicare rebate freeze and bulk billing, the Minister said, “I am not just focussing on one thing. There is so much more we are doing in health that is just not related to that.”

“A lot of things we are doing around hospital payments, around modernising the MBS, around the Health Care Home initiative…all of these things are all part of the discussion.”

While the Medicare rebate has stagnated since 2014, Ms Ley said the Government’s Health Care Home initiative would give GPs access to a new stream of revenue by providing “a different way of paying for quality health outcomes”.

But the Government could face problems trying to have parts of its policy agenda supported in Parliament.

The deal struck by Ms Ley with pathology and diagnostic imaging providers over the scrapping of the bulk billing incentive for their services has yet to be approved by Parliament, and was opposed by Labor during the election.

The Government is also facing opposition from some of the minor parties over its funding cuts to aged care.

Adrian Rollins

All quiet on the health policy front

The success of Labor’s Medicare campaign and the Coalition’s slender margin of support in Parliament have virtually killed off the chances of significant health reforms in this term of government, according to investors.

While re-appointed Health Minister Sussan Ley is pushing ahead with the Medical Benefits Schedule review, the Health Care Homes trial, pilots of the My Health Record e-health system and reforms to mental health, analysts at Macquarie Group and UBS think the window to further major health changes has been slammed shut by the tight election.

UBS healthcare analyst Andrew Goodsall has put the chances that the Government will abandon the Medicare rebate freeze by next election at 75 per cent, and told The Australian it would be leery of undertaking any other major policy initiatives.

“Classically, the political cycle allows more substantial reform to occur in a post-election Budget,” Mr Goodsall said. “However, the success of the Labor Party campaign against the privatisation of Medicare may limit Government reforms on Medicare in the near-term.”

His doubts were shared by Macquarie analysts who, in a note to clients, said the Government would have little appetite for “meaningful” reform in the short- to medium-term given the resistance it has faced in Parliament and its near-run election result.

This period of relative policy stagnation would help ensure those parts of the healthcare industry that were prospering under current arrangements to continue enjoying solid growth.

“In our view, the benign political outlook for healthcare reform suggests private hospital growth is set to continue unabated at the lofty levels seen historically,” they said.

Adrian Rollins

 

 

Pharmacists: shopkeepers or health professionals?

Pharmacists could face restrictions on the amount of shelf space they devote to selling vitamins, shampoo, toothpaste and other retail products as their dual role as health care professionals and shopkeepers comes under scrutiny in a Federal Government review.

The Government’s Review of Pharmacy Remuneration and Regulation is looking into whether there should be limits imposed on the retail activities of community pharmacies amid accusations that pharmacists are misleading consumers and undermining their own professional integrity by selling vitamins, herbal remedies and other complementary medicines that have no proven health benefit.

While dispensing prescriptions is the principle source of pharmacy earnings, generating 61.5 per cent of income in 2015-16, sales of cold and flu remedies, cough syrup and other non-prescription medicines contributed 16 per cent of revenue, purchases of vitamins, herbal remedies and other complementary medicines provided 15.5 per cent of earnings and sales of cosmetics and beauty products generated 7 per cent of income.

The review panel, led by Professor Stephen King, has been told that community pharmacists face a conflict of interest between their role as a health care professional and a shopkeeper, particularly when stocking their shelves with products for which there is no evidence of efficacy.

As community pharmacists push for an expanded role as health service providers, they are coming under scrutiny over their business practices, particularly regarding the sale of complementary medicines.

The issue is probed in a discussion paper released as part of the review, which has been set up to examine the role of pharmacists and community pharmacy in delivering health services, now and in the future.

The review panel said it had heard of numerous examples where community pharmacists had gone “above and beyond in providing additional services that are in the patient’s best interest, even though they may not be compensated for these valuable services”.

But, it added, there were those who objected to the current direction in which community pharmacy was headed, and were concerned that issues around their dual roles as a retailer and health service provider were yet to be resolved.

“It was put to the Panel that community pharmacists face conflicts of interest between their role as retailers and as health care professionals,” the discussion paper said. “This tension between treating consumers as customers or patients was attributed to the contrast in the remuneration from dispensing and the revenue generated from the sale of over-the-counter medicines and complementary products.”

The Panel said it had heard concerns that financial pressures might cause pharmacists to compromise on the professional advice they provide, such as recommending medicines or products that were not necessary.

“It was also claimed that many complementary products do not have evidence-based health benefits and, as such, the sale of these products in a pharmacy setting may misinform consumers of their effectiveness and undermine the professional integrity of community pharmacists.”

The review has been set up under the terms of the current Community Pharmacy Agreement, and the panel is seeking comment on possible reforms in the sector, including changes to the pharmacy business model.

The discussion paper cited Guild Digest data showing that community pharmacies have an average annual turnover of $2.8 million, and a net profit of $107,000 (excluding proprietor salaries).

Among the proposals up for consideration is that Government funding, which is worth $13.2 billion under the life of the current five-year agreement, should be made conditional on the amount of revenue pharmacists generate from other sales.

“Should Government funding take into account the business model of the pharmacy when determining remuneration, recognising that some businesses receive significant revenue from retail activities?” is one of the question raised in the discussion paper.

“Should there be limitations on some of the retail products that community pharmacies are allowed to sell? For instance, is it confusing for patients if non-evidence-based therapies are sold alongside prescription medicines?”

It noted that some hospital pharmacies have designed their service area to resemble a clinic, getting rid of a counter and “providing a private environment without distraction, which maximises the professionalism of patient-pharmacist interaction”.

The review is being undertaken in the context of a sustained push by pharmacists for an expanded role as health providers.

Health Minister Sussan Ley said pharmacists were already taking on a greater role, including providing routine vaccinations and blood pressure checks, and the industry is pushing to be allowed to undertake broader screening and patient health checks.

The AMA has raised concerns about the risk to patients from pharmacists providing services beyond their realm of expertise, and is expected to make a submission to the review.

The Pharmacy Guild said the discussion paper raised many “thought-provoking questions” about the pharmacy sector and was preparing a formal response.

The review panel will conduct a series of public forums over the next five weeks, and those interested have until 23 September to provide a written submission.

Details of the review, including the discussion paper and the consultation process, are at: http://www.health.gov.au/internet/main/publishing.nsf/Content/review-pharmacy-remuneration-regulation

Adrian Rollins

Medicinal cannabis can now be prescribed by NSW GPs

New regulation means that from 1st August 2016, NSW doctors can seek approval to write up scripts of medicinal cannabis for patients who need it.

Previously, patients could only legally access cannabis-based medicines through clinical trials. However thanks to changes under the Poisons and Therapeutic Goods Amendment (Designated Non-ARTG Products) Regulation 2016 (under the Poisons and Therapeutic Goods Act 1966), the drugs can now be prescribed for patients who have exhausted their standard treatment options.

“People who are seriously ill should be able to access these medicines if they are the most appropriate next step in their treatment,” NSW Premier Mike Baird said on Sunday.

Related: Slow and steady on medicinal cannabis

How do doctors get approval to prescribe?

In order to prescribe the drugs, doctors will need to get approval from both the Commonwealth Therapeutic Goods Administration and NSW Health.

According to NSW Health, in making their decision, the Commonwealth “will consider the prescriber’s expertise, the suitability of the product to treat the patient’s condition, and the quality of the product.”

A committee of medical experts from NSW Health will review the prescriber’s application, and will consider “whether the unregistered cannabis-based product is being appropriately prescribed for the patient’s condition.”

Related: MJA – Medicinal cannabis in Australia: the missing links

What can be prescribed?

Some cannabis-based products have already been assessed for quality, safety and efficacy by the medicines regulator. These include:

  • Nabiximols (Sativex®) – registered in Australia with the Therapeutic Goods Administration for managing spasticity associated with multiple sclerosis.
  • Dronabinol – registered by the US Food and Drug Administration for anorexia in patients with AIDS and chemotherapyinduced nausea and vomiting, where standard treatment has failed.
  • Nabilone – registered by the US Food and Drug Administration for chemotherapyinduced nausea and vomiting.

Although applications aren’t limited to the above products, the products applied for must be legally produced and manufactured to appropriate quality standards. There must also be evidence that supports use for that product for the patient.

How do doctors apply?

For more information and to apply for authority to prescribe and supply cannabis products, visit NSW Health’s Pharmaceutical page. More information can also be found at their Cannabis and cannabis products information site.

Latest news:

[Editorial] Evidence-based policy for salt reduction is needed

Evidence-based medicine has become the bedrock of treatment guidelines, but why does evidence-based medicine not translate into evidence-based policy? Governments and health organisations around the world are advocating salt intake be reduced, but little robust evidence exists to support a reduction in salt for the general population. Indeed, the few randomised controlled trials (RCTs) available have not strongly supported the benefit of salt reduction in normotensive populations. There is no real disagreement that high salt intake is associated with high blood pressure, and most studies indicate that high blood pressure is associated with more cardiovascular events.

Doctors challenge Border Force gag laws

Image: paintings%20/%20Shutterstock.com“>paintings / Shutterstock.com

Controversial Federal Government laws to suppress information regarding the operation of immigration detention centres are being challenged by a group doctors who claim they are being used to intimidate health workers.

The group Doctors for Refugees and the Fitzroy Legal Service have jointly launched action in the High Court challenging the constitutionality of secrecy provisions in the Australian Border Force Act which threaten up to two years imprisonment for workers who disclose conditions in detention centres.

In a Statement of Claim filed with the High Court on 27 July, Doctors for Refugees said it was bringing the action to “advocate for the public’s right to know what their Government is doing in their name, and to support the public health imperative of transparency to mitigate harm occurring in detention centres on and offshore”.

The action asks for the High Court to rule on whether the public disclosure of information regarding the operation of detention centres, including conditions, health care, mandatory detention and offshore detention, are protected by the freedom of political communication implied in the Constitution, and whether the ABF Act invalidly prohibits such communications.

The Act, which was introduced last year, includes provisions which make it a criminal offence for those contracted to provide services to the Department of Immigration and Border Protection to record or disclose information obtained in the course of their work. The penalty is up to two years’ imprisonment. The legislation was passed with support from Labor.

The Act was introduced amid widespread concern regarding conditions in detention centres, including reports of widespread sexual abuse and significant physical illness and mental health problems, particularly among children.

The Moss review substantiated allegations of sexual abuse at the Nauru Detention Centre, and operator Transfield Services reported 67 claims of child abuse, 33 allegations of sexual assault or rape, and five alleged instances of sexual favours traded for contraband.

Soon after being elected, the Coalition Government abolished an independent panel of medical experts that was overseeing health care in detention centres, and has so far ignored AMA calls to replace it with a group of health experts empowered to investigate and report on detention centre conditions directly to Parliament.

Doctors have protested that the secrecy provisions in the ABF Act conflict with their ethical duties and their obligations under the Medical Board of Australia’s Code of Conduct, most particularly their paramount obligation to the health of their patients.

These concerns have been magnified by a number of cases in which, it is claimed, authorities have sought to intervene in or override clinical advice on the transfer of detainees in need of medical attention, including the death of Omid Masoumali, who was medically evacuated to Australia from Nauru more than 24 hours after setting himself alight.

Suspicion that the Government has sought to interfere in the clinical decisions of doctors has been heightened by documents obtained by The Australian under Freedom of Information laws showing Immigration officials devised a strategy to prevent detainees from being evacuated to Australia for medical treatment because of a “propensity of those transferred to Australia to join legal action which prevents their subsequent return to PNG or Nauru”.

The Government has denied that the intention of the law is to prevent doctors from speaking up on behalf of their patients, and Immigration Minister Peter Dutton has indicated he thinks it unlikely that health practitioners would be prosecuted under the Act.

But it has since been revealed that Dr Peter Young, who oversaw the mental health care of detainees for three years, was the subject of Australian Federal Police investigation, including access to his electronic communications.

At its most recent Naiotnal Conference, the AMA passed an urgency motion asking the Federal Council to “look into the matter” of AFP surveillance of doctors.

In its Statement of Claim, Doctors for Refugees said the Government’s assurances had “not altered the perception that the ostensible intent of the ABF Act is to silence doctors, teachers, social workers and others working in detention centres”.

“Regardless of whether prosecutors exercise a discretion to charge health practitioners working with refugees and asylum [seekers], the law remains in place,” the Statement said. “Practitioners speaking out are subject to a Sword of Damocles, unsure when or if they might be investigated or charged for adhering to their ethical (and moral) obligations.”

Doctors for Refugees said that even if the High Court found that the ABF Act’s secrecy provisions served a legitimate purpose, it would also have to decide whether the constraint they imposed on political communication was “proportionate”.

“The ultimate question is whether the secrecy provisions…undermine the proper functioning of our democracy and the right of electors to be informed accurately, openly and truthfully about matters of national political importance,” the group said.

Adrian Rollins

 

Royal Commission must shine light on NT juvenile justice and health

The AMA has thrown its support behind the Federal Government’s decision to establish a Royal Commission into the mistreatment and abuse of young people being held in detention in the Northern Territory.

AMA President Dr Michael Gannon said shocking images and revelations broadcast by the ABC’s Four Corners program had sent shockwaves through the community, and reinforced warnings made by the AMA over many years about the treatment of people, particularly children, incarcerated in the NT.

“The cruelty, violence, and victimisation experienced by these young people will have impacts on their mental and physical health for the rest of their lives,” Dr Gannon said.

“The unacceptable abuse that took place at the Don Dale Detention Centre is clearly indicative of broader problems in the detention and prison systems in the Northern Territory. The AMA, at both the Federal and Territory level, has raised concerns over many years based on reports from doctors and other health professionals, including AMA members, about the poor condition and treatment of people in detention in the Territory, especially children – very often Indigenous teenagers.”

Rates of incarceration among Aboriginal and Torres Strait Islander people are startlingly high – they comprise 28 per cent of all prisoners, and are 13 times more likely to be locked up than other Australians.

Young Indigenous people are even more likely to be imprisoned – they make up half of all children aged between 10 and 17 years held in detention, and are 17 times more likely to be under “youth justice supervision” than children of the same age in the broader community.

Dr Gannon said the Royal Commission would “put a spotlight” on juvenile justice and the health issues that were often involved in getting young people locked up, and called for “brave and creative” thinking about alternatives to imprisonment.

“Health issues – notably mental health conditions, alcohol and drug use, substance abuse disorders, cognitive disabilities – are among the most significant drivers of incarceration. We must also look at the intergenerational effects of incarceration,” the AMA President said.

The revelations of shocking abuse at the Don Dale Centre have also focused attention on police practices that are seen to be contributing to high rates of imprisonment among Indigenous children, particularly the NT’s ‘paperless arrest’ powers that allow police to detain people for up to four hours for minor offences.

“There must be a community debate about alternatives to incarceration, and serious investigation into alternative methods of rehabilitation for young offenders,” Dr Gannon said. “This will require considering new ideas, and brave and creative thinking.”

The health impacts of high rates of Indigenous imprisonment were highlighted by the AMA in its Indigenous Health Report Card 2015 – Treating the high rates of imprisonment of Aboriginal and Torres Strait Islander peoples as a symptom of the health gap: an integrated approach to both released last year.

“The rate of imprisonment of Aboriginal and Torres Strait Islander people is rising dramatically, and is an issue that demands immediate action,” the Report Card said.

The AMA has called for the Federal Government to set a national target to close the gap in imprisonment rates between Indigenous people and the rest of the community, with children and young people the immediate priority.

Adrian Rollins

Your postcode shouldn’t determine your health – or whether you’re admitted to hospital

People ending up in hospital for diabetes, tooth decay, or other conditions that should be treatable or manageable out of hospital is a warning sign of system failure. And Australia’s health system is consistently failing some communities.

A Grattan Institute report, Perils of place: identifying hotspots of health inequalities, released today, identifies a number of geographical areas where high rates of potentially preventable hospital admissions have persisted for a decade. This is unacceptable place‑based inequality.

Using data from Queensland and Victoria, the report identifies 38 places in Queensland and 25 in Victoria that have had potentially preventable hospitalisation rates at least 50% higher than the state average in every year for a decade. There is no evidence to suggest the pattern is any different in other states and territories.

Reducing potentially preventable hospitalisations in these places to average levels would save at least A$10 million a year for the Queensland and Victorian health systems. Indirect savings, such as improving the productivity of the people affected, should be significantly larger.

Different places, different problems

Some of the areas identified as having high rates of potentially preventable admissions were in remote areas such as Mt Isa in Queensland. Others were in suburban centres such as Broadmeadows in Melbourne.

In some places, the high rates of admissions were driven by high rates of re-admissions – a small number of people each having a large number of admissions each year. In these places, better targeting care to high-risk individuals may help to reduce rates.

Yet in other places, re-admissions did not contribute to the problem at all.

Areas that have a low socioeconomic status, are regional, and/or have a high proportion of Indigenous people are more likely to experience health inequalities.

But even in Australia’s most disadvantaged areas, persistently high rates of potentially preventable hospitalisations are rare. Because many such areas have low rates of potentially preventable hospitalisations, examining why some have a problem while others do not may help to understand what needs to improve.

What can governments do about it?

The Grattan Institute’s report has three clear messages for governments and local health agencies such as Primary Health Networks.

First, make sure prevention efforts are focused in places where high rates of potentially preventable hospitalisations have existed for a while. These are the places where health inequalities are already entrenched and, without intervention, are most likely to endure.

On average, about half of areas which had a high rate of potentially preventable hospitalisations in one year had dropped back to closer to the state average the next year (55% in Victoria, 45% in Queensland). This means that if governments or Primary Health Networks make their intervention decisions based on just one year of data, they will have a false sense of reassurance that their interventions are working when in fact their success might just be the result of random chance.

Second, think local. Australia is not a uniform country and a one-size-fits-all approach will not work. Some areas may have excellent local primary health care services but, in the face of very severe disease burdens, the area ends up with a high rate of potentially preventable hospitalisations. Other areas might have poor access to primary care services.

There is no uniform pattern for the causes of high rates of potentially preventable hospitalisations. Tailored policy responses are required.

Primary Health Networks have been given responsibility to identify and address health needs in their regions. They must identify the areas with high rates of potentially preventable hospitalisations and distil why these rates are occurring. They then need to design locally tailored responses, in partnership with local health authorities and communities.

Unfortunately, there is as yet only limited evidence of what works in reducing potentially preventable hospitalisations. Governments should therefore invest in trials to reduce potentially preventable hospitalisations in places identified as having high rates.

The cost-effectiveness of interventions must be established on a small scale before they are rolled out to further areas.

This leads to the third message: interventions must be rigorously evaluated so they expand the evidence about what works. As Primary Health Networks become more sophisticated at identifying the people most in need and as the evidence from trials builds, efforts to reduce health inequalities should be strengthened and expanded beyond the priority places identified here.

The role of place in shaping people’s health and opportunity is well-established. Governments and Primary Health Networks must ensure all communities get a fair go.

Improving the health of people in these places with high rates of potentially preventable hospitalisations will, in the long-run, reduce health costs. Even more importantly, it will increase social cohesion and inclusion, workforce participation and productivity, by making many more people healthy and able to make the most of their lives.

Stephen Duckett, Director, Health Program, Grattan Institute. The ConversationThis article was originally published on The Conversation. Read the original article. 

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