Patients feel the pain as drug prices jump

The Federal Government’s move to de-list Panadol Osteo from the Pharmaceutical Benefits Schedule have become embroiled in controversy amid claims of price gouging and broken agreements that could double out-of-pocket costs for patients.

Pharmacists warn concession card holders could end up paying more than $15 – twice as much they did under the PBS – for Panadol Osteo after the Government announced that the common painkiller would no longer be subsidised through the PBS.

The warning came as Health Minister Sussan Ley asked the consumer watchdog to investigate after GlaxoSmithKline announced it would jack up the price of its popular painkiller Panadol Osteo by 50 per cent from the start of the year.

Ms Ley said the two decisions were unrelated and there was no obvious explanation for Glaxo’s price hike, prompting her to refer the matter to the Australian Competition and Consumer Commission.

“There are no obvious market changes that justify such a substantial increase,” the Minister said. “Attempts by the makers of Panadol Osteo to link their proposed 50 per cent price increase to Government regulatory changes, without any detail to support their claims, can only be interpreted as an attempt to mislead consumers and pharmacists.

“With such a dominant share of the Australian market, this action by the makers of Panadol Osteo also raises questions about their intentions behind this 50 per cent price increase and, at the very least, requires examination.”

Last year Ms Ley announced that she had accepted a recommendation from the Pharmaceutical Benefits Advisory Committee (PBAC) that a number of over-the-counter medicines, including Panadol Osteo, no longer be listed on the PBS.

The change was to correct an anomaly in which people without a prescription could buy Panadol Osteo off the shelf for less than $5, while a concession card holder purchasing it on prescription would pay $7.52.

But the Government has itself come under scrutiny over the change.

The Pharmacy Guild of Australia has warned that, as a result of the de-listing, Panadol Osteo will actually cost patients more, breaking the terms of the agreement the Guild struck with the Government over the delisting of a number of medicines.

The Guild said it agreed to the delisting of several over-the-counter drugs based on assurances from the Government that they would be available at prices comparable to those paid by Concession Card holders through the PBS.

“It is now clear that this is not the case with Panadol Osteo, which is a recommended first-line therapy for the pain management of osteoarthritis,” the Guild said.

Under the PBS, concessional patients could buy two packs of 96 Panadol Osteo tablets for $7.52.

But the Guild said its analysis showed that the same patients would now pay between $11.90 and $15.00 for the same purchase, even before GlaxoSmithKline’s price hike.

It said the decision by the drug maker to increase the manufacturer price of a 96-tablet pack from $4.28 to $6.31 would push the wholesale price up to $6.65.

“This means patients are likely to have to pay more than $15 to purchase two packs of 96 Panadol Osteo, compared with $7.50 for a concessional patient under the PBS,” the Guild said.

In addition, because the purchases would no longer be made through the PBS, they would not count toward the Safety Net amount (general patients who spend more than $1475.50 on PBS medicines in a year get the rest at the rate of $6.20 per prescription. For concession patients the threshold is $372, after which medicines are free).

The Guild said it was concerned that “many people with chronic, debilitating osteoarthritis will have increased difficulty in affording their treatment” as a result of the changes.

It has asked the PBAC to undertake an analysis of the over-the-counter prices of delisted medicines, and to review its delisting recommendation of a number of medications, particularly Panadol Osteo,

Anti-vax dodge a dubious legal ploy

Doctors are being urged not to sign a form being circulated by anti-vaccination campaigners attempting to circumvent new ‘No Jab, No Pay’ laws.

The AMA’s senior legal advisor John Alati said the form, which asks doctors to acknowledge the ‘involuntary consent’ of a parent to the vaccination of their children, used unusual, confusing and misleading wording, and was of dubious legal status.

“This is not a Government-issued form, and there is no legal obligation whatsoever on a doctor to sign it, or even consider it,” Mr Alati said. “It is likely to be meaningless in the legal sense.”

The form has been circulated among anti-vaccination groups ahead of the 2016 school year following Federal Government welfare changes aimed at denying certain welfare payments to parents who refuse to vaccinate their child.

Under the No Jab, No Pay laws, from 1 January this year parents of children whose vaccination is not up-to-date will not be eligible for the Family Tax Benefit Part A end-of-year supplement, or for Child Care Benefit and Child Care Rebate payments. The only exemption will be for children who cannot be vaccinated for medical reasons.

The new laws are aimed at penalising parents who claim a conscientious objection to vaccination, and to provide an incentive for parents who have neglected their child’s vaccination to bring it up-to-date.

The new laws were introduced amid mounting concern that vaccination rates in some areas were slipping to dangerously low levels, increasing the risk of a sustained outbreak of potentially deadly diseases such as measles.

The Australian Childhood Immunisation Register shows there has been a sharp increase in the proportion of parents registering a conscientious objection to the vaccination of their child, from just 0.23 per cent in late 1999 to 1.77 per cent by the end of 2014.

In all, around a fifth of all young children who are not fully immunised are that way because of the conscientious objection of their parents.

The form being circulated by anti-vaccination groups, headed “Acknowledgement of involuntary consent to vaccination”, is intended to circumvent the No Jab, No Pay laws and allow conscientious objectors to receive Government benefits without allowing the vaccination of their children.

But Mr Alati said the dubious nature of the document made it highly unlikely it would be effective in achieving its goal.

He said the very claim of ‘involuntary consent’ in the form’s title was muddled.

“[Consent] may be grudging or doubtful, but if it is given by a person with capacity, apprised of relevant facts, it is consent,” Mr Alati said. “If it is not voluntary, it is presumably not consent.”

In the form, the doctor is asked to sign a statement that “consent provided by (name of parent) is not given ‘voluntarily in the absence of undue pressure, coercion or manipulation’, and hence that, according to Section 2.1.3 Valid Consent of the Australian Immunisation Handbook 10^th edition, the consent is not legally valid. Given the absence of valid consent, I am/am not willing to proceed with the vaccination of (name of child).”

Mr Alati said the wording of the acknowledgment was “confusing, to say the least”.

But he warned that although the form was likely to be legally meaningless, its wording was concerning.

He said the fact that it did not include a statement that the doctor had outlined the risks and benefits of vaccination may be used as evidence that the patient was not properly informed of the implications of not being immunised.

And he said the wording of the line “I am/am not willing to proceed with the vaccination of…”, created the false impression that the choice of whether or not to proceed with the vaccination lay with the doctor, not the parent.

Mr Alati said where there was no medical reason for exemption, the doctor’s job was to outline the relevant facts about immunisation and to provide vaccination where consent was given. Where it was withheld, “the doctor should not perform the procedure as it might constitute trespass to the person”.

The AMA legal expert advised doctors presented with the form not to sign it.

“Given the unusual, confusing and misleading wording of the form and its dubious legal status, we do not recommend that any doctor sign it,” he said. “Doctors should explain to the parent or carer that it is their choice whether to proceed with the vaccination, based on what they have been told, and note the situation on the patient’s health record.”

He said any doctor considering signing the form should “carefully weigh up the potential risks of doing so”.

Adrian Rollins

Pap smear scare a warning

As the Federal Government embarks on an election year, Health Minister Sussan Ley has had a sobering lesson in the power of social media.

When a story was posted on website Mamamia early on 6 January claiming women would be charged $30 for a pap smear because of the Federal Government’s cuts to pathology and diagnostic imaging bulk billing incentives, it sparked a storm of protest.

A petition on change.org protesting the cuts rapidly gained momentum. By late that morning, it had garnered more than 10,000 signatures.

It was not until almost midday that Ms Ley responded, going on Twitter to argue that there had been “no cut 2 $ value of Medicare Rebate YOU receive 4 pap smear/test or your access to it as falsely claimed 2day”.

But by then the horse had well and truly bolted.

The message that women would for the first time likely to be charged out-of-pocket expenses for a pap smear had spread far and wide through Twitter, Facebook, and other social media, and was being picked up by mainstream news outlets.

As the day wore on, the Minster posted more tweets trying to calm the storm, and her office issued a statement attacking what it said were misleading claims.

In it, her spokesperson said there had been no shift in the cost of having a pap smear or the Medicare rebate.

The sole change, the spokesperson said, was to scrap the incentive paid directly to pathology providers, worth between $1.40 and $3.40 for each pap smear.

“It is therefore not part of the patient’s Medicare rebate, as some have tried to claim,” the spokesperson said, and Ms Ley has insisted that competitive pressures in the pathology industry mean providers will have to absorb the cost rather than pass it on to patients – an assertion the sector disputes.

The Government has struggled to gain traction on the issue.

Its complex and nuanced argument has been drowned out by the simple message being broadcast far and wide on social media that women will be charged for a pap smear.

The scale of the Government’s problem has been laid bare by the fact that, despite numerous media interviews and statements rebutting the $30 pap smear claim, by mid-Friday the petition was closing in on 200,000 signatures.

The episode is a salutary lesson for the Minister and the Government in the perils of blindsiding health groups and the public with unheralded cuts and changes.

There was no consultation prior to the announcement in the Mid Year Economic and Fiscal Outlook on 15 December of $650 million cuts to the bulk billing incentive for pathology and diagnostic imaging services, and little subsequent detail about the measure, leaving a virtual vacuum in which confusion and apprehension could quickly develop.

In the febrile atmosphere of a Federal Election, where the pressure for instant judgement calls and responses is intense, issues can quickly spiral out of any political control.

It could be a very long year for the Government unless it changes tack on how it does business.

Adrian Rollins

Profit-hungry insurers put health system at risk

Aggressive cost-cutting by health insurers is leaving patients stranded without adequate cover and putting the private health system at risk, the AMA has warned.

The peak medical group has told the Federal Government’s Private Health Insurance Review that industry practices including downgrading existing policies, habitually rejecting claims, lumbering patients with bigger out-of-pocket costs, pressuring policyholders into reducing their cover and selling people cover they don’t need, were badly compromising the value of private health cover and could eventually upset the delicate balance between the public and private health systems.

“On their own, these activities reduce the value of the private health insurance product,” the AMA said in its submission to the Review. “Collectively, they are having a destabilising effect on privately insured in-hospital patient care and treatment.”

Health Minister Sussan Ley launched the Review amid growing outrage about the remorseless rise of private health insurance premiums, which far outstrip inflation.

Ms Ley said people were increasingly calling into question the value for money in private health insurance, and late last year sought consumer views on changes including allowing insurers to charge different premiums according to age, gender and smoking status – effectively ending the system of community rating.

But whereas the Health Minister has put the focus on industry regulation as much of the cause of the problem, AMA President Professor Brian Owler said it was being driven largely by the hunger for profit.

Professor Owler said there were several emerging trends in private health insurance that were alarming, most notably a steady downgrading in the quality of cover on offer.

He said that in the last six years the proportion of people with policies that had exclusions had jumped from 10 to 35 per cent, often with serious consequences.

The AMA President said it had become virtually a daily occurrence for patients booked in for common treatments to discover upon arrival that they were not covered by their insurance.

He said all too often insurers made changes to a policy after it had been bought without informing policyholders, leaving many unexpectedly stranded.

“People are shocked to make this discovery only when they need a particular treatment, and doctors are seeing this happen on a daily basis,” Professor Owler said.

The AMA is also concerned by growth in policies that only cover admission as a private patient in a public hospital, or which contain significant exclusions, such as for cardiac treatment or joint replacement.

“A high rate of ‘insured’ people with exclusion policies is effectively creating a risk rating system, as insurers reduce their exposure by offering products that are less likely to require them to pay benefits,” it said, adding that many were inadvertently buying “junk” policies that are designed solely to avoid incurring the Medicare surcharge and provide no practical health cover.

“People think they have purchased a product that will allow them [a] choice of doctor and to jump the public waiting list, but this is unlikely in reality,” the AMA said.

Another development in the peak medical group’s sights is the decision of some insurers not to cover the costs of patients readmitted to private hospital because of complications arising from their treatment.

The AMA said the new approach, pioneered by Medibank Private, the nation’s largest insurer, has serious implications for patient care, and interfere with established safety and quality arrangements.

It warned this could lead private hospitals to refuse to admit patients at high risk of complications, directly compromising the ability of doctors to care for their patients and likely forcing more patients with chronic and complex conditions into the public system.

This risk would be compounded by the possibility, aired by Ms Ley in her consumer survey, that insurers could charge different premiums according perceived health risk.

The AMA warned that such a change would fatally undermine the central tenet of community rating, which requires that all holders of a particular policy pay the same premium – a requirement that helps ensure private cover is available to all.

Professor Owler said that, taken together, these developments in private health insurance did not bode well for the nation’s health system.

“The nature of the current policy offerings, coupled with the behaviour of some insurers to minimise the benefits they pay, is undermining the quality of the product,” he warned. “If consumers withdraw from private health insurance because it is a low value product, or quality products are unaffordable, or risk-rating means some people are uninsurable, there will be additional pressure on the public hospital sector, which is already struggling to meet demand.”

Professor Owler said the Private Health Insurance Review needed to take account of how developments in private health insurance would affect the balance between the public and private health systems.

But he said the Government appeared to have little interest in this, and was instead “more focused on removing itself from financial and regulatory responsibility for the private health sector”.

The Government has flagged interest in dumping the private health insurance rebate and substituting it with a Medicare-style rebate system for hospital treatment that could be used in both the private and public sectors.

Adrian Rollins

[Comment] Civil–military cooperation in Ebola and beyond

The 2014 Ebola outbreak in west Africa blurred the lines between a public health emergency and humanitarian crisis. In so doing, it highlighted serious problems with coordinating disaster responses. Civilian agencies were overwhelmed; several non-government organisations closed down their operations and exited the affected countries; and, although the health sector in Liberia stepped up, Sierra Leone and Guinea remained in disarray. Since then WHO declared Sierra Leone to be Ebola free on Nov 7, 2015,1 and declared the end of human-to-human transmission of Ebola virus in Guinea on Dec 29, 2015.

Government policy, not consumer behaviour, is driving rising Medicare costs

By Professor Stephen Duckett, Director, Health Program, Grattan Institute

This article first appeared in The Conversation on 2 December, 2015, and can be viewed at: https://theconversation.com/governmentpolicynotconsumerbehaviour…

Announcing the ill-fated 2014 budget initiative to introduce a consumer co-payment for general practice visits, the-then Health Minister, Peter Dutton, lamented that annual Commonwealth health costs had increased from $8 billion to $19 billion over a decade.

He described the increase as “unsustainable”, and used it to justify the Budget’s bitter pill.

The implication of his announcement was that consumers were driving the increase in costs, and that action to change consumer behaviour was necessary to rein them in.

The growth numbers were presented as part of the government’s then mantra of a “debt and deficit disaster”, and massaged to create maximum shock and awe. The minister’s numbers did not adjust either for population growth or inflation.

Nonetheless, a more legitimate set of growth numbers would still show Medicare Benefits Schedule (MBS) payments growing at an annual rate of 2.3 per cent in real per head terms, faster than growth in Government expenditure overall (1.8 per cent).

But this still leaves open the question of whether consumer behaviour is driving rising costs, or whether there may be other causes.

A report released in late November by the Parliamentary Budget Office shows that Government policy has driven a significant proportion of the growth in MBS costs. In fact, of the $325 real increase in MBS spending per head since 1993-94, all but $74 has been the result of explicit government decisions.

MBS spending per head is the product of the rebate for each MBS item and the per head use of those items. Both elements of this calculation have been tinkered with as part of policy change over the last two decades.

A significant proportion of the growth in Medicare costs has been driven by Government policies such as items for new services and larger rebates.

Governments have increased rebates for some items faster than inflation. This has been done, for example, to encourage an increased rate of bulk billing.

New item numbers have also been added as part of major policy reviews. (Each MBS service involves one or more item numbers and an associated description. For example, an ordinary consultation with a general practitioner is item number 24.) The single largest cost impact ($51 per head) came from changes to diagnostic imaging items, including new items for magnetic resonance imaging (MRI).

But implementation of policies to expand magnetic resonance imaging and reform diagnostic imaging items more generally has been poor. It is questionable whether consumers are getting value for money from this investment. Also, some diagnostic imaging tests appear to be overused.

Policies designed to increase bulk billing accounted for an extra $70 per head: increasing the GP rebate from 85 per cent of the schedule fee to 100 per cent accounted for $42 per head; targeted increases in the rebate to increase bulk billing rates accounted for the rest.

When did Medicare spending soar?

In the decade to 2003-044, Medicare spending grew by $53 per head. Just over half of that was attributable to the addition of new diagnostic imaging items to the schedule. In the next decade, spending grew at five times that rate – by $272 per head.

Most of the growth was due to decisions taken when Tony Abbott was Health Minister, between 2003 and 2007. In fact, almost half (47 per cent) of the growth in Medicare spending over the last two decades is the result of policy decisions taken when he was running the health portfolio.

The changes were introduced over the years for a mix of policy and political reasons.

The decline in bulk billing was associated with public dissatisfaction with Medicare and was clearly having political impacts. This led to new bulk billing incentives and increases to the rebates for general practitioner fees.

The increasing prevalence of chronic diseases, such as diabetes and heart disease, led to new assessment and care planning items.

A decline in the proportion of GPs providing after-hours care led to new items to redress that as well.

General practitioners got more rebate income (in real terms) for seeing the same number of patients, so it was actually changes initiated by Government that led to the increase in spending.

What does this mean for Medicare reform?

Two main lessons can be drawn from the Parliamentary Budget Office report.

First, the Government must be clear about what is driving growth in expenditure. The co-payment proposal sank like a lead balloon partly because it was seen as inefficient and unfair, but also because the public didn’t have any ownership of the “problem” the changes sought to address. The way the problem was initially presented was wrong, causing confusion between Medicare services (which include diagnostic tests) and GP visits. The vast majority of the population, who have few visits, refused to accept that per head use was going up.

Second, the report shows how much governments have relied on tinkering with the Medicare Benefits Schedule to drive system change in the last decade. “Here a new item, there a new item, everywhere a new item”, became the Canberra policy song sheet.

Health Minister Sussan Ley wiped the slate clean when she was appointed in December, setting up a raft of reviews to look at everything from primary care to disinvestment.

Importantly, reviews must consider whether the Medicare Schedule is still “fit for purpose” in the context of the increase in chronic disease and the impact this is having on clinical practice.

It must be hoped new policies developed in response will be both more sophisticated and less profligate than we have seen over recent decades.

Brit doctors strike over dangerous work changes

Picture credit: William Perugini / Shutterstock.com

Junior doctors working in British public hospitals are set to go on strike in landmark industrial action following the failure to resolve a dispute over safe working hours and pay rates.

The British Medical Association has announced that a 24-hour strike planned for 12 January will go ahead because it remains at loggerheads with the Government and the National Health Service (NHS) over planned changes it warns will increase doctor fatigue, compromise patient safety and undermine staff retention and recruitment.

During the strike, which has the backing of hundreds of other NHS staff including nurses, health care assistants and porters, junior doctors will provide emergency care only. Similar strike action is planned for 26 January, and junior doctors are threatening full withdrawal of their labour on 10 February if the dispute is not resolved by then.

The action centres on a push by Health Secretary Jeremy Hunt to roster more doctors on the weekend and water down safeguards against excessive hours without offering any extra compensation.

The Minister’s plans were overwhelmingly rejected by junior doctors in November, when 98 per cent voted to strike. The BMA called off a strike planned for late last year and instead organised mediated talks with the Government and the NHS.

But, in a statement issued last week, BMA Council Chair Dr Mark Porter accused the Government of failing to take doctor concerns seriously.

“Throughout this process, the BMA has been clear that it wants to reach agreement on a contract that is good for patients, junior doctors and the NHS,” Dr Porter said. “This is why, despite overwhelming support for industrial action, the BMA instead sought conciliation talks with the Government; talks which were initially rejected and delayed by Jeremy Hunt.

“After weeks of further negotiations, it is clear that the Government is still not taking junior doctors’ concerns seriously.

“We sincerely regret the disruption that industrial action will cause, but junior doctors have been left with no option.

“It is because the Government’s proposals would be bad for patient care as well as junior doctors in the long-term that we are taking this stand.”

The doctors and the Government appear to be close to reaching an agreement on changes to salary arrangements, including basing pay progression on undertaking greater responsibilities and the principle of pay for all work done.

But the two sides are deadlocked on rostering changes.

To fulfil Mr Hunt’s vision for a “seven-day NHS”, the Government wants junior doctors to work to a round-the-clock, seven-day week roster without any additional compensation.

The BMA said junior doctors were willing to work with the Government on ways to realise the Minister’s goal, but “only in a sustainable way that does not make a career in medical practice in the UK less attractive”.

“This is a significant area of disagreement,” the Association said. “The BMA fundamentally rejects the idea that Saturday is a normal working day and should be paid as a weekday.”

Doctors are particularly concerned that the Government is trying to push through rostering changes without sufficient safeguards.

The BMA said patient and doctor safety must be the primary focus, and raised fears that the arrangements sought by Mr Hunt and employers could result in “extremely detrimental rotas for non-resident on-call shifts”, including forcing doctors to work the day after being on-call, without an adequate break.

It said there needed to be limits set on working hours “to ensure that patients are not treated by tired, overworked doctors”. This should include caps on hours worked per shift, the number and type of shifts worked in each rolling seven-day period, and provision for adequate breaks.

The BMA said that in addition to ensuring patient and doctor safety, such safeguards would improve the ability of the NHS to attract and retain staff.

“Ensuring that junior doctors are paid fairly for work they do in unsocial hours will go some way to addressing recruitment problems in specialties that work most intensely across 24 hours,” it said. “This is crucial in order to safeguard the future workforce of the NHS.”

Mr Hunt has condemned the proposed strike, saying it “helps no-one”.

He claimed that the only outstanding area of disagreement was cuts to weekend pay, implying the industrial action was unnecessary.

Adrian Rollins

[Correspondence] Iran’s health-care system in transition

Iran’s health system has undergone several reforms in the past three decades with many challenges and successes. The most important reform was the establishment of the National Health Network in 1983, which aimed to reduce inequities and expand coverage and access to health care in deprived areas.1 The Iranian Government has since implemented several other reforms, such as the Family Physician Programme, integration of health services and medical education, the hospital autonomy policy, and the Health Sector Evolution Plan, all of which have had benefits and disadvantages.

Govt faces storm over cuts to pap smear payments

Women face being charged to get their pap smear results under Federal Government plans to axe bulk billing incentives for pathology services.

Calculations by the AMA show the Government’s contribution to the cost of a pap smear will be cut by 12 per cent to $23.55 from 1 July, a $3.20 reduction. There were almost 1.8 million pap smears conducted in 2014-15, suggesting the cut will save the Government around $5.7 million a year.

Pathology providers, who have had no increase in the Medicare rebate for their services for almost two decades, have warned that many labs will not be able to absorb the cut and will instead have to pass it on to their patients.

The amount charged to patients is likely to increase above $3.20 to account for the additional administrative costs of billing individuals, including processing payments and chasing up amounts owing.

Royal College of Pathologists of Australasia Chief Executive Debra Graves told Sydney radio station 2SER FM that most pathology labs would have to reduce the rate at which they bulk bill patients, meaning many will be forced to make a co-payment.

The issue has alarmed doctors and pathologists because of concerns that out-of-pocket costs will convince many patients to forego a pap smear, reducing the chances of early detection of cervical cancer.

AMA President Professor Brian Owler condemned the bulk billing incentive cuts at the time they were announced, describing them as “a co-payment by stealth”.

“Cutting Medicare patient rebates for important pathology and imaging services is another example of putting the Budget bottom line ahead of good health policy,” Professor Owler said. “These services are critical to early diagnosis and management of health conditions to allow people to remain productive in their jobs for the good of the economy.”

Health Minister Sussan Ley has tried to head off a social media campaign on the issue by arguing that the Government has not touched the Medicare rebate it pays for pap smear tests, and the bulk billing incentive was an “inefficient” payment to pathology companies.

In its Mid-Year Economic and Fiscal Outlook statement, the Government estimated that axing the incentive for pathology services and reducing it for diagnostic imaging would save $650 million over four years.

But the AMA said that the bulk billing incentive had been used by successive governments to help offset the fact that the Medicare rebate for pathology services including pap smears had not been increased in 17 years, and the net effect of axing the incentive was a cut in the Government’s contribution to the cost of a pap smear.

An online petition objecting to the change, which is due to come into effect from 1 July this year, has so far collected almost 34,000 signatures.

Those signing the petition claim the cuts are unfair and will lead to the late detection of illness, which would end up costing the health system more.

Professor Owler said the AMA strongly opposed the changes and would be working to convince the Senate to disallow them.

Adrian Rollins

Female doctors in Australia are hitting glass ceilings – why?

Over the past 30 years, there have been some great achievements in gender equity. The number of women enrolled in professional degrees, such as law and medicine, rose from less than 25% in the 1970s to more than 50% in 2015. Australia has introduced a number of equal opportunity policies in health care and in 2000 achieved gender parity in medical schools.

Today, women are typically the dominant group within medical schools and yet remain under-represented in formal leadership positions and particular speciality areas. Although today there is greater female participation in medical roles, it still appears that women are hitting the glass ceiling.

Similar sorts of trends in gender participation are found in other countries such as the UK, Canada and the US. Given these broader trends, we could infer that these patterns are the result of “natural” processes related to the relative merits of the sexes.

Yet studies in Sweden show remarkably similar preferences for speciality areas across male and female medical students. Like Australia, these preferences have not typically translated into representation across the health workforce. This suggests there are forces in place that mean women do not go into their preferred roles.

Women in leadership

Despite the significant representation of women within the medical workforce, today fewer than 12.5% of hospitals with more than 1000 employees have a female chief executive. 28% of medical schools have female deans. 33% of state and federal chief medical officers or chief health officers are female.

In 1986, fewer than 16% of specialists were women. This rose to 34% in 2011.

While this is a substantial increase, women are also woefully underrepresented in these figures. There are also distinct gender patterns across specialist roles. Women’s participation is skewed towards pathology (58%), paediatrics (53%), obstetrics and gynaecology (49%) and underrepresented in orthopaedic surgery (6%), vascular surgery (11%) and cardiothoracic surgery (12%).

A popular explanation for these patterns is that there is a lag phenomenon at play. Once current women advance through their career, figures will self-correct and result in more gender balance in the system.

A more pessimistic view (and one we would subscribe to) is that women are being channelled into particular areas of the profession that are lower status and attract lower pay, while more high-profile roles remain in the hands of men.

This is not to say that male doctors are (all) actively working to keep women excluded from these roles. There are a range of reasons for the barriers around perceptions of capability, capacity and credibility.

Capability, capacity, credibility

The evidence suggests that women are as (and possibly more in some cases) intellectually capable of the high-profile roles that they are poorly represented in.

Our research found that some women may lack self-confidence or doubt their ability to undertake certain roles. What this means is that women may be less willing to self-promote or to put themselves forward for positions traditionally held by men.

Women are more likely than men to have caring responsibilities, which can have implications for perceived capacity. Juggling leadership or the long hours associated with some speciality areas with motherhood can be a challenge.

Many of the areas where women are poorly represented in offer limited options for flexible ways of working and cultivating work-life balance. Some speciality areas have additional years of training which, again, can make them difficult to access for some women.

Perceived credibility is a further barrier, with women not being taken seriously as leaders or surgeons – roles typically associated with males. Sociology has a long tradition of scholarship arguing that organisations and professions are highly gendered and valorise masculine values.

Where work environments are heavily gendered, they can be alienating for some women. Some speciality areas are traditionally considered to be highly male (think surgery) in a way that paediatrics or palliative care may be less so.

These barriers are not simply externally imposed on women by men and may be internalised in women through the broader culture and values of organisations. Internalised beliefs about the traits and qualities required for particular roles can dissuade some women from actively seeking out these roles, unless they received mentoring and support from others.

At an interpersonal level, unconscious biases, sexist micro-aggressions, and a “club culture” contribute to a hostile environment for women within some health-care settings. At a structural level, conservative social norms and male-dominated career pathways can make it difficult for women to balance the pressures and demands of maternity leave, child-rearing, care-giving and running a household with leadership roles.

What is clear is that with such a broad range of barriers, there will be no easy or quick solutions. If we are to successfully smash these glass ceilings then solutions will need to be structural as well as cultural. Women will be unable to overcome these issues alone and solutions will need to be both multifaceted and supported through a broad base.

Helen Dickinson, Associate Professor, Public Governance, University of Melbourne and Marie Bismark, Senior Research Fellow, Public Health Law, University of Melbourne

This article was originally published on The Conversation. Read the original article.

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