[Correspondence] Exclusive and partial enteral nutrition for Crohn’s disease – Authors’ reply

We appreciate the letter from Nizar Senussi about the use of exclusive or partial enteral nutrition in children with Crohn’s disease. We agree that enteral nutrition has many beneficial effects and is probably underused in practice.

Sugar tax might be the sweetener to change behaviour

The sugar tax concept has divided opinion in Australia, and both major political parties have rejected the idea of introducing the tax.

However, sales of soft drinks within a Melbourne hospital dropped by more than a quarter during an Australian-first trial of a sugar tax, monitored by researchers at Deakin University’s Global Obesity Centre.

The trial, carried out at a convenience store in The Alfred over 17 weeks, increased the cost of sugary drinks by 20 per cent.

The results, recently published in the Journal of the Academy of Nutrition and Dietetics, showed sales of the sugary drinks dropped by 27.6 per cent by the final week of the trial, while sales of water increased by almost the same amount.

The team behind the research believe there had, up until their trial, been limited real-world evidence of how an increase to the price of sugar sweetened beverages would change purchasing behaviour in Australia.

Lead researcher Miranda Blake, Associate Research Fellow at the Global Obesity Centre in Deakin’s School of Health and Social Development, said that the trial shows that an increase to the cost of sugary drinks can have a significant impact on lowering consumption.

“Sugary drinks are considered a good target for price manipulation because of their association with increased risk of health issues like obesity and dental decay, their minimal nutritional benefits and the apparent responsiveness of purchases to price changes,” Ms Blake said.

“Voluntary changes by retailers, which make healthy choices relatively more attractive and affordable, may be particularly appealing to retail outlets in community health promotion settings like hospitals, healthcare centres and sports and recreation facilities.”

Project supervisor Dr Kathryn Backholer, a Senior Research Fellow at the Deakin centre, said researchers interviewed customers and staff to get their perspective on the price increase, as part of the trial.

“About a third of the customers surveyed said the price difference had changed their purchasing decision, or would have changed it. Nearly two thirds of those surveyed said they agreed with intervention,” Dr Backholer said.

The World Health Organization (WHO) last year said that a tax of 20 per cent or more results in the drop of soft drink sales, which they say would also cut healthcare costs if it succeeded in improving health outcomes.

The Grattan Institute has suggested a tax of 40 cents per 100 grams of sugar, and calculated that obesity costs Australians $5.3 billion a year. The savings they have projected would mean an extra $500 million for the Budget.

And a study led by researchers from the Australian National University, performed in Thailand, suggested that thousands of cases of type 2 diabetes could be prevented every year by cutting out sugary drinks.

The AMA believes a sugar tax sends a message to parents of children and other consumers that there is a problem with these drinks. While acknowledging a sugar tax is not a magic bullet, it is time start sending the message that highly sugared carbonated drinks are a part of the problem with a growing obesity epidemic.

MEREDITH HORNE

[Perspectives] Ann Ashworth: pioneer in child nutrition

Ann Ashworth may have retired in 2005, but is still closely involved with work in the sphere in which she has made such a contribution over the past half century. She currently co-convenes an international malnutrition taskforce, which aims to build capacity to prevent and treat malnutrition and to highlight malnutrition as a major cause of child death. “Sub-Saharan Africa remains a major problem, but awareness has increased since the launch of the taskforce”, she says.

Sugar tax might be the sweetener to change behavior

The sugar tax concept has divided opinion in Australia, and both major political parties have rejected the idea of introducing the tax.

The trial, carried out at a convenience store in The Alfred over 17 weeks, increased the cost of sugary drinks by 20 per cent.

MEREDITH HORNE

[Global Health Metrics] Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016

The past 37 years have featured declining rates of communicable, maternal, neonatal, and nutritional diseases across all quintiles of SDI, with faster than expected gains for many locations relative to their SDI. A global shift towards deaths at older ages suggests success in reducing many causes of early death. YLLs have increased globally for causes such as diabetes mellitus or some neoplasms, and in some locations for causes such as drug use disorders, and conflict and terrorism. Increasing levels of YLLs might reflect outcomes from conditions that required high levels of care but for which effective treatments remain elusive, potentially increasing costs to health systems.

Paying the piper. So what’s the tune (and how good is it)?

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Healthcare funding challenges us as a nation on three levels. The most obvious and basic is: Where does the money come from? The second is: How can we be certain that the money is being well spent on health gain? The third is: How does our funding of health care match our values as a society? While these challenges interlock, looking at each separately can help us determine if we are on the right track. Let’s look at values first.

How much do we value health care?

Most advanced economies agree that funding health care should be a major call on public money and hence paid for through taxation. This is a political response to social attitudes that see illness as capricious and accidental and hence not something for which the individual can be held to be responsible. Even when groups engage in risky behaviour – smoking or drinking for example – what happens to an individual remains very much a matter of chance.

Who pays? The individual or all of us?

Which smoker develops lung cancer is currently unpredictable. You cannot hold the sufferer responsible for their illness. As a reflection of social solidarity, most societies like ours choose to defray costs for health care by spreading them across all of us.

This approach is not universal: when money is scarce health care costs are sheeted home to the individual. The proportion of government expenditure going to health care is lower as a proportion of GDP in low- and middle-income countries.

The slow slide to privatising health care

Gradually, since the inception of Medicare in 1984, a decade after Medibank, successive Australian governments have sought to contain health care costs by shifting more of them to the individual. This matters – for equity and fairness.

The New York-based Commonwealth Fund ranks health care in eleven economically advanced nations every two years.

It compares health care on 72 indicators in five domains: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes. Australian health care comes second overall but has lost its top-ranking on the dimension of equity. This is because of rising co-payments that now rival those of the US.

Although this “privatisation” was not the focus of the Mediscare furore before the 2016 federal election, it could have been. Rather, it passes almost without comment.

The latest survey can be found here: http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

Funding for activity and outcome

Other strategies to ring-fence the amount of public spending employed in Australia include payments made by the Commonwealth to the States and Territories based on hospital activity as measured by the volume of services they provide.

Efforts put into this approach were mentioned recently in an article in The Australian by Sean Parnell. Parnell wrote that: “Before the last federal election, Prime Minister Malcolm Turnbull struck a deal with the States that the Commonwealth would fund 45 per cent of the growth in activity-based funding, capped at 6.5 per cent nationally each year.” The problem, of course, will be whether growth can be limited to this figure.

This move has liberated us from complete ignorance of what it is that we are paying for and opens the door for the next step – to find out not just what we are doing but what it is achieving. This requires better information about clinical outcomes and this may follow from improved IT systems.

Getting more value for what we spend is a necessary corollary of capping activity. We must rearrange our processes of care to match the decades-long needs of people with chronic problems in the community rather than in hospital.

We can do better with programs of prevention – directed at nutrition, activity, alcohol and tobacco use for example and the commercial forces that determine these. We should continue our efforts to sort through the lengthy Medical Benefits Schedule to remove those items we now know do not work. We are fortunate to live in a country that enjoys good health and high-grade health care. Ensuring that this remains the case for the future would be fine legacy.

Commitment to safety and quality or new cuts to Commonwealth hospital funding?

BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS COMMITTEE

A key focus of the Health Financing and Economics Committee (HFE) is the pricing and funding of public hospitals.

Public hospitals are a critical part of our health system but remain historically and chronically underfunded. They struggle to manage the demands of aging populations, the burden of chronic disease and new technologies and treatments.

At the April 2016 COAG meeting, the Commonwealth committed an extra $2.9 billion to hospital funding. At the same time they secured State and Territories agreement to:

“Incorporate safety and quality into the pricing and funding of public hospitals services with the aim of improving health outcomes, avoid funding unnecessary or unsafe care and decrease avoidable demand for public hospital services.” (IHPA, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 p4)

In February 2017, the Commonwealth Minister for Health directed the Independent Hospital Pricing Authority (IHPA) to reduce the level of Commonwealth contribution to activity based hospital pricing for:

i. Sentinel events;

ii. Hospital acquired complications (HACs); and

iii. Avoidable readmissions.

The events listed in each category are developed by the Australian Commission on Safety and Quality in Healthcare. See Sentinel Events List of Hospital Acquired Complications (HACs). The list of avoidable readmissions is due for release later in 2017.

The Independent Hospital Pricing Authority Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 detailed implementation timeframes and pricing adjustment methodology for the three categories of safety and quality events.

1 July 2017 Sentinel events will not be funded.

1 July 2018 HACs funding will be reduced by a patient “risk adjusted” factor.

1 July 2018 Avoidable hospital readmissions funding will be reduced.

The AMA supports sensible and well-considered initiatives to improve safety and quality in our public hospitals. The AMA wants to see a reduction in HACs and avoidable readmissions but does not endorse the use of Commonwealth financial penalties as an effective way to achieve this. Adverse outcomes result from a complexity of patient and institution factors. If hospitals are overstretched and under-resourced, errors are more likely to occur and less likely to be recognised or remediated.

Safety and quality funding penalties will not assist these hospitals to lift performance. It will instead entrench a spiralling decline in the hospital’s capacity to undertake the internal changes needed to focus on safety and avoid future penalties.

The HAC list

The HFE Committee also questioned the validity of some of the HACs that will incur a financial penalty. Examples include:

i. Malnutrition – Patients admitted to hospital with pre-existing skin eruptions that have, with exclusion of other causes, been diagnosed in hospital as nutrition related. The hospital should not be financially penalised for diagnostic accuracy;

ii. Respiratory complications – aspiration pneumonia. Superficially this seems a reasonable HAC inclusion except it may occur through no negligence, for example as a non-preventable consequence of “grand mal” fit;

iii. Gastrointestinal bleeding – A patient with gastric bleeding secondary to biopsy of melanoma metastasis. While bleeding in this setting is an identifiable risk, it was not avoidable; and

iv. Delirium is another poorly defined HAC that should be excluded.

Patients are unique and respond to treatment differently. Unless a root cause analysis is undertaken it will not be possible to justifiably attribute the event or apportion all of the adverse consequence to “poor or mismanaged public hospital care”.

The timeframe before HAC penalties take effect from 1 July 2018 is too rushed. A three to four month HAC shadow data collection (July–Sept 2017) will not permit reliable indications of financial impact on jurisdictions or identify unintended negative outcomes for patients as hospitals adapt to the financial penalty risks.

We raised similar concerns about the rush to penalise public hospitals for avoidable readmissions from 1 July 2018. The AMA wonders how genuine the planned stakeholder consultation will be given the avoidable admissions list will not be known until late 2017 and IHPA must report to COAG before they meet on 30 November 2017.

The AMA wants to see significantly less HACs and genuinely avoidable readmissions in public hospitals but does not endorse the rushed, bizarre notion that financial penalties will lead to a positive culture of hospital improvement in a severely underfunded and chronically overloaded system. Safety and quality improvement is more likely in “no blame” hospital reporting cultures such as those adopted in Norway and Denmark and recommended in 2014 by the European Commission. I have grave concerns that much of the progress public hospitals have made to date in areas of open reporting and transparency will be lost in the move to a defensive, financially penalised performance system.

Communiqué from Federal Council meeting 17-18 August 2017

BY DR BEVERLEY ROWBOTHAM, CHAIR OF FEDERAL COUNCIL

Welcome to the inaugural communiqué from Federal Council highlighting the debates had, and decisions taken, at its meeting in Canberra in the depths of winter on 17-18 August.

In giving his report, AMA President Dr Michael Gannon made mention of the many recent advocacy wins of the AMA. He reported that the working relationship with the Federal Government has evolved following the compact agreed at the time of the Federal Budget in March, enabling frank and effective engagement with Health Minister Greg Hunt.

Dr Gannon reported that benefits of this engagement can be seen in recent successes with the Minister moving to scrap the draft national maternity services framework which was opposed by the AMA for lack of obstetrician and GP involvement; and support by Minister Hunt to work with State and Territory colleagues to remove mandatory reporting from the National Law. Advocacy on this latter issue has been strongly supported by Federal, State and Territory AMAs, which uniformly endorse the WA approach to mandatory reporting.

The Secretary General’s report provided a comprehensive overview of the AMA’s medico-political advocacy. The Secretary General Anne Trimmer noted that the Governance Institute’s 2016 Ethics Index, with research undertaken by IPSOS, ranked the AMA as the most ethical of the national membership and industry associations.

She reported that the secretariat is working with the Minister’s advisers and the Department of Health to shape appropriately targeted after hours GP services, arising from the draft MBS Review report into these services. The secretariat is working with the NBN to finalise criteria for improved access to broadband in rural areas with a proposal to grant Public Interest Premises status to medical practices under the satellite footprint.

Two of Federal Council’s committees are working with the secretariat to develop a new advocacy strategy for aged care with funding and technology identified as priority areas. Federal Council also agreed to campaign for additional funding for the incoming Practice Incentive Program Quality Incentive and strongly opposed recently flagged proposals to increase the return of service periods for future bonded medical places program participants.

The Federal Council noted updates on the two major government reviews currently underway, the MBS Review and the Private Health Ministerial Advisory Committee review of private health insurance arrangements. An informal grouping of approximately 30 members is working with the AMA to inform its response to the draft reports. Work on the PHMAC review has slowed over the winter period although a new working group on risk equalisation has been established. The AMA will be advocating for changes to the risk equalisation pool to facilitate coverage OF pregnancy under all levels of PHI cover.

Federal Council discussed the Government’s review of the medical indemnity schemes. The AMA has worked closely with the Department of Health to shape the terms of reference and remains strongly committed to the schemes as an effective mechanism to moderate the cost impact on practices and patients. The AMA has been communicating to the profession the need for active engagement in the review by Colleges, Associations and Societies.

The AMA is represented on a small working group to review the Health Professional Online Services (HPOS) system, which emerged as vulnerable to fraud. The Minister for Human Services, Alan Tudge, kept the President informed of the steps taken to ensure integrity of the system prior to the establishment of the review of health provider access to Medicare numbers.

With a Senate inquiry underway into the value of private health insurance and medical out of pocket costs, the Federal Council set aside a policy session to consider the issues in depth. The AMA lodged its submission at the end of July (the submission can be read at submission/submissions-out-pocket-costs-australian-he…).

The submission included data on billing practices collected from a poll of members.

Federal Council, noting the growing public commentary calling on limits on out of pocket medical expenses, agreed that the priority was to correct misleading statements about the role of doctors’ fees in the debate about affordability of health care. An animated debate ensued with Councillors contributing a range of views based on their personal experience.

The issue has been largely driven by private health insurance and the growth in gaps in coverage and exclusions. Federal Council noted that there had been limited complaints to the Private Health Insurance Ombudsman about out of pocket expenses. Federal Council also noted that many medical services had always had an element of out of pocket contribution, not to be confused with the charging of an excessive fee which the AMA strongly opposes. Federal Council agreed that there needs to be greater clarity on what constitutes an excessive fee and that this needs to be clearly communicated to the public.

The President acknowledged the comments of Federal Council and noted that he had an opportunity to address these issues in his upcoming address to the National Press Club (the transcript of the President’s address can be read at media/dr-gannon-national-press-club-address-0).

The AMA’s work on public health initiatives continues, ranging from road safety to obesity and physical activity. Federal Council heard progress reports from working groups led by Councillors and debated draft position statements on road safety, obesity and physical inactivity. Other working groups are considering nutrition, mental health and the social determinants of health. A revised position statement on mental health is in development in conjunction with the AMA psychiatrists’ group.

Federal Council received reports from each of its practice group councils, and from its committees. The State and Territory AMAs and Australian Medical Students’ Association provided reports on current areas of advocacy.

Health Star Rating – five years on

Five years ago I authored a column in Australian Medicine advising members that after concerted advocacy on the need for easy to improve food labelling, the AMA had been recognised as a key stakeholder and invited to join the Front of Pack Labelling Stakeholder Working Group.

The Group, chaired by Jane Halton AO PSM, then Secretary of the Federal Department of Health and Ageing, was tasked with developing a new approach to front-of-pack labelling that would help consumers identify healthier packaged food options.

We recognised that the Nutrition Information Panel was too complex, and often too small to help consumers. The move also recognised that there was some level of dissatisfaction with the two most popular front-of-pack labelling approaches at the time. I welcomed the invitation to participate but am sure there was a level of scepticism about whether this diverse group of stakeholders could work together to create and implement a system that would support Australians to make healthier choices.

Five years on and the AMA has just lodged its submission to the Five Year Evaluation of the Health Star Rating system. Health Star Ratings (HSR) are now found on over 7,000 products, produced by 122 manufacturers, in major supermarkets Coles, Woolworths and Aldi. It appears that the HSR system is largely working as intended. A representative survey conducted with 1000 participants recently found that:

59 per cent were aware of the Health Star Rating system;
50 per cent were likely to use HSR on a regular basis; and
Of those using HSR, 33 per cent recalled buying a different product because it had a higher HSR.

Some food producers are reformulating their products in order to achieve a higher HSR. Regardless of the motive, removing unnecessary salt, sugar and fats from processed foods is beneficial. The AMA’s submission has recommended monitoring the number of reformulations to provide important insights into the effectiveness of the HSR system in driving change.

Consumers report that they would like to see HSR on more products. If uptake in a particular food category is low it can make comparisons difficult. The HSR system is currently voluntary, but it is essential that the food industry recognises the benefit to consumers and displays the HSR on as many products as possible. On this point, the AMA’s submission argued that any slowing of uptake should result in active consideration of the HSR becoming mandatory.

There have been some vocal critics of the HSR, but the reality is that most are not responsible for the weekly grocery shopping, the target audience for HSR. The criticisms typically focus on three issues. Firstly, that the system can’t be used to compare a can of baked beans with a tub of yogurt. This was never the intention of the HSR, rather instead it helps consumers compare similar products in order to identify the healthiest option.

Further criticism highlights that certain foods receive an inappropriately high HSR. The HSR Advisory Committee takes these concerns seriously. For example, the rules around products that display HSR based on how they are prepared (cake mixes, powdered soup, sauce mixes or drink flavourings) are currently under review.

Finally, some advocate that HSR apply to fresh foods. This was never the intention, with the HSR applying only to manufactured and processed products. A general principle that “fresh is best” is recognised by the AMA and we continue to advocate for more public education on nutrition. The HSR isn’t perfect, but it is certainly much better than nothing.

The AMA submission also advocates that HSR play a role in helping consumers to reduce consumption of ‘added sugars’ through penalisation of these additions. A recent report by the George Institute found that 70 per cent of packaged foods contain added sugars. Current labelling doesn’t provide any distinction between naturally occurring and added sugars, making it extremely difficult for consumers to identify products that contain unnecessary added sugars. Food labelling alone will not address obesity, but supporting consumers to identify healthier food products will play a part.

PROFESSOR GEOFF DOBB
AMA BOARD MEMBER

The AMA’s submission is available from: submission/ama-submission-five-year-review-health-star-rating-system

Disease and nutrition being targeted in the Pacific

Combating disease and improving nutrition among Pacific islands populations is the focus of new initiatives funded by the Australian Government.

Foreign Minister Julie Bishop has announced a $7.7 million commitment towards innovative pilot programs targeting mosquito-borne diseases in Fiji, Vanuatu and Kiribati.

Another $2.5 million is being contributed towards nutrition programs in the Pacific.

Australia’s innovationXchange has partnered with Monash University’s Eliminate Dengue Program and national health ministries to target dengue, Zika virus, and Chikungunya.

The program uses naturally occurring Wolbachia bacteria to stop mosquitoes from transmitting these diseases to human populations.

“Dengue is an insidious virus that emerges quickly when the conditions are right and in its severe form, it can be fatal,” Ms Bishop said.

“In Fiji, Vanuatu and Kiribati, over 30,000 people have been infected in the last decade.

“These pilots build on Australia’s existing efforts to promote health security in the Pacific by building countries’ capacities to detect, assess and respond to diseases with epidemic potential.

“Given Australia’s close proximity to our Pacific neighbours, supporting regional health security also works to ensure our own national health security.”

Malnutrition is also a challenge in the Pacific, with about half of all children in Papua New Guinea stunted because of chronic under-nutrition.

Across the Pacific the prevalence of non-communicable diseases, including diabetes, is rising, and linked to poor diet choices.

The Government will invest $4 million in winners of the LAUNCH Food Challenge to improve nutrition in our region, including $2.5 million in the Pacific.

Winning initiatives will work to increase local production of healthy food using innovative technology and drive healthier food choices through improved public health communication.

LAUNCH Food is a global innovation challenge supported by Australia’s innovationXchange, USAID’s Global Development Lab and regional stakeholders.

The innovationXchange was established in March 2015 within the Department of Foreign Affairs and Trade to form new partnerships and identify innovative approaches to improve the effectiveness and impact of the Australian aid program, and public policy more generally.

CHRIS JOHNSON