Financial capacity in older adults: a growing concern for clinicians

Determination of whether an older person is capable of managing their own financial affairs is a vexing question for health and legal professionals, as well as government agencies such as courts and tribunals. This process is often stressful for older people, and families can find that deciding when to take over is a frustrating and divisive exercise. Having family members manage an older person’s assets may result in or exacerbate existing family conflict.

In this article, we define financial capacity and provide an overview of the assessment process, the potential impact of impaired capacity on older adults and implications for clinicians. We focus on best-practice suggestions for clinical management of questions of financial capacity.

What is financial capacity?

Financial capacity entails the ability to satisfactorily manage one’s financial affairs in a manner consistent with personal self-interest and values.1 Although the terms competency and capacity are often used interchangeably in this literature,2 we will refer to capacity throughout. The capacity to appropriately manage financial affairs has both performance and judgement aspects,3 which are distinct in that older people can have limitations in one or both. For example, an older person may be capable of carrying out financial transactions such as purchasing items, but not have the judgement required to spend within their financial means. Conversely, an older adult might have the judgement to assess the relative merits of competing demands on their financial resources, but lack the technical capacity to carry out financial transactions.

Financial capacity is just one domain of capacity. Others include the capacity to consent to medical treatment, make or revoke an enduring power of attorney, participate in research, make their own will, consent to sex, marry or divorce, vote, drive and live independently (covering a broad range of abilities). Eighteen key abilities covering nine domains of financial capacity have been identified4 and these range from simple tasks, such as being able to name coins and notes, to more complex tasks, such as making and explaining investment decisions (see Box 1).

Decision making and referral

Decision making can be conceptualised as a spectrum with complete autonomy at one end and substitute decision making at the other. A person is presumed to have capacity, and thus be able to make their own decisions, unless proven otherwise; however, this capacity is decision specific and may fluctuate. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) entered into force in May 2008 and Australia ratified the CRPD in July 2008. The CRPD promotes supported, rather than substitute, decision making. Supported decision making can, however, be problematic. Examples of this include cases where those providing the support are not motivated to do what is in the best interests of the impaired person or where the person’s level of impairment is so severe that any form of decision making by the impaired person is no longer possible. Informal arrangements to cover both these situations are available and are outlined in a guide to guardianship and administration laws across Australia published by the Intellectual Disability Rights Service.6 The involvement of family and friends is important, and a referral to social work services or other allied health professionals may facilitate such informal arrangements. Formal arrangements can be made through guardianship boards or tribunals that operate in most states and territories (http://www.agac.org.au). Again, referral to such bodies can be intimidating for family (and sometimes even for institutions such as residential aged care facilities). Assistance and support with such a referral from allied health professionals, general practitioners or peak bodies such as Alzheimer’s Australia and Dementia Behaviour Management Advisory Services may be invaluable.

What are the potential impacts on older adults?

Impaired financial capacity renders an individual vulnerable to financial exploitation through actions such as undue influence and consumer fraud. Financial abuse is estimated to affect 1.1% of older Australians,7 and was found to be the most common form of elder abuse in a Western Australian study, particularly for older women and very old people.8 Undue influence describes a situation in which an individual is able to convince another to act in a way contrary to their will. Such influence might manifest in situations where an older person is financially capable but the family or other caregivers decide to manage the older person’s finances based on their own interests. Furthermore, consumer fraud is estimated to affect 5% of older Australians.9 Examples of such schemes often include taking advantage of cognitive decline in a vulnerable older person — as when a person purporting to be a tradesman comes to the door demanding payment for services supposedly carried out at an earlier time. Older adults who are more socially isolated or who are more dependent on paid external services in order to continue living in the community may be more vulnerable to such exploitation.

Given that older people’s share of total wealth has increased over the past two decades and is likely to continue to do so,10 the problem of financial capacity will become more pressing, and it is likely that more questions of capacity will present in primary and community health care settings.

Who is more at risk?

Recently there has been a focus on the clinical aspects of financial capacity, which broadly span cognitive, affective, instrumental and social capacity functioning.2 Older people with neurodegenerative disorders such as Alzheimer disease, Parkinson disease, frontotemporal dementia and mild cognitive impairment appear particularly vulnerable to diminishing financial capacity.3 How such changes manifest themselves, from a lifespan perspective, might be conceptualised11 as amounting to relatively minimal changes in financial capacity with normal ageing, particularly if older people have good social and instrumental support from family and friends. However, people with mild cognitive impairment may have increasing difficulty with more complex financial skills including bank statement management, bill payments and financial judgement,4 and it is important for families and health professionals to be mindful of reports or observations of such decline. Ideally, early intervention would allow for smoother transfer of financial responsibilities and perhaps avoidance of distress or embarrassment on the part of the person with declining financial skills.

People with mild Alzheimer disease have been reported to have impairments in both simple and complex financial skills, with rapid decline in a 1-year period.5 More global impairment of financial skills with probable financial incapacity has been reported in most people with moderate Alzheimer disease;12 and complete lack of financial capacity in severe Alzheimer disease.11 Over time and with increasing severity of dementia, older adults may show declining interest and engagement in their financial affairs, as well as reduced concerns about the consequences of their inaction. Such a situation may continue without family members being aware that anything is amiss. Sorting out financial concerns in cases of advanced dementia, particularly in the context of familial discord, can be challenging for health care professionals.

How to assess financial capacity

There is currently no universal standard for evaluating financial capacity. Overreliance on clinical judgement or non-specific assessment tools (such as the mini-mental state examination13) for determining specific aspects of capacity, such as the ability to make a will and distribute assets or to determine the presence of undue influence, is worrying. Failure to include specific objective measures of financial capacity as well as emotional and cognitive functioning may result in overreliance on clinical impressions rather than objective data, and may be less useful in a legal context.

A review of clinical assessment approaches to financial capacity in older adults found that current methods were based around a clinical interview, neuropsychological assessment and performance-based assessments.2 The authors stressed the need for a multipronged evaluation. The extant literature suggests that cognitive domains relevant to capacity assessment in Alzheimer disease include conceptualisation, expressive language, numeracy skills, semantic memory, verbal recall, executive function and receptive language.14 However, all relevant cognitive domains are often not systematically tested, or may be overassessed.15 Important contextual and social variables that inform interpretation of objective data16 and may be directly tied to the potential for financial abuse17 are often ignored. Moreover, reduced insight in patients about their own limitations and abilities, as well as the presence of psychiatric conditions such as depression and anxiety, can also lead to errors in judgement by patients with cognitive decline. Abilities such as insight are only infrequently examined by clinicians in the course of assessing financial capacity. Assessment of a person’s ability to understand the facts and choices related to their decisions, to distinguish between alternatives and weigh up consequences, and to make an informed choice and communicate their decision should also be made.

Unfortunately, the research literature related to financial capacity has been difficult to translate into sound clinical practice in health care settings. Capacity assessments at times rely almost completely on clinical judgement, which is not evidence-based and which may be vulnerable to bias.18 Comparability and consistency between approaches, even in a single case, may be lacking.19 Approaches to determining capacity have rarely been empirically validated with respect to their real-world reliability and utility.20 Part of the difficulty has been establishing a credible gold standard.15

What does this mean for clinicians working with older people?

Primary care providers such as GPs and community nurses are often the first to encounter older people with diminishing financial capacity,11 and they have an important role to play in acting on their concerns; for example, by discussing them with the family or referring the patient for more formal capacity assessment. Five different roles that clinicians may choose to adopt have been suggested:11 educating patients and families about the need for advance financial planning; recognising signs of possible impaired financial capacity; assessing financial impairment, financial abuse or both; recommending interventions to help patients maintain financial independence; and making timely and appropriate medical and legal referrals. This approach seems relevant to all clinicians working with older people. Ideally, all three of the suggested assessments — clinical interview, neuropsychiatry assessment and performance-based tests — would be conducted to assess capacity.

A comprehensive clinical interview is vital to directly assessing financial capacity with respect to a patient’s physical and emotional health. Objective assessment of cognitive function and potential psychiatric disorders, such as depression, anxiety, and psychosis and related symptoms such as delusions, are important and should use instruments that have been appropriately normed and, wherever possible, developed for geriatric populations. Performance-based assessment of financial capacity and decision making, as well as an assessment of a person’s vulnerability to undue influence and exploitation, are also important.2 A brief list of relevant instruments to consider appears in Box 2; this list is indicative rather than exhaustive.

Conclusions

Financial capacity is emerging as an important concern related to older people and those involved in their care. Assessment of financial capacity should include formal objective assessment in addition to a clinical interview and gathering of contextual data. There is no one instrument that can be used in isolation; use of multiple sources of data, objective performance-based tests, neuropsychiatric assessments and self-report clinical interview data is recommended. The decisions that result from an assessment of capacity can have far-reaching consequences. In order to better meet the needs of patients, their families and their carers, as well as clinicians involved in such assessments, standards and guidelines for the assessment of capacity are needed.

1 Financial conceptual model*

Domain and task

Task description

Difficulty

1 Basic monetary skills

a Naming coins/currency

Identify specific coins and currency

Simple

b Coin/currency relationships

Indicate relative monetary values of coins/currency

Simple

c Counting coins/currency

Accurately count groups of coins and currency

Simple

2 Financial conceptual knowledge

a Define financial concepts

Define a variety of simple financial concepts

Complex

b Apply financial concepts

Practical application/computation using concepts

Complex

3 Cash transactions

a One-item grocery purchase

Enter into simulated one-item transaction; verify change

Simple

b Three-item grocery purchase

Enter into simulated three-item transaction; verify change

Complex

c Change/vending machine

Obtain change for vending machine use; verify charge

Complex

d Tipping

Understand tipping convention; calculate/identify tips

Complex

4 Chequebook management

a Understand chequebook

Identify and explain parts of cheque and cheque register

Simple

b Use chequebook/register

Enter into simulated transaction; pay by cheque

Complex

5 Bank statement management

a Understand bank statement

Identify and explain parts of a bank statement

Complex

b Use bank statement

Identify specific transactions on bank statement

Complex

6 Financial judgement

a Detect mail fraud risk

Detect and explain risks in mail fraud solicitation

Simple

b Detect telephone fraud risk

Detect and explain risks in telephone fraud solicitation

Simple

7 Bill payment

a Understand bills

Explain meaning and purpose of bills

Simple

b Prioritise bills

Identify overdue utility bill

Simple

c Prepare bills for mailing

Prepare simulated bills, cheques, envelopes for mailing

Complex

8 Knowledge of personal assets/estate arrangements†

Indicate asset ownership, estate arrangements

Simple

9 Investment decision making

Understand options; determine returns; make decision

Complex

Overall financial capacity

Overall functioning across tasks and domains

Complex

* Reproduced from: Martin RC, Griffith HR, Belue K, et al. Declining financial capacity in patients with mild Alzheimer’s disease: a one-year longitudinal study. Am J Geriatr Psychiatry 2008; 16: 209-2195 with permission from Elsevier. † Requires corroboration by informant.

2 A brief list of instruments available for assessing financial capacity, decision making and vulnerability

Addenbrooke’s Cognitive Examination – III21

Informant Questionnaire on Cognitive Decline in the Elderly22

Semi-Structured Clinical Interview for Financial Capacity12

Financial Competence Assessment Inventory23

Geriatric Depression Scale24

Geriatric Anxiety Inventory25

Instrumental Activities of Daily Living Scale for elderly people26

Ethical challenges for doctors working in immigration detention

To the Editor: We applaud the professional stance taken by Sanggaran and colleagues in highlighting the ethical challenges for medical practitioners working in Australia’s immigration detention centres,1 and extend our support to other clinicians and custodial officers who carry out their duties with respect, care and consideration for human rights.

The authors make a clear and compelling case for a “robust, independent and transparent monitoring” system in places of detention.1 The Australian Medical Association has worked with previous and current federal governments towards achieving such a system, through formal ratification of the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).2 This would create, within 3 years of the protocol’s ratification, a “national preventive mechanism” to oversee compliance with human rights obligations in places of detention — immigration detention centres, prisons, juvenile detention centres and locked mental health facilities. Australian enterprises in offshore locations such as Nauru and Manus Island may also be subject to independent review.

Australia signed OPCAT in 2009 but has not yet ratified the decision, despite a National Interest Analysis and a bipartisan parliamentary committee recommending prompt ratification.3 As of October 2014, 74 other countries had ratified the protocol.4 Some Australian state and territory parliaments have introduced enabling legislation, which is the jurisdictional mechanism for implementing internationally binding obligations. This will be part of the robust, independent and transparent monitoring system that Sanggaran and colleagues called for.

We call on the Australian Government to heed their request to provide a safe environment for people living in detention and to allow health practitioners to practise ethically.

Ethical challenges for doctors working in immigration detention

To the Editor: As psychiatrists and physicians working with adults and children in mandatory, often prolonged, immigration detention, we confirm Sanggaran and colleagues’ account.1

Quality evidence from diverse, independent, multinational sources, including legal and medical investigations over two decades, finds that immigration detention:

contravenes multiple international conventions that Australia has signed;2
harms mental health of detained children and adults, and detention employees, in a process likened to torture;3
incurs vastly greater financial and legal costs than alternatives, and makes profits for multinational companies from desperate, traumatised people;4
fails to deter people from seeking asylum and is unnecessary to prevent their absconding (because they rarely abscond);2
compromises ethics, through mandating secrecy, neutralising advocacy and destroying independent oversight;5 and
fosters conditions for systematic institutional child abuse and its lifelong consequences.6

Immigration detention fails every standard of medicine — science, ethics, health economics, pragmatics and human rights (including freedom from abuse and the right to highest attainable health standards). Yet despite accumulated evidence and established opposition from national professional bodies — including medicine, paediatrics, psychiatry, public health, psychology, nursing, social work and medical students — successive governments deny or rationalise inveterate harms, arguably implicate professionals in legitimating abuses the professionals cannot prevent, and deflect needed policy change.7 The case against immigration detention is irrefutable.

As immigration detention’s damages are unmitigated by any (mental) health intervention, and immigration detention renders clinicians ineffectual, a strong clinical and ethical argument exists for withdrawing services. Rather than health care for asylum seekers and detainees remaining with the Department of Immigration and Border Protection or being outsourced, federal or state health departments should provide and manage services and monitor standards independently. This will not resolve the problem of immigration detention, but it may attenuate some of its worst effects.

The Australian medical response to Typhoon Haiyan

Our well equipped civilian professionals made a rapid and valuable contribution to internationally coordinated aid

On the morning of 8 November 2013, category 5 Typhoon Haiyan (known locally as Typhoon Yolanda) made first landfall over Eastern Samar province in the Philippines. Sustained, damaging winds of 235 km/h gusting to 275 km/h were accompanied by a tidal storm surge and subsequent inundation. The official number of fatalities stands at 6190, with 28 626 injuries attributed to the event, and over 16 million people affected.1

On 9 November, as reports indicated the scale of the disaster, the government of the Philippines officially requested international humanitarian assistance. Eastern Samar and Leyte provinces, including the major population centre of Tacloban (population 220 000) sustained catastrophic damage.

As part of a $40 million assistance package, the Australian Government deployed a field hospital and a fully self-sustaining civilian medical team with a mandate to assist the Philippines Department of Health in immediate postdisaster medical care. The first Australian medical assistance team (AUSMAT) of 37 medical, nursing, paramedical and logistics professionals deployed on 13 November with over 28 tonnes of equipment. They were relieved on 27 November by a second team of 37.

At the direction of the Philippines Department of Health, a field hospital with 35 inpatient beds, two operating tables, an outpatient clinic and a resuscitation room was deployed to Tacloban, the most critically affected population centre. Clinical activity commenced 7 days after Typhoon Haiyan made landfall — one of the fastest deployments of a foreign field hospital to a sudden-onset disaster.2 The field hospital was registered as a Type 2 facility under the new World Health Organization guidelines for foreign medical teams in sudden-onset disasters.3 This was the first occasion on which a host government was able to use the WHO guidelines to assess the contribution of foreign medical teams.

The AUSMAT field hospital rapidly became a critical adjunct to the overall medical response in Tacloban, providing surgical and trauma care while the major local referral centre gradually restored its own surgical services. The surgical casemix, reflecting the nature of the disaster, comprised a high proportion of traumatic injuries from high-velocity debris. As the deployment continued, individuals with minor to moderate injuries, but who had not yet sought medical care, presented with wound infections that were frequently exacerbated by intercurrent type 2 diabetes. Many of these patients had either been searching for lost family or attempting to rebuild their homes and livelihoods, but not attending to their own need for health care.

During a 23-day operational period, 238 surgical procedures were performed, of which 90 were considered major. A total of 2734 patients were seen. Based on average numbers of outpatients, this meant that, for the time it was operational, the AUSMAT field hospital was as busy as the Royal Darwin Hospital emergency department. In addition to surgical patients, our clinicians treated patients with a variety of acute and chronic medical conditions, ranging from respiratory tract infections and diarrhoeal illness through to uncontrolled hypertension.

Operation Philippines Assist marked two critical points in the evolution of Australia’s capacity to provide professional, emergent medical relief after sudden-onset disasters. It was the first occasion on which a clinical team comprising members from each state and territory was deployed (it also included an orthopaedic surgeon and logistician from the New Zealand Medical Assistance Team). This was also the AUSMAT field hospital’s first deployment overseas as part of an Australian response.

Historical perspective on AUSMAT

Previous responses funded by the Australian Government to regional natural disasters such as those in Aceh, Yogyakarta, Samoa and Christchurch were managed through the state-based disaster medical assistance teams model, with involvement of some multijurisdictional teams. Since 2010, the AUSMAT concept, derived from the global movement towards professional, trained medical disaster-relief teams, has become the national model for medical disaster response. AUSMAT training and deployment is primarily coordinated via the Darwin-based National Critical Care and Trauma Response Centre under the auspices of the Australian Government Department of Health. Each state and territory has a coordination focal point linking local health departments to the national team.

Since 2010, over 400 health professionals and medical logisticians have undergone specific and tailored training to deliver care in typical austere, resource-poor environments. The team member training course focuses on safety and security, cultural awareness, team dynamics in the field and familiarisation with equipment. Its centrepiece is a high-fidelity 36-hour simulated deployment to a fictitious nation where each key competency is tested in field conditions. Specific courses for surgeons and anaesthetists, team leaders and medical logisticians have also been developed.

AUSMAT also has a nationally agreed set of standards governing all aspects of deployment including vaccination and predeparture health checks, in-country codes of conduct and postdeployment psychological debriefing. These standards, documented in the national AUSMAT manual,4 have been endorsed by the Australian Health Protection Principal Committee and ensure that the Australian Government maintains a consistent and predictable medical response to regional disasters.

The need for standards in disaster response

Sudden-onset disasters attract a wide variety of responders, from clinicians trained specifically in humanitarian and disaster response to well meaning but untrained individuals or teams. As seen over a number of natural disasters in the 20th and 21st centuries, significant harm to a disaster-affected population can be caused by foreign medical teams who are either untrained in disaster medicine or poorly resourced and not self-sufficient.5

Analysis of responses to the 2010 Haiti earthquake provided clear evidence of the effects of underprepared and underresourced teams. A review of the surgical response in Haiti found that amputation rates varied considerably between foreign surgical teams, from 1% of surgical procedures to over 45%. The lowest rates occurred among specialised orthoplastic teams experienced in limb salvage.6

One account of a trauma team’s experience in Haiti documents the rapid overwhelming of the team by the scale of the disaster, forcing them to self-evacuate. The authors suggest that individual and institutional medical responders partner with experienced disaster-relief organisations to “facilitate the personnel from the more developed countries to learn how to live and work under unfamiliar austere circumstances”.7

Typhoon Haiyan was a typical natural disaster in that it attracted responders with varied training and differing levels of self-sufficiency, ranging from skilled government teams from Australia, Japan, Korea and Belgium, and well known non-government organisations (NGOs) such as the International Committee of the Red Cross and Médecins Sans Frontières, through to individuals who were essentially “disaster tourists”. In between were many small NGOs and philanthropic organisations. Frequently, the AUSMAT team was asked to supply medications or other supplies to teams that had arrived in the country inadequately equipped to provide effective care. Typically, these teams were not participants in the WHO and Philippines Department of Health global health cluster coordination process.

An extensive body of literature points to the key competencies required by medical disaster responders. Clinical medicine, public health and disaster incident management are the core disciplines practised by disaster health professionals.8

Similarly, the AUSMAT concept is firmly rooted in the philosophy that disaster health professionals must have key clinical and humanitarian competencies. First, they must be registered to practise in their stated profession. Too often, clinicians, under the pretext of saving lives at all costs, extend themselves far beyond their scope of practice without following the fundamental principle of medical practice — first do no harm.

Second, health professionals must be able to perform their clinical specialty in a disaster context. It is outdated practice to pluck individuals from their clinical practice in developed-world tertiary hospitals and deposit them in a disaster zone, expecting them to be able to function in austere circumstances with limited resources. Not only does poor patient care result, but it may cause psychological and professional distress for the clinician. Fortunately, in Australia, the clinical experience of many doctors and nurses in rural and remote settings means they are ideally suited to the demands of practice in an austere environment.

Finally, to appreciate the context in which they work, health professionals must have a set of core humanitarian competencies. These range from an understanding of international humanitarian norms through to self-management skills in the field and an ability to operate safely and securely in difficult circumstances.

AUSMAT’s efficient and timely deployment to Tacloban demonstrated the importance of preparedness and consistency. A repository of well trained and prepared clinicians and support staff with a suite of appropriate skills meant an effective response could be mounted. While training is obviously required for preparedness, the importance of an agreed consistency in disaster training is less obvious. The AUSMAT response to Typhoon Haiyan showed well the advantages of both.

The need for qualified and capable medical professionals to be deployed to assist disaster-affected populations will continue into the future. It is the responsibility of organisations rendering assistance to ensure that personnel are trained in the nuances of humanitarian and disaster medicine and to adhere to the new international standards for deployment of foreign medical teams.

The devastation of Tacloban in the wake of Typhoon Haiyan was mirrored across the Philippine provinces of Leyte and Eastern Samar

Surgeons Vaughan Poutawera (New Zealand) and Cea-Cea Moller (South Australia) complete a skin graft for a diabetic patient with typhoon-related injuries

The Australian field hospital in Tacloban, with outpatient tents in the foreground and wards and operating theatre behind (blue-and-white tents)

Closing the dental divide

Ending the dental–medical divide is essential for efficient health care expenditure and improved health outcomes

A smile from any Australian, young or old, tells an instant story of a dental divide that is painful, costly and harmful to health and wellbeing. Their oral health and dentition are measures of their socioeconomic status, employability and self-esteem and predictors of their physical health.

Oral diseases can ravage the rest of the body and physical illnesses and trauma affect oral health.1 Moreover, the risk factors for oral disease and dental decay — high sugar diets, poor hygiene, smoking and excessive alcohol consumption — are also risk factors for heart disease and cancers.1 Yet medicine and dentistry remain distinct practices that have never been treated the same way by the health care system, health insurance funds, public health professionals, policymakers and the public.

Medicare was established to ensure all Australians have affordable access to health care, but from the beginning routine dental care was excluded.2 It is a separation that is increasingly hard to rationalise on health grounds.

The burden of disease associated with oral health problems is huge. Tooth decay is Australia’s most prevalent health problem, and edentulism (loss of all natural teeth) is also very prevalent.3 In terms of quality of life, the impact of oral conditions is estimated to be greater over a 12-month period than the effect of all infectious diseases combined or of either breast cancer or lung cancer.4 But it is telling that the data supporting these statements have not been updated in over a decade.

The Australian dental black hole

A recent report from the Australian Institute of Health and Welfare highlights that Australians’ dental health has not improved in recent years.5 There has been a rise in the average number of children’s baby teeth affected by decay and an increase in the number of adults reporting adverse oral impacts. Nearly half of all children aged 12 years had decay in their permanent teeth, over one-third of adults had untreated decay, over 50% of people aged 65 years and over had gum disease and over 20% of this age group had complete tooth loss.5

There are consequences for the people involved, the health care system and the economy as a whole. The pain, infection and tooth loss that result from untreated dental caries and oral disease cause eating and speaking difficulties and disrupt sleep and productivity. Poor oral health has been linked to infective carditis, coronary heart disease, stroke, adverse pregnancy outcomes and aspiration pneumonia. Destruction of the soft tissues in the mouth can cause lasting disability and even death.6 Impairment of appearance and speech by dental disease may inhibit opportunities for education, employment and social interaction.6

In terms of overall numbers, Australia has an adequate dental workforce, but there is a gross distortion in its distribution; 80% of dentists, 84% of dental hygienists and 63% of dental therapists work in metropolitan areas, most of these in the private sector.7 There is an adequate supply of dentists only in the major cities for those who can afford private dental care.

In the absence of regular dental checks, and when access to dental services is limited by geography, affordability and long waiting times for public services, dental problems quickly become medical problems. Many patients seek pain relief from general practitioners and emergency departments. In the 2011–12 financial year there were 63 327 potentially preventable hospitalisations for dental conditions and 128 712 separations for dental procedures requiring a general anaesthetic.5

The costs are substantial: $7.857 billion was spent on dental treatment in 2010–11 and additional care costs exceeded $1 billion.1 Dental care constitutes around 6.4% of national health spending — to which individuals contributed 58% in 2010–11. The federal government, via direct outlays and premium rebates, contributed $1.437 billion.8

Who pays for better teeth?

While people who can afford regular and routine care report low levels of extractions and relatively low levels of fillings,9 for too many Australians a visit to the dentist — for any reason — is an unaffordable luxury. People who have private health insurance are more likely to access dental care, but insurance cover is clearly inadequate, with 78.7% of people with ancillary cover reporting that they paid some of the cost of care, and 9.4% of people reporting they paid all of their expenses.5

If we are serious about a focus on effective and efficient health care expenditure, equitable access and closing the gaps in health disparities, then it is time to end the dental–medical divide. I am putting forward the following initiatives for consideration in the current political and economic environment in which integrating dental care into Medicare is seen as a step too far. Implementing my proposals will require concerted action from all stakeholders, but depends more on changes in cultures and focus than increased resources.

Integrating medical and dental care

First, it is time to make dental and medical professionals partners in delivering health care services and to include the mouth as part of the body. At the very least this should entail some shared training, recognition that dental services are an integral part of primary care, inclusion of dental information on personally controlled electronic health records, and professional courtesies around patient referrals. Primary care doctors, nurses and allied health professionals need training and skills in oral health screening, providing oral hygiene advice and emergency pain management. Specialists need to consider the dental implications of their patients’ diagnoses and treatments. And dental professionals need to advise patients’ doctors about infections and other oral health problems. In particular, they have a key role in screening for cancerous and precancerous lesions.

Second, health promotion activities related to eating well, smoking and substance misuse, breastfeeding and better management of chronic conditions and polypharmacy need to include oral health information. It is not just health professionals who need to bridge the dental–medical divide, it is the public too. They need to be educated that bad teeth and poor oral hygiene are not simply cosmetic problems but the cause of sickness, disability and even death.

Third, oral hygiene is a critical aspect of care for the frail aged, people with mental illness, people with disabilities and those on certain medication regimens. Children with spasticity and people with developmental disabilities will need special services, and there is little point to investing in dental care if, at the end of life, there is no one to help nursing home residents brush their teeth.

Fourth, if private health insurance funds are keen to play a role in primary care to ensure that their customers are less likely to need acute care services, then it is time for them to consider their role in providing better dental care with reduced costs. The caps on current services mean that even an annual check-up can leave the patient out of pocket.

Where best to invest

In the absence of universal dental care, the best-value investments for governments are in three broad areas: fluoridation, preventive services for children, and preventive and treatment services for the poor and those with special needs. This will require dental services that are more accessible, especially to those living outside metropolitan areas, and more affordable.

So my final recommendation is for an investment in a “Dental Health Service Corps” made up of dentists and dental staff, doctors, nurses, community and Aboriginal health workers and public health professionals to take oral health services and education where they are needed. This could be modelled on the Commissioned Corps of the US Public Health Service (but without the military affiliation), where professionals enlist for a defined period and are rewarded by having their tertiary education debts paid off.10 To be really effective it needs a public health focus, because dental caries and associated problems are largely diseases of social deprivation and their control is as much about improving the social environment as about intervening to improve the oral environment.5 It might also prove cost-effective to set up emergency dental services within hospital emergency departments, at least on weekends.

It is time for governments, health professionals, policymakers and community groups to put their money where their mouths are and act together to improve the oral health of all Australians, so that in the future the only gap-toothed Australian smiles are those indicating a visit from the tooth fairy.

Riding the buses

How to retain the rewards of engaging with others when retirement moves life beyond the consulting room

Retirement embraces all practitioners at some time in the course of their careers, provided they are spared “dying in harness”. For those in salaried service, her blandishments may entice quite early. Those whose discipline has been less than absorbing may court her openly from the first opportunity. Those whose professional involvement has been passionate and requited may yield reluctantly as mental and physical acuity gradually falters. Peers and patients sound the tocsin. Skills requiring long hours of dexterity are increasingly scrutinised with the passage of the years. Doctors who continue to practise despite advancing age and dwindling clinical intelligence survive largely on trust and wisdom gained through experience, fortified by the inertia engendered by loyal patient patronage. But they too will eventually totter or be gently pushed into her arms.

Depending on their preparedness, health and agility, retirees can choose one of many different pathways to cope with the marked change that retirement from medical practice entails. Each has the backdrop of a life spent in service bringing gratitude, satisfaction, stimulation and even love. These rewards are not abandoned lightly.

There are ways to maintain the redolence of this lifestyle. As a physician accustomed to an uninterrupted hour with each new patient, I could forge an understanding of the whole person in that mosaic wherein the disease is an incident in a continuum of life. Even when the cloistered privilege of the consulting room is lacking, there is potential for bonding between two individuals seated together on a bus, if one possesses empathy and interest and the other recognises the safety of an exchange that most of us deeply desire. Having disposed of my car, I now ride the buses and, in the 20 minutes or so of my daily travel, I can recapture the insights, pleasures and surprises of intimate human engagement, facilitated by a narrow bench seat and a mutual destination.

People love to talk. Encouraged by an aura of involvement and lack of interruption that is alien to most medical consultations, they will divulge the most interesting and intimate confidences, particularly if the exchange is devoid of the need for the listener to maintain the objectivity that an integrated diagnosis demands. My journal documenting these exchanges overflows. The front cover has inscribed La Comédie humaine and the back, What the bus driver said. Between the covers lies a treasure trove of human experience.

The bus drivers are often men and women with much life experience and considerable life trauma. For them, the sheer discipline of a timetable, regular hours, reasonable remuneration and a sense of responsibility do not make the job romantic, but are sufficient to make it palatable. I usually try to occupy the jump seat, whence I can illegally converse with them. This involves leaning forward and crosswise. Apart from the risk of ultimately developing scoliosis, the position appears to carry only one hazard — recently, an elderly myopic lady “tagged off” on my forehead with her electronic ticket, causing me to offer up a beep to requite her.

Here, in brief, are some of the experiences I have enjoyed and which, I hope, may induce the reader to abandon the car and take to the bus.

***

Terry came here from Bristol 15 years ago. He lost his first wife to Huntington disease at the age of 45 and his elder daughter at 35 as the disease predictably anticipated itself. His son is unaffected, but his father-in-law was killed when his truck struck a lamp post. Terry remembers him as having curious waving motions of his arms a long time before the accident. When he suggested to the family that this flailing might be an adumbration of the dreadful disorder which took his wife and daughter, he was disowned, lest their insurance claim for accidental death be rescinded.

***

On a bleak, wintry public holiday, waiting for a bus that failed to appear, a metropolitan transport, empty and depot-bound, halted at my feet. “I can’t have you loitering here”, said the driver; “get in and I’ll drive you to the terminus”. As I thankfully mounted the steps I said, “I really wasn’t loitering, I’m not a paedophile; actually I’m a flasher”. “No way”, he said, “you’ve got the wrong sort of raincoat!”

***

Saturday mornings find me taking a bus across the city to the synagogue. Attired in a jacket and tie, I recently mounted a “limited stops” bus and asked the driver if I could disembark at the infrequently used stop close to the house of worship. “You shouldn’t be driving in a bus on a Saturday, my friend”, he said, whereupon the whole journey was occupied by discussion of death rituals across various faiths. He was extremely knowledgeable.

***

Broaching the boundaries of human communication in this way is a wonderful pursuit. There are, however, some rules for successful kibitzing:

If earphones remain in place, let them be.
Really listen. Listen in the way we are not taught to do as clinicians, where we are seeking clues and gauging innuendos, often to the detriment of mutual understanding.
Be prepared, early on, to exchange first names. This simple act of bonding engenders trust and ensures a dissipation of barriers.
Respond as much as you wish; most encounters become more frank and fruitful thereby.
Avoid advice and discussion of any medical matters unless they are integral to the exchange.
In rare circumstances, follow up any evident need that you divine your interlocutor has. Strong friendships and wonderful benefices may accrue, enhancing your health, your mood and your wellbeing.

Bon voyage!

The health impacts of the 2018 Gold Coast Commonwealth Games: proactive planning is required, but who will do this?

To the Editor: The recent Commonwealth Games in Glasgow are a timely reminder of the 2018 Games planned for the City of Gold Coast. In 2013, the Queensland Government, in collaboration with Gold Coast City Council, produced a legacy plan to identify actions to be taken across government and to invite community input and engagement with the Games, including creating a health legacy.1 However, in the document supporting this plan, only two explicit health actions stand out: an accessible and inclusive active living and healthy eating program, and a local health and knowledge precinct to help generate economic development.2

In early 2013, separate to legacy planning, the Gold Coast City Council also commissioned a social and health impact assessment (IA). The IA, which is not publicly available, reviewed the evidence base to reveal a more mixed picture about health concerns than is included in the legacy plan, and found:

Mass gatherings provide ideal conditions for influenza transmission and amplification of preseasonal viruses, even in contexts of low seasonal influenza activity.3 Cases of Neisseria meningitides type b and leptospirosis occurring during sporting events have been documented, the latter associated with heavy rains.4 Risks to mental health and from sexually transmissible infections can be mitigated by prior planning.
With regard to exposure to environmental risks, in addition to the more obvious areas of health and safety and food hygiene, transport infrastructure and planning for Games also have major health implications.5
The population health benefits of Games are at risk of being inequitable. The anticipated “festival effect” of Games, whereby the whole population increases healthy behaviour such as physical activity, has yet to be demonstrated.6 The inevitable increased police presence heightens the risk of negative health consequences for already at-risk groups such as homeless people, injecting drug users, and sex workers.7

Since the IA was conducted, there have been three suspected cases of Ebola virus disease — later proven not to be Ebola — in Queensland, including the Gold Coast.

System preparedness for 2018 across the health system and non-health agencies is required. However, cuts to the Queensland health system in 2012 resulted in the loss of around 4000 staff (5%) and the dismantling of population health services. Given that population health is the point in the health system for proactive health-focused planning, who will do the required comprehensive planning for the Games to ensure the health of the community is fully promoted and protected?

Sustainable workforce and sustainable health systems for rural and remote Australia

This is a republished version of an article previously published in MJA Open

Lack of access to quality health care providers is one of the primary root causes of health inequity and is disproportionately experienced by people living in remote and rural communities.1

Recruiting and retaining an appropriately skilled health workforce in sufficient numbers is a central plank of rural health policies and programs globally. Currently in Australia, there is tension between national health workforce policy initiatives designed to address the rural workforce problem and several broader countervailing demographic, socioeconomic and political forces. National policies, on the one hand, offer various incentives to take up practice in rural and remote areas; have increased numbers of training places for doctors, nurses and allied health professionals; have provided rural student scholarships; have restrictive elements that account for the high proportion of international medical graduates in rural Australia; and have fostered the development of regional academic infrastructure designed to provide students with rural and remote-based training.2 On the other hand, these initiatives are occurring against continued rural population decline, industry contraction (mining excepted), small town settlement demise, service rationalisation, and the ageing of both the rural and remote population and the health workforce.3,4

The evidence for whether current workforce positive initiatives are overcoming the health workforce maldistribution in Australia is inconclusive.5 While
trends show increasing numbers of doctors across both metropolitan and rural areas6 and increasing numbers
of nurses in all but very remote areas,7 the changing aspirations and work patterns of recent graduates explain why the number of effective full-time workers does not show a commensurate increase.8 In addition, changes
in demography will result in shrinkage of the entire workforce and markedly lower rates of overall workforce entry.4 It is too early to tell whether the significant increase in medical student numbers will result in increased numbers of doctors in rural and remote regions.

The current workforce shortage in remote and rural areas is reflected in and exacerbated by the significant disparity in health resource distribution between metropolitan and rural Australia. Available per capita expenditure data for both primary and secondary care utilisation amount to an estimated shortfall in excess of $2 billion.5,9 Moreover, many small rural communities have experienced ongoing problems with maintaining health staff and hospital services, such as local birthing services.10 This demise of local procedural services reflects not just population loss and ageing, but also the continued rationalisation of these services in regional centres as health authorities continue to be guided by fiscal policies rather than by those aimed at maximising the health and wellbeing of the population.3

At the same time, health status is, on the whole,
worse in non-metropolitan Australia. For example, life expectancy decreases with increasing remoteness; it is 1–2 years and up to 7 years lower in regional and remote areas, respectively, compared with major cities. While much of this gap is due to the higher proportion of Aboriginal and Torres Strait Islander people in rural areas, the probability of non-Indigenous Australian men and women living to 65 years is 2%–3% and 1% lower in regional and remote areas, respectively, compared with major cities.11 Thus rural and remote populations have the highest health needs while experiencing the poorest access to health and community services.

Where should we be in 2025?

To ensure equity in health outcomes, we need to provide accessible, appropriate, affordable health services, regardless of geography. A focus on health workforce issues alone will not achieve optimal health outcomes for all Australians. We envision a health system that privileges primary health care and disease prevention; that ensures coordinated care; and that employs a variety of service delivery models appropriate to context, each addressing
an evidence-based set of essential service requirements.

In pursuing a national health reform agenda, the current Australian government has made explicit an appealing picture of what health services should be available in the future. There will be a greater emphasis on primary health care (PHC) and disease prevention, with a focus on chronic disease prevention and coordinated care for those with (expensive) chronic diseases to ensure effective secondary prevention. The new National Primary Health Care Strategy, the increased focus on prevention with the establishment of a National Preventive Health Agency, and many of the current health care reform initiatives reflect the planned, patient-centred, integrated, comprehensive PHC services, well coordinated with secondary and tertiary services, to which we should aspire.

Sustainable PHC services are likely to bring about the biggest improvement in health outcomes in rural and remote areas because they address outstanding issues
in the broader environment that affect morbidity and mortality patterns in these areas,12,13 they will improve patient access through the complex maze of the current health system and improved early intervention will minimise the need for expensive secondary care.14,15

Arguably, different models of service delivery and workforce configuration will be required to meet the different rural and remote contexts. These will range from traditional fixed services, to “hub-and-spoke” models, visiting services, and telehealth and telemedicine.16 Regardless of the model, however, all services will need to be underpinned by a number of essential requirements — including adequate funding through an appropriate financing mechanism; sufficient number and mix of health professionals; adequate infrastructure, both physical and information and communication technology; strong internal and external linkages; high-quality management, governance and leadership; and rigorous performance evaluation.17

What are the challenges in getting there?

Many effective, sustainable rural and remote PHC models exist, together with evidence they can improve health outcomes and sustain an appropriate health workforce.18 There is also evidence of how health policies and programs affect rural populations.19 If we know what works and what does not, why are there continued barriers to achieving accessible, sustainable, integrated, comprehensive and adequately staffed health services in the bush?

One critical challenge is the predominant “deficit” view of working in the bush.20,21 For too long, the media have focused on the negative views of rural and remote life. This view is often perpetuated by professional bodies and researchers advocating for “a better deal for the bush”, and has ultimately made the problem of workforce recruitment more difficult.

Although health workforce reform remains integral to the provision of adequate and appropriate care in rural and remote areas, workforce problems need to be addressed in the context of other essential service requirements. The challenge of developing comprehensive teams of health workers and generalist programs of training across the nation22 is embedded in the need to develop a rational macro policy environment; to provide adequate funding; to ensure strong management, governance and leadership; and to support strong community participation in PHC and Local Hospital Network governance. Our research
has highlighted the importance of genuine community participation, which takes different forms in different contexts, in the provision of effective sustainable primary health services for rural and remote communities.18

Getting the policy settings right is necessary in order to, inter alia, attain greater clarity in federal–state accountabilities in the current reforms. Unfortunately, strong leadership for rural health care from politicians
has often been lacking. Appropriate policy is also linked
to ensuring adequate funding based on need and, importantly, the capacity to generalise successful models. We have previously described cases of successful Aboriginal community-controlled multipurpose services, hub-and-spoke visiting allied health services and discrete general practitioner-led primary care services.18 With some exceptions, such as multipurpose services, Australian governments have displayed difficulty in generalising effective models and pilot programs into coordinated, national programs. Part of the reason for this has been the lack of consistent, reliable data from systematic, rigorous measurement of outputs and health outcomes as they relate to inputs. Rigorous health service evaluation can both contribute to health service quality improvement
and inform evidence-based policy and practice.16,23,24 Governments also need to move away from the dominant silo mentality to a genuinely whole-of-government approach in order to meet the health needs of rural and remote communities and address the underlying social and economic determinants of health.

How will we overcome these workforce impediments?

Even with strategic policies to guide rural and remote programs, their implementation remains notoriously slow in Australia.25 Indeed, incrementalism remains the norm. More radical change is required on at least four fronts.

Changing the prevailing ethos about rural and
remote health

We need to provide a “realistic job preview” for the potential rural and remote health workforce that better describes both the challenges and positive attributes of living and working in the bush. There is ample lived experience and documented evidence about the joy of rural living20 and about increased job satisfaction and work engagement.26,27 We need to build on these strengths and not focus solely on the challenges.

Workforce education and training

There is a need to address persistent training gaps for allied health and nursing professionals, both at an undergraduate and postgraduate level, appropriate to context. For international medical graduates, improved and consistent orientation and preparation is needed.28 There is also scope to explore the benefits of alternative workforce roles, including generalist training and providers such as physician assistants and nurse practitioners.29 Initiatives such as full-year rural generalist internships are needed to expand and strengthen rural medical generalist training. These initiatives can all build on existing rural and remote academic infrastructure. Many of the pieces of the education and training puzzle are in place — Rural Clinical Schools, university departments of rural health, the RAMUS (Rural Australia Medical Undergraduate Scholarship) scheme, and so on. There is evidence of the effectiveness of increasing rural exposure and training in rural environments for medical students30 and other disciplines.31,32 These programs need to be better integrated and expanded to improve geographical coverage and to enhance involvement of non-medical disciplines with a view to creating team-ready graduates.

Comprehensive service models

Addressing workforce in isolation from other essential service requirements is not effective. A systemic approach that ensures adequate funding, infrastructure, effective management and governance, community participation, and professional development opportunities has been shown to minimise recruitment problems and result in workforce stabilisation. Rural and remote health services have always been incubators of health service innovation (Royal Flying Doctor Service, telehealth, multipurpose services, “cashing-out” to compensate for lack of Medicare income in areas with few doctors, de facto “academic health science systems” with close collaboration between researchers and health services, etc). At the same time, information and communication technology infrastructure in many locations is not adequate for current education and service delivery needs. It is hoped that the rollout of the National Broadband Network, and associated telehealth initiatives introduced in July 2011, will enhance service access. At the same time, this must not be viewed as a panacea to workforce recruitment problems, but rather as an adjunct to support effective teams on the ground.

Accountability

Evaluation of health services will be enhanced through agreed indicators and benchmarks for health inputs and outputs. The availability of reliable national health and workforce data and improved monitoring and evaluation will provide essential information to policymakers, practitioners and health consumers about the impact of current and future investments. While there are existing mechanisms of accountability to some communities, for example the election of community boards of Aboriginal community-controlled health services, with this additional information all communities will know what type and level of services they can expect in a given location. Improved monitoring and evaluation will provide evidence about program effectiveness and value. An improved measure of access will also assist with equitable resource allocation and help to determine the effectiveness of health service development.

Conclusion

While recognising the unique characteristics that distinguish urban, rural and remote Australia, we need to be more cautious about the “city versus country” division, which appears to have been exacerbated by recent national political tensions over balance of power. We also recognise the realities of political power and the struggle over limited resources. Nonetheless, metropolitan and rural Australia remain closely interdependent. Ideally, a bipartisan acceptance that the national health of the population
and economy is a function of thriving cities, country towns and remote settlements may lead to a more sustainable economic base for non-metropolitan communities.

The vision of an effective and accessible rural and remote health system is attainable and a number of policy settings are in place. Rural and remote health workforce difficulties are not insurmountable. They can be overcome by changing the way we view and talk about rural and remote areas. These are places of challenge and opportunity. The challenges of fewer health resources, greater sickness and obtaining access to a range of services are undeniable. However, the rewards of rural and remote practice can be great and the opportunity to effect change in small rural communities can be enormous. The potential for fostering innovative service approaches, the possibility of solving problems at both individual and community levels and the amenity of a rural lifestyle are all positive aspects that attract and retain health workers. Evidence indicates that professional satisfaction with rural and remote practice is at least as high as in metropolitan areas.27 We need to dispel the notion that take-up of rural and remote practice is a “sentence for life”! It has been the most rewarding and formative stage of a lifelong career in health for many doctors, nurses and allied health professionals.

Peers or pariahs? The quest for fairer conditions for international medical graduates in Australia

Implementing recommendations of the parliamentary inquiry and international codes of practice on employment of IMGs

It has been more than 2 years since the final report of the inquiry into the registration processes and support for overseas-trained doctors1 was tabled in Parliament. The scope of the inquiry was extensive, involving over 200 submissions and 22 public hearings held in 12 different locations across Australia. In the foreword of the report, entitled Lost in the labyrinth, Steve Georganas, Chair of the Committee, acknowledged that “whilst IMGs [international medical graduates] generally have very strong community support, [they] do not always receive the same level of support from institutions and agencies that accredit and register them”.1 The report outlined 45 recommendations which, if implemented, would create a fairer registration and accreditation system without compromising patient safety.

In spite of the significant cost of the inquiry, borne by taxpayers, its recommendations have yet to be formally endorsed by the federal government. This is not a new situation. Over the past 25 years, a number of major inquiries have investigated the fairness and/or effectiveness of the registration and accreditation system, but have largely failed to produce meaningful improvements.2 For instance, in 2005 the Australian Competition and Consumer Commission and Australian Health Workforce Officials’ Committee recommended fairer methods of assessing and recognising the credentials of overseas-trained specialists, but those recommendations were not fully implemented either.

The failure to implement meaningful reforms in line with the recommendations has meant that the current two-tier system for IMGs and Australian-trained doctors persists. These differences arise from a complex array of registration, accreditation, immigration and workforce policies, which perpetuates a multifaceted process of discrimination and exploitation of qualified medical practitioners.3

A case in point is section 19AB of the Health Insurance Act 1973 (Cwlth), more widely known as the 10-year moratorium. The moratorium stipulates that IMGs must work in underserviced areas for up to 10 years. This restriction is unparalleled in the developed world. Not only does it cause significant personal hardship, family stress and cultural isolation, it also places limits on professional development and career opportunities.

In addition, the 10-year moratorium may be ineffective as a strategy to sustainably increase the number of doctors in rural Australia. Results of a study examining career progressions of doctors 5 years after they completed their training in rural practices showed that 73% of Australian-born doctors remained working in rural practice, whereas only 23% of IMGs followed a similar career path.4 Australian-born doctors choose to remain in rural practice because of their familiarity with a country lifestyle and the presence of a support network for spouses and children. However, “lack of familiarity with rural living and isolation from family and friends”4 were reasons mentioned to account for the relocation of most of IMGs to urban settings after they had satisfied the regulatory mechanisms that compelled them to remain in rural areas.

The author of a Prairie Centre of Excellence for Research on Immigration and Integration working paper stated that, in Canada, placement schemes under which IMGs from overseas are recruited to work under limited registration in remote regions “have not provided a long-term solution for provinces seeking to address the needs of under served areas”.5 He concluded that placing IMGs in underserved areas has produced a “medical carousel” of IMGs leaving rural areas once they obtain their unrestricted licenses.5 Given the failure of such a policy to produce its intended results in a country with an arguably comparable health care system, the 10-year moratorium should be progressively phased out in Australia. In the Lost in the labyrinth report, the Chair concluded that “a review of the 10 year moratorium would be appropriate and timely”.1

Many of the doctors recruited to redress health care workforce shortages were never informed about the restrictions they would be subject to on their arrival in Australia. Yet, pursuant to section 72 of the Health Practitioner Regulation National Law (enacted in all states and territories), any IMG on a Temporary Work (Skilled) (subclass 457) visa who, for any reason, ceases to be registered with the Medical Board of Australia, will be left with only 28 days to find an immediate alternative or leave the country. Also, there is no fair appeal and grievance process for IMGs with 457 visas, many of whom work in designated Area of Need (AoN) positions. The impact of restrictive policies on the personal and professional lives of IMGs in Australia has been ruinous. For example, doctors with 457 visas and their families do not qualify for health care services under Medicare. In a recent case in rural Queensland, a United States-born doctor had to pay a thousand dollars for treating his own daughter’s broken arm while he was on duty at the local hospital.6 Overseas-trained doctors and nurses are intrinsically involved with providing health services under Medicare, a characteristic not shared with any other group of temporary worker in Australia.

An independent integrity review commissioned by the Ministry for Immigration and Citizenship7 confirmed that 457 visa holders are potentially vulnerable to exploitation. For example, IMGs have reportedly been forced to work up to 80 hours per week, as documented in one of the submissions to the parliamentary inquiry1 (submission 101, page 75). The current system contravenes recommendations of major government policy reviews. The first recommendation of the final report of the Visa Subclass 457 Integrity Review advises that subclass 457 visa holders should “have the same terms and conditions of employment as all other employees in the workplace”.7

In addition, the Commonwealth code of practice for the international recruitment of health workers, adopted by Commonwealth Health Ministers in 2003, determined that IMGs should be “protected by the same employment regulations and have the same rights” as their local counterparts.8 Similarly, The World Health Organization Global code of practice on the international recruitment of health personnel, adopted by the 63rd World Health Assembly in 2010, of which Australia was a signatory member, established that migrant health personnel should “enjoy the same legal rights and responsibilities as the domestically trained health workforce in all terms of employment and conditions of work”.9

In Australia, IMGs who attained medical qualifications in the United Kingdom, United States, Canada, New Zealand and Ireland are entitled to an accelerated registration process (competent authority pathway), whereas IMGs who qualified elsewhere must undergo a multiple choice examination and a structured clinical assessment (standard pathway). Local graduates are not required to undergo a similar formal assessment. The waiting period to sit for the clinical component can be long, which may curtail employment opportunities for many IMGs. The procedures involved in the registration and integration of IMGs have been described as not ideal.10

Workplace based assessment (WBA) is an alternative route based on a 6-month assessment process, which can also be delivered in regional Australia. Entry into the WBA program has the same eligibility criteria as the standard pathway, which includes an English language proficiency test. It has been shown that the WBA is a cost-effective form of assessment that facilitates a straightforward integration of doctors into the local health care system.10 The committee that conducted the parliamentary inquiry recommended that colleges of specialists also adopt the WBA model to assess the clinical competence of specialist IMGs (recommendation 8, chapter 4, page 96), given that this assessment methodology is “a much more reliable and accurate evaluation of clinical skills of the IMG” (chapter 4, page 84).1

Notwithstanding the recommendations of the parliamentary enquiry,1 the WBA remains available only in a limited number of training sites for non-specialists, and only a limited number of colleges of specialists have incorporated the WBA into their evaluation processes. Many overseas-trained specialists remain working in AoN positions for years when this period could have counted towards their registrations through WBA. There remain colleges who still insist on using simulated assessment conditions to determine whether a colleague and specialist in his or her own right is sufficiently qualified to practise in a jurisdiction where he or she has in fact been practising competently for several years.

There is no argument that patient safety must be the number one consideration in recommending reforms to the system. A central conclusion of the Lost in the labyrinth report was that “improvements in registration processes for IMGs must be achieved without compromising the high standards that Australians expect from medical practitioners”. Yet, there remain the flagrant breaches of the codes of practice mentioned above, which buttress a de-facto two-tier system in Australia whereby disempowered IMGs have to bear the burden of hindrances that do not apply to local graduates. These discriminatory policies are ethically indefensible, given the overt violations of principles of non-maleficence, beneficence and justice that result.

The unfair hindrances faced by IMGs are irreconcilable with principles of equity and mateship that are at the core of Australian society. There is still an opportunity for political leaders and medical authorities to rectify these inequities by implementing the recommendations from the parliamentary inquiry and the principles sanctioned in international codes of practice.

Ethical challenges for doctors working in immigration detention

The health of asylum seekers in Australia’s immigration detention centres has been the subject of a doctors’ letter of concern and two recent reports.1–3 Here, we present an analysis of the ethical dilemmas faced by health practitioners working in these centres1 and seek to promote a strong and considered policy discussion.

Australia’s Department of Immigration and Border Protection (DIBP) contracts a private health service provider, International Health and Medical Services (IHMS), to provide health care to immigration centre detainees at an Australian standard.4 However, media and other reports from Christmas Island,1 Manus Island2 and Nauru3 have raised serious concerns about the quality of care provided and whether health care professionals have been able to fulfil their professional and ethical obligations to patients in these facilities.1–3

Ethical conflicts and challenges

Doctors working within the immigration detention system may experience conflicting loyalties to their patients, their employer and the DIBP. The Australian Health Practitioner Regulation Agency (AHPRA) code of conduct for doctors recognises the significance of conflicts of interest:

Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise, or might reasonably be perceived by an independent observer to compromise, the doctor’s primary duty to the patient, doctors must recognise and resolve this conflict in the best interests of the patient.5

The Australian Medical Association (AMA) code of ethics6 also advises how doctors should respond to conflicts of interest and to conditions that are judged to be unacceptable for adequate health care:

Refrain from entering into any contract with a colleague or organisation which may conflict with professional integrity, clinical independence or your primary obligation to the patient.

… ensure that you do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures …6

The AMA statement on medical professionalism7 further describes how a doctor’s ability to deliver patient-centred care may be compromised by an employer or government and advises that:

When responding to these challenges, the medical profession and its individual members have a duty to advocate that the health care environment remains patient-centred at all times and a responsibility to ensure that the health needs of patients remains the doctor’s primary duty.7

Despite its obligations to both its patients and the DIBP, IHMS has publicly maintained that no conflict of interest exists.8 However, the inadequate health screenings of asylum seekers on Christmas Island in 2013 demonstrate this type of conflict. In response to DIBP targets, health assessments were rushed, fewer investigations were performed and asylum seekers were transferred to regional processing centres within 48 hours, before results of investigations were available.1 This resulted in failure to identify acute and chronic illnesses before patients were transferred to sites with limited medical facilities.1 This practice continued in the face of objections from the Royal Australasian College of Physicians.1

Some tasks requested of doctors in immigration detention centres are inappropriate in the context of health care, such as requests to refer patients for age assessment by the DIBP. This process is not a part of the patients’ health care and is not in their best interests.1,9 Doctors have been required to prescribe medication en masse to expedite transfer to regional processing centres, with no patient consultation and despite potential contraindications.1 For example, the combination drug for malaria prophylaxis, atovaquone–proguanil hydrochloride, was prescribed without any individual patient consultation, and it was not clear if asylum seekers were informed about the indications for and possible adverse reactions to this drug.

Degrading, harmful and inappropriate incidents have occurred, including requiring asylum seekers to undergo health assessments while exhausted, dehydrated and filthy, with clothing soiled by urine and faeces; addressing individuals by number instead of name;1,2 artificial delays in transfer of patients for tertiary care;1 confiscation and destruction of medications, medical records and medical devices;1 and detention of children despite clear evidence of significant harm.1,9–11

These rushed and inappropriate practices can have harmful consequences for patient wellbeing. These have included the loss of an unaccompanied child’s hearing aid, which was not replaced, and the child went on to develop self-harming behaviour; and the abrupt cessation of anticonvulsants in a child, resulting in worsening of seizures.1 0,11 Tragically, delays in transfer are likely to have contributed to the recent death of an asylum seeker from sepsis, resulting from a cut to his foot.12

Responding to conditions of practice in immigration detention centres

Doctors who work in detention centres may feel an ethical responsibility to voice their concerns, but this may conflict with their obligations to their employer. The question should be asked: is working within immigration detention an ethically tenable prospect for Australian doctors and other health professionals? Several answers present themselves.

First, a doctor may advance the “no worse off” argument — that any individuals refusing to work within the system will be replaced by others willing to do so.

Second, it might be argued that it is better to have a compassionate person delivering the best care possible within the constraints of the detention system than to have that person leave, not knowing who the replacement will be. However, remaining silent goes against the imperative to advocate for patients’ interests.7

Third, a doctor might work as contracted in the system, yet still advocate for asylum seekers by speaking out about deficiencies in their care. But it is unclear how much “advocacy from within” is enough. If that advocacy becomes ineffective, is there a point at which the doctor becomes effectively complicit with the system?

Finally, some doctors terminate their contracts when they see the realities of the detention health care environment. However, while this strategy preserves the individual’s professional integrity, it may jeopardise patient care by resulting in an immediate workforce shortage.

The work culture in immigration detention centres discourages open expression of personal concerns by staff, with documented cases ending in dismissal.13 Formal complaints can be made but have rarely effected change.1 The diffusion of personal responsibility associated with reporting complaints to senior staff is a powerful factor in the immigration detention system. Health practitioners who lodge complaints to formalise their objections may judge this to have met their responsibilities. However, in reality, this may not represent effective advocacy for patients when failure to act on complaints is a systemic problem. Other doctors, increasingly frustrated with the lack of progress, may burn out and abandon their advocacy attempts. In our experience, many resolve to wait out their contracts and leave, never to return.

Appealing to bodies external to their employer becomes a last resort. However, individuals who do so face the possibility of legal action for breaching confidentiality agreements. Health care professionals can notify AHPRA, which provides protection from such agreements, but AHPRA’s scope is limited to the conduct of individual practitioners rather than dysfunctional health systems as a whole.14 There is little else individuals can do without significant personal risk.

Is it time for a boycott?

Given reports that the health care currently provided to asylum seekers in immigration detention may be both substandard and harmful, a coordinated response to the problem is now needed to ensure change occurs.

Should health care professionals consider boycotting the provision of services in immigration detention until conditions are made satisfactory? The potential role of a professional boycott to motivate change should be openly discussed. Any decision made requires leadership from the professional bodies responsible for ensuring standards of care and ethical conduct. Any resulting policy and advice in relation to health care within immigration detention needs to be clear.

We call on the colleges and the AMA to lobby for effective change, so that asylum seekers receive appropriate care and those delivering it are not professionally compromised. We also call for robust, independent and transparent monitoring of standards within immigration detention, and a system to register and independently deal with complaints.