Last week I had a headache. Two hours in a traffic jam, hot day, no water, plans thrown into chaos. That day I was one of the five million Australians affected by headache or migraine. Over a year one person in two will experience a headache.
Headaches are really common, so here are five things the research evidence indicates are worth trying to help manage or avoid them.
A study was conducted in people who got at least two moderately intense or more than five mild headaches a month. The participants received a stress management and sleep quality intervention with or without increasing their water intake by an extra 1.5 litres a day.
The water intervention group got a significant improvement in migraine-specific quality of life scores over the three months, with 47% reporting their headaches were much improved, compared to 25% of the control group.
However, it did not reduce the number or duration of headaches. Drinking more water is worth a try. Take a water bottle everywhere you go and refill it regularly to remind you to drink more water.
Caffeine can have opposing effects. It can help relieve some headaches due to analgesic effects but also contribute to them, due to caffeine withdrawal. A review of caffeine withdrawal studies confirmed that getting a headache was the number one symptom of withdrawal, followed by fatigue, reduced energy and alertness, drowsiness, depressed mood, difficulty concentrating, fuzzy head and others.
When people were experimentally put though controlled caffeine withdrawal, 50% got a headache, with withdrawal symptoms occurring within 12-24 hours, peaking between 20-51 hours and lasting from two to nine days. Caffeine withdrawal can happen from a usual daily dose as low as 100 mg/day. One cup of brewed coffee contains 100-150mg caffeine, instant coffee has 50-100 mg depending on how strong you make it and a cup of tea can vary from 10-90mg. It appears that maintaining usual caffeine consumption may subconsciously relate to avoidance of withdrawal symptoms.
Caffeine can dampen down pain. in a systematic review that included five headache studies with 1,503 participants with migraine or tension-type headache, 33% of participants achieved pain relief of at least 50% of the maximum possible after receiving 100 mg or more caffeine plus analgesic pain medication (ibuprofen or paracetamol) compared to 25% for the analgesic group alone.
A study in over 50,000 Norwegians, who have high caffeine intakes (more than 400 milligrams a day), examined the relationship with headaches. Those with the highest caffeine intakes (more than 540mg/day) were 10% more likely to get headaches, including migraine.
But when headache frequency was examined, high caffeine consumers were more likely to experience non-migraine headaches infrequently (less than seven per month) compared to those considered low caffeine consumers (less than 240mg a day). This was attributed to potential “reverse causation” where high caffeine consumers use caffeine to damp down headache pain. They found those with the lowest caffeine intakes (125mg a day) were more likely to report more than 14 headaches per month, which may have been due to greater sensitivity and avoidance of caffeine.
Hypnic headaches are a rare type that occurs in association with sleep. They typically last 15-180 minutes and are more common in the elderly. Hypnic headaches are treated by giving caffeine in roughly the amount found in a cup of strong coffee.
Some people get a headache after fasting for about 16 hours, which equates to not eating between 6pm and 10am the next day. A study in Denmark found one person in 25 has been affected by a fasting headache. These headaches are most likely to occur when fasting for a blood test or medical procedure or if you are following a “fasting” weight loss diet or a very low energy meal replacement diet.
Fasting headaches are likely to be confounded by caffeine withdrawal. Check the test procedure instructions to see what fluids, such as tea, coffee and water are allowed and drink within those recommendations.
In a study 34 people with new-onset migraine who kept a headache diary for about a month, those who ate a night-time snack were 40% less likely to experience a headache compared to those who didn’t snack. For susceptible individuals this may prevent fasting headaches. Try a slice or wholegrain toast with a topping like cheese and tomato or avocado and tuna, with a cuppa.
Headache is the classic feature of alcohol induced hangovers. The amount of alcohol needed to trigger a hangover varies widely between individuals, from one drink to many. A number of factors mash up to produce a throbbing post alcohol headache. Increased urination and vomiting both increase risk of dehydration which leads to changes in blood and oxygen flowing to the brain.
Congeners, a group of chemicals produced in small amounts during fermentation, give alcoholic drinks their taste, smell and colour. Metabolites of alcohol breakdown in the liver can cross the blood-brain barrier contributing to hangover.
Alcohol can trigger tension-type headaches, cluster headaches and migraine. People with migraines have been shown to have lower alcohol intakes compared to others.
The wise advice is to drink responsibly, boost your water intake and don’t drink on an empty stomach. If you are sensitive to alcohol, avoidance is your best option.
5. Boost your intake of folate-rich foods
Some migraineurs are diet-sensitive. Triggers include cheese, chocolate, alcohol or other specific foods. A recent study found women with low dietary folate intakes had more frequent migraines. However a daily folic acid (1mg) supplement made no difference.
Boost your intake of foods rich in folate such as green leafy vegetables, legumes, seeds, chicken, eggs and citrus fruits. Use our Healthy Eating Quiz to check your nutrition, diet quality and variety. Keep a headache diary to identify triggers and then discuss it with your GP.
But our new study goes one step further. It predicts that higher taxes on sugar-sweetened drinks will benefit the wider economy through increased economic productivity, by having more, healthier people in paid and unpaid work.
Obesity delivers a double whammy
A total of 63% Australian adults and one in four children are overweight or obese, making this both a health and an economic problem.
Obesity increases the risk of diseases including cancer, diabetes, heart disease and stroke. Obesity has also been estimated to cost Australia about A$8.6 billion a year or more. Not only does obesity drive up health-care costs, by causing illness and premature death, it also reduces people’s ability to work and contribute to the economy.
Added sugar contributes energy to the diet, but no useful nutrients. Increasingly, health experts suggest we should be treating sugar, and in particular sugar in soft drinks, as we do tobacco or alcohol, by taxing it to reduce consumption and so reduce obesity rates.
Taxing sugar is not a new concept. In the 1700s, Scottish economist Adam Smith wrote in An Inquiry into the Nature and Causes of the Wealth of Nations:
Sugar, rum, and tobacco, are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.
Smith’s proposal to tax sugar was not aimed at improving health, as it is today. Now organisations like the World Health Organisation, the Australian Medical Association and many non-governmental organisations are advocating a tax on drinks with added sugar, as part of wider efforts to tackle obesity.
What we did and what we found
Until our study, few worldwide had looked at the wider economic effects of taxing sugary drinks.
We modelled the Australian adult population as it was in 2010, in terms of consumption of sugar-sweetened drinks, body mass, obesity-related diseases, death rates, and the amount of paid or unpaid work people were likely to do.
We compared a scenario in which the prices of sugared drinks went up by 20%, compared to business-as-usual, and estimated what difference this would make for the number of obese people, the number of years lived, and for overall economic production.
Further reading: Dietary guidelines don’t work. Here’s how to fix them
We used data from the 2011-12 Australian Health Survey and found that obese people aged 15-64 had a lower chance of being in a paid job, compared to people whose weight was normal. We assumed this was related to illness.
Of people in work, obese workers needed more sick leave, but only about an hour a year.
We also looked at unpaid work (like cooking, cleaning and caring, and volunteer work). We included gains due to more people surviving for longer due to lower body weight. We assumed that if work was not done as unpaid work, somebody would have to be hired to do it (so there would be a replacement cost).
Our results show that a 20% sugar tax would mean about 400,000 fewer people would be obese. Three-quarters of these would be in the workforce, so that about 300,000 fewer employed people would be obese.
Over the lifetime of the adult population of Australia in 2010, this would add about A$750 million to the formal, paid economy, due to more, healthier people producing more goods and services.
The gains in unpaid work were even larger at A$1.17 billion. Fewer obese people means more healthy people, who have a greater likelihood to do unpaid work, in the household or as volunteers.
These indirect economic benefits from increased employment in the workforce and from greater participation in unpaid work were larger than the savings in health care costs, which we estimated at about A$425 million over the lifetime of the adult population.
In all, the tax could deliver over A$2 billion in economic benefits in indirect economic benefits plus health care savings. And that does not even include the value of the gains in people’s quality of life and how long they lived.
Further reading: Fat nation: the rise and fall of obesity on the political agenda
The exact size of the benefits depend on assumptions about what people would drink (and eat) if they drink fewer sugared drinks. In this study, we used Australian evidence that found an increase only for diet drinks, which contain virtually no energy.
Other evidence finds a sugar tax reduces the consumption of sugar and energy-rich foods, but may also lead to people eating fewer fruit and vegetables and more salt. This would reduce the health benefit, and that study suggests it would be even better to tax all sugar instead of only sugared drinks.
Nevertheless, the available evidence shows health benefits of increased taxation of sugared drinks.
What’s happening overseas?
Studies in other countries have predicted similar effects of a sugar tax on the proportion of obese people. For example, a 20% tax is expected to reduce the number of obese people by about 1.3% in the UK and 2-4% in South Africa.
And an increasing number of countries, including the UK, France, Denmark, Finland, Hungary and recently Estonia and Saudi Arabia, have already announced or have implemented a tax on drinks with added sugar.
If Australia introduces a 20% tax on sugar-sweetened drinks, as many health advocates and economists have called for, that would not only improve health, our results predict it would also promote economic growth.
The author of this article will be available for a live Q&A today 1-2pm. Please post your questions in the comments below.
As we get older we have a greater risk of developing impairments in areas of cognitive function – such as memory, reasoning and verbal ability. We also have a greater risk of dementia, which is what we call cognitive decline that interferes with daily life. The trajectory of this cognitive decline can vary considerably from one person to the next.
Despite these varying trajectories, one thing is for sure: even cognitively normal people experience pathological changes in their brain, including degeneration and atrophy, as they age. By the time a person reaches the age of 70 to 80, these changes closely resemble those seen in the brains of people with Alzheimer’s Disease.
Even so, many people are able to function normally in the presence of significant brain damage and pathology. So why do some experience symptoms of Alzheimer’s and dementia, while others remain sharp of mind?
It comes down to something called cognitive reserve. This is a concept used to explain a person’s capacity to maintain normal cognitive function in the presence of brain pathology. To put it simply, some people have better cognitive reserve than others.
Evidence shows the extent of someone’s cognitive decline doesn’t occur in line with the amount of biological damage in their brain as it ages. Rather, certain life experiences determine someone’s cognitive reserve and, therefore, their ability to avoid dementia or memory loss.
How do we know?
Being educated, having higher levels of social interaction or working in cognitively demanding occupations (managerial or professional roles, for instance) increases resilience to cognitive decline and dementia. Many studies have shown this. These studies followed people over a number of years and looked for signs of them developing cognitive decline or dementia in that period.
Cognitive reserve is traditionally measured and quantified based on self reports of life experience such as education level, occupational complexity and social engagement. While these measures provide an indication of reserve, they’re only of limited use if we want to identify those at risk of cognitive decline. Genetic influences obviously play a part in our brain development and will influence resilience.
The fundamental brain mechanisms that underpin cognitive reserve are still unclear.
The brain consists of complex, richly interconnected networks that are responsible for our cognitive ability. These networks have the capacity to change and adapt to task demands or brain damage. And this capacity is essential not only for normal brain function, but also for maintaining cognitive performance in later life.
This adaptation is governed by brain plasticity. This is the brain’s ability to continuously modulate its structure and function throughout life in response to different experiences. So, plasticity and flexibility in brain networks likely contribute in a major way to cognitive reserve and these processes are influenced by both genetic profiles and life experiences.
A major focus of our research is examining how brain connectivity and plasticity relate to reserve and cognitive function. We hope this will help identify a measure of reserve that reliably identifies individuals at risk of cognitive decline.
Strengthening your brain
While there is little we can do about our genetic profile, adapting our lifestyles to include certain types of behaviours offers a significant opportunity to improve our cognitive reserve.
Activities that engage your brain, such as learning a new language and completing crosswords, as well as having high levels of social interaction, increase reserve and can reduce your risk of developing dementia.
Regular physical activity also improves cognitive function and reduces the risk of dementia. Unfortunately, little evidence is available to suggest what type of physical activity, as well as intensity and amount, is required to best increase reserve and protect against cognitive impairment.
There is also mounting evidence that being sedentary for long periods of the day is bad for health. This might even undo any benefits gained from periods of physical activity. So, it is important to understand how the composition of physical activity across the day impacts brain health and reserve, and this is an aim of our work.
Our ongoing studies should contribute to the development of evidence-based guidelines that provide clear advice on physical activity patterns for optimising brain health and resilience.
The National Disability Insurance Scheme (NDIS) is “on track in terms of costs”, according to a position paper released by the Productivity Commission this week. The report further stated that:
if implemented well, it will substantially improve the well-being of people with disability and Australians more generally.
But the Commission’s paper also expressed some significant concerns at the speed the scheme is being rolled out, and that this could undermine its overall effectiveness. The report highlighted a number of areas that are proving challenging for those accessing the scheme. It noted that such barriers to access are, in fact, contributing to keeping the costs on track.
Where the NDIS is succeeding
Rarely a day has gone by in recent months without a news story about the perceived failings of the NDIS. The scheme has been reported as “plagued with problems” and concerns aired about a potential “cost blowout” .
As a result, the government asked the Productivity Commission to undertake an independent review into the overall costs of the scheme, its value for money and long-term sustainability. The full report is due by September.
The current position paper goes to great lengths to acknowledge the size of the challenge in delivering the NDIS. It argues that the
scale, pace and nature of the changes it is driving are unprecedented in Australia.
When fully implemented, the scheme will involve the delivery of individualised support to 475,000 people at a cost of A$22 billion per year.
There is no doubt the NDIS is complex, but the Commission finds that there is “extraordinary” commitment to the success and sustainability of the scheme. It notes that making the scheme work is not simply the job of the National Disability Insurance Agency (NDIA), but also that of government, participants, families and carers, providers and the community.
Based on the data collected, the Commission finds NDIS costs are broadly on track with the modelling of the NDIA. A greater number of children are entering the scheme than expected, leading to some cost pressures, but the report notes the NDIA is putting initiatives in place to help deal with these challenges.
The report also finds benefits of the NDIS becoming apparent, with many, but not all, NDIS participants receiving more disability support than previously and having more choice and control.
Problems with the scheme
Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans. This kind of under-utilisation of services is a factor contributing to keeping costs on track. Such findings are in line with recent independent research into consumer experiences of the scheme.
Overall the report finds there is insufficient flexibility in the NDIA’s operational budget and that money could be spent more in a way that reflects the insurance principles of the scheme, such as greater amounts of funding being invested in prevention and early intervention services.
The process of care planning needs greater attention. Pressure on the NDIA to get numbers of people on to the scheme means that the quality of the care planning processes have been decreased in some cases. This has caused “confusion for many participants about planning processes” and has resulted in poor outcomes for them.
There is a significant challenge in relation to the disability care workforce. The Commission estimates that one in five new jobs created in Australia in the next few years will need to be in the disability care sector. The report notes that current approaches to generating greater numbers of workers and providers are insufficient.
A range of responses required to address these include a more targeted approach to skilled migration, better market management, and allowing formal and informal carers to provide paid care and better price monitoring and regulation.
The interface between the NDIS and other disability and mainstream services has also proved problematic. There is a lack of clarity in terms of where the responsibilities of different levels of government lie and who should be providing which services. Some people with a disability have lost access to supports they used to get as state government disability services close down.
Need for political will
The Commission describes the roll-out to the full scheme as “highly ambitious” and expresses concern it risks not being implemented as intended. Indeed the speed of the NDIS roll-out is described as having “put the scheme’s success and financial sustainability at risk”.
The report concludes that if the scheme is to achieve its objectives there needs to be a
better balance between participant intake, the quality of plans, participant outcomes, and financial sustainability.
The NDIS is taking a number of steps to deal with these issues but the Commission “is unable to form a judgement on whether such a refocus can be achieved while also meeting the roll-out timetable”.
What all of this means is that we will need to see some enormous political will to enable the scheme to be supported to reach its full potential. This will likely involve some slowing of the timetable for implementation and some difficult work to deal with a number of the areas that have been identified as problematic. Whether the government has an appetite to see this through remains to be seen.
If you have a blocked or runny nose, chances are you’ll reach for a tissue or hanky to clear the mucus by having a good blow.
But is there a right way to blow your nose? Could some ways make your cold worse? And could you actually do some damage?
The three most common reasons for extra mucus or snot are the common cold, sinusitis (infection or inflammation of the sinuses, the air-filled spaces inside the face bones) and hay fever. Each of these conditions cause the lining in the nose to swell up, and to produce extra mucus to flush away infection, irritants or allergens.
Both the swelling and extra mucus lead to nasal congestion. This is when the narrowed passages increase the effort of breathing through the nose. Clearing the mucus by blowing the nose should reduce this congestion somewhat.
At the beginning of colds and for most of the time with hay fever, there’s lots of runny mucus. Blowing the nose regularly prevents mucus building up and running down from the nostrils towards the upper lip, the all-too-familiar runny nose.
Later in colds and with sinusitis, nasal mucus can become thick, sticky and harder to clear.
Further reading: Health Check: what you need to know about mucus and phlegm
Think of “snotty nosed kids”, in particular infants or toddlers who haven’t yet learnt to coordinate the mechanics of blowing their noses. They tend to repeatedly sniff thick mucus back into their nose or allow it to dribble down their upper lip.
Keeping this mucus (rather than blowing it out) is thought to contribute to a cycle of irritation that causes the snotty nose to persist for weeks or longer.
This may be due to the retained mucus acting as a good “home” for bacteria to grow in, as well as fatigue of the “hairs” (cilia) that cleanse the nose by moving along mucus and carrying with it irritants, inhaled debris and bacteria.
Thick retained mucus is also more likely to be transported to the throat rather than gravity working it from the nostrils, leading to throat irritation and possibly a cough. This is the mechanism behind the most common cause of prolonged cough after a viral infection or hay fever, known as the post-nasal drip cough.
So it makes sense to encourage people to blow their nose to remove unwanted mucus.
Rare risks if you blow too hard and too often
Although extremely rare, there are a few examples in the medical literature of people blowing so hard they generated pressures high enough to cause serious damage. In most of these cases people had underlying chronic sinusitis or an existing weakness in the structure they damaged after blowing too hard.
These injuries included fractures of the base of the eye socket; air forced into the tissue between the two lobes of the lung; severe headache from air forced inside the skull; and rupture of the oesophagus, the tube that sends food to the stomach.
One study looked at the pressures generated when people with and without a range of nasal complaints blew their noses.
People with chronic sinusitis generated pressures significantly higher than people without a nasal complaint, up to 9,130 Pascals of pressure. They also found blowing by blocking both nostrils generated much higher pressures than blowing with one nostril open.
Another study comparing pressures from nose blowing, sneezing and coughing found pressures generated during blowing were about ten times higher than during the other two activities.
More worrying was their second finding – viscous fluid from the nose had found its way into the sinus cavities after vigorous nose blowing. The researchers said this could be a mechanism for sinus infection complicating some colds, with the introduction of nasal bacteria to the sinuses. But they did not produce evidence for this.
On balance it seems repeated and vigorous blowing of the nose may carry more risk than benefit, even though it seems to be a natural response to nasal congestion.
Can I take anything to stop the snot?
So looking to remove the need to blow so forcefully is probably a better option.
Decongestants and antihistamines, which you can buy without prescription from pharmacies, reduce both nasal congestion and the volume of mucus.
Decongestants contain ingredients like oxymetazoline and phenylephrine and come in tablets or sprays, and are often included in cold and flu tablets. They work by constricting (narrowing) dilated blood vessels in the inflamed lining of the nose, and decreasing the volume of mucus produced.
While decongestant sprays are effective, they are probably underused due to concerns about nasal congestion when you stop taking them after long-term use (rhinitis medicamentosa). But further studies have questioned this increased risk.
Antihistamines treat nasal congestion associated with hay fever, but may be less effective for treating cold symptoms.
Saline nose sprays have some evidence they work for acute and chronic rhinosinusitis (inflammation of the nasal lining and sinuses), and can reduce the need for medications. They are believed to clear mucus through increasing the effectiveness of the cilia as well as diluting thick and sticky mucus.
A related technique, known as nasal aspiration, is when you squirt liquid saline up the nose with a special medical device to flush out mucus and debris from the nose and sinuses. One study found it lowered the risk of developing acute otitis media (inflammation of the middle ear) and rhinosinusitis.
What’s the verdict?
If you have mucus in the nose, it is probably best to get it out, so blow gently or by clearing one nostril at a time. Use of appropriate treatments can lessen the need to blow, and the force required to clear your nose.
If you are repeatedly blowing your nose you probably have a nasal condition, like hay fever or sinusitis, which should be treated more comprehensively.
And if you see a snotty-nosed kid, please wipe away the mucus discharge for the benefit of all.
The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same – statistically at least.
With 3.5 practising doctors for every 1,000 people in 2014 (4.4 per 1,000 in major cities) we’ve never had so many. In 2003, there were 2.6 doctors for every 1,000 people in Australia, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).
And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government granted 2,820 temporary work visas to overseas-trained doctors in 2014-15. In the same year, Australian medical schools graduated another 3,547.
This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only Denmark and Ireland in the same league of doctor-production for population.
So why do we have too many doctors, but think we have too few?
Our approach to medical training
In a Medical Journal of Australia editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.
To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?
There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.
Back in the early 2000s, the biggest issue relating to the training of Australia’s medical workforce was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas.
While results of these policies have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school.
That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a fierce competition for ever-more sub-specialised training jobs.
Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the recently announced funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.
2. Excessive specialisation
There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, there’s now an imbalance between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field.
Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.
3. Financing and models of care
Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs.
Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments.
However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to inappropriate medical care, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions.
An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can lead to higher rates of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.
Time for action
Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate.
Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.
Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved.
We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres.
And we especially need to expand the number of broadly-skilled rural generalists and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession – and the time to act is now.
Treasurer Scott Morrison pulled a health-related rabbit out of his hat on budget night, announcing the government will “guarantee” the future of Medicare.
It will do this by allocating revenue from the recently increased (from 2% to 2.5%) Medicare levy, after paying for the National Disability Insurance Scheme (NDIS), into a Medicare Guarantee Fund.
The government will then cover the shortfall to cover the costs of Medicare – defined in these budget announcements as a combination of expenditure from the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). In Morrison’s words:
Proceeds from the Medicare levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.
Based on the sketchy information so far available, this fund appears to be no more than an accounting trick. The size of the fund will be determined each year based on projected MBS and PBS expenditure. The balancing item, which is the extra proportion of non-NDIS revenue, will also be adjusted each year in line with those expenditure projections.
The guarantee part is that only the MBS and PBS expenditures can be paid from the fund, “by law”. This might sound good, but don’t be fooled. The Medicare Guarantee Fund is nothing more than a rebadging exercise: it changes the badge on a policy in the hope people might think it is a new policy.
It merely provides an additional line in the budget papers, supplementing information that was already there for MBS and PBS expenditure, albeit separately. And by defining Medicare as MBS and PBS expenditure, the government has seamlessly airbrushed public hospitals out of the picture.
What is Medicare?
Until budget night this week, most people would have thought of Medicare as the medical services and public hospital scheme, and probably still do.
When Medicare was introduced in 1984, it changed funding arrangements for medical services and public hospitals, removing or reducing financial barriers to access to these services. It did not touch PBS arrangements.
It may now be appropriate to add the PBS as a third component of Medicare, as it is about access to health care. But the PBS should be an addition to how Medicare is defined. It shouldn’t be used to airbrush public hospital access out of any Commonwealth definition of Medicare.
To put it more simply, the Medicare Guarantee Fund does not include the Commonwealth’s contribution to public hospital funding. But it does include the PBS, adopting a unique and idiosyncratic definition of Medicare.
The Medicare Guarantee Fund is being created using a partial statement of Medicare spending: if the public were to assume the Medicare Guarantee Fund is purely about a public commitment to Medicare, they would be misled.
So despite Morrison’s claims the fund will provide “transparency about what it really costs to run Medicare”, Medicare funding will actually be less transparent.
What does the fund guarantee?
The government probably hopes the Medicare Guarantee Fund will be its armour against a revised Mediscare campaign, like the one Labor ran before the 2016 election. The word “guarantee” linked with “Medicare” sounds good, costs nothing and does not bind the government in any way. But it may be enough to ward off the Mediscare vampires.
Mediscare resonated in 2016 because of the 2014 budget decisions. These were seen as a breach of trust as they were policies that had been explicitly ruled out in the previous election campaign.
The controversial 2014 budget proposals aimed to reduce Commonwealth expenditure by shifting costs onto consumers and onto states. One way of doing this was through co-payments that required patients to make an out-of-pocket payment when they see a doctor.
Another cost-shifting policy was the Medicare rebate freeze, which froze MBS rebates for visits to doctors at 2013 levels, despite inflation since then which has been tracking at around 2% a year. Since rebates are also paid to consumers, this was another example of a consumer cost shift, although the burden of this strategy probably fell on providers, particularly general practitioners.
Some of the 2014 changes (like the co-payment) required legislation to implement, while others (like the rebate freeze) could be implemented by administrative action without requiring parliamentary approval.
Importantly, none of the changes that required legislation were successful. The only changes in the 2014 budget that were eventually implemented were the ones that didn’t require legislation, such as the rebate freeze and draconian public hospital budget cuts. These tore up a previous agreement under which the Commonwealth matched cost increases in public hospitals.
Even these two measures have now been partially wound back – the hospital cuts before the 2016 election, and the rebate freeze in the 2017 budget.
What should a Medicare guarantee look like?
A Medicare guarantee worth its salt would be one that protects the public from the administrative assaults of the 2014 budget. This would involve enshrining in legislation the Commonwealth-state health care agreements – as well as the “partnership” payments, which are other Commonwealth grants to the states for health care – and introducing automatic indexation of Medicare rebates.
The Medicare Guarantee Fund as proposed in the 2017 budget does not do this. It provides no guarantee of policy stability, no guarantee of additional funding, and no guarantee that a future budget will not tear into the Medicare fabric in the way that characterised the 2014 debacle.
This week’s federal budget allocated A$115 million in new funding over four years. This is one of the smallest investments in the sector in recent years.
This compounds a situation in which, in 2014-15, mental health received around 5.25% of the overall health budget while representing 12% of the total burden of disease. There is no reason those figures should exactly match, but the gap is large and revealing.
They speak to the fact mental health remains chronically underfunded. Mental health’s share of overall health spending was 4.9% in 2004-05. Despite rhetoric to the contrary, funding has changed very little over the past decade.
We lack a coherent national strategy to tackle mental health. New services have been established this year, but access to them may well depend on where you live or who is looking after you. This is chance, not good planning.
The general focus of care when it comes to mental health remains hospital-based services. Inpatient – when admitted to hospital – and outpatient clinic care or in the emergency room represent the bulk of spending. (The Australian Institute of Health and Welfare includes hospital outpatient services under the heading “Community”, which makes definitive estimates of the proportion of funding impossible.)
Outside of primary care such as general practice, or Medicare-funded services (such as psychology services provided under a mental health care plan), mental health services in the community are hard to find.
An encouraging aspect of this year’s budget is the government’s recognition of this deficiency. The largest element of new mental health spending was a commitment to establish a pool of $80 million to fund so-called psychosocial services in the community.
As Treasurer Scott Morrison said in his budget speech, this money is for:
Australians with a mental illness such as severe depression, eating disorders, schizophrenia and post-natal depression resulting in a psychosocial disability, including those who had been at risk of losing their services during the transition to the NDIS.
Yet, the money is contingent on states and territories matching federal funds, meaning up to $160 million could be made available over the next four years if the states all chip in with their share of $80 million. But this commitment was made “noting that states and territories retain primary responsibility for CMH [community mental health] services”. Whether the states agree is another matter.
This new funding seems partly a response to the federal transfer of programs such as Partners in Recovery and Personal Helpers and Mentors to the National Disability Insurance Scheme (NDIS). Both these programs offered critical new capacity to community organisations to provide mental health services and better coordinate care.
Partners in Recovery was established in the 2011-12 budget with $550 million to be spent over five years. Personal Helpers and Mentors (along with other similar programs) was established in the same year with $270 million in funding over five years.
With these programs now (or soon to be) cordoned off to recipients of NDIS packages, the 2017 budget measure appears to be designed to offset their loss. However, not all states may choose to match the federal funds. And some may choose to do so but try to use new federal funds to reduce their own overall mental health spending.
States already vary in the types of services they offer. All this raises the prospect that people’s access to, and experience of, mental health care is likely to vary considerably depending on where they live. In a budget espousing fairness, this is a recipe for inequity.
Lack of coherent strategy
The budget does attempt to improve the uneven distribution of mental health professionals by providing $9 million over four years to enable psychology services to rural areas though telehealth. It’s well known mental health services in the bush are inadequate.
This investment seems sensible, but $9 million pales in comparison to spending on the Better Access Program, which I have calculated to be $15 million each week. This program provides Medicare subsidies for face-to-face mental health services under mental health care plans. While this program is available for those in rural areas, accessing it is more difficult than in cities.
This budget’s commitment to mental health shows a lack of an overarching strategy. Rather than offering a coherent approach to mental health planning, this budget continues Australia’s piecemeal, patchwork structure, where the system is driven mostly by who pays rather than what works or is needed.
The development of a national community mental health strategy would be most welcome now. This would demonstrate how the primary and tertiary mental health sectors will join up to provide the blend of clinical, psychological and social support necessary to finally enable people with a mental illness to live well in the community.
You could be forgiven for thinking that, albeit slowly, the well-known problems in mental health across Australia are being addressed. But the small pool of funding in this year’s budget says otherwise. And the lack of coherent strategy is a shame. You can’t complete a jigsaw puzzle if you keep adding new pieces.