An edited version of this paper was published in the Mandarin on 26 February 2019.
Australian media regularly reports concerns about the over-use of drugs to treat our most vulnerable. However, what this reporting has missed is the subtle but underlying trend toward medicalisation in public policy.
I first met Dorothy as part of a national evaluation of community-based services for older Australians. We met in her small home, nestled away amongst a retirement village in suburban Brisbane. Even though this meeting was several years ago, our conversation stays with me.
Dorothy suffered with incontinence. She had done so for more than five years. It was uncomfortable. It was a source of embarrassment. It resulted in her having little contact outside of her home or over the phone. She had been to see her GP on numerous occasions, but her incontinence was never mentioned. It was always issue four or five on the list. There was only time for the most urgent presenting issue.
That was until Dorothy was visited by a community Nurse Practitioner. Instead of asking ‘what is wrong with you today?’, the NP asked ‘what is it that you would like to do?’
Dorothy said she would really love to attend her grand-daughter’s wedding in Melbourne. ‘Why can’t you go?’ was the obvious question. That is how her incontinence problem became known.
A few months later, Dorothy’s attendance at her family’s special event made it even more special. It gave her and her family a memory that will last for many years to come.
I recall this story because, for me, it captures a growing challenge for health and social service delivery. It highlights the challenge of policy and price drivers privileging the medical over the holistic. It’s not that primary care and drug prescription are the wrong option, rather that they increasingly risk being the only option.
This trend has been noted by the Australian media. Recent reports reveal concerns around the overuse of drugs to ‘treat’ older Australians, children with behaviour issues, loneliness and childbirth. Academics call this trend medicalisation.
Medicalisation is used to refer to the way that human and social conditions are increasingly defined and managed as clinical conditions. The medicalisation scholars, largely working out of the United States, attribute this trend to the cultural authority of the medical profession and substantial direct marketing from the pharmaceutical industry. However, my ongoing research on medicalisationsuggests this isn’t necessarily the case in Australia.
It is some time since stay-at-home mothers were told to ‘Take a Bex and lie down’. There are now a range of challenges to medical authority, not the least of which is the search engine. Meanwhile, the Australian medical profession have often been the first to sound the alarm about medicalisation and the overuse of drugs. We should also note that Australia has much stricter regulation of advertising and direct marketing of pharmaceuticals than in the United States.
Our research suggests that more attention needs to be given to the role of public policy in the medicalisation of Australian society.
We first identified this when studying the rise in drug treatment for ADHD in Australia. What we found was that in the 1990s, when psychostimulant use grew dramatically, there was a gap between federal disability legislation (that recognised ADHD and the need for support) and state/territory policy (which was responsible for service delivery but did not). This left many families to fund and provide their own support. It meant that for poorer families, the only viable option was a bulkbilled visit to a GP, a MBS referral to a clinician and access to PBS-subsidised medication. Our 20 year statistical analysis of psychostimulant use for ADHD in Australia (1) (2) (3) found a strong link between higher drug use and low socio-economic regions, which starkly contradicted the US experience.
Admittedly, the disability and mental health policy contexts have changed dramatically over the last decade and it is not that clinical and pharmaceutical treatments are bad things. But as former CSSA CEO and now Head of Mental Health Australia, Frank Quinlan, recently put it:
“In recent years we have seen a shift towards the provision of services that are individualistic and transactional… Yes – individuals need access to better, more integrated, more streamlined services – but as a country, we need much more than that.”
For instance, a MBS model that splits human and social conditions into individual and clinical services is not always best suited to address clustered needs, complex comorbidities and the social determinants that can undermine interventions. A range of other health and social services are needed.
Private health insurance can help some with these costs, but they can be prohibitive for some groups. These pressures will only intensify as the medicalised MBS philosophy is translated into other areas of health and social service policy.
There at least two more potential public policy drivers for medicalisation in Australian society.
One is the relationship between pricing and markets. It has been generally acknowledged that the shift from block funding to user-pays in health and social services has left a gap in funding for coordination services. A lot of this now falls to the local GP, where understanding and support for holistic approaches can vary greatly. Even the supportive local GP can struggle to coordinate a tailored package. As price settings are reduced and cheaper service models are required, which usually involve less face-to-face involvement and less service professional time, this gets even harder. Without a constant carer or coach and in the face of complex systems there is a real chance that the only response will be a medical one.
A second is the devolution of service delivery to clinically-led local bodies, such as Primary Health Networks (PHNs). PHNs have become central to regional responses to health and social service needs. Leveraging off the knowledge and relationships of local GPs, PHNs identify regional health priorities, coordinate local responses and commission services. To support this work, previous funding that was tied to specific health and social services has been bundled into a PHN flexible funding pool. This means that increasingly those making the decisions over what services do and don’t go ahead, do so with a primarily medical and clinical orientation.
This also needs to be viewed in the light of social and psychosocial services providing preventative, short-term or transitional supports prior without clinical diagnosis and labelling. The reduction of these services may contribute to greater medicalisation by creating a void of services around clinical or drug interventions.
In my work with CSSA, I have interviewed representatives from across our national network of 50 service providers. Occasionally, I have heard reports of PHNs entering into very productive relationships with local health and social service partners. But there are also reports coming back of some PHNs referring to clinical specialists, relying on teleconferencing, or commissioning to their own newly established service entities. Some change is to be expected as new service markets evolve. But this highlights the potential for the introduction of PHNs to result in less funding to keep complementary health, psychosocial and social services viable, with the untended consequence of greater medicalisation.
So how do we respond to the perhaps unintended but influential drift toward medicalisation in Australian public policy?
First, we need to remember what is already know – that social determinants are significant barriers to otherwise successful clinical, health and social outcomes. This insight challenges the logic of drug-only responses. We need to advocate further funding for client coordination as the backbone to integrated services. This is particularly important for the poor and most vulnerable in our community. But improving the social determinants of health and wellbeing will also reduce the costs of support over the long term and maximise opportunities over a lifetime.
We will also need greater community education and genuine opportunity for collaboration across medical, health and social service professions. Health and social service providers need to form strong relationships with PHNs, GPs, pharmacists and others who help inform the community and coordinate holistic service delivery.
Finally, we need to explore specific investment into public health and social services research to demonstrate the significant contribution made by these professions and complement the insights from clinical and medical research.
The medicalisation of Australian society will continue to be a topic of academic, policy and media interest. What a greater recognition of the potential role of public policy in this medicalisation can do is reduce the potential for drug overuse. It can also contribute to the expansion of strategies that support a more holistic integration of primary care, health and social service delivery.
It is through measures such as these that we will be able to work together to raise awareness and resist the subtly unfolding trend toward a greater reliance on drugs within Australian public policy.
Catholic Social Services Australia is seeking to support its membership in cases where the medicalisation of public policy is having an impact on holistic support and service viability. For this reason, medicalisation is part of its longer-term research and advocacy work. If you have concerns about the impact of this, please contact Director (Research) Brenton.Prosser@cssa.org.au to share your experience.