Medicalisation-nation: Australia’s growing public policy dependence on drugs
As published in The Mandarin, 26th February 2019
By Brenton Prosser, PhD, Director (Research), Catholic Social Services Australia
Recent media reports have revealed concerns around the overuse of drugs to ‘treat’ older Australians, children with behaviourial issues and the process of childbirth. Academics call this trend medicalisation.
US scholars attribute the rising trend of medicalising human and social behaviours to the medical profession’s cultural authority and the pharmaceutical industry’s substantial direct marketing. But my ongoing research on medicalisation suggests this isn’t necessarily the case in Australia. A range of challenges to medical authority now exist, not the least of which is the search engine, and it’s been some time since Australia’s stay-at-home mothers were told to “Take a Bex and lie down”.
Our study of the dramatic rise in psychostimulant drug treatment for ADHD in Australia in the 1990s showed a gap between federal disability legislation recognising ADHD and the need for family support, and state/territory policies responsible for service delivery. Put simply, the support was not delivered. For many families, that meant resorting to a bulkbilled GP visit, an MBS referral to a clinician and access to PBS-subsidised medication. Further, 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, starkly contradicting the US experience.
The past decade has brought dramatic changes to Australia’s disability and mental health policy contexts, and it’s not that clinical and pharmaceutical treatments are bad things. But an MBS model that splits human and social conditions into individual and clinical services is not always best-suited to addressing the clustered needs, complex comorbidities and social determinants that can undermine interventions. It seems a range of other health and social services are needed; private health insurance could cover that cost—but private insurance is 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.
Market pricing is also a potential public policy driver for Australia’s medicalisation. For example, the shift from block funding to user-pays in health and social services leaves a coordination-services funding gap. Local GPs, among whom understanding of and support for holistic approaches varies greatly, are now the go-to for coordination services. Even a supportive local GP can struggle to coordinate a tailored package, and it gets harder still when price-settings are reduced, cheaper service models are required, and there is less time for face-to-face involvement with patients. Without a constant carer or coach, and in the face of complex systems, there is a real chance that the only available response will be a medical one.
The devolution of service delivery to clinically-led local bodies such as Primary Health Networks(PHNs) is another matter for public policy consideration. PHNs have become central to regional responses to health and social service needs. Leveraging a PHN flexible funding pool (sourced from the funding previously tied to specific health and social services), PHNs tap into local GP knowledge and networks to identify regional health priorities, coordinate local responses, and commission services.
Increasingly, the green-lighted services are primarily medically and clinically oriented. This development needs to be viewed in the light of social and psychosocial services providing preventative, short-term or transitional support prior to 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.
I have interviewed representatives across a peak social services body’s national network of 50 service providers, for my current research work. Occasionally, I have heard reports of PHNs entering into very productive relationships with local health and social service partners. However, other reports say some PHNs are referring to clinical specialists, relying on teleconferencing, or commissioning their own, newly established service entities. Some change is to be expected as new service markets evolve, but in evidence is the potential for PHNs to result in less funding for keeping viable complementary health, psychosocial and social services, with the unintended 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 known—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 the support for client coordination and addressing 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 in 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. Greater recognition of the potential role of public policy in medicalisation will reduce the potential for drug overuse. It could also contribute to the expansion of strategies that support a more holistic integration of primary care, health and social service delivery.
Brenton Prosser is Director, Research, Catholic Social Services Australia. Prior to that, he was Director, Public Policy, with the international private management consulting firm, Nous Group. He also has over two decades of research experience in leading Australian, UK and US universities. Brenton has worked at the highest levels of Australian government policymaking, including as a senior public servant and Chief of Staff to a cross-bench Senator.