Hodgson: AGM of NZ Self Medication Industry
23 February 2006
Hodgson: Speech for AGM of New Zealand Self Medication Industry
"Good health begins at home" - the role of self-care in maintaining health.
Thank you very much for inviting me here today to speak at your Annual General Meeting. Prior to your invitation and reading the material you sent to my office, I have to say that while the concept of self-care was something I regularly practice, it was not a term I had come across very often in my readings on health policy.
New Zealand policy framework and examples of self-care
While I have stated that I haven't seen the term self-care explicitly described in health policy terms, reflection demonstrates that the principles of self-care are deeply embedded in the New Zealand Health Strategy. First published by the Ministry of Health in 2000, the Health Strategy identifies and prioritises a number of population health objectives such as: · reducing smoking; · reducing obesity; and · reducing the impact of cardiovascular disease and diabetes.
We are all aware that we are faced with an emerging epidemic of chronic diseases caused by poor lifestyle choices and an aging population. If we examine the various strategies implemented by the Ministry of Health and the District Health Boards in response to the strategy document, it is obvious that most of the population health objectives are based firmly on education and self-care. The Healthy Eating Healthy Action (HEHA) strategy is a marvellous example of providing the community with the education and tools required to empower individuals to improve their health and prevent disease. HEHA is an excellent example of self-care yet it does not involve the use of medications in any shape or form.
The Ministry of Health's pandemic plan for avian influenza is yet another example of how we support the concepts of self-care as being at the very heart of public health. As you are no doubt aware, we have developed extensive plans to deal with avian influenza, should we ever be unlucky enough to find ourselves having to respond to an outbreak of this infection, in New Zealand. Although most of this plan is about delivering health services under disaster-type scenarios, individuals taking responsibility for their own health by implementing simple hygiene methods is central to the plan. In short stopping the spread of infection through measures such as "safe sneezing" and hand washing will save more lives than expensive medications. Appropriate self-treatment of flu-related symptoms with medicines such as paracetamol or ibuprofen for fever, and other over-the-counter cough products for symptom control is also an essential part of the plan.
Quality information the key to self-care
As you all are in the business of selling medicines your marketing people will tell you that the key to promotion is to ensure that consumers have access to enough quality information to allow them to make the informed decision to buy your product. I do not subscribe to such a narrow definition of quality information. For a self-care strategy to be truly effective the consumer must be given enough information to be informed about the health issue and the treatment options, and then make an informed decision as to which option is best for them and their family. This requires the information to be delivered to be accurate, evidence-based and unbiased; it also requires that information to be delivered in an open and transparent fashion in a manner that everyone can understand.
It is clear from the literature that self-care is a broad church and we should not forget that it can involve a near limitless range of possible interventions ranging from "Ottawa Charter" type community development initiatives, through to integration of primary and secondary care for the management of some chronic diseases. If self-care is to be successful, consumer empowerment and the creation of a partnership between the consumer and the professional is essential if we are to avoid merely substituting one form of professional dominance for another. Strategies aimed at increasing self-care always lead to reconfiguration of the consumer-professional interface by decreasing the information asymmetry between these two parties.
Self-care and Health policy
So, when I look at the various strategies being implemented in response to the challenges set by the Ministry of Health, what do I see? The general thrust of most interventions to improve population health fall into three broad categories: community empowerment and development, improved coordination of primary and secondary care services to improve equity of access to appropriate services, and strategies to decrease other risk factors for chronic disease e.g. smoking and obesity.
All of these strategies have the ability to become "virtuous cycles" improving the community health, decreasing unnecessary demand, and ultimately allowing health interventions to be focused and delivered in a more equitably and timely fashion. On reviewing the New Zealand literature it is interesting to note however, that there is little or no discussion of the role self-medication could play in delivering some of our desired health outcomes.
Smoking cessation programmes are perhaps the best example of how effective self-medication self-care programmes can be. In material Tony Miller sent to me, I read with interest the glowing reports about the success of the Quitline programme in Australia. It was with a certain amount of satisfaction, however, that I then read that the New Zealand Quitline using Government subsidised self-medication is not only continuing to grow after 3 years of running but has research to prove it is more effective than the Australian approach.
The success of Quitline, I understand, is now spilling over into increased consumer purchase of smoking cessation products from retail outlets, an option facilitated by earlier decisions to allow these products to be sold from supermarkets.
Indeed I understand that the Australian decision to make nicotine-containing smoking cessation products available from supermarkets was driven entirely by the success of the New Zealand Quitline scheme. It strikes me that this convergence of public health policy, Government facilitation (through subsidization), and reclassification of a medicine to increase consumer access, to achieve desired health outcomes is potentially a powerful model for change management.
I note, however, that I am not the first Government official to have these thoughts. The Governments of Australia and the United Kingdom are far ahead of us in examining the possible synergies between Government, consumers and industry with respect to self-care and improving access to medicines. I therefore will briefly discuss the United Kingdom proposal, as in many ways it is a more radical and innovative approach to self-care than that adopted by Australia, and how it might impact on New Zealand thinking.
UK Government policy promotes self-care
In July 2000, the United Kingdom government released a plan for the National Health Service (NHS), which among other things, promoted consumers back to the centre of all healthcare delivery. The NHS plan also committed the Government to introduce a wider range of over-the-counter medicines by 2002, providing a stimulus for a strategic review of classification of medicines.
The strategic review was conducted by the UK Medicines Control Agency, (the equivalent to Medsafe), in collaboration with a multidisciplinary group of stakeholders. The terms of reference included a review of the reclassification process and identification of therapeutic categories that may be suitable for consideration for reclassification.
Information the key to consumer empowerment
The NHS plan and Medicines Control Agency (MCA) review both concluded that: · The future management of healthcare should be people-centred rather than doctor-centred, as is the case presently; · Many patients, especially those with chronic conditions, don't want to spend any more time than is necessary visiting their GPs and many are experts in their own conditions; · Enabling patients to make a choice of how they access such medicines empowers patients to help them manage their own care, with the help of skilled healthcare staff; and · Removing the restriction on reclassification has the potential to bring real public health benefits by giving more power and information direct to patients.
The review concluded that supply of quality information about medicines is a key requirement for delivering improvements in public health and increasing consumer access to medicines, as an alternative to, but not in place of, going to the doctor. The working group that created the proposals to improve access recommended that pharmaceutical companies should be encouraged to work with healthcare professionals and self-help groups to ensure consistency of message and information. It also recommended that companies should work with health professionals to develop guidelines and standards for use of reclassified medicines that reflect best medical practice.
In addition to the creation of guidelines the working group also recommended that: · Labelling should include certain basic product information, as well as including, or referencing, support information on safe use of the product, management of the condition, self-help advice and treatment protocols for the management of chronic conditions; · Companies should develop health professional training programmes for implementing classification changes in collaboration with appropriate health professionals.
UK proposing collaborative care model
It is important to note that the proposed UK scenario is not a win-lose situation, (i.e. one profession ceding authority to another), but rather it is a win-win-win, as changing the game to a patient-centred model of healthcare, doctors, pharmacists and consumers all gain by participating in the process.
Their report recommends that health professional bodies should work together to keep each other informed of changes to guidelines, and to develop possible mechanisms for shared patient records. The ability of all healthcare professionals involved in the care of a patient to know what medicines are being used by the consumer is seen as a vitally important if patient-centred healthcare is to be safe. To facilitate consumer self-care the report proposes that information about medicines available to consumers should be made available to doctors, pharmacists and patients.
UK regulatory changes proposed
The MCA is leading the implementation of Government policy in the process to improve consumer access to medicines. The proposals in the UK report are not based on lowering safety standards or deregulation. If anything, the increased requirements on stakeholders and professional bodies to regulate and police the behaviour of their members, represents an increase in the regulatory environment. While the proposals leave the standards for reclassification largely unchanged they propose significant changes to the process and regulatory perspective for reclassification. The regulator has proposed that applications for reclassification will only be referred to an expert advisory committee if the regulator's evaluation or the public consultation raises significant safety issues. This represents a change in regulatory perspective from a sponsor having to make a special case for reclassification to one where the expectation is that reclassification is normal and flows naturally as the safety of the product becomes more clearly defined.
Convergence the irresistible force
The convergence of public health policy, the rise of the consumer movement and evolving medical practice has resulted in the UK report advocating that nearly two hundred prescription medicines, intended for the management of chronic conditions, should be considered for reclassification including treatments for: gastro-oesophageal reflux disease; stable angina and hypertension; chronic stable asthma chronic obstructive airways disease; contraception; hormone replacement therapy; postmenopausal osteoporosis; malaria prophylaxis; influenza treatment; erectile dysfunction; obesity; rheumatic and arthritic pain; gout; nasal and ocular allergy; acne, psoriasis and impetigo; and skin and mucosal fungal infections.
Where these products are intended for chronic use, supply by a pharmacist is proposed to be on the basis of an initial consultation with a doctor.
Where to for New Zealand?
As we all know, New Zealand has undergone its own revolution in healthcare in recent years and it is interesting to note that without explicitly hanging our hat on self-care, we have reached similar positions to those proposed in the United Kingdom. As I mentioned earlier, many of our population health strategies are clearly based on self-care, consumer and community empowerment models. The Primary Health Care Strategy with its emphasis on population health, health promotion and preventative care, community involvement, multidisciplinary approaches to decision making, is another example of convergence both within New Zealand and with the United Kingdom's proposals.
The establishment of Primary Healthcare Organisations and initiatives to extend prescribing to other healthcare professionals, such as nurse practitioners; and the passage of the Health Practitioner Competence Assurance legislation are all designed to increase consumer access to medicines and to make the prescribing professionals more responsive to the community needs.
We have the infrastructure to support change in New Zealand and we are committed to putting the patient back at the centre of our healthcare systems. I am more than confident that our professional organisations and consumer groups are ready to respond to the demands for improved access to a wider range of medicines.
As we move towards the establishment of the Australian New Zealand Therapeutic Products Authority, I can assure you this new regulatory authority has been designed to meet best international regulatory practice. The concepts of matching risk to regulation described in the early consultation documents proposing such an organisation have been taken up and carried forward into the risk management framework for the Authority.
I am sure that once the package of legislation to establish the Authority is released, and this is currently planned for the middle of this year, you will agree that it will introduce an appropriate risk: benefit assessment process for all types of medicines be they pharmaceuticals or complementary products.
One of the exciting aspects associated with the establishment of the new Authority is that we will create a new expert advisory committee for considering the scheduling or classification of medicines for both Australia and New Zealand. I am certain that New Zealand will be an active member of this committee and our history of innovation in scheduling will successfully be transplanted into this new environment.
As self-care is a major component of the operational environment that this committee will interact with in Australia, I am sure that there is plenty of opportunity for the industry to make major changes to the range of medicines available over-the-counter to patients simply by submitting applications for reclassification. The relative lack of an explicit policy towards self-medication in New Zealand will not hinder the reclassification process.
Ultimately it is you, the self-care industry that have to agree to make and market new products; you therefore have the ability to drive this agenda for change if you want to take it. I therefore would urge you to start making applications to reschedule medicines; once you start running we will keep up. Waiting for policy development in New Zealand will simply slow down the rate of change.