Introduction
6.1
Although approximately one third of a human lifespan is spent sleeping, the importance of sleep to overall health and general wellbeing is often taken for granted. To resolve this, the Sleep Health Foundation (SHF) and the Australasian Sleep Association (ASA) has advocated for a preventive health campaign to educate Australians on how and why they should improve their sleep habits.
6.2
Sleep is a multidisciplinary issue. In addition to specialist practitioners, contributions to sleep medicine are made by a range of health professionals including general practitioners (GPs), psychologists, nurses, dentists, and pharmacists.
6.3
The Australian sleep research community is based across clinical and university research settings, and receives funding from the National Health and Medical Research Council (NHMRC). Opportunities to resolve gaps in the existing body of research knowledge were identified by inquiry participants. The expansion of sleep health knowledge is also closely intertwined with data collection for the monitoring of sleep health issues in the Australian population.
Community Awareness of Sleep Health Issues
6.4
The Melbourne Sleep Disorders Clinic (MSDC) stated that when it opened its clinic 25 years ago the awareness of sleep disorders in the community was ‘very poor.’ The MSDC added that the number of sleep clinics in Melbourne had grown significantly during the time it has been in operation. Beyond awareness of clinical sleep disorder diagnosis and treatment, the Public Health Association of Australia (PHAA) stated that the awareness of good sleep health as part of ‘everyday lifestyle and routine’ in the community has not yet occurred.
6.5
Neuroscience Research Australia (NeuRA) held concerns that some ‘people think it’s some heroic feat if you can get by on not much sleep’, and further stated that it has never had a patient ‘in the lab that can get by on four hours of sleep and function optimally.’ The MSDC stated that in the ‘business world’, working through the night is seen as a ‘positive trait’, despite the memory and judgement impairment.
6.6
The MSDC stated that there ‘has to be a society-wide shift about not seeing sleep as something that can be traded off as an optional extra.’ The SHF recognised the difficulty for an individual alone to change their sleep behaviour, and stated that ‘when we see changing attitudes around us, then our own behaviours will change with them.’
6.7
In response to concerns about community attitudes regarding sleep, the SHF and the ASA have called for a national campaign to improve the awareness of sleep health in the community. The SHF stated that a national sleep health awareness campaign should:
… educate Australians about the purpose of sleep, normal sleep requirements, the consequences of inadequate sleep (because of insufficient duration, inappropriate timing relative to time of day, or inadequate quality due to an unrecognised sleep disorder or other problem), self-help measures to improve sleep and sources of professional help where problems persist.
6.8
The SHF stated that a key message of a national sleep health awareness campaign should be to inform the public that behavioural changes can be an effective first step in resolving sleep issues:
We know there are behavioural things that people can do, and that's the message that we need to get out to the public: 'you can problem-solve some of your sleep problems yourself by seeking out information, and you can make behavioural changes that could well make a difference. If that doesn't work and your GP thinks that you may have a sleep disorder, then go down that track’.
6.9
The SHF and ASA estimated that a national community education campaign would cost $18.26 million over four years. The SHF and ASA stated that this would include funding for:
‘a national media and social media educational campaign focused on the value of making lifestyle choices that promote wellbeing and alertness through prioritising sleep’;
a community speaker program;
resources and a speaker program for schools;
a website with educational material;
‘translation of information into the most widespread community languages [other than English] spoken by Australians.’
6.10
There are limited examples of public awareness campaigns relating to sleep, both locally and globally. The Department of Health has published sleep guidelines for children up to five years of age, as part of its 24-Hour Movement Guidelines for the Early Years. The Department of Health, however, does not have specific programs relating to sleep health, and further stated that:
[Sleep health has] not been an area that's been specifically focused on within the department, so there's not a sleep plan or a sleep health plan being developed.
6.11
Campaigns targeting drowsy driving were cited as an example of Australian public health campaign related to sleep. The University of Sydney (USyd) Brain and Mind Centre (BMC) commented on the number of billboards warning against drowsy driving, and stated this is an example where sleep awareness has been taken seriously. Similarly, the Adelaide Institute for Sleep Health (AISH) praised the drowsy driving campaign run by the Victorian Transport Accident Commission which uses the key slogan of ‘a 15 minute power nap could save your life.’
6.12
In addition, the University of Western Australia (UWA) School of Psychological Science recommended the inclusion of sleep health education as part of licensing for new drivers.
6.13
Preventive health campaigns addressing other health issues can serve as models for how a sleep health public awareness campaign can be structured and targeted. The USyd-BMC suggested, however, that a sleep health awareness campaign may be more complex to implement than other public health campaigns. Comparing sleep health to the Quit smoking campaign, the USyd-BMC stated that sleep is not a single problem:
There isn't a single target there in the way that the behaviour of lighting a cigarette and smoking it is. So, from a public health point of view, it's not a unitary problem that you can just whack with about 15 different things in the way we did with smoking. … Sleep is not one problem; it's hundreds of problems. So it's not going to be as simple.
6.14
SleepFit stated that organisations focus on ‘mental health yet there is much research that points to sleep [as] underpinning’ mental health conditions. The National Mental Health Commission (NMHC) and SleepFit saw the potential for sleep problems to be addressed in a ‘non-stigmatising way’, which does not always occur where there are also mental health issues. The NMHC further stated that discussion of sleep issues may provide an avenue for ‘early intervention and prevention’ of ‘suicidal ideation and behaviours.’
6.15
The Parenting Research Centre described the ‘ingredients’ of a successful public health campaign. The Parenting Research Centre stated they seek to embed their ‘resources into the daily practice of those who work with families’, such as ‘maternal and child health nurses, general practitioners, teachers and early years educators.’ The Parenting Research Centre further elaborated on the message they wanted to send when communicating a public health issue:
… this is an important issue, it's okay not to know everything, there are things you can do, here are some very practical … tips and strategies that you can incorporate into every day.
6.16
Red Nose, which has led the public awareness campaigns to reduce the risk of Sudden Infant Death Syndrome (SIDS), advocated for simple messaging. Red Nose stated that overseas bodies had up to 22 safe sleeping recommendations which is too ‘confusing’ and hard to remember. Instead, Red Nose has concentrated on just six safe sleep recommendations.
6.17
Red Nose also explained that its safe sleeping message had been less successful reaching people in ‘Indigenous, rural and remote, culturally and linguistically diverse communities’. Red Nose stated that ‘Indigenous people were seeing that SIDS was a European problem’ and wanted to keep their babies in bed with them. In response, Red Nose developed a targeted program for Aboriginal and Torres Strait Islander communities that aims to provide a safe and separate sleeping space for babies in the parental bed.
School Hours
6.18
As adolescents have a naturally delayed sleep phase than adults, the possibility of delaying school start times has been raised as a means of helping adolescents get adequate sleep. The Royal Australasian College of Physicians (RACP), however, stated that the proposals were ‘not necessarily translatable to Australia’ as the research is mostly from the United States of America (USA), where school start times are earlier than in Australia. Let Sleep Happen and the RACP stated that there was a risk that later school start times could create a population with a delayed sleep phase disorder.
6.19
The ASA stated that, rather than changing school start times, the school program could be rescheduled to account for adolescent micro-napping in the morning. The ASA suggested having ‘sports classes first in the morning rather than after school’ and more academic classes in the afternoon.
Education and Training for Healthcare Workers
Sleep Medicine as a Field
6.20
The RACP stated that it ‘recognises sleep medicine as a subspecialty of internal medicine.’ Professor Ron Grunstein stated that due to its nature, sleep medicine is a cross-disciplinary field:
Sleep medicine is not an organ-based specialty such as cardiology or respiratory medicine. It is a predominantly cross-disciplinary field where skills need to be drawn from areas such as respiratory medicine, neurology, … psychiatry, and other specialities.
6.21
Sleep practitioners are currently categorised by the Australian Health Practitioner Recognition Agency (AHPRA) as ‘Respiratory and Sleep Medicine’ practitioners. The Woolcock Institute of Medical Research (WIMR) advocated that AHPRA ‘recognise sleep medicine as a truly independent specialty separate from respiratory medicine.’ The ASA stated that this has not occurred due to the cost of AHPRA recognition:
Three or four years ago we did a lot of work with the College of Physicians and AHPRA trying to get a sleep physician category up and we were told that, yes, it would be possible but it's going to cost us about $2 million, and we didn't have the $2 million so we didn't pursue it.
6.22
Ms Fiona Mobbs, who is living with narcolepsy, stated that specialised sleep professionals needed to handle sleep disorders such as narcolepsy. Ms Eliza Wells, who is also living with narcolepsy, stated that the ‘local GPs that I have seen not only have no understanding of narcolepsy, they also appear to have little to no interest in gaining one.’
6.23
The SHF stated that the USA has ‘a more completely evolved specialty of sleep medicine—they have their sleep medicine boards; they recruit from all sorts of specialties, but it's unashamedly sleep.’ Similarly, the Canberra Sleep Clinic (CSC) stated that Australia is ‘out of step with the diversity of sleep physician practice in Europe and the [USA].’ The CSC added that ‘almost all sleep physicians are respiratory physicians’ but there is a need for ‘neurologists, psychiatrists, general physicians, ear nose and throat, and oromaxillofacial surgeons trained in sleep medicine.’
6.24
The WIMR recommended ‘a review of specialist sleep medicine training, involving the relevant colleges and the AHPRA.’ The SHF stated that an independent sleep speciality would mean that ‘sleep can receive its separate advocacy and its special concentration that the problem needs, for health reasons but also for economic ones.’
Clinical Training for Sleep Practitioners
Sleep Physicians
6.25
After the completion of a medical degree, sleep physician training primarily occurs through teaching hospitals. The Queensland Government reported that there is no formal sleep medicine training offered to medical practitioners through Queensland Health. The Queensland Government stated, however, that the RACP offered Respiratory Medicine and Sleep Medicine training that could be undertaken at one of ten hospitals in Queensland.
6.26
The Australian Capital Territory (ACT) Government stated that the Canberra Hospital offers a one year respiratory training program that allows ‘registration as a respiratory and sleep physician.’ The ACT Government further stated that this course:
… does not result in accreditation as a sleep medicine physician, which is a separate programme that requires at least two years of core training in sleep medicine. Trainees wishing to take this specialisation often undertake dual training in respiratory medicine, neurology or another subspecialty in addition to sleep medicine training.
6.27
The WIMR commented on the dominance of respiratory medicine as a pathway to sleep medicine, and stated that this is a ‘lopsided arrangement’ not reflected in other countries. The WIMR added:
Virtually all sleep medicine practitioners spend most of their time in respiratory, not sleep, medicine and never get three years training in sleep medicine. Even with sleep training, there was an overwhelming emphasis on respiratory sleep disorders. For example, in a one year training program in sleep medicine, a trainee is only expected to see 30 new patients with non‑respiratory sleep disorders—a truly worryingly low number, considering they're meant to see 500 new and old cases.
6.28
Professor Grunstein added that as a consequence of the respiratory medicine training pathway, sleep physicians receive training that does not equip them to engage in sleep medicine more broadly. Professor Grunstein explained:
… many sleep physicians lack the necessary training to engage in sleep medicine in its broad sense. For example, skills in pulmonary function testing, bronchoscopy, lung cancer or interstitial lung disease management have no relevance to sleep medicine whereas skills in basic neurology, psychiatry or obesity medicine would be far more important.
6.29
The RACP offers Advanced Training in Respiratory and Sleep Medicine to practitioners working towards qualifying as a Fellow of the RACP. The RACP agreed that ‘improved training pathways … with a better focus on non-respiratory sleep disorders’ is needed. The MSDC stated that the RACP’s curriculum had become broader in recent years:
With respect to the sleep curriculum for the advanced trainees in respiratory and sleep medicine—those doctors finishing off their training as consultant physicians—the curriculum has changed in recent years to re-emphasise the fact that there [is more to] sleep medicine than just sleep apnoea. It really reflects how our practice has evolved, which is to manage all of the sleep disorders.
6.30
Dr Sadasivam Singh stated that the available training places for sleep medicine are limited in comparison to the USA and Canada. Dr Singh added that there is a particular shortage for paediatric sleep medicine places as there are ‘very few paediatric-training centres.’
6.31
In the case of adult sleep medicine, the Thoracic Society of Australia and New Zealand (TSANZ) stated that the Royal Adelaide Hospital will no longer be accredited by the RACP to provide respiratory and sleep medicine training due to the loss of the Royal Adelaide Hospital’s sleep laboratory.
6.32
The WIMR stated it is attempting to develop a multidisciplinary sleep training structure but that this is ‘difficult to achieve’ as all the funded ‘positons are largely based in hospitals.’ The RACP stated that ‘what happens on the ground within hospital environments’ is not conducive for funding outpatient sleep physician positions:
… the training largely takes place within public hospitals, which deal with a lot of inpatient work—and sleep being a predominantly outpatient specialty—it has a lot of trouble getting access to resources. So the funding for sleep specific positions is difficult.
6.33
The MSDC stated that it sought to train new practitioners to cope with the ‘the avalanche of demand in this area.’ The MSDC elaborated that it trains registrars (specialist trainees) in sleep medicine through the Department of Health’s Specialist Training Program. This program ‘funds advanced training in private settings’ and provides trainees with experience not available in wholly hospital-based programs. The MSDC stated:
We've formed a joint training network so that we provide the type of training that's not usually available in the public setting, so non-respiratory types of sleep problem like narcolepsy, restless legs, insomnia—the sort of stuff that's not inpatient, government hospital type of work. In the other four-tenths of the week, they're at the state government hospital being exposed to that side of it. We're now in our 11th year of funding. The trainees are really regarded highly.
Sleep Scientists and Technologists
6.34
Sleep scientists and technologists are allied health professionals ‘who prepare and record people overnight while they're having their sleep studies.’ In addition to analysing sleep study recordings, sleep scientists and technologists also set up Continuous Positive Airway Pressure (CPAP) devices for patients, and conduct research studies.
6.35
The ACT Government stated that the Canberra Hospital provides training to ‘science graduates to become sleep scientists.’ This training ‘aims to ensure that all aspects of sleep polysomnography training are covered.’ Experienced sleep scientists may also seek accreditation with the USA-based Board of Registered Polysomnographic Technologists.
Sleep Health in University Education
6.36
The time devoted to sleep health in university medical curricula was viewed to be insufficient. Ms Hailey Meaklim and colleagues provided research from 2011 which stated an average of 369 minutes (approximately six hours) and median of 300 minutes (five hours) of sleep education was offered in medical programs in Australia. Globally, this research found that an average of approximately two hours was spent on adult sleep education.
6.37
The ASA stated that the UWA included one week of sleep training in its medical degree, and suspected that this was ‘probably the most anywhere in Australia.’ The Monash Children’s Hospital stated that there were two hours of training spent at its university.
6.38
The ASA further stated that changing the university curriculum is difficult, as curriculum is a matter for individual universities. Similarly for psychology education, the UWA School of Psychological Science stated that it is ‘up to individual schools of psychology to what extent sleep is addressed within the curriculum.’
Education and Training for the Broader Healthcare Profession
Awareness of Sleep Health Among General Practitioners
6.39
The UWA Centre for Sleep Science and the Monash Children’s Hospital stated that General Practitioners (GPs) have an important role as the ‘gatekeepers’ of healthcare,’ however opportunities for sleep education are limited. Ms Meaklim and colleagues stated that ‘for those graduates who subsequently choose to enter the General Practice training program, there is no further formal teaching relating to sleep and sleep disorders in Australia or New Zealand.’ Austin Health stated that as a result, it is ‘up to individuals in primary care to say, “I've got an interest” and seek out specific education if they want to do that.’
6.40
The AISH stated that the new Medicare Benefits Schedule items, introduced in November 2018, require GPs to ‘have a better understanding of [Obstructive Sleep Apnoea (OSA)] diagnosis, sleep study interpretation and treatment options.’ The TSANZ recognised the pressure on GPs, and stated that ‘GPs have to be an expert at everything’ and that sleep disorders are ‘just another disease that's going to be thrust on top of them.’
6.41
The role of the Royal Australian College of General Practitioners (RACGP) in GP education was recognised as important. The Queensland Government stated that ‘the RACGP has online resources, including a list of evidence‑based non-pharmaceutical treatments and articles, addressing sleep disorders.’
6.42
The RACGP’s Prescribing Drugs of Dependence in General Practice guidelines state:
short-term use of benzodiazepines as hypnotic agents should only be one aspect of general management [of episodic insomnia].
first-line therapy for chronic insomnia should be non-drug interventions.
6.43
Reconnexion stated that ‘despite [the RACGP] guidelines … benzodiazepines are inappropriately prescribed and dispensed.’
6.44
Reconnexion further stated that GPs need to be educated on how to manage benzodiazepine prescriptions:
… not just is it simply education for doctors about [benzodiazepines] and their effects but it's also education about how to think about managing the prescription and to make sure they have an exit plan right at the beginning. They've actually got to have a plan to stop prescribing after two to four weeks.
6.45
The ASA recommended that a formal assessment of the current knowledge levels of GPs in relation to sleep health be undertaken. The ASA further stated that sleep education should be included in the training course and examination for qualification as a Fellow of the RACGP.
6.46
As an example of structured training, Sleep GP provides ‘RACGP accredited’ training for GPs. This training produces ‘GPs with a special interest in sleep’ that are capable of managing routine sleep disorders in the primary care setting.
6.47
Digital tools were suggested as a potential mechanism for providing GP training. The ASA and the RACGP have produced an online sleep disorders training module for GPs. The Monash Children’s Hospital disseminated information through an online platform, HealthPathways, to ‘improve the education of GPs around the diagnosis and management of [OSA].’
6.48
The Sleep Management Group similarly suggested digital tools as a solution, and stated that software used by GPs ‘is starting to move closer to’ flagging patients to be at risk of a sleep disorder ‘based on their [body mass index].’ The AISH stated that they are investigating decision support systems for GPs that incorporate the:
… standard questionnaires and tools that … screen an individual for the particular sleep problem or sleep disorder they might have and recommend a personalised therapy that they can pursue to deal with that particular problem.
Awareness of Sleep Health Among Psychologists
6.49
Psychologists deliver the recommended first-line treatment of insomnia, Cognitive Behavioural Therapy for insomnia (CBT-I). The AISH stated ‘we need to train more people and make them more available’ to meet demand for CBT-I. The AISH also suggested that there would never be ‘enough trained psychologists available to manage entirely the behavioural side of the therapy’ and that for this reason patients should be provided with tools they can use at home before being referred to a psychologist.
6.50
Sleep Matters stated that delivery of CBT-I requires specific sleep training due to the important distinctions from other types of CBT:
… anybody who's done a postgraduate master’s degree in clinical psychology will be really well versed in CBT. What they're not well versed in is behavioural sleep medicine. … There are lots of similarities with CBT for depression or an anxiety disorder, but … in the case of insomnia, things like the regulation of sleep, so having that sleep-science background, are actually really important for getting the treatment to be effective.
6.51
The Australian Psychological Society provides a Practice Certificate in Sleep Psychology, which is a four module program designed to train psychologists in assessing and managing sleep disorders, such as insomnia. Emeritus Professor Dorothy Bruck and Dr Moira Junge stated that only 121 psychologists in Australia have completed the full certificate, with a further 800 psychologists completing only the introductory module. Professor Bruck and Dr Junge added that the certificate should be made more rigorous:
[The certificate] is offered purely online and has a simple open-book multiple choice test as its only assessment. There is scope to improve the rigour of this training and also the uptake of enrolments.’
Awareness of Sleep Health Among Nurses
6.52
Ms Meaklim and colleagues stated that nurses are aware of the importance of sleep, but are constrained by limited knowledge about sleep interventions:
… intensive care unit nurses display an overall awareness of the importance of sleep and are interested in helping to promote sleep in their patients. However, a lack of knowledge, as well as the pressures of caring for critically ill patients, may limit these nurses’ ability to deliver evidence-based sleep‑promoting interventions.
6.53
The SHF stated that the United Kingdom has been successful in training ‘nurses to deliver treatments for insomnia.’ Professor Grunstein stated that a CBT-I program based in Tamworth delivered by nurses in GP practices had positive outcomes, and highlighted that the ‘training of rural practice nurses would be an important strategy for insomnia management in rural areas.’ Further, Ms Meaklim and colleagues stated that while digitally delivered CBT-I is useful, nurses can ‘play an effective and integral role’ when delivering interventions to older populations where ‘there is a need for more face to face treatment.’
6.54
The Queensland Nurses and Midwives Union stated that the education that nurses and midwives ‘receive on sleep should include how they handle their own sleep health and how to cope with working shift work.’
Awareness of Sleep Health Among Dentists
6.55
Dentists are involved in the management of OSA through the provision of Mandibular Advancement Splints (MAS). Absolute Sleep stated ‘the problem is that within dentistry [the provision of MAS] is considered in the normal scope of practice, which is unfortunate because’ dentists providing MAS do not just treat a dental condition, they treat a medical condition. As such, Absolute Sleep stated that appropriate sleep medicine training is required. Absolute Sleep stated:
… We’re talking upper airway mechanics and we're manipulating them. You have to know what you're treating. You have to know what sleep apnoea is. You have to be able to read a sleep report or a sleep study, et cetera, which is more science and medicine.
6.56
The Australian Dental Association (ADA) stated that any dentist will have the ‘pathophysiology training’ and ‘prosthodontics expertise to manipulate the device,’ however, specialised expertise would be developed over time. Further, the ADA stated the level of dentist involvement will vary depending on whether a sleep physician knowledgeable about MAS is also involved in the patients care:
It depends on which level a dentist wants to get involved. ... If the patient is managed very well by a sleep physician who is knowledgeable with the whole scheme of these devices then that is going to be a different take [than] when taking on the whole case without such an informed sleep physician involved.
6.57
The principal dentist of Absolute Sleep, Dr Christopher Pantin, was involved in the development of the Graduate Diploma in Dental Sleep Medicine at the University of Western Australia. Dr Pantin stated that the Graduate Diploma ‘was the first of its kind in the world and has over 24 graduates.’
6.58
The Dental Sleep Medicine Council of the ASA stated that while this is the benchmark program, ‘this program has a limited capacity of places and the fees can be prohibitive.’ Further, Dr Pantin stated that due to the difficulty of the Graduate Diploma, ‘a more palatable version that will still tick all the boxes for qualified dentists’ is needed.
Awareness of Sleep Health Among Pharmacists
6.59
Ms Meaklim and colleagues stated that limited training for pharmacists in sleep health results in ‘a missed opportunity for early interventions that can be provided to the Australian public seeking help for their sleep issues and presenting at pharmacies for treatments and help.’
6.60
The Pharmaceutical Society of Australia (PSA) in collaboration with the ASA developed a ‘blended training program for sleep apnoea services, combining online modules and a practical workshop’ for pharmacists. The PSA stated that pharmacists are providing services for OSA:
… as people have come into pharmacies, there's an unmet need where either people have not been aware that they're snoring or other complaints are a signal of a health concern. So the pharmacy service will screen these people and either facilitate their management by referring them to a medical person for a proper medical assessment or put them through a structured model of care that is supported by practice guidance and supported by standards and expertise to provide support through CPAP machines to assist the management of their sleep apnoea.
Research, Investment and Data Collection on Sleep Health and Sleep Disorders
6.61
Inquiry participants described the successes achieved by the Australian sleep research community, including the invention of CPAP devices to treat OSA by Professor Collin Sullivan. The NeuRA stated the success was due to the collaborative nature of the Australian sleep community:
We are collegial, we work with multidisciplinary field teams across the country to solve these big problems and that is why we are on the world stage at the forefront, leading the biggest trials in the world.
6.62
The Cooperative Research Centre for Alertness, Safety, and Productivity stated that there has been a ‘push recently to improve the capacity of researchers to commercialise and innovate.’ Professor Grunstein stated that ‘Australia has a relatively large medical device sector in sleep health’, including ‘ResMed, Compumedics, Somnomed, Oventus.’
6.63
Opportunities for translating research into policy or clinical application were thought to exist. The Monash Children’s Hospital stated that ‘there's a lot of evidence out there that just sits there because there's no mechanism or money to implement it so that it makes a difference.’
6.64
The Public Health Association of Australia stated ‘it is currently unknown what types of community-based interventions can improve the sleep of the community, and funding to support the evaluation of such public health programs is required.’ Considering the workplace, ‘collaborative industry‑driven research’ into shift working environments was also recommended. Associate Professor Jillian Dorrian, Dr Stephanie Centofanti, Dr Amy Reynolds and Professor Kurt Lushington stated that this research and resulting solutions should consider roster design and other workplace considerations to limit fatigue.
6.65
Australian sleep research, however, was described as heavily concentrated on investigating OSA. The USyd-BMC stated, however, that there are a ‘hundred sleep disorders, many of which have never really been studied at all.’
6.66
Mr Aaron Schokman stated that he had difficulty in finding PhD opportunities in Sydney to study sleep disorders other than OSA. The WIMR added that:
Narcolepsy and the probably much more prevalent hypersomnia are an area where we have real weakness in research. That's an effect of both training—having the scientists and clinicians who can work in the area—as well as obviously the funding that would follow if you had people doing quality work in that area.
6.67
Table 6.1 provides a breakdown of NHMRC research funding for specific sleep conditions.
Table 6.1: NHMRC supported research for specific sleep conditions 2000 to 2018
|
|
|
|
|
Sleep apnoea
|
74 412 821
|
54
|
|
Insomnia
|
14 688 457
|
11
|
|
Sudden Infant Death Syndrome
|
8 303 428
|
6
|
|
Narcolepsy
|
1 121 282
|
1
|
|
Sleep research not attributed to the conditions above
|
39 137 292
|
28
|
|
Total
|
137 663 280
|
100
|
Source: Department of Health, Submission 131, p. [6].
6.68
Professor Grunstein stated that there is limited basic science research looking at sleep in Australia. Professor Grunstein stated that this has flow-on consequences to university and high school education:
Without such scientists, the opportunity for developing new biomarker tests or pharmacotherapy is limited. This also results in lack of teaching on sleep health and sleep biology in science faculties. In turn, this reduces the number of people progressing to sleep research and also there is less background on sleep for science teachers in high schools.
6.69
The WIMR stated that the sleep field has an ageing workforce, which creates a lot of problems in succession planning for clinical research. Professor Grunstein stated that ‘many young specialists who have PhDs and have had research experience are often discouraged from working actively in research as this is seen as lower value than clinics or ward work.’
Research Funding
6.70
The NHMRC is a major funding source for sleep researchers. The Department of Health stated that $137.7 million has been provided for research into sleep or sleep disorders between 2000 and 2018 through the NHMRC.
6.71
Table 6.2 provides a breakdown of NHMRC funding for sleep research by broad research area.
Table 6.2: NHMRC supported research relating to sleep or sleep disorders 2000 to 2018
|
|
|
|
|
|
Clinical Medicine and Science
|
97 075 614
|
71
|
222
|
|
Basic Science
|
27 135 151
|
20
|
61
|
|
Public Health
|
11 203 124
|
8
|
29
|
|
Health Services Research
|
2 249 391
|
2
|
6
|
|
Total
|
137 663 280
|
100
|
318
|
Source: Department of Health, Submission 131, p. [6].
6.72
The NHMRC Centres of Research Excellence (CRE) program has also provided funding to establish CREs for five year periods, including: the Centre for Integrated Research and Understanding of Sleep, NeuroSleep, the CRE to Optimise Sleep in Brain Ageing and Neurodegeneration, and National Centre for Sleep Health Services Research.
6.73
The NeuRA stated there has been a decline in research funding over the last five years. Professor Grunstein agreed there appears ‘to be a decline in NHMRC and [Australian Research Council] funding in sleep health.’ Professor Grunstein stated that sleep is not recorded in the categories used to classify research funding and so ‘it is difficult to have an accurate understanding’ of the amount of funding for sleep health research.’
6.74
Similarly, the TSANZ stated that:
NHMRC data shows that in 2017 respiratory and sleep medicine combined received only five per cent of NHMRC funding, with one-third of that going to asthma and the remainder going to research for all other respiratory and sleep disorders. Importantly, sleep funding data alone is minimal and not reported.
6.75
Professor Robert Adams, Professor Gary Wittert and Dr Sarah Appleton stated that ‘sleep research is underfunded relative to the prevalence and scope of sleep problems and its importance to health in general.’ Associate Professor Darren Mansfield stated that sleep medicine ‘shares a [NHMRC] funding panel with respiratory medicine and pharmacology. It is the smallest of these three fields in terms of research grant applications and hence only a small number of research ideas are funded, regardless of overall quality.’
6.76
The ASA stated that the collaborative nature of the sleep research community results in expert sleep reviewers having conflicts of interest with other researchers, requiring the reviewers to absent themselves from many of the NHMRC peer assessment processes. The ASA stated that while the NHMRC ‘has really transparent and exceptional processes, [it] works against a smaller field like sleep.’
6.77
The Australian Epidemiological Association (AEA) stated that sleep researchers have yet to convince the wider medical research community that sleep is an important area of research:
It is just a very competitive funding environment. I think part of our job, really, as sleep researchers who deal in epidemiology, is to try and convince other people who assess our [grants] as worth funding. Part of it is on us to try and convince the research community in general that sleep is important, but we haven’t quite got there yet. I think, as others have mentioned, we’re still trying to convince our colleagues that sleep is important for health conditions and not just for sleep conditions.
6.78
The ASA called for investment into sleep research, and stated an interest in funding via the Medical Research Future Fund. The TSANZ stated that ‘we don't really want to take money [for sleep research] from the other respiratory disorders. We need separate or more funding across the board for sleep in general.’
6.79
The NeuRA and the ASA stated that $200 million over the next five to 10 years should be allocated to the following research priorities:
Sleep-specific research fellowships;
Targeted therapies for sleep disorders;
Understudied and underrepresented populations;
Translation research studies into combination therapies;
New cross-disciplinary approaches to clinical care and health care delivery models for sleep problems;
Cross-disciplinary research to understand bidirectional links between inadequate sleep and sleep disorders, and other medical conditions; and
Sleep awareness programs for children, and health care professionals.
Data Collection
6.80
Inquiry participants stated that existing data about sleep collected from large-scale cohort and longitudinal studies could be better capitalised upon.
6.81
The Charles Perkins Centre stated that ‘extensive time and expertise is required to undertake the analysis of such data, but there is limited funding support to carry out such studies.’ Current longitudinal studies that asked questions about sleep included:
Longitudinal Study of Indigenous Children (LSIC);
Australian Longitudinal Study on Women’s Health;
Australian Longitudinal Study on Male Health;
Australian Breakthrough Cancer Study;
Household Income and Labour Dynamics in Australia Survey;
West Australian Sleep Health Study;
West Australian Pregnancy Cohort (Raine) Study; and
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The ASA stated they would like to see questions about sleep ‘asked more in some of the administrative datasets coming out from the Department of Health.’ Similarly, the AEA recommended that existing labour and social surveys that collect data on shift work should ‘monitor sleep behaviours and practices to provide national and occupation-specific information on current practice.’ Collecting data on workers who cope well with shift work was another recommended focus area.
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Australia was described as a challenging environment for successful epidemiological studies. The USyd-BMC stated Australia’s ‘unusual urban geography’ creates challenges in obtaining national population estimates. The USyd-BMC added that ‘we don’t have enough people trained in public health’ to undertake this research.
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Professor Sarah Blunden, Dr Yaqoot Fatima, Dr Stephanie Yiallourou, and Associate Professor Chris Magee called for ‘high standard epidemiological studies to gather data on sleep health on Indigenous people.’ Professor Blunden and colleagues added ‘continued access to longitudinal studies such as LSIC can include a more precise focus on sleep health to inform our understanding of childhood sleep in Indigenous children but a broader understanding is needed.’
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Datasets are also used to understand medication and prescribing trends by GPs. The USyd-BMC stated that the Bettering the Evaluation and Care of Health study was a ‘rolling cross-sectional study of GPs’ used to understand GP behaviour, however ‘it was defunded a few years ago.’ The AISH stated that they are conducting ‘another population survey to assess what the 2018 situation is like.’ In addition, the Pharmaceutical Benefits Schedule (PBS) dataset can be used to understand what medication is being used in Australia, and the AEA stated from 2012 onwards the data should be ‘relatively complete’ because it ‘covers all medications.’
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Commenting on the impact of prescribing sleep medication, NeuRA drew attention to the limitations of some sleep health data. The NeuRA stated that most of the data consisted of ‘associations’ and was not obtained from ‘randomised control trials.’ The NeuRA explained, as an example, that it does not know the answer to whether ‘sleeping pills cause harm versus benefit in certain groups’:
… people in general who are taking more sleeping pills have more risk of falls, and falls are a huge issue in the medical system in the elderly. So there are groups that you need to be very careful with and monitor what is used. These are associations. They probably have other medical ailments going on as well. They try to control for that as best they can but is there gold-quality evidence on whether sleeping pills cause harm versus benefit in certain groups? We don't know.
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Professor Grunstein recommended that a ‘Sleep Health Monitoring Centre similar [to] the Asthma Monitoring Centre’ be established. Professor Grunstein stated that funding should ‘be provided for an initial 5 year period to provide data cross-sectional and longitudinal data on sleep health and sleep disorders in Australia.’
Concluding Comment
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Sleep is a crucial element in the maintenance of health and wellbeing. Despite this, sleep receives far less attention than nutrition and exercise in current healthcare and policy settings. The Committee is concerned that the Department of Health does not have any policy or community awareness programs on sleep health.
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Four in every ten people in Australia are regularly not getting enough quality sleep. Many of these people may not be prioritising sleep as highly as other activities in their lives and this could be because they are unaware of the health risks associated with inadequate sleep. The Committee agrees with many of the organisations who contributed to the Inquiry that there is a need for a government-led awareness campaign focussed on the risks of inadequate sleep with the communication and education of practical steps individuals can take to improve their sleep hygiene.
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The Committee heard that medical students receive very limited education in relation to sleep. Elevating the status of sleep health and hygiene within medical degrees would improve the awareness of sleep health among new medical students.
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There is also a need for primary care practitioners, in particular general practitioners (GPs) to take on an expanded role in the diagnosis, treatment and management of sleep health. This requires the development and delivery of additional training material targeted at increasing the knowledge of sleep health issues among GPs, nurses, and psychologists. Enabling primary healthcare practitioners to deliver sleep health services would assist in relieving the burden of lengthy wait times and help address issues around access to sleep medicine in regional and rural Australia.
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The Committee is concerned that the integration of sleep medicine with respiratory medicine may be hindering the operation and development of the sleep health field in Australia. Whilst Obstructive Sleep Apnoea is a highly prevalent breathing-related condition, sleep practitioners also encounter a number of other linked non-respiratory health conditions. At both the clinical and research level, a broader understanding of sleep-related conditions could result in new approaches to diagnosis, management and treatment that may improve care for patients.
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Since the development of the Continuous Positive Airway Pressure technology by Professor Colin Sullivan, Australia has been a leader in the field of sleep health research and innovation. The Committee is pleased to hear that the Australian sleep research community continues to promote collaboration between organisations and across disciplines.
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Given the significance of sleep to health and wellbeing, and the innovative companies that have emerged from the Australian sleep health research sector there is value in ensuring that the sector is appropriately funded.
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The Committee recommends that the Australian Government, in partnership with the states, territories and key stakeholder groups, work to develop and implement a national sleep health awareness campaign. The campaign should:
Promote sleep as the foundation of ensuring positive health and wellbeing outcomes in combination with nutrition and exercise;
Provide practical information in relation to sleep hygiene and measures an individual can use to improve their sleep;
Provide information on the symptoms, causes, and health impacts of sleep disorders and available medical support for sleep disorders; and
Communicate that improved sleep health can reduce the risk of: developing a serious health condition, impaired judgement and mental functioning, and decreased productivity and performance.
Consider the proposed education campaign developed by the Australasian Sleep Association and the Sleep Health Foundation as part of their 2019 budget submission as a solid basis and estimate of costs for such a campaign.
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The Committee recommends that the Australian Government in consultation with the Royal Australian College of General Practitioners and other key stakeholders:
Assess the current knowledge levels of general practitioners, nurses and psychologists in relation to sleep health, and
Develop effective training mechanisms to improve the knowledge of primary healthcare practitioners in diagnosing and managing sleep health problems.
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The Committee recommends that the Australian Government investigate options to separate the existing ‘Respiratory and Sleep Medicine’ speciality into independent ‘Respiratory’ and ‘Sleep Medicine’ specialities under the Australian Health Practitioners Regulation Agency framework.
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The Committee recommends that the Australian Government fund research focussed on:
The prevalence of sleep disorders with a particular focus on under‑researched population groups such as women and Aboriginal and Torres Strait Islander peoples;
The prevalence, causes, and mechanisms of rare or not well understood sleep disorders, including narcolepsy and idiopathic hypersomnia;
Further analysis of existing population health and longitudinal studies that have collected data relating to sleep;
The impact of long-term shift work on sleep health and potential measures to minimise the associated health risks; and
The effects of digital devices and electronic media on sleep health, especially among children and adolescents.