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Preference: Administration and Health Services

2

Graduate supply and public hospital funding – when will Government get this the right way around?

BY DR RODERICK McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

As I write, Victorian salaried doctors are voting on its recommended Enterprise Bargaining Agreement, and other jurisdictions are in advanced negotiations in the new industrial relations frameworks. Relevant reports will follow. 

My attendance at the sobering March 3 AMA Workforce and Training Summit convened in Melbourne, together with inspection of AMA’s 2018 Public Hospital Report Card, explains my continued exasperation at the consistent failure of Government to introduce realistic, necessary policy responses that deal with the now clearly apparent multiple medical training pipeline obstacles and poor public hospital access. Currently we have too much medical graduate supply and insufficient funding for appropriately training our junior colleagues in a manner that will meaningfully lead to reasonable public access to public hospital services. 

The Summit attitude was constructive with about 80 national stakeholders combining to produce many broadly supported actions which AMA can prosecute.  The Summit’s challenge was to consider what measures are needed further ‘downstream’ in training provision to ensure sufficient high quality training places in all medical specialties as they are needed for community benefit. While I fear the problems we now face are actually fast becoming too entrenched to solve, the Summit made it apparent that the medical profession is looking to the AMA, and within it your Council of Public Hospitals Doctors (CPHD), to lead the case for major reform.  Accordingly, CPHD will be guided by the outcome strategies of the Summit, and will press to further inform and influence our health policy makers. 

Two certain consensus points emerged from the Summit: stop opening new medical schools, and start rationalising resources towards regions and specialties where they are most needed. Government has regularly failed to fully listen to AMA’s advance warnings that there is real structural constraint to training capacity and that substantial ongoing investment is necessary to maintain training standards. Additionally, we need to urgently find sustainable, equitable paths to tackle the maldistribution of doctors (particularly across rural settings) and the shortages or bottlenecks arising in some craft areas. 

I observe that it was AMA advocacy that achieved for most medical school graduates (and including many International Medical Graduates) guaranteed internship after graduation when, incredibly, Government had not actually originally factored this in to its expansion decision. Just another Federal/State divide. And, let’s not forget, the massive increase of new graduates doesn’t actually have true tsunami characteristics of quick destruction by ingress then receding as fast as it came, enabling an early, planned, rebuild. Instead, there is actually a permanent rising of the water table, overwhelming teaching infrastructure capacity, which means patients in public hospital beds. 

The point is, we are graduating medical students in numbers far in excess of the OECD average without ensuring the adequate provision of the essential training places, both prevocational and specialist. This is at the same time that Commonwealth funding investment is not keeping pace with population growth.  Any economist would reel. 

In my December 2017 Australian Medicine piece, I discussed the ‘doing more with less’ implications of the Commonwealth financially penalising public hospitals who report acquired conditions, sentinel events and avoidable readmissions, otherwise known as possible healthcare outcomes (as if we are exercising choice to not provide optimum care now!). Added to that is the idea of penalising ‘low value care’ based on what are imposed and unsophisticated definitions, all with the aim of minimising financing, and a country mile from favourable health outcomes. This Commonwealth approach is in conjunction with them not offering any additional long term hospital funding via its 2020 State Agreement. 

So, we have no additional funding despite AMA’s 2018 Public Hospital Report Card establishing there has been a 3.3 percent year-on-year average increase in separations (that’s called increased productivity), that one third of urgent emergency department patients are not seen within the recommended 30 minutes and that most States’ urgent elective surgery is not performed within the 90 day clinically indicated timeframe (that’s called increased demand). Don’t get me started on the sometimes years of a patient waiting to be seen in outpatients before actually being counted on an elective waiting list! And they want to claw back already insufficient funding when a complication happens. That economic management is called madness. If only health care really was like slapping a motor vehicle together on a production line; but it just is not. 

The Summit’s Report will help us work together to develop initiatives to build a sustainable, well-trained, well-qualified and accessible medical workforce. The AMA’s Report Card is true evidence-based advocacy about hospital performance and the need for Government funding support to improve public access. Both suggest the public health climate is ominous with Government offering less funding but at the same time pressing for improved outcomes and offering more graduates but with no clear, coordinated, training pipeline management. Government must listen to us because of the implications for the community’s fair access to appropriate public hospital services, and for the career aspirations of our best and brightest. 

[Correspondence] In support of UNRWA appeal for health and dignity of Palestinian refugees

Our research into the UN Relief and Works Agency (UNRWA)’s delivery of health services to Palestinian refugees during the Syria crisis1 puts us in a unique position to anticipate the challenges of the organisation’s current funding crisis.2 We have conducted over 90 interviews with health workers and managers, a series of systems modelling sessions, and rigorous analysis of UNRWA health data from 2007–16, and conclude the following.

[Comment] Offline: The Palestinian health predicament worsens

The United Nations Relief and Works Agency (UNRWA), which administers health services to 5·3 million Palestinian refugees through 143 primary health facilities, is in acute crisis. After President Trump cut almost US$300 million from UNRWA’s 2018 budget, services will run out of money by the end of May. Irrespective of one’s views about the complex politics of the Middle East, America’s decision to threaten the provision of basic health care to millions of dependent people seems utterly cruel. This emergency was a major theme of last week’s annual Lancet Palestinian Health Alliance (LPHA) scientific meeting, held in Beirut, Lebanon.

[Editorial] Cybersecurity and patient protection

Network-connected devices and data are vulnerable to attack, exploitation, and unintended loss. The alleged harvesting of profiles from 50 million people by Cambridge Analytica through friend networks on Facebook is the most recent and egregious example. In May, 2017, the WannaCry ransomware that infected more than 200 000 computers across 100 countries also infiltrated a third of National Health Service trusts, and brought some services to a standstill. Yet, despite agreement on the need for better cyber hygiene (risk management and online health), there is no consensus on what form it should take.

How safe are older doctors?

 

Older doctors are considerably more likely to be the subject of an AHPRA notification than their younger peers, according to new research.

The University of Melbourne study, which looked at all 12,878 notifications lodged with Australian medical regulators over a four-year period, found doctors over the age of 65 had 37% more notifications than their younger peers, aged 36 to 60.

The type of notification varied substantially between the two age groups. Health-related notifications, covering both physical illness and cognitive decline, were twice as high among older doctors. They were 40% higher for conduct-related notifications and 10% higher for performance-related notifications, compared with younger doctors.

The researchers from the Melbourne School of Population and Global Health said they had identified several “hot spots” of risk for older doctors. One of these was the prescribing, use and supply of medicines.

“Some older doctors are known to maintain registration in order to prescribe for themselves of for families and friends. Whilst this practice is in breach of ‘Good medical practice: a code of conduct for doctors in Australia’, some older doctors have been slow to adapt to evolving professional standards,” the researchers noted.

They also pointed to some older doctors’ failure to keep abreast of new drugs or changes in drug regimens, their reversion to older, more familiar patterns of practice, and their reluctance or inability to follow new protocols.

“Well documented age-related declines in cognition and physical abilities in the general population are likely to be reflected in the health practitioner community with possible implications for safe clinical decision-making,” the authors write.

“Previous research suggests that some health practitioners lack the ability or insight to self-assess competence and may not be aware of a decline in their cognitive ability or skills.”

But the authors note there are no internationally recognised thresholds of cognitive impairment at which a doctor is considered to be a risk to the public.

The study follows reforms proposed by the Medical Board of Australia late last year that would require doctors aged 70 and over to prove they are competent to continue practising. The reforms would require peer review and health checks for these doctors to be incorporated into their CPD requirements. The health checks would include issues such as cognitive function, eyesight and hearing. But there have been no moves towards introducing a mandatory retirement age for doctors.

There are over 6,600 doctors over 70 registered in Australia, with more than 85% of them still practising.

You can access the study on older doctors and notifications here.

Report Card shines a light on PHI

The AMA has revealed the best and worst of private health insurance coverage, with the release of its AMA Private Health Insurance Report Card 2018.

Following the recent decision by Bupa, which is one of Australia’s largest health insurers, to significantly reduce patient choice and coverage – while at the same receiving the go-ahead to increase its premiums – the Report Card is a timely reminder that private health insurance consumers should shop around.

In releasing the Report Card, AMA President Dr Michael Gannon warned that changes being implemented by Bupa and pursued by some other health insurers will reduce patient choice of doctor and hospital.

And they will leave policy holders questioning the value of their significant investment in private health insurance, he said.

“The big insurers are pursuing a US-style managed care agenda to save costs and further increase profits by making it harder for patients to receive care from the doctor they want in the most appropriate hospital for their condition,” Dr Gannon said.

“Bupa’s new arrangements, which only provide maximum benefits for patients in hospitals with Bupa contracts, undermine the role of the doctor in providing and advising the most appropriate care – and could ultimately drive up out of pocket costs for patients.

“Public confidence in private health insurance is already at an all-time low. These changes will further devalue policies, which are a major financial burden for Australian families, and will place dangerous pressure on the already stressed public hospital system.”

The Report Card provides an overview of how private health insurance should work to benefit patients, and explains how proposed new arrangements will result in less choice and value for policy holders.

It shows that there are a lot of policies on offer that provide significantly varying levels of benefits, cover, and gaps.

“There are also a lot of policies on the market that will not provide the cover that consumers expect when they need it,” Dr Gannon said.

“If people have one of these ‘junk policies’, they should consider carefully what cover they really need.

“The Government has undertaken some important reforms to private health insurance to help people understand the different conditions that each policy category – gold, silver, bronze, and basic – will cover.

“The funds must not be allowed to sabotage these reforms.”

The Report Card shows that some insurers perform well over all, and some only perform well for certain conditions.

It reveals that the same doctor performing the same procedure can be paid significantly different rates by each fund, which is often the untold story behind patient out of pocket costs, despite there being high levels of no gap and known gap billing statistics.

The latest APRA statistics show an overall no gap rate of 88.1 per cent and a known gap rate of 7.3 per cent.

Dr Gannon said the medical profession is working hard to ensure patients receive value for money.

“Our Report Card shows that the profits of the insurers continue to rise, the growth of policies with exclusions continues to grow, and policy holder complaints continue to rise,” he said.

“We explain what insurance may cover, what the Medicare Benefits Schedule (MBS) covers, and what an out-of-pocket fee may be under different scenarios. 

“We also highlight the frustrating fact that what an insurer pays can vary from State to State – even within the same fund.

“To help consumers better understand what they are buying, we set out the percentage of hospital charges covered by State and insurer, and the percentage of services with no gap, State by State.

“There is also a breakdown of the complaints received by provider and organisation, which shows that the number of private insurance complaints are significant, and on the rise.”

The data in the AMA Private Health Insurance Report Card 2018 is publicly available – drawn primarily from the Australian Prudential Regulation Authority (APRA), the Private Health Insurance Ombudsman, and the insurers’ own websites.

The AMA Private Health Insurance Report Card 2018 is at article/ama-private-health-insurance-report-card-2018

Further coverage of the AMA Private Health Insurance Report Card 2018 will be a feature of the next edition of Australian Medicine.

CHRIS JOHNSON

Tobacco addiction grows from dirty deeds

A damning report launched at the 17th World Congress of Tobacco (WCTOH) shows the tobacco industry is increasingly targeting vulnerable populations in Africa, Asia, and the Middle East where people are not protected by strong tobacco control regulations.

The figures in The Tobacco Atlas are nothing short of alarming. In 2016 alone, tobacco use caused over 7.1 million deaths worldwide (5.1 million in men, 2.0 million in women).

Most of these deaths were attributable to cigarette smoking, while 884,000 were related to secondhand smoke. But while tobacco-related disease and death grows in some communities, so do tobacco industry profits.

The combined profits of the world’s biggest tobacco companies exceeded US $62.27 billion in 2015. This is equivalent to US $9,730 for the death of each smoker, an increase of 39 per cent since the last Atlas was published, when the figure stood at US$7,000.

“The Atlas shows that progress is possible in every region of the world. African countries in particular are at a critical point – both because they are targets of the industry but also because many have opportunity to strengthen policies and act before smoking is at epidemic levels.” said Dr Jeffrey Drope, co-editor and author of The Atlas.

In sub-Saharan Africa alone, consumption increased by 52 per cent between 1980 and 2016 (to 250 billion cigarettes from 164 billion cigarettes). This is being driven by population growth and aggressive tobacco marketing in countries like Lesotho, where prevalence is estimated to have increased from 15 per cent in 2004 to 54 per cent in 2015.

José Luis Castro, President and Chief Executive Officer of Vital Strategies, co-author of The Atlas said it: “Shows that wherever tobacco control is implemented, it works… People benefit economically and in improved health. And the industry rightly suffers.”

Gender inequity was also address at the WTCOH, highlighting the negative economic impacts of tobacco use on women – not just in healthcare costs resulting from tobacco-related illness, but also in the diversion of family income, from food and education to tobacco. The emphasis was that tobacco use drives families into poverty.

WHO Regional Director for Africa, Dr Matshidiso Moeti, said: “The tobacco industry views this region as virgin territory to be exploited. They are targeting women and girls specifically and interfering in the adoption of tobacco control policies that will protect health when properly enforced.”

Tactics of fear by tobacco companies were also heard at the conference from several tobacco control advocates who had bravely fought violence or threats because of their advocacy against the expansion of smoking in their countries, including Indonesia and Nigeria.

Dr Lekan Ayo-Yusuf, Chair of the WCTOH Scientific Committee, said the research showed the need to look at the totality of the supply chain of tobacco products, and to follow the whole process from farming, through to taxation, through to point-of-sale restrictions.

WHO launched new guidance at WCTOH on the role tobacco product regulation can play to reduce tobacco demand, save lives and raise revenues for health services to treat tobacco-related disease, in the context of comprehensive tobacco control.

Many countries have developed advanced policies to reduce the demand for tobacco, but Governments can do much more to implement regulations to control tobacco use, especially by exploiting tobacco product regulation.

Dr Douglas Bettcher, WHO’s Director of the Department for the Prevention and Control of Non-communicable diseases (NCDs), said: “Tobacco product regulation is an under-utilised tool which has a critical role to play in reducing tobacco use.”

“The tobacco industry has enjoyed years of little or no regulation, mainly due to the complexity of tobacco product regulation and lack of appropriate guidance in this area. These new tools provide a useful resource to countries to either introduce or improve existing tobacco product regulation provisions and end the tobacco industry ‘reign’.

“Only a handful of countries currently regulate the contents, design features and emissions of tobacco products and tobacco products are one of the few openly available consumer products that are virtually unregulated in terms of contents, design features and emissions,” Dr Bettcher said.

A copy of The Atlas can be seen here: https://tobaccoatlas.org/.

MEREDITH HORNE

[Obituary] Walter Werner Holland

Pioneer of UK health services research. He was born in Teplice-Sanov, Czech Republic, on March 5, 1929, and died of prostate cancer in London, UK, on Feb 9, 2017, aged 88 years.

Aged Care Commission needed to address workforce issues

The AMA has made a detailed submission to the Government’s Aged Care Workforce Strategy Taskforce, arguing that the aged care workforce does not have the capability, capacity and connectedness needed to provide quality care to older people.

It calls for an Aged Care Commission to be introduced.

Australia has an ageing population that has multiple chronic and complex medical conditions, but older people face major barriers in accessing appropriate and timely medical care.

Medical practitioners must be supported by the Government and aged care providers to enhance and facilitate much needed access to medical care for people living in residential aged care facilities. 

The submission argues that aged care providers need to be supported to ensure access to an appropriate quantity of well-trained staff who work in a rewarding environment with a manageable workload.

“This would ensure older people’s care is not neglected due to shortages of appropriate staff,” it states.

An Aged Care Commission could streamline the aged care system and to help ensures there is an adequate supply of appropriate, well-trained staff to meet the demand of holistic care to a multicultural, ageing population.

An Aged Care Commission would also ensure the aged care workforce has clear roles and responsibilities.

“Australia has an ageing population that is experiencing chronic, complex medical conditions that require more medical attention than ever before,” the submission states.

“For example, 53 per cent of residents in Residential Aged Care Facilities (RACFs) have dementia. This proportion will continue to grow over time, with projections reaching up to 1,100,890 people with dementia by 2056, which is estimated to cost Australia $36.85 billion by the same year.

“A recent study identified that residents of RACFs with dementia had direct health and residential care costs of $88 000 per year. Currently, the aged care system as a whole, and its workforce, does not have the capacity or capability to adequately deal with this growing, ageing population.”

The aged care system needs a strategy, the submission states, to ensure the workforce is appropriate to meet the demands of older people in the future. In order to improve the quality of the aged care workforce, the following is required:

  • An overarching, independent, Aged Care Commission that provides a clear, well communicated, governance hierarchy that brings leadership and accountability to the aged care system;
  • Medical practitioners need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care, and outcomes for older people; and
  • Aged care needs funding for the significant recruitment and retention of, and support for, nursing staff and carers, specifically trained in dealing with the issues that older people face.

Care of an older person involves a diverse range of professions. All providers of aged care services need to collaborate together to ensure the optimal level of care for the older person. The strategy will be able to provide an ultimate goal for the whole aged care workforce, which should include access to the older person in order for each workforce profession to be able to provide quality care for that older person.

There needs to be a focus on prevention to ensure older people remain healthy for as long as possible to remain in their own home, the submission states, but also to reduce demand and pressure on the aged care workforce.

“Medical practitioners, in particular GPs, regularly incorporate prevention methods as part of providing holistic health and medical care,” it says.

“This includes immunisation, screening for diseases, providing education and counselling to their patient, and also referring the patient to a specialist or allied health professional if required. It is therefore imperative that older people have access to a GP and other services provided by health professionals.”

In its submission, the AMA stresses that the current policy settings do not support GPs visiting RACFs, working after hours, or being available to answer telephone concerns about their patients.

“Our members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s care management plan is not well known,” it says.

“This creates an environment where the default step for RACF staff may be to refer the patient to a hospital emergency department (ED). In a study of 2880 residents of RACFs presented to the ED, one third of presentations could have been avoided by incorporating primary care services.

“Reasons for decisions to transfer residents to an ED include limited skilled staff, delays in GP consultations, and a lack of suitable equipment.”

Medical practitioners also need to be supported within the broader health care system to provide high quality care in RACFs. For example, by local hospitals providing secondary referral, timely specialist opinion, specialist services and rapid referral pathways to advice and services.

Older people are often burdened with complex and multiple medical disorders that requires the regular attention of medical practitioners, quality nursing care and allied health care professionals.

Embracing Information and Communication Technology (ICT) potentially has huge benefits for the aged care sector. It can increase communication between healthcare providers, reduce administrative burden, and assist to improve the health and independence of older people.

Aged care providers require improved ICT systems that are interoperable with the My Health Record, in particular its Medication Overview feature. This would ensure medical health professionals have the tools in place to access all relevant medical information with all relevant stakeholders to improve prescribing and to reduce the risk of adverse reactions and interactions between medications.

“Although working with older people is generally a rewarding experience, it comes with multiple challenges,” the submission states.

“For example, older people can be highly reliant on an aged care worker, and many have behavioural conditions that make day-to-day tasks difficult, and sometimes dangerous for the carer to carry out if the older person’s mental health is not appropriately managed.

“Carers are known to have high rates of moderate stress and depression. The health and wellbeing of aged care staff must be considered for the wellbeing of the workers, and so this stressful environment does not deter people from wanting to work in the aged care sector, or force existing workers to leave.”

Many of the issues outlined in the submission can be rectified by improving the capability, capacity and connectedness of the aged care workforce. Currently, this workforce is not adequately trained to be able to care for older Australians, as older peoples’ care needs are growing in both complexity and volume.

In addition, although medical practitioners are well-equipped to provide quality medical care to residents living in RACFs, they are not adequately supported or remunerated to do so due to the range of issues described above. This has resulted in an unnecessary barrier to quality medical services for RACF residents.

“The aged care workforce needs clear leadership and accountability, which an Aged Care Commission could provide,” the statement says.

“Many aged care governance (and workforce) issues described above have already been addressed in recommendations to the Government as a result of the multiple aged care reviews. Now is the time to act on these recommendations to prevent more unacceptable examples of neglect and bad quality care in RACFs, and to give people living in RACFs the quality of life that they deserve.”

The full submission can be viewed at:  ausmed/aged-care-commission-needed-address-workforce-…

CHRIS JOHNSON