AMA tells Canberra that obstetricians must lead maternity services

The AMA insists that national maternity services must use a collaborative care model that is led by obstetricians or general practice obstetricians.

It has said exactly that in its submission to the Commonwealth Department of Health and Ageing on the proposed new National Maternity Services Strategy.

AMA President Dr Tony Bartone said best-practice maternity care in the 21st century is provided by a multi-disciplinary team of health professionals.

“Obstetricians are the leaders and, along with midwives, are the key carers, but the team also includes general practitioners, anaesthetists, psychiatrists, obstetric physicians, pathologists, haematologists, paediatricians, and nurses,” Dr Bartone said.

“Current evidence supports that this model of care – led by an obstetrician or GP obstetrician – is the safest for mothers and babies, and optimises a range of other health outcomes.

“Obstetrician-led or GP obstetrician-led care means that, at a minimum, there will be initial assessment by either an obstetrician or GP obstetrician, and assessment and regular review during labour.

“Models of care should not result in situations where obstetricians only become aware of a labour problem once it has become acute or serious.

“Women should be encouraged and supported to make their own choices about their maternity care.

“But they should be fully informed about the risks and benefits of each model as it relates to their own specific health situation, pregnancy, and circumstances, after assessment by an obstetrician or GP obstetrician.

“In many instances, GPs are the health professionals who start the conversation with women about having children.

“GPs are best placed to provide continuity of care for women before, during, and after their pregnancies.

“And GPs are especially important in providing whole of maternity care for women in rural and remote communities.”

Dr Bartone said significant additional Federal Government funding will be needed to ensure safe, high-quality, and easily accessible maternity services across Australia.

The AMA used the following principles to assess the draft strategy:

The primary objective of all maternity services should be healthy mothers and babies.
Ideology and practitioner-specific agendas should not determine maternity policies and services.
Policies and services should be evidence-based.
Policies and services should consider the woman, her baby, and family.
Funding should follow models of care which improve the health and survival of mothers and babies, are cost effective, and improve women’s experiences.

Measles growing in some countries

Gaps in vaccination coverage have led to an increase in reported cases of measles around the world. In 2017, numerous countries experienced severe and protracted outbreaks of the disease.

Because of these immunisation gaps, measles outbreaks occurred in all regions, and there were an estimated 110 000 deaths related to the disease.

Updated disease modelling data provides the most comprehensive estimates of measles trends over the last 17 years. It shows that since 2000, over 21 million lives have been saved through measles immunisations. However, reported cases increased by more than 30 percent worldwide from 2016.

The Americas, the Eastern Mediterranean Region, and Europe experienced the greatest upsurges in cases in 2017, with the Western Pacific the only World Health Organisation (WHO) region where measles incidence fell.

“The resurgence of measles is of serious concern, with extended outbreaks occurring across regions, and particularly in countries that had achieved, or were close to achieving measles elimination,” said Dr Soumya Swaminathan, Deputy Director General for Programs at WHO.

“Without urgent efforts to increase vaccination coverage and identify populations with unacceptable levels of under-immunised or unimmunised children, we risk losing decades of progress in protecting children and communities against this devastating, but entirely preventable disease.”

Measles is a serious and highly contagious disease. It can cause debilitating or fatal complications, including, severe diarrhoea and dehydration, pneumonia, ear infections and permanent vision loss. Babies and young children with malnutrition and weak immune systems are particularly vulnerable to complications and death.

The disease is preventable through two doses of a safe and effective vaccine. For several years, however, global coverage with the first dose of measles vaccine has stalled at 85 per cent. This is far short of the 95 per cent needed to prevent outbreaks, and leaves many people, in many communities, susceptible to the disease. Second dose coverage stands at 67 per cent.

“The increase in measles cases is deeply concerning, but not surprising,” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance.

“Complacency about the disease and the spread of falsehoods about the vaccine in Europe, a collapsing health system in Venezuela and pockets of fragility and low immunisation coverage in Africa are combining to bring about a global resurgence of measles after years of progress. Existing strategies need to change: more effort needs to go into increasing routine immunisation coverage and strengthening health systems. Otherwise we will continue chasing one outbreak after another.”

Responding to the recent outbreaks, health agencies are calling for sustained investment in immunisation systems, alongside efforts to strengthen routine vaccination services. These efforts must focus especially on reaching the poorest, most marginalised communities, including people affected by conflict and displacement.

The agencies also call for actions to build broad-based public support for immunisations, while tackling misinformation and hesitancy around vaccines where these exist.

“Sustained investments are needed to strengthen immunization service delivery and to use every opportunity for delivering vaccines to those who need them,” said Dr Robert Linkins, Branch Chief of Accelerated Disease Control and Vaccine Preventable Disease Surveillance at the U.S. Centers for Disease Control and Prevention (CDC) and Measles and Rubella Initiative Management Team Chairman.

The Measles and Rubella Initiative is a partnership formed in 2001 of the American Red Cross, CDC, the United Nations Foundation, UNICEF, and WHO.

[Correspondence] The health of Palestinians

I commend Richard Horton (Nov 2, p 1612)1 for discussing Israeli military occupation of Palestinian land, including the siege of the Gaza Strip, and the effects this occupation has on health and access to health care. It also includes WHO data2 on attacks by Israel on Palestinian health services, affecting patients, health workers, ambulances, and health facilities. Horton also includes his Israeli colleagues’ response to WHO’s report.2

[Obituary] Judith Lumley

Influential public health researcher who focused on perinatal epidemiology and maternity services. Born in Cardiff, UK, on Feb 15, 1941, she died from complications of Alzheimer’s disease in Melbourne, VIC, Australia, on Oct 25, 2018, aged 77 years.

[Essay] Universal health coverage: breakthrough or great white elephant?

Will the Sustainable Development Goal 3 sub-goal “Achieve universal health coverage, including financial risk protection, access to quality essential health care services and…safe, effective, quality and affordable essential medicines and vaccines for all” be judged a breakthrough or a great white elephant in implementation, when we look back with the clear eyes of hindsight in 2030? What are the ways in which this agenda might play out in implementation and why might it do so? Drawing on a desk review, this Essay explores dominant ideas, ideology, institutions, and interests in relation to global versus Ghana national health priorities since the WHO constitution came into effect in 1948, to reflect on these questions.

The gap isn’t closing

The nation is failing in its efforts to close the health and life expectancy gap between Indigenous and non-Indigenous Australians.

The AMA Indigenous Health Report Card 2018, launched in Brisbane on November 22, scrutinises the 10-year-old Closing the Gap Strategy and concludes that it is unravelling.

The strategy must now be rebuilt, not refreshed, said AMA President Dr Tony Bartone.

One of the strategy’s main targets was to close the life expectancy gap by 2031, but Dr Bartone said it was obvious Australia is not on track to meet that goal.

“Ten years on, progress is limited, mixed, and disappointing,” he said.

“If anything, the gap is widening as Aboriginal and Torres Strait Islander health gains are outpaced by improvement in non-Indigenous health outcomes.

“The strategy has all but unravelled, and efforts underway now to refresh the strategy run the risk of simply perpetuating the current implementation failures.

“The strategy needs to be rebuilt from the ground up, not simply refreshed without adequate funding and commitment from all governments to a national approach.”

Political leadership and increased funding are lacking on the issue, Dr Bartone said.

A refocussing of effort and priorities is needed.

“It is time to address the myth that it is some form of special treatment to provide additional health funding to address additional health needs in the Aboriginal and Torres Strait Islander population,” he said.

“Government spends proportionally more on the health of older Australians when compared to young Australians, simply because elderly people’s health needs are proportionally greater.

“The same principle should be applied when assessing what equitable Indigenous health spending is, relative to non-Indigenous health expenditure.”

The Australian Institute of Health and Welfare estimates that the Aboriginal and Torres Strait Islander burden of disease is 2.3 times greater than the non-Indigenous burden, meaning that the Indigenous population has 2.3 times the health needs of the non-Indigenous population.

This means that for every $1 spent on health care for a non-Indigenous person, $2.30 should be spent on care for an Indigenous person.

But this is not the case, Dr Bartone said. For every $1 spent by the Commonwealth on primary health care, including Medicare, for a non-Indigenous person, only 90 cents is spent on an Indigenous person – a 61 per cent shortfall.

For the Pharmaceutical Benefits Scheme, the gap is even greater – 63 cents for every dollar, or a 73 per cent shortfall from the equitable spend.

“Spending less per capita on those with worse health, and particularly on their primary health care services, is dysfunctional national policy,” he said.

“It leads to us spending six times more on hospital care for Indigenous Australians than we do on prevention-oriented care from GPs and other doctors.”

The Report Card outlines six areas where the Closing the Gap Strategy can be rebuilt.

These include: equitable, needs-based expenditure; implementing health and mental health plans; filling primary health care service gaps; environmental health and housing; addressing social determinants; and placing Aboriginal health in Aboriginal hands.

“We need those leaders, those health leaders in those various communities, to come together with the peak bodies, with the Aboriginal controlled community health organisations, and all the other people as stakeholders in this space to come together to work collaboratively and with common purpose,” Dr Bartone said.

“We will not close the gap until we provide equitable levels of health funding. We need our political leaders and commentators to tackle the irresponsible equating of equitable expenditure with ‘special treatment’ that has hindered efforts to secure the level of funding needed to close the health and life expectancy gap.”

National Aboriginal Community Controlled Health Organisation (NACCHO) welcomed the release of the Report Card and joined the AMA in calling for the Closing the Gap Strategy to be rebuilt from the ground up.

NACCHO Chairwoman Donnella Mills called for the immediate adoption of the Report Card’s recommendations.

“We congratulate the AMA on their work to support closing the gap and endorse the recommendations in the Report,” she said.

“The Report highlights research which indicates the mortality gaps between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians are widening, not narrowing.

“Urgent and systematic action is needed to reverse these failures and to have any prospect of meeting the Council of Australian Governments’ goal to Close the Gap in life expectancy by 2031.”

The AMA 2018 Indigenous Health Report Card is on the AMA website.

[Comment] Political and technical barriers to improving quality of health care

With the currently renewed emphasis on universal health coverage, the study by Margaret Kruk and colleagues1 in The Lancet is a timely reminder of the need to examine inadequacies in both access to and quality of health care.2 Their key finding that poor quality of health care is a major driver of excess mortality in low-income and middle-income countries (LMIC) will not surprise those working in such settings.3 However, the authors’ quantitative comparison indicating that improvements in the quality of health services would have a greater overall effect on mortality than expansion of service coverage (without attention to quality) provides new evidence to inform the resource allocation strategies of health policy makers and funding agencies.

NSW govt ‘addressing’ hospital concerns

Health bureaucrats say doctors’ concerns about the running of Sydney’s new $600 million hospital are being addressed.

The public-private Northern Beaches Hospital has come under scrutiny since its opening three weeks ago after staff issues and supply shortages became public.

Staff working up to 110 hours a week, junior doctors being responsible for up to 60 patients, a lack of supervision and a lack of hand hygiene pumps were among the issues raised by the Australian Salaried Medical Officers’ Federation last week on behalf of its members, AAP understands.

Midwives and doctors have also complained they were given an inadequate orientation before the 488-bed hospital opened.

Hospital management has begun addressing concerns including assigning two doctors to move between wards to improve staff-to-patient ratios in busy areas.

However, Fairfax Media reported on Tuesday anaesthetists were threatening to refuse elective surgery patients unless staff shortages, supply shortages and systematic problems were fixed.

The health department said it met with hospital operator Healthscope and the Australian Medical Association on Tuesday to “ensure all necessary steps are taken to respond to clinicians’ concerns”.

“Patient care is front and centre for NSW Health and we are ensuring that clinicians’ concerns are addressed,” a Northern Sydney Local Health District spokeswoman said in a statement.

“Healthscope has assured NSW Health that they are taking immediate action to address all issues.”

NSW Premier Gladys Berejiklian told reporters on Monday although there had been some “teething problems,” the hospital has already completed more than 600 surgeries.

Meanwhile, supporters of the lobby group Save Mona Vale Hospital will rally outside the NSW parliament on Wednesday after acute services were transferred to the new hospital 12km away.

Chairman Parry Thomas says population growth meant the government would inevitably need to reopen pediatrics, emergency and other acute services at the beachside hospital.

The new hospital has a 50-bed public emergency department, about 243 public beds and 195 private beds.

WILLINGNESS GROWS TO END RHD

BY AMA PRESIDENT DR TONY BARTONE

Rheumatic heart disease (RHD) is a preventable illness affecting about 6,000 Australians, with Indigenous children 55 times more likely to die from the disease than their non-Indigenous peers.

The AMA recognises the role RHD contributes to the widening of the life expectancy gap between Indigenous and non-Indigenous Australians. In 2016, we launched a Report Card on Indigenous Health, A call to action to prevent new cases of RHD in Indigenous Australia by 2031 (target year for ‘closing the gap’ in Indigenous life expectancy).

Our Report Card made a strong statement on the devastating impact of RHD and the importance of new, collaborative strategies to control the disease. Its recommendations included calling for Australian Governments to commit to a target to prevent RHD. It also recommended that governments work in partnership with the Indigenous community to fund and implement a strategy to end RHD.

The Report Card also provided an opportunity for a group of leading health, community, and research organisations to form a coalition END RHD. The purpose of the coalition is to advocate for urgent, comprehensive action on this preventable disease of inequality, and to support those living with the disease and prevent new cases arising.

The founding members of END RHD are the AMA, Heart Foundation, RHD Australia (based at the Menzies School of Health Research), the END RHD Centre of Research Excellence (based at Telethon Kids Institute), the National Aboriginal Community Controlled Health Organisation (NACCHO), the Aboriginal Medical Services Alliance Northern Territory (AMSANT), the Aboriginal Health Council of Western Australia (AHCWA), the Aboriginal Health Council of South Australia (AHCSA), the Queensland Aboriginal and Islander Health Council (QAIHC), and the Aboriginal Health and Medical Research Council of NSW (AH&MRC).

To eliminate rheumatic heart disease in Australia, the coalition calls on the Federal Government to:

guarantee that the Aboriginal and Torres Strait Islander leadership drives the development and implementation of RHD prevention strategies;
set targets to end RHD in Australia;
fund a roadmap to end RHD by 2031;
commit to immediate action in communities at high risk of rheumatic heart disease; and
invest in strategic research and technology to prevent and treat acute rheumatic fever and rheumatic heart disease.

In the two years since the Alliance was formed, END RHD has been working with the communities at risk, securing funding and political will to translate research into action and educating Australians to play a role in ending RHD.

I believe the momentum is growing. RHD was discussed at the COAG meetings in August and October 2018. This has been further helped by the recent commitment from Indigenous Health Minister Ken Wyatt, to a Roadmap to end RHD in Australia, which is due to be completed by early 2019.

There is no doubt that funding is a crucial part of the equation to ending RHD. Recent developments include $3.7m being allocated to five Aboriginal medical services for local community-led pilot Acute Rheumatic Fever (ARF) and RHD prevention programs.

A further $950,000 has been granted to the Telethon Kids Institute to work with the Kimberley Aboriginal Medical Services to establish an innovative END RHD community program focussed on environmental health and local workforce development.

On 23^rd October 2018 an advocacy event at Parliament House, co-hosted by END RHD and the Snow Foundation, where the Government was asked for non-partisan commitment to eliminate RHD in Australia. Minister Wyatt and Shadow Assistant Minister for Indigenous Health Warren Snowden both made commitments in public to tackle RHD as a non-partisan issue. It is an important step for political leaders to acknowledge the seriousness of the problem.

Now, with community-driven change and funding to enable the change, we can hopefully start to bring about the end for RHD in Australia.

MBS Review – Chance for your say

BY ASSOCIATE PROFESSOR ANDREW C MILLER, CHAIR, AMA MEDICAL PRACTICE COMMITTEE

The AMA support for a review of the MBS has always been contingent on it being clinician-led, with a strong focus on supporting quality patient care. This includes having the right mix of practising clinicians on each committee, with genuine input into a process of transparent decision making.

The AMA, of course, would like to see a review process that delivers a schedule that reflects modern medical practice, by identifying outdated items and replacing them with new items that describe the medical services that are provided today. In doing so, it is crucial that any savings from the MBS review be reinvested into the MBS, and that the review is not simply a savings exercise.

The MBS Review is by no means a small feat, undertaking to review 5,700 items, some which have not been reviewed in 30 years. Obviously, the outcomes of this herculean review not only impact on Government operations and budgets, but significantly affect the entire health system—the always difficult balancing act between the public and private health sectors, the vast number and range of medical practitioners, specialties and medical services, and of course the public.

It was noted by the AMA that the Senate estimates transcripts (30 May 2018) indicated about $600 million in Government savings from the MBS reviews over the 2017 and 2018 budgets, with only $36 million reinvested into new items.

With so much at stake the AMA, specialty colleges, associations and societies must all work individually, and together to hold the MBS Review clinical committees, Taskforce and Government to account on their considerations and recommendations. They cannot be based on anecdotal evidence and narrow perspectives, rather than on data, scientific or robust evidence, or extensive and lived perspectives.

In that vein, I thought it timely to provide a sample of some of the AMA work in this space.

MBS Review clinical committee reports – consultation timeframes

Within the last two months, the Department of Health has requested feedback from AMA on 25 MBS Review clinical committee reports. The reports included around 2,000 MBS items and more than 2,000 pages. The number of items reviewed in these reports are almost 40 per cent of the total number of items in the entire Medicare schedule.

The MBS Review Taskforce has provided the AMA, colleges, associations and societies with only a few months to respond, whilst the Taskforce has deliberated on the review over the last three years. Furthermore, the reports are not publicly available – rather they are sent in a targeted fashion to certain stakeholders. The AMA has pushed back on this and called for them to be posted publicly online.

Obviously, this expediated consultation timeframe presents risks for having the ability to interrogate the clinical appropriateness of proposed changes for the profession, and increases potential for unintended consequences to go unremarked. The AMA has raised these issues with the Minister’s office and the Department to call for timeframes to be pushed out, as is reasonably practical, to ensure the profession are appropriately and adequately consulted on the recommendations.

Surgical assistants

In September, the AMA worked extensively behind the scenes with the Medical Surgical Assistants Society of Australia (MSASA), the Royal Australasian College Of Surgeons (RACS), individual surgical assistants (AMA members and non-members) and AMA Council members to tease out the key issues and lodge a submission strongly opposing the MBS Review Taskforce’s proposed changes to remuneration arrangements for surgical assistants. The AMA was also responsible for ensuring other groups were aware of the submission process.

A number of AMA communications and medical media was generated around the proposed changes and AMA’s response. This included AMA ‘Rounds’ and GP Network News, and in the medical press and social media.

The following key issues formed the basis of the AMA submission:

that surgical assistants are independent practitioners and they should remain so;
negative impact on surgical training;
risk of de-skilling GPs in rural and remote areas;
proposed derived fee – baseless assumptions;
Private Health Insurance and Out of Pockets Reforms already underway;
there are alternative mechanisms to address Taskforce’s concerns; and
no data provided on the problem.

MBS Review Clinical Committee reports – Gynaecology, Breast Imaging, Nuclear Medicine

The AMA has also lodged a submission to the Department of Health on the MBS Reviews on gynaecology, breast imaging and nuclear medicine.

The main issues raised in the submission related to the gynaecology review and the following were discussed:

Inadequate profession engagement;
Time based item descriptors – perverse incentive and unintended consequences;
Additional auditing provisions – onerous and unnecessary;
Item restructure – simplification and streamlining are required; and
Recommendation 19, Item Number 35750 – disagree with recommendations.

In this submission, the AMA also provided broad observations on the MBS Review including concerns regarding operation of committees, as well as inadequate communication and consultation and the removal of the reports from the public website.

MBS Review Clinical Committee reports – Anaesthesia and maximum 3 item rule for surgical items

The AMA recently wrote to the Chair of the MBS Review Taskforce (Prof Bruce Robinson) supporting the Australian Society of Anaesthetists (ASA) opposition to the majority of the MBS Review anaesthesia clinical committee (ACC) recommendations. In the same letter the AMA also raised concerns regarding the maximum three item rule for Group T8 surgical items.

The AMA urged the MBS Taskforce and Government to work with the ASA to come to mutually agreeable changes to the anaesthesia items in the MBS that align with contemporary clinical evidence and practice and improve health outcomes for patients.

The AMA also communicated to Prof Robinson that it is deeply concerned that whilst on the one hand the PRC deferred its decision regarding the three-item rule, due to consultation feedback, but on the other hand this recommendation is taken forward and applied in a specialty clinical committee report (eg urology) without reference to any previous profession feedback on the recommendation.

The AMA sought Prof Robinson’s assurances that the three-item rule is open for further discussions and that the MBS Taskforce will coordinate with the affected Colleges, Associations, and Societies to come to mutually agreeable changes; that is consistent, as much as is reasonable, across the specialties; that align with contemporary clinical evidence and practice and improve health outcomes for patients.

AMA MBS Review Webpage

Finally, the AMA ‘s own MBS Review webpage is now live and provides AMA members (and the public) with a one-stop bulletin board on AMA’s engagement and advocacy with the MBS Reviews. I encourage you to visit the website for further information and future updates on AMA’s advocacy work on MBS Reviews. There you will also find all of the AMA’s submissions to date to the MBS Reviews, and advice on what we are currently working on. Furthermore, it provides the contact details so that those members who are interested in helping the AMA formulate its response to reviews can have their voices heard.

Only by members being engaged can the AMA hope to have a positive influence the direction, and outcomes, of the MBS Reviews.