[Perspectives] Virtual care for improved global health

Global access to health care is far from adequate, with health disparities widening; the rise of economic inequities and shortages in the health workforce are contributors. This is especially true for people who live in rural areas in low-income countries without access to essential health services. Yet digital infrastructure and technologies exist that could allow virtual and rapid provision of health care for many health conditions, for almost everyone, at any time, irrespective of their location.

[Comment] The global fight against cancer: challenges and opportunities

By 2030, the number of cancer cases is projected to increase to 24·6 million and the number of cancer deaths to 13 million.1 Worldwide, health systems, especially in low-income and middle-income countries (LMICs), are ill prepared to manage the increasing cancer burden.2 Globally, there is a shortfall in coverage of cancer services for prevention, screening, treatment, and palliative care.3–5 If cost-effective interventions for cancer screening, prevention, and treatment were delivered through strengthened health systems, they could help largely avoid many premature deaths, unnecessary suffering, and unacceptable inequalities.

[Comment] Amid US funding cuts, UNRWA appeals for health and dignity of Palestinian refugees

The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) faces a major challenge in upholding its mandate and preserving key services such as education and health care for Palestinian refugees. On Jan 16, 2018, the US Government announced a contribution of US$60 million for 2018 so far,1,2 in support of UNRWA’s efforts to keep our schools open, health clinics running, and emergency food and cash distribution systems functioning. Although important, this funding is dramatically below past levels.

Encouraging more doctors to go rural

The AMA has released its Position Statement – Rural Workforce Initiatives, a comprehensive five-point plan to encourage more doctors to work in rural and remote locations, and improve patient access to care.

The plan proposes initiatives in education and training, rural generalist pathways, work environments, support for doctors and their families, and financial incentives.

It says that at least one-third of all new medical students should be from rural backgrounds.

And more medical students should be required to do at least one year of training in a rural area to encourage graduates to live and work in regional Australia.

In releasing the Position Statement, AMA President Dr Michael Gannon noted that about seven million Australians live in regional, rural, and remote areas, and they often have more difficulty accessing health services than their city cousins.

They often have to travel long distances for care, and rural hospital closures and downgrades are seriously affecting the future delivery of health care in rural areas.

For example, Dr Gannon said, more than 50 per cent of small rural maternity units have been closed in the past two decades.

“Australia does not need more medical schools or more medical school places,” he said.

“Workforce projections suggest that Australia is heading for an oversupply of doctors.

“Targeted initiatives to increase the size of the rural medical, nursing, and allied health workforce are what is required.

“There has been a considerable increase in the number of medical graduates in recent years, but more than three-quarters of locally trained graduates live in capital cities.

“International medical graduates (IMGs) make up more than 40 per cent of the rural medical workforce and while they do excellent work, we must reduce this reliance and build a more sustainable system.”

The AMA Rural Workforce Initiatives plan outlines five key areas where Governments and other stakeholders must focus their policy efforts:

Encourage students from rural areas to enrol in medical school, and provide medical students with opportunities for positive and continuing exposure to regional/rural medical training;
Provide a dedicated and quality training pathway with the right skill mix to ensure doctors are adequately trained to work in rural areas;
Provide a rewarding and sustainable work environment with adequate facilities, professional support and education, and flexible work arrangements, including locum relief;
Provide family support that includes spousal opportunities/employment, educational opportunities for children’s education, subsidies for housing/relocation and/or tax relief; and
Provide financial incentives to ensure competitive remuneration.

“Rural workforce policy must reflect the evidence. Doctors who come from a rural background, or who spend time training in a rural area, are more likely to take up long-term practice in a rural location,” Dr Gannon said.

“Selecting a greater proportion of medical students with a rural background, and giving medical students and graduates an early taste of rural practice, can have a profound effect on medical workforce distribution.

“Our proposals to lift both the targeted intake of rural medical students and the proportion of medical students required to undertake at least one year of clinical training in a rural area from 25 per cent to 33 per cent are built on this approach.

“More Indigenous people must be encouraged to train and work in health care, as there is a strong link between the health of Indigenous people in rural areas and their access to culturally appropriate health services.

“Fixing rural medical workforce shortages requires a holistic approach that takes into account not only the needs of the doctor, but also their immediate family members.

“Many doctors who work in rural areas find the medicine to be very rewarding, but their partner may not be able to find suitable employment, and educational opportunities for their children may be limited.

“The work environment for rural doctors presents unique challenges, and Governments must work collaboratively to attract a sustainable health workforce. This includes rural hospitals having modern facilities and equipment that support doctors in providing the best possible care for patients and maintaining their own skills.

“Finally, more effort must be made to improve internet services in regional and rural areas, given the difficulties of running a practice or practising telehealth with inadequate broadband.

“All Australians deserve equitable access to high-speed broadband, and rural doctors and their families should not miss out on the benefits that the growing use of the internet is bringing.”

The AMA Position Statement – Rural Workforce Initiatives is available at position-statement/rural-workforce-initiatives-2017

CHRIS JOHNSON

Background:

Most Australians live in major cities (70 per cent), while 18 per cent live in inner regional areas, 9 per cent in outer regional areas, and 2.4 per cent in both remote and very remote areas.
Life expectancy is lower for people in regional and remote Australia. Compared with major cities, the life expectancy in regional areas is one to two years lower, and in remote areas is up to seven years lower.
The age standardised rate of the burden of disease increases with increasing remoteness, with very remote areas experiencing 1.7 times the rate for major cities.
Coronary heart disease, suicide, COPD, and cancer show a clear trend of greater rates of burden in rural and remote areas.
The number of medical practitioners, particularly specialists, steadily decreases with increasing rurality. The AIHW reports that while the number of full time workload equivalent doctors per 100,000 population in major cities is 437, there were 272 in outer regional areas, and only 264 in very remote areas.
Rural medical practitioners work longer hours than those in major cities. In 2012, GPs in major cities worked 38 hours per week on average, while those in inner regional areas worked 41 hours, and those in remote/very remote areas worked 46 hours.
The average age of rural doctors in Australia is nearing 55 years, while the average age of remaining rural GP proceduralists – rural GP anaesthetists, rural GP obstetricians and rural GP surgeons – is approaching 60 years.
International medical graduates (IMGs) now make up over 40 per cent of the medical workforce in rural and remote areas.
There is a health care deficit of at least $2.1 billion in rural and remote areas, reflecting chronic underspend of Medicare and the Pharmaceutical Benefits Scheme (MBS) and publicly-provided allied health services.

National architecture needed for mental health

Almost one in two Australian adults will experience a mental health condition in their lifetime, yet mental health and psychiatric care are grossly underfunded when compared to physical health.

Those statistics were the stark reality AMA President Dr Michael Gannon laid out when releasing the AMA Position Statement on Mental Health 2018.

In doing so, he called for strategic leadership to integrate all components of mental health prevention and care.

The AMA is calling for a national, overarching mental health “architecture”, and proper investment in both prevention and treatment of mental illnesses.

“Many Australians will experience a mental illness at some time in their lives, and almost every Australian will experience the effects of mental illness in a family member, friend, or work colleague,” Dr Gannon said.

“For mental health consumers and their families, navigating the system and finding the right care at the right time can be difficult and frustrating.

“Australia lacks an overarching mental health architecture. There is no vision of what the mental health system will look like in the future, nor is there any agreed national design or structure that will facilitate prevention and proper care for people with mental illness.”

The AMA has called for the balance between funding acute care in public hospitals, primary care, and community-managed mental health to be correctly weighted.

Funding should be on the basis of need, demand, and disease burden, Dr Gannon said, not a competition between sectors and specific conditions.

“Policies that try to strip resources from one area of mental health to pay for another are disastrous,” he said.

“Poor access to acute beds for major illness leads to extended delays in emergency departments, poor access to community care leads to delayed or failed discharges from hospitals, and poor funding of community services makes it harder to access and coordinate prevention, support services, and early intervention.

“Significant investment is urgently needed to reduce the deficits in care, fragmentation, poor coordination, and access to effective care.

“As with physical health, prevention is just as important in mental health, and evidence-based prevention can be socially and economically superior to treatment.”

Dr Gannon said community-managed mental health services had not been appropriately structured or funded since the movement towards de-institutionalisation in the 1970s and 1980s, which shifted much of the care and treatment of people with a mental illness out of institutions and into the community.

The AMA Position Statement supports coordinated and properly funded community-managed mental health services for people with psychosocial disability, as this will reduce the need for costly hospital admissions.

The Position Statement calls for Governments to address underfunding in mental health services and programs for adolescents, refugees and migrants, Aboriginal and Torres Strait Islander people, and people in regional and remote areas.

It also calls for Government recognition and support for carers of people with mental illness.

“Caring for people with a mental illness is often the result of necessity, not choice, and can involve very intense demands on carers,” Dr Gannon said.

“Access to respite care is vital for many people with mental illness and their families, who bear the largest burden of care.”

The AMA Position Statement on Mental Health 2018 is available at position-statement/mental-health-2018

CHRIS JOHNSON

[Comment] Offline: The misuse of universal health coverage

Health workers are taught to see their purpose as imbued with special human importance. Possessed with the values of knowledge, judgment, respect, responsibility, integrity, compassion, altruism, excellence, continuous improvement, and partnership, medicine is often said to be endowed with particularly moral attributes. This vocational foundation gives ethical momentum to the case for universal health coverage, the big idea of the Sustainable Development Goals. The creation of national health services, we doctors may suggest, are critical humanitarian milestones in the histories of nations.

[Comment] Scaling up integration of health services

Almost 40 years after the Alma-Ata Declaration1 championed a comprehensive vision of health service delivery (panel), the movement towards universal health coverage (UHC) has seen the global health policy pendulum swing back towards the need for integrated people-centred health systems.2–4 For UHC to be sustainable, resources cannot be wasted on services that are inaccessible, fragmented, and of poor quality. There is a growing need to increase the responsiveness and efficiency of service delivery and to put the needs of people and communities back at the centre of health systems.

Christmas message from AMA President

It has been a very busy and very successful year for the Federal AMA. Your elected representatives and the hardworking staff in the Secretariat in Canberra have delivered significant achievements in policy, advocacy, political influence, professional standards, doctors’ health, media profile, and public relations.

We have worked tirelessly to ensure that health policy and bureaucratic processes are shaped to provide the best possible professional working environments for Australian doctors and the highest quality care for our patients.

Our priority at all times is to provide value for your membership of the AMA.

As 2017 draws to a close, I would like to provide you with a summary of the work we have undertaken on behalf of you, our valued members.

General Practice and Workplace Policy

Our strong advocacy led to a decision to lift the freeze on Medicare patient rebates.
AMA coordination of Doctors’ Health Services around the country, with funding support from the Medical Board of Australia.
Launched the AMA Safe Hours Audit Report, giving added focus to the issue of doctors’ health and wellbeing.
Maintained a strong focus on medical workforce and training places, with the National Medical Training Network significantly increasing its workforce modelling and projection work following sustained advocacy by the AMA.
Secured a number of concessions in the proposed redesign of the Practice Incentive Program (PIP), as well as a delay in the introduction of changes.
Lobbied at the highest level for a more durable solution to concerns over Pathology collection centre rents, focusing on effective compliance, and achieving a fair balance between the interests of GP members and pathologist members.
Led the Reforms to After-hours GP services provided through Medical Deputising Services (MDSs) to ensure that these services are better targeted and there is stronger communication between the MDS and a patient’s usual GP.
Successfully lobbied the ACCC to renew the AMA’s existing authorisation that permits GPs to engage in intra-practice price setting, potentially saving GPs thousands of dollars annually in legal and other compliance costs.
Ensured a proportionate response from the Government in response to concerns over the security of Medicare card numbers, avoiding more draconian proposals that would have added to the compliance burden on practices, and added a barrier to care for patients.

Medical Practice

Fundamentally altered the direction of the Medical Indemnity Insurance Review, discussing its importance to medical practice at the highest level, helping to ensure the review is not used as a blunt savings exercise, and saving doctors and their patients millions of dollars in increased premiums.
Led a nationally co-ordinated campaign with the State AMAs and other peak bodies to uphold the TGA’s decision to up-schedule Codeine.
Campaigned against an inadequate, poorly conceived, and ideological National Maternity Services Framework, which has now been scrapped.
Campaigned on the issue of Doctors’ Health and the need for COAG to change mandatory reporting laws, promoting the WA model.
Launched the AMA Public Hospital Report Card.
Pressed the case for vastly improved Private Health Insurance products through membership of the Private Health Ministerial Advisory Committee (PHMAC), my annual National Press Club Address, an appearance before a Senate Select Committee, and regular and ongoing media and advocacy.
Launched the AMA Private Health Insurance Report Card.
Successfully convinced the Government to address concerns with the MBS Skin items, and will continue to do so with the MBS Review more broadly.
Successfully lobbied for changes to the direction of the Anaesthesia Clinical Committee of the MBS Review.
Launched a new AMA Fees List with all the associated benefits of mobility and regular updates.
Saw a number of our Aged Care policy recommendations included in a number of Government reviews.
Lobbied against the ill-thought-out Revalidation proposal, which resulted in a vastly improved Professional Performance Framework based around enhanced continuing professional development.
Successfully held off the latest attempt to have a non-Medical Chair of the Medical Board of Australia appointed.

Public Health

Launched the AMA Indigenous Health Report Card, which this year focused on ear health, and specifically chronic otitis media, in conjunction with the Minister for Indigenous Health, The Hon Ken Wyatt AM.
Led the medical community by being the first to release a Position Statement on Marriage Equality, and advocated for the legislative change that eventuated in late 2017.
Released the updated AMA Position Statement on Obesity, following a policy session at the AMA National Conference, which brought together representatives from the medical profession, sports sector, food industry, and health economists.
Launched the AMA Position Statement on an Australian Centre for Disease Control (CDC), which was welcomed by experts in communicable diseases.
Released the AMA Position Statement on Female Genital Mutilation, which provided a platform for the AMA to engage in advocacy on preventing this practice.
Released the AMA Position Statement on Infant Feeding and Maternal Health.
Released the progressive and widely-supported AMA Position Statement on Harmful substance use, dependence, and behavioural addiction (Addiction).
Successfully lobbied against the proposal to drug test welfare recipients, including a strongly worded submission to a Parliamentary Inquiry on the proposal, which resulted in defeat of the proposed measure in the Parliament.
Released the AMA Position Statement on Firearms, generating considerable media coverage and interest, in Australia and overseas. Most importantly, it is a factor in Australia maintaining its tough approach to gun control.
Released the AMA Position Statement on Blood Borne Viruses (BBVs), which called for needle and syringe programs (NSPs) to be introduced in prisons and other custodial settings to reduce the spread of BBVs. This policy has been promoted by other health organisations and saw the AMA create strong ties within the sector.
Ongoing and prominent advocacy for the health and wellbeing of Asylum Seekers and Refugees, including a meeting with the Minister for Immigration and Border Protection, The Hon Peter Dutton MP, and lobbying on behalf of individual patients behind the scenes.
AMA lobbying of manufacturers saw a change to the sale of sugar-sweetened beverages in some remote Aboriginal communities, which will improve health outcomes.
Promoted the benefits of Immunisation to individuals and the broader community. Our advocacy has contributed to an increase in child and adult vaccination rates.
Provided strong advocacy on climate change and health.
Consistently advocated for better women’s health services.
Lobbied for the establishment of a No-Fault Compensation Scheme for people adversely affected by vaccines.

We promoted our carefully-constructed Position Statement on Euthanasia and Physician Assisted Suicide during consideration of legislation in Tasmania, Victoria, NSW, and WA.

I would like to thank Dr David Gillespie for his contribution to the Rural Health portfolio, and hope that his legacy will be seen in the success of the new Rural Health Commissioner, a position the AMA lobbied for and supports.

In the New Year, we will release new Position Statements on Mental Health, Road Safety, Nutrition, Organ Donation and Transplantation, and Rural Workforce.

As your President, I have had face-to-face meetings with Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Health Minister Greg Hunt, Shadow Health Minister Catherine King, Greens Leader Dr Richard Di Natale, and a host of Ministers and Shadow Ministers.

We also organised lunch briefings with backbenchers from all Parties to promote AMA policies.

In July, our advocacy was publicly recognised when the Governance Institute rated the AMA as the most ethical and successful lobby group in Australia.

I have met regularly with stakeholders across the health sector, including the Colleges, Associations, and Societies, other health professional groups, and consumer groups.

As your President, I have been active on the international stage, representing Australia’s doctors at meetings in Zambia, Britain, Japan, and the United States.

The highlight of the international calendar was the annual General Assembly of the World Medical Association. Outcomes from that meeting included high level discussions on End-of-life care, numerous ethical issues, Doctors’ health, and an editorial revision of the Declaration of Geneva.

But our focus remains at home, and your AMA has been very active in promoting our Mission: Leading Australia’s Doctors – Promoting Australia’s Health.

We have had great successes. We have earned and maintained the respect of our politicians, the bureaucracy, and the health sector. We have won the support of the public as we have fought for a better health system for all Australians.

We have worked hard to add even greater value to your AMA membership.

May I take this opportunity to wish you, your families, and loved ones a safe, happy, and joyous Christmas, and a relaxing and rewarding holiday season. I hope you all get some quality private and leisure time – you deserve it.

Dr Michael Gannon
Federal AMA President

[Articles] The cumulative burden of surviving childhood cancer: an initial report from the St Jude Lifetime Cohort Study (SJLIFE)

The burden of CHCs in survivors of childhood cancer is substantial and highly variable. Our assessment of total cumulative burden in survivors of paediatric cancer, with detailed characterisation of long-term CHCs, provide data to better inform future clinical guidelines, research investigations, and health services planning for this vulnerable, medically complex population.

Unacceptable kidney transplant rate for Indigenous Australians

AMA President Dr Michael Gannon has called for urgent attention in addressing the gap between Indigenous and non-Indigenous Australians accessing kidney transplants.

Figures just released show that Indigenous patients are 10 times less likely than non-Indigenous patients to be added to the waiting list for a kidney donation transplant.

About 13 per cent of patients receiving dialysis treatment in Australia are Indigenous. Only 241 of 10,551 patients with a functioning kidney transplant are Indigenous.

Some renal experts have pointed to a racially-based bias, suggesting some non-Indigenous doctors favour non-Indigenous dialysis patients.

Other specialists in the field insist the gap is not fuelled by racism.

During an interview with the ABC, Dr Gannon said these figures were unacceptable and more needed to be done to ensure Indigenous Australians received transplants when needed.

“I’m shocked by those figures. A ten-fold gap is entirely unacceptable,” Dr Gannon said.

“The topic of racism in our health system is an uncomfortable one for doctors, nurses, but it has to be one of the possible reasons for this kind of disparity.

“If there’s reasons why Aboriginal and Torres Strait Islanders are not being transplant-listed, they need to be investigated, but the problems need to be fixed.”

Dr Paul Lawton, a specialist at the Menzies School of Health Research, told the ABC that while Australian kidney specialists were well meaning, there was a “structural racism” that had led to low transplant rates for Indigenous patients.

“Currently, our system is structured so that us non-Indigenous, often male, middle-aged white kidney specialists offer kidney transplants to people like ourselves,” Dr Lawton said.

“It both makes me sad and angry that in Australia in the 21st century, we see such great disparities in access to good quality care.”

Indigenous Health Minister Ken Wyatt said he was disheartened with the figures and wanted to focus on building a heightened awareness of the issue over the next year.

According to Kidney Health Australia, about 30 of 800 kidney transplants performed each year are received by Indigenous Australians.

This under-representation can be attributed to a variety of reasons such as comorbidities, delays in listing and significant tissue matching issues. Importantly, the outcomes from transplantation are considerable poorer than among non-indigenous people.

To improve access to transplantation by Aboriginal and Torres Strait Islander renal patients, there needs to be a better understanding of how to address the barriers. There also needs to be improved support services for patients.

Kidneys for transplantation are largely from deceased donors. There are very few living kidney donors in Aboriginal and Torres Strait Islander communities, due to burden of disease and likelihood of comorbidities evident. Increasing live donations or listing more people on the waiting list is very unlikely to see improvements, given the burden of disease experienced and current barriers in the system.

The reasons for poor access to transplantation experienced by Aboriginal and Torres Strait Islander Australians are complex and can be attributed to:

• The greater burden of comorbid illness amongst Aboriginal and Torres Strait Islander dialysis patients leading to fewer patients being judge medically suitable;

• The shortage of living and deceased donors from within Aboriginal and Torres Strait Islander communities;

• The length of time on the waiting list and matching system;

• The challenges in delivering appropriate health services to people living in remote areas who might also have low health literacy and not speak English as a first language;

• The dislocation that follows from moving to transplant centres in distant capital cities; and

• The high complication rate, particularly in terms of early infectious complications leading to poor transplant outcomes, including substantially higher death and graft loss rates.

The poorer outcomes among those who receive transplants are due to higher rates of rejection, less well-matched kidneys, higher rates of infection and infection-related deaths. There are downsides to transplantation.

Prior to transplantation, these include a requirement for significant work up tests and assessments which require visits to major centres. After transplantation there is the prospect of a post-operative stay and side effects away from home and supports. The number of medications usually increases, and there is an increased risk of infections and cancers

CHRIS JOHNSON AND LUKE TOY