Maternity Review a wasted opportunity

BY AMA PRESIDENT DR MICHAEL GANNON

After months of behind-the-scenes activity and growing angst from the profession, the AMA went public in June with our outrage over the process for the planned new National Framework for Maternity Services (NFMS).

The Framework is doomed to fail due to inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

Following an agreement at the April 2016 COAG Health Council meeting, the Queensland Government was tasked to lead the project to develop the NFMS, under the auspices of the Australian Health Ministers’ Advisory Council (AHMAC).

The AMA first became aware of the NFMS project in December 2016 – eight months after it commenced, and without any direct contact from AHMAC’s Maternity Care Policy Working Group (MCPWG) or its consultants – and we have raised concerns about the project ever since.

The AMA’s concerns are shared by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG).

It is outrageous that specialist obstetricians and GPs have been marginalised in this process. You could be forgiven for thinking it a joke.

Obstetrician-led care is an essential tenet of Australia’s maternity system. There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

When issues and problems arise during labour, it is invariably an obstetrician who is called on to assume responsibility and manage care, working to ensure the best possible outcome for mother and baby.

The AMA is pleased that midwives were strongly represented on the Working Group responsible for drafting the NFMS. They are key members of the maternity team.

But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.

AMA members have reported maternity services and outcomes in their respective States have deteriorated under the current National Maternity Services Plan.

Obstetricians are concerned that not enough is being done to ensure women have access to high quality, collaborative models of care. Despite this, the consultation undertaken to develop the NFMS has neglected to actively engage specialist medical practitioners who are at the centre of care for mothers and babies.

The draft Framework, which was released for public comment in March 2017, lacked substance and provided no guidance for public hospital maternity services about what high quality care should look like.

The NFMS is shaping up as a lost opportunity to achieve the best possible maternity care for mothers and babies in Australia.

GPs, too, have been ignored in the process.

GPs not only routinely offer obstetric services in outer metropolitan, rural, and regional areas, but deliver antenatal and postnatal care to thousands of Australian women. There was not a single GP representative appointed.

Further, there is no acknowledgement that best practice care of mothers involves anaesthetists, obstetric physicians, psychiatrists, pathologists, and haematologists, none of whom were invited to assist in the development and drafting of the NFMS.

The AMA wants to see a strong NFMS. It must be developed in genuine partnership with the medical profession and its peak bodies. These are the medical professionals who deal with maternity services, day in and day out.

They’ve seen what works, and they know where the system is not working well. Their experiences and views should have been at the table, from the beginning.

Inviting them to a consultation a month before completion of the draft NFMS does not seem a genuine attempt to listen to experts at the coalface of maternity services.

The AMA has called on COAG, AHMAC, and the NFMS Working Group to formally and genuinely engage with the medical profession – obstetricians in particular – before there is any further policy development or public reporting on the Framework.

The health of mothers and their babies deserves a thorough and professional Framework to ensure the best possible care.

AMA voicing concern over some political moves

Two issues dominating recent health policy discussions have seen the AMA at the forefront of political debate, expressing concerns over the direction of some processes and decisions.

The medicinal cannabis and maternity services debates have kept AMA President Dr Michael Gannon a familiar face around Parliament House in Canberra, explaining doctors’ views to Government and the media.

Medicinal cannabis

After a surprise result from a Senate vote in June, terminally ill patients with a doctor’s prescription will be able to get faster access to medicinal cannabis and be allowed to import three months’ worth of their own personal supply of the drug.

The Greens pushed for changes to Government restrictions and they found support from Labor, One Nation and some independents.

But Health Minister Greg Hunt, who with his Government colleagues tried to stymie the move, said the outcome could put lives at risk.

He said the changes could open the way for questionable and unregulated products to be introduced to the market, as well as making it easier for criminals to access drugs.

“It is unfortunately a reckless and irresponsible decision,” Mr Hunt said.

Dr Gannon agrees, saying the AMA was disappointed with the move.

“You’ve already got a situation where doctors are querying exactly how effective medicinal cannabis is. If you in any way put any doubt in their minds about the safety, you’re simply not going to see it prescribed by many doctors,” he said.

“We remain concerned about potential diversion into the general community. And let’s not forget, we’re talking about cannabis. We’re talking about a substance that, used in the form it’s used by most people, is a major source of mental illness in our community.”

Dr Gannon said the AMA was satisfied with the process put in train by the Government through the Therapeutic Goods Administration.

“The TGA’s got a process in place. Let’s support that careful process to make sure what is used is perfectly safe.”

The binding vote, which passed in the Senate 40 to 30, means medicinal cannabis will be put on the TGA’s Category A list, giving qualifying patients priority and faster access.

Maternity Services

The AMA is also warning that the planned new National Framework for Maternity Services (NFMS) was doomed to fail due to inadequate stakeholder consultation.

Describing the process as spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development, Dr Gannon said opportunities for improvement were being lost.

The AMA has raised concerns about the project ever since.

In June, however, Dr Gannon, an obstetrician, said it was outrageous that specialist obstetricians and GPs had been marginalised in the process.

“You could be forgiven for thinking it a joke,” he said.

“Obstetrician-led care is an essential tenet of Australia’s maternity system.

“But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.”

On June 23, the process did indeed fail and was scrapped.

Dr Gino Pecoraro, AMA Federal Councillor, attended an NFMA consultation on that day to discuss concerns.

He described the subsequent decision to scrap the process as a win for patients.

Dr Pecoraro said the process to date had been a monumental waste of time and money.

“The AMA has been clear that unless they went back and started again, then it wouldn’t go anywhere,” he said.

“It is a win for the women and children of Australia.”

Chris Johnson

National Framework for Maternity Services scrapped following AMA concerns

The AMA has welcomed the decision to scrap the National Framework for Maternity Services (NFMS) due to its flawed process.

The process involved inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

AMA Vice President Dr Tony Bartone said obstetricians and GPs share the bulk of the care for women throughout their pregnancies and leaving them out of the NFMS process was a critical misjudgement.

“GPs are there with mothers at every stage of their pregnancy, including their postnatal care, and should never have been overlooked in the NFMS,” Dr Bartone said.

“The AMA has consistently warned that without genuine engagement with the medical profession, the review would be doomed to fail – which is exactly what has happened today.”

AMA Federal Councillor Dr Gino Pecoraro, an obstetrician and gynaecologist, attended a consultation forum on June 23 that led to the decision to scrap the NFMS.

“Today’s decision to scrap the flawed NFMS is a win for the women and children of Australia,” Dr Pecoraro said.

“What has happened has been a monumental missed opportunity to achieve the best possible maternity care for mothers and babies.”

Obstetrician-led care is an essential tenet of Australia’s maternity system.

There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

“The AMA remains committed to work to see a strong NFMS,” said Dr Bartone.

Chris Johnson

[Editorial] Kenya’s nurses strike takes its toll on health-care system

Strike action by government nurses in Kenya over poor pay and dreadful working conditions has led to the deaths of 12 patients who were not able to access vital services and care. Recent reports on Kenyan news wires described an 8-month-old child with severe malaria and anaemia not receiving the treatment he needed to survive. A critically ill elderly woman with asthma was left unattended for days. Patients with mental illness or substance addiction are being discharged or turned away, and maternity services are barely functioning.

Future Leader Receives AMA Award

A junior doctor and researcher, whose experiences as the child of refugee parents inspired her to establish a health promotion charity for migrants, refugees, and asylum seekers, has won the AMA Doctor in Training 2017 Award.

Dr Linny Phuong, a Paediatric Infectious Disease Fellow at the Royal Children’s Hospital Melbourne, was presented with the award by AMA President Dr Michael Gannon at the AMA National Conference 2017 in Melbourne.

Dr Phuong is the second winner of the Award, which was introduced in 2016 to recognise outstanding leadership, advocacy, and accomplishments of a doctor in training. The recipient is awarded a place at the AMA’s Future Leaders Program.

Dr Gannon praised Dr Phuong, the founder and director of the Water Well Project, for her contributions to teaching, medical education, research, and doctors’ wellbeing, as well as her professionalism and compassion towards children and their families.

“Dr Phuong exemplifies the characteristics of a caring doctor, an inspiring leader, and a tireless philanthropist and humanitarian,” Dr Gannon said.

Dr Phuong is highly regarded by her peers at the Royal Children’s Hospital where, as Deputy Chief Resident, she is in charge of the doctors’ wellbeing portfolio. She is also a successful medical researcher, having published several papers.

Dr Gannon also paid tribute to Dr Phuong’s awareness of the many challenges faced by refugee families in accessing health services, noting that five years ago, she founded the Water Well Project, a not-for-profit health promotion charity which improves the health and wellbeing of migrants, refugees, and asylum seekers by providing health literacy support and education.

Meredith Horne

AMA a key player in federal politics

AMA President Dr Michael Gannon opened the 2017 National Conference letting delegates know that while the past 12 months had been eventful, much had been achieved in the realm of health policy.

He continued with that theme throughout the three-day event in Melbourne, which brought together not only the elite of the medical profession but also the highest level of Australian political leaders.

“The AMA is a key player in federal politics in Canberra. The range of issues we deal with every day is extensive,” Dr Gannon said.

“Our engagement with the Government, the bureaucracy, and with other health groups is constant and at the highest levels.

“Our policy work is across the health spectrum, and is highly regarded.

“The AMA’s political influence is significant.”

Describing the political environment over the past year as volatile – which included a federal election and two Health Ministers to deal with – Dr Gannon said the AMA had spent the year negotiating openly and positively with all sides of politics.

“Our standing is evidenced by the attendance at this conference of Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Greens Leader Senator Richard Di Natale, Health Minister Greg Hunt, Minister for Aged Care and Minister for Indigenous Health Ken Wyatt AM, and Shadow Health Minister Catherine King,” he said.

“Health policy has been a priority for all of them, as it has been for the AMA.”

While the Medicare rebate freeze was the issue to have dominated medical politics, there are still more policy areas to deal with in the coming year.

The freeze was bad policy that hurt doctors and patients.

“I was pleased just weeks ago on Budget night to welcome the Government’s decision to end the freeze,” Dr Gannon told the conference.

“The freeze will be wound back over three years. We would have preferred an immediate across the board lifting of the freeze, but at least now practices can plan ahead with confidence.

“Lifting the freeze has effectively allowed the Government to rid itself of the legacy of the disastrous 2014 Health Budget.

“We can now move on with our other priorities… We will maintain our role of speaking out on any matter that needs to be addressed in health.”

Dr Gannon said while the Medicare freeze hit general practice hard, it was not the only factor making things tough for hardworking GPs.

General practice is under constant pressure, he said, yet it continues to deliver great outcomes for patients.

GPs are delivering high quality care and are the most cost effective part of the health system.

“One of the most divisive issues that the AMA has had to resolve in the past 12 months is the Government’s ill-considered election deal with Pathology Australia to try and cap rents paid for co-located pathology collection centres,” Dr Gannon said.

“We all know that our pathologist members play a critical role in helping us to make the right decisions about our patients’ care. They are essential to what we do every day.

“It was disappointing to see the Government’s deal pit pathologists against GPs.

“The recent Budget saw the rents deal dumped in favour of a more robust compliance framework, based on existing laws. This is a more balanced approach.”

Other issues the President highlighted as areas the AMA is having significant influence included: Health Care Home Trial; the Practice Incentive Program; My Health Record; Indigenous Health; After-Hours GP Services; the MBS Review; public hospitals; private insurance; and the medical workforce.

Chris Johnson

AMA lends support to build the Indigenous health workforce

As a 13-year-old, James Chapman watched his father, a proud Indigenous man from Yuwlaaraay country, die after a short, seven-week battle with acute myeloid leukaemia. As a school leaver, he became his mother’s carer for 12 months as she recovered from brain surgery.

Today, the 25-year-old, second-year medical student has won the 2017 AMA Indigenous Medical Scholarship – $10,000 a year for each year of study – to help him pursue his dream of becoming a medical professional.

AMA President Dr Michael Gannon, who presented the Scholarship at the AMA National Conference in Melbourne said that Mr Chapman’s story was inspiring.

Dr Gannon believes the award is important because Indigenous people have improved health outcomes when they are treated by Indigenous doctors and health professionals. This is highlighted by the need to build the building the Indigenous health workforce where in 2017, there are just 281 medical practitioners employed in Australia as Aboriginal or Torres Strait Islander – representing 0.3 per cent of the workforce.

Mr Chapman said that while he did not realise it at the time, his father was a victim of the gap that exists between Indigenous and non-Indigenous Australians when he saw firsthand communities with access only to a visiting doctor and nurse.

He dreamed of one day becoming a doctor, but was discouraged by his teachers. As a young student at the University of Wollongong his study was derailed when his mother was diagnosed with a brain tumour, and he became her carer for a year while she recovered.

“Constantly in clinical environments, my dream of becoming a medical professional became more intense, and after my mother recovered, I began a Science degree with the intention of completing post graduate medicine,” Mr Chapman said.

Now in his second year, Mr Chapman intends to study from Wagga Wagga from his third year onwards to experience rural health, and rural and remote Indigenous health care. He hopes to become a GP, working with Indigenous women and children in rural and remote Australia.

Dr Gannon said that, in 2017, a total of 286 Aboriginal and Torres Strait Islander medical students are enrolled across all year levels across Australia. However, four of the 15 colleges are yet to have an Indigenous trainee.

“The AMA Scholarship has assisted many Indigenous men and women, who may not have otherwise had the financial resources to study medicine, to graduate to work in Indigenous and mainstream health services,” Dr Gannon said.

The AMA Indigenous Medical Scholarship was established in 1994 with a contribution from the Commonwealth Government. The AMA is looking for further sponsorships to continue this important contribution to Indigenous health.

Donations are tax-deductible. For more information, go to advocacy/indigenous-peoples-medical-scholarship

Meredith Horne

2017 AMA media and advocacy awards

At the 2017 AMA National Conference, six media and advocacy awards were presented.

A new award category was opened for this year’s entries – the Best Public Health Initiative. State and Territory AMAs were invited to nominate an outstanding public health initiative or campaign – other than smoking and tobacco control – launched by their State or Territory Government in calendar year 2016.

Nominated by AMA NSW, The NSW Government, won this award for its campaign to combat childhood obesity. The NSW Health campaign is a comprehensive whole-of-government plan with the specific target of reducing overweight and obesity rates of children by 5 per cent over 10 years.

The judging panel, headed by Public Health Association of Australia CEO Michael Moore, noted that the campaign stood out for its clear strategic directions, and its strong focus on children and young people.

The Best Lobby Campaign 2017 was awarded to AMA Western Australia for their ‘Three-year Employment Contracts for Interns’ campaign.

The successful introduction of the three-year employment contracts for interns is a standout achievement. The reform eliminates the previous system of annual contracts, thereby eliminating both the cost and the stress of interns having to reapply for their jobs on an annual basis.

The judges commented that AMA WA’s policy success should contribute to improved health outcomes across the WA system, with the hope that this initiative may spread nationally over time. In addition, the successful recombination of the Minister of Health and Mental Health is also a noteworthy success for the WA branch.

Best Public Health Campaign from a State or Territory 2017 was awarded to AMA Western Australia for highlighting ‘Australia’s Mental Health Crisis’.

AMA WA has developed a state-of-the-art best practice mental health program that is being recognised Australia-wide as the best of its kind using a dual approach to reach youth at school and adults in the workplace – two groups under severe mental health pressure.

Judges commended the branch on the clarity and quality of the campaign. They said the effectiveness in engaging and delivering its important message pointed to a significant public health intervention that deserved to be recognised.

AMA Victoria received Best State Publication 2017 for ‘Vicdoc’, whichcovers the ethical, political, clinical, and work based issues facing the medical profession in great detail.

Judges commented that the publication was valuable and informative and a must-read for any Victorian doctor. The front covers were simple and with compelling use of images. The standard of writing in this publication was extremely high and very informative.

AMA Victoria was also awarded with the National Advocacy Award 2017 for their cooperation between federal AMA during the introduction of the Victorian Government’s ‘Assisted Dying’ legislation.

AMA Victoria’s actions and commentary on assisted dying have always referenced and reflected AMA Federal’s policy position.

AMA Victoria called for improved funding for palliative care services, and legislative changes to the Doctrine of Double Effect through the enactment of legislation to provide legal certainty to medical practitioners in connection with the accepted clinical practices of double effect and non-provision of futile care.

Judges commended AMA Victoria on its clear and concise submission to the inquiry into a very sensitive and often divisive issue.

Most Innovative Use of Website or New Media 2017 was awarded to AMA Western Australia for their creation of WAhealthfirst.com.au.

This website utilised a new media approach that generates conversation from content advocating AMA WA’s position on key political issues, most relevant to the recent State election earlier this year. An expected outcome of new media is to use technology available to provide clear and easy communication to the user. Judges commended AMA WA in the success of WAhealthfirst.com.au and said it was clear it simplified the voter education process of health policy while also providing the facts.

Meredith Horne

Medical role models honoured at AMA National Conference

AMA Woman in Medicine

Dr Genevieve Goulding, an anaesthetist with a strong social conscience and a passion for doctors’ mental health and welfare, has been named the AMA Woman in Medicine for 2017.

Described by her colleagues as a quiet achiever, ANZCA’s fourth successive female President, Dr Goulding has used her term to focus on professionalism, workforce issues, advocacy, and strengthening ANZCA services for Fellows and trainees.

Dr Goulding is a founding member of the Welfare of Anaesthetists Group, which raises awareness of the many personal and professional issues that can affect the physical and emotional wellbeing of anaesthetists throughout their careers.

Dr Michael Gannon, who presented the award at the AMA National Conference, said that Dr Goulding was a role model for all in the medical profession.

“She has raised the profile and practice of safe and quality anaesthesia. She is committed to ensuring patients – no matter their background or position – can rely on and benefit from our health system,” Dr Gannon said.

Dr Goulding continues to effect change with her work on the ANZCA Council and on the Queensland Medical Board, her numerous positions with the Australian Society of Anaesthetists, and her current work with the Anaesthesia Clinical Committee of the MBS Review.

Excellence in Healthcare Award

This year, AMA recognised a true medical leader Dr Denis Lennox, who has made an outstanding contribution to rural and remote health care in Queensland, and to the training of rural doctors.

Dr Lennox has had an extraordinary career since starting as a physician and medical administrator in his home town of Bundaberg in the 1970s.

Dr Gannon said that Dr Lennox had earned this award through his vision and revolutionary training of rural general practitioners and specialist generalists.

“Dr Lennox has been responsible for real workforce and healthcare improvements in all parts of Queensland, particularly through the Queensland Rural Generalist Program which has delivered more than 130 well-prepared Fellows and trainees into rural practice across Queensland since 2005 – an incredible achievement,” Dr Gannon said when presenting the award.

An Adjunct Associate Professor at James Cook University and Executive Director of Rural and Remote Medical Support at Darling Downs Hospital Health Service, Dr Lennox prepares to retire from 40 years of public service.

AMA Women’s Health Award

A nurse and midwife in Darwin, Eleanor Crighton has been awarded the Women’s Health Award – an award that goes to a person or group, not necessarily a doctor or female, who has made a major contribution to women’s health.

Ms Crighton won the award for her outstanding commitment to Indigenous women’s health.

Dr Gannon when presenting the award to Ms Crighton said that she had made a real difference to the lives of Aboriginal women in the greater Darwin region through them gaining access to affordable family planning.

“As an obstetrician, I know the importance of the work of women’s health teams, particularly in Aboriginal community-controlled organisations like Danila Dilba,” Dr Gannon said.

As the Women’s Health Team leader at Danila Dilba Health Service, Ms Crighton has shown her commitment to Indigenous health by pursuing additional studies and gaining personal skills with the aim of filling gaps in health care services.

Ms Crighton has also worked tirelessly to raise awareness of Fetal Alcohol Spectrum Disorder, and has started training Danila Dilba’s first home-grown trainee midwife, at the same time as pursuing her own Nurse Practitioner studies.

Meredith Horne

Doctors caring for doctors

BY AMA PRESIDENT DR MICHAEL GANNON

The health of doctors, especially our mental health, has been very topical in recent weeks.

It was a major focus at the AMA National Conference in late May, and it went viral on social media through the Crazy Socks for Docs awareness campaign, which was pioneered by Melbourne cardiologist, Dr Geoffrey Toogood.

Following National Conference, Minister Hunt announced a $47 million suicide prevention initiative, with $1 million set aside specifically to support mental health and reduce suicide in the health workforce. This was most welcome.

I have since written to the Minister about programs for mental health suicide prevention in the medical workforce.

I stressed to the Minister the importance of having the mandatory reporting requirements under the National Law amended, so as to not dissuade medical practitioners from seeking necessary medical treatment or assistance.

It is well known that doctors are at greater risk of suicidal ideation and death by suicide.

So far this year, we have lost several colleagues to suicide–and these are not isolated incidents.

While there is a wide range of factors involved in suicide, we know that early intervention could be critical to avoiding many of these tragic losses.

Unfortunately, the reality is that there are significant barriers, real and perceived, that prevent some doctors from seeking access to formal health care.

The AMA is working to change this situation, and is currently working with the Medical Board of Australia to establish accessible and robust doctors’ health services across the country.

One of the key barriers that the AMA has identified to accessing care is mandatory reporting.

Mandatory reporting for doctors was introduced in NSW in 2008, and then into the National Law for all practitioners in 2010.

The intention of the legislation was to ensure the protection of the public by requiring doctors and other health practitioners to report colleagues under defined circumstances.

The legislation intentionally created a very significant bar for reporting by stating that only matters of grave significance should be reported to the regulator.

One of the requirements for mandatory reporting is to report on health and impairment. This obligation applies to both colleagues and treating doctors.

The AMA, medical colleges, and the medical defence organisations have been concerned for some time that this provision creates a barrier to health professionals in accessing health care, particularly in relation to mental illness.

The lived experience of doctors’ health advisory services across the country confirms these fears.

An extensive study of over 12,000 doctors undertaken by beyondblue in 2013 revealed that one of the most common barriers to seeking treatment for a mental health condition were concerns about the impact of this on medical registration.

The Western Australian Government recognised this concern and after dogged, persistent, and forceful representation from AMA WA over many months, created a provision in their legislation to exempt treating practitioners from the requirements of the Act in WA.

While it has been difficult to collect clear evidence of the impact of the mandatory reporting provisions on doctors seeking treatment, the AMA, doctors’ health services, medical colleges, and the medical defence organisations receive feedback from doctors regarding their fears about seeking medical treatment.

We know anecdotally of cases of doctors travelling to WA for treatment.

Of great concern, it is very clear that some doctors are actively avoiding medical care, where possible, out of fear of the mandatory reporting obligations.

The Western Australian exemption has not made a material difference to the rate of mandatory notifications in that jurisdiction.

The Independent Review of the National Registration and Accreditation Scheme for health professions commissioned by the COAG Health Council in 2014 listened to the concerns of the medical profession and other groups, recommending that the National Law to be amended to reflect the same mandatory notification exemptions for treating practitioners established in the Western Australian law.

As health practitioners, we know the dangers of delaying access to medical treatment or of only providing limited information.

This risk is particularly pronounced with mental illness, where delaying treatment can result in a person ending up with a far greater level of impairment.

As such, we believe the current legislative arrangements are not protecting health practitioners and, equally importantly, they are failing to protect the public.

In my letter to him, I told Minister Hunt it is time for Health Ministers in the seven jurisdictions (excepting WA) to act on the recommendation of the 2014 review report. I am hoping for his support on this most important matter.