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Preference: Administration and Health Services

2

Billions start flowing for medical research

Almost $1.3 billion of funds stripped from the Health portfolio have been funnelled to the Medical Research Future Fund as the Federal Government makes good on its controversial plan to divert billions of dollars from other areas of health to support research.

Late last month the Government, with little fanfare, transferred $1.277 billion to the MRFF’s Special Account, the first instalment of what is expected to be $20 billion injected into the Fund in coming years.

Prime Minister Malcolm Turnbull is persisting with the Medicare rebate freeze, reduced public hospital funding and cuts to bulk billing incentives in pathology and diagnostic imaging, with a share of the savings being directed to the MRFF.

The plan, unveiled in the 2014 Budget, was heavily criticised at the time by the AMA, which argued that although increased investment in medical research was welcome, it should not come at the expense of medical services and other areas of health.

But the $1.2 billion transfer is the clearest demonstration yet that the Government has no intention to abandon or scale back its plan, which has the backing of parts of the medical research community.

The Research Australia alliance, which claims to have 160 members and supporters, welcomed the initial investment as a “significant step to secure Australia’s health and medical research future”.

Research Australia Chief Executive Officer Nadia Levin said the transfer of the money to the MRFF Special Account was “words in action”.

“This is Prime Minister Turnbull and Health Minister Ley doing exactly what they said they would do – build our health system and build an innovation nation,” Ms Levin said. “This is not just words. It’s action and it’s money, and it is going to make an enormous difference to the health of Australians and the health of the economy.”

Following months of consultation, the MRFF is developing a document setting out the strategy and principles which will guide its investment in research projects.

Initially, the Fund intends to direct $61 million toward health and medical research project this financial year.

Under the Government’s plan, the Fund will expand rapidly in the next few years to reach $20 billion in the early 2020s, enabling it to invest around $1 billion a year in research.

Adrian Rollins

AMA President meets with Border Force chief medical officer

AMA President, Dr Michael Gannon, continued the AMA’s ongoing advocacy on behalf of asylum seekers and refugees when he met the Australian Border Force Chief Medical Officer, Dr John Brayley, in Canberra on 9 September, 2016.

It was the second meeting between an AMA President and Dr Brayley since the CMO role was created a year ago.

Dr Gannon noted that the AMA’s position on health care of asylum seekers has not changed, and reiterated that the AMA will always be focussed on ensuring the proper provision of health care to those in need. 

“The AMA has received representations from asylum seekers, refugees and their advocates concerning the provision of health care and, in some cases, asking the AMA for specific help,” Dr Gannon said. 

“Dr Brayley and I discussed the complexities of offshore immigration detention facilities and the difficulties in dealing with individual asylum seeker cases, along with the standards of care and the measures being undertaken to improve the health care available in offshore detention facilities.

“The Department of Immigration and Border Protection has been providing the AMA with regular updates and information about the health of asylum seekers. 

“Dr Brayley and I agreed to meet again to continue this important advocacy and dialogue on the health and well-being of asylum seekers and refugees.”

Dr Brayley was appointed as CMO and inaugural Surgeon General of the Australian Border Force (ABF) in September 2015.

His role is to oversee and coordinate a consolidated health function within ABF, including at offshore detention centres, leading to improved and more consistent health policies.

“This new position will also allow doctors to raise issues through appropriate clinical channels and advocate on behalf of their patients,” Department of Immigration and Border Protection Secretary, Mike Pezzullo, said at the time.

Dr Brayley is a consultant psychiatrist, health administrator and statutory office holder, who served as the Public Advocate of South Australia from 2008 until taking up the ABF appointment.

He used the role of Public Advocate to campaign for the rights of people with mental illness and disability, and exposed the plight of mental health patients in South Australian prisons.

In an interview with InDaily last year, Dr Brayley said the CMO role had enough power to make meaningful change.

“Questions about standards of health care, and also issues raised by doctors and other health professionals about their patients in immigration detention, will be able to be brought to this new role,” Dr Brayley said.

“Many of the same issues that I deal with as Public Advocate, and suggest solutions about in my present role, I will be responding to in this new role … ensuring that high quality health services are delivered, including mental health services, that are comparable in standard to those that are generally provided to the Australian community.

“Rather than being the advocate, I expect to be responding to advocacy from health practitioners about their patients.

“This new position is an opportunity to contribute to ongoing improvements in health services for people in immigration detention both in Australia and at the offshore centres on Nauru and Manus Island.”

Maria Hawthorne

 

 

Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012

The known The risk of suicide may be higher for medical practitioners and nurses than for those in other occupations. This problem had not been assessed at a national level or by sex. 

The new Age-standardised rates of suicide were higher for female medical practitioners, and for male and female nurses, than for other occupations. The rate of suicide for health professionals with access to prescription medicines was higher than for health professionals without ready access to these means. 

The implications Suicide prevention initiatives should focus on workplace factors and differential risks for men and women employed as health professionals. 

In general, health professionals are healthier and live longer than the general population.1 However, research has identified elevated rates of suicidal ideation and death by suicide among certain groups of health professionals, including doctors, nurses and dentists.2–4

Suicides by health professionals typically have two distinguishing features. First, they are more likely to involve poisoning5–7 than methods such as hanging, which is more common in the general population.8 Second, women working in health professions appear to be at particular risk; whereas in the general population the rate of suicide for men is nearly four times as high as that for women,8 the rates of suicide among female health professionals are comparable with those of their male peers.2–4 These two findings may be related, as the lethality of self-poisoning increases with access to prescription medicines, and women are more likely than men to choose poisoning as the method of suicide. Other possible explanations for the elevated rates of suicide among female health professionals include greater exposure to work-related stressors.9

Australian research on suicide by health professionals has been restricted to Queensland;6 there are no published analyses at the national level. Further, research has been restricted to studying doctors and nurses, with a notable lack of published data on the burden of suicide in other health care professions in Australia. A better understanding of whether suicide rates are elevated for all health professionals, or for medical professionals specifically, would assist efforts to prevent suicide. We therefore used a national register of occupationally coded suicide cases to determine the rates of suicide by health professionals in Australia and the suicide methods used, and to compare these with data for suicides by people in other occupations. We also assessed whether suicide rates for female health professionals were higher than for their male colleagues.

Methods

Study design

We conducted a nationwide study of deaths by suicide between 2001 and 2012. The study included all employed adults with a known occupation who were at least 20 years old at the time of their death.

Ascertainment of suicide deaths

We identified suicide cases using the National Coronial Information System (NCIS). The NCIS is an internet-based data storage and retrieval system that enables coroners, government agencies, and researchers to monitor external causes of death in Australia and to identify cases for further investigation and analysis. The NCIS provides basic demographic information, as well as employment status and occupation at the time of death as recorded in coronial files.

The quality and completeness of NCIS data vary between cases, particularly for the early years of the scheme (the system was launched in 2000), and suicide may be under-reported because of legislative and professional differences between states and between coroners.10 In addition, there is a significant lag between deaths and their recording in the NCIS caused by the duration of the coronial process, meaning that 2012 was the most recent complete year with full available data for inclusion in our study. Nevertheless, the NCIS offers the best available information on suicide mortality in Australia, and is used as the basis for compiling the official death statistics published by the Australian Bureau of Statistics (ABS).

We classified suicide methods according to the International Classification of Disease, 10th revision (ICD-10), codes X60–X84.11 We were unable to code the method of suicide for 5.4% of cases.

Ascertainment of occupational groups

Our study only included persons employed in a known occupation at the time of death. Occupational information was coded according to the Australian and New Zealand Standard Classification of Occupations (ANZSCO) to the four digit level.12 Information on the coding procedure we used is included in Appendix 1.

We divided occupations into two broad groups: health professions, and all other occupations. “Health professions” included all health care-related occupations classified by ANZSCO as professions, based on the educational requirements and skills required for the job (ANZSCO codes 25xx and 2723). It did not include health care workers who are classified as community and personal service workers (code 1220), such as paramedics and Indigenous health workers. We analysed data for three health profession groups: medical practitioners (code 253x), midwifery and nursing professionals (code 254x), and other health professions, which included health diagnostic and promotion professions (codes 251x and 252x; such as pharmacists and optometrists), therapy professions (code 252x; such as physiotherapists and occupational therapists), and psychologists (code 2723). The “other occupations” category included all people employed in any other occupation at the time of death.

Ascertainment of population size

We extracted ABS 2006 census data (the midpoint of our study) on the size of the population aged 20–70 years, by age, sex and occupation, using TableBuilder (http://www.abs.gov.au/websitedbs/censushome.nsf/home/tablebuilder?opendocument&navpos=240). Age was coded into 10-year bands; ANZSCO codes were used for occupation.

Statistical analysis

Descriptive analysis and age-standardised suicide rates

We report the age and sex of individuals in the four occupational groups: medical practitioners, nurses and midwives, other health professions, and all other occupations. We also report the suicide methods used by members of these groups. Suicide rates per 100 000 person-years were calculated for each of the four groups, stratified by sex. These rates were age-standardised to the Australian standard population (2001),13 restricting the standard population to those aged 20–70 years (the range of ages at death for the analysed health professionals).

Regression models

We compared the rates of suicide for the four occupational groups in negative binomial regression models. We used the “other occupations” group as the reference category, and the model was controlled for year of death, age and sex. We initially tested for effect modification by sex by including an interaction term in the model; as there was strong evidence of effect modification, in this article we report models stratified by sex.

We then assessed the influence of occupational access to prescription medicines by comparing suicide rates among health professionals who have ready access to prescription medicines in the course of their work with those for health professionals who do not. We defined health care professions with access to these lethal means as registered professions whose members are legally allowed to prescribe, supply or administer prescription medicines. This includes doctors, nurses and midwives, dental practitioners and pharmacists (Appendix 1). We did not include optometrists and podiatrists, although some practitioners in these professions are permitted to prescribe certain medicines. We assumed that sex would not be an interacting factor, as male and female health professionals would have the same level of knowledge about and access to prescription medicines.

For all models, coefficients were transformed to incidence rate ratios (IRRs) to aid interpretation. Analysis was undertaken in Stata 13.1 (StataCorp).

Ethics approval

The study was approved by the Deakin University Human Research Ethics Committee (reference, 2015-278) and the Justice Human Research Ethics Committee (reference, CF/15/13534).

Results

We identified 9828 suicides in Australia during the 12-year study period by employed adults aged 20–70 years, including 369 (3.8% of all suicides) by health professionals (Box 1). The age-standardised rate of suicide for male medical practitioners was 14.8 per 100 000 person-years, and 22.7 per 100 000 person-years for male nurses and midwives; the rate for men in other (non-health care) occupations was 14.9 per 100 000 person-years. The age-standardised rate of suicide among female health professionals was 6.4 per 100 000 person-years for medical practitioners, 8.2 per 100 000 person-years for midwives and nurses, and 4.5 per 100 000 person-years for other health professionals; this compares with 2.8 per 100 000 person-years for women in other occupations. Crude suicide rates by occupational group and sex are summarised in Appendix 2.

Hanging as the method of suicide was much less common among doctors (24%) and nurses and midwives (28%) than among other health professionals (43%) and those in other occupations (48%) (Box 2). Practitioners in these groups used self-poisoning (doctors, 51%; nurses and midwives, 40%) more often than did members of other occupations (10%).

A significant interaction between sex and occupation with respect to suicide rate was detected (χ2 test, P < 0.001), so models stratified by sex were calculated. After adjusting for year and age, we found a significantly higher suicide rate for men employed as nurses and midwives than for men in occupations other than health professions (IRR, 1.50; P = 0.006) (Box 3). The suicide rate for male “other health professionals” was slightly lower than for men employed in non-health care occupations (IRR, 0.75; P = 0.061). For women, being employed as a doctor (IRR, 2.52; P < 0.001) or as a nurse or midwife (IRR, 2.65; P < 0.001) was associated with significantly higher suicide rates than for women in non-health care occupations.

The rate of suicide among health professionals with ready access to prescription medicines was 1.62 times that for health professionals without this access (P < 0.001) (Box 4).

Discussion

In this national study of suicide in Australia, we found important sex differences between health professionals and other occupational groups in the epidemiology of suicide. The rate of suicide among women employed in any health profession was higher than for women in other occupations; the difference was statistically significant for women employed as nurses or medical practitioners. Compared with that for men in other occupations, the suicide rate was higher only among male health professionals in the fields of nursing and midwifery. Further, the rate of suicide was 62% higher among health professionals with ready access to prescription medicines than among health professionals without such access. Our findings also suggest that suicide rates across the entire working population have decreased slightly over time, and that suicide rates are lower among older working people (those over 50 years of age) than among younger working people (20–39 years of age) (Box 3, Box 4).

Sex-related stressors

Almost 15 years ago, Hawton and colleagues14 speculated that the rate of suicide by female health professionals would decline as more women entered the medical professions. Unfortunately, rates have not declined, despite the increasing number of women in these professions. It has been suggested that women working in male-dominated areas of medicine face a number of barriers that hinder their career advancement.15,16 In addition, female professionals may still feel pressure to undertake child care and household roles, leading to considerable gender role stress. This premise has been supported by studies in which young female doctors reported considerable pressure associated with combining work and family.17

Occupational gender norms may also play a role in explaining the high suicide rate among male nurses and midwives. These occupations are organised to reinforce traditionally feminine behaviours of caring and support. Qualitative research has found that some male nurses experience anxiety about the perceived stigma associated with their non-traditional career choice.18 These anxieties may constitute a risk factor for suicide for men in these occupations.

Work-related stressors

There is strong evidence that doctors experience a considerable number of psychosocial job stresses, including work–family conflict,19 long working hours, high job demands, and the fear of making mistakes at work.20 These psychosocial job stressors have been associated with common mental disorders (anxiety and depression) in several prospective cohort studies.21 Those working in caring professions, including nursing, may be particularly exposed to trauma, and they may also experience it vicariously through contact with patients and their families. Further, many health professionals operate their own businesses and may thus experience the stress of being sole operators.22

Suicide by self-poisoning

We found strong evidence of higher rates of suicide by self-poisoning among health professionals than by people in other occupations. We also found a higher rate of suicide for health professionals with ready access to prescription medicines than for health professionals without such access. These findings are consistent with those of several other studies. For example, a national study based on Danish population registers found differences in the use of medicinal drugs for deliberate fatal overdoses. Compared with teachers, who employed them in 22% of suicides, medicinal drugs were used far more frequently by nurses (55%), doctors (56%) and pharmacists (66%).2 An analysis of the Queensland suicide register found that poisoning was used more often by medical professionals (59% of suicides) and nurses (44%) than by education professionals (24%) and other groups (19%).6 A recent review of nine studies of suicide by nurses concluded that medication poisoning was the predominant method used for taking their own lives.5 Similarly, pharmacists employed poisoning as a suicide method more often than other employed people.7 It thus appears likely that access to prescription medicines as a lethal means is a risk factor in suicide by health professionals.

Limitations of our study

Major strengths of the study include the use of the best available individual-level data on suicide in Australia, the inclusion of multiple health care professions, and coverage of an entire national population over a 12-year period. We note, however, a number of limitations. First, under-reporting of suicide in the NCIS because of misclassification of the cause of death is a problem, as in any official record of deaths.10 Second, our study only included people who were employed at the time of death, so that health professionals who had stopped working because of illness, who were suspended from medical practice or de-registered, or who had retired were not included in our analysis. In addition, occupation may have been miscoded by police when collecting information, or during the coding process, despite independent coding by two researchers and the use of a structured approach to classification. Third, data on the method of suicide is incomplete, as initial data collection from the NCIS did not include this information. We have subsequently obtained these data for most suicides, but were unable to match suicide method for a small proportion of cases. Fourth, we note that the ANZSCO list of health professions is not perfectly aligned with the occupations regulated as health professions under the National Registration and Accreditation Scheme for health practitioners. For example, dental hygienists are a registered health profession, but are not listed as a health profession by ANZSCO; nutrition professionals are not a registered health profession, but are listed as such by ANZSCO.

The suicide rates for men in several of the jobs classified as “other occupations” (the denominator for our risk estimation) were particularly high, including men employed in lower skilled occupations and in technical and trade occupations.23 This circumstance will have affected the results of our analysis, as it will have reduced the calculated IRR when comparing suicide rates in male health professionals with those in other occupations. We did not have sufficient data to analyse suicide rates within specific medical specialties, such as anaesthesia, or within smaller health professions, such as dentistry. We cannot exclude the possibility that men working in these occupations may be at increased risk of suicide. Finally, we acknowledge the different age structures of the population of those in medical professions and of the standard Australian population; those employed in health professions were substantially older.

Conclusion

Our findings suggest that the rate of suicide among women employed in a range of health professions, including medicine, is markedly higher than that for women in other, non-health care occupations. An understanding of the specific stressors and risk factors experienced by women in these professions may shed additional light on targeted prevention strategies. Attention should also be given to the high rate of suicide among men, including those employed in health care. Strategies targeted at health professionals should also pay heed to the higher rate of suicide among professionals with access to prescription medicines.

Box 1 –
Age-standardised rates of suicide by employed adults aged 20–70 years, Australia, 2001–2012, for health professional groups and for all other occupations

All persons

Men

Women

Medical practitioners

Number of suicides

79

62

17

Mean age, years

44.7

46.3

39.0

Population*

53 672

34 649

19 023

Adjusted suicide rate† (95% CI)

12.2 (9.4–15.0)

14.8 (11.0–18.7)

6.4 (3.4–9.5)

Midwives and nurses

Number of suicides

216

49

167

Mean age, years

44.1

41.6

44.8

Population*

198 961

17 710

181 251

Adjusted suicide rate† (95% CI)

9.5 (8.0–11.0)

22.7 (14.8–30.7)

8.2 (6.7–9.7)

Other health professionals‡

Number of suicides

74

47

27

Mean age, years

43.9

45.8

40.7

Population*

88 633

34 800

53 833

Adjusted suicide rate† (95% CI)

7.6 (5.7–9.6)

11.5 (8.0–14.9)

4.5 (2.3–6.6)

Other occupations

Number of suicides

9459

8172

1287

Mean age, years

40.3

40.4

39.6

Population*

8 060 397

4 441 462

3 618 935

Adjusted suicide rate† (95% CI)

9.6 (9.3–9.8)

14.9 (14.5–15.2)

2.8 (2.6–3.0)

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Age-standardised rate per 100 000 person-years. ‡ Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists.

Box 2 –
Suicide methods used by health professionals and by members of other occupations aged 20–70 years, Australia, 2001–2012

* General practitioners and resident medical officers, anaesthetists, specialist physicians, psychiatrists, surgeons, other medical practitioners. † Midwives, nurse educators and researchers, nurse managers, registered nurses. ‡ Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists.

Box 3 –
Negative binomial regression model comparing suicide rates for health professionals with rates for members of other occupations aged 20–70-years, Australia, 2001–2012, stratified by sex

Suicides

Population*

Incidence rate ratio (95% CI)

P

Men

Occupation

Medical practitioners

62

34 649

1.01 (0.78–1.31)

0.929

Midwives and nurses

49

17 710

1.50 (1.12–2.01)

0.006

Other health professionals†

47

34 800

0.75 (0.56–1.01)

0.061

Other occupations (reference)

8172

4 441 462

1

—

Age‡

60–70 years

531

379 933

0.75 (0.64–0.88)

< 0.001

50–59 years

1406

917 291

0.82 (0.71–0.95)

0.007

40–49 years

2344

1 146 076

1.07 (0.94–1.23)

0.295

20–39 years (reference)

4049

2 085 321

1

—

Year (as continuous variable)§

8330

4 528 621

0.98 (0.97–1.00)

0.017

Women

—

Occupation

Medical practitioners

17

19 023

2.52 (1.55–4.09)

< 0.001

Midwives and nurses

167

181 251

2.65 (2.22–3.15)

< 0.001

Other health professionals†

27

53 833

1.41 (0.96–2.08)

0.083

Other occupations (reference)

1287

3 618 935

1

—

Age‡

60–70 years

65

216 119

0.74 (0.56–0.97)

0.030

50–59 years

287

775 659

0.90 (0.76–1.06)

0.200

40–49 years

406

1 042 075

0.94 (0.80–1.10)

0.439

20–39 years (reference)

740

1 839 189

1

—

Year (as continuous variable)§

1498

3 873 042

0.96 (0.95–0.98)

< 0.001

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Nutrition, medical imaging, occupational and environmental health professionals, optometrists and orthoptists, pharmacists, other health care diagnostic and promotion professionals, chiropractors and osteopaths, complementary health therapists, dental practitioners, occupational therapists, physiotherapists, podiatrists, audiologists and speech pathologists and therapists, psychologists. ‡ All occupations. § *Incidence rate ratio refers to the effect of a one-year increase in time on the suicide rate.

Box 4 –
Negative binomial regression model of suicide rate, comparing suicide rate for health professionals with access to prescription medicines with that for members of all other occupations aged 20–70-years, Australia 2001–2012

Suicides

Population*

Incidence rate ratio (95% CI)

P

Occupation

Health professionals without access to lethal means (reference)

55

64 365

1

—

Health professional with access to lethal means†

314

276 091

1.62 (1.20–2.17)

0.001

Other occupations

9459

8 060 397

0.98 (0.75–1.29)

0.887

Age‡

60–70 years

596

596 052

0.76 (0.66–0.88)

< 0.001

50–59 years

1693

1 692 950

0.86 (0.76–0.97)

0.013

40–49 years

2750

2 188 151

1.03 (0.92–1.16)

0.571

20–39 years (reference)

4789

3 924 510

1

—

Sex‡

Women

1498

3 873 042

0.22 (0.20–0.25)

< 0.001

Men (reference)

8330

4 528 621

1

—

Year§

9828

8 401 663

0.98 (0.96–0.99)

< 0.001

* Australian Bureau of Statistics 2006 census data. The data for health professionals exclude non-clinicians. † Pharmacists, dental practitioners, generalist medical practitioners, anaesthetists, internal medicine specialists, psychiatrists, surgeons, other medical practitioners, midwives, nurses. ‡ All occupations. § Incidence rate ratio refers to the effect of a one-year increase in time on the suicide rate.

AMA President meets with Border Force chief medical officer

AMA President, Dr Michael Gannon, continued the AMA’s ongoing advocacy on behalf of asylum seekers and refugees when he met the Australian Border Force Chief Medical Officer, Dr John Brayley, in Canberra on 9 September, 2016.

It was the second meeting between an AMA President and Dr Brayley since the CMO role was created a year ago.

Dr Gannon noted that the AMA’s position on health care of asylum seekers has not changed, and reiterated that the AMA will always be focussed on ensuring the proper provision of health care to those in need. 

“The AMA has received representations from asylum seekers, refugees and their advocates concerning the provision of health care and, in some cases, asking the AMA for specific help,” Dr Gannon said. 

“Dr Brayley and I discussed the complexities of offshore immigration detention facilities and the difficulties in dealing with individual asylum seeker cases, along with the standards of care and the measures being undertaken to improve the health care available in offshore detention facilities.

“The Department of Immigration and Border Protection has been providing the AMA with regular updates and information about the health of asylum seekers. 

“Dr Brayley and I agreed to meet again to continue this important advocacy and dialogue on the health and well-being of asylum seekers and refugees.”

Dr Brayley was appointed as CMO and inaugural Surgeon General of the Australian Border Force (ABF) in September 2015.

His role is to oversee and coordinate a consolidated health function within ABF, including at offshore detention centres, leading to improved and more consistent health policies.

“This new position will also allow doctors to raise issues through appropriate clinical channels and advocate on behalf of their patients,” Department of Immigration and Border Protection Secretary, Mike Pezzullo, said at the time.

Dr Brayley is a consultant psychiatrist, health administrator and statutory office holder, who served as the Public Advocate of South Australia from 2008 until taking up the ABF appointment.

He used the role of Public Advocate to campaign for the rights of people with mental illness and disability, and exposed the plight of mental health patients in South Australian prisons.

In an interview with InDaily last year, Dr Brayley said the CMO role had enough power to make meaningful change.

“Questions about standards of health care, and also issues raised by doctors and other health professionals about their patients in immigration detention, will be able to be brought to this new role,” Dr Brayley said.

“Many of the same issues that I deal with as Public Advocate, and suggest solutions about in my present role, I will be responding to in this new role … ensuring that high quality health services are delivered, including mental health services, that are comparable in standard to those that are generally provided to the Australian community.

“Rather than being the advocate, I expect to be responding to advocacy from health practitioners about their patients.

“This new position is an opportunity to contribute to ongoing improvements in health services for people in immigration detention both in Australia and at the offshore centres on Nauru and Manus Island.”

Maria Hawthorne

Government taskforce doesn’t back sick certificate scare

The MBS Review Taskforce has sounded a warning on assertions that doctors are blowing out health costs by issuing sick certificates, ordering prescription repeats and writing specialist referrals.

Two-thirds of health professionals responding to an online survey run by the Taskforce called for MBS rules to be reviewed, particularly regarding the use of referrals and restrictions on eligible providers, seemingly lending weight to claims that GPs were wasting much of their time on ‘routine’ tasks like filling out medical certificates and writing referrals.

Related: Review reveals Medicare wastage gripes

Health Minister Sussan Ley seized on the claims, telling ABC radio that “if the Government is paying effectively too much for small appointments that aren’t necessarily adding to a person’s overall health, particularly if they have chronic conditions, then that money does need to be reinvested”.

Extending her attack on primary health care, Ms Ley said a quarter of patients believed they had been recommended tests or treatments that were unnecessary.

The suggestion has fuelled calls, including from the Pharmacy Guild of Australia, for pharmacists, nurses and other allied health professionals to be granted an increased scope of practice to ease the burden on family doctors.

But the Taskforce itself has cast doubt on the extent of the problem, and has instead inferred that its prominence was being driven by health groups like pharmacists and nurses keen to expand their scope of practice.

“Many health professional respondents argued that referrals through GPs were unnecessary, particularly when accessing allied health services,” the Taskforce said in an interim report on its consultation. “It should be noted that the prevalence of this issue may reflect the skew towards allied health providers in the respondent group”.

AMA President Dr Michael Gannon dismissed the claim that valuable health dollars and GP time was being wasted on writing out certificates and referrals.

Dr Gannon said that not only was general practice very cost effective – accounting for just 6 per cent of total health spending – but performing such services was often a valuable opportunity to undertake preventive health care such as performing blood tests and assessing for diabetes and heart disease risk.

Related: Patient charges rising fast

In its discussion of the results of the online survey and stakeholder consultations, the Taskforce notably avoided the issue and turned its focus elsewhere.

It backed proposals for greater transparency on Medicare fees, and endorsed the idea of giving practitioners data on their own Medicare item usage, benchmarked against their peers.

But it flagged a cautious approach to changes to Medicare pay arrangements and MBS items.

In consultations there were calls for the fee-for-service model to be scrapped and replaced with an outcomes-based payment system.

But although expressing interest in pay for performance as a complement to fee-for-service in supporting multidisciplinary care, it was lukewarm on a wholesale change.

“The evidence suggests that clinically-based outcomes linked to payment have mixed success and may not be superior to activity-based payments in driving high-value care,” the Taskforce said. “Indeed, the MBS itself has many examples where incentive payments directed to addressing service deficits have had undesirable outcomes.”

And, while the Government has emphasised the scope for the MBS Review to axe Medicare items, the Taskforce indicated it would be moving with careful deliberation.

It noted that its terms of reference “do not preclude” recommending new items, and was considering “the addition of temporary item numbers to be used specifically for the acquisition of evidence to support the long-term retention or removal of items from the MBS”.

The case to remove items will depend on more than simply how often it is used.

“The Taskforce recognises that low usage of an item is not in itself conclusive evidence of obsolescence,” the Taskforce said.

View the Taskforce interim report here.

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Small investments can make a big difference

For the AMA, Aboriginal and Torres Strait Islander health has been, and will remain, a priority. It is our responsibility to advocate for and support efforts to improve health and life outcomes for Australia’s First Peoples.

The AMA works closely with Aboriginal and Torres Strait Islander people in a number of ways to contribute to our mutual goal of closing the health and life expectancy gap between Indigenous and non-Indigenous Australians.

We have close relationships with NACCHO, the Australian Indigenous Doctors’ Association and the Close the Gap Steering Committee, through which we collectively contribute to the national debate on Indigenous health issues. The Taskforce on Indigenous Health, which I Chair, is another way that the AMA works in partnership with Indigenous people.

Each year, through the Taskforce, the AMA produces an annual Report Card on Indigenous Health – a landmark publication that makes practical recommendations to governments on how key Aboriginal and Torres Strait Islander health issues should be addressed.

This year the Report Card will have as its focus the eradication of rheumatic heart disease (RHD). RHD is an entirely preventable, third world condition that is wreaking havoc on the lives of Indigenous people in remote communities, primarily those in central and northern Australia. The 2016 Report Card on Indigenous Health will be a vital contribution to addressing RHD – a disease that should not be seen in Australia in the 21st century.

The AMA also supports policies and initiatives that aim to reduce other chronic and preventable diseases – many of which have an unacceptably high prevalence in remote Indigenous communities. An example of this is the little-known blood-borne virus HTLV-1, which in Australia occurs exclusively in remote Aboriginal communities in central Australia.

The AMA recognises that Aboriginal people living in Central Australia face many unique and complex health issues, and that these require specific research, training and clinical practice to properly manage and treat.

The AMA, as part of our broader 2016 election statement, called on the next government to support the establishment of a Central Australian Academic Health Science Centre. This is a collaboration driven by a consortium of leading health professionals and institutions, including: AMSANT, Baker IDI Heart & Diabetes Institute, Central Australian Aboriginal Congress, Central Australia Health Service, Centre for Remote Health, Charles Darwin University, Flinders University, Menzies School of Health Research, Ngaanyatjarra Health Service and Nganampa Health Service.

The AMA sees the proposed Health Science Centre as a very significant endeavour to improve the health outcomes of Aboriginal people living in remote communities. There are already tangible benefits from this type of collaborative and multi-disciplinary approach to health services and research.

The aim of the AHSC is to prioritise their joint efforts, principally around workforce and capacity building and to increase the participation of Aboriginal people in health services and medical research.  

Some examples of achievements include: the Central Australia Renal Study, which informs effective allocation of scarce health resources in the region; the Alice Springs Hospital Readmissions Prevention Project, which aims to reduce frequent readmissions to hospital; and the Health Determinants and Risk Factors program, which better informs health and social policy by understanding the relationship between health and other factors such as housing, trauma and food security.

Having a designated Health Science Centre would be a massive boost for research, clinical services, and lead to greater medical research and investment. The Centre would likely see more expertise and opportunities to develop Aboriginal researchers and health care workers.

Establishing and operating this Centre would cost $4 million a year – a modest ask considering the potential benefits it could deliver.

The AMA recognises that Aboriginal and Torres Strait Islander people have a lead role in identifying and developing solutions to respond to their health needs – the proposed Central Australian Academic Health Science Centre is a clear example of this. The AMA will continue to support the efforts of Indigenous people to improve health outcomes and urges governments to do the same.

 

Poor GP relations put ‘essential’ reform at risk

One of the boldest reforms to Medicare in decades could collapse if the Federal Government persists with the Medicare rebate freeze, AMA President Dr Michael Gannon has said.

Dr Gannon praised the Commonwealth’s plan to establish a Health Care Home model of care for patients with chronic illness, but warned that its chances of success were being hobbled by inadequate investment and relentless Government attacks on general practice, particularly the rebate freeze.

“Unless the Government restores some goodwill by unravelling the freeze and invests the extra funding that is required for enhanced patient services, GPs will not engage with the trial, and will walk away from this essential reform,” he said.

Under the model, also known as the Medical Home, patients suffering from complex and chronic health problems will be able to voluntarily enrol with a preferred general practice, with a particular GP to coordinate all care delivered.

Dr Gannon told the National Press Club the Health Care Home, if properly implemented, could deliver big improvements in quality of care, reduced hospital admissions and fewer emergency department visits.

“This is potentially one of the biggest reforms to Medicare in decades”, the AMA President said, and the AMA was keen for it to succeed.

But he warned that it faced major obstacles without a change in approach by Government.

The Government has initiated a two-year trial of the Health Care Home model, involving 65,000 patients and 200 practices across 10 Primary Health Networks.

It has committed $21 million to pay for test infrastructure, training and evaluation, and has allocated more than $90 million in payments for patient services.

But the Dr Gannon said these funds were simply being shifting from other areas of health, and the Government must invest if the reform was to be a success.

“There is no new funding for the Health Care Homes trial,” he said. “GPs are being asked to deliver enhanced care to patients with no extra support. This simply does not stack up.

Dr Gannon warned that “if the funding model is not right, GPs will not engage with the trial, and the model will struggle to succeed”.

Adding to the Government’s challenge, it is trying to recruit GP support for the policy while at the same time freezing the Medicare rebate and threatening to axe incentive payments to practices that do not upload enough health records to its My Health Record e-health system.

All this in addition to two aborted attempts to introduce a GP co-payment.

Dr Gannon said that these polices had damaged the relationship between the Government and GPs, and it would need to be repaired if Health Care Homes was to realise its potential.

“For the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. To do this, it must first overcome the significant trust and goodwill deficit attached to the co-payment saga and the Medicare freeze,” he said.

Adrian Rollins

Chiro caught up in crackdown

A chiropractor has been charged with false advertising in the latest action by regulators to crack down on practitioners making inflated health claims or practising outside their area of expertise.

The Australian Health Practitioner Regulation Agency (AHPRA) has taken a New South Wales chiropractor to court over allegations that his website advertised services “in a way that was likely to be false, misleading or deceptive”.

The case follows recent action in which chiropractor Dr Ian Rossborough was banned from manipulating the spines of children younger than six years after a video in which he cracked the back of a four-day-old baby was made public.

In June, AHPRA imposed a number of conditions on Dr Rossborough including banning him from any chiropractic treatment of children younger than two years and excluding any spinal manipulation for two to six-year-olds. In addition, he will be subject to monitoring and assessment by the Chiropractic Board of Australia.

The cases underline long-standing AMA concerns about health professionals promoting and practising unproven therapies.

While evidence-based aspects of complementary medicine can be part of patient care, unproven therapies could put patient health at risk, either directly through misuse, or indirectly where patients defer seeking medical advice or fail to inform a treating doctor about a complementary medicine they may be taking.

The AMA said children were a particularly vulnerable group because of the complexities of diagnosing and treating their ailments, and a medical practitioner should always be informed of any diagnosis and ongoing treatment plan.

There have been several reports of chiropractors “sneaking” into maternity wards to treat newborn babies without the knowledge and consent of either hospitals or treating doctors, and the Chiropractic Board told Fairfax Media it was investigating a number of such complaints.

Chiropractic Australia President Rodney Bonello told the Sydney Morning Herald many in the profession were horrified and embarrassed by such actions.

“If there’s no [hospital] approval, then that’s a travesty and should never be acceptable,” Professor Bonello said.

The Chiropractic Board said that chiropractors must provide evidence-based care, and “are expected to practise safely and within the limits of their competency, training and expertise”.

Adrian Rollins

AMA LIST OF MEDICAL SERVICES AND FEES

The 1 November 2016 edition of the AMA Fees List will soon be available in hard copy and electronic formats.

The hard copy book is for AMA members in private practice or with rights of private practice, and salaried members who have requested a book. Dispatch of the book will commence on 14th October 2016.

The AMA Fees List is available in the following electronic formats:

  • PDF of the hard copy book
  • CSV file for importing into practice software
  • Online database where members can search for individual or groups of items and download the latest updates and electronic files.

PDF and CSV versions of the AMA Fees List will be available to all members via the Members Only area of the AMA website http://www.ama.com.au/resources/fees-list from 21st October 2016. The Fees List Online Database will be updated on 1st November 2016.

Access the Fees List via the AMA website

To access the AMA Fees List online, simply go to the AMA homepage and logon by clicking on the  symbol icon the right corner of the blue task bar and entering your AMA username and password. Once logged in, on the right hand side of the page, click on ‘Access the AMA Fees List’.  From here you will find all electronic formats of the Fees List.

Access the AMA Fees List Online Database

The AMA Fees List Online Database is an easy-to-use online version of the AMA Fees List.  To access the database follow the steps above or go to: article/ama-fees-list-online   

AMA Fees Indexation Calculator

Also available to members is the AMA Fees Indexation Calculator, this allows you to calculate your own fee increase based on your individual cost profile. To access the AMA Fees Indexation Calculator, follow these steps:

1) From the home page hover over Resources at the top of the page. A drop down box will appear. Under this, select Fees List.

2)   Select AMA Fees Indexation Calculator (Members Only)

Members who do not currently have a username and password should email their name, address and AMA member services number to memberservices@ama.com.au requesting a username and password.

If you would like to request a copy of the AMA Fees List please contact the AMA on 02 6270 5400 or email feeslist@ama.com.au.