Govt investment in doctors of the future still falling short

As the new Chair of the Medical Workforce Committee (MWC), I am looking forward to harnessing the committee to drive the AMA’s response to the medical workforce crisis.

I would like to acknowledge Dr Stephen Parnis for his stewardship of the MWC as inaugural Chair. Like Stephen, I have a long-standing interest in medical workforce issues, and believe that ensuring Australia has the medical workforce to meet community needs is a critical challenge for governments and health policymakers.

Over the last 15 years the number of medical school places has increased substantially in response to past workforce shortages. But the need for more medical schools is over, as we know from successive sets of workforce data that Australia now has sufficient numbers of medical students. We must now focus on improving the distribution of the medical workforce, and providing enough postgraduate medical training places, particularly in rural and remote areas and the under-supplied specialty areas.

At the recent Federal Election, the AMA offered four important policy proposals to help achieve this outcome:

expanding the National Medical Training Advisory Network’s (NMTAN) workforce modelling program;
establishing a Community Residency Program;
increasing the GP training program intake; and
expanding the Specialist Training Program.

NMTAN is the Commonwealth’s main medical workforce training advisory body, and focuses on planning and coordination. It has representatives from the main stakeholder groups in medical education, training and employment.

NMTAN’s report on the psychiatry workforce was released in March. This is the first specialty report to be finalised by NMTAN since Health Workforce Australia was axed in 2014. It contains valuable data and analysis, including a projected undersupply of 125 practitioners by 2030 for the psychiatry workforce, despite a likely increase in the number of Australian-trained psychiatrists.

NMTAN is intending to beef up its work program. The AMA has argued consistently for complete workforce modelling and reporting across all medical specialties by the end of 2018; it is vital to have data sooner rather than later on imbalances across the specialties to enable effective workforce planning.

We will continue to engage with the Government of this issue. In the meantime, we await with interest the expected release of the reports on the anaesthesia and general practice workforces later this year.

An important piece of work undertaken by the MWC last year was developing the Community Residency Program for Junior Medical Officers (CRP). This is the AMA’s proposal to establish and fund a program for high-quality prevocational placements in general practice for junior doctors as a replacement for the valuable Prevocational General Practice Placements Program abolished by the Government in 2014.

We continue to lobby for our CRP. The Government’s announcement late last year that it will fund 240 rotations in general practice settings for rural-based interns is a partial replacement for the PGPPP, and was an admission by the Government that its decision to abolish the program was a backward step, especially for rural health.

As a practising GP, I am keenly aware that more resources are needed to build and maintain a sustainable GP workforce.

The AMA’s call to increase the GP training program intake to 1700 places a year by 2018 is worthy of the Government’s consideration. This must be backed with solid measures to support GP training, including incentives for supervisors and investment in training infrastructure. Rural general practices need grants to help them expand their facilities and provide more teaching opportunities for medicals students and GP registrars, and to enhance the range of services they provide.

The Commonwealth’s Specialist Training Program (STP) is a valuable workforce program that is giving specialist trainees the opportunity to train in settings outside traditional metropolitan teaching hospitals. Though the Government has committed to provide 1000 placements by 2018, the AMA strongly believes that the STP must be expanded to 1400 places a year, with the focus on encouraging specialist training in rural settings and specialties that are under-supplied.

Other areas of focus for the MWC will be promoting generalism in the medical workforce, encouraging greater gender diversity in medical leadership, and increasing clinical supervision capacity.

Progress, but much more to do.

Evaluation of the performance and outcomes for the first year of a diabetes rapid access clinic

Diabetes rapid access clinics (DRACs) have been identified by the New South Wales Agency for Clinical Innovation as a key component of an integrated diabetes model of care.1 This cost-effective model provides fast and comprehensive outpatient review and has been shown to circumvent hospital admission, decrease hospital length of stay and improve patient outcomes.2–5 Based on this approach, a nurse practitioner-led DRAC was established in February 2015 at Royal North Shore Hospital (RNSH) in Sydney as a pilot program to assess the suitability of the DRAC for scalability across the Northern Sydney Local Health District (NSLHD).

The DRAC is an outpatient clinic, operating on weekdays, which adopts the principle that high-risk patients who present to the emergency department (ED) could be diverted from hospitalisation if they were well enough for outpatient management of their condition (Appendix). Patients are referred from general practice, the ED or the endocrinologist on call and require rapid review (within 72 hours) of complex diabetes problems, such as an episode (or episodes) of severe hypoglycaemia, recurring mild hypoglycaemia or hyperglycaemia not needing hospitalisation.

We prospectively collected data during the first year since inception of the DRAC, with a particular focus on reasons for referral and cost evaluation. The study was approved by the NSLHD Human Research Ethics Committee (RESP/16/62).

Within the first year of the DRAC pilot program at RNSH, 61 patients attended the clinic. About a quarter of these patients (n = 15) would have been hospitalised had they not been reviewed at the DRAC and they were successfully managed as outpatients. Although these patients met the criteria for admission, they were deemed appropriate for the DRAC by the endocrinologist on call. In addition, 26% of the patients were referred back to general practice, while the remainder required ongoing endocrinologist review. Most patients presented with hyperglycaemia-related problems (n = 40; 66%; Box), including 15 patients with newly diagnosed diabetes. A further 11 patients presented with severe hypoglycaemia. Within 30 days of review at the DRAC, one patient presented to the ED and required hospitalisation.

Using a conservative costing approach, whereby patients were assumed to be uncomplicated with an average length of stay of 2.5 days (based on data from the NSLHD Performance Unit), the cost analysis demonstrated that for 15 patients for whom hospitalisation was avoided, about $46 700 would have been incurred in their inpatient stay. The DRAC was established through a restructure of existing services; however, if nursing costs associated with running the DRAC were included (about $23 400), the analysis showed that the cost of management in the clinic was half the cost of an inpatient stay (Box).

A nurse practitioner-led DRAC was successfully established at a tertiary referral hospital in NSW. Our preliminary evaluation has demonstrated improved patient outcomes and assistance for general practice in managing ongoing outpatient diabetes-related problems. In addition, for a quarter of patients presenting to the DRAC, hospitalisation was prevented. Future directions include the expansion of the DRAC across the local health district and the incorporation of a “hotline” to assist general practitioners with urgent and complex diabetes management.

Box –
Royal North Shore Hospital Diabetes Rapid Access Clinic (DRAC) evaluation: overview of patient demographics and cost analysis data

Patient demographic

No. of patients*

Patients seen (February – December 2015)

Male

Mean age, years (SD)

56 ± 16

Mean glycated haemoglobin value (SD)

9.7% ± 2.5%

Mean duration of diabetes, years (SD)

13 ± 13

Type 1 diabetes

14 (23%)

Type 2 diabetes

47 (77%)

Reason for referral to DRAC

Newly diagnosed type 1 diabetes

Newly diagnosed type 2 diabetes

Hyperglycaemia

Hypoglycaemia (severe)

Other

Cost analysis

No. of hospitalisations prevented^†

15 (25%)

Hospitalisation cost per day

$1245

Average length of stay, days

2.5

Total hospitalisation cost that would have been incurred

$46 687.50

Cost of nursing at DRAC

$23 339.52

Cost management difference

$23 347.98

* Data are number of patients unless otherwise indicated. † One patient sent to the emergency department via DRAC — not diabetes related.

Trends in suicidal behaviour and use of mental health services in Canadian military and civilian populations [Research]

Background:

In the context of the Canadian mission in Afghanistan, substantial media attention has been placed on mental health and lack of access to treatment among Canadian Forces personnel. We compared trends in the prevalence of suicidal behaviour and the use of mental health services between Canadian military personnel and the general population from 2002 to 2012/13.

Methods:

We obtained data for respondents aged 18–60 years who participated in 4 nationally representative surveys by Statistics Canada designed to permit comparisons between populations and trends over time. Surveys of the general population were conducted in 2002 (n = 25 643) and 2012 (n = 15 981); those of military personnel were conducted in 2002 (n = 5153) and 2013 (n = 6700). We assessed the lifetime and past-year prevalence of suicidal ideation, plans and attempts, as well as use of mental health services.

Results:

In 2012/13, but not in 2002, military personnel had significantly higher odds of both lifetime and past-year suicidal ideation than the civilian population (lifetime: adjusted odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17–1.50; past year: adjusted OR 1.34, 95% CI 1.09–1.66). The same was true for suicidal plans (lifetime: adjusted OR 1.64, 95% CI 1.35–1.99; past year: adjusted OR 1.66, 95% CI 1.18–2.33). Among respondents who reported past-year suicidal ideation, those in the military had a significantly higher past-year utilization rate of mental health services than those in the civilian population in both 2002 (adjusted OR 2.02, 95% CI 1.31–3.13) and 2012/13 (adjusted OR 3.14, 95% CI 1.86–5.28).

Interpretation:

Canadian Forces personnel had a higher prevalence of suicidal ideation and plans in 2012/13 and a higher use of mental health services in 2002 and 2012/13 than the civilian population.

AMA calls for independent scrutiny of asylum seeker health

Picture credit: paintings%20/%20Shutterstock.com“>paintings / Shutterstock.com

Disturbing accounts of sexual assault, neglect and harm among asylum seekers being held at the Nauru detention centre reinforce the need for oversight by an independent statutory body of clinical experts, AMA President Dr Michael Gannon has said.

Leaked details of more than 2000 incident reports from staff at the Nauru Regional Processing Centre, published by Guardian Australia, reveal a litany of abuse, self-harm, sexual assault, inadequate health care and deplorable living conditions at the centre. The details come less than a week after a joint Amnesty International-Human Rights Watch investigation resulted in a scathing assessment of conditions at the centre.

Dr Gannon said the “disturbing” revelations, particularly regarding the treatment of children, leant fresh urgency to long-standing AMA calls for much greater scrutiny of detention centre operations and the provision of health services to asylum seekers.

“These disturbing reports echo long-held concerns by the AMA about the lack of proper physical and mental health care being provided to people in immigration detention,” Dr Gannon said. “The reports detail high levels of trauma and mental illness, especially in children being detained on Nauru.”

The AMA regularly received reports from asylum seekers and their advocates – from within and outside the medical profession – detailing failures to provide proper physical and mental health treatment and services for asylum seekers, he said, and called for children to be removed from detention and placed into care in the community.

Conditions at the Nauru detention centre have been condemned by Amnesty International and Human Rights Watch, who have accused the Federal Government of a deliberate policy of “appalling abuse and deliberate neglect” in its treatment of refugees and asylum seekers being held there.

In their report, based on interviews with 84 refugees and asylum seekers as well as an unspecified number of service providers, the non-government organisations described medical facilities on Nauru as rudimentary and said those with serious conditions frequently faced long delays before receiving specialist care.

In one account, a service provider said ambulances sometimes took up to three hours to respond to calls from the centre, and often people were discharged from the local hospital while they were still sick or half-conscious.

“We are not allowed to ask the hospital why they are being discharged, or what medication they’ve been prescribed, or for their medical records,” the service provider said.

Among the 2116 incident reports from detention centre guards, caseworkers and teachers leaked to Guardian Australia are numerous accounts of children threatening to kill themselves, engaging in highly sexualised behaviour, or suffering great emotional distress.

In one account, a group of security guards was heard to laugh moments after one of them was called to a young girl who had sewn her lips together. In another, a teacher reported that a student was “dreaming of blood and death and zombies” because his mother was on hunger strike and refused to hug him. Several reports detailed children sitting on the laps of security guards, including one girl who was “leaning her backside into the crotch of [name redacted]”, and a boy who was being bounced on the lap of a guard who was whispering in his ear.

Amnesty International and Human Rights Watch representatives who visited the island for 12 days last month said the circumstances in which people were being detained – a third of the 1200 refugees were living in cramped tents in hot and humid conditions, and all were limited to two-minute showers and forced to use filthy toilets – were physically draining and exacerbated mental health problems.

“Prolonged detention in appalling conditions exacerbated the trauma many had suffered from persecution in their home countries,” the report said.

Many of those interviewed reported having developed severe anxiety, insomnia, mood swings, prolonged depression and short-term memory loss while on the island, while children were suffering from nightmares and engaging in disruptive and troubling behaviour.

“Adults and children spoke openly of having wanted to end their lives. More than a dozen of the adults interviewed said they had tried to kill themselves…and many more said that they had seriously considered ending their lives,” the report said.

It included the account of a nine-year-old boy who told his mother that, “I want to burn myself. Why should I be alive? I want my daddy. I miss my daddy”, after his father was transferred to Australia, without his family, for medical treatment.

Amnesty International and Human Rights Watch said support and treatment for those suffering mental health problems was inadequate, and patients whose illness was severe enough to justify their transfer to Australia were returned several months later to the same conditions that had contributed to their trauma in the first place.

Dr Gannon said such treatment was unacceptable.

“The AMA’s position is clear – people who are seeking, or who have been granted, asylum within Australia have the right to receive appropriate medical care without discrimination, regardless of citizenship, visa status, or ability to pay,” Dr Gannon said. “Asylum seekers and refugees under the protection of the Australian Government should be treated with compassion, respect, and dignity.”

The AMA has reiterated its call for the creation of a national statutory body of clinical experts, independent of Government, with the power to investigate and report to the Parliament on the health and welfare of asylum seekers and refugees in Australia and in offshore detention.

“Australia’s atrocious treatment of the refugees on Nauru over the past three years has taken an enormous toll on their wellbeing,” Human Rights Watch Senior Counsel on Children’s Rights Michael Bochenek said. “Driving adult, and even child, refugees to the breaking point with sustained abuse appears to be one of Australia’s aims on Nauru.”

Amnesty International Senior Director of Research Anna Neistat, who was one of the researchers who visited Nauru, condemned the treatment of asylum seekers as “cruel in the extreme”.

The human rights organisations said the Australian Government’s failure to address what they described as serious abuses “appears to be a deliberate policy to deter further asylum seekers from arriving in the country by boat”.

But the Department of Immigration and Border Protection rejected the findings of the Amnesty report, which it said was conducted without consultation.

“We strongly refute many of the allegations in the report, and would encourage Amnesty International to contact the Department before airing allegations of this kind,” it said in a statement.

The Department said Australia did not “exert control” over the Nauruan Government, though it did fund accommodation and support services for “all transferees and refugees, including welfare and health services”.

“We welcome independent scrutiny of regional processing matters, noting that access to the [Regional Processing] Centre is a matter for the Government of Nauru.”

But the Government’s has been accused of trying to hide its treatment of asylum seekers behind a shroud of secrecy.

The Australian Border Force Act, passed last year, threatens up to two years imprisonment for detention centre staff and contractors who publicly disclose information about operations.

But Dr Gannon said doctors should be able to speak out without fear of retribution or prosecution, and the legality of the Act is being challenged in the High Court by the group Doctors for Refugees.

The AMA Federal Council is also looking into claims former medical director of mental health services for detention centre contractor International Health and Medical Services, Dr Peter Yong, was subject to surveillance by the Australian Federal Police.

Adrian Rollins

[Comment] Reducing research waste with implementation laboratories

The Lancet REWARD (REduce research Waste And Reward Diligence) campaign has encouraged researchers to examine how they work and make efforts to reduce waste and maximise efficiency. Research waste is undermining efforts to improve the effectiveness of health systems. A consistent finding in health services research is inappropriate variations in care and evidence–practice gaps. Implementation science—the study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice1—can inform health systems on how to reliably improve care and outcomes.

Assisted reproduction: we need to talk

AMA President Dr Michael Gannon has called for the “mother of all debates” over the funding and regulation of assisted reproduction following revelations that a 63-year-old Tasmanian woman has become a first-time mother using IVF technology.

Dr Gannon criticised the mother’s decision to use IVF to conceive a child at such an advanced age as “selfish and wrong”, and said the community needed to consider carefully who should have access to assisted reproduction technology, and the consequences it can have for children, parents and broader society.

“As a community, we need to consider the rights of the child, the rights of society, the responsibilities of proper parenting, the health of the parents, the health risks to the child at birth and beyond, and the costs to the health system and the taxpayers that fund it,” the AMA President said. “This must not be narrowly viewed as a women’s rights issue. Nor is it about ageism.”

Dr Gannon, who is a Perth-based obstetrician, sparked a firestorm of comment after he responded to news of the birth by commenting on Twitter that the use of IVF to have a child so late in life was “madness”. He said the not only were women “not designed” to give birth in their 60s, but the decision disregarded the rights of the child and the burden on taxpayers.

Critics accused Dr Gannon of making a moral judgment about the mother and downplaying the role of the father, who is 78 years old.

But the AMA President said there were compelling medical, social, financial and ethical reasons for ensuring that such cases did not become commonplace.

Most IVF clinics in Australia do not offer treatment to women beyond the age of 53 years, and the Tasmanian mother went overseas to be impregnated with a donor embryo before returning to Australia and giving birth at 34 weeks at Melbourne’s Frances Perry House private hospital.

Dr Gannon said there was good reason why Australian IVF services would not treat a woman so late in life.

He said that from around the age of 30 years onward problems associated with pregnancy and birth gradually increased, including miscarriage, chromosomal abnormalities, pre-eclampsia and the risk of stillbirth: “None of this is avoidable, and no amount of anti-oxidant supplements or kale smoothies can arrest the inevitability of ageing”.

By the time women were in their 50s and 60s, the effect of ageing on their blood vessels meant they were more susceptible to blood clots, heart attacks and strokes – “a potentially high price to pay to have a baby”.

Dr Gannon said the baby, because it was born premature, also faced an elevated risk of health problems such as breathing difficulties and jaundice, and would be more vulnerable to chest infections, asthma, diabetes and hypertension later in life. Because it potentially missed out on crucial in utero brain development, the child could also experience learning problems and developmental delay.

Costs to society and taxpayers also needed to be considered, he said. It cost about $2500 a day to care for a baby in the Neonatal Intensive Care Unit, much of it subsidised by the taxpayer, and such demands diverted resources from other parts of an already-stretched health system.

He said the decision of couples denied IVF in Australia to seek treatment overseas was “not simply an expression of choice, or a case of ‘user pays’. The health system picks up the bill”.

Dr Gannon said the birth of a child to a 63-year-old mother was not what the pioneers of IVF had in mind when the developed the technology in the late 1970s.

“This amazing technology has brought much joy to many across the world. But just because medical science can do something does not mean we have to do it, or should do it,” he said. “Stories like this cannot become the norm. Let’s talk to Australian women and men about starting their families in their 20s, not normalise the dubious use of medical science and powerful hormones to wake the womb from its normal, physiological, post-menopausal sleep.”

Adrian Rollins

Costs force ill to skip care

Almost half of patients with depression, anxiety or other mental health conditions and a third of those suffering asthma, emphysema and other chronic respiratory illnesses are skipping treatment because of out-of-pocket costs.

As the Medicare rebate freeze forces a growing number of general practices to cut back on bulk billing and increase patient charges, researchers have found that out-of-pocket costs for medical services and medications are deterring many with chronic illnesses from seeing their doctor or filling their prescription, potentially making their health problems more difficult and costly to treat.

They found that those with mental illnesses were the most price sensitive – 44 per cent reported deferring an appointment or leaving a script unfilled because of cost, as did 32 per cent with asthma or chronic obstructive pulmonary disorder and 27 per cent of those with diabetes. Even a fifth of cancer patients reported skipping treatment because of the expense.

Out-of-pocket charges were cited as a barrier to care even for some of those without a long-term health problem – 9 per cent said deferred care because of cost.

Lead researcher Dr Emily Callander from James Cook University said that although, as a whole, Australia enjoyed good health outcomes, her study showed that out-of-pocket costs were a substantial barrier to care, particularly for vulnerable and at-risk patients like the chronically ill.

She said the problem was particularly acute for patients with mental health problems.

“Those with mental health conditions were shown to have particularly large out-of-pocket expenditure and be more likely to forgo care, which indicates that the costs of mental health services may be prohibitively high,” Dr Callander and her colleagues wrote.

Out-of-pocket costs high

The research, which is part of an international Commonwealth Fund health policy study and draws on data from a NSW Bureau of Health Information survey of 2200 respondents, found that out-of-pocket expenses for Australia patients were high by world standards.

It showed that Australians paid an average of $1185 in out-of-pocket costs, compared with $987 for Germans, $947 for Canadians, $639 for New Zealanders, $488 for British patients and $421 for the French.

Dr Callander’s said research showed expenses for patients with chronic illnesses can be particularly high.

Stroke survivors, for example, spent an average of $1110 a year on health costs, including up to $32,411 in the first 12 months following their stroke. Those with arthritis, meanwhile, paid out an average of $1513 a year on treatment, with some spending as much as $20,527.

Those with asthma, emphysema and COPD reported spending an average of $1642 a year on out-of-pocket expenses, while those with a mental illness spent $1350 a year and those with high cholesterol spent $1423 annually.

By comparison, those without a chronic illness spent on average $660 a year on out-of-pocket health costs.

Dr Callander said the point of her research was not that out-of-pocket costs were inherently wrong, but could have a much more significant effect on vulnerable patients, like the chronically ill, than the broader community.

“I don’t think that out-of-pocket costs per se are a bad thing,” the researcher said. “I am not saying that we should not have them.

“But while maybe a $30 GP out-of-pocket charge might not seem much to most of us, for someone with a chronic disease who is unemployed it might seem a lot. For them it might mean a choice between seeing the doctor or having some extra food.

“It is the disadvantaged – the people with low incomes and ones with chronic health problems – who are the worst affected.”

Chronic catch-22

The chronically ill are caught in a double-bind. They often face much higher health expenses than most, while the effect of their illness is often to make it difficult for them to work.

Dr Callander said it was well documented that people with chronic illnesses were on lower incomes, had less wealth, and were more likely to be in income poverty, “which is likely because of the effect that chronic health conditions have on their ability to participate in the labour force”.

And, of course, the more they defer or forgo treatment, the worse their health becomes and the more expensive the treatment required.

Dr Callander’s research found that the combined effect of high out-of-pocket expenses and low incomes was to force 25 per cent of chronically ill Australians to skip care, exceeded only by the United States, where 42 per cent of patients with a chronic illness said they deferred treatment because of cost. By comparison, just 8 per cent of chronically ill Swedish patients and 5 per cent of British patients admitted to the same thing.

While in the past research had concentrated on a lack of available services as a common barrier to care, Dr Callander said the effect of cost had often been overlooked.

“The [study shows] that the cost of health care does act as a barrier to receiving treatment, particularly for those with mental health conditions,” the researcher said. “These findings come at a vital time when there has been much discussion abour the possibility of raising the cost of healthcare to individuals.”

She said it was of “vital importance” that there be policies aimed at promoting affordable health care for at-risk and vulnerable patients, “to ensure that out-of-pocket cost is not a barrier to treatment and do not widen the gap in health status between those of high and low socioeconomic status”.

The study has been published in the Australian Journal of Primary Health.

Adrian Rollins

[Series] Serving transgender people: clinical care considerations and service delivery models in transgender health

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner.

Your Family Doctor: Invaluable to your health

AMA Family Doctor Week, 24 – 30 July 2016

The AMA used this year’s Family Doctor Week to not only celebrate the hard work and dedication of Australia’s 30,000 GPs, but to put the re-elected Coalition Government on notice that changes in health care policy are urgently needed.

The traditional National Press Club address has been moved to August to allow for continued campaigning against the Medicare rebate freeze, cuts to public hospital funding, and cuts to bulk billing incentives for pathology and radiology.

Media outlets around the country, including the national WIN network of regional television stations, picked up on the message that GPs are the most cost-effective sector of the health system and need support.

AMA President, Dr Michael Gannon, said that the personalised care and preventive health advice provided by family doctors helps to keep people out of hospitals, and keep health costs down.

“Australian GPs provide the community with more than 137 million consultations, treat more than 11 million people with chronic disease, and dedicate more than 33 million hours tending to patients each year,” Dr Gannon said.

“Nearly 90 per cent of Australians have a regular GP, and enjoy better health because of that ongoing trusted relationship.”

The AMA used the week to outline a series of proposals for improving the health of Australians while also delivering savings to the Government.

The Pharmacist in General Practice Incentive Program (PGPIP) proposal would integrate non-dispensing pharmacists into GP-led primary care teams, allowing pharmacists to assist with medication management, provide patient education on their medications, and support GP prescribing with advice on medication interactions and newly available medications.

“Evidence shows that the AMA plan would reduce unnecessary hospitalisations from adverse drug events, improve prescribing and use of medicine, and governments would save more than $500 million,” Dr Gannon said.

“When the Government is looking to make significant savings to the Budget bottom line, the AMA’s proposal delivers value without compromising patient care or harming the health sector.”

Independent analysis from Deloitte Access Economics identified that the proposal would deliver $1.56 in savings for every dollar invested in it.

The AMA also stepped up the pressure for more appropriate funding for the Government’s trial of the Health Care Home model of care for patients with chronic disease.

In March, the Government committed $21 million to allow about 65,000 Australians to participate in initial two-year trials in up to 200 medical practices from 1 July 2017. However, the funding is not directed at services for patients.

“GPs are managing more chronic disease, but they are under substantial financial pressure due to the Medicare freeze and a range of other funding cuts,” Dr Gannon said.

“GPs cannot afford to deliver enhanced care to patients with no extra support. If the funding model is not right, GPs will not engage with the trial, and the model will struggle to succeed.”

With chronic conditions accounting for approximately 85 per cent of the total burden of disease in Australasia and 83 per cent of premature deaths in Australia, it was vital that Australians could turn to their family doctor for advice, Dr Gannon said.

“The Government uses concerns about the sustainability of the health system to justify funding cuts, but instead of making short-sighted and short-term savings, it should invest in preventing disease in the first place,” he said.

Family doctors in rural and regional communities, in particular, needed more support.

The AMA called on the Government to rethink its approach to prevocational training in general practice, and to revamp and expand its infrastructure grants program for rural and regional practices.

Maria Hawthorne

This is where the health system fails

The effect of where you live on your health is nowhere more apparent than on Palm Island.

Inhabitants of the small island just north of Townsville are being hospitalised for chronic obstructive pulmonary disease at almost 21 times the rate of other Queenslanders, are being admitted for epilepsy and the bacterial skin infection cellulitis at 12 times the state-wide rate, are in hospital for diabetes complications at almost nine times the state-wide rate, and are six times more likely to be admitted for a urinary tract infection.

Leading health economist Professor Stephen Duckett says these figures show a community that is being failed by the health system.

“When people end up in hospital for diabetes, tooth decay or other conditions that should be treatable or manageable out of hospital, it’s a warning sign of system failure. Australia’s health system is consistently failing some communities,” he says.

Palm Island is among 63 locations in two states – Queensland and Victoria – identified by Professor Duckett and his colleagues at the Grattan Institute in their report Perils of place: identifying hotspots of health inequalitywhere rates of preventable hospitalisation are at least 50 per cent above the state-wide average for a decade or more. These include conditions such as asthma, diabetes, high blood pressure and malnutrition.

“Persistently high rates of potentially preventable hospitalisations are not normal,” the health economist says. “They are a signal that the existing health policies are not working or are insufficient.”

What causes these areas to have such high rates of health disadvantage are as individual as the places themselves, and influences include air and water quality, housing standards, employment, services like schools, clinics, roads and public transport, crime and community cohesion.

Professor Duckett says that while these areas tend to be more disadvantaged, “we found that potentially preventable hospitalisations are actually generally widely spread, and the places where hospitalisations are most concentrated are quite different for different diseases”.

The complex picture means that policy prescriptions have to be tailored to the individual characteristics of each location: “There is no single solution. The driving forces will be different in each place”.

But just because they defy generalisation and a one-size-fits-all solution, that is no reason not to address the issue, and the rewards in improved health and lower expenditure are considerable – Professor Duckett calculates that reducing preventable hospitalisation rates in the 63 areas identified in the Grattan Institute report to the state-wide average would, conservatively, save between $10 and $15 million a year in direct health costs alone, without taking into account indirect savings from fewer sick days and improved workforce participation.

Professor Duckett says the Commonwealth should fund trials, led by local Primary Health Networks, to test solutions and, crucially, commission rigorous and independent evaluations to identify what works and what does not.

PHNs should also develop tools to more precisely identify and target preventable hospitalisation hotspots. As data from trials is accumulated and lessons drawn, PHNs should use this information and experience to strengthen and expand their efforts.

Professor Duckett admits the priority areas identified in his report represent only a fraction of the problem, and “prevention efforts in these areas alone will not substantially reduce the overall burden of potentially preventable hospitalisations”.

“But,” he added, “they will help to efficiently reduce the worst health inequalities and will build the evidence base for how to address health inequalities more broadly.”

The bottom 10

The nation’s worst preventable hospitalisation hotspots

Palm Island

Yarrabah

Mount Isa

Mount Morgan

Northern Peninsula

Donald

Langwarrin South and Baxter

Broadmeadows

Frankston North

Kingaroy

Source: Grattan Institute

Adrian Rollins