Counter-terror powers could extend to mental health records

The Federal Government is considering whether to allow security authorities access to mental health records as part of efforts to prevent so-called ‘lone wolf’ terror attacks.

In what he admitted would be a “huge step”, Prime Minister Malcolm Turnbull has asked Counter-Terrorism Coordinator Greg Moriarty to examine the possibility of police and intelligence service access to the mental health records of terrorist suspects as part of a review of the nation’s defences.

“It is important this be looked at carefully. Let me come to another point, you’ve got a number of important interests to balance here. Mental health alone, leaving aside issues of terrorism, is a gigantic challenge,” Mr Turnbull said. “But my most important obligation, my most important responsibility to Australia, is to keep the people of Australia safe, and so that is why we are constantly improving, upgrading our legislation – that is why we provide additional resources to our police and security services.”

The Prime Minister said a change in approach was necessary because of a recent spate of attacks, including in Orlando, Nice and Germany, suggested the terrorist threat was evolving to include individuals not previously considered to be a threat but who were socially, emotionally or mentally unstable and were susceptible to rapid radicalisation.

“What we are seeing at the moment is people being radicalised or adopting Islamist, murderous Islamist ideology very, very quickly. So that you have people that are not on the counter terrorism radar screen who then often, as a result of mental illness, will then attach themselves to this murderous ideology and then act very quickly,” Mr Turnbull said on radio 3AW. “They appear to be drawn to Islamist extremism very late and very fast, not necessarily because of a long-term religious or ideological belief, but as a means of filling a void and providing meaning or rationalisation. The Lindt Café attacker, who converted from Shia to Sunni in the days leading into the siege, might also fit this profile.”

But he admitted giving the security services access to mental health records would involve overriding “very significant privacy protections”.

There are also doubts about whether the breach of doctor-patient confidentiality involved would necessarily achieve much in detecting or heading off potential terror attacks.

Even if those contemplating undertaking a ‘lone wolf’ terror attack have a mental illness, they may not necessarily have sought treatment. Furthermore, they might be deterred from seeking care if they thought their health records could be accessed by the police or intelligence services, exacerbating their illness and potentially making them more of a threat to themselves and others.

Mr Turnbull admitted that there would need to be a balance struck between patient confidentiality and the possibility of being alerted to a terror attack.

Adrian Rollins

Co-payment is ‘poison’

AMA President Dr Michael Gannon has declared that the idea of a patient co-payment is dead, with no desire on the part of the Government or the AMA to see it resurrected.

Speaking following a meeting with Health Minister Sussan Ley, Dr Gannon told ABC News 24 that he thought there was no chance the Coalition Government would try to introduce some form of GP co-payment after two earlier versions were shot down amid a fierce backlash from the AMA and patients.

“I think that the co-payment word is poison to Government, and it’s poison to the AMA,” Dr Gannon said. “We opposed both versions of the co-payment back in 2014…[and] I don’t think that there’s any desire from either the Government or the AMA or anyone else in the health sphere to see the co-payments introduced.”

The AMA President said the evidence showed that even nominal out-of-pocket expenses would deter some patients from seeing their doctor, causing health problems to deteriorate and need more expensive hospital care later on.

The Abbott Government initially proposed a $7 co-payment for all doctor visits, which was watered down to $5 cut to Medicare rebates that doctors could pass on to patients. But both ideas were withdrawn following a massive public backlash and staunch opposition in the Senate.

Instead, the Government has extended a freeze on Medicare rebate indexation to 2020, which has been described as a co-payment by stealth because it will force an increasing number of GPs to abandon bulk billing.

Dr Gannon is pushing the Government to unfreeze Medicare rebates, and expects the policy to be gone by the next Federal election.

He said the tight result of the election just fought sent a clear message to the Coalition about how much the people valued access to health care.

“I think that the Australian people want their affordable access to see their GP, access to public hospitals. They’ve spoken. They’ve said that they are absolutely key things that they expect from their Government. They regard them as absolutely core services and I think the post polling, the exit polling, the private polling has told the Government that,” he said.

Instead of a co-payment, Dr Gannon said the AMA supported GPs privately billing those patients who could afford to pay, while ensuring there were robust safeguards in place to give the neediest and most vulnerable ready access to care.

“The reason the co-payment models of 2014 were so wrong is that they didn’t give individual doctors the ability to make those judgements. They also didn’t give the system the ability to protect the neediest in the community and we know that even small $5, $6, $7 out of pocket expenses are enough to stop some people from going to see the doctor,” he said.

Adrian Rollins

[Articles] Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study

This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing.

Health policy in play as Coalition licks wounds

AMA President Dr Michael Gannon has intensified his calls on the Government to dump its Medicare rebate freeze policy and reverse other health cuts amid mounting pressure within the Coalition for changes to health policy following the narrow Federal election result.

Seizing on admissions from Prime Minister Malcolm Turnbull that health policy concerns swayed many voters away from his party, Dr Gannon has called on the Coalition to change course and treat health as an investment, rather than a cost.

“The Prime Minister, the Coalition, have had the scare of their life,” Dr Gannon said. “It’s very clear that Australians value their health, and many of them voted on the grounds that they were worried about their health care.”

Last week the Coalition secured the 76 seats needed to form Government in its own right after suffering a national swing of 3.4 per cent against it. The narrow victory (the ABC predicts Labor will hold 68 seats, the Greens and Xenophon Team one each, and three independents) prompted a wave of finger-pointing and recriminations within conservative party ranks, including calls to revisit health cuts made in the 2014 and 2016 budgets.

Rancour over the close election result extended to include speculation that Health Minister Sussan Ley would be dumped amid complaints she had not done enough to counter Labor’s attack lines on the Government over Medicare. Her supporters, though, revealed that she had been muzzled from speaking out during the campaign by Liberal strategists, and Dr Gannon said that, from afar, it seemed “that the Coalition didn’t want to talk about health in the campaign, and that they had silenced Minister Ley”.

Dr Gannon said the big lesson for the Government from the election was that the public valued the health system highly, and in post-election talks with the Prime Minister he had reinforced the need to invest in general practice, increase public hospital funding and reverse cuts to bulk billing incentives for pathology and diagnostic imaging services.

The AMA President said Mr Turnbull understood the AMA’s concerns.

“I think that in an ideal world he would unravel the freeze tomorrow,” he told ABC radio. “What we have seen in the past, going back to the 2014 Budget, was a desire by the Coalition to introduce a co-payment to try and work out ways that those who can afford it can contribute more to the cost of their health care.

“Now, the reason that proposal failed so badly is because it didn’t give the opportunity for individual GPs to make a judgement, knowing their patients well, who can and can’t afford even a modest amount of money.”

Asked if he would re-visit the idea of a patient co-payment, Dr Gannon said he was not seeking “a re-energisation” of the co-payment debate, but instead wanted a serious discussion about the future funding of Medicare.

“My comments…are about being able to have conversations about why those two [co-payment] proposals from two years ago were not good policy, being able to have a conversation about how we fund Medicare, 15, 20 years in advance,” he said on radio station 2GB.

“We’re not far off the balance in Australia, it just needs some tinkering around the edges. And I’m really keen to, in this next Parliament, with a knife-edge result in the Lower House and a very interesting Senate…I’m just hopeful we can have these conversations that make sure that Medicare is there to protect people in 20 years’ time, and have more than that two- or three-year view of it.”

The Government appears receptive to calls to re-visit its health policies.

As the Coalition took stock of the extremely tight Federal election result, Mr Turnbull said it was clear that Labor’s message that the Coalition posed a threat to Medicare had fallen on “some fertile ground”.

“What we have to recognise is that many Australians were troubled by it. They believed it, or at least had anxieties raised with it. It is very clear – it is very, very clear – that [Deputy Prime Minister] Barnaby [Joyce] and I and our colleagues have to work harder to rebuild or strengthen the trust of the Australian people in our side of politics when it comes to health. There is no question about that,” Mr Turnbull said.

“We have to recognise that there is a real issue for us if people voted Labor because they genuinely believed or they feared that we were not committed to Medicare, because that is not the case. So that is why Barnaby and I, as we reflect on this and our colleagues reflect on this, that is something that is an issue we have to address,” Mr Turnbull said.

Dr Gannon told ABC radio the election result had shown just how important health policy was for voters, and it was clear that the Medicare rebate freeze, combined with earlier polices such as the GP co-payment, meant Labor’s scare campaign on Medicare had resonated with voters.

“If we go back to the first co-payment model in 2014, which came out of the much-maligned Budget that year, if we look at Co-payment Mark II which came out later that year, it possibly showed that health policy was being run out of Treasury,” Dr Gannon said. “The Coalition has realised maybe too late…that people do worry about their health, they do vote on it, they do regard it as one of the major issues when they decide how to vote.”

Adrian Rollins

Cancer success more than skin deep

Advances in the detection and treatment of melanoma have meant those diagnosed with the potentially deadly disease have far greater chances of survival than for most other forms of cancer.

While Australia has an unwelcome record for having the second-highest rates of melanoma in the world, the Australian Institute of Health and Welfare (AIHW) has reported that those with melanoma have a five-year survival rate that is 90 per cent of their counterparts in the general population – well in excess of the 67 per cent five-year survival rate for all types of cancers combined.

In further good news, the Institute has found that although skin cancer is a major cause of illness, its prevalence among younger people is declining. After peaking at 13 cases per 100,000 in 2002, the incidence of melanoma in people aged 39 years or younger has since declined to 9.4 cases per 100,000.

The result has been seen by some as a sign that young people are heeding sun-safe messages, and has spurred calls from public health advocates for greater Government investment in campaigns encouraging people to protect their skin.

The Cancer Council Australia said this was much more cost-effective than the huge expense of treating skin cancer once it develops.

The AIHW said Medicare benefits worth almost $137 million were spent on skin cancer services in 2014, and the Cancer Council has estimated that treating the disease costs the country more than $1 billion a year.

Those costs appear likely to escalate.

While the incidence of melanoma in young people is declining, it is rising strongly in the broader population.

Australia’s melanoma rate has doubled in the last 34 years from 27 to 49 cases per 100,000, according to the AIHW, and its incidence (35 new cases a year per 100,000) is now second only to New Zealand (36 per 100,000) in the world.

The Institute estimates that almost 13,300 people will be diagnosed with melanoma this year and 1770 will die, while further 560 will be killed by other forms of skin cancer, and almost 140,000 will be hospitalised.

Even though the prognosis for many is good, the distress for individuals and families, and the costs to the health system, are substantial.

The hospitalisation rate for patients with melanoma surged 63 per cent between 2002-03 and 2013-14, while the number of surgical procedures undertaken to treat melanoma jumped almost 54 per cent over the same period and the number of chemotherapy treatments more than doubled.

Though the hospitalisation rate for those diagnosed with other forms of skin cancer did not increase as sharply over this period (up 39 per cent between 2002-03 and 2013-14), surgical procedures increased 40 per cent and chemotherapy treatments were up 65 per cent.

In addition, effective but hugely expensive drugs are being used to treat melanoma. In the latest development, Melanoma Institute Australia is reporting promising results from the use of two immunotherapy medicines, Yervoy and Keytruda, in combination to treat advanced melanoma. The two drugs, which can cost up to $120,000, are available at a reduced price through the Pharmaceutical Benefits Scheme, but have so far been denied full listing.

The AIHW findings have fuelled a backlash against celebrity chef Pete Evans, who last week described sunscreens as “poisonous chemicals” that gave people the illusion of protection from the sun’s harmful rays.

Cancer Council Chief Executive Professor Sanchia Aranda said skin cancer was the most preventable form of cancer, and the AIHW data underlined the need for campaigns to encourage people to take steps to protect themselves from sun damage.

“Given the rapid growth in skin cancer treatment costs, and mounting pressures on the health system as our population ages, there is an urgent need to get skin cancer prevention back on the federal agenda,” Professor Aranda said. “We need a mass media campaign, this summer and the next.”

Adrian Rollins

Managing elderly diabetes no simple task

Most elderly diabetics are prescribed glucose-lowering medications, and only one in five use insulin to manage their diabetes, according to a report by the Australian Institute of Health and Welfare.

Highlighting the complexity of treating type 2 diabetes in older patients, the AIHW used linked data from the Pharmaceutical Benefits Scheme and the National Diabetes Services Scheme (NDSS) to show that while most (85 per cent) of patients 65 years and older were on glucose lowering medications, just 40 per cent used a single medication. One in five used two glucose lowering therapies simultaneously, and 11 per cent were on triple therapies.

In addition, 77 per cent were also using agents to lower their blood pressure, 74 per cent were using drugs to modify lipids (68 per cent were using both), 24 per cent were being supplied with anti-depressants, 20 per cent were using insulin and 4 per cent were on anti-psychotics.

Generally, the authors of the report said, the longer since type 2 diabetes was diagnosed, the more likely it was that a patient would be prescribed with all medicine types, and the more intensive (dual or triple therapy) their glucose lowering treatment regimens would be.

Increasingly, type 2 diabetes in older patients is being treated with drugs rather than diet and exercise alone.

This was significant, the authors said, because the high prevalence of co-morbidities in such patients made the balance of risks and benefits in using medicines a finely-tuned calculation.

The release of the report coincides with changes to the NDSS that came into effect on 1 July.

Under the changes, people with diabetes can continue to access NDSS products such as needles, syringes, blood glucose test strips and urine test strips from NDSS community pharmacies, but can no longer access the products from Diabetes Australia or local state and territory diabetes organisations.

In addition, people with type 2 diabetes not using insulin will receive an initial six month supply of subsidised blood glucose test strips under the NDSS. After six months, they will only be eligible for further access to subsidised test strips if their doctor or other authorised health professional considers it clinically necessary to use test strips.

The change follows advice from the Pharmaceutical Benefits Advisory Committee which recommended restrictions to access blood glucose test strips based on research which found there was limited evidence that self-monitoring of blood glucose improved blood glucose control, quality of life or long term complications in people with type 2 diabetes who are not using insulin.

Patients with diabetes using insulin or women with gestational diabetes will not be affected by these changes.

The restrictions will come into effect six months from the date of a NDSS Registrant’s first test strip purchase.

There is no limit on the number of extensions to access that may be obtained from an authorised health professional while there is a continuing clinical need.

For more information about the changes visit https://www.ndss.com.au/important-changes-to-the-ndss

The AIHW report can be found at http://www.aihw.gov.au/publication-detail/?id=60129555607

Kirsty Waterford

Aged care sector calls for cuts to be deferred

The aged care sector has called for a taskforce to review the sector’s funding process, as new analysis shows the 2016-17 Budget would strip funding to older people in care by 11 per cent per resident each year.

The Turnbull Government announced $1.2 billion in cuts to aged care funding in the May Budget, largely through reductions in the complex care component of the Aged Care Funding Instrument.

The Government argued that providers were overclaiming by wrongly classifying residents as high complex care patients.

“There’s no hiding away from the fact that the residential aged care budget will blow out by a further $3.8 billion over the next four years without action to address inconsistencies in the way claims are made, with as many as one in five ruled to be too high,” Minister for Health Sussan Ley said in June.

Ms Ley’s comments were borne out by a Health Department response to a Freedom of Information request by the Australian Financial Review.

The Department rejected the request, saying that there were more than 26,000 pages detailing non-compliance in relation to claims for Government funding from aged care providers.

Making public such a significant volume of related information would be too time-consuming, the Department said.

“A preliminary search has identified that there are approximately 1100 emails, 430 documents and 800 page reports, comprising over 26,000 pages that may fall within the scope of the request,” it told the newspaper in July.

The Labor Opposition has also refused to reverse the cuts.

But a coalition of service providers said, while the sector understood the need to manage growth in health care spending, the cuts went too far.

UnitingCare Australia (UCA), Aged and Community Services Australia (ACSA), and Catholic Health Australia (CHA) commissioned Ansell Strategic to undertake a review of 501 aged care homes and almost 39,000 residents around the country.

The modelling indicated that the actual impact of the cuts would be more than $2.5 billion over the next four years alone, nearly $840 million more than the Government’s forward estimates.

“The 2016-17 Budget was particularly harsh as it targeted people with complex health care needs and those receiving treatment for severe pain and chronic diseases like heart disease, diabetes, and dementia,” UCA Chair Steve Teulan said.

“We wanted to fully assess the impact of the funding reductions so we commissioned modelling that looked at the potential impact on nearly 39,000 people in aged care homes.

“The results are stark. The cuts far exceed the amounts stated by Government and will reduce funding to support older people in care by $6,655 – or 11 per cent – per resident each year.”

Under these arrangements, the funding would not cover the costs of services currently provided to residents with complex needs, meaning many older people in care might miss out on vital treatments including physiotherapy, pain management, and skin care, Mr Teulan said.

“If these cuts are implemented as stated, by 2017 service providers will be forced to seriously consider both turning away sick old people who are seeking admission from hospital and reducing services, particularly allied health,” Mr Teulan said.

The providers called on the Government to defer the proposed cuts until it undertook proper analysis of their impact, and an evaluation of the relative costs of providing care to frail aged people in nursing homes.

They also called for a taskforce to review the funding process for aged care, with a view to establishing a more sustainable model which provides certainty to providers, residents, their families and carers, and long-term affordability for taxpayers.

Maria Hawthorne

More funding needed for Health Care Homes trial

GPs are still waiting for clarity on whether appropriate funding will be offered for services to patients under the Government’s $21 million Health Care Homes trial.

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.

The Government announced the model in March, with $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.

The trial was one of the recommendations of the report of the 2015 Primary Health Care Advisory Group, headed by former AMA President Dr Steve Hambleton.

It was hailed as a step in the right direction for chronic disease management, with the Labor Opposition announcing plans for a similar trial.

However, the Labor proposal came with $100 million of funding, while under the Government model, the funding is not directed at services for patients, but rather on clinical need.

Professor Jane Gunn, the head of the General Practice Department at the University of Melbourne’s medical school, said the outcomes of similar trials, such as the 1994 coordinated care trials and the more recent diabetes care project, highlighted the difficulty in driving health delivery reform.

“The coordinated care trials showed some promise but were costly to implement and too costly to scale up,” Professor Gunn wrote on The Conversation website.

“They were difficult to replicate and few were sustained outside the trial environment.

“The impact of the diabetes care project was also disappointing. The diabetes care project included many of the elements of [the advisory group’s] report, such as bundled payments, yet only small gains were made in health outcomes and the cost-effectiveness of the model was not proven.

“The bundled payment used in the diabetes care project was viewed as inadequate.”

Making improvements in chronic disease management would require strong buy-in from all stakeholders, but it would be a challenge to get eligible practices and patients to sign on for the trial, she said.

“One of the biggest challenges will be to work out exactly how much the Government should pay a practice for providing a person with all their chronic disease care in a year,” Professor Gunn said.

“Working out how an individual GP will get their fair share of the chronic disease payment is likely to make for interesting negotiations and new ways of working for practice managers.

“Female GPs will be vulnerable to further pay inequities as they are less likely to be practice owners and more likely to work part-time.

“It is also not clear whether the recommended ‘bundled payment’ would include more radical models where the practice has to fund payment for pathology, imaging and medications from the ‘bundled payment’.”

AMA President, Dr Michael Gannon, said the AMA was keen to work with the Government to make the trial a success, but appropriate funding would be a critical test.

“The Medical Home is fundamental to the concept of the family doctor who can provide holistic and longitudinal care and, in leading the multidisciplinary care team, safeguard the appropriateness and continuity of care,” Dr Gannon said.

“BEACH data shows that 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.

“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 the right support, GPs can provide more preventive care services and greater management and coordination of care, keeping patients healthier and out of hospital, he said.

“Health played a major part in the Federal Election and the Government must now demonstrate that it has heard the people’s concern regarding the ongoing affordability of their health care,” Dr Gannon said.

“The Medical Home must be appropriately funded to succeed.”

Maria Hawthorne

National Core Maternity Indicators stage 3 and 4 results from 2010–2013

National Core Maternity Indicators (NCMIs) are designed to assist in improving the quality of maternity services in Australia by establishing baseline data for monitoring and evaluating practice change. This report and the data portal covers the period from 2004 to 2013, and includes data for the vast majority of women who gave birth in Australia over that period. The 10 measures previously reported have been updated with 2010–2013 perinatal data, while 2 new measures are reported for the first time. Data are presented by jurisdiction, by Primary Health Network, and at the national level by hospital annual number of births, hospital sector, and mother’s Indigenous status. Some indicators are presented by remoteness

Family doctors: invaluable to health

As the new Chair of the AMA Council of General Practice, I am honoured to follow on from my predecessor, Dr Brian Morton, and wish to acknowledge him for his six years of leadership and service to the Council and to general practitioners.

It is certain that as a profession we will have some interesting times ahead of us as the dust from the Federal Election settles. If there is one thing we know for sure from the last few weeks, it is that putting health on the backburner is risky business. The Government must be in no doubt now that health is a priority, and that it will have to do more than it has to date to ensure vulnerable patients do not have to worry about whether or not they can afford to see their GP when required, and to have pathology and radiology investigations when requested.

Next week we will be celebrating general practice and the primary role played by Australia’s GPs, our family doctors, as frontline and holistic health care providers. Throughout Family Doctor Week (24-30 July), the AMA will be highlighting how invaluable the family doctor is to patient health, and to the health system more broadly.

We know from international comparisons that countries with a strong GP-led primary care system have lower rates of ill health, better access to care, reduced rates of hospital admissions, fewer referrals to other specialists, less use of emergency services, and better detection of adverse effects of medication.

The comprehensive care provided by our nation’s family doctors needs to be seen by Government as an investment rather than as an expense. With only 6 per cent of Australia’s total health expenditure on general practice, our family doctors have proven the value of their care. Ending the freeze on Medicare rebates, raising the rebates and lifting rates of indexation to cover the true costs of care must be at the top of the Government’s to-do list.

For most patients, our general practices are their medical home. If appropriately funded, rather than struggling for viability, we know we can do more to help our patients live the healthiest life they can. We can do this though appropriate health screening and life-stage assessments, through structured care that is patient-centred and planned, through greater use of innovative technology that not only empowers patients in managing their conditions, but enables us to monitor their progress, through better use of medicines, and through care that is streamlined and coordinated within our multidisciplinary health care team.

Family Doctor Week will highlight that, properly funded, the medical home has the potential to both improve the care patients receive, and to save on more costly downstream health costs.

Supporting general practices to bring non-dispensing pharmacists into the health care team is but one way Government can invest to deliver better patient outcomes and minimise avoidable hospital admissions. The AMA’s Pharmacist in General Practice Program would deliver $1.56 in savings for every $1 invested by ensuring the quality use of medicines, medication optimisation and increased medication compliance, reducing adverse drug events and hospitalisations as a result.

In rural and remote areas, Government needs to assist general practices with appropriately designed and implemented infrastructure grants to expand their facilities to better meet the complex health needs of people in these communities.

You can support us in supporting you by visiting the website family-doctor-week-2016 and downloading and displaying the poster and your Family Doctor Logo, and by using #amafdw16 if tweeting or sharing FDW content on social media.