[Comment] Safeguarding children and improving their care in the UK

The Health and Social Care (Safety and Quality) Act 2015 came into force after it received Royal assent in the UK Parliament on March 26, 2015.1 One of its purposes is to enable integration of information for the users of adult health and social services in England and allow sharing of an individual’s information for the purposes of providing health or social care services to that individual. The Act specifies that a consistent identifier for the individual must be included in the information processed provided that it facilitates the provision of services to the individual and is in his or her best interests.

Young people returning to sentenced youth justice supervision 2015

The rate of return to sentenced youth justice supervision is an indicator of the effectiveness of the services provided to young people serving supervised sentences. Around 20% of those aged 10–16 when released from sentenced community-based supervision in 2012–13 returned to sentenced supervision in 6 months, and 44% returned within 12 months. The rate of return was higher for those released from sentenced detention: 50% returned to sentenced supervision within 6 months and 76% returned within 12 months.

Nation pays high price for unnecessary tests, unproven treatments

Cracking down on inefficient and clinically unnecessary practices like over-ordering diagnostic tests, prescribing inappropriate medications and using unproven or speculative treatments could save the health system more than $15 billion a year, a leading epidemiologist has said.

In a provocative speech to the AMA National Conference in which he called for a transformation in the way in care is conceived and delivered, Associate Professor Ian Scott said up to 30 per cent of health spending was wasteful or went on procedures and treatments that were of little benefit or could actually be harmful.

A/Professor Scott, who is director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, said while some interventions and treatments, like vaccination programs, public health campaigns, chemotherapy, renal dialysis and some cancer screening programs were effective uses of scarce health funds, the pay-off from many other practices was more questionable.

He questioned the bias in the medical profession to provide intensive care, including “heroic interventions”, for very ill patients – 30 per cent of health funds are spent on health care in the last year of life, including $2.4 billion on providing hospital care to the elderly – and suggested a more conservative approach involving a shift in focus away from treatments that do not improve survival beyond six months or enhance quality of life.

One of the oft-cited sources of inefficiency and cost blow-outs in the health system is in the area of diagnosis, including the tendency to over-prescribe diagnostic tests.

Much of this has been attributed to the rise of “defensive medicine”, which MDA National Manager of Medico-legal and Advisory Services, Dr Sara Bird, defined as the ordering of treatments, tests and procedures “primarily to help protect the doctor from liability”, rather than to substantially advance patient diagnosis or treatment.

Dr Bird, who addressed the same AMA National Conference policy session as A/Professor Scott, said that although the incidence of defensive medicine was difficult to measure, evidence suggested it was widespread.

In the United States, 96 per cent of specialists practising in fields at high risk of litigation confessed to practising defensively, including 43 per cent who reported ordering unnecessary diagnostic imaging tests.

Dr Bird said the situation appeared to be similar in the United Kingdom, where almost 80 per cent of hospital-based doctors said they practised defensive medicine, including 60 per cent who admitted ordering unnecessary tests and 55 per cent who said they made unnecessary referrals.

In Australia, research indicates that doctors who have been the subject of legal action are much more likely to practise defensively – 55 per cent ordered more tests and 43 per cent made more referrals than was considered usual.

A/Professor Scott said that in addition to unnecessary tests, often clinicians provided treatments that were of little or no value.

He lauded the National Prescribing Service’s Choosing Wisely initiative, under which so far more than 200 routinely used treatments have been placed under scrutiny.

The Federal Government has also commissioned a review of Medicare Benefit Schedule items, led by Sydney Medical School Dean Professor Bruce Robinson, to scrutinise and assess the appropriateness of more than 5500 listed services.

AMA President Professor Brian Owler has cautiously welcomed the reviews.

Professor Owler said that although it was important to rigorously assess the value and appropriateness of procedures and treatments, it was vital the process was not driven primarily a search for savings, and that it had the support and involvement of medical colleges and societies.

A/Professor Scott warned of “indication creep”, where a treatment proved to be of benefit to one group of patients is uncritically applied more broadly , such as cardioverter defibrillators, cardiac resynchronisation pacemakers and transcatheter aortic valves.

He urged a much more considered and cautious approach to the use of new interventions until there was rigorous evaluation of their safety and effectiveness.

A/Professor Scott said told the conference that clinical guidelines should take into account cost-effectiveness in recommending interventions.

He said often less intensive and cheaper management regimes for conditions such as bleeding peptic ulcers and urinary tract infections in children were just as safe and effective as higher-intensity regimens.

A/Professor Scott recommended that analyses of the comparative cost effectiveness be an integral part of the assessment of each new service or intervention.

He told the conference this cost-effectiveness approach should also inform the selection of patients for a particular treatment.

The epidemiologist said interventions should be targeted to those who would derive greatest benefit.

Adrian Rollins

Medibank-Calvary contracts stand-off: what it means for doctors and patients

Medibank Private Ltd has announced that its contract with private hospitals operated by Calvary Health Care will end on 31 August this year.

Medibank cited a breakdown in negotiations over the rates Medibank pays for services provided by Calvary hospitals and new quality criteria for the failure to renew the contract, while Calvary has stated the new demands are financially rather than quality driven.

This will not affect the fees paid by Medibank to medical practitioners.

However, medical practitioners will need to ensure patients insured with Medibank seek information directly from Medibank about their out-of-pocket costs for accommodation, theatre and other items if they are admitted to a Calvary Health Care hospital.

Medibank has advised that it will continue to pay benefits for hospital expenses at the current contracted rates for any procedures pre-booked before 31 August, for a period of:

nine months if the pre-booking is obstetrics-related
six months if the pre-booking is to treat a chronic condition, e.g. chemotherapy or dialysis
two months for all other pre-booked admissions.

After this, Medibank will pay previously-contracted Calvary Health Care private hospital expenses at ‘second tier’ rates which are set at 85% of Medibank’s average contracted rate.

Medical practitioners can call Medibank’s dedicated ‘doctor hotline’ on 1300 130 460 for further information.

Georgia Morris

Future of public hospitals up for grabs at leaders’ retreat

Radical plans that could see the Federal Government dump all responsibility for public hospitals onto the States or pay for hospital treatment through a Medicare-style benefit scheme are up for discussion when Prime Minister Tony Abbott meets with his State and Territory counterparts at a special leaders’ retreat later this week.

The Prime Minister called the retreat to discuss reform of the Federation, and the division of responsibility for health services, particularly the funding and operation of public hospitals, is expected to be a central plank of the talks.

Since coming to office, the Abbott Government has engaged in a high-stakes stand-off with the States and Territories over public hospital funding. In its first Budget, it disowned funding guarantees made under the National Health Reform Agreement and reduced the indexation of post-2017 funding to CPI plus population growth, ripping $57 billion out of the public hospital system over 10 years.

The move is seen as part of a broader gambit by the Federal Government to pressure the states into looking at alternate sources of revenue, including increasing the GST or broadening its base.

Treasurer Joe Hockey last week increased the pressure on the States by declaring that each level of government should be responsible for raising the revenue needed to pay for the services they provide.

Mr Hockey said reforms discussed at the leaders’ retreat must include “the States taking responsibility for their own budgets in order to ensure they can afford their ever-increasing expenditure – such as the costs of their public hospital systems as our population ages”.

The tactic has echoes in the Government’s current strategy – likened by AMA President Professor Brian Owler to introducing a patient co-payment “by stealth” – to freeze the indexation of Medicare rebates until mid-2018, forcing many practices to cut bulk billing and introduce or increase patient charges in order to remain financially viable.

The AMA is a fierce critic of both policies, and Professor Owler – who will deliver a nationally-televised address to the National Press Club Wednesday – warned of an “impending crisis” for the nation’s public hospitals unless more money was injected into the system.

Professor Owler said public hospitals were facing a “perfect storm” of increasing demand, missed performance targets and major funding changes.

“The combination of these factors will have devastating consequences for our public hospital system,” he told the AMA National Conference in late May.

State and Territory leaders, particularly NSW Premier Mike Baird, are similarly outraged by the Federal Government’s tactic. Mr Baird warned earlier this year that the States simply “do not have the capacity to meet those health costs on their own”.

The Queensland Government estimates the Commonwealth’s decision to claw back public hospital finding will leave the State $11.8 billion worse off by the middle of next decade, with serious consequences for the quality and availability of care.

“Unless these federal funding cuts are reversed, there will be a shortfall in funding for Queensland hospitals – and a resultant decline in the quality and timeliness of services – from July 1, 2017,” it warned.

It is in this heated atmosphere that the leaders are expected to discuss ideas for future hospital funding, including those prepared by the Department of Prime Minister and Cabinet.

In its Green Paper it makes five suggestions, including the Federal Government shifting full operational and funding responsibility for public hospitals onto the States and Territories, the creation of an MBS-style hospital benefits scheme, jointly funded individualised patient care packages, or the establishment of a single national or regional agencies to purchase health services.

Grattan Institute Health Program Director Professor Stephen Duckett and colleague Peter Breadon said introducing a Hospital Benefits Schedule was a promising idea that could see a return to shared incentives by exposing both the Commonwealth and States to the cost of growing demand for hospital care.

Although many of the factors forcing health costs up have little to do with the structure of the Federation, the Reform of the Federation Green Paper 2015 said improving the way the health system was funded and operated could improve prevention and care while making better use of funds – particularly by providing funding on the basis of outcomes rather than activity.

Professor Owler said that, whatever the funding model that might be developed, it needed to ensure public hospitals were given the resources they need to meet the growing demand for care while also providing the quality teaching and training that the next generation of doctors required.

He said that pushing responsibility for public hospital funding back to the States and Territories without providing them with the means to generate more revenue would be “irresponsible”.

Mr Baird declared public hospital funding was the most significant finance issue facing the States and Territories, and Professor Owler said he was particularly concerned about prospects for the smaller jurisdictions, some of which had areas of significant disadvantage and inequitable access to care, but which had limited revenue-raising capacity to fund improvements on their own.

“If the planned changes [announced in the 2014 Budget] go ahead, there will be serious consequences for frontline clinical services,” he said.

Adrian Rollins

How to pay for health?

Government funding reform options (as set out in Department of Prime Minister and Cabinet’s Reform of the Federation 2015 Discussion Paper)

Option 1

States and Territories handed full responsibility for public hospitals – the Commonwealth would withdraw all funding.

Option 2

Hospital benefit scheme

The Commonwealth would establish an MBS-style benefits scheme to fund a proportion of the cost of each hospital procedure, with the States asked to cover any gap between rebate and service cost.

Option 3

Individual care packages

The Commonwealth and States jointly fund individualised care packages for patients with, or at risk of developing, chronic or complex conditions.

Option 4

Regional Purchasing Agencies

The two tiers of government would jointly establish agencies to purchase health services for patients in their catchment areas.

Option 5

National Health Purchasing Agency

Commonwealth-funded agency to commission full suite of services, from primary through to acute, to meet community need.

Practices dumping bulk billing as Medicare rebate freeze bites

Pensioners and the chronically ill are being charged up to $30 to see their GP as cash-strapped medical practices squeezed by the Federal Government’s Medicare rebate freeze are being forced to abandon bulk billing and begin charging even their most disadvantaged patients.

In a development that bears out warnings from AMA President Professor Brian Owler that the four-year rebate freeze for GP services amounted to the introduction of a GP co-payment “by stealth”, numerous doctors and practice managers have contacted the AMA to report how they had been forced to increase patient charges – and in at least one case, shut down – because of a growing shortfall in the Government’s contribution to the cost of care.

Among them is Tasmanian GP Emil Djakic, whose practice – in Ulverstone and Penguin – has just introduced a $30 charge for the hundreds of patients who had previously been bulk billed.

Dr Djakic said it was a difficult decision given the tough financial circumstances of many of his patients, but the practice’s own financial position made it unavoidable.

He said that absorbing the full impact of the Medicare rebate freeze would have cost the practice $60,000 a year – $240,000 if it remains in place for four years – which would have undermined its viability.

“In our practice, we have charged those who are better off to help provide services at a discount for those less well off,” Dr Djakic said. “But we have now reached an inflexion point, triggered by the rebate freeze, where it is increasingly unaffordable.”

The practice, which has a 10 full-time equivalent GP workforce, has been bulk billing about 75 per cent of patients. Under changes that came into effect from 1 July, every patient will be charged a $30 fee for the first consultation of the financial year. Any subsequent charges are at the discretion of the individual practitioner, though Dr Djakic said staff were asked to be mindful of the growing gap between the value of the rebate and practice costs in deciding whether or not to ask for a contribution.

Dr Djakic said the practice was bracing for an increase in defaulted payments, but added that so far patients had been surprisingly receptive to the change.

He said the lack of widespread outrage showed the Federal Government had been “incredibly deft” in introducing this latest version of a GP co-payment.

“Just from the viewpoint of a political exercise in shifting costs onto the patient from the Government, it has been very elegant,” Dr Djakic said.

While some practices are increasing patient charges, others are succumbing to the accumulated financial strain caused by the ever-diminishing value of the Medicare rebate.

In Redfern, doctors operating a small practice that has served the community for 34 years have made the painful decision to shut down.

Dr Marie Healy, who for the past 11 years has worked at the practice owned and operated by Dr Adrian Jones, said rising running costs, inadequate Medicare rebates and the inability of a high proportion of patients to pay a gap fee had over time made the practice’s financial position increasingly perilous.

“Yes, Redfern house prices are very high, but there is still a lot of disadvantage here,” Dr Healy said. “We have a lot of patients who are concessional, are elderly, who have chronic diseases, who have diabetes and who are on multiple meds.”

Dr Healy said she bulk billed around two-thirds of her patients because they could not otherwise afford the care they need, and the Federal Government’s original plan to impose a $7 patient co-payment had sent many “into a tizz and caused a high level of anxiety”.

She said two years ago the practice introduced a gap fee for non-concession patients, concession patients seeking a second opinion, and patients who needed a mental health plan, and it increased the charge on 1 July.

Last year, to further trim costs, it dropped out of the practice accreditation system because it was “too costly”.

But Dr Healy said that, with such a high proportion of patients on concession cards who were simply unable to pay, the extra revenue from gaps fees proved to be insufficient to keep the doors open.

The accumulated financial pressure from years of increasingly inadequate Medicare rebates meant that when the rebate freeze came into effect, it was the proverbial straw that broke the camel’s back, she said.

“Adrian Jones is a very conscientious and ethical doctor who is always doing stuff free for patients – visiting an elderly patient at home because they can’t come in, filling out forms for them – but it all hits the bottom line, and we just can’t keep doing it.”

Other practices have indicated they can no longer afford to bulk bill patients and have, or soon will, begin charging patients – including full pensioners – a fee.

Related: AMA: How to pay for Health

In addition to abandoning bulk billing, many are also looking to cut costs and make savings, including by trimming work hours, deferring equipment and facility upgrades and purchases, and reducing services.

The Government expects the Medicare rebate freeze will save it $1.3 billion by mid-2018, but Professor Owler said that cost was simply being dumped onto patients and doctors.

“This funding shortfall has to be met by patients and practices,” he said. “While the rebates have remained unchanged, the costs of providing quality medical services, such as wages for practice staff, rent, electricity, technology, and insurance are increasing every year. Medical practices cannot absorb these increasing costs for four years in a row and remain viable.”

Dr Healy said she felt the rebate freeze was part of a general assault by the Federal Government on primary health care that was particularly difficult to stomach when it had recently concluded an $18.9 billion, five-year deal with the pharmacy sector.

The AMA President warned the freeze would also have a significant effect on private health insurance, including forcing up premiums.

“Some private health insurers have indexed their schedules of medical benefits, which means they are covering the Government’s shortfall, but others will not index their medical benefits until the Government lifts the freeze,” he said. “This will put upward pressure on the costs of medical services and private health insurance premiums.”

Your AMA Federal Council at work

What AMA Federal Councillors and other AMA members have been doing to advance your interests in the past month:

Name	Position on Council	Activity/Meeting	Date
Dr Stephen Parnis	AMA Vice President	National Medical Training Advisory Network	19/05/2015
Dr Danika Thiemt	Chair AMA Council of Doctors in Training	National Medical Training Advisory Network	19/05/2015
Dr Roderick McRae	AMA Federal Councillor	ACHS Council meeting	25/05/2015
A/Prof Robyn Langham	AMA Federal Councillor – Victoria nominee and Chair of AMA Medical Practice Committee	Australian Health Practitioner Regulation Agency’s (AHPRA) Prescribing Working Group (PWG)	7/5/2015
Dr Omar Khorshid	AMA Federal Council Representative for Orthropaedic Surgeons	MSAC (Medical Services Advisory Committee) Review Working Group on Arthroscopic Hip Procedures	29/5/2015
Dr Tracey Soh	AMA Federal Councillor	Australian Medical Council Inter-Professional education workshop	9/6/2015
Dr Chris Moy	AMA Federal Councillor	Australian Medical Council Inter-Professional education workshop	9/6/2015
Dr Richard Kidd	AMA Federal Councillor	GP Roundtable telco – MERS briefing	17/6/2015
		DVA Stakeholder Engagement Design Workshop	16/6/2015
		Aged Care Gateway Advisory Group meeting	12/6/2015
		Aged Care Gateway meeting	4/5/2015
Dr Gino Pecoraro	AMA Federal Council Representative for Obstetricians and Gynaecologists	Diagnostic Imaging Advisory Committee	19/6/2015

AMA in the News – 21 July

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Doctors, teachers face gags under immigration laws, Sydney Morning Herald, 4 June 2015
Doctors and teachers working in immigration detention facilities could face up to two years in prison if they speak out against conditions in the centres or provide information to journalists. AMA President Professor Brian Owler said this was the first time doctors had been threatened with jail for revealing inadequate conditions.

Medical research fund could be ‘slush’ fund: Labor, The Age, 5 June 2015
The Abbott Government could raid its Medical Research Future Fund to pay for election promises and “pet projects” under proposals before federal Parliament, Labor has claimed. AMA President Professor Brian Owler said decisions about which research projects would be funded needed to be made at arm’s length from the minister.

Help for violence victims, Northern Territory News, 5 June 2015
A new resource to assist doctors in providing better support for victims of family violence was launched by the AMA at the AMA National Conference. AMA President Professor Brian Owler said the medical profession had a key role to play in the early detection, intervention and treatment of patients who has experience family violence.

Experts fear flu season shaping as the worst on record, The Saturday Age, 6 June 2015
The first five months of 2015 have been the worst on record for influenza, with experts warning Australia could be in for a rotten flu season. AMA Chair of General Practice Dr Brian Morton said Australia tended to follow the northern hemisphere’s flu season, which had been severe due to the emergence of new flu strains.

Banned flu drug still being given to children, Sunday Mail Brisbane, 7 June 2015
A disturbing number of doctors have ignored multiple warnings against administering the flu vaccine Fluvax to children younger than five years, even though there are safe alternatives. AMA President Professor Brian Owler said this risked undermining an otherwise safe vaccine schedule.

Leaked trade deal terms prompt fears for Pharmaceutical Benefits Scheme, The Guardian, 11 June 2015
The leak of new information on the Trans-Pacific Partnership agreement (TPP) shows the mega-trade deal could provide more ways for multinational corporations to influence Australia’s control of its pharmaceutical regulations. AMA president Professor Brian Owler said while doctors were very concerned at the possible effects on Australia’s health care system, their fears were routinely dismissed by Trade Minister Andrew Robb.

Save the planet for better health, The Canberra Times, 24 June 2015
The biggest boost to public health this century could come from action to tackle climate change, such as shutting down coal-fired power plants and designing better cities, according to a Lancet Commission report. AMA President Professor Brian Owler said the Australian health system was not prepared for climate change.

‘Whistleblowers’ challenge Australia’s law on reporting refugee conditions, CNN, 2 July 2015
More than 40 doctors, nurses, teachers, and other humanitarian workers have signed an open letter to the Australian government, challenging a new bill that could put whistleblowers in jail for disclosing the conditions of Australian detention centres. AMA President Professor Brian Owler said the act puts doctors in a dilemma when treating detainees and asylum seekers if they have concerns about the provision of their health care.

Medibank dust-up sparks care debate, The Saturday Age, 11 July 2015
AMA President Professor Brian Owler said the contract clauses being pushed by Medibank Private that put financial risk for unplanned patient readmissions and preventable falls back on private hospitals are evidence the newly listed market leader has shifted its priority to shareholders.

Radio

Professor Brian Owler, 666 ABC Canberra, 28 May 2015
AMA President Professor Brian Owler talked about the issues surrounding the bulk billing of GPs. Professor Owler said a doctor can bulk bill and this means they can accept the amounts from Medicare.

Dr Brian Morton, 5AA, 3 June 2015
AMA Chair of General Practice Dr Brian Morton discussed medicines on the drug subsidy scheme will rise in price on July 1. Dr Morton said that any medicine that currently costs consumers less than $36 will be hit by the rise.

Professor Brian Owler, 702 ABC Sydney, 4 June 2014
AMA President Professor Brian Owler talked about Medicare. Professor Owler said there have been a number of reviews but, these have never really been dealt with the schedule as a whole.

Professor Brian Owler, ABC Classic FM, 11 June 2014
AMA President Professor Brian Owler discussed health issues including the “Don’t Rush” road safety campaign, neurosurgery, and vaccinations.

Dr Brian Morton, 3AW, 29 June 2015
AMA Chair of General Practice Dr Brian Morton talked about issues with Dr Google. Dr Morton said it could be beneficial when trying to understand a treatment a patient is undergoing.

Professor Brian Owler, 612, 13 July 2015
AMA President Professor Brian Owler discussed diabetes in Australia. Professor Owler said the majority of type 2 diabetes cases were preventable and encouraged people to eat healthier food and get regular exercise.

Television

Prof Brian Owler, ABC Brisbane, 29 May 2015
The AMA has warned that doctors’ fees could go up if the freeze on Medicare rebates for GP visits continues, and that even patients with private health insurance could end up paying more

Prof Brian Owler, Channel 9, 31 May 2015
A new online tool to help doctors identify and respond to family violence has been rolled out. The resource launched by the AMA allows doctors to provide information on support services.

Dr Stephen Parnis, Channel 7, 13 June 2015
AMA Vice President Dr Stephen Parnis discussed warnings Victoria was on the verge of a whooping cough epidemic. Dr Parnis said deaths from whooping cough were not common but were entirely avoidable.

Dr Brian Morton, Channel 10, 20 June 2015
AMA Chair of General Practice Dr Brian Morton warned of a spike in emergency department admissions, with the price of some of the most common Pharmaceutical Benefits Scheme prescription medications set to rise.

[Articles] The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting

Present forecasts underestimate the expected rise in life expectancy, especially for men, and hence the need to provide improved health and social services and pensions for elderly people in England and Wales. Health and social policies are needed to curb widening life expectancy inequalities, help deprived districts catch up in longevity gains, and avoid a so-called grand divergence in health and longevity.

Name

Position on Council

Activity/Meeting

Date