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Preference: Education

190

The jugular veins: gateway to the heart

Inspection of the jugular veins provides a simple means of determining whether pressures in the right side of the heart are normal or elevated. With practice, clinicians can derive accurate and reliable information relevant to diagnosis and patient care.

Identifying a venous pulsation

It is not necessary to position the patient at precisely 45 degrees.1,2 If your patient is in a chair, examine them in that position. If they are on a couch or bed, examine them in the position that you find them.

Explain to the patient why you want to look at their neck. Traditionally, the right side of the neck has been used for jugular vein examination. However, it is often more difficult to see pulsations on the same side as you are positioned and, importantly, it is known that measurements made from the left side of the neck have similar accuracy.3 Further, inspection of the external, rather than internal jugular vein are also of similar accuracy.4 If you do use the ipsilateral side of the neck, try side-lighting with a torch or looking tangentially across the skin, rather than directly at it. Whichever side you use, and whichever vein, there must be visible pulsation at the top of the venous column. If there is no visible pulsation, do not use that vein as a manometer.

Ask the patient to turn their head slightly away from the side you are observing and focus on the area where the internal jugular vein is located — the anterior triangle (Box 1).

If you cannot see any pulsation at all, try lying the patient flatter or sitting them up — this may make a venous pulsation visible. If you still cannot see any pulsation, try sustained firm pressure in the upper abdomen. This is known as abdominojugular reflux and may transiently elevate a venous pulsation from below the clavicle and make it visible. If you have to do this to make a venous pulsation visible, it usually means that the right atrial pressure is not elevated.

When you identify a pulsation, decide whether it is arterial or venous. Box 2 shows the key distinguishing features.

If you decide that the pulsation is arterial, try abdominojugular reflux or changing the position of the patient to see if any additional pulsation appears.

If the veins of the neck seem distended but are non-pulsatile, sit the patient up at 90 degrees. This may make the pulsatile top of a venous column visible.

On most occasions, unless the patient is very obese, this systematic approach will allow confident identification of a venous pulsation. You can then use the pulsation to estimate right atrial pressure, whatever position the patient is in.

Estimating the right atrial pressure from observation of a jugular vein pulsation

When you identify a jugular vein pulsation, do not try and make a measurement in centimetres, just decide whether the pressure is normal or elevated. The simplest way to do this is as follows. If the top of the pulsating venous column can be seen to be more than 3 cm above the angle of Louis (sternal angle) in whichever way you have positioned the patient, this is highly predictive of an elevated right atrial pressure.1 Remember that clinical evaluation of the jugular vein pressure, just like ultrasound evaluation, typically underestimates the right atrial pressure.1 If you are confident that the jugular vein pressure is elevated, this reinforces the likelihood that the right atrial pressure is high.

What do I need to know about the waveform?

The jugular vein waveform is complex with three peaks — atrial contraction (a), ventricular contraction (c) and venous filling of the atrium (v) — and two troughs — atrial relaxation (x) and ventricular filling (y). Most clinicians can recognise the multiphasic quality of the venous pulsation but cannot confidently identify the specific peaks and troughs or their abnormalities. In real life clinical practice, this is of little importance. However, one abnormality of waveform is not uncommon. The video at www.mja.com.au demonstrates the giant v wave, which makes the venous pulsation almost look uniphasic and can mimic arterial pulsation if the steps described in Box 2 are not followed. This waveform is highly predictive of the presence of tricuspid regurgitation.5

Clinical value of jugular vein pressure estimation

In situations when accurate and multiple measurements of right atrial pressure are required — for example, the acutely unwell patient in a high dependency or intensive care setting — direct measurement by invasive (catheter) or non-invasive (ultrasound) means is usually preferred.

However, for the large numbers of patients cared for in ambulatory or general ward settings — particularly when heart failure is questioned as a diagnosis, or is known to be present and decisions about treatment are required — evaluation of the venous pressure by the method described here remains valuable. In the longer term, bedside ultrasound may supersede this technique. However, in the immediate future and in the absence of widespread access to such technology, bedside assessment of jugular venous pulsation is accurate and convenient, and continues to be a gateway to good clinical care of patients with heart disease.

Box 1 –
Jugular vein anatomy — the anterior triangle

Box 2 –
Features that help distinguish an arterial from a venous pulsation in the neck

Arterial pulsation

Venous pulsation

Appearance

Uniphasic, single

Multiphasic, undulating, flickering*

Effect of changing the position of the patient

None

May change its position in the neck

Effect of respiration

None

Falls on inspiration, rises with expiration

Palpation over the pulsation

Palpable

Impalpable (but beware of pressing too deeply, as you may feel the carotid)

Effect of gentle pressure at base of neck

None

Ceases

Effect of sustained pressure on the upper abdomen (abdominojugular reflux)

None

Transient rise

* The video at www.mja.com.au shows an exception to this general rule.

[Correspondence] Austerity threatens universal health coverage in Brazil

Michael Temer, Brazil’s new interim president from the centre-right Brazilian Democratic Movement Party (PMDB), has unveiled an agenda of austerity measures to stimulate economic growth. In the manifesto Uma Ponte Para Futuro (October, 2015), he announced plans to reduce public spending, including the education and health-care sector. The minimum budget guaranteed by the constitution (3·8% of gross domestic product at present) would be abolished. The new Health Minister, Ricardo Barros, has revealed plans to end the monitoring of private health-care quality by the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar), while encouraging Brazilian citizens to seek private health care instead of relying on the Brazilian National Unified Health System (Sistema Único de Saúde [SUS]).

Older male doctors face scrutiny

Older male doctors who have been the subject of several patient complaints could be targeted as part of proposals to “proactively” identify those most likely to pose a risk to patients.

Members of the medical profession would be profiled on their propensity to provide sub-standard care as part of a two-pronged process to support quality care and protect patients set out by a group of experts advising the Medical Board of Australia on the revalidation of doctor skills and knowledge.

A discussion paper on options for revalidation, issued by the Medical Board on 17 August, proposed that doctors undertake a ‘strengthened’ CPD [Continuing Professional Development] program. Simultaneously, there would be a “proactive” screening process to identify and assess doctors who may be performing poorly and pose a risk to patients.

“CPD alone, however rigorous, may not identify the practitioner who may be putting the public at risk. A regulatory approach, however thorough, cannot reliably, single-handedly improve the quality of care provided by most competent doctors,” the Revalidation Expert Advisory Group said in a report which formed the basis for options canvassed in the discussion paper.

The expert group recommended that all practitioners undertake evidence-based, profession-led CPD activities that, in addition to attending conferences and workshops, would involve peer review of performance and medical records, feedback from patients, clinical audits and comparison of data with local, regional and national outcomes.

Medical Board Chair Dr Joanna Flynn said the intention was to keep the public safe and manage risk to patients, and “part of this involves making sure that medical practitioners keep their skills and knowledge up-to-date”.

The recommendations come amid concerns that regular reports of misconduct by a small number of doctors are undermining public confidence and damaging the reputation of the medical profession.

In an interim report to the Medical Board, the Revalidation Expert Advisory Group said international evidence showed that only about 6 per cent of doctors provided sub-standard care.

The group said it was critical to “develop accurate and reliable indicators” so that practitioners who were performing poorly and posing a risk to their patients could be identified and helped before they harmed anyone.

“Prevention is better than cure,” the group said in its interim report, setting out the characteristics international experience showed were most common in those likely to pose a risk to patients, including:

  • being 35 years or older (with the risk increasing as age advances);
  • being male;
  • number of prior complaints; and
  • time since last complaint.

The interim report said studies had identified a number of additional individual risk factors, including:

  • doctors getting their primary medical qualification in certain countries (not specified);
  • specialty;
  • failing to respond to feedback;
  • an unrecognised cognitive impairment;
  • practising in isolation;
  • few high quality CPD activities; and
  • a change in the scope of practice.

“We propose that there is now enough evidence to trigger discussion and draw on insights available about how various risk factors might be used to proactively identify practitioners at risk of poor performance,” the export group said.

Once groups of at-risk practitioners were identified, it was important to determine which individuals actually posed a threat to public safety.

Just because someone was in an at-risk group did not mean they were underperforming, the interim report said, emphasising that early detection and remediation was preventive and should not be punitive.

Those identified as underperforming would face a “tiered approach” of assessment, scaled to match the level of potential risk.

It would start with specialty-specific “multi-source feedback” involving input from colleagues, patients and co-workers – a process the expert group judged would be effective many cases in returning doctors to safe practice.

Doctors assessed as posing a greater threat could face peer review of their medical records, and practice and outcomes data.

Those determined to be the greatest risk to patients would face “extensive performance assessment”.

The Medical Board said the proposed changes would not have “a significant impact” on doctors already undertaking effective CPD activities, though some would need to change their focus to include performance review, outcome measurement and validated educational activities.

It likened the profiling used to identify at-risk practitioners to disease screening tests.

“Most of the practitioners in the at-risk groups will be able to demonstrate that they are performing satisfactorily, just as most people who are screened in a public health intervention do not have the disease for which the screen program is testing,” the Board said.

The Board has appointed a committee to conduct consultations with the medical profession and the broader community regarding the revalidation proposals.

Those interested are invited to participate in online discussions, take a short survey and provide written submissions. The deadline for feedback is 30 November this year,

The Revalidation Expert Advisory Group will provide a final report to the Board in mid-2017.

For further details, including copies of the discussion paper and interim report, go to: http://www.medicalboard.gov.au/News/Current-Consultations.aspx

Adrian Rollins 

Invest in health to avoid political disaster, Gannon tells Govt

The Federal Government must boost investment in general practice and public hospitals if it wants to avoid “a major Medicare headache” at the next election, AMA President Dr Michael Gannon has warned.

As the re-elected Turnbull Government finalises plans to put $6.5 billion of spending cuts, including in health, before the new Parliament, Dr Gannon has called for a change in the Coalition’s mindset away from seeing health as a cost and instead view it as an investment, warning that the Government’s political survival is at stake.

In his inaugural address to the National Press Club, the AMA President said the knife-edge result of the Federal election showed that Australians were “very comfortable with the state being in charge of their health and education” and did not like political parties messing with the system.

“There is no doubt that health was a game-changer in the election. It was very nearly a government-changer, too,” Dr Gannon said. “For many Australians, the health system – doctors, nurses, allied health, hospitals – is called Medicare. They see any threat to Medicare as bad.”

Prime Minister Malcolm Turnbull has acknowledged the political damage the Government inflicted on itself through its plans to introduce a co-payment for GP services and its cuts to public hospital funding, and has already had several meetings with Dr Gannon in an effort to try and improve his Government’s relationship with the medical profession.

But Dr Gannon said that, while the more consultative approach was welcome, it had to result in better policy, reiterating the AMA’s demands for an end to the Medicare rebate freeze, increased funding for public hospitals, the restoration of bulk billing incentives for pathology and diagnostic imaging tests and increased investment in preventive health.

The Government has so far shown no signs of budging on its decision to freeze Medicare rebates until 2020 as it tries to hold health expenditure down.

But Dr Gannon said the policy was a false economy because it was hurting GPs, who were providing the most cost-effective care in the health system. Furthermore, it would result in more patients deferring seeing their family doctor and eventually requiring much more expensive hospital care, and was undermining the goodwill of GPs, which would be needed for the successful implementation of the Health Care Homes initiative.

Just 6 per cent of the Government’s health spending goes on GP services, and Dr Gannon said general practice represented “very, very good value for money”.

But instead of getting support, GPs were being crushed in a “diabolical squeeze” as funding has been held down and cut even as demand for their services has continued to climb.

“GPs are now at breaking point,” the AMA President said. “Unless there is substantial investment in general practice, there is no doubt that the quality of care will start to suffer – and patients will face growing out of pocket costs.”

He warned that patients who are currently bulk billed may face out-of-pocket costs of $20 or more and “without a big re-think on the range of policies that affect general practice, the Government could have another major Medicare headache at the next election”.

Health Care Homes

One of the Government’s boldest reforms is to establish the Health Care Home model of care for patients with chronic illness. Under the plan GPs would, in addition to their current fee-for-service remuneration, be paid to help the chronically ill manage their disease.

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

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

So far, the Government has only committed $21 million for a trial of the concept, none of which will go toward patient care.

Dr Gannon said that asking GP to provide enhanced care without any extra support “simply does not stack up”.

The Government also need to overcome the “significant trust and goodwill deficit” it had with general practitioners.

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

Prevention better than cure

Dr Gannon used his Press Club speech to intensify the pressure on the health insurance industry, accusing health funds of putting profits before patients and warning of a slide toward US-style managed care if they had their way.

The Government has acted on mounting discontent with the quality of health cover by announcing plans to ban ‘junk’ public hospital-only policies, mandating minimum levels of cover and introducing a simplified rating system for policies.

The AMA President said these were important steps, but the Commonwealth needed to provide much greater support for public hospitals.

In 2014, the Abbott Government controversially walked away from the previous Labor Government’s hospital funding agreement with the states, at a cost of $57 billion over 10 years.

Dr Gannon said public hospitals were “an everyday saviour for Australian families”, but were failing to meet waiting time and treatment targets as “a direct consequence of the Commonwealth’s failure to fund their share”.

He said the States and Territories did not have the revenue base to increase their funding, and the “Commonwealth Government needs to step up”.

To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.

He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.

“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”

He said the success of action to curb smoking showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.

In his speech, Dr Gannon also highlighted the urgency for action to improve Indigenous health. He expressed strong support for the Royal Commission into juvenile detention in the Northern Territory, and backed constitutional recognition as a way to “help heal some of the wounds that underlie Indigenous disadvantage”.

 Adrian Rollins

Striving for truly healthy growth

The limitations of political slogans – the ‘privatisation of Medicare’ or ‘jobs and growth’ – are severe. Ideas are shorn of nuance and words stripped of definition. What is meant by ‘privitisation’ and ‘Medicare’, and what by ‘growth’?

While privatising Medicare may at first blush be the phrase of greatest interest to doctors, I suggest that ‘growth’ is of deeper concern. Growth – unqualified – could be a curse and not a cure, a health hazard rather than a health promoter, a cancerous thing rather than a positive developmental pathway.

True, decades of free market-based economic growth have achieved remarkable improvements in global health. Whole nations have been lifted from poverty, death and suffering. In economically-advanced nations unimaginable affluence has been achieved with improved average life expectancy.

But with this growth have come unintended side effects. The global challenge of climate change is one such consequence. Inequality is another. In the US, the rich have become disproportionately richer without improvement in economic well-being among workers. This has substantial political effects. Commentators speak of how this inequality, present also in the UK, has contributed to Trump and Brexit.

Growth with attitude

Jeffrey Sachs, an economist at Columbia University with a long-standing passionate interest in sustainable development and health in less developed economies, wrote recently in the Boston Globe about the need for a fresh understanding of what we mean by growth. Sachs played a major part in the development of what are called the Sustainable Development Goals, or SDGs, under the auspices of the United Nations. The goals were agreed upon one year ago by more than 100 nations, including Australia. 

In brief, the SDGs, to quote Sachs, aim at economic growth, but defined in a manner that promotes decency and environmental sustainability. The 17 goals involve the achievement of more than 100 specific objectives. They fall into three groups: those associated with classical economic progress; those that have to do with ensuring environmental sustainability; and those that concern justice and social fairness.

Now, almost a year later, in New York on July 20, ministers and country representatives at the annual UN High-Level Political Forum attended the launch of an index, a measuring device, designed to allow countries to assess how they stand now in relation to the SDGs, and how they can judge their progress. The index is aimed at strengthening the commitment to growth in a way that is consistent with improving human decency and honouring the environment. It provides a current assessment for 149 of the 193 UN member states. It asks each nation to rank itself on indicators of poverty, nutrition, health care, education and pollution – all elements of the SDGs.

The goals include universal education, gender equality, clean water and sanitation, affordable clean energy, decent work and economic growth, reducing inequalities and developing sustainable cities.

Three are of special interest to medical and other health professionals. They concern further efforts to reduce poverty; to do what is needed to promote health and wellbeing; and to ensure food security for all.

In one sense these goals could hardly be disputed. But the real question is whether they have enough grunt to motivate change.

Critics, including The Economist, refer to the goals as “sprawling” and not sufficiently specific, especially when compared with the much fewer (12) Millennium Development Goals that were associated with great progress in infant mortality, HIV and other forms of health promotion and disease control for example.

Nevertheless, despite the ambitious spread of the SDGs, they take account of current urgent global challenges from which Australia cannot hope to remain immune.

Moving Australia toward sustainable growth

The world leaders on the SDG index are the Scandinavian countries, followed by others from Northern Europe. Canada was 13th, Australia 20th and the US 25th. Sweden’s homicide rate is around one-seventh of America’s, and its incarceration rate one-tenth. Infant and maternal mortality rates are lower, as is income inequality.

In summary, the SDGs are an international expression of an attempt to seek truly global health – for people, the environment and the planet.

While achieving these goals is a lofty ideal, we can only make progress if we use words like ‘growth’ accurately. If we mean growth that advances the economy while also promoting environmental sustainability and reducing social inequality, then we will be on a solid path to the future.

 

How do you choose a leader (hint: it may not be what you think)

In 2016, women are less likely to be our leaders in the highest levels of medical education, hospital management and representation of the medical profession. This remains true even at the level of student leadership, despite a little over 50 per cent of medical students being female.

There are many societal reasons why women are underrepresented in leadership roles, such as absorbing a higher load of unpaid domestic work and a paucity of female leaders to model themselves after. There’s also something going wrong with the way that all of us – men and women alike – perceive our female leaders. 

In choosing leaders and in judging their success, we all do our best to make the right decision. But our inherent biases have a nasty habit of getting in the way.

So how does gender impact the people we promote and the leaders we vote for? Research says ‘quite a lot’, and it starts long before we’re reading a person’s CV or hearing their election pitch. In spite of ourselves, the evidence shows that gender colours the way we view our day-to-day interactions.

Some examples? In an election scenario, a recording of a lower-pitched voice is perceived as more competent, stronger and more trustworthy than the same recording digitally manipulated to reflect a higher pitch. As such, the lower-pitched candidate was more likely to be chosen as leader by study participants. Our view of women, who on average have higher-pitched voices than men, is being formed the moment we hear them speak.

There are studies to show that women speak less than men in meetings, but are perceived to speak more. Another study that analysed the talking behaviour of US Senators found that when women did speak more than their share of the conversation, they were rated 14 per cent less competent by observers. Men who spoke more than their share were instead perceived as being 10 per cent more competent. So our female leaders walk the double bind of having less opportunity to demonstrate competency by contributing to discussion and decision, or instead speaking more and being viewed as less competent as a result.

When it comes to nominating for and receiving positions, both men and women are more likely to offer a job to a male candidate than to a female candidate with an identical CV. Additionally, if a fictitious advertisement for a leadership role is given to equally qualified men and women, women perceive themselves to be less suitable for the job than the men perceive themselves to be. So, women are less likely to put themselves forward for a leadership position than men, and we’re all less likely to believe a women who does put herself forward should be given the role.

However, many of these effects can be reversed where an effort is made to do so. For example, the same study that identified a gender disparity in the amount of time speaking at meetings also found that when a decision was being made by unanimous vote rather than majority rule the effect disappeared, and female voices were equally heard. Additionally, while research shows that the characteristics typically associated with leadership are stereotypically masculine, it also shows that this effect is decreasing over time, and suggests flatter organisational hierarchies which promote teamwork and interaction as the cause.

When we find ourselves forming an opinion about a male leader, or a female one, we owe it to them to think about why. To reflect on which judgements are valid, and which are instead the result of seeing a majority of leaders look a particular type of way. Only once we’ve understood our biases can we set about changing them.

All of us are responsible for the promotion and election of our leaders; within medical education, within hospital management, and as our professions’ representatives. And we need to get those decisions right.

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.

 

 

 

 

[Articles] Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials

Our findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA. The previously unrecognised effect of aspirin on severity of early recurrent stroke, the diminishing benefit with longer-term use, and the contrasting time course of effects of dipyridamole have implications for understanding mechanisms of action.

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