Where are general practitioners when disaster strikes?

GPs, inevitably involved in disasters, should be appropriately engaged in preparedness, response and recovery systems

In the past two decades it is estimated that Australians have experienced 1.5 million disaster exposures to natural disasters alone.1 General practitioners are a widely dispersed, inevitably involved medical resource who have the capacity to deal with both emergency need and long-term disaster-related health concerns. Despite the high likelihood of spontaneous involvement, formal systems of disaster response do not systematically include GPs.

An Australian Government review of the national health sector response to pandemic (H1N1) 2009 influenza suggested: “General practice had a larger role than had been considered in planning”.2 It commented that “structures . . . in place to liaise with, support and provide information to GPs were not well developed”; personal protective equipment provision to GPs was “a significant issue”; and planned administration of vaccinations through mass vaccination clinics was instead administered through GP surgeries.2

GPs are well positioned to help

As of the financial year 2013–14, Australia had 32 401 GPs,3 distributed through rural and urban communities. GPs are onsite with local knowledge when disaster affects their communities. External assistance may be delayed, and the local doctor may be integral in initial community response and feel compelled to act, yet have a poorly defined role.

GPs can identify vulnerable community members, and are situated in local medical infrastructure with medical resources. When other agencies withdraw in the months after disaster, GPs remain, providing continuity of care, which is likely to be important at this time of high distress and medical need (Box 1). Primary health care during extreme events can support preparedness, response and recovery, with the potential to improve health outcomes.4 The challenge lies in linking GPs with the existing medical assistance response.

Australian GPs’ experience of responding to disasters

Australian GPs have a strong sense of responsibility and moral obligation to their patients. They have spontaneously demonstrated willingness and capacity to respond in recent disasters, including the 2011 Australian floods, the 2009 pandemic influenza, and recent bushfires. In interviews with 60 Tasmanian GPs, 100% of GPs surveyed intended to contribute to patient care in the event of a pandemic, with expression of a strong sense that to do otherwise was unethical, although this was dependent on provision of appropriate personal protective equipment.5

What is lacking is consistent support for GPs, their families and their practices. Local GPs may be personally affected and immersed in the disaster, or experience repetitive exposure to their patients’ trauma. Changes in patient presentations, workload, income and working conditions create additional stress, particularly if compounded by personal loss or injury.6 GPs involved in ad hoc spontaneous response may experience uncertainty of their role or efficacy, reluctance to stand down, or may prefer no involvement. GPs interviewed after the 2011 Christchurch earthquake noted experiencing “emotional exhaustion” and physical fatigue; some were aware of the need for personal care at the time, and others only in retrospect.6

Principles of disaster management

The principles of disaster management follow the internationally accepted all-hazards, all-agencies approach through the phases of prevention, preparedness, response and recovery (PPRR).7 Despite the variation in GP roles due to practice locations and context, the GP role in disaster management is most evident across the time frames of PPRR. As shown in Box 1, GPs provide continuity of care across these periods, but with the least consistency in the response phase.

Preparedness

Our discussions with key GP groups and leaders in the field suggest that despite a rapid increase in the number of practices engaging in disaster planning over the past year, most GPs are currently underprepared for disasters (Box 2). Lack of preparedness increases vulnerability. To redress this global problem, the World Medical Association recommends disaster medicine training for medical students and postgraduates. This could include education on existing disaster response systems, mass casualty triage skills, psychological first aid and the epidemiology of disaster morbidity in the first instance.

Response

In the response phase, it is important that GPs are aware of the overarching plan following the incident management system that coordinates multiple disciplines (including fire, police, ambulance and health) to respond to all types of emergencies, from natural disasters to terrorism. With this in mind, roles for GPs have previously included accepting patients from a neighbouring affected practice, assisting at other practices or with surges in hospital emergency department presentations and at GP after-hours services, or keeping patients out of hospitals through “hospital in the home” services. It may involve providing prescriptions and medical treatment in an evacuation centre, being included in medical teams such as St John Ambulance or identifying more vulnerable patients for evacuation assistance. Most importantly, GPs should maintain usual practice activities where possible. These response models are aligned with the range of GP skills and have clear operational requirements.

Recovery

GP involvement is imperative in the recovery phase, ensuring continuity of physical and psychosocial health care during the ensuing months to years. While most patients recover with minimal assistance, it is crucial that individuals in need of increased support are recognised, particularly those with pre-existing chronic disease. Some presentations may be related to particular hazards, eg, smoke inhalation after bushfire, but many others are risks regardless of the hazard. These include increased substance use, anxiety, depression, acute or post-traumatic stress disorder, chronic disease deterioration, and the emergence of new conditions, including hypertension, ischaemic heart disease and respiratory conditions.8 Children are particularly vulnerable, and changes in behaviour or school performance may indicate residual problems.

Support from general practice organisations (GPOs)

During the 2009 Victorian bushfires, Divisions of General Practice provided strong support to enable general practices affected by the fires to continue to offer health care, by providing human and material resources, skills training, advocacy and media liaison. During the 2013 New South Wales bushfires, there was strong GP linkage by the Nepean-Blue Mountains Medicare Local to existing systems through the Nepean Blue Mountains Local Health District and the state health emergency operations centre, as well as to GPOs at a state level. Lessons learnt need to be incorporated into systems planning.

The need for unified disaster planning is increasingly recognised at both individual GP and GPO levels. The General Practice Roundtable, with input from all the major GPOs, has diverse GP representation, providing an opportunity for broad input into disaster planning across PPRR. Important recent initiatives by GPOs include position statements for GPs,9 and ongoing development of disaster resources, promotion of general practice disaster planning, and the recent formation of a national Disaster Management Special Interest Group within the Royal Australian College of General Practitioners.

Where to from here?

Disasters are devastating events and by nature are unpredictable. While recognising and acknowledging the critical role of the formal emergency response agencies in the existing system of specialised health response and management, the strength of general practice lies in the provision of comprehensive continuity of care, and this lends itself to greatest involvement in the preparedness and recovery phases. There is a need for a clear definition of roles in the response stage. GPs as local medical providers in disaster-affected communities need to be systematically integrated into the existing stages of PPRR with clear responsibilities, lines of communication, and support from GPOs, avoiding duplication of other responders’ tasks. Valuing and using the expertise and resources that GPs can bring to disasters may improve long-term patient and community health outcomes.

1 Current defined roles for general practitioners in disasters

2 Potential roles for general practitioners and GP-related groups in disasters

Prevention and preparedness — before the disaster

national position on the role of GPs in disasters across PPRR;
clearly defined roles that integrate with other responding agencies;
GPO representation on national, state and local disaster management committees;
unified disaster planning across GPOs through the GPRT;
information for other agencies on GPs’ skills and roles through the GPRT and GPOs;
education and training in core aspects of disaster medicine for GPs and medical students;
involvement of local GPs in local disaster planning and exercises through ML or PHN;
general practice business continuity and disaster response practice planning;
assisting patient preparedness to reduce vulnerability;
GP personal and family preparedness; and
vaccination, infection control measures and surveillance in infectious events.

Response — during the disaster

representation in EOCs for communication and coordination with other responders (including ambulance, mental health, public health, etc);
unified disaster response from GPOs, including information, resources and phone support;
coordination through GP networks for workforce support for affected practices;
clearly defined integrated roles in existing systems for GPs involved in response, such as:
- maintaining usual practice activities where possible to help surge capacity
- expanding practice capacity to treat extra patients if needed
- expanded use of practice infrastructure, medical resources and trained staff as appropriate
- supporting existing medical teams such as St John Ambulance
- assisting at the scene, evacuation centre or local clinic as appropriate;
assistance in identification of potentially vulnerable and at-risk individuals and families;
ongoing communication with and referral between other local primary care health providers;
patient education on hazard-related health matters, eg, asbestos, infectious outbreaks, etc;
preventive vaccination — tetanus (clean-up injuries); and
surveillance for future outbreaks and emerging community disease threats.

Recovery — after the disaster

inclusion in the review process to improve future PPRR;2
representation on recovery committees to improve interagency referral and communication;
ongoing support from GPOs for affected GPs and staff through regular contact and resources;
GPOs and ML or PHN support for those practices that are more affected;
management of deterioration of pre-existing physical and mental health conditions;
surveillance for new physical and psychological conditions to improve patient outcomes;
surveillance for emerging community disease threats; and
linkage and communication with community groups and allied health on recovery activities.

EOC = emergency operations centre. GPO = general practice organisations. GPRT = General Practice Roundtable. ML = Medicare Locals. PHN = Primary Health Networks. PPRR = prevention, preparedness, response and recovery.

Doctors get carrot, anti-vax parents the stick, in immunisation boost

Doctors will be paid a $6 incentive to chase up the parents of children who have fallen behind on their vaccinations as part of Federal Government measures aimed at boosting immunisation rates.

Health Minister Sussan Ley said an extra $26 million will be allocated in the Federal Budget to the national immunisation program to encourage doctors to identify children more than two months behind on their vaccinations, as well as to develop an Australian School Vaccination Register and upgrade efforts to educate parents.

It has been revealed last year 166,000 children were more than two months behind on their vaccinations, in addition to 39,000 whose parents had expressed a conscientious objection to immunisation, and Ms Ley said the $6 incentive, which would be in addition to the $6 paid to doctors to deliver vaccinations, was part of a “carrot and stick” approach to deepening the country’s immunity to serious diseases.

“I believe most parents have genuine concerns about those who deliberately choose not to vaccinate their children and put the wider community at risk,” the Minister said. “However, it’s important parents also understand complacency presents as a much of a threat to immunisation rates and the safety of our children as conscientious objections do. Immunisations don’t just protect your child, but others as well.”

The announcement came as the Government intensified its crackdown on anti-vaccination parents claiming childcare subsidies and other benefits.

Social Services Minister Scott Morrison has declared parents can no longer claim an exemption from welfare payment vaccination requirements on religious grounds, adding to the scrapping of exemptions for parents who make a conscientious objection.

It means that the only authorised exemption for the vaccination requirements of the Child Care and Family Tax Benefit Part A schemes, which provide childcare subsidies worth up to $205 a week, a $7500 annual childcare rebate and a tax supplement worth up to $726 a year, is on medical grounds.

Mr Morrison said only one religious group, the Church of Christ, Scientist, had a vaccination exemption, and it was not exercising it.

“The Government has…formed the view that this exemption, in place since 1998, is no longer current or necessary, and will therefore be removed,” the Minister said, adding that it will not be accepting or authorising any further applications for exemption from religious groups.

“The only authorised exemption from being required to have children immunised in order to receive benefits, is on medical grounds,” Mr Morrison said. “This will remain the sole ground for exemption.”

The Government’s tough stand has been backed by the AMA, though President Associate Professor Brian Owler said children should not be “punished” for the decisions of their parents and urged greater efforts to educate parents on the benefits of vaccination.

A/Professor Owler said a recent sharp increase in the number of parents lodging conscientious objections to immunisation meant it was “not unreasonable” for the Government to look at new ways to lift the nation’s vaccination rate.

“The number of conscientious objectors has been rising, so that’s why I think it’s not unreasonable for the Government to come up with another measure,” A/Professor Owler said. “I think it should be seen in that light, that it is really another mechanism, another lever to pull, to try and get the vaccination rates up. It’s not going to solve all of the problems, but I think it’s probably a step in the right direction.”

“The overwhelming advice and position of those in the health profession is it’s the smart thing and it’s the right thing to do to immunise your children,” Mr Morrison said.

“While parents have the right to decide not to vaccinate their children, if they are doing so as a vaccination objector, they are no longer eligible for assistance from the Australian Government.”

Child vaccination rates, particularly among pre-schoolers, are above 90 per cent in most of the country, but figures show significant pockets of much lower coverage, including affluent inner-Sydney suburbs such as Manly and Annandale, where the vaccination rate is as low as 80 per cent, as well as northern New South Wales coastal areas.

High rates of immunisation, above 90 per cent, are considered important in providing community protection against potentially deadly communicable diseases such as measles, diphtheria and whooping cough (pertussis).

Objectors regularly claim vaccination is linked to autism. But this has been scientifically disproved, most recently in a Journal of the American Medical Association study which found that the measles-mumps-rubella vaccine did not affect autism rates among children with autistic older siblings.

A/Professor Owler said there were occasional instances of adverse reactions to vaccination in some individuals, “but they are by far a minority compared to the overall benefits of vaccination. Vaccination is probably the most effective public health measure that we have.”

While he said the Government’s latest measure might help increase the immunisation rate, it was important to continue with efforts to educate parents about the importance of vaccination and encourage them to ensure their children were covered.

“The anti-vaccination lobby has been very successful in putting lots of rubbish out there on the internet in particular. Often it’s notions that have been completely discredited,” he said. “One of the things we’ve got to keep going with [is] education – encouraging parents, giving them the right messages, and getting them to go to the credible source of information, which should be their family doctor or GP.”

A/Professor Owler said often children were not vaccinated simply because it was overlooked by busy parents, and it was important to ensure people were given timely reminders.

The Government’s changes have bipartisan support and are due to come into effect from 1 January next year.

Adrian Rollins

GP training – into the great unknown

By Dr Danielle McMullen, a GP registrar, Chair AMA NSW DiT Committee, and AMA CDT representative on AMA Council of General Practice.

Last week thousands of hopeful GP registrars, the future of our GP workforce, were asked to apply for the Australian General Practice Training Program. But, as it stands today, they are applying to an unknown beast. These doctors must surely feel like they are bravely stepping into a dense fog.

In its 2014-15 Budget, the Commonwealth systematically dismantled the program that has trained many of our highly qualified GPs since 2001.

For more than a decade General Practice Education and Training (GPET) coordinated and oversaw general practice training delivered across the country by regional training providers (RTPs).

While controversial at the outset, GPET then flourished in a growing and increasingly complex environment – it allowed registrars a single point of application and entry, with the flexibility to choose a training pathway towards fellowship of the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM).

At the end of 2014, GPET was quietly rolled into the Department of Health, and in December 2015 the current RTPs will cease to exist. The change is worrying enough (after all, doctors can be creatures of habit), but what is most alarming is that nearly 12 months after the Budget announcement of these changes, we are no clearer on the details of what training will look like in 2016.

At time of writing, the new training organisations remain nameless, shapeless, faceless – we understand there will be fewer of them, but we don’t know how many, where they will be or who they will be.

The tender process for new training organisations has not yet begun, much less been completed.

In addition to the significant changes to vocational training, the 2014-15 Budget also scrapped the Prevocational General Practice Placements Program, which was the only avenue for prevocational doctors in their intern or Postgraduate Year Two year to experience the general practice environment. This gaping hole in the general practice workforce pipeline will result in fewer numbers of interested GP trainees, and throw general practice back to an option of last resort.

We run a real risk of setting GP training back 15 years, to before GPET, when GP training was fragmented, less attractive to junior doctors and we were facing a significant shortage of quality GPs, especially in rural and remote Australia.

At best, we will suffer one or two years of chaos. At worst, the flow on effects of this upheaval will be felt for years to come.

Excellent clinical supervisors, those GPs welcoming registrars into their practices, will forever form the cornerstone of quality general practice training. But they need to be supported by high quality training organisations. And registrars deserve a well-organised, well-supported training environment.

A change is coming – that is for certain. And time is running short but it’s not out yet.

We need urgent clarity and real consultation to plan well and shape the future of general practice training in Australia.

The AMA supports RACGP and ACCRM taking back control of general practice training. The Department of Health should not be the new GPET – the Colleges are best placed to train the specialist GPs of our future. But even they are being kept in the dark.

General practice is an incredible career offering variety, flexibility and fantastic medicine. We need to sing its praises, protect its future, and safeguard its quality. The time for that is now.

Dr McMullen will chair the “General practice training – the future is in our hands” policy session at the AMA National Conference in Brisbane on Saturday 30 May at 2:15pm.

National system urgently needed to counter doctor shopping, drug deaths

Medical defence organisation Avant has joined calls for a national system to provide a real-time record of patient prescriptions amid an alarming rise in doctor shopping and deaths and hospitalisations involving the use of prescribed drugs of dependence.

Avant said the lack of national system to track prescriptions was putting patients at risk and leaving doctors prescribing opioids and other strong pain relievers exposed to legal action by depriving them of vital clinical information.

“Doctors are stuck. It’s like they’re prescribing blind, as they don’t have the benefit of the complete clinical picture,” Avant’s Senior Medical Advisor Dr Walid Jammal said. “Avant is adding its voice to those of a number of coroners, health groups and colleges calling for a national real-time prescription monitoring system as a matter of urgency.”

In the past two decades there has been a 15-fold increase in the prescription of opioids, and state coroners have expressed alarm at a concurrent jump in the abuse of prescription drugs, leading to dependency, harm and death.

In 2013, the Coroners Court of Victoria reported that almost 83 per cent of drug-related deaths involved prescription drugs, predominantly opioid analgesics and benzodiazepines.

Adding to the complexity, many GPs face demands from patients addicted to prescription drugs, or who want to sell them on the black market, Avant said, warning “this can lead to inappropriate prescribing to patients who should not receive drugs of dependence, and inappropriate non-prescribing to patient who should receive them”.

In a position statement on the issue released on 23 April, Avant said the prescription of drugs of dependence was becoming an increasingly legally and clinically fraught area of medical practice, with GPs in particular falling foul of often confusing and contradictory laws and regulations regarding their use.

The defence fund said that since 2009 it had seen a 56 per cent jump in calls to its medico-legal advisory service from doctors prescribing drugs of dependence, and the issue was the cause of more than 230 claims made against medical practitioners, including accusations of over-prescribing, prescribing without authority and denial of a prescription, underlining the extent of uncertainty and concern among the medical profession.

Altogether, more than a fifth of doctor professional misconduct cases involved illegal or unethical prescribing as the primary issue, Avant said, and argued that the incidence could be reduced through better education about the legal and clinical aspects of prescribing drugs of dependence.

“In Avant’s experience, many practitioners have little knowledge of their legal obligations around prescribing drugs of dependence and the regulations applicable in their state. In our view, there is also confusion amongst practitioners over the role of the PBS in providing authority to prescribe certain medications,” it said.

Almost 90 per cent of doctors surveyed by Avant backed the call, and three-quarters said a national real-time prescription monitoring system would help them.

Coroners in three states have made repeated recommendations for the establishment of such a system, and Avant said its introduction was now a matter of urgency.

“This system will go towards supporting the safety of patients and minimising the risk of doctor shopping for the purpose of drug diversion or on-selling,” the defence fund said.

Adrian Rollins

AHPRA Prescribing Working Group

By Associate Professor Robyn Langham, Chair, Medical Practice Committee

AHPRA and the Chairs of the National Boards have convened a Prescribing Working Group (PWG) with the aim of developing a governance framework to support the development and review of National Boards’ regulatory policy for prescribing scheduled medicines.

I represent the AMA on the PWG.

The AMA welcomes the establishment of the PWG.

In our view, the Intergovernmental Agreement and the Health Practitioner Regulation National Law Act 2009 have not delivered adequate safeguards for determining the competencies for prescribing rights.

This has been demonstrated by the fact three health professions in recent years – optometry, nursing and midwifery, and pharmacy – are taking different approaches to expand their scopes of practice with respect to prescribing.

More recently, the Physiotherapy Board applied to the Australian Health Workforce Ministerial Council for approval to endorse the registration of physiotherapists for scheduled medicines under the National Law, before the Board had worked through the process of ensuring appropriate accreditation standards and programs of study for prescribing practice were available.

The approaches adopted by these Boards have not conformed with the frameworks set out in the National Prescribing Service (NPS) Competencies Required to Prescribe Medicines, which establishes the competencies that health professionals need in order to safely, appropriately and effectively prescribe, or in Health Workforce Australia’s Health Professionals Prescribing Pathway (HPPP), which provides a structure for health professional National Boards and Accreditation Councils to make their education requirements, competency standards and assessment processes nationally consistent.

There is no high level evidence that independent non-medical prescribing is safe for patients or cost‑effective for the health system.

The current process of Ministerial sign-off on ad hoc approaches to non-medical prescribing that do not involve first establishing the education and training standards, practitioner competencies, and accredited education and training courses, is not sufficient to safeguard patient safety or the quality use of medicines.

For the work of the PWG to be effective, there needs to be a mechanism for establishing a rigorous governance framework that requires the Boards to work together to ensure consistent standards of education and training, and of practice, underpinning prescribing rights. This would provide the community with the necessary assurance that new prescribing rights are adopted safely, in accordance with the NPS and HPPP frameworks.

Importantly, the process of expanding scope of practice to prescribing scheduled medicines needs to be supported by a robust review mechanism that validates regulatory policy compliance and rationalises cost effectiveness.

The evidence base for safety and cost-effectiveness is unlikely to increase without arrangements by the professions or their Boards to evaluate and review the expanded scopes of prescribing practice they adopt.

The AMA will continue its strong advocacy for robust regulatory oversight for safe practitioner prescribing practice.

The PWG meets quarterly by teleconference, and the next meeting is scheduled for 7 May.

The global challenge of women’s health

Sierra Leone, a West African state of 6 million, saw 11 000 cases and over 3000 deaths during last year’s Ebola outbreak. A bitter civil war from 1991 to 2002, fuelled largely by fierce factions from neighbouring countries, led to 50 000 deaths and degradation of the country’s infrastructure and social fabric. Sierra Leone’s exports of diamonds and bauxite notwithstanding, the lack of a socially responsive polity and a largely agrarian population set the scene for the epidemic. Over 70% of its population live in extreme poverty.1

Sierra Leone also tops the 2013 chart when it comes to maternal deaths — 1100 per 100 000 live births.2 The comparable figure for Australia is six. UNICEF estimates that 88% of the women have been subject to genital mutilation.3

Improving maternal health

The Millennium Development Goals, promulgated by the United Nations in September 2000 and endorsed by 189 countries, sought to halve desperate poverty, defined as living on less than a dollar a day, by 2015. The metrics suggest that this goal has been achieved, and it is a remarkable tribute to international efforts. Among the eight goals, five concern health, and most have been achieved, including huge reductions in infant mortality.

Improving maternal health is one of the health-related goals that has proved harder to reach. Under Goal 5, countries committed to reducing maternal mortality by three-quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 45%.4

Maternal mortality — often due to blood loss and infection — has proved more resistant to efforts to substantially reduce it as a global health problem. It has been intractable in areas of poverty and social turmoil. There were 289 000 maternal deaths worldwide reported in 2013.4

The explanation for these disturbing figures has much to do with social attitudes and investment. When we encounter health disparities, the explanation is most often found outside the clinic, in society and politics. In preventing maternal death, strong investment in education for women is fundamental. Provision of the basic infrastructure necessary for safe childbirth comes next. But even more basic is a pathological view of women — that they are not a priority and that public resources should be invested elsewhere.

Broadening the focus

The World Health Organization draws our attention in 2015 to food security. Its importance is great for women’s health, before and during reproduction and throughout all adulthood, to reduce the risk of nutritional deficiencies, diabetes and heart disease.

When, in 2003–2004, my colleagues at Columbia University and I were examining cardiovascular disease in emerging economies, I was amazed to discover that it far outweighed obstetric and perinatal disorders, HIV and malaria as causes of death of women in the years of family formation and support. In seven out of nine developing countries that we studied, chronic diseases caused over 20% of deaths among women aged 15–34 years, while reproductive causes and HIV together accounted for about 10% of deaths.5 We questioned why the traditional conceptualisation of women’s health has more to do with disorders that impair their performance as reproductive machines than with the real threats to their wellbeing, including the precursors of cardiovascular catastrophe. Those who work on global programs to abate the scourge of diabetes make a major contribution to reducing deaths among women from cardiovascular disease.

Shaking stereotypic thinking

Even if our view of women’s health is restricted to an understanding of causes of death, it is clear we have a task to shake the stereotypic thinking and social relegation of women that foster a completely inadequate global response to their health needs.

There are tasks aplenty for those with advocacy in their blood at governmental, educational and individual levels. Heroic clinicians such as 91-year-old Dr Catherine Hamlin AC and her co-workers at the Addis Ababa Fistula Hospital, its five regional hospitals and the Hamlin College of Midwives set outstanding examples of other pathways.

GP training confusion: call for urgent talks

The AMA has voiced “grave concerns” about the Federal Government’s handling of far-reaching changes to general practitioner training under the shadow of looming doctor shortages.

AMA President Associate Professor Brian Owler has written to Health Minister Sussan Ley seeking an urgent meeting to discuss the implementation of changes to GP training announced in last year’s Budget.

A/Professor Owler warned the Minister that the medical profession was “fast losing confidence in the process, and history shows that the last time GP training was reformed by the Government it took many years to recover”.

In its 2014-15 Budget, the Federal Government abolished General Practice Education and Training (GPET) and the Prevocational General Practice Placements Program (PGPPP), axed funding to the Confederation of Postgraduate Medical Education Councils and absorbed Health Workforce Australia and GPET within the Health Department.

Under the sweeping changes, the Health Department will have responsibility for overseeing GP training.

The changes have stoked warnings that, combined with cuts to valuable programs and fears of massive hikes in student fees, they pose a serious risk to the quality and viability of general practice training, placing the profession at long-term risk.

Concerns have centred on the short time frame to implement the changes, the Department’s lack of experience in managing training programs, and the profession’s loss of supervision over training.

A/Professor Owler said expert AMA representatives who have been consulting with the Government and Health Department on the implementation of the changes have been alarmed by on-going delays and a lack of detail being provided by the Department on crucial matters such as the funding of professional oversight and governance arrangements.

“Unfortunately, we are now in a position where we simply do not know what the structure and delivery of GP training will look like beyond 2015,” the AMA President said in his letter to Ms Ley.

He said briefing papers provided by the Health Department for those attending its stakeholder meetings were “generally scant on detail and do not adequately deal with key issues, such as the future role of the GP Colleges”.

A/Professor Owler said the overwhelming view in the medical profession was that the Colleges should be given responsibility for the governance and management of GP training.

Anxiety about the changes has been heightened by predictions the nation could face a critical shortage of doctors in the next decade.

The ageing of the GP workforce and the struggle to attract students to specialise in general practice has contributed to forecasts of a shortfall of 2700 doctors by 2025 unless there is a major investment in training.

Last month Health Minister Sussan Ley re-announced the allocation of $157 million to extend the life of two medical training programs – the Specialist Training Program and the Emergency Medicine Program – through to the end of 2016.

Ms Ley said the programs were being sustained for an extra year while the Government continued to consult with the medical Colleges and other stakeholders about reforms to come into effect in 2017.

“This consultation will focus on in-depth workforce planning to better match investments in training with identified specialities of potential shortage and areas that may be over-subscribed into the future,” the Minister said. “Workforce planning is something that doctors and health professionals have been raising with me during my country-wide consultations to ensure those areas of expected shortages are addressed sooner rather than later.”

But Shadow Health Minister Catherine King condemned what she described as a “short-term fix”.

Ms King said the Government had thrown the entire field of specialist medical training into chaos by delaying confirmation of contracts just weeks before candidate interviews were due to commence.

Ms King warned that any cut to funding to specialist training would result I fewer specialists working in areas where they are needed most.

Adrian Rollins

Health at the core of closing the gap

AMA President Associate Professor Brian Owler has warned that governments need to increase their investment in health in order to close the yawning gap in life expectancy and wellbeing between Indigenous people and other Australians.

In a veiled swipe at the Federal Government’s policy focus on school attendance and employment in Indigenous communities, A/Professor Owler told a major international conference on the social determinants of health that too often the importance of wellbeing was overlooked.

“Health is the cornerstone on which education and economics are built,” the AMA President said. “If you can’t go to school because you or your family are sick, truancy officers won’t work. If you can’t hear because of otitis media, you won’t learn. If you miss training opportunities because of depression or ill health, you won’t progress to employment. You can’t hold down a job if you keep having sick days.”

His remarks to a British Medical Association symposium on the role of physicians in addressing the social determinants of health came a month after Prime Minister Tony Abbott admitted that the nation had fallen behind on meeting most of its Closing the Gap targets.

While there has been some improvement in the life expectancy of Aboriginal and Torres Strait Islander people, Indigenous men still on average 10.6 years earlier than other Australian males, and the gap for women is 9.5 years.

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said the fact that chronic and non-communicable diseases and other preventable occurrences such as suicide, trauma and injury accounted for a major proportion of the gap in life expectancy underlined the need for greater investment in health care, particularly Aboriginal community controlled health services.

“While those with chronic disease need to be cared for, prevention, particularly in the early part of life, is the key if we are going to see a generational change in health outcomes,” A/Professor Owler said.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

“There have been many examples of governments trying to address the social determinants of health – but often they have failed,” he said, referring to policies including building inappropriate housing and taking children from their families.

The AMA President said any attempt to improve Indigenous health needed to acknowledge the fundamental importance for Aboriginal and Torres Strait Islander people of their connection with the land, and understand that in many Aboriginal languages health was a concept of social and emotional wellbeing rather than a physical attribute.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

“Constitutional recognition is a vital step towards making Aboriginal and Torres Strait Islander people feel historically and integrally part of the modern Australian nation,” A/Professor Owler said. “Recognising Indigenous people in the Constitution will improve their self-esteem, their wellbeing, and their physical and mental health.”

Prime Minister Tony Abbott has taken a personal interest in Indigenous affairs, concentrating responsibility for many Indigenous policy areas within the Department of Prime Minister and Cabinet and overseeing the development of the Indigenous Advancement Strategy.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

“What is missing from the core of the IAS is a focus on health,” the AMA President said. “Health underpins many of these outcomes. We need to get the balance right and we, the AMA, need to ensure that health is seen as a foundation to these outcomes.”

He said that “spending on health is an investment. Investing in health must underpin our future policies to Close the Gap, and to address what is, for Australia, a prominent blight on our nation”.

Adrian Rollins

AMA approves Govt jab at anti-vax parents

The AMA has backed the Federal Government’s move to rip childcare and welfare benefits from parents who refuse to have their children vaccinated, while emphasising the need for greater parent education.

AMA President Associate Professor Brian Owler said that although children should not be “punished” for the decisions of their parents, an increase in the number of people lodging conscientious objections to immunisation meant it was “not unreasonable” for the Government to look at new ways to lift the nation’s vaccination rate.

Parents who conscientiously object to the vaccination of their children could be up to $15,000 a year worse off after Social Services Minister Scott Morrison announced they would lose their entitlements to a range of Government subsidies and benefits.

Under current arrangements, parents who lodge a conscientious objection to vaccination are granted a special exemption from the immunisation requirements of the Child Care and Family Tax Benefit Part A schemes, giving them access to childcare subsidies worth up to $205 a week, a $7500 annual childcare rebate and a tax supplement worth up to $726 a year.

Mr Morrsion said there had been an alarming jump in the past decade in the number of children not immunised because their parents claimed to have a conscientious objection to vaccination, from around 15,000 to 39,000.

He said there would still be exemptions from vaccination on medical and religious grounds, (though adding there were only a “very, very small number” of religious groups that had registered an objection) but those with a conscientious objection would no longer have their choice subsidised by taxpayers.

“The overwhelming advice and position of those in the health profession is it’s the smart thing and it’s the right thing to do to immunise your children,” Mr Morrison said. “If they [conscientious objector parents] choose to not do that, well, the taxpayers aren’t going to subsidise that choice for them.”

Claims that vaccination is linked to autism have been scientifically discredited, but anti-vaccination groups continue to peddle misinformation about the safety and risks of immunisation.

A/Professor Owler said there were occasional instances of adverse reaction to vaccination in some individuals, “but they are by far a minority compared to the overall benefits of vaccination. Vaccination is probably the most effective public health measure that we have.”

A/Professor Owler said often children were not vaccinated simply because it was overlooked by busy parents, and it was important to ensure people were given timely reminders.

The Government’s changes have bipartisan support and are due to come into effect from 1 January next year.

Adrian Rollins

Health at the core of closing the gap

In his speech, A/Professor Owler said that in many respects the term ‘social determinants of health’ was misconstrued, because health was in fact a determinant of social and other outcomes.

He said hard-earned experience showed that health was fundamental to closing the gap, as was the need to work in partnership with Indigenous communities themselves.

He told the London conference that this was one of reasons why the AMA was a foundation member of the campaign to achieve constitutional recognition for Indigenous Australians.

Priorities for the Strategy include improving school attendance, boosting Indigenous employment and improving community safety.

A/Professor Owler said these were all worthy aims, but the Strategy overlooked the central importance of health.

Adrian Rollins