Effectiveness of a financial incentive to physicians for timely follow-up after hospital discharge: a population-based time series analysis [Research]

BACKGROUND:

Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge.

METHODS:

We conducted an interventional time series analysis of all medical and surgical patients who were discharged home from hospital between Apr. 1, 2002, and Jan. 30, 2015, in Ontario, Canada. The intervention was a supplemental billing code for physician follow-up within 14 days of discharge from hospital, introduced in 2006. The primary outcome was an outpatient visit within 14 days of discharge. Secondary outcomes were 7-day follow-up and a composite of emergency department visits, nonelective hospital readmission and death within 14 days.

RESULTS:

We included 8 008 934 patient discharge records. The incentive code was claimed in 31% of eligible visits by 51% of eligible physicians, and cost $17.5 million over the study period. There was no change in the average monthly rate of outcomes in the year before the incentive was introduced compared with the year following introduction: 14-day follow-up (66.5% v. 67.0%, overall p = 0.5), 7-day follow-up (44.9% v. 44.9%, overall p = 0.5) and composite outcome (16.7% v. 16.9%, overall p = 0.2).

INTERPRETATION:

Despite uptake by physicians, a financial incentive did not alter follow-up after hospital discharge. This lack of effect may be explained by features of the incentive or by extra-physician barriers to follow-up. These barriers should be considered by policymakers before introducing similar initiatives.

Emergency department use in developed countries

A global study undertaken by George Washington University has evaluated the use of emergency departments in seven developed countries and has identified areas where efficiencies are needed.

The study, conducted with Royal Philips researchers, found that Australia has a low use of emergency departments when compared to Canada, the US, the UK, the Netherlands, Switzerland and Germany.

This finding points to Australia’s strong access to primary care resulting in less frequent use of emergency resources.

The paper, Acute unscheduled care in seven developed nations: a cross-country comparison, compares the similarities and differences across nations with a focus on care delivery and the impact of socio-economic factors.

The research from Philips and the GWU School of Medicine and Health Sciences reveals unsustainable ED use in some developed nations.

Better access to primary care can result in lower ED use.

The findings of the report show Germany (22 per cent) and Australia (22 per cent) as having the lowest ED use, likely resulting from better and faster access to primary care — nearly two-thirds of Australians (58 per cent) and three-quarters of Germans (72 per cent) were able to make same or next day appointments with their primary care physicians (PCPs) compared to less than half of Americans (48 per cent) and Canadians (41 per cent).

“In looking at the way emergency departments are used around the world, we were able to obtain valuable new insights to help improve care delivery,” said Jesse Pines, from GWU.

“Because of research findings presented in this report, all emergency departments, no matter their location, have the opportunity to efficiently improve the way care is delivered in emergency department settings.”

Kevin Barrow, managing director of Philips Australia and New Zealand said the research shows Australia ranked relatively well when it comes to hospital emergency department admissions.

“And (for) the cost of health care for both government and individuals, in comparison to other countries surveyed, reflecting the relative ease of access to primary care in our country,” he said

“However, the findings also identified a need to improve departmental efficiencies and increase activities to minimise the burden on acute care facilities, by continuing to focus on preventive care, chronic disease management and the education of patients on the appropriate care for their health needs.”

Data has been formulated into a list of key areas researchers say impact the way care is delivered in emergency settings, and the broad differences in available treatments across countries.

They include:

• Social determinants (smoking, eating, violence, substance abuse and poverty) have a strong impact on the use of EDs;

• Reduced access to health insurance results in poorer population health; placing a greater strain on emergency departments;

• Sick patients do not make the most efficient decisions about when and where to seek medical care;

• Extensive provider training is mandatory for effective delivery of acute unscheduled care; and

• Quality measures for EDs are immature and not standardised.

“There’s a belief that easy access to primary care can result in lower emergency department use,” said Mark Feinberg of Philips North America.

“However, as a result of this report, it is clear that even if people have easy access to primary care and full healthcare coverage, there is no guarantee the patients will make economically prudent decisions to seek the most appropriate medical care setting.”

The complete report can be accessed at: www.healthsystems.philips.com/acute-unscheduled-care

CHRIS JOHNSON

Is there a doctor on board? What to do in an in-flight emergency

You’re a couple of hours out of Sydney on your way to Europe, you’ve settled into your in-flight movie and you’re finishing your second glass of shiraz when the announcement goes out: “If you are a doctor, could you please make yourself known to a crew member?”

If you’ve been practising medicine for some time, you may well have encountered such a scenario: by one estimate, an emergency requiring medical assistance occurs on one in 600 commercial flights. But as a doctor, what are your legal and ethical duties and your liabilities, and do your two glasses of shiraz matter?

The question of legal duty is complex. A new viewpoint published this week in JAMA states that physicians do not have the legal obligation to assist in the United States, Canada or the United Kingdom, but they may do in Australia and some European countries.

The situation in Australian airspace is ambiguous to say the least. Morag Smith, Senior Solicitor at Avant Law, says there is no common law requirement for doctors to provide assistance to non-patients in an emergency. But that advice would seem to be contradicted by a 1996 case in which a GP declined, when asked, to assist a child on holiday who was having an epileptic fit. The child ended up neurologically damaged and the doctor was successfully sued for negligence.

Regardless of legal obligation, most doctors and medical associations would agree that there is at the very least an ethical duty to assist if you feel you can make a difference.

The question of liability if you do assist in an in-flight emergency is more clear-cut. So-called ‘good Samaritan’ laws protect doctors and healthcare providers from legal liability as long as the care is given in good faith and the doctor is not impaired by alcohol or drugs at the time. Similar laws apply in the United States.

So then there’s the question of your shiraz, because, let’s face it, a long-haul flight without a glass of wine is a rare thing indeed for the non-tee-totallers among us.

It’s a grey area, but if you consider your competence may be impaired due to your alcohol intake, you may wish to inform the cabin crew before deciding whether you are in a position to assist. It may well be that there is another doctor on board who would perform better than you.

Here are a few tips should you ever find yourself being the “doctor on board” during a medical emergency:

Inform the crew of any limits to your medical competence. If you haven’t practised for some time, it may be that another doctor or nurse on board is more competent;
Check what medical equipment there is on board. This can vary considerably from airline to airline;
Many airlines have access to surface medical support: ask the crew if this is the case and request immediate contact with the ground medical team;
Get a history from the patient and obtain their consent to examination and any treatment;
If a patient can’t consent, and there is no family member to consent for them, you can still proceed with treatment if you believe there are reasonable grounds to suppose the patient will benefit;
Be ready to make a judgement call as to whether a patient can be helped by the plane being diverted or turned back.

Sources: Avant, JAMA

My gender and my degree

BY DR DANIKA THIEMT

The ﬁrst documented English-speaking female doctor was Dr James Miranda Barry, a medical ofﬁcer of the British Army between 1813 and 1865. Dr Barry devoted her life to the British Army, earning the highest medical rank available: Inspector General of military hospitals. In an era when academic professions were the sole privilege of male members of society, it was necessary for Dr Barry to conceal her gender, living and practising medicine as a man. Her sad reality was exposed only posthumously where examination revealed her secret. Even in death, she was denied her right to her true identity; her gender kept secret for a further 100 years.

In Australia, medical training was opened to women in the late 1800s, and our ﬁrst female graduate was registered to practice in 1891. Female medical trainees are now thriving, with female medical graduates in Australia outnumbering men since the mid-1990s. Women currently make up more than two-ﬁfths of vocational trainees, focused largely in obstetrics and gynaecology (74.5 per cent), paediatrics (72.8 per cent) and general practice (63.1 per cent). Contrast this to the ﬁgures from oral and maxillofacial surgery, intensive care and surgery and female trainees make up less than a third of trainees. How, when we see women making up half or more of medical graduates and provisional trainees, are we still seeing unequally representation in the ongoing workforce? What is happening along the way? How and why does a speciality that starts out gender-neutral result in a specialist workforce that is predominantly male?

Fixing gender inequity in medicine requires supporting women in leadership. Diversity in the boardroom enhances corporate performance and, to advance as a profession, we need to attract and retain female leaders. Female specialists, on average, earn 16.6 per cent less than their male counterparts. Although differences in average hours worked account for some discrepancies, other contributory factors include a lack of women in senior positions and a lack of part-time or ﬂexible senior roles. There are already inspiring and engaged female leaders within our profession, leading the world in clinical practice, medical research and education. We should be harnessing their talent to inspire the next generation.

The changing demographic of our workforce could, in part, be to blame. Trainees are graduating from medical school later and spending more time in vocational training. This leads to greater family and social pressures on trainees and possibly an increase in the need for breaks or ﬂexible training options. Evidence shows that access to ﬂexible training helps to retain female trainees and is desired by both female and male trainees regardless of parental status. We need to dispel the belief that trainees must choose between career and family and instead focus on how we enable trainees to have both.

Gender inequity extends beyond medical workforce.Many of my female colleagues report being mistaken for nursing or allied health staff, a rare occurrence among my male colleagues. Similarly, senior female doctors are often overlooked by patients who prefer to talk to the male junior by her side. How do women thrive in medicine and become leaders when public perception seems to favour male doctors? I watch senior medical staff respond to “Miss” in conversation rather than the respectful “Dr”. Although this seems petty in the scheme of everyday practice, it is easy for female doctors to believe that our degrees come second to our gender. Although the actions of some do not make a rule, it is time that we stand together as a profession to advance women in medicine. It is time to advocate for female leadership not only in the eyes of the profession but also in the eyes of the public.

Equity isn’t about creating a false forced equality. We aren’t all equal and that should be celebrated. It certainly shouldn’t hold us back. Opportunities to become leaders won’t be taken by all of our trainees, but they should be provided to all, regardless of gender.

(A version of this article first appeared in Emergency Medicine Australasia in 2016.)

[Comment] Procalcitonin-guided antibiotic stewardship from newborns to centennials

In 1993, Assicot and colleagues1 reported in The Lancet that procalcitonin was a marker of systemic infections in neonates and paediatric patients. In 2004, Christ-Crain and colleagues2 reported that procalcitonin guidance substantially reduced antibiotic use in adult patients presenting to the emergency room with lower respiratory tract infections, and in 2010, Bouadma and colleagues3 reported that a procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical adult patients in intensive care units reduced antibiotic exposure and selective pressure with no apparent adverse outcome.

This bondage isn’t right

BY DR JOHN ZORBAS, CHAIR, AMA COUNICL OF DOCTORS IN TRAINING

There’s a key difference between bondage and bonding. One is a contract between two or more parties, requiring informed consent, and designed for the mutual benefit of all involved. The other is a terribly flawed stick that the Australian Government seems intent on bashing medical graduates with, in a poorly informed attempt to provide a rural workforce.

In Australia, we have two medical bonding programs: the Bonded Medical Places (BMP) scheme and the Medical Rural Bonded Scholarship (MRBS). There are several different versions of these schemes, if you count the number of different contracts that now exist since their inception, but they can broadly be summarised as follows. The BMP scheme provides participants with a Commonwealth Supported Place (CSP) in medical school in exchange for a return of service of one to six years in rural and regional Australia. The MRBS scheme provided participants with a CSP in medical school and by the time it was axed a scholarship of $26,310 a year in exchange for six continuous years of work as a specialist in rural and regional Australia. Sounds simple enough, but the more you dig, the more you realise just how bad a deal this is for these future doctors and the patients they’re supposed to be serving.

You see, the first major flaw in this plan is that bonding just doesn’t work. Funnily enough, if you force someone to do something on your terms in an uncertain and inflexible manner, it turns out that people don’t appreciate the experience and they don’t come back. When bonding in medical school was first conjured up, the AMA provided evidence that similar schemes overseas, especially in North America, had failed to provide any form of sustainable medical workforce. More than 13 years have now passed and an exceedingly small number of scheme participants have completed their return of service. In fact, more participants have withdrawn or breached their agreement than those who have completed their return of service. Not exactly a ringing endorsement.

Compare this with the other measures and programs that are supported by the AMA. We know that having a rural background significantly increases your chance of going rural, and we have strongly supported increasing the quota of students from rural backgrounds. We floated the idea of Regional Training Networks in 2014, to help allow those who wanted to work and stay rural obtain fellowship in a more sustainable manner and reduce infrastructure duplication in what is already a resource poor area of medical training. We supported the Prevocational General Practice Placements Program and, following its abolition by the Abbott Government, subsequently developed an alternative proposal for a Community Residency Program (CRP), to enable doctors to have meaningful rural experiences in their pre-vocational years, while they work out exactly what career they want to pursue. And we have long supported an increased rural focus in the Specialist Training Program (STP), allowing registrars to be adequately funded to work in rural areas on progression to fellowship. It’s a suite of measures that encourages positive experiences and supports trainees along their often complicated and difficult path.

But the Government has chosen to focus on draconian bonding schemes. Let’s explore the MRBS for a second, mostly as initially on paper it looks very attractive. You take a 17-year-old undergraduate student and you promise them $26,310 tax free and a place in medical school for a return of service. Sounds reasonable. Except what 17-year-old understands Medicare? Hell, how many healthcare workers and bureaucrats even understand Medicare? Do we adequately explain to them that leaving the scheme will result in a 12-year ban from Medicare, effectively killing their medical career there and then, simply because of a change in their life situation and circumstances? Do we explain to them that as they train to become a rural general practitioner, they will be effectively forbidden from working in the city for short periods of time, preventing them from upskilling in crucial rural skill sets such as emergency medicine, obstetrics and anaesthetics? Do we explain to the orthopaedic trainee that they only have 16 years from the start of medical school to complete their requirements? Caveat emptor is one thing, but conscriptive blackmail is another.

And even if you are one of the few to complete your return of service, just how happy will you be at the end of it all? What doctor, having had to deny themselves the opportunities of personal and professional development at the behest of such an authoritarian scheme, will look kindly on rural Australia? When you take away mastery, autonomy and purpose, you’re left with a bitter, angry human. That’s not the kind of person that rural Australia deserves.

The AMA Council of Doctors in Training is continuing to lobby government to adjust the BMP and MRBS for the good of its participants and the Australian public that it purports to serve. Nobody is arguing that a return of service isn’t owed, but it certainly shouldn’t function like this. If you or someone you know is affected by these schemes, we’d like to hear about it. Please contact me at cdt.chair@ama.com.au and let’s see if we can’t loosen the bureaucratic nipple clamps, just a little bit.

Public Hospital Doctors role central to AMA

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

I’d like to state my thanks for all the input and interest from PHD members at our recent National Conference. It was invigorating to experience your enthusiasm for the many issues directly affecting public hospital doctors. An important issue about which I do want to remind you is actually how you “describe” yourself for AMA membership purposes. In order to keep the CPHD vibrant and relevant to key issues, we must have a solid base. Today we can choose our membership category more accurately. I hope more doctors based in public hospitals, particularly those with a Specialist qualification, will choose to identify in the public hospital doctor membership category as opposed to their medical craft group if they have one, when it comes to identifying their AMA membership as you will be invited to do soon, and thus remain engaged with the CPHD.

Vale Dr Patrick Pritzwald-Stegmann

Multiple issues are before the CPHD. None is more relevant than safety in the workplace. On July 21, a Memorial Service was held for AMA member Dr Patrick Pritzwald-Stegmann, who died after substantial time ventilated in one of our ICUs after an alleged “coward’s punch” received in the foyer of a Melbourne metropolitan public hospital resulted in a profound brain injury. This is now a Coroner’s and police matter. I am regularly horrified at the experiences of violence in our community and our workplaces, but this is all the more poignant for me as Patrick was a recent close colleague of mine with whom I had worked extensively.

There are many intersecting issues in our community, most of which lead to the public hospital system. They include mental health issues, whether acute, chronic or acute-on-chronic, illicit drug use, perhaps loading up on mental health issues, increased passive tolerance of greater violence in and by the now metropolises (as opposed to tight-knit communities), and a general lack of respect for those providing any type of community service. Emergency service providers and our colleagues and other healthcare workers in emergency departments face the brunt, but it is throughout the public hospital system. I note that our population is growing remarkably, we have generated profound productivity improvements, but there remains a yawning gap of lack of public hospital capacity investment to match the essential hospital requirements of the complex, multi-system, elderly and/or obese, chronic illness sufferers. It is readily observable how “house full” messages contribute to patient frustration, then anger and venting in our workplace. It was equally offensive to see lauding of “this is what 182 blows to the head looks like” related to a recent violent “sport” designed to inflict brain injury. It is easy to see some might link these ingredients, resulting in an unsafe workplace for us.

In perhaps a curious coincidence, I am now chairing an Australian Standards committee revising the standard Security for Health Care Facilities. It will be a template for consideration of security risks for any and all health care facilities in Australia. Its origin related to large public hospitals, but changes in technology and hospital interventions means security issues are everywhere that medicine is practised, including hospital-in-the-home and all points travelling between, patient record security, medication and medical gas security, microorganism security, IT security, food security, let alone staff safety and security. I will be pleased to receive your thoughts on this topic. Obviously not everything will be totally relevant to all, but in these days of terrorism and bioterrorism, it will be a useful tool for risk analysis. It will be a sad day if every part time medical point of care in a high rise tower through to our major teaching hospitals needs to have the same security we now take for granted on getting to the airside of an airport, surveillance cameras or requires trained and authorised security personnel with Tasers and policing powers comparable to Protective Service Officers.

Of note, none of the above may have prevented Patrick’s injury, or some of them may have caused the alleged perpetrator to pause.

Public Hospital Funding

It is clear an expansion and greater funding of public hospital’s is required to meet the increasing demand, separate to security investments. This is about to accelerate in my view as more reduce private health insurance due to increasing premiums coupled with increasing mortgage, energy and education costs pressures. An important discussion will be how best to use the now billions of tax dollars shoring up publically listed health insurance companies’ profits and employee bonus payments, whilst squeezing the marketplace and offering frequently inadequate products to bamboozled patients seeking a tax break.

Recently the Government rejected a proposal to abolish the private health insurance rebate and effectively take funds it saves from that, along with hospital funding, to provide a standard benefit for services, regardless if they happen in a public or in a private hospital. This would effectively take Commonwealth funds from public hospitals and force patients to pay more for coverage. This would reduce the amount the Commonwealth contributes to the cost of public hospitals to a paltry 35 per cent. The 42 or 43 per cent funding we’re getting from the Commonwealth now is not sustainable for future public hospital operation.

A 35 per cent share would be a disaster in the super-stretched public system and in the private system for that matter. In recent years we’ve seen the Commonwealth’s share of funding to public hospitals drop below 45 per cent with a formula that only relies on growth in CPI and population. The AMA’s Public Hospital Report Card shows that performance in the system, such as wait times in the emergency department or for elective surgery, are not improving, or indeed are going backwards. So we can be thankful that this reduction has been ruled out.

But with consideration of the way hospitals are funded, we need to focus on priorities and things that might work in the hospital system. This especially includes quality and safety initiatives as well as increasing the utility of secondary hospitals or in the community. We must put more resources into primary care prevention as a long-term strategy for reducing the rate of increase of pressure on public hospitals.

Let’s hope governments see sense and realise that proper health care is a sound investment and saves money in the long term, and that engaging with doctors is the only way to develop sound health policy. I look forward to discussing these and other issues with you in upcoming CPHD meetings and other events.

[Comment] Azithromycin in uncontrolled asthma

Asthma is a highly prevalent chronic airway disease affecting more than 300 million people worldwide. Despite treatment with inhaled corticosteroids and long-acting bronchodilators, asthma is uncontrolled in a substantial number of patients who remain symptomatic and are at risk of asthma exacerbations. These asthma attacks are often triggered by viral respiratory infections and might lead to emergency room visits, hospitalisations, and rarely, death; they result in a huge personal and societal burden.

AMA delivers submission to Government review into aged care facilities

The AMA has submitted its views on the Federal Government’s regulatory activities applying to quality of care in aged care residential facilities.

The Oakden report shed light on a wide range of issues facing aged care. AMA members have reported that the occurrences at the Oakden Older Mental Health Service were not isolated incidents – indicating a problem with the current aged care system.

The proportion of Australians 65 years of age and over is predicted to increase to 18 per cent by 2026. It is also predicted that 900,000 Australians will have dementia by 2050, almost triple the 342,800 recorded in 2015.

It is evident that the health care needs of residents in residential aged care facilities (RACFs) are increasing in complexity.

The majority of Aged Care Funding Instrument (ACFI) assessments indicate a “high” need of care across all three assessment categories (activities of daily living, behaviour, and complex health care). The Government must ensure the sector has the capacity to provide quality care for this growing, more complex, ageing population.

The issues at Oakden were brought to the attention of the Northern Adelaide Local Health Network when a client was admitted to an Emergency Department with significant bruising to his hip. A person’s health status is a significant identifier for the quality of an aged care facility or home service. When serious health issues arise, aged care issues are commonly noticed.

Medical practitioners – whether at the Emergency Department, or consulting patients at an aged care facility – may have a unique opportunity to identify issues with the quality of an aged care home or signs of elder abuse.

Medical practitioners are also the second highest profession Australians trust and should be considered part of the aged care workforce to increase quality of care.

Many points made in the submission have been previously made by the AMA, and they are not newly arising issues in the aged care sector. The AMA has been advocating for some time to ensure medical and nursing care for older Australians, including lodging submissions to the multiple aged care reviews that have occurred recently.

In this submission, the AMA argues that:

Medical practitioners should be included as part of the aged care workforce to ensure residents of aged care facilities are receiving quality care;
Aged care needs funding for the recruitment and retention of registered nursing staff and carers, specifically trained in dealing with the issues that older people face;
The aged care sector needs a contemporary system that embraces information technology infrastructure for patient management;
A contemporary IT system for medication management will reduce the risk of polypharmacy, and in turn reduce the likelihood of cognitive impairment, delirium, frailty, falls, and mortality in RACFs;
There needs to be clear, specific, and confidential complaints referral pathways in each RACF so information on complaints processes are easily accessible to both residents and staff;
There needs to be increased awareness of mental health issues to include funding for appropriate mental health services in the ACFI assessment process; and
The aged care system needs an overarching, independent, Aged Care Commissioner who provides a clear, well-communicated, governance hierarchy that brings leadership and accountability to the aged care system.

Many of these issues need to be reflected in specific accreditation standards that have a strong focus on health. In particular, an “access to medical care” standard should be introduced. To receive funding from the Federal Government, an aged care facility must pass accreditation standards that are assessed by the Australian Aged Care Quality Agency.

The AMA recognises that these standards will vary with the introduction of the single set of aged care quality standards, however, there are several required improvements that should be included in the new standards.

For some standards a flexible approach is adequate, as different services have different capabilities and capacities. However, this may lead to inconsistencies between each assessor, or the assessment process not picking up on vital signs of incompetence.

Standards that relate to medical care should not be subject to interpretation to ensure quality care is received. RACFs must be aware of their specific responsibilities.

Residents should have access to, and their medical needs met by, qualified medical practitioners. Rather than vague standards that say RACFs should ensure compliance with all relevant legislation, a medical care standard should reflect aspects of the National Safety and Quality Health Service Standard.

People living in aged care facilities should have access to the same quality health services as other Australians. The AMA has been advised that currently, RACFs (with the exception of facilities that provide acute services) do not have to comply with these standards.

The current policy settings do not support GPs working after hours, neither does it acknowledge the benefits of continuity of care. AMA members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s management plan is not well known. This creates an environment where the default step for RACF staff may be to refer the patient to an ED.

One concept worth considering is an MBS item for phone consultations with a nurse or carer from an RACF to incentivise doctors to be on call after hours. This could in turn increase the number of doctors who make themselves available out of normal business hours and reduce costs in comparison to reimbursing a GP physically-attended consultation. In addition, the care of patients’ regular GP would avoid unnecessary referrals to the ED and the associated triage issues.

AMA members have reported cases where registered nurses are being replaced by junior personal care attendants, and some RACFs do not have any nurses staffed after hours. This presents significant communication difficulties.

A recent survey identified low staffing levels in residential aged care as the main cause of missed care. The Government must ensure that aged care facilities are not restricted due to a workforce shortage. The decline in the proportion of nurses and enrolled nurses needs to be reversed to ensure residents are provided with timely and appropriate clinical care. This is critical to the success of the aged care system.

While the Government’s complaints process is seeing improvements, there also needs to be a focus on the RACF’s internal complaints process. The culture in many RACFs discourages making complaints, and this was especially seen at Oakden – where staff complaints were answered with bullying and harassment from management. The Government needs to ensure that the privacy and confidentiality of both aged care staff and consumers are protected when making a complaint.

Aged care staff should be properly trained on the ethical, medical and legal issues that can arise from using a restraint, and also educated on ways to improve the aged care environment through ensuring a friendly physical space, and through social and staffing structures.

In order for the aged care system to evolve, we must also consider that, like the broader health system, aged care impacts upon State, Territory, and Federal Governments. However, there is a lack of coordination between the levels of jurisdiction. Aged care is the purview of the Commonwealth but when a health complication arises, residents are often transferred to a hospital which is the responsibility of the State or Territory Government. This means that the States often bear a financial cost resulting from issues that arise in a Commonwealth-run aged care environment.

The Australian aged care system is heavily regulated and, with reform underway, regulation may increase over time. Without adequate financial support, guidance, and accountability from the Government, RACFs and other aged care services will continue to struggle to meet these complex regulations.

CHRIS JOHNSON

The full submission can be viewed at: submission/ama-submission-review-commonwealth-government%E2%80%99s-regulatory-activities-applying-quality

[Editorial] Losing the fight against HIV in the Philippines

The Philippines is facing an unprecedented HIV crisis. New infections have doubled in the past 6 years to more than 10 000 new cases last year alone. Undoubtedly, stigma remains one of the major reasons for the spread of HIV in the Philippines, as Risa Hontiveros, Filipina Senator and Vice-Chairperson of the Senate Committee on Health, said on Aug 2, urging the Government to declare the HIV epidemic a national emergency.