Budget 2017-18 from a public health perspective

Analyses of federal budgets are typically couched in clichés. Government’s talk about jobs and growth, initiatives, priorities and investments; while oppositions and minor parties respond with the language of not enough, missed opportunities, disappointments and failures.

In regard to public health and health prevention, the 2017-18 Coalition Budget is all of these things.

There are many welcome and positive public health initiatives in the Budget. The Government has listened to the AMA and is investing $5.5 million into an immunisation awareness campaign. There is a further $14 million to expand the National Immunisation Plan to provide catch-up vaccinations to 10-19 year-olds who missed out on childhood vaccinations. These are measures the AMA has been advocating directly with the Government for.

New mental health funding is also welcome. There is $9 million for a telehealth initiative to improve access to psychologists for people living in rural and remote areas, and an extra $15 million for mental health research initiatives. The big ticket item is $80 million of additional funding to maintain community psychosocial services for people with mental illness who do not qualify for the NDIS. This is a very good measure and shows that Health Minister Greg Hunt has taken on-board concerns the AMA and others raised about people falling through the cracks that exist between the NDIS and State and Territory community services.

However, this funding is contingent on the States and Territories matching the Commonwealth’s commitment. The Government said it will allocate the entire $80 million, even if some States or Territories do not sign up to the matched funding offer. In other words, the money will only go to those jurisdictions who offer a matched dollar-for-dollar commitment. What we don’t know is how these funds will be allocated and what happens if a State or Territory does not sign up or provide new money for psychosocial services. Will the people in those jurisdictions be left with no psychosocial supports? I suspect that the Australian Health Ministers’ Advisory Council (AHMAC), the advisory and support body to the COAG Health Council, may be the entity that negotiates this funding measure.

The mental health sector has been encouraged by this Budget and Minister Hunt’s dedication to mental health reform. Preventative health didn’t get the same attention as mental health in this budget. The Prime Minister told the National Press Club in February: “In 2017, a new focus on preventive health will give people the right tools and information to live active and healthy lives.”

There was, therefore, an expectation that this Budget would deliver in key areas of preventative health, most importantly in tackling obesity. The AMA has been calling for a range of initiatives and measures that are urgently needed to address the rise in obesity, and in this respect the cliché of ‘missed opportunity’ is applicable.

There is a $10 million initiative to establish a Prime Minister’s Walk for Life Challenge and a further $5 million for a GPs Healthy Heart partnership with the RACGP to support GPs to encourage patients to lead a healthy lifestyle. These are small but good measures. The AMA has been calling for a national obesity prevention strategy that recognises obesity as a complex problem that can only be addressed through a broad range of measures. The measures announced in the Budget are a start, but fall well short of the funding for community-based initiatives and restrictions on the marketing of junk food and sugary drinks to children that we say are needed to address obesity.

There was no National Alcohol Strategy or any measures that help Australians manage the misuse and abuse of alcohol, and the alcohol-fuelled violence that emergency department staff know all too well.

There were no measures or initiatives that address climate change and health.

The Government has indicated that there will be a ‘third wave’ of preventative health measures, possibly in the next budget. We hope so, because investment in preventative and public health initiatives is smart, cost-efficient and a benefit to future generations.

Simon Tatz
Director, Public Health

Technology set to change children’s health

A national initiative, My Health Record, has been designed to help the access and sharing of information to improve children’s health outcomes by using a digital platform.

The new children’s digital health network, the National Collaborative Network for Child Health Informatics, is a collaborative project between eHealth NSW, Sydney Children’s Hospital Network and the Australian Digital Health Agency (ADHA).

My Health Record’s aim is to be patient centred and clinician friendly so as to support integrated care for children and their families. It will also enhance the quality of clinician care through improved decision making tools, including a child’s safety in an emergency.

My Health Record will be a digital summary of a patient’s medical information including diagnosis, outcomes, medications, reactions and allergies. Clinical documents added by healthcare providers could also include Shared Health Summaries and Hospital Discharge Summaries.

Parents choose what information gets loaded onto their child’s record. They also control what information stays on their child’s record and who can access the information. The patient’s record will be part of a national system that will travel with each child.

Accessing and sharing information about their children’s health using a new technology platform will enable parents to accurately keep track of their children’s healthcare that can be easily shared with healthcare providers.

“This can improve their ability to access health services and enhance their experience of health services because their providers have real-time information about each child’s health status, immunisation status, and interaction across the entire health system. The work of the Network will help us realise this vision,” said ADHA Chief Executive Tim Kelsey.

Because My Health Record is a part of the Australian Government’s Digital Health Agency it is protected by security and safety laws at a nationally recognised level.

Meredith Horne

World Medical Association meets in Zambia

AMA President Dr Michael Gannon represented Australian doctors at the 206th World Medical Association Council meeting.

Medical practitioners from national medical associations around the world gathered to debate a number of key issues in Livingstone, Zambia on April 20 to 22. The event was attended by almost 200 delegates from more than 30 national medical associations.

Medical cannabis was one of the key discussions at the meeting. A Position Statement was developed to be presented at the WMA’s General Assembly in October.

A debate also took place on proposals to revise the WMA’s long-held policy on boxing so as to include safety regulations until a ban could be put in place. A recommendation to revise the policy at the General Assembly was agreed.

The Council agreed they needed to update their position on availability and effectiveness of in-flight medical care, along with the idea of allowing physicians to provide emergency care during flights without fear of legal reprisals.

Discussions also took place on bullying and harassment in the medical workplace; updating ethical advice on hunger strikes for doctors; armed conflicts; medical education; alcohol; and water and health.

All new policy proposals will be forwarded to the General Assembly.

WMA leaders heard from the Confederation of Latin American National Medical Associations (CONFEMEL) that restrictions on the professional freedom of physicians to practice medicine was leaving patients without basic medical care. They reported that medical prescriptions and laboratory tests were being restricted, leading to disappointed and sometimes angry patients.

Dr Ketan Desai, President of the WMA, said: ‘We have been told that doctors in Venezuela feel helpless to resolve the situation, which is getting worse day by day. Junior doctors in particular are having to face angry patients and are often suicidal.

“For the sake of patients and physicians in Venezuela this situation cannot be allowed to continue. We urge the Government of Venezuela to allocate the necessary resources to the health care system and to ensure the independence of physicians to allow them to deliver high quality medical care to their patients. At the moment patients’ fundamental rights to health are being violated.”

WMA is now considering sending a delegation to Venezuela to express support to local doctors as well as report on the situation.

Extreme concern was expressed by the WMA as well as calling for the immediate release of a Turkish doctor, Dr Serdar Küni who is jailed in Turkey for providing medical treatment to alleged members of Kurdish armed groups.

Dr Küni, a respected member of the local community, and former chairperson of the Şırnak Medical Chamber was the Human Rights Foundation of Turkey’s representative in Cizre. He has remained detained since his arrest last October and is awaiting trial. Concerns have been raised by human rights organisations regarding his access to a fair trial and fair hearing rights at that trial.

The WMA believe the case of Dr Küni is one example among many of arrests, detentions, and dismissals of physicians and other health professionals in Turkey since July 2015, when unrest broke out in the southeast of the country.

The WMA moved an emergency resolution that condemned such practices that: “Threaten gravely the safety of physicians and the provision of health care services. The protection of health professionals is fundamental, so that they can fulfil their duties to provide care for those in need, without regard to any element of identity, affiliation, or political opinion.”

It added: “The WMA considers that punishing a physician for providing care to a patient constitutes a flagrant breach of international humanitarian and human rights standards as well as medical ethics. Ultimately it contravenes the principle of humanity that includes the imperative to preserve human dignity.”

The United Nations Security Council has declared, states should not punish medical personnel for carrying out medical activities compatible with medical ethics, or compel them to undertake actions that contravene these standards.

Meredith Horne

1st Australasian Diagnostic Error in Medicine Conference

Local and world leaders in medical diagnosis will meet in Melbourne in May to explore ways to improve diagnosis and patient safety.

The theme of the 1^st Australasian Diagnostic Error in Medicine Conference is “teamwork and collaboration for safer diagnosis”, so it will bring together GPs, radiologists, pathologists, emergency department physicians and trainees, as well as nurses and other allied health workers.

Joined by leaders in diagnostic error, the safety sciences, health IT, medical indemnity providers, clinicians, cognitive psychologists, and advocates for patients, the attendees share a passion for making diagnosis more accurate, timely, and safe.

The language of diagnosis will be explored and the contribution that medical culture makes to diagnostic error, both positive and negative, will be examined.

The Conference is being held on 24-25 May (just before the AMA National Conference 2017 on 26-28 May, also in Melbourne) and more information can be found at https://improvediagnosis.site-ym.com/page/AusDEM17

Maria Hawthorne

Domestic violence leading cause for women and girls hospitalised from assault

New data released by the Australian Institute of Health and Welfare (AIHW) shows that nearly 6,500 women and girls were hospitalised due to assault in Australia in 2013–14, with the violence usually perpetrated by a partner or spouse.

The statistics on the deaths and serious injuries resulting from family and domestic violence has been called a national epidemic, and one of Australia’s biggest social, legal and health problems.

The AIHW examined cases of hospitalised assault against women during that period and it exposed that when place of occurrence was specified, 69 per cent of assaults against women and girls took place in the home.

“While women and girls are, overall, hospitalised as the result of assault at a rate that is less than half the equivalent rate for men (56 cases per 100,000 females compared to 121 cases per 100,000 males), the patterns of injury seen for females are different to that seen for males,” AIHW spokesperson Professor James Harrison said.

AIHW data highlights:

Nearly 60 per cent of hospitalised assaults against women and girls were perpetrated by a spouse or domestic partner.
More than half (59 per cent or 3,685) of all women and girls hospitalised due to assault were victims of an assault by bodily force and a further quarter of all hospitalised assault cases against women and girls involved a blunt (17 per cent or 1,048 cases) or sharp object (9 per cent or 551 cases).
Open wounds (22 per cent or 1,400 cases), fractures (22 per cent or 1,375) and superficial injuries (19 per cent or 1,194) accounted for almost two-thirds of the types of assault injuries sustained by women and girls.
In the 15 years and older age group, 8 per cent of victims were pregnant at the time of the assault.

The AIHW notes that the data used in their report probably underestimates the incidence of hospitalised assault resulting from domestic violence, as victims can be reluctant to report an incident to hospital personnel or to identify a perpetrator for hospital records.

The AMA believes the medical profession has key roles to play in early detection, intervention and provision of specialised treatment of those who suffer the consequences of family and domestic violence, whether it be physical, sexual or emotional.

Further the AMA advocates that medical practitioners must encourage attitudes and actions necessary to prevent family and domestic violence, identify women, men, families and children ‘at risk’, prevent further violence and assist patients to receive appropriate help and protection.

If you or someone you know is impacted by sexual assault or family violence, call 1800RESPECT on 1800 737 732 or visit www.1800RESPECT.org.au In an emergency, call 000

Meredith Horne

Cholera vaccination campaign focussing on Somalia

A second stage of a major vaccination campaign to halt the spread of cholera got underway in March and April in three drought-ravaged regions of Somalia.

Gavi, the Vaccine Alliance, delivered 953,000 doses of Oral Cholera Vaccine to the country to protect more than 450,000 people from the disease.

The campaign took place in three of the worst-hit regions, Banadir, Kismayo and Beledweyne, with the vaccine being given in two doses to everyone over the age of one. The first round ran from 15-19 March and the second from 18-22 April.

The vaccines were procured, transported and stored at the appropriate temperature by UNICEF. They are being administered by the Government of Somalia with the support of World Health Organisation (WHO) and UNICEF; while UNICEF and others continue to improve water and sanitation infrastructure and promote behaviour change. As well as providing the vaccines, Gavi has provided US$550,000 to support the campaign.

Seth Berkley, CEO of Gavi, said the people of Somalia are going through unimaginable suffering.

“After years of conflict, a severe drought has brought the country to the brink of famine and now a suspected cholera outbreak threatens to become a nationwide epidemic,” he said.

“These lifesaving vaccines will play a vital role in slowing the spread of the disease, buying valuable time to put the right water, sanitation and hygiene infrastructure in place to stop the root causes of this outbreak.”

Dr Ghulam Popal, WHO Representative in Somalia, said cholera was a major health issue in Somalia.

“The current drought has worsened the situation for many. Therefore we’re very glad to have the support of Gavi to implement the first OCV campaign in Somalia,” Dr Popal said.

“We are very hopeful that the vaccination campaign will control outbreaks, and eventually save lives.”

The current severe drought in Somalia has forced communities to use contaminated water, helping cholera to spread. A total of 25,000 cases of Acute Watery Diarrhoea/cholera have been reported since the beginning of 2017, causing at least 524 deaths. Surveillance reports indicate that the epidemic is now spreading to areas inaccessible to aid workers.

UNICEF Somalia Representative, Steven Lauwerier said the vaccination campaign was an emergency measure.

“We need to continue to tackle the main cause of such outbreaks,” he said.

“UNICEF, donors, government and other stakeholders are making some progress in improving access to safe water and promoting good sanitation and hygiene practices and this needs to be scaled up urgently.”

Gavi, the Vaccine Alliance is a public-private partnership committed to saving children’s lives and protecting people’s health by increasing equitable use of vaccines in lower-income countries.

The Vaccine Alliance brings together developing country and donor governments, the World Health Organization, UNICEF, the World Bank, the vaccine industry, technical agencies, civil society, the Bill & Melinda Gates Foundation and other private sector partners.

Gavi uses innovative finance mechanisms, including co-financing by recipient countries, to secure sustainable funding and adequate supply of quality vaccines. Since 2000, Gavi has contributed to the immunisation of nearly 580 million children and the prevention of approximately 8 million future deaths.

Chris Johnson

[Editorial] Prospects for neonatal intensive care

In today’s Lancet we publish a clinical Series on neonatal intensive care in higher resource settings. The Series, led by Lex Doyle from The Royal Women’s Hospital in Melbourne, VIC, Australia, includes new approaches to the old nemesis of bronchopulmonary dysplasia (which still affects up to 50% of infants born before 28 weeks’ gestation), discusses the delicacy of fine-tuning interventions in response to evolving evidence, and explores the frontier of nutritional research by referring to preterm birth as a nutritional emergency.

News briefs

Hidden risk population for thunderstorm asthma

Research presented at the Thoracic Society for Australia and New Zealand (TSANZ) Annual Scientific Meeting in Canberra last month identified “a potentially hidden and significant population susceptible to thunderstorm asthma”. “This is a wake-up call for all of Australia, but particularly Victoria as it prepares for its next pollen season,” said Professor Peter Gibson, president of TSANZ. “Many more people than previously thought are at risk of sudden, unforeseen asthma attack. It is essential that we invest more research into this phenomenon and educate our health services and public to take preventative and preparedness measures.” Nine people died in Victoria late last year and over 8500 required emergency hospital care when a freak weather event combining high pollen count with hot winds and sudden downpour led to the release of thousands of tiny allergen particles triggering sudden and severe asthma attacks. Those most seriously affected were people who were unaware they were at risk of asthma and therefore had no medication to hand. In the study of over 500 health care workers, led by the Department of Respiratory and Sleep Medicine, Eastern Health, Victoria, almost half the respondents with asthma experienced symptoms during the thunderstorm event. Most took their own treatment, a few sought medical attention and one was hospitalised. More alarming was the 37% of respondents with no prior history of asthma who reported symptoms such as hayfever, shortness of breath, cough, chest tightness and wheeze during the storms. The study also found that people with a history of sensitivity to environmental aeroallergens (eg, ryegrass or mould) were far more likely to report symptoms than those with a history of either no allergy or allergy to dust mite/cats. Physical location, described as predominantly indoors versus outdoors, was not a risk factor. “This study gives us an indication of the proportion of our population that might be at risk of thunderstorm asthma, but are unaware of it as they have no history of asthma. It also suggests that a history of hayfever is one of the greatest risk factors,” said lead researcher Dr Daniel Clayton-Chubb. “The key message from our work is that anyone with hayfever should ensure that they have ready access to quick-acting asthma treatments such as bronchodilators at all times, but particularly in pollen season or if thunderstorms are predicted. Severe thunderstorm asthma symptoms can strike rapidly and without warning.”

New genetic causes of ovarian cancer identified

A major international collaboration has identified new genetic drivers of ovarian cancer, findings which have been published in Nature Genetics. The study involved 418 researchers from both the Ovarian Cancer Association Consortium, led by Dr Andrew Berchuck from the United States, and the Consortium of Investigators of Modifiers of BRCA1/2, led by Professor Georgia Chenevix-Trench from QIMR Berghofer Medical Research Institute. Professor Chenevix-Trench said it was known that a woman’s genetic make-up accounts for about one-third of her overall risk of developing ovarian cancer. “This is the inherited component of the disease risk,” Professor Chenevix-Trench said. “Inherited faults in genes such as BRCA1 and BRCA2 account for about 40% of that genetic risk. Other variants that are more common in the population (carried by more than one in 100 people) are believed to account for most of the rest of the inherited component of risk. We’re less certain of environmental factors that increase the risk, but we do know that several factors reduce the risk of ovarian cancer, including taking the oral contraceptive pill, having your tubes tied and having children. In this study, we trawled through the DNA of nearly 100 000 people, including patients with the most common types of ovarian cancer and healthy controls. We have identified 12 new genetic variants that increase a woman’s risk of developing the cancer. We have also confirmed that 18 variants that had been previously identified do increase the risk. As a result of this study, we now know about a total of 30 genetic variants in addition to BRCA1 and BRCA2 that increase a woman’s risk of developing ovarian cancer. Together, these 30 variants account for another 6.5% of the genetic component of ovarian cancer risk.”

Not alarmist, just the boring truth

DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

The truth is often incredibly boring. It doesn’t sell papers. It doesn’t get people tuning in. It doesn’t win votes. And thus it follows that when things don’t make sense, one should assume incompetence before malice. But I’m finding it incredibly hard to suspend my disbelief when I stand back and take a look at the medical training system that we have in front of us today.

I’m not trying to be alarmist. I’m not here to tell you all that medical training is broken, and we should burn the books, burn the witches and behead Ned Stark. But I hope that I can convince you at the very least that the current progression to Fellowship is entirely unnatural and is fertile ground for unhealthy professional culture. To really understand this progression, I want you to pair up with each other, junior and senior doctors alike, and I want you to compare your respective paths through your medical journey. I find that often people have no idea what is or was on the other side of the fence. Let’s begin.

We finish medical school as the ultimate in medical pluripotency: the intern. We complete a year of heavily regulated and supervised training where we meander through medicine, surgery, emergency and whatever else might lie in our path that year. We then transition to residency, where without the pressure of training progression, we expand our medical buffet of specialisation and become more attuned to our final path in the journey. Armed with the knowledge of our experiences in areas such as general practice, ICU and plastics, and well rested from the safe hours worked, we apply for a training college. We get onto a program and begin to complete the pathway to specialty. Along the way, we have kids, and we do this by working part time at points along the way to balance the load. We complete our final exams and we become a Fellow of our chosen College, and apply for jobs in what is a reasonably well-balanced workplace. Right? Wrong. The truth is boring, but the truth is the truth, and this picture definitely isn’t the truth.

We finish medical school as the ultimate in medical pluripotency: the intern. We apply for internships, and a number of us will fail to get them as State governments are defaulting on their COAG agreement to provide medical graduates with internships. Without an internship, a number of doctors are unable to progress to general registration and are out before they begin. Those who remain become residents. With no national body to oversee PGY2+ terms, and with health services hungry to provide services to increasing populations with shrinking budgets, these residents work terms that don’t provide any meaningful experience. This veritable army of night cover and discharge summary monkeys are forced to scrounge around for the breadcrumbs falling off the training table. The smart ones quit, locum and complete further study, but not without further financial and temporal penalty. We’ve built a system in which the best way to advance your career is to quit the system for a while; a perverse incentive. This of course leaves behind fewer residents to fill the gaps in the roster, who are already at breaking point due to being denied leave for three years.

Nevertheless, you move towards a College. You identify the entry requirements and you undertake the extra mile to become a candidate with a chance. In some instances, that means completing a $5000 exam before you’re even a trainee. Once in, you work full-time and then the rest of it. You complete graduate diplomas, Masters and PhDs to progress. You fill your CV with publications and courses that cost thousands of dollars to progress. But you do it anyway. Because at this point you’re the blackjack player with a hard twelve. You’ve sunk enough cost into this game that you can’t quit, and there’s a glimmer of a nine sitting on top of that deck. But there are many more face cards, and maybe it’s just me, but I swear I’m seeing more and more doctors folding and busting around me.

So, you make it through. With everyone else. You’ve completed a number of extra qualifications and courses. With everyone else. You’ve participated in the medical arms race, and you’re surrounded by tens of thousands of other nuclear nations who’ll do anything for that job. The fat has been trimmed and now we’ve hit muscle. Welcome to exit block; a nation of Australian Fellows who can’t move on to consultant positions because we’re doing more with less, in every sense of the phrase. Competition is one thing, but when you’ve got multiples of trainees to every consultant position, you don’t have a competition. You’ve got a war.

I told you I wasn’t going to be alarmist and I stand by that. My examples above are all based on real life cases. I believe firmly in having a competitive workplace. I believe that smart hard work should be rewarded in the workplace. But this is not the system we currently have. We have a system that rewards the single-minded.

This is nobody’s fault. But it’s definitely our problem. It’s up to us as a profession to recognise that this isn’t about doctors eschewing hard work. It isn’t about people wanting an easy life. This is about a culture that has not kept up with the times and it’s important for those working in well-run institutions to recognise that this is not the norm anymore.

[Editorial] How best to assess children presenting to emergency care

Every paediatrician remembers a time when a young child presented with non-specific symptoms to an accident and emergency department—for example with unusual quietness, fever, and pallor—and it is completely unclear at that moment what will happen next. From becoming critically ill in a very short time to happily playing or eating and drinking, every outcome is possible. Paediatricians often have to act on instinct whether to admit a child to hospital overnight for close observation or not. In countries where there is good availability of hospital beds, children are more likely to be admitted as a precaution and in some cases, unnecessarily so.