Poor GP relations put ‘essential’ reform at risk

One of the boldest reforms to Medicare in decades could collapse if the Federal Government persists with the Medicare rebate freeze, AMA President Dr Michael Gannon has said.

Dr Gannon praised the Commonwealth’s plan to establish a Health Care Home model of care for patients with chronic illness, but warned that its chances of success were being hobbled by inadequate investment and relentless Government attacks on general practice, particularly the rebate freeze.

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

Under the model, also known as the Medical Home, patients suffering from complex and chronic health problems will be able to voluntarily enrol with a preferred general practice, with a particular GP to coordinate all care delivered.

Dr Gannon told the National Press Club the Health Care Home, if properly implemented, could deliver big improvements in quality of care, reduced hospital admissions and fewer emergency department visits.

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

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

The Government has initiated a two-year trial of the Health Care Home model, involving 65,000 patients and 200 practices across 10 Primary Health Networks.

It has committed $21 million to pay for test infrastructure, training and evaluation, and has allocated more than $90 million in payments for patient services.

But the Dr Gannon said these funds were simply being shifting from other areas of health, and the Government must invest if the reform was to be a success.

“There is no new funding for the Health Care Homes trial,” he said. “GPs are being asked to deliver enhanced care to patients with no extra support. This simply does not stack up.

Dr Gannon warned that “if the funding model is not right, GPs will not engage with the trial, and the model will struggle to succeed”.

Adding to the Government’s challenge, it is trying to recruit GP support for the policy while at the same time freezing the Medicare rebate and threatening to axe incentive payments to practices that do not upload enough health records to its My Health Record e-health system.

All this in addition to two aborted attempts to introduce a GP co-payment.

Dr Gannon said that these polices had damaged the relationship between the Government and GPs, and it would need to be repaired if Health Care Homes was to realise its potential.

“For the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. To do this, it must first overcome the significant trust and goodwill deficit attached to the co-payment saga and the Medicare freeze,” he said.

Adrian Rollins

[Comment] Surveillance of Zika virus infection and microcephaly in Brazil

Zika virus has been spreading rapidly in Brazil and the Americas, with a sharp increase in the number of notified microcephaly cases since September, 2015.1,2 Based on the high number of cases, and the association between Zika virus infection and microcephaly,3,4 WHO on Feb 1, 2016, declared a Public Health Emergency of International Concern.5 Recently, animal models have shown that the Brazilian Zika virus strain causes intrauterine growth restriction and microcephaly.6

[World Report] Frontline: Providing health care in Greece’s refugee camps

Mahmood Elahi is a general practitioner in Toronto, ON, Canada, and assistant professor in the Department of Family Medicine, Queen’s University, ON, Canada. A delegate with the Canadian Red Cross, he has been working in the refugee camps in northern Greece as a senior medical officer for the Finnish Red Cross Emergency Response Unit.

Aleppo’s dying children and shattered health system: is there light at the end of the tunnel?

Being a doctor can be risky business, some times more than others.

During my dozen medical missions to Syria, I had to crawl under a border fence, jump over walls, walk in the mountains at night for hours without any light, pass through the sniper alley in Aleppo, negotiate with smugglers and work in bombed, underground hospitals.

The Syrian crisis is now in its fifth year. The country’s health services are under unprecedented strain due to the protracted war, deliberate targeting of health staff and infrastructure by the Syrian regime and Russian forces, the exodus of physicians and nurses, shortages of medical supplies and medications and the disruption of medical education and training.

Syria’s largest city, Aleppo, has 85,000 children, including around 20,000 below the age of two. Dozens are injured every week, just like five-year-old Omran Daqneesh whose pictures have shocked the world. Many have far worse injuries and will not survive.

I took care of some of these unlucky children, such as Ahmad Hijazi, also five years old. He was hit by one of Assad’s barrel bombs. These are containers the size of barrels, stuffed with TNT and metal shrapnel, which the Syrian regime throws from helicopters onto urban areas such as hospitals, civilian neighbourhoods, fruit markets and schools.

Hijazi had shrapnel lodged in his spinal cord and was paralysed from his neck down. When I saw him, he was breathing with great difficulty, so we put a breathing tube in his mouth and put him on life support. The day after I left, he had a cardiac arrest and died.

Around half-a-million people have been killed in the conflict. Half of the population has been displaced. There seems to be no light at the end of the tunnel.

Medical neutrality is a principle under international humanitarian law that ensures protection of medical personnel, patients, facilities and transport from attack or interference. It also underpins unhindered access to medical care and treatment; humane treatment of all civilians; and non-discriminatory treatment of the injured and sick.

Systematic attacks on health care, mostly by the Syrian government and recently Russia, are violations of medical neutrality and therefore war crimes under the Geneva Conventions.

A health system in ruins

Before the onset of fighting, Syria’s health care system was comparable with that of other middle-income countries, such as Iran. By 2015, all sectors of the country’s health infrastructure had disintegrated.

Within only a few years, the life expectancy of resident Syrians has declined by 20 years; from 76 in 2010 to 56 by the end of 2014. This isn’t all due to the direct effects of war.

Many more Syrians have died prematurely from infections and chronic disease than from the fighting – this includes diseases such as pneumonia, hepatitis, tuberculosis and diarrhoeal infections, as well as heart disease, kidney disease, diabetes, cancer and chronic obstructive pulmonary disease.

Hospitals and clinics have been destroyed. Eight out of the ten hospitals in Eastern Aleppo are partially functional or out of service as a result of targeted attacks. From March 2011 to the end of May 2016, at least 738 Syrian doctors, nurses and medical aides died in 373 attacks on medical facilities.

Aleppo's dying children and shattered health system: is there light at the end of the tunnel? - Featured Image

Pictures of Omran Daqneesh have shocked the world, but doctors in Aleppo see dozens of desperate children like him every week.
ALEPPO MEDIA CENTER, @AleppoAMC / HANDOUT

The working conditions of Aleppo’s remaining doctors are unsustainable. An estimated 35 doctors are left in Eastern Aleppo which, with a population of approximately 300,000, means there is one doctor for every 8,570 people. There is not a single critical-care doctor – my own speciality – despite the abundance of critically ill patients.

Doctors, local administrators and NGOs are struggling in substandard conditions and often use unorthodox methods to do their work. They work in underground makeshift hospitals, hospitals dug into mountains or in natural caves for protection. They perform surgeries without light, proper anaesthesia or sterilisation, transfuse blood without proper matching and have medical students or dentists perform life-saving procedures due to the shortage of specialists.

Much-needed medical supplies are channelled through dangerous routes across the borders of Lebanon, Jordan and Turkey. As physicians, we can’t wait for politicians to fix the crisis.

What needs to be done

Fifteen Aleppo doctors recently penned an open letter to US President Obama, in which they wrote that “there is an attack on a medical facility every 17 hours” by the Russian-backed Syrian air force.

Meanwhile, the charity Syrian American Medical Society reported that July has been the worst month for attacks on health care since the beginning of the conflict. There were 43 attacks on health facilities in the month – more than one a day. By comparison, this number of attacks occurred over six months in 2015, with 47 attacks from January to May.

Charities and other organisations, such as the Syrian American Medical Society, have pioneered solutions to some of the resource gaps. These include portable ultrasounds and other point-of-care diagnostic tools, as well as virtual wards connecting nurses and doctors in besieged areas with specialists in the United States.

Doctors in the US and other Western nations have helped Syrian counterparts make the best of the situation by providing training and helping with technology and treatment. But more needs to be done to support remaining health workers.

International medical organisations should advocate on behalf of their Syrian colleagues and champion an end to violations of international humanitarian law.

Educational opportunities to support Syrian health professionals, including scholarships for medical students, would help with ensuring there are enough staff to rebuild the Syrian health system. More resources should be directed to research the impact of conflicts on health care and the use of technology and other innovative solutions to mitigate harms.

Consensus should be achieved and acted on by the international community on the urgent need to protect civilians from airstrikes and chemical attacks. This is needed to apply pressure on the Syrian government to stop targeting the remaining health care staff and hospitals.

We should share knowledge, skills and technology with all patients, across the world. Although our local patients are a priority, we can also benefit the global community.

Zaher Sahloul, Associate Clinical Professor, University of Illinois at Chicago This article was originally published on The Conversation. Read the original article.

Main photo: kafeinkolik / Shutterstock.com

Other doctorportal blogs

[Editorial] Health-care crisis in Turkey: urgent actions needed

“When we finally entered, the emergency room was like a military base. There were sandbags lining the walls, men with guns everywhere. It wasn’t a hospital, it was a fortress”, said a resident of Cizre, a district in southeastern Turkey. The health-care crisis and allegations of pervasive grave human rights violations provoked by Turkish security forces in southeastern Turkey over the past year is documented extensively in a new report released by Physicians for Human Rights (PHR) on Aug 9.

Govt must wise up after bruising election result

After a substantial delay, we now have a Government, and both major parties are in soul-searching mode.

What was clear from the election campaign was the significant focus on health. Prime Minister Malcolm Turnbull indicated that the so-called ‘scare campaign’ on the privatisation of Medicare had had some effect, and the Coalition needed to do more to reassure the electorate that his Government was committed to health, hospitals and Medicare funding.

This is all highly noble in hindsight, but it is clear the Government had left the door wide open for the scare campaign, with several health-related faux-pas leading up to the election, including the proposal for co-payments, and some of its lingering health policies. Australians value their health, but particularly the work of public hospital doctors. A scare campaign does little to instil confidence in a system buckling under the pressure of enormous budget cuts and ongoing high expectations for service delivery.

You will remember that there were two models of co-payment, and both of them were roundly rejected by the AMA. Neither model accounted for the neediest in our community, who frequent our public hospitals. Evidence suggests that some people, when faced with even nominal costs, will defer necessary visits to the doctor, and even potentially life-saving procedures or investigations such as blood tests, x-rays or ultrasounds. This just compounds problems down the track, with patients more likely to face emergency presentations.

We understand the Government’s desire to constrain health spending, but sustained health care available to all Australians is the most economical model in the long run. We don’t want to emulate highly-paid CEOs and their short-term financial goals. Whatever model we develop, we must account for those in the community whose access to health care is constrained by factors such as location and/or social and economic circumstances.

The AMA needs to be part of an open, responsible debate about funding the national health system. There are elements of the health system that the Commonwealth pays for directly, but State Governments are struggling to fund the increasing demands on health and public hospitals, leading to the budget cuts we know too well.

It should not be forgotten that our health system represents great value for money by world standards, particularly in certain areas, but our public hospitals are now overtly overworked and underfunded. They are truly an investment in the health of our nation, our economic productivity and our future. Minister Ley must continue to make these arguments at the highest levels of Cabinet.

Having admitted that health worked against it in the election, the Government must now “wise up” and set a new health policy direction. Alongside issues such as the Medicare rebate freeze, the Government must, from the public hospital doctors’ perspective, properly fund public hospitals and make a renewed commitment to investing in preventive health measures.

Most importantly, the Government must consult closely with the profession in the development of health policies to ensure better outcomes. They must recognise that the medical profession is best placed to advise on health policy.

I look forward to engaging with you through the Council of Public Hospital Doctors as we advocate on these and other important issues and brace for the journey ahead.

Cardiac tamponade in undiagnosed systemic lupus erythematosus

A 22-year-old woman presented with a 3-day history of fever, retrosternal chest pain and exertional dyspnoea. Her heart rate was 130 bpm with a blood pressure level of 109/68 mmHg. Physical examination suggested tamponade: distended jugular veins, pulsus paradoxus and muffled heart tones. The chest radiography was notable for the characteristic water-bottle sign (Figure, A).1 Contrast-enhanced chest computed tomography demonstrated a massive pericardial effusion (Figure, B) associated with venous engorgement of the superior and inferior vena cava (SVC, IVC), prevascular space (arrows), and bilateral axillary veins (arrowheads). An emergency thoracoscopic pericardial window was performed and 620 mL of bloody fluid was drained.

The presence of anti-nuclear, anti-double-stranded DNA, anti-Smith antibodies and hypocomplementaemia supported the diagnosis of systemic lupus erythematosus.2 The patient recovered after 1 week of intravenous methylprednisolone pulse therapy. At an 8-month follow-up, there have been no recurrences.

Figure

News briefs

Fungus v Aedes aegypti: battle on

Scientists looking to combat the Zika virus are trying to “weaponise” a fungus called Metarhizium brunneum which has the happy knack of being able to eat mosquito larvae from the inside out, Wired reports. Research published in PLOS Pathogens has shown that the fungus spore sticks to the mosquito larva, then “eats its way through the exoskeleton and starts to grow, fast”. The larva itself helps the process by eating more spores, which work their way through its gut and into its body cavity. The fungus grows, destroying the larva from the inside. “The fungus actually attacks mosquitoes in two ways. One variety of the fungus spore, the conidium, is airborne — it attacks adult mosquitoes. The blastospore, though, does better underwater — that’s the one that attacks the larvae … [and] is so much more virulent than the conidium. Mosquitoes are now developing resistance to pesticides, but it’s harder to resist predators and parasites that are evolving right along with them. Metarhizium brunneum could be a crucial part of the arsenal [against Zika] — as long as it doesn’t spread so widely that it starts killing more than mosquitoes.”

Aussie heads WHO’s Health Emergencies program

Dr Peter Salama, a medical epidemiologist and a University of Melbourne and Harvard University alumnus, has been appointed as the Executive Director of the World Health Organization’s (WHO) new Health Emergencies Program. Dr Salama, 47, has spent the last 18 months as the United Nations Children’s Emergency Fund (UNICEF) Regional Director for Middle East and North Africa and Global Emergency Coordinator for the crises in Syria, Iraq and Yemen. Before that was UNICEF’s Country Representative in Ethiopia and Zimbabwe, as Global Coordinator for Ebola, and as Chief of Global Health. He previously worked at the Centers for Disease Control in the US and with Medecins Sans Frontieres. According to a statement from the WHO: “WHO’s new Health Emergencies Program is designed to deliver rapid, predictable and comprehensive support to countries and communities as they prepare for, face or recover from emergencies caused by any type of hazard to human health, whether disease outbreaks, natural or man-made disasters or conflicts. The development of the new Program is the result of a reform effort, based on recommendations from a range of independent and expert external reports, involving all levels of WHO — country offices, regional offices and headquarters.

Australia’s hospitals 2014–15 at a glance

Australia’s hospitals 2014–15 at a glance provides summary information on Australia’s public and private hospitals. In 2014–15, there were 10.2 million hospitalisations, including 2.5 million involving surgery. Public hospitals provided care for 7.4 million presentations to emergency departments, with 74% of patients seen within recommended times for their triage category and about 73% completed within 4 hours. This publication is a companion to the 2014–15 Australian hospital statistics suite of publications.

[Comment] Human resources for health: time to move out of crisis mode

For the past decade, attention on the global health workforce has been characterised by crisis. Advocacy efforts persistently frame this issue as a global emergency, with more than 50 countries identified to be facing “critical shortages” of health workers with “immediate action” required to “overcome the crisis”.1,2 In light of the new global strategy on human resources for health presented at the 2016 World Health Assembly,3 we call for an end to this cataclysmic framing of the health workforce agenda.