The US President’s Emergency Plan for AIDS Relief celebrates its 15th anniversary this year, prompting calls for continued support for the initiative. Paul Webster reports.
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The US President’s Emergency Plan for AIDS Relief celebrates its 15th anniversary this year, prompting calls for continued support for the initiative. Paul Webster reports.
Family Doctor Week
Tasmania – Dr Jane Gorman
Variety is the spice of life for Tasmanian Dr Jane Gorman.
A general practitioner at the Augusta Road Medical Centre in Hobart’s northern suburbs, Dr Gorman has many strings to her bow – and that’s what keeps it real for her.
“I like flexibility. I’m a GP, I’ve been involved in travel medicine, family planning, diet, GP-land, and orthopaedics in my past life so I get called on for that a lot,” she said.
“I am eminently travelable. I’ve done two locums to Lord Howe Island in the past couple of years and I found it fantastic. You have to be prepared for trauma and such to that kind of work in those kind of locations, but I really enjoy the work.
“I do two days as a GP and two days as a private assistant and orthopaedic work. On an average day in my clinic I would see about 20 patients.”
Dr Gorman has been at her current practice for nine years, but previously she worked in orthopaedics in Sydney for four years, then two years advanced work in the area before moving onto a year working an Emergency Department.
“Then I met a dentist from Tasmania and eventually we moved here, and we now have three kids together,” she said with a smile.
“I love living and working in Tasmania and I really love treating the patients I have.
“I have quite a few families where I am treating generations. I really enjoy that because it gives me a great insight into them. Hearing what parents say about their kids and what kids say about their parents can be very helpful.
“I find working with families really very rewarding. I love seeing what happens to them, which is something you don’t get in orthopaedics – you do the surgery and then they’re gone. But as a GP you get to see how your patients develop and you’re with them two years down the track.
“I love watching kids grow up and I love watching older people grow older.
“I was once asked to use a prop to describe what being a family doctor is like and I turned up with a kaleidoscope. With a kaleidoscope, you get to look down this little hole where you get insights you wouldn’t experience anywhere else.
“There are jewels and patterns that no one else sees. That’s what it’s like being a doctor. It’s quite a privilege.”
CHRIS JOHNSON
AMA President Dr Tony Bartone has used an address to the National Press Club to salute Australia’s general practitioners, and to call for significant reform of primary care.
In his first major speech since being elected in May, Dr Bartone said the challenge of transforming general practice was severely underestimated by the nation’s policy makers.
He said the AMA has a plan, but it is one which will require upfront and meaningful new investment, in anticipation of long-term savings in downstream health costs.
Delivering the nationally televised address during Family Doctor Week in July, Dr Bartone said his overarching concern as a GP himself has always been the patient journey and ensuring that people get the right care at the right time in the right place by the right practitioner.
“The priorities for me are always universal access to care, and affordability,” he said.
“GPs of Australia, I salute you. We all salute you. Your hard work and dedication is highly valued. The AMA will always support you and promote you.”
But he described there being “something really crook” about how GPs have been treated by successive Governments.
“They have paid lip service to the critical role GPs play in our health system, often borne out of ignorance and often in a misguided attempt to control costs,” Dr Bartone said.
“General practice has been the target of continual funding cuts over many years. These cuts have systematically eaten away at the capacity of general practice to deliver the highest quality care for our patients. They threaten the viability of many practices.”
The AMA President said Australia has seen too many poor decisions and mistakes in health policy.
General practice must be put front and centre in future health policy development.
“Despite the Government’s best intentions – and lots of goodwill within the profession – the Health Care Homes trial and implementation failed to win the support of GPs or patients,” Dr Bartone said.
“Instead of real investment, the trial largely shifted existing buckets of money around. It has fallen well short of its practice enrolment targets, and it looks like only a small fraction of the targeted 65,000 patients will sign up.
“But general practice still needs transformation and rejuvenation to meet growing patient demand and to keep GPs working in general practice.”
Dr Bartone outlined the AMA’s plan for general practice, which included in the short term:
“In the longer term, we need to look at moving to a more blended model of funding for general practice,” he said.
“While retaining our proven fee-for-service model at its core, the new funding model must have an increased emphasis on other funding streams, which are designed to support a high performing primary care system.
“This will allow for increasing the capability and improving the infrastructure supporting general practice to allow it to become the real engine room of our health system.
“It is about scaling up our GP-led patient-centred multidisciplinary practice teams to better provide the envelope of health care around the patient in their journey through the health system.”
On public hospitals, Dr Bartone said a better plan was needed.
Instead of helping the hospitals improve safety and quality, Governments decided to financially punish hospitals for poor safety events.
“There is no evidence to show that financial penalties work,” he said.
“Public hospitals are a critical part of our health system. They are highly visible. They are greatly loved institutions in the community. They are vote changers.
“The doctors, nurses, and other staff who work in our public hospitals are some of the most skilled in the world…
“Despite their importance, and despite our reliance on our hospitals to save lives and improve quality of life, they have been chronically underfunded for too long.
“Between 2010-11 and 2015-16, average annual real growth in Federal Government recurrent funding for public hospitals has been virtually stagnant – a mere 2.8 per cent.
“The AMA welcomes that, between 2014-15 and 2015-16, the Federal Government boosted its recurrent public hospital expenditure by 8.4 per cent.
“But a one-off modest boost from a very low base is not enough.”
Dr Bartone called on the major political parties to boost funding for public hospitals beyond that which is outlined in the next agreement.
There must be a plan to lift public hospitals out of their current funding crisis, which is putting doctors and patients at risk.
And Governments must stop penalising hospitals for adverse patient safety events, he said.
The wide-ranging Press Club address also went to aged care, with Dr Bartone describing it as “one of the highest profile segments of the health system – but for all the wrong reasons”.
He added that aged care was now emerging as an area in need of significant reform as the population ages and lives longer.
“An increase in funding for GP visits to aged care facilities would result in many savings, including from reduced ambulance transfers to hospital emergency departments,” he said.
“Changes to after-hours care remuneration must consider services that are currently provided under ‘urgent’ item numbers to patients in aged care facilities.
“We also need to ensure that the critical role that nurses play in caring for older Australians is recognised in those facilities.”
On private health insurance, the President said affordability meant very little without value, and that the Government knows the issue is at crisis point.
“Australians want reasonable and simple things from their insurance,” he said.
“They want coverage. They want a choice of the practitioner, and a choice of the hospital. They want treatment when they need it.
“We can’t have patients finding out they aren’t covered after the event, or when they require treatment and it’s all too late…
“Australians do not support a US-style managed care health system. Neither does the AMA. One area we are disappointed with in the recent announcements is pregnancy cover.
“It does not make sense to us, as clinicians, to have pregnancy cover in a higher level of insurance only.
“Many pregnancies are unplanned – meaning people are caught out underinsured when pregnancy is restricted to high-end policies.
“Pregnancy is a major reason that the younger population considers taking up private health insurance.
“They are less likely to be able to afford the higher-level policies. We need to make sure it is within reach.
“And having female reproductive services at a different level to pregnancy coverage is, to us, problematic, and will leave a lot of people caught out.
“There will be much more to talk about as the private health reforms are finalised and bedded down.”
Dr Bartone’s full address to the National Press Club of Australia can be found at: media/dr-tony-bartone-speech-national-press-club
Whatever it takes to clear up ambiguity over My Health Record privacy concerns
During the Q&A segment of his National Press Club address, AMA President Dr Tony Bartone said promised a face-to-face meeting with Health Minister Greg Hunt to gain assurances the Government will take further steps to ensure the privacy and security of the My Health Record.
Dr Bartone said there had been a groundswell of concern from AMA members, the broader medical profession, and the public about the 2012 legislation framing the My Health Record, particularly Section 70, which deals with the disclosure of health information for law enforcement purposes.
“The priority of the AMA at all times has been to support the My Health Record, and its precursors, for the important clinical benefits it will deliver to doctors, patients, and the health system,” Dr Bartone said.
“The AMA has always been protective and vigilant about the privacy of the doctor-patient relationship, and this should not be affected by the My Health Record.
“Given the public debate, I support calls for the Government to provide solid guarantees about the long-term security of the privacy of the My Health Record.
“I will do whatever it takes to ensure that the security concerns are raised and cleared up as a matter of urgency.
“This may involve examining the legislation.”
Mr Hunt contacted Dr Bartone directly after the Press Club to set up a meeting to discuss all aspects of the rollout of the My Health Record.
CHRIS JOHNSON
Information for AMA Members from the Australian Digital Health Agency about My Health Record.
By Professor Meredith Makeham
Australians are being offered an important choice over the next three months about how they want to interact with their health information.
By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.
The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.
They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.
Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.
The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.
People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.
The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.
The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.
Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.
The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.
We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.
The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.
Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.
This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.
Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.
Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.
BACKGROUND:
There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury.
METHODS:
This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13–15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule.
RESULTS:
Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%–98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%–99.2%) for predicting brain injury. Adding “≥ 4 episodes of vomiting” resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%–100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%–100%) sensitivity for brain injury.
INTERPRETATION:
Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.
A 51-year-old man presented to the emergency department with a 2-day history of cognitive decline. He was admitted to the neurology department for an assessment where he was found to be confused and disorientated, and his attention, concentration, and memory were affected. He scored 12 on the Glasgow Coma Scale.
40 944 people have migrated to Europe so far in 2018. 960 people have died trying to do so, making migration an immediate European health emergency. Yet the medical and public health communities across Europe remain strangely silent. Why is that? The main destinations for those leaving their homelands have been Italy (16 228), Greece (12 514), and Spain (12 155). Although the political consequences of migration seem to be growing—a new and abrasive anti-immigration regime in Italy, Angela Merkel’s precarious coalition in Germany, and continuing fears of free movement of people to Brexit Britain—these figures are actually in decline.
Volunteer medical emergency first aid worker for the Palestinian Medical Relief Society. She was born on Sept 13, 1997, in Khuza’a, Gaza Strip, occupied Palestinian territory, and died after being shot while helping the wounded near the Israel–Gaza border, on June 1, 2018, aged 20 years.
BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS
I love the word reform. Form it again. Redo.
A simple concept. Kids do it. Their hunk of play dough gets smashed back together if they do not like the shape that came out. What forms at the second try may be a very different animal than the first start.
Potters at wheels who cannot quickly remould, will lump the clay back in a ball and re-form the vessel.
The process requires:
The adjectives ‘courageous’ and ‘inspired’ often describe ideas of reform.
Notice this is not tinkering at the corners, fussing with little wins and making small changes. This is thinking outside the box. Maybe even crushing the box with an elephant foot. It is the antithesis of expecting different results by doing things the old way.
Reforms and reformers are not popular. The status quo, no matter how dysfunctional, is known, comfortable, predictable. Change causes stress. I believe reforms occur when the pain of the old is greater than the discomforts of making the change.
So in our rural medical life, we need reform. You and I know it because it’s just not working. Rural health has so many gaps. The statistics are there: insufficient manpower, longer hours, less downtime, more mental illness. I am talking about us.
We struggle to gain a sense of self-actualisation. There is the black cloud of uncertainty associated with working with limited resources such as diagnostic imaging and tests. One word of criticism from our non-collegial colleagues diminishes us. The frustrations of slow or non-existent internet, the cost of living, the distance to families, our loves. Our networks can be paper thin. The comfort of a nearby specialist is on our wish list.
No wonder the IMG who has completed their 19A/B moratorium heads straight for the comforts of urban life. Rural locum coverage are the norm, patients are weary, yet accepting, of yet another new (transient) doctor. We know there is inequity in health care delivery. And in our tired minds we know there is a better way.
So, some needed reforms include:
Medicare indexation. To quote the previous Chair of this Council, David Rivett: “I think it’s time for a harder-nosed approach. In future, I’d love to see the AMA get a fighting fund established on behalf of GPs to try to get both (political) parties to index (rebates) fully.” A fighting fund may mean altruistic dips into your pocket to fund a strong pre-election campaign to revamp the rebates to the patients. The picture is bigger than indexing our MBS payments, it is about how it effects patient life – in either dollars or access to care.
Medicare MBS and incentive restructuring to reward quality care. To quote a Federal Councillor: “Support quality care, get money back to the practices that are providing quality (and not high through-put corporate style clinics).” And another councilor: “Focus on the attendance items which are quite separate from rooms based items” and “articulate a vision for the future of high quality, cost effective Primary Care that will save money in the long run. Our practices should become the ‘hospitals of the future’. Community care should revolve around general practice.” And: “Go big, or go home”.
The Rural Generalist. The Collingrove agreement between Professor Paul Worley, the rural health commissioner, ACRRM and RACGP defines a generalist as “medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team”.
Head up, Rural doctors. Reform is on your doorstep. You may not like it. There will be discomfort in the process of change, maybe loud voices, bewilderment and naysayers. Too much, too fast, too slow, too little, too late.
But kids can reform their clay. We can too.
Opposition Leader Bill Shorten recently used an appearance on ABC’s Q&A program to declare aged care is in a fundamental state of crisis and that he aims to make it a central national issue.
Mr Shorten said if the aged care system was not adequately funded at the national level, it was simply being set up to fail.
“It is a problem. It is a crisis,” he said.
“We need to sit down as a nation. Forget the politics, take off your Liberal hat or your Labor hat when you walk in the door, and start talking about how we properly fund aged care.”
The Government maintains that the latest Budget has seen a considerable boost in the overall spend for aged care, increasing from $18 billion a year to $23 billion over four years.
However, the Opposition believes that the Government has cut $2 billion from aged care by moving money from residential care and reallocating it to home care.
Speaking in Adelaide following the Q&A program, Mr Shorten said that there were many things to do to help improve aged care, and he has not ruled out a Royal Commission.
“We’ve got to make sure that aged care staff are valued, paid properly and properly trained. Two, we’ve got to make sure that the promises being made to vulnerable people in their care are being delivered on. Three, we’ve actually got to do a lot more to challenge the scourge of dementia,” he said.
In April, the AMA launched its Position Statement on Resourcing Aged Care 2018 to outline the workforce and funding measures that the AMA believes are required to achieve a high quality, efficient aged care system that enables equitable access to health care for older people.
AMA President Dr Tony Bartone said Australia’s ageing population will require an increasing amount of medical support due to significant growth in the prevalence of chronic and complex medical disorders and associated increase in life expectancy.
The AMA has called for more Government funding and support to allow ongoing access to medical and health care at home, so people can remain in their home for as long as is appropriate.
The AMA also believes there needs to be improved access for older people in residential aged care facilities (RACFs) to doctors through enhanced Medical Benefits Schedule (MBS) funding, and research into improved models to facilitate medical care in RACFs. Currently, inadequate MBS funding is a barrier for GPs to attend residents of aged care facilities, as they do not compensate for the significant non-face-to-face time (travel, finding residents and staff, etc) that comes with caring for RACF residents.
The AMA also believes that more nurses are needed in full time employment in aged care, and a minimum nurse to resident ratio should be included in the Aged Care Quality Standards.
Dr Bartone said AMA members have reported cases where nurses are being replaced by junior personal care attendants, and some residential aged care facilities do not have any nurses on staff after hours.
“It is unacceptable that some residents, who have high care needs, cannot access nursing care after hours without being transferred to a hospital Emergency Department,” he said.
The House of Representatives is currently conducting an Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia. At the time of publication, more than 100 submissions had been received.
The AMA gave evidence at the inquiry in May and the submission can be read here: www.aph.gov.au/DocumentStore.ashx?id=00ae9808-57c3-476f-8533-385e701fa619&subId=563295
The AMA Position Statement on Aged Care Resourcing can be found here: www.ama.com.au/position-statement/aged-care-resourcing-2018
MEREDITH HORNE