Sad loss of GP advocate

Many in the AMA and across the medical profession were saddened last month with the passing of popular and highly respected GP, general practice advocate, writer, and editor, Dr Kerri Parnell, following a battle with breast cancer.

Working as a GP in Sydney, Kerri found herself recruited to the world of medical publishing, where she quickly became a passionate and informed champion for her colleagues in general practice.

She spent many years with Australian Doctor, before moving in recent years to The Medical Republic.

When I joined the AMA, Kerri became a friend and confidant, helping me understand the mysteries of the general practice world.

Kerri was a friend and colleague of many at the AMA, including Federal and State Presidents, Chairs of the AMACGP, and grassroots members.

Her editorials and articles gave voice to the ideas, concerns, pressures, and experiences of hardworking local GPs across the country. She helped give GPs political clout.

Kerri was a mentor to many young journalists who started or built their careers in medical publishing.

A great conversationalist and networker, and a talented and colourful writer and editor, Dr Kerri Parnell will be sorely missed.

JOHN FLANNERY

Grants to help country practices

The Federal Government has given $13 million in grants towards general practices in regional Australia, to enable more doctors, nurses and other health professionals to complete their training there.

Assistant Health Minister David Gillespie recently announced that grants of up to $300,000 each have been offered to successful applicants across Australia to upgrade their facilities and allow for more training in country practice.

The grants must be matched by the selected practices.

“These grants will enable more doctors and other health professionals to get their hands-on training in regional communities,” Dr Gillespie said.

“That provides an immediate benefit to the communities, with more health professionals available to attend to their needs.”

The grants will be used to expand practice facilities with additional consultation rooms and space to allow for more teaching. Grants will also be used to create meeting rooms where patients can receive education about health conditions, such as diabetes, so they can take a more active role in managing their own health.

As well as construction or renovation, they may be spent on fit out, computing technology or medical equipment.

“In the longer term, it also makes it more likely that junior doctors will choose to stay in these or other rural communities, when they are fully qualified,” the Minister said.

“The Government supports a strong primary care workforce that can meet Australia’s future healthcare needs.

“Improving access to doctors and other health professionals in rural and regional Australia is a priority for our long term national health plan.”

The list of successful applicants is available on the Department of Health’s website www.health.gov.au. The successful applicants will receive their grants during 2016-17 and 2017-18.

CHRIS JOHNSON

Why GPs prescribe too many antibiotics and why it’s time to set targets

Published this week, our study estimates Australian GPs are prescribing about five million too many scripts for antibiotics a year for run-of-the-mill respiratory infections. But this is not a simple case of “blame the GP”.

What our study does show is many years of educating GPs about appropriate antibiotic prescribing, and the link to antimicrobial resistance, has failed to stem over-prescribing.

So, it’s time to set a national target for antibiotic prescribing in general practice, just like we set targets for carbon dioxide emissions to control the effects of climate change. Local Primary Health Networks could support GPs to meet these targets.

We’d also need to support GPs to easily and cheaply acquire the skills to help them reduce their prescribing safely. There are already moves towards supporting GPs this way. However, we should be prepared for a slow and sustained effort.

If GPs can’t make these changes, they risk more draconian measures being imposed on them by government or bodies like the Australian Commission on Safety and Quality in Health Care. This might include GPs needing to seek an Authority Prescription from the Pharmaceutical Benefits Scheme to prescribe some antibiotics, and punitive measures being imposed on those prescribing beyond some arbitrary limits.

What did we do and what did we find?

We looked at the actual rates of antibiotic prescribing for acute respiratory infections, like sore throats, acute coughs (also called acute bronchitis), and acute middle ear infections. Our data was collected by a survey of about 500 GPs from across Australia, who recorded what they did in every consultation for two weeks.

We then compared that with the rate that would have occurred had every GP stuck rigidly to Therapeutic Guidelines, highly respected national prescribing guidelines many GPs use.

While we had expected about half of actual prescribing to meet the guidelines, we found just 11-23% met them. In national terms, that’s almost six million antibiotic prescriptions a year for these acute respiratory infections, compared with around one million a year had GPs stuck to the guidelines, a difference of roughly five million prescriptions a year.

Why is this important?

Each course of antibiotics contains roughly five grams of antibiotics. So, if GPs had stuck to the guidelines, we could safely reduce antibiotics use by 25 tonnes a year.

This mound of antibiotic represents an aspiration – what we could avoid, with minimal harm to the Australian public, and enormous benefits to reducing the generation of community acquired antibiotic resistance.

Further reading: We know why bacteria become resistant to antibiotics, but how does this actually happen?

In the past we have not really had any target to aim for, but instead wondered if we should aim for the rates achieved by other countries such as the Netherlands (about half of our rates).

Our data show we could take that target much further.

Why do GPs prescribe too many antibiotics?

There are many reasons GPs prescribe too many antibiotics. GPs (and their patients) might want to minimise the risk of their patients being exposed to a dangerous bacterial infection that might have been avoided by prescribing antibiotics early.

Then there’s the diagnostic uncertainty that bedevils this part of primary care. Every apparently trivial cough or cold a GP sees could be the early stages of a dangerously serious infection, like community acquired pneumonia, meningitis, or quinsy (a complication of tonsilitis), and it is often very difficult to be sure in a single visit.

Symptoms of a run-of-the-mill respiratory infection could be the early stages of something more serious.
from www.shutterstock.com

Improving diagnosis might be possible using near-patient testing – a quick test in the surgery, rather than sending off a sample to a laboratory for testing. But these tests are only partly satisfactory because they are not always accurate enough, and they are very expensive, perhaps doubling the cost of the consultation.

Other important factors are:

pressure from patients for GPs to prescribe antibiotics, either real or supposed by the GP. GPs often say this is a major influence, but other studies say it is often over-estimated by GPs
an assumption the consultation will be over quicker with a terminating prescription in time-poor general practice
commercial anxieties (“if I don’t give the patients what they’ve come for, they might go to other GPs more willing”)
habit (“why change what’s been working just fine 10 or 20 years ago if it isn’t broke?”), remembering that the consequences of antibiotic resistance happen in hospital care, far removed from this patient now
“failure of the commons”, in which a shared resource (in this case the absence of antibiotic resistance) is threatened by many individual interests (the individual is sick and wants whatever might quickest make them feel well again).

What needs to happen?

It’s easy to jump to the conclusion from our findings that GPs should “stick to guidelines” when it comes to prescribing antibiotics. But that’s unrealistic. Guidelines are no more than their name suggests, simply a guide to how to manage a patient and their illness.

The real world is much more complicated: patients have additional illnesses, and other demands (often social, psychological or even just preference – for example, avoiding the risks of some symptoms even at the expense of some harms) – and the skillful GP needs to balance all this.

Our results, which demonstrate higher than expected rates of excess antibiotics prescribed, means we have a lot of antibiotic savings we could safely make.

Chris Del Mar, Professor of Public Health

This article was originally published on The Conversation. Read the original article.

Everything you ever wanted to know about thrombosis in primary care…

Learn more about the best practice use of new oral anticoagulants (NOACs) in preventing stroke and thromboembolic events in patients with non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE).

Doctorportal Learning presents a new CPD accredited ALM aimed at helping GPs better understand their role in managing NVAF and VTE in practice.

This is an opportunity to learn best practice from an expert faculty directly involved in developing the module, including Dr Andrew Sindone, Dr David Lim, and Professor Christopher Ward. The multi-modal learning approach, incorporates slide content, expert video vignettes, interactive case studies, and quizzes.

Why is this education important?

Learn how to identify signs and symptoms of AF and VTE so that you can better distinguish other differential diagnoses
Improve patient safety by being able to identify risk factors that put patients with AF and VTE at risk of stroke and bleeding
Develop appropriate systems to ensure effective management of AF and VTE patients on anticoagulants by gaining a greater understanding of the role of NOACs in the management of AF and VTE.

Click here for an overview of our module covering thrombosis in primary care. Not registered with doctorportal Learning? Click here to get started.

Maternity Review a wasted opportunity

BY AMA PRESIDENT DR MICHAEL GANNON

After months of behind-the-scenes activity and growing angst from the profession, the AMA went public in June with our outrage over the process for the planned new National Framework for Maternity Services (NFMS).

The Framework is doomed to fail due to inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

Following an agreement at the April 2016 COAG Health Council meeting, the Queensland Government was tasked to lead the project to develop the NFMS, under the auspices of the Australian Health Ministers’ Advisory Council (AHMAC).

The AMA first became aware of the NFMS project in December 2016 – eight months after it commenced, and without any direct contact from AHMAC’s Maternity Care Policy Working Group (MCPWG) or its consultants – and we have raised concerns about the project ever since.

The AMA’s concerns are shared by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG).

It is outrageous that specialist obstetricians and GPs have been marginalised in this process. You could be forgiven for thinking it a joke.

Obstetrician-led care is an essential tenet of Australia’s maternity system. There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

When issues and problems arise during labour, it is invariably an obstetrician who is called on to assume responsibility and manage care, working to ensure the best possible outcome for mother and baby.

The AMA is pleased that midwives were strongly represented on the Working Group responsible for drafting the NFMS. They are key members of the maternity team.

But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.

AMA members have reported maternity services and outcomes in their respective States have deteriorated under the current National Maternity Services Plan.

Obstetricians are concerned that not enough is being done to ensure women have access to high quality, collaborative models of care. Despite this, the consultation undertaken to develop the NFMS has neglected to actively engage specialist medical practitioners who are at the centre of care for mothers and babies.

The draft Framework, which was released for public comment in March 2017, lacked substance and provided no guidance for public hospital maternity services about what high quality care should look like.

The NFMS is shaping up as a lost opportunity to achieve the best possible maternity care for mothers and babies in Australia.

GPs, too, have been ignored in the process.

GPs not only routinely offer obstetric services in outer metropolitan, rural, and regional areas, but deliver antenatal and postnatal care to thousands of Australian women. There was not a single GP representative appointed.

Further, there is no acknowledgement that best practice care of mothers involves anaesthetists, obstetric physicians, psychiatrists, pathologists, and haematologists, none of whom were invited to assist in the development and drafting of the NFMS.

The AMA wants to see a strong NFMS. It must be developed in genuine partnership with the medical profession and its peak bodies. These are the medical professionals who deal with maternity services, day in and day out.

They’ve seen what works, and they know where the system is not working well. Their experiences and views should have been at the table, from the beginning.

Inviting them to a consultation a month before completion of the draft NFMS does not seem a genuine attempt to listen to experts at the coalface of maternity services.

The AMA has called on COAG, AHMAC, and the NFMS Working Group to formally and genuinely engage with the medical profession – obstetricians in particular – before there is any further policy development or public reporting on the Framework.

The health of mothers and their babies deserves a thorough and professional Framework to ensure the best possible care.

AMA voicing concern over some political moves

Two issues dominating recent health policy discussions have seen the AMA at the forefront of political debate, expressing concerns over the direction of some processes and decisions.

The medicinal cannabis and maternity services debates have kept AMA President Dr Michael Gannon a familiar face around Parliament House in Canberra, explaining doctors’ views to Government and the media.

Medicinal cannabis

After a surprise result from a Senate vote in June, terminally ill patients with a doctor’s prescription will be able to get faster access to medicinal cannabis and be allowed to import three months’ worth of their own personal supply of the drug.

The Greens pushed for changes to Government restrictions and they found support from Labor, One Nation and some independents.

But Health Minister Greg Hunt, who with his Government colleagues tried to stymie the move, said the outcome could put lives at risk.

He said the changes could open the way for questionable and unregulated products to be introduced to the market, as well as making it easier for criminals to access drugs.

“It is unfortunately a reckless and irresponsible decision,” Mr Hunt said.

Dr Gannon agrees, saying the AMA was disappointed with the move.

“You’ve already got a situation where doctors are querying exactly how effective medicinal cannabis is. If you in any way put any doubt in their minds about the safety, you’re simply not going to see it prescribed by many doctors,” he said.

“We remain concerned about potential diversion into the general community. And let’s not forget, we’re talking about cannabis. We’re talking about a substance that, used in the form it’s used by most people, is a major source of mental illness in our community.”

Dr Gannon said the AMA was satisfied with the process put in train by the Government through the Therapeutic Goods Administration.

“The TGA’s got a process in place. Let’s support that careful process to make sure what is used is perfectly safe.”

The binding vote, which passed in the Senate 40 to 30, means medicinal cannabis will be put on the TGA’s Category A list, giving qualifying patients priority and faster access.

Maternity Services

The AMA is also warning that the planned new National Framework for Maternity Services (NFMS) was doomed to fail due to inadequate stakeholder consultation.

Describing the process as spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development, Dr Gannon said opportunities for improvement were being lost.

The AMA has raised concerns about the project ever since.

In June, however, Dr Gannon, an obstetrician, said it was outrageous that specialist obstetricians and GPs had been marginalised in the process.

“You could be forgiven for thinking it a joke,” he said.

“Obstetrician-led care is an essential tenet of Australia’s maternity system.

“But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.”

On June 23, the process did indeed fail and was scrapped.

Dr Gino Pecoraro, AMA Federal Councillor, attended an NFMA consultation on that day to discuss concerns.

He described the subsequent decision to scrap the process as a win for patients.

Dr Pecoraro said the process to date had been a monumental waste of time and money.

“The AMA has been clear that unless they went back and started again, then it wouldn’t go anywhere,” he said.

“It is a win for the women and children of Australia.”

Chris Johnson

National Framework for Maternity Services scrapped following AMA concerns

The AMA has welcomed the decision to scrap the National Framework for Maternity Services (NFMS) due to its flawed process.

The process involved inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

AMA Vice President Dr Tony Bartone said obstetricians and GPs share the bulk of the care for women throughout their pregnancies and leaving them out of the NFMS process was a critical misjudgement.

“GPs are there with mothers at every stage of their pregnancy, including their postnatal care, and should never have been overlooked in the NFMS,” Dr Bartone said.

“The AMA has consistently warned that without genuine engagement with the medical profession, the review would be doomed to fail – which is exactly what has happened today.”

AMA Federal Councillor Dr Gino Pecoraro, an obstetrician and gynaecologist, attended a consultation forum on June 23 that led to the decision to scrap the NFMS.

“Today’s decision to scrap the flawed NFMS is a win for the women and children of Australia,” Dr Pecoraro said.

“What has happened has been a monumental missed opportunity to achieve the best possible maternity care for mothers and babies.”

Obstetrician-led care is an essential tenet of Australia’s maternity system.

There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

“The AMA remains committed to work to see a strong NFMS,” said Dr Bartone.

Chris Johnson

AMA a key player in federal politics

AMA President Dr Michael Gannon opened the 2017 National Conference letting delegates know that while the past 12 months had been eventful, much had been achieved in the realm of health policy.

He continued with that theme throughout the three-day event in Melbourne, which brought together not only the elite of the medical profession but also the highest level of Australian political leaders.

“The AMA is a key player in federal politics in Canberra. The range of issues we deal with every day is extensive,” Dr Gannon said.

“Our engagement with the Government, the bureaucracy, and with other health groups is constant and at the highest levels.

“Our policy work is across the health spectrum, and is highly regarded.

“The AMA’s political influence is significant.”

Describing the political environment over the past year as volatile – which included a federal election and two Health Ministers to deal with – Dr Gannon said the AMA had spent the year negotiating openly and positively with all sides of politics.

“Our standing is evidenced by the attendance at this conference of Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Greens Leader Senator Richard Di Natale, Health Minister Greg Hunt, Minister for Aged Care and Minister for Indigenous Health Ken Wyatt AM, and Shadow Health Minister Catherine King,” he said.

“Health policy has been a priority for all of them, as it has been for the AMA.”

While the Medicare rebate freeze was the issue to have dominated medical politics, there are still more policy areas to deal with in the coming year.

The freeze was bad policy that hurt doctors and patients.

“I was pleased just weeks ago on Budget night to welcome the Government’s decision to end the freeze,” Dr Gannon told the conference.

“The freeze will be wound back over three years. We would have preferred an immediate across the board lifting of the freeze, but at least now practices can plan ahead with confidence.

“Lifting the freeze has effectively allowed the Government to rid itself of the legacy of the disastrous 2014 Health Budget.

“We can now move on with our other priorities… We will maintain our role of speaking out on any matter that needs to be addressed in health.”

Dr Gannon said while the Medicare freeze hit general practice hard, it was not the only factor making things tough for hardworking GPs.

General practice is under constant pressure, he said, yet it continues to deliver great outcomes for patients.

GPs are delivering high quality care and are the most cost effective part of the health system.

“One of the most divisive issues that the AMA has had to resolve in the past 12 months is the Government’s ill-considered election deal with Pathology Australia to try and cap rents paid for co-located pathology collection centres,” Dr Gannon said.

“We all know that our pathologist members play a critical role in helping us to make the right decisions about our patients’ care. They are essential to what we do every day.

“It was disappointing to see the Government’s deal pit pathologists against GPs.

“The recent Budget saw the rents deal dumped in favour of a more robust compliance framework, based on existing laws. This is a more balanced approach.”

Other issues the President highlighted as areas the AMA is having significant influence included: Health Care Home Trial; the Practice Incentive Program; My Health Record; Indigenous Health; After-Hours GP Services; the MBS Review; public hospitals; private insurance; and the medical workforce.

Chris Johnson

AMA President’s Award presented to a long-serving and dedicated GP

Professor Bernard Pearn-Rowe, who has been a constant advocate for general practice for almost three decades, has been recognised with one of the AMA’s highest awards, the President’s Award.

Professor Bernard Pearn-Rowe has juggled maintaining his solo GP practice in Perth with his active roles in AMA WA medical politics, including a term as AMA WA President, and his appointment as Foundation Professor of Clinical Studies at the University of Notre Dame.

Dr Gannon presented Professor Pearn-Rowe with his Award at the AMA National Conference 2017 Gala Dinner in Melbourne.

“During his time as Convenor of the federal AMA Council of General Practice (CGP), he has contributed to key policy areas including the role of general practice in primary care, e-health, medical education and training, GP workforce, red tape reduction, Health Care Homes, and the role of GPs in disaster situations,” Dr Gannon said.

“Professor Pearn-Rowe has been part of an AMA CGP that has emphasised the importance of quality general practice and the need for Governments to support this as part of a high quality, sustainable health care system.”

Amid his many commitments, Professor Pearn-Rowe has also found the time to pen a weekly medical column in The West Australian newspaper, making him an outstanding face of the AMA in WA.

Professor Pearn-Rowe was chair of the Royal Australian College of General Practice (RACGP) in Western Australia from 1989 to 1993, Chair of the AMA WA Council of General Practice (CGP) from 1998 to 2001, and Convenor of the Federal AMA CGP since 2004. He was appointed a Fellow of the federal AMA in 2004.

Professor Pearn-Rowe graduated in Medicine from the University of London in 1972 and joined the AMA in 1976. He has been active in AMA WA medical politics since that time, including a period as President of the AMA in Western Australia from 2002-2004. He was appointed a Fellow of the AMA in 2004.

He was appointed Foundation Professor of Clinical Studies at the University of Notre Dame in 2004 and was Foundation Professor and Head of Discipline of General Practice in the School of Medicine at the University of Notre Dame from 2006-2010. Since that time he has continued as an Adjunct Professor.

Meredith Horne

My Health Record – lessons from the opt-out trial

By Dr Richard Kidd, Chair, AMA Council of General Practice

The recent Federal Budget confirmed that the My Health Record will move to an opt-out model.

While the AMA has drawn attention to the shortcomings of the My Health Record over the past five years, we have always acknowledged the potential for a well-designed and constructed electronic health record to improve patient care.

The AMA originally proposed an opt out model and the Evaluation of the Participation Trials for the My Health Record has demonstrated this is the right approach, with the evaluation report saying opt-out is the only sustainable way forward. Ensuring universal coverage with cross-sector clinical input over time will enhance the value of the My Health Record for patients, their doctors and a patient’s other healthcare providers.

One of the clear outcomes from the trial was that once patients understood the benefits of having a shared electronic health record and the measures in place to protect their information and its use, any concerns they had about privacy and the security of their information were allayed. In fact, the trial highlighted that patients already fully expected their doctors to be sharing their health information with one another.

This is a strong signal to the profession that, whatever reservations we have about the MyHealth record, our patients want us to use it.

Not surprisingly, the trial highlighted a number of critical improvements to the MyHealth record that are needed. These go to the heart of its ease of use, utility and accessibility.

Several of the Evaluation recommendations targeted these areas and reflect much of what the AMA has been saying for some time.

Certainly, more work needs to be done to convince GPs of the merits of the My Health Record and to address its shortcomings. One of the interesting findings in the evaluation was that while most health care providers made it clear that the MyHealth record required additional time with patients, practice managers and practice nurses reported that it made the practice more efficient with less need to chase information from patients and other health care providers. This represents an interesting tension, given that GPs are not funded for this effort. My view, along with the AMA, is GPs need to be properly funded for this work.

The evaluation report contains a number of recommendations on ‘strategy’ to increase uptake and use of the My Health Record. These particular recommendations, which touch on funding mechanisms, are vague and unclear but seem to suggest making use of the My Health Record a requirement for funding. This approach has delivered very mixed results in relation to the PIP e-health incentive and there is no way the AMA would support any change that linked the use of the MyHealth record to patient rebates.

I was pleased instead to see Health Minister Greg Hunt, at the AMA National Conference, say he intends to explore “real incentives to assist the medical workforce in their work”. The profession is looking for support, not punitive approaches that can impact on doctors and their patients.

Over time, we can expect that utilisation of the My Health Record will be woven into standards for practice and accreditation across healthcare, from general practices to hospitals (public and private), to pharmacies and other allied health service providers, and to aged care facilities. Obviously, the AMA’s role is to ensure that this does not happen until we have a clinically useful system.

Digital health will become a key part of future undergraduate and postgraduate training programs, meaning supervisors like me will need to ensure that we too are up to speed.

With more useful content being added to the record such as patient medications, pathology and diagnostic imaging reports, and discharge summaries, the more valuable the record will be for doctors and the patient’s care. In my view, the value of the MyHR could be further enhanced by enabling the uploading of other documents where useful such as Care Plans, including Advance Care Plans and Advance Care Directives. This would help ensure the manner of a patient’s care, particularly if away from home, aligns with their agreed goals and stated preferences.

Changes such as these, along with the reality that the vast majority of Australians will have a record created, should remove some barriers for engagement and facilitate greater interaction.

The AMA will continue working to ensure the My Health Record fulfils the promise that an effective shared health record can deliver.