Holistic medicine provision in the outback

Overcoming the barriers to chronic disease management in rural areas

The Royal Flying Doctor Service (RFDS) has been providing essential medical services to rural and remote Australia since its inception in 1927. The service, founded by Reverend John Flynn, started as a single base at Cloncurry in Queensland1 and now operates out of 21 bases, providing both primary care clinics and emergency retrieval services. RFDS has been servicing clinics from its Broken Hill base since the 1940s; by 1970, there were three full-time doctors conducting the clinics and running the on-call service via the radio network. In 2016, Broken Hill doctors treated patients in 17 different clinic locations each month. On most weekdays, there are general practitioners at three clinic sites, along with dentists, nurses and mental health practitioners.

RFDS is well recognised within Australia and internationally as the only provider of emergency care to large swathes of the outback. Television shows, such as The Flying Doctors and Outback ER, make acute care and cutting-edge medicine familiar to the public. What is less well known, however, is the organisation’s extensive involvement in delivering primary care services to people living in remote locations.

Chronic disease management (CDM) is a key component of the primary care services offered, and the appointment of a practice nurse in 2011 was the first step taken to focus on CDM. The nurse’s initial task was to create and manage the chronic disease register. This formalised the disease database and enabled the setting up of recalls to ensure that patients received regular follow-ups, and it also required doctors to comply with the full functionality of the MedicalDirector system. In addition, the opening of the Clive Bishop Medical Centre (CBMC) at the airport base, in August 2014, allows patients from remote locations to see an RFDS doctor when they are in town in between remote clinic days. Thus, in recent years, the RFDS has redefined its role from bush clinics and emergency evacuations to include a more comprehensive primary care approach in an effort to improve chronic disease outcomes.2 However, due to a number of factors, RFDS is still limited in its ability to deliver high quality primary care.

This model of care in remote New South Wales requires significant investment in medical staff. In an area of 640 000 km² and with about 6000 patients who live outside Broken Hill,3 eight whole-time-equivalent (WTE) GPs are needed to provide appropriate primary care and emergency services — an increase from four WTEs in 2000. Staff fatigue management and CDM considerations have driven the increase in staff numbers. Clinical, pilot and engineering staff salaries, along with aviation fuel, are all required to enable aircraft-serviced clinics and incur a high cost per patient.

In a metropolitan setting, a patient may need an emergency ambulance ride to hospital at a cost of $364 plus $3.29 per km travelled.4 However, in remote locations an $8 million dollar aircraft will need to be sent out at a cost of about $3000 per hour flown. Although the secondary care costs may be expected to be comparable, the approximate tenfold transport cost impacts significantly on health budgets, and demands optimised local CDM and patient concordance.5,6

Western countries have resourced primary care significantly in the past decade, with GPs incentivised to improve CDM. For example, the United Kingdom Qualities and Outcomes Framework rewards GP practices for the overall control of diabetes, chronic obstructive pulmonary disease and cardiovascular disease.7 In Australia, GP management plans (GPMPs) can be charged at a significant premium ($144.25) compared with a standard long Medicare consultation ($71.70).When done well, this should have the effect of more reliable monitoring and control of chronic conditions.8

The Commonwealth contract for the RFDS South Eastern Section, however, does not place a premium on these services. Standard RFDS consultations outside Broken Hill are funded based on historical data; CBMC consultations are Medicare bulk billed under a separate arrangement. When GPMPs are used in remote settings, they do not enable patients to access allied health services — such as diabetes educators, podiatry or physiotherapy — under the Medicare-funded scheme. Patients must either finance it themselves, or book an appointment in a Medicare billed location to access Team Care Arrangements funding.

By involving its in-house multidisciplinary team (funded by a variety of income streams), including practice nurses, women’s and children’s nurses, mental health practitioners and substance misuse workers, RFDS has sought to develop services in line with current best practice. Additional integrated team-based care with medical (generalist and specialist), nursing and allied health staff is known to be associated with improved health outcomes in patients with chronic illnesses.9 Rural and remote primary care centres, such as clinics in far west NSW, are less likely to have a team approach because of limited access to allied health workers.9,10

Recruitment and retention of doctors

RFDS doctors at Broken Hill are required to have a fellowship of the Royal Australian College of General Practitioners or a fellowship of the Australian College of Rural and Remote Medicine. Attainment of these qualifications ensures the standard of knowledge and training of the GPs responsible for treating patients in remote settings. However, the reality is that a full-time doctor may only conduct 2–3 clinics per week (spending the rest of their time on call). With travel time to clinics of up to 2 hours each way, and the attendance varying from 8 to 16 patients per day, clinical skills are used less often and confidence may diminish. Some doctors find this frustrating; others are happy to have time out of private general practice.

The maintenance of clinical skills in emergency care is more challenging. Practitioners need to complete a regular cycle of courses — including Advanced Paediatric Life Support, Advanced Life Support in Obstetrics, Early Management of Severe Trauma and airway skills updates — but there may be months between course completion and the need to use the skills. The gap between competence and confidence may be too much for some doctors to bear, and for those who prefer the emergency to the routine, there is not enough excitement.

Therefore, there are two competing challenges to address: where to find GPs who are experienced enough in their field to be able to manage well the uncertainty in remote places — whether face to face or over the phone — and enough emergency cases to keep this self-selecting group interested. Then of course, there is the remoteness of the place; 1200 km from Sydney and 500 km from Adelaide is too much for most Australian GPs. At present, the full-time practitioners are UK or Irish graduates, and the longest serving of them has been employed for 3 years.

Continuity of care

If a high staff turnover is not controlled, continuity of care in each clinic site will be adversely affected. Even when fully staffed, manning 17 clinic sites and rostering night shifts means that doctors have to be rotated. However, it has been shown that both patients and doctors prefer to know each other as part of an effective therapeutic relationship.11,12 This is an important factor in the effectiveness of CDM and patient engagement.

In addition to the RFDS doctors, health services in Wilcannia, Ivanhoe and Menindee are simultaneously provided by GPs from Maari Ma Health, which is the Indigenous community controlled health organisation. Five Local Health District (LHD) facilities, which include these three, also provide nursing staff at these sites. With the rotating system of both RFDS and Maari Ma Health rosters, along with significant use of agency nursing in remote sites, it is easy to recognise the fragmentation of what should ideally be integrated care. The responsibility for CDM of certain groups falls between the gaps sometimes, and it is not always clear who should be keeping track of follow-up and recall systems. There is, therefore, room for further system development and collaboration here.

Medical records

GP and hospital records are now multi-user friendly and most sites enable multidisciplinary teams to make entries within the same system. However, Maari Ma Health has a separate MedicalDirector system from RFDS, and LHD has recently upgraded to NSW Health’s latest hospital electronic medical record system. Thus, the usual norms of primary care, in which a GP is confident that the electronic record is complete, have not been possible to achieve in recent years. RFDS doctors are fully oriented to the need of keeping updated records for emergency and primary care consults, so that colleagues may be apprised of their decision making.

Social considerations

In remote NSW, there are many circumstances that may impact the clinical follow-up of medical conditions. It is widely believed that logistical, economic and cultural factors affect the low attendance rates for CDM in remote settings.13,14 The reasons for low RFDS clinic attendance rates include socio-economic conditions, the lower likelihood that males in rural communities will use preventive health services than urban males, and a higher proportion of Indigenous people.14 Logistical dimensions of proximity, affordability, accommodation, timeliness and psychosocial attitudes and beliefs are well known to hinder continued primary care in remote regions.13–15 Identifying infrequent users of primary health care who have chronic disease, with consideration of culturally appropriate preventive care, will assist in targeting those patients who require medical services.

There are still many barriers to the high quality management of chronic conditions. Efforts to improve this situation should focus on enhancing continuity of care, follow-up systems and planning of a team care approach. The increased use of telehealth technologies will be an important part of remote consultations, and current initiatives to improve CDM are of the utmost importance.

Overcoming negative perceptions among Australian medical students about a career in general practice

Encouraging medical students to pursue a career in general practice is a global problem with an Australian solution

General practice is the cornerstone of the Australian health care system, and a critical component of health care systems around the world. However, recruiting a general practice workforce capable of meeting community needs remains a global challenge.

Canada is experiencing a critical shortage of general practitioners, with 14.9% of the population without a GP in 2014.1 Similarly, the United Kingdom faces a severe shortage of GPs, coupled with insufficient numbers of medical students choosing general practice as a career.2 The number of applications for GP training in the UK fell between 2013 and 2015, with 12.4% of training posts unfilled in 2015.3 In the United States, only 11.7% of 2016 residency training positions were for general practice, and 155 places were left unfilled.4 Further, an international study found that general practice is poorly perceived by medical students, with students across seven countries indicating that they were less interested in the specialty, perceiving general practice as less intellectually challenging, with lower prestige and poor remuneration.5

In 2007, Australia was facing a similar situation. Negative perceptions of general practice among medical students were a barrier to overcoming a looming GP shortage6 and graduates were increasingly choosing to not pursue the specialty as a career.7 In 2005, only 532 of 600 available GP training positions were filled.6 An ageing workforce6 and medical students’ lack of interest in general practice presented a challenge for policy makers — how could this negative perception be overcome?

Creating the General Practice Students Network

In 2005, Joe Rotella, a Melbourne medical student, recognised the negativity about general practice in Australian medical schools. With the support of General Practice Registrars Australia (GPRA) and a successful funding application to the federal government, he developed the concept of a network of student clubs to reverse this negativity.

Today, General Practice Students Network (GPSN) clubs exist in each Australian medical school. They are run by student volunteers who organise educational events to promote general practice to medical students, including educational talks from local GPs, career networking nights, clinical skills workshops and rural and Indigenous health events. Each event is planned and presented by students and supported by local organisations, including other student clubs, regional training providers and academic staff at each university. The national council of local clubs is overseen by the GPSN National Executive, a team of students who advocate on behalf of the organisation and oversee the running of the network, with support from staff at GPRA.

Between 2007 and 2016, the membership of the GPSN grew from 121 to 14 199 student members. This rapid growth led to the addition of two new programs:

the Going Places Network (GPN), which promotes general practice to prevocational doctors in training hospitals and currently has 3500 junior doctor members; and
the John Murtagh First Wave Scholarship, a program that provides placements in general practice for preclinical medical students.

Collectively, the GPSN, GPN and John Murtagh First Wave Scholarship are known as GP First, a pipeline that promotes general practice from the first day of medical school until the commencement of specialty training.

GP First

The strategy of GP First has been to target directly the factors that are known to increase interest in general practice. Enthusiasm for, and commitment to, general practice is an important determinant of whether students will pursue it as a career path.5 Since its inception, the GPSN has worked to foster this enthusiasm by using a peer-to-peer model that takes advantage of the known positive influence peers can have on student’s perceptions of the specialty.5,8 In 2014, the 21 local GPSN clubs ran 98 events which were attended by 7259 students. Research has also shown that positive role models influence student perceptions of general practice,5 and GPSN events have provided opportunities for students to network with GP registrars who are seen by students as the most current and accurate source of career information.8

Positive exposure to general practice has also been found to improve student perceptions of general practice,5,9,10 and since 2008, the John Murtagh First Wave Scholarship has provided general practice placements for over 600 medical students. Of these students, more than 92% found the program extremely useful in helping them with their future career choice and more than 77% said the program made them more likely to consider general practice as a career.11

Since the GPSN was founded, there has been a significant shift in the GP training landscape. In 2005, the Australian General Practice Training (AGPT) program was only able to fill 532 of its 600 training places. Only 366 of these applicants (69%) were Australian medical school graduates,12 representing 24.4% of the 1503 medical students who had graduated the previous year.13

In 2014, there were 2026 applications for 1500 AGPT training places; 1421 of these were graduates from Australian medical schools,14 representing 41.3% of the 3441 students who had graduated from Australian medical schools in the previous year.13 This represents not only an increase in the number of applications in absolute terms, but also substantial growth in the percentage of graduates pursuing general practice training.

Between 2011 and 2013, GPRA worked with General Practice Education and Training (GPET) to quantify the success of the GP First program by tracking the number of AGPT applicants who were either First Wave scholars or members of the GPSN and GPN. The percentage of applicants from GP First increased from 11% in 2011 to 25.6% in 2012 and in 2013, 35% of acceptances into training were from GP First.11

The more than doubling of graduating medical students over the 10 years has undoubtedly contributed to the increase in GP training applicants. However, there is little recent research quantifying the impact of other contributors to this increase. A 2011 study found that factors contributing to choice of career for GP registrars included the quality of undergraduate general practice placements, exposure to GP role models, awareness of AGPT and the GP colleges at the student level, as well as the flexibility of GP training.12

During the time that the GPSN program has operated in Australian medical schools, there has been a significant improvement in medical students’ perception of general practice since its low popularity in 2005. From 2010 to 2013 the percentage of graduates identifying general practice as their top choice for future medical specialty increased from 12.3% to 17%.15 Indeed, general practice topped the list in 2013, placing higher than internal medicine (16.6%) and surgery (16%).15

GP First is undoubtedly only one of a number of factors that may have helped to improve the perception of general practice among medical students and, unfortunately, the impacts of its three programs for students have not been quantified. With the increase in applicants for GP training, the federal government no longer sees a need for a program to promote general practice to medical students. In December 2015, the government cut all funding for the GPSN, the GPN and the John Murtagh First Wave Scholarship.

The future

The focus of GPSN clubs across Australia has shifted from promoting general practice to supporting the future leaders of the specialty. Local events and projects from the four national working groups will continue to focus on areas of need in the community, including rural health and Indigenous health, while also working on closing gaps in general practice education for medical students and junior doctors. The John Murtagh First Wave Scholarship will survive in a reduced form, supported by corporate sponsorship, to ensure that future medical students continue to have positive experiences of general practice.

In less than 10 years, the GPSN has grown from one medical student’s idea into a successful national organisation run by hundreds of volunteers who organise events attended by thousands of students each year. With the loss of government funding, GPSN clubs now face the challenge of securing their own survival while continuing to run events that inspire the next generation of GPs and ensure students are equipped to navigate the changing landscape of primary health care in Australia.

Australia has reversed the downward trend in GP training numbers seen around world, with the demand for places now exceeding supply. The GPSN is just one of several possible contributors to medical students’ increased interest in general practice. Research is needed to identify and quantify the impact of the various demographic factors and workforce programs that are contributing to this change, so that other nations can learn from Australia’s success in securing our future primary care workforce.

Delays and confusion cloud roll-out of new cervical cancer screening program

Australia’s new national cervical cancer screening program has had a bad week.

The government announced it would delay the May 1 roll-out of its new program until Dec 1, 2017. And a petition opposing the new program swept social media.

But it’s not all bad news. The delay gives the Standing Committee on Screening, which is responsible for implementing the new program, the chance to engage with the public and communicate why the changes are being made and what they mean.

If the online petition is anything to go by, this is badly needed to counter the widespread misunderstanding of the new cervical screening program and the role of human papillomavirus (HPV) in causing cervical cancer.

How did we get here?

In 2014 the Medical Services Advisory Committee recommended the national cervical screening program be “renewed” to provide better protection against cervical cancer.

Key changes included raising the screening age to 25 and replacing Pap tests every two years with HPV tests every five years. The HPV test is more accurate than the existing Pap test, which looks for abnormal cells on the cervix rather than HPV, and its accuracy means it is safer for women to go longer between tests.

Another important change is setting up a national cancer screening register to record people’s cervical cancer screening histories.

But last week, Commonwealth Chief Medical Officer Brendan Murphy announced the Telstra Health-managed register would not be ready for May.

As a result, the new cervical screening test will not be made available on the Medicare Benefits Schedule from May 1; instead, the health department advised women continue to be screened using the existing Pap test.

Online petition shows women want to know more

The past week saw 70,000 people (so far) sign an online petition opposing the changes to the cervical screening program.

The letter accompanying the petition, since removed, unfortunately misrepresented the effectiveness of screening women under the age of 25, the role of HPV as the cause of cervical cancer and the rationale behind the new screening program.

The petition struck a chord and quickly gathered steam.

In an interview, the person behind the petition said she was motivated by “concern and worry”, because “[she] didn’t know about it and no one seemed to know about it”, and because “[she’d] love someone to be able to get down on our level and explain the testing”.

Responses to her petition indicated widespread concern about safety of the new starting age and the wider screening interval. In addition, women perceived the renewed program as a cutback – that less screening is being driven by cost-savings rather than the availability of a better test.

A response from Michael Gannon for the Australian Medical Association provided a large number of facts.

It also portrayed the petitioners as “well-intentioned […] but woefully misinformed and misguided”, but did not respond to the factors motivating the anger in many petition comments.

How to handle concerns?

Petitioners’ concerns should not be dismissed. If the public is “misinformed and misguided” about changes to cervical screening, it is the result of a failure to effectively communicate the changes and their rationale.

An implementation phase was to be undertaken that included engaging with the public to assess acceptability and educating clinicians and women about the changes. No public information has been released about this phase, so it is not clear what has been done or who may have been consulted.

Other countries that have introduced HPV testing to their cervical screening programs have noted the importance of responding to women’s concerns around screening changes, especially when and how they receive information about HPV. Research also
highlights some people’s reluctance to accept less-frequent screening.

How do we communicate change?

Screening programs generally change because the evidence about screening changes. It’s a good thing for screening programs to be responsive, to make adjustments when it becomes apparent harms may be occurring, or that benefits can be retained with less burden on participants and the health system.

Now, with the delay to the cancer screening register, there is an opportunity to take seriously the responsibilities of a screening program to communicate well with the population it serves.

The epidemiology that guides screening is complex, but its simple communication is a vital part of any public health program. Good communication and understanding what matters to stakeholders are as important as the scientific evidence that programs are based on.

In this case, a reasonable message to take from the petition opposing the renewal is that communication and consultation have not been sufficient or effective.

Unfortunately, this seems to have become a feature of Australian health policy. For instance, last year people were confused about pathology rebates and GP rebate freezes.

Meaningful public engagement and communication are neither easy nor cheap, but shying away from them is not an acceptable response.

Jane Williams, Researcher at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney and Sally Wortley, Research Fellow and PhD candidate School of Public Health, University of Sydney

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

Latest news

What would make you see a doctor?

There has recently been a more dedicated conversation to help doctors find better ways of improving their whole-body health.

Instead of relying on self-diagnosis and ‘corridor consultations’, doctors are being urged to find a GP and proactively maintain their own mental and physical health.

Improving doctors’ health is not a new topic; dedicated doctors have been working on this issue for decades.

According to Dr Margaret Kay, medical director Queensland Doctors’ Health Service, there have been conferences in Australasia around the topic since 1999.

However recently, more people have been speaking out over the importance of doctors’ health.

“We’re seeing is quite a significant voice from the council of doctors in training and doctors at the junior doctor/registrar level,” Dr Kay noted.

Significantly, there have been some senior medical voices speaking out.

It is this voice of experience that is vital for changing the culture, particularly for junior doctors.

According to Dr Kay, when a junior doctor or registrar is sick, the senior doctors should give them permission to take care of themselves and see a doctor.

“Your consultant should be putting his or her hand on your shoulder and saying ‘I really get how you feel and I think you need to go home to bed. I’m not going to penalise you for being sick’,” she explained.

She said ‘eye-rolling’ when someone isn’t feeling well needs to stop.

“We need to be aware of it and have a conversation with each other. Senior people need to support each other in enabling that.”

Dr Kay said often doctors who call up the Queensland Doctors’ Health Programme phone line are looking for permission to see a doctor.

According to one of Dr Kay’s studies, Developing a framework for understanding doctors’ health access, published in the Australian Journal of Primary Health in 2011, finding the right time to see a GP is one of the barriers for doctors.

One respondent said: “You tend to trivialise your complaints and it might be just that once that you’re too busy to go and you miss the boat completely and you get yourself into serious trouble.”

However Dr Kay said the ideal time to see a GP is not for something serious, but for a check-up or immunisations, so there is an opportunity to build a rapport with the GP and talk about further health issues and preventions.

“There are so many conversations that a GP can enter into with a doctor once they’ve come in for a simple consultation.”

It’s also the training for doctors to learn the best way to treat other doctors that’s important. Websites such as Drs4drs.com.au, a newly launched website hosted on doctorportal, aims to provide a resource for doctors to maintain their own health and access to training programs for GPs wanting to help treat other doctors.

“GPs particularly be trained up, and should be engaged with their primary health network to let them know it’s the type of training they’re interested in,” Dr Kay advised.

To find more doctors’ health resources or be connected with your state advisory service, visit Drs4drs.com.au

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Service aims to remove the stigma of doctors seeking medical help

Doctors are used to being the carers in our communities, however many find it difficult to seek professional health advice for themselves.

Historically, a professional culture has encouraged longer working hours and high levels of a doctor’s dedication, often to the detriment of their health.

However there is a new national website with dedicated resources specifically aimed at the medical profession.

Drs4drs.com.au launched recently to provide a vital resource for all doctors to help maintain their own health.

Hosted on doctorportal, it provides a springboard for finding health-related triage, advice, referral services and other online health resources.

In 2014, the Medical Board of Australia launched a significant boost in resources to doctors’ health, partnering with the Australian Medical Association to develop a national health program.

As a result, the AMA established a subsidiary company, Doctors’ Health Services (DrHS) to administer health programs at arm’s length from regulatory authorities like the MBA and AHPRA.

According to chair of the DrsH board, Dr Janette Randall, doctors’ health has been an ongoing cultural issue.

“As a profession we are self-reliant and tend to see illness as a weakness or failing. Taking time off isn’t an option when it means letting your patients and colleagues down, and young doctors in particular worry about the impact on their future careers if they are seen as not coping or not being tough enough.”

Related: What would make you see a doctor?

Although doctors generally have a higher level of health than the general community, they’re not as good at seeking help, often preferring to speak to a colleague or self-manage conditions rather than following a formal route of medical investigation.

According to Dr Randall: “Encouraging all doctors to have their own GP is an essential element of good self-care, and we need to change the culture so that help seeking is a normal and desirable thing for doctors to do.”

The mental health of doctors is of particular concern. According to the Beyond Blue National Mental Health Survey of Doctors and Medical Students, doctor have higher rates of psychological distress and suicide attempts compared to the Australian population.

Women and younger doctors are of particular concern: the survey found female doctors had higher rates of current psychological distress, higher likelihood of minor psychiatric disorders and current diagnoses of specific mental health disorders. They were also more likely to have had suicidal thoughts. Younger doctors are more vulnerable to poor mental health and levels of stress with higher rates of burnout compared to older doctors.

Doctors with a mental illness often don’t seek help due to fear that they won’t be seen as competent.

Drs4drs.com.au aims to reduce this stigma and provide doctors with the tools and resources to improve both their mental and physical health.

“While doctors’ health services provide an important source of support and advice for doctors in crisis, including those experiencing mental health and substance use issues, what we really want is for doctors health services to be real focus for everyone taking care of their health,” Dr Randall explained.

As a starting point, doctors can be linked straight through to their state based health advisory services. In addition to providing confidential health-related triage and advice, these advisory services provide follow up services and support for doctors and medical students who need help returning to work, training for doctors treating other doctors and support groups for doctors with significant health problems.

The drs4drs website also a range of resources including wellbeing guides for junior doctors, mental health resources and health guides for doctors in certain fields like rural health and general practice.

The aim is to encourage a profession wide response that is compassionate and supportive of medical colleagues experiencing any kind of health challenge.

For more information, visit drs4drs.com.au

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AMA, Govt hold talks on ‘more balanced’ approach to pathology rents

AMA President Dr Michael Gannon met with Health Minister Sussan Ley in Canberra on 24 November to discuss the Government’s proposal to change the definition of market value for pathology collection centre leases.

Dr Gannon told the Minister that the AMA was prepared to work with the Government to try and come up with a more balanced policy approach that genuinely targeted inappropriate rental arrangements and did not interfere with legitimate commercial arrangements.

The AMA President also highlighted that the Government’s proposed changes had significant implications for existing leases that had been entered into freely, and on the basis of which financial commitments have been made by practices.

The discussion followed a meeting of the AMA Federal Council which reiterated its support for prohibited practices laws, but recommended significant changes to the Government’s election policy.

The Federal Council stressed the need for a more a targeted approach that focused on inducements to refer, consistent with the original intent of the prohibited practices laws, and that pathology referrals should be solely based on the quality of services, as opposed to commercial relationships.

Federal Council resolved to support the right of medical practices to negotiate collection centre leases freely with pathology providers, provided rents were not linked to a stream of referrals and that any new definition of market value must not adversely affect those medical practices that were acting ethically when entering into leasing arrangements.

The Council stated that reasonable transition arrangements would need to accompany any changes, and the Government would need to develop an appropriate educational strategy to ensure requesters and providers were aware of their obligations under existing prohibited practices laws and ensure that these and any future laws were properly administered and enforced.

Responding to allegations of sham leasing arrangements, Federal Council agreed that the Government needed to work with stakeholders to establish whether these could be sustained and, if so, develop measures to address them with urgency.

The AMA Federal Council also expressed its disappointment in successive Federal Governments for their failure to adequately fund patient access to medical care, including the prolonged freeze on Medicare rebate indexation, which increasingly threatened the viability of pathology, general practice and other specialist services.

During his meeting with the Minister, Dr Gannon welcomed her advice that the Government would not proceed with its planned 1 January 2017 commencement date, and the Minister’s commitment to allowing more time for consultation with general practice and pathology practice over the definition of market value and what transition arrangements might be needed. In this regard, the Minister stated that the Department of Health would be expected to work closely with the AMA as it developed further advice to Government.

[Comment] Rethinking primary care systems for obesity

Paul Aveyard and colleagues, in The Lancet, provide optimistic news for the management of obesity in primary care.1 In this parallel, two-arm, randomised trial of screening and a brief intervention for obesity in primary care, Aveyard and colleagues identified a net weight loss benefit at 12 months from a 30 s active intervention by primary care physicians. A striking feature of the study was that patients with obesity (body-mass index of at least 30 kg/m2 or at least 25 kg/m2 if of Asian ethnicity) were invited to participate with no assessment of their readiness to change, yet the majority (2263 [83%] of 2728 potentially eligible participants) were willing to do so, of whom 1882 individuals were eligible to enrol in the trial.

Health Care Homes must be tailored to Indigenous needs

I am continuing the important tradition of chairing the Taskforce on Indigenous Health as AMA President. The taskforce acts to identify and recommend Indigenous health policy strategies for the AMA.

On 8 October 2016, it was my privilege to chair my first meeting of the Taskforce. A number of important issues were discussed, including the AMA’s election priorities relating to Aboriginal and Torres Strait Islander health, the AMA’s support for the establishment of an Academic Health Science Centre in Central Australia, as proposed by Baker IDI Heart and Diabetes Institute and its partners, and the Indigenous health focus of the Medicare Benefits Schedule (MBS) Review.

One issue that was raised as being of particular concern was how the proposed Health Care Homes initiative will affect health care for Aboriginal and Torres Strait Islander peoples. The AMA supports the concept of Health Care Homes – a policy announcement made by the Coalition prior to the 2016 election, and we are pleased that the Australian Government has committed to an extended trial of the concept.

The AMA has concerns about the Health Care Homes model in relation to Indigenous health, and we assert that the specific health needs of Aboriginal and Torres Strait Islander people must be addressed through the scheme.

The concept of the medical home is not new in Australia. For many Australians, their local general practice is already their Health Care Home, and their GP, their primary carer. Patients whose care is well managed and co-ordinated by their GP are likely to have a better quality of life and to make a positive contribution to the economy through improved workforce participation. Health Care Homes should mean more expensive downstream costs can be avoided. Chronic conditions, if treated early and effectively managed, are less likely to result in the patient requiring hospital care for the condition or any complications.

The Health Care Home model has worked overseas and the evidence is of significant reductions in avoidable hospital admissions, emergency department use, and overall costs.

The AMA sees Health Care Homes as potentially one of the biggest reforms to Medicare in decades.

However, we know that, for the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. We also need to see greater detail about how the Health Care Home model will operate in remote and Indigenous communities.

Indigenous communities face a range of unique health problems and chronic diseases uncommon in our cities. A high turnover of medical practitioners and support services in these areas means continuity of care and follow up treatment can be difficult to maintain.

Trust is a vital component of health care, especially for Aboriginal and Torres Strait Islander peoples, and knowing and trusting a GP is critical in the management of chronic conditions. How the Health Care Home model will deliver consistent, ongoing GP care and management of chronic health conditions is not known, and the AMA has been urging the Government to provide greater details about funding and operation.

There is a degree of anxiety among the Aboriginal Community Controlled Health Organisation (ACCHO) sector that any announcements made by the current Government will result in cuts to Indigenous health. There is a strong view that building up the ACCHO sector is the best model of care for Aboriginal and Torres Strait Islander peoples, particularly as ACCHOs are the preferred provider of Indigenous health services.

ACCHOs, like Health Care Homes, need to be built on existing relationships and investment in models that work. The Government must not rush the Health Care Homes trial and, if it is to be successful, it must be adequately funded.

As a model, it has the potential to help close the gaps in health outcomes between Aboriginal and Torres Strait Islanders and non-indigenous Australians. The AMA’s position will be to closely monitor what works and what does not work, and work constructively with Government to ensure the necessary changes are made.

Govt’s dodgy deal with big pathology ‘not the answer’: Gannon

AMA President Dr Michael Gannon has told pathologists that capping pathology collection centre rents is “simply not the answer” to the challenge the sector faces from almost 20 years of frozen Medicare rebates.

In a message to AMA pathologist members, Dr Gannon said the surprise deal struck between the Federal Government and Pathology Australia during the Federal election to impose a rent ceiling was a “poorly targeted” policy that would deliver a massive windfall for the big pathology companies at the expense of medical practices, and did nothing for individual pathologists.

“The Government’s proposal goes too far, interfering with legitimate commercial arrangements that have been entered into by willing parties,” he said. “It will unfairly damage medical practices that have made business decisions based on projected rental streams, including investment in infrastructure and staffing.”

The AMA President said there was no guarantee from Pathology Australia, whose biggest member is Sonic Healthcare (which holds 43 per cent of the market), that any money pathology companies saved by cutting their collection centre rents would be re-invested in pathology services or the pathology workforce.

Instead, the rents deal controversy was overshadowing important issues such as the impact of the near 20-year rebate freeze for pathology services and the need for a much more sustainable funding base, he said.

In striking his deal with Pathology Australia, Prime Minister Malcolm Turnbull blindsided groups including the AMA and the Royal College of Pathologists of Australasia, who had been involved in discussions with the Government earlier this year on ways to improve transparency and strengthen compliance within the existing regulatory framework governing pathology collection centre (ACC) rents.

ACC rents have risen strongly since their deregulation in 2010, and there have been fears of a nexus between leases and the number of pathology tests a practice orders.

But the Health Department has reported in several different forums that it has not detected any such link, and told a roundtable meeting of stakeholders attended by the AMA on 27 April that it had found no evidence that rents were substantially above market value.

Instead, rents are being driven higher by intense competition for market share. Consolidation in the industry has intensified since deregulation, and the two big pathology companies, Sonic and Primary Health Care, between them now hold about 77 per cent of the market – a 12 per cent increase in five years.

Instead of addressing issues around the structure of the industry and how that was affecting competition and rents, Dr Gannon said the Government’s unilateral move to cap rents was simply a “knee jerk reaction” to head-off a politically damaging campaign.

The Government struck the deal in the early days of the Federal election in order to get Pathology Australia to drop its threat to axe the bulk billing of pathology services following the abolition of the pathology bulk billing incentive.

The terms of the agreement were laid out in a Senate Estimates hearing last month by Health Department Deputy Secretary Andrew Stuart, who said the “nature of the deal between the Government and Pathology Australia is to work to bring rents down to a more reasonable level and, at the same time or in some relationship to that, to continue with the Government’s proposal to remove the bulk billing incentive”.

Government Minister Senator Fiona Nash told the Estimates hearing the Coalition had received assurances from the pathology industry that “it is going to keep the bulk billing levels at its rates [and] we are taking it in good faith that that is exactly what they meant, and we expect they will do that”.

Dr Gannon said that in rushing to strike its deal with Pathology Australia, the Government had failed to take into account the consequences for GPs.

The Government’s plan went well beyond the intent of existing laws and gave pathology providers an unfair advantage in commercial negotiations with medical practices, he warned.

His concerns were borne out by the testimony of Mr Stuart, who admitted that the Department had not modelled the likely effect of the pathology rents cap on general practices, particularly when combined with the Medicare rebate freeze.

The senior health official, who made pointed reference to the fact the deal was “a Government negotiation, not a departmental negotiation”, said details of the arrangement, especially regarding its implementation, were still being finalised.

Significantly, the deal leaves the contentious issue of what should be defined as ‘market value’ unresolved – something admitted by Health Department First Assistant Secretary Maria Jolly in her testimony to the Senate committee.

She said how the new arrangement would be introduced was also yet to be determined, including how existing leases would be treated, and how the new deal would relate to the current regime governing prohibited practices.

Adrian Rollins

E-health dream comes a step closer

The dream of a trustworthy, seamless and secure system for sending health information between providers, regardless of where they are or the platform they are using, is a step closer.

The Australian Digital Health Agency (ADHA), which began operations four months ago and has former AMA President Dr Steve Hambleton as a senior adviser, has launched a major program to realise the health potential of digital technology by developing a secure, fully interoperable sector-wide messaging system to enable practitioners to quickly and confidently send and receive vital medical information.

Years after many other industries have moved to predominantly digital communication, most healthcare providers continue to rely on fax machines because they do not have a way to securely send highly sensitive medical information or receive notification that it has been delivered or received, ADHA Chief Executive Tim Kelsey said.

“I keep hearing that our health professionals want to talk to each other routinely, securely, electronically – a situation that many currently find themselves unable to do,” Mr Kelsey said. “One of the first priorities for the Agency will be to partner with [medical software] industry, jurisdictions and healthcare professionals to solve the daily challenge of not having a way to send electronic messages to others in the health sector in a seamless, secure way.”

To keep the program on track and make sure it delivers the right outcomes for users, the Agency has appointed an external panel of advisers to lead it.

Designated as Senior Responsible Owners, the three experts, Dr Nathan Pinskier, Chair of the RACGP Expert Committee on E-health and Practice Systems, Dr Mal Thatcher, CEO of eHealth Queensland, and community representative Fiona Panagoulias, will “shape the direction of the program and hold the Agency to account for delivering a program that results in clear benefits for the community”.

“The number one issue to be resolved in health care communications is the ability for healthcare providers to electronically communicate with each other directly, seamlessly and securely,” Dr Pinksier said. “Solving the provider-to-provider secure messaging usability issue will create the potential to leverage these healthcare communications for other purposes, including uploads to the My Health Record. The interoperability solution is within our grasp.”

The three experts will be supported by a Program Board comprising health providers and representatives from the technology industry, general practice, hospitals, Primary Health Networks and HealthDirect Australia.

No deadline for the work has been made public.

Adrian Rollins