Richard Nesbit Evans, MB BS, MRCP(UK), FAFOM

Richard Nesbit Evans was born on 14 May 1944 in Birmingham, United Kingdom. A natural all-rounder, he attended Winchester College from 1957 to 1962, where he excelled at athletics and won the science prize. He studied politics, philosophy, economics and natural sciences at the University of Cambridge in the early 1960s and joined The Economist, where he worked as an investigative journalist from 1964 to 1967.

Richard then changed career paths, studying medicine at King’s College London, where he served as president of the Medical Students’ Association. After graduating in 1972, Richard worked at hospitals in London, Coventry and Epsom and became a member of the Royal College of Physicians of the United Kingdom in 1975.

From 1975 to 1979, Richard was the chief medical officer for several airlines including British Caledonian, Laker Airways, British Airways and Cathay Pacific. His interest in aviation came from his father, who was a de Havilland Mosquito test pilot during the Second World War. During this time, Richard organised the dispatch of chemotherapy medications to various African nations and was involved in aeromedical retrieval missions. He was also a regular contributor to the “from the doctor” column of the Cathay Pacific in-flight magazine.

He moved to Perth, Western Australia, in 1979. He was the medical officer at the BP Kwinana Refinery and at Cockburn Cement from 1980 to 1985. He was then appointed medical registrar at the Royal Perth Hospital from 1985 to 1988 and became a Fellow of the Australian Faculty of Occupational Medicine in 1985.

Richard ran a general practice in Leederville for 7 years and subsequently spent the next 20 years working across rural and urban Australia as a locum, becoming well known in towns such as Coober Pedy, Boddington and Halls Creek. He was also surveyor of general practice in Western Australia from 2002 to 2007.

Richard wore many non-medical hats: fisherman, birdwatcher, gold-fossicker and master handyman. He played for the international Ghanaian rugby union team while on medical student elective and followed the San Francisco 49ers in American football and Aston Villa in soccer. He was also an active member of the Australian Baha’i community and of the Men of the Trees society.

Richard died in Perth on 22 December 2015, just 4 months after being diagnosed with glioblastoma multiforme. He was a gentle, patient and kind doctor and a man of great humility. He is survived by his wife Faeghe, sons James, Matthew, Stephen and Eric, and grandsons Oliver and Leo.

Patient charges rising fast

Patient out-of-pocket costs have surged and are now growing at their fastest pace in four years as general practices react to the financial squeeze from frozen Medicare rebates and rising running costs.

While the Federal Government has trumpeted official figures showing the proportion of GP services being bulk billed has risen to a record high of 85.1 per cent, the statistics also indicated that those patients that are being charged a fee are paying more.

Medicare data show that average out-of-pocket costs reached $34.25 last financial year, up 6.5 per cent from 2014-15 – the fastest pace of growth since 2011-12 and well above the rate of inflation.

The increase in patient charges follows warnings from AMA President Dr Michael Gannon that many general practices were “now at breaking point” because of the Medicare rebate freeze, cuts to incentive payments and reduced mental health funding.

“Many patients who are currently bulk billed will face out-of-pocket costs well over $20,” Dr Gannon said.

Hopes that the Turnbull Government, stung by voters over health policy, might move the scrap the rebate freeze are fading, heightening concerns that hard-pressed medical practices will have little choice but to abandon or cut back on bulk billing and increase charges for those patients judged to be able to pay a fee.

But instead, the Government has used the high incidence of bulk billing to argue its policies are sustainable.

Health Minister Sussan Ley seized on the increase in the bulk billing rate, claiming it was “good news for Australians”.

Ms Ley said the figures showed 123 million GP services were fully funded by the Government last financial year, and put the lie to Labor claims that the Government was anti-Medicare.

“These figure expose the blatant and remorseless Mediscare lies Labor have been telling the Australian public over the last 12 months,” Ms Ley said. “There’s no doubt we still have work to do, but Australians should tale assurance from the fact no Government has invested more into Medicare than the Turnbull Government.”

But Shadow Health Minister Catherine King said the figures seized on by the Government were misleading because they focused solely the number of services that were bulk billed, rather than the number of patients, and ignored the rise in out-of-pocket costs.

Ms King said that as the rebate freeze has continued, a growing number of practices were abandoning bulk billing, including on Magnetic Island and in Hobart.

“Australians know that Malcolm Turnbull’s six-year freeze on Medicare rebates is driving bulk billing down and out-of-pocket costs up,” Ms King said. “The Government’s insistence otherwise only shows how out of touch they are.”

In his 17 August speech to the National Press Club, AMA President Dr Michael Gannon reiterated the AMA’s opposition to the rebate freeze, which he warned was undermining general practice, which was one of the key strengths of the nation’s health system.

“General practice has been under sustained pressure for years,” Dr Gannon said. “GPs have been treated poorly by both Coalition and Labor governments.”

The AMA President said that the ageing population and the growing burden of chronic and complex disease meant GPs were seeing more patients than ever before – an extra 42 million services in the past decade.

Despite this growth in demand, Government support for GPs was in decline.

“GPs are caught in a diabolical squeeze,” Dr Gannon said. “They are caring for increasingly sick patients while the Government tightens the financial screws in the name of budget repair.”

“GPs are now at breaking point. Many patients who are currently bulk billed will face out-of-pocket costs well over $20,” he warned.

Latest news:

More doctors opting for specialist roles

The number of medical practitioners opting for specialist roles over general practice has spiked in the last decade.

The supply of specialists-in-training has more than doubled from 7,269 to 15,336 in the past ten years – that’s a jump from 43.4 to 74.8 specialists-in-training per 100,000 people – according to a report released by the Australian Institute of Health and welfare (AIHW).

The Medical practitioner workforce 2015 data shows general practitioner numbers have not had the same upward trend, remaining comparatively stagnant with 109 GPs per 100,000 people in 2008 to 114 in 2015.

AIHW spokesperson Dr Adrian Webster said that despite the slower increase in GP numbers, the supply had stayed abreast of Australia’s growing population.

Assistant minister for Rural Health Dr David Gillespie said the sharp increase in the supply of specialists wasn’t reflected with better access to their services in remote communities.

“Many people in rural and regional communities must still travel for long distances and experience lengthy delays in order to see a specialist for diagnosis or treatment. This must change,” he said.

Dr Gillespie, a former rural physician, said the data did reflect improved availability of general practitioners for Australians living in regional and remote areas.

“The overall number of medical practitioners is continuing to increase and access to GPs in regional areas is now comparable to access in metropolitan areas,” he said.

The AIHW cautioned, however, that the remote area figures could be skewed based on the different delivery models and higher levels of demand in some regions.”

Latest news:

Progress in the care of familial hypercholesterolaemia: 2016

Familial hypercholesterolaemia (FH) is the most common autosomal dominant condition.1 FH reduces the catabolism of low-density lipoprotein cholesterol (LDL-c) and increases rates of premature atherosclerotic cardiovascular disease (CVD). This review focuses on recent advances in the management of FH, and the implications for both primary and secondary care, noting that the majority of individuals with FH remain undiagnosed.2

FH was previously considered to have a prevalence of one in 500 in the general community, including in Australia.3 Recent evidence, however, suggests the prevalence is between one in 200 and one in 350, which equates to over 30 million people estimated to have FH worldwide.4,5 These prevalence figures relate to the general population, and while FH is present in all ethnic groups, communities with gene founder effects and high rates of consanguinity, such as the Afrikaans, Christian Lebanese and Québécois populations, have a higher prevalence of the condition.

Further, the prevalence of homozygous or compound heterozygous FH has been demonstrated to be at least three times more common than previously reported, with a prevalence of about one in 300 000 people in the Netherlands.4 The detection and management of individuals with homozygous FH has been described in a consensus report from the European Atherosclerosis Society.6 Homozygous FH is a very severe disorder, with untreated people often developing severe atherosclerotic CVD before 20 years of age. Such individuals often have LDL-c concentrations > 13 mmol/L and severe cutaneous and tendon xanthomata. While diet and statins are the mainstays of therapy, early intervention (before 8 years of age) with LDL apheresis or novel lipid-lowering medication, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors or microsomal triglyceride transfer protein inhibitors, is indicated. Patients with suspected homozygous FH should be referred to a specialist centre.6

Several recent international guidelines on the care of FH have been published.3,7–10 These have focused on early detection and treatment of individuals with FH. However, there is still no international consensus on the diagnostic criteria for FH, or on the utility of genetic testing. The Dutch Lipid Clinic Network criteria (DLCNC) are preferred for diagnosing FH in index cases in Australia (Box 1).2 The International FH Foundation guidance acknowledges geographical differences in care, and recognises the need for countries to individualise service delivery. CVD risk in FH is dependent on classic CVD risk factors. However, FH is appropriately excluded from general absolute CVD algorithms, since these underestimate the absolute risk in FH.

FH guidelines provide therapeutic goals, which vary depending on the specific absolute CVD risk for patients with FH. In adults, the general LDL-c goal is a least a 50% reduction in pre-therapy LDL-c levels, followed by a target of LDL-c < 2.5 mmol/L, or < 1.8 mmol/L in individuals with CVD or other major CVD risk factors; these international targets update those of previously published Australian FH recommendations.2,3,10 Currently only about 20% of individuals with FH attain an LDL-c level < 2.5 mmol/L.11

Detecting FH in children

The European Atherosclerosis Society published a guideline focusing on paediatric aspects of the diagnosis and treatment of children with FH in 2015.8 This guideline outlined the benefit of early treatment of children with FH using statins. There is a significant difference in the carotid intima medial thickness (a measure of subclinical atherosclerosis) in children with FH and their unaffected siblings by 7 years of age, with implications for the value of early treatment. Lifestyle modifications and statins from 8 years of age can reduce the progression of atherosclerosis to the same rate as unaffected siblings over a 10-year period.8 Early treatment of children improves CVD-free survival by 30 years of age (100%) compared with their untreated parents (93%; P = 0.002).8 While further long term data on statin use in children are required, there are 10-year follow up data for children who were initiated on pravastatin between the ages of 8 and 18 years, which demonstrate that statin therapy is safe and effective.12 Hence, the balance of risk and benefit suggests that use of statins in children with FH is safe and efficacious, at least in the short to intermediate term, with all recommendations appropriately requiring that potential toxicity and adverse events be closely monitored.

Childhood is the optimal period for detecting FH, as LDL-c concentration is a better discriminator between affected and unaffected individuals in this age group. After excluding secondary causes and optimising lifestyle and repeating fasting LDL-c on two occasions, a child is considered likely to have FH if they have:

an LDL-c level ≥ 5.0 mmol/L;
a family history of premature CVD and an LDL-c level ≥ 4.0 mmol/L; or
a first-degree relative with genetically confirmed FH and an LDL-c level ≥ 3.5 mmol/L.

Universal screening for FH in children has been demonstrated to be effective in Slovenia, but experience is limited elsewhere.13 The therapeutic targets for children are less aggressive than for adults: a reduction in LDL-c of over 50% in children aged 8–10 years and an LDL-c level < 3.5 mmol/L from the age of 10 years.8

Cascade screening

Recent reports from Western Australia confirm that cascade screening is efficacious and cost-effective.11,14 The genetic cascade screening and risk notification process followed in Western Australia is shown in Box 2.11 Cascade screening involves testing close relatives of individuals diagnosed with FH. The autosomal dominant inheritance suggests 50% of first-degree relatives would be expected to have FH. Two new cases of FH were found by cascade screening for each index case in WA.11 These individuals were younger and had less atherosclerotic CVD than index cases. Interestingly, about 50% were already on lipid-lowering therapy, but they were not treated to the recommended goals and further lipid reductions were achieved overall. Over 90% of patients were satisfied with the cascade screening process and care provided by this service .11 However, for individuals who have not had genetic testing performed, or for individuals with clinical FH in whom a mutation has not been identified, cascade screening should also be undertaken using LDL-c alone.

Although we have recently shown that genetic testing is cost-effective in the cascade screening setting ($4155 per life year saved),14 only a few centres in Australia have this facility and testing is currently not Medicare rebatable. However, combining increased awareness of the benefits of identifying people with FH with the reducing analytical costs may increase the use of genetic testing. This in turn could guide advocacy and lobbying Medicare to support genetic testing for FH.

Detecting FH in the community

A novel approach that utilises the community laboratory to augment the detection of FH has recently been tested in Australia. The community laboratory is well placed to perform opportunistic screening, since they perform large numbers of lipid profiles, the majority (> 90%) of which are requested by general practitioners.15 Clinical biochemists can append an interpretive comment to the lipid profile reports of individuals at high risk of FH based on their LDL-c results. These interpretive comments on high risk individuals (LDL-c ≥ 6.5 mmol/L) led to a significant additional reduction in LDL-c and increased referral to a specialist clinic.16 A phone call from the clinical biochemist to the requesting GP improved both the referral rate of high risk (LDL-c ≥ 6.5 mmol/L) individuals to a lipid specialist and the subsequent confirmation of phenotypic FH in 70% of those referred, with genetic testing identifying a mutation in 30% of individuals.17 There is a list of specialists with an interest in lipids on the Australian Atherosclerosis Society website (http://www.athero.org.au/fh/health-professionals/fh-specialists).

In Australia, GPs consider they are the best placed health professionals to detect and treat individuals with FH in the community.18 A large primary care FH detection program in a rural community demonstrated that using pathology and GP practice databases was the most successful method to systematically detect people with FH in the community.19 However, a survey of GPs uncovered some key knowledge deficits in the prevalence, inheritance and clinical features of FH, which would need to be addressed before GPs can effectively detect and treat individuals with FH in the community.18 A primary care-centred FH model of care for Australia has recently been proposed to assist GPs with FH detection and management, but this requires validation.20 The model of care includes an algorithm that is initiated when an individual is found to have an LDL-c level ≥ 5.0 mmol/L, which could be highlighted as at risk of FH by either a laboratory or the GP practice software.20,21 The doctor is then directed to calculate the likelihood of FH using the DLCNC. Patients found to have probable or definite FH are assessed for clinical complexity and considered for cascade testing. See the Appendix at mja.com.au for the algorithm and definition of complexity categories. FH-possible patients should be treated according to general cardiovascular disease prevention guidelines.

Molecular aspects

There have also been advances in molecular aspects of FH. A recent community-based study in the United States confirmed that among patients with hypercholesterolaemia, the presence of a mutation was independently predictive of CVD, underscoring the value of genetic testing.22 The mutation spectrum of FH was described in an Australian population and was found to be similar to that in Europe and the United Kingdom.23 Mutation detection yields in Australia are comparable with the international literature; for example, 70% of individuals identified with clinically definite FH (DLCNC score > 8) had an identifiable mutation, whereas only 30% of those with clinically probable FH had a mutation.23

Polygenic hypercholesterolaemia (multiple genetic variants that each cause a small increase in LDL-c but collectively have a major effect in elevating LDL-c levels) is one explanation for not identifying an FH mutation. An LDL-c gene score has been described to differentiate individuals with FH (lower score) from those with polygenic hypercholesterolaemia (higher score), but this requires validation.24 About 30% of individuals with clinical FH are likely to have polygenic hypercholesterolaemia, and cascade screening their family members may not be justified.25

A further possible explanation for failure to detect a mutation causative of FH in an individual with clinically definite FH may lie in the limitations of current analytical methods such as restricting analysis to panels of known mutations. Further, FH is genetically heterogeneous and there may be unknown alleles and loci that cause FH. Next generation sequencing is capable of sequencing the whole genome or targeted exomes rapidly at a relatively low cost, and may improve mutation detection and identify novel genes causing FH, but further experience with its precise value in a clinical setting is required. Whole exome sequencing was able to identify a mutation causing FH in 20% of a cohort of “mutation negative” but clinically definite FH patients.25 However, when applied to patients with hypercholesterolaemia in a primary care setting, pathogenic mutations were only detected in 2% of individuals, with uncertain or non-pathogenic variants detected in a further 1.4%.26

Cardiovascular risk assessment

Absolute CVD risk assessment, employing risk factor counting, should be performed as atherosclerotic CVD risk is variable in FH.10,27 This involves appraisal of classic CVD risk factors including, age, sex, hypertension, diabetes, chronic kidney disease and smoking. The prevalence of classic CVD risk factors among Western Australians with recently identified FH was 13% for hypertension, 3% for diabetes and 16% for smokers, all of which were amenable to clinical intervention.11

Other non-classic CVD risk factors are also important for individuals with FH, especially chronic kidney disease and elevated levels of lipoprotein(a).28 Lipoprotein(a) is a circulating lipoprotein consisting of an LDL particle with a covalently linked apolipoprotein A. Its plasma concentration is genetically determined and it is a causal risk factor for CVD in both the general population and FH patients.29,30 Lipoprotein(a) concentrations are not affected by diet or lowered by statins.31

Management and new therapies

The past 2 years have also seen the development of new treatments for FH, but lifestyle modifications and statins remain the cornerstones of therapy for FH. Ezetimibe has been demonstrated to reduce coronary events against a background of simvastatin in non-FH patients with established CVD.32 PCSK9 inhibitors have recently been approved to treat individuals with FH or atherosclerotic CVD not meeting current LDL-c targets in Europe and America. PCSK9 is a hepatic convertase that controls the degradation and hence the lifespan of the LDL receptor. PSCK9 is secreted by the hepatocyte and binds to the LDL receptor on the surface of the hepatocyte. The LDL receptor–PCSK9–LDL-c complex is then internalised via clathrin-dependent endocytosis, but the PSCK9 directs the LDL receptor towards lysosomal degradation instead of recycling it back to the hepatocyte surface.33 A recent meta-analysis of early PCSK9 inhibition trials involving over 10 000 patients demonstrated a 50% reduction in LDL-c, a 25% reduction in lipoprotein(a), and significant reductions in all-cause and cardiovascular mortality.34

The PCSK9 inhibitors alirocumab and evolocumab were approved by the European Medicines Agency in 2016 for homozygous and heterozygous FH and non-FH individuals unable to reach LDL-c targets, and for individuals with hypercholesterolemia who are statin intolerant. In the US, the Food and Drug Administration has approved alirocumab for heterozygous FH and individuals with atherosclerotic CVD who require additional reduction of LDL-c levels. Evolocumab and alirocumab have recently been approved by the Therapeutic Goods Administration in Australia for people with FH. Adverse events are generally similar to placebo, but reported side effects include influenza-like reaction, nasopharyngitis, myalgia and raised creatine kinase levels, and there have been reports of neurocognitive side effects (confusion, perception, memory and attention disturbances).34 The cost of these agents is likely to be the major limitation to their clinical use. The indications and use of lipoprotein apheresis and other novel therapies, including lomitapide, a microsomal triglyceride transfer protein inhibitor, and mipomersen (an antisense oligonucleotide that targets apolipoprotein B), have been recently reviewed.35

Despite the advances reviewed, the implementation and optimisation of models of care for FH remain a major challenge for preventive medicine. Areas of future research should focus on better approaches for detecting FH in the young and on enhancing the integration of care between GPs and specialists. The value of genetic testing and imaging of pre-clinical atherosclerosis in stratifying risk and personalising therapy merits particular attention. Further, with families now living in a global community, more efficient methods of communication and data sharing are required. This may be enabled by international Web-based registries.36 Care for people with FH needs to be incorporated into health policy and planning in all countries.10

Conclusion

There have been significant advances in the care of individuals with FH over the past 3 years. An integrated model of care has been proposed for primary care in Australia. Progress has also been made in the treatment of FH with the emergence of PCSK9 inhibitors capable of allowing more patients already on statins to attain therapeutic LDL-c targets and hence redressing the residual risk of atherosclerotic CVD. Future research is required in the areas of models of care, population science and epidemiology, basic science (including genetics), clinical trials, and patient-centric studies.37 Finally, the onus rests on all health care professionals to improve the care of families with FH, in order to save lives, relieve suffering and reduce health care expenditure.

Box 1 –
Dutch Lipid Clinic Network Criteria score for the diagnosis of familial hypercholesterolaemia (FH)2

Criteria

Score

Family history

First-degree relative with known premature coronary and/or vascular disease (men aged < 55 years, women aged < 60 years); or

First-degree relative with known LDL-c > 95th percentile for age and sex

First-degree relative with tendon xanthomas and/or arcus cornealis; or

Children aged < 18 years with LDL-c > 95th percentile for age and sex

Clinical history

Patient with premature coronary artery disease (ages as above)

Patient with premature cerebral or peripheral vascular disease (ages as above)

Physical examination

Tendon xanthomata

Arcus cornealis at age < 45 years

LDL-c

≥ 8.5 mmol/L

6.5–8.4 mmol/L

5.0–6.4 mmol/L

4.0–4.9 mmol/L

DNA analysis: functional mutation in the LDL receptor, apolipoprotein B or PCSK9 gene

Stratification

Definite FH

> 8

Probable FH

6–8

Possible FH

3–5

Unlikely FH

< 3

LDL-c = low-density lipoprotein cholesterol. PCSK9 = proprotein convertase subtilisin/kexin type 9.

Box 2 –
Protocol for genetic cascade screening in Western Australia*

* Family cascade screening process performed according to national guidelines2 after obtaining written consent from the index case.11 This was undertaken by a trained nurse who contacted the family members and obtained verbal consent to contact further family members, after providing counselling and offering specialist review as indicated.

[Editorial] Atrial fibrillation and stroke: unrecognised and undertreated

When did you or your primary care physician last palpate your wrist to check for a regular heart rate? This simple action, followed by an electrocardiogram if the heart rate is irregular, might be crucial in preventing death and disability from ischaemic stroke, heart failure, or myocardial infarction. In this week’s issue, we publish a clinical Series of three papers on atrial fibrillation ahead of the annual European Society of Cardiology (ESC) meeting held in Rome, Italy, Aug 27–31. Atrial fibrillation is estimated to affect 33 million people worldwide.

Invest in health to avoid political disaster, Gannon tells Govt

The Federal Government must boost investment in general practice and public hospitals if it wants to avoid “a major Medicare headache” at the next election, AMA President Dr Michael Gannon has warned.

As the re-elected Turnbull Government finalises plans to put $6.5 billion of spending cuts, including in health, before the new Parliament, Dr Gannon has called for a change in the Coalition’s mindset away from seeing health as a cost and instead view it as an investment, warning that the Government’s political survival is at stake.

In his inaugural address to the National Press Club, the AMA President said the knife-edge result of the Federal election showed that Australians were “very comfortable with the state being in charge of their health and education” and did not like political parties messing with the system.

“There is no doubt that health was a game-changer in the election. It was very nearly a government-changer, too,” Dr Gannon said. “For many Australians, the health system – doctors, nurses, allied health, hospitals – is called Medicare. They see any threat to Medicare as bad.”

Prime Minister Malcolm Turnbull has acknowledged the political damage the Government inflicted on itself through its plans to introduce a co-payment for GP services and its cuts to public hospital funding, and has already had several meetings with Dr Gannon in an effort to try and improve his Government’s relationship with the medical profession.

But Dr Gannon said that, while the more consultative approach was welcome, it had to result in better policy, reiterating the AMA’s demands for an end to the Medicare rebate freeze, increased funding for public hospitals, the restoration of bulk billing incentives for pathology and diagnostic imaging tests and increased investment in preventive health.

The Government has so far shown no signs of budging on its decision to freeze Medicare rebates until 2020 as it tries to hold health expenditure down.

But Dr Gannon said the policy was a false economy because it was hurting GPs, who were providing the most cost-effective care in the health system. Furthermore, it would result in more patients deferring seeing their family doctor and eventually requiring much more expensive hospital care, and was undermining the goodwill of GPs, which would be needed for the successful implementation of the Health Care Homes initiative.

Just 6 per cent of the Government’s health spending goes on GP services, and Dr Gannon said general practice represented “very, very good value for money”.

But instead of getting support, GPs were being crushed in a “diabolical squeeze” as funding has been held down and cut even as demand for their services has continued to climb.

“GPs are now at breaking point,” the AMA President said. “Unless there is substantial investment in general practice, there is no doubt that the quality of care will start to suffer – and patients will face growing out of pocket costs.”

He warned that patients who are currently bulk billed may face out-of-pocket costs of $20 or more and “without a big re-think on the range of policies that affect general practice, the Government could have another major Medicare headache at the next election”.

Health Care Homes

One of the Government’s boldest reforms is to establish the Health Care Home model of care for patients with chronic illness. Under the plan GPs would, in addition to their current fee-for-service remuneration, be paid to help the chronically ill manage their disease.

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

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

So far, the Government has only committed $21 million for a trial of the concept, none of which will go toward patient care.

Dr Gannon said that asking GP to provide enhanced care without any extra support “simply does not stack up”.

The Government also need to overcome the “significant trust and goodwill deficit” it had with general practitioners.

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

Prevention better than cure

Dr Gannon used his Press Club speech to intensify the pressure on the health insurance industry, accusing health funds of putting profits before patients and warning of a slide toward US-style managed care if they had their way.

The Government has acted on mounting discontent with the quality of health cover by announcing plans to ban ‘junk’ public hospital-only policies, mandating minimum levels of cover and introducing a simplified rating system for policies.

The AMA President said these were important steps, but the Commonwealth needed to provide much greater support for public hospitals.

In 2014, the Abbott Government controversially walked away from the previous Labor Government’s hospital funding agreement with the states, at a cost of $57 billion over 10 years.

Dr Gannon said public hospitals were “an everyday saviour for Australian families”, but were failing to meet waiting time and treatment targets as “a direct consequence of the Commonwealth’s failure to fund their share”.

He said the States and Territories did not have the revenue base to increase their funding, and the “Commonwealth Government needs to step up”.

To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.

He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.

“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”

He said the success of action to curb smoking showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.

In his speech, Dr Gannon also highlighted the urgency for action to improve Indigenous health. He expressed strong support for the Royal Commission into juvenile detention in the Northern Territory, and backed constitutional recognition as a way to “help heal some of the wounds that underlie Indigenous disadvantage”.

Adrian Rollins

Doctors need to be taught how to discuss their patients’ excess weight

With 80% of adults and close to one-third of children expected to be overweight or obese by 2025, doctors are increasingly likely to be working with people who are overweight or obese.

An individual’s weight is a complex and sensitive issue, which may be related to many factors that are not only medical but social, environmental and emotional. The skills to address the issue in a way that communicates the health risks of being overweight without judgement and without inciting negative responses are not easy to acquire or universally taught.

Health professionals repeatedly report a lack of confidence in knowing how to address obesity in their patients. They report minimal, if any, training on obesity as well as limited resources for effective conversations and insufficient clinical time to be able to do this well.

Starting a conversation about weight requires not only empathy but awareness of strategies people can use to manage weight issues and an understanding of the range of local services available to assist. It has been shown that although behavioural and medical strategies can be effective, uninformed discussion in the clinic can disengage, stigmatise or shame patients, which then has negative impacts on the outcomes.

Many patients do expect weight-loss guidance from health professionals and the discussion can influence outcomes. In fact, having the conversation and formally diagnosing and documenting excess weight or obesity is the strongest predictor of having a treatment plan and weight-loss success.

Choice of language is crucial

Research has identified the terms “fat” and “fatness” are the least preferred terms. The words “obese” and “obesity” have also been found to arouse negative responses. The National Institute of Clinical Excellence in the UK suggests patients may be more receptive if the conversation is about achieving or maintaining a “healthy weight”.

The STOP Obesity Alliance in the US suggests using “people first” language such that a person “has” obesity rather than “is” obese, similar to “having” cancer or diabetes.

This is part of a debate about whether obesity should be labelled as a disease rather than a risk factor.

Regardless of how this issue is classified, doctors and patients both require the knowledge to understand effective therapies do exist and obesity treatment is not futile. Losing 5-10% of body weight can have a significant impact on risk factors such as blood pressure and can lower the risks of later health problems such as heart disease or type 2 diabetes.

This sort of weight loss also often improves other factors more immediately beneficial to the patient, such as energy levels, mood and mobility.

A communication style that encourages shared decision-making and helps people change their behaviour is key. The objective is not to solve the problem but to help the patient begin to believe change is possible and develop a plan about health goals.

Let’s take the case of a woman who presents with urinary incontinence. The woman may describe the problem of needing to wear sanitary pads because of daily leaking of urine. Factors such as obesity will worsen the problem, but the woman may not be aware of this.

The doctor might say:

“I hear you’re concerned about your loss of urine, is that correct? Let’s talk about that; and would it be OK to discuss your weight too, as that may be related?”

The practitioner might listen for a willingness to have further discussion and then pose a goal-orientated question:

“If, as part of our plan to help your urinary symptoms, you decide to work on getting to a healthier weight, what might be a first step?”

Repercussions for our kids

For men and women of reproductive age the conversation is potentially not just about their own health but also about that of their children. Women who have higher pre-conception weight and pregnancy weight gain are at increased risk of developing diabetes and heart disease in later life and are less likely to lose weight after they give birth.

This vicious cycle results in larger babies that are predisposed to short-term risks as newborns, longer-term risks of increased childhood obesity and an increased lifetime risk of obesity, diabetes and heart disease.

Between 1985 and 1995 the rate of excess weight and obesity in childhood increased by 50% and obesity tripled in Australia. Animal studies also suggest obesity in the male parent can increase the chance of their offspring developing obesity or diabetes.

The intergenerational nature of obesity therefore means until we address overweight and obesity in adults who are planning a pregnancy, it may be impossible to lower rates of childhood obesity.

The framing of the issue as a problem for patients’ own health as well as for the health of their children is even more complex. However, unless there is a greater understanding of this risk and more training of doctors in talking to patients about obesity this will be difficult to tackle.

Currently, many health professionals remain uncomfortable and unsure in this area of practice. Ensuring the workforce is skilled will also mean there is the ability to discuss weight when it is not the primary issue a patient presents with, but where an important conversation at a critical life stage may actually have lasting effects on patients’ health and that of their children.

Adrienne Gordon, Neonatal Staff Specialist, NHMRC Early Career Research Fellow, University of Sydney and Kirsten Black, Associate Professor & Joint Head of Discipline Obstetrics, Gynaecology and Neonatology, University of Sydney

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

Other doctorportal blogs

Health Care Home success depends on GP goodwill

General practice is the corner stone of primary care. I am sure you will all agree with this. General practice in Australia has an exemplary record compared with many other countries around the world. It is efficient and extremely low cost, especially compared with an uncomplicated ED presentation.

The public, and the public purse, is extremely well served by general practice. The cost of MBS expenditure on general practice is just 6 per cent of total Government spending on health. Fee for service (FFS) has been the predominant funding model of general practice over that time.

The Government’s Health Care Home (HCH) is a model of care for patients with chronic disease. It is also known as the Medical Home. Under the model, patients have a continuing relationship with a particular GP to coordinate the care delivered by all members of the patient’s care team.

Do we need it? Especially when we consider the exceptional current performance and achievements of GP in Australia?

The significant twin burdens of burgeoning chronic disease and advancing age presentations are challenging the economic resources for delivering primary care. In an environment where fiscal resources are tight, the FFS model’s ability to cope with the pressure on the public purse is under the microscope.

Superimpose this on years of cuts to GPs – years of continued underfunding and non-investment by successive governments in general practice has brought GPs to the brink.

BEACH data shows that GPs are managing more chronic disease than ever before. GPs are already under substantial financial pressure due to the Medicare freeze and a range of other funding cuts. The HCH model is certainly not a way for the Government to arrange funding to general practice in the current Medicare rebate freeze environment.

The Medical Home is fundamental to the concept of the family doctor who can provide holistic and longitudinal care and, in leading the multidisciplinary care team, safeguard the appropriateness and continuity of care.

All this is academic if the funding for HCH is not appropriate, and not simply at the expense of FFS. Which brings us to the trial (or as the Health Department wishes to view it, as phase one of the implementation).

In March, the Government committed $21 million to allow about 65,000 Australians to participate in an initial two-year trial involving up to 200 medical practices from 1 July 2017. This funding is not for services, just for the infrastructure required to support the trial, as well as its evaluation.

The Health Department is busily preparing for this implementation. There is a hive of activity as it seeks to implement this key part of the Government’s strategy for reform. The overarching implementation advisory group will liaise to ensure that best practice and appropriate strategies are followed in the trial. AMA is on both the implementation group and underpinning subgroups involved in the mechanics of selecting patients and the economics of payment mechanisms.

The next few months will see many announcements, including the identification of the Primary Health Network (PHN) regions and an invitation for expressions of interest from practices in those regions to be part of the trials. The success of this policy initative will also depend on developments and further progress on the MyHealth Record and the PHNs (not without their challenges also).

The Department rightly understands that the goodwill of GPs is crucial for the success of the trial.

That goodwill will evaporate significantly if there is not the appropriate funding. However, I have made it clear that with additional funding support, GPs can provide more preventive care services and greater management and coordination of care. More important still, they can keep patients healthier and out of hospital, saving unnecessary and more expensive presentations and hospital admissions down the track – a measure which will form a key part of the evaluation of the success of the trial.

Making a difference

As a doctor, one of my key objectives is to improve my patients’ health, wellbeing and quality of life. I’m sure that you share this goal. Making a real difference in someone’s life is what gets me up every day. But how do I really know that I’m making the difference I think I am?

Often the results of my interventions are more immediate. I help a patient make an informed decision about an immunisation, or I clean and stitch a wound minimising the scar and risk of infection. I might have diagnosed a case of pneumonia and prescribed a course of treatment to relieve and eradicate my patient’s symptoms.

Other times it is less immediate. I might work with a patient to empower them to better manage their chronic disease, aiming to minimise its advance, the risks of associated multi-morbidities and its impact on their everyday life. This is much harder to measure and assess.

Aside from what I can see with my own eyes at an individual level, to confirm I am making a difference, the reality is that I need to record my actions, review the outcomes of my actions and evaluate this against my peers, or a best practice benchmark.

Understanding how I am performing can enable me to identify where I could do better and provide a personal benchmark from which I can follow a process of continuous improvement that will improve the efficiency of my practice and the quality of the health care I provide my patients.

While this can be challenging, it is very important to ensure my clinical practice is evolving in line with my peers, enhancing my effectiveness and helping me to deliver the health care my patients value.

Continuous quality improvement is often sold as a package of principles, methods and techniques that can be overwhelming and seemingly unsustainable for a busy GP. The best way to eat an elephant, I’ve been told, is one mouthful at a time. This is the approach I believe is required to implement a sustainable process of continuous quality improvement in general practice. But where to start?

The key to any objective evaluation is quality data. The key to quality data is standardised clinical terminology – in other words, coding. Before the end of this year it is expected that the two largest providers of clinical software will have enabled mapping of their coding systems to the SNOMED clinical terminology. This will be a huge enabler for many practices when extracting and analysing their data. They will be able to undertake simplified data extractions and compare apples with apples.

Accreditation and incentives such as those provided under the Practice Incentive Program, Quality Improvement and Continuing Professional Development requirements have been instrumental in facilitating GPs in improving their practices and processes, and in keeping their knowledge and skills up to date. But at the end of the day, the question that really matters is – did we make a difference.

The challenge is how to answer this question. Much of the answer is potentially at our finger tips or sitting in front of us, in our clinical data. For example, what percentage of our patients have their cholesterol levels recorded, what percentage have improved their levels in 12 months since a diagnosis of high cholesterol. How many have levels within the optimum range. Do our patients feel better, can they cope, can they move more freely, is their pain managed, did we listen to them, did we help them understand their condition and treatment options, did we follow up on them?

The discussion about quality improvement in general practice has started. The Health Care Home initiative will look at how practices can develop quality assurance processes, and it is important for general practice to do more to demonstrate to Government just how good our standards of care are. This is not about pay-for-performance but rather, how we ensure that GPs have the tools and information they need to better support a culture of continuous quality improvement.

Govt investment in doctors of the future still falling short

As the new Chair of the Medical Workforce Committee (MWC), I am looking forward to harnessing the committee to drive the AMA’s response to the medical workforce crisis.

I would like to acknowledge Dr Stephen Parnis for his stewardship of the MWC as inaugural Chair. Like Stephen, I have a long-standing interest in medical workforce issues, and believe that ensuring Australia has the medical workforce to meet community needs is a critical challenge for governments and health policymakers.

Over the last 15 years the number of medical school places has increased substantially in response to past workforce shortages. But the need for more medical schools is over, as we know from successive sets of workforce data that Australia now has sufficient numbers of medical students. We must now focus on improving the distribution of the medical workforce, and providing enough postgraduate medical training places, particularly in rural and remote areas and the under-supplied specialty areas.

At the recent Federal Election, the AMA offered four important policy proposals to help achieve this outcome:

expanding the National Medical Training Advisory Network’s (NMTAN) workforce modelling program;
establishing a Community Residency Program;
increasing the GP training program intake; and
expanding the Specialist Training Program.

NMTAN is the Commonwealth’s main medical workforce training advisory body, and focuses on planning and coordination. It has representatives from the main stakeholder groups in medical education, training and employment.

NMTAN’s report on the psychiatry workforce was released in March. This is the first specialty report to be finalised by NMTAN since Health Workforce Australia was axed in 2014. It contains valuable data and analysis, including a projected undersupply of 125 practitioners by 2030 for the psychiatry workforce, despite a likely increase in the number of Australian-trained psychiatrists.

NMTAN is intending to beef up its work program. The AMA has argued consistently for complete workforce modelling and reporting across all medical specialties by the end of 2018; it is vital to have data sooner rather than later on imbalances across the specialties to enable effective workforce planning.

We will continue to engage with the Government of this issue. In the meantime, we await with interest the expected release of the reports on the anaesthesia and general practice workforces later this year.

An important piece of work undertaken by the MWC last year was developing the Community Residency Program for Junior Medical Officers (CRP). This is the AMA’s proposal to establish and fund a program for high-quality prevocational placements in general practice for junior doctors as a replacement for the valuable Prevocational General Practice Placements Program abolished by the Government in 2014.

We continue to lobby for our CRP. The Government’s announcement late last year that it will fund 240 rotations in general practice settings for rural-based interns is a partial replacement for the PGPPP, and was an admission by the Government that its decision to abolish the program was a backward step, especially for rural health.

As a practising GP, I am keenly aware that more resources are needed to build and maintain a sustainable GP workforce.

The AMA’s call to increase the GP training program intake to 1700 places a year by 2018 is worthy of the Government’s consideration. This must be backed with solid measures to support GP training, including incentives for supervisors and investment in training infrastructure. Rural general practices need grants to help them expand their facilities and provide more teaching opportunities for medicals students and GP registrars, and to enhance the range of services they provide.

The Commonwealth’s Specialist Training Program (STP) is a valuable workforce program that is giving specialist trainees the opportunity to train in settings outside traditional metropolitan teaching hospitals. Though the Government has committed to provide 1000 placements by 2018, the AMA strongly believes that the STP must be expanded to 1400 places a year, with the focus on encouraging specialist training in rural settings and specialties that are under-supplied.

Other areas of focus for the MWC will be promoting generalism in the medical workforce, encouraging greater gender diversity in medical leadership, and increasing clinical supervision capacity.

Progress, but much more to do.