Global lessons for Australian general practice

We have much to share, but also much to learn, about providing truly universal health coverage

Ageing populations, overcrowded hospitals and emergency departments, increases in the numbers of people with chronic diseases and mental health concerns, consumer demands for improvements in health care services and access to new discoveries and technologies, struggling health budgets with a reduced focus on prevention and health promotion — these are just some of the global health challenges facing many countries, including Australia.

Yet, universal health coverage remains the greatest global health challenge. How do we ensure that all people have access to timely, acceptable and affordable health care of appropriate quality, making possible “the highest attainable standard of health as a fundamental right of every human being”, as enshrined in the constitution of the World Health Organization?1

In September 2015, the 193 member states of the United Nations General Assembly, including Australia, adopted Transforming our world: the 2030 agenda for sustainable development.2 This document outlines the 17 sustainable development goals (SDGs) that aim to end poverty and hunger, improve health and education for all people, and protect the global environment.3 Only one of these SDGs is specifically a health goal. It is to “ensure healthy lives and promote well-being for all at all ages”, and represents a call for universal health coverage.

This renewed global focus on universal health coverage is putting a spotlight on ways to reinforce the contribution that primary health care, and especially models of team-based general practice services, can make to strengthening health care systems in high-, middle- and low-income nations around the world.4

Australia has a strong model of universal health coverage through Medicare, the taxpayer-funded national health insurance scheme that subsidises access to general practice, other medical services and essential medicines, and augments the nation’s system of free public hospitals. However, there are gaps in Australia’s universal health coverage, and disparities in provision of health care services mean that some people miss out on equitable access to health care, including many Aboriginal and Torres Strait Islander people, people living in rural and remote areas with limited access to health care services, people with intellectual disability and mental health concerns, people who are refugees or seeking asylum, and people who are housebound and unable to get to our clinics at a time when home visits have become increasingly rare in many parts of our nation.5

There is also patchiness in the quality of the primary health care services available to some, especially older people, those with disability and those with complex chronic health care conditions. This is something that the Australian Government’s new Health Care Homes program seeks to tackle by having patients register with a single general practice.6 There has been advocacy for such a model of care for many years given the evidence that inadequacies in the prevention, early detection and management of chronic disease leads to an avoidable increase in the use of expensive hospital services.7 However, without support for increased community outreach and primary health care services delivered to homes and residential aged care facilities, especially for frail older people and those with disability, these reforms may not go far enough.

As President of the World Organization of Family Doctors (WONCA), I have had the privilege of examining primary health care models in many countries and to identify models of care that may provide solutions for Australia. Brazil, for example, has adopted a national model of Family Health Teams that provide coverage for the 200 000 000 people of that country, with a specific focus on meeting the challenges of access for people living in low-income housing and in rural and remote areas. Each general practitioner works in a team with nurses and community health workers, providing comprehensive clinic-based and home-based care to a population of around 4500 people. Each team is responsible for the care of every person living in a defined geographical area. Team members visit each household, document the health care needs of the residents, ensure that this care is provided, and report on the health status of their community, thereby contributing to population-based planning. A national network of 40 000 Family Health Teams ensures that nobody misses out on health care.8

Another example is Cuba, a small island nation of 11 million people with an enviable system of health care, based on strong primary care. Every person in Cuba has access to his or her own primary care doctor and nurse team. Again, each team is responsible for knowing the health status of all the people in their community, and provides clinic-based and home-based care for those who are older and frail or have a disability that prevents them visiting the clinic. This proactive outreach model ensures that all people, and especially the most vulnerable, have access to health care.9

Denmark ensures universal health coverage to its citizens through a health care system based on strong general practice. Each GP has a defined list of patients and is responsible for providing those people with primary health care services and coordinating any required referrals to other health services. All citizens are covered by the national insurance scheme and have free access to general practice services, regardless of their ability to pay. While general practices are privately owned, like in Australia, health care is entirely publicly funded with 75% of funding coming from fee-for-service and 25% from capitation payments. Each full-time GP provides care for around 1600 people, delivering about seven consultations each year for each citizen. Danish GPs face similar challenges to those of Australian GPs, with an ageing population with more people with complex comorbid chronic health concerns as well as expectations from government that they will provide increased preventive care activities without being given additional resources.10

Danish general practice is also a world leader in the use of electronic medical records. Danish GPs code each consultation, using the International Classification of Primary Care (ICPC), which allows GPs to analyse their own clinical activity to better understand the health needs of their patient populations, and also allows national aggregation of consultation data through the Danish General Practice Database.11 Primary care researchers can investigate the health status of the whole community, analyse the quality of care being delivered, provide comparative feedback to individual GPs about their own activity and make national recommendations for continuing improvements to health care services.

The fundamental importance of general practice research in Denmark and other nations provides additional important lessons for Australia. Several countries that are serious about ensuring the strength of their general practice services invest in primary care research that supports policy makers to make informed decisions about the allocation of resources and the planning of future services. Among the leading international models are the United Kingdom’s School for Primary Care Research, part of the publicly funded National Institute for Health Research. This School attracts annual government investment of 12.5 million pounds and involves eight of the nation’s leading academic general practice departments, which work together to conduct high quality health services research to support primary care development and train future primary health care research leaders.12 The Netherlands School of Primary Care Research is another global leader in this field, making major contributions to the global primary care evidence base.13

The Australian Government has recently made substantial reductions in investment in primary care research.14 It is to be hoped that the new Medical Research Future Fund, with its promise of a focus on research funding to improve health outcomes,15 will provide much needed resources to re-establish our own national institute for primary care research to lead the research needed to ensure that future primary health care investment decisions are based on sound evidence about community needs and effective interventions.

The education and training of the current and future primary care workforce is another critical component of ensuring strong general practice. Recent government reforms of family medicine in countries such as China, Indonesia and Vietnam are influencing a change in the pattern of the medical workforce in each of these nations, with a shift to formal postgraduate training of GPs. China, in particular, has embarked on postgraduate training for an additional 400 000 GPs over the coming 7 years.16

While successive Australian governments have recognised the need to train more medical graduates in the specialty of general practice and many other countries look to Australia as a source of inspiration in postgraduate GP training, the overall proportion of GPs to other specialists in Australia has been declining. The OECD reported in 2006 that the percentage of generalist doctors relative to other specialists in Australia had declined from 59.9% in 1990 to 51.9% in 2000.17 Using different methods, Health Workforce Australia reported that, in 2009, the percentage of GPs relative to other specialists and hospital-based non-specialists had declined to less than 45%.18 Given the benefits of a strong primary care workforce in providing cost-effective, equitable health care, can Australia afford to reduce the percentage of GPs further?

Australian general practice has much to share with the rest of the world about clinical care, research and education, but we also have much to learn that could further strengthen our own health care system to ensure true universal health coverage.

Online PBS approvals system goes live

Doctors can now get an authority number to prescribe PBS Authority medicines online – that’s right – no more dialling the approvals phone line and waiting on hold until a clerk gives you an authority number. The catch is that prescribers need to log into Medicare’s Health Professionals Online System (HPOS) until medical practice software providers get on board.

The AMA urges everyone who prescribes PBS Authority medicines to contact their practice software provider now, urging them to add this functionality to their prescriber software. Obviously the online PBS Authorities system must be available directly from doctors’ clinical and prescribing software, with online forms automatically populated from existing data. However medical practice software providers will only develop products that include online PBS Authority approvals functionality on the basis of ‘client interest’.

The AMA has already written to the overarching organisation representing medical software providers, the Medical Software Industry Association (MSIA), urging early adoption but it’s important that the industry also sees strong interest directly from its clients.

In the meantime, you can use the online approvals system through HPOS to:

request a new PBS authority approval
enquire about authority approvals previously requested, and
cancel or amend a PBS authority approval if the:
- medicine has not been supplied or dispensed to the patient, and
- approved prescriber applied for the PBS authority approval within one year.

Repatriation Pharmaceutical Benefits Scheme (RPBS) authority approvals are not currently available through the online channels. Existing phone and written arrangements for RPBS approvals through the Veterans’ Affairs Pharmaceutical Approvals Centre (VAPAC) remain.

For more information go to:

PBS Authorities
HPOS
PBS Authorities Education

This was first published on GP Network News.

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Australian GPs are offered guidelines not relevant to their patients, and they often ignore them

Guidelines for GPs are often based on evidence and studies performed outside of general practice itself. This affects doctors’ judgements of the risk-to-benefit ratio of treatments and the performance of diagnostic tests.

As Tania Winzenberg, Professor of chronic disease management at the University of Tasmania, and I write in the Medical Journal of Australia today, interventions (such as medications and other treatments) are often tested in hospitals and other settings where the patient cohort is markedly different to the one seen in primary care.

A study from the United Kingdom indicates GPs ignore advice from guidelines not relevant to general practice. This means GPs could ignore potentially good advice, disadvantaging their patients and increasing costs.

General practitioners

General practice provides the majority of medical primary health care for Australians. About 85% of the Australian population see their GP at least once a year.

More than 137 million GP medical services were delivered by 33,279 general practitioners in 2014-15. In 2011-12, general practice spending was A$14.2 billion, equating to 9.7% of total health expenditure. GPs, the taxpayer and patients would all wish to believe this expenditure provided effective, safe and high-value services.

The reality is somewhat different, for several reasons.

Unlike many specialists, GPs see a wide range of medical conditions. Australian data from the BEACH study show 167 conditions form 85% of a GP’s work compared to five that form the same proportion of a specialist’s.

In half of all GP consultations, it is not possible to make a diagnosis that fits with the diagnostic criteria of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10), the current international classification of disease. This is not because GPs are bad at diagnosis but because much of what they see is mild illness; the symptoms of which are vague and fleeting and that often resolve on their own.

So one the of primary roles of GPs is to rule out significant illness; and if they suspect something sinister, to take appropriate action which may result in hospital or specialist referral.

National guidelines

The Australian health care system requires patients be reviewed and assessed by a GP first before they can access Medicare subsidies for specialist treatment. This ensures those referred for specialist review have a high probability of significant illness. This in turn keeps the cost of specialist care down and ensures the patient sees the most appropriate specialist.

Many patients, particularly as they age, have multiple problems (multimorbidity), which complicates diagnosis and treatment. To ensure GPs provide consistent care among themselves, that patients are referred in an appropriate manner to specialists and hospitals, and that care is as safe as possible, guidelines have been developed to assist GPs.

These work a bit like a GPS in your car. They offer advice on how to get to where you need to be but are not infallible and it is sometimes wise to ignore their advice.

The National Health and Medical Research Council has developed protocols for guideline development that rely on what are called levels of evidence. There are four levels of evidence and these are listed in order of reliability:

systematic reviews of multiple controlled trials (studies where one group of people receives the intervention tested while the other receives the comparison, such as a placebo)
a single controlled trial
observational studies (where trends are observed over time)
expert opinion.

Where possible, we’d like to have the highest level of evidence – expert opinion is often wrong.

A good example from Australia is the belief from doctors and patients that skin wounds need to be kept dry to prevent infection developing. But a 2011 controlled trial showed showering does not increase wound infection rates.

Trial evidence

But then, even when there is controlled trial evidence available, it may not be appropriate for primary care. Patients who participate in controlled trials are often different to those seen by GPs.

Children, women of child bearing age and older people are less frequent participants in trials. Trial subjects tend not to have chaotic lifestyles, do not have literacy or language problems, or rarely have several conditions at once.

Depression is a common condition in Australia. Around one-third of the population will suffer at least one episode in their life time. The type of depression seen by GPs is very different from that seen by psychiatrists and psychiatric inpatient units.

GPs treat milder disease that responds to counselling and psychological therapies. Psychiatrists see severe cases where physical treatments such as medication or electroconvulsive therapy (where an electrical current introduced into a patient’s scalp causes a mild seizure) may be needed to improve the patient’s condition.

If GPs follow advice based on evidence in patients seen by psychiatrists to treat their patients with milder depression, the GP could over-treat or even harm their patient through inappropriate therapies.

Yet an Australian study of international general practice depression guidelines found most are derived from trials conducted in psychiatric settings rather than general practice settings.

How can this change?

There is a need to improve the research capabilities of Australian general practice. It is particularly difficult to get funding for controlled trials of non-medicine therapies or for medicines that are off-patent.

We lack the required trained general practice research workforce, research infrastructure and some certainty of ongoing support. Our current general practice researchers are good, and have high international recognition, but we just do not have enough to address the urgent needs of Australian GPs and their patients.

Gerard Gill, Professor, Alfred Felton Chair In General Practice For Rural And Regional Victoria, Deakin University

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

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Prioritising general practice research

Cuts to federal funding put us in grave danger of wasting the investment made to achieve current gains in research capacity

General practice is critical to the provision of primary health care (PHC) for Australians. About 85% of the Australian population claim at least one general practice service from Medicare per year.1 Over 137 million such consultations were delivered by 33 279 general practitioners in 2014–15.1 In 2011–12, PHC spending was $50.6 billion (36.1% of total health expenditure), with $28.6 billion spent on predominantly general practice-based medical services and medications.2 Multiple studies have shown that a strong PHC system is associated with greater efficiency, lower rates of hospitalisation, fewer health inequalities and better health outcomes, including lower mortality.3 Thus, ensuring that the cornerstone of PHC delivery, general practice, has a robust evidence base is of paramount importance. Despite this, there are major gaps in the evidence supporting clinical practice and health service delivery in general practice.

From the perspective of general practice, health and medical research appears poorly targeted. There is a mismatch between the burden of diseases commonly managed in general practice and the number of randomised controlled trials exploring their effective management,4,5 and between the frequency with which conditions are encountered in general practice and publication rates of research and clinical guidelines.6 There are unmet needs for evidence specific to general practice in the recognition and management of early stage disease; assessment and management of disease risk for prevention; and patient care in complex situations, including multimoribidity.7

Recommendations for PHC made in disease-specific clinical guidelines are often based on evidence from studies performed outside general practice. For example, in 22 National Institute for Health and Care Excellence guidelines, only 38% of the publications that were cited to support primary care-relevant recommendations had studied patients typical of primary care.8 Yet, patients seen in tertiary referral centres with morbidities commonly seen in general practice differ markedly from the average general practice patient. This affects judgements on the risk–benefit ratio of treatments and the performance of diagnostic tests. Treatment benefits are usually higher in people at higher risk of adverse outcomes from their disease (eg, those attending tertiary referral centres) than in lower-risk patients seen in general practice, so testing an intervention in a hospital setting and then applying that expected benefit to general practice patients may result in overtreatment or less cost-effective treatment.

Further, exclusion criteria of clinical trials frequently eliminate patients with complex conditions, leading to potential underestimation of the risks of harm from treatment for general practice patients, in whom multimorbidity is common. In one example of this, at best 21% and at worst only 3% of “ordinary patients” would have been eligible to participate in a range of trials of osteoporosis treatments.9 Most were excluded due to comorbidities and concurrent medications such as glucocorticoids, but these patients still require treatment in the real world of general practice! The dangers of applying diagnostic testing in general practice, where diseases typically have a lower prevalence or are early stage, are also known. In an Australian study, just over half of general practice patients with fatigue had pathology testing performed, but only 3% had a significant clinical diagnosis based on an abnormal pathology test result.10 The low pre-test probability of illness in general practice patients11 reduces the post-test probability of them having a condition, given a positive test result. As post-test probability drives clinical decision making, applying an overestimated post-test probability observed in a high risk population to general practice patients can lead to inappropriate management.

None of this is news. Recognition of the importance of general practice research to the profession, government and community has been increasing since the 1990s, coinciding with a period of substantial commitment to building general practice and PHC research and evaluation capacity. As early as 1990, the General Practice Evaluation Program (GPEP) was established to develop the evaluation skills of researchers in general practice.12 The GPEP was part of the federal government’s General Practice Strategy, the review of which, in the late 1990s, increased focus on the need for a strong general practice research culture and workforce, with part of its vision into the 21st century being that GPs would be “actively involved in research, evaluation and teaching and be appropriately remunerated for these activities”.12

In 2000, the Primary Health Care Research, Evaluation and Development (PHCRED) program commenced, with four key components:

the Australian Primary Health Care Research Institute (APHCRI), with a focus on providing leadership in PHC research;
the Research Capacity Building Initiative (RCBI), which funded university departments of general practice and rural health to provide training and support in PHC research, particularly for GPs;
PHC research grants, administered through the National Health and Medical Research Council (NHMRC); and
the Primary Health Care Research and Information Service (PHCRIS), established to support dissemination and exchange of knowledge.

These efforts have resulted in many high quality research projects being conducted, and their results published. A small sample of such research conducted by Australian GPs includes a decade of research altering post-excision wound care in general practice13,14 and publications in the world’s top clinical medical journals on other important matters for GPs and their patients, such as counselling for women disclosing intimate partner violence15 and treatment for chronic knee pain.16

So why do we have to justify the importance of prioritising general practice research yet again? Put simply, the plug is being pulled on federal funding when the job is only partly done! The RCBI was defunded in 2011. More recently, funding to APHCRI has ceased; PHCRIS has just received a 6-month reprieve of withdrawal of funding; and the federal government contribution to the Bettering the Evaluation and Care of Health (BEACH) program has ceased. BEACH has been the major source of data on general practice activity in Australia. Government provided only about 18% of the total funding for this longstanding program (Associate Professor Helena Britt, University of Sydney, personal communication) but, combined with other difficulties in securing funding, BEACH now has to close.17 This incredibly cost-effective source of data for government and the profession will not readily be replaced.

Two ways to measure general practice research capacity and output are publication rates and numbers of successful doctoral candidates. General practice publication rates increased threefold from 1990–1999 to 2000–2007,18 which sounds impressive until one examines the absolute figures — this still amounts to only three publications per 1000 GPs per year, comparing poorly with rates for physicians (160/1000/year) and surgeons (68/1000/year).18 From 2005 to 2014, 76 GPs were awarded a PhD from an Australian university.19,20 There are no corresponding data for other disciplines but, in the same period, at least 200 physicians completed a doctorate under NHMRC scholarships.

Access to research funding for general practice research remains very challenging. The General Practice Strategy review noted that, “in Australia there is a considerable imbalance between the amount of funding devoted to research in secondary care compared with what is spent on primary and community-based research (including general practice)”.12 This imbalance remains. From 2000 to 2008, only about 1.9% of NHMRC-administered grants were PHC-related, and over a quarter of these were actually funded through the PHCRED strategy.21 This suggest two things. First, the moiety of research funds directed at PHC research is completely out of proportion when one considers the health dollars spent on PHC and its importance to the community. Second, PHC researchers may not yet be sufficiently developed to be competitive in what is arguably the most important health and medical research funding stream to which they have access in Australia.

This latter point is critically important. Underpinning the decisions to withdraw funding from capacity-building initiatives appears to be a failure to recognise that progressing high-performing general practice researchers from PhDs to independent research leaders is a long term challenge. Specific people support for the career development of general practice researchers has been sporadic and inconsistent. From 2009 to 2014, NHMRC grant outcome data show that eight general practice or PHC Early Career Fellowships (available to researchers within 2 years of achieving their PhD) were awarded, but none subsequent to this.22 In 2011, four NHMRC/PHCRED Career Development Fellowships (aimed at people 2 to 12 years after achieving their PhD) were awarded.23 Data before 2013 specifying if other levels of people support for GP researchers were awarded are not available on the NHMRC website at this time, but from our knowledge of the general practice research environment, this support has been minimal.

General practice research workforce issues are substantial. The challenge of supporting general practice research is now left to the university departments of general practice and rural health, which are hamstrung by lack of resourcing for capacity-building since the RCBI funding was withdrawn. As they are currently structured, general practice academic departments will find it hard to increase their activities. From examining university websites, we estimate that in June 2015 there were 72 GPs with Level D or E (Associate Professor or Professor) appointments employed at Australian universities, only 52 of whom had a doctorate. Only two universities had a sufficient concentration of these appointments at the one site to make an effective potential research team. A quarter of these GP academics were aged 60 years or older. The median time since primary medical qualification for successful GP PhD candidates was 23 years, giving them a potential median research career of about 17 years.20 Replacing the ageing GP research workforce will be difficult if this low rate of young doctoral students continues.

There are other problems affecting general practice research capacity, including:

lack of funding for the infrastructure needs of general practices to participate fully in data collection and research;
lack of support for practice-based research networks (PBRNs);
lack of clearly defined clinical research career pathways; and
the ongoing need for strengthening research culture within general practice.

PBRNs provide the equivalent of the biomedical laboratory for primary care. Currently, there are 17 university-linked PBRNs in Australia, whose research efforts are coordinated by the Australian Primary Care Research Network (APCReN). These networks have contributed to quality Australian research, including some mentioned above and the internationally important ASPREE randomised controlled trial of low dose aspirin for primary prevention in healthy older people,24 which has recruited over 16 000 general practice patients. Overseas, public funding has proved essential for the development and governance of PBRNs,25 but federal government funding of APCReN has been limited and may not be ongoing.

Prioritising general practice research was a key part of the Royal Australian College of General Practitioners’ (RACGP’s) pre-Budget submission to the federal government this year.26 The RACGP’s recommendations (Box), if implemented, would go a long way towards overcoming the obstacles blocking the continued development of sustainable, long term general practice research capacity for Australia. This is doable, through a more balanced distribution of current research funds to prioritise general practice research or through the Medical Research Future Fund, given the Australian Government’s wish “to support the sustainability of the health system and drive medical innovation through transforming how health and medical research is conducted in Australia”.27 In the meantime, we are in grave danger of wasting the investment made to achieve current gains in capacity, leaving our profession and the Australian population to make do with a severely restricted evidence base to support PHC in this country.

Box –
Recommendations of the Royal Australian College of General Practitioners (RACGP) for prioritising general practice research*

The RACGP recommends that the federal government prioritises primary health care research and:

commits $27 million over nine years to establish a general practice research fellowship program, offering eight 4–5-year fellowships to develop general practitioner (GP) research leaders
allocates 10% of the National Health and Medical Research Council’s (NHMRC’s) project grants budget to general practice-specific research projects (ie, projects with direct relevance to general practice and which involve one or more GPs as chief investigators)
invests $2.5 million to establish an NHMRC Centre for Research Excellence in General Practice/Primary Care
invests $200 000 per annum to support the maintenance of practice-based research networks, specifically the Australian Primary Care Research Network (APCReN)
provides $2 million per annum across university departments of general practice and rural health to facilitate practice-based research networks
implements a practice incentive payment to enable practices to facilitate and implement research

* Reproduced with permission from the Royal Australian College of General Practitioners. 2016–17 pre-budget submission. East Melbourne, Vic: RACGP, 2016. Available at: http://www.racgp.org.au/yourracgp/news/reports/20160205prebudget

Pharmacy vaccinations in Queensland and the slippery slope of health services in community pharmacies

New legislation in Queensland supports pharmacy-based health care services on the basis of pilots of feasibility, embellished as evidence of effectiveness. Family doctors are concerned and disappointed that, despite lack of independent analysis, these pilots have resulted in new legislation with little consideration given to the broader health impacts. This move is paving the way for an expansion into other pharmacy-based health services, which have been successfully delivered in general practice for decades. It is also threatening the medical home model, which the federal government ostensibly supports.

When doctors speak about concerns with pharmacy vaccination programs, they talk about evidence, quality, patient safety and fragmentation of care. However, these messages are heard as ‘self interest’.

Pharmacists on the other hand talk about better access, availability, and gaps in healthcare delivery due to excessive GP waiting times. Pharmacists are not heard as being self-interested, rather as providing a beneficial service for the community. Public health arguments are also intuitively compelling; to a public health advocate it doesn’t matter where vaccinations are delivered.

However, these arguments need to be examined further. We have to look at the bigger picture and take into account adverse effects on our proven Australian general practice model, costs to the consumer, conflicts of interest of the pharmacy industry and issues with the Queensland vaccination trials.

Proven general practice model

Australia’s large network of general practitioners and their teams have been very successful in keeping Australians healthy at a low cost, compared to international standards.

National surveillance data on vaccine-preventable diseases in Australia documents a remarkable success story for vaccinations delivered by general practice, which have caused extraordinary declines in child and adult morbidity, mortality and hospitalisations over the years.

“Vaccinations delivered by general practice have caused extraordinary declines in morbidity, mortality and hospitalisations.”

Major changes to our primary care model must be based on evidence and not just sound like ‘a good idea’. There is little evidence that delivering vaccinations and other health services via pharmacists will improve efficiency, safety or quality of care for patients. Although there is a convenience factor, people need to ask how commercial interests have been allowed to be placed before health benefits to the Queensland population.

Issues with the trials

In 2014 the Queensland Department of Health approved an application by the Queensland branches of the Pharmacy Guild Australia and the Pharmaceutical Society of Australia, which led to the start of two trials to vaccinate adults over the age of 18 at community pharmacies against influenza, dTPa (diphtheria, tetanus and whooping cough) and MMR (measles, mumps, rubella).

Interestingly, no independent analysis of the trials seems to have been performed. The data that has been reported is superficial, selective and shows elements of observer bias. No analysis was undertaken to establish the clinical need for the vaccinations. No analysis was undertaken to determine what proportion of these vaccinations were high risk.

The trials did not reveal evidence about the impact on vaccine-preventable disease outbreaks. There was no comparison with alternatives such as walk-in vaccination clinics in general practice. General practitioners frequently conduct opportunistic screening and preventive healthcare during consultations for vaccinations, but the impact of missed opportunities for screening and other preventative care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.

It seems no independent analysis was undertaken to determine whether the standard elements of privacy, documentation or GP notification were met. Further, no mention of commercial add-on practices was monitored, for example, using vaccinations as a means to on-sell other products. As we know the pharmacy business model relies heavily on upselling products to consumers.

The argument seems to be to improve vaccination coverage with claims of managing people ‘who have not been vaccinated’ – these claims are neither verified, nor explained; for example, are these new patients or inappropriate patients? It is a reasonable question as to why these claims have not been subject to closer scrutiny.

The stakeholders’ evaluation contained leading questions, such as: “The results of the trials show that there is increased uptake of influenza vaccination among adults who have never previously been vaccinated or who were not regularly vaccinated. Do you consider this an important public health function?” This raises questions about the objectivity of the process.

Conflicts of interest

There is an inherent conflict of interest in pharmacists delivering general practice services including vaccinations. One of the great strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. This enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is a strong argument against moving more health services into the pharmacy environment.

“One of the great strengths of medication prescribing in Australia is the separation between prescriber and medication dispenser”

The core role of pharmacy is to dispense medication safely and effectively, but the financial viability of pharmacies depends on operating successfully as small retail businesses. Concerns have been raised regarding the environment of pharmacy being more conducive to medication sales than primary care services. The pharmacy sector is seeking new ways to broaden its health services to provide new income streams, sometimes in conjunction with pharmaceutical companies with the prime purpose of profit.

Commercialisation of pharmacy vaccinations has occurred overseas and here in Australia. For example, a pharmaceutical company which produced vaccines involved in the trials, provided financial support to a pharmacy chain for their vaccination training. This illustrates the problem with delivering health services in pharmacies – but this was not reported in the evaluation of the trials.

If it ain’t broke…

There is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. However, each time a task is given to other providers, the effectiveness and safety of our current proven GP-model is eroded and this will ultimately have consequences for the care delivered to Australian communities.

Despite concerns from doctors’ groups, the Queensland government announced in April 2016 that an amendment to the legislation now allows registered pharmacists to administer influenza vaccinations, diphtheria-tetanus-acellular pertussis vaccinations, measles-mumps-rubella vaccinations to adults.

“We should avoid a trade-off between our values and creating monetary value.”

Pharmacists are ready to roll out more ‘enhanced pharmacy support services’ in the near future. The impact of patients presenting to pharmacies instead of general practice will result in more fragmentation of care, missed opportunities for screening and preventive health care, unnecessary and non-evidence based care, and possibly increased risk and wasted health resources. It also clashes with the innovative national medical home model.

We should avoid a trade-off between our values and creating monetary value; recommendations for treatment and prescribing must only be evidence-based and should not be influenced by commercial factors.

Medical groups should continue to monitor these developments, highlighting the risks to policy makers and reinforce the message that we need evidence-based decision making in healthcare. It is dangerous to rely on short-term financial benefits at the expense of long-term, whole-of-system considerations. In the interest of all Queenslanders, decision makers should focus on strengthening general practice, not dismantling it.

The RACGP remains committed to working collaboratively with both state and federal governments to develop innovative and effective models of care, and strongly advocates for solutions that support integration, not fragmentation.

This article was originally published in AMA QLD’s Doctor Q and in Doctors Bag. Dr Edwin Kruys is Chair of RACGP Queensland and member of the AMA Queensland Council of General Practice. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

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Nation’s health only partly on track

Australia is making progress in reducing rates of smoking and dangerous drinking but is losing the battle to rein in weight gain, high blood pressure, and salt and sugar consumption, according to a national snapshot of health trends.

Australia’s Health Tracker, produced by the Australian Health Policy Collaboration with the support of 50 public health organisations, shows that the nation is making good progress toward reducing drinking and smoking, with the proportion of adults drinking at risky levels trending down toward 18 per cent and the country on track to cut the number of adults who strike up on a daily basis down to 10.6 per cent by 2025.

But adults and children are continuing to put on weight, eating too much sugar (and salt) and not doing enough exercise, according to the tracker.

It shows that more than 63 per cent of adults are overweight or obese, along with more than a quarter of children, and almost a half of adults and 70 per cent of children are eating too much sugar.

The tracker found that people are not doing enough exercise, particularly in light of their energy-rich diets – just 55 per cent of adults and less than 10 per cent of teens meet physical activity recommendations.

These readings underline concerns that not enough is being done to reduce the incidence of chronic disease by changing behaviour and encouraging healthier lifestyles.

According to the authors of the Health Tracker, 50 per cent of Australians have a chronic disease, and they estimate that almost a third of such illnesses could be prevented by eliminating smoking, losing weight, cutting down on drinking, taking exercise and reducing blood pressure.

“Chronic disease is the biggest health challenge of the twenty-first century,” the authors said. “Australia lags well behind comparable countries in tackling the risk factors for preventable chronic diseases.”

But, they said, “much of Australia’s chronic disease burden is preventable or capable of significant amelioration”, and urged that there be “population-level interventions that target risk factors shared by many population groups and communities”.

There have been concerns that preventive health has been undermined in recent years by Federal Government policies and cutbacks, including the abolition of the Australian Preventive Health Agency, reducing spending on public health education campaigns, funding cuts for community organisations and programs undertaking preventive health activities and reduced policy emphasis on public health initiatives.

But both the Coalition and Labor have committed to trialling new models of chronic care in the primary health sector centred on general practice as the ‘home’ of health care and involving remuneration based not only on fee-for-service but also incorporating regular payments tied to the management of individual patients with complex and chronic illnesses.

But Public Health Association of Australia Chief Executive Officer Michael Moore said action was now needed.

“A lot of promises were made before the election to fight chronic disease,” Mr Moore said. “This research is the first of its kind, and should be taken as not only a warning, but as a call to action. What we need to see is action from the elected Government.”

Australia’s Health Tracker can be viewed at: https://www.vu.edu.au/sites/default/files/AHPC/pdfs/australias-health-tr…

Adrian Rollins

Health must be focus whoever wins Government: Gannon

The tight Federal election result was “compelling evidence” that voters want a strong Medicare and health system that supports general practice and public hospitals, AMA President Dr Michael Gannon said.

As the outcome of the election remains in the balance two days after voting day, Dr Gannon said the clear message from the poll was that health policy was a vote changer.

“The exit polls confirmed what the AMA had been hearing from its members in the lead-up to the election: people want confidence that they can see their doctor or get to a hospital when they or their loved ones need health advice or care,” Dr Gannon said.

The Turnbull-led Coalition is facing the very real prospect of minority government, having to negotiate deals with independent and minority party MPs if it is to return to office.

The latest tally from the Australian Electoral Commission gives the Coalition 67 seats, Labor 71 seats, two to the Nick Xenophon Team, one each to the Greens and Katter’s Australian Party and two independents. The Commission reports that six seats remain too close to call.

Health issues figured prominently in the campaign. The AMA campaigned strongly on lifting the Medicare rebate freeze, funding public hospitals, and reversing cuts to pathology and diagnostic imaging bulk billing incentives – all issues seized on by Labor and the Greens in their own campaigns.

The Coalition also found itself on the back foot over accusations by Labor – discredited by Dr Gannon – that it had a secret plan to privatise Medicare.

During the campaign, the AMA President rubbished Labor’s attempts to portray the possible outsourcing of the Medicare payments system as amounting to its privatisation, but said the Coalition’s refusal to change key policies allowed the Opposition to spread such misinformation.

He said that, rather than scare campaigns, voters were swayed by the genuine concerns expressed by their family doctors.

“We believe that people who voted because of health policy were influenced by credible information from trusted doctors and other health professionals who campaigned against the Medicare freeze,” Dr Gannon said. “Grassroots doctors across the country shared their concerns with their patients. Local family doctors had genuine fears about the livelihoods of their practices.”

It is expected to be days, or maybe even weeks, before the final result of the election is known, but Dr Gannon said the AMA stood ready to work cooperatively with whoever formed Government.

Either way, he said, health needed to be at the centre of the national policy agenda.

“The election result is compelling evidence that people want a strong Medicare and a health system that promotes quality primary care, supports general practice, and properly funds public hospitals,” Dr Gannon said.

Adrian Rollins

Life expectancy up, but Africa still behind – WHO

A new report has highlighted the disturbing extent of health inequality across the globe, showing that while life expectancy has risen at its fastest rate since the 1960s, sub-Saharan Africa still lags the rest of the world by a considerable margin.

The World Health Organisation (WHO) figures show that global life expectancy increased by five years between 2000 and 2015 – the fastest increase since the 1960s.

The African region had the strongest growth, up by 9.4 years, driven by improvements in child survival, malaria control and access to retrovirals for HIV treatment.

The increase has narrowed the gap between African life expectancy and European life expectancy by 4.9 years since 2000.

But even so, a child born in Africa in 2015 can only expect to live to the age of 60, compared with the global average of 71.4 years.

A child born in Sierra Leone has a life expectancy of just 50.1 years, more than 33 years less than a child born in Switzerland (83.4). An Australian (82.8 years) can look forward to three more decades than an Angolan (52.4 years).

“The world has made great strides in reducing the needless suffering and premature deaths that arise from preventable and treatable disease,” WHO Director-General Dr Margaret Chan said.

“But the gains have been uneven. Supporting countries to move towards universal health coverage based on strong primary care is the best thing we can do to make sure no-one is left behind.”

The World Health Statistics: Monitoring Health for the SDGs report shows that the declines in life expectancy experienced in the 1990s, caused by the AIDS epidemic in Africa and the impact of the collapse of the Soviet Union on eastern Europe, have been reversed.

“The global average increase in life expectancy at birth since 2000 exceeds the overall average rate of life expectancy increase achieved by the best performing countries over the past century,” WHO said.

“The world as a whole is catching up with those countries, and improvements in outcomes for all major causes of death have contributed to these huge gains.”

WHO said it was worth considering a proposal to measure premature mortality – deaths before the age of 70 – as it was more sensitive to interventions.

“There were an estimated 30 million deaths under age 70 in 2015 and, if the Sustainable Development Goals (SDG) mortality targets had been achieved in 2015, this would have been reduced to 19 million deaths,” the report said.

“This represents a 36 per cent reduction (almost 11 million averted premature deaths) – close to the proposed 40 per cent target.”

Had those deaths been averted, five million people would not have died from infectious diseases, malnutrition, and child and maternal mortality. A further five million would not have lost their lives to non-communicable diseases, and 900,000 people would not have died from injuries.

The report found that Japan topped the life expectancy list, at 83.7 years, and Sierra Leone was the lowest (50.1).

Healthy life expectancy, a measure of the number of years of good health a 2015 newborn can expect, stands at 63.1 years globally – 64.6 years for women and 61.5 for men.

On average, women (73.8 years) live longer than men (69.1 years) in every country of the world. Scandinavian countries had the lowest male-female gaps (Iceland 3.0 years, Sweden 3.4) while some former Soviet countries were among the highest (Russia 11.6 years, Ukraine 9.8 years).

The full report can be found on the WHO website at http://www.who.int/gho/publications/world_health_statistics/2016/en/

Maria Hawthorne

Committee backs AMA on primary care

A parliamentary committee has called on the Federal Government to consider reforms to the Medicare Benefits Schedule to help GPs better manage chronic disease in patients.

The House of Representatives Standing Committee on Health handed down its report on Chronic Disease Prevention and Management in Primary Health Care last month, noting that the groundwork for improvements to the primary health care system already existed.

“It is clear, however, that this cannot occur without cooperation, coordination, evaluation and adequate data and records to support Primary Health Networks in fulfilling their important role as coordinators of care,” the committee said.

“Performance measurements, expansion of chronic disease items, improved referral and rebate claiming processes and encouraging private health insurers to manage their members in cooperation with the primary health care system is a clear goal.”

The AMA made a submission to the inquiry in August last year, noting that primary health care was critical to providing quality, effective and empowering health care for people with chronic disease.

“With more than half of all potentially preventable hospital admissions due to chronic conditions, costing more than $1.3 billion a year, there are significant benefits in ensuring access to timely, clinically necessary and well-coordinated health care,” the AMA said.

The AMA called for reform of the MBS to restructure specific chronic disease management (CDM) items to cut red tape and reflect modern clinical practice.

It also called for formal engagement protocols between Primary Health Networks (PHNs) and Local Hospital Networks (LHNs) to work together on areas such as transitioning patients out of hospitals and into aged care.

It recognised that there was scope for private health insurers to explore the potential for greater engagement with general practice, but urged caution on expanding their role into a managed care model.

The Committee picked up many of the AMA’s recommendations.

It recommended the Government investigate expanding the number of allied health treatments that can attract an MBS rebate within a year, on the proviso that the patient has the relevant General Practitioner Management Plan and Team Care Arrangements in place.

It also recommended that the Government examine reforms to the MBS to allow for a practitioner to claim a rebate for a chronic disease management consultation and a general consultation benefit, for the same person on the same day.

It recommended considering expanding the Practice Incentives Program to include programs for breast, bowel and skin cancer screening, as well as the Integrated Health Check developed by the National Vascular Disease Prevention Alliance.

“Preventive health promotion as well as expanded health checks will help to provide the awareness and early detection required to help combat these diseases,” the committee said.

“The Health Care Home trials which are expected to commence in 2017 will help to improve this outcome, and with appropriate funding, privacy considerations, capture and consolidation of data, and a focus on research and improvement, the cooperative care goals required to improve chronic disease primary care can become a reality.”

Maria Hawthorne

Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study

The known The availability of effective and acceptable contraception is critical to the realisation of sexual health, with an increasing shift toward promoting long-acting reversible contraception (LARC) methods at an international level.

The new LARC methods were used more frequently by contraception users in three Western Desert communities in Western Australia than at the national level. Continuation rates for etonogestrel implants compared well with those reported for other populations in Australia and internationally.

The implications Service delivery models incorporating community engagement and health promotion can be used to achieve high uptake and acceptability of LARC methods.

The right to decide the number and timing of pregnancies is recognised as critical to the realisation of sexual health.1 This is optimally achieved by making acceptable and effective contraception available, reducing the rates of unintended pregnancy. Long-acting reversible contraceptives (LARCs) are recommended as the first line approach because of their superior effectiveness, the limited contraindications, high user satisfaction, and suitability across the reproductive life cycle.2

In Australia, as in other developed countries, high rates of unintended pregnancy persist in association with high rates of use of contraception methods that require daily user compliance.3 In the 2007–2011 Bettering the Evaluation and Care of Health (BEACH) study, the combined oral contraceptive pill was the most common contraceptive managed in Australian general practice consultations (68.6% of contraception-related encounters).4 The uptake of LARCs in Australia has been lower than in European countries (7% v 10–32% of contraception users)5 despite the international consensus favouring their adoption.2,6,7

The limited data available suggest a very different profile of contraceptive use in remote Aboriginal communities. The 2008 Central Australian STI (Sexually Transmissible Infection) Risk Factor study reported that 54% of 137 Aboriginal women used contraception (self-report by participants recruited while presenting to the local clinic); the most common contraceptive used was a LARC (74% used etonogestrel implants, 16.2% medroxyprogesterone depot).8 This is also consistent with the understanding of contraception by Indigenous women reported by a recent northern Australian remote Aboriginal community ethnographic study.9

Although frequently overshadowed by the focus on STIs, access to contraception is vital to sexual health, and is as important in Aboriginal and Torres Strait Islander communities as in any other Australian community. Assertions about the reasons for contraceptive choice in Aboriginal communities have recently been prominent in the media discussions of possible community closures.10 In view of the lack of published data, this study aimed to document the patterns of use, efficacy and acceptability of contraception in three remote Western Australian Aboriginal communities.

Methods

Our study had a mixed method design, using medical record data to describe patterns of contraception use, and semi-structured interviews to assess user attitudes and acceptance. The participants were Aboriginal women of reproductive age from three very remote communities in the WA Western Desert region with a combined population of 915 at the 2011 census.11 The two smaller communities are located within 90 minutes’ drive of the larger community. General practitioners employed by the Kimberley Aboriginal Medical Services (KAMS) live in the largest community, and provide medical services to all three. A remote area nurse (author DF), employed as a sexual health coordinator for all three communities since January 2013, resided and delivered services in these communities on a continuous basis. Information on services delivered during the audit period was compiled from reports produced to meet program funding requirements and from research notes (Box 1).12,13

Contraception use

An electronic medical record system (MMEx; ISA Technologies) has been used and shared by the three communities since November 2010. Some patients had also shared records with other Kimberley Aboriginal community-controlled health services. Prescriptions and consultation and medical history records, which included patient self-reports of contraceptives prescribed elsewhere, were searched for the keywords “contraception”, “implan*”, “depo*”, “tubal”, “hysterectomy”, “Mirena” and “intra-uterine” to identify contraceptive use during the audit period of 1 November 2010 – 1 September 2014. Billing records were searched for item numbers corresponding to contraceptive implant insertion or removal. A patient met the inclusion criteria if she was aged 12–50 years on 1 September 2014, was a regular patient (ie, one of the three clinics was recorded in MMEx as their primary health care provider and they had at least three recorded clinic attendances), and was recorded as being an Aboriginal and/or Torres Strait Islander.

An episode of use was defined as commencing with the time of initiation and lasting until the medication was ceased or removed, or the patient was lost to follow-up (documented as having moved from the communities, or after unsuccessful clinic recall attempts). Medroxyprogesterone episodes were classified as lapsed if the next dose was not given by 16 weeks, as per World Health Organization guidelines.14 Insertion dates for etonogestrel implants were recorded, if known, to the nearest month; alternatively, the earliest and latest dates an implant was known to be in situ were used to calculate the episode duration. Cases for which there were insufficient data to estimate duration of use were excluded from the survival analysis. An implant in situ beyond 3 years was considered to be still continuous.

Statistical analysis

Data extracted from MMEx were transferred into Excel 2010 (Microsoft) for initial data cleaning, and then imported into Stata 13 (StataCorp). One, 2- and 3-year etonogestrel implant and medroxyprogesterone injection continuation rates were evaluated with Kaplan–Meier survival analyses. Patients were censored for loss to follow-up and the removal of implants.

Acceptability of types of contraception

Proposed interview questions were discussed with groups of Aboriginal women at local yarning sessions before deciding the final list. Aboriginal women aged 16 years or more were then invited to participate in semi-structured interviews when presenting to any of the three clinics, and at community yarning events between 3 November 2014 and 13 January 2015. Responses and direct quotes were written down by the main investigator during the interview, then promptly transcribed into Word 2010 (Microsoft) documents. Questions focused on pregnancy planning and experiences, and the acceptability of different contraception options.

The individual documents were integrated into a textual database with the tabular functions of Word 2010. The research team then reviewed and conducted thematic analyses of the data. The initial focus was to explore the women’s personal experiences with contraception, and attitudes and beliefs about available options, with segments of text coded appropriately. The research team included an experienced Kimberley Aboriginal sexual health coordinator. The content of the coding categories was reviewed, and important and recurring themes identified. Conclusions were developed and triangulated with data from the database and quantitative data; rates of use and continuation (as markers of acceptability) were compared with narrative data about the women’s personal experiences.

Ethics approval and consultation

Aboriginal women elders from the communities were initially consulted to ensure that the project was consistent with local priorities. Women’s yarning sessions were then held in each community to inform local women about the project. This project received ethics approval from the Western Australian Aboriginal Health Ethics Committee Human Research Ethics Committee (reference, 585) and was supported by the Kimberley Aboriginal Health Planning Forum Research Subcommittee.

Results

Five hundred and sixty-six women met the inclusion criteria, for 191 of whom (34%) a prescribed contraception method during the study period was recorded (Box 2). The etonogestrel implant was the most common contraceptive used; at the census date, 93 of 121 (77%) women with currently prescribed contraception were using the implant (Box 3), and a further ten had been lost to follow-up with an implant in situ. Medroxyprogesterone was the second most frequently prescribed contraceptive, but was used by only 9 of 121 women (7%) at the census date. Emergency contraception was only prescribed twice. Service providers in the communities reported that terminations of pregnancy were rare. Only 15% of women under 15 years of age had contraception prescriptions on record, rising to 55% for those aged 15–19 years.

Two hundred episodes of etonogestrel implant use were recorded for 170 of the 566 women (30%), for a total of 373 patient-years. The median age at commencement was 20 years (interquartile range [IQR], 15–25 years). Most episodes (124 of 200, 62%) involved women under 25 years of age. The rate of continuation of use after one year was 87% (95% CI, 81–92%), after 2 years it was 72% (95% CI, 64–78%), and after 3 years it was 51% (95% CI, 41–60%) (Box 4). For 80 of 183 episodes (44%) for which prior parity was recorded, the woman was nulliparous at the time of insertion. For 67 of 200 episodes (34%), implants were inserted during the post partum period. The longest time in situ for a single implant was 4.4 years. No woman became pregnant with an implant in situ.

Forty-three women (8%) received 162 doses of medroxyprogesterone in 94 episodes of contraceptive use. The median age at the first dose was 24 years (IQR, 17–37 years); the median number of doses per episode of continuous use was one (range, 1–8). In 29 of 71 episodes for which prior parity was known, the woman was nulliparous at the time of the first dose. Eleven of 43 medroxyprogesterone users subsequently became pregnant, all at least 26.5 weeks (median, 81 weeks) after the last dose. Only 14% of women used this method continuously for one year after initiation (95% CI, 8–22%) (Box 5).

Acceptability of types of contraception

Individual semi-structured interviews were conducted with 20 Aboriginal women: 17 had previously been pregnant, and 15 had living children. Seventeen had used an etonogestrel implant and eight had used medroxyprogesterone. One woman had used an intra-uterine contraceptive device (IUCD), and another woman alluded to this: “It goes inside you” (interviewee p20). Eleven women were asked directly which methods they knew; they mentioned implants, injections, and one woman described an IUCD. None mentioned oral forms of contraception.

Most women spoke positively of the etonogestrel implant: “It’s good” (p1); “Better than taking tablets or getting needles” (p3); “Yeah, I had that one. That was right, no problem with that” (p13). Two women preferred medroxyprogesterone, as they did not like the feel of the implant: “Sometimes it confusing … and it feels like it stuck in your skin” (p9). Four women had had menstrual irregularities that resulted in cessation of use. When contraception had resulted in lighter periods, this was perceived as positive. Two women related stories of the implant “moving” (p6, p18), and one reported suspicions in the community that it had secondary purposes: “it controls them” (p11). When asked directly if there was any shame in having the implant in situ, six of six interviewees said it did not (“No, it’s in a good spot, private”: p20). The upper arm was the place of insertion with which all women were familiar, and gestures indicating the arm were used in conversation by women to indicate the implant. When asked if women were ever pressured to use contraception, five interviewees reported that some boyfriends wanted women to have their implant removed so that they could have a baby: “Yeah. There was a friend I had; her boyfriend wanted her to take it off, but she too young” (p15). No women reported receiving any unwanted attention because they had an implant in situ.

Mothers were asked if they would be happy for their daughters to use the etonogestrel implant for contraception. All replied positively, and two women described supporting their daughter when receiving the implant at the clinic: “Yeah, I took her to [the clinic] to get it” (p13). Women described the importance of being healthy and not too young when having babies, and of communication between mothers and daughters about contraception: “Good to learn these girls to look after their bodies” (p16); “girls too young have problems pushing them [babies] out” (p9).

Discussion

This is the first population-based study using medical records to determine rates of contraception use in Aboriginal Australian communities. We found a high uptake of LARCs (especially the etonogestrel implant) in three remote Western Desert communities, with one year continuation rates that compare favourably with those in other populations (87% in this study v 65–82%; details in Appendix).15–22 Together with the generally positive feedback from the community, this suggests good acceptance of LARCs, particularly among younger women.

Factors that may have contributed to the preferred use of the etonogestrel implant include the long term presence of a dedicated sexual health coordinator who provides counselling and referrals, and good access to trained inserters. Ready availability of the etonogestrel implant may predispose prescribers to recommend it; in comparison, the 900 km journey required to have an IUCD inserted probably contributes to their low use in these communities. During the final 12 months of the audit period, KAMS staff delivering sexual health services (including DF and EG) observed increasing numbers of women who presented unprompted for reproductive health consultations.

Key activities and outputs in sexual health program delivery include health promotion, staff development, and flexible service delivery, constituting a multifaceted approach to sexual health. This high acceptance of LARCs that we found and the changes to clinic practice as a result of these activities should inform future program design and delivery. This is particularly important when considering the high rates of teenage pregnancy in some Aboriginal populations,23 potentially indicating a group with unmet contraceptive needs that could be addressed by using LARCs.

There was less adherence to medroxyprogesterone injection. Possible explanations include the ambivalent contraceptive intent of the user, limited contraceptive literacy, and sub-optimal clinic recall systems. The infrequent use of emergency contraception warrants further exploration of patient acceptance and understanding, and of service delivery factors.

Current contraception was documented for only one-fifth of women in these communities, compared with two-thirds of all Australian women aged 18-49 years in 1998.24 This could also indicate unmet contraceptive needs. It could also reflect the relatively recent introduction of a locally based full-time general practitioner and the increased availability of trained inserters of LARCs. The interview participants were a group with a high rate of contraceptive use, and the voices of women not using contraception may have been missed.

This study was limited by the retrospective cohort design used to assess contraception use. Some under-reporting is likely, as contraception initiated at other health centres was not always documented, and some records were incomplete. Few women were recorded as having had permanent or surgical contraceptive procedures; procedures carried out elsewhere may not have been documented. However, our study provides a picture of contraception prescribing and use in a remote part of Australia that may well be relevant to other remote areas. Recent articles have highlighted the importance of understanding the values, attitudes and aspirations of a community when delivering reproductive health services.25

Some women described side effects of contraception, particularly menstrual side effects, but the implant was otherwise well tolerated. Where coercion to use contraception was reported, it related to partners desiring pregnancy and their pressure to cease contraception. None of the participating women reported any concerns that the presence of an implant attracted unwanted sexual attention.

While more than half of the women aged 20–24 years had some experience of contraception, its use by women under the age of 15 was uncommon. Lack of national prescribing data prevents direct comparison with other communities, but a national survey of high school students found that more than one-fifth of year 10 girls (median age, 15 years) had been sexually active, with the oral contraceptive pill the most frequent contraceptive method reported.26 This study suggests that while the choice of contraception method differs, the rate of contraception use among young women in these remote communities may not differ markedly from that of urban young non-Indigenous women. Our data show that, with sustained appropriate services, LARCs can be highly effective in remote Aboriginal communities. This supports a model of service delivery that promotes the reproductive health of Aboriginal women through community engagement and capacity building, aiming to broaden the focus of sexual health for women above and beyond the detection and management of STIs.

Box 1 –
Sexual and reproductive health activities conducted in the Western Desert region during the audit period

Increased general practitioner workforce consistency, with decreasing use of locum practitioners from 2011
Employment of a dedicated sexual health coordinator for the three communities from January 2013
61 community education sessions conducted 2013–2014, with a total attendance of 296 men and 607 women
Upskilling of local nursing staff to perform pap smears and to insert and remove etonogestrel implants from 2013
Production of Desert mob stories about good health, a collection of stories and art about questions that affect relationships (2013–2015)
Engagement with external research projects; eg, The STI in remote communities: improved and enhanced primary health care (STRIVE) project, 201312
Engagement with the Indigenous Hip Hop Project (2014)13
Partnership development with several government and non-government agencies
Pilot of after-hours clinics for young people from 2014
Increased community engagement by clinic staff, with a focus on reducing stigma and encouraging regular check-ups and clinic attendance

Box 2 –
Contraception history of regular Aboriginal patients of the participating clinics, aged 12–50 years

Box 3 –
Prescription contraceptive history and current contraceptive use, at 1 September 2014*

Age group (years)	Number of women	Prescription contraception history at 1 September 2014, by method
Age group (years)	Number of women	Never used contraception	Etonogestrel implant^†	MPA injection^†	Intra-uterine device^†	COCP^†

12–14	61	52 (85%)	8 (13%)	1 (2%)	0	0
15–19	94	42 (45%)	48 (51%)	15 (16%)	0	2 (2%)
20–24	93	46 (49%)	44 (47%)	10 (11%)	0	2 (2%)
25–29	71	47 (66%)	19 (27%)	2 (3%)	0	4 (6%)
30–39	151	100 (66%)	44 (29%)	7 (5%)	0	2 (1%)
40–49	96	81 (84%)	7 (7%)	8 (8%)	1 (1%)	0
All	566	368 (65%)	170 (30%)	43 (8%)	1 (< 1%)	10 (2%)
Age group (years)	Number of women	Contraception in use at 1 September 2014, by method^‡
Age group (years)	Number of women	Not using contraception	Etonogestrel implant	Etonogestrel implant, LTFU^§	MPA injection	Intra-uterine device	Surgical/permanent

12–14	61	53 (87%)	6 (9%)	2 (4%)	0	0	0
15–19	94	59 (63%)	26 (28%)	5 (5%)	4 (4%)	0	0
20–24	93	71 (76%)	21 (23%)	1 (1%)	0	0	0
25–29	71	60 (85%)	8 (11%)	1 (1%)	0	0	2 (3%)
30–39	151	117 (77%)	29 (19%)	0	1 (1%)	0	4 (3%)
40–49	96	85 (89%)	3 (3%)	1 (1%)	4 (4%)	1 (1%)	2 (2%)
All	566	445 (79%)	93 (16%)	10 (2%)	9 (2%)	1 (<1%)	7 (<1%)

COCP = combined oral contraceptive pill; LTFU = lost to follow-up; MPA = medroxyprogesterone acetate. * All percentages are row percentages. † Women may have used more than one type of contraception. ‡ No women were current users of oral contraception. § Women lost to follow-up with an etonogestrel implant in situ at last contact.

Box 4 –
Continuation of use of etonogestrel implants by 170 Indigenous women in three Western Desert communities (Kaplan–Meier survival function)

Box 5 –
Continuation of use of medroxyprogesterone injections by 43 Indigenous women in three Western Desert communities (Kaplan–Meier survival function)