Invest in quality improvement: Have doctors got the PIPs?

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

While having tried to play a constructive role to date, growing concerns at level of funding that will be available for the Practice Incentives Program (PIP) Quality Improvement Incentive (QII) has seen the AMA Federal Council decide that the AMA cannot support the current cost neutral approach to the introduction of the incentive.

The AMA has delivered a blunt message to the Health Minister – the AMA’s support for this initiative is in peril unless the PIP receives a significant boost in funding.

While the AMA has backed the concept of an incentive to support practices in their quality improvement journey, we have consistently opposed the idea that some practices could finish up worse off. Instead of properly funding the new incentive, the Government has decided to rob Peter to pay Paul. Worthy incentives will be lost including the quality prescribing, cervical screening, asthma, diabetes and the Aged Care Access Incentive (ACAI).

The value of the ACAI must be considered in more than just monetary terms. The results of the recent AMA Aged Care Survey indicated that more than a third of doctors currently providing services to residential aged care facilities (RACFs) would either cut back or cease their visits over the next two years. I don’t think it is a stretch to suggest that the impending loss of the ACAI is a contributing factor.

For general practices struggling to remain viable in the face of seemingly unending cuts and the lingering impact of the MBS freeze, PIP is a vital funding source for general practices. The AMA estimates that an injection of about $44million per annum to the PIP is required to support a meaningful PIP QII so it can deliver on its objectives.

The AMA wants to see practices embrace the QII because it has potential to improve current funding arrangements by recognising the value of quality improvement. Value for the health system, value for the practitioners, value for the patient, and value to the population through better outcomes.

Our data is the key driver to meaningful quality improvement activities. We must collect it, understand what it tells us, and use it to inform our decisions about the quality initiatives that would most benefit our patients. Data-driven quality improvement is the second building block in the Bodenheimer’s 10 building blocks of high-performing primary care. By focusing on this area, we can strengthen the delivery of care to our patients and demonstrate the value of general practice in the health care system.

Good policy requires real foresight and, in cases like this, real investment. Continuing to short change the most cost-effective part of the health system will inevitably lead to downstream costs to the health system. The PIP QII is a good idea, but it is being poorly executed by a Government and Department that needs to stop paying lip-service to the importance of general practice and put their money where their mouth is.

Will a Wii help relieve your back pain?

A University of Sydney study has shown promising results for reducing chronic back pain when patients undergo a home-based video game program of activity.

But the game must be one where they practise flexibility, strengthening and aerobic exercises for 60 minutes, three times per week at home.

The exercises are undertaken without therapist supervision, and the effect of the eight-week video-game program was comparable to exercise programs completed under the supervision of a physiotherapist.

Published in Physical Therapy journal, this first-of-its-kind study investigated the effectiveness of self-managed home-based video game exercises in people over 55 years using a Nintendo Wii-Fit-U.

“Our study found that home-based video game exercises are a valuable treatment option for older people suffering from chronic low back pain as participants experienced a 27 per cent reduction in pain and a 23 per cent increase in function from the exercises,” said Dr Joshua Zadro, a physiotherapist and postdoctoral research fellow from the University of Sydney School of Public Health.

Dr Zadro also said the interactive video treatment program was shown to be extremely motivating and the resulting compliance to this program was much higher than other trials that have instructed patients to exercise without supervision.

Poor compliance to unsupervised home exercises continues to be a concern for treatment options with low back pain sufferers. Another bonus, the research suggests is that older people with poor physical functioning also prefer home-based exercises as travelling to treatment facilities can be difficult.

“These exercise programs could be a unique solution to increase older people’s motivation to self-manage their chronic LBP through home exercise and improve their ability to continue with their daily activities despite having pain,” he explained.

A recent paper in the Lancet discussed how low back pain is becoming rapidly prevalent in in high-income countries and a major global challenge. The Lancet article also discussed the challenges for treatment and highlighted the need for low cost and accessible treatments for a condition that is expected to to triple by 2050, in the population over 60 years old.

The Australian Institute of Health and Welfare (AIHW) estimates that one in six Australians (16 per cent, equalling 3.7 million people) reported back problems in 2014–15.

The AIHW also says that back problems are among the most commonly managed conditions in general practice. In 2015–16, 3.1 of every 100 GP-patient encounters were for the management of back problems — about 3.7 million GP encounters. This has increased significantly from 2.6 of every 100 GP-patient encounters in 2006–07.

WMA calls for stronger physician-led health care systems worldwide

World Medical Association President Dr Yoshitake Yokokura has called on world leaders to strengthen healthcare systems based on physician-led primary care.

Using a United Nations General Assembly meeting in New York discussing non-communicable diseases (NCDs), Dr Yokokura welcomed the Political Declaration on the prevention and control of NCDs.

The emphasis of the declaration is on strengthening the link between NCDs and the social-economic and environmental determinants of health.

Dr Yokokura added, however, that he regretted the declaration does not include clear and measurable commitments.

He said the WMA is particularly concerned by the lack of specific commitments and targets for funding. The WMA is advocating for the inclusion of more NCDs to avoid a silo approach.

“Health care professionals see first-hand the devastating impact of NCDs on patients and their families,” Dr Yokokura said.

“Physicians are treating an increasing number of cases and are seeing more and more complex cases. NCDs are increasing the bill and burden on already under-resourced health care systems.

“In the light of the expected increased demand for 18 million more health workers, primarily in low and lower middle-income countries by 2030, healthcare system strengthening is of the utmost importance to reduce the growing burden of NCDs.”

The WMA called for UN member states to use the momentum of the declaration to set ambitious country targets, to commit to additional funding for NCDs and to draw up policies and measures in country action plans which aim to support.

CHRIS JOHNSON

Video game physiotherapy could help with back pain in older patients: research

An Australian study has found that a unique video game physiotherapy program is effective in improving pain and function in older patients with chronic lower back pain.

The randomised controlled trial, published in Physical Therapy, is the first of its kind and recruited 60 participants, aged 55 years or older, with chronic lower back pain. Patients were randomised to receive the video game exercise program or to continue their usual activities for 8 weeks. The video game operates through the Nintendo Wii Fit U.

The authors measured the primary outcomes of pain self-efficacy and care seeking, in addition to the secondary outcomes of physical activity, pain, function, disability, fear of movement/re-injury, falls-efficacy, recruitment and response rates, experience with the intervention, and adverse events.

Participants receiving the video game intervention practised flexibility, strengthening and aerobic exercises at home for 60-minute sessions three times a week, without the supervision of a physiotherapist.

Physiotherapist and post-doctoral research fellow from the University of Sydney’s School of Public Health, Dr Joshua Zadro, led the study and told doctorportal that the results were encouraging. The research revealed that total adherence to the total recommended exercise time was 70.8%, and no adverse events were reported.

“What our trial showed was that a video game exercise program, performed in the comfort of older peoples’ homes, reduced their pain and improved their function.”

“Participants on average experienced a 27% reduction in pain, and 23% increase in function”, he said.

While those completing Wii Fit U exercises demonstrated significantly greater improvements in pain efficacy and function, and were more likely to engage in flexibility exercises at 6 months, there were no significant between-group differences for the remaining outcomes.

The benefits of video game physiotherapy – compliance, convenience and cost-effective

Dr Zadro said that one of the benefits of this program over conventional approaches to back pain is that video game exercise is interactive and provides patients with video and audio instructions. While playing the video game, participants also get feedback on their technique and scores on their performance.

“So, these patients are quite good at maintaining adherence to the exercise program over time, which is often a limitation of existing programs where people are asked to self-manage.” Similarly, the program would have a great advantage for patients living in rural and remote areas, where service access is an issue.

Dr Zadro said another benefit of the program was its potential to effectively operate within the MBS, which currently covers only five physiotherapy sessions – despite traditional exercise programs generally requiring many more sessions.

“As you’d need only one session for the physiotherapist to set up the video program and teach how to use it, participants could then manage their exercise independently, in the comfort of their own home, without needing regular follow up.”

“They can really do as many video game sessions as they feel is necessary to get the benefit.”

Looking ahead, Dr Zadro is keen to investigate how effective the video game approach is in different groups of patient populations.

“It would be good to see if this same program could be applied to other patients – maybe younger people or even the very old people with chronic lower back pain.”

[Seminar] Melanoma

Cutaneous melanoma causes 55 500 deaths annually. The incidence and mortality rates of the disease differ widely across the globe depending on access to early detection and primary care. Once melanoma has spread, this type of cancer rapidly becomes life-threatening. For more than 40 years, few treatment options were available, and clinical trials during that time were all unsuccessful. Over the past 10 years, increased biological understanding and access to innovative therapeutic substances have transformed advanced melanoma into a new oncological model for treating solid cancers.

Need for stability in health leadership

BY AMA PRESIDENT DR TONY BARTONE

Last month’s leadership spills, which resulted in Australia having a new Prime Minister in Scott Morrison, almost delivered us the fourth Health Minister in five years. That would have been a disaster; especially with an election no more than nine months away (maybe even less).

Since the Coalition was elected in 2013, we have seen Peter Dutton and Sussan Ley come and go, and Greg Hunt resign as Health Minister amid the Government’s leadership chaos.

Prime Minister Morrison could easily have left Greg Hunt out of his new Ministry, but he chose not to. He opted for consistency and stability. He made the right call.

In January 2017, Greg Hunt became Health Minister at a difficult time. His predecessor, Sussan Ley, left the portfolio in controversial circumstances. He inherited a lot of unfinished business.

To his credit, he worked hard from day one to get across his new portfolio, one of the toughest in politics, and he went out of his way to build personal relationships with the leaders of all the major stakeholders.

He worked closely with my predecessor, Dr Michael Gannon, and I am pleased that close relationship has extended to my Presidency, talking regularly on the phone and meeting often in person.

As Health Minister you need to understand the many issues and numerous policies and all the potholes and roadblocks in health to appreciate the vital need to have consistent leadership at the top of the Health Ministry.

It takes months to get across the detail and to get to know the key people.

Greg Hunt had to almost immediately deal with the fallout of the GP co-payment fiasco and the slow burn of the Medicare rebate freeze, which were undermining all efforts by the Government to be on the front foot on a range of policies – anything but the cursed co-payment and the feared freeze.

He fought hard within Cabinet to achieve the gradual lifting of the Medicare freeze.

He has had to gain thorough knowledge of the complex MBS Review process.

There was the ongoing review of Private Health Insurance and out of pocket expenses.

The rollout of the My Health Record.

The problems with the Health Care Homes trial.

Then there were the more tricky and delicate issues of mandatory reporting, medical workforce, climate change and health, the health of asylum seekers, Indigenous health, and mental health, to name but a few.

Add to this the complexities of the PBS, immunisation, and issues pertaining to scope of practice – the so-called ‘turf wars’.

Then he had to consider contemporary major issues like aged care reform and the issue that we want him to concentrate on right now ahead of the election – general practice reform and investment.

It takes time to learn to be a Health Minister. And it takes even more time to become a good Health Minister. Greg Hunt has been easy to work with and always ready to listen.

That is why we went public with our calls for Greg Hunt to be re-appointed Health Minister in the new Ministry. Prime Minister Morrison obliged. A smart move I would say. If the Coalition had changed Ministers, their policy agenda would have drifted and left them extremely vulnerable on a sensitive policy front.

I met with Minister Hunt in the week of the election spills, when he was still the Minster, and we have spoken in the days that followed and since he was re-appointed.

Continuity of care is always important, even in politics. The AMA will build on this close relationship to improve health policy ahead of the next election.

Equally; I have also met with Opposition Leader, Bill Shorten, in recent weeks.

The AMA is in regular contact with Shadow Minister Catherine King, the Greens, and any party or Independent with an interest in good health policy.

It is important that all sides of the political divide understand and appreciate our health policies and why they are important to the Australian people. Our patients, their families and the community deserve no less.

Let me be very clear in assuring all that the AMA is in a very good position to influence health policy across the political spectrum in the months before the election, and even better placed to pass judgement on the health policies once the campaign itself is in full swing.

Collaboration, not competition

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Team work in providing comprehensive and quality patient care is not a new concept. Within the medical profession, we recognise our professional limitations and operate only within our scope of practice. When needed, we seek the opinion, or skills and expertise of other colleagues.

With an aging population and the rising incidence of chronic disease adding to the complexity of patient care, there is an enhanced focus on the role and importance of well-coordinated multidisciplinary health care teams. However, it is critical that these teams work effectively. Mutual respect for the skills and expertise of team members is fundamental, with each making their contribution within their scope of practice to meet the health care needs of the patient.

We all know the dangers to our patients of poorly coordinated, fragmented care. We also know that best practice care starts with the right assessment and diagnosis by a medical practitioner and, in the case of general practice, a longitudinal relationship with the patient. Despite this, we see ceaseless ambition of some pharmacist groups for prescribing rights and a greater role in the provision of health services, such as preventative health, disease screening and detection and chronic disease management.

For a GP, the community pharmacist, who is responsible for the dispensing and supply of medications, provides an important and complementary role in the delivery of quality patient care. Pharmacists are vital to the safe provision and use of medicines. They provide assurance that correct dosages are dispensed and that patients understand when and how to take their medications.

The AMA places a high value on the professional role of pharmacists working with medical practitioners and patients to: ensure medication adherence; improve medication management; and provide education about patient safety.

The AMA fully supports pharmacists undertaking roles within their scope of practices to support patient health care. But the community needs a clear understanding of how the core education and training differentiates medical practitioner and pharmacist scopes of practice.

Taking comprehensive histories, undertaking examinations, determining appropriate diagnostic investigations, making a diagnosis, and managing and treating a patient are the domain of the medical profession because that is what we, not pharmacists, are trained to do.

Certainly, the AMA recognises the benefits of integrating non-dispensing pharmacists into general practice to provide enhanced patient care. That is why we worked with the Pharmaceutical Society of Australia in developing such a plan that now, through the incoming Workforce Incentive Program, will see GPs and pharmacists supported to work even more collaboratively in the best interest of patients. With medical oversight, the current role of pharmacists may well expand to support a greater role in the provision of more holistic patient care. Patient wellbeing, after all, is a fundamental tenet of both our professions’ codes of ethics.

What we don’t want to see is patient care further fragmented, services duplicated, and access to the right care delayed. This simply causes undue costs to the health system and poor health outcomes for patients. What GPs and pharmacists should do is continue to work together respectfully, acknowledging the different skills and expertise we bring to the team for the patient. Our patients deserve collaboration, not competition, and policy makers must continue to avoid simplistic ideas that are driven by commercial needs and not good patient care.

Increasing the length of internship – what will we actually achieve?

BY DR CHRIS WILSON, CO-DEPUTY CHAIR AMA COUNCIL OF DOCTORS IN TRAINING

In 2015, a COAG review of Australian Medical Intern Training was completed. The intent of the review was to look at the internship model and assess if internship was producing “fit for purpose” clinicians. As part of the review, four models for change were proposed. Model A, the least revolutionary with no significant change to the structure but increased access to non-traditional settings including general practice, was the most preferred by doctors in training. Model B proposed shifting from a time-based internship to one focussed on specific mandatory skills and exposure to the “patient journey” and “different care contexts”. Models C and D were more revolutionary, with a proposed two year program either starting in the final university year or covering the first two postgraduate years.

As mentioned, the opinion of the AMA CDT and DiTs across the country at the time of the review was that, while there is always room for improvement, internship is not broken. Despite this, after the release of a COAG Health Council response to the review in July this year, we look to be pressing towards the two year model.

In a postgraduate world, internship commencing during university would be unworkable for obvious reasons, so the current preferred model is an internship covering PGY1 and 2.

While on the surface this looks like significant change, what does the second year actually achieve? There is agreement that general registration should be granted after successfully completing the first year, as it is now, so no change on the registration front. If it comes with increased opportunities for exposure to patients across the health spectrum and more structured learning, this will be to the advantage of doctors in training, the healthcare system and in the long run, our patients. It’s not clear though how this would be distinguishable from the current roles undertaken by PGY2 doctors. Changing the role title to ‘intern’ does not automatically reduce the service requirements and increase the educational value of rotations – someone still has to write the discharge summaries.

One potential benefit would be an expectation that all rotations are accredited as suitable training environments by a Medical Board delegate (like the Post Graduate Medical Councils). Thankfully, this already happens in most jurisdictions, however, there is a danger that without additional resources, regions where it is not standard to accredit beyond PGY1 could see their accreditation processes watered down to meet demand. Currently, the federal body responsible for the coordination of State/Territory-based accreditation bodies, the Confederation of Postgraduate Medical Education Councils, remains unfunded. It seems absurd for the Government to push for change in the makeup of internship yet not fund the body responsible for enacting it.

Should we move to a two year model, we would also expect doctors in training be able to obtain job surety over the period of internship in the form of a minimum two year contract. This would be a sign of good faith from employing health services that they intend to train and support their doctors in training during this transition period.

AMA CDT’s position in 2015 was that internship is not broken and that position remains unchanged. Without tackling the creep of increasing service need forcing education and training to become ancillary components of internship, it’s hard to see a second year bringing with it much improvement.

President meets Opposition Leader while PM changes

Opposition Leader Bill Shorten recently met with AMA President Dr Tony Bartone in what Dr Bartone described as a “very productive” meeting.

The pair met immediately following the change of Prime Ministership, giving them more than enough to talk about.

But Dr Bartone focussed on health policy, discussing issues surrounding general practice, mental health, aged care, and dementia.

Although talking about health with the AMA President was enough to make the Labor leader happy, a buoyant Mr Shorten had an additional reason. The meeting was held on the same day that Newspoll reported him as Australia’s preferred Prime Minister.

[Perspectives] Ulana Suprun: the accidental reformer

You would not have gambled on Ulana Suprun staying long in post as Ukraine’s Acting Minister of Health. The average length of the term in office of her predecessors in the past 26 years had been 11 months, and 22 ministers have tried and failed to implement health reforms. Suprun has now been in the job just over 2 years and believes her plans to reform the country’s health-care system have started to pay off. “We created the National Health Service of Ukraine, we started signing declarations with the primary care doctors.