Into the great unknown

Dr Danielle McMullen

As 2015 rolls rapidly on, current and future GP registrars grow ever more nervous about the uncertainties in GP training from 2016.

We’ve all heard about the GP co-payment, frozen Medicare rebates and planned changes to level B consultations.

But there is another, at least equally important, issue lurking quietly in the corner. In its 2014 Budget, the Commonwealth announced radical changes to GP training across Australia. General Practice Education and Training, which had coordinated and overseen the GP training provided by regional training providers (RTPs) since 2001, closed its doors last December and its functions were transferred to the Department of Health. In December this year, the RTPs will also be wound up, and their replacements are yet to be announced.

The boundaries for the new training organisations have recently been released. But, for current registrars in particular, these raise more questions than are answered given we still don’t know who will form these new organisations and what the transition process will look like.

The tender process for new training organisations has not yet begun, much less been completed. As the days and weeks and months tick by we grow ever more nervous as to when these doctors will have any certainty about their training location and governance.

In addition to the significant changes to vocational training, the 2014 Budget also scrapped the Prevocational General Practice Placements Program, which was the only avenue for prevocational doctors in their intern or PGY2 year to experience the general practice environment. This gaping hole in the general practice workforce pipeline will result in fewer interested GP trainees, and throw general practice back to being an option of last resort.

Excellent GP clinical supervisors will forever form the cornerstone of quality general practice training. But they need to be supported by high quality training organisations. And registrars deserve a well-organised, well-supported training environment.

Change is coming – that is for certain. And time is running short but it’s not out yet. We need urgent clarity and real consultation to plan and shape the future of general practice training in Australia.

In the short term, registrars need certainty around the transition to new training organisations. In the longer term, we need to ensure these organisations continue to provide the high quality, flexible general practice training we’ve become accustomed to.

General practice is an incredible career offering variety, flexibility and fantastic medicine. We need to sing its praises, protect its future, and safeguard its quality. The time for that is now!

Quality selection, training vital to safeguarding GP future

By Dr Penelope Need, Director of General Practice training at Southern Adelaide Local Health Network; tutor in Medical Professional and Personal Development, University of Adelaide; Partner, Pioneer Medical Centre, Tea Tree Gully, South Australia.

General practice training is having its first shake up since the implementation of the training providers more than 10 years ago.

The last couple of years have seen large numbers of applicants. General practice is a specialty of choice for many junior doctors. We need to keep it that way.

Quality general practice training is mandatory if we wish to maintain high standards in primary care.

General practice is a challenging career. Future GPs need to be carefully selected and trained to a high standard.

We all know that primary care is the most cost effective area of the health system. Why then is it being targeted for so much reform?

I have a tutorial group of nine year 3 medical students, none of whom have a GP. If these carefully selected medical students don’t see the value in general practice then how can the rest of the community?

At interviews, potential GP registrars can tout “continuity of care”, but is this still a reality?

Access is a real issue in general practice at the moment. Chronic disease management, and an aging and increasingly overweight and mentally distressed population puts a strain on well-meaning general practitioners.

The current model of funding rewards throughput. Is this what we want to see into the future? Are we going to be palliating our own patients or leaving it to the ambulance officers?

Pharmacists are providing vaccinations, physiotherapists are requesting referral rights. Why? How has this gap been created that someone wants to fill?

That other catch cry of general practice, “holistic care”, is also under threat.

The solution to these problems starts with selection. We need to select appropriate individuals. Selecting rural students has been shown to increase rural retention.

We then need to ensure they are adequately trained.

The loss of the Prevocational General Practice Placements Program is a real blow for general practice. It was vital for improving inter-professional communication and respect. Emergency, medicine and surgery are all mandated in internship. Why not primary care? Like anything, until you are exposed to general practice you do not understand the complexity and the challenges.

The AMA is looking at alternative models of reviving prevocational exposure to general practice. I personally feel this is vital for the ongoing health of the profession.

Just because we have a lot of applicants for general practice training does not mean that we will have a lot of quality GPs in another three years. We need to select the right people for the job and train them to a high standard.

Maybe a litmus test – would you be happy to be treated by doctors trained under this program? Don’t be like my third year medical students – everyone needs a good GP. Let’s just hope there will be enough to go around.

GP training – the path ahead

This is a tumultuous time for GP practice and training.

A four-year freeze on Medicare rebate indexation is expected to force many doctors to abandon bulk billing for their patients, and may even threaten the viability of some practices, while the adoption and subsequent abandonment of several different proposals for a patient co-payment have jolted the specialty.

To top it all, the Government has launched a major overhaul of the GP training system, axing key bodies including General Practice Education and Training and the Prevocational General Practice Placements Program (PGPPP) in last year’s Budget.

Understandably, it is has been a deeply unsettling period for GPs that has done little to encourage aspiring family doctors to take up the speciality.

In a step toward giving shape to the new training system, Health Minister Sussan Ley last month revealed the Australian General Practice Training program would be delivered through 11 training regions, and announced the creation of the profession-led General Practice Training Advisory Committee to advise the Government on the design and delivery of training.

In addition, a tender process to select GP training providers for each of the regions is to get underway in time to enrol students in 2016.

But there remain many unanswered questions about the provision of GP training – the AMA, for example, has proposed a community residency program for junior medical officers to fill what it sees as a gaping hole left by the abolition of the PGPPP.

The issue of GP training and what can be done to attract trainees and ensure they get a quality education will the focus of discussion during a key session at the AMA National Conference being held in Brisbane from 29 to 31 May.

The General practice training – the future is in our hands session, to be held on Saturday, 30 May at 2.15pm, will feature presentations from leading GP practitioners and educators.

Three of the presenters, Dr Penny Need, Dr Sally Banfield and Dr Danielle McMullen, give their views on what lies ahead for GP training and the specialty.

Strengthening primary health care: achieving health gains in a remote region of Australia

The health status of rural and remote Australian communities is poorer than that of urban communities. Comprehensive primary health care (PHC) services can reduce these health inequities, which by definition are unfair and remediable,1 through the provision of competent clinical care, population health programs, good access to secondary and tertiary care, and client and community advocacy to address health risk factors and social determinants.2

In rural and especially remote areas, there is strong evidence that poor access to PHC remains a critical barrier, particularly for Aboriginal and Torres Strait Islander people, and this is reflected in the high rate of avoidable hospitalisations.3 However, there is a paucity of rigorous studies showing the nature of the relationship between models of health care in remote areas and health outcomes.4 Given increasingly scarce resources, high costs and workforce shortages in remote areas, understanding how well services are meeting community needs and improving health outcomes is essential.

This study addresses this gap in knowledge by evaluating a health service partnership in the Fitzroy Valley in the remote Kimberley region of north-west Western Australia.5 The Fitzroy Valley covers an area of 30 000 km2, and the population of about 3500 people is dispersed across 44 communities with a stable core population. Services are provided to both Aboriginal (80%) and non-Aboriginal residents. The hospital, main community clinic and Aboriginal community controlled health services are co-located in the town of Fitzroy Crossing. Daily primary care services and occasional specialist services are provided through community health clinics in larger outlying communities and less frequent services to smaller satellite communities.

The aim of the partnership was to reorientate the existing health services from an acute reactive approach to a more comprehensive PHC approach, as recommended in the National Strategies for Improving Indigenous Health and Health Care.6 Before the partnership, care was largely episodic and reactive to patient-initiated presentations. The objective of this article is to examine how changes in the model of service delivery were associated with increased use of primary care and resultant health outcomes for the population.

Methods

In 2011, after the health service reorientation, a WA State Health Research Advisory Council Research Translation Project grant was awarded to the research team to implement a retrospective evaluation to identify the key events leading to change and their impact.

Evaluation framework

A framework for monitoring the impact of changes to PHC services on population outcomes was developed for the Fitzroy Valley to take into account its specific demography and characteristics. Building on a similar framework used for a small rural community in Victoria,7 this framework incorporates the key requirements for high-quality health service performance8 and draws on the links between structure, process and outcomes described by Donabedian.9 The development of this evaluation framework required a targeted literature review and validation workshops with stakeholders and national experts in rural and remote PHC evaluation.

In order to maximise its transferability to other health services, the framework indicators are consistent with the National Health Performance Authority Performance and Accountability Framework10 and the Aboriginal and Torres Strait Islander Health Performance Framework.11 The program logic approach underpinning our framework is recommended by the National Strategies for Improving Indigenous Health and Health Care.6 A program logic model uses change theory to describe and identify relationships, and enables the impact of service inputs to be associated with predetermined output indicators, providing an indication of progress towards long-term health improvements. Key inputs were identified and primary health care activity and usage measures were monitored to assess the impact of changes on quality-of-care indicators, mortality, morbidity and health behaviours.12 Indicators and their relationship to policy and the logic model are shown in the Appendix.

Data collection and analysis

Health service data for all residents in the Fitzroy Valley (defined by postcode) from 1 July 2006 to 30 June 2012 were collected and analysed from the commencement of the formal partnership and reorientation of the service. Input data were collected from annual reports, financial reports, workforce data, formal agreement documents and meeting minutes of the three partner health service organisations responsible for delivering care into the Fitzroy Valley: the Kimberley Population Health Unit (KPHU), Fitzroy Crossing Hospital (FCH) and Nindilingarri Cultural Health Services (NCHS).

Output data relating to PHC activity and service use were accessed directly from health department databases and PHC program implementation from annual reports. Outcome quality-of-care indicators (such as glycated haemoglobin level, blood pressure and receiving antihypertensives) were generated from the electronic patient medical records. The proportion of those eligible who received the service was calculated against individuals enrolled in the health service.

Data were collected by an externally funded research officer. Indicators were extracted electronically from the health department databases and the electronic medical record used by Fitzroy Valley Health Services (Communicare [Communicare Systems]). Quality-of-care indicators were assessed against the National Key Performance Indicators for Aboriginal and Torres Strait Islander for primary health care.13

Data were compared over time to monitor trends in health service usage, activity, quality of care and population health outcomes. Data were analysed using the non-parametric trend command in Stata version 10 (StataCorp), which performs the non-parametric Mann–Kendall test for trend across ordered groups.14 All trend lines with P < 0.05 showed a significant change in values over 2006–2011.

Ethics approval

Ethics approval for this study was provided by the Western Australian Aboriginal Health Ethics Committee and the Western Australian Country Health Service Research Ethics Committee, and was supported by the Kimberley Aboriginal Health Planning Forum Research Subcommittee.

Inputs and intervention

Several key policy events were identified, which together formed the intervention during this natural experiment. Supportive state and Commonwealth primary health care policy was a key fundamental enabler that provided the funding to strengthen primary health care services.

The formal Fitzroy Valley Health Partnership Agreement memorandum of understanding in 2006 between the government health services (comprising a 12-bed hospital [FCH] and community health services [the KPHU and NCHS]) and the community controlled health service facilitated the integration of primary health care services. The formal partnership agreement negotiated over a 1-year period enabled the three organisations to have a single governance structure for allocating funding, sharing a single electronic medical record and delineating areas of responsibility. Responsibility for health promotion, environmental health and cultural safety belonged to the community controlled NCHS; acute inpatient care, primary care clinic and specialist care to the state district hospital (the FCH); and public health, screening and primary care community clinics and programs to the state-operated KPHU.

The partnership accessed Commonwealth funding for PHC programs through Healthy for Life (an Australian Government program to improve chronic disease, men’s health, and maternal and child health primary care services for Aboriginal and Torres Strait Islander peoples), enabling the implementation of a shared electronic medical record with the capacity to collect evaluation data.

Western Australian state health funding (through the Council of Australian Governments Closing the Gap initiative) for chronic disease in 2010 provided funding for additional primary health care positions which were able to be consolidated through the partnership and provided chronic disease management and care planning.

In 2009, an application for a section 19(2) exemption (Health Insurance Act 1973 [Cwlth]) to allow Medicare billing for primary care patient visits was successful.15 This was a significant driver of increased PHC activity by providing additional resources and incentives to commence adult Indigenous health checks and care plans leading to their integration into primary care clinics. Medicare billings by all providers were reinvested in primary health care under the governance of the partnership.

Another key event was the implementation of alcohol restrictions in the Fitzroy Valley in 2008 driven by local community leadership.16 This decreased the acute care workload on health care staff and appeared to increase patient presentation for non-acute care.17

Results

Key policy and structural inputs resulted in an increase in primary care activity (Box 1). There was an overall increase in service activity over the 6-year period, with a relatively constant number of hospitalisations. The increasing trend of emergency department presentations (mostly non-urgent triage category 4 and 5) was reversed, as an increasing number of patients were seen in the PHC clinic (Box 2).

Short-term impact: preventive activity and more equitable access to primary care

Changes in key indicators leading to improved health service performance are summarised in Box 3. There was a significant overall increase in access to PHC services particularly for outlying communities in the Fitzroy Valley. More appropriate service provision led to a large increase in health checks in accordance with national guidelines18 (particularly for males after the commencement of the men’s health program in 2008), and a subsequent increase in the proportion of patients identified with chronic disease or risk factors. Increasing proportional investment in primary health care enabled increased access and appropriateness of services provided.

The NCHS provided regular feedback from the Aboriginal community enabling the health services to provide more culturally appropriate and respectful services. Some of these changes included increased employment of Aboriginal staff and cultural training for all staff, thereby leading to a better understanding of the importance of families and their guardianship roles. In addition, more patient-support people were admitted as boarders, there was increased provision of transport to assist patients to attend appointments and a less structured approach to appointments which enabled patients to attend when it was more convenient. Traditional healers became available on request and smoking of rooms after a death was introduced. These responses to community feedback resulting in more patient centred care were reflected in an increased attendance at follow-up appointments.

Medium-term impact: quality of care

Identifying patients with chronic disease or its risk factors and placing them on care plans with regular interdisciplinary follow-up was prioritised, and resulted in 73% of patients with diabetes having care plans. This systematic approach targeting patients with chronic disease led to an increase in primary health episodes from two to 10 per person per year and a higher proportion of the community attending health services regularly for follow-up and in response to recalls. Despite increasing numbers of patients receiving regular care and completing annual cycles of care for diabetes, there was no statistically significant improvement in glycated haemoglobin levels (< 7%) or in blood pressure levels reaching target values (≤ 130/80 mmHg). (A more detailed study of diabetes management showed improvements in cholesterol levels.)19

Long-term outcomes

There was a decrease in numbers of deaths over the study period, and a decreasing trend in the proportion of hospital admissions requiring emergency evacuation.

There was an increase in screening for alcohol and tobacco use over the 6 years, and a significant increase in the numbers of patients who were ex-smokers, intending to quit and drinking within safe limits (Box 4).

Discussion

Positive changes in health service usage and clinical outcomes were demonstrable despite a number of limitations. Using routine health service data retrospectively reflects the accuracy of individual input and limits data collection to indicators routinely available. The transition from paper-based data recording to dual recording using the electronic patient record between 2006 and 2009 may have contributed to some of the variation in trends before 2009, when the electronic records became largely complete. This may account for small changes in trend in some indicators but not the large increases in key indicators such as increased primary care occasions of service, health assessments and care planning.

These limitations notwithstanding, the partnership between community controlled and government organisations drove a change in philosophy from a reactive acute care system to a more proactive, comprehensive PHC approach. This provided two key elements: population health programs targeting prevention and early intervention for high-risk groups and community advocacy around health risk factors at a population level.

Structural changes led to improvements in performance when compared with mean national key performance indicator data for Aboriginal and Torres Strait Islander people.13 These intermediate outcomes are expected to result in further improvements in health outcomes over time.2 This is important given that two-thirds of the gap in health outcomes is estimated to be due to chronic disease.11 Extant literature shows that, after accounting for burden of illness, remoteness and the increased costs of infrastructure, two to seven times the average per capita funding is required by remote Indigenous populations to maximise effectiveness and equity.20 Our study demonstrates that increased primary care investment where capacity to benefit is high can result in measurable positive outcomes in a relatively short period of time.

While improvements in health outcomes are the ultimate goal, intermediate outcome indicators are the most useful for assessing the contributions of PHC because they are sensitive to PHC interventions, and the long lead time from implementation may preclude direct improvements to health outcomes in the short term.2 However, there was an improvement in mortality in the region. Mortality figures for the Derby–Fitzroy Valley statistical local area are decreasing in contrast to other similar regions.21 While we need to be cautious in interpretation because of the small numbers involved, there was a significant drop in the mortality rate over this period. This decrease may have been due to the effects of the alcohol restrictions and was supported by anecdotal evidence from community leaders: “We don’t go to funerals every month like we used to”.

Despite the poor socioeconomic circumstances of the population, improvements in health behaviours can be credited to the health promotion activities of the NCHS, which implemented a comprehensive health promotion program across the Fitzroy Valley, including a quit smoking program. Not only has health education at the individual and community level been a feature of the service, but the alcohol restrictions brought about by strong community action addressing upstream determinants of health were also significant.16,22

The Aboriginal and Torres Strait Islander PHC sector is leading the way with innovative, integrated PHC delivery models under community governance and research linking health service delivery to intermediate health outcomes.23 Our case study builds on the legacy of outstanding leadership and culture of quality improvement across the Kimberley region.24

This study demonstrates changes that are possible with a comprehensive PHC model focusing on the upstream determinants of health, prevention and improved clinical care to meet community needs, even in a challenging remote context. Strong community leadership can maximise the opportunities provided by policy changes and increases in funding, translating them into improvements in practice and health service delivery. These factors are essential enablers and need to be dealt with concurrently for service sustainability requirements to be met.25 Attending to only one or two of these factors is likely to be ineffective, and it was the systematic approach to all of them simultaneously and comprehensively that enabled sustainable change to occur.

Our study is an example of the potency of research embedded in service delivery26 and demonstrates the importance of monitoring the impact of service delivery on the health outcomes of the population. Linking structure to process and outcomes through key indicators can be used as a planning, monitoring and evaluation tool to measure the impact of national and local policies. Resultant evidence can be used to inform policy direction and translate into service delivery changes consistent with the goals underpinning current national health care reform and Closing the Gap policies.

1 Key inputs strengthening primary health care, and their impact on service outputs, Fitzroy Valley, 2006–07 to 2011–12

Partnership = Fitzroy Valley Health Partnership Agreement. 19.2 = section 19(2) exemption (Health Insurance Act 1973 [Cwlth]). COAG = Council of Australian Governments Closing the Gap initiative.

2 Trends in health service use, Fitzroy Valley, 2006–07 to 2011–12

3 Fitzroy Valley Health Service performance indicators, 2006–07 to 2011–12: trends in primary health care activity

Sentinel indicator	2006–07	2007–08	2008–09	2009–10	2010–11	2011–12	P	Mann–Kendall

Individuals on electronic health record	2160	3147	3573	4176	5626	5410
Occasions of service*
Town	4150	8666	13 433	19 628	27 087	35 940	0.03	< 0.01
Hubs	499	1925	5665	8788	10257	10 147	0.04	0.02
Satellites	364	182	476	693	1205	1191	0.05	0.06
Total	5013	10 773	19 574	29 109	38 549	47 278
No. of health assessments	340	475	525	1080	1617	1789	0.03	< 0.01
No. of male health checks performed	0	0	2	159	268	322	0.03	< 0.01
Immunisation
Children aged 24–36 months, coverage	92%	94%	95%	95%	96%	96%	0.04	0.02
No. of adults immunised against influenza	107	908	1397	996	1310	1405	0.07	0.06
No. of Aboriginal patients aged > 15 years screened for biomedical risk factors
Body mass index	143	199	277	519	760	881	0.03	< 0.01
Alcohol consumption	139	142	49	352	262	489	0.09	0.14
Smoking	184	151	82	468	727	845	0.09	0.14
Mean primary care episodes per individual per year	2	4	5	6	8	10	0.03	<0.01
Primary care investment: proportion of total funding	23%	20%	25%	25%	39%	34%	0.06	0.09
Resident population estimate	2664	2718	2773	2828	2885	2942

* Primary health care occasions of service: Fitzroy Crossing town, daily; hubs (Noonkanbah, Bayulu, Wangkatjungka) — community health clinics, Mon–Thu; satellites — community health clinics, 2–4 weekly.

4 Trends in service quality-of-care outcomes, 2006–07 to 2011–12*

Sentinel indicator	2006–07	2007–08	2008–09	2009–10	2010–11	2011–12	P	Mann–Kendall

All-cause mortality, crude death rates per 1000 population (95% CI)	9.38 (5.71 –13.06)	4.78 (2.18–7.38)	9.01 (5.48–12.80)	3.89 (1.59–6.19)	3.12 (1.08–5.16)	2.72 (0.83–4.60)	0.04	0.02
Diabetes
No. of patients	310	337	347	347	380	419	0.06	0.07
Care plans	0	0	0	18%	7%	78%	0.04	0.03
Team care arrangements	0	0	0	5%	13%	73%	0.04	0.03
No. of annual cycles of care completed	2	1	0	9	27	34	0.09	0.14
ACE inhibitor or ABR	43%	56%	57%	79%	82%	87%	0.03	< 0.01
HbA1c level measured in previous 6 months	51%	53%	45%	69%	72%	71%	0.09	0.14
HbA1c level ≤ 7%†	25%	27%	20%	25%	20%	26%	0.8	1.00
HbA1c level < 8%	39%	19%	39%	48%	41%	43%
HbA1c level > 10%	31%	35%	34%	31%	37%	34%
BP ≤ 130/80 mmHg†	44%	34%	34%	42%	42%	39%	0.9	1.00
Health behaviour
No. of attendees	1290	1568	2015	2164	2327	2504
Regular attendees, > 3 visits over 2 years	49%	68%	77%	78%	82%	79%	0.04	0.02
Smoking
No. of patients screened‡	184	151	82	468	727	845
Ex-smoker	2%	5%	10%	11%	12%	13%	0.03	< 0.01
Intention to quit	10%	24%	24%	26%	32%	34%	0.03	0.01
Alcohol consumption
No. of patients screened‡	139	142	49	352	262	489
Within safe limit	11%	9%	29%	21%	26%	28%	0.2	0.27

ABR = angiotensin-receptor blocker. ACE = angiotensin-converting enzyme. BP = blood pressure. HbA1c = glycated haemoglobin. * Data are proportion of patients unless otherwise indicated. † Reference interval. ‡ Aboriginal patients aged > 15 years.

$19 billion pharmacy deal sign of skewed health priorities

The AMA has accused the Federal Government of skewed health priorities after it announced it would pay pharmacists an extra $600 million to provide an unspecified range of patient services as part of a push to increase their role in the provision of primary health care.

Health Minister Sussan Ley has announced pharmacists will receive $1.2 billion for programs and services as part of an $18.9 billion five-year in-principle Community Pharmacy Agreement struck with the Pharmacy Guild of Australia.

If ratified, the deal – which delivers the sector an annual 4.54 per cent pay rise – would mark a major advance for the nation’s pharmacists in their campaign for an expanded scope of practice, including the delivery of flu vaccinations and the conduct of patient health checks.

Ms Ley said the deal was “recognition of the increasingly important role pharmacists play in a patient’s ‘medical team’ of health professionals, and further demonstrates the Abbott Government’s commitment to delivering greater integration between health services in Australia’s primary care system”.

But AMA Vice President Dr Stephen Parnis said the Government’s decision to award the pharmacy sector a $3 billion pay rise at the same time as imposing a four-year freeze on funding for medical services showed its priorities were “all wrong”.

“Patients have been hit with a Medicare rebate freeze until 2018. Public hospital funding to the states has been cut dramatically. More health programs and services suffered funding cuts in [the] week’s Budget. But the pharmacy sector gets a huge funding boost with no questions asked,” Dr Parnis said. “The Government has its health priorities all wrong.”

As part of the deal, the Government will pay pharmacists a set fee for dispensing medicines instead the current arrangement under which their fee is a percentage of price. Ms Ley claimed the change would ensure no increase in the average dispensing cost, saving $1.5 billion.

The sector has also reluctantly accepted the introduction of a discount of up to $1 on the PBS patient co-payment, which the Government said would make medicines cheaper. The change would also slow the rate at which patients reach the PBS safety net threshold, cutting costs for the Commonwealth.

Last year, the Government increased the PBS safety net thresholds and the patient co-payment. For concession card holders, who account for 80 per cent of all prescriptions dispensed through the PBS, the co-payment is $6.10 per prescription, but medicines are free once the safety net threshold of $366 or 60 prescriptions is reached. For non-concession patients, the co-payment is $37.70, and once the threshold of $1453.90 is reached, further prescriptions are $6.80 each.

The Pharmacy Guild made it clear it was unhappy with the proposed $1 co-payment discount. President George Tambassis said it supported the savings the Government was seeking to achieve through the agreement, “with the exception of the discounting of the PBS co-payment measure, which is a matter for government”.

The Pharmaceutical Society of Australia said it was concerned about the “health impact” of the discount and other savings measures, including the co-payment increase and the life in safety net thresholds.

But Ms Ley said the discount would give pharmacists flexibility to compete on price and quality while saving taxpayers up to $360 million.

In a warning to the sector, the Minister said the measure was also part of a drive to encourage greater competition in the sector.

Current regulations stifle competition by limiting pharmacy ownership to registered pharmacists and banning outlets from opening within 1.5 kilometres of each other.

A Government-commissioned competition review recommended scrapping these restrictions, and the new Community Pharmacy Agreement includes what Ms Ley said was the “most significant independent and public review of the pharmacy sector ever conducted over the next two years, including consideration of both remuneration and regulation, such as location rules”.

The push for an overhaul of these arrangements was given extra impetus earlier this year when the Commonwealth Auditor-General issued a scathing report on the administration of the current Community Pharmacy Agreement, including savings shortfalls, a $300 million blow-out in pharmacist incentive payments, and the diversion of almost $6 million from professional development programs into a “communications strategy”.

Dr Parnis has raised concerns about the allocation, under the new Agreement, of $1.2 billion to fund what the Government said would be “support programs for patients”.

“This is a lot of money for programs that are yet to be devised. We have seen past proposals and worry about fragmentation of patient care because these pharmacy ‘services’ may not add any value to patient outcomes,” he said.

Mr Tambassis said the funding would include $50 million for a Pharmacy Trial Program and $600 million in a contingency reserve to support new and existing community pharmacy programs and services.

And Ms Ley tried to reassure that the money would be used carefully, insisting that all pharmacy programs would be subject to scrutiny and approval by the Medical Services Advisory Committee.

But Dr Parnis said the current concerted push by pharmacists into new and expanded areas of practice, including vaccinations, skin and health checks, mental health assessments and wound dressing was of great concern.

“The Health Minister said that the Government wants pharmacists to play a greater role in the patient’s ‘medical team’ – but pharmacists are pharmacists, not doctors,” he said. “Pharmacists have real expertise. I consult and work with pharmacists every day I’m in my hospital, and that works extremely well.

“I’m just not sure that – the proposals being put forward in this agreement make sense, particularly when they talk about allocating $1.2 billion for this and then we’ll work out the details later.

“Pharmacists are not medically trained to provide medical services, nor are they indemnified to do so. The best primary care is provided by the local family doctor, the GP – the most cost-efficient part of the health system,” he said.

Adrian Rollins

Govt wants kids to have cut-price health checks

The Federal Government wants children to have cut-price health checks after confirming it will rip almost $145 million out of general practice by abolishing a Medicare program that last year provided comprehensive pre-school health assessments for 154,000 children.

But Health Minister Sussan Ley said parents would still be able to get their GP to conduct a similar Medicare-funded health check of their child, though at a fraction of the cost to the taxpayer.

The Minister was forced to make the clarification after an announcement in the Federal Budget that $144.6 million would be taken out of general practice over the next four years by “removing the current duplication” Medicare-funded health checks and child health assessments provided by the states and territories.

AMA President Associate Professor Brian Owler voiced concern about the cut, saying it was “very unclear” whether or not there was duplication occurring.

The measure was also heavily criticised by health groups angered by what appeared to be a decision to axe comprehensive health checks for children aged three to five years, introduced by the former Labor Government in 2008.

But Ms Ley rushed to assure parents that they could still get Medicare-funded health checks for their children.

“Parents needing to access the pre-school health check for their child in order to access income support will still be able to do so through a GP or the various state-based nurse infant and children checks, as is currently the case,” the Minister said. “The only change in the Budget is to the Medicare items GPs can bill taxpayers and patients for undertaking the check.”

The Government has moved to scrap Labor’s “Healthy Kids Check”, which costs Medicare $268.80 per visit, and instead allow GPs to bill for the check as a standard GP item costing $105.55 for an equivalent amount of time.

“Instead of GPs billing a special Medicare item worth hundreds of dollars per visit, they will instead be able to deliver the pre-school health check for three- and four-year-olds through a standard GP item worth about half that,” Ms Ley said.

The Government said an increase in the number of people using the Healthy Kids Check in recent years had sent the cost spiralling.

It reported that the number of assessments had jumped from 40,031 in 2008-09 to 153,725 last financial year, driving the annual cost from $1.8 million to $20 million.

While lamenting the cost of the program, Ms Ley simultaneously criticised it for not being comprehensive enough.

“Currently, only half of Australia’s 300,000-plus four-year-olds have accessed a pre-school health check at the more expensive billing rates,” the Minister said, adding there was no evidence show Labor’s program provided health checks superior to standard GP and state infant check services.

But a study published in the Medical Journal of Australia last year did not support this conclusion.

It found the program was effective in detecting problems with speech, toileting, hearing, vision and behaviour in about 20 per cent of children, and directly led to changes in the clinical management of between 3 and 11 per cent of such children.

The study’s authors said their results suggested “GPs are identifying important child health concerns during the Healthy Kids Checks, using appropriate clinical judgement for the management of some conditions, and referring when concerned”.

They added that GPs were also using the checks as an opportunity to identify other health problems.

The authors admitted to having no knowledge of the cost-effectiveness of the program, “although, given that its timing coincides with vaccination at four years of age, the incremental cost is likely small”.

It followed a study published in the MJA in 2010 which found that although the evidence behind the Healthy Kids Check at that stage was “not compelling”, it had the potential to play a important role in monitoring child development by filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services.

Adrian Rollins

Specialist patients up for thousands as rebate freeze bites

Patients undergoing heart surgery and other specialist treatments face a major hike in out-of-pocket expenses in the next three years that could leave them thousands of dollars poorer if the Federal Government persists with its Medicare rebate freeze, an AMA analysis has found.

Figures prepared by the AMA show the freeze will save the Government almost $2 billion by mid-2018, with more than half of this coming from medical specialists, their patients and health insurers as the value of the Medicare rebate declines and the cost of providing care rises.

The Government has kept the rebate freeze, first announced in last year’s Budget, as a device to encourage the AMA and other medical groups to assist in identifying efficiencies and savings through the Medicare Benefits Schedule review initiated last month.

Health Minister Sussan Ley has described the freeze as a regrettable necessity, though indicating that, “as an article of good faith, I am open to a future review of the current indexation pause as work progresses to identify waste and inefficiencies in the system”.

But the AMA analysis shows it will come at an enormous cost to patients, as the Government dumps a bigger share of health care cost onto households and practitioners.

The AMA estimates the freeze will have caused a $127 million shortfall in Medicare funding this year alone, rising to almost $364 million next financial year, $604.1 million in 2016-17, and almost $850 million in 2017-18. Even without any increase in the number of services provided, the rebate freeze will cumulatively rip $1.94 billion out of the system over four years.

Its effect in general practice has been likened to a “co-payment by stealth”, after University of Sydney research suggested GPs may have to charge non-concession patients more than $8 a visit to make up for the money withheld from the system as a result of the rebate freeze.

AMA President Associate Professor Brian Owler said patients would bear the brunt of the funding shortfall.

“We know that doctors’ costs are going to keep rising. The costs for their practice staff is going to keep rising. The costs to lease their premises and to provide quality practice as a GP or a specialist is going to keep rising,” A/Professor Owler said. “If the rebates don’t rise, those costs have to be passed on in out-of-pocket expenses – we will see less bulk-billing, and there is the possibility of seeing a co-payment by stealth, as has been alluded to by some.”

The AMA President said the effect on patients in need of specialist care would be even more profound, warning that, “the out-of-pocket expenses for specialists are going to be most severely hit”.

Under current arrangements, the Medicare rebate only covers a proportion of the cost of specialist care, and private health funds commit to covering an extra 25 per cent of the MBS fee, plus a loading on top of that for doctors who participate in “gap cover” schemes.

In the past, the health funds have indexed their cover in tandem with increases in the Medicare rebate – and have on occasion increased their cover even when rebates have been held flat.

But A/Professor Owler is among those fearful that insurers will be reluctant increase their cover without any lift in the rebate. If this occurs, many specialists may opt-out of gap cover schemes, which would mean private health cover would revert to the bare minimum 25 per cent of the Medicare rebate, with patients left to pick up the tab.

“I think there is a real issue for private health insurers,” he said. “If they choose to index independently of the MBS, they are going to have to pass on higher private health insurance premiums to people, or, if they choose not to index, there is a real chance that out-of-pocket expenses for specialist costs are going to rise significantly.”

The AMA has prepared resources for doctors and patients to help explain the Medicare rebate indexation freeze and its impact, including a patient guide and clinical examples. The resources are available at: article/medicare-indexation-freeze-support-materials-…

Adrian Rollins

Almost $150m ripped out of general practice

The Federal Government has slashed almost $145 million from general practice funding in a crackdown on what it claims was duplication in child health assessments.

In an unheralded change, the Budget revealed $144.6 million would be saved over four years by axing Medicare Benefits Schedule rebates for child health assessments which it said were already being provided by the states and territories.

The Government has also overhauled incentives for GPs to provide after-hours care, redirecting funding from the After Hours GP Helpline and the Medicare Locals After Hours Program into a new Practice Incentive Program After Hours Payment, to come into effect from 1 July.

AMA President Associate Professor Brian Owler voiced concern about the cut to child health assessment funding, saying it was premature when the Primary Health Care Review announced by the Government was yet to get underway.

“Unfortunately, we have seen near $150 million taken out of general practice from changes to the child health checks, apparently because of duplication – although it is very unclear in my mind as to whether or not there is any duplication,” A/Professor Owler said. “The Primary Health Care Review would have obviously have been the perfect place to assess whether the child health assessments were a necessary part, and whether any changes should be made to those assessments. Hopefully, there will be an opportunity to revisit that.”

Adrian Rollins

The ghosts of Budgets past

While listening to the Secretary of the Department of Health in the Health Budget lock-up in Canberra on Tuesday night, I was more than a little surprised that the sales pitch to Australia’s health leaders was that the centrepiece of the 2015 Health Budget was the Review of the Medicare Benefits Schedule (MBS) – a measure that had been announced some months earlier with supposedly no Budget revenue implications.

I was even more surprised when the Secretary inferred that the MBS Review would deliver further considerable savings to the Government. Health Minister, Susan Ley, has since clarified that this was not the Government’s intention.

It is not purely about a savings measure, it is about making sure that we have a modern MBS that actually reflects modern medical practice, and it actually maintains access for patient services.

Nevertheless, given the damage caused to the Government from last year’s Budget co-payment proposals and public hospital funding cuts – misguided measures that brought misery to the Government for the best part of a year – the general expectation was that the Government would play some strong suits in health policy.

That was not the case. Instead, we saw a range of modest (but welcome) announcements that remain completely overshadowed by the lingering negative effects of the Medicare patient rebate freeze and public hospital funding cuts – the ghosts of Budgets past.

The Budget unfortunately does not go anywhere near addressing the concerns of the AMA from last year’s Budget.

There is no indication that the public hospital cuts are going to be restored. Nor is there any indication about the required changes for the indexation freeze that we are seeing for GP and specialist patient rebates.

People need to remember that the indexation freeze is a freeze for the patient’s rebate. It is not about the doctor’s income. It is actually about the patient’s rebate and their access to services. There is no indication that those freezes are going to be lifted any earlier than 2018.

There have also been cuts of nearly $150 million taken out of general practice from changes to the child health checks, apparently because of ‘duplication’. It is very unclear where the so-called duplication occurs. Such a change would have been better dealt with as part of the MBS Review, rather than as a hastily conceived Budget saving measure.

There is also a lack of clarity around some of the announced cuts. There was a mystery package of $1.7 billion in cuts that was claimed to cover child health assessments, a number of dental programs, and ‘flexible funds’ for NGOs in the health sector. A big number, but little detail. The end result is a number of small organisations that do very good work looking after vulnerable people left wondering about their funding and their future.

The focus should have been on positives.

The AMA welcomed a range of other measures, including:

e-health changes, including the myHealth Record, particularly the opt-out component;
mental health plan;
support for the National Critical Care and Trauma Response Centre;
funding for Aboriginal Community Controlled health organisations;
organ donation programs; and
the Ice Action strategy.

The AMA has been invited by the Minister for briefing and clarification of issues such as Indigenous health program funding, after hours care, and preventive health.

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Medics to fix ‘fear’ culture, The Daily Telegraph, 4 April 2015

A change in the way doctors and nurses report abuse is needed to buck the scourge of sexual harassment and protect whistleblowers within the medical industry. AMA President A/Professor Brian Owler was committed to bringing about cultural change within the profession.

$8.40 more to see doctor, Herald Sun, 7 April 2015

Patients could be paying up to $8.40 for a visit to the doctor by 2018, more than they would have paid under the GP co-payment. AMA President A/Professor Brian Owler said the lazy policy would mean fewer patients would be offered bulk-billing.

Religious belief saw mum and baby die, The Daily Telegraph, 8 April 2015

The AMA has defended doctors at a top Sydney hospital forced to let a heavily pregnant woman and her unborn child die after the mother refused a blood transfusion because she was a Jehovah’s Witness. AMA Vice President Dr Stephen Parnis said doctors could not force a patient to accept treatment.

Not in the script – chemists selling your data, Sunday Mail Adelaide, 12 April 2015

Some chemists are selling their patients’ prescription information to a global health information company, which sells it on to drug firms, trying to boost their sales. AMA Chair of General Practice Dr Brian Morton called it an amazing invasion of privacy for purely commercial reasons.

Coalition’s ‘no jab, no pay’ policy ties benefits to immunisation, Australian Financial Review, 13 April 2015

Australian parents will lose thousands of dollars’ worth of childcare and welfare benefits if they refuse to vaccinate their children. AMA President A/Professor Brian Owler said the AMA backed the plan and said vaccination remained one of the most effective public health measures that we have.

Hospitals ‘storm’ warning, Adelaide Advertiser, 16 April 2015

The number of public hospital beds across Australia has fallen by more than 200 and no State has met emergency department targets. AMA President A/Professor Brian Owler said hospital performance benchmarks are not being met and things will only get worse as funding declines.

AMA hospital report card gives states fuel for fight, The Australian, 16 April 2015

Tony Abbott will face heightened pressure to reverse cuts of $80 billion to health and education, with a snapshot of public hospital performance handing the states fresh ammunition to press home their case. AMA President A/Professor Brian Owler will use the report to warn the Government that its extreme public hospital cuts are unjustified.

Church no longer exempt for jabs, Hobart Mercury, 20 April 2015

A religious exemption loophole, that allowed parents who opposed vaccinations to continue to receive childcare and family tax payments has been scrapped. AMA President A/Professor Brian Owler praised the move.

AMA warns against continued freeze on rebates, ABC News, 22 April 2015

AMA President A/Professor Brian Owler said at a time when the Government should be increasing its investment in general practice, the Medicare rebate freeze will eat away at the viability of individual practices.

Rape row over new anti-jab campaign, Adelaide Advertiser, 23 April 2015

A Facebook graphic on the Australian Vaccination Network site that compares vaccination to rape has been condemned by doctors, the Rape Crisis Centre, and politicians as abhorrent and insulting. AMA President A/Professor Brian Owler said the post undermines the organisation and shows lack of intelligence and common sense.

Doctors back review of Medicare rebates, West Australian, 23 April 2015

Doctors have backed a sweeping review of the Medicare Benefits Schedule, but warned the Federal Government not use it as an excuse to cut patient services. AMA President A/Professor Brian Owler agreed the MBS was outdated and said any savings from the review should be reinvested into the health system.

Aussie in sick new IS video, Sunday Herald Sun, 26 March 2015

The shocking new public face of Islamic State death cult is an Australian doctor. AMA President A/Professor Brian Owler said he was appalled that any medical professional would want to work for terrorists.

Transparency on dug company payments and trips a step closer, The Age, 28 April 2015

Patients will find out what payments and educational trips their doctors have received from drug companies. AMA Chair of General Practice Dr Brian Morton said it was insulting and naïve to suggest doctors would be unduly influenced by a free meal.

Terror doctor free to practise, Adelaide Advertiser, 28 April 2015

The Medical Board is refusing to deregister the former Adelaide doctor who left Australia to join the Islamic State terrorist group. AMA Vice President Dr Stephen Parnis said he expected the Medical Board to look closely at the case from legal and professional standards perspectives.

Scientists call for action on disease risks from climate change, Sydney Morning Herald, 30 April 2015

The Australian Academy of Science has released a report which shows a range of tropical diseases becoming more widespread in Australia due to climate change. AMA President A/Professor Brian Owler said the report should be a catalyst for the Abbott government to show leadership on reducing greenhouse gas emissions and mitigating their effects on health.

Radio

A/Professor Brian Owler, 774 ABC Melbourne, 7 April 2015

AMA President A/Professor Brian Owler talked about the decision to axe the proposed $5 Medicare co-payment in favour of an alternative Government plan to freeze the amount received by doctors in rebates.

Dr Stephen Parnis, 6PR Perth, 13 April 2015

AMA Vice President Dr Stephen Parnis discussed the use of the welfare system to boost immunisation rates. Dr Parnis said in the 1990s the Howard Government also linked immunisation to social security, which resulted in a big increase in vaccination rates.

A/Professor Brian Owler, Radio National, 16 April 2015

AMA President A/Professor Brian Owler discussed Federal funding for health. A/Professor Owler said the health system has never been adequately funded and doctors and nurses have done well to meet a rise in demand.

A/Professor Brian Owler, 2SM Radio, 16 April 2015

AMA President A/Professor Brian Owler talked about the use of paw paw for chronic back pain. A/Professor Owler said paw paw is a well-known treatment, but that people do not tend to use it as much nowadays.

A/Professor Brian Owler, 4BC Brisbane, 16 April 2015

AMA President A/Professor Brian Owler talked about the issue of health funding and the AMA Public Hospital Report Card. A/Professor Owler said the issue is capacity and resources, and that he is concerned about the future given reduced Commonwealth funding.

Dr Stephen Parnis, 2GB Sydney, 23 April 2015

AMA Vice President Dr Stephen Parnis talked about the recent Facebook post from the Australian Vaccination Skeptics Network, which compares forced vaccination to rape. Dr Parnis said the campaign shows how disgraceful and unhinged some anti-vaccination campaigners are.

A/Professor Brian Owler, 2UE Sydney, 28 April 2015

AMA President A/Professor Brian Owler talked about the Medical Board’s handling of the case of an Australian-registered doctor who has joined Islamic State. A/Professor Owler said he understands the Medical Board is working with security agencies to ensure that the public is safe, and to prevent any possibility of Dr Kamleh returning to Australia to continue practising medicine.

A/Professor Brian Owler, ABC NewsRadio, 30 April 2015

The Australian Academy of Science is warning of the impacts of global warming predicting food and water shortages, along with extreme weather events. AMA President A/Professor Brian Owler said climate change has been a political battleground and that Australia is not ready to cope with its impacts.

Television

A/Professor Brian Owler, Channel 9, 16 April 2015

AMA President A/Professor Brian Owler talked about the AMA’s Public Hospital Report Card. A/Professor Owler said many hospitals are not reaching targets in the emergency department treatment and elective surgery wait times.

Dr Stephen Parnis, Channel 9, 12 April 2015

AMA Vice President Dr Stephen Parnis talked about the Government’s announcement that childcare rebate payments will be cut for families who do not vaccinate their children. Dr Parnis said the children involved are innocent, and their futures need to be insured.

A/Professor Brian Owler, ABC News 24, 16 April 2015

AMA President A/Professor Brian Owler discussed the crisis in Australia’s public hospitals as Commonwealth funding is wound back. A/Professor Owler said the Commonwealth are not living up to their responsibilities to fund States and Territories properly to run hospitals.

A/Professor Brian Owler, Channel 9, 22 April 2015

AMA President A/Professor Brian Owler discussed welcoming the plans for a major review of the Medicare Benefits Schedule. A/Professor Owler said the review is clinician-led and is not just about finding savings.

A/Professor Brian Owler, Sky News, 29 April 2015

AMA President A/Professor Brian Owler discussed the future of the public hospital system if Federal Government cuts come into effect. A/Professor Owler said state governments lack the capacity to increase revenue to pick up the slack.

A/Professor Brian Owler, ABC News 24, 30 April 2015

AMA President A/Professor Brian Owler called on the Federal Government to show leadership on climate change or risk the health of Australians. A/Professor Owler said there was overwhelming scientific consensus that the climate is changing and there will be consequences for health.