Your AMA Federal Council at work

What AMA Federal Councillors and other AMA members have been doing to advance your interests in the past month:

Name	Position on Council	Activity/Meeting	Date
A/Prof Brian Owler	AMA President	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia	5/3/2015
A/Prof Brian Owler	AMA President	Meeting with Royal Australasian College of Surgeons and Australian Plastic Surgery Association Presidents	4/3/2015
Dr Brian Morton	AMA Chair of General Practice	GP Roundtable	8/4/2015
		UGPA	25/03/2015
		GP Roundtable	17/3/2015
Dr Stephen Parnis	AMA Vice President	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Andrew Miller	AMA Federal Council Representative for Dermatologists	PBS Authority medicines review reference group	13/4/2015
Dr Andrew Miller	AMA Federal Council Representative for Dermatologists	MSAC (Medical Services Advisory Committee) Review Working Group for Skin Services	20/2/2015
Dr Antonio Di Dio	AMA Member	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Roderick McRae	AMA Federal Councillor – Salaried Doctors	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Susan Neuhaus	AMA Federal Councillor – Surgeons	Meeting with Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) on improving practitioner experience with notifications	5/3/2015
Dr Robyn Langham	AMA Federal Councillor – Victoria nominee and Chair of AMA Medical Practice Committee	Australian Health Practitioner Regulation Agency’s (AHPRA) Prescribing Working Group (PWG)	5/3/2015
Dr David Rivett	AMA Federal Councillor	IHPA Small Rural Hospitals Working Group	5/2/2015
Dr Chris Moy	AMA Federal Councillor	PCEHR Safe Use Guides consultation (KPMG/ACSQHC)	11/3/2015
Dr Chris Moy	AMA Federal Councillor	NeHTA (National E-Health Transition Authority) Clinical Usability Program (CUP) Steering Group	19/2/2015
Dr Richard Kidd	AMA Federal Councillor	PCEHR Safe Use Guides consultation (KPMG/ACSQHC)	10/3/2015
Dr Richard Kidd	AMA Federal Councillor	Gateway Advisory Group	9/2/2015

Where are general practitioners when disaster strikes?

GPs, inevitably involved in disasters, should be appropriately engaged in preparedness, response and recovery systems

In the past two decades it is estimated that Australians have experienced 1.5 million disaster exposures to natural disasters alone.1 General practitioners are a widely dispersed, inevitably involved medical resource who have the capacity to deal with both emergency need and long-term disaster-related health concerns. Despite the high likelihood of spontaneous involvement, formal systems of disaster response do not systematically include GPs.

An Australian Government review of the national health sector response to pandemic (H1N1) 2009 influenza suggested: “General practice had a larger role than had been considered in planning”.2 It commented that “structures . . . in place to liaise with, support and provide information to GPs were not well developed”; personal protective equipment provision to GPs was “a significant issue”; and planned administration of vaccinations through mass vaccination clinics was instead administered through GP surgeries.2

GPs are well positioned to help

As of the financial year 2013–14, Australia had 32 401 GPs,3 distributed through rural and urban communities. GPs are onsite with local knowledge when disaster affects their communities. External assistance may be delayed, and the local doctor may be integral in initial community response and feel compelled to act, yet have a poorly defined role.

GPs can identify vulnerable community members, and are situated in local medical infrastructure with medical resources. When other agencies withdraw in the months after disaster, GPs remain, providing continuity of care, which is likely to be important at this time of high distress and medical need (Box 1). Primary health care during extreme events can support preparedness, response and recovery, with the potential to improve health outcomes.4 The challenge lies in linking GPs with the existing medical assistance response.

Australian GPs’ experience of responding to disasters

Australian GPs have a strong sense of responsibility and moral obligation to their patients. They have spontaneously demonstrated willingness and capacity to respond in recent disasters, including the 2011 Australian floods, the 2009 pandemic influenza, and recent bushfires. In interviews with 60 Tasmanian GPs, 100% of GPs surveyed intended to contribute to patient care in the event of a pandemic, with expression of a strong sense that to do otherwise was unethical, although this was dependent on provision of appropriate personal protective equipment.5

What is lacking is consistent support for GPs, their families and their practices. Local GPs may be personally affected and immersed in the disaster, or experience repetitive exposure to their patients’ trauma. Changes in patient presentations, workload, income and working conditions create additional stress, particularly if compounded by personal loss or injury.6 GPs involved in ad hoc spontaneous response may experience uncertainty of their role or efficacy, reluctance to stand down, or may prefer no involvement. GPs interviewed after the 2011 Christchurch earthquake noted experiencing “emotional exhaustion” and physical fatigue; some were aware of the need for personal care at the time, and others only in retrospect.6

Principles of disaster management

The principles of disaster management follow the internationally accepted all-hazards, all-agencies approach through the phases of prevention, preparedness, response and recovery (PPRR).7 Despite the variation in GP roles due to practice locations and context, the GP role in disaster management is most evident across the time frames of PPRR. As shown in Box 1, GPs provide continuity of care across these periods, but with the least consistency in the response phase.

Preparedness

Our discussions with key GP groups and leaders in the field suggest that despite a rapid increase in the number of practices engaging in disaster planning over the past year, most GPs are currently underprepared for disasters (Box 2). Lack of preparedness increases vulnerability. To redress this global problem, the World Medical Association recommends disaster medicine training for medical students and postgraduates. This could include education on existing disaster response systems, mass casualty triage skills, psychological first aid and the epidemiology of disaster morbidity in the first instance.

Response

In the response phase, it is important that GPs are aware of the overarching plan following the incident management system that coordinates multiple disciplines (including fire, police, ambulance and health) to respond to all types of emergencies, from natural disasters to terrorism. With this in mind, roles for GPs have previously included accepting patients from a neighbouring affected practice, assisting at other practices or with surges in hospital emergency department presentations and at GP after-hours services, or keeping patients out of hospitals through “hospital in the home” services. It may involve providing prescriptions and medical treatment in an evacuation centre, being included in medical teams such as St John Ambulance or identifying more vulnerable patients for evacuation assistance. Most importantly, GPs should maintain usual practice activities where possible. These response models are aligned with the range of GP skills and have clear operational requirements.

Recovery

GP involvement is imperative in the recovery phase, ensuring continuity of physical and psychosocial health care during the ensuing months to years. While most patients recover with minimal assistance, it is crucial that individuals in need of increased support are recognised, particularly those with pre-existing chronic disease. Some presentations may be related to particular hazards, eg, smoke inhalation after bushfire, but many others are risks regardless of the hazard. These include increased substance use, anxiety, depression, acute or post-traumatic stress disorder, chronic disease deterioration, and the emergence of new conditions, including hypertension, ischaemic heart disease and respiratory conditions.8 Children are particularly vulnerable, and changes in behaviour or school performance may indicate residual problems.

Support from general practice organisations (GPOs)

During the 2009 Victorian bushfires, Divisions of General Practice provided strong support to enable general practices affected by the fires to continue to offer health care, by providing human and material resources, skills training, advocacy and media liaison. During the 2013 New South Wales bushfires, there was strong GP linkage by the Nepean-Blue Mountains Medicare Local to existing systems through the Nepean Blue Mountains Local Health District and the state health emergency operations centre, as well as to GPOs at a state level. Lessons learnt need to be incorporated into systems planning.

The need for unified disaster planning is increasingly recognised at both individual GP and GPO levels. The General Practice Roundtable, with input from all the major GPOs, has diverse GP representation, providing an opportunity for broad input into disaster planning across PPRR. Important recent initiatives by GPOs include position statements for GPs,9 and ongoing development of disaster resources, promotion of general practice disaster planning, and the recent formation of a national Disaster Management Special Interest Group within the Royal Australian College of General Practitioners.

Where to from here?

Disasters are devastating events and by nature are unpredictable. While recognising and acknowledging the critical role of the formal emergency response agencies in the existing system of specialised health response and management, the strength of general practice lies in the provision of comprehensive continuity of care, and this lends itself to greatest involvement in the preparedness and recovery phases. There is a need for a clear definition of roles in the response stage. GPs as local medical providers in disaster-affected communities need to be systematically integrated into the existing stages of PPRR with clear responsibilities, lines of communication, and support from GPOs, avoiding duplication of other responders’ tasks. Valuing and using the expertise and resources that GPs can bring to disasters may improve long-term patient and community health outcomes.

1 Current defined roles for general practitioners in disasters

2 Potential roles for general practitioners and GP-related groups in disasters

Prevention and preparedness — before the disaster

national position on the role of GPs in disasters across PPRR;
clearly defined roles that integrate with other responding agencies;
GPO representation on national, state and local disaster management committees;
unified disaster planning across GPOs through the GPRT;
information for other agencies on GPs’ skills and roles through the GPRT and GPOs;
education and training in core aspects of disaster medicine for GPs and medical students;
involvement of local GPs in local disaster planning and exercises through ML or PHN;
general practice business continuity and disaster response practice planning;
assisting patient preparedness to reduce vulnerability;
GP personal and family preparedness; and
vaccination, infection control measures and surveillance in infectious events.

Response — during the disaster

representation in EOCs for communication and coordination with other responders (including ambulance, mental health, public health, etc);
unified disaster response from GPOs, including information, resources and phone support;
coordination through GP networks for workforce support for affected practices;
clearly defined integrated roles in existing systems for GPs involved in response, such as:
- maintaining usual practice activities where possible to help surge capacity
- expanding practice capacity to treat extra patients if needed
- expanded use of practice infrastructure, medical resources and trained staff as appropriate
- supporting existing medical teams such as St John Ambulance
- assisting at the scene, evacuation centre or local clinic as appropriate;
assistance in identification of potentially vulnerable and at-risk individuals and families;
ongoing communication with and referral between other local primary care health providers;
patient education on hazard-related health matters, eg, asbestos, infectious outbreaks, etc;
preventive vaccination — tetanus (clean-up injuries); and
surveillance for future outbreaks and emerging community disease threats.

Recovery — after the disaster

inclusion in the review process to improve future PPRR;2
representation on recovery committees to improve interagency referral and communication;
ongoing support from GPOs for affected GPs and staff through regular contact and resources;
GPOs and ML or PHN support for those practices that are more affected;
management of deterioration of pre-existing physical and mental health conditions;
surveillance for new physical and psychological conditions to improve patient outcomes;
surveillance for emerging community disease threats; and
linkage and communication with community groups and allied health on recovery activities.

EOC = emergency operations centre. GPO = general practice organisations. GPRT = General Practice Roundtable. ML = Medicare Locals. PHN = Primary Health Networks. PPRR = prevention, preparedness, response and recovery.

Getting the levers right: a way forward for rural medicine

To the Editor: We agree with the points raised by Kamerman in his erudite article.1 There are, however, two things that should be mentioned.

The first is that Townsville and Gundagai do not have the same Australian Standard Geographical Classification — Remoteness Area (ASGC-RA) classification: Townsville is categorised as RA3 (outer regional Australia), whereas Gundagai receives the less remote classification of RA2 (inner regional Australia). This magnifies the absurdity of the current classification situation even further.

The second is that not only would the general practitioner copayment policy have led to practices deciding against taking on registrars, but it would also have had an even greater potential for practices to decide against accepting medical students. Although the proposed Medicare rebate freeze will not have the immediate impact on undergraduate and vocational training that the copayment would have had, the net effect will ultimately be very similar.

Placement in rural general practices forms a key part of our medical student training and is a major factor in the success that we have had to date in our graduates choosing both generalist and rural career pathways. An unintended consequence of the copayment policy could have been to derail these positive outcomes with a stroke of the pen. We predict that, as the impacts of the Medicare rebate freeze take effect, enough practices will eventually decide to withdraw from training to have a significant negative impact on training programs and, ultimately, the primary health care workforce.

First use of creatine hydrochloride in premanifest Huntington disease

Huntington disease is a devastating autosomal dominant neurodegenerative disorder that typically manifests between ages 30 and 50 years. Promising high-dose creatine monophosphate trials have been limited by patient tolerance. This is the first report of use of creatine hydrochloride in two premanifest Huntington disease patients, with excellent tolerability over more than 2 years of use.

Clinical record

A 33-year-old patient in our general practice carried the autosomal dominant gene for Huntington disease (HD). The abnormal number of cytosine-adenine-guanine triplet repeats in the huntingtin gene she carried meant she would eventually become symptomatic for this dreadful disease.

The patient requested information regarding potential treatments, as she had become aware of clinical trials for HD and of compounds used by patients with HD. A neurologist had previously recommended a healthy diet, exercise, avoiding excessive toxins (such as alcohol), social enrichment and cognitive stimulation, which together may modestly slow clinical disease progression and improve quality of life.1 She had used preimplantation genetic diagnosis during her pregnancies but preferred otherwise not to focus on her condition. She understood that there were no proven therapies for this incurable condition and did not want to attend HD clinics. She was asymptomatic.

At her request, I searched the PubMed database for possible treatment options. There were some that were unproven in HD but had been used safely in humans for other indications, had a reasonable rationale regarding known HD pathophysiology, and had positive results in animal models of HD and/or early-phase human HD trials.2

In January 2012, I sought advice on using these options (eg, high-dose creatine, melatonin, coenzyme Q10, trehalose, ultra-low-dose lithium with valproate) from a specialist HD clinic but was advised against this approach. Instead, it was suggested that the patient might be able to sign up for clinical trials including high-dose creatine. The patient chose subsequently to participate in an observational trial (PREDICT-HD) which did not limit her options. However, she declined consideration for the Creatine Safety, Tolerability, and Efficacy in Huntington’s Disease (CREST-E) study,3 an international Phase III placebo-controlled trial of creatine monophosphate (CM) in early symptomatic HD. It is also very unlikely she would have been accepted for this trial as she was asymptomatic.

In February 2014, the Creatine Safety and Tolerability in Premanifest HD trial (PRECREST),4 a Phase II trial, showed significant slowing of brain atrophy in CM-treated premanifest HD patients. If convincingly replicated, this would be a major advance.

The main practical problem with high-dose CM (20–30 g daily) is tolerability. Adverse effects are common, especially nausea, diarrhoea and bloating. In people who have normal renal function before commencing creatine supplementation, creatine does not appear to adversely affect renal function.5

In PRECREST, about two-thirds of patients tolerated the maximum dose (30 g daily) and 13% of those on placebo were unable to tolerate CM when they switched to it. Moderate intolerance appears to be common. A high dropout rate affected the HD gene carriers in this study despite assumed high motivation.6 Recommended additional water intake for patients on CM therapy is 70–100 mL per gram of creatine per day, which is problematic at high doses of CM.

The patient again requested assistance as she wanted to seek the best available potential treatment to face her condition with equanimity.7 I decided that, provided safety was paramount, I would assist her on an informed consent basis as part of my duty of care, respecting her informed autonomy.

A case presentation and treatment plan was prepared and an expert team of relevant medical specialists was assembled. Comprehensive informed written consent, including consent from the patient’s partner for additional medicolegal protection, was obtained. The New South Wales off-label prescribing protocol8 was followed, actions were consistent with article 37 of the Declaration of Helsinki,9 and medical defence coverage for the proposed treatment was specifically confirmed by my indemnity insurer.

After baseline assessment, including renal function and careful attention to hydration, the patient commenced oral CM therapy at 2 g/day. This was slowly increased to 12 g/day but she was unable to maintain this dosage due to gastrointestinal adverse effects.

Creatine hydrochloride (CHCl), a creatine salt that has greater oral absorption and bioavailability than CM, and requires less water and a lower dose, offered a possible solution.10 The reduced dose also reduces intake of contaminants, which is very important for extended use. Use of CHCl has been confined to the bodybuilding industry and, to the best of my knowledge after a careful search of PubMed, nothing has previously been published in the context of neurodegenerative disorders.

After review by a pharmacologist and consultation with the co-inventor of the available formulation of CHCl,10 a daily dose of 12 g (equivalent to about 19 g CM) with 100 mL water per 4 g of CHCl was proposed. The manufacturer (AtroCon Vireo Systems) provided 1 g capsules of pharmaceutical grade CHCl at reduced cost. The patient decided to commence CHCl therapy after ceasing CM therapy. The dose of CHCl was slowly increased to 4 g three times a day (12 g daily) with a minimum of 100 mL additional fluid per 4 g dose.

The patient has been taking this dosage since January 2013 without any significant adverse effects and is keen to continue. Her serum creatinine levels are stable. Her serum creatine levels before and after doses have also been measured, and this confirmed that the CHCl is being absorbed.

Shortly after this patient began CHCl therapy, a second related premanifest HD patient requested access to CHCl. After a similar informed consent process, the second patient commenced the same dose of CHCl and has also not developed significant adverse effects. Clinically, both patients remain well.

Discussion

This is the first report of CHCl use in HD, with excellent tolerability for more than 2 years by two patients. If replication of the PRECREST findings confirms high-dose creatine as the first potentially disease-modifying treatment for HD, CHCl may represent an important option for patients, warranting further studies.

In this context, it is disappointing that CREST-E was closed in late 2014 after interim analysis showed it was unlikely to show that creatine was effective in slowing loss of function in early symptomatic HD based on clinical rating assessment to date. There were no safety concerns.11

It will be interesting to see, when eventually analysed and published, whether the magnetic resonance imaging (MRI) data from CREST-E showed any benefit in any subgroup and whether the trial cohort as a whole were in fact all in early-stage disease, and to consider whether the clinical rating scales were sensitive enough in this specific trial context.

Although others disagree, I argue that it remains unclear based on PRECREST findings whether the lack of benefit of creatine for early symptomatic disease in CREST-E is strictly relevant to the much earlier presymptomatic stage of the disease, especially when patients are far from onset.

HD symptoms take 30–50 years to develop, and the disease generally progresses to early dementia and death. Progressive MRI abnormalities accumulate for 20 or more years before onset. It appears that by the time the disease becomes symptomatic after 30–50 years, a multiplicity of interacting pathogenic mechanisms have become active (eg, excitotoxicity, mitochondrial energy deficit, transcriptional dysregulation, loss of melatonin receptor type 1, protein misfolding, microglial activation, early loss of cannabinoid receptors, loss of medium spiny striatal neurones, oxidative stress), and early and late events have occurred. The authors of a study of postmortem HD brain tissue refer to these mechanisms as a “pathogenetic cascade”,12 while others refer to them as multiple interacting molecular-level disease processes.13 “Early” downregulation of type 1 cannabinoid receptors has been identified as a key pathogenic factor in HD.14 In a recent review on the pathophysiology of HD, the authors described “a complex series of alterations that are region-specific and time-dependent” and noted that “many changes are bidirectional depending on the degree of disease progression, i.e., early versus late”.15 These and other findings suggest that HD has a complex temporal and mechanistic evolution that has not been fully elucidated. For this reason, we should think carefully before abandoning an agent when it fails at the relatively late symptomatic stage of this devastating and incurable disease.

As creatine is thought to have a useful potential for action in relation to only one of the many relevant disease mechanisms — mitochondrial energy deficit — was it too much to expect creatine to have a significant impact on symptomatic-stage disease in CREST-E? It seems possible, based on the references cited above, that there are fewer (or less intense) pathogenic mechanisms operating at much earlier presymptomatic stages of the disease, when the brain is more intact and plastic. If so, treatment trials in presymptomatic patients assessed using MRI or other biomarkers might offer better prospects for benefit.

I believe that sophisticated replication of PRECREST (or at least clarification as to whether the slowed rate of atrophy on MRI in premanifest patients was genuine or artefactual) is an ethical obligation that we owe to the HD community who contributed so much to CREST-E.

There are significant ethical and sociomedical issues associated with HD research. In reviewing the literature, it was obvious that early-phase research contains multiple examples of existing, out-of-patent or non-patentable potential therapies that appear to warrant modern clinical trials and, I argue, at an appropriate early stage of the disease.2,16,17 Early-phase studies of combination therapies with existing agents appear frequently to receive little, if any, follow-up.2,18

Currently, any drug for which US Food and Drug Administration or European Medicines Agency approval is sought for presymptomatic HD must achieve a clinical end point first in symptomatic HD, then requalify in presymptomatic HD, meeting combined clinical and biomarker end points. Does this arbitrarily overprivilege the clinically observable stage of a disease, which is now understood (based on relatively recent MRI studies) to have a course of 20 or more years before symptoms begin?

Because of the enormous costs associated with drug development, and the uncertainty of such research, I believe that it is time for a renewed focus on small, targeted clinical trials, especially in premanifest HD, using existing and novel agents. Recent advances in MRI and additional biomarkers that are under development19 open the possibility of meaningful small trials that aim to slow HD progression until gene therapy arrives.

None of this, however, will achieve its full potential unless we address the barriers to genetic testing. The true incidence of many genetic conditions, including HD, in Australia is unknown. If a treatment becomes available, more people will want to be tested. The decision to have genetic testing is complex, controversial and uniquely personal. Respecting this, I believe that we need to urgently follow the lead of the United States, Germany, Sweden, France, Denmark and other countries in legislating to end genetic discrimination in health, insurance, employment and services.20 I urge policymakers to replicate and clarify PRECREST and, in full collaboration with the HD community, trial existing and available medications alongside novel agents.

GP training – into the great unknown

By Dr Danielle McMullen, a GP registrar, Chair AMA NSW DiT Committee, and AMA CDT representative on AMA Council of General Practice.

Last week thousands of hopeful GP registrars, the future of our GP workforce, were asked to apply for the Australian General Practice Training Program. But, as it stands today, they are applying to an unknown beast. These doctors must surely feel like they are bravely stepping into a dense fog.

In its 2014-15 Budget, the Commonwealth systematically dismantled the program that has trained many of our highly qualified GPs since 2001.

For more than a decade General Practice Education and Training (GPET) coordinated and oversaw general practice training delivered across the country by regional training providers (RTPs).

While controversial at the outset, GPET then flourished in a growing and increasingly complex environment – it allowed registrars a single point of application and entry, with the flexibility to choose a training pathway towards fellowship of the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM).

At the end of 2014, GPET was quietly rolled into the Department of Health, and in December 2015 the current RTPs will cease to exist. The change is worrying enough (after all, doctors can be creatures of habit), but what is most alarming is that nearly 12 months after the Budget announcement of these changes, we are no clearer on the details of what training will look like in 2016.

At time of writing, the new training organisations remain nameless, shapeless, faceless – we understand there will be fewer of them, but we don’t know how many, where they will be or who they will be.

The tender process for new training organisations has not yet begun, much less been completed.

In addition to the significant changes to vocational training, the 2014-15 Budget also scrapped the Prevocational General Practice Placements Program, which was the only avenue for prevocational doctors in their intern or Postgraduate Year Two year to experience the general practice environment. This gaping hole in the general practice workforce pipeline will result in fewer numbers of interested GP trainees, and throw general practice back to an option of last resort.

We run a real risk of setting GP training back 15 years, to before GPET, when GP training was fragmented, less attractive to junior doctors and we were facing a significant shortage of quality GPs, especially in rural and remote Australia.

At best, we will suffer one or two years of chaos. At worst, the flow on effects of this upheaval will be felt for years to come.

Excellent clinical supervisors, those GPs welcoming registrars into their practices, 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.

A 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 well and shape the future of general practice training in Australia.

The AMA supports RACGP and ACCRM taking back control of general practice training. The Department of Health should not be the new GPET – the Colleges are best placed to train the specialist GPs of our future. But even they are being kept in the dark.

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.

Dr McMullen will chair the “General practice training – the future is in our hands” policy session at the AMA National Conference in Brisbane on Saturday 30 May at 2:15pm.

AMA Guide to 10 minimum standards for medical forms

1. The form is available in an electronic format that is compatible with existing electronic general practice medical records software.

2. Forms are distributed through medical software vendors. Access to forms does not require web surfing during consultations, nor form-filling online.

3. The form has a clear notation that states that medical practitioners may charge a reasonable fee for their services and whether the services are eligible for rebate by Medicare or other insurers.

4. Demographic and medical data can be selected to automatically populate the electronic form with adequate space being provided for comments.

5. Only information essential for the purpose is requested and must not unnecessarily intrude upon patient privacy.

6. Forms do not require the doctor to supply information when a patient can reasonably provide this in their own right.

7. A copy is saved in the patient electronic medical file for future reference.

8. Data file storage size is kept to a minimum.

9. Prior to their release, forms are field tested under the auspices of a recognised medical representative organisation such as the AMA and the RACGP, in association with the MSIA (Medical Software Industry Association).

10. Consideration should be given to future compliance with encrypted electronics transmission capability, in line with new technologies being introduced into general practice.

Plan to boost GP mental health role fails to win Govt support

Health Minister Sussan Ley has ruled out a recommendation of a Government-commissioned review of the mental health system to boost the role of GPs and Primary Health Networks in providing mental health care by redirecting $1 billion of Commonwealth funding from public hospitals to primary health providers and community-based mental health services.

A leaked copy of the long-awaited National Mental Health Commission review of mental health care, obtained by the ABC’s 7.30 Report, has urged a shift in funding priorities away from ‘downstream’ services like acute care and the Disability Support Pension income support to prevention and early intervention care provided by GPs and other primary health providers.

“It is clear the mental health system has fundamental structural shortcomings,” the review said. “The overall impact of a poorly planned and badly integrated system is a massive drain on peoples’ wellbeing and participation in the community.”

The Commission has argued that changing to a “stepped care approach” with a major focus on prevention and early intervention would reduce the severity and duration of mental health issues, ultimately slowing demand for expensive acute hospital care and lowering the incidence of long-term disability.

“The Commission believes one of the most fundamental elements of the stepped care approach lies in prioritising delivery of care through general practice and the primary health care sector,” the report said, citing modelling from consultancy KPMG suggesting this would “slow the rate of increase in Disability Support Pension and Carer Payment costs and the costs of acute care and crisis management”.

The Commission report said international evidence showed that strong primary health care made for healthier people and less costly health care than a focus on specialist and acute care, and suggested the creation of Primary Health Networks was an opportunity to “better target mental health resources”.

Commission Chair Professor Alan Fels told ABC’s AM program that, “we believe that over the next couple of years the Commonwealth should get ready to somewhat rebalance its spending away from it all going into hospitals when it would be better spent on services that keep people out of hospitals”.

The Commission found that mental health problems are inflicting enormous costs on the country despite massive Commonwealth spending.

It said that, despite the expenditure of $9.6 billion on mental health care in 2012-13, around 3.6 million Australians experience mental ill-health every year – including 9000 who die prematurely – and the problem costs the country up to $40 billion a year.

“Our ‘mental health system’ is instead a collection of often uncoordinated services introduced on an often ad hoc basis, with no clarity of roles and responsibilities or strategic approach,” the Commission’s report said. “We need system reform to rebalance expenditure away from services which indicate system failure and invest in evidence-based services like prevention and early intervention.”

Professor Fels said the Commission was not arguing for money to be taken out of mental health care, but that the focus of effort be redirected, suggesting the reallocation of “a minimum” of $1 billion of Commonwealth funding from acute hospitals to community-based mental health services from 2017-18.

“There’s a great deal of Commonwealth spending on people, for example, going into the disability support payment scheme because they’re not well and haven’t been treated well. So, we believe there should be better prevention mechanisms, and system needs to be rebalanced in that direction.”

But Ms Ley has poured cold water on the idea, saying the Commonwealth will not make such a change without the full support and co-operation of the states and territories.

“My strong view is we need to be partners with the states if we are to address serious mental health issues in this country long-term,” the Minister told the West Australian. “Our preference, therefore, is to work with the states to deliver better co-ordination of existing roles and funding arrangements, rather than reduce the part they play.”

The Commission’s report was delivered to the Government on 30 November, but it is yet to make a formal response, causing frustration in the mental health sector.

Adrian Rollins

GP training confusion: call for urgent talks

The AMA has voiced “grave concerns” about the Federal Government’s handling of far-reaching changes to general practitioner training under the shadow of looming doctor shortages.

AMA President Associate Professor Brian Owler has written to Health Minister Sussan Ley seeking an urgent meeting to discuss the implementation of changes to GP training announced in last year’s Budget.

A/Professor Owler warned the Minister that the medical profession was “fast losing confidence in the process, and history shows that the last time GP training was reformed by the Government it took many years to recover”.

In its 2014-15 Budget, the Federal Government abolished General Practice Education and Training (GPET) and the Prevocational General Practice Placements Program (PGPPP), axed funding to the Confederation of Postgraduate Medical Education Councils and absorbed Health Workforce Australia and GPET within the Health Department.

Under the sweeping changes, the Health Department will have responsibility for overseeing GP training.

The changes have stoked warnings that, combined with cuts to valuable programs and fears of massive hikes in student fees, they pose a serious risk to the quality and viability of general practice training, placing the profession at long-term risk.

Concerns have centred on the short time frame to implement the changes, the Department’s lack of experience in managing training programs, and the profession’s loss of supervision over training.

A/Professor Owler said expert AMA representatives who have been consulting with the Government and Health Department on the implementation of the changes have been alarmed by on-going delays and a lack of detail being provided by the Department on crucial matters such as the funding of professional oversight and governance arrangements.

“Unfortunately, we are now in a position where we simply do not know what the structure and delivery of GP training will look like beyond 2015,” the AMA President said in his letter to Ms Ley.

He said briefing papers provided by the Health Department for those attending its stakeholder meetings were “generally scant on detail and do not adequately deal with key issues, such as the future role of the GP Colleges”.

A/Professor Owler said the overwhelming view in the medical profession was that the Colleges should be given responsibility for the governance and management of GP training.

Anxiety about the changes has been heightened by predictions the nation could face a critical shortage of doctors in the next decade.

The ageing of the GP workforce and the struggle to attract students to specialise in general practice has contributed to forecasts of a shortfall of 2700 doctors by 2025 unless there is a major investment in training.

Last month Health Minister Sussan Ley re-announced the allocation of $157 million to extend the life of two medical training programs – the Specialist Training Program and the Emergency Medicine Program – through to the end of 2016.

Ms Ley said the programs were being sustained for an extra year while the Government continued to consult with the medical Colleges and other stakeholders about reforms to come into effect in 2017.

“This consultation will focus on in-depth workforce planning to better match investments in training with identified specialities of potential shortage and areas that may be over-subscribed into the future,” the Minister said. “Workforce planning is something that doctors and health professionals have been raising with me during my country-wide consultations to ensure those areas of expected shortages are addressed sooner rather than later.”

But Shadow Health Minister Catherine King condemned what she described as a “short-term fix”.

Ms King said the Government had thrown the entire field of specialist medical training into chaos by delaying confirmation of contracts just weeks before candidate interviews were due to commence.

Ms King warned that any cut to funding to specialist training would result I fewer specialists working in areas where they are needed most.

Adrian Rollins

PHNs give many Medicare Locals new lease of life

Medicare Locals are involved in more than half the organisations selected by the Federal Government to succeed them, details of successful Primary Health Network applicants show.

The 28 preferred Primary Health Network operators announced by Health Minister Sussan Ley include at least 18 in which Medicare Locals are a dominant or major partner, including for PHNs in Northern and South Western Sydney, North West Melbourne, Gippsland, South Brisbane, Adelaide, Perth (both North and South), Tasmania, the Northern Territory and the ACT.

The Government has committed $900 million to create 31 PHNs to replace Labor’s Medicare Locals scheme, which is being shutdown following the results of the Horvath Review that found many were top-heavy, expensive and failed in their primary goal of supporting seamless patient care.

Ms Ley said that, by being much more closely aligned with the boundaries of state Local Hospital Networks and having a clearer focus on outcomes, the PHNs would ensure far better integration between primary and acute care services.

The Minister said the PHNs would work directly with GPs, hospitals, other health professionals and the community to ensure better care, including by reducing the merry-go-round of treatment experienced by many patients with chronic and complex conditions.

“Primary Health Networks will reshape the delivery of primary health care across the nation,” Ms Ley said. “The key difference between Primary Health Networks and Medicare Locals is that PHNs will focus on improving access to frontline services, not backroom bureaucracy.”

But, ironically, Medicare Locals appear to be the backbone of many of the consortiums that have successfully tendered to operate PHNs – a fact acknowledged by the Minister.

Many of the successful PHNs were harnessing skills and knowledge from a range of sources, including allied health providers, universities, private health insurers and “some of the more successful former Medicare Locals”.

“There’s no doubting that, individually, there were some high-quality Medicare Locals across the country,” Ms Ley said. “However, there were also plenty that haven’t lived up to Labor’s promise.”

The AMA was a leading critic of Labor’s Medicare Local scheme because it had limited the involvement of local GPs.

At the time the Horvath Review was released, AMA President Associate Professor Brian Owler said that while some individual Medicare Locals had performed well in improving access to care, “the overall Medicare Local experiment has clearly failed, largely due to deliberate policy decisions to marginalise the involvement of GPs”.

Concerns have also been expressed that private health funds might try to use PHNs to interfere in the provision of primary care, and insurers Bupa and HCF have been involved in supporting tenders for four PHN consortia, including the Partners 4 Health consortium in Brisbane North, and the WA Primary Health Alliance covering the three Western Australian PHNs (Perth North, Perth South and Country WA).

But, according to an investigation by Medical Observer, the insurers will have no operational role and were involved strictly as support players.

Partners 4 Health is the trading name of Metro North Brisbane Medicare Local, and Chief Executive Abbe Anderson told Medical Observer HCF and Bupa were just two of many groups that had backed the successful application from her organisation.

“While MNBML has the support of a wide range of key participants – including those listed – I think we had over 30 organisations that provided us with letters of support and endorsement in our application,” Ms Anderson said. “But the PHN itself will be governed and managed by the same organisation that has been running the ML since its inception.”

Adrian Rollins

Obesity management in general practice: does current practice match guideline recommendations?

Primary health care, generally the first point of contact for people seeking health services, has been identified as a good environment for implementing strategies for preventing and managing obesity.1 Clinical practice guidelines for managing overweight and obesity in adults, adolescents and children in Australia have been developed by the National Health and Medical Research Council (NHMRC), providing evidence-based recommendations that support a systematic approach to preventing overweight and obesity.2,3 The guidelines emphasise patient engagement in decision making, tailored recommendations, co-management and/or referral, and long-term follow-up with regular monitoring by a general practitioner. We examined the documentation of quantitative measures as recommended in the NHMRC guidelines by GPs in a metropolitan region of Melbourne, to assess whether GPs’ practice was consistent with these recommendations.

Methods

Study population

We performed a retrospective analysis of general practice patient data retrieved from the Melbourne East Monash General Practice Database (MAGNET). This database holds patient data collected from the computerised medical records of 78 participating general practice clinics in the inner-eastern region of Melbourne between 1 July 2011 and 31 December 2013. The data are collected by Inner East Melbourne Medicare Local, one of 61 organisations across Australia tasked with improving primary care service delivery.

Data collection

We examined recommendations 1 and 2 of the NHMRC guidelines, relating to the documentation of body mass index (BMI) and waist circumference. Data on “active” patients (those who had visited the same practice more than three times in the previous 2 years) aged over 18 years were extracted, along with other relevant demographic data such as the patient’s age, sex, quintile on the Index of Relative Socio-Economic Disadvantage,4 and clinical information related to diagnoses and prescribed medications. Ethics approval for the study was granted by the Monash University Human Research Ethics Committee.

Statistical analysis

Documentation of height, weight and waist circumference was examined across demographic and clinical groups. Patients with both a height measurement and weight measurement recorded in the previous 2 years were identified as having a documented BMI. Logistic regression by means of generalised estimating equations to account for clustering within practices (intracluster correlation, 0.25) was used to examine the associations between documentation of BMI and sociodemographic and clinical characteristics. Effect estimates were reported as odds ratios with associated 95% CIs, adjusted for sociodemographic and clinical characteristics. Analyses were conducted using SAS, version 9.4 (SAS Institute).

Results

A total of 270 426 active patients were included in the study (Box 1). Three-quarters of the patients (77.3%) were aged between 19 and 64 years, and the sociodemographic distribution of patients was strongly skewed (64.5% living in areas of least disadvantage). Hypertension was the most commonly recorded condition, followed by hyperlipidaemia, musculoskeletal problems and depression or anxiety.

Documentation of height, weight and waist circumference

Height was recorded for 99 704 patients (36.9%), while 69 807 patients (25.8%) were found to have a weight recorded in the previous 2 years. Consequently, 59 987 patients (22.2%) had a documented BMI, and 11 684 patients (4.3%) had a waist circumference measurement recorded (Box 2). Documentation varied across age groups, with older patients generally having better documentation.

Predictors of BMI documentation

Box 2 shows that patients aged over 75 years were more likely to have a BMI recorded, and women had lower levels of BMI documentation than men. Patients with three or more listed diagnoses were most likely to have their BMI recorded. Specific diagnoses of diabetes, hyperlipidaemia, hypertension and musculoskeletal problems were found to be associated with an increase in BMI documentation (Box 2). Lower levels of BMI documentation were associated with diagnoses for depression and anxiety, and stroke. The prescription of medications related to diabetes, depression and anxiety, and for blood pressure and cardiovascular disease, were found to be associated with increased BMI documentation.

Discussion

Documentation of BMI and waist circumference was found to be considerably lower than that observed in studies in other primary care settings, although legislative requirements in these systems and the age of the patients in some studies may account for the higher rates.5–8 The documentation rates we found in this study imply a continued need for programs of support to increase screening for obesity and documentation of related clinical information, in accordance with the recommendations in the NHMRC guidelines. Increasing screening for obesity in general practice has been found to be problematic for a number of reasons, including problems in identifying obesity in the patient, difficulty in approaching the discussion of obesity, a perceived lack of appropriate training, and clinical software restrictions.9–15 Factors have been identified that can contribute to improved support for implementation of guidelines, particularly those aimed at enhancing organisational capacity.16 For example, Inner East Melbourne Medicare Local has initiated support to general practices by assigning practice liaison officers to generate regular feedback reports for individual practices on data quality and population-level health indicators. This facilitates good data governance and standardised collection and recording throughout practices, and has resulted in improved data quality and completeness.17,18

Our study has some limitations. It was not possible to assess free-text components of the patient medical records for instances where height and weight had been entered in free-text form rather than in the specific height and weight fields, which may also have led to an underestimation of BMI reporting. Also, because patient identifiers were practice-specific, it was not possible to track patients across practices.

By examining routine general practice data, we found that further support is needed to improve levels of screening for obesity and overweight in Australian general practice. Continued research is required to assess how documentation of obesity-related clinical information changes over time as the NHMRC guidelines on managing overweight and obesity become embedded in clinical practice, and to examine barriers and enablers to increased obesity screening. To improve the quality of patient care, GPs should be supported to increase levels of obesity screening in accordance with the NHMRC guidelines.

1 Characteristics of the cohort of 270 426 patients on the Melbourne East Monash General Practice Database*

Characteristic	Patients	Characteristic	Patients

Age group		Number of diagnoses recorded
19–44 years	122 136 (45.2%)	0	136 858 (50.6%)
45–64 years	86 915 (32.1%)	1	60 079 (22.2%)
65–74 years	30 596 (11.3%)	2	32 574 (12.1%)
75 + years	30 779 (11.4%)	3 +	40 915 (15.1%)
Sex		Specific diagnoses recorded
Male	109 346 (40.4%)	Hypertension	46 928 (17.4%)
Female	160 695 (59.4%)	Hyperlipidaemia	36 089 (13.4%)
IRSD (quintiles)		Musculoskeletal problems	35 329 (13.1%)
1 (most disadvantaged)	4 842 (1.8%)	Depression and anxiety	32 635 (12.1%)
2	5 393 (2.0%)	Diabetes	14 789 (5.5%)
3	11 977 (4.4%)	Cardiovascular-related†	14 538 (5.4%)
4	72 612 (26.9%)	Stroke	4 165 (1.5%)
5 (least disadvantaged)	174 487 (64.5%)	Kidney disease	3 177 (1.2%)

IRSD = Index of Relative Socio-Economic Disadvantage. * Percentages may not sum to 100% because of missing data. † Includes acute coronary syndrome, myocardial infarction, chronic heart failure, heart failure, atrial fibrillation and chronic heart disease.

2 Frequency of recording for height, weight, body mass index (BMI) and waist circumference

Variable	BMI	Waist circumference	Adjusted odds ratio* (95% CI) for BMI documentation

Total patients with records	59 987 (22.2%)	11 684 (4.3%)
Age group
19–44 years	18 498 (15.1%)*	2 114 (1.7%)	1 [Reference]
45–64 years	21 533 (24.8%)	4 782 (5.5%)	1.31 (1.25–1.38)
65–74 years	8 618 (28.2%)	2 348 (7.7%)	1.20 (1.13–1.27)
75 + years	11 338 (36.8%)	2 440 (7.9%)	1.60 (1.48–1.72)
Sex
Male	26 498 (24.2%)	6 163 (5.6%)	1 [Reference]
Female	33 471 (20.8%)	5 520 (3.4%)	0.86 (0.78–0.94)
Number of diagnoses recorded
0	20 583 (15.0%)	2 832 (2.1%)	1 [Reference]
1	13 497 (22.5%)	2 565 (4.3%)	1.25 (1.21–1.30)
2	9 622 (29.5%)	2 185 (6.7%)	1.45 (1.38–1.52)
3 +	16 285 (39.8%)	4 102 (10.0%)	1.69 (1.59–1.79)
Specific diagnoses recorded (“yes”)†
Hypertension	17 886 (38.1%)	4 515 (9.0%)	1.18 (1.11–1.24)
Hyperlipidaemia	13 859 (38.4%)	3 238 (9.6%)	1.26 (1.20–1.33)
Musculoskeletal problems	12 606 (35.7%)	2 896 (8.2%)	1.07 (1.02–1.12)
Depression and anxiety	8 352 (25.6%)	1 845 (5.7%)	0.94 (0.90–0.98)
Diabetes	7 484 (50.6%)	2 520 (17.0%)	1.85 (1.70–1.99)
Cardiovascular-related‡	5 509 (37.9%)	1 268 (8.7%)	0.91 (0.85–0.97)
Stroke	1 513 (36.3%)	356 (8.6%)	0.87 (0.78–0.95)
Kidney disease	1 316 (41.4%)	295 (9.3%)	0.99 (0.90–1.08)
Medication (“yes”)†
Blood pressure/cardiovascular	12 157 (34.7%)	2 800 (7.9%)	1.07 (1.02–1.12)
Depression and anxiety	9 183 (25.3%)	1 935 (5.3%)	1.07 (1.03–1.11)
Diabetes-related	3 390 (49.0%)	1 002 (14.5%)	1.24 (1.12–1.35)
Lipids	6 172 (36.1%)	1 549 (9.1%)	1.01 (0.96–1.06)
Anticoagulants	5 899 (36.5%)	1 362 (8.4%)	1.02 (0.95–1.08)

* Adjusted for Index of Relative Socio-Economic Disadvantage and all other variables in this Box. † Reference category is “no” for each diagnosis and each type of medication. ‡ Includes acute coronary syndrome, myocardial infarction, chronic heart failure, heart failure, atrial fibrillation and chronic heart disease.

Name

Activity/Meeting

Date

GPs are well positioned to help

Australian GPs’ experience of responding to disasters

Principles of disaster management

Preparedness

Response

Recovery

Support from general practice organisations (GPOs)

Where to from here?

Clinical record

Discussion

Methods

Study population

Data collection

Statistical analysis

Results

Documentation of height, weight and waist circumference

Predictors of BMI documentation

Discussion