AMA House a perfect location for headquarters

AMA House was constructed throughout 1990 on a special 99-year lease block on the edge of what is known as the Parliamentary Triangle in Canberra.

The Parliamentary Triangle is the largely ceremonial precinct in the nation’s capital and straddles the part of Lake Burley Griffin where some of Australia’s most significant institutional buildings find their home on its banks.

The High Court, the National Gallery, the National Library, the National Science and Technology Centre (Questacon), the National Archives, the Treasury, Old Parliament House and, of course, Parliament House are all located in the Triangle – as is the Aboriginal Tent Embassy and Reconciliation Place.

Other Federal Government departments are also located either inside or close to the Triangle, with a smaller triangle within the precinct known as the Parliamentary Zone on the lake’s southern shore.

AMA House is located on the edges of the Triangle’s official boundary and within close walking distance to Parliament House.

It was a longstanding ambition of the AMA to have a national headquarters in Canberra.

The Federal Secretariat at that time had been working out of a building in Sydney owned since 1924 by the Australasian Medical Publishing Company (AMPCo, publisher of the MJA), but which was sold in 1989 to The University of Sydney.

During the construction period, Federal Secretariat staff occupied an office in Queanbeyan, on the NSW-ACT border just a few kilometres from where the organisation’s new home was being built.

During this period, the AMA also adopted a new national logo and launched a new national journal, Australian Medicine (this publication).

On March 7, 1991, AMA House was officially opened in Canberra by the highly esteemed biologist Professor Sir Gustav Nossal, who was/is also an AMA member.

At the time of its opening, Dr Bruce Shepherd was the AMA Federal President and Allan Passmore the Secretary General.

Once in its new home, the Federal Secretariat quickly created AMA departments with expertise in general practice, medical fees and medical insurance, public relations and communications, public health and hospital and health funding.

Staff for the most part were all located on the third and fourth (top) floors of the building.

In recent years, housing of staff was reduced exclusively to the fourth floor, with the third floor used for membership workshops and meetings of the Federal Council.

Offices were leased out to other organisations and businesses on the remaining floors.

With the sale of AMA House, the organisation retains naming rights and the exclusive lease of the fourth floor.

CHRIS JOHNSON

Pic: AMA House under construction.

[Correspondence] Healthier lives for all Africans

In their Commission, Irene Agyepong and colleagues (Dec 23, 2017, p 2803)1 provide a comprehensive report on the pathway to healthier lives for all Africans by 2030. As highlighted in the Commission, we have been involved in training family physicians in Africa for the past 20 years within the framework of the Primary Care and Family Medicine Education (Primafamed) network, a South–South cooperation that brings together family medicine, primary care, and public health in more than 20 African countries.

Snippets

Get your flu shots … but not too early

The AMA has urged people to wait until at least mid-April before getting flu shots, following a push by some pharmacy chains to get the vaccinations too early.

Some big name pharmacies began advertising in March for people to get their shots to avoid a repeat of last year’s deadly influenza outbreak.

But AMA Vice President Dr Tony Bartone said getting vaccinated for the flu too early could be counterproductive.

He said the vaccine’s effectiveness begins to wear off after three or four months. With the flu’s peak season being from July to September, a March shot was too early.

“If we’re going to maximise our protection before that effectiveness starts to wane, we want to match the timing of the vaccination with the timing of the peak,” Dr Bartone said.

“And for that reason, mid-April onwards is a perfect time to start having your vaccination.”

Feed time at Federal Council

History was made when the AMA Federal Council met at Canberra in March.

For the first time ever (we think), a baby was breastfed during Council proceedings.

While it made no ripple at all, we here at Australian Medicine thought it was so cool that we wanted to let you all know about it.

Dr Jill Tomlinson introduced daughter Anna to the Council on March 16. “She is four weeks old today,” proud Mum told AusMed.

We are not a hundred per cent sure that Anna didn’t vote during the Bupa motions.

PICTURE: Dr Jill Tomlinson and daughter Anna

Culturally safe waiting rooms

The promotion of designated waiting rooms for Aboriginal people in NSW hospitals has been met with a mixed reaction.

The State’s health department undertook research into why Indigenous patients are more likely than non-Indigenous patients to leave waiting rooms without receiving treatment.

The research found that some Aboriginal patients did not feel safe in waiting rooms, sparking calls for “designated Aboriginal waiting rooms” or “culturally appropriate space” for Indigenous patients.

Hanging Aboriginal artwork on waiting room walls could also help, the study concluded.

The recommendations have been both applauded and criticised.

AMA President Dr Michael Gannon said it was good that the concept of cultural safety is entering the popular narrative.

“The truth is that health outcomes for Indigenous Australians are significantly worse than non-Indigenous Australians according to just about every possible metric,” he said.

“The AMA strongly supports Aboriginal control when it comes to primary care and when it comes to Aboriginal and Torres Strait Islanders being in larger health facilities like our hospitals, I think we need to do everything we can to make them the appropriate settings for them to seek care.”

Doctors have role to play in drug-free sport

To coincide with the XXI Commonwealth Games, played on the Gold Coast this month, the AMA released its revised Position Statement on Drugs in Sport, and called on both doctors and athletes to ensure the event was free from any banned performance-enhancing drugs.

AMA President Dr Michael Gannon said the Games provided an opportunity to uphold Australia’s reputation for drug-free competition at all levels.

“While some athletes deliberately use prohibited substances to improve their performance, others may inadvertently ingest a banned substance in a prescription or over-the-counter medication,” he said.

“Doctors have an important role to play in reducing the use of performance-enhancing drugs in sport, and in helping athletes to avoid unwittingly taking banned substances in otherwise legal medications.”

The AMA Position Statement on Drugs in Sport – 2018 can be read in full at:

position-statement/drugs-sport-2018

CHRIS JOHNSON

Communiqué from March Federal Council meeting

DR BEVERLEY ROWBOTHAM, CHAIR, FEDERAL COUNCIL

Federal Council met in Canberra on March 16 and 17. Debate was robust as always and productive, with numerous Position Statements approved for adoption. These will be released to members and the public over coming weeks.

The President reported, as is our usual practice, in a town hall format, with questions of the President from Councillors and some debate. The President reported that the AMA had maintained a very high media profile over the summer period, with many press releases on summer lifestyle issues. These included avoiding heat stress, drinking in moderation, and driving safely. There were also significant Position Statements released, including the AMA Position Statement on Mental Health, which attracted a lot of positive interest from the mental health community.

In the week prior to the Federal Council meeting, the President had released the Public Hospital Report Card, highlighting the need for continued investment by Federal and State Governments in our public hospitals.

The major focus of discussion at this meeting was the recent actions of Bupa in announcing changes to its cover, which will impact doctors and patients alike. Federal Council urged the President to maintain his advocacy on the issue.

The Secretary General’s report again highlighted the scope of activity underway within the Federal AMA secretariat and the success of AMA advocacy on behalf of members; workforce initiatives; the granting by the ACCC of a further authorisation to permit certain billing arrangements to benefit general practices; discussions with the Department of Health on its review of medical indemnity insurance schemes; the raft of reviews relevant to reforms to private health insurance; the ongoing MBS reviews, and much more.

Federal Council considered a proposal for the introduction of post nominal letters to denote membership of the AMA, a move that has been long in the gestation. Further work is required before the Board considers amendments to the By Laws to make provision for the introduction.

Another key discussion was the change to the format of National Conference this year with the introduction of a day of policy debate. This change is being made in response to feedback from delegates that the opportunity for debate on issues by delegates needed to be enhanced. Federal Council considered a number of draft policy resolutions put forward by the membership, which will be further refined before distribution to delegates attending National Conference. Participation in the debate on the resolutions will be open to all AMA members attending the Conference, whether as an appointed delegate or fee-paying member.

Public health working groups brought forward a Position Statement on Men’s Health, and on Drugs in Sport. Council debated the issue of funding of access to bariatric surgery in the public health system. It also agreed to establish two new working groups to look at the issues of child abuse and neglect, and health literacy.

The Ethics and Medico Legal Committee tabled a revision to the Guidelines for Doctors on Managing Conflicts of Interest in Medicine, which was approved by Council. It is part of a wider piece of work before the Committee, looking at relationships between medical practitioners and industry.

Federal Council approved a new Position Statement on Diagnostic Imaging; and another on Resourcing Aged Care. The latter is one of the many advocacy documents in development or under review as part of the AMA’s expanded work on aged care issues. Council noted the report on the recent AMA survey of doctors’ views about providing care in aged care settings, noting the anticipated decline in the number of practitioners providing care.

A recent meeting of the Health Financing and Economics Committee had considered the issue of value based care as a model with the potential to concurrently increase hospital efficiency and improve patient outcomes. Quality data is needed to inform this work within public hospitals.

The Task Force on Indigenous Health, which advises the President on issues relevant to Indigenous health, continues its close involvement with Close the Gap initiatives. Its 2017 report card on ear health continues to be well received.

The various Councils of Federal Council provided their reports. The Council of Private Specialist Practice is monitoring the various reviews of private health insurance, including out of pocket costs and options to manage low value care in mental health and rehabilitation.

The Council of Doctors in Training (DiTs) discussed proposed reforms to bonded medical workforce schemes. The AMA has been active in influencing changes to the schemes which the Council of DiTs has strongly endorsed. The Chair of the Council of DiTs reported on the very successful AMA Medical Workforce and Training Summit held on 3 March 2018. The Summit brought together more than 70 important stakeholders in medical workforce and training to discuss the concerns of the AMA and many others in the profession with the distribution of the medical workforce, the long-standing imbalance between generalist training and sub- specialisation, the workforce position of different specialties and the growing evidence of a specialty ‘training bottleneck’ and lack of subsequent consultant positions.

The Council of General Practice tabled two Position Statements for approval. The first dealt with General Practice Accreditation and the second provides a Framework for Evaluating Appropriate Outcome Measures.

Federal Council supported a motion put forward by the Council of General Practice to endorse funding of universal catch-up vaccines through the National Immunisation Program for anyone living in Australia wishing to become up to date with clinically appropriate NIP vaccinations, irrespective of age, race, country of origin and State or Territory of residence.

The Council of Rural Doctors reported on its recent meeting with the new Rural Health Commissioner, Professor Paul Worley and discussions on the national rural generalist pathway.

The final item of business, but by no means the least important, was the adoption by Federal Council of a position statement on the National Disability Insurance Scheme, which followed a detailed discussion on the Scheme at the November meeting of Council.

Federal Council now prepares for the National Conference and its last meeting with its current membership in May. Elections are underway for several positions on the Council, evidence of increased member interest in its work.

Bringing pharmacists into the fold

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

It has been almost three years since the AMA put forward its proposal to make non-dispensing pharmacists a key part of the future general practice healthcare team. Our advocacy on this issue has not wavered and since we launched our policy more evidence has accumulated to support the valuable role pharmacists can play when they are integrated into the general practice team.

General practice pharmacists would enhance medication management and reduce hospitalisations from adverse drug events (ADEs). An independent analysis from Deloitte Access Economics (DAE), which was released with the AMA’s proposal, showed that integrating pharmacists into general practice would deliver a benefit-cost ratio of 1.56. If general practices were supported to employ non-dispensing pharmacists as part of their healthcare team, they would be able deliver real cost savings to the health system, of $1.56 for every dollar invested.

An in-house pharmacist would be able to assist GPs address overprescribing and medication non-adherence by patients. We would see better coordination of patient care, improved prescribing, improved medication use, and fewer medication-related problems. Hospitalisation rates from ADEs would fall and our patients’ quality of life would be improved as would their health outcomes.

A recently released research article in the International Journal of Clinical Pharmacy, titled Pharmacists in general practice: a focus on drug-related problems, shows that where pharmacists are working within a general practice that their recommendations are more readily accepted by practice GPs.

This bears out research published in 2013 titled An evaluation of medication review reports across different settings, which had similar findings. Access to the patient’s medical file and the relevant clinical information within when conducting a medication review enabled recommendations that were more targeted and less conjectural. The recommendations from these better-informed reviews resulted in greater acceptance of the pharmacist’s recommendations by the GP.

With chronic disease on the rise, and an ageing population, it is estimated that there are more than 700,000 patients with co-morbidities who would benefit from a review of their medications. This figure represents just the top 10 per cent of patients who could benefit from having their medications reviewed. In-house pharmacists could be a valuable resource for patients in understanding their medications and how to use them.

With over 230,000 medication related admissions to hospitals every year at a cost of $1.2 billion per annum and patient medication non-compliances estimated at 33 per cent, the time has well and truly come for action on this front.

With another trial; utilising non-dispensing pharmacists in 14 medical centres across the greater Brisbane area; winding up, the AMA Council of General Practice is looking forward to hearing the interim results.

With increasing evidence that where pharmacists are integrated within general practice patient care is improved, the AMA continues to advocate for Government funding to make this an everyday reality for general practice and for patients.

Risk of ketoacidosis in children at the time of diabetes mellitus diagnosis by primary caregiver status: a population-based retrospective cohort study [Research]

BACKGROUND:

Diabetic ketoacidosis is the leading cause of death among children with type 1 diabetes mellitus, and is an avoidable complication at first-time diagnosis of diabetes. Because having a usual provider of primary care is important in improving health outcomes for children, we tested the association between having a usual provider of care and risk of diabetic ketoacidosis at onset of diabetes.

METHODS:

Using linked health administrative data for the province of Quebec, we conducted a population-based retrospective cohort study of children aged 1–17 years in whom diabetes was diagnosed from 2006 to 2015. We estimated adjusted risk ratios (RRs) for an episode of diabetic ketoacidosis at the time of diabetes diagnosis in relation to usual provider of care (family physician, pediatrician or none) using Poisson regression models with robust error variance.

RESULTS:

We identified 3704 new cases of diabetes in Quebec children from 2006 to 2015. Of these, 996 (26.9%) presented with diabetic ketoacidosis. A decreased risk of this complication was associated with having a usual provider of care; the association was stronger with increasing age, reaching statistical significance among those aged 12–17 years. Within this age group, those who had a family physician or a pediatrician were 31% less likely (adjusted RR 0.69, 95% confidence interval [CI] 0.56–0.85) or 38% less likely (adjusted RR 0.62, 95% CI 0.45–0.86), respectively, to present with diabetic ketoacidosis, relative to those without a usual provider of care.

INTERPRETATION:

For children with newly diagnosed diabetes, having a usual provider of care appears to be important in decreasing the risk of diabetic ketoacidosis at the time of diabetes diagnosis. Our results provide further evidence concerning the need for initiatives that promote access to primary care for children.

Aged Care Commission needed to address workforce issues

The AMA has made a detailed submission to the Government’s Aged Care Workforce Strategy Taskforce, arguing that the aged care workforce does not have the capability, capacity and connectedness needed to provide quality care to older people.

It calls for an Aged Care Commission to be introduced.

Australia has an ageing population that has multiple chronic and complex medical conditions, but older people face major barriers in accessing appropriate and timely medical care.

Medical practitioners must be supported by the Government and aged care providers to enhance and facilitate much needed access to medical care for people living in residential aged care facilities.

The submission argues that aged care providers need to be supported to ensure access to an appropriate quantity of well-trained staff who work in a rewarding environment with a manageable workload.

“This would ensure older people’s care is not neglected due to shortages of appropriate staff,” it states.

An Aged Care Commission could streamline the aged care system and to help ensures there is an adequate supply of appropriate, well-trained staff to meet the demand of holistic care to a multicultural, ageing population.

An Aged Care Commission would also ensure the aged care workforce has clear roles and responsibilities.

“Australia has an ageing population that is experiencing chronic, complex medical conditions that require more medical attention than ever before,” the submission states.

“For example, 53 per cent of residents in Residential Aged Care Facilities (RACFs) have dementia. This proportion will continue to grow over time, with projections reaching up to 1,100,890 people with dementia by 2056, which is estimated to cost Australia $36.85 billion by the same year.

“A recent study identified that residents of RACFs with dementia had direct health and residential care costs of $88 000 per year. Currently, the aged care system as a whole, and its workforce, does not have the capacity or capability to adequately deal with this growing, ageing population.”

The aged care system needs a strategy, the submission states, to ensure the workforce is appropriate to meet the demands of older people in the future. In order to improve the quality of the aged care workforce, the following is required:

An overarching, independent, Aged Care Commission that provides a clear, well communicated, governance hierarchy that brings leadership and accountability to the aged care system;
Medical practitioners need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care, and outcomes for older people; and
Aged care needs funding for the significant recruitment and retention of, and support for, nursing staff and carers, specifically trained in dealing with the issues that older people face.

Care of an older person involves a diverse range of professions. All providers of aged care services need to collaborate together to ensure the optimal level of care for the older person. The strategy will be able to provide an ultimate goal for the whole aged care workforce, which should include access to the older person in order for each workforce profession to be able to provide quality care for that older person.

There needs to be a focus on prevention to ensure older people remain healthy for as long as possible to remain in their own home, the submission states, but also to reduce demand and pressure on the aged care workforce.

“Medical practitioners, in particular GPs, regularly incorporate prevention methods as part of providing holistic health and medical care,” it says.

“This includes immunisation, screening for diseases, providing education and counselling to their patient, and also referring the patient to a specialist or allied health professional if required. It is therefore imperative that older people have access to a GP and other services provided by health professionals.”

In its submission, the AMA stresses that the current policy settings do not support GPs visiting RACFs, working after hours, or being available to answer telephone concerns about their patients.

“Our members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s care management plan is not well known,” it says.

“This creates an environment where the default step for RACF staff may be to refer the patient to a hospital emergency department (ED). In a study of 2880 residents of RACFs presented to the ED, one third of presentations could have been avoided by incorporating primary care services.

“Reasons for decisions to transfer residents to an ED include limited skilled staff, delays in GP consultations, and a lack of suitable equipment.”

Medical practitioners also need to be supported within the broader health care system to provide high quality care in RACFs. For example, by local hospitals providing secondary referral, timely specialist opinion, specialist services and rapid referral pathways to advice and services.

Older people are often burdened with complex and multiple medical disorders that requires the regular attention of medical practitioners, quality nursing care and allied health care professionals.

Embracing Information and Communication Technology (ICT) potentially has huge benefits for the aged care sector. It can increase communication between healthcare providers, reduce administrative burden, and assist to improve the health and independence of older people.

Aged care providers require improved ICT systems that are interoperable with the My Health Record, in particular its Medication Overview feature. This would ensure medical health professionals have the tools in place to access all relevant medical information with all relevant stakeholders to improve prescribing and to reduce the risk of adverse reactions and interactions between medications.

“Although working with older people is generally a rewarding experience, it comes with multiple challenges,” the submission states.

“For example, older people can be highly reliant on an aged care worker, and many have behavioural conditions that make day-to-day tasks difficult, and sometimes dangerous for the carer to carry out if the older person’s mental health is not appropriately managed.

“Carers are known to have high rates of moderate stress and depression. The health and wellbeing of aged care staff must be considered for the wellbeing of the workers, and so this stressful environment does not deter people from wanting to work in the aged care sector, or force existing workers to leave.”

Many of the issues outlined in the submission can be rectified by improving the capability, capacity and connectedness of the aged care workforce. Currently, this workforce is not adequately trained to be able to care for older Australians, as older peoples’ care needs are growing in both complexity and volume.

In addition, although medical practitioners are well-equipped to provide quality medical care to residents living in RACFs, they are not adequately supported or remunerated to do so due to the range of issues described above. This has resulted in an unnecessary barrier to quality medical services for RACF residents.

“The aged care workforce needs clear leadership and accountability, which an Aged Care Commission could provide,” the statement says.

“Many aged care governance (and workforce) issues described above have already been addressed in recommendations to the Government as a result of the multiple aged care reviews. Now is the time to act on these recommendations to prevent more unacceptable examples of neglect and bad quality care in RACFs, and to give people living in RACFs the quality of life that they deserve.”

The full submission can be viewed at: ausmed/aged-care-commission-needed-address-workforce-…

CHRIS JOHNSON

[Articles] Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial

Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions [Research]

BACKGROUND:

Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care.

METHODS:

We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months.

RESULTS:

Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96–0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93–0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03–1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07–1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years.

INTERPRETATION:

Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.

[Comment] Primary care research: a call for papers

To mark the 40th anniversary of the Alma-Ata Declaration, The Lancet will dedicate the issue of Oct 20, 2018, to primary care and related themes. While we welcome submissions on all aspects of primary care at all times, and across all Lancet titles, this call for papers is particularly aimed at researchers in primary care settings.