more_vertThe United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) faces a major challenge in upholding its mandate and preserving key services such as education and health care for Palestinian refugees. On Jan 16, 2018, the US Government announced a contribution of US$60 million for 2018 so far,1,2 in support of UNRWA’s efforts to keep our schools open, health clinics running, and emergency food and cash distribution systems functioning. Although important, this funding is dramatically below past levels.
Preference: Government and politics
Long-term plan lacking in private health insurance
The AMA continues to be at the forefront of the campaign for better products from the private health insurance sector, repeating its warning that any increase on a product that is not offering value to its consumers has got to be a concern.
Following the Federal Government’s assurance that Australians would get the lowest insurance premium increase in more than a decade, albeit at double the rate of inflation, AMA Vice President Dr Tony Bartone undertook a number of media interviews to stress that the AMA had been asking for better value products, not products that actually increase in cost.
“Consumers and patients alike are making decisions based on information, and then purchasing products and then finding they’re not covered for what they thought they were covered for,” Dr Bartone told the ABC.
“Or there are exclusions or restrictions on those policies. We need better value in those products before we can talk about any increase. We need sustainable private health insurance, and if consumers are making decisions to opt out based on further increases on a product that they see of little or no value, well, that’s only bad for the health industry as a whole.
“There are so many tens of thousands of policies out there. It’s extremely confusing. You’d need a double degree to actually work through all that, and then at the end of the day, you still might not be correct.
“There is a review, there is a roundtable at the moment, but we need all parties to get together and to come out with a process that actually makes it very clear to the consumers what they’re getting, that offers them value for money, and offers them an insurance that gives them the cover they need, when they need it.”
The cost of private health insurance is set to be the lowest hike in more than 15 years, with the average increase to be about 3.9 per cent.
The premium changes come into effect on April 1 and will represent a rise that is double the inflation rate.
The average family can expect to pay more than $150 a year extra on hospital cover.
The announcement comes at a time when more Australians are opting out of private health insurance.
“No doubt many are opting out because of a bad experience,” Dr Bartone said.
“They’ve come to use their product that they’ve been paying for for many, many years, and then find, when the crunch comes, they’re not covered or they’re significantly out of pocket.
“This is about ensuring the long-term viability of the private health insurance area to make sure that we’re taking the burden off the public hospital system. A necessary part. The two work hand-in-hand, like hand in glove, and we need a really good functioning private hospital area to take the burden, another option.
“The vast majority of elective surgery happens in private hospitals, and we need people not to opt out but we need them to maintain it. And where people have the ability, they should be facilitated in making that decision to keep that.”
Dr Bartone said it was not a question of criticising the private health insurance sector, but about making it very clear that more needs to be done.
“Everyone’s at the table, everyone has their specific little wish list or agenda, but we need to make sure that the Australian public, the Australian patients, are getting value for money,” he said.
“They’re the ones at the end of the day that are left holding the baby… and they need value for money. We don’t need them opting out because that’s, as I say, bad for everybody.”
The AMA has called for a simplification of the policies into gold, silver, or bronze, so consumers know exactly if they are getting a premium product, a middle of the road, or another product.
“We don’t need products that all they do is deliver a tax deduction and offer you nothing other than just a public hospital treatment,” Dr Bartone said.
“That’s in nobody’s interest. Junk policies do no consumer and no patient any worthwhile benefit, and we need to ensure that there is that clarity. And our gold, silver, bronze allocation with some having no excesses or no exclusions or no restrictions and others having a combination – that’s very clear, is in everybody’s interest.
In a subsequent doorstop media conference, Dr Bartone said the announcement of increases in private health insurance was concerning because the increases were not being matched by increasing value.
“Right along we’ve said that private health insurance needs to deliver more value to patients, more value to consumers, to make their products both affordable and attractive,” he said.
“Every day, Australians are making decisions to opt out of private health insurance. These increases will only bring that question even further into light. We need to ensure that Australians keep their private health insurance, because the private health system delivers significant benefits to the entire health system.
“It takes the pressure off the public health system, and any decision of Australians to continue to opt out of private health insurance will only put pressure on an already overburdened public hospital system.”
Dr Bartone said consumers must take particular note of the fine print of private health insurance premiums.
“It’s the exclusion for this particular surgery or that particular surgery,” he said.
“Pregnancy, for example, is not covered in a majority of policies and that in itself is a concern, when a vast number of the many thousands of pregnancies are unplanned, and leaving people having to make decisions then.
“It’s about understanding that across all those things.”
CHRIS JOHNSON
Encouraging more doctors to go rural
The AMA has released its Position Statement – Rural Workforce Initiatives, a comprehensive five-point plan to encourage more doctors to work in rural and remote locations, and improve patient access to care.
The plan proposes initiatives in education and training, rural generalist pathways, work environments, support for doctors and their families, and financial incentives.
It says that at least one-third of all new medical students should be from rural backgrounds.
And more medical students should be required to do at least one year of training in a rural area to encourage graduates to live and work in regional Australia.
In releasing the Position Statement, AMA President Dr Michael Gannon noted that about seven million Australians live in regional, rural, and remote areas, and they often have more difficulty accessing health services than their city cousins.
They often have to travel long distances for care, and rural hospital closures and downgrades are seriously affecting the future delivery of health care in rural areas.
For example, Dr Gannon said, more than 50 per cent of small rural maternity units have been closed in the past two decades.
“Australia does not need more medical schools or more medical school places,” he said.
“Workforce projections suggest that Australia is heading for an oversupply of doctors.
“Targeted initiatives to increase the size of the rural medical, nursing, and allied health workforce are what is required.
“There has been a considerable increase in the number of medical graduates in recent years, but more than three-quarters of locally trained graduates live in capital cities.
“International medical graduates (IMGs) make up more than 40 per cent of the rural medical workforce and while they do excellent work, we must reduce this reliance and build a more sustainable system.”
The AMA Rural Workforce Initiatives plan outlines five key areas where Governments and other stakeholders must focus their policy efforts:
- Encourage students from rural areas to enrol in medical school, and provide medical students with opportunities for positive and continuing exposure to regional/rural medical training;
- Provide a dedicated and quality training pathway with the right skill mix to ensure doctors are adequately trained to work in rural areas;
- Provide a rewarding and sustainable work environment with adequate facilities, professional support and education, and flexible work arrangements, including locum relief;
- Provide family support that includes spousal opportunities/employment, educational opportunities for children’s education, subsidies for housing/relocation and/or tax relief; and
- Provide financial incentives to ensure competitive remuneration.
“Rural workforce policy must reflect the evidence. Doctors who come from a rural background, or who spend time training in a rural area, are more likely to take up long-term practice in a rural location,” Dr Gannon said.
“Selecting a greater proportion of medical students with a rural background, and giving medical students and graduates an early taste of rural practice, can have a profound effect on medical workforce distribution.
“Our proposals to lift both the targeted intake of rural medical students and the proportion of medical students required to undertake at least one year of clinical training in a rural area from 25 per cent to 33 per cent are built on this approach.
“More Indigenous people must be encouraged to train and work in health care, as there is a strong link between the health of Indigenous people in rural areas and their access to culturally appropriate health services.
“Fixing rural medical workforce shortages requires a holistic approach that takes into account not only the needs of the doctor, but also their immediate family members.
“Many doctors who work in rural areas find the medicine to be very rewarding, but their partner may not be able to find suitable employment, and educational opportunities for their children may be limited.
“The work environment for rural doctors presents unique challenges, and Governments must work collaboratively to attract a sustainable health workforce. This includes rural hospitals having modern facilities and equipment that support doctors in providing the best possible care for patients and maintaining their own skills.
“Finally, more effort must be made to improve internet services in regional and rural areas, given the difficulties of running a practice or practising telehealth with inadequate broadband.
“All Australians deserve equitable access to high-speed broadband, and rural doctors and their families should not miss out on the benefits that the growing use of the internet is bringing.”
The AMA Position Statement – Rural Workforce Initiatives is available at position-statement/rural-workforce-initiatives-2017
CHRIS JOHNSON
Background:
- Most Australians live in major cities (70 per cent), while 18 per cent live in inner regional areas, 9 per cent in outer regional areas, and 2.4 per cent in both remote and very remote areas.
- Life expectancy is lower for people in regional and remote Australia. Compared with major cities, the life expectancy in regional areas is one to two years lower, and in remote areas is up to seven years lower.
- The age standardised rate of the burden of disease increases with increasing remoteness, with very remote areas experiencing 1.7 times the rate for major cities.
- Coronary heart disease, suicide, COPD, and cancer show a clear trend of greater rates of burden in rural and remote areas.
- The number of medical practitioners, particularly specialists, steadily decreases with increasing rurality. The AIHW reports that while the number of full time workload equivalent doctors per 100,000 population in major cities is 437, there were 272 in outer regional areas, and only 264 in very remote areas.
- Rural medical practitioners work longer hours than those in major cities. In 2012, GPs in major cities worked 38 hours per week on average, while those in inner regional areas worked 41 hours, and those in remote/very remote areas worked 46 hours.
- The average age of rural doctors in Australia is nearing 55 years, while the average age of remaining rural GP proceduralists – rural GP anaesthetists, rural GP obstetricians and rural GP surgeons – is approaching 60 years.
- International medical graduates (IMGs) now make up over 40 per cent of the medical workforce in rural and remote areas.
- There is a health care deficit of at least $2.1 billion in rural and remote areas, reflecting chronic underspend of Medicare and the Pharmaceutical Benefits Scheme (MBS) and publicly-provided allied health services.
National architecture needed for mental health
Almost one in two Australian adults will experience a mental health condition in their lifetime, yet mental health and psychiatric care are grossly underfunded when compared to physical health.
Those statistics were the stark reality AMA President Dr Michael Gannon laid out when releasing the AMA Position Statement on Mental Health 2018.
In doing so, he called for strategic leadership to integrate all components of mental health prevention and care.
The AMA is calling for a national, overarching mental health “architecture”, and proper investment in both prevention and treatment of mental illnesses.
“Many Australians will experience a mental illness at some time in their lives, and almost every Australian will experience the effects of mental illness in a family member, friend, or work colleague,” Dr Gannon said.
“For mental health consumers and their families, navigating the system and finding the right care at the right time can be difficult and frustrating.
“Australia lacks an overarching mental health architecture. There is no vision of what the mental health system will look like in the future, nor is there any agreed national design or structure that will facilitate prevention and proper care for people with mental illness.”
The AMA has called for the balance between funding acute care in public hospitals, primary care, and community-managed mental health to be correctly weighted.
Funding should be on the basis of need, demand, and disease burden, Dr Gannon said, not a competition between sectors and specific conditions.
“Policies that try to strip resources from one area of mental health to pay for another are disastrous,” he said.
“Poor access to acute beds for major illness leads to extended delays in emergency departments, poor access to community care leads to delayed or failed discharges from hospitals, and poor funding of community services makes it harder to access and coordinate prevention, support services, and early intervention.
“Significant investment is urgently needed to reduce the deficits in care, fragmentation, poor coordination, and access to effective care.
“As with physical health, prevention is just as important in mental health, and evidence-based prevention can be socially and economically superior to treatment.”
Dr Gannon said community-managed mental health services had not been appropriately structured or funded since the movement towards de-institutionalisation in the 1970s and 1980s, which shifted much of the care and treatment of people with a mental illness out of institutions and into the community.
The AMA Position Statement supports coordinated and properly funded community-managed mental health services for people with psychosocial disability, as this will reduce the need for costly hospital admissions.
The Position Statement calls for Governments to address underfunding in mental health services and programs for adolescents, refugees and migrants, Aboriginal and Torres Strait Islander people, and people in regional and remote areas.
It also calls for Government recognition and support for carers of people with mental illness.
“Caring for people with a mental illness is often the result of necessity, not choice, and can involve very intense demands on carers,” Dr Gannon said.
“Access to respite care is vital for many people with mental illness and their families, who bear the largest burden of care.”
The AMA Position Statement on Mental Health 2018 is available at position-statement/mental-health-2018
CHRIS JOHNSON
Action needed to protect children from too much sugar
The AMA has taken a strong position on sugar, calling for a tax on sugary drinks and a ban on junk food marketing aimed at children.
Releasing its AMA Position Statement on Nutrition 2018 in early January, the AMA said the tax should be introduced as a priority.
AMA President Dr Michael Gannon said eating habits and attitudes toward food are established in early childhood and so advertising of junk food and sugary drinks to children should be banned.
“Improving the nutrition and eating habits of Australians must become a priority for all levels of government,” Dr Gannon said.
“Governments should consider the full complement of measures available to them to support improved nutrition, from increased nutrition education and food literacy programs through to mandatory food fortification, price signals to influence consumption, and restrictions on food and beverage advertising to children.
“Eating habits and attitudes start early, and if we can establish healthy habits from the start, it is much more likely that they will continue throughout adolescence and into adulthood.
“The AMA is alarmed by the continued, targeted marketing of unhealthy foods and drinks to children.
“Children are easily influenced, and this marketing – which takes place across all media platforms, from radio and television to online, social media, and apps – undermines healthy food education and makes eating junk food seem normal.”
Dr Gannon said advertising and marketing unhealthy food and drink to children should be prohibited all together, and the loophole that allows children to be exposed to junk food and alcohol advertising during coverage of sporting events must be closed.
“The food industry claims to subscribe to a voluntary code, but the reality is that this kind of advertising is increasing,” he said.
“The AMA calls on the food industry to stop this practice immediately.”
The Position Statement also calls for increased nutrition education and support to be provided to new or expecting parents, and notes that good nutrition during pregnancy is also vital.
It recognises that eating habits can be affected by practices at institutions such as child care centres, schools, hospitals, and aged care homes.
“Whether people are admitted to hospital or just visiting a friend or family member, they can be very receptive to messages from doctors and other health workers about healthy eating,” Dr Gannon said.
“Hospitals and other health facilities must provide healthy food options for residents, visitors, and employees.
“Vending machines containing sugary drinks and unhealthy food options should be removed from all health care settings, and replaced with machines offering only healthy options.
“Water should be the default beverage option, including at fast food restaurants in combination meals where soft drinks are typically provided as the beverage.”
The Position Statement says a tax on sugar-sweetened beverages should be introduced.
The recommendations were warmly welcomed by health and children’s advocates.
The AMA Position Statement on Nutrition 2018 is available at position-statement/nutrition-2018 and the key recommendations are listed here.
CHRIS JOHNSON
Key Recommendations:
- Advertising and marketing of unhealthy food and beverages to children to be prohibited.
- Water to be provided as the default beverage option, and a tax on sugar-sweetened beverages to be introduced.
- Healthy foods to be provided in all health care settings, and vending machines containing unhealthy food and drinks to be removed.
- Better food labelling to improve consumers’ ability to distinguish between naturally occurring and added sugars.
- Regular review and updating of national dietary guidelines and associated clinical guidelines to reflect new and emerging evidence.
- Continued uptake of the Health Star Rating system, as well as refinement to ensure it provides shoppers with the most pertinent information.
A long way to go regarding medicinal marijuana
The AMA has repeated its position on medicinal marijuana, following the Victorian Government’s decision to expand the sector, conduct more trials, and make cannabis products more widely available to severely sick children.
AMA Vice President Dr Tony Bartone told journalists at a Melbourne media conference that the AMA’s position on medicinal cannabis continues to be one of support for the clinical trials to establish clinical guidelines, and only then wider promulgation throughout the community if needs be.
“We need the evidence and we need the clinical guidelines and the validation of the local product in terms of dosages, formations, composition, to assist us in then determining where, when, and how its place will be,” Dr Bartone said.
“It’s still early days, we’re very much guided by international evidence but we need the local evidence to validate and further give us the information required to then determine its exact goal.
“Evidence to date has been clearly that it is not going to be a first-line product. It has really got a specific niche in terms of some specialised neurological conditions, conditions involving the cachexia of chemotherapy, and of AIDS, of multiple sclerosis, and other neurological conditions.
“So, we’re talking specific conditions and not as a first line, but more in terms of refractory cases or difficult cases, and that’s what the clinical guidelines would give us information about. We’re supportive of the trials, we’re supportive of the fact-finding, and then – and only then – as the evidence dictates will we then see a wider usage if it’s deemed appropriate.
“These trials will be very instructive in terms of the long-term usages and availability of medicinal cannabis in Australia, so it’s important that these trials are completed and are resourced as appropriate.
“The announcements will then see those trials become more robust and more detailed, allowing further evidence and further information to be gleaned and obtained. It’s a positive step, but it’s still another piece of the puzzle that needs to be put together before we can significantly depend upon medicinal cannabis having a regular role in the treatment armamentarium in Australia.
“Let’s be very clear about this. What we want to see is the gathering of information, the evidence and the research to validate the clinical guidelines. As that is all obtained, as that’s all put together, then we can establish a clear pathway in terms of the where, the when, and the how. And that’s what we’re about.
“Once the research is there, once it’s really validated in terms of the conditions, the dosages, the local product, et cetera, then the clinical guidelines will be developed, and that’s what we’ve said all along. And then there’ll be a place for it in terms of the treatment scale, the treatment options for doctors in Australia.
“At the moment, we’re still very much in its infancy, and these trials are about obtaining the information, the foundations on which to build the recommendations going forward.”
Information obtained from around the world suggests that there is a role in certain difficult cases. Dr Bartone pointed to refractory cases, of paediatric epilepsy, of multiple sclerosis, or the wasting that goes along with HIV and post-chemotherapy.
“So there are some roles for it, potentially, and what we need to do is rapidly try to get the information and the evidence to do that,” he said.
“What we’ve seen to date is that there is potential for it. We need to really validate and really build upon that potential so that we’re very clear about when we can offer it and how we can offer it.
“Whatever the evidence dictates, whatever the evidence shows, is what you will see clinicians really then offer to their patients, because that’s what they want to do – offer their patients the very best of care, and world-class care at that.
“It’s quite likely that, at the end of the day, medicinal cannabis will have a significant but very small role to play in a suite of options to offer.
“It won’t be a first-line therapy for established conditions, but it’s more where we’ve got difficult or what we call refractory cases, cases which have not responded to first or second or third line options.
“So, it’s about understanding that it isn’t going to be a magic option that we can use in any difficult case. But we’re going to be guided by the evidence, and at this stage it’s still working through that, and the indications are small and potentially not that expansive. But we’ll be guided by what comes through the pipeline.”
CHRIS JOHNSON
Indigenous Scholarship applications closing soon
Applications close on 31 January for the 2018 AMA Indigenous Medical Scholarship, a program that has supported Aboriginal and Torres Strait Islander students to study medicine since 1994. The successful applicant will receive $10,000 each year for the duration of their course.
Fewer than 300 doctors working in Australia identify as Aboriginal and/or Torres Strait Islander – representing 0.3 per cent of the workforce – and only 286 Indigenous medical students were enrolled across the nation in 2017.
“The significant gap in life expectancy between Indigenous and non-Indigenous Australians is a national disgrace that must be tackled by all levels of Government, the private and corporate sectors, and all segments of our community,” AMA President Dr Michael Gannon said.
“It’s evident that Indigenous people have a greater chance of improved health outcomes when they are treated by Indigenous doctors and health professionals.
“Indigenous people are more likely to make and keep medical appointments when they are confident that they will be treated by someone who understands their culture, their language, and their unique circumstances.
“The AMA strongly encourages Indigenous students to apply for the Scholarship, which, along with the AMA’s annual Report Card on Indigenous Health and the work of the AMA Taskforce on Indigenous Health, is part of the AMA’s commitment to improving the health of Aboriginal and Torres Strait Islander Australians.”
Previous winners have gone on to become prominent leaders in health and medicine, including Associate Professor Kelvin Kong, Australia’s first Aboriginal surgeon.
Applicants must be currently enrolled at an Australian medical school, be in at least their first year of medicine, and be of Aboriginal and/or Torres Strait Islander descent. Further information, including the application form, can be found at https://www.ama.com.au/indigenous-medical-scholarship-2018.
The AMA Indigenous Medical Scholarship was established in 1994 with a contribution from the Commonwealth Government. The AMA is seeking further donations and sponsorships from individuals and corporations to continue this important contribution to Indigenous health.
More information is available at donate-indigenous-medical-scholarship. For enquiries, please contact the AMA via email at indigenousscholarship@ama.com.au or phone (02) 6270 5400.
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[Comment] Offline: Are China’s global ambitions good for global health?
A bitter argument is taking place between two nations, a dispute that could have profound effects for the future of global health. China and Australia are geographic neighbours. During the past decade, both countries have worked hard to build strong trading and diplomatic relationships. They have succeeded. But those relationships are now being torn apart. China’s Xinhua News Agency last week claimed that Australia’s Government was “obsessed” with “criticising China”. Xinhua argued that Australia’s Government was trying “to undermine bilateral political trust”.
[Editorial] Dangerous words
Medicine is underpinned by both art and science. Art that relies upon strong therapeutic relationships with patients and populations. And science that brings statistical rigour to clinical and public health practice. If allegations reported in The Washington Post on Dec 15 are credible, the Trump administration has seriously undermined both foundations by banning the words “vulnerable”, “entitlement”, “diversity”, “transgender”, “fetus”, “evidence-based”, and “science-based” from government documents for the US$7 billion budget discussions about the Centers for Disease Control and Prevention (CDC).