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Preference: Government and politics

China increases commitment to world health

The People’s Republic of China has agreed to an enhanced relationship with the World Health Organization (WHO), collaborating to reduce the impact of health emergencies around the globe.

WHO Director-General Dr Tedros Adhanom Ghebreyesus recently completed a three-day official visit to China and said the meetings held there had paved the way for more strategic alliances on delivering universal health coverage.

While in Beijing, Dr Tedros met privately with Premier Li Keqiang for high-level discussions on how China can expand its international health security cooperation. Dr Tedros also met with Vice Premier Liu Yandong, Vice Chairman Han Qide of the Chinese People’s Political Consultative Conference (CPPCC), and National Health and Family Planning Commission Minister Li Bin.

During the meeting with Minister Li Bin, China signed a memorandum of understanding with WHO for an additional voluntary contribution of US$20 million in support of WHO’s global work. WHO and China agreed to enhanced collaboration to reduce the impact of health emergencies; build stronger health systems to deliver universal health coverage; and focus on the well-being of women, children and adolescents at the centre of global health efforts.

“China’s health reforms show it’s possible to implement far-reaching, quality transformations in a short time,” Dr Tedros said.

“Its success in providing 95 per cent of its population with access to health insurance is a model for other countries in how to make our world fairer, healthier and safer. We can all learn something from China.”

In addition to official government meetings, Dr Tedros met China’s next generation at an event in Beijing with more than 200 young health leaders. He encouraged the young leaders to inspire their peers and loved ones to make healthy choices, telling them: “You are the future, it is true. But you are also the present. Your ideas and actions matter now, and I believe in you.” 

CHRIS JOHNSON

[Comment] Beating NCDs can help deliver universal health coverage

In WHO’s drive to ensure good health and care for all, there is a pressing need to step up global and national action on non-communicable diseases (NCDs), and the factors that put so many people at risk of illness and death from these conditions worldwide. By action, we mean coordinated action that is led by the highest levels of government and that inserts health concerns into all policy making—from trade and finance to education, environment, and urban planning. Action needs to go beyond government and must bring in civil society, academia, business, and other stakeholders to promote health.

[Correspondence] The physician as dictator

In the wake of the atrocities committed by the regime of ophthalmologist-cum-dictator Bashar al-Assad, the medical community has been horrified by the devastation caused by one of its own.1 Considering the frequent criticisms of the hierarchical power structure in medicine, we sought to establish whether physicians disproportionately tend to be the leaders of autocracies. We analysed the governments of 176 countries over 71 years (1945–2015), identifying the de-facto ruler of every country for each year.

President’s speech highlights AMA’s influential voice

BY AMA SECRETARY GENERAL ANNE TRIMMER

You might not have caught the speech given by the AMA President Dr Michael Gannon to the National Press Club in Canberra in August. It was a good speech, well-delivered, and touched on many of the major policy and advocacy debates currently being prosecuted by the AMA.

The President’s comments on the strength of the AMA brought to mind the frequently-stated truism that the AMA represents all doctors but that not all choose to pay the membership subscription. In his speech, Dr Gannon reflected on the AMA’s positioning on major community health and social issues.

“The significance of challenging social issues like Indigenous health, marriage equality, and euthanasia is that they highlight the unique position and strengths of the AMA.

We are completely independent of governments.

We rely near totally on member subscription income to survive. I can promise you, as a Board member, it is often a concern.

But unlike many other lobby groups, inside and outside the health industry, this gives us a total legitimacy to speak honestly, robustly, and without fear or favour in line with our mission – to lead Australia’s doctors, to promote the health of all Australians.

We have strong public support and respect as the peak medical organisation.

The AMA was recently ranked the most ethical organisation in the country in the Ethics Index produced by the Governance Institute of Australia.

People want and expect us to have a view, an opinion. Sometimes a second opinion.

The media demand that we have an opinion. And not just on bread and butter health issues. But also on social issues that have an impact on health.

Our view is never knee-jerk.

We consult our members and the broader medical profession. Often we encourage feedback from other health professionals – the ones who provide quality health care with us in teams.

We attract public feedback whether we like it or not. I can promise you that social media has taken this to a whole new level.”

These reflections accurately represent the contribution of the AMA to public debate on health issues, and on broader social issues that impact on the health of the community. The AMA’s Constitution spells out that the role of the AMA is to represent the interests of its members, and also to promote the well-being of patients, taking an active part in the promotion of programs for the benefit of the community and to participate in the resolution of major social and community interests.

The AMA draws its legitimacy as a powerful voice in public debate through its representation of medical practitioners across the broad sweep of the profession from medical students to retired doctors, and across all specialties and places of work. The development of medico-political policy within the AMA is robust, through the specialist councils and committees of Federal Council and then to debate within Federal Council itself. The President and Vice President are the public faces of the AMA but behind them is a substantial process that ensures a representative voice for the medical profession. 

 

No place for photo ID checks in General Practice

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

Universal access to health care is highly valued by Australians. The furore caused when a badly designed co-payment model was proposed provided strong evidence that Australians will not tolerate any threat to their right to access medical care when needed. The AMA strongly advocated to protect vulnerable patients’ access to care at the time.

Following the sale of a small number of Medicare numbers on the dark web, AMA advocacy is needed to ensure the Government’s response is proportionate and that attempts to improve the security of Medicare numbers do not diminish patient access to care.

To the Government’s credit, it was quick to react to security concerns raised by the alleged breach, commissioning an independent review of the accessibility by health providers of Medicare card numbers. The Review is being led by Professor Peter Shergold, with the AMA represented on the review panel. The panel recently released a discussion paper, giving stakeholders the opportunity to provide submissions, with a final report due by the end of this month. 

The AMA President has met with both the Ministers for Health and Human Services on this issue and the AMA has also provided a submission in response to the discussion paper.

This is a good opportunity for the Government to assess the risks to its systems. However, the AMA has made it very clear that an excessive response could impact adversely on patients and practitioners.

The Department of Human Services’ Health Professional Online Services (HPOS) is a valued service for health care providers and their delegates, enabling streamlined and secure access to Medicare Australia and Department of Human Services programs, services, tools and resources. Every day there are around 45,000 interactions with HPOS.

HPOS has continuously evolved since its introduction to ensure it increasingly enables secure and streamlined transfer of data between providers and Government entities and timely access to information. Nevertheless, there are still some clunky aspects to using HPOS, particularly when it comes to the use of PKI certificates.

The introduction of PRODA has made it much simpler for individual health care providers or delegates to securely access HPOS. However, PRODA is yet to provide the same secure business to business functionality of the PKI site certificate.

The AMA believes that introducing this functionality in PRODA as soon as possible would make it easier for providers to interact with HPOS. It would ensure provider systems flexibility by removing the need for a physical certificate tied to a physical machine, retain secure capability, and streamline provider access. We need to keep up with technological developments in an increasingly mobile, digital, online and cloud based world.

What we don’t want to see as an outcome of this Review is over-the-top security measures that go well beyond the problem that has been identified. Ideas like requiring photo ID to see a GP are heavy handed and simply add to a practice’s administrative burden. It could also see patients unable to access care and place reception staff in a very difficult environment, facing sick and often distressed people who will not be able to understand why their Medicare card is no longer sufficient enough evidence to access a basic right – health care.  

Paying the piper. So what’s the tune (and how good is it)?

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Healthcare funding challenges us as a nation on three levels.  The most obvious and basic is: Where does the money come from?  The second is: How can we be certain that the money is being well spent on health gain?  The third is: How does our funding of health care match our values as a society?  While these challenges interlock, looking at each separately can help us determine if we are on the right track. Let’s look at values first.

How much do we value health care?

Most advanced economies agree that funding health care should be a major call on public money and hence paid for through taxation. This is a political response to social attitudes that see illness as capricious and accidental and hence not something for which the individual can be held to be responsible.  Even when groups engage in risky behaviour – smoking or drinking for example – what happens to an individual remains very much a matter of chance. 

Who pays?  The individual or all of us?

Which smoker develops lung cancer is currently unpredictable.  You cannot hold the sufferer responsible for their illness.  As a reflection of social solidarity, most societies like ours choose to defray costs for health care by spreading them across all of us.

This approach is not universal: when money is scarce health care costs are sheeted home to the individual.  The proportion of government expenditure going to health care is lower as a proportion of GDP in low- and middle-income countries.

The slow slide to privatising health care

Gradually, since the inception of Medicare in 1984, a decade after Medibank, successive Australian governments have sought to contain health care costs by shifting more of them to the individual. This matters – for equity and fairness.

The New York-based Commonwealth Fund ranks health care in eleven economically advanced nations every two years.

It compares health care on 72 indicators in five domains: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes. Australian health care comes second overall but has lost its top-ranking on the dimension of equity.  This is because of rising co-payments that now rival those of the US. 

Although this “privatisation” was not the focus of the Mediscare furore before the 2016 federal election, it could have been.  Rather, it passes almost without comment.

The latest survey can be found here: http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

Funding for activity and outcome

Other strategies to ring-fence the amount of public spending employed in Australia include payments made by the Commonwealth to the States and Territories based on hospital activity as measured by the volume of services they provide. 

Efforts put into this approach were mentioned recently in an article in The Australian by Sean Parnell.  Parnell wrote that: “Before the last federal election, Prime Minister Malcolm Turnbull struck a deal with the States that the Commonwealth would fund 45 per cent of the growth in activity-based funding, capped at 6.5 per cent nationally each year.”  The problem, of course, will be whether growth can be limited to this figure.

This move has liberated us from complete ignorance of what it is that we are paying for and opens the door for the next step – to find out not just what we are doing but what it is achieving.  This requires better information about clinical outcomes and this may follow from improved IT systems. 

Getting more value for what we spend is a necessary corollary of capping activity.  We must rearrange our processes of care to match the decades-long needs of people with chronic problems in the community rather than in hospital. 

We can do better with programs of prevention – directed at nutrition, activity, alcohol and tobacco use for example and the commercial forces that determine these.  We should continue our efforts to sort through the lengthy Medical Benefits Schedule to remove those items we now know do not work. We are fortunate to live in a country that enjoys good health and high-grade health care.  Ensuring that this remains the case for the future would be fine legacy. 

Tough toes a requirement in the bush

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

Rural Doctors need to have fairly tough toes. They get stepped on so often.   We know when our toes have been stepped on because it hurts.  Stepping on rural doctors’ toes can take on subtle forms.

Role Substitution

Throughout Australia this is happening: nurse practitioners prescribing medications; pharmacists giving out medical certificates and flu shots; physician assistants doing colonoscopies. In the rural regions this role substitution was based on a dire need for manpower – understandable but if the doctor is there, please mobilise these role substitutes elsewhere.  Further, it would be nice to let local rural doctors know and have a say in how the allied professionals will be liaising with us. 

When another cook comes into the kitchen, it’s okay if we invited them.  However it is toe crunching when they come into the kitchen, chuck out the soufflé, move the pots and pans around and tell the diners they cook better than we do.  I ask you, is this going to motivate me to stay in the kitchen?

The other day a patient said she would wait for the visiting pap smear nurse to visit to get her routine pap smear done.  Ouch.  I am a pap smear queen.  I travel with my pap equipment, what’s wrong with me, the good ol’ family doctor doing it?

The Non-Existent Discharge Summaries

Patients often come to us saying: “Back two or three months ago they cut out my appendix. You know, they must have told you.” Or:  “They told me to get my blood pressure and sugars checked as soon as I got back home.” Or even: “Sorry, doc I just remembered I was supposed to show you my scar.”  I cover for my hospital colleagues by saying their bookkeeping must be behind, I am glad they are okay, I regret that I did not know until this minute that they just about died two months ago.

Retrieval Service Extraordinaire

They swooped into my ED, looking through me as If I was not there, stern blue with flashy fluorescent stripes on their trouser side seams. Efficient, military precision, hardly saying a word.  They pulled out the IV I had carefully started and replaced it. They took off the splint I fashioned and replaced it, hoisted my patient on their snap-snap stretcher and they were off.  At one point I tried to introduce myself: “Hi, I’m Dr S….”.  I think one of them nodded, never introduced themselves, never gave me a thump on my shoulders to tell me “well done”, and they did not tell me what was wrong with my IV and splint.  Later I commented to the nurse they could have just kidnapped my patient.  I have every confidence my patient is okay, but my toes hurt.

Rolled Up Eyes

Oh, that doctor from St Elsewhere put the patient on the wrong “xyz” drug, they missed the “abc” sign of the obvious disease called blankety blank.  Yes we make mistakes, but we need the support from you, not the criticisms.  When we catch our own failings, we step on our own toes in shame and self-recriminations.  Can you be kind and advise us to not to crunch our own toes so hard?  It will help keep us here in the outback healthy.

Continuing Medical Education

How do you think it feels to hear that nurses and medics who take the exact same rural procedural courses pay almost half what we do to attend?  Do we pay more because we get a $2000/day stipend for taking rural procedural courses?  Why should a rural GP spend precious Government funds on attending a course that has only the intrinsic value of less than the quoted price?  Shouldn’t the course reflect the unique difficulty of the work of a rural medical officer and not the allied health provider?  The Department of Health’s toes must hurt this time.

The Visiting Specialist

Please remember you are visiting. I live in this God-forsaken part of the world.  Scabies, chronic suppurative otitis media, syphilis, rheumatic heart disease, post streptococcal glomerulonephritis, chronic disease management plans, is my meat and potatoes work.  So how do you suppose my toes feel when a visiting team tells the community they have come to “clean up” the scabies, the CSOM, and get “caught up” with all the management plans?  Hey guys, I am trying to do the same thing, with limited resources, could we join forces?

In the end it comes to patient care.  It is their toes we are all looking after.

Tobacco smoking – enough of the puff

BY ROB THOMAS, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

It is no surprise that the smoking of tobacco has decreased significantly from a generation ago, amid targeted and widespread programs to deter its use. Indeed, in Australia we seem to view our stringent tobacco legislation and divestment movements as huge wins for public health. However, what may come as a surprise is that our smoking rates are still roughly one in seven people, and it continues to cause more deaths than alcohol and illicit drugs combined.

As a young person, I’m astounded when I see friends and other young people lighting up. On the one hand, it’s probably good that myself and others have such a cultural distaste for this deadly habit, but on the other it’s tragic to see people beginning something that they will inevitably struggle with for years.

Like many medical students, I’ve spent time in respiratory medicine and seen patients dying of cancer, infection and chronic obstructive pulmonary disease, where people describe their existence as “slowly drowning”. There is simply no safe level of tobacco consumption. It shocks me that this harsh reality, not just the threat of cancer, causes more than 15,000 Australian deaths per year and yet young people continue to pretend they’re invincible.

Interestingly, in the US and UK, smoking rates are now dropping to comparable or even lower levels than in Australia, where our plain packaging and advertising laws are very strong. On a pure price disincentive, we still have some of the most expensive cigs in the world, yet perhaps we are starting to see diminishing returns on smoking rates. Clearly, more needs to be done.

Earlier in the year, AMA President Dr Michael Gannon gave out the “Dirty Ashtray Award” to the State most behind on their smoking crackdown. The Northern Territory, 11-time recipient of that award, has a rate of smoking of more than one in five, with comparatively lax laws regarding smoking in pubs, clubs and even schools. We cannot sit by while children and young people are indoctrinated into a culture where smoking is tacitly accepted.

Some advocates for smoking reduction have looked at the possibility of e-cigarettes as a tool for cessation or alternative. We must be wary of these products, none of which have yet proved to be useful as cessation tools, and may in their use and marketing make smoking more socially acceptable.

Many universities have some form of a tobacco-free policy available on their websites. However, many of these are not enforced or incomplete, meaning that smoking and particularly passive smoking continue. As medical students, we call for more stringent tobacco-free policies to reduce prevalence and change attitudes.

While universities are a great target, we need also to ensure that smoking-related disease does not become a disease of the poor. There is a significant gap in smoking rates between the highest and lowest economic quintiles (8.0 per cent and 21.4 per cent respectively). Although this gap is slowly closing, we need to pursue methods of education and intervention that promote equity and work for the people most at risk.

At the patient level, it’s important for doctors to remain vigilant, to work with smokers to quit. We acknowledge this is not easy, it is often a long and relapsing process, but ultimately it cannot just be ignored. Thankfully in medical school we are taught some of the tools of motivational interviewing, but we can’t afford complacency.

Complacency cannot be afforded at the Government level, too. The Council of Australian Governments several years ago made the target of 10 per cent daily smokers by 2018, a rate we may just fall short of. Continued efforts, including banning in public places, availability of support to quit programs and widespread public education need to continue. This is not a fight we can say we’ve won just yet.

Twitter: robmtom
Email: rob.thomas@amsa.org.au

Indigenous sexual health

BY AMA PRESIDENT DR MICHAEL GANNON

While successive governments have made significant efforts to address major chronic health problems experienced by Aboriginal and Torres Strait Islander people, sexual health issues are often left off the agenda. The rates of HIV and sexually transmitted infections (STIs) within Indigenous communities are increasing at alarming rates, and Aboriginal and Torres Strait Islander people are disproportionately affected by these conditions.

The serious consequences of untreated STIs are well documented, some of which are known have long-term effects on health. Syphilis, for example, is highly infectious and can cause heart and brain damage, while diseases such as gonorrhoea and chlamydia can lead to infertility and chronic abdominal pain. Not only do STIs affect a person’s physical wellbeing and further increase the risk of HIV infection, but the stigma attached to STIs can result in social isolation.

In 2015, the rate of syphilis among Aboriginal and Torres Strait Islander peoples was over six times higher than that of the non-Indigenous population, and in some remote areas, this rate rose up to a staggering 132 times higher. Indeed, almost 80 per cent of STIs among Indigenous Australians are found in remote communities, and a number of underlying risk factors such as poor access to health services, culturally inexperienced clinical staff, and a particularly young population contribute to such high infection rates.

In recent years we have seen significant progress in both the diagnosis and treatment of STIs and other preventable diseases. However, a syphilis outbreak across northern Australia has recently caused the number of STIs to rapidly rise and has already led to the death of at least four Indigenous Australians. This is completely unacceptable.

These statistics, while incredibly concerning, highlight a growing problem facing Indigenous Australians when it comes to their sexual health and wellbeing. It is clear that urgent action must be taken to address the high rates of STIs in Indigenous communities.

The Federal Government has shown some promise in addressing sexual health issues in Indigenous communities, by forming a Multi-jurisdictional Syphilis Outbreak Working Group to help prevent disease transmission and outbreak, and supporting the South Australian Health and Medical Research Institute to partner with the Aboriginal Nations Torres Strait Islander HIV Youth Mob to deliver awareness and education campaigns to Indigenous Australians across the country.

Yet, in March 2017, the Government confirmed the inexplicable scrapping of federal funding for both the Northern Territory AIDS and Hepatitis Council and the Queensland AIDS Council, all without conducting any community consultations or directly evaluating the programs themselves. For more than two decades, both services have delivered vital sexual health programs to remote and regional communities that experience difficulties accessing mainstream health services, and have developed close relationships with the communities that they serve. The cut in federal funding is set to bring these programs to an unfortunate and indefinite close, but it is services like these that play a key role in improving sexual health outcomes for Aboriginal and Torres Strait Islander people.

Living with a sexually transmitted disease is not just an individual health issue, but one that can impact the entire community. As HIV and STI rates for Aboriginal and Torres Strait Islander people continues to rise, we should not be cutting existing services aimed at improving sexual health practices in Indigenous communities.

The AMA understands that the Government has confirmed it will undertake an evaluation of a $24 million funding proposal to address STIs in Indigenous communities through eliminating syphilis, preventing HIV, health education, and STI screenings through outreach in vulnerable regions. However, we also understand that an outcome on this evaluation has yet to be announced.

The AMA would like to see the Government invest in areas to support ongoing efforts to address Indigenous sexual health problems, and ensure that culturally safe health care remains accessible to all Aboriginal and Torres Strait Islander people to help control the spread of STIs.