[Editorial] An African-driven health agenda

The first WHO Africa health forum closed on June 28 in Kigali, Rwanda, with commitments from governments to ensure universal health coverage. 700 delegates attended the forum organised by the WHO regional office for Africa to review progress towards the health-related sustainable development goals. The promises of universal health coverage chime well with the instalment of Dr Tedros as WHO’s 9th director-general on July 1. He has said “all roads should lead to universal health coverage”. Being the first African director-general, and having transformed Ethiopia’s health system, Dr Tedros’ leadership bodes well for Africa’s visibility on the international health stage and may translate into needed health gains.

[Comment] Data linkage studies can help to explain the weekend effect

Is the weekend effect a worrying manifestation of systematic deficiencies in the quality and safety of health care, or instead simply an artefact, constructed from confounding, bias, and the imperfections of existing methods for making sense of observational data? This question has not only motivated a huge number of research studies,1 but also entered the arena of politics and policy, contributing in England to the first industrial protest by junior doctors in 40 years.2 Although the consequences are hard to measure, popular awareness of the weekend effect could plausibly have fostered anxiety in the minds of patients and families about the safety of seeking health care at the weekend.

Maternity services framework to be redrafted

Work has been terminated on a controversial new framework for maternity services that was drawn up with no input from obstetricians or GPs.

The Australian Health Ministers’ Advisory Council (AHMAC) agreed to start afresh on a new draft following a hostile stakeholder consultation meeting on 23 June at which not a single stakeholder voiced support for the project.

Both the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG) boycotted the meeting in protest.

AMA Federal Councillor Dr Gino Pecoraro, who represented the AMA at the meeting, said that the stakeholders – doctors, nurses, midwives and health consumers – were united in their opposition to the proposals.

“The decision to scrap the National Framework for Maternity Services (NFMS) is a win for the women and children of Australia,” Dr Pecoraro said.

“What has happened has been a monumental missed opportunity to achieve the best possible maternity care for mothers and babies.”

The NFMS was designed as a guide for future maternity care policy in Australia. Following an agreement at the April 2016 COAG Health Council, the Queensland Government was tasked with leading the project, under the auspices of AHMAC.

The AMA first became aware of the NFMS project in December 2016 – eight months after it commenced, and without any direct contact from AHMAC’s 12-member Maternity Care Policy Working Group (MCPWG) or consultants Deloitte.

AMA President Dr Michael Gannon raised the AMA’s concerns with federal Health Minister Greg Hunt and Queensland Health Minister Cameron Dick.

“If it was an episode of Yes Minister or Fawlty Towers, you could have a bit of a laugh,” Dr Gannon told Medical Republic.

“Even if you had a predicted outcome in mind, you could at least window-dress it with one obstetrician or one GP.”

AMA Vice President, Dr Tony Bartone, said that obstetricians and GPs share the bulk of the care for women throughout their pregnancies, and leaving them out of the process was a critical misjudgement.

“The AMA has consistently warned that without genuine engagement with the medical profession, the review would be doomed to fail – which is exactly what has happened,” Dr Bartone said.

“The AMA remains committed to working with Government and all stakeholders to see a strong and safe framework.”

Following the stakeholder meeting, Queensland Health representatives recommended to AHMAC that the current process be terminated, replaced with a more substantial consultation phase, and a complete redrafting of the Framework.

The Australian College of Rural and Remote Medicine (ACRRM) and the Rural Doctors Association of Australia (RDAA) said the decision to start again was the right one.

“RDAA and ACRRM were very concerned there had been no specific consultation with rural clinicians, no recognition of the role of procedural GPs in rural maternity services, nor any mention of the guidelines developed by RANZCOG, the organisation that trains the procedural GPs and specialists in this field,” RDAA Vice President Dr John Hall said.

“With over 34,000 babies born each year in locations classified as outer regional, remote and very remote, it is essential that rural maternity service models are supported as part of the NMSF – and that the doctors who provide care as part of these services are closely consulted in its development.”

Maria Hawthorne

Call to action to end elder abuse

The Government is considering recommendations to come out of a long-running Federal inquiry into elder abuse.

The Human Rights Commission has made a call on all Australians to recognise the rights of older people and end the abuse and neglect so many of them face.

The call comes as the Australian Law Reform Commission (ALRC) releases its findings and recommendations following a 15-month Federal Inquiry into elder abuse.

The report, Elder Abuse – A National Legal Response, is the result of 117 national stakeholder meetings and more than 450 submissions.

The Age Discrimination Commissioner, Dr Kay Patterson AO, said the report was a seminal piece of research that has the power to change lives. She also believes the report puts all Australians on notice (in particular those working with older people) that they have a responsibility to understand what elder abuse is and to commit to its elimination.

“The report contains 43 recommendations and my plan is to work with Governments and stakeholders to drive the adoption of these recommendations. This includes a national plan to protect the rights and well-being of older Australians with a goal to end elder abuse,” she said.

Elder abuse includes psychological or emotional abuse, financial abuse, physical abuse, neglect and sexual abuse. It has a devastating impact on individuals, families and communities across the country.

ALRC president Professor Rosalind Croucher said the framework could be used to implement wide-ranging reform.

“In developing the recommendations in this report, we have worked to balance the autonomy of older people with providing appropriate protections, respecting the choices that older persons make, but also safeguarding them from abuse,” Professor Croucher said.

One of the key recommendations in the report is implementing a national study to examine how common elder abuse in Australia is – to research the overall number and severity of incidents of elder abuse and neglect in Australia.

The report did not examine the impacts of elder abuse on health and well-being. Also not included in the report is whether providing inappropriate health care is a form of abuse.

Law Society of NSW President Pauline Wright also welcomed the report and its recommendations, noting increasingly older Australians were facing abuse which could be in the form of physical, psychological, emotional, financial, sexual abuse or neglect.

“Sadly, financial abuse also frequently occurs, often perpetrated within families or by someone known to the victim such as a friend, carer or neighbour,” Ms Wright said.

“Measures to prevent financial abuse are particularly critical given the rise in Australia’s ageing population and the increasing number of Australians living with dementia.”

In a statement, Attorney-General George Brandis said the Turnbull Government would carefully consider the recommendations and work across portfolios to develop a response.

The AMA believes that family and domestic violence (FDV) is unacceptable in any circumstances. A recent position statement by the AMA points out that elder abuse is a less well covered form of family and domestic violence. It too can be physical, but also involves psychological and financial abuse. A copy of the position statement can be found at: position-statement/family-and-domestic-violence-2016 .

Meredith Horne

US kids dropping vaping and smoking

American teenagers are turning away from e-cigarettes, sparking fresh hopes that youth smoking in the United States could be on the decline.

Overall tobacco use dropped among teenagers last year, but the use of e-cigarettes fell dramatically, according to the Centers for Disease Control and Prevention’s annual report on youth and tobacco.

The report found that 11.3 per cent of high school students used e-cigarettes in 2016, compared with 16 per cent the year before. It is the first drop recorded.

Only 8 per cent of high school students smoked cigarettes last year.

Just over 20 per cent said they had used “any tobacco product”. That includes cigarettes, cigars, pipes, chewing tobacco and small, leaf-wrapped cigarettes, as well as e-cigarettes.

Both percentages are the lowest on record.

President of the non-profit Campaign for Tobacco-Free Kids, Matthew Myers, described the results as “unimaginable, extraordinary progress” and said almost 30 per cent of young people smoked cigarettes in 2000.

“This is a change of a cosmic nature that has the potential to dramatically impact lung cancer, heart disease, asthma and other problems,” he said.

But with the Trump administration already delaying enforcement of some tobacco regulations, health agencies are concerned there could be a weakening of the rules about the use and sale of e-cigarettes and other tobacco-related products.

Fears are that any such moves could reverse the progress being made in encouraging teenagers to resist the smoking habit.

Robin Koval, chief executive of Truth Initiative, a non-government organisation focussing on tobacco use by young people, said the new report suggested Americans could be “well on our way to finishing smoking for good”.

She said the rapid decline in e-cigarettes among teenagers suggested much of their use had been experimental and that the current offering of products was less appealing than it had once been.

Senior author of the CDC report, Brian King, said the decrease in e-cigarette use was likely a result of several factors, including efforts by the government and public health groups to educate young people about possible hazards of the products.

He said that while e-cigarettes don’t contain some of the harmful substances in conventional cigarettes, the inhaled vapour usually contains nicotine, which is highly addictive and can harm the adolescent brain, as well as ultrafine particulates and heavy metals.

Mr King also said declines in tobacco use could be due to increases in State and local tobacco taxes.

He added that the inclusion of e-cigarettes in anti-smoking rules banning smoking in restaurants and bars could also be contributing to the decline in the use of the products.

The US Government and a number of non-government organisations have mounted effective campaigns warning about the dangers of smoking.

The Food and Drug Administration stamped its authority on the regulation of e-cigarettes in 2016. But in May this year, it delayed for three months the enforcement of some regulations.

The delay came as the vaping and tobacco industries launched a forceful and strategic effort to wind back, through both legislation and litigation, the FDA regulations.

Chris Johnson

Maternity Review a wasted opportunity

BY AMA PRESIDENT DR MICHAEL GANNON

After months of behind-the-scenes activity and growing angst from the profession, the AMA went public in June with our outrage over the process for the planned new National Framework for Maternity Services (NFMS).

The Framework is doomed to fail due to inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

Following an agreement at the April 2016 COAG Health Council meeting, the Queensland Government was tasked to lead the project to develop the NFMS, under the auspices of the Australian Health Ministers’ Advisory Council (AHMAC).

The AMA first became aware of the NFMS project in December 2016 – eight months after it commenced, and without any direct contact from AHMAC’s Maternity Care Policy Working Group (MCPWG) or its consultants – and we have raised concerns about the project ever since.

The AMA’s concerns are shared by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG).

It is outrageous that specialist obstetricians and GPs have been marginalised in this process. You could be forgiven for thinking it a joke.

Obstetrician-led care is an essential tenet of Australia’s maternity system. There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

When issues and problems arise during labour, it is invariably an obstetrician who is called on to assume responsibility and manage care, working to ensure the best possible outcome for mother and baby.

The AMA is pleased that midwives were strongly represented on the Working Group responsible for drafting the NFMS. They are key members of the maternity team.

But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.

AMA members have reported maternity services and outcomes in their respective States have deteriorated under the current National Maternity Services Plan.

Obstetricians are concerned that not enough is being done to ensure women have access to high quality, collaborative models of care. Despite this, the consultation undertaken to develop the NFMS has neglected to actively engage specialist medical practitioners who are at the centre of care for mothers and babies.

The draft Framework, which was released for public comment in March 2017, lacked substance and provided no guidance for public hospital maternity services about what high quality care should look like.

The NFMS is shaping up as a lost opportunity to achieve the best possible maternity care for mothers and babies in Australia.

GPs, too, have been ignored in the process.

GPs not only routinely offer obstetric services in outer metropolitan, rural, and regional areas, but deliver antenatal and postnatal care to thousands of Australian women. There was not a single GP representative appointed.

Further, there is no acknowledgement that best practice care of mothers involves anaesthetists, obstetric physicians, psychiatrists, pathologists, and haematologists, none of whom were invited to assist in the development and drafting of the NFMS.

The AMA wants to see a strong NFMS. It must be developed in genuine partnership with the medical profession and its peak bodies. These are the medical professionals who deal with maternity services, day in and day out.

They’ve seen what works, and they know where the system is not working well. Their experiences and views should have been at the table, from the beginning.

Inviting them to a consultation a month before completion of the draft NFMS does not seem a genuine attempt to listen to experts at the coalface of maternity services.

The AMA has called on COAG, AHMAC, and the NFMS Working Group to formally and genuinely engage with the medical profession – obstetricians in particular – before there is any further policy development or public reporting on the Framework.

The health of mothers and their babies deserves a thorough and professional Framework to ensure the best possible care.

AMA voicing concern over some political moves

Two issues dominating recent health policy discussions have seen the AMA at the forefront of political debate, expressing concerns over the direction of some processes and decisions.

The medicinal cannabis and maternity services debates have kept AMA President Dr Michael Gannon a familiar face around Parliament House in Canberra, explaining doctors’ views to Government and the media.

Medicinal cannabis

After a surprise result from a Senate vote in June, terminally ill patients with a doctor’s prescription will be able to get faster access to medicinal cannabis and be allowed to import three months’ worth of their own personal supply of the drug.

The Greens pushed for changes to Government restrictions and they found support from Labor, One Nation and some independents.

But Health Minister Greg Hunt, who with his Government colleagues tried to stymie the move, said the outcome could put lives at risk.

He said the changes could open the way for questionable and unregulated products to be introduced to the market, as well as making it easier for criminals to access drugs.

“It is unfortunately a reckless and irresponsible decision,” Mr Hunt said.

Dr Gannon agrees, saying the AMA was disappointed with the move.

“You’ve already got a situation where doctors are querying exactly how effective medicinal cannabis is. If you in any way put any doubt in their minds about the safety, you’re simply not going to see it prescribed by many doctors,” he said.

“We remain concerned about potential diversion into the general community. And let’s not forget, we’re talking about cannabis. We’re talking about a substance that, used in the form it’s used by most people, is a major source of mental illness in our community.”

Dr Gannon said the AMA was satisfied with the process put in train by the Government through the Therapeutic Goods Administration.

“The TGA’s got a process in place. Let’s support that careful process to make sure what is used is perfectly safe.”

The binding vote, which passed in the Senate 40 to 30, means medicinal cannabis will be put on the TGA’s Category A list, giving qualifying patients priority and faster access.

Maternity Services

The AMA is also warning that the planned new National Framework for Maternity Services (NFMS) was doomed to fail due to inadequate stakeholder consultation.

Describing the process as spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development, Dr Gannon said opportunities for improvement were being lost.

The AMA has raised concerns about the project ever since.

In June, however, Dr Gannon, an obstetrician, said it was outrageous that specialist obstetricians and GPs had been marginalised in the process.

“You could be forgiven for thinking it a joke,” he said.

“Obstetrician-led care is an essential tenet of Australia’s maternity system.

“But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.”

On June 23, the process did indeed fail and was scrapped.

Dr Gino Pecoraro, AMA Federal Councillor, attended an NFMA consultation on that day to discuss concerns.

He described the subsequent decision to scrap the process as a win for patients.

Dr Pecoraro said the process to date had been a monumental waste of time and money.

“The AMA has been clear that unless they went back and started again, then it wouldn’t go anywhere,” he said.

“It is a win for the women and children of Australia.”

Chris Johnson

Medicinal cannabis – still a lot of misinformation

BY AMA VICE PRESIDENT TONY BARTONE

It seems hardly a week goes by without a news story on medicinal cannabis or a media interview request on the subject.

However,despite all of the information, the amount of misinformation in the general community is significant and at times is very concerning. Many in the media believe that it is currently possible to go to your local GP and have medicinal cannabis prescribed for chronic pain. If not; why not? Presumably the patient would then go down to the local pharmacist and have it dispensed. Journalists are amazed when told that there are both State and Federal government laws and restrictions that still present significant barriers and that these restrictions need to be adhered to.

Medicinal cannabis certainly has had a very political and community driven introduction in this country. Things have been moving quickly, beginning with the passage of legislation in November 2016 involving the Therapeutic Goods Administration. Since that time, medicinal cannabis no longer falls under Australia’s most stringent of schedules – reserved for dangerous drugs – thereby allowing for provisions to be put in place to use cannabis on medical grounds.

Just this month we have had a Senate vote to increase the ease of availability of all forms of medicinal cannabis for terminally ill patients. Some have described this as a political stunt and posturing. In essence, moves in this space are happening so quickly that it is quite likely opportunities and processes are evolving that render the recent Senate amendments potentially unnecessary.

More importantly and perhaps of more concern is that the usual guidelines and requirements for the introduction of new medications seem to have been forgotten in respect of medicinal cannabis. It seems that safety and concern for rigorous, clinically proven guidelines are dispensed with – all in the name of compassion for a patient population who are just as deserving of the same standard of care as the rest of the community when it comes to safety and harm minimisation. It seems that all the tenets of our world-class system have been forgotten and are suddenly archaic and of little value in the face of a voracious community perceived need. This is spurred on by numerous media stories featuring long-suffering patients and their families who are forced to access the illegal black market.

Under the TGA Special Access Scheme, some forms of medicinal cannabis are already available. This scheme provides for the import and supply of an unapproved therapeutic good to individual patients on a case-by-case basis.

What also has been forgotten in all of this is that there is a significant amount of State legislation to be complied with. The States and Territories will decide whether medical cannabis will be made available – and more importantly, which type of patients will be able to use it. Some States and Territories have indicated they will list the conditions (e.g. QLD: Legal for specialists to prescribe for some patients; NSW: Available for adults with end-of-life illnesses; VIC: Available for children with epilepsy) The TGA is currently undertaking significant amount of education and information sharing with the medical community. This is especially necessary when a large portion of the media reporting is on access to prescribers and the relatively small numbers of prescribers or applications to prescribe. This is not surprising when clinical guidelines are in a state of evolution and there is uncertainty among many doctors about who should be eligible. Right from the beginning we have also maintained that there needs to be great clarity around how the medical cannabis system will operate. There is a paucity of information from the Government, which is adding to the confusion.

The AMA has many other concerns.So much still remains to be clarified. Information about either the dosage or form of medicinal cannabis needs to be available to patients. In countries that have medical cannabis (Canada, Holland, Israel) there are only a few types of cannabis available and they are packaged and dispensed like any other pharmaceutical product, with information on strength, use, dosage etc. The different types of cannabis are prescribed for designated medical conditions. It is not yet clear how medical cannabis will be dispensed. Is it to be dispensed through pharmacies, secure home delivery or from nominated GPs?

It is also not yet clear who will be able to approve medical cannabis prescribing and whether doctors will need to undertake additional training to become an “approved” cannabis prescriber/dispenser. The AMA has been told that modules are being created for doctors, but we don’t know exactly how or where this will be implemented.

There are some pharmaceutical cannabis products already approved by TGA (like Sativex) and controlled and standardised herbal cannabis, such as the products produced in the Netherlands. The system may be so convoluted and complicated for patients and prescribers that it won’t be able to fulfil the reason it was established and patients may continue to use the black market.

The recent Senate vote effectively means the Senate has supported an amendment to therapeutic goods laws to change category A of the Special Access Scheme for cannabis. The effect of this will speed access to medicinal cannabis for people with a terminal illness. What this means is that from now on, a patient can go and see a doctor who can order medicinal cannabis for that patient if they have a terminal illness. If medicinal cannabis is not available in Australia, they can obtain it from overseas. This is most concerning in terms of guaranteeing safety and efficacy of the product imported. Doctors will only need to notify the TGA within a 28 day period.

What is needed is for the current consultative processes between TGA, Federal and State Governments with the appropriate stakeholders to continue. A lot has been achieved in a very short space of time. However, safety and reliability of product as well as clear clinical guidelines for use need to be firmly developed and supported by clear information sharing and training of doctors concerned. Politics should not be allowed to influence and certainly media and community information needs to be facilitated so that expectations do not exceed practicality.

National Framework for Maternity Services scrapped following AMA concerns

The AMA has welcomed the decision to scrap the National Framework for Maternity Services (NFMS) due to its flawed process.

The process involved inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

AMA Vice President Dr Tony Bartone said obstetricians and GPs share the bulk of the care for women throughout their pregnancies and leaving them out of the NFMS process was a critical misjudgement.

“GPs are there with mothers at every stage of their pregnancy, including their postnatal care, and should never have been overlooked in the NFMS,” Dr Bartone said.

“The AMA has consistently warned that without genuine engagement with the medical profession, the review would be doomed to fail – which is exactly what has happened today.”

AMA Federal Councillor Dr Gino Pecoraro, an obstetrician and gynaecologist, attended a consultation forum on June 23 that led to the decision to scrap the NFMS.

“Today’s decision to scrap the flawed NFMS is a win for the women and children of Australia,” Dr Pecoraro said.

“What has happened has been a monumental missed opportunity to achieve the best possible maternity care for mothers and babies.”

Obstetrician-led care is an essential tenet of Australia’s maternity system.

There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

“The AMA remains committed to work to see a strong NFMS,” said Dr Bartone.

Chris Johnson

[Editorial] Kenya’s nurses strike takes its toll on health-care system

Strike action by government nurses in Kenya over poor pay and dreadful working conditions has led to the deaths of 12 patients who were not able to access vital services and care. Recent reports on Kenyan news wires described an 8-month-old child with severe malaria and anaemia not receiving the treatment he needed to survive. A critically ill elderly woman with asthma was left unattended for days. Patients with mental illness or substance addiction are being discharged or turned away, and maternity services are barely functioning.