Poor GP relations put ‘essential’ reform at risk

One of the boldest reforms to Medicare in decades could collapse if the Federal Government persists with the Medicare rebate freeze, AMA President Dr Michael Gannon has said.

Dr Gannon praised the Commonwealth’s plan to establish a Health Care Home model of care for patients with chronic illness, but warned that its chances of success were being hobbled by inadequate investment and relentless Government attacks on general practice, particularly the rebate freeze.

“Unless the Government restores some goodwill by unravelling the freeze and invests the extra funding that is required for enhanced patient services, GPs will not engage with the trial, and will walk away from this essential reform,” he said.

Under the model, also known as the Medical Home, patients suffering from complex and chronic health problems will be able to voluntarily enrol with a preferred general practice, with a particular GP to coordinate all care delivered.

Dr Gannon told the National Press Club the Health Care Home, if properly implemented, could deliver big improvements in quality of care, reduced hospital admissions and fewer emergency department visits.

“This is potentially one of the biggest reforms to Medicare in decades”, the AMA President said, and the AMA was keen for it to succeed.

But he warned that it faced major obstacles without a change in approach by Government.

The Government has initiated a two-year trial of the Health Care Home model, involving 65,000 patients and 200 practices across 10 Primary Health Networks.

It has committed $21 million to pay for test infrastructure, training and evaluation, and has allocated more than $90 million in payments for patient services.

But the Dr Gannon said these funds were simply being shifting from other areas of health, and the Government must invest if the reform was to be a success.

“There is no new funding for the Health Care Homes trial,” he said. “GPs are being asked to deliver enhanced care to patients with no extra support. This simply does not stack up.

Dr Gannon warned that “if the funding model is not right, GPs will not engage with the trial, and the model will struggle to succeed”.

Adding to the Government’s challenge, it is trying to recruit GP support for the policy while at the same time freezing the Medicare rebate and threatening to axe incentive payments to practices that do not upload enough health records to its My Health Record e-health system.

All this in addition to two aborted attempts to introduce a GP co-payment.

Dr Gannon said that these polices had damaged the relationship between the Government and GPs, and it would need to be repaired if Health Care Homes was to realise its potential.

“For the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. To do this, it must first overcome the significant trust and goodwill deficit attached to the co-payment saga and the Medicare freeze,” he said.

Adrian Rollins

Prevention key to contain costs

The nation is “going backwards” in tackling its obesity problem and facing a blowout in health care costs unless it ramps up its health prevention efforts, AMA President Dr Michael Gannon has warned.

Reiterating the AMA’s support for a sugar tax as part of a range of measures to promote healthier eating, Dr Gannon said it was not about “demonising” particular foods like Coca Cola or McDonald’s but a much broader approach to help people make more informed choices and help them live more active lives.

The AMA President said that a sugar tax, on its own, would not “fix the problem”.

“Too often…we hear the demonisation of Coca-Cola, we see the demonisation of McDonald’s, when people make bad decisions about the food they put in their mouth every day, the food that they buy from supermarkets, the fact that we all eat so much processed foods,” Dr Gannon told the National Press Club.

“We can’t just have a simple idea that this is the one solution. We need a whole-of-government, whole-of-society approach investing in public health campaigns, thinking about sport and recreation, thinking about how we design our suburbs, looking at traffic-light systems for healthy foods, investing in some really decent public health campaigns so that people…are making informed choices.”

Dr Gannon said the burden of health costs was being largely driven by patients being hospitalised for preventable health problems like obesity, and there needed to be much greater investment in public health campaigns to improve individual wellbeing and hold down the nation’s health bill.

“We are going backwards in addressing obesity, and the effects are felt in almost every area of the health system,” where morbidly obese patients are much more difficult and expensive to treat, he said.

To help contain this cost in the long term, Dr Gannon said the Government should lift its investment in preventive health.

He said health literacy levels were low, and every day people were making bad choices about what they ate, drink and did that would have consequences for their own health and for demand for health care.

“Preventive health is not about implementing a ‘nanny state’ or taking away people’s ‘choices’,” Dr Gannon said. “There are not enough public health campaigns and we continue to fund, at tremendous expense, the consequences of failures to prevent chronic health conditions.”

The AMA President told the National Press Club that Australia’s spending on preventive health was woefully inadequate. Just 1.7 per cent of all health spending in 2011-12 went on health prevention, compared with 7 per cent in New Zealand and 6 per cent in Canada.

He said the success of action to curb smoking, including increased taxes, marketing restrictions, no smoking rules and tobacco plain packaging laws, showed what could be achieved, and it was time alcohol was taken out of the ‘too hard’ basket.

Adrian Rollins

Nurturing the AMA’s future leaders

Picture: Members of the AMA Future Leaders program in the Marble Hall of Australian Parliament House

In adopting its strategic plan for 2015-2017, the Board of the AMA recognised that one of the key responsibilities of the AMA is to develop its future leaders.

To address this need a program to develop potential leaders in the AMA was launched in 2016, aimed at members within the first five years of joining a State or Federal AMA committee, council or board.

Following a call for applications, 11 doctors in training, including the winner of the 2016 DiT of the Year Award, Dr Ruth Mitchell, participated in an immersion program on AMA advocacy, federal politics and health policy, the life of an MP, understanding how the Parliamentary system works, and using the media and social media.

The group had presentations from Member for Canberra, Gai Brodtmann, the Director General of Health in the ACT, Nicole Feely, the Clerk of the House of Representatives, David Elder, and senior members of the Senate staff.

The policy and media teams from Federal AMA worked through case studies outlining the effectiveness and influence of AMA advocacy, including the use of media and social media to publicise and advance the AMA policy agenda.

The weekend was well received by participants and will become a regular feature of the annual calendar.

Anne Trimmer

Assisted dying advocates won’t lie down

The major parties are being challenged to declare their position on assisted dying after the Australian Greens announced plans to introduce national assisted dying legislation during the current term of Parliament.

As a review of the AMA’s policy on euthanasia and physician-assisted suicide reaches its final stages, Greens leader Senator Richard Di Natale has flagged his intention to put proposed Dying with Dignity laws up for debate.

“It’s never easy to talk about death, but our political leaders need to have the courage to take on challenging issues, especially when it concerns the rights of every Australian,” Senator Di Natale said. “The Greens believe that patients with intolerable suffering should have the right to have a say in the timing of their death. As a doctor, I know many patients would be comforted just by knowledge that the right existed, even if they never exercised it.”

While history suggests the Greens will fall well short of the support they need to make their Bill law, there is a growing push to make assisted dying legal.

In Victoria, a cross-party parliamentary committee has recommended that assisted dying be legalised for patients with serious and incurable illnesses, and high-profile television producer Andrew Denton has founded Go Gentle Australia to campaign for the right for patient to choose what happens at the end of their life.

In a nationally televised speech, Mr Denton accused conservative politicians from both the major parties of conspiring to thwart efforts to legalise euthanasia, and called on those with religious or moral objections to assisted dying to accept the right of others to have such a choice.

The presenter has urged the adoption of laws that, subject to strict criteria, would provide legal protection for doctors who assisted patients with terminal illness to die.

He said it would not be “a licence to bump off granny”, and would in practice make legal what was “already happening in Australia without regulation, without support, without transparency or accountability and, from the evidence received, sometimes without consent”.

The Greens Bill follows similar legislation in Canada and California.

In Canada, the Trudeau Government has proposed laws to allow adults with serious and irreversible medical conditions to seek a doctor-assisted death. To do so they must apply in writing, with two witnesses, and the request must be evaluated by two doctors or nurses. Once a request is granted there is a mandatory 15-day waiting period.

California has passed laws that allow people with less than six months to live to seek physician-assisted death, subject to assessment that they are of sound mind.

But in the United Kingdom, the House of Commons last year overwhelmingly rejected a similar proposal.

The issue of assisted dying was debated at length at the recent AMA National Conference, where a panel of medical practitioners and a medico-legal expert argued the merits of the idea.

See: On assisted dying

Though there were sharply divergent views on whether or not doctors should be involved in helping patients to die, there was broad agreement that the medical profession could do better in supporting patients, families and friends at the end of life.

The results of an AMA member survey on the issue were discussed at an AMA Federal Council meeting last month, along with issues raised at the National Conference forum and a separate consultation on current AMA policy conducted through the pages of Australian Medicine.

Doctors, nurses and other health professionals working in acute care settings can learn more about caring for patients approaching death and their families through Flinders University’s End-of-Life Essentials package. The free online resource includes three learning modules looking at managing end-of-life issues in hospitals, recognising dying, and communication and decision-making.

The modules can be accessed at: www.caresearch.com.au/EndofLifeEssentials

Adrian Rollins

[Correspondence] Increased momentum in antimicrobial resistance research

Working against pathogenic microbes in a globalised world is a matter of self-interest at least as much as a responsibility to our neighbours. Antimicrobial resistance (AMR) is responsible for an estimated 700 000 deaths annually worldwide. The review1 on AMR, commissioned by the British Government and chaired by Jim O’Neill, estimates that, if current trends continue, annual fatalities from drug-resistant microbes could rise to more than 10 million by 2050, exceeding deaths caused by cancer.

Patient charges rising fast

Patient out-of-pocket costs have surged and are now growing at their fastest pace in four years as general practices react to the financial squeeze from frozen Medicare rebates and rising running costs.

While the Federal Government has trumpeted official figures showing the proportion of GP services being bulk billed has risen to a record high of 85.1 per cent, the statistics also indicated that those patients that are being charged a fee are paying more.

Medicare data show that average out-of-pocket costs reached $34.25 last financial year, up 6.5 per cent from 2014-15 – the fastest pace of growth since 2011-12 and well above the rate of inflation.

The increase in patient charges follows warnings from AMA President Dr Michael Gannon that many general practices were “now at breaking point” because of the Medicare rebate freeze, cuts to incentive payments and reduced mental health funding.

“Many patients who are currently bulk billed will face out-of-pocket costs well over $20,” Dr Gannon said.

Hopes that the Turnbull Government, stung by voters over health policy, might move the scrap the rebate freeze are fading, heightening concerns that hard-pressed medical practices will have little choice but to abandon or cut back on bulk billing and increase charges for those patients judged to be able to pay a fee.

But instead, the Government has used the high incidence of bulk billing to argue its policies are sustainable.

Health Minister Sussan Ley seized on the increase in the bulk billing rate, claiming it was “good news for Australians”.

Ms Ley said the figures showed 123 million GP services were fully funded by the Government last financial year, and put the lie to Labor claims that the Government was anti-Medicare.

“These figure expose the blatant and remorseless Mediscare lies Labor have been telling the Australian public over the last 12 months,” Ms Ley said. “There’s no doubt we still have work to do, but Australians should tale assurance from the fact no Government has invested more into Medicare than the Turnbull Government.”

But Shadow Health Minister Catherine King said the figures seized on by the Government were misleading because they focused solely the number of services that were bulk billed, rather than the number of patients, and ignored the rise in out-of-pocket costs.

Ms King said that as the rebate freeze has continued, a growing number of practices were abandoning bulk billing, including on Magnetic Island and in Hobart.

“Australians know that Malcolm Turnbull’s six-year freeze on Medicare rebates is driving bulk billing down and out-of-pocket costs up,” Ms King said. “The Government’s insistence otherwise only shows how out of touch they are.”

In his 17 August speech to the National Press Club, AMA President Dr Michael Gannon reiterated the AMA’s opposition to the rebate freeze, which he warned was undermining general practice, which was one of the key strengths of the nation’s health system.

“General practice has been under sustained pressure for years,” Dr Gannon said. “GPs have been treated poorly by both Coalition and Labor governments.”

The AMA President said that the ageing population and the growing burden of chronic and complex disease meant GPs were seeing more patients than ever before – an extra 42 million services in the past decade.

Despite this growth in demand, Government support for GPs was in decline.

“GPs are caught in a diabolical squeeze,” Dr Gannon said. “They are caring for increasingly sick patients while the Government tightens the financial screws in the name of budget repair.”

“GPs are now at breaking point. Many patients who are currently bulk billed will face out-of-pocket costs well over $20,” he warned.

Latest news:

[Editorial] UK Government won’t step up to the plate on childhood obesity

The UK Government’s long-anticipated response to the childhood obesity crisis disappointed everyone. From doctors, health charities, and celebrities to the very industry it seeks to propitiate, the Childhood Obesity Plan, published with as little noise as possible in the summer recess, has met with resounding criticism. As a Comment in today’s Lancet highlights, the strategy has been delayed for a year, and in that time it has been watered down to a vague Plan with no teeth.

Aleppo’s dying children and shattered health system: is there light at the end of the tunnel?

Being a doctor can be risky business, some times more than others.

During my dozen medical missions to Syria, I had to crawl under a border fence, jump over walls, walk in the mountains at night for hours without any light, pass through the sniper alley in Aleppo, negotiate with smugglers and work in bombed, underground hospitals.

The Syrian crisis is now in its fifth year. The country’s health services are under unprecedented strain due to the protracted war, deliberate targeting of health staff and infrastructure by the Syrian regime and Russian forces, the exodus of physicians and nurses, shortages of medical supplies and medications and the disruption of medical education and training.

Syria’s largest city, Aleppo, has 85,000 children, including around 20,000 below the age of two. Dozens are injured every week, just like five-year-old Omran Daqneesh whose pictures have shocked the world. Many have far worse injuries and will not survive.

I took care of some of these unlucky children, such as Ahmad Hijazi, also five years old. He was hit by one of Assad’s barrel bombs. These are containers the size of barrels, stuffed with TNT and metal shrapnel, which the Syrian regime throws from helicopters onto urban areas such as hospitals, civilian neighbourhoods, fruit markets and schools.

Hijazi had shrapnel lodged in his spinal cord and was paralysed from his neck down. When I saw him, he was breathing with great difficulty, so we put a breathing tube in his mouth and put him on life support. The day after I left, he had a cardiac arrest and died.

Around half-a-million people have been killed in the conflict. Half of the population has been displaced. There seems to be no light at the end of the tunnel.

Medical neutrality is a principle under international humanitarian law that ensures protection of medical personnel, patients, facilities and transport from attack or interference. It also underpins unhindered access to medical care and treatment; humane treatment of all civilians; and non-discriminatory treatment of the injured and sick.

Systematic attacks on health care, mostly by the Syrian government and recently Russia, are violations of medical neutrality and therefore war crimes under the Geneva Conventions.

A health system in ruins

Before the onset of fighting, Syria’s health care system was comparable with that of other middle-income countries, such as Iran. By 2015, all sectors of the country’s health infrastructure had disintegrated.

Within only a few years, the life expectancy of resident Syrians has declined by 20 years; from 76 in 2010 to 56 by the end of 2014. This isn’t all due to the direct effects of war.

Many more Syrians have died prematurely from infections and chronic disease than from the fighting – this includes diseases such as pneumonia, hepatitis, tuberculosis and diarrhoeal infections, as well as heart disease, kidney disease, diabetes, cancer and chronic obstructive pulmonary disease.

Hospitals and clinics have been destroyed. Eight out of the ten hospitals in Eastern Aleppo are partially functional or out of service as a result of targeted attacks. From March 2011 to the end of May 2016, at least 738 Syrian doctors, nurses and medical aides died in 373 attacks on medical facilities.

Aleppo's dying children and shattered health system: is there light at the end of the tunnel? - Featured Image

Pictures of Omran Daqneesh have shocked the world, but doctors in Aleppo see dozens of desperate children like him every week.
ALEPPO MEDIA CENTER, @AleppoAMC / HANDOUT

The working conditions of Aleppo’s remaining doctors are unsustainable. An estimated 35 doctors are left in Eastern Aleppo which, with a population of approximately 300,000, means there is one doctor for every 8,570 people. There is not a single critical-care doctor – my own speciality – despite the abundance of critically ill patients.

Doctors, local administrators and NGOs are struggling in substandard conditions and often use unorthodox methods to do their work. They work in underground makeshift hospitals, hospitals dug into mountains or in natural caves for protection. They perform surgeries without light, proper anaesthesia or sterilisation, transfuse blood without proper matching and have medical students or dentists perform life-saving procedures due to the shortage of specialists.

Much-needed medical supplies are channelled through dangerous routes across the borders of Lebanon, Jordan and Turkey. As physicians, we can’t wait for politicians to fix the crisis.

What needs to be done

Fifteen Aleppo doctors recently penned an open letter to US President Obama, in which they wrote that “there is an attack on a medical facility every 17 hours” by the Russian-backed Syrian air force.

Meanwhile, the charity Syrian American Medical Society reported that July has been the worst month for attacks on health care since the beginning of the conflict. There were 43 attacks on health facilities in the month – more than one a day. By comparison, this number of attacks occurred over six months in 2015, with 47 attacks from January to May.

Charities and other organisations, such as the Syrian American Medical Society, have pioneered solutions to some of the resource gaps. These include portable ultrasounds and other point-of-care diagnostic tools, as well as virtual wards connecting nurses and doctors in besieged areas with specialists in the United States.

Doctors in the US and other Western nations have helped Syrian counterparts make the best of the situation by providing training and helping with technology and treatment. But more needs to be done to support remaining health workers.

International medical organisations should advocate on behalf of their Syrian colleagues and champion an end to violations of international humanitarian law.

Educational opportunities to support Syrian health professionals, including scholarships for medical students, would help with ensuring there are enough staff to rebuild the Syrian health system. More resources should be directed to research the impact of conflicts on health care and the use of technology and other innovative solutions to mitigate harms.

Consensus should be achieved and acted on by the international community on the urgent need to protect civilians from airstrikes and chemical attacks. This is needed to apply pressure on the Syrian government to stop targeting the remaining health care staff and hospitals.

We should share knowledge, skills and technology with all patients, across the world. Although our local patients are a priority, we can also benefit the global community.

Zaher Sahloul, Associate Clinical Professor, University of Illinois at Chicago This article was originally published on The Conversation. Read the original article.

Main photo: kafeinkolik / Shutterstock.com

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Cardiac machines linked to infection

Health departments around the country are contacting open heart surgery patients who may have been exposed to a rare infection that can be found in some heater-cooler units used in surgery.

According to international reports the design and manufacture of some heart bypass heater-cooler units made by Sorin have made them susceptible to harbouring the rare bacterium mycobacterium chimaera.

M. chimaera infections in cardiac surgery patients overseas have been linked to the heater-cooler units made by medical equipment manufacturer Sorin. It is thought that the units were contaminated during their manufacture.

It’s a common bacterium that occurs naturally in the environment and only causes rare infection. The infections tend to be slow to develop (it can take from several months to over a year for an infection to develop) and often affect people with compromised immune systems.

There has been one reported possible patient infection following an open cardiac surgery in 2015.

According to a statement by the Therapeutic Goods Association: “These infections have been associated with the use of heater-cooler devices which are used within the operating theatre to control the temperature of blood diverted to cardio-pulmonary bypass machines. Heater-cooler devices contain water tanks that provide temperature-controlled water for the operation of the device. This water does not come in contact with the patient.”

The TGA says it’s monitoring the situation and has updated its advice for health facilities regarding how to manage devices that test positive for mycobacterium chimaera.

In NSW, the hospitals that have used the potentially contaminated machines are Prince of Wales, St George, Sydney Children’s Hospital and The Children’s Hospital at Westmead.

All machines have been cleaned or replaced and the risk to patients is low.

Related: Cheap way to cut infection risk

“The risk of infections to an individual patient is very small, but it’s important that we’ve alerted clinicians to the risk and put systems in place to reduce the risk further,” infectious disease specialist Dr Kate Clezy, from the NSW Clinical Excellence Commission, said in a statement.

In Victoria, Fairfax media reports that the bacterium has been detected in heater-cooler units at The Alfred, Austin and Cabrini hospitals in Melbourne.

“All the units were decommissioned and replaced once the test results were known,” a department spokesman said.

It’s believed doctors are checking patient records to see whether anyone has been harmed by the bacterium.

According to director of infectious diseases and microbiology at the Austin Hospital Professor Lindsay Grayson, there is about a 1 in 10 000 chance of the bacterium causing an infection.

“If you think about this, the chances of having a car accident are one in 4000, so it is very rare.”

He said the infection could be cured with surgery and use of specific antibiotics.

According to NSW Health, the signs of possible M. chimaera infection include:
fatigue
difficulty breathing
persistent cough or cough with blood
fever
night sweats
redness, heat, or pus at the surgical site
muscle pain
joint pain
abdominal pain
weight loss
nausea
vomiting

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[Editorial] Canada’s inquiry into violence toward Indigenous women

On Aug 3, the Government of Canada announced a national inquiry on the epidemic of violence toward Indigenous women. The inquiry follows decades of urging by advocates, international human rights groups, and the UN to investigate and explain the 1200 women and girls who have been murdered or gone missing in the country since 1980. Indigenous women in Canada are eight times more likely to be killed by an intimate partner than are non-Indigenous women and three and a half times more likely to be victimised.