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[Editorial] A good first step

The UK Government’s appointment of Jackie Doyle-Price to the newly created role of Minister for Suicide Prevention marks a welcome development in the approach to an area of some concern. While suicide rates have fallen heavily in the UK since the Office for National Statistics began keeping records in 1981, almost no progress has been made in suicide rate reduction during 2007–17, with the overall suicide rate rising from 10·0 deaths per 100 000 to 10·1 deaths per 100 000.

AMA keeps up pressure over Nauru

Aggressive lobbying from the AMA has sparked a groundswell of support for the urgent removal of refugee families from Nauru.

While the Australian Government grapples with an onslaught of criticism over its handling of the worsening asylum seeker issue, AMA President Dr Tony Bartone continues to pressure the highest levels of power.

Following his recent letter to Prime Minister Scott Morrison, demanding a policy rethink and the urgent transfer of children and their families from Nauru, Dr Bartone has maintained the call through numerous media appearances as well as closed-door meetings.  

The Prime Minister initially dismissed the AMA’s call, but since being swamped with expressions of outrage from both inside and outside of his own party – all in the face of a potential by-election loss in Wentworth – he put on the table the prospect of refugees being resettled in New Zealand.

The New Zealand Government has repeatedly offered to take 150 asylum seekers from Nauru, but the offer has been continually met with rejection by the Australian Government.

Opposition Leader Bill Shorten has also received internal and community pressure over Labor’s position on asylum seekers, and so flagged a private member’s bill aimed at making medical transfers from Nauru much simpler.

This all happened in a week when Médecins Sans Frontières confirmed its people had been kicked off of Nauru, and also when the senior Australian doctor contracted by IHMS to provide medical care to the asylum seekers, Dr Nicole Montana, was removed.

Dr Bartone described the developments as “extremely concerning” and pointed to “crisis upon crisis” developing on the island.

“It highlights the confusion and chaos around the medical treatment being provided to a group of very vulnerable people and various stages of medical care required on their behalf,” he told ABC Radio.

“What we’re very clear about is that doctors working on Nauru, or any other processing centre, should be able to deliver the best care, the best appropriate care required by their patients.

“These people are under the care entrusted to the Australian Government, they are responsible for their health and wellbeing while in those centres, and they need to ensure that the provision of medical care is foremost unimpeded in that process.”

Dr Bartone said the AMA was continuing its advocacy on the issue and in addition to wanting all children and their families removed from Nauru, it is calling on the Government to allow an independent delegation of Australian medical professionals to visit the island.

“We need a solution in this area. We need a solution which brings to a head this ongoing crisis. We’re talking about the lives of children, in particular, many in very, very serious states of urgent medical care requirement, and we really do need to know that every day that goes by is another day of suffering for these children in particular,” he said.

What we’re saying is the Government and the appropriate department there is remaining steadfast with the lack of transparency in the approaches, in the information sharing. The information flow is very, very slow, very, very guarded, and very, very piecemeal when it does come our way. This is unacceptable obviously.”

The AMA President has met with Shadow Immigration Minister Shayne Neumann and has said Labor’s proposal is pragmatic – in the absence of anything meaningful coming from the Government – and the AMA was backing it.

“This approach, this legislation, will seek to both reduce the bureaucratic process in this transfer, increase the transparency, increase the medical decision-making powers, and increase the independent medical oversight of the whole medical treatment process on the facilities… and ensure that vulnerable children, in particular, but anyone who requires urgent medical attention is afforded that care, appropriate care, before they get too far down the track,” Dr Bartone said.

“What we know is that if the Minister has the final decision, that needs to be independently verified by a second medical doctor within 24 hours of that decision. That both speeds up the process of the decision-making capacity and it would be a very, very brave Minister who would refuse the advice of two treating doctors, independent, and then have to report back to Parliament in a transparent way to the Australian public that that decision was not proceeded with.”

A number of the Government’s own MPs publicly broke ranks this week to demand action and the urgent removal of children from Nauru.

A host of other medical and health groups, as well as the Law Council of Australia, have backed the AMA’s call for the immediate removal of asylum seeker children and their families off Nauru.

CHRIS JOHNSON

 

Related story:

ausmed/ama-demands-urgent-fix-humanitarian-emergency-nauru

 

 

NSANZ asks Government to clear up PHI concerns over pain management

Neuromodulation Society of Australia and New Zealand (NSANZ) has expressed its concern to the Federal Government that changes to private health insurance could deny access to life-changing pain management for many Australians.

About one-in-three patients prescribed strong opioids for chronic pain misuse them, and up to 12 per cent of these patients develop a strong opioid use disorder.

NSANZ said these numbers could skyrocket if Australian patients are forced to upgrade their insurance policies, or miss-out on pain management treatments with devices.

The organisation pointed to Health Minister Greg Hunt’s promise in July that: “We take the existing policies, no change in price, no change in coverage, but we make it simpler so as everybody can see in one page exactly what is in place.”

Dr Richard Sullivan, pain medicine specialist physician and NSANZ President, Melbourne, called on the Government to make good on that promise.

He said all existing procedures for pain management, including devices, should be made available in Bronze, Silver and Gold policies – not just in the top-tier Gold policies.

“Australian strong opioid-related deaths now exceed heroin deaths by two-and-a-half-times, and estimates suggest more than a quarter of chronic pain patients are misusing prescription strong opioids,” Dr Sullivan said

“These numbers will increase should patients be denied access to chronic pain procedures they currently have under their existing policies.”  

 

 

 

[Comment] FIGO position paper: how to stop the caesarean section epidemic

Worldwide there is an alarming increase in caesarean section (CS) rates. The medical profession on its own cannot reverse this trend. Joint actions with governmental bodies, the health-care insurance industry, and women’s groups are urgently needed to stop unnecessary CSs and enable women and families to be confident of receiving the most appropriate obstetric care for their individual circumstances.

Terms of reference deliberately broad for aged care inquiry

Prime Minister Scott Morrison has unveiled the terms of reference for the Royal Commission into Aged Care Quality and Safety, saying he expected it to uncover some horror stories in the sector.

“I think the country is going to have to brace itself for some difficult stories, some difficult circumstances, some difficult experiences,” Mr Morrison said.

Flanked by Health Minister Greg Hunt and Aged Care Minister Ken Wyatt, the Prime Minister said the Royal Commission wasn’t just about the terrible incidents of abuse and neglect, but also about how to deal with “this problem and this challenge” into the future.

“We need to establish a national culture of respect for senior Australians and Australians as they age,” he said.

The PM has appointed Supreme Court Justice Joseph McGrath and former Australian Public Service Commissioner Lynelle Briggs to head up the Royal Commission.

The inquiry will travel the nation but will be headquartered in Adelaide, the epicentre of neglect in the aged care sector following the uncovering of shocking abuse in the Oakden nursing home there.

The terms of reference are “deliberately broad” and go to the investigation of mistreatment and all forms of abuse; how best to deliver services to people with dementia; and how to care for young disable people living in aged care facilities.

The Royal Commission has until April 2020 to complete its investigation and report to the Government, but must deliver an interim report in October next year.

CHRIS JOHNSON

 

Act now on climate change and health

 

Act now on climate change and health

The AMA has warned the Government not to ignore the future health implications of climate change.

Describing some details in the latest report from the Intergovernmental Panel on Climate Change (IPCC) as “worrying predictions for human health,” AMA President Dr Tony Bartone they simply must not be dismissed.

The just released report – Global Warming of 1.5°C, an IPCC special report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty – highlights the scientifically-based threats to human health that could occur if governments do not act to tackle climate change.

It states that limiting global warming to 1.5°C would require rapid, far-reaching changes in all aspects of society.

But limiting global warming to 1.5°C compared to 2°C could go hand in hand with ensuring a more sustainable and equitable society.

Dr Bartone said the report was consistent with AMA policy.

He added that it reiterated the scientific reality that climate change affects health and wellbeing by increasing the environment and situations in which infectious diseases can be transmitted, and through more extreme weather events, particularly heatwaves.

The IPCC has previously concluded that there is high to very high confidence that climate change will lead to greater risks of injuries, disease, and death due to more intense heatwaves and fires; increased risks of undernutrition; and consequences of reduced labour productivity in vulnerable populations.

“The 2018 report shows that the magnitude of projected heat-related morbidity and mortality would be even greater with global warming at 2°C than by limiting global warming at 1.5°C,” Dr Bartone said.

“The impact on human life is significant. The AMA urges the Government to seriously consider these predictions, and act accordingly.”

According to the Appendix of the 2018 IPCC Report:

  • Years of life lost due to heat-related illness in Brisbane are projected to increase from 616 in 2000, to 1178 at 1.5°C, and then to 2845 at 2°C.
  • In Australia’s five largest cities, with estimated population change, heat-related deaths are projected to increase from a baseline of 214 per year, to 475 per year at 1.5°C, and to 970 per year at 2°C.

Other impacts at 1.5°C compared to 2°C include:

  • A higher increase in ozone-related mortality.
  • A higher risk of malaria due to an expanded geographic range and season of the anopheles mosquito.
  • A higher risk of dengue, yellow fever, and Zika virus due to an increased number and range of the aedes mosquito.
  • A more significant increase in vector-borne disease transmission in North America and Europe, including West Nile Virus and tick-borne diseases.

The IPCC report cites 6,000 scientific references, includes the contribution of thousands of expert and government reviewers worldwide, and was prepared by 91 authors and review editors from 40 countries.

 

JOHN FLANNERY and CHRIS JOHNSON

 

The AMA Position Statement on Climate Change and Human Health is at position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

 

Greetings from the new Secretary-General

BY AMA SECRETARY-GENERAL DR MICHAEL SCHAPER

It’s a great pleasure to take up the role as your new national Secretary-General.

The SG’s role is pretty straight forward: to ensure that the machinery of the national secretariat is working efficiently and effectively, supporting our elected officebearers in their role as the national public face of the profession, and helping the different State and Territory AMAs in their work.

Advocacy and public campaigning is central to the work of the AMA, and to do this well we need to have a sophisticated team of policy personnel, media experts and administrators backing them up.

Doctors and the members of the broader medical community continue to be rated by Australians as one of – if not the – most trusted professions in the country. Medicine matters to everyone. It affects us all, and we need to ensure that Governments always keep this at the centre of their decision-making.

We will continue being active advocates for the sector. AMA members need to be getting value for money, they need to be kept informed of our policy debates and have the chance to contribute to them. We need as many doctors as possible to join, and to get involved.

The federal structure of the organisation needs to be respected and supported, so that local AMAs can also deal with local issues. We also have some great staff working in the Canberra office on your behalf, and I’m keen to attract other high-calibre recruits to join us when vacancies emerge.

Finally, we have to manage the finances of the organisation carefully, and ensure that member funds – your funds – are spent effectively. These are some of the early priorities I’ll be working on.

Previous office-bearers in this position have come from a wide variety of different walks of life: while originally most Secretaries-General were doctors, over the last 30 years the reach has expanded to include lawyers, ministerial advisers, health sector administrators, and a range of others.

My own background is also similarly diverse, with experience in small business advocacy, senior government administration, politics, academia, professional associations and national regulation. (Incidentally, that’s where the “Dr” title comes from – a PhD based on research into some professional practice management issues in the allied health sector.)

Finally, I hope also to be able to get out and meet as many members and local office-bearers as possible. A national organisation has its membership spread right over the country, and I’ll be working with our President to ensure that we both get to meet with, and hear the concerns of, AMA cardholders across Australia.

After all, it’s your organisation, and we’re here to serve you.

 

Paying for performance

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

Assessing the quality of care in general practice can mislead if it is not based on observations of that care. Asking doctors what they have done and judging quality on the basis of medical records is not good enough. 

The perils of judging what happens in the clinical setting on the basis of what doctors record is obvious in a study of a health care funding agency, in this case the NHS, ceasing to pay doctors for providing additional services it regarded as so desirable that for which it had previously provided incentive payments. 

A paper in the September 5 issue of the New England Journal of Medicine by five authors from the National Institute for Health and Care Excellence in the UK [N Engl J Med 2018; 379:948-957 or  www.nejm.org/doi/full/10.1056/NEJMsa180149] used electronic medical records from 2010 to 2017 in UK general practices to assess the effects of removing, in 2014, 12 incentives linked to 12 indicators and compared the outcomes for six indicators where the incentives were maintained.

The study was set in 2,819 English general practices with more than 20 million registered patients. There were big drops – 62 per cent – in records of indicators ‘related to lifestyle counselling for patients with hypertension’ when the incentives were withdrawn.  

The authors noted that reductions in the documentation of clinical processes varied widely among conditions – from a 6 per cent reduction for smoking counselling to a 30 per cent decrease in documenting BMI of 30 per cent among patients with mental illnesses.

The authors observe: “Several studies show that what is gained on incentive introduction is essentially lost on incentive withdrawal.”

But – and here’s the rub – what was gained?  The authors note: “The uncertainty about whether changes in the documentation [my italics] of care represent true changes in patient care.”

We do not know to what extent the reduced documentation of the incentivised clinical behaviours reflected reduced clinical care.

Other than the automatically updated markers (like lab tests) in the records, frequencies of other interventions were measured purely on their action being documented.

It is quite possible that the desired actions were still taking place at a similar rate, but were simply not documented. Ask any busy clinician about how record keeping can diminish when the day is long or when there’s an emergency. It is hardly surprising that documentary markers decrease after removal of incentive.

An example of the disconnect between the record and the action given in the paper is that of prescription of long-term contraceptives. Although the records suggested a fall in prescriptions after the withdrawal of the incentive, actual use assessed from other sources increased.

I hold to the view, based on long observation, including a five-year stint chairing a district health board in Sydney, that our health system would grind to a halt were it not for the altruism of health professionals, including doctors. Yes, getting the right mechanism for paying for health care matters intensely, and doctors are well paid, but creating the conditions where doctors can express and apply more altruism in the system may offer the best yield in clinical care. Worth an experiment, anyway.

Recently I read Out of the Wreckage: A New Politics for an Age of Crisis by British journalist George Monbiot. It is an exciting and optimistic book despite the prevailing uncertainties in many democracies.

A major thesis is that the distinctive human attribute which has led humanity to its current zenith, and which Monbiot considers to be critical to our approach to the future, is altruism – by which he means people looking out for others and caring for them. You can assess the strength of his argument for yourself or watch him on YouTube www.youtube.com/watch?v=uE63Y7srr_Y

If you consider that more needs to be done in improving health care, proceed cautiously with the idea of incentive payments.

Do not be beguiled in assessing their effectiveness by the documentation of process. Rather, measure their effects on actual care and outcomes. And when considering what doctors and other health professionals do day by day and how this might be strengthened, remember that altruism – doing caring things without concern about reward – still ranks highly on the scale of what motivates them.  This is why they do what they do. Make it easier for them.

Invest in quality improvement: Have doctors got the PIPs?

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

While having tried to play a constructive role to date, growing concerns at level of funding that will be available for the Practice Incentives Program (PIP) Quality Improvement Incentive (QII) has seen the AMA Federal Council decide that the AMA cannot support the current cost neutral approach to the introduction of the incentive.

The AMA has delivered a blunt message to the Health Minister – the AMA’s support for this initiative is in peril unless the PIP receives a significant boost in funding.

While the AMA has backed the concept of an incentive to support practices in their quality improvement journey, we have consistently opposed the idea that some practices could finish up worse off. Instead of properly funding the new incentive, the Government has decided to rob Peter to pay Paul. Worthy incentives will be lost including the quality prescribing, cervical screening, asthma, diabetes and the Aged Care Access Incentive (ACAI).

The value of the ACAI must be considered in more than just monetary terms. The results of the recent AMA Aged Care Survey indicated that more than a third of doctors currently providing services to residential aged care facilities (RACFs) would either cut back or cease their visits over the next two years. I don’t think it is a stretch to suggest that the impending loss of the ACAI is a contributing factor.

For general practices struggling to remain viable in the face of seemingly unending cuts and the lingering impact of the MBS freeze, PIP is a vital funding source for general practices. The AMA estimates that an injection of about $44million per annum to the PIP is required to support a meaningful PIP QII so it can deliver on its objectives.

The AMA wants to see practices embrace the QII because it has potential to improve current funding arrangements by recognising the value of quality improvement. Value for the health system, value for the practitioners, value for the patient, and value to the population through better outcomes.

Our data is the key driver to meaningful quality improvement activities. We must collect it, understand what it tells us, and use it to inform our decisions about the quality initiatives that would most benefit our patients. Data-driven quality improvement is the second building block in the Bodenheimer’s 10 building blocks of high-performing primary care. By focusing on this area, we can strengthen the delivery of care to our patients and demonstrate the value of general practice in the health care system.

Good policy requires real foresight and, in cases like this, real investment. Continuing to short change the most cost-effective part of the health system will inevitably lead to downstream costs to the health system. The PIP QII is a good idea, but it is being poorly executed by a Government and Department that needs to stop paying lip-service to the importance of general practice and put their money where their mouth is.