Aboriginal and Torres Strait Islander health organisations: Online Services Report—key results 2014–15

This is the seventh national report on organisations funded by the Australian Government to provide health services to Aboriginal and Torres Strait Islander people. In 2014–15: – 203 organisations provided primary health-care services to around 434,600 clients through 5.0 million client contacts and 3.5 million episodes of care; – 221 counsellors provided social and emotional wellbeing services to around 21,100 clients through 100,200 client contacts; – 67 organisations provided substance-use rehabilitation and treatment services to around 25,200 clients through 151,000 episodes of care.

Death in offshore detention: predictable and preventable

Asylum seeker Hamid Khazaei suddenly became ill last year from a leg infection which escalated to septicaemia. He needed rapid evacuation from Manus Island to receive appropriate specialist medical care. This was delayed by almost 30 hours, by which time he was gravely ill. He died a few days later.

The course of events leading up to Khazaei’s death, while harrowing, came as no surprise. Health professionals have long warned that conditions in offshore detention centres are inhumane, degrading and pose life-threatening risks to asylum seekers and refugees.

Monday’s ABC Four Corners program highlighted a disturbing litany of delays, poor judgement, ill-informed decisions and above all, the serious consequences of a detention system that neglects warnings and fails to heed clinical advice.

Offshore detention centres cannot provide quality health care. Their remote location prevents rapid and accessible specialist level care. Many health professionals have expressed concern about the standard of local health care provided and the absence of transparent, independent oversight.

Doctors’ responsibilities

Few issues have united the health profession as strongly as the dissatisfaction with our country’s response to people fleeing persecution. Australia’s asylum seeker policies prevent health professionals from treating all our patients with clinical excellence, dignity and respect.

The Royal Australasian College of Physicians advised the government in 2015 that:

asylum seekers seeking protection from Australia should not be transferred to, detained or resettled in regional processing countries.

Over the past year, many professional and religious organisations, public protests and social media campaigns have called on the government to “end detention” and expedite the processing of refugee claims in the community.

Under the Australian Border Force Act, health professionals, including those who spoke on the Four Corners program, can be jailed for speaking in public about conditions in immigration detention. This includes unmet health care needs, children suffering abuse, or even severe errors of judgement that could be regarded as criminal or negligent in Australia.

The options for health care professionals are limited: silently accept, speak out and be labelled “whistle-blowers”, or boycott, which presents its own health risks to patients.

The Border Force Act compels health professionals to be complicit with an inadequate and harmful system. It should be repealed without delay.

Harms of detention

Immigration detention is detrimental to the health of people of all ages, both in the short and long term.

A recent review of Australian government mental health screening data reveals that around half of the 215 adult detainees who completed the Harvard Trauma Questionnaire in 2014 had symptoms of post-traumatic stress disorder. On clinician-rated measures, one-third of adults and children had symptoms severe enough to require referral for specialist mental health assessment.

People detained for more than two years have particularly poor health, both mental and physical. Health problems in adults increase with the duration of detention, and include mental health and musculoskeletal problems, dental issues and lacerations.

The most extreme risk is to children. A review of the evidence over the last 15 years in Australia shows immigration detention has harmful health, developmental and psychological consequences for children. It also has negative impacts on parenting. Typical symptoms among children include developmental regression, nightmares, abnormal sleep and toileting, behavioural disturbance, self-harm, depression and anxiety.

Children who have been detained in immigration detention have higher rates of psychiatric disorders than children with similar pre-migration traumatic events who have not been detained.

There is a clear link between the duration of detention and developmental and psychological symptoms. However even brief periods in detention can affect children’s functioning.

Policy response

While we welcome the government’s recent decision to release children and their families from detention facilities in Australia, major issues are unresolved. Nearly 150 children and their families remain on Nauru.

At the end of February, 1,753 people were in mainland immigration detention facilities, and a further 1,379 in offshore facilities.

Those who are released into the community cannot be assured of permanent protection, but face years of uncertainty on temporary visas. These uncertain conditions are harmful to health, with those offered temporary protection experiencing worse health and mental health outcomes than those with permanent protection. This includes an increase in anxiety, depression and post-traumatic stress disorder.

It is not possible to provide high quality and timely health care in offshore detention. And health providers cannot address health issues inherently caused by detention offshore, such as self-harm, suicide or treatment delays caused by inadequate local health care systems. They also face the challenge of bureaucratic barriers over-riding their clinical decisions.

If quality health care in offshore detention cannot be provided, offshore detention simply needs to cease.

Hamid Khazaei’s friend told Four Corners that he “wanted to be a person that Australia would be proud of” and his death should prompt an independent high-level inquest.

We predict that in ten or 20 years there will inevitably be an inquiry to investigate the serious harms inflicted by immigration detention more broadly. We will listen to the stories people will tell and ask ourselves why “good people stood by”.

Karen Zwi, Paediatrician and Associate Professor, UNSW Australia and Nicholas Talley, Pro Vice-Chancellor, Global Research and Laureate Professor of Medicine, University of Newcastle

This article was originally published on The Conversation. Read the original article.

Other doctorportal blogs

Note: Since this article was published in The Conversation, the Papua New Guinea Prime Minister Peter O’Neill has said the Manus Island regional processing centre will be closed following a ruling from the country’s Supreme Court. The Australian Government has been asked to make alternative arrangements for the asylum seekers.

[Articles] Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study

Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies.

Hospital cuts will hurt all

Households face a big jump in health costs and waiting times for treatment will blow out as a result of the Commonwealth’s cuts to public hospital funding.

A report on the impact of the Federal Government’s decision to slash public hospital spending by $57 billion from mid-2017 has found that households, state governments and private insurers will be forced to foot a growing share of the nation’s health bill, while public hospitals will have to increasingly ration their services, forcing many patients to seek treatment in the private system or face lengthy delays.

The analysis was undertaken by consultancy Ernst & Young at the behest of the South Australian Government, and focused on the effects of the slowdown in Commonwealth funding on the South Australian health system.

It found that spending on the state’s public hospitals was increasing at an average 6.7 per cent year, driven by the demands of an expanding but older and sicker population, as well as fixed costs like staff wages and improvements in technology.

But the Commonwealth’s revised funding formula, under which its expenditure will be indexed to population growth and inflation, means its contribution will grow at just 3.4 per cent a year.

If the State Government sustains its current rate of funding growth of 4.9 per cent a year, and the contribution from households and health funds continues to increase by 8.1 per cent a year, the Ernst & Young report warned this would leave a funding hole of 2 per cent a year.

It said this would force changes in the way public hospitals operate, with knock-on effects for the rest of the health system.

To cope with increasing financial constraints, hospitals will increasingly defer less critical or complex cases like tooth extractions and knee procedures, with an increasing proportion of their resources devoted to more complicated cases such as liver and heart transplants.

As a result, Ernst & Young estimated the number of separations handled would drop so that by 2019-20 more than 56,000 patients a year would be left untreated, reaching 107,000 a year by 2024-25.

Patients with less complex or serious ailments would face a choice of an increasingly long wait for treatment or, for those who could afford it, seeking care in the private system.

The report’s authors estimated that about one in five of those waiting for public hospital treatment would instead opt for the private sector, driving increased demand for private health insurance and adding 0.5 per cent a year to premiums.

This in turn would discourage younger, healthier people from taking out or maintaining private health cover, adding further upward pressure to premiums and increasing the cost for the Commonwealth of its private health insurance rebate scheme.

South Australian Premier Jay Weatherill said it was “an unavoidable fact” that the Commonwealth’s cuts would be felt hardest by the most vulnerable.

“But this is not just a South Australian problem,” he said. “This is something that affects every State in Australia. The states and territories simply cannot afford to bear the brunt of these cuts.”

Adrian Rollins

In brief…

How to spend $20bn

Eminent medical researcher Professor Ian Frazer will lead a board charged with advising the Federal Government on investing funds from the $20 billion Medical Research Future Fund.

Professor Frazer, who will be joined by seven other directors drawn from the private sector and academia, will develop the five-year Australian Medical Research and Innovation Strategy, and set priorities every two years.

“The Advisory Board will ensure that any expenditure from the MRFF will have a strong business case, ensuring that the financial assistance provided…delivers the greatest value for all Australians,” Health Minister Sussan Ley said.

E-health overseer

The Commonwealth and the states and territories have agreed to set up the Australian Digital Health Agency to oversee the provision of national electronic health records and other digital health services.

The agency, which will begin operations in July, will be responsible for management of the national digital health strategy, and the design and operation of systems including the Commonwealth’s My Health Record.

Greens target ‘wasteful’ rebate

The Australian Greens would scrap the private health insurance rebate and reinvest the funds in public hospitals.

As political parties sharpen their policies ahead of the Federal election, the Greens have pledged to axe the “wasteful” PHI rebate, freeing up $10 billion over four years which would be redirected to the public hospital system.

Greens leader and public health specialist Dr Richard Di Natale said his party would also reinstate the joint Federal-State hospital funding model scrapped by the Coalition so that the Commonwealth would match 50 per cent of the efficient growth in hospital costs, with the change enshrined in law.

Trial run

The nation’s health ministers have committed to making Australia more attractive for clinical trials to boost investment and improve access to new medicines.

The ministers said that more needed to be done to make Australia a preferred location for clinical trials, including reducing fragmentation and inefficiencies. They have asked the Australian Health Ministers’ Advisory Council to develop options to organise sites, increase administrative efficiencies, improve engagement with sponsors, and reduce trial start-up times.

All the same

The nation’s hospitals will save $270 million over the next decade with the introduction of single standardised chart for the supply and reimbursement of Pharmaceutical Benefit Scheme medicines.

Commonwealth, state and territory health ministers have agreed to harmonise legislation to allow for the use of the standardised chart, in a move that will ease the regulatory burden on prescribers, pharmacists and nurses, improve patient safety and cut hospital administration overheads by around $27 a year. The new charts will be available from July.

A joint approach

The Commonwealth and the states will look at opportunities to jointly commission mental health services, including through Primary Healthcare Networks, following an agreement struck at the COAG Health Council meeting.

The agreement was suggested by the Queensland Government, which emphasised the need to identify opportunities for the joint commissioning of services across the Commonwealth and state-funded health services “[to] support a more integrated approach to service delivery and reduce any potential duplication”.

The meeting agreed that mental health was one of the areas where opportunities for joint commissioning would be explored, and called on PHNs to work with Local Health Networks to “align mental health commissioning efforts” from July.

Adrian Rollins

Preparing for change in aged care and e-health

The AMA has advocated for some time to secure the appropriate recognition and resourcing of medical care for older Australians. This is even more necessary now given that 15 per cent of the population are over 65 years of age, and the proportion continues to grow.

The Medical Practice Committee, in conjunction with the AMA Council of General Practice, developed a submission in response to the Senate Standing Committee on Community Affairs Inquiry into the Future of Australia’s Aged Care Sector
Workforce.

The AMA argued strongly that the aged care sector must evolve to be able to care for older Australians while preserving a person’s access to quality medical care. The AMA’s submission highlighted that medical practitioners, especially general practitioners, are underutilised in the provision of care for the ageing. This leads to a substandard outcome for the patient, and inefficiencies for the practitioner and the health system.

The AMA also recommended that providers of aged care should have arrangements in place to ensure that residents’ needs for medical care are identified promptly, and that they receive ongoing access to medical care, preferably within the aged care facility. Strategies to achieve this include:

ensuring adequate numbers of appropriately skilled nurses are employed;
having management practices in place to ensure residents who require medical attention from a doctor are identified quickly, and that the appropriate doctor is contacted;
providing doctors with access to properly equipped clinical treatment rooms that provide patient privacy; and
providing doctors with access to information technology infrastructure, and patient records, so ensure continuity of care.

The key message is that medical practitioners are an essential component of the aged care workforce.

The AMA submission was lodged on 4 March and is published on the AMA’s website at: submission/ama-submission-senate-community-affairs-in…

Medical Practice Committee is also reviewing the AMA’s policy and position on shared electronic medical records.

In March this year, the Government relaunched My Health Record (previously the Personally Controlled Electronic Health Record), announcing two trials of ‘opt-out’ arrangements as the basis for patients to participate in, as well as a new legislative framework.

The ongoing review and updating of our policies will ensure a rapid and informed response to any new Government proposals as a result of the trials.

We will be reviewing the AMA’s position statement Shared Electronic Medical Records (2010) to ensure it still clearly defines the needs of clinicians in relation to shared electronic medical records.

Of particular concern is a requirement that core clinical information is reliably available (not subject to access controls); that governance arrangements include the real involvement of clinicians; and that medical specialists and GPs are supported to make full use of electronic medical records.

I welcome any comments on either the AMA’s position on aged care or electronic medical records to ama@ama.com.au.

Assisted dying laws spread as euthanasia debate intensifies

Canada and California are set to join several European countries and US states in legalising doctor-assisted deaths amid calls for Australia to follow suit.

Canada is on track to allow physician-assisted dying from 6 June after the Trudeau Government introduced legislation to the Canadian Parliament, while the practice is set to become law in California on 9 June, nine months after a Bill was passed by the State’s legislature.

The international developments have come as debate about euthanasia in Australia intensifies.

High profile entertainer Andrew Denton has become a passionate advocate for legalising euthanasia, and last week he was joined by former Prime Minister Bob Hawke, who said it was “absurd” that patients in pain could not ask their doctor to help end their life.

“I think it is absurd that we should say that it is illegal that a person who is suffering terribly, and is in an irremediable condition, should be forced to continue to suffer,” Mr Hawke said in an interview on Mr Denton’s Better Off Dead podcast series. “It doesn’t meet any requirements of morality or good sense.”

Euthanasia will be debated in a policy session at the annual AMA National Conference next month, and the AMA’s Ethics and Medico-legal Committee is conducting a survey of member views on the issue as part of a review of the peak medical organisation’s policy on assisted dying.

Under the Canadian legislation, only adults with serious and irreversible medical conditions may seek a doctor-assisted death. They must apply in writing, with two witnesses, and the request must be evaluated by two doctors or nurses. Even once a request is granted there is a mandatory 15-day waiting period.

To prevent an influx of people from other countries seeking to avail themselves of the new law, it only applies to those eligible for Canadian Government-funded health services.

Under the new Californian laws, a person seeking assisted death must first have undergone rigorous questioning to determine that they were of sound mind and understood what they were seeking, and two doctors must have agreed that they had less than six months to live.

Opponents often fret that such laws will trigger a rash of doctor-assisted suicides, but experience in areas where they are in place suggests this is unlikely. In almost 20 years since similar legislation came into effect in Oregon, The Economist reported fewer than 1000 people have used it to take their own lives.

California’s Department of Health Care Services has estimated that in its first year, fewer than 450 seriously ill people will seek a prescription of lethal drugs through the Medicaid program, and even less will actually use them.

Adrian Rollins

Diabetes affects almost one in 10

Diabetes is rapidly emerging as one of the world’s most serious public health problems, affecting almost 500 million adults and contributing to the deaths of close to four million people a year.

An alarming report from the World Health Organization has found that incidence of diabetes, once mainly confined to high income countries, is rapidly spreading, and by 2014 422 million adults were living with the disease – almost one in every 10 adults worldwide. In 1980, its prevalence among adults was less than 5 per cent.

WHO Director-General Dr Margaret Chan said the disease’s emergence in low- and middle-income countries was particularly problematic because they often lacked the resources to adequately diagnose and manage the disease, resulting in needless complications and premature deaths.

According to the WHO’s Global Report on Diabetes, the condition was directly responsible for 1.5 million deaths in 2012 and contributed to a further 2.2 million fatalities by increasing the risk of cardiovascular and other diseases.

Diabetes takes a relatively heavy toll of younger people, particularly in less wealthy countries. Of the 3.7 million deaths linked to diabetes in 2012, 43 per cent occurred in people younger than 70 years of age, and the proportion was even higher in low- and middle-income countries.

The rise in diabetes has coincided with an increase in associated risk factors, most particularly a jump in global rates of overweight and obesity. Currently, 10.8 per cent of men and 14.9 per cent of women worldwide are considered to be obese, and on current trends that will increase to 18 per cent of men and 21 per cent of women by 2025.

While rates of obesity and diabetes are continuing to climb in rich countries, the WHO said this is being outstripped in other parts of the world, particularly middle-income nations.

The relative lack of resources to prevent, diagnose and manage diabetes in less wealthy countries is exacerbating its spread and impact.

Programs and policies to encourage physical activity, promote health diets, avoid smoking and controlling blood pressure and lipids are generally better funded in rich countries, where GPs and other frontline health services are better equipped to detect diabetes early and patients generally have good access to insulin and other treatments.

The WHO said that even though most countries have national diabetes policies in place, often they lack for funding and implementation.

“In general, primary health care practitioners in low-income countries do not have access to the basic technologies needed to help people with diabetes properly manage their disease,” the agency said. “Only one in three low- and middle-income countries report that the most basic technologies for diabetes diagnosis and management are generally available in primary health care facilities.”

In particular, it highlighted serious problems with access to treatments.

“The lack of access to affordable insulin remains a key impediment to successful treatment and results in needless complications and premature deaths,” the WHO report said. “Insulin and oral hypoglycaemic agents are reported as generally available in only a minority of low-income countries. Moreover, essential medicines critical to gaining control of diabetes, such as agents to lower blood pressure and lipid levels, are frequently unavailable in low- and middle-income countries.”

Diabetes has been identified as one of four priority non communicable diseases targeted under the 2030 Agenda for Sustainable Development, but Dr Chan said the WHO report showed there was “an enormous task at hand”.

“From the analysis it is clear we need stronger responses not only from different sectors of government, but also from civil society and people with diabetes themselves, and also producers of food and manufacturers of medicines and medical technologies,” the WHO leader said.

Adrian Rollins

Maelstrom of money blows over wind farms

The nation’s peak medical research organisation has committed more than $3 million to investigate whether or not wind farms effect human health amid ongoing controversy on the issue.

There have been persistent claims that wind farms are responsible for a range of health problems despite a lack of evidence, and the National Health and Medical Research Council (NHMRC) has commissioned two studies to try to determine if there is a link.

The Sydney-based Woolcock Institute of Medical Research has been awarded $1.94 million to conduct two randomised controlled trials to examine whether inaudible sounds emanating from wind turbines are causing health problems including headaches, dizziness, nausea and sleep disturbances, while a Flinders University researcher has been provided with $1.36 million to compare the relative effects of wind farms and traffic noise on sleep.

The announcement has come less than a year after the NHMRC completed its own exhaustive study, which found that there was “currently no consistent evidence that wind farms cause adverse effects in humans”.

A year earlier, the AMA had come to a similar conclusion. In a Position Statement released in 2014, the AMA found that “available Australian and international evidence does not support the view that the…sound generated by wind farms…causes adverse health effects”.

The-then Chair of the AMA’s Public Health Committee, Professor Geoffrey Dobb, said that although some people living near wind farms may genuinely experience health problems, these were not directly attributable to wind turbines.

Instead, it has been suggested many may be suffering from a ‘nocebo’ effect, and are becoming ill because of anxiety and dislike of wind farms rather than as a result of any sounds emanating from them.

But this has been vociferously rejected by advocates, who insist the health effects are real, and have campaigned hard for more research.

They have influential political backers in Parliament, including senior Nationals MPs and key crossbench senators, and found a receptive audience in former Prime Minister Tony Abbott. Under Mr Abbott’s leadership, the Government appointed a National Wind Farm Commissioner to monitor and investigate complaints about the wind industry, and established an Independent Scientific Committee on Wind Turbines to advise on the potential health and environmental effects of the industry, at a combined cost of more than $2.5 million over four years.

An investigation by Fairfax Media has found that a third of all complaints to the Commissioner have related to wind farms not yet constructed, while the Scientific Committee has held just two brief meetings since it was formed and is yet to provide any advice to Government.

A leading critic of the Government’s policy agenda, including the NHMRC’s research program, Sydney University public health expert Professor Simon Chapman, said internationally there had been at least 25 reviews which found little evidence that wind farms harmed health.

Professor Chapman told the Sydney Morning Herald the health effects that did exist could be put down psycho-social factors like pre-existing antipathy to wind farms and anxiety, and the research was a waste of money.

“It’s really quite disgraceful – it’s money literally poured down the drain,” he told the SMH.

But lead researcher for the Woolcock project, Professor Guy Marks, defended the research, arguing that there existed a “genuine scientific question that needs to be solved”.

“This is a hotly debated area, with many residents convinced that their health is suffering, and other people sure that it’s all a figment of their imagination,” Professor Marks said.

“As far as I am concerned, the science isn’t settled yet [and] it’s important to find out, for the sake of the communities and interests involved,” his co-researcher, Professor Ron Grunstein, said.

But even if the Woolcock and Flinders University studies find that there is no link, few expect it to be the end of the matter.

“Regardless of what we find, there will be passionate advocates that will never be convinced of our conclusion,” Professor Grunstein admitted.

The AMA Position Statement on Wind Farms and Health 2014 can be viewed at: position-statement/wind-farms-and-health-2014

Adrian Rollins

Fight to save GP research BEACH project after closure announced

The medical community has been in uproar this week with the announcement that Australia’s largest GP research program, the Sydney University BEACH project, would be shut down in June this year.

BEACH has been running for 18 years and collects information about clinical activities in general practice.

Its closure will leave: “very little reliable, independent national information about GP clinical activity in the future,” Director of the Family Medicine Research Centre, University of Sydney, Professor Helena Britt said in a statement.

Professor Britt explained that funding from the Department of Health ceased after June 30^th this year.

“BEACH has always struggled to gain sufficient funds each year. However, this notification comes when we also have a large shortfall in funding coming from other organisations such as NGOs and pharmaceutical companies, due to closure of many Government instrumentalities and authorities, and the heavy squeeze on pharmaceutical companies’ profits, resulting from changes to the PBS,” she wrote.

However there is hope, with an announcement late on Monday that the University of Sydney is looking into a range of options to ensure the continuing operation of BEACH over the next 12 months while it develops a longer term future plan with the Family Medicine Research Centre.

There has been shock and disappointment felt in the medical community.

RACGP President Dr Frank R Jones said the closure was a ‘bitter loss’.

“BEACH data allows us to measure patterns and change over time, providing valuable insight into the delivery of patient care, including consultation time, the number of problems managed in each encounter, and treatment provided. None of this can be gleaned from the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and hospital data,” he said.

Over 5000 citations of the BEACH program have been made in medical journals and publications over the past 18 years, according to Dr Jones.

“There is no logic to this move. It has simply added insult to injury for general practice,” he said.

“BEACH data has made a critical contribution to primary healthcare policy, providing the evidence by which decisions can be made by government.”

The Australian Medical Association President Professor Brian Owler said he had written to Health Minister Sussan Ley to urge her to reconsider.

He said the Commonwealth had contributed just $4.6 million of the $26 million that had been used to fund the BEACH program over the years.

“This is a very small investment that has delivered significant policy outcomes and, with all the changes planned for general practice and primary care, I think there is a very strong case to extend funding for the program,” he said.

Professor Britt told the AMA’s Australian Medicine she had been inundated with inquiries and messages of support from individuals and groups around the country and internationally.

She said one of the biggest concerns is what will happen to the data accumulated through the program’s 18 years of operation, during which time more than 11,000 GPs have been surveyed.

Professor Britt said her group was looking at ways to ensure people would continue to have access to it.

“We would be happy to find a place with a senior analyst who could take request to analyse the data for specific purposes,” she said. “We would like to be able to keep that access up there for at least a little while.”

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