more_vertAmid the raging US Civil War, Abraham Lincoln, the nation’s 16th President, vowed that America’s “government of the people, by the people, for the people, shall not perish from the earth”. At a time of deep ideological and political schism, it was a notion of government predicated on promoting the welfare—and wellbeing—of its citizens. With the 45th presidency of Donald Trump, that foundational vision has come under siege and the US Government and its commitments are at risk of capture by a privileged few for private gain.
Preference: Government and politics
[Editorial] NCD Countdown 2030: strengthening accountability
One of the most powerful forces to emerge from the MDG era has been the idea of accountability. At its most elementary level, accountability means holding those with responsibility for health accountable for their commitments. It is a controversial concept. Few governments wish to be judged by their actions. Global health is replete with pledges, agreements, and declarations guaranteeing outcomes. A Marshall Plan for west Africa after Ebola? Financial assistance to deliver universal health coverage? Scaling up human resources for health? Empty promises.
AMA demands urgent fix to humanitarian emergency on Nauru
AMA demands urgent fix to humanitarian emergency on Nauru
The AMA has called on the Government to urgently transfer refugee families from Nauru, describing the situation there as a humanitarian emergency.
In a letter to Prime Minister Scott Morrison, AMA President Dr Tony Bartone urged a policy rethink and demanded that asylum seeker children and their families be removed from Nauru as a matter of priority.
Dr Bartone said deteriorating physical and mental health among refugee children and their families meant they should be relocated to more appropriate places, preferably in mainland Australia.
“Put bluntly, we want some urgent action to help these vulnerable people who find themselves in a hopeless, despairing situation,” Dr Bartone wrote in his letter to the PM.
“The AMA has been calling for a more humanitarian approach, including independent assessment of health care arrangements, for many years now.
“The medical situation for the children on Nauru has been described by health experts, including medical staff who have worked on Nauru, as critical and getting worse. It is a humanitarian emergency requiring urgent intervention.
“We have been given some hope at the bureaucratic level, but a slammed door at the political level.
“The AMA and the medical profession are demanding a change of policy – a change of policy that reflects community concern for the health of asylum seekers.”
Dr Bartone said the AMA wants to see a more compassionate Government approach to the health care of refugees and asylum seekers in the care of the Australian Government.
He said there had been a recent groundswell of concern and agitation across the AMA membership and the medical profession about conditions on Nauru and the escalation in reports of catastrophic mental and physical health conditions being experienced by the asylum seekers, especially children.
“As a suburban Melbourne GP for more than 30 years, and a grassroots Australian with strong community connections and Christian values, I passionately believe we can and must do more to look after the health of these people, many of whom have fled war, conflict, or persecution,” he wrote.
“There are now too many credible reports concerning the effects of long-term detention and uncertainty on the physical and mental health of asylum seekers.
“It is within the power of the Government to move on this issue and play its part in allowing traumatised people to begin rebuilding their lives.
“Australia is a caring nation with a long history of compassion and respect for human rights. We need to show the Australian people and the world that we are still a caring nation.
“The AMA believes that asylum seeker children and their families on Nauru must be removed and given access to physical and mental health care of an appropriate standard.”
Dr Bartone repeated the AMA’s call for the Government to facilitate access to Nauru for a delegation of Australian medical professionals to assess the health and welfare of child refugees and asylum seekers.
“This includes access to the children and their families and/or carers, the International Health and Medical Services (IHMS) medical professionals administering to the children, and any Nauruan Government officials administering to the children,” he said.
“Membership of the delegation would be determined in consultation with the AMA and the delegation would make public the findings of its inspections and interviews to assure the Australian public that the Australian Government has done all that is possible to protect the health and wellbeing of asylum seekers and refugees.”
In a separate letter to all MPs and Senators urging support and advocacy for the AMA position, Dr Bartone reminded politicians that, in April 2017, the Senate Legal and Constitutional Affairs Committee released the report of its inquiry into asylum seekers on Nauru.
The inquiry made two recommendations about the availability of medical services and medical transfers:
- Recommendation 1: The committee recommends that the Department of Immigration and Border Protection, as a matter of urgency, commission an external review of its medical transfer procedures in offshore processing centres.
- Recommendation 2: The committee recommends that the Australian Government undertake to seek advice in relation to whether improvements are required to the medical treatment options available to asylum seekers and refugees in the Republic of Nauru and Papua New Guinea, particularly mental health services.
The Government has not yet responded to the inquiry.
Dr Bartone praised the hard work and dedication of doctors and health workers who have been providing care with IHMS on Nauru.
“These health professionals and their employer have been doing their best in very trying conditions in isolation – and under a veil of secrecy not of their doing,” Dr Bartone said.
“The Government must get fair dinkum and give these long-suffering asylum seeker children, many of whom are extremely ill, and their families a fair go – bring them to Australia for proper care in the best possible environment for their severe mental and physical health conditions.”
There are about 100 children on Nauru. Many have been in detention long-term. Media reports suggest about 20 of the children are refusing food and fluids.
CHRIS JOHNSON
Royal Commission set to look into aged care quality and safety
The AMA has welcomed the Federal Government’s commitment to launch a Royal Commission into Aged Care Quality and Safety.
The Royal Commission is expected to investigate the quality of care in private and government-run aged care homes following the exposure of cases of neglect, elder abuse, and a lack of staff.
The ABC’s Four Corners program will screen a two-part investigation into the treatment of older Australians in aged care homes.
AMA President, Dr Tony Bartone, said that the AMA has for many years voiced serious concerns about the care being given to older Australians, and the lack of resourcing to a sector that provides care to people who deserve special support at a vulnerable time in their lives.
“The AMA has long called for reform of the aged care sector,” Dr Bartone, a GP in Melbourne who regularly visits residential aged care facilities, said.
“There is a serious lack of resources. There is a serious lack of staff. And there is a serious lack of coordination between all the sectors involved in caring for older Australians.”
Dr Bartone said it was a certainity that the Royal Commission will uncover uncomfortable and distressing stories, and systemic failures.
“The AMA has made consistent and repeated approaches to Government about the need for better resourcing and regulation of the aged care sector,” he said.
“The most recent AMA Aged Care Survey found that one in three doctors plan to cut back on or completely end their visits to patients in residential aged care facilities over the next two years. The Survey also found there are not enough suitably trained and experienced nurses in aged care.
“There must be proper planning to ensure that medical, nursing, and other specialised care are built into the design and operation of aged care facilities.
“The AMA hopes that the Royal Commission will give victims a voice, and lead to real reform of a sector that has been woefully neglected for decades.
“We need to see the ‘care’ put back into aged care.”
Need for stability in health leadership
BY AMA PRESIDENT DR TONY BARTONE
Last month’s leadership spills, which resulted in Australia having a new Prime Minister in Scott Morrison, almost delivered us the fourth Health Minister in five years. That would have been a disaster; especially with an election no more than nine months away (maybe even less).
Since the Coalition was elected in 2013, we have seen Peter Dutton and Sussan Ley come and go, and Greg Hunt resign as Health Minister amid the Government’s leadership chaos.
Prime Minister Morrison could easily have left Greg Hunt out of his new Ministry, but he chose not to. He opted for consistency and stability. He made the right call.
In January 2017, Greg Hunt became Health Minister at a difficult time. His predecessor, Sussan Ley, left the portfolio in controversial circumstances. He inherited a lot of unfinished business.
To his credit, he worked hard from day one to get across his new portfolio, one of the toughest in politics, and he went out of his way to build personal relationships with the leaders of all the major stakeholders.
He worked closely with my predecessor, Dr Michael Gannon, and I am pleased that close relationship has extended to my Presidency, talking regularly on the phone and meeting often in person.
As Health Minister you need to understand the many issues and numerous policies and all the potholes and roadblocks in health to appreciate the vital need to have consistent leadership at the top of the Health Ministry.
It takes months to get across the detail and to get to know the key people.
Greg Hunt had to almost immediately deal with the fallout of the GP co-payment fiasco and the slow burn of the Medicare rebate freeze, which were undermining all efforts by the Government to be on the front foot on a range of policies – anything but the cursed co-payment and the feared freeze.
He fought hard within Cabinet to achieve the gradual lifting of the Medicare freeze.
He has had to gain thorough knowledge of the complex MBS Review process.
There was the ongoing review of Private Health Insurance and out of pocket expenses.
The rollout of the My Health Record.
The problems with the Health Care Homes trial.
Then there were the more tricky and delicate issues of mandatory reporting, medical workforce, climate change and health, the health of asylum seekers, Indigenous health, and mental health, to name but a few.
Add to this the complexities of the PBS, immunisation, and issues pertaining to scope of practice – the so-called ‘turf wars’.
Then he had to consider contemporary major issues like aged care reform and the issue that we want him to concentrate on right now ahead of the election – general practice reform and investment.
It takes time to learn to be a Health Minister. And it takes even more time to become a good Health Minister. Greg Hunt has been easy to work with and always ready to listen.
That is why we went public with our calls for Greg Hunt to be re-appointed Health Minister in the new Ministry. Prime Minister Morrison obliged. A smart move I would say. If the Coalition had changed Ministers, their policy agenda would have drifted and left them extremely vulnerable on a sensitive policy front.
I met with Minister Hunt in the week of the election spills, when he was still the Minster, and we have spoken in the days that followed and since he was re-appointed.
Continuity of care is always important, even in politics. The AMA will build on this close relationship to improve health policy ahead of the next election.
Equally; I have also met with Opposition Leader, Bill Shorten, in recent weeks.
The AMA is in regular contact with Shadow Minister Catherine King, the Greens, and any party or Independent with an interest in good health policy.
It is important that all sides of the political divide understand and appreciate our health policies and why they are important to the Australian people. Our patients, their families and the community deserve no less.
Let me be very clear in assuring all that the AMA is in a very good position to influence health policy across the political spectrum in the months before the election, and even better placed to pass judgement on the health policies once the campaign itself is in full swing.
The profession must help solve the egregious fees problem
BY AMA VICE PRESIDENT DR CHRIS ZAPPALA
This issue will not go away.
The shrill voices of opposition and those zealously defending their own turf (by blaming doctors) will only get more stentorian and insistent. The health funds, all hatching plans for managed care, are desperately trying to preserve their $1.8 billion profit. The politicians want to claim victory in increasing bulk billing rates without having to pay as much as they should either. The Government must be delighted with the emerging public expectation that bulk billing is a fair price for medical care – it is lamentable that we have not been more effective at changing this view. Our medico-political strategy perhaps needs to change here…
Dr Linda Swan, Chief Medical Officer for Medibank, recently made the point in The Australian that cost is not an indicator of quality (in health care). This is not true though, is it? While high fees might not always correlate with high quality (but absolutely can correlate), you can be fairly certain that low cost will always put quality in jeopardy. The saying ‘cheap and nasty’ has real meaning. If Government designs a budget, no frills, ‘free’ healthcare system it will necessarily produce a budget health outcome – as occurs in everything else in life. We have no problem generally accepting this truth and moreover, paying for quality when we perceive it elsewhere – the same should also apply for health care.
The extension of this observation is that we should not be ashamed to value ourselves properly. We work long hours, get woken in the middle of the night to come into work, accept significant responsibility and continuing education (which is costly), and so on… While in theory we can charge whatever we want – as can any other professional, business, sole proprietor etc – it does not mean we can obfuscate when it comes to explaining our fees. Patients should always have a choice not to proceed and an appropriate ability to ask questions. Regretfully, this does not always occur and I do not think anyone really regards this as appropriate.
There are three points that need to be underlined in this discussion and that we must find a way to have Government and our patients clearly understand.
- If we keep wanting a bargain basement health service (i.e. bulk billing) we must expect quality cannot be achieved in all circumstances.
- Bulk billing and health insurance rebates are not designed with the true costs of medicine – rather, funders wish to pay the least they can to preserve profits or for Government to spend money on something else (it really would be refreshing if Government and the health funds cracked open the AMA fees list and took heed).
- You get what you pay (or don’t pay) for.
Having said all of this, there are some doctors’ fees that do seem excessive, i.e. many times above the AMA fees (which have kept pace with inflation over time and better represent fair value and the cost of practice). Quite clearly, we need to be honest with patients about the full costs of their care before it happens when they still have time to opt out and ask questions. The huge majority of the profession agree that booking/administrative fees are not appropriate. Even if we were wavering on this issue, we must realise that patients (plus Government and funders) are going to be increasingly derisive of this practice. Let’s please deal with all of this now in our own way rather than have to endure an imposed solution from one of the funders who remain conflicted by their desire to pay as little as possible.
There are four initial solutions that we, the profession, should consider implementing immediately.
- Administrative/booking fees must go. Bill honestly and up front.
- Obtain informed and signed financial consent from all patients (if you cannot give an exact price give a reasonable range and stick to it).
- Allow an appropriate ‘cooling off’ period for the patient to consider options and opt out if they desire.
- Let’s develop a definition of what is unequivocally ‘egregious’ billing and develop a credible strategy of how we deal with this.
Health funds and Government are going to define their own version of what is appropriate or not, so the profession should take the lead. We must preserve a system that rewards increased effort or superior skill, otherwise everyone just regresses to the mean where there is no incentive to do anything other than the bare minimum. We cannot strike this happy medium that preserves ‘fee for service’ medicine if the few outliers do not realise the harm they are doing to us all.
New taskforce to battle HTLV-1
BY AMA PRESIDENT DR TONY BARTONE
The Federal Government recently announced the formation of a new taskforce consisting of relevant health care providers, researchers, clinicians, and all levels of government to combat HTLV-1 in remote Indigenous communities.
Human T-cell lymphotropic virus (HTLV) – an oncogenic virus first discovered in 1979, and the first retrovirus to be discovered – predominantly affects CD4+T cells, which play an important role in the body’s immune system.
HTLV-1 infects up to 20 million people globally, with the virus prevalent in south-western Japan and the developing countries of the Caribbean basin, South Americ, and sub-Saharan Africa.
HTLV-1 was first detected in 1988 in Central Australia in the Indigenous population, and recent studies indicate that 45 per cent of Indigenous adults who reside in remote communities in Central Australia have been infected with HTLV-1.
Commonly transmitted through contaminated blood, unprotected sex, and breast milk, the virus is associated with a fatal haematological malignancy – Adult T cell Leukemia/Lymphoma (ATLL) – and inflammatory diseases involving organs including the spinal cord, eyes, and lungs.
In Indigenous Australians, the most typical clinical manifestation of HTLV-1 is bronchiectasis (a condition in which the airways of the lungs become damaged).
The extent and seriousness of the disease is dependent on the viral load in the blood stream.
Uveitis (inflammation of the middle layer of tissue in the eye) is another serious complication of HTLV-1, which was found through a case study done in Central Australia.
It can result in blindness, so it is important for treating professionals to be well informed about HTLV-1.
Unfortunately, there are no treatments currently available for HTLV-1 infection, but the following prevention strategies could result in the reduction of transmission and, ultimately, the eradication of the virus:
- Encourage the use of condoms among the sexually active population, and routine testing for HTLV-1 in areas where the virus is prevalent.
- Organ donors and blood transfusion products should be tested, and transfusions and transplantations avoided where testing shows a positive result. Monitoring and follow-up are vital in these instances.
- Mothers who test positive to HTLV-1 should be advised to avoid breastfeeding or reduce it to three to six months, and alternative methods of infant feeding should be advised.
- Injecting drug users should be educated and advised to use sterile needles, and regular testing for HTLV-1 should be available.
- Evidence-based and up-to-date information regarding HTLV-1 should be available to health care providers so they can educate their clients on how to protect themselves.
The AMA supports an enhanced focus on Aboriginal and Torres Strait Islander people at risk of blood-borne viruses, including specific resourcing of management and research to address HTLV-1.
This is consistent with the AMA’s active participation in the Close the Gap strategy, and our series of Indigenous Health Report Cards, which have highlighted diseases such as rheumatic heart disease and otitis media, and which later this year will provide an audit of success or failure in Indigenous health policy over the past decade.
On top of this, the AMA supports other policies and initiatives that aim to reduce preventable diseases, many of which have an unacceptably high prevalence in remote Indigenous communities.
The AMA remains committed to working in partnership with Aboriginal and Torres Strait Islander groups to advocate for Government investment and cohesive and coordinated strategies to improve health outcomes for Indigenous people.
Increasing the length of internship – what will we actually achieve?
BY DR CHRIS WILSON, CO-DEPUTY CHAIR AMA COUNCIL OF DOCTORS IN TRAINING
In 2015, a COAG review of Australian Medical Intern Training was completed. The intent of the review was to look at the internship model and assess if internship was producing “fit for purpose” clinicians. As part of the review, four models for change were proposed. Model A, the least revolutionary with no significant change to the structure but increased access to non-traditional settings including general practice, was the most preferred by doctors in training. Model B proposed shifting from a time-based internship to one focussed on specific mandatory skills and exposure to the “patient journey” and “different care contexts”. Models C and D were more revolutionary, with a proposed two year program either starting in the final university year or covering the first two postgraduate years.
As mentioned, the opinion of the AMA CDT and DiTs across the country at the time of the review was that, while there is always room for improvement, internship is not broken. Despite this, after the release of a COAG Health Council response to the review in July this year, we look to be pressing towards the two year model.
In a postgraduate world, internship commencing during university would be unworkable for obvious reasons, so the current preferred model is an internship covering PGY1 and 2.
While on the surface this looks like significant change, what does the second year actually achieve? There is agreement that general registration should be granted after successfully completing the first year, as it is now, so no change on the registration front. If it comes with increased opportunities for exposure to patients across the health spectrum and more structured learning, this will be to the advantage of doctors in training, the healthcare system and in the long run, our patients. It’s not clear though how this would be distinguishable from the current roles undertaken by PGY2 doctors. Changing the role title to ‘intern’ does not automatically reduce the service requirements and increase the educational value of rotations – someone still has to write the discharge summaries.
One potential benefit would be an expectation that all rotations are accredited as suitable training environments by a Medical Board delegate (like the Post Graduate Medical Councils). Thankfully, this already happens in most jurisdictions, however, there is a danger that without additional resources, regions where it is not standard to accredit beyond PGY1 could see their accreditation processes watered down to meet demand. Currently, the federal body responsible for the coordination of State/Territory-based accreditation bodies, the Confederation of Postgraduate Medical Education Councils, remains unfunded. It seems absurd for the Government to push for change in the makeup of internship yet not fund the body responsible for enacting it.
Should we move to a two year model, we would also expect doctors in training be able to obtain job surety over the period of internship in the form of a minimum two year contract. This would be a sign of good faith from employing health services that they intend to train and support their doctors in training during this transition period.
AMA CDT’s position in 2015 was that internship is not broken and that position remains unchanged. Without tackling the creep of increasing service need forcing education and training to become ancillary components of internship, it’s hard to see a second year bringing with it much improvement.
Summit emphasises need for national medical workforce strategy
By AMA VICE PRESIDENT DR CHRIS ZAPPALA
The Medical Workforce and Training Summit convened by the AMA in March, the first since 2010, is notable. The Summit drove home the importance of ending the expansion of medical schools, finding strategies to address workforce maldistribution and ending the poor coordination between the Commonwealth and State governments when it comes to workforce planning and training. If we are to preserve the public-private balance in medicine with a focus on quality, then we need to help Government solve this problem. It’s vital that the Summit’s call for a national medical workforce strategy overseen by the nation’s health ministers will be heeded.
Australia is now becoming saturated with doctors, as emphasised by recent workforce data. AIHW projects that there will be an oversupply of at least 5,000 doctors in 2020 (I suspect this is under-estimated). The prospect of organising vocational training for all these graduates is daunting and as we are currently finding, not really feasible. Some Colleges are training record numbers of trainees with, it appears, no real sense of what all of these specialists are going to do.
Everyone must make a living somehow, so this is when we see fringe medical practices emerge and the enervating effects of bulkbilling become prominent. The obstetricians provide a worsening example of this problem. Ultimately high quality, ‘fee-for-service’ medicine is in jeopardy and we set the stage for an indentured medical workforce trapped in managed care practices without independent decision-making, public practice (which will always be underfunded) or doing something else.
A 2015 OECD study showed that Australia has the highest medical graduate rate per capita with 3.4 per 1000, compared to New Zealand and the United Kingdom (2.8 per 1000) and the United States and Canada (2.6 per 1000), with Australian medical graduate numbers more than doubling in the past decade. We will graduate just under 4,000 new doctors in 2018 and this number will increase as Curtin and Macquarie Universities come online with increased Commonwealth places over the next couple of years. Unemployment looms……
It is estimated there will be 118,803 doctors registered in Australia in 2019. This compares to 79,653 employed in medicine in 2012. Health Workforce Australia estimated our doctor to patient ratio has increased to 3.6/1,000 which is well above the OECD average of 3.2/1,000 and well above the UK (2.8/1,000) and USA (2.5/1,000).
The universities like the thought of their graduates getting jobs but this is unashamedly not their primary concern. They are not concerned at the prospect of their graduates obtaining vocational training. They are not concerned about the profession’s ability to mentor and train the extra junior doctors as residents. All the university wants to do is fill seats. They’re not worried about doctors or the profession – this is our concern. I accept this is how universities operate – they are a business selling education. Therefore, we definitely should not let them (or Government) dictate workforce outcomes for the profession.
The high graduating workforce numbers adds to the pressure on the growing cohort of vulnerable doctors in training. They should be assured of transparent and fair selection and examination processes with open knowledge of workforce trends. The AMA has a clear need to strengthen relationships with the Colleges and move us collectively in this direction.
Post-graduate training opportunities have grown by 2.5 times in the last 15 years or so, but there remain real challenges in resourcing vocational training opportunities for registrars such that this will remain a bottleneck that will only become more problematic as graduating numbers increase. In this environment it is clearly imperative that medical student and vocational training numbers should reflect credible workforce data and not be driven by political/institutional desires or parochial interests.
It is important to acknowledge the strides being made to meet the health needs of our rural communities with the design of the National Rural Generalist Pathway now underway; nevertheless, as a physician who practises in both metropolitan and regional Queensland, I am keenly aware of the shortages of specialists and sub-specialists in the regions and outer-metropolitan areas. It’s perhaps forgotten sometimes that regional centres servicing large geographical areas also need specialists and sub-specialists. Innovative solutions that will not cost much are part of the solution e.g. combined public-private jobs that capture the principles of easy entry-gracious exit as espoused by the AMA, with industrial recognition of the difficulties faced by regional/rural doctors.
As well as moderating the size of the workforce which requires urgent attention, an important area of work for the MWC will therefore be advocating for the colleges and jurisdictions to increase specialty training positions in areas of unmet community need, based on the advice of the National Medical Training Advisory Network.
[World Report] India advises against electronic nicotine delivery systems
The onus is now on Indian state governments to decide whether or not to take action. Sophie Cousins reports.