Spatial distribution of the supply of the clinical health workforce 2014: relationship to the distribution of the Indigenous population

This report uses a new measure developed by the Australian Institute of Health and Welfare—the Geographically-adjusted Index of Relative Supply (GIRS)—to examine the geographic supply of the clinical health workforce in seven key professions with particular relevance to Indigenous Australians. These professions were general practitioners, nurses, midwives, pharmacists, dentists, psychologists and optometrists. Areas with lower GIRS scores are more likely to face workforce supply challenges than those with higher GIRS scores. The GIRS scores were compared with the distribution of the Indigenous population to assess the extent to which Indigenous people live in areas with lower relative levels of workforce supply.

Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: second national report 2016

This is the second national report on the 21 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people, with updated data available to report on 11 measures. For some of the measures, a better or similar rate for Indigenous Australians compared with non-Indigenous Australians was apparent, while on other measures, higher rates of ill health and death from cardiac conditions and lower rates of in-hospital treatment services among Indigenous Australians were evident. A number of measures suggested improvements for Indigenous Australians over time; examples include a decline in the death rate due to cardiac conditions and an increase in the proportion who received an MBS health assessment.

Health Care Homes must be tailored to Indigenous needs

I am continuing the important tradition of chairing the Taskforce on Indigenous Health as AMA President. The taskforce acts to identify and recommend Indigenous health policy strategies for the AMA.

On 8 October 2016, it was my privilege to chair my first meeting of the Taskforce. A number of important issues were discussed, including the AMA’s election priorities relating to Aboriginal and Torres Strait Islander health, the AMA’s support for the establishment of an Academic Health Science Centre in Central Australia, as proposed by Baker IDI Heart and Diabetes Institute and its partners, and the Indigenous health focus of the Medicare Benefits Schedule (MBS) Review.

One issue that was raised as being of particular concern was how the proposed Health Care Homes initiative will affect health care for Aboriginal and Torres Strait Islander peoples. The AMA supports the concept of Health Care Homes – a policy announcement made by the Coalition prior to the 2016 election, and we are pleased that the Australian Government has committed to an extended trial of the concept.

The AMA has concerns about the Health Care Homes model in relation to Indigenous health, and we assert that the specific health needs of Aboriginal and Torres Strait Islander people must be addressed through the scheme.

The concept of the medical home is not new in Australia. For many Australians, their local general practice is already their Health Care Home, and their GP, their primary carer. Patients whose care is well managed and co-ordinated by their GP are likely to have a better quality of life and to make a positive contribution to the economy through improved workforce participation. Health Care Homes should mean more expensive downstream costs can be avoided. Chronic conditions, if treated early and effectively managed, are less likely to result in the patient requiring hospital care for the condition or any complications.

The Health Care Home model has worked overseas and the evidence is of significant reductions in avoidable hospital admissions, emergency department use, and overall costs.

The AMA sees Health Care Homes as potentially one of the biggest reforms to Medicare in decades.

However, we know that, for the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. We also need to see greater detail about how the Health Care Home model will operate in remote and Indigenous communities.

Indigenous communities face a range of unique health problems and chronic diseases uncommon in our cities. A high turnover of medical practitioners and support services in these areas means continuity of care and follow up treatment can be difficult to maintain.

Trust is a vital component of health care, especially for Aboriginal and Torres Strait Islander peoples, and knowing and trusting a GP is critical in the management of chronic conditions. How the Health Care Home model will deliver consistent, ongoing GP care and management of chronic health conditions is not known, and the AMA has been urging the Government to provide greater details about funding and operation.

There is a degree of anxiety among the Aboriginal Community Controlled Health Organisation (ACCHO) sector that any announcements made by the current Government will result in cuts to Indigenous health. There is a strong view that building up the ACCHO sector is the best model of care for Aboriginal and Torres Strait Islander peoples, particularly as ACCHOs are the preferred provider of Indigenous health services.

ACCHOs, like Health Care Homes, need to be built on existing relationships and investment in models that work. The Government must not rush the Health Care Homes trial and, if it is to be successful, it must be adequately funded.

As a model, it has the potential to help close the gaps in health outcomes between Aboriginal and Torres Strait Islanders and non-indigenous Australians. The AMA’s position will be to closely monitor what works and what does not work, and work constructively with Government to ensure the necessary changes are made.

Government targets quality in proposed PIP overhaul

The AMA has expressed concern that a proposed major shake-up of the Practice Incentives Program is not being supported by increased investment in general practice.

The Health Department has unveiled plans to “refresh” the 18-year-old PIP system by slashing the number of incentive payment categories on offer, reducing the administrative burden on practices and intensifying the focus on quality.

Under the proposal, outlined in a discussion paper released by the Department, seven existing payments covering asthma, cervical screening, diabetes, aged care access, prescribing, Indigenous health and procedural GP incentives would be axed; four existing payments, covering rural loading, after hours services, teaching and e-health – would be maintained; and a new Quality Improvement Incentive payment would be introduced.

The AMA has welcomed the increased focus on quality, and is in consultation with the Department over the proposal to collapse the PIP payment categories.

But it voiced concern that the changes were not being supported by an increase in financial support for GPs, particularly given that many practices are being pushed to the financial brink by the Medicare rebate freeze and the prospect of cuts to pathology collection centre rents.

The Department has indicated that there will be no extra money injected in the PIP scheme.

It said the quality incentive payment would be used to “give general practices increased flexibility to improve their detection and management of a range of chronic conditions, and to focus on issues specific to their practice population”.

The push to overhaul the PIP system comes at the same time the Government is launching the initial stage of its Health Care Home model of care and undertaking a comprehensive review of the 5700 services listed on the MBS.

The Department said the initiatives together would “take the health system towards services that are aligned with contemporary practice”.

The case for changes to the PIP has been mounting in recent years, with a number of organisations including the Australian National Audit Office, the Organisation for Economic Co-operation and Development and the Grattan Institute all raising concerns that the system imposed an unduly heavy administrative burden on practices and was failing to keep up with evolving health needs and priorities.

The Department said the evidence showed that many existing incentives might be no longer appropriate, and that the more could be achieved by intensifying the focus on quality, including by making better use of data.

“Redesigning the PIP would enable it to move away from process-focused funding towards a simpler system that encourages quality improvement and innovation, and allows practices to see improvements in measures that are important to them,” it said.

Precisely how this could be achieved was up for consultation and debate, the Department added.

It suggested two options. One would be to merge all five PIP items (including the new Quality Improvement Incentive) into a single payment administered by the Department of Humans Services – essentially building on and adapting existing arrangements. Eligible practices would receive sign-on and quarterly payments, to be used to make quality improvements of their choosing.

Under the second option, the Department would no longer directly fund practices. Instead, practices would use PIP funds to engage third-party providers to support their quality improvement work.

Whatever the option chosen, practices would be required to regularly share data to map quality improvements, individually, locally and nationally.

The Government is inviting submissions on the proposed PIP overhaul. The deadline is 30 November.

The Department’s consultation paper can be downloaded here.

Latest news

[Correspondence] Indigenous data matter: spotlight on Negev Bedouin Arabs

Several articles published in The Lancet in April focused directly or indirectly on the situation of Indigenous peoples. The Article by Ian Anderson and colleagues1 (July 9, p 131) on Indigenous peoples’ health highlighted gaps in the availability of data on key health and social indicators, in both the 23 countries included in their summary, and the 67 countries excluded due to insufficient data. In an Offline by Richard Horton,2 he described the predicament of the Negev Bedouin Arabs in southern Israel.

Family doctors need help to tackle domestic violence

Family doctors are more likely than police to see the results of family and domestic violence, and have a key role to play in early intervention and treatment, the AMA says in an updated Position Statement.

AMA President, Dr Michael Gannon, said the trusted role of the family doctor gave GPs a clear insight into the damage caused by the violence.

“Two women are killed nearly every week in Australia due to family and domestic violence,” Dr Gannon said.

“The health effects of family and domestic violence in both the immediate victims and their families are devastating, and it is not only women who are the victims.

“Women experiencing domestic violence will share their experiences with their GPs more often than with any other professional group, and the health impacts persist long after the violence ceases.”

Women who have experienced domestic or family violence have higher levels of mental and physical disorders, higher rates of suicide attempts, and are more likely to have an impaired quality of life than other women.

“Children who grow up witnessing and experiencing domestic violence can also be profoundly affected.”

The AMA is committed to providing important information and guidance to empower doctors, particularly GPs, to provide better support for victims.

The release of the revised and updated Position Statement on Family and Domestic Violence 2016 this week coincided with a major meeting of Commonwealth, State, and Territory ministers at the COAG National Summit on Reducing Violence Against Women and their Children.

It calls on all Australian governments to properly fund and resource specialised family and domestic violence support services, including housing and crisis accommodation.

“Family violence affects people of all genders, sexualities, ages, socio-economic background, and cultures,” Dr Gannon said.

“And we are now also seeing increasing instances of elder abuse, with grandmothers and grandfathers, many frail and vulnerable, being subjected to violence from family members.

“Men can be victims. Women can be perpetrators. But it is clear that the overwhelming majority of people who experience such violence are women.”

Stamping out family and domestic violence requires commitment and coordination from governments; support services; the related professions, especially medical, health and legal; neighbourhoods; and families – backed by adequate funding.

The Women’s Electoral Lobby (WEL) backed the AMA’s call for funding, saying it was disappointing that crisis services for women and children escaping violence were not on the agenda for the COAG Summit in Brisbane.

“The Summit plans to hold roundtable discussions on such topics as ‘using behavioural insights to reduce domestic violence’ and ‘innovative uses of technology’, as well as important discussions on the Family Court, Indigenous insights and experiences, and the effects of domestic violence on children, but there is nothing on the agenda about crisis services, including women’s refuges,” WEL said in a statement.

“WEL calls on the COAG Summit to include support for long-term, secure Commonwealth-State funding for women’s crisis services in its deliberation and follow-up actions.”

Latest news

Better cancer care for all

Clinicians and bureaucrats hope to boost the survival rate of cancer sufferers following the adoption of national guides for the optimal treatment of 15 forms of the deadly disease.

In an effort to stamp out wide variations in the occurrence and outcomes of cancer in the community, the nation’s health ministers have endorsed 11 tumour specific Optimal Cancer Care Pathways (OCP) to be used as guides for specialists, GPs, health administrators, other health professionals and consumer.

Acting Commonwealth Chief Medical Officer Dr Anthony Hobbs said each pathway “maps the key steps in a cancer patient’s journey, from diagnosis to survivorship or end-of-life care, and describes the key principles and expected standards of care at each stage”.

Dr Hobbs said they had been developed by the National Cancer Expert Reference Group [NCERG], comprising clinical oncologists, GPs and consumers, in consultation with medical colleges and peak health organisations including the AMA, with the aim of reducing significant differences in outcomes for cancer sufferers according to their background, wealth and location.

“Outcomes for Australian cancer patients have improved dramatically over the past 30 years, with current survival rates now about 67 per cent overall,” he said.

Dr Hobbs said this had been achieved through a combination of preventive action, cancer screening and action on early diagnosis.

“However despite the progress, Australia still has unacceptable variation in cancer rates and outcomes which differ by Indigenous status, geographical location and socioeconomic status. The NCERG’s major focus has been on reducing this variation,” he said.

Altogether, pathways for 15 tumour types have been developed and adopted by the Australian Health Ministers’ Advisory Council for implementation by all states and territories, and 11 have been endorsed by the COAG Health Council. The remaining four are due to be considered later this year. All have been endorsed by Cancer Australia and Cancer Council Australia.

The 15 tumour streams covered by the OCPs are: lung, colorectal, hepatocellular carcinoma, prostate, lymphoma, melanoma, pancreatic, ovarian, malignant glioma, head and neck, breast, oesophagogastric, basal cell and squamous cell carcinoma, endometrial and acute myeloid leukaemia.

Each Pathway is presented in three formats.

Detailed clinical pathways for cancer specialists, health professionals and administrators and quick reference guides for GPs and other primary providers can both be found at: http://www.cancer.org.au/health-professionals/optimal-cancer-care-pathways.html.

‘What to expect’ guides for patients and their carers can be found at: http://www.cancerpathways.org.au/optimal-care-pathways

Adrian Rollins

Maternal mortality trends in Australia

Maternal death is low and decreasing in Australia, but continuing surveillance is important

The death of a mother or a baby has significant short and long term impacts for the surviving family members and for the community and health workers who cared for them. The World Health Organization estimates that 303 000 women died in pregnancy and childbirth in 2015, with 99% of these deaths occurring in low income countries.1

In Australia, a series of reports regarding maternal deaths has been published over the past five decades; the first in the series covered the 1964–1966 triennium.2 These reports examine the deaths that occurred during pregnancy or within 42 days of the end of pregnancy. They are compilations of data sourced from multidisciplinary state maternal mortality review committees that undertake detailed reviews of each case.

The incidence of maternal death is expressed as a maternal mortality ratio (MMR). The MMR is the number of deaths due to complications of the pregnancy (direct deaths) or aggravation of existing disease processes by the pregnancy (indirect deaths) per 100 000 women giving birth. The calculation does not include deaths from unrelated causes that occur in pregnancy or the puerperium (incidental deaths) and deaths that occur more than 42 days after the end of a pregnancy.

The MMR in Australia is low; it has decreased from 41.2 in the 1964–1966 period to 7.1 in the years 2008–2012.3 The comparable figures are 14.7 for the period 2010–2012 in New Zealand4 and 9.0 for the period 2011–2013 in the United Kingdom.5

Until now, publications in the Maternal deaths in Australia series have been irregular. The Australian Institute of Health and Welfare (AIHW) established the National Maternity Data Development Project (NMDDP) in response to the recommendations in the 2008 Maternity Services Review from the Commonwealth and the subsequent 2010–2015 National Maternity Services Plan.6 A recent report regarding the progress of the NMDDP notes that sustainable data collection on national maternal mortality will be established to facilitate “consistent and regular national reporting” of maternal mortality in the future.6

The genesis of the almost sixfold reduction in maternal death rates in Australia is multifactorial, including the improved general health of the population and the availability of better health care options, such as the availability of antibiotics, blood transfusion, safer anaesthesia and effective diagnostic ultrasound. Advanced maternal age, maternal obesity and caesarean deliveries3,5 are all associated with an increase in the risk of maternal death, and any future growth in their incidence will threaten the efforts to further reduce the maternal mortality rate.

In the list of most common causes of death, infection, abortion and pre-eclampsia have been replaced by maternal cardiovascular disease and psychosocial health problems, while obstetric haemorrhage and thromboembolism remain prominent. The current method of classifying maternal deaths into direct, indirect and incidental deaths was first used in the report on the 1973–1975 triennium.7 Between that first 1973–1975 report and the most recent one for 2008–2012, 944 direct and indirect maternal deaths have been reported in Australia. Over that 48-year period, cardiovascular disease (MMR, 1.5), sepsis (MMR, 1.3) and obstetric haemorrhage (MMR, 1.1) have been the most prominent causes of death.

Aboriginal and Torres Strait Islander women are twice as likely to die in association with pregnancy and childbirth as other Australian women. In 2008–2012, the Aboriginal and Torres Strait Islander MMR was 13.8 compared with 6.6 for non-Indigenous Australian women who gave birth.3 The differential between the MMRs is decreasing and caution should be exercised in drawing conclusions due to the small numbers analysed. The leading causes of maternal deaths among Aboriginal and Torres Strait Islander women were cardiovascular conditions, sepsis and psychosocial conditions.

Women aged 35 years or over were more than twice as likely as their younger counterparts to die in association with pregnancy and childbirth, and those aged 40 years or more were over three times more likely to die in association with pregnancy and childbirth.3

Of the six most prominent causes of maternal death between 1973 and 2012, psychosocial death is the only group where the MMR is rising; the incidence of maternal death due to cardiovascular disease, obstetric haemorrhage, thromboembolism, hypertensive disorders and sepsis are all decreasing. Most of the deaths classified as psychosocial deaths are due to suicide, although some are related to fatal complications of substance misuse and homicide in domestic situations. While some of that apparent rise may be due to changes in the ascertainment of maternal deaths in general and to problems reporting both maternal suicide and deaths due to substance misuse in particular, it is clear that more needs to be done in this sphere. There is a growing belief that a significant portion of late maternal deaths are related to suicide; however, without a clear review of the cases by multidisciplinary committees, the relationship between pregnancy and suicide more than 42 days after the end of pregnancy remains speculative.

It is not clear whether the incidence of suicide in association with pregnancy is more or less common than in comparable non-pregnant women. This comparison is fraught, as the true denominator for pregnancy is not known due to lack of information regarding pregnancies lost as a result of miscarriage and termination. Given that caveat, the overall suicide rate in the 15- to 45-year-old Australian female population in 2006–2010 was 6.0 per 100 000 women,8 while the maternal mortality rate due to psychosocial issues in the same period was 0.9 per 100 000 women giving birth. A similar finding has recently been noted in the United States.9 Nevertheless, the apparently increasing incidence of psychosocial maternal death is a matter of concern, given that pregnant women are among the most medically supervised members of the population.

Screening during pregnancy for mental health, substance misuse and domestic violence problems is recommended,10 but it is not universally undertaken. All maternity care providers should commit to making these items a standard part of their care delivery. The follow-up of identified concerns by the relevant specialist services must be a priority and should continue for a significant period after the end of pregnancy. Similar screening attention is needed for women who had miscarriages and pregnancy terminations.

In many cases, an autopsy is necessary to understand the true cause of a maternal death. A number of causes of maternal death, such as amniotic fluid embolism and pulmonary thromboembolism, may be easily confused clinically. In the case of amniotic fluid embolism, for example, the diagnosis can only be confirmed by autopsy. The question of an autopsy should be pursued with the family by a senior clinician, and the presumption of a diagnosis that has been made in an intensive care unit or similar setting should not be an excuse to not request this critical form of investigation.

Maternal death is one of the few defined core sentinel events in health care; however, it is disturbing to find that a significant portion of these deaths have not been subjected to a root cause analysis or similar review. The application of a systematic review to identify gaps in hospital systems and health care processes, which are not immediately apparent and may have contributed to the occurrence of an event, should be applied to all maternal deaths, whether occurring in the public or private health systems.

The question of the presence or absence of contributory factors is now being actively pursued by some state and territory maternal mortality review committees, and similar questions are also being raised internationally. A consolidation of such information is yet to be published in an Australia-wide context. Experience with such review in New Zealand11 has shown that more than 50% of maternal deaths were associated with contributory factors, and 35% of the deaths were potentially avoidable.

The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity model12 appears to be of value, and examines two questions:

Were suboptimal care factors identified?
What was the relevance of any suboptimal care factors identified?

Suboptimal care factors may be classified as factors related to the woman, her family and social situation, factors related to access to care and factors related to professional care. Moreover, these factors may be classified as identified but unlikely to have contributed to the outcome (insignificant), identified and might have contributed to the outcome (possible), or identified and likely to have contributed to the outcome (significant).

It is critical to maintain a continuing intensive surveillance of maternal death — with particular reference to recognised risk factors — and to examine the contributory factors. Health departments must require that all direct and indirect maternal deaths are subjected to a systematic review. At present, data on late maternal deaths — occurring more than 42 days after the end of pregnancy — are not collected in all states and territories and are not reported nationally. Reviews of late maternal deaths and of severe maternal morbidity are future necessities, but the resources and methodologies are not yet available at a national level.

Govt adviser calls for public hospitals to be ‘contestable’

Mortality rates and treatment outcomes for individual hospitals and medical practitioners could be made publicly available and patients given a choice of hospital and specialist under Productivity Commission proposals to improve the quality and accessibility of health services.

In the preliminary findings of a review initiated by Treasurer Scott Morrison into options for increased competition and consumer choice in the $300 billion human services sector, the Commission has proposed increased information disclosure by hospitals and practitioners and greater contestability between services.

“Greater competition, contestability and informed user choice could improve outcomes in many human services,” the PC said. “Well-designed reform, underpinned by strong government stewardship, could improve the quality of services, increase access…and help people have a greater say over the services they use and who provides them.”

Mr Morrison said he had ordered the review to improve the efficiency and cost effectiveness of human services.

But Opposition leader Bill Shorten, reprising Labor’s scare campaign during the Federal election on the privatisation of Medicare, said he feared it would be used to justify the wholesale handover of human services to the private sector.

“We’ve all seen this move before,” Mr Shorten said. “When Malcolm Turnbull and the Liberal Party start talking about changing human services it means that poor people get it in the neck.”

The Commission said that not all human services were amenable to increased competition, contestability and choice, but identified public hospitals and palliative care services among six priority areas targeted for reform.

While Australian public hospitals performed well by international standards, “there is scope to improve”, the PC said, including by matching domestic best practice and publicly disclosing more information.

“Public patients are often given little or no choice over who treats them or where. Overseas experience indicates that, when hospital patients are able to plan services in advance and access useful information to compare providers (doctors and hospitals), user choice can lead to improved service quality and efficiency,” the PC said.

It said that any reforms to boost user choice would have to be supported by “user-oriented information”, and suggested the English model in which increased choice is offered at the point where GPs refer patients to a specialist.

The Commission said experience in England had shown that patients given a choice of hospital and consultant-led team sought out better performing providers, and hospitals in locations where competition was most intense recorded the biggest improvements in service quality.

In order to exercise their choice, patients had access to web-based information enabling them to compare providers according to waiting times and mortality rates, and could use an online booking service.

The enormous variety of Australia’s public hospitals, including big differences in the populations they serve, workforce arrangements and characteristics and the complexity of their links to the rest of the health system, militate against like-for-like competition – something the Commission admitted.

If such issues or political considerations made fostering direct competition unfeasible, the Commission instead suggested exerting pressure for improved performance by making the position of senior hospital managers more precarious.

“There have been difficulties in the past commissioning non-government providers, and lessons from these attempts should not be forgotten,” it said. “As a result, it may be more feasible to implement contestability as a more transparent mechanism to replace an underperforming public hospital’s management team (or board of the local health network) rather than switch to a non-government provider.”

The Commission said State and Territory governments could also take a more contestable approach to commissioning services when renegotiating service agreements with local health networks.

On palliative care, the PC lamented that a dearth of comprehensive, publicly available national data hampered accountability and helped drive big differences in the quality and range of services available.

It said there was little evidence that low quality providers were being held to account.

The PC acknowledged that the “emotionally taxing and psychologically distressing” environment in which a person was approaching the end of their life militated against making choices about palliative care.

“Taboos about discussing death can prevent this from happening,” the Commission said. “Patients often rely on medical professionals to initiate conversations about palliative care, many of whom are inadequately trained about, and intimidated by, holding such conversations.”

Notwithstanding such challenges, the PC argued that introducing greater competition, contestability and user choice in palliative care would improve outcomes and reduce current substantial variation in the quality of, and access to, services in different areas of the country.

To achieve this, though, “would require careful design to ensure that the interests of patients and their families are well served. Special measures for consumer protection may be needed”.

Indeed, even where reform ushered in greater competition and contestability, the PC said the unique nature of human services meant the Government would need to maintain strong oversight.

“Government stewardship is critical,” the agency said. “This includes ensuring human services meet standards of quality, suitability and accessibility, giving people the support they need to make choices, ensuring the appropriate consumer safeguards are in place, and encouraging and adopting ongoing improvements to service provision.”

Other priority areas of human services nominated by the Commission for increased competition and contestability included public dental services, social housing, services in remote Indigenous communities and grant-based family and community services.

Among those areas assessed for reform but not identified as a priority by the PC at this stage were general practice, primary health networks (PHNs), mental health services, community health services and child and family health services.

The preliminary report is open for submissions until 27 October, and the Commission is due to deliver its final report by October 2017.

Adrian Rollins

Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011

This report provides estimates of the non-fatal and fatal burden of disease for the Aboriginal and Torres Strait Islander population as well as estimates of the gap in disease burden between Indigenous and non-Indigenous Australians. The disease groups causing the most burden among Indigenous Australians in 2011 were mental and substance use disorders, injuries, cardiovascular diseases, cancer and respiratory diseases. Indigenous Australians experienced a burden of disease that was 2.3 times the rate of non-Indigenous Australians. Over one third of the overall disease burden experienced by Indigenous Australians could be prevented by removing exposure to risk factors such as tobacco and alcohol use, high body mass, physical inactivity and high blood pressure.