Cheaper drugs a path to better health

Medicines save lives and improve health and wellbeing when they are available, affordable, and properly used.

With Aboriginal and Torres Strait Islander people experiencing double the rate of chronic illnesses than their non-Indigenous peers, access to affordable prescription medicines is essential. Unfortunately, Aboriginal and Torres Strait Islander people are not accessing medicines at a level that is appropriate to their needs, with cost being reported as a major barrier.

As evidenced by the Closing the Gap (CTG) Pharmaceuticals Benefits Scheme (PBS) Co-payment measure, reducing out-of-pocket costs for medications increases access to, and use of medications, ultimately resulting in improved health outcomes.

Since its inception in 2010, the CTG PBS Co-payment measure has increased access to medicines for more than 280,000 Aboriginal and Torres Strait Islander people in urban and rural areas, by reducing or removing the patient co-payment for PBS medicines. Substantial reductions in hospitalisations have also been seen in areas with the greatest uptake of the CTG PBS Co-payment incentive.

While the outcomes under this measure have been encouraging, there is still a long way to go until we achieve equality in access to medicines for Aboriginal and Torres Strait Islander people.

A good starting point is to promote the CTG PBS Co-payment more widely to all prescribing doctors across Australia, to increase awareness and uptake of the initiative and build on its success.

In August 2012, Australian Doctor reported that, alarmingly, thousands of doctors were unaware of the existence of the CTG PBS Co-payment measure – an important initiative that has the potential to make a real contribution to closing the gap.

With chronic diseases being one of the main reasons for the life expectancy gap between Indigenous and non-Indigenous people, it is unacceptable that so many Australian doctors are unaware of such an important scheme.

Doctors working in Aboriginal and Torres Strait Islander Community Controlled Health Services are generally aware of this initiative, and regularly prescribe medications covered by the CTG PBS Co-payment measure for the benefit of their patients. However, many doctors working in mainstream general practice may not be aware of this scheme.

To participate in the CTG PBS Co-payment measure, practices must be able to first identify eligible Aboriginal and Torres Strait Islander patients. All patients across Australian medical practices should be asked whether they identify as being of Aboriginal and Torres Strait Islander origin by asking the National Standard Identification question – ‘Are you of Aboriginal or Torres Strait Islander origin?’ Once Indigenous patients are recognised, they are eligible to be registered for co-payment assistance.

Improved access to medicines is critically important if we are to see generational change in health outcomes for Aboriginal and Torres Strait Islander people.

The Australian Medical Association encourages all medical practitioners to increase their awareness of the CTG PBS Co-payment measure to improve health outcomes for Aboriginal and Torres Strait Islander patients.

Vote #1 Health

The AMA has called on whoever wins the Federal Election to bring an immediate end to the Medicare rebate freeze, boost public hospital funding and retain bulk billing incentives for pathology and diagnostic imaging services.

Launching the AMA’s policy manifesto for the election at Parliament House today, AMA President Professor Brian Owler said health will be at the core of the contest between the major parties, and whoever forms government “must significantly invest in the health of the Australian people”.

“Elections are about choices. The type of health system we want is one of those crucial decisions,” Professor Owler said.

The Turnbull Government is facing a backlash from patients and the medical profession over a series of controversial funding cuts, including the Budget move to extend the Medicare rebate freeze to 2020, to slash billions from the future funding of public hospitals, and to axe bulk billing incentives for pathology services.

The Medicare rebate freeze, initially introduced by Labor in 2013 and extended twice by the Coalition since, has been condemned as a policy to introduce a patient co-payment “by stealth”, with warnings it threatens the financial viability of many practices and will force many GPs to abandon bulk billing and begin to charge their patients.

“The freeze on MBS indexation will create a two-tier health system, where those who can afford to pay for their medical treatment receive the best care and those who cannot are forced to delay their treatment or avoid it altogether,” the AMA’s Key Health Issues for the 2016 Federal Election document said.

Professor Owler said the freeze will mean “patients pay more for their health care. It also affects the viability of medical practices.”

The AMA President has also warned that massive cuts to public hospital funding were likely to stymie improvements in their performance and increase the delays patients face.

In 2014, the Coalition Government announced it would scale back growth in hospital funding, savings $57 billion over 10 years, provoking a storm of protest from State and Territory governments. To try to placate them ahead of the Federal Election, Prime Minister Malcolm Turnbull thrashed out a deal to provide an extra $2.9 billion over the three years to 2020.

But Professor Owler said the funds were an inadequate short-term fix that fell “well short of what is needed for the long term”.

The AMA has called on the major parties to commit to adequate long-term public hospital funding, including an annual rate indexation that provides for population growth and demographic change.

The Government is also under pressure over its decision to save $650 million over four years by scrapping bulk billing incentives for pathology services and reducing them for diagnostic imaging services, with loud warnings it will deter many patients, particularly the sickest and most vulnerable, from undertaking the tests they need to manage their health and stay out of hospital.

The AMA said the move was a “short-sighted policy that will ultimately cost future government and the Australian community much more in having to treat more complicated disease – disease that could have been identified or avoided through good access to pathology and diagnostic imaging services”.

It said the major parties should commit to maintaining the current subsidies.

In addition, the AMA is calling for all those contesting the Federal Election to commit to:

advancing the care of patients with chronic illnesses by providing adequate funding of the Government’s Health Care Homes trial;
ensuring the medical workforce meets future community need by boosting GP and specialist training programs and completing workforce modelling by the end of 2018;
increasing funding for Indigenous health services and strengthen programs to address preventable health problems;
improving the GP infrastructure grants program;
increasing investment in preventive health initiatives;
cracking down on the marketing and promotion of e-cigarettes, including banning their sale to children; and
adopting a National Physical Activity Strategy to improve health and reduce the incidence of obesity, heart disease, diabetes, stroke and other illnesses.

“The next Government must significantly invest in the health of the Australian people,” Professor Owler said. “Investment in health is the best investment that governments can make.”

The AMA’s Key Health Issues for the 2016 Federal Election document is available at article/key-health-issues-federal-election-2016

Adrian Rollins

‘Elements’ of racism in how health system treats Indigenous

Indigenous life expectancy in some parts of Australia is 26 years below that of the national average, and there is an “element” of racism in how the health system treats Aboriginal and Torres Strait Islander people, according to AMA President Professor Brian Owler.

Speaking at the launch of a document in which the AMA called for an end to the under-funding of Indigenous health services, Professor Owler said that although people who worked in the health system were not racist, the way the system itself treated Aboriginal and Torres Strait Islander people was often culturally inappropriate.

“Racism is a word that needs to be used cautiously, but there is no doubt that there is an element in terms of how we deal with Indigenous people,” the AMA President said. “Now, it’s not to say that the people in the system are racist, it is about the way that we recognise and provide culturally appropriate care.”

Professor Owler, who visited Alice Springs and several Aboriginal communities in the Northern Territory earlier this year, said the Alice Springs Hospital was much more culturally sensitive in the way it dealt with Indigenous people compared with other hospitals and health centres, including those with a significant number of Indigenous people as patients.

“I think in that way…there is an element of racism, and those are the sorts of things that we need to deal with,” he said. “I don’t think people should understand that the people in the system itself are racist, it’s the way that the system needs to change and develop to make sure that we look after Indigenous people in the way that is more appropriate, safer in terms of culture, and that is likely to engage them more and deliver much better outcomes.”

Nationally, the life expectancy of Aboriginal and Torres Strait Islander people lags 10 years behind that of the rest of the community. But in parts the gap reaches 26 years, and Professor Owler said Indigenous children as young as seven years old were developing type 2 diabetes – probably the youngest of anyone in the world.

Indigenous health services have been hit by Government spending cuts and uncertainty over future funding, and the AMA, in its Key Health Issues for the 2016 Federal Election document, has called for an end of what it said was chronic under-funding of the sector and an investment boost in Aboriginal and Torres Strait Islander community controlled health organisations.

“Having toured central Australia and the Northern Territory, and spoken to people that work in this field, they have seen a cut in Indigenous health over the past few years,” Professor Owler said. “While we’ve made ground in Indigenous health, there is so much more to do. But when you go and talk to people, when you see the realities on the ground, the issues that are being faced by Indigenous people, particularly in remote and rural communities and regional Australia, you can see that there’s so much more that needs to be done.”

The AMA’s Key Health Issues for the 2016 Federal Election document is available at article/key-health-issues-federal-election-2016

Adrian Rollins

Don’t shoot the messenger

The Turnbull Government, led by Health Minister Sussan Ley, has recently made a habit of launching attacks on health professionals to justify its health policy decisions, especially the cuts to funding and services and the cost shifting.

It has not just been doctors in the firing line, although the Government has made a habit of demonising GPs, surgeons, radiologists, pathologists, and anaesthetists on a regular basis.

If not through direct attack, it has been via friendly journalists on the drip, or under cover of disenchanted private health insurers desperate to avoid the spotlight as their own sector is under forensic review.

Dentists have been copping it lately, joining the growing queue of health professionals being blamed for the Government’s health policy mistakes and misadventures. Pharmacists and nurses have also come under attack, and they are not amused, and do not take these attacks lightly.

None of the health professions appreciate being criticised publicly in the media, especially when these attacks do not reflect what is discussed in private meetings.

The public – voters – do not like it, either.

Every poll of the professions in living memory has doctors, nurses, and pharmacists rated as the most trusted professions in the community. People trust their doctors and other health professionals. They do not like the ugly spectacle of politicians and some in the media attacking the integrity of health professionals. Needless to say, politicians rate very low on the trusted profession scale.

So, what is behind the misguided strategy of demonising doctors and other health professionals so close to an election? There can’t be any votes in it.

You would think that an incumbent Government would want to win the hearts and minds of health sector leaders in the months ahead of a Federal Election, and on the eve of the Federal Budget, which will shape the direction of the Coalition’s election health policies.

But this is not the case.

Doctors, pharmacists, nurses, Aboriginal health services, and even medical receptionists, have in the past week been blamed for rorts and waste in the system, with incorrect and inaccurate statistics being used to push these mischievous claims.

This is all subterfuge to keep the public focus off the main game – the fact that the Government’s health policies, in the main, are all about making savings to the Budget, not improving access to quality affordable health care for all Australians.

The Government’s ongoing justification for its extreme health savings measures, including cuts to public hospital funding, has been that Australia’s health spending is unsustainable. This is simply not true.

The most recent comparative figures reported by the OECD show Australia’s health expenditure as a proportion of GDP was below the OECD average and lower than 18 other OECD countries.

Australia’s health costs (8.8 per cent), as assessed by the OECD, were just over half the corresponding proportion for the USA (16.4 per cent). Australia achieves better health outcomes for its significantly lower proportional spend than the USA and many other countries, with the second highest life expectancy in the world, with the exception of Indigenous Australians.

Moreover, the Commonwealth Government’s total health expenditure is reducing as a percentage of the total Commonwealth Budget. In the 2014-15 Commonwealth Budget, health was 16.13 per cent of the total, down from 18.09 per cent in 2006-07. It reduced further in the 2015-16 Budget, representing only 15.97 per cent of the total Commonwealth Budget.

Clearly, total health spending is not out of control. Nor is spending on medical services.

The reality is that today we are not spending any more on medical services as a proportion of total health spending than we were a decade ago.

The proportion today is 18.2 per cent, compared with 18.5 per cent a decade ago. While we are spending more on health in total, we are spending less on medical services.

Today, 86 per cent of privately insured medical services are charged at no gap by the doctor – which means that the doctor accepts the fee level set by the patient’s private health insurer.

A further 6.4 per cent are charged under ‘known’ gap arrangements. This means that less than 8 per cent of privately insured patients may be charged fees exceeding private health insurance levels, including known gap amounts.

The number of doctors charging ‘excessive’ fees is in the absolute minority, and the AMA continues to work with the relevant specialist colleges, associations and societies to address this.

Nor are doctors’ fees contributing to Budget woes, with specialist fees in many cases not being indexed for up to a decade.

Contrary to the line being pushed by the Government and the private health insurers, medical services are not an issue for the insurers or for patients.

Some insurers have been only too eager to vilify doctors even though the publicly listed PHIs have posted record profits, their executives are paid multimillion dollar salaries, and when doctors charge above the PHI schedule, i.e. a gap, the PHI contribution falls to 25 per cent of the scheduled fee.

During the December 2015 quarter, insurers paid $3,542 million in hospital treatment benefits. This was broken down into 70 per cent on hospital services such as accommodation and nursing, approximately 15 per cent on medical services, and 14 per cent on prostheses.

General practice, too, has demonstrated a real willingness to work with the Government to deliver high quality reforms, particularly in relation to the treatment of patients with complex and chronic disease.

The 2016 Budget provided the Government with a real opportunity to steer a new course and a new strategy of health policy and health sector engagement, but they passed on this opportunity. We can only hope the Government is saving some health largesse to be announced ahead of the election.

Doctors and the other health professions are restless and demanding better health policy, better consultation, and greater respect in public conversations and pronouncements. We need a mature and honest exchanges of views, not sneaky media leaks and cheap attacks on our integrity and professionalism.

Doctors see millions of Australians face-to-face every day. Multiply that number when you count radiology and pathology centres, pharmacies, and other health professionals.

Some groups have already commenced campaigns against Government health policies. More will join them if there is not a change in policy direction and a change in the Government’s public relationship with the health sector.

* An edited version of this column first appeared in the Australian Financial Review on 4 May 2016.

Govt targets big savings in Medicare crackdown

Main points

Medicare crackdown to save $66 million
Axing, amending MBS items delivers $56 million

The Federal Government expects to save more than $120 million by cracking down on Medicare waste and fraud and axing obsolete service items.

As the Government intensifies its hunt for savings, Health Minister Sussan Ley has announced she will toughen Medicare compliance activities and expects to save $66.2 million over the next four years by using advanced data analysis techniques to “better detect fraud, abuse, waste and errors in Medicare claims”.

The Health Department said it will audit an extra 500 providers each year, and will use sophisticated software to identify irregular payments and behaviours.

It said similar methods used by private insurers had in some instances achieved a 10-fold increase in the number of non-compliant activities detected.

The Government expects to achieve a further $56 million in savings by removing and amending listings on the Medicare Benefits Schedule.

In the first instalment of savings delivered by the MBS Review Taskforce led by Professor Bruce Robinson, the Budget has revealed the Government expects to save $5.1 million over the next four years by deleting 24 items and restricting access to two others.

These include gall bladder x-rays, larynx biopsies, the injection of hormones to manage habitual miscarriage and the use of x-rays to diagnose deep vein thrombosis.

In addition to these changes, the Government estimates it will save $51.4 million by axing a further 60 items identified by the Medical Services Advisory Committee and replacing them with around 30 new items.

These items include skin patch tests used by dermatologists, hip arthroscopy changes, fat grafting in spinal surgery and skin flap items for small excisions.

While the AMA supports work to modernise the MBS and remove obsolete or dangerous items, it is wary that it is being used by the Government as primarily a cost-cutting exercise.

Professor Robinson told an AMA-hosted forum earlier this year that his task was “not to save money. The Government may make savings, but I hope that the money is reinvested in health”.

AMA President Professor Brian Owler acknowledged the review was like to deliver some savings, but warned the medical profession’s goodwill and support for the process was contingent on any savings made being “held within health, to provide better services to patients”.

Against the $122 million of Medicare savings identified in the Budget, the Government announced it would spend $33.8 million over four years on tests for Indigenous people whose eyesight is threatened by diabetic retinopathy.

In addition, the Government has allocated $3 million over the next four years to provide for magnetic resonance imaging for breast cancer patients where conventional techniques fail to show the source of the tumour.

Adrian Rollins

Budget another hit on households

Main points

Medicare rebate freeze extended to 2020
Indexation delays cost households $370m
Bulk billing set to fall
$2.9 billion for public hospitals
$60 million for new drugs

The Federal Government is increasingly pushing the cost of care onto patients and households as it screws down on health spending, undermining Medicare and putting the poorest and sickest at risk, AMA President Professor Brian Owler has warned.

As the Federal Government prepares for a 2 July election, it has raided Medicare for almost $1 billion in savings by extending the rebate freeze, pushing the system to the point where GPs will be forced to cut back on bulk billing and begin charging patients, Professor Owler said.

At the same time, it has taken an axe to aged care, public dentistry and community health program funding, is targeting the Medicare Benefits Schedule for multi-million dollar savings, and has further delayed indexation of the Medicare Levy Surcharge and the Private Health Insurance Rebate thresholds, costing families an extra $370.9 million between 2018-19 and 2019-20.

Professor Owler said the Budget continued the Government’s “stranglehold” on the Medicare system, constituted “another hit to household budgets, and represent extra disincentives to people accessing health care when they need it”.

The Government’s decision to extend the freeze on Medicare rebates to 202 would be the “tipping point” for many medical practices, the AMA President warned, forcing many to wind back bulk billing and begin charging patients.

The Budget confirmed Prime Minister Malcolm Turnbull’s pledge to provide an extra $2.9 billion for public hospitals, and included more than $57 million for new drugs, almost $10 million to help protect the nation against the overuse of antibiotics, more than $33 million for Indigenous eye tests and $21 million for a trial of Health Care homes.

Health Minister Sussan Ley said the Budget showed the Government would lift its spending on health, aged care and sport to $89.5 billion next financial year – a 4.1 per cent increase from 2015-16.

“Our reforms are targeted to meet the growing needs and expectations of the modern consumer and are bold and broad, but also affordable, achievable and, most importantly, fair,” Ms Ley said.

The Minister said the Government had a “clear focus” on integration and innovation, and she pledged that it would “eliminate waste, inefficiency and duplication wherever we find it”.

“The Turnbull Government will make sure every health dollar lands as close to the patient as possible,” Ms Ley said.

But Professor Owler said the positive initiatives in the Budget had been overshadowed by the cuts, and the document was a missed opportunity for the Government to “steer a new course and a new strategy of health policy and health sector engagement”.

The AMA President said that instead, the Government’s strategy had been to attack health professionals.

“Doctors, pharmacists, nurses, Aboriginal health services, and even medical receptionists, have in the past week been blamed for rorts and waste in the system, with incorrect and inaccurate statistics being used to push these mischievous claims,” he said.

Professor Owler said the attacks were a subterfuge being used by the Government to distract public attention from “the main game – the fact that the Government’s health policies, in the main, are all about making savings to the Budget, not improving access to quality affordable health care for all Australians”.

The AMA President said it was a myth that health spending was out of control, as the Government has claimed – this financial year it comprised less than 16 per cent of the Commonwealth Budget, down from 18 per cent a decade ago.

He also took issue with health insurer complaints that doctors were driving up their costs, pointing out that in many cases specialist fees had not been indexed in a decade.

“Contrary to the line being pushed by the Government and the private health insurers, medical services are not an issue for the insurers or for patients,” Professor Owler said. “Some insurers have been only too eager to vilify doctors even though the publicly listed PHIs have posted record profits, their executives are paid multimillion dollar salaries, and when doctors charge above the PHI schedule, ithe PHI contribution falls to 25 per cent of the scheduled fee.”

The Government already faces a campaign from pathologists and diagnostic imaging providers over its decision to axe and reduce bulk billing incentives, and Professor Owler warned it ran the risk of more health groups joining them if it did not change policy direction and improve it public relationship with the health sector.

What they said

“Tonight we’ve seen an extension of the Medicare rebate freeze, and that means that the Government has extended its stranglehold on patients’ rebates. That means 925 more million dollars out of the pockets of everyday Australians; it means that people are going to have to pay more out of their own pockets when they receive medical treatment” – AMA President Professor Brian Owler

“This is a plan that will ensure our children and our grandchildren enjoy the great opportunities these times offer them. This is a responsible economic plan for growth and for jobs” – Prime Minster Malcolm Turnbull

“If you earn less than $80,000, which is 75 per cent of all Australian workers, you will not get a cent out of this budget, but your schools will be cut, the hospitals will be cut and we will see precious little action on climate change” – Opposition leader Bill Shorten

“Our reforms are targeted to meet the growing needs and expectations of the modern consumer and are bold and broad, but also affordable, achievable and, most importantly, fair” – Health Minister Sussan Ley

“Mr Turnbull has again smashed Australia’s health system, ripping another $2.1 billion out of health spending and keeping the GP tax in place for another two years – a measure that will cost Australian families $925 million” – Shadow Health Minister Catherine King

“It [the Medicare rebate freeze] will very likely see consumers paying greater gap payments as the price the Government pays for Medicare services won’t even keep up with inflation” – CHOICE CEO Alan Kirkland

“The 2016 Federal Budget has done absolutely nothing to reverse the increasing pressure on Australia’s world-class health care system” Royal Australian College of General Practitioners President Dr Frank Jones

Adrian Rollins

Tick a box – For the good of whom?

As a new intern, I am an infant in medicine and Indigenous medicine. I chose to study medicine because I wanted to work in the area of Indigenous social justice, with a particular interest in research and mental health. Seeing the medical world from a professional perspective has informally and formally educated me about Indigenous health, but also highlighted the ways that the health system can disempower and discriminate against Indigenous people. Although I currently have limited clinical experience in Indigenous health, I have a breadth of personal experience that I would like to share.

I identify with two Aboriginal communities from the north of Western Australia. On my father’s side the Palku people and on my mother’s side the Yindjibarndi people, who are both situated in the Pilbara region of Western Australia. Although I identify with both these communities, I have never lived in them, and grew up in Perth until high school when I moved to Sydney. I have always been proud of my heritage, keen to learn about it and tell others about it. Growing up in a Perth suburb where you and your brother are the only Indigenous students in your primary school however means I have always felt somewhat different. Despite this, being judged for being Indigenous and being a victim of racism has been a relatively uncommon experience in my life. This has been due to the fact that I do not fit the stereotype. I don’t look, speak and act as people expect of an Indigenous person. I have never thought of myself as, nor have been, disadvantaged: I went to a great school, my parents and family are all successful in their chosen careers and I have never gone without. Throughout my life I have found that many in Australian society equate being Indigenous with poverty and disadvantage, and therefore I do not fit the common stereotype of Aboriginality. Not being perceived as Aboriginal has been a challenge in medicine and my personal life because it means that people speak freely about Indigenous people in front of me, and say things they probably would not, if they knew I was Indigenous. I feel like a spy: secretly gathering racial intelligence in the medical world. This is equally true for my experience of seeing how doctors treat their Indigenous patients and my own experiences as an Indigenous patient.

Three years ago I took my nine-month-old daughter to the emergency department with a broken arm after she fell from a trampoline. It was one of those injuries every parent has a story about – one second of lapsed supervision leading to disaster. While in the waiting room I filled out the generic admission form and ticked the ‘Yes Aboriginal’ box. I did not hesitate. After all, why should it matter? There are posters everywhere about how knowing this information helps the hospital to treat you better and helps the health system by contributing to public health data. And I am proud to be Aboriginal. There is no reason to be ashamed. However during our admission my partner and I were interrogated multiple times about the circumstances of the injury, my GP to whom I had first presented was called to ask what kind of people we were and we were reported to the Department of Family and Community Services with a concern of child abuse. I felt my morals and parenting were judged. I felt that all my interactions with my daughter thereafter were being scrutinised. There was no single moment or comment that made me think the way we were treated was related to our Indigenous status but somehow I felt like it contributed. She had to have a cast which meant a lot of sleepless nights with a very annoyed child, but she recovered well. As for the report I assume it has been filed in a database, as we never had any other contact regarding the situation. I do not blame the doctor who was managing us. I know they were doing their job and in matters of child abuse nobody wants to miss something by under-calling a situation. But I did feel as if my, and my daughter’s Aboriginality, rather than our individual clinical picture, played too much into the decision to take that pathway, and I can’t help but wonder if things may have turned out differently if I hadn’t ticked that box.

Other members of my family and friends have had similar experiences: where they have felt their identification as Aboriginal impacted negatively on the perceptions of the professionals treating them or their children. Where parenting integrity has been called into question or our children are seen to be automatically disadvantaged because of their heritage. Where we are guilty until proven innocent. The overwhelming experience is one where we are left feeling either degraded and judged or pitied and patronised. This encounter made me reluctant to take my children to the emergency department for any reason after that, despite the fact that I have a positive view of the healthcare system. So I can easily see how someone who has been disenfranchised or experienced racism in other areas of their life, could easily become distrusting of health care institutions. In addition, when someone is encountering a system they do not know particularly well, it would be easy to attribute how you have been treated to your race, rather than thinking that this is just how everyone is treated in a similar situation.

National health guideline recommendations clearly encourage the use of standardised identification of Aboriginal and Torres Strait Islander clients in order to maximise the ability to collect reliable data about service delivery, service effectiveness and inform policies on healthcare strategy (Australian Institute of Health and Welfare, 2010). Nowhere in the recommendations is it suggested that a client’s identification as Indigenous should have a bearing on the treatment they are given and more specifically

‘the collection of Indigenous status as a routine administrative procedure does not in itself contravene a service’s commitment to equitable service provision’.

Additionally, failure to ask about Indigenous status has been identified as a barrier in the uptake and application of Indigenous specific services. Knowing if someone is Indigenous can improve management by allowing them to maximise the in-hospital and community services that might be available. It allows us as providers to think holistically about our patient and what we as a service can offer to benefit them moving forward. However, it is not the asking of the question that is the issue. Tick box systems and asking patients outright should be standard practice. However it is the response to the answer that becomes a more important outcome of the interaction due to the potential for discrimination or scrutiny based on Indigenous status alone.

Presuming Aboriginality is associated with poverty and disadvantage is a flawed and disempowering stereotype. Although, disappointingly Aboriginality and poverty are often interconnected, they are not interchangeable. It seems there is a pervading discourse within the health care system, structures and policies that frame Indigenous people with the assumption of deficit and inferiority.

We are taught to approach each patient with an aim to understand their current complaint in the context of the multitude of factors that individually contribute to that person’s health, including their past medical, familial, social and racial characteristics. Viewing every Aboriginal patient as a representation of statistics that are drawn from national data means that patient centered care is erroneously replaced with pattern centered care.

The key to understanding Aboriginal patients, I believe, is not presuming to know them; by not presuming in either a good or bad way to know their story, their history or their health concerns. Be open-minded. If we believe we know, then we stop trying to learn. I never claim to know medicine despite having a wealth of information at the end of a grueling medical degree. Because if I think I know medicine I will stop trying to learn it. Not knowing medicine is what makes it exciting and challenging and it is why, for the rest of my working life, I will have the privilege of being a student. The medical profession has a lot more learning to do about the best way to manage Indigenous health care needs and delivery of effective services. In addition, it is important to change the discourse surrounding Indigenous people to one where patients can feel empowered by their Indigenous status rather than inadequate. Research into Indigenous health is a great place to begin, but allowing Indigenous patients to tell their stories and feel safe doing so is something that each clinician should strive for.

I cannot know with certainty how ticking the box that day in the ED impacted my treatment. But I still regret it. I felt for the rest of my time in that emergency department I was treated, not with less care, but differently. If a patient has a pre-conception of how they will be treated, our actions can be misinterpreted as racially driven, rather than standard practice. Nevertheless, there are innumerable encounters between health professionals and Indigenous and non-Indigenous people everyday. If every encounter became an opportunity to educate, reassure, or reassess our own perspectives the medical community would become a force for change for the better.

This blog was first published for onthewards on 12 March 2016 and can be read at its original location at Tick a box – For the good of whom?. onthewards.org is a free open access medical education website and not for profit organisation that aims to improve the availability of resources for medical students and junior doctors. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

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Photo: Oliver Tacke

Youth justice in Australia 2014–15

There were about 5,600 young people (aged 10 and older) under youth justice supervision in Australia on an average day in 2014–15, due to their involvement, or alleged involvement, in crime. This number has decreased by 23% over the 5 years to 2014–15. Around 4 in 5 (82%) young people under supervision on an average day were male. Most (85%) young people were supervised in the community and the remainder were in detention. Although rates of supervision decreased over the 5-year period for both Indigenous and non-Indigenous young people, the level of Indigenous over-representation increased.

National talks on remote area nurse safety

Improvements in the security of remote area nurses have been put off to a future meeting of Federal, State and Territory health ministers.

In a statement issued following a meeting with remote health service operators and representatives, Rural Health Minister Fiona Nash said there had been “a number of worthy, original and thoughtful ideas” which the she would carefully consider and raise with her State and Territory counterparts “over the coming weeks”.

The meeting was convened in the wake of the fatal attack on Gayle Woodford, 56, who was working as a nurse in the remote Fregon community in the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of north-west South Australia. A 34-year-old man, Dudley Davey, has been charged with her murder.

The murder has ignited a campaign for improved security for nurses working in remote areas, including calls for the abolition of single-nurse posts and new rules requiring health workers attending call-outs and emergencies to operate in pairs. As at 8 April, almost 130,000 people had signed a petition calling for the changes.

The sector also faces the threat of a mass walkout of staff. A survey of 800 regional nurses cited by the Adelaide Advertiser indicates 42 would quit if single nurse posts are retained.

The fatal attack on Ms Woodford is but the latest in a series of incidents and assaults on remote area nurses. A University of South Australia study of 349 such nurses, undertaken in 2008, found almost 29 per cent had experienced physical violence, and 66 per cent had felt concerned for their safety.

The study found that there had been a drop in violence against nurses since 1995, coinciding with a reduction in the number of single nurse posts.

Senator Nash paid tribute to health workers in remote areas and acknowledged that they faced “unique and difficult challenges”, but held back from endorsing any particular course of action to improve security.

Part of the problem she faces is that the ability of Federal and State governments to act to improve health worker safety is constrained because remote area health services are independently run, often by Aboriginal communities.

Senator Nash said she would respect the independence of service operators.

“Whilst the Federal Government funds many of these remote services, they are, in fact, independently run, as they should be,” she said. “I will not break Australia’s long-standing multi-partisan commitment to Indigenous self-determination by telling these health providers how to run their services.

“Remote health services do the work on the ground and they know best, so I will be asking them for their ideas on this important issue.”

Adrian Rollins

Whiff of an election

With rumblings of an early (or at least earlier) double dissolution election gathering pace in Canberra, the AMA is refining its pre-election strategy. The key policy issues are well documented in the AMA’s pre-Budget submission, which can be read on the AMA website.

The focus of AMA’s advocacy remains unchanged. This includes ensuring adequate Commonwealth funding of the public hospital system, with changes required to the proposed arrangements with the states that were announced in the 2014 Federal Budget.

The second concern is with the sustainability of primary care as the most cost-effective and efficient part of the health system. The ongoing freeze to Medicare rebates has not stopped the rise in bulk billing rates, but it does mean that general practitioners have to make difficult choices about the way they deliver optimal care to their patients.

The third concern is ensuring the value of the private health system, which will be informed by the several reviews currently underway at the instigation of the Federal Minister for Health. These include the review of the MBS, the review of private health insurance and, as a corollary to that review, a review of the benefits paid by private health insurers for prostheses listed on the Prostheses List.

The AMA also remains concerned with the gap in Indigenous health outcomes, and the impact that a series of Budget cuts have had on areas of health most relevant to Indigenous communities.

Elsewhere in this edition of Australian Medicine is a report on the recent forum convened by the AMA on the heath of asylum seekers in detention, particularly children.

The forum was well attended by doctors, nurses, and other health care workers, with speakers highlighting the health issues faced by detainees. The forum endorsed the call by the AMA for four outcomes, including independent oversight of the health of asylum seekers in detention.

A small number of members have queried the AMA’s involvement in the debate about asylum seeker health. There is clear Federal Council policy that backs the AMA speaking on the issue – not on the question of Australia’s border protection laws, but on the more focused issue of health care.

The AMA’s National Conference is coming up at the end of May, with early registration now available via the Federal AMA website – www.ama.com.au.

One of the key events is a debate about assisted dying, and this presents an opportunity to explore the views of AMA members. The debate forms part of the regular five-year review of current AMA policy. The session will be facilitated by Tony Jones of Q&A fame.

Nominations have been called for several awards which are given as part of National Conference. These include the AMA Woman in Medicine Award and the AMA Excellence in Healthcare Award, as well as several more specific public health awards. I encourage you to consider nominating suitable candidates for these prestigious awards.