Sad loss of GP advocate

Many in the AMA and across the medical profession were saddened last month with the passing of popular and highly respected GP, general practice advocate, writer, and editor, Dr Kerri Parnell, following a battle with breast cancer.

Working as a GP in Sydney, Kerri found herself recruited to the world of medical publishing, where she quickly became a passionate and informed champion for her colleagues in general practice.

She spent many years with Australian Doctor, before moving in recent years to The Medical Republic.

When I joined the AMA, Kerri became a friend and confidant, helping me understand the mysteries of the general practice world.

Kerri was a friend and colleague of many at the AMA, including Federal and State Presidents, Chairs of the AMACGP, and grassroots members.

Her editorials and articles gave voice to the ideas, concerns, pressures, and experiences of hardworking local GPs across the country. She helped give GPs political clout.

Kerri was a mentor to many young journalists who started or built their careers in medical publishing.

A great conversationalist and networker, and a talented and colourful writer and editor, Dr Kerri Parnell will be sorely missed.

JOHN FLANNERY

[Comment] Offline: Israel and Palestine—a joint search for the truth

In July, 2014, amid the tragedy of a war between Israel and Hamas-controlled Gaza—a conflict in which thousands of rockets and missiles were fired, leaving hundreds of children and women dead—The Lancet published a letter by Paola Manduca and colleagues. We had been working with Palestinian health professionals since 2007 to help advance their health and health care through research collaboration. The intention of publishing the letter from Manduca et al was to signal a cry of anguish for a people we had come to know well.

Advice on professional standards submissions released for public comment

PROFESSOR ROBYN LANGHAM, CHAIR, MEDICAL PRACTICE COMMITTEE

One of the benefits of the National Registration and Accreditation Scheme is the transparent development and revision of all registered health practitioners’ professional standards.

Whenever one of the 14 national boards under the Scheme wishes to revise, update or expand its professional standards, it must undertake a public consultation process, which includes disseminating a discussion paper, inviting submissions, and publishing the submissions and outcomes.

This allows considerable public scrutiny of proposals by Boards that sometimes seek to expand their practitioners’ scopes of practice beyond their training and education, and without sufficiently heeding workforce or public safety considerations.

In March, the Medical Practice Committee provided advice on the AMA’s submissions to two professional standards released for public consultation.

The first was the draft revised Professional Practice Standards for pharmacists developed by the Pharmaceutical Society of Australia (PSA). The draft standards, which have not been updated since 2010, are comprehensive and set a high bar for pharmacist practice.

Our submission commended the PSA for emphasising that standards in collaborative care, ethics and professionalism, evidence-based practice, and quality use of medicines must underpin the application of all pharmacists’ professional practice standards.

However, we made recommendations to further strengthen and clarify some of the draft standards to enhance patient privacy, patient safety, the quality of patient health care, and the collaboration between medical practitioners and pharmacists in providing person-centred care and services.

For example, in upholding principles of providing safe, evidence-based, effective and cost-effective services, the AMA commented that pharmacists must limit screening and risk assessment to services that:

provide a demonstrated benefit to patients (actually lead to better health care outcomes);
complement and do not duplicate existing services provided by other health professionals or services (e.g. general practitioners, community-based clinics); and
do not lead to higher out-of-pocket costs for patients or higher costs to the health system as a whole.

The AMA’s second submission responded to the Optometry Board of Australia’s (OBA) revised Endorsement for scheduled medicines registration standard, which sets out the requirements for an optometrist to have their registration endorsed to prescribe scheduled medicines. This standard was also last updated in 2010.

The OBA is proposing to remove the list of scheduled medicines (including prescription-only medicines) that is currently attached to the standard, and attaching it instead to the Guidelines for endorsement for use of scheduled medicines. Changes to the standard must be approved by the Australian Health Workforce Ministerial Council, while changes to the guidelines do not. So moving the list of medicines from the standard to the guidelines would mean the OBA could make changes to the list of medicines without Ministerial approval.

The OBA argues that the current situation is slow, inefficient and causes unnecessary delays to patient access to new medicines.

However, the AMA strongly opposes this proposal.

Australian Health Workforce Ministerial Council approval of the standard and the medicines list is an important measure, ensuring that there is additional scrutiny at the highest level of any changes to prescription-only medicines within an optometrist’s scope of practice.

Administrative efficiency should not compromise patient safety. No evidence has been provided to support the claim that patient access to appropriate eye care is being compromised because the list is attached to the standard or that removing the list from the standard will enhance delivery of care.

It’s important that the AMA is vigilant in ensuring that non-medical practitioner prescribing does not expand beyond their scope of practice, training and education.

Medicare data breach prompts law change

The Federal Government has moved to tighten privacy laws after doctor provider numbers were disclosed in a breach of security around Medicare and Pharmaceutical Benefit Scheme data.

Attorney-General George Brandis has announced plans to amend the Privacy Act to make it a criminal offence to re-identify de-identified Government data following a discovery that encrypted MBS and PBS data published by the Health Department had been compromised.

The Department was alerted on 12 September to the worrying security lapse by Melbourne University Department of Computing and Information researchers Dr Chris Culnane, Dr Benjamin Rubinstein and Dr Vanessa Teague, who found they were able to decrypt some service provider ID numbers in the publicly available Medicare 10 per cent dataset. They immediately alerted the Department.

In a statement, the Department said no patient information had been compromised in the incident.

“The dataset does not include names and addresses of service providers, and no patient information was identified,” the Department said. “However, as a result of the potential to extract some doctor and other service provider ID numbers, the Department of Health immediately removed the dataset from the website to ensure the security and integrity of the data is maintained.”

But Shadow Health Minster Catherine King questioned why it had taken the Government 17 days to reveal the security breach, and voiced concerns that there may have been 1500 downloads of the dataset before it was withdrawn by the Department.

“The Government’s 17 day delay in admitting to a breach of health data under their watch is unacceptable,” Ms King said.

Notice of the breach came as a Senate inquiry heard concerns about data security surrounding the decision to award Telstra Health $220 million contract to design and operate the National Cancer Screening Registry, and follows the collapse of Australian Bureau of Statistics systems on census night.

The AMA said that although the data security breach was concerning, it should not result in governments withholding data from being available for research and policy development.

The Association said that although it was paramount that personal information be properly secured and protected, it was important that de-identified and encrypted data be made available by Government to help inform research and the analysis of health information.

Senator Brandis reassured that the Government remained committed to making valuable data publicly available.

“The publication of major datasets is an important part of twenty-first century government providing a great benefit to the community,” the Attorney-General said. “It enables…policymakers, researchers and other interested persons to take full advantage of the opportunities that new technology creates to improve research and policy outcomes.”

But Senator Brandis said that advances in technology had meant that methods used in the past to de-identify data “may become susceptible to re-identification in the future”.

Under his proposed changes to the Privacy Act, it would be a criminal offence to re-identify de-identified Government data, encourage someone else to do it, or to publish or communicate such data.

The Health Department said it was conducting a “full, independent audit” of the process followed in compiling, reviewing and publishing the data, and promised that “this dataset will only be restored when concerns about its potential vulnerabilities are resolved”.

The Office of the Australian Information Commission is undertaking a separate investigation.

Adrian Rollins

Medicare data breach prompts law change

The Federal Government has moved to tighten privacy laws after doctor provider numbers were disclosed in a breach of security around Medicare and Pharmaceutical Benefit Scheme data.

The Department was alerted to the worrying security lapse by Melbourne University Department of Computing and Information researcher Dr Vanessa Teague, who found she was able to decrypt some service provider ID numbers in a dataset being used by her and several of her colleagues. She immediately alerted the Department.

In a statement, the Department said no patient information had been compromised in the incident.

The security breach has come as a Senate inquiry hears concerns about data security surrounding the decision to award Telstra Health $220 million contract to design and operate the National Cancer Screening Registry, and follows the collapse of Australian Bureau of Statistics systems on census night.

The AMA said that although the data security breach was concerning, it should not result in governments withholding data.

Senator Brandis reassured that the Government remained committed to making valuable data publicly available.

But Senator Brandis said that advances in technology had meant that methods used in the past to de-identify data “may become susceptible to re-identification in the future”.

Under his proposed changes to the Privacy Act, it would be a criminal offence to re-identify de-identified Government data, encourage someone else to do it, or to publish or communicate such data.

The Office of the Australian Information Commission is undertaking a separate investigation.

Adrian Rollins

[Comment] Offline: Data sharing—why editors may have got it wrong

Last week, the Editor-in-Chief of The New England Journal of Medicine, Jeff Drazen, was in London. NEJM, like The Lancet, is a member of the International Committee of Medical Journal Editors (ICMJE). Although gentle rivalries exist, ICMJE editors try to find reasons to work together harmoniously on common problems. One example was clinical trial registration. In 2004, the ICMJE committed its members to publishing trials only if the study had been registered before enrolment of the first patient.

Government taskforce doesn’t back sick certificate scare

The MBS Review Taskforce has sounded a warning on assertions that doctors are blowing out health costs by issuing sick certificates, ordering prescription repeats and writing specialist referrals.

Two-thirds of health professionals responding to an online survey run by the Taskforce called for MBS rules to be reviewed, particularly regarding the use of referrals and restrictions on eligible providers, seemingly lending weight to claims that GPs were wasting much of their time on ‘routine’ tasks like filling out medical certificates and writing referrals.

Health Minister Sussan Ley seized on the claims, telling ABC radio that “if the Government is paying effectively too much for small appointments that aren’t necessarily adding to a person’s overall health, particularly if they have chronic conditions, then that money does need to be reinvested”.

Extending her attack on primary health care, Ms Ley said a quarter of patients believed they had been recommended tests or treatments that were unnecessary.

The suggestion has fuelled calls, including from the Pharmacy Guild of Australia, for pharmacists, nurses and other allied health professionals to be granted an increased scope of practice to ease the burden on family doctors.

But the Taskforce itself has cast doubt on the extent of the problem, and has instead inferred that its prominence was being driven by health groups like pharmacists and nurses keen to expand their scope of practice.

“Many health professional respondents argued that referrals through GPs were unnecessary, particularly when accessing allied health services,” the Taskforce said in an interim report on its consultation. “It should be noted that the prevalence of this issue may reflect the skew towards allied health providers in the respondent group”.

AMA President Dr Michael Gannon dismissed the claim that valuable health dollars and GP time was being wasted on writing out certificates and referrals.

Dr Gannon said that not only was general practice very cost effective – accounting for just 6 per cent of total health spending – but performing such services was often a valuable opportunity to undertake preventive health care such as performing blood tests and assessing for diabetes and heart disease risk.

Related: Patient charges rising fast

In its discussion of the results of the online survey and stakeholder consultations, the Taskforce notably avoided the issue and turned its focus elsewhere.

It backed proposals for greater transparency on Medicare fees, and endorsed the idea of giving practitioners data on their own Medicare item usage, benchmarked against their peers.

But it flagged a cautious approach to changes to Medicare pay arrangements and MBS items.

In consultations there were calls for the fee-for-service model to be scrapped and replaced with an outcomes-based payment system.

But although expressing interest in pay for performance as a complement to fee-for-service in supporting multidisciplinary care, it was lukewarm on a wholesale change.

“The evidence suggests that clinically-based outcomes linked to payment have mixed success and may not be superior to activity-based payments in driving high-value care,” the Taskforce said. “Indeed, the MBS itself has many examples where incentive payments directed to addressing service deficits have had undesirable outcomes.”

And, while the Government has emphasised the scope for the MBS Review to axe Medicare items, the Taskforce indicated it would be moving with careful deliberation.

It noted that its terms of reference “do not preclude” recommending new items, and was considering “the addition of temporary item numbers to be used specifically for the acquisition of evidence to support the long-term retention or removal of items from the MBS”.

The case to remove items will depend on more than simply how often it is used.

“The Taskforce recognises that low usage of an item is not in itself conclusive evidence of obsolescence,” the Taskforce said.

View the Taskforce interim report here.

Latest news

[Correspondence] Foot print of a paper: accountability in academic publishing

At the moment, the publishing process is unaccountable to the readers and is not transparent. In a published paper, there is no record of previous submissions to other journals and the comments it might have received in the journey to the final publication. A paper that might have been rejected by three or four journals goes into press, and people hear about the results without any of the background scientific debate and conversation that led to this publication, especially those debates that contributed to the previous rejections.

Pharmacists: shopkeepers or health professionals?

Pharmacists could face restrictions on the amount of shelf space they devote to selling vitamins, shampoo, toothpaste and other retail products as their dual role as health care professionals and shopkeepers comes under scrutiny in a Federal Government review.

The Government’s Review of Pharmacy Remuneration and Regulation is looking into whether there should be limits imposed on the retail activities of community pharmacies amid accusations that pharmacists are misleading consumers and undermining their own professional integrity by selling vitamins, herbal remedies and other complementary medicines that have no proven health benefit.

While dispensing prescriptions is the principle source of pharmacy earnings, generating 61.5 per cent of income in 2015-16, sales of cold and flu remedies, cough syrup and other non-prescription medicines contributed 16 per cent of revenue, purchases of vitamins, herbal remedies and other complementary medicines provided 15.5 per cent of earnings and sales of cosmetics and beauty products generated 7 per cent of income.

The review panel, led by Professor Stephen King, has been told that community pharmacists face a conflict of interest between their role as a health care professional and a shopkeeper, particularly when stocking their shelves with products for which there is no evidence of efficacy.

As community pharmacists push for an expanded role as health service providers, they are coming under scrutiny over their business practices, particularly regarding the sale of complementary medicines.

The issue is probed in a discussion paper released as part of the review, which has been set up to examine the role of pharmacists and community pharmacy in delivering health services, now and in the future.

The review panel said it had heard of numerous examples where community pharmacists had gone “above and beyond in providing additional services that are in the patient’s best interest, even though they may not be compensated for these valuable services”.

But, it added, there were those who objected to the current direction in which community pharmacy was headed, and were concerned that issues around their dual roles as a retailer and health service provider were yet to be resolved.

“It was put to the Panel that community pharmacists face conflicts of interest between their role as retailers and as health care professionals,” the discussion paper said. “This tension between treating consumers as customers or patients was attributed to the contrast in the remuneration from dispensing and the revenue generated from the sale of over-the-counter medicines and complementary products.”

The Panel said it had heard concerns that financial pressures might cause pharmacists to compromise on the professional advice they provide, such as recommending medicines or products that were not necessary.

“It was also claimed that many complementary products do not have evidence-based health benefits and, as such, the sale of these products in a pharmacy setting may misinform consumers of their effectiveness and undermine the professional integrity of community pharmacists.”

The review has been set up under the terms of the current Community Pharmacy Agreement, and the panel is seeking comment on possible reforms in the sector, including changes to the pharmacy business model.

The discussion paper cited Guild Digest data showing that community pharmacies have an average annual turnover of $2.8 million, and a net profit of $107,000 (excluding proprietor salaries).

Among the proposals up for consideration is that Government funding, which is worth $13.2 billion under the life of the current five-year agreement, should be made conditional on the amount of revenue pharmacists generate from other sales.

“Should Government funding take into account the business model of the pharmacy when determining remuneration, recognising that some businesses receive significant revenue from retail activities?” is one of the question raised in the discussion paper.

“Should there be limitations on some of the retail products that community pharmacies are allowed to sell? For instance, is it confusing for patients if non-evidence-based therapies are sold alongside prescription medicines?”

It noted that some hospital pharmacies have designed their service area to resemble a clinic, getting rid of a counter and “providing a private environment without distraction, which maximises the professionalism of patient-pharmacist interaction”.

The review is being undertaken in the context of a sustained push by pharmacists for an expanded role as health providers.

Health Minister Sussan Ley said pharmacists were already taking on a greater role, including providing routine vaccinations and blood pressure checks, and the industry is pushing to be allowed to undertake broader screening and patient health checks.

The AMA has raised concerns about the risk to patients from pharmacists providing services beyond their realm of expertise, and is expected to make a submission to the review.

The Pharmacy Guild said the discussion paper raised many “thought-provoking questions” about the pharmacy sector and was preparing a formal response.

The review panel will conduct a series of public forums over the next five weeks, and those interested have until 23 September to provide a written submission.

Details of the review, including the discussion paper and the consultation process, are at: http://www.health.gov.au/internet/main/publishing.nsf/Content/review-pharmacy-remuneration-regulation

Adrian Rollins

[Comment] Offline: The crisis in scientific publishing

Back in 1990, no one used the words strategy, brand, or monetisation. Scientific publishing was a gentle and languorous affair. Manuscripts edited by pencil. Page layout with scissors and glue. Proof reading over a pint of beer at our typesetters. And when the weekly issue went to press, a small toast made with a glass of sherry. The Lancet then occupied a beautiful rabbit warren of an 18th-century town house in Bloomsbury. You could see a blue plaque across Bedford Square marking the home of the journal’s founder, Thomas Wakley.