[Obituary] Simone Veil

Former French Health Minister and architect of the law legalising abortion in France. Born in Nice, France, on July 13, 1927, she died at home in Paris, France, on June 30, 2017, aged 89 years.

Slater and Gordon health grants open

Invitations are being invited for this year’s Slater and Gordon Health Projects and Research Fund grants.

The law firm opened its 2017 grants applications process on July 3 and will close them on 17 August.

AMA members have been invited to apply for eligible projects.

Small grants of up to $3,000 are available to support the continuing education of medical and allied health professionals seeking to enhance their expertise in caring for and treating patients or clients in these areas.

The Fund also provides grants of up to $25, 000 to eligible not-for-profit organisations in Australia and the UK that focus on illness and prevention and the improvement of treatment and care for people with: an asbestos related disease; a occupational caused cancer; or significant disability caused by catastrophic spinal cord or brain injury.

The Fund has provided $300,000 in grants for medical research and health projects since it was established in 2014.

The Fund was built on the Slater and Gordon Asbestos Research Fund, which provided $1.4 million towards education, medical research, and other projects designed to improve the treatment of people who have an asbestos related disease.

Further details on the grant should be directed to the Manager of Secretariat, Ms Suzy Mallet on 03 8644 8466 or researchfund@slatergordon.com.au

[Department of Error] Department of Error

Cleaver G. Access to abortion in the USA—the legal battle. Lancet 2017; 389: 2361–62—In this World Report, the following sentence should have read “Gorsuch is, as lawyer and graduate of the Yale University School of Medicine Julie Cantor says, an ‘unknown’”. This correction has been made to the online version as of June 20, 2017.

[Correspondence] The INFANT trial

Robert Keith1 (April 28, p 1697) suggests that the INFANT trial2 is flawed by design. Previous reports3,4 suggested that a key element in substandard intrapartum care is the failure of clinicians to recognise an abnormal fetal heart-rate pattern, so the trial was set up to investigate whether decision support that detects and highlights abnormality of the fetal heart rate could improve outcomes. We compared decision support with no decision support. All other aspects of care were kept constant, including the use of the Guardian platform, which is the electronic data collection system in which the decision-support software operates.

[Series] Health and health care in Israel: an introduction

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922–48), the development of many of today’s health services predated the state’s establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law.

[Series] Maternal and child health in Israel: building lives

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development.

Call to action to end elder abuse

The Government is considering recommendations to come out of a long-running Federal inquiry into elder abuse.

The Human Rights Commission has made a call on all Australians to recognise the rights of older people and end the abuse and neglect so many of them face.

The call comes as the Australian Law Reform Commission (ALRC) releases its findings and recommendations following a 15-month Federal Inquiry into elder abuse.

The report, Elder Abuse – A National Legal Response, is the result of 117 national stakeholder meetings and more than 450 submissions.

The Age Discrimination Commissioner, Dr Kay Patterson AO, said the report was a seminal piece of research that has the power to change lives. She also believes the report puts all Australians on notice (in particular those working with older people) that they have a responsibility to understand what elder abuse is and to commit to its elimination.

“The report contains 43 recommendations and my plan is to work with Governments and stakeholders to drive the adoption of these recommendations. This includes a national plan to protect the rights and well-being of older Australians with a goal to end elder abuse,” she said.

Elder abuse includes psychological or emotional abuse, financial abuse, physical abuse, neglect and sexual abuse. It has a devastating impact on individuals, families and communities across the country.

ALRC president Professor Rosalind Croucher said the framework could be used to implement wide-ranging reform.

“In developing the recommendations in this report, we have worked to balance the autonomy of older people with providing appropriate protections, respecting the choices that older persons make, but also safeguarding them from abuse,” Professor Croucher said.

One of the key recommendations in the report is implementing a national study to examine how common elder abuse in Australia is – to research the overall number and severity of incidents of elder abuse and neglect in Australia.

The report did not examine the impacts of elder abuse on health and well-being. Also not included in the report is whether providing inappropriate health care is a form of abuse.

Law Society of NSW President Pauline Wright also welcomed the report and its recommendations, noting increasingly older Australians were facing abuse which could be in the form of physical, psychological, emotional, financial, sexual abuse or neglect.

“Sadly, financial abuse also frequently occurs, often perpetrated within families or by someone known to the victim such as a friend, carer or neighbour,” Ms Wright said.

“Measures to prevent financial abuse are particularly critical given the rise in Australia’s ageing population and the increasing number of Australians living with dementia.”

In a statement, Attorney-General George Brandis said the Turnbull Government would carefully consider the recommendations and work across portfolios to develop a response.

The AMA believes that family and domestic violence (FDV) is unacceptable in any circumstances. A recent position statement by the AMA points out that elder abuse is a less well covered form of family and domestic violence. It too can be physical, but also involves psychological and financial abuse. A copy of the position statement can be found at: position-statement/family-and-domestic-violence-2016 .

Meredith Horne

Maternity Review a wasted opportunity

BY AMA PRESIDENT DR MICHAEL GANNON

After months of behind-the-scenes activity and growing angst from the profession, the AMA went public in June with our outrage over the process for the planned new National Framework for Maternity Services (NFMS).

The Framework is doomed to fail due to inadequate stakeholder consultation and the spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development.

Following an agreement at the April 2016 COAG Health Council meeting, the Queensland Government was tasked to lead the project to develop the NFMS, under the auspices of the Australian Health Ministers’ Advisory Council (AHMAC).

The AMA first became aware of the NFMS project in December 2016 – eight months after it commenced, and without any direct contact from AHMAC’s Maternity Care Policy Working Group (MCPWG) or its consultants – and we have raised concerns about the project ever since.

The AMA’s concerns are shared by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the National Association of Specialist Obstetricians and Gynaecologists (NASOG).

It is outrageous that specialist obstetricians and GPs have been marginalised in this process. You could be forgiven for thinking it a joke.

Obstetrician-led care is an essential tenet of Australia’s maternity system. There is clear and compelling evidence that shows that obstetrician involvement translates into lower mortality rates and fewer complications, not to mention lower costs.

When issues and problems arise during labour, it is invariably an obstetrician who is called on to assume responsibility and manage care, working to ensure the best possible outcome for mother and baby.

The AMA is pleased that midwives were strongly represented on the Working Group responsible for drafting the NFMS. They are key members of the maternity team.

But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.

AMA members have reported maternity services and outcomes in their respective States have deteriorated under the current National Maternity Services Plan.

Obstetricians are concerned that not enough is being done to ensure women have access to high quality, collaborative models of care. Despite this, the consultation undertaken to develop the NFMS has neglected to actively engage specialist medical practitioners who are at the centre of care for mothers and babies.

The draft Framework, which was released for public comment in March 2017, lacked substance and provided no guidance for public hospital maternity services about what high quality care should look like.

The NFMS is shaping up as a lost opportunity to achieve the best possible maternity care for mothers and babies in Australia.

GPs, too, have been ignored in the process.

GPs not only routinely offer obstetric services in outer metropolitan, rural, and regional areas, but deliver antenatal and postnatal care to thousands of Australian women. There was not a single GP representative appointed.

Further, there is no acknowledgement that best practice care of mothers involves anaesthetists, obstetric physicians, psychiatrists, pathologists, and haematologists, none of whom were invited to assist in the development and drafting of the NFMS.

The AMA wants to see a strong NFMS. It must be developed in genuine partnership with the medical profession and its peak bodies. These are the medical professionals who deal with maternity services, day in and day out.

They’ve seen what works, and they know where the system is not working well. Their experiences and views should have been at the table, from the beginning.

Inviting them to a consultation a month before completion of the draft NFMS does not seem a genuine attempt to listen to experts at the coalface of maternity services.

The AMA has called on COAG, AHMAC, and the NFMS Working Group to formally and genuinely engage with the medical profession – obstetricians in particular – before there is any further policy development or public reporting on the Framework.

The health of mothers and their babies deserves a thorough and professional Framework to ensure the best possible care.

AMA voicing concern over some political moves

Two issues dominating recent health policy discussions have seen the AMA at the forefront of political debate, expressing concerns over the direction of some processes and decisions.

The medicinal cannabis and maternity services debates have kept AMA President Dr Michael Gannon a familiar face around Parliament House in Canberra, explaining doctors’ views to Government and the media.

Medicinal cannabis

After a surprise result from a Senate vote in June, terminally ill patients with a doctor’s prescription will be able to get faster access to medicinal cannabis and be allowed to import three months’ worth of their own personal supply of the drug.

The Greens pushed for changes to Government restrictions and they found support from Labor, One Nation and some independents.

But Health Minister Greg Hunt, who with his Government colleagues tried to stymie the move, said the outcome could put lives at risk.

He said the changes could open the way for questionable and unregulated products to be introduced to the market, as well as making it easier for criminals to access drugs.

“It is unfortunately a reckless and irresponsible decision,” Mr Hunt said.

Dr Gannon agrees, saying the AMA was disappointed with the move.

“You’ve already got a situation where doctors are querying exactly how effective medicinal cannabis is. If you in any way put any doubt in their minds about the safety, you’re simply not going to see it prescribed by many doctors,” he said.

“We remain concerned about potential diversion into the general community. And let’s not forget, we’re talking about cannabis. We’re talking about a substance that, used in the form it’s used by most people, is a major source of mental illness in our community.”

Dr Gannon said the AMA was satisfied with the process put in train by the Government through the Therapeutic Goods Administration.

“The TGA’s got a process in place. Let’s support that careful process to make sure what is used is perfectly safe.”

The binding vote, which passed in the Senate 40 to 30, means medicinal cannabis will be put on the TGA’s Category A list, giving qualifying patients priority and faster access.

Maternity Services

The AMA is also warning that the planned new National Framework for Maternity Services (NFMS) was doomed to fail due to inadequate stakeholder consultation.

Describing the process as spectacular failure to adequately engage expert obstetric, general practice, and other crucial medical specialists in its development, Dr Gannon said opportunities for improvement were being lost.

The AMA has raised concerns about the project ever since.

In June, however, Dr Gannon, an obstetrician, said it was outrageous that specialist obstetricians and GPs had been marginalised in the process.

“You could be forgiven for thinking it a joke,” he said.

“Obstetrician-led care is an essential tenet of Australia’s maternity system.

“But not involving a single obstetrician in a 12-member group tasked with looking at maternity services is like conducting a law and order review without talking to the police.”

On June 23, the process did indeed fail and was scrapped.

Dr Gino Pecoraro, AMA Federal Councillor, attended an NFMA consultation on that day to discuss concerns.

He described the subsequent decision to scrap the process as a win for patients.

Dr Pecoraro said the process to date had been a monumental waste of time and money.

“The AMA has been clear that unless they went back and started again, then it wouldn’t go anywhere,” he said.

“It is a win for the women and children of Australia.”

Chris Johnson

Medicinal cannabis – still a lot of misinformation

BY AMA VICE PRESIDENT TONY BARTONE

It seems hardly a week goes by without a news story on medicinal cannabis or a media interview request on the subject.

However,despite all of the information, the amount of misinformation in the general community is significant and at times is very concerning. Many in the media believe that it is currently possible to go to your local GP and have medicinal cannabis prescribed for chronic pain. If not; why not? Presumably the patient would then go down to the local pharmacist and have it dispensed. Journalists are amazed when told that there are both State and Federal government laws and restrictions that still present significant barriers and that these restrictions need to be adhered to.

Medicinal cannabis certainly has had a very political and community driven introduction in this country. Things have been moving quickly, beginning with the passage of legislation in November 2016 involving the Therapeutic Goods Administration. Since that time, medicinal cannabis no longer falls under Australia’s most stringent of schedules – reserved for dangerous drugs – thereby allowing for provisions to be put in place to use cannabis on medical grounds.

Just this month we have had a Senate vote to increase the ease of availability of all forms of medicinal cannabis for terminally ill patients. Some have described this as a political stunt and posturing. In essence, moves in this space are happening so quickly that it is quite likely opportunities and processes are evolving that render the recent Senate amendments potentially unnecessary.

More importantly and perhaps of more concern is that the usual guidelines and requirements for the introduction of new medications seem to have been forgotten in respect of medicinal cannabis. It seems that safety and concern for rigorous, clinically proven guidelines are dispensed with – all in the name of compassion for a patient population who are just as deserving of the same standard of care as the rest of the community when it comes to safety and harm minimisation. It seems that all the tenets of our world-class system have been forgotten and are suddenly archaic and of little value in the face of a voracious community perceived need. This is spurred on by numerous media stories featuring long-suffering patients and their families who are forced to access the illegal black market.

Under the TGA Special Access Scheme, some forms of medicinal cannabis are already available. This scheme provides for the import and supply of an unapproved therapeutic good to individual patients on a case-by-case basis.

What also has been forgotten in all of this is that there is a significant amount of State legislation to be complied with. The States and Territories will decide whether medical cannabis will be made available – and more importantly, which type of patients will be able to use it. Some States and Territories have indicated they will list the conditions (e.g. QLD: Legal for specialists to prescribe for some patients; NSW: Available for adults with end-of-life illnesses; VIC: Available for children with epilepsy) The TGA is currently undertaking significant amount of education and information sharing with the medical community. This is especially necessary when a large portion of the media reporting is on access to prescribers and the relatively small numbers of prescribers or applications to prescribe. This is not surprising when clinical guidelines are in a state of evolution and there is uncertainty among many doctors about who should be eligible. Right from the beginning we have also maintained that there needs to be great clarity around how the medical cannabis system will operate. There is a paucity of information from the Government, which is adding to the confusion.

The AMA has many other concerns.So much still remains to be clarified. Information about either the dosage or form of medicinal cannabis needs to be available to patients. In countries that have medical cannabis (Canada, Holland, Israel) there are only a few types of cannabis available and they are packaged and dispensed like any other pharmaceutical product, with information on strength, use, dosage etc. The different types of cannabis are prescribed for designated medical conditions. It is not yet clear how medical cannabis will be dispensed. Is it to be dispensed through pharmacies, secure home delivery or from nominated GPs?

It is also not yet clear who will be able to approve medical cannabis prescribing and whether doctors will need to undertake additional training to become an “approved” cannabis prescriber/dispenser. The AMA has been told that modules are being created for doctors, but we don’t know exactly how or where this will be implemented.

There are some pharmaceutical cannabis products already approved by TGA (like Sativex) and controlled and standardised herbal cannabis, such as the products produced in the Netherlands. The system may be so convoluted and complicated for patients and prescribers that it won’t be able to fulfil the reason it was established and patients may continue to use the black market.

The recent Senate vote effectively means the Senate has supported an amendment to therapeutic goods laws to change category A of the Special Access Scheme for cannabis. The effect of this will speed access to medicinal cannabis for people with a terminal illness. What this means is that from now on, a patient can go and see a doctor who can order medicinal cannabis for that patient if they have a terminal illness. If medicinal cannabis is not available in Australia, they can obtain it from overseas. This is most concerning in terms of guaranteeing safety and efficacy of the product imported. Doctors will only need to notify the TGA within a 28 day period.

What is needed is for the current consultative processes between TGA, Federal and State Governments with the appropriate stakeholders to continue. A lot has been achieved in a very short space of time. However, safety and reliability of product as well as clear clinical guidelines for use need to be firmly developed and supported by clear information sharing and training of doctors concerned. Politics should not be allowed to influence and certainly media and community information needs to be facilitated so that expectations do not exceed practicality.