[Correspondence] Barriers in palliative care in China

The 2015 Quality of Death Index1 compiled by The Economist Intelligence Unit warned that ageing and booming populations would make palliative care a growing worldwide issue. The Index was based on extensive research and interviews with more than 120 palliative-care experts across the world. The rankings took into account hospitals and hospice environments, staffing numbers and skills, affordability of care, and quality of care. China ranked 71st of 80 countries, and was reported to be “facing difficulties from slow adoption of palliative care and a rapidly aging population”.

Death not hastened for those who choose to die at home

A large Japanese study has found terminal cancer patients who choose to die at home tend to live longer than those who die in hospital.

The study, published in Cancer journal, reassures oncologists that patients aren’t worse off when choosing home-based palliative care.

Jun Hamano, MD, of the University of Tsukuba in Japan studied 2069 patients: 1582 patients received hospital-based palliative care and 487 chose to receive palliative care at home.

The survival of patients who died at home was much longer than those who died in hospital, even after patients’ demographic and clinical characteristics were factored in.

The authors note that the patients who were referred for home-based palliative care “might be inherently different from those referred for hospital-based care, although all known confounding factors were successfully adjusted.”

They also said that not all medical treatments were recorded. “An exploration of the potential effect of the place of death on survival needs further investigation.”

“The cancer patient and family tend to be concerned that the quality of medical treatment provided at home will be inferior to that given in a hospital and that survival might be shortened; however, our finding—that home death does not actually have a negative influence on the survival of cancer patients at all, and rather may have a positive influence—could suggest that the patient and family can choose the place of death in terms of their preference and values,” said Dr. Hamano.

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Identifying low-value care: the Royal Australasian College of Physicians’ EVOLVE initiative

Challenges and lessons arising from early adoption of a new approach towards determining what is good clinical practice

In March 2015, 41 medical specialties of the Royal Australasian College of Physicians (RACP) came together as part of the College’s EVOLVE initiative. The main aim of EVOLVE is to drive safer, higher-quality patient care through identifying and reducing low-value medical practices.1 In EVOLVE, “low-value” practices are defined as tests, procedures or interventions that are overused, inappropriate or of limited effectiveness (and, in extreme cases, potentially harmful). The name of the initiative reflects the dynamic and evolving nature of evidence-based medicine. EVOLVE is modelled on the Choosing Wisely initiative in the United States and similar initiatives underway in Canada, Italy and the United Kingdom.2

In EVOLVE’s first year, more than 20 specialties have completed or commenced work on lists of “top-five” low-value clinical practices in their respective fields. Here, we examine the approaches of three early adopter EVOLVE specialties — geriatric medicine, palliative medicine and rheumatology. We also share insights that have arisen so far that are relevant to the Medicare Benefits Schedule (MBS) Review Taskforce.

The EVOLVE approach

EVOLVE recognises the breadth of physicians’ practice, uniting specialties through their commitment to reducing low-value care. It is a partnership between specialty societies and the RACP. EVOLVE is clinician-led, with each specialty responsible for developing lists, engaging with its members and providing feedback to the RACP on systemic barriers to adoption of each list’s recommendations. The RACP is the umbrella body, developing common frameworks and a robust methodology, coordinating across and between specialties, connecting EVOLVE with associated initiatives such as Choosing Wisely Australia, and communicating about and advocating for high-value care.

To avoid the early mistakes of Choosing Wisely in the US, where some participating specialties identified “low-impact” practices on their lists and singled out clinical practices performed by other specialties,3 EVOLVE’s participating specialties agreed to robust principles and methods. These included:

Practices under consideration by each specialty should be “within or significantly impact their domain of practice”. This can be interpreted as including practices involving shared decision making with other health care specialties and those that are the subject of referral to and from other specialties. Specialties also have broad discretion to consider practices that they consider can “make a difference” in reducing low-value care (eg, rheumatologists and geriatric medicine specialists examined practices that affected people with conditions they commonly treated).
Practices under consideration should be either growing in use or currently commonly used. Some specialties interpreted “commonly used” as encompassing cost, not just volume (eg, rheumatologists excluded from consideration practices that were not very costly to the health care system).
Use of the Delphi method4 as the overarching methodology for identifying a top-five list.

The three specialties reviewed the US and Canadian Choosing Wisely lists as part of their development process, but this was not a substitute for formulating their own lists, as not every international practice is relevant to Australia. For example, performing whole-body bone scans (eg, scintigraphy) for diagnostic screening for peripheral and axial arthritis is included in the Canadian rheumatology list but is not material to Australia.

Three Delphi method case studies

EVOLVE recommends use of the Delphi method for identifying low-value care practices, in keeping with initiatives elsewhere.5 This survey-based approach derives consensus based on purposive sampling of experts in the field of interest, panellist anonymity and iterative questionnaire presentation.4

There were three subtle differences in the way the method was applied by the specialties:

Both geriatric medicine and palliative medicine working groups consulted their memberships early in the process to seek comment on provisionally identified practices and suggest new ones. Only after processing membership feedback and refinement of the provisional list was an evidence review conducted.
Both geriatric medicine and palliative medicine working groups shortlisted their identified practices by requiring respondents to assign scores to each practice based on multiple criteria. Geriatric medicine used seven criteria, while palliative medicine used three. “Strength of evidence”, “significance” and “opportunity to make a difference” were criteria common to both.
Rheumatology recruited additional members (including three trainees) into the working group so they could invest effort in building on the RACP’s initial evidence review. With this larger working group, they could break into smaller teams and assign to each team a practice for further research. The evidence was summarised in an online survey distributed to the broader membership, with links to a full discussion of the evidence embedded in the survey questions.

Remaining challenges

Notwithstanding EVOLVE’s established principles and methods, some challenges remain.

First, without a requirement for compulsory participation, there is an element of self-selection in participation in specialty working groups and surveys. It is unclear whether this will lead to bias in the list of practices compiled for investigation and final shortlisting.

Second, there may be a risk of limited buy-in by specialty members if survey participation rates are low or if consensus cannot be reached, potentially reducing the impact of EVOLVE lists on clinician behaviour. The rheumatology working group aims to overcome this by encouraging high survey participation and by requiring that each top-five list practice be selected by at least 70% of survey respondents, in the hope that this represents a sufficiently high threshold for buy-in.

Third, ensuring that practices being considered are commonly used or increasing in use is difficult. For some practices, regularly collected publicly available data are incomplete (eg, MBS data that do not cover all hospital-provided services or do not provide sufficiently detailed breakdowns by indication). In other cases, the judgement of survey respondents or working group members (most of whom are in active clinical practice) was relied upon to remove practices considered irrelevant because of low levels of use.

Fourth, due to the clinical expertise required to formulate EVOLVE lists, the process is specialist-dominated. Nevertheless, achieving buy-in from consumers and non-RACP clinicians is critical, as sustaining changes in clinical practice requires cooperation from these groups. This task will benefit from support from Choosing Wisely Australia, led by NPS MedicineWise, to which EVOLVE is a contributor.

Finally, implementation of the EVOLVE recommendations into practice will be the greatest challenge. A recent study of the Choosing Wisely campaign in the US found significant declines being achieved in only two of seven low-value services identified by the campaign.6 Translating the EVOLVE recommendations into clinical practice requires both consumer and clinician education and a systemic cultural shift towards high-value care. This might be achievable if there is a systematic and coordinated approach, but a substantial investment in time and support may be required to ensure that the aims of EVOLVE are achieved and are sustainable over time.

Insights relevant to the MBS Review Taskforce

The MBS Review Taskforce’s early work has focused on identifying “obsolete” MBS items.7 EVOLVE’s focus is on reducing low-value care. Use of the 23 obsolete items identified by the Taskforce will, by definition, be declining, so aiming to reduce their use will have minimal impact. By contrast, one of the EVOLVE criteria is that the practice examined is commonly used or growing in usage.

A critical EVOLVE insight is that few practices are unambiguously low value for all clinical indications, and low-value care is contextual. Hence, there will be few genuinely low-value clinical practices that could be reduced by deleting particular MBS items.

Clinical practice is more likely to be improved by ensuring tests and treatments are targeted at people with appropriate clinical indications. The following low-value practices identified by the three specialties illustrate the importance of this:

use of ultrasound imaging to guide glucocorticoid injections into the shoulder or lateral hip compared with non-image-guided injections (rheumatology)
use of antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia (geriatric medicine)
use of oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety and as routine treatment at the end of life (palliative medicine).

Although these three practices identify low-value applications of ultrasound imaging, antipsychotics and oxygen therapy for specific indications or groups, this does not justify withdrawing subsidies entirely from these tests and treatments, as they are valuable in other clinical contexts.

While some clinical change can be induced by restricting conditions under which particular MBS items are covered, our examples also illustrate the limits of this approach. First, there are tests and treatments that are at risk of being misused but are not funded by the MBS. Second, imposing additional restrictions on the use of MBS items does not guarantee adherence unless proof of correct indication is required.

Financial incentives have been found to have limited effectiveness in driving sustained changes in clinical practice.8 Thus, it is likely that a systems-based approach employing multiple complementary strategies is needed. Initiatives like EVOLVE, that create endorsed and recognised peer judgements on what is good clinical practice, combined with other strategies such as the current MBS Review and mechanisms to improve clinician and consumer understanding of what constitutes low-value care, are needed. Working together, such strategies may shift clinician behaviour and consumer preference towards opting for the most appropriate evidence-based tests and treatments.

When not doing something may be the best choice

X-rays for sprained ankles, antibiotics for ear infections and colds and colonoscopies to screen for bowel cancer are among more than 60 tests, treatments and procedures medical experts say should be avoided because they are wasteful and unnecessarily risky.

Fourteen specialist colleges, societies and associations have taken the lead in identifying 61 tests and procedures that should no longer be used because they expose patients to harm, undermine the effectiveness of lifesaving antibiotics and are a poor use of scarce health dollars.

The list, compiled under the Choosing Wisely initiative of NPS Medicinewise, includes many practices and treatments often considered routine and uncontroversial, but which evidence shows achieve little and are potentially harmful.

An area of particular focus is the use of antibiotics, amid fears that they are being overused, fostering bacterial resistance and the rise of superbugs impervious to known medicines.

In changes that could improve patient outcomes and potentially save millions of dollars, doctors and parents are being urged to make much more careful use of antibiotics, including in the treatment of middle ear infections in children, and in the treatment of colds and other upper respiratory tract infections.

The Royal Australian College of General Practitioners (RACGP) has recommended against the initial use of antibiotics for children aged between two and 12 years with a middle ear infection, where a review is possible in the following 24 to 48 hours.

AMA President Professor Brian Owler said it was important advice that would avert unnecessary treatment while helping to preserve the effectiveness of antibiotics.

“In the case of an ear infection, if there is a chance of review in 24 to 48 hours and the ear looks red, just come back and have a review rather than going straight to antibiotics, so that we try and reduce this over-prescribing of antibiotics,” Professor Owler told Channel Nine’s Today show.

The AMA President said it was advice aimed not only at doctors, but also parents and patients.

“Part of the problem here is not just to educate doctors in terms of when antibiotic prescribing is or isn’t called for, it is also to educate parents and patients themselves so that we don’t prescribe too many antibiotics, because we know if we do that we are likely to see more resistant infections. That’s going to mean that people’s infections are going to be much harder to treat in the future,” he said.

Two Bond University academics, Professor of Clinical Epidemiology Tammy Hoffmann and Professor of Public Health Chris Del Mar said the Choosing Wisely initiative was important not because of the money that could be saved, but because of a change in a approach that it represented.

They wrote in The Conversation that clinicians were guilty of doing too much rather than too little, and Choosing Wisely helped to signal “a very important departure from normal business for clinicians – thinking about not doing things”.

“The premise behind Choosing Wisely is not about cost-cutting. It is one of the few existing processes for dealing with the one-way ratchet caused by more treatments and tests being generated every year, all of which increases the amount of things that can – but not necessarily should – be provided to patients,” they wrote.

Other therapies that have come under question include chest x-rays, one of the test most commonly ordered by GPs.

The RACGP has advised that GPs should no longer, as a matter of routine, order chest x-rays for patients with acute uncomplicated bronchitis.

The Royal Australasian College of Surgeons, meanwhile, has recommended against CT scans for suspected appendicitis without first considering an ultrasound, the Australian Physiotherapy Association has advised that there is “no advantage from routine imaging of non-specific low back pain”, and the Australian and New Zealand Society of Palliative Medicine has advised against the use of stomach feed tubes for patients with advanced dementia.

Professor Owler said the initiative demonstrated that doctors were keen to get rid of wasteful and potentially harmful practices, and supported efforts to improve the effectiveness of health spending.

He said doctors took seriously their responsibility as stewards of the health care system, and were constantly reviewing their practices and the evidence to ensure patients received the best possible care.

His comments were echoed by Australasian College of Dermatologists President Associate Professor Chris Baker, who said that one of the challenges of modern medicine was to determine which of the multiplicity of tests and treatments available were of benefit to patients.

A/Professor Baker said his College had identified several instances where the use of antibiotics was unnecessary and could help undermine their effectiveness, including in the treatment of acne vulgaris, epidermal cysts and redness and swelling of both lower legs.

The Choosing Wisely campaign is running in parallel with, but is unrelated to, a Federal Government taskforce review of the Medicare Benefits Schedule, which was set up last year and is not expected to complete its work until 2017.

The goal of updating the MBS to reflect modern clinical practice has been backed by the AMA, but there are concerns that the Government wants to use it primarily as a cost-cutting exercise that will be quick to de-list old treatments but slow to add new ones.

Adrian Rollins

The acute care conveyor belt: a personal experience

This wasn’t “end of life”; this was his life.

Perhaps the best comment I read at the time of the big 2015 bacon scare was “So what are we allowed to die of?”. Every stage of life has now become medicalised, not just birth and death. The fact that there is even a conveniently euphemistic acronym for the end of life, “EOL”, rather than the words themselves, is symptomatic of how removed we are as a profession from the reality that despite our very best efforts, life has only one ultimate outcome. But Hillman and colleagues’ description of the “acute care conveyor belt”1 eloquently describes the path that I impotently watched my father travel.

At 86, he was extremely well — still golfing and travelling, dining out and never missing the latest films. There was the usual raft of preventive medications to control his sugar and lipid levels, his gastric acid and his blood pressure. There was even an indolent carcinoma that created some inconvenient symptoms requiring increasingly regular trips to hospital for antibiotics and a first-name relationship with the local ambos.

This wasn’t “end of life”. This was his life — each day just like every day before presenting its own unique challenges and pleasures. That he would die sometime in the next while, he knew and accepted. What mattered was today and whether health and weather would align to get him to the golf course.

For my father, the conveyor belt started with one of his trips to hospital. Acute renal failure was unexplained but managed well and resolving. After transfer to a ward pending discharge home and community nursing, he suffered a massive stroke. Had this occurred at home on an early Saturday morning, it is unlikely he would have survived. But it occurred in a hospital ward, where he was surrounded by people with the skills and knowledge to keep him alive. And they did. And they transferred him to intensive care.

When I was a medical student, it was pretty unusual for anyone over 75 to get to intensive care. These days, it’s pretty unusual if they don’t. It seems that my father has the constitution of an ox. Even off his barrage of meds because of the renal failure mystery, his heart doesn’t miss a beat: perfect systolic rhythm; his saturation hovers around 100%, breathing on his own with just nasal prongs; and his blood pressure is excellent. Only his brain is refusing to cooperate, big time — bilateral infarcts, seizures and midline shift.

The nephrologists, the neurologists, the intensivists and the gastroenterologist have all had their say. In intensive care, no one uses the “D” word. In medicine, dying equals defeat. I couldn’t be clearer with the team about what my father wanted. This is not a case of “the failure of people to have stated their wishes regarding EOL care”.1 We had had this conversation many times, especially since the cancer diagnosis.

They tell us that if he does survive, he will need high-dependency care. I ask the team about their palliation plan. They are shocked and refuse to engage. I am shocked that they refuse to engage, despite their determination to move him back to the ward. We all know this is just another euphemism for palliation, for covert euthanasia. We know he is dying. Why can’t we talk about it?

Ironically, the person most comfortable discussing the topic is the youngest resident, a graduate of one of our newer medical schools. She’s not recommending euthanasia, but at least she is willing to acknowledge our agony of indecision and our horror at the idea of “comfort feeding”: a euphemism for starvation and dehydration.2

In intensive care, visiting is limited. Visitors are forced to wrap themselves in cloying yellow plastic that makes the sweat run down your back and arms despite the air conditioning. On the weekend, staff are casual, comforting and relaxed, and we hold vigil by his bedside for extended periods. I am terrified to leave in case he dies alone. But come Monday, the rules snap back into place: two visitors only, visiting hours only, meaning long hours when he has no family by his side.

I want to take him home. I am told not to get ahead of myself, but I know just how good the local palliative care team is. My mother died at home in her own bed surrounded by almost everyone she loved. But she died of cancer. It’s OK to die of cancer; the system supports you. They give you painkillers and personal care and don’t pretend they can do anything more. The palliative care nurses live by the tenet “medicine at this time has nothing more to offer” — but good nursing care certainly has more to offer.

There will be no more rapid response teams in my father’s care. We have made that quite clear. But unless his body declares a ceasefire, he will remain hostage to the acute hospital system until the conveyor belt chugs him into a high-dependency nursing home bed possibly far away, with a percutaneous endoscopic gastrostomy tube and incontinence pads. Some days the golf may even be on the TV droning in the background.

There are no more holes-in-one or beers with his mates at the 19th in my dad’s future. A more humane system would help him off the conveyor belt and onto the fairway in the sky. Thank you, Drs Hillman, Rubenfeld and Braithwaite, for daring to start this essential conversation.

Postscript

Dad finally died 10 days after his stroke. He never regained consciousness. We were able to be with him right to the end. The medical and palliative care that he received was exemplary, but this does not negate the need for a robust discussion about the role of euthanasia at the end of life and the ethical ambiguity of current means of palliation.

How much time have I got, doc? The problems with predicting survival at end of life

If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

Predicting how long a patient will survive is critically important for them and their families to guide future planning, yet notoriously difficult for doctors to predict accurately. While many patients request this information, others do not wish to know, or are incapable of knowing due to disease progression.

Fuelling this complexity are families who prefer the patient not to be told for fear of torpedoing hope and reducing the quality of time remaining. Conversely, patients may want to know themselves, but do not want to distress their loved ones with this knowledge.

We can’t ever be sure

Central to these scenarios is whether accurate prognostication at end of life is actually possible. Providing a meaningful survival time to patients is often genuinely challenging for doctors. Accuracy declines further the longer the patient is expected to live.

A number of studies indicate clinicians tend to be over-optimistic in predicting survival times. Research from 2011 indicated surgeons’ prognosis for survival time for patients with abdominal malignancies was accurate in 27% of cases, too optimistic in 42% and too pessimistic in 31% of cases.

This is one of the reasons some doctors are reluctant to attempt to predict survival time at end of life. This has traditionally been seen as part of the doctor’s special domain of knowledge to be communicated at the doctor’s discretion (if and when it is the right time to tell the patient, so it is not going to cause harm).

This archaic and paternalistic view melds conveniently with popular positive thinking, replete with militaristic vocabulary such as “fighting to the end”, which some doctors share.

This mindset views meaningful discussions of prognosis as harmful, as it may cause the patient to lose hope and give up the fight. It underpins those not uncommon cases when a family requests the clinician not to disclose a prognosis or a diagnosis to their dying relative. Unfortunately, it may also shut down meaningful end-of-life discussion and planning and result in harm, including to the grieving who remain.

When patients do not want to know their prognosis, this should be respected. For others who ask and the outlook is poor, a relationship built on trust is important.

Author Bill, an emergency and palliative care physician, is asked to give a prognosis every day. A discussion about prognosis includes the caveat that the accuracy the patient usually seeks is elusive, if not impossible to nail down.

Much can be said, however, including an explanation of why there is no firm prognosis. If it is possible to estimate survival time (derived from a mixture of medical details about the clinical history, prior response to treatment, imaging results, pathology results, functional status of the patient and experience), this is best communicated in terms of a short number of months, (long months is very difficult), long weeks or short weeks, a week or a few days or a few hours.

The accuracy of survival time can become more obvious as time progresses, just as the doctor-patient relationship develops, enabling more explicit discussions about survival time. In emergency medicine, when there is no time for these relationships to develop and time is short, patients frequently seek honesty and are extremely good at telling if the doctor is hiding something. This may then lead to them imagining something worse than the reality.

If the doctor does get the prognosis wrong, there is surprisingly little Australian authority as to whether a doctor will be liable. Considering the general principles of medical negligence is useful here. It suggests that if a doctor provides a prognosis that is widely accepted as competent professional practice, shared by other respected clinical peers, then that prognosis is not negligent.

Even if the doctor provided a prognosis that was not widely accepted as competent professional practice, provided the incorrect prognosis did not cause additional damage to the patient, then no liability will follow.

How long have I got, doc?

Most of us are going to have to ask this one day – presuming we have not confronted it personally or through close relationships already. Despite the understandable imperative for those who want to know, the answer is rarely as crisp or accurate as the original diagnosis.

Breaking bad news to a patient is much more a process than an event, unfolding as symptoms develop and viable treatments recede. Best medical practice aims consistently for open, honest communication that is delivered sensitively.

Most doctors try to provide accurate information if able, despite clinical uncertainty. The aim is to maximise the good and minimise harm. When a prognosis appears wildly inaccurate, is not supported by a group of peer doctors and causes significant harm, Australians may be able to pursue the matter through legal action.

Sarah Winch, Health Care Ethicist and Sociologist, The University of Queensland; Bill Lukin, Consultant Emergency Physician and Palliative Medicine Trainee Physician, School of Medicine, The University of Queensland, and John Devereux, Professor of Law, The University of Queensland. Photo: Christine Gleason/Flickr, CC BY-SA

This article was originally published on The Conversation. Read the original article.

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A 3-year study of high-cost users of health care [Research]

Background:

Characterizing high-cost users of health care resources is essential for the development of appropriate interventions to improve the management of these patients. We sought to determine the concentration of health care spending, characterize demographic characteristics and clinical diagnoses of high-cost users and examine the consistency of their health care consumption over time.

Methods:

We conducted a retrospective analysis of all residents of Ontario, Canada, who were eligible for publicly funded health care between 2009 and 2011. We estimated the total attributable government health care spending for every individual in all health care sectors.

Results:

More than $30 billion in annual health expenditures, representing 75% of total government health care spending, was attributed to individual costs. One-third of high-cost users (individuals with the highest 5% of costs) in 2009 remained in this category in the subsequent 2 years. Most spending among high-cost users was for institutional care, in contrast to lower-cost users, among whom spending was predominantly for ambulatory care services. Costs were far more concentrated among children than among older adults. The most common reasons for hospital admissions among high-cost users were chronic diseases, infections, acute events and palliative care.

Interpretation:

Although high health care costs were concentrated in a small minority of the population, these related to a diverse set of patient health care needs and were incurred in a wide array of health care settings. Improving the sustainability of the health care system through better management of high-cost users will require different tactics for different high-cost populations.

Government faces ballot box pain if no policy shift

The Federal Government could pay a hefty price at the ballot box unless it changes course on health policy, the AMA President Professor Brian Owler has warned.

As senior Ministers thrash out details of the all-important pre-election Budget behind closed doors, Professor Owler cautioned that how the Government responds to the many reviews it has commissioned across health, particularly regarding Medicare, primary health and private health insurance, “may well have a significant electoral impact, especially if key health stakeholders are not properly engaged”.

Professor Owler called for a fundamental shift away from the Government’s current emphasis on cutting spending and offloading the funding burden onto patients and the states and territories.

“The Government is on a path of funding cuts and shifting costs to patients,” the AMA President said. “This is not good for the Australian health system or the health of Australians.

He urged it to “change tack…before it is too late”, warning the Government its current approach might m.

Professor Owler’s comments framed the AMA’s Pre-Budget Submission, which includes detailed recommendations across 18 areas of health policy, from Medicare indexation and reform of hospital funding to GP infrastructure grants, palliative care, alcohol and tobacco policy and immunisation.

The AMA President said the submission gave the Government a guide on how to recalibrate its policy to end the current retreat from core responsibilities in funding and delivering health services.

“There is an urgent need to put the focus back on the strong foundations of the health system,” Professor Owler said. “We need a strong balance between the public and private system, properly funded public hospitals, strong investment in general practice, and a priority put on prevention.”

There are already signs that Government decisions are having an adverse effect on health services.

The AMA Public Hospital Report Card released in late January showed that improvements in hospital performance have stalled, and in some instances have gone backwards, since the Government’s decision to 2014 to rip hundreds of millions of extra funding out of the system.

Professor Owler said the cuts, combined with a downshift in the indexation of Commonwealth hospital funding from next year, showed the Government’s preoccupation with funding cuts came at the expense of good health policy.

The Government’s response to the mental health review provided more worrying signs of how it might approach other areas of reform, he said.

Under the new approach, Primary Health Networks will be paid by the Commonwealth to provide tailored “integrated care packages” for patients with mental health problems.

Professor Owler said there was no commitment to a key role for GPs in providing care, and the Government had provided scant other detail.

“The worry is that the mental health approach may be a signal for what is to come with the Primary Health Review,” he said, and added that a proposal for hospital funding to be replaced by a Medicare-style “hospital benefit payment” that would follow patients was also a worrying sign.

The AMA President said the Government had actively demonised doctors in its MBS review process, had encouraged private health funds to play a more active role in all areas of health despite concerns over inappropriate behaviour and poor value products, and showed signs of pursuing a US-style managed care system.

He warned that “this is not a health policy platform to take to a Federal election”.

In its 27-page Budget submission, the AMA proposed the Government immediately reinstate indexation of Medicare rebates; increase indexation of public hospital funding to a rate that reflects growth in the cost of health goods and services; recognise the both the Commonwealth and the state and territories all have a role in funding and providing health services; explicitly address the role of the private sector in delivering care; and give patients the right to assign their Medicare benefit direct to the provider.

Professor Owler said the nation needed a health system built on “modern health policies, not outdated economic policies designed only to improve the bottom line”.

Adrian Rollins

[Editorial] Morocco’s long road to comprehensive palliative care

In May, 2014, the World Health Assembly unanimously adopted the resolution on strengthening of palliative care as a component of comprehensive care throughout the life course and called on member states to ensure that it is integrated into all levels of the health-care system. Many countries—not only low-income and middle-income ones—struggle with the provision of comprehensive palliative care. Morocco is no exception, but an assessment of its progress and failures highlights important areas for others to consider.

2015: a year of action on many fronts

It has certainly been a year of pressing issues for the Council of Salaried Doctors. Some we’ve been directly involved in, others we’ve observed with interest. There are too many issues to cover in detail, but here are the highlights:

Bullying and harassment in the medical workplace

You can’t be precious when you work in a medical workplace. People say things in the heat of what is frequently a tense health care moment that may shock those from other environments. At other times, staff need firm direction, even performance management. Australian workplace law recognises that “reasonable management action” is not harassment.

The key thing for us is to recognise when things can go too far, or when there is deliberate sexual or other harassment of a staff member. That is not acceptable, and we must speak out about it. The AMA, along with its associated body, the Australian Salaried Medical Officers Federation, is developing a Position Statement on sexual harassment in the medical workplace to give doctors a framework for appropriate behaviour and responses to harassment.

End of Life/ palliative care

Demand for palliative care is increasing as our population ages. Patients and their families are seeking access to services to provide relevant care to people who are actually dying from their chronic and complex conditions.

Gaps remain, as our health system is not always able to offer the care that is sought. In an ideal world, governments would work together to provide the necessary funding, as well as a strong legal framework within which patient-centred palliative care can be conducted with dignity and certainty. We intend to keep this important issue in our sights.

Employment issues

Once again, the medical workforce has faced challenges to its structures and ability to cope, particularly related to teaching, research and substitution.

The China-Australia Free Trade Agreement may allow Australian health care providers to set up private clinics in China, but its effect on pharmaceuticals and other areas of health care in Australia are, as yet, undetermined.

Activity-based funding has created a situation where funding models may not adequately compensate hospitals in certain areas, leaving salaried doctors to do more work with fewer resources.

The appearance of hospitalists has been considered by the Committee and the Industrial Coordination Meeting (ICM). There aren’t many yet, but numbers are likely to increase, so we are monitoring the situation, and there will be an update of our Position Statement. We don’t want the hospitalist role to usurp that of either Visiting Medical Officers or Doctors in Training.

Safety of doctors in the workplace

The AMA has highlighted evidence that doctors are at greater risk of stress-related problems than the general population. This is why doctors’ health services are vital to both the profession and the public good.

Doctors need physically safe workplaces. They need to be sure that they are safe from hostile patients. Sound policy and proper funding are vital to this. The AMA is reviewing its Position Statement on Personal Safety and Privacy for Doctors, and the Committee is providing valuable input.

The Australian Border Force Act (ABF Act)

The ABF Act threatens two years’ jail for health workers who speak out against conditions in immigration detention centres. Despite this, more than 400 Royal Children’s Hospital Melbourne staff have refused to discharge patients who face being returned to detention, and have demanded that all children be released from detention. The ABF Act is an outrage to medical independence, clinical judgment and the industrial wellbeing of those involved in treating asylum seekers. We will continue to make representations to the Government on this issue.

Alterations to salary packaging arrangements

The Government announced in its 2015-16 Budget that it would introduce a cap of $5000 for salary sacrificed meal entertainment allowances from April 2016. A consultation process saw more than 64 submissions received, AMA included. This change affects salaried doctors more than any other group of doctors. We are greatly concerned about its potential effect on the ability of hospitals to attract and retain staff, especially struggling rural hospitals. Let’s hope the Government recognises the value to hospitals of this small incentive, though to date senators appear unmoved on the issue.

Medicare Benefits Schedule Review

On 22 April, the Government announced a review of the more than 5500 items on the MBS. What this will mean for rights of private practice (RoPP) in public hospitals is not clear yet, but various governments have in the past targeted RoPP with outrageous and unsubstantiated claims of impropriety. Let’s hope we’re not facing another witch hunt, and that the benefits of RoPP will not be overlooked.

This is the final report from the Committee for the year, so I bid you farewell until next year. Enjoy a well-earned break as we prepare for another, doubtless hectic, year ahead. Best wishes for the Festive Season.