Changes to the GP training environment

By Dr Sally Banfield, an Australian College of Rural and Remote Medicine (ACRRM) trainee with Northern Territory General Practice Education in Central Australia, and is likely to complete vocational training in 2016 with an AST in remote medicine.

Like any changes, those made to the GP training environment in last year’s Federal Budget pose obvious threats but significant opportunities.

The medical community needs to remain united to sustain high-quality training and meet the diverse health needs of our country. To improve the training system, the experience, feedback and input of trainees is essential.

GP registrars often encounter undifferentiated patients and are required to make decisions on their own early on in their careers. We rely heavily on a broad prevocational training experience, followed by a well-structured and supportive vocational training program.

Currently, the delineation of training responsibilities between Government, colleges, regional training providers and the individual is often difficult to navigate.

Large variations in the delivery of vocational training programs mean confusion and often frustration for the registrar trying to meet the requirements for Fellowship.

As trainee numbers increase, both supervision and education capacity is being stretched, and new training methods need to be explored and shared between providers. This can all be improved in this time of change.

Current issues include defining the training and education roles of the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the regional training providers.

The potential for greater college involvement could provide a more seamless general practice training pipeline, with a stronger link to our profession and our colleagues.

Ultimately, we need a system that challenges, supports and mentors registrars to meet the requirements for safe independent practice.

The sustainability of the ‘apprenticeship model’ of training relies on a system that supports the large investment supervisors, educators and registrars put into excellence.

The newly formed GP Training Advisory Committee must continue to foster medical education, supervision and research opportunities for trainees.

The profession must work closely with Government to ensure the ultimate goal of meeting health equality for our community.

This change to the GP training environment can place further focus on drivers for servicing the most disadvantaged. We should use our increasing evidence base to influence selection and training delivery to drive change in workplace shortages.

This will need support from all sectors of the health care system across the training pipeline.

The transition will create points of tension and hurdles to overcome; but we should use this as an opportunity for development.

The Government and the medical profession need to continue to involve future general practitioners in this conversation. Collectively, we have the vision and the passion to meet the future needs of our community.

AMA continuing support for public hospital employed members

More than two years ago, Treasury’s not-for-profit Sector Tax Concession Working Group released a consultation paper reflecting upon various tax conce3ssions for the not-for-profit sector.

The main area of concern for salaried doctors was Fringe Benefits Tax Concessions.

At that time, the AMA and the Australian Salaried Medical Officers Federation made a joint submission supporting the retention of current concessions and highlighting how essential it would be to have a cautious approach to any potential taxation reforms in this area.

The submission noted that public hospitals rely on salary packaging arrangements to ensure that they can compete with the private sector for medical practitioners (and other staff), and any changes would effect recruitment and retention in the public hospital sector.

The submission also highlighted the particular significance of any changes for regional hospitals, the additional administrative and compliance burden they would create, and the impact on industrial entitlements.

The Working Group’s final report conceded that removing the concessions altogether without arrangements to provided similar support would have a significant impact. It proposed an alternative support payment to employers, possibly through the tax system, to replace these FBT concessions.

Soon after it was elected, the Abbott Government announced that it would no proceed with tax changes for not-for-profits, and instead said the issue would be addressed as part of its White Paper on tax reform.

In March this year, Treasurer Joe Hockey announced a ‘conversation’ on tax by releasing the Re:think Tax discussion paper.[1]

The AMA is once again concerned by the possibility the Government will consider changes that will undermine salary packaging arrangements for our members, which are now such an extremely important consideration in the employment terms and conditions for salaried doctors.

The AMA supports a fair, efficient and equitable taxation system, and believes the current tax concessions available to the NFP sector strike a sensible balance and reflect practical public policy by supporting the recruitment and retention of qualified and experienced staff in areas that would otherwise struggle to be able to compete with the private sector.

As State and Territory health budgets dwindle, NFP tax concessions are a relatively small way in which the Commonwealth can contribute to the smooth operation of public hospitals without the impost of direct funding.

The loss of experienced staff that could occur if FBT and other tax concessions are withdrawn would do immeasurable damage in terms of quality health outcomes, teaching and research in a sector already under great stress from multiple “efficiency dividends”.

History has shown that our health system requires solid long-term strategies to remain efficient, as opposed to quick-fix initiatives underpinned by a drive for cost-cutting. Changing the current tax concession arrangements is unlikely to lead to any improvement in patient care.

This taxation review, like the last one, needs to proceed with caution and ensure that it thoroughly assesses the impact of potential reforms, including downstream effects.

It isn’t all about achieving a notional line entry in a balance sheet. Public hospitals are far too important for us all to fall victim to cheap political point-scoring.

The AMA will be making a submission on this current discussion paper, as will many other concerned organisations, and I trust that good judgment will prevail and not permit interference with this ultimately small fiscal issue when balanced with the health care of the nation.

[1] The complete discussion paper, and individual chapters, are available at:

http://bettertax.gov.au/publications/discussion-paper/

Reclaiming our future

‘Back in my day…’ is a phrase that every doctor in training is familiar with. Whether it ends with ‘…I used to work 60 hour shifts’, or ‘…people used to die of this condition’, it is blindingly clear that the medical world that you and I are a part of today is not the same one that our senior colleagues entered upon their graduation.

I found myself using a similar phrase just last week. While I didn’t jump to the cliché bestowed upon me by others many a time, I did find myself imparting wisdom about a medical world we left behind just a few short years ago, and was struck by the speed in which our environment is changing.

As I watch medicine evolve around me, it is easy to be proud of a profession that gives everything they can to their patients. I watch my colleagues change medical practice with their research, marvelling at all the names I recognise in the Medical Journal of Australia every month. I watch my colleagues battle day in and day out to make clinical practice just a little safer or more efficient.

I watch my colleagues promote primary health, fight for the health of those in need, or give up their own needs to change the health of someone else, and I am struck by just how powerful we can be as a profession.

Conversely, some days make it hard to remember that we work in one of the best health systems in the world. Some days, I watch the hospital system that I belong to bursting at the seams, with more patients and more doctors than ever before.

I watch my over-worked colleagues fight an impossibly bureaucratic system, just to achieve something that they believe is in the best interests of their patients. Put simply, I watch a health system in crisis being propped up by the hard work of those with limited resources and a whole lot of patience.

As we draw near to the 2015 AMA National Conference, this idea of change remains central. When we gather in Brisbane next week, the AMA hopes to provide a platform for Australia’s leading doctors to share their ideas on how we preserve the health system in the midst of this changing landscape.

This year, CDT’s policy session, ‘General Practice Training – Reclaiming Our Future’ looks at the recent plight of our general practice colleagues. This session will explore the impact of the abolition of General Practice Education and Training Ltd, the expansion of GP training places and proposals for governance arrangements with a view to making some clear recommendations about GP training and governance.

The only constant to all of this change is that none of it comes about through inaction. It only comes about through the hard and persistent work of those who want to change the system for the better. It is those who stand for what they believe to be right to whom we owe the most; both in what is right for their patients, and what is right for our colleagues.

While I watch the medical world evolve around me, I can’t help but think about what it will look like tomorrow.

I urge you to consider the change that you would like to see when you look back in years to come, and to be part of that change.

The AMA and CDT will continue to fight for our profession, for our health system and for our patients. Join us today to help shape medicine tomorrow.

[Perspectives] Fergus Cameron: getting the big picture in childhood diabetes

Fergus Cameron’s father encouraged him to study medicine because he thought “I’d do better in medicine rather than in business”, recalls Cameron. It turned out to be a good call. After decades as a clinician researcher, Cameron finds himself as Head of the Diabetes Services and Deputy Director of the Department of Endocrinology Unit at the Royal Children’s Hospital Melbourne (RCH), as well as a diabetes research group leader at the Murdoch Children’s Research Institute.

Specialist patients up for thousands as rebate freeze bites

Patients undergoing heart surgery and other specialist treatments face a major hike in out-of-pocket expenses in the next three years that could leave them thousands of dollars poorer if the Federal Government persists with its Medicare rebate freeze, an AMA analysis has found.

Figures prepared by the AMA show the freeze will save the Government almost $2 billion by mid-2018, with more than half of this coming from medical specialists, their patients and health insurers as the value of the Medicare rebate declines and the cost of providing care rises.

The Government has kept the rebate freeze, first announced in last year’s Budget, as a device to encourage the AMA and other medical groups to assist in identifying efficiencies and savings through the Medicare Benefits Schedule review initiated last month.

Health Minister Sussan Ley has described the freeze as a regrettable necessity, though indicating that, “as an article of good faith, I am open to a future review of the current indexation pause as work progresses to identify waste and inefficiencies in the system”.

But the AMA analysis shows it will come at an enormous cost to patients, as the Government dumps a bigger share of health care cost onto households and practitioners.

The AMA estimates the freeze will have caused a $127 million shortfall in Medicare funding this year alone, rising to almost $364 million next financial year, $604.1 million in 2016-17, and almost $850 million in 2017-18. Even without any increase in the number of services provided, the rebate freeze will cumulatively rip $1.94 billion out of the system over four years.

Its effect in general practice has been likened to a “co-payment by stealth”, after University of Sydney research suggested GPs may have to charge non-concession patients more than $8 a visit to make up for the money withheld from the system as a result of the rebate freeze.

AMA President Associate Professor Brian Owler said patients would bear the brunt of the funding shortfall.

“We know that doctors’ costs are going to keep rising. The costs for their practice staff is going to keep rising. The costs to lease their premises and to provide quality practice as a GP or a specialist is going to keep rising,” A/Professor Owler said. “If the rebates don’t rise, those costs have to be passed on in out-of-pocket expenses – we will see less bulk-billing, and there is the possibility of seeing a co-payment by stealth, as has been alluded to by some.”

The AMA President said the effect on patients in need of specialist care would be even more profound, warning that, “the out-of-pocket expenses for specialists are going to be most severely hit”.

Under current arrangements, the Medicare rebate only covers a proportion of the cost of specialist care, and private health funds commit to covering an extra 25 per cent of the MBS fee, plus a loading on top of that for doctors who participate in “gap cover” schemes.

In the past, the health funds have indexed their cover in tandem with increases in the Medicare rebate – and have on occasion increased their cover even when rebates have been held flat.

But A/Professor Owler is among those fearful that insurers will be reluctant increase their cover without any lift in the rebate. If this occurs, many specialists may opt-out of gap cover schemes, which would mean private health cover would revert to the bare minimum 25 per cent of the Medicare rebate, with patients left to pick up the tab.

“I think there is a real issue for private health insurers,” he said. “If they choose to index independently of the MBS, they are going to have to pass on higher private health insurance premiums to people, or, if they choose not to index, there is a real chance that out-of-pocket expenses for specialist costs are going to rise significantly.”

The AMA has prepared resources for doctors and patients to help explain the Medicare rebate indexation freeze and its impact, including a patient guide and clinical examples. The resources are available at: article/medicare-indexation-freeze-support-materials-…

Adrian Rollins

Budget breakdowns

Organ and Tissue Donation

Despite programs to encourage more donors there has been a decline in the rate of organ donations over the past two years according to ShareLife.

The Australian Government hope to improve organ and tissue donation rates by providing $10.2 million over the next two years. The funding will go towards delivering clinical education to hospitals, developing a new Australian Organ Matching System and enhancing the Australian Organ Donor Register.

Currently around 1500 people are on Australian organ transplant waiting lists at any time. One organ and tissue donor can transform the lives of 10 or more people.

The Government will also continue to provide minimum wage for up to nine week to employers of people who have taken leave to donate organs as part of the Supporting Leave for Living Organ Donors Programme. The aim of the Programme is to help alleviate the financial stress that can be experienced by living organ donors by reimbursing employers for payments or leave credits provided to their employees for leave taken to donate an organ and recover from the procedure. The Government announced that the Programme will continue for the next two years.

Tropical health

The Government will provide $15.3 million over four years to invest in research into exotic disease threats to Australia and the region.

The National Health and Medical Research Council will receive 6.8 million to support research into tropical diseases, build collaboration and capacity in the health and medical research workforce, and promote the translation of this research into health policy and practice.

The Government will also provide $8.5 million to establish an Australian Tropical medicine Commercialisation grants program to support Australian researchers to commercialise therapeutics and diagnostics in tropical medicine.

National Drugs Campaign

The Government will provide $20 million over two years to renew the National Drugs Campaign. The Campaign aims to reduce young Australians’ motivation to use illicit drugs by increasing their knowledge about the potential negative consequences of drug use. It is a media campaign to promote the avoidance and cessation of illicit drug use.

The campaign will focus on raising awareness to young people and their parents about the harm caused by illicit drug use, in particular methamphetamine also known as ice.

Royal Flying Doctor Service

The Government has committed additional funding to support the Royal Flying Doctors Service to deliver emergency and primary health care services to people in rural and remote communities of Australia.

The Service will receive an extra $20 million as part of the Government’s commitment to rural and remote communities.

Kirsty Waterford

Public and preventive health programs under cloud

The future of important public and preventive health and support programs for Alzheimer’s, palliative care, alcohol and addiction, rural and Indigenous health are under a cloud after the Federal Government announced almost $1 billion of cuts from health programs.

In a decision that has thrown doubts over the funding of organisations including Alzheimer’s Australia, Palliative Care Australia and the Foundation for Alcohol Research and Education, the Government said it would achieve savings of $962.8 million over the next five years by “rationalising and streamlining funding across a range of Health programs”, including so-called Health Department Flexible Funds, dental workforce programs, preventive health research, GP Super Clinics and several other sources.

AMA President Associate Professor Brian Owler the lack of detail around the savings was concerning.

“There is a lot of uncertainty in Canberra and around the country at the moment as to whether those important programs, those important organisations, such as Palliative Care Australia, Alzheimer’s Australia, the Foundation for Alcohol Research and Education, and many other non-government organisations, are going to be continued to be funded,” A/Professor Owler said. “Rather than announcing that these cuts of almost $1 billion are going to be made to those flexible funds, and leaving it up in the air for these organisations, we need to see certainty around where those cuts are going to be made, how they are going to be applied, so that these organisations can not only plan for their future but also continue their very important work.”

In addition, the Government has tagged the Health Department for an extra $113.1 million of savings in the next five years as part of its Smaller Government initiative.

It said this would be achieved by measures including consolidating the Therapeutic Goods Administration’s corporate and legal services into the Health Department, axing the National Lead Clinicians Group, replacing IT contractors by recruiting full-time staff and “ceasing activities that mirror the work of specialist agencies”, such as the Independent Hospital Pricing Authority, the National Blood Authority, and the Australian Institute of Health and Welfare.

Adrian Rollins

MBS review savings must stay in health: AMA

AMA President Associate Professor Brian Owler says he has received assurances from Health Minister Sussan Ley that any savings realised from the review of the Medicare Benefits Schedule will be ploughed back in to funding new treatments.

Ms Ley provoked a surge of concern about the review last week when she told Sky News that any money freed up by the process would be diverted into the $20 billion dollar Medical Research Future Fund rather than being reinvested in new MBS items.

“If there are savings, it [sic] will go into the Medical Research Future Fund, as we promised in the last Budget,” the Minister said.

But A/Professor Owler told News Corp he had sought assurances from Ms Ley that this would not be the case.

“I clarified with the Minister’s office, and if there are savings identified through the review, these would be reinvested into health rather than the Medical Research Future Fund,” the AMA President said.

The AMA has backed the creation of the Fund, but has been highly critical of plans to pay for it using money taken from patients and primary health care, such as through GP co-payments, various forms of which have been proposed and dumped by the Government.

Although several savings measures to free up money for the Fund have come into effect, including the abolition of stand-alone health agencies, the Government is yet to set up the Fund amid speculation its size and scope will be considerably reduced.

But A/Professor Owler has previously said the money was there to get the Fund going, and last week he repeated his challenge to the Government to set it up.

“If the Fund is so important, why hasn’t it yet been established?” he told the Northern Territory News.

Earlier, the AMA President commented on rumours the health portfolio had been targeted for $7 billion of savings in the forthcoming Budget.

“That would be a very big surprise for the AMA and, I’m sure, doctors and the Australian public,” he said. “The Prime Minister has said on a number of occasions that there would, first of all, [be] no cuts to health, but second of all, has said that there will be no new health initiatives without the broad support of the medical profession.

“So, I would be very surprised if those sorts of measures were introduced without talking to the AMA or other health groups.

“I heard some of those rumours…and I put those questions directly to the Minister for Health, who has reassured me that that is not going to be the case. But, obviously, we will be watching the Budget very closely.”

Adrian Rollins

[Viewpoint] Aligning incentives to fulfil the promise of personalised medicine

Personalised medicine has generated global policy interest in the past few years. In 2012, the European Union established the European Alliance for Personalised Medicine with the aim to accelerate the development, delivery, and uptake of personalised health care, broadly defined. In the same year, the UK’s Medical Research Council and National Institute for Health Research funded the National Phenome Centre to deliver broad access to a world-class capability in metabolic phenotyping for biomarker discovery and validation, improved patient stratification, and early identification of drug efficacy and safety.

Infected jails on Sovaldi frontline

Some of the nation’s most dangerous criminals will be among the first to test Sovaldi’s effectiveness in curing hepatitis C and preventing its transmission.

Hepatitis C is rife in the nation’s prisons, with estimates as many as 50 per cent of inmates are infected – including about two-thirds of female prisoners.

Researchers are recruiting inmates at two New South Wales high-security prisons, Goulburn and Lithgow, to assess the drug’s performance.

Prisoners taking part in the trial will be given one pill a day during a 12-week course of the medicine, which manufacturers claim has a cure rate above 90 per cent.

Prison authorities are grappling with the problem of how to curb the spread of hepatitis C among inmates, who are most commonly infected while injecting illicit drugs using shared contaminated needles.

Public health groups have argued the need for needle and syringe exchange programs within prisons to help slow the spread of hepatitis C, a suggestion vehemently opposed by unions representing prison staff, who claim such measures would make prisons more dangerous.

Liberal MP Steve Irons, who is chairing a House of Representatives committee inquiring into the prevalence of hepatitis C in prisons, said it was an important issue because of the threat of infection in the broader community posed by prisoners as they moved in and out of custody.

Advocates hope Sovaldi could provide an alternative path to breaking the cycle of infection in the nation’s jails.

Adrian Rollins