Dr Ayman Shenouda
 
Despite having had the best policy intentions, we still have too many specialists, and too few general practitioners. The policy response has led to an unprecedented supply of junior doctors feeding a training crisis that will take many years to resolve. Here I’d like to share some ideas around how we can deliver a training model that prioritises need.
 
Making general practice more attractive
 
Ensuing graduates meet the needs of the community requires a new training model and approach.
 
It’s time for a rethink. If we are going to address general practice recruitment, we first need to deal with our image problem. We need to stop general practice from being a second choice. To do this we need to work through the problems in recruitment and this means doing thing very differently.
 
In making general practice a specialty of choice – we need to impart an early positive image which can then be backed by positive experience. Key to making this work is having more control as a specialty in ensuring exposure during those prevocational years.
 
Lost in the prevocational space
 
In increasing its attractiveness as a career choice for junior doctors we need to increase the status of generalism at all stages of medical education and training. It’s clear we are losing them in the prevocational space. It comes down to sufficiency of exposure to general practice and the need for specialty control at that point.
 
In getting them this exposure – which is currently intermittent – postgraduate medical curriculums need more focus on general practice and rural health. While there are now new programs to direct our efforts – the Hubs, RJDTIF and more recently through MDRAP - it is the uncoordinated decision making that will continue to limited our success.
 
The prevocational years remain problematic due to differing state arrangements dominated by hospital need and an underlying lack of ownership. The only consistency through the layers of complexity is the trainee. The funding needs to follow the trainee but we need to build in incentives to retain them on a specific pathway.
 
A collaborative approach led by the colleges of general practice and all organizations involved in those programs is urgently needed    
 
There is also a need to formalise a supportive structure through funding the relationship between the trainee and the GP Colleges. This would support a key shift in establishing the relationship earlier, focusing on early identification and continuous support. It provides for the much-needed connection to general practice throughout prevocational and into vocational general practice training.
 
Remuneration is also important
 
GPs are overworked, undervalued and underpaid. We know that expected future earnings influence specialty choice with many choosing general practice following rejection of another specialty. In attracting more to general practice, we need to be able to compete with the higher earing specialties. The way we are paying registrars also needs to be reviewed. GP job satisfaction is also falling which further impacts on GP recruitment and retention.[i] The solution lies in the need to reform the funding model to prioritise primary care and generalism.
 
Funding for general practice
 
The current system devalues primary care. The government needs to be thinking seriously about funding for general practice. Income growth is impacted by decisions around incentives, the prolonged impact of stagnant Medicare reimbursement rates and a continued narrow focus on bulk billing. Significant new investment is required to enable longer consultations particularly in addressing chronic disease and factoring the real costs of delivering this care.
 
Flexible supportive pathway
 
The delivery of quality training through a flexible supportive pathway design needs continuity of funding. We need a long-term commitment that can continue to channel doctors into rural areas. We also need to change this perception that going rural means you have to stay rural forever. Enabling real flexibility of choice comes from building general practice training capacity in rural and remote areas to support the development of high-quality training.
 
Prevocational and postgraduate medical training also has to be aligned with the needs of the health care system. This means the incentives have to be aligned towards general practice and this needs to be led by the GP Colleges.
 
 


[i] Scott A. 2017. ANZ – Melbourne Institute Health Sector Report. General practice trends. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne.
 

Policy responses to increasing workforce supply: IMGs, policy failure and continued reliance
 
Dr Ayman Shenouda
 
 
Over the coming weeks I’d like to start a discussion to support planning around a future Australian medical training model. The first starts here with IMGs and our continued reliance on them and what’s next in the context of national self-sufficiency planning.
 

 
A rural workforce reality: IMGs remain a key part of the rural medical workforce despite increasing graduate supply.
 
Whether described as policy failure or policy still in motion, it is clear we are yet to harness our increased domestic supply as intended. Our planned approach for less reliance on IMGs towards self-sufficiency has clearly not met its objective.
 
We’ve seen an increase in domestic supply of 2.7 per cent per year and above population growth. The raw numbers show an overall increase of 5.3 per cent per year, from 59,359 in 2005 to just under 94,000 in 2017.[i] But, despite these results, we just haven’t effectively utilised gains from increased supply to improve distribution.
 
It is a lack of a coordinated national planning approach which has seen a strong policy response in increasing local medical workforce supply fail at both the prevocational and vocational training points. This has made workforce supplementation through migration less of a temporary fix and more of a permanent policy fixture.
 
Visa reform
 
Despite slow gains in workforce planning we’re starting to see some key shifts coinciding with changes to the visa system and a broader commitment towards a national workforce strategy.
 
Policy announced earlier this year through the Commonwealth’s Visas for GPs initiative sees a reduction in IMG intake over the next four years. This remains a short-term measure. The wider medical workforce maldistribution problem in rural Australia needs a stronger national medical workforce plan and approach as discussed in newsGP when the policy was announced.
 
This strategy brings rural workforce planning into alignment with the broader skilled migration policy changes with the introduction of the Temporary Skill Shortage visa (subclass 482) replacing the former 457 visa. In facilitating targeted use of overseas workers to address temporary skill shortages – it provides stronger policy controls to direct these doctors to where they are needed the most.
 
Getting this policy lever to work for us and towards national workforce planning objectives is an important step in the right direction. This should always have been the aim and is more policy realignment than reform but represents an important first step.
 
Policy implications
 
Workforce distribution through migration can lead to unintended policy consequences in the absence of a national medical workforce plan.
 
Workforce supplementation through migration is a divisive issue: many will say the most obvious solution is forced distribution of our domestic supply. But we know forced policies just don’t work. We already have one, in the form of the 10-year moratorium, and this has seen most IMGs return to urban settings once they’ve satisfied the regulatory requirements.
 
Broader than policy, and putting cultural isolation issues aside, there are still plenty of negatives for the IMG. Often described as a two-tiered system, we place limits on their professional development and career opportunities while placing them in an unsupported and clinically complex environment.
 
Our failure to nurture rural retention just makes it so much harder for those wanting to stay. This makes this forced distribution scheme just flawed policy working against retention aims. It has led to a constant stream of IMGs leaving rural areas once they obtain their unrestricted licenses.
 
So, despite considerable policy efforts, the issue we started with nearly two decades ago remains. We still don’t have enough doctors in the areas where we need them the most. In fact, forced measures like these have just make rural practice less viable and appealing.
 
More broadly though, it is a lack of coordinated national medical workforce planning has led us here. The recent COAG Health Ministers commitment towards a national medical workforce planning strategy will enable a much stronger needs-based approach providing a way forward towards self-sufficiency.
 
Self-sufficiency planning
 
Important to self-sufficiency planning, a recent review on the reliance of our IMG workforce highlights our obligation to consider global maldistribution and not just our own in workforce planning.[ii] 
 
The review led by O’Sullivan et al. 2019 states that our ability to minimise our reliance on IMGs is important for equitable global workforce distribution. It highlights a key role in workforce planning, specifically in developing national workforce data capacity to help inform sustainable medical health workforce planning.
 
For Australia, in achieving the right balance of locally trained doctors, this review states policy to reduce our reliance on IMGs has to be mindful of the flow on effects to developing countries. This is an important point that often gets lost in the urgency to fill local positions. And, while I think more recent shifts to our visa controls brings us closer to meeting our moral obligations here, we still need to fully utilise the significant data and associate studies to support a national plan.
 
In working through this aim, this review skilfully demonstrates how the available data, in this case from the MABEL study findings can be used to consolidate the best available national evidence to inform self-sufficiency planning. 
 
New stratified analyses of MABEL data have been captured to identify IMG work location patterns. Results show the proportion of IMGs among rural GPs and other specialists increases for each cohort of doctors entering medicine since 1970 peaking for entrants in 2005-2009. In our efforts to build a locally trained workforce for rural Australia, the review also confirms recent domestic graduates are less likely to work either as GPs or in rural communities.
 
This study helps to identify the key drivers to successfully growing a local rural medical workforce - what we’ve done well and where we now need to focus our efforts. These are the broader reforms with many initiatives already in train.
 
These key policy enablers, important to recruitment and retention, will be the focus of my next blog in this series. They include the required focus on generalism in ensuring the right balance of skills in moving closer to the National Rural Generalist Pathway. In addition, the more recent work towards an Integrated Rural Training Pipeline to support high quality rural medical training and as a key component of reform to ensure growth in graduates flows through to gains for rural Australia.
 
A more supportive approach
 
Distribution policies which can allow for self-sufficiency remain our key objective but benefits from increasing domestic supply will take time. However, it is clear that IMGs continue to address critical shortages in rural and remote areas and we need to continue to support them.
 
The focus should include a mix of retention strategies and education supports toward Fellowship which encourage a permanent place in the community they’ve served. The recently announced More Doctors for Rural Australia Program (MDRAP) will provide targeted support for non-VR doctors providing GP services towards attaining Fellowship.
 
A further positive shift in the new RACGP Practice Experience Program (PEP) Specialist Stream, replacing the current Specialist Recognition Program (SRP) from September, will allow doctors to access the highest Medicare benefits while working towards Fellowship. The PEP Stream encompasses educational modules as well as a workplace-based assessment with a core aim is to support professional development providing feedback on individual progress towards Fellowship. newsGP
 
Importantly, the O’Sullivan led study[iii] also highlights the need for continued support. The authors conclude that IMGs are a key part of ongoing rural medical workforce planning and while we need to monitor our reliance, we also need to continue to support them.
 
The positive is that we are now starting to see recognised our continued reliance on IMGs and the fact that they remain a key part of rural medical workforce. Importantly, we are seeing a strengthening of the data-policy link in national medical workforce planning leading to greater support. My message has always been: If you don’t need them – don’t get them. But if you need them then you must support them. It’s clear we need them and they must be continued to be supported in policy.
 
[i] Scott A.(2019) Health Sector Report The future of the medical workforce. ANZ Melbourne Institute: Applied Economic & Social Research, The University of Melbourne.
[ii] O'Sullivan, Belinda, Russell, Deborah J., McGrail, Matthew R. and Scott, Anthony (2019) Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence. Human Resources for Health, 17 1: 8. doi:10.1186/s12960-018-0339-z
[iii] Ibid.

​Future GP workforce: The strategies needed to get ahead of the crisis curve
 
Dr Ayman Shenouda
 
A recent GP workforce discussion in the Herald Sun has warned supply is set to worsen over the next decade due to recruitment failures and broader impacts brought about by casualisation.
 
There are some key issues impacting here and at this point in the election cycle, it is a good time to highlight precisely what has led us to these recruitment failures and how to fix them.
 
We know what the path to a sustainable health system looks like and it involves a solid commitment to properly fund general practice and primary care.
 
If we want to design a system around patient needs then it is in primary care where we must focus our health reforms.
 
We have strong evidence to support this. We know that general practitioner supply is significantly associated with better population health.
 
Countless studies have confirmed this – the most notable being those from Starfield and Shi – yet successive governments have failed to put in place an action plan to realise these benefits.
 
Getting ahead of the crisis curve
 
In order to get ourselves ahead of the GP workforce crisis curve, a cohesive national strategy is now required.
 
It will certainly require a much stronger national policy focus to both recruitment and retention planning than we’ve seen in the past in order to build the GP workforce of the future.
 
A longer-term vision is what is required: half promises set within short-term electoral cycles will not build the health system our patients deserve.
 
At the heart of the issue is valuing general practice as a specialist discipline. The fact is that there is a lot of devaluing happening.
 
Professional negativism exposure during training, which seems firmly entrenched within the hospital-based specialties, is very much part of the problem.
 
We have to find a way to ensure general practice is high on the list in junior doctor’s specialisation choices.
 
To do this, we need to work on the perception of primary as distinct from, and of lower status than, secondary care.
 
When to direct our efforts
 
Medical career decision making is complex and much of that occurs during the early postgraduate years.
 
This is one or two years after graduation and for most their influences or role models will be from within the hospital system.
 
This is the time that doctors are making important career decisions and where positive exposure to general practice needs to occur.
 
Understanding the career choice determinants is important and there is an abundance of literature around this.
 
I would like to see a strategy that prioritises general practice and primary care with targeted attraction policies that trigger at those key decision points for junior doctors.
 
We need to work with other specialties to address professional negativism and find ways to provide more GP role models at these critical points in career decision making.
 
Other factors at play
 
Beyond recognition, it is important to highlight that there are other factors impacting significantly on our profession.
 
These not only limit our ability to attract doctors to our specialty but are adding to professional dissatisfaction among the current GP workforce.
 
Whether it is in its financing, remuneration or barriers to integration with the broader health system these are key capacity issues which persistently impact on our specialty.
 
We can already see that the Medicare Review Taskforce’s proposed revamp of GP items is set to place a whole new set of restrictions.
 
This combined with the impacts from the Medicare freeze and a persistent lack of investment in primary care is what makes our specialty a less attractive choice.
 
These all contribute to the pressures of working in the current health system and places restrictions on the value of care we can provide as specialists.
 
GP workforce action plan
 
It is clear that GP workforce reform would need to see more funding to strengthen primary care.
 
It would need less bureaucracy and significantly more funding to support patients with complex care needs for a system aligned with the multimorbidity in the community.
 
It would require a sustained effort to lift the profile and prioritise supports to encourage junior doctors towards careers in general practice.
 
We’re doing more to ensure the training occurs in primary care but that effort is diminished if all they see is a system in crisis.
 
There is a need to include a targeted strategy which financially incentivises GPs into training and practices where they are most needed.
 
But overall, we need to strengthen the role of generalist within the health system.
 
A high-performing health system built on integrated models of care must prioritise primary care and GP leadership.
 
We need to see a comprehensive GP workforce action plan prioritised by the major parties at the 2019 federal election.

Rural maternity services: It takes a team to make it work
 
Dr Ayman Shenouda
 
Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics.
 
For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role.
 
Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care.
 
The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas.
 
The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely.
 
We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement.
 
Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion.
 
We have the solution
 
The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here.
 
We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one.
 
The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs.
 
It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded.
.
This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need.
 
And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills.
 
But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing.
 
State of play
 
Here’s a brief outline of the current state of play.
 
Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November).
 
The Australian Health Ministers’ Advisory Council’s consultation draft  Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised.
 
Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care.
 
Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out.
 
The WA shifts
 
In WA we are hearing that this shift has been occurring gradually over a five-year period.
 
The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent.
 
Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care.
 
This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce.
 
This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce.
 
Choice for women
 
But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all.
 
With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result.
 
In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost.
 
In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth.
 
We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families.
 
Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas.
 
A collaborative model
 
What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns.
 
That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services.
 
We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health.
 
What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality.
 
It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them.
 
This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal.
 
We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop.
 
A vital skill set
 
GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set.
 
At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied.
 
These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline.
 
The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework.
 
It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia.
 
The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare.
 

​MHR – It’s time for a policy reset
 
Dr Ayman Shenouda
 
It’s a particularly hectic Monday morning and first up I have a 70-year-old male patient who has just been discharged from hospital.
 
It will be no surprise that there is no information from the hospital. He’s had some blood tests though and his potassium is very high. This is why he was admitted - that along with some kidney problems.
 
He’s accompanied by his son who is not aware of any previous conditions and not forthcoming about much at all.
 
There’s some patchy interpretation offered of what was conveyed to them in hospital – but too cryptic to work through and the confusion was just making this patient more anxious.
 
But what we do have is all his medication in a bag – a complication mix of current and old meds to sift through – so with that, the usual diagnostic challenge begins.
 
Looking through I find Spironolactone – a potassium-sparing diuretic – and an obvious issue for a patient admitted with high potassium  if he continue on this meds it  can be life-threatening. He also had a very severe itch and swollen legs and few other chronic disease including renal failure 
 
This mixed bag of medications alongside some troubling symptoms makes for a very complicated patient.
 
It took half a day to sort this patient out. More blood tests, phone calls and inquiry in order to reassure that all issues were adequately covered.
 
It is when you have to deal with this spaghetti of information around a patient that access to their record in real time would have been helpful.
 
Particularly when combined with the lack of discharge summary and the fact that both patient and son had little to no health literacy.
 
It is those times when patients are moving between doctors, during emergencies and for post-acute episode follow-up that having this information to hand really counts.
 
This is where My Health Record (MHR) would support better healthcare decisions and enable GPs to find information quickly.
 
MHR Implementation
 
The crisis of progress – in terms of resistance and technology – is something we’ve come to expect when introducing significant change.
 
People resist change and with technology, this is intensified commensurate with risk, perceived or otherwise, which is precisely what we’ve just seen with MHR implementation.
 
Expecting resistance to change and planning for it is something good policy planners do.
 
But with this one, the MHR, really from its outset, there have been problems really from the early policy development to now in attempting implementation.
 
There were problems on a number of fronts in working through the opt-in then opt-out rather than compulsion. But these are just your usual pain points in working through complex policy implementation.
 
There were issues during the design phase and a seeming reluctance to take technical advice at critical points.
 
With the focus now of course predominantly on the risks: the risks to privacy, cybersecurity and hacking with minimal success in lessening privacy concerns.  
 
From the very first day of the opt-out period, those opposed were stating that it is an ‘uncontrolled’ data dump.[i]
 
Right up to the penultimate day as the deadline to opt-out loomed yesterday the movement in the Senate called for a delay for a further 12 months.  
 
This last-hour intervention was made while Australians were rushing to opt-out causing system overload with both website and phone line were being reported as down.
 
I’m pleased to see Minister Hunt has decided to extend the opt-out period to 31 January 2019 which should enable some time to work through the many issues and hopefully reassure the public.  
 
Where to next?
 
Our entire lives, it seems, are already in a databank of sorts and this lack of control is precisely why consumers needed that reassurance around privacy in this rollout.
 
A centralised database with widespread access is of course problematic. It required precision in design and diligence around patient privacy concerns and effective responsive communication to implement.
 
This needed a framework of trust and any attempt to implement without it was always going to lead to this point.
 
From the lack of informed consent, privacy and security challenges and limited protections around these - some have suggested the MHR is the health sector’s NBN and there are certain similarities here.
 
The risks are high and the right to privacy in the digital age relies on good laws and the lack of privacy and security provisions made it not ready in my view. These are complex technical and privacy concerns and this is where the problem lies.
 
These risks are poorly understood and the fact that we’ve only just reached some consensus around some new protections through recent RACGP-led negotiations this makes for a good time for a policy reset.
 
The extension to the end of January provides some time to work through the Senate Standing Committee on Community Affairs Report (which doesn’t recommend the abandonment of the system).
 
The benefits of the MHR or any redesign can only be realised through regular use so that it becomes a routine part of healthcare and only then will its full benefits be realised.
 
Broader take up can only eventuate once trust has been restored and there’s still quite a journey ahead before we get even close to this level given the policy implementation failures to date.
 
 
 


[i] Zhou N. Media Article: My Health Record: privacy, cybersecurity and the hacking risk. 16 Jul 2018. Available at: https://amp.theguardian.com/australia-news/2018/jul/16/my-health-record-privacy-cybersecurity-and-the-hacking-risk

New models of care: making integrated out-of-hospital care a reality
 
Dr Ayman Shenouda
 
 
As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities.
 
Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge.
 
We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions.
 
We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings.
 
For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting.
 
But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems.
 
This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care.
 
It is about bringing teams together consolidating different points of access to care and providing that care in the home.
 
This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery.
 
Hospital in the Home
 
Recently I met a doctor who is working hard to realise this vision for his community in Townsville.
 
Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital.
 
For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville.
 
Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups.
 
These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model.
 
Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital.
 
What makes the model work?
 
Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting.
 
Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion.
 
Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers.
 
It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home.
 
The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist.
 
These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment.
 
The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners.
 
The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills.
 
This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting. 
 
Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services.
 
Hospital in the Nursing Home (HINH)
 
I believe a step-up approach within nursing homes is another way to apply this model.
 
The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care.
 
However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model.
 
We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes.
 
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
 
It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital.
 
It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments.
 
Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home.
 
Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission.
 
But technology is only an enabler and we need to focus on investing in the model that underpins that technology.
 
Getting started
 
In summary some key enablers for getting the model to work.
 
Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past.
 
Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key.
 
It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base.
 
Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need.
 
Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF.
 
Key barriers
 
The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult.
 
This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care.  This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care.
 
It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there.
 
Whole care continuum
 
The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP.
 
Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home.
 
As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back. 
 
We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality. 
 
 

​Raising the Care Factor: Royal Commission into Aged Care
 
Dr Ayman Shenouda
 
 
There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care.
 
I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve.
 
This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents.
 
What have we learnt?
 
Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind.
 
The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years.
 
The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive.  
 
It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009.
 
Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift:
 
"…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies".
 
Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here.
 
The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers.
 
Ensuring quality care
 
This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction.
 
Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector.
 
I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission.
 
One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model.
 
This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised.
 
Ensuring a key role of general practice in aged care service provision is integral to the solution.
 
The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time.
 
It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review.
 
What are the priorities?
 
A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels.

We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes.
 
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
 
It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness.
 
Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS.
 
Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement.
 
Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this.
 
More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity.


In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team.
 
These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences.
 
Training and roles
 
Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care.
 
In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios.
 
The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles.
 
Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets.
 
They must be properly paid and qualified for what is a role which carries with it a lot of responsibility.
 
Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents.
 
But RNs who work for nursing homes also tend to earn less than those working for other major employers.
 
In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure.
 
Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night.
 
This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care.
 
New models of nursing-home care
 
It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place.
 
There are also excellent models of care within Australia but we need a funding system to prioritise support of their development.
 
We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing.
 
These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
 

​Dr Ayman Shenouda
 
There remains a deep undercurrent of racism in this country but it is not mainstream Australian opinion driving it.
 
The problem is that the public debate in and around migration is persistently led by a far-right minority.
 
And actively challenging such intolerance is vital otherwise I think these low debates will come at a high price for us all.
 
I really think all doctors must unite against racist attacks on IMGs. This is doing considerable damage and we need to challenge these views.
 
Where’s the evidence?
 
If you were looking for more evidence that the media is complicit in fueling racism it could be clearly seen on the front page of The Weekend Australian last weekend.
 
Beneath a headline that read ‘Foreign doctors blow out Medicare’ sprawled the most unbalanced, uninformed piece which firmly targets International Medical Graduates (IMGs) as exploiters of Medicare.
 
This article, whether deliberate or not, purely through a sole focus on IMGs infers that they alone are responsible for driving some very complex problems facing our health system.
 
Issues around over servicing and professional standards are not confined to IMGs and we have effective non-discriminatory processes in place through various codes, guidelines, and policies to address these.
 
Let’s unpack the bias
 
Starting with over-servicing and alleged Medicare fraud we’re told about “a rampant increase in IMG Medicare billing”.
 
The article, of course, fails to balance this with required comparators for Gross Billings for Australian Trained Doctors (ATDs).
 
There is also policy in place which addresses such issues – the Professional Services Review - and this is not confined to IMGs.
 
Some much-needed context around what might be driving such increases other than the inferred fraud would have helped balance it.
 
Issues such as long hours and caseload, acuity and complexity of patient need, and broader need for the specific population and working to align resources to need all factor strongly.
 
The predictable narrow migration narrative
 
The article then forewarns a policy shakeup which will see the number of IMGs or ‘imported GPs’ slashed in coming years and then states a budget return for policy justification.
 
This just adds to a growing trend which sees skilled migration used as political fodder.
 
Skills lists really are a decision for government and if we don’t need them then don’t get them.
 
I actually don’t disagree that we should place strict parameters around skilled migration policy to ensure we are targeting the skills most in need.
 
But if we do need them then we need to support them and that is the key issue here. More on that later!
 
Recent policy through the new Temporary Skill Shortage (TSS) visa now works through short and medium-term skill requirement.
 
This is a good policy reform which also works to limit the pathway to permanent residency. 
 
Where’s the detail behind the analysis?
 
The article alludes to some analysis that claims average billing of IMGs — across Medicare, the Pharmaceutical Benefits Scheme, and referrals — has tripled in three years.
 
Let’s be clear here defining total cost as MBS + PBS + referrals in no way reflects a GPs actual income.
 
We’re then told that removing IMGs would result in a forecast saving of $415.5 million. This, of course, assumes that most if not all the services provided by the IMG equated to over-servicing.
 
The article claims this is based on a policy assumption that other doctors would not cover the equivalent Medicare services or subsidised drugs and only half as many referrals.
 
This is a very big assumption and one that is impossible to verify against such diverse need.
 
Now to provide a much-needed defense for IMGs.
 
A reality check on the doctor shortage
 
Statistics might show there is no doctor shortage in Australia but there certainly remains a maldistribution issue.
 
Maldistribution persists in rural Australia and with increasing remoteness you can expect to see both workforce shortages and a higher burden of disease.
 
This is despite efforts to increase supply through policy measures which see increasing numbers of Australian Trained Doctors (ATDs) and broader workforce supplementation measures through skilled migration.
 
Some policy insights
 
Benefits from increasing domestic supply will of course take time and we’ve made great progress with more students training in rural areas through the Rural Clinical Schools.
 
What is not seen beneath the supply stats are the policy complexities in regard to addressing population need, ensuring the right workforce mix, health infrastructure deficits, and distance and geographic location.
 
There are still too many one doctor towns in rural Australia in need of an urgent injection of basic medical facilities.
 
Keeping services viable in these contexts is the story not told. And it is for all these reasons IMGs remain an integral part of our workforce.
 
Rural Generalist Training
 
Excessive specialisation means there are not enough generalists particularly in rural Australia.
 
We’ve been working hard to address this through the National Rural Generalist Framework.
 
This is key to ensuring a supportive pathway providing rural exposure in order to prepare trainees for work in a rural and remote setting.
 
There is significant policy work currently being undertaken in this area led by the National Rural Health Commissioner.
 
We need to facilitate some key shifts which turns a structure which currently sees most of the training being undertaken in the bigger tertiary hospital in the cities.
 
We need to turn that on its head to provide more training in regional locations to encourage more domestic graduates to take up and retain postings in rural and remote areas.
 
Currently, they are seconded for six months to a rural area but it’s just not going to be enough to give them the exposure they need to entice them to return.
 
They spend most of their time training in cities and naturally build a life around that. We need to provide more opportunity for them to work in rural areas and experience the rewards.
 
It is just about facilitating the training to connect these doctors to the communities that need them the most. It’s really quite simple and we’re now on the right path to make this happen.
 
IMGs and their contribution
 
IMGs are the lifeblood of rural towns. They are the backbone of our healthcare services in rural areas. You see without them many rural communities would be without a doctor.
 
It is estimated that IMGs comprise approximately 40% of the medical workforce in Australia and 46% of general practitioners in rural and remote locations.
 
IMGs saved this country from a disaster over the past 10-15 years and this type of reporting is just unhelpful.
 
Let’s not forget that they are often recruited to work in some of the most difficult environments, with little support.
 
IMG is also a broad definition
 
If we are going to persist with a debate that sets IMGs up against ATDs then lets first clarify the definition. I don’t think it is well understood just how broad this term is. And it’s a term that sticks.
 
IMG simply means that you have been trained overseas and while we’re on that point it also means that you’ve not cost the country a cent in your training.
 
Many IMGs have been through the system, working in rural areas for many years and achieved Fellowship. These doctors are serving their communities delivering a very high standard of care.
 
Legacy of forced distribution
 
The legacy of a forced distribution policy – the 10-year Moratorium – is that the gains for our rural communities are only short term, as doctors seek to return to more populated areas.
 
The policy may only provide intermittent gains, and ultimately fail to provide a stable workforce for the rural and remote areas in need.
 
For it to work, it is reliant on a longer-term commitment from IMGs – a key consideration which currently lacks policy focus.
 
For some practical policy solutions, here’s a link to a conference paper from the 14th National Rural Health Conference last year:  Keeping them there: shifting our focus toward IMG retention, beyond moratorium obligations
 
Shifting focus
 
Now one final word on the debate we ought to be having. The discussion we need to be having is keeping doctors where we need them.
 
For rural and remote communities, we need to shift the focus toward IMG retention, beyond moratorium obligations.
 
But we also need to focus most on a policy which prioritises and secures domestic graduates for regional, rural and remote Australia.
 
A strong investment in the National Rural Generalist Pathway will support this outcome. 
 
The reality is that we will also need to continue to rely on those IMGs currently working in regional, rural and remote Australia to help train our domestic workforce coming through.
 
IMGs are vital in securing the next generation of rural GPs and this is a really important point that just gets lost in these divisive debates.
 

​The health effects of drought and our role in planning
 
Dr Ayman Shenouda
 
Last week’s blog on GP-led strategies to reach out to drought-affected farmers has started some good discussion around the role of GPs and our broader public health role.
 
What we are seeing is a significant drought particularly in the worst-affected parts of NSW where the current dry conditions have spread to most inland parts of the state.
 
The recent media focus is a good thing to keep some philanthropic and government dollars flowing, but we really need a better preventative strategy to protect our farmers and our food resources from these extremes.
 
What we are seeing is reactive policy which only demonstrates the ineffectiveness of our national drought management policies.
 
While short-term drought-related health shocks can be more obvious, it is those longer term, more indirect health implications that are harder to measure and monitor.
 
In helping our communities prepare for drought, GPs should have a leading public health role in developing drought-related public health vulnerability assessments.
 
This involves working with the community and key partners to ensure coordinated preparedness and response efforts. Staying engaged through non-drought periods is essential.
 
Here are some key steps that we could consider in undertaking drought planning and vulnerability assessments in our own communities.
 
Step 1
Identify vulnerable populations
 
It is clear that drought severity and the vulnerability of particular populations requires a more targeted and planned response.
 
While the health effects of drought can be severe, the health disparities in diverse rural communities can make public health planning a challenge.
 
This is why GPs need to have an active role in identifying those priority groups within our community.
 
Most rural practices sustain themselves by being attentive to key changes within their communities and know how to work within constrained resources.
 
We need to allocate a greater proportion of total health resources to drought impact mitigation and prevention.
 
A key part of this is enabling planning and establishing a leadership role for GPs in decisions to develop appropriate models of health care for these at-risk groups.
 
It is important to note that there is also a doctor drought in some regions too.
 
The distribution of GPs to underserved areas requires similar planning together with ensuring the adequacy of health infrastructure for longer-term service viability.
 
Step 2
Make disease projections
 
We need more data around this but generally, populations face an increased risk of illness in the year they are exposed to drought.
 
A formal role for GPs in addressing the data gaps to build more evidence around the causal links between health and the environment is needed to inform future policy nationally.
 
More research dollars and faster research into what works at the local level to help us better understand the risks and health status of populations.
 
This requires a sustained research effort and is part of a broader investment strategy and structured support towards disease prevention.
 
Step 3
Planning for specific health effects
 
Droughts have many consequences for health. Social impacts are quite obvious as drought contributes to debt burden and the psychological impacts run deep.
 
Generally, we will see more air and water-borne diseases and infections, with effects on air quality including related respiratory illness.
 
The worsening of chronic illnesses and mental health conditions through social impacts and compromised food and nutrition.
 
The more immediate impacts of heat include increased risk of dehydration and heat stress.
 
A community capacity-building program for drought response should be prioritised to both assess drought impacts and explore actions in response from a health perspective.
 
We have a good understanding of what the health vulnerabilities are for our own communities in times of drought. Allocation of funds towards drought mitigation in relation to health is needed.
 
Step 4
Establish intervention strategies
 
Inadequate social impact indicators make this task harder but we need to think about building resilience to drought.
 
In building resilience, implementing critical programs to protect the most vulnerable health populations in specific locations is important.
 
Building the evidence base for population-level interventions will also help close the gap between research and practice.
 
A national program to support communities to undertake drought-related public health vulnerability assessments is a good way to make this happen.
 
GPs should have a leading role in supporting proactive mitigation and health planning measures in managing drought risk and health impacts for their communities.

Healing in times of drought: GP-led strategies to reach out to drought-affected farmers

Dr Ayman Shenouda

Those living in rural Australia don’t need to see a politician donning an Akubra to confirm just how bad this drought is.
Rural communities know only too well what this almost constant climate of suffering looks like. How this hardship can impact on community morale and health and particularly for mental health.
 
This is clearly seen at the practice level in our patients with notable increases in the rates of depression and anxiety and with more and more patients disclosing suicidal thoughts.
 
The most devastating reality of drought is of course suicide which is in part a system failure and a shift in placing prevention at its heart will require a very different model to the one we have.
 
Only this week a patient came to me and described just how close he had come to suicide:
 
‘I came very close this time. Opening my shed looking at the rifle - it was very tempting to finish it all.’
 
This was a farmer reaching out for support and with this key step, the healing journey can begin.
 
The depression begins with a downturn in cash flow and in a multi-year drought, there is often no clear way forward for them.
 
A key hurdle for us is in reaching out to those more adept at hiding the problem. Trust is a big part of it.
 
In rural people, particularly men, this is sometimes very well hidden. They often try and hide the problem and all too often we find it is too late to help.
 
We are missing a lot of patients – those who won’t come forward – and this is where our funding dollars are most needed right now.
 
It is often the case that even when mental health services do exist within a community, farmers are unlikely to utilise these services.
 
A solution is for the GP to get out to the community and this is precisely what we’ve been doing in Wagga and The Rock Communities
It involves taking your practice to the patient and there’s currently no real funding tied to this. This effort relies on the goodwill of the GPs, nurses, other clinicians and allied health professionals.
These are ground-up initiatives to help communities manage their health and mental health. And these are the strategies that we know work in rural communities.
I’d like to share a couple of practical strategies we’ve undertaken to reach out to those harder to reach farming patients.

The Pub Patient information nights
The pub is a good place to start. We often do talks in the pub which will have a formal health topic for the evening inviting the community to join us in the discussion.
 
We see two groups form here. The ones actively involved in the discussion and those sitting at the bar (but listening). It is the latter that is often the most critical to reach.
 
But it can start the conversation and importantly their involvement in their own health and wellbeing as well as new strategies to cope.
​
Field day pitstop
The field day pitstop check-up clinic places us right in the thick of the action. This is where farmers gather to exchange ideas, trade their goods and importantly just get together.
 
We usually set up a tent clinic with a couple of doctors and practice nurses providing health and lifestyle assessments.
 
We cover emotional wellbeing and general health checks looking at BMI, blood pressure, respiratory testing, blood glucose and covering other risk factors including cholesterol screening.
 
These tests are vital and will often get them into your clinic and under your care longer term.
 
Sparking that vital conversation around mental health is a key objective here and we aim to provide links to rural helplines and connect through to outreach initiatives.
 

 
Dr Ayman Shenouda
 
Patient loyalty and trust
 
It’s hard to pinpoint precisely what inspires long-term patient loyalty.
 
Quality of care and trust must come into it. The ability to listen, having a caring presence and reliability would also factor highly.  
 
From my own experience, I think patient loyalty is mostly about trust. And it is timely and effective communication that builds that trust.
 
Of course, for doctors, communication also involves giving the patient bad news. Listening actively and providing comfort being core communication skills.
 
There are very few studies that have explored those factors seen to build and maintain a patient’s loyalty towards their GP or a practice.
 
Some recent research in France provides some specific insights while a more recent study closer to home provides a new novel way to measure both GP and practice loyalty.  
 
The loyalty equation
 
First, let’s look at a possible loyalty equation. A 2016 French study tested aspects of patient loyalty in the general practice context.
 
This study found that loyalty was more complex than commonly assumed and is reliant on a few factors. It involves dimensions of trust, listening, quality of care, availability, and familiarity.[1]
 
So, the loyalty equation from this study looks like this:
 
Trust + Listening + Quality of Care + Availability + Familiarly = Patient Loyalty
 
This is interesting enough but I think what makes this study really interesting is that the loyalty factor was seen as important enough to formalise it in policy.
 
The efficiency factor to loyalty
 
In France, the Caisse d’Assurance Maladie (public health insurance fund) recognises a coherence in maintaining the doctor-patient relationship in terms of efficiency and healthcare costs.[2]
 
This has been formalised in law since 2004 and was part of broader reforms to health insurance which requires a ‘preferred doctor declaration’.
 
The policy requires adult patients who want optimal coverage of their care by national health insurance to choose a preferred doctor - typically a general practitioner.[3] [4]
 
What we see in France is the use of a single lever-regulation through what it calls its ‘gatekeeping’ reform.
 
The carrot and stick approach of this effectively means that every adult must first choose a primary doctor, or médecin traitant, or risk higher healthcare fees and being reimbursed at a lower rate.
 
The policy aim is to control both the demand and supply side of health care provision to improve care coordination and reduce utilisation of specialists’ services.
 
The policy operates by encouraging patients to choose one GP and imposes financial sanctions if they don’t. This gives value to the relationship and makes the patient’s loyalty official.[5]  
 
One evaluation of this reform explored effect and found that specialist visits fell slightly while self-referred visits and the number of different GPs seen also declined.[6]  
 
In other words – policy success – but does a forced scheme generate patient loyalty?
 
What can we learn from the French experiment?
 
Forced schemes like this are never good policy. But while this scheme is perhaps set out to control access to specialists the positives will be seen over time through continuity of care.
 
The French patient loyalty study actually found this to be true. That, by inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.[7]
 
Patient loyalty in the Australian policy context has resulted through a stronger policy framework which enables choice. So, where are we at in terms of policy success against the loyalty factor?
 
The Australian context
 
The richness and potential of de-identified Medicare data were shown through a recent Australian study led by the Centre for Big Data Research in Health, UNSW, and published this month in the MJA. [8]
 
This study is said to open up a new toolbox for exploring how patients use healthcare services. It’s the innovative approach using network analysis that makes this a standout.
 
It uses network analysis of big data analysing millions of Medicare claims to gain insights into the organisation and characteristics of Australian general practice over a 20-year period.
 
New ways to measure loyalty
 
Providing a novel way to measure change in Australian general practice over two decades, the study shows that while there has been a move towards bigger GP practices, patient loyalty remains high.
 
These results were found by looking at the claims to see when patients were visiting different doctors for their GP services.
 
By applying a network analysis approach, it showed where doctors had many patients in common that they were likely to be sharing the care for these patients in the same practice.
 
These were grouped as a provider-practice community or PPC which also provided new insights into patient loyalty.
 
The results showed that patients’ loyalty to their usual GP and usual GP practice is high and has been stable over the last 20 years.
 
Policy application
 
The loyalty result is exciting combined with the innovative approach used in this study to find that the density of patient sharing within a PPC correlated with patient loyalty.
 
The fact that patients see multiple GPs within a practice is also significant in terms of practice design and enabling more team-based GP care models.
 
The further link made in this study in terms of supporting future program design in terms of where to target incentives for encouraging quality primary care is also good news for our practices.
 
For good policy reach, program success relies in part on the patients’ choice of practice and this fact is now more keenly linked to that loyalty factor as a result of this study.
 
Australian success story
 
These results provide a really positive outlook on Australian general practice and our approach to healthcare policy in enabling equity in access.
 
In contrast to the French policy experience whereby a forced scheme has formalised patient loyalty in a way, the Australian experience shows that patient loyalty and choice of practice comes through less forced means.
 
It will be interesting to see what more can be explored through big data analytics and the network analysis approach used in this study to better understand our health system.
 
References
[1] Gérard L, François M, de Chefdebien M, Saint-Lary O, Jami A. The patient, the doctor, and the patient’s loyalty: A qualitative study in French general practice. Br J Gen Pract 10 October 2016; bjgpnov-2016-66-652-gerard-fl-p. DOI: https://doi.org/10.3399/bjgp16X687541  Available at http://bjgp.org/content/early/2016/10/10/bjgp16X687541#ref-9
[2] Ibid.
[3] Law No. 2004-810 of 13 August 2004 concerning health insurance. Article 7. Published in JORF n°190 2004–08–17: 14598. [In French]. Legifrance Paris, 2015. 
[4] Le Fur P, Yilmaz E. (2008) Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform. 2004 and 2006 Health, Health Care and Insurance surveys. Questions d’Économie de la Santé 134:http://www.irdes.fr/EspaceAnglais/Publications/IrdesPublications/QES134.pdf
[5] Gerard 2016 Op. cit.
[6] Dumontet M, Buchmueller T, Dourgnon P, Jusot F, Wittwer J. Original research article. Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform. ScienceDirect Health Policy Volume121,Issue6,June2017,Pages675-682.Availableat: https://www.sciencedirect.com/science/article/pii/S016885101730115X
[7] Gerard 2016 Op. cit.
[8] Tran B, Straka P, O Falster M, Douglas KA, Britz T, Jorm LR. Research. Overcoming the data drought: exploring general practice in Australia by network analysis of big data. MJA 209 (2) j 16 July 2018. Pages 68-73. Available at:
https://www.mja.com.au/journal/2018/209/2/overcoming-data-drought-exploring-general-practice-australia-network-analysis

GPDU18 – Proving we’re better together!
 
Dr Ayman Shenouda
 
GPs Down Under
 
There was plenty of discussion about collaboration at the recent GPDU18 inaugural conference on the Gold Coast. This was collegiality at its best and perhaps not surprising given we know that flat hierarchies are where innovation and collaboration will thrive the most.
 
GPDU offers healthy debate which is open and inclusive with all members encouraged to moderate. There is very little censorship here provided you remain on topic – GP learning, peer support, and advocacy.
 
Enabling an inclusive dialogue is why this Facebook community of over 5000 members exists and thrives. It provides the opportunity for real-time online discussion in a forum for GPs - one that is free from corporate vetting offering a rare open communication channel. 
 
Better collaboration
 
If there was one clear connect from this conference it was that we need better collaboration.
 
Collaboration creates value in communities. It is about sharing vulnerabilities and being open and being brave enough to distribute your power to many.
 
For GPDU18, day one great debate certainly focused on a rather divisive topic: ‘The Three, Two, One Debate (how many colleges is too many?) which saw an overwhelming yes (79%) for a single united college.
 
Panelists’ Drs Cameron Loy, Fiona McKinnon, and Liza Lack in this session provided either the for or against – one, two or three (college) - noting they didn’t get to choose which side they were on. They each worked through issues including what a college should be doing for their members and more broadly about their values.
 
There was also a discussion during conference on tribalism and the stages of tribal culture led by Dr Edwin Kruys. Based on the work by Logan, King, and Wright in their bestseller Tribal Leadership which takes you through the five kinds of tribes that humans naturally form and the benefit of establishing triadic relationships.
 
It was a timely and interesting reflection allowing us to turn our attention towards building the culture we want. You could sum up both sessions in three words - we’re better together!
 
Building the culture, we want
 
In building the culture we want, it is important to understand why tribes exist. This is really important as an understanding of tribalism is a key strategy for improving collaboration.
 
And, certainly on both topics – one college and that of tribalism - I really don’t think these issues are necessarily separate. Collaboration begins with organisational culture and we are all seeking a more collaborative approach and there were plenty of lessons to take home here.
 
While I doubt the vision for a single college will ever be realised, I think what we certainly do need is more coalition building. This is what GPDU does really well and why it works. It forms coalitions with those holding similar values, interests, and goals to combine expertise and resources for a common purpose.
 
Primary care and collaboration
 
In a past blog about the possibilities of having a united front in primary care and the need to find some common ground, we established that for collaboration to work then this relies on respect and trust. A lack of trust only stifles collaboration. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up for it.
 
In a more recent blog, we discussed ways to position ourselves as leaders of primary care into the future and the idea of a College for Primary Care. Getting back to our value proposition to achieve integration as well as satisfy funders positioning ourselves together in the health system will be important. This is key to ensuring we make the shifts towards a health care system based on wellness rather than the treatment of illness.
 
Collaborative healthcare leadership
 
We need a focus on positioning ourselves together to advance primary care reform and to help orchestrate a collaborative culture. Formalising this structure more would create a work culture that values collaboration. It would help us to put in place the adaptive collaborative learning systems required for the future.
 
For me, GPDU18 just proved that we’re better together and certainly the key themes that emerged particularly around collaboration reinforced a need for a stronger focus around this.
Building trust and blurring traditional boundaries will help end tribalism and silos – it would help bring the ‘we’ (as in the primary care team) instead of ‘me’ (the GP) back into focus.
 
Our sector needs to find a place for more inclusive reform and opportunities for collaboration through communities like GPDU. Working together towards a common agenda is the only way we will see the sector-wide change required. Improving health value in the healthcare system starts with us and it’s time to reconnect.

​Untapping resilience
 
Dr Ayman Shenouda
 
 
Overcoming adversity
 
When each of us experience hardship, it changes us - yet not all of us experience lasting harm as a result. Stress affects people differently with many factors influencing the strength of our stress response.
 
Resilience is our capacity to overcome adversity and our resilience is shaped by our experiences – both good and bad. And it’s really only when you’re faced with extreme stress that your level of resilience can be determined.
 
‘You only know what you are made of when you are broken.’
 
This was the moving statement from a father who lost his unborn baby during the recent Grenfell Tower inquiry.
 
It is said that we can all overcome adversity and choose to be resilient. But how can we increase emotional resilience and cultivate more resilience for ourselves and for others?
 
Neuroplasticity and resilience
 
Can neuroplasticity help us to understand resilience?
 
Mindfulness sites are full of the promise of rewiring your brain through neurally inspired therapies to increase emotional resilience.
 
Brain researchers reassure us that the brain can change and that brain reorganisation is not limited by age. That it is the brain’s plasticity that can help us to overcome adversity.
 
Neuroplasticity is the brain’s ability to grow and change in response to experience. It is supported by chemical, by structural and by functional changes across the whole brain and together they support learning.
 
Personalised learning
 
What is it that limits and facilitates neuroplasticity?
 
Dr Lara Boyd Neuroscientist and Physical Therapist at the University of British Columbia explains this well in her work which looks at what can be done to help patients recover from stroke.
 
In looking at how we learn she states that the best driver of neuroplastic change in your brain is your behaviour. But that it needs practice and you have to do the work with increased difficulty leading to more learning and greater structural change.
 
Our uniqueness holds the key
 
Dr Boyd’s research has looked to therapies that prime or prepare the brain to learn – brain stimulation, exercise, and robotics. But she also states that a major limitation is that patterns of neuroplasticity are highly variable from person to person.
 
It is this variability in studying the brain after stroke that she believes provides some valuable transferable lessons. Learnt neuroplasticity after stroke applies to everyone. It is these individual patterns and variabilities in change that allow us to develop new and effective interventions.
 
It is partly personalised medicine with each individual requiring their own intervention. However, this concept is then broadened through embracing our uniqueness with personalised learning being key.  
 
This research shows that biomarkers are helpful to match specific therapies with individual patients. More specifically it is a combination of biomarkers that best predicts neuroplastic change and patterns of recovery after stroke.
 
Applying this learning
 
Dr Boyd’s advice is to study how and what you learn best. Repeat those behaviours that are healthy for your brain and break those that are not.
 
In applying this learning, it is clear that resilience can be taught. But it requires supportive relationships and opportunities for personalised learning.
 
Bringing this back to our own workplace, how can we harness the brain’s innate capacity to change? Not only in our patients and ourselves but applying this knowledge in equipping our trainees with strategies to cope in dealing with stress.
 
Resilience in the workplace
 
I think it is important to look at how can we inspire resilience in others. Working through what strategies work for the individual is important but so is providing a workplace free from harm, neglect, and disrespect.
 
More emphasis on building positive work environments, coping strategies and the importance of self-care is needed. Training in neuroplasticity and how to exploit it should be part of our armoury.
 
For our trainees, we need to think more about building their stress fitness and coaching and mentoring are helpful in developing this resilience. Trainees would benefit from a buddy and a mentor to improve resilience and this needs to be formalised in our training system.
 
Funding for formalised training programs to improve resilience in our trainees should also be prioritised. Webinars in workplace wellbeing, resilience, mindfulness, cognitive reappraisal training should all be pursued.
 
Thinking differently
 
Resilient people are able to see things from others perspectives. They also tend to value others.
Simply conversing in a compassionate way changes the brain.
 
Coming back to neuroplasticity, if we repeat certain throughs or behaviours often enough the neural pathway can be created. Forming new connections and weakening those patterns that are not working for you being key.
 
In mastering resilience, we know that much of it has to come down to the individual and effort. Fixing a self-critical neural network is doable but takes practice and training to chart new pathways.
 
In untapping resilience by harnessing the brain’s innate capacity to change we must prioritise the tools proven to bring about these shifts. This is particularly important in supporting our trainees so that together we can inspire and create a more resilient workforce.
 
[ends]
 

Federal Budget 2018
 
Dr Ayman Shenouda
 
Budget expectations
 
Expectations around this year’s Federal Budget were high. The Government certainly worked hard in its lead up trying to lower expectations promising an economically responsible and fair budget.
 
We knew we would see an election budget here and with that, we expected a strong focus on some key areas important to the majority of Australians.
 
Voters wanted to see a focus on cost of living pressures and improving the health system and these two items came out on top in earlier polling.
 
A budget for a healthier Australia?
 
So, what is the verdict - is this a budget for a healthier Australia?
 
There were certainly strong gains in rural health, aged care, mental health and medical research.
 
There are some really positive initiatives in this budget but at a time of record inequality, more wellness measures through formalising a preventative health strategy would have made this a great budget.  
 
This is required to help drive a strategy forward to really address some of those causes of ill health.  
 
Spending measures in countering the high numbers of our population who are overweight or obese, for example, are needed and it would have been good to see some strategy around this.
 
We all know to get to the bottom of the causes of health disparities then the focus needs to be on those social determinants of health.
 
The investment is beyond health and an overall policy approach to protect those factors which stretch a range of personal, social, economic and environmental factors.
 
Primary prevention focus
 
A strong and broad primary prevention focus is needed to counter those health risks factors and improve health outcomes for all Australians.
 
This budget does pick up a number of these issues, including for women’s health and wellbeing and more broadly through its More Choices for a Longer Life Package.
 
Mental Health funding of $338 million and priority on suicide prevention clearly goes a long way towards addressing the system gap around crisis support.
 
The allocation for older Australians which includes $83 million for more services within the RACF, again addressing a significant gap, is a really positive step forward.
 
While short on detail, the new primary care funding model for the Indigenous Australians’ Health Program is another key area which required focus.
 
The increases for PBS and new funding for medical research, development of diagnostic tools and medical technologies, and clinical trials of new drugs all represent a significant health investment.
 
The standout here in terms of addressing disparities and ensuring a primary prevention focus is the rural investment and the Government has certainly delivered here.
 
Equity for rural Australians
 
The key rural health workforce measures are provided through the $83.3 million new Stronger Rural Health Strategy which includes some solid measures to secure more GPs for rural Australia.
 
This is a 10-year plan and a $550 million commitment which promises 3000 more doctors, 3000 nurses and hundreds of allied health professionals to our regions.
 
The plan provides an unprecedented level of funding and commitment for rural Australia and its packed with measures that show the Government has listened on addressing rural health need.
 
The workforce component will see integration through the entire training continuum as well as measures to support the existing rural workforce with an important focus on retention.
 
Stronger targeting of rural bulk billing incentives and key focus on accessing rural services particularly for older Australians with $40 million towards rural aged care infrastructure another positive shift.
 
For Aboriginal and Torres Strait Islander communities, there is a $105 million boost towards access to services which are culturally appropriate and closer to home.
 
There is a new MBS item to deliver dialysis services to remote areas representing a $35 million investment.
 
We have some great leadership here at the moment in our Rural Health Minister, Senator the Hon Bridget McKenzie and Commissioner Professor Paul Worley and it shows in the budget.
 
Rural pathway package
 
The rural workforce package is certainly comprehensive and a significant step forward in securing a stable rural workforce with a number of the key components to this strategy covered in earlier blogs.
 
There is a priority placed on establishing a homegrown rural medical workforce with an important emphasis on skills.
 
Many of the placement gaps that make it harder to remain in a rural area have been addressed.
 
More intern placements in general practice and an additional 100 vocational training places are committed. The latter committed from 2021 as part of the National Rural Generalist Pathway.
 
New training facilities to help rural students aspiring to become rural doctors study closer to home is also welcomed.
 
The $95.4 million new Murray-Darling Medical Schools Network will help universities work together to support medical teaching in our regions.
 
It’s also great to see that the new Workforce Incentive Program will extend to supporting general practices to employ more allied health workers.
 
Strong IMG focus
 
It’s great to see strong action to ensure we retain the rural workforce in this package of measures which extends to providing incentives for IMGs to progress towards Fellowship.
 
Those working in rural areas know the huge contribution IMGs make and it is great to see the shift here towards IMG retention. These doctors play a vital role in rural and remote communities and they deserve some support.
 
The rural strategy outlined in this budget invests in the next generation through domestic recruitment to rural areas but shows a commitment to the existing workforce through investment in skills and retention with an important focus on IMG retention.
 
Aged Care
 
In Aged Care, reduced waiting lists and incentives to stay in the home longer sees another important policy shift.
 
Measures which keep older patients in their homes longer is welcomed policy with this initiative providing $1.6 billion for 14,000 new places for home-care recipients.
 
This is a good start but not nearly enough with more than 100,000 people on the waiting list. However, the policy is certainly headed in the right direction towards an integrated care at home program.
 
Some of these measures will restore some of the cuts to the aged care sector of recent years. But it is unclear if they will provide for the targeted supports needed to deliver the complex care required which needs more focus on enabling more GP-led care.
 
A healthier future
 
There are some major challenges in funding and delivery of healthcare in securing a healthier future and for this budget, we’re seeing shifts in the right direction.
 
Health is so integral to our nation’s prosperity and the Government through its investment particularly in rural Australia shows that it understands the value of general practice and primary care.
 
This budget will certainly improve the lives of the seven million people living in rural and remote Australia.
 
The rural health measures will help to address disparities and important gains will be realised through this investment and this is a clear win for the sector.
 
The mental health and aged care gains are also significant and it is great to see those more vulnerable Australians being prioritised.
 
[ends]
 

 
 
Dr Ayman Shenouda
 
Proving our value
 
Recent coverage around the failed Health Care Homes roll-out saw some unsettling truths coming through in the comments by the reform architect Dr Steve Hambleton.
 
This is in the context of the continuing trend for value-based care models, Dr Hambleton’s comments highlight a need in general practice to strengthen our data capture capability to prove our value.
 
What was said really cuts to the truth in terms of where our focus needs to be and how we ought to align or perhaps realign ourselves to better capture outcomes measurement.
 
For those who missed it, here’s the quote:
“What I will say to GPs is that unless we have the [patient outcome] data to take to the government that proves the value of the healthcare we are providing, they are going to keep investing in the bits of the health system where they do have the data, which is hospitals.” Dr Steve Hambleton[1]
 
The case for Primary Care
 
In delivering more effective, equitable, and efficient health services, it is clear that strong investment in primary care would see fewer disparities across populations.
 
The value and need of strong primary health care systems are already well established. There is robust evidence to show that good primary care is associated with better health outcomes. [2]
 
Primary care improves quality and reduces costs. But primary care integration and care management are made harder by a system that has at its core a prime focus on episodic acute care.
 
System barriers
 
The shift to value-based care is inevitable. However, creating savings in the healthcare system is as much about structures as it is about payment reform or data capture in driving that reform.
 
In measuring value, the current system and structure makes this very challenging. In many ways, the Health Care Homes model provided that answer in terms of how to provide and organise care in the future while enabling measurement and the policy is still worth pursuing.
 
The key requirement in embedding value-based care as a business model into general practice will require a shift in terms of enabling more team-based care to occur in order to remain viable.
 
Value in healthcare
 
Value in healthcare is measured around patient populations requiring different bundles care, these are defined patient groups with similar needs determined by combined efforts over the full cycle of care. [3]
 
This confirms the focus needs to be on primary care or new models of primary care but we need a stronger team-based focus and more support structures to make this work.
 
We need to leverage as much as we can from the current payment system to provide integration across settings. Much of this already falls to the general practice but enabling integration is hard and often non-remunerable work.
 
Our value proposition
 
The lack of networked or organisational architecture to support the level of data capture required to measure the quality of care and outcomes achieved through preventive primary care lets us down.
 
If we are going to achieve the level of integration required, satisfy funders with data capture demonstrating value then I think part of the solution also lies in how we position ourselves in the health system.
 
We already have the right strategy to fix healthcare and that solution lies in more investment in primary and preventive care through a Health Care Homes model.
 
In establishing our value proposition, if we must face off as Dr Hambleton suggests against advanced data-capture systems like those used in hospitals to capture detail right down to the bandages, then clearly, we need to get organised.
 
Transitioning challenges
 
Capturing quality measures and measuring performance on a continuous basis will be complex and creating reliable structures will be key to our success.
 
Part of that challenge is around data capture and standardising that process and in particular who’s holding the data. 
 
The strength of our primary care system is associated with improved population health outcomes and we know that enabling service integration is key in terms of realising these aims.
 
The other challenge will be our capacity to leverage technology, integrate more and build up those required team structures.
 
It’s clear there is still much to work through here. But what often gets missed is the need to enhance professional experience and I think it is here where we have some real opportunities.
 
Time for a rethink?
 
Right now, we should be thinking about what we can do to be more proactive in terms of redesigning what we can for ourselves.
 
We’ve been a College of GPs for some time now and certainly, that structure has been integral to the world-class health system we have today through supporting Australian GPs to provide the best possible care.
 
We need to ensure we have in place the adaptive collaborative learning systems required for the future. Is it now time to think about primary care as the future and not only GPs as the centre of that model?
 
College for Primary Care
 
The new models of primary care required in response to the healthcare system shifts towards value-based care will rely more and more on team-based care.
 
In demonstrating value, we need to think about those finite costs capturing those bandages too but this also needs to be about developing the primary care team. There is a real opportunity to support all the individuals working in general practice and train the whole team to enable more integration.
 
Collaborative healthcare leadership will be needed in shaping the future workforce to support new models of care. The existing College structure can help provide this leadership model to bring about the transformative change required.
 
Taking a more proactive approach to designing the health system means less focus on payment reform and more interest in investing in the primary care team.
 
[ends]
 


[1] News Article. Health Care Homes roll out 'went wrong somewhere' says reform architect March 27, 2018. Australian Doctor. Available at: https://www.australiandoctor.com.au/news/health-care-homes-roll-out-went-wrong-somewhere-says-reform-architect

[2] Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91.

[3] Porter ME. Perspective. What Is Value in Health Care? December 23, 2010. N Engl J Med 2010; 363:2477-2481
DOI: 10.1056/NEJMp1011024 Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1011024
to edit.

Let’s fix the health deficit through a more equitable distribution
 
Dr Ayman Shenouda
 
Highlighting inequity
 
The alarming population growth in our major cities is not surprising and highlights a lack of a national population planning approach for sustainable development.
 
This issue has been in the news recently and these conversations for me always highlight inequity and missed opportunities. There is usually fallout in distributional terms for rural Australia which continue to be left behind. This is despite the fact that rural areas don’t even get a mention in the discussion.
 
The lack of rural focus is the underlying problem here with no attention to the broader spatial dimensions which result in increasing inequities. This is a much bigger issue than the inconvenience of the long city commute to work. It’s about the fair distribution of impacts to bring about more equitable outcomes.
 
Persistent disparities
 
In prioritising health, we know a community’s economic health is closely tied to health outcomes. There are persistent inequities in Australia and particularly in our remote Aboriginal communities.
 
Returning from the Solomon Island’s recently and talking to a colleague about the plight of the people in the Pacific, I was reminded that some remote communities in Australia are worse than Third World.
 
To get to the bottom of the causes of health disparities you need to look to the social determinants of health. Invest in policies which protect those factors which stretch a range of personal, social, economic and environmental factors and you will get results.
 
Rural health disparities
 
The converse is, of course, true and this is why we have such marked health disparities in rural areas.
 
There is an estimated health deficit of $2.1 billion in rural and remote Australia.[1]
 
The impact in health terms is that rural Australians are living shorter lives and they have poorer health outcomes and higher rates of disease. The more remote you go, the worse it is.
 
It is the compounding effect that impacts here - where we see high levels of socio-economic vulnerability combined with lack of access to services.
 
In addressing these issues, health workforce distribution is of course key to enabling access but so is getting to the bottom of what’s driving the disadvantage.
 
Causal factors
 
We need to focus on the value of working across sectors to address those causal factors.
​
It is those causal or upstream factors – social disadvantage, risk exposure and social inequities – that present the real opportunities for improving health and reducing health disparities.[2]

These powerful determinants of health inequality are why we need to put the spatial dimension back into population planning. More collaborative planning is needed to address the unique needs of these communities.
 
Rural health investments
 
Part of the planning discussion needs to focus on the role that rural health investments have creating healthy and sustainable communities. There is a failure to recognise the comprehensive impact of health care funding as a driver for local economic development. [3]  

I know from my own experience that just bringing a health service to an area will help to sustain it. When I established my practice at The Rock the medical facility was being run out of a rented room in the CWA building.
We worked hard to not only establish our practice but build the required broader health service around us. Through our sustained efforts the pharmacy soon followed, then a pathology service and now finally an aged care facility.
 
The economics of poor health
 
We know all too well the economic effects of poor health.
An investment in rural health boosts these local economies. A fairer health budget spend would realise strong returns and a healthier future for 30 percent of our population.

But, it is not just a rural issue as there are pockets of disadvantage elsewhere including in our cities and on the fringes and of course in regional centres as well.

Whether in urban or rural areas, pockets of entrenched disadvantage will remain unless we start to align health and causal factors in national planning.
 
Fixing the health deficit
 
We need to fix the health deficit through a more equitable distribution.
In planning for a healthier Australia, a much broader focus is required which targets and acts on those upstream determinants.
It’s not just medical care alone that influences health with social factors known powerful determinants of health.[4] This is the formula for a healthy Australia.
 
[ends]
 

[1] NRHA Fact Sheet. The extent of the rural health deficit. National Rural Health Alliance. 2016. http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-27-election2016-13-may-2016.pdf
[2] Bharmal N, Pitkin Derose K, Felician M, Weden MM. Working Paper. Understanding the Upstream Social Determinants of Health. RAND Health. May 2015. https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
[3] Russell L. The economics of delivering primary health care in rural and underserved areas—what works? Menzies Centre for Health Policy. University of Sydney. 14th National Rural Health Conference. http://www.ruralhealth.org.au/14nrhc/sites/default/files/Russell%2C%20Kesley%2C%20KN.pdf
[4] Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863696/

Nowhere to go: tackling homelessness for older women

Dr Ayman Shenouda

A measure of our society
 
It was Ghandi who said ‘a nation's greatness is measured by how it treats its weakest members’.  I’m not sure where that places us as a society particularly with the rise of homelessness in Australia. I strongly believe that governments are there for those who need them the most. Better still, if we had their focussed investment on preventive strategies it is certain that our country would be much better off.
 
On the issue of homelessness, we’ve seen very slow progress. This is despite a strong focus by state and territory governments. But this issue cut across departments and really requires a national focus in my view particularly to direct funds to improve healthcare management in primary care.
 
Housing and employment are two significant social determinants of health. We know homelessness can significantly impact on health outcomes. While social and economic factors lead to increased risk exposures. The patient-centred medical home can help meet the healthcare needs of the homeless population but this is reliant on a targeted program of funding.
 
Rising rates of homeless older women
 
One in three older women are living in income poverty in Australia.[i] Older single women are particularly at risk of becoming homeless with significant numbers experiencing rental stress. This is a public health crisis and requires careful policy planning overtime which is difficult to do in our short-term electoral cycles. Health status must remain a priority across government and not just health to provide for integrated services and supports.
 
Social workers have warned that Australia is facing a generational “tsunami” of this older demographic in coming years. This policy catastrophe is really not all that surprising when you consider the soft policy responses to those known drivers of poverty.  
 
Women have less super due to disparity in earnings with years of lost income due to time out for family. There are cost impacts which include high-priced housing or losing a job as well as broader factors such as the rising divorce rate or death of a spouse. There is also less capacity to earn with the casualisation of the workforce which is also marred by ageist stereotypes.
 
Combating ageism
 
Combating ageism in our society is something this country really needs to work on.
 
How is it even plausible that in the modern workplace you are considered old at 45 or 50? This seems to be the case yet Australia’s future prosperity is reliant on older workers. Perhaps this factor alone will make our policymakers more focussed on solutions in future.
 
Older women are locked out of the jobs market. Losing a job is said to be one of the most common triggers that can plunge older women into poverty.[ii]  Ageism has very real mental and physical health consequences. There is less discussion on the impact that ageism has on health and we need to be louder here. These are two clear areas which require more policy development.
 
Addressing isolation
 
My older female patients often describe feeling invisible and that’s always heartbreaking to hear. But it seems this invisibility may have also crept into the policy space. Like so many things, we know policy inaction will be more costly over time.
 
The UK in prioritising a Minister for Loneliness is perhaps a step in the right direction. Addressing issues of isolation will help build stronger, healthier older Australians and we really need that national policy setting.
 
Homelessness prevention
 
We’ve been treating the symptoms and not the know causes for too long.
 
Securing long-term tenancy options for this vulnerable cohort has to be prioritised. The fact is that we have had enough warnings in order to evacuate safely from the impending tsunami. We need to address wealth inequality, and particularly gender and income disparity in later life. Addressing ageism and particularly employment-based age discrimination too.
 
It is about helping women before they reach crisis point. More integration across the health and homelessness support systems would help to identify earlier those at risk. Also, understanding those pathways to homelessness among older adults and ensuring prevention and service interventions are adapted to meet different needs is another key piece to this policy puzzle. [iii]  
 
[ends]


[i] O’Keefe, D. One in three older women living in income poverty in Australia: study. Australian Ageing Agenda. March 9, 2016. Available at: https://www.australianageingagenda.com.au/2016/03/09/one-in-three-older-women-living-in-income-poverty-in-australia-study/

[ii] Ibid.

[iii] Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB (2016) Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS ONE 11(5): e0155065. https://doi.org/10.1371/journal.pone.0155065
 

​Building healthcare capacity in the Solomon Islands
 
Dr Ayman Shenouda

Unmatched resilience
 
A recent visit to the Solomon Islands provided some new insights into what it really means to be resilient. It is one of the least developed countries in the Pacific Region, the population languishes in poverty yet they make the most out of limited resources.  
 
The community here face significant health challenges and on multiple fronts. They lack even the basic health infrastructure, and universal access seems an almost impossible health policy goal. Despite this, I found the healthcare teams here work with courage and resolve.
 
Health system challenges
 
Persisting social disparities mean they face significant health challenges through what is termed the “triple burden” of disease. The community deals with communicable diseases alongside rising rates of non-communicable diseases combined with the threat of climate change which we know already hits hard too regularly.
 
The Solomon Islands suffer from significant resource deficits and the underdevelopment of infrastructure is driving inequalities. There is no CT scanner in the country – that places new meaning on what it is to be deficient in resources here. This is a country of over 620,000 people spread across more than 900 islands and it is without essential imaging diagnostic tools.
 
Coverage of services is very weak. This is partly because past development efforts have lacked the required multi-level coordination to support any sort of integrated health system. Almost half of all health expenditure comes from donors which is mostly put to disease management with little left for service system development. [i]
 
The Good Samaritan
 
My visit to the Solomon Islands was unexpected and prompted by a local MP who approach me following some donations I made to the hospital in Tetere. They were relatively small contributions in the form of blood pressure and haemoglobin machines. From this visit, I learnt that while small they were vital and are the sorts of supports that help to develop capacity and reliability.
 
The Good Samaritan hospital is on the coast in Tetere in Guadalcanal province which is about 40km from Honiara. The caseload here is overwhelming. The hospital is basic with about 30 beds, that provides mainly chronic disease management, emergency medicine and obstetrics. There is one doctor per 60,000 population, two midwives and two nurses. But with that they perform miracles here - this team provides obstetric care averaging 170 delivers a month.
 
This is a population facing serious health problems yet you would be amazed by how well they cope with very little. The four most common conditions leading to critical illness are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis.[ii] Screening programs are grossly underdeveloped which increases critical care demand.
 
Most facilities are short staffed and without basic equipment. From Tetere it is one hour  to Honiara for Xray or just to do bloods.
 
Despite the many challenges, the team use their clinical skills to the highest levels to provide the best care for their patients. It is the practical supports that they need the most and I think as a community of GPs we are well placed to do more.
 
Improving critical care
 
It is clear that the underdevelopment of healthcare infrastructure compounds inequalities.
 
In Pacific Island countries, including the Solomon Islands, there is a high need for basic critical care resources. Equipment such as oximeters and oxygen concentrators are needed as well as greater access to medications and blood products and laboratory services. [iii]  
 
A cross-sectional survey study examining critical care resources in the Solomon Islands found that inadequate resources from primary prevention and healthcare contribute to the high degree of critical illness. This study suggested that the solution lies in simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality.[iv]
 
Therefore, the emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment. This helps to prevent critical care from diverting resources away from other important parts of the health system. [v]
 
This makes perfect sense in these resource-poor contexts and certainly, the healthcare team in Tetere provide a stunning example of making it work with almost nothing at all.
 
Enabling partnerships
 
Empowerment is key to improving health service development in the Solomon Islands. The focus needs to be on strengthening the health system and improving access to services but bringing health care to these areas is no easy task.
 
It needs a partnership which filters right down to the community level. The Ministry of Health and Medical Services (MHMS) is really working hard towards enabling these partnerships to ensure a more planned approach to funding health services.
 
Australia is the largest provider of Official Development Assistance (ODA) to the Solomon Islands, providing almost two-thirds of overseas aid in 2016-17. We are the lead donor in the Solomon Islands health sector, with Australia’s main bilateral assistance provided through the Health Sector Support Program (HSSP) (equates to AUD 66m over four years to 2020). [vi]
 
Since 2008, the MHMS, with their development partners including Australia, has led a sector-wide approach (SWAp) to the delivery of health services in the Solomon Islands. The overall program goal for HSSP3 is to improve the access and quality of universal health care in the Solomon Islands. The current funding supports the Solomon Islands National Health Strategic Plan 2016-2020 and provides direct budget support, performance-linked funding and technical assistance.[vii]
 
What more can be done?
 
It is clear that Australia is doing its fair share for the Solomon Islands. There is now alignment in terms of ensuring best outcomes from this funding. This will certainly help build health services for this nation. But there is always more to do and GPs, in particular, can make a significant difference.
 
We need strategies to work through how best we can support our disadvantaged pacific neighbours from a community of GPs. Education partnerships being key and the RACGP already contributes in this way particularly in Papua New Guinea.
 
From my recent visit to the Solomon Islands, I have seen how the community there through their own resilience can achieve so much. Those working in Aboriginal Health would be familiar with what it takes to support patients in low-resource, laboratory-free settings. It would be great to share some of these learnings and provide more support for the Solomon Island communities.
 
[Ends]
 
[i] World Health Organisation. Article. Health closer to home: transforming care in the Solomon Islands. March 2017. Available at: http://www.who.int/features/2017/health-solomon-islands/en/
[ii]Westcott M, Martiniuk AL, Fowler RA, Adhikari NK, Dalipanda T. Critical care resources in the Solomon Islands: a cross-sectional survey. BMCInternationalHealthandHumanRights.Mar1,2012.doi:10.1186/1472-698X-12-1.Availableat: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307438/
[iii] ibid.
[iv] ibid.
[v]  ibid.
[vi] Commonwealth of Australia. Independent Performance Assessment. Solomon Islands – Health Sector Support Program. Specialist Health Service. May 29, 2017; revised 24 July 2017.
[vii] ibid.

Australia needs to place a levy on sugary drinks now
 
Dr Ayman Shenouda
 






​ 
A sugar fix anyone?
 
Sugar certainly got some attention this week prompted by some important, corresponding, new research undertaken here in Australia[i] and in France[ii].
 
The first focussed on risks associated with fizzy drinks, while the other a little broader and on ultra-processed foods, but both found similar findings in terms of increased cancer risk. In a third article featured this week, in Meds Obs opinion, Dr Jon Fogarty wrote that we cannot allow another 50-year con job. I couldn’t agree more.
 
Rapid increasing consumption of lower nutritional quality foods is clearly driving an increased disease burden. It is those ultra-processed foods that we need to look at which contain high salt, trans fats and saturated fats along with sugar.
 
Prevention focus
 
It was quite telling that the recent PC Report Shifting the Dial: 5-year Productivity Review, released in August last year fell short of recommending a sugar tax. This is despite a strong obesity emphasis in the report only called for a soft market control solution through voluntary reductions in sugar content (by major manufacturers of SSBs).
 
Many are comparing the current policy complacency in response to sugar, in particular, with the dangerously slow response to tobacco. And, I truly believe that if we were serious around prevention then we would be looking to a sugar tax here in Australia. If we are to shift health outcomes then we need to think less about a system which drives episodic care and more about those broader factors that influence health outcomes. I’ve said that before but it needs restating particularly on this issue.
 
Policy levers
 
Consumers clearly need more help to identify those foods with added sugar.
 
Some of this work has been done through the Federal Government’s Health Stars Rating scheme designed to help consumers make more informed choices. But manipulative marketing seems to be out-tricking the system by making unhealthy products look healthy.
 
Choice put forward some good recommendations in August to make this system better. Making sure foods high in sugar, fat or salt can’t get a high star rating being their number one!
 
A Navigation Paper of the 5-year review of the Health Star Rating System was released in January. It will be interesting to see what changes are made in response to the review.
 
Sugar levy
 
Placing a fiscal incentive through increasing the price of these foods would make for an effective solution. But, I really think a sugar tax is warranted here. And, if not a full sugar tax, then perhaps a health levy on sugary drinks is a good start.
 
The UK is leading the way with its plans to introduce a levy on sugar-sweetened beverages this year. Importantly, revenue will fund a prevention focus through expanded programs to reduce obesity and encourage physical activity and balanced diets for school children.[iii] Ireland is following with a levy coming into effect in April.
 
Closer to home, there seems very little appetite to introduce a similar levy in Australia despite calls from various leading health experts and many of the peak bodies.
 
Despite twenty-six countries placing a health levy on sugary drinks, we are not seeing similar leadership from our Government. Federal minister for agriculture and water resources, David Littleproud, said in January that governments “should not dictate the diet of citizens”, much to the delight of those industries that benefit from inaction.[iv]
 
Minister Littleproud heads a portfolio responsible for the investment in the development of Australia’s sugarcane industry. In my view, this is an issue that falls in the food safety category as excess refined sugar has undesirable health consequences. Therefore, despite where the legislation may sit, this is more an issue for the health minister.
 
There’s plenty of evidence
 
In terms of a need to take immediate action, we’re certainly not short on evidence here. And there’s now increased evidence to act on sugary soft drinks.
 
The French research I mentioned earlier looked at the risk between ultra-processed food and cancer. In this prospective study published in the BMJ, found a 10 per cent increase in the proportion of ultra-processed foods in the diet was associated with a significant increase of greater than 10 per cent in the risk of overall and breast cancer. ii
 
Proving that soft drinks elevated risk of cancer, the new research from the University of Melbourne and the Cancer Council Victoria released this week also found people who regularly drink sugary soft drinks were more at risk of cancer. i
 
Interestingly, this Victorian study showed that higher consumption of both sugar-sweetened and artificially sweetened soft drinks is associated with higher waist circumference. However, cancer risk was only higher among those who drink more sugar-sweetened soft drinks. This is an important finding as many opt for the alternative diet option or sugar substitute thinking it better, yet it also may be contributing to our obesity epidemic. i
 
Even more surprising, the key finding from this study that increased cancer risk is not driven completely by obesity. Those who are not overweight have an increased cancer risk if they regularly drink sugary soft drinks. i
 
We need action now
 
It is always those who can least afford it that suffer the most. Poor diet is more a result of poverty than a lack of understanding around the risks. The only food the poor can afford is making them unhealthy.
 
The key findings from these recent studies both in terms of ultra-processed foods and sugary soft drinks now link to increased cancer risk. This issue is a health priority and needs to be a key focus for the health ministry.
Let’s not sugar coat it – sugar and sugar sweetened drinks kill - we need action on this now.
 
[Ends]
 
[i] Hannink, N. Increased cancer risk from fizzy drinks – no matter what size you are. University of Melbourne. 22 February 2018. Available at: https://pursuit.unimelb.edu.au/articles/increased-cancer-risk-from-fizzy-drinks-no-matter-what-size-you-are
[ii] Fiolet, T., Srour, B., Sellem, L., Kesse-Guyot, E., Allès, B., Méjean, C., et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322. Available at: http://www.bmj.com/content/360/bmj.k322
[iii] Gov. UK. Department of Health and Social Care. Guidance: Childhood obesity. A plan for action. 20 January 2017. Available at: https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
[iv] Davey, M. Article. Health experts support sugar tax as coalition calls for personal responsibility. The Guardian. 8 January 2018. Available at:https://www.theguardian.com/australia-news/2018/jan/08/health-experts-support-sugar-tax-as-coalition-calls-for-personal-responsibility

Dr Ayman Shenouda 

Announcing the Collingrove Agreement following the rural and regional health forum in Canberra on Friday 9 February 2018 from L–R: ACRRM’s Dr Michael Beckoff, National Rural Health Commissioner Professor Paul Worley, Minister for Rural Health Bridget McKenzie, RACGP Rural Chair A/Prof Ayman Shenouda.
 
A milestone agreement
 
Those who have been part of this journey will understand the significance of the Collingrove Agreement. Although I think on this topic, even the most casual observer will be across the division that has chocked us for so long.
 
It’s been a long and often dusty road but we’re now steered in the right direction and towards developing a national rural generalist pathway together.
 
Finding that common ground was relatively easy in one sense.
 
You see, the one thing I’ve noticed having travelled extensively over the past four years as Chair of the RACGP rural faculty is that patience, passion and persistence is a common trait of rural GPs or any GP for that matter.
 
From Longreach to Carnavon or Katherine to Goolwa and everywhere in-between and regardless of which camp they belonged – ACRRM or RACGP - there lies a great determination and commitment for their patient and rural community. An unbreakable connection which binds us all in addressing rural health disadvantage and securing a healthier future for all.
 
Navigating slightly rougher terrain
 
But in finding that common ground between the two GP colleges - while the destination remained the same - the road itself was indeed rocky. So rocky in fact it required an all-terrain vehicle for all involved and sometimes perhaps a tank may have been a slightly better choice!
 
Still, despite years of division, I think it was that same spirit that made the Collingrove Agreement possible.
 
An easy headline it may have seemed to those filtering the news last Friday, but the “RACGP and ACRRM collaborating on national generalist pathway” was truly momentous. And certainly, for those around the table at Collingrove Homestead in the Barossa Valley, South Australia, collaboration soon became the only solution.
 
Sharing a picture for history’s sake of those present on those momentous couple of days 11-12 January 2018. 

Securing the milestone agreement from L-R: Dr Melanie Considine, RACGP Rural Deputy Chair, RACGP Rural Chair A/Prof Ayman Shenouda, ACRRM Censor in Chief A/Prof David Campbell, our National Rural Health Commissioner Professor Paul Worley, ACRRM President A/Prof Ruth Steward and Dr Rose Ellis from the Rural Doctors Network.
 
A common goal
 
While the agreement itself is only four paragraphs long - the common ground here was significant. We had 7 million reasons to get this right.
 
It is about equity of access in meeting the health care needs of rural and remote Australians through a responsive needs-based solution.
 
Together we were determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of these communities.
 
More than a definition
 
This is, of course, more than a about a definition but it was always a sticking point.
 
On one hand there were those focussed on the name or a tendency to favour a definition over others. On the other, we knew that developing skills around the ongoing care considerations are the areas that best serve the community.
 
And there’s the commonality – supporting doctors to acquire the skills to meet the needs of their communities. A dedicated and clear pathway for rural GPs to acquire those skills and utilise them in a way that is valued and recognised are important workforce factors.
 
This was the cohesion that brought the clarity to the definition.
 
So here is it -
 
“A Rural Generalist (RG) is a medical practitioner who is trained to meet the specific current and future health care needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care, and required components of other medical specialist care in hospital and community settings as part of a rural healthcare team.”
 
Pathway design
 
Beyond the definition, it is the careful design of the pathway itself that will make the most difference. It needs to be a lot of things but at its core it is about ensuring the right skill mix against demand with supportive elements offering flexibility and choice.
 
Key features which include a clear pathway for young doctors with flexibility that allows entry and exit at different stages. Ensuring adequate funding for the pathway itself alongside essential factors in establishing a critical mass of trainees but with enough flexibility for it to work within the varying jurisdictions.
 
It should also allow lateral entry for practising GPs and other rural doctors who want to acquire new skills to address the shifting need in these communities. Ever changing needs like mental health and palliative care and in dealing with the extra problems which depend on the health needs and context of the community.
 
The full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts. Or quite simply, training young doctors with the right skill set that makes them feel safe and supported to do their job which is addressing rural and remote community needs.
 
There’s usually some bleeding before healing
 
Despite years of focus, the disparity of health service delivery in rural and remote Australia remains a key policy failure. Much has been left to our overseas trained doctors who have been the backbone in delivering this care over this time. The lack of a solid training or workforce solution meant that the rural health system depended on individual efforts with very mixed results.
 
Sometimes I feel the split between the colleges had to happen for us to be able to reach this agreement. The Collingrove Agreement is the culmination of 20 years of hard work by both Colleges in building capacity to deliver a needs-based solution for rural health.
 
We’ve seen more collaboration over the past year than in the preceding 20 - through Bi-College Accreditation to this historic Collingrove Agreement. So, let’s keep it up!
 
A Rural Generalist Pathway Taskforce is being formed in the coming months to work through the pathway design. There may still be a long road beyond Collingrove Homestead but I think this time it will be the recently resurfaced type! 
​
Ayman Shenouda 

 A significant step in securing a stable rural medical workforce
 
Dr Ayman Shenouda
 
 
A rural renaissance
 
It is great to see the Federal Government delivering on its commitment to increase the number of rural-based doctors in training.What we are experiencing right now in rural health can only be described as a rural renaissance. We have great leadership in our Rural Health Commissioner and now in our new Rural Health Minister making her mark and building on the great work of her predecessor.
 
More intern placements in general practice is great news for rural doctors and their communities. This is an essential step in securing the next generation of rural GPs by ensuring our trainees receive broad exposure through prioritising primary care and general practice.  These programs really work as they provide trainees with that essential insight to community medicine.
 
Intern rotations in general practice
 
The Rural Junior Doctor Training Innovation Fund (RJDTIF) program provides primary care rotations for rurally based first-year interns. It builds on existing state and territory arrangements to provide primary care rotations in addition to hospital rotations.
.
Last week, Rural Health Minister, Senator the Hon Bridget McKenzie, announced a $1,304,967 Federal Government grant for the Murrumbidgee Local Health District to increase intern rotations throughout the region. I’m proud to be contributing with my practice in Wagga selected to participate and we will be rotating five interns a year through this program.
 
It was great to show Minister McKenzie around my practice and have a chance to discuss how to provide that valuable community exposure early. The Minister showed a deep understanding of what is required in placing policy priority on general practice. She shared my vision that every junior doctor should have a rotation in general practice as part of the first two to three years of training.
 
Quality training experience
 
In our practice, we have GP specialists, new fellows, GP registrars, interns and medical students working alongside nurses and allied health professionals. We aim to support the integration of vertical and horizontal teaching enhanced through a multidisciplinary team environment.
 
A strong teaching culture and established education networks also ensure we have the hospital and community partnerships to enhance exposure and demonstrate for our trainees the diversity of general practice. We’ve worked hard to build the required supportive infrastructure and systems to make this work which needless to say is also reliant on a solid business model.
 
Keeping them there
 
Targeted exposure strategies like these ensure trainees can develop the broad range of skills required. It provides essential rural exposure for interns to learn the complexities of delivering services in rural areas while in a supportive general practice setting.
 
My own experience with the PGPPP where I had 12 interns rotated in my practice really yielded results. From that cohort, about 70 per cent of them have chosen general practice as their training speciality. They loved the diversity and complexity general practice offered. It challenged them, kept them engaged and provided that important insight into the doctor-patient relationship.
 
A little on the policy journey
 
Addressing maldistribution has been dominant in the discussion at many Rural Health Stakeholder Roundtables in Canberra over recent years.
 
Certainly, greater exposure to general practice for junior doctors has been central to RACGP Rural advocacy around securing an integrated rural training pathway. Particularly in ensuring more emphasis on primary care and generalism early in medical education.
 
But really making generalism a foundation of junior medical training – a discussion made more difficult on the back of a defunded PGPPP. This was a significant policy obstacle when you consider that what we were pursuing was more of a supercharged PGPPP but specifically for rural areas.
 
We needed a solution that would boost the number of GPs as well as address the gap in the rural pathway by providing intern rotations in general practice and primary care. We knew there was a strong learner preference for rurally based internships. We also knew that potentially we had lost a cohort of potential rural GPs as the gap from the PGPPP hit hard and narrowed our opportunities.
 
A win for general practice
 
It certainly was a long policy process getting here. This is the why this program, which was the result of a long period of sustained advocacy, is such a significant win for general practice. It is clear much of the hard work over many years is starting to pay off particularly in rural health. This is a significant step forward in securing a stable medical workforce to address maldistribution. 

​Health Advocacy in 2018
 
Dr Ayman Shenouda
 
 
Where are we now?
 
I’m not the first to say that the 24-hour media cycle has taken a toll on our democracy. Some even say it killed journalism. I think the true damage lies in a loss of thoroughness and depth of thought. More specifically, the effects of the demise of principled advocacy and what it now takes to shape and change policy.
 
Twitter now seems to set the policy agenda. But we’ve been in this chaotic and unpredictable world for some time now and we’re never going back to the pre-digital era of journalism. In mobilising support, is there the time and patience left to build a policy dialogue? Without it, we are just left with a policy vacuum and random tweets that lead us nowhere.
 
Inclusive policy
 
Considered policy development takes time. Good public policy relies on effective community involvement and consultation.
 
Good implementation is also important. The process of implementation seems to be skipped entirely from the process these days, which makes the type of incremental change required in healthcare almost impossible.
 
There seems neither the time nor the inclination for the inclusive process required for good policymaking. Even when good policy process does occur, it can all fall over in an instant as was the case recently for constitution recognition which went down without the noise it deserved.
 
The doctor as advocate would be familiar with similar policy disappointment. It’s been a long road to reform and there has been plenty of blocks along the way. It’s clear that it is harder to get attention in such a cluttered space.
 
Healthcare advocacy
 
What does it take to shape and change policy in our own policy space?
 
We advocate at different levels from individual patient advocacy through to more public advocacy or policy leadership roles on the national and sometimes international level.
 
In a world ruled by Twitter, there’s not a lot of time for considered well design policy solutions. The type you need to communicate the evidence base or get the required policy reasoning across. But we still need to build that policy dialogue. This is why it is so important for us – as a community of healthcare professionals – to get it right.
 
By getting it right I mean following good policy process. But how can we avoid the pitfalls of advocacy? Media can certainly help to set the agenda but I think a focus on inclusion is the best place to start.
 
Right place, right time
 
Magic happens when the right people are at the right place at the right time.
 
When things are politically aligned and people at the table are smart and genuine in their intent -  the moment when they recognise what leadership is all about - then Magic follows.
 
When there is no personal or financial gain, leaders start to have a sense of what can be gained through collective advocacy for the benefit of their community. When the vision is clear and simple to understand by all involved implementation becomes a lot easier.
 
Integrity always shines through
 
Some people believe that politics is about being smart enough to make a lie look convincing. Sometimes this falls somewhere between a lie and a falsehood or the new “alternative facts” and post-truth era we now find ourselves in.
 
Some politicians think they know better. They might even get away with some temporary gain but believe me, the power of truth has a longer and more effective success. People can smell dishonesty no matter how enticing a master deceiver may be. It is integrity that always shines through the brightest here.
 
Making collective impact work
 
When there is a genuine and clear goal that addresses the common agenda, people get together to make what look like impossible change feel like a walk in the park. This requires a collaborative approach to creating change to facilitate mutual support and collective impact.
 
When you win the hearts and souls of people, what seemed impossible becomes not only possible but a lot easier to achieve. When everyone in the room feels safe and heard by others, suddenly they will be able to see and value others contributions.
 
In my opinion, you should leave your personal views and judgment of others outside the room. After all, we need to be clear about one thing - it is not about you, it is about others and the trust they’ve placed in you to present their opinion. Some may not agree with me but at the end of the day, everyone is entitled to have their own views.
 
Let’s hope health advocacy in 2018 is a place of inclusive reform. That we work together towards collective impact and a common agenda that will see sector-wide improvements. 

​National Rural Health Commissioner: Putting the rural health agenda back on track
 
Dr Ayman Shenouda
 
A rural champion
 
A visit this week to Wagga from our National Rural Health Commissioner Professor Paul Worley provided a great chance to work through some of our highest rural health priorities.
 
This new champion for rural patients is exactly what we needed.
 
He fits the job description well – independent, impartial and “a fearless champion” for rural health. He also has alongside him a strong rural health sector full of ideas for building a strong Australian rural health system.
 
Getting the agenda back on track
 
Rural patients are finally getting the focus they deserve and this is our chance to get the rural health agenda back on track.
 
I think we finally have the policy settings in place for this to occur. But it all has to be orchestrated in a way that sees very specific locational needs acknowledged and addressed.
 
This is where the new rural commissioner role comes in. We all have a key role here. There’s still a great deal of work which now needs to occur to ensure every instrument in this vital ensemble can be fully utilised.
 
It is those featured instruments – whether string, woodwind, brass or percussion – each with its own unique qualities that really need to shine. These are the ones that fill in a critical gap and vital if we are going to provide a performance worthy of rural Australians.
 
National Rural Generalist Pathway
 
The first task is the National Rural Generalist Pathway.
 
If we are to get this policy right we will need a broad policy lens with a commitment to needs-based planning encompassing all disciplines.
 
We know that a sustainable health workforce solution for rural Australia needs to factor in flexibility in policy design. By this, I mean allowing for an optimal skill mix which is capable of meeting the very specific service needs of that community.
 
Local needs analysis
 
It is clear that we need reforms that can address maldistribution to meet growing service demand. But to do this we need to look at what is really happening in these communities.
 
Skills planning through a rural generalist pathway solution must, therefore, encompass a much broader skill mapping exercise. This needs to be steered toward more integrated care and with a focus on the full multidisciplinary skill mix required to keep those services going.
 
We need to find ways to capture current skill depth so that this can be prioritised better in policy. Reinforcing the importance of primary care and coordination of care so that the policies can follow. But really plotting that essential skill mix required to support rural models of care.
 
Future supply and demand (against need)
 
It is about having that critical mass of health professionals to achieve a sustainable service environment.
 
This not only lifts constraints enabling more equitable access to services but creates a way to mobilise and build on peer support. In turn, reducing burn-out by formalising mechanisms for peer support-support networks. It provides safer working hours and leaves room for internal backfill for relief, as well as professional development or space to take on a supervising role.
 
There’s been plenty of workforce planning occurring – PHNs, LHNs, and RHWAs – but we lack that common formula.
 
No-one can see at a national level where the true hotspots are. We need to establish what constitutes a minimum workforce requirement or mix for a particular population size and then apply that across the country.
 
Matching and forecasting the needs is complex but we have evidence-based approaches to estimating health workforce demand. HWA did years of work around it. I think we must clarify this area of workforce policy as a first key step.
 
Once we have this formula then we’ll see a situation where training investment meets demand.
 
There is just not enough aligning in terms of training pathways with workforce planning. This is vital as you can’t have a situation where you have three GP anaesthetists and no GP-obstetrician.
 
This level of planning would also help in terms of succession planning and reassure those committing to these pathways that there is or will be a position for them. It provides a planned career pathway for them.
 
Broad skill depth
 
Broad skill depth is vital to addressing patient need in rural communities. We need to find a way to embed in workforce policy those skills most relied on in meeting this need.
 
I think the discussion is also broader than the training pathway itself. We have to have an equal focus on the requirements of the existing workforce in meeting shifting community need.
 
Training solutions need to enable private community-based practice. We really need to ensure we encompass a range of approaches factoring both procedural and non-procedural skills if we are going to align closely to need.
 
If we support the full skillset required then we are closer to reflecting within the training the full scope of skills practised in rural general practice to meet community needs. This is how we can ensure we produce the next generation of doctors with the skills needed to provide both primary and secondary care.
 
Training Hubs
 
Past policies have had an impact on both recruitment and retention. It all comes back to securing that critical mass (of students). Early exposure which can establish that community connection early which can continue through to intern, prevocational and vocational training years.
 
We’ve always said that we need to invest in more localised training solutions to provide for that community connection and rebuild a teaching culture. The hubs are well positioned to facilitate that vital community connection and link the various stages of training in a rural setting across the full training continuum.
 
The training hubs provide that essential framework now but it is about facilitating those vital partnerships. This is how we can structure training against local healthcare need and service construct and build in those supportive factors so early exposure can be a positive experience.
 
Nurture rural intention
 
We need to nurture rural intention through targeted incentives and sufficient rural exposure strategies.
 
A strong commitment to rural should come with benefits. Capture those wanting to pursue rural through a nurtured pathway and supports which include an investment in mentoring. Truly support RMOs skills and career path aspirations and reinvesting in these years by getting back the PGPPP in its true form.
 
Newly developed policy offering primary care rotations through the new rural community-based interns is certainly acknowledged but it is a minimised model which really needs to be expanded.
 
Vertical continuity over time
 
Focusing more effort on areas that provide both a training benefit and meet a community health need is a way to secure an enduring rural benefit. Realising that a focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies.
 
Building this capacity through vertical integration of teaching and learning which promotes shared responsibilities. It’s that continuity that is needed most – vertical continuity over time to allow for varied exposure which results in the more resilient doctor.
 
Flexibility is needed to ensure training reflects the local service context with an equal focus on community-based training. It helps develop that understanding of optimal care pathways providing continuity of care and a collaborative integrated care approach.
 
Team and teaching culture
 
Developing a strong team culture early has to also be a key focus. Those working in rural Australia know that it takes a dedicated team and an enduring local commitment to tackling the many challenges in delivering regional, rural and remote healthcare.
 
We need to ensure more exposure to multidisciplinary team environments as well as enabling hospital and community partnerships through supportive policy. This is where the pathway solution has to extend beyond a focus solely on medicine.
 
Improved support for supervisors has never had the policy focus it deserves. We need to increase the teaching capacity of rural communities while minimising the impact of burnout. Practice viability is a major consideration here.
 
All these factors need to be considered in terms of ensuring a rural GP can take on a training or teaching role. Succession planning and providing that easy entry, gracious exit is key and would lift the load for many already overcommitted.
 
A more sustainable future
 
In designing rural policies which can provide a more sustainable future, the focus clearly has to come back to addressing health disparities between rural and urban Australians. A resilient multi-skilled generalist workforce capable of meeting current patient need now and into the future is all part of meeting that key requirement.
 
We really need to capitalise on the policy settings we already have in place. The strong planning role of the PHNs and LHNs in identifying local level need. The facilitation role of the new training hubs in ensuring a more positive rural training experience. Existing strong College pathways and well-developed rural skills training program with inter-professional partnerships to build from.
 
We now have that vital role in the National Rural Health Commissioner to ensure a more coordinated national policy and planning effort can occur. We’re well on our way in putting the rural health agenda back on track ensuring lasting change for rural Australians.
 
[ends]
 
 
Source: RACGP 2014. New approaches to integrated rural training for medical practitioners. Final Report. Available at: https://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 

A digital health future: The risks and opportunities
 
Dr Ayman Shenouda
 
An uncertain future
 
Technology will never replace doctors. That part is clear (or to me at least).
 
But there’s still a lot of uncertainty ahead and we’re all being told to prepare for significant changes. We’re now seeing daily discussions around the Fourth Industrial Revolution and that it will see unprecedented workforce change.
 
Despite threats of robot doctors, online lawyers and automated architects, it will be those distinctly human capabilities that will prevail. It is our heart that distinguishes here and no amount of automation can replace it.[1]
 
At the same time, we will need to be ready for it. Because, if, as predicted, technology sees radically different healthcare systems emerge we need to be ready to embrace this change. Leadership will be required in shaping and refining quality standards to ensure continued best care for our patients.
 
Change is already here
 
There are already some significant advances taking place providing a glimpse of what is to come. Much of what we are seeing now is user-driven as technology uptake in the community increases such as through iPhone health monitoring apps.
 
There is certain strength in technology in empowering patients to take responsibility for their own health. Many aim to support self-management outcomes through patient empowerment, but it is clear that a lack of evidence-base undermines quality and safety in some.
 
There is discussion around how certain free medical apps are placing patients at risk through false or misleading claims. From instant blood pressure apps giving falsely normal values to apps that claim to measure blood pressure, oxygenation, and more – all without any peripherals.[2]
 
Health apps present significant challenges to regulatory authorities. And I’m sure it’s not easy for developers to navigate the regulatory pathways either.
 
In Australia, we have TGA guidelines for what software constitutes a medical device. But how much monitoring is being undertaken to identify non-compliance, particularly around claims on these apps, is unclear.
 
The next phase of change
 
It’s clear a soulless search engine or app device is a long way from replacing a GP.
 
But what about the next phase of change? Deep learning breakthroughs of machine learning and artificial intelligence and precision medicine are likely to influence the way we provide care.

Big data analytics involve descriptive analytics, predictive analytics, and prescriptive analytics. It is the latter, in prescriptive analytics, which leverages descriptive reports and predictive data to identify actions that would produce maximum value to help us develop and adhere to optimal clinical pathways.[3]

Clinical decision support (CDS) on the other hand is set to enhance health and healthcare teams. It will provide both healthcare teams and individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow.[4]
 
GP leadership
If the future of medicine is based on data and analytics in guiding decision making, then most critical to success will be that the GP remains in control of the clinical decision-making.

To safeguard patients, address questions of liability, and foster trust we need transparency in terms of how clinical decision support tools derive their results.[5] Developers and vendors of clinical decision support tools must be transparent about their methodologies, capabilities, data sources, and limitations.[6]

CDS in developing treatment plans will require leadership from the profession in terms of how we can integrate these systems successfully into our practices. In testing the efficacy of these emerging technology in improving the care and treatment of patients there will be a need for strong consistent discipline specific input.

For Australian general practice, there is a role for our College in joining multidisciplinary technology assessment committees. Currently, the RACGP Expert Committee – eHealth and Practice Systems lead much of this work.
​
The RACGP Technology Survey released earlier this month will help to gain more insight into the current trends in technology adoption in general practice.[7] It will be interesting to see these results (which closed 3 December) particularly the views of technology use to improve collection of patient data and for clinical decision making.
 
Benefits in service improvements
Emergent technologies which present new opportunities for healthcare service provision provide great promise. These are technologies that interface with patients in maintaining health, receiving care, and managing a condition.
 
These new types of technologies – wearables, ingestibles, and embeddables – will be transformative.
 
Management in the home for the elderly and frail will benefit significantly from new technical innovations. Just by adding in a number of sensors to the body to monitor we will support older Australian’s independence as well as take some pressures off the service system while keeping them safe.
 
Reliance on these systems would need to be balanced or potentially worsen social isolation and loneliness which are already significant health risks for the elderly. The value of human contact and continued doctor-patient and nurse-patient relationships are vital here.
 
Wearable technology
 
The next phase of wearable technologies will see patients constantly monitored remotely through wearable skins sensors or smartphone apps with data uploaded directly to their health record.[8] These technologies aim to support the management of chronic diseases, such as diabetes and heart disease.
 
The advent of the digital health coach (Next IT) to remind patients to take medications, schedule doctor appointments represent a new type of technology to support medication adherence.
 
The UK is leading the wearable technology space with pilots underway which will see patients’ issues with state of the art wearable technology.
 
These initiatives are designed to take pressure off the system but also to monitor conditions more effectively for a diverse patient cohort. Some pilots will enable independence for the aged through home monitoring systems with others supporting mental health patients stay in touch with support networks.[9]
 
It is predicted that, as part of a widespread digital revolution of healthcare in Britain, within 5 years patients across the country will go online to speak to their GP via video link, order prescriptions or see their entire health record.[10]
 
Digital divide
 
For implementation in Australia, a final note on the digital divide is warranted. Equity remains an issue despite the promises of high patient engagement through new technologies.
 
So much of the discussion around technology as an access enabler really misses this point. What about those millions of Australian households living without an internet connection?
 
Telehealth implementation has been patchy in rural Australia due to the lack of fast and reliable internet, despite the (slow) rollout of NBN. Assuming we all get access by the time these technologies are fully realised, not all Australians can afford access to the internet or the digital resources required to drive new innovations.
 
For equitable access, we would need to see policies that can provide unmetered online access for the disadvantaged. A commitment to extend the Health Care Card to address the digital divide should be in the planning if we are to strive for equitable access outcomes.
 
Leading the discussion
 
Healthcare’s technology revolution is likely to see significant change. Doctors have been described as late adopters of technology in the past. It will be important to be ready and even more important to be part of the discussion. That is, the one that is occurring now!
 
Finding new ways to connect patients to our practice is positive and possible right now. Future broader technology enabled supports to integrate services and strengthen monitoring of patients can see a positive new change which can only enrich patient care. We’re on the cusp of enormous change and our combined leadership is required in balancing risk with opportunity. Let’s all take up the challenge.
 End 

[1] PwC. 20th CEO Survey. The talent challenge: Harnessing the power of human skills in the machine age. PwC. 2017. Available at: https://www.pwc.com/gx/en/ceo-survey/2017/deep-dives/ceo-survey-global-talent.pdf
[2] Misra, S. IMedicalApps Feature. Another top free medical app that puts patients at risk with claims to measure blood pressure, oxygenation, and more. 26 October 2016. Available at: https://www.imedicalapps.com/2016/10/icare-health-monitor-health-app-patient-risk/
[3] Bresnick J. HealthIT Analytics Feature. The Difference Between Clinical Decision Support, Big Data Analytics. 31 August 2017. Available at: https://healthitanalytics.com/news/the-difference-between-clinical-decision-support-big-data-analytics
[4] Ibid.
[5]  Bresnick J. HealthIT Analytics Feature. Transparency is key for clinical decision support, machine learning tools. 6 September 2017. https://healthitanalytics.com/news/transparency-is-key-for-clinical-decision-support-machine-learning-vendors
[6] Ibid.
[7] RACGP. Webpage. RACGP Technology Survey 2017. Available at: https://www.racgp.org.au/your-practice/ehealth/additional-resources/racgp-technology-survey/
[8] Skokowski P. Wearable Tech Feature. Wear your health on your sleeve: The next phase of wearable technology. 25 September 2015. Available at: http://www.wearabletechnology-news.com/news/2015/sep/25/wear-your-health-your-sleeve-next-phase-wearable-technology/
[9] Knapton S. The Telegraph. NHS remote monitoring will allow dementia patients to stay at home. 22 January 2016. Available at: http://www.telegraph.co.uk/news/health/elder/12113536/NHS-remote-monitoring-will-allow-dementia-patients-to-stay-at-home.html
[10] Rigby M. Digital Health London. Spotlight: Innovation and Integration – The Future of General Practice. Available at: https://digitalhealth.london/spotlight-innovation-integration-future-general-practice/
 

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Dr Ayman Shenouda
 
Shaping Australia: one GP at a time
 
For those who attended GP17 in October, I’m sure you will agree that it was delivered to its usual high standard and there was plenty of diversity in terms of viewpoints. Some perspectives were what could only be described as poles apart. Dr Jay Parkinson and Sir Harry Burns for example.
 
Dr Parkinson with his discussion around consulting in the cloud through to Sir Harry’s on tackling poverty. There have been some blogs and articles around the technology discussion including recent Opinion in the Medical Observer.
 
It was Sir Harry’s discussion that moved me the most as he provided some important insights into poverty and particularly around social chaos and its flow-on effects in eroding wellness. In some ways, this discussion gave me renewed hope. That as a community we can together tackle disadvantage particularly in ensuring our children get the best start in life.
 
Not enough wellness
 
Sir Harry Burns from Strathclyde University and former Chief Medical Officer for Scotland provided the research keynote address. This was a spirited defence of poverty which really got to the heart of the issue.
 
The issue, of course, being disparities in terms of health outcomes and ways to counter these. It’s about how societies can create wellness and also how they can destroy it. In explaining this, he brings the consequences of poverty and inequity into sharp focus.
 
His own country’s poor health, he says, is a reflection only of the health of the poor. Studies he’d undertaken led him to believe that the problem was in fact not enough wellness (and not too much illness). Social conditions as fundamental causes of health could be seen through countless studies he shared.
 
We’ve all seen this of course in our own communities. I know in Wagga like most regional towns there are some deeply entrenched social disparities. But in addressing these, our national policy I think is structured in a way to deal with consequences, not poverty prevention and reduction. And without significant change, these patterns will only continue.
 
The science behind wellness
 
Sir Harry’s work has sought to unravel the science behind wellness. And I think some of the key learnings from his research can really transform our policies here in Australia today.
 
It was the work of a colleague, Professor Alastair Leyland, which examined his own community of Glasgow against the slope index of inequality, which began his own inquiry around what causes health inequalities.
 
Some very specific insights were shown in terms of what happened in society to slow down growth and life expectancy in the poor. The peak in mortality shown in these studies was in the young – teenage and young working age people – and from very specific causes – drugs, alcohol, suicide, and violence.
 
Inequality mortality was not a feature of the elderly. These were not people dying from heart disease or cancer but there was something else going on in the population. These outcomes were pyschosoically determined - society determined causes of premature death - and they needed to work out what the key drivers were.
 
It was social chaos that intervened which came with the housing disruption more than five decades ago. Traditional communities were broken as a consequence alongside loss of employment, opportunity, and hope. This was what eroded wellness and it is clear the same social disruption occurred here and we are also dealing with these same issues.
 
Causes of wellness
 
Looking more to those causes of wellness. Salutogenesis and the work of an American Sociology Dr Anton Antonovsky around a Sense of Coherence which relies on a life which is structured, predictable, explainable. Having resilience or the internal resources and will to deal with challenges.
 
In quoting Antonovsky he said: “Unless you can see the world as comprehensible, manageable and meaningful you will experience a state of chronic stress.”  This provided what he was looking for. It showed the link between social circumstances and ill health.
 
Poverty and elevated stress
 
The research presented really showed the relationship between poverty and elevated stress and how that leads to chronic disease and ill health. Those with a difficult start are less equipped to adapt to change which often manifests in poor behaviours.
 
Studies by Bruce McEwen of Rockefeller University has made those links as well as Sir Harry’s own associated work undertaken in Glasgow. Early-life stress and the long-lasting behavioural, mental and physical consequences. For those wanting to learn the full science behind this here is his presentation and this discussion is about 20 minutes in.
 
And there’s something in a cuddle.
 
The molecular biology of a cuddle was shown. Comforting and its effect on suppressing the stress response. The biochemical toll of early neglect. Stress in infancy and the fact that neglected babies don’t get enough 5-HT.
 
The work of Michael Meaney’s and the difference in brain development for those children who experience adversity in early life was shown. Other studies were shown which have looked at different types of adverse childhood events – neglect, abuse, domestic violence, alcoholic parent – which is then linked to outcome. It showed children exposed to adverse events in early life had a higher risk of alcoholism, depression or drug abuse.
 
Breaking the cycle
 
Social turbulence was the description used. More specifically, he described a cycle that alienates people and impairs their ability to control their wellbeing. And that it starts with chaotic early years.
 
The policy learnings for us include around Scotland’s approach to improving wellness. That is to focus on breaking that cycle by doing things in early life.
 
Policy solutions
 
There are some key learnings in the policy approach itself. It was those at the front-line who developed the policy solutions in Scotland in response to these issues. They asked front-line staff for solutions, then took their ideas and tested them and shared them across the country.
 
The secret, he says, is in marginal gains. Go out there try lots of things see what works and then do it all consistency.  I think there’s a lesson in that for our own policy development.
 
It is through those small gains which from a range of interventions that add up to produce significant overall improvements. In early years, it was simple things like attachment is improved if kids are read bedtime stories. The solution lies in enabling that to occur.
 
Policy approach
 
The shift in policy approach is really about enabling policy change. That is change as opposed to full reform. It is in enabling those incremental shifts to existing structures, or the adoption of new and innovative approaches that can facilitate that change.
 
The risk in full reform is that it stifles innovation which can limit participation and if it’s not realised quickly then all is lost including those approaches that proved to work. Politicians turn to the next new thing which may not be as effective.
 
In Scotland, they’ve had 1500 small tests of change carried out in child health with 60 or 70 of them now implemented. Similar community strengthening type approaches which can facilitate incremental gains are what we need here to shift disparities.
 
Conclusion
 
The key message from the discussion is that it is those experiences in early life which can set off a life course of adversity. Those clear links in social circumstances and the beginnings of chronic ill health.
 
We need much more focus here in Australia on what causes wellness. It’s not that we haven’t had a focus here on concepts which include community resilience. Those social capital discussions were full of it in the early 2000s.
 
There seems less focus now and perhaps its due to governments not realising fully how investments now pay health dividends later on. There also may not be that political will to invest in wellness knowing the results will not be seen in the space of an electoral term.