29 September 2017
Dr Ayman Shenouda
Cybersecurity in healthcare
The recent darknet Medicare breach came only a few months after the UK malware attack on the NHS locking its systems. You would expect the focus of authorities on potential threats to be high given the fallout from that. But we’re told the Government only became aware of the darknet issue from the media. And, that it had been there a while too: the data had been for sale on the darknet auction site for nearly nine months. So, while 75 Australians’ had their Medicare details sold, it appears neither the Department nor our security services were actively monitoring this posting.
We clearly need to get better at this. The Government had already demonstrated through the botched handling of the 2016 Census how unready it really was when it comes to predicting even the most predictable of attacks. The ABS website was crashed by a series of DDoS attacks which shut the census website down for nearly two days. Unfortunately, successive security and data breaches from government agencies like these only serve to undermine public trust.
Risks and benefits
Digitalisation of healthcare is a positive innovation but it comes with certain risks. It is a simple fact that the value of healthcare data makes our system more vulnerable to privacy breaches. You could say that publishing data of any kind potentially holds great risk to privacy. But certainly, the benefits in terms of service planning and health research outweigh those risks. It all comes down to how risks are managed so not to stifle policy or undermine public trust.
If we want to achieve a more integrated healthcare system then the only way forward is through enabling policies. The integration solution lies in policies such as those being pursued through the My Health Record.
We know the risk on our healthcare system and organisations through data theft attacks are becoming more common. As in health, prevention is always better than a cure and on this issue, the approach is the same. The focus here not only needs to be on how governments’ handle our personal information but how providers can be better supported to ensure organisational readiness.
My Health Record
There are a number of policy implications in terms of increased health information technology-based reforms. As the complexity of health services increase, the number of entities involved will increase and with that comes more risk around potential privacy breaches. We’re on the cusp of implementing long-awaited reform through the rollout of opt-out participation of the My Health Record system. It’s important to ask if this latest breach has shifted patients’ perceptions or altered their digital trust in moving forward on this policy.
We know that a Medicare card number alone is not enough to access a patient’s My Health Record. The official website reassures us that My Health Record is a secure online summary of a patient’s health information. That it is up to you what goes into it, and who is allowed to access it. While that last statement may be true, how well can this containment really be controlled?
Meanwhile, it seems take up in the pre-implementation phase of the opt-out My Health Record seems quite promising. The official stats show that almost 21 percent of Australians have already registered. The web page boasts that over 5 million people already have a My Health Record, with an average of 1 new record being created every 38 seconds. As with any good policy news, you can even follow progress with a helpful link provided: Keep up-to-date with the latest statistics on the My Health Record here.
Digital trust and implications for My Health Record
The Senate Finance and Public Administration References Committee Inquiry in August following the dark web breach has brought some new perspectives to the issue of digital trust. The 13 submissions provide some valuable insights, some of these I’ve summarised below.
The first cab off the rank, the Centre for Internet Safety, certainly didn’t hold back on the implementation of My Health Record. Stating that the shift to an opt-out system ‘has done little to quell public anxiety surrounding the placement of sensitive health details into the online world’. Critical also of the Government’s communication strategy which it says has not managed to convince on matters of security. This, combined with the constant reporting of breaches is all contributing to diminished trust, safety and confidence.
Their submission also states that the promotion of privacy issues and the importance of the protection of personal information is critical to the ongoing functioning of the online environment. To secure buy-in, it is important to create ‘benefit profiles’ alongside these new technology projects to truly test measures of ‘consumer trust, safety and confidence in the intended service delivery’. In terms of My Health Records, they warn uptake will be very slow unless the Department can adequately address the trust, safety and confidence benefits and competently communicate these to the public.
The Australian Information Commissioner’s input provided some useful guidance stating that ‘the use of personal information should be necessary, proportionate and reasonable to achieve the policy goals’. The Privacy Impact Assessment (PIA) is a policy tool designed to assist agencies to consider these matters measuring possible impacts on the privacy of individuals. The Commissioner stated that, in the case of the Medicare breach, a PIA would have highlighted privacy impacts associated with assessing Medicare care numbers through an online portal environment. Importantly, it would have identified any further proactive measures required to mitigate those impacts.
Both the RACGP and the AMA do not believe this latest breach will have any implications for the My Health Record roll-out. The University of Western Australia, while outlining the value of Medicare identification information to a criminal – identity fraud, prescriptions to obtain painkillers and possibly S8 medications as well as to divert Medicare rebate payments from a legitimate account to a false one - also state motivations to access to My Health Records or medical records of any kind as being less likely.
Importantly, the RACGP highlighted that even with preventative measures in place, real risks persist for any organisation in terms of internal or external data breaches in an interconnected world. There are College resources to support GPs to minimise risks including the RACGP Computer information security standards (CISS). It states that those practices implementing the cybersecurity and privacy guidance provided here are less vulnerable to a data breach.
Both the Department of Health and the System Operator of the My Health Record System, the Australian Digital Health Agency, state that is important to note that illegally obtained Medicare card numbers are not sufficient on their own to provide access to clinical records or an individual’s My Health Record.
The System Operator appropriately provides a detailed response to the impact on the rollout from the Medicare information breach. Reassuringly, it states that security and operation of the system protect against the unauthorised disclosure of health information from the My Health Records for individuals with access to Medicare numbers. Additional information is required to authenticate consumers and healthcare providers. But, despite these reassurances, it is clear in other submissions including those from the University of Melbourne, Deakin University and the University of Newcastle that concerns remain with the My Health Record system and its pending rollout. Future Wise give an excellent technical response to the issue as well as policy solutions in moving forward.
The policy lessons
It is important to see the risks in terms of potential implications to the rollout of the opt-out My Health Record system tested through this consultation. It will be interesting to see what recommendations are made in the Senate Finance and Public Administration References Committee Inquiry in its report due in October. Overall, I think more work needs to be done here with much more focus required on strategies to protect patient data in rebuilding trust.
From these consultations, mechanisms for overseeing and monitoring access seem lacking, so are the required assurances around data storage and controls and the system-wide capacity to provide the security controls to mitigate risks remain unconvincing. The collective wisdom provided in these submissions will help guide policy to safeguard from further threats in the future. As stated earlier, the success of important reforms including My Health Record comes down to how risks are managed so not to stifle policy or undermine public trust.
 Yaraghi N. Hackers, phishers, and disappearing thumb drives: Lessons learned from major health care data breaches. Centre for Technology Innovation at Brookings. May 2016. Available from: http://wikiurls.com/?https://www.brookings.edu/research/hackers-phishers-and-disappearing-thumb-drives-lessons-learned-from-major-health-care-data-breaches/
22 September 2017
Dr Ayman Shenouda
Influence or overload
We spend a lot of time trying to influence policy makers around what’s best for our patients. Advice which is always well-intentioned and usually offering the right policy fix, GPs work hard to influence and bring about positive sector change. We are passionate advocates for the patients and families we care for. Too often we see for ourselves the impact poor policy has on people’s lives. The solutions mostly lie in the evidence-based care that informs our everyday practice making us important policy participants.
a political perspective, it must be quite hard being on the receiving end of all this advice. Having to work through submissions from every health organisation in the country with their list on how best to fix it. Sifting through the detail trying to find some common ground against their own checklist of whose voice beckons their closest attention politically. Then trying to work through the conflicting areas of advice, where the bias may lurk, to find the most workable solution.
What’s really in the message?
The Political Alerts allow us all to participate in this spectacle checking online what each has had to say. If you’re like me you sit back and try to see if there is alignment in any of it. Next, comes the quick filter on who’s come up with the best response to the actual issue at hand.
The media too has its favorite. The go-to spokesperson on just about every health issue that impacts the sector. Not always the actual peak or expert on the issue either and for those at the grassroots the message sometimes seems a little apart. But then those real issues are just reduced to sound bites and random visuals if there is time around the spokesperson. In the end, the message is either oversimplified or reduced and likely to confuse.
Unfortunately, there will always be that competing tinges leaving an identifiable stain that prioritises first the organisation it represents. This almost always comes through and sometimes only subtlety but easy to spot for those within the system.
Finding common ground
Perhaps this could be made so much simpler – not only for the policy maker but in terms of outcomes – if we just came together as a united group and settled policy first.
This is not to say that collaboration doesn’t occur around issues. It does and usually at the highest levels. There are a number of unifying structures in place: The Council of Presidents of Medical Colleges, United General Practice Australia and of course on rural issues, the National Rural Health Alliance.
Often finding that common issue or cause is not all that hard. We already have it and it lies in patient centred care and that focus in primary care is what unites us. But this simple message becomes distilled when there are parts of the system vying for their space, sometimes even survival.
Primary care and collaboration
Primary care is just one of those areas where we can’t afford to lose focus.
It is a sector, which relies on teamwork. We already collaborate well by working together to share our expertise or to find ways to integrate for stronger outcomes but we can become easily undone by professional interests.
Over the past two decades, I have been involved or have been a director of a number of peak organisations involved in primary care. Obviously, an organisations first priority will always be to make sure it is able to achieve its own goals and aspirations. As a director, you learn to work within these boundaries. But these organisational-level priorities sometimes make collaboration more difficult.
Some strategies for collaboration
For collaboration to work, respect and trust are key.
Quite often it is the lack of trust among organisations in terms of intentions, which makes it so much harder to find common ground. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up to it.
It’s also important to look to the other influences that help us collaborate.
Take the time to build the relationships that support collaboration. This often means to value and embrace difference and healthy conflict. There can be great value from opposing points of view in terms of finding new solutions to tired problems.
We should also challenge the status quo together so no one has to face difficult change alone. And always strive for win-win outcomes where possible.
Finally, strong interpersonal skills among leaders are important to build the collaboration required to influence change.
More effort in bringing together the right mix of people to respond to issues impacting on our sector would support stronger outcomes. We have such a great diversity of talent within primary care which can be tapped into relatively easily bringing stronger depth to so many issues.
Sometimes referred to as coalition building it is about forming coalitions with those holding similar values, interests and goals to combine expertise and resources for a common purpose. In our case it is about having a ready-made alliance structured around targeted areas of expertise or the various issues our sector is likely to face.
It is well understood that a broad-based, grassroots coalition enhances credibility. Bringing together diverse participants with similarly diverse skillsets and access to target populations for stronger reach makes sense. Encouraging broad participation also ensures we can bring new ideas and fresh energy to an issue.
These types of strategies help bring a united voice to an issue. We should be supporting each other across issues that impact on primary care as a whole – at both the local and national levels. It would be great to start a discussion around this and we can start now. I’d be interested in your views around how we might be able to better facilitate these types of policy alliances in the future.
We’re better together
The whole is greater than the sum of its parts. It’s quite simple.
I think most working in primary care would consider that the whole is greater than the sum of its parts. First coined by the philosopher Aristotle, I love this phrase as it reminds us that we are better when we work together. And I really think that should guide our future policy contributions, particularly in primary care. It’s not always easy to implement but I think we need to get much better at it. It’s really just a case of an overcrowded agenda, which needs uniting or risk being overlooked. We most certainly need a united front in primary care.
Changing our healthcare system starts in the consulting room
15 September 2017
Dr Ayman Shenouda
There’s been a lot of discussion around empowering the patient more in their treatment decisions. That we need to shift our focus toward a system that empowers and facilitates choice. But undermining a shared decision-making model – one which has room to provide for both clinical choice and patient choice – is our healthcare system. We have a system which is based on a disease-based model of care which leaves little room to take into account the context of the patient's illness. A system that can allow us to refocus on the patient-centered, personal and unique experience of “illness” must be prioritised.
Patient experience in the health system is so vitally important and has to be valued. For me, changing our healthcare system really starts in the consulting room. It’s that doctor-patient relationship that I really value. And this often goes unnoticed by our decision makers – but it is here where lasting change can be realised. Discussions in general practice are of great value for helping patients take charge of their own health. A more focussed effort here not only helps to improve health but will support quality reform measures which can reduce costs.
Research shows us the benefits of a shared decision-making model approach. These include knowledge gain by patients, more confidence in decisions, and more active patient involvement. Studies have shown that, in many cases, informed patients elect for more conservative treatment options.
Preparing for the challenges ahead
The health system cannot cope with what it is facing. Health care demand on the system is reaching crisis point with public spending at unsustainable levels. Empowering patients is most certainly part of the solution if we are ever going to meet rising demand with an ageing population. But to do this, empowerment needs to be met with a system that can facilitate choice.
Recently I attended an event organised by the RACGP NSW Faculty delivered by an ICU Physician who led an impressive discussion around frailty. He spoke about the elderly intensive care unit (ICU) patient and poor outcomes. More specifically, the need to identify frail patients at high risk of poor outcomes and plan accordingly.
We were brought across a study which investigated the effects of frailty on clinical outcomes of patients in an ICU. It used a frailty index (FI) which was derived from comprehensive geriatric assessment parameters. It found that the use of a FI could be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs. Another study found frailty is common in patients admitted to ICU and is associated with worsened outcomes. It recommended that this vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans.
Identifying patients at high risk of poor outcomes is key here. But the system cannot identify what frail means, nor does it empower GP decision making at the cold face. Applying the FI is one way to ensure we’re not placing patients where there is no real benefit. But the culture within hospitals makes it hard to implement this tool. Enabling end-of-life discussions particularly at a point when there is a crisis situation is also a barrier.
Planning for end of life and putting in place an Advance Care Plan early is essential. GPs are very good at this. It should be undertaken as part of the Over-75 Health Check. and helps equip the patient, and their family, well for what lies ahead. It’s a good time to talk to the patient about prevention, maintaining functionality, minimising pain or complexity of disease as well as strategies to address them. It is also time to start the discussion around being frail and their expectations around that.
High price for poor outcomes
We know that more than 30 percent of patients admitted to intensive care units never make it out. Those that do rarely make it back to their own home. It costs around $4,000 per night in ICU . This spend can be better utilised if redirected to support patients in their own home.
I know from my own elderly patients’ experience that it is often hard for the patient not to end up in ICU. The system makes it hard to facilitate this care in the community. And it’s hard to take on the system during a crisis. It takes a strong family who is across their loved one's wishes.
Care in the community
I recall consulting at my surgery in The Rock some years ago and receiving an urgent phone call. It was the daughter of my 82-year-old patient and she needed my help in preventing the transfer of her mother from Wagga Base to Sydney. She told me the specialist was transferring her and that the family did not want her to go through this and that her mum didn’t want this either. They understood that their mum was in a critical condition but wanted her close to home.
I immediately made the call to the Specialist Respiratory Physician who explained she had a flouting clot in her pulmonary artery and needed an embolectomy and a filter in her IVC. The specialist had already discussed her case with the Cardiothoracic Surgeon in Sydney and organised the transfer. I explained that the family had called and that this was not what my patient, nor her family, wanted. I also explained that I was prepared to look after her in the community. Fortunately, the specialist at Wagga was comfortable provided she sign a discharge against medical advice.
This patient lived for a further five years. She was able to attend her grandson’s wedding in Sydney two years before she died peacefully at her home with her family around her. A testament to her strength and also that of her family. They ensured she stayed in Wagga to receive care an appropriate level of care in the community. They insisted that she was not transferred to a Sydney hospital where she was likely to end up in ICU and never to come home.
Making the system work
How can we ensure that the system can default to enable care in the community, rather than automatically preference for tertiary care? While there exists a frailty tool there’s reluctance to use it. There’s plenty of GPs happy to care for their patients in the community if that’s their choice. But rarely will the patient’s GP be consulted at that critical stage. There is also limited funding to facilitate this care.
A reality check is well-overdue in terms of outcomes particularly in dealing with the frail. We’re missing the point on where to focus care. This needs to be where there is the greater need and where the efficiencies can be found. And this is not on a system which is disease focussed and already crippled by expensive treatments. To prevent waste, more realistic expectations around outcomes can be achieved through person centred care enabling empowerment. One of the strengths of general practice is the unique relationship between patients and their GPs. Patient centred communication and shared decision making is the foundation on which our health system can be remodelled. Let’s prioritise it.
 Green AR, Carrillo JE, Betancourt JR. Why the disease-based model of medicine fails our patients. Western Journal of Medicine. 2002;176(2):141-143.
 Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner, M Llewellyn-Thomas, H Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011;as well as(10):CD001431.
 Kizilarslanoglu, M.C., Civelek, R., Kilic, M.K. et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res (2017) 29: 247. https://doi.org/10.1007/s40520-016-0557-y
 Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Medicine (2017). 43: 1105.https://doi.org/10.1007/s00134-017-4867-0
Health sector reform: towards a sustainable system.
8 September 2017
Dr Ayman Shenouda
A decade of reform
We’ve had a multitude of reforms over the past decade or so with much of it stemming from the National Health and Hospitals Reform Commission (NHHRC). A strengthened consumer voice and empowerment was perhaps the most important shift in the reform discussion at that time. A shift which held great promise in realising change through a more patient-centred approach and one which prioritised primary care and its role in achieving the required shifts.
During the NHHRC years of review, significant structural reform was recommended including in terms of responsibility for primary health care services as well as a more transparent and equitable funding model for public hospitals. The latter has seen some sizeable shifts, particularly in the way we determine funding to public hospitals through the introduction of activity-based funding.
We’ve seen other changes too in formalising shared policy commitment in the form of National Partnership Agreements to help set and agree upon priorities and measure progress across a range of areas.
Structure reform requirements
It’s clear that much has been done to improve the performance of Australia’s health system. But after years of review and with policy fatigue well and truly set in are we any closer to a framework which will secure the future sustainability of Australia’s health system?
Key to realising patient-centred health policy lies in structural reform to promote more integrated care. Our past attempts haven’t brought us much closer to realising this clear requirement, noting we are still implementing much of it as many reforms are ongoing. Information Technology provides certain opportunity here. The My Health Record (formerly PCEHR), as one key measure, is still being implemented and yet to deliver on its promise. As it transitions towards the planned opt-out phase mid-2018 there is still much hope that it will succeed.
Organising primary care through a medical home model of care would also support integration and provide patients with continuous, accessible, high-quality and patient-centred care. Australian general practice encapsulates the medical home model, and a supported policy shift here, if funded appropriately, together with further incentives to promote integrated care across different care settings, would bring us closer to the level of reform required to address current and future demand.
But fragmentation in health care structure exists largely due to the primary and secondary care divide. Each which is then further complicated by its own arrangements through compartmentalised funding streams. This, of course, leaves little to no room to integrate at least not to the level we need to.
Complex governance structure
It’s clear that system complexities brought about by a governance structure with responsibilities falling between the Commonwealth and the states and territories have not served the health consumer well. It’s hard to navigate and even harder for patients with complex or multiple illness or disease.
Bringing the responsibility for acute and primary care together at one level of government is one clear solution. Devolving primary care to the states and territories might just help provide the structures and incentives needed to promote integration. A way forward might be in the form of a state-level trial to integrate local hospitals and health services with primary health networks piloting integrated models in one health service/local health district.
Integrated funding and management have been suggested before, many times in fact and it wasn’t that long ago that we had a serious discussion around it from former Prime Minister Rudd, although with a Commonwealth dominated role in mind.
More recent discussions lead to a similar conclusion, that a move to a single or pooled source of government funding would help to eliminate bureaucratic cost shifting and duplication. This alongside more private sector contributions and alignment to outcomes. Integrated funding and management is one of five central policy levers available to reform Australia’s health system. The other four are around consumer empowerment and responsibility; wellness and prevention; optimised care pathways; and information-enabled health networks. 
Making it better
It is important to acknowledge that Australia has a strong system of healthcare. A high-quality universal healthcare system with coverage through Medicare to the main components of care extending across public hospitals, medical services and pharmaceuticals. The Commonwealth remains the dominant policy maker, which is due to the simple fact that it generates most of the funding. There is a complex division of roles and responsibilities across levels of government with the involvement of both public and private sectors.
The financial dependency of the states on the Commonwealth makes it harder for them to lead in this area. The required focus on outcomes likely to become a bit blurred when it is confined to funding limits and controls imposed by it. While there may exist a shared policy objective - whether that is to help people sustain and improve their health or improving quality or even equity in access - in attaining those measurable outcomes compromise is always tied to the narrow confines of what has been negotiated.
It seems the way forward comes back to a question around who’s best positioned to lead? The current division of responsibilities and roles across levels of government impacts significantly. Devolution of responsibility and funding to one level should be tested to see if integrated funding translates to integrated delivery. If we can move beyond the control being where most of the funding is generated for one moment then we might get a little closer to fixing our fragmented system. This is where we remain stuck and unless tackled we will not move forward.
 The Royal Australian College of General Practitioners. What is General Practice? Melbourne: RACGP; 2012. Available at www.racgp.org.au/becomingagp/what-is-a-gp/what-is-general-practice
 Bartlett C, Butler S, Haines L. Reimaging Health Reform in Australia. Taking a systems approach to health and wellness. PwC; 2016 Australia. Available at: https://www.strategyand.pwc.com/reports/health-reform-australia
 OECD Health Policy Overview. Health Policy in Australia. OECD; 2015. Available at: http://www.oecd.org/australia/Health-Policy-in-Australia-December-2015.pdf
 PwC 2016, op. cit., p. 22.
 PwC 2016, op. cit., p. 8.
 The Commonwealth Fund. Health Care System and Health Policy in Australia. Available at: http://www.commonwealthfund.org/grants-and-fellowships/fellowships/australian-american-health-policy-fellowship/health-care-system-and-health-policy-in-australia
Let’s not lose another rural obstetrics service
1 September 2017 Dr Ayman Shenouda
Decline of rural obstetrics services
It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.
In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service?
The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained. There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way.
Impacts for the local workforce
Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.
We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.
Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade.
A strong focus on policy
This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available.
It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services.
We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce.
Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development.
The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations. The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf .
While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making.
Protecting rural services
Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services.
The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre.
 Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006.
 The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017.
 Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/
 Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia. University Centre for Rural Health North Coast, Lismore.
Dr Ayman Shenouda