Bushfires continue and the essential role of GPs in supporting their communities
This week, it has been heartening to learn about the contribution of general practitioners during the Australian bushfire crisis. A number of GPs have contacted me to share their experiences. The recent RACGP article on the role of GPs in Merimbula is a great example of GPs coordinating the health care needs of their fire affected community. https://www1.racgp.org.au/newsgp/professional/paper-cups-for-spacers-oxygen-from-dive-shops-how
I have also heard first-hand about the challenges GPs have experienced in providing essential primary care in partnership with state and federal agencies. It is evident there are lessons to be learnt. Conversations and planning is needed now to ensure, state and federal agencies immediately collaborate with general practitioners.
Along with my colleagues, I am advocating for greater recognition of the role of GPs during an emergency crisis. General practitioners have the required expertise and need to be part of future disaster planning at a state and commonwealth level.
For bushfire affected communities, GPs are central to community rebuilding. General practitioners will be there to support individuals and families as they assess their situation and begin the task of rebuilding their homes, lives and incomes. Patients in these communities will want timely access to GPs. They will expect continuity of care and coordinated support from their GP as they engage with multiple agencies to rebuild their lives. General practitioners are ready for this work.
The two new Bushfire Recovery Agencies, one at a Commonwealth level to be led by Mr Andrew Colvin, and one in Victoria to be chaired by Mr Ken Lay have important work to do. Their work will benefit from engaging now with rural general practitioners working on the ground with fire affected communities. I recommend these agencies appoint a general practitioner to work alongside the leadership. The role of the GP would be to inform appropriate consultation, ensure genuine community responses and smart investments that benefit the long term health needs of communities impacted by bushfires.
As the threats from Australian bushfires continue, I extend my thanks to GPs in these communities for their work and I hope they continue to be safe.
Dr Ayman Shenouda
General practice is the foundation of Australia’s healthcare system. Our profession is vital to the health of our nation, yet it remains the most devalued profession. We are underpaid, underprioritised and overstretched by rising demand. This is despite the strong trust patients place in their GP’s - being the most accessed healthcare service with more than two million appointments made every week. Here I discuss some key areas in tackling the funding crisis in general practice.
General practice in crisis
General practice in Australia is now at crisis point.
Many general practices remain on the edge of viability. Practice closures are on the increase as GPs are simply struggling to maintain quality services. There are more and more timebomb towns emerging where GP to patient ratios stretch to breaking point.
Despite the rhetoric, bulk billing rates have dropped by -0.1% to -0.5% throughout rural Australia, while out-of-pocket cost has risen by over a dollar to $38.05. These are all factors deterring our doctors in training from pursuing a career in general practice.
This all leads to a worsening workforce crisis, particularly in rural Australia. Rural registrar placements have already declined by 40% in some areas and unless we start making careers in general practice attractive, including remuneration in line with hospital specialities, there will be serious consequences.
And with a declining general practice workforce, the true cost will be seen in future years in the declining health of the nation. Urgent trust and investment in general practice is now needed.
The shift needed
Our healthcare system is already the envy of many countries around the world. But how healthy is it when less than 9% of annual funding goes to general practice?
The hospital system and other tertiary services continue to be prioritised. Despite the evidence, policy makers seem intent on preserving a reactive and acute care focused system. Yet we know the impact of chronic disease will only intensify and this requires a strong preventive focus.
Australia faces a rising chronic disease burden, an ageing population and a significant rise in mental health problems and palliative care need. According to the latest National Health Survey almost half of all Australians (47.3%) are now living with a chronic disease. We know that a third of chronic disease is preventable yet there is an allocated health spend of only 1.3% of our health total budget.
We know that without strong and effective primary health care countries will struggle to maintain their health services. It is by far the most efficient and cost-effective part of the healthcare system yet it remains so grossly underfunded.
There is clear global evidence that health systems with strong primary care will secure long term efficiencies. Benefits from prioritised investment include achieving lower rates of hospitalisation, fewer health inequities and better health outcomes including lower mortality.
A solid foundation
Chronic disease is complex and difficult to manage. The only way to curb the impacts of the rise in chronic diseases is through prevention.
We have the key components already in place to underpin strong population health outcomes.
The unsustainable rise in healthcare funding needs structures towards prevention and management and we already have a solid foundation to work from.
General practice provides the foundation for what can be the best and most effective, high-quality and sustainable health system. An equitable system that supports optimal outcomes which see patients actively managing their healthcare needs to stay as healthy as possible.
The Government is clearly not capitalising on this opportunity. Why do we find it so hard to direct funding to where it is most needed?
Despite having had the best policy intentions the funding committed towards primary care unfortunately has not been spent in the right places. Lots of investment in different organisations has had a destabilising effect – contestable funding and competitive service markets are just not commensurate with addressing significant unmet health need.
This approach is having a negative impact on the delivery of vital health services. It stifles innovation making it very difficult to be creative to deliver quality care for patients. Direct investment in the most effective part of our health system – general practice - in driving patient centred outcomes is what’s needed.
In my journey in general practice I have met a lot of amazing GPs. My colleagues continually inspire me with their passion and tenacity to overcome these challenges and their enduring commitment to serving their communities. The reality is that the majority of GPs are doing exactly that.
Governments are using this passion and commitment to their advantage. A lack of appropriate government investment in general practice has put our health system at risk. General practice services in Australia are close to breaking point. A strong investment in general practice is what is needed to secure a healthier future for all Australians.
The health of our nation is an enormous responsibility and more funding is needed so that we can continue to provide optimal care. Strong united leadership with a united approach to this major crisis is now urgently needed.
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.
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.
Federal Budget 2018
Dr Ayman Shenouda
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.
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.
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
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. 
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.
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. 
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.
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.
 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
 Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087-91.
 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
Let’s fix the health deficit through a more equitable distribution
Dr Ayman Shenouda
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.
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.
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.
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.
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. 
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. This is the formula for a healthy Australia.
 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
 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
 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
 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 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.
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.
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]
[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/
[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
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.
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.
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.
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.
[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.”
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!
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.
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.
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.
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.
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.
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.
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.
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.
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. Developers and vendors of clinical decision support tools must be transparent about their methodologies, capabilities, data sources, and limitations.
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. 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.
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. 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.
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.
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.
 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
 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/
 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
 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
 RACGP. Webpage. RACGP Technology Survey 2017. Available at: https://www.racgp.org.au/your-practice/ehealth/additional-resources/racgp-technology-survey/
 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/
 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
 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/
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.
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.
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.
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.
24 November 2017
Dr Ayman Shenouda
Who’s looking after the doctor?
Federal Health Minister Greg Hunt made a commitment in May to reduce suicide and improve mental health among doctors. This commitment came following the tragic loss of NSW junior doctor Dr Chloe Abbott with Minister Hunt admitting that ‘too often the care is not there for the carers’.
We’re now starting to see some action around this issue. The progress on the mandatory reporting issue for one. It is clear that medical professionals need to seek mental health treatment without fear of retribution. Fixing the mandatory reporting laws is the first key step in supporting doctor health.
A nationally consistent proposal was to be considered this month by COAG Health Council. Minister Hunt has since made assurances following this meeting that work is now being progressed towards a standard by the end of the year. More discussion through COAG will follow to secure agreement but we’re getting closer.
2013 beyondblue study
As in the general population, depression doesn’t discriminate and this was made evidently clear through work led by beyondblue. Beyondblue’s National Mental Health Survey of Doctors and Medical Students revealed for the first time the true extent of the problem. This major study, undertaken in 2013, surveyed more than 12,000 doctors and around 1,900 medical students. 
The stats that emerged from this were alarming. It confirmed high general and specific levels of distress, and high levels of burnout among doctors and medical students. Substantially higher rates of psychological distress and suicide attempts were found than in the general community. Around 10% of doctors reported suicidal ideation in the previous year and one in four reported suicidal thoughts prior to the previous year. 
The study also confirmed that medical students and young or female doctors were most at risk and identified significant levels of stigma towards people with mental health problems. Not surprisingly some experienced bullying and racism as well. 
This is just the start
Despite this major study confirming what we already knew about higher rates of psychological distress among medical students and doctors, there’s still slow policy action around this issue.
At the time, there were calls for urgent action to improve the mental health and save the lives of Australian doctors and medical students. But progress has been slow – very slow. Four years later and we’re still working through one of the key barriers to getting help – which is mandatory reporting.
Minister Hunt is the first federal health minister to acknowledge that mental health issues are tormenting our sector.  Acknowledging the problem is a good start but there is much more to be done. And it’s not all up to government either. We all have a role here and it starts with how we look after each other as doctors. A much broader conversation now needs to occur and it will take all of us to make this happen.
Let’s start with taking our own advice
It’s clear that work-related stressors impact particularly those at the earlier learning or career stage.
We’d all be familiar with the risk factors in the workplace – high-intensity work, long hours, conflicting time demands with a heavy professional responsibility. For some, there is bullying and harassment in the workplace. Broader issues like those stigmatising attitudes which persist despite us coming so far in terms of destigmatising mental health issues in the general community need attention.
The advice we’d offer to our patients around the importance of maintaining work-life balance to counter these issues should also apply to us. The work we’ve all done to destigmatise mental health issues in the community and the shifts achieved here need to be reflected in our own workplaces too.
In achieving a better balance, the answer lies in ‘restoring the pleasure of work – the satisfaction inherent in meaningful work done well’. Working towards ‘addressing the imbalance between excessive demand and perceived low control, and between effort and insufficient extrinsic reward’. This was the advice of Geoffrey J Riley in what remains one of the best pieces written on the subject: ‘Understanding the stresses and strains of being a doctor’ (MJA, 2004). There’s a link as it is a must-read.
Driving toxic culture out
Leadership in terms of dealing with discrimination, bullying and sexual harassment (DBSH) is required.
The extent and impact of workplace bullying and harassment has been exposed in recent years through the press. Reports in 2015 of sexual harassment and ‘toxic culture’ among surgeons led to a public apology to victims from the Royal Australasian College of Surgeons. The apology came after a survey found nearly half of all surgeons had experienced discrimination, bullying or sexual harassment.
A Senate Inquiry into bullying and harassment in the medical profession followed. During hearings in November last year, senators were told of an ingrained culture of harassment and bullying of medical students. There were reports of endemic bullying and underreporting of abuse due to fear of consequence. Gender discrimination and ‘teaching by humiliation’ was also exposed. AMSA evidence stated that up to half of all medical students believing this mistreatment necessary and beneficial for learning.
Positive policy responses include those from the Victorian Government in its work to eliminate bullying and harassment in healthcare. Their strategy focuses on strengthening leadership and accountability; building the capability within the health sector to act and respond appropriately and creating a positive environment that promotes and supports both staff and patient safety.
We need to see more strategies like these. We know that medical students, interns, IMGs and female colleagues have been identified as most at risk. These are issues we need to tackle within our own disciplines and collectively as a medical profession.
We also need more focus on self-care
Self-care has the potential not only to minimise the harm from burnout, compassion fatigue, and moral distress but to promote personal and professional well-being. Developing a self-care plan is important. We all need strategies to mitigate stress and burnout and promote well-being.
More focus on the importance of self-care in the training to develop early those required coping skills is also important. The RACGP in the White Book, Chapter 14, The doctor and the importance of self-care provide comprehensive guidelines encouraging self-reflection, peer support and working as a team within the practice to protect against stress. It provides some practical strategies which are worth pursuing at an individual and practice level.
Responding as a profession
Mentoring is also a key part of remaining resilient as creating (and maintaining) a network of peers is so vitally important. It still is for me. I think we all need to check in with each other regularly. But what more can we do to ensure we are active as a profession to support and mentor our young doctors? Collegiality matters here. Our strength is in our membership and we need to value and nurture our next generation.
It is clear that we need more action on bullying and doctor burnout and mental health issues. I think part of the solution is through formalising a mentoring role in the training system. It provides that safe place to solve problems. But it is currently an add-on for many of us and hard to sustain in terms of an ongoing commitment. It usually comes down to one individual and relies on altruism (alongside so many unfunded parts of our profession). There are formalised scholarship programs but only for a select few. We are relying on a limited pool of mentors which undermines the effectiveness and funding this important role forms part of the solution towards ensuring a more resilient workforce.
The Daily Telegraph. Minister commits funding to address issues crippling young doctors’ mental health. 27 May 2017. Available at: https://www.dailytelegraph.com.au/news/nsw/minister-commits-funding-to-address-issues-crippling-young-doctors-mental-health/news-story/ed7f7871fef2eec8f1d3766b62200854
 AMA. Health COAG progresses approach on mandatory reporting. 13 November 2017. Available at: https://ama.com.au/ausmed/health-coag-progresses-approach-mandatory-reporting
 Beyondblue. National Mental Health Survey of Doctors and Medical Students. October 2013. Available at: https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report---nmhdmss-full-report_web.pdf?sfvrsn=845cb8e9_4
 Beyondblue. Media releases. Urgent action needed to improve the mental health and save the lives of Australian doctors and medical students. 7 October 2013. Available at: https://www.beyondblue.org.au/media/media-releases/media-releases/action-to-improve-the-mental-health-of-australian-doctors-and-medical-students
 Op. cit. The Daily Telegraph.
 ABC News. Culture of bullying, sexual harassment widespread among surgeons, report reveals. 10 September 2015. Available at: http://www.abc.net.au/news/2015-09-10/damning-report-reveals-bullying-harassment-among-surgeons/6763490
 The Sydney Morning Herald. 'Ingrained culture' of harassment and bullying of medical students, inquiry told. 1 November 2016. Available at: http://www.smh.com.au/national/health/ingrained-culture-of-harassment-and-bullying-of-medical-students-inquiry-told-20161101-gsfbuu.html
 State Government of Victoria. Policy Summary. Eliminating bullying and harassment in healthcare. Available at:https://www2.health.vic.gov.au/about/publications/policiesandguidelines/eliminating-bullying-harassment-healthcare
 Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care for others: physicians and their self-care. The journal of supportive oncology. 2013;11(2):75-81.
24 November 2017
Dr Ayman Shenouda
National Aged Care Quality Regulatory Processes Review
The recent Review of National Aged Care Quality Regulatory Processes was released on 25 October. The review looked at past failures in terms of the limitations of the regulatory controls to recognise abuse and care issues. It’s emphasis, therefore, was on improved regulatory measures to improve national monitoring arrangements.
Aged Care Minister Ken Wyatt, in his announcement on releasing the report, stated that the majority of facilities provide excellent care and are working to continually improve services. Some might argue that media reports of endemic abuse in nursing homes paint a very different picture. That aside, the Minister stated that focus was on seeing improvements to the system that can address those not delivering quality care.
Aged care safety and quality
It is appropriate for the review to have a core focus on safety and quality. The capacity of the current regulatory environment to protect residents from ‘restrictive practices’ is of course appropriate. A key recommendation was the use of unannounced audits across Australia’s residential aged care facilities (RACF). This is a positive outcome and the commitment by the government to implement this recommendation quickly is also positive news.
There were 10 recommendations in total to improve aged care resident protections through more transparent compliance and monitoring. Other key recommendations included establishing an independent Aged Care Quality Commission with provision for a quality commissioner, complaints commissioner, consumer commissioner as well as a chief clinical advisor. This new commission would develop and maintain a centralised database with the view of creating a star-rated system on provider performance.
In addition, there would be more protections to curb abuse which would see a recommendation from the Australian Law Reform Commission for a new independent serious incident response scheme (SIRS). On accreditation and compliance, the unannounced visits were the major recommendation with more public disclosure on matters of non-compliance. In addition, if supported, there would be strengthened controls around medication reviews and compliance. Medication reviews were recommended on admission, after hospitalisation, upon deterioration or when changing medication regimes.
Where’s the focus on general practice?
This is an important body of work but again we see a lack of insight into the key role of general practice in aged care service provision. This is another example of a review which has missed an opportunity to ensure a stronger role for GPs. There should have been scope to work through key issues including those areas of clinical governance as a key quality enhancement measure.
It’s all very well to make sure that there are controls to pick up those not doing the right thing. But doesn’t it make better policy sense to place an equal emphasis on why the issues are there in the first place?
It is very disappointing that this review did not extend to service solutions through general practice.
This oversight being on the back of the recent Productivity Commission’s 5-year productivity review – Shifting the Dial - which also underplayed the role of general practice in a discussion which focussed on prevention and primary care.
To a certain extent, even the changes in Victoria with the voluntary assisted dying legislation seem to lack a focus on service capability. Palliative care is one area which lacks clarity in terms of roles and most certainly there is a lack of data, fed by physician only item numbers, which can only constrain services and planning. GPs too do a lot in this area but this mostly goes unnoticed and underfunded. Ensuring there are funding levels to enabling access to palliative care services should be a priority moving forward.
Valuing general practice
Why is there a lack of focus on general practice? It’s clear that success in terms of prevention makes us far less visible. Such is our role that if we do it well then it goes unnoticed. Best practice interventions for heart disease and stroke, for example, will translate over time through improvements in data. But there’s a very limited audience with not many from outside of the profession interested in this level of detail.
The RACGP has made strong investments in recent years to lift our profile. However, the lack of focus is still a key problem. This is evident in this latest report where glaring service solutions – solutions to lift quality - have been again overlooked.
The missing GP perspective
In a recent Medical Observer article by Professor Leanne Rowe, ‘Why are GPs missing for the national aged care review?’, this lack of focus was also seen as a key issue which limited the report’s findings. The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities.
Those obvious service issues, central to ensuring quality, were ignored. A focus on quality needs to also look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
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.
GP-led care or collaborative care solutions are relevant to achieving those safeguards for residents sought through this review. Stronger integration of GPs and improved collaboration with aged care staff and formalising these models of care would assure safe and high quality coordinated care for residents.
More broadly, variable skillsets are important factors that impact on quality of care standards in these facilities. Inadequate staffing levels including the need for more skilled nursing staff is central to many of the quality and compliance issues central to this review. The recent Senate community affairs committee report made specific recommendations in this regard and again it is very relevant to a review focused on quality.
Ensuring there are transparent and workable processes in place to uphold standards and community expectations in terms of care is very important. The recommendations offered through this review will go a long way towards strengthening these. But a great deal of the issues relates to the corporate ownership structure of the RACFs. More specifically, the limitations that brings in terms of ensuring quality service provision.
Improving the lives of older Australians needs a firm policy focus and we’re starting to see that through this Minister. There is an opportunity to build off this review to fix some of those glaring issues limiting the quality of care. I’d like to see a stronger role prioritised for general practice and formalised in national policy. Limitations in terms of remuneration which also fail to capture the complexity of this care needs addressing. Valuing the role of the aged care workforce more broadly is central to ensuring quality outcomes. There’s so much more to be done here to ensure older Australians receive the care they deserve and we cannot afford to drop the focus on GP-led care solutions
10 November 2017
Dr Ayman Shenouda
PC Report: We can do better in health
The recently tabled Productivity Commission Report ‘Shifting the Dial: 5 year productivity review’ takes a broad policy lens on only on a few key areas which it states are likely to impact overall economic performance over the medium term. Health, of course, made it into this five-year review of the nation’s productivity alongside education and cities.
Overall the report turns to technology as an enabler for change and in parts more government control. The report suggests some major policy shifts to achieve a number of efficiency measures. Applying automation to healthcare as a cost reduction strategy specifically to achieve a smaller pharmacy workforce is one such shift. There are some familiar ideas floated throughout with many not pursued in the past for good reason. There is a lack of emphasis on the role of general practice in the health discussion which in turn weakens the piece.
A quick snapshot
While there are a number of recommendations for health against Healthier Australians many seem short on detail (and evidence). The sharpest shifts are pointed at education system reform, while health seems a little less disruptive. This is, of course, other than the recommendation for pharmacies to be turned into automatic dispensing outlets! In terms of the rest, well tackling those low-value healthcare procedures is really already in train and an important efficiency measure. Creating scorecards for the performance of providers to enable patients to compare outcomes is another idea which has merit but there are many higher priorities to pursue first.
There’s certainly a push to utilise more both the PHNs and LHNs to help overcome the federal and state funding standoff and related care gaps. This is both positive and problematic in terms of enabling integration. On one hand it will force more joining up through a funding means but on the other it will be reliant on forging strong relationships with general practice. The latter is not made a priority in this paper and instead implies more control (of general practice).
The paper states the need for a new funding pool for the PHNs and LHNs towards population health activities including some commissioning of GP services.There is certainly a need to create better structures and incentives to realign toward prevent and chronic disease management and localised solutions makes the most sense. However, the commissioning approach to procuring medical and health care services is still a work in progress in my view and much much more effort is required to engage general practice. That is the only way to establish trust and work through to those new ways of working in partnership with general practice.
The positives …
The overall positives of our healthcare system in terms of outcomes are at least acknowledged. We’re living longer, with less disability. Against OECD countries we have high overall health outcomes with the greatest life expectancy at birth. The third greatest life expectancy at birth in fact at 82.8 years (2015). On prevention and injury, we’re seeing a reduction in smoking rates and few deaths on our roads. And perhaps most importantly for a report focussed on fiscal pressures we’re spending less on health when compared to the other OECD countries.
And the negatives …
But holding us back, according to the report, noting this is from a perspective of lost productivity, are the 27.5% of adults who are obese and the 11 years spent in ill health which is the highest in the OECD. The last being despite having the third-highest life expectancy in the developed world.
It doesn’t hold back …
There are some scathing comments around some of the broader perceived negatives driving costs up. The comment in setting up the need to defund low-value healthcare procedures is both harsh and without (strong) cited evidence:
“Unjustified clinical variations, including the use of practices and medicines contraindicated by evidence, remain excessive, an indicator of inadequate diffusion of best practice, insufficient accountability by practitioners, and a permissive funding system that pays for low-value services.”
The example used here is knee arthroscopy which again is something we all knew about. The new Australian Commission on Safety and Quality in Health Care Standards developed to discourage the use of arthroscopy for patients with knee osteoarthritis is mentioned, yet criticised as it is an advisory and able to be ignored. The report cites some other examples to illustrate their concerns around quality: 75% of bronchitis treated with antibiotics, against best practice; and 27,500 hysterectomies without a diagnosis of cancer.
In finding efficiencies in health the report states:
“Doing better with our health resources can act as a safety valve for mounting fiscal pressures.”
This, of course, is quite obvious and not without (current) policy focus as finding healthcare efficiencies have really dominated the policy debate for nearly a decade. The report states that ‘some suggest that approximately 10 to 15 percent of health spending is used inefficiency due to poor quality care’. That last statement is (again) not referenced but let’s assume ‘some’ have stated it. We all know that the system is far from perfect but there are also many parts worth protecting including the gains realised in primary care. In this report, the efficiency measures are embedded in the detail, not necessarily making it to the recommendations and worth noting.
Observations on the detail
The report states that the patient experience of care receives little focus as a goal of the system. It accurately picks up some failures in terms of enabling choice – palliative care being one. But, it is in primary care where patient centred care remains core and where stronger gains have been realised. Particularly in terms of patient empowerment and ensuring prevention is prioritised and this is not really highlighted here. I really don’t think the review has reached out much at all to general practice, otherwise we would see this reflected more in the solutions.
I think the piece gets to the real issue where it states the current system encourages activity, not outcomes. It includes one of the strongest statements in this report:
“Australia’s messy suite of payments are largely accomplices of illness rather than wellness, only countered by the ingenuity and ethical beliefs of providers to swim against the current.”
From a primary care perspective, I agree that those limited MBS payments oriented towards preventative health and chronic disease are too narrow and inflexible limiting both outcomes and reach. But when considering other payment options, it worth remembering that general practice is a private business model and needs to remain as such. Whether that be maintaining fee-for-service combined with risk-adjusted capitation payments but particularly for pay-for-performance initiatives – ensuring continued practice viability must factor strongly. For this to work, pay-for-performance should only be used to drive quality improvement in certain priority areas – similarly to how the PIP currently operates - and be part of a mix of payment arrangements, not the sole driver.
The focus on enabling stronger integration is of course key and the stumbling blocks preventing more of it is put down to system deficiencies in the structure of our healthcare system – funding governance, linkages, and attitudes. More linking between PHNs and LHNs – fusing those government layers - at the regional level will achieve more integration. It’s about partnerships or more specifically, cultivating relationships between hospitals and GPs that will create these formal linkages to bring about stronger prevention, early intervention, and chronic disease management.
The word partnership is key here and for this to work we would need to see a genuine partnership with general practice, not seek to control it (as the earlier commentary suggests in imposing new funding models). This emphasis really highlights the greenness of this policy piece as it is general practice where the opportunities lie, yet so many opportunities have not been pursued here.
Reassuringly, this report also states that the solution is not to destroy the current system which it states would result in a policy adventure with many risks and uncertain outcomes. Instead, we should focus on those parts of the system already making that required shift towards a more integrated patient-centered system. Some might still say that this report takes us on a journey of (policy) misadventure. This might be true (in parts) but there are some areas worth testing.
Here's a short synopsis on the key recommendations
There are six key recommendations arranged against five identified problem areas – integrated care, patient-centered care, funding for health, quality of health and using information effectively. The recommendations:
2.1 Implement nimble funding arrangements at the regional level
2.2 Eliminate low-value health interventions
2.3 Make the patient the centre of care
2.4 Use information better
2.5 Embrace technology to change the pharmacy model
2.6 Amend alcohol taxation arrangements
I’ve hand-picked a few areas here.
The first recommendation (2.1), to implement nimble funding arrangements at the regional level, calls on all governments to allocation (modest) funding pools to PHNs and LHNs for improving population health, managing chronic conditions and reducing hospitalisation (at the regional level). This recommendation would provide a flexible fund to PHNs and LHNs to work through more localised solutions. It is the type of flexible funding solution we’ve called for in primary care for years but the enclosed word ‘modest’ is interesting.
This initiative builds on the PHN/LHN partnership discussion throughout the chapter and would help address some of the key barriers to integration. But, in my view, this would also require significant, not modest, funding levels to make a real difference and address current gaps impeding integration.
There are some real opportunities to pursue through general practice in order to address some of the clear service gaps or policy failures identified. Palliative care in the home being one of them. Building capacity of general practice in population health to invest in those preventive measures is another. The PHNs were sees an opportunity to enable more GP-led care particularly in preventive care and integration with the LHNs were already part of their remit. Therefore, this specific initiative is almost wholly reliant on general practice and it is disappointing not to see that emphasis made.
Eliminating low-value health interventions (2.2) states that progress to limit low or no-value services has been slow. There remain too many unjustified medical procedures (some we covered off earlier). The report also highlights that Australian procedure rates are markedly higher than other comparable OECD countries. There is also some discussion around patient expectations contributing and more broadly health literacy and the need for improvements there. Broader solutions include the faster development of clinical standards and ‘do not do lists’ by the ACSQHC. The report states that Medical Colleges should also disseminate best practice (which already occurs in general practice). De-funding (interventions) mechanisms as well as removing the tax rebate for private health insurance ancillaries is also discussed.
A key recommendation (2.3) to make the patient the centre of care is of course welcome. It is already a core value in general practice and expansion is really key to fixing our healthcare system. Empowerment measures including improving patient literacy and embedding patient-centered care in training all very important and picked up in this report.
The report highlights that ‘the OECD has characterised Australia as relatively poor in its capacity to collect and link health data’. As part of the solution, the PC suggests a new role for the ACSQHC in placing the patient front and centre. This would involve developing well-defined measures of patient experience of care. It would capture outcomes from a patient perspective to help build a picture of how the system is working at the grassroots level. I agree patient-reported outcomes measures or PROMs is important but this should only be used as a balance measure. Outcomes measures (high-level clinical), as well as process measures (evidence-based best practice in driving improvements), must continue to be prioritised if we have any chance of realising our health gains or goals over time.
Recommendation 2.4 (and 2.5)
Recommendation 2.4 picks up on this broader theme around data capture and related shifts in the previous recommendation. It calls for the establishment of the Office of the National Data Custodian. This change would help to ‘remove the current messy, partial and duplicated presentation of information and data, and provide easy access to health care data for providers, researchers, and consumers’. Much of the remaining parts to this recommendation sets up the requirement for a new model of pharmacy. The next recommendation (2.5) of course deals with the shift to pharmacy automation and The Pharmacy Guild of Australia’s response to it is worth reading.
The final recommendation (2.6) has a focus on public health initiatives and recommends moves towards an alcohol tax system. Interestingly, it falls short on measures to curb sugar intake despite the strong obesity emphasis throughout. Market control through voluntary reductions in sugar content (by major manufacturers of SSBs) is instead floated. This perhaps was one of the key areas worth exploring in enabling a more productive workforce and alleviating those 11 years spent in ill health. The report falls short here. I would welcome an expanded discussion including a stronger focus on physical activity as a key prevention measure.
For more information: Inquiry Report No. 84. Shifting the Dial: 5-year Productivity Review 3 August 2017
30 October 2017
Dr Ayman Shenouda
Investing in health
A greater investment in health requires a strong focus on patient-centred care prioritising both prevention and primary care. In progressing these shifts we’re currently locked within the constraints of our reactive healthcare system. Despite significant levels of funding, we’re just feeding a sick system here. This is less about payment reform or performance-based models but more one of prioritising and getting that focus right.
In making that shift towards a healthier population and sustainable healthcare system it comes down to priorities, not just savings. Removing waste including through the removal of obsolete, redundant or unsafe treatments from the MBS item numbers is important. But so is ensuring we transition from our episodic, acute care or reactive model towards a more proactive one.
Preventive care solutions
To shift health outcomes then we need to address those causal factors. It’s not just medical care alone that influences health with social factors known powerful determinants of health. Those causal factors affecting health status must be also be tackled. Socioeconomic factors – income, wealth and education – all impact.
Those “upstream” factors which include social disadvantage, risk exposure and social inequities that play a fundamental causal role in poor health outcomes and must be addressed. These are issues which play out over long periods and much longer than electoral cycles. But stopping the onset of illness is the only way to contain our rising disease burden. Therefore, it is those emerging preventive care solutions, which fall as either proactive or predictive care, where we now need to focus.
A prescription for health
This prescription for health is very different to the one we currently have and involves a Proactive, Preventive Approach with Increased Engagement. The shift is something we’ve been trying to do in primary care for some time but barriers from without our framework are limiting a full transition.
The policy response involves a mix of proactive and predictive care solutions.
For proactive care solutions, this involves improving treatment outcomes through stratifying at-risk individuals based on known algorithms ensuring preventive action is taken well before the onset of symptoms.  We know that certain behavioural risk factors - tobacco use, alcohol consumption, physical inactivity and unhealthy eating - are most amenable to change. We can do more to modify these behaviours as part of proactive care through stratifying individuals based on key risk factors for chronic disease.
While predictive care is about leveraging emerging technologies and using big data to not only stratify risk but predict risk and intervene even further upstream. More predictive care, through improved analytics, genetic risk testing and technological developments build an even clearer picture. These early insights will help us anticipate issues pinpointing those behaviours to avoid and actions to take much earlier than before and before risk factors arise. 
Risk and protective factors
In transforming our health system, it is a focus on those risk and protective factors over time that really holds the answers. The Life Course Health Development (LCHD) framework offers a new approach to health measurement, health system design, and long-term investment in health development. It takes into account those risk and protective factors and early-life experiences in determining long-term health and disease outcomes. 
More understanding of how these health trajectories develop over a lifetime helps us influence change for optimal health development through more effective preventive strategies and interventions. 
2. Then an equal focus on protective factors –These are those protective or health-promoting factors which are of course broader than health but have a positive influence on our lives and are health affirming. From the best start through breastfeeding, positive educational influences or being more physically active throughout through to access to quality healthcare and strong social capital are just some examples.
3. Finally, increased engagement in striving for our own good health –Population health management really offers the collaborative approach required to empower patients and patient centred care. Informed and involved patients who are active participants in setting their own goals for wellness are central. Those social factors and the government’s part in that to ensure we all have the best start and life possible is really key.
Strategies for intervention
It is these focus areas which hold promising strategies for intervention. Still, we see very few health dollars being prioritised for prevention. To fully support a stronger focus on prevention we need to pursue new data on risk and protective factors, investigating how and when they develop across the life course. Through these key learnings, new proactive and predictive care solutions will need to be developed and prioritised in our healthcare system. This is not a new concept; many general practices already do this – identify and stratify patients according to risk – but it our current payment system really restricts us here in limiting to diagnoses. It is really just the difference between disease focus care and actually enabling more patient centred care. More incentives around prevention and in reducing risk are required to make this work particularly in general practice for an optimal business model.
More broadly, this requires a whole of government shift, not just from within the health budget but towards a Health in All Policies (HiAP) approach. This will help redress inequities and give everyone a fair chance for health. The policy remit extends well beyond health and also beyond any discussions occurring right now around fee-for-service and performance-based models. If the government is really serious about shifting 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.
 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/
 Bharmal N, Pitkin Derose K, Felician M, and Weden, M. Working Paper: Understanding the Upstream Social Determinants of Health. RAND Health. Prepared for the RAND Social Determinants of Health Interest Group. WR-1096-RCMay 2015. Available at: https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
 MacIntosh E, Rajakulendran N, Khayat Z, Wise A. Transforming health: Shifting from reactive to proactive and predictive care. MaRS. 29 Mar 16. Part of the Transforming Health Market Insights Series. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Ibid. https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
 Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. The MilbankQuarterly.2002;80(3):433-479. doi:10.1111/1468-0009.00019. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/
 Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/
 Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690118/
 Halfon N, Larson K, Russ S. Theories And Consequences. Why Social Determinants? Healthcare Quarterly, 14(Sp) October 2010: 8-20.doi:10.12927/hcq.2010.21979. Available at: http://www.longwoods.com/content/21979
 Tasmanian Government. Determinants of Health. Department of Health and Human Services. Available at: http://www.dhhs.tas.gov.au/wihpw/principles/determinants_of_health
 Op. cit. Halfon et al. Available at: . http://www.longwoods.com/content/21979
 Ernst & Young. Population Health Management. EY Health Industry Post. News and analysis of current issues affecting health care providersandpayers.2014.Availableat: http://www.ey.com/Publication/vwLUAssets/Health_Industry_Post_population_health_management/$FILE/Health_Industry_post.pdf
 Public Health Agency of Canada. Strategic Plan 2016-19. Improving Health Outcomes. A Paradigm Shift. Publication date: December 2015. Cat.: HP35-39/2015E-PDF ISBN: 978-0-660-03990-9 Pub.: 150173. Available at: http://www.phac-aspc.gc.ca/cd-mc/assets/pdf/ccdp-strategic-plan-2016-2019-plan-strategique-cpmc-eng.pdf
16 October 2017
Dr Ayman Shenouda
What really lies ahead?
While the impending changes from the Redesigning the Practice Incentives Program (PIP) still looms over us, among this deafening silence there’s concern around what lies ahead. It’s not so much the proposed changes to the PIP but more the underlying policy consequences in terms of broader payment reform and control over the profession.
The fee-for-service payment system remains the predominant commonwealth funding mechanism that assists patients to access primary care. The system is not well aligned to address chronic disease management and the complex health issues of our aging patient population. There is a need to find an optimal mix in addressing current need and future demand. We need funding mechanisms to tackle both complex chronic conditions and issues around disadvantage. Key is the priority shift toward improved patient outcomes and value, not just volume of service.
Key questions remain around what a value based primary health care system will look like. It will no doubt involve extensions of bureaucratic controls used to regulate professional practice with potential impacts on professional autonomy.
Health payment reform
The Government has not been shy in terms of its core focus on health payment reform in securing broader fiscal sustainability. However, in finding solutions, the policy jam seems well and truly fixed on finding savings from within one sector – from within primary care – despite it already being largely cost efficient.
Aspects of primary care payment reform alongside structural reforms are already being tested. The Health Care Homes’ voluntary trial, the Medicare Benefits Schedule (MBS) Review and to some extent the Primary Health Networks (PHNs) are key examples. These shifts have been occurring for some time and this latest redesign targeting PIP signals some further key changes.
The PIP redesign will see, even more, conditions imposed on general practice with an apparent shift toward imposing more funding controls through increased reporting. The policy lens again is on general practice where Medicare spending is value for money. Is this same focus being applied to the broader medical specialties? Driving prices down to regulate perceived skill based premiums might just bring some equity back into the discussion.
The QI measure
The key aim of the PIP is to support general practice activities in recognition of comprehensive, quality care. It provides a blended payment approach for general practices in addition to fee-for-service income. We know the most significant reform will be from the Quality Improvement (QI) measure which will require practices to collect full datasets alongside individualised targets for improvement.
The issue around who sets these targets is still a little unclear – self-selected or enforced. However, if the aim is to capture specifics of a practice’s patient population then I would suggest that the practice takes the lead here, not the bureaucracy. This in some way formalises a broader population health framework approach. This is positive but does a new QI measure involving data capture really provide the best way forward?
The rationale is around the use of data to measure and drive improvement. And certainly, no one is arguing that quality data on outcomes has not been lacking. Clearly, it has had its limitations and one would be around funding commitment to evaluation.
The long-term aim of the redesign is said to be around assisting practices to participate in quality improvement processes. Payments will be tiered to how this data has been used in terms of improvement measures. Those PIPs likely to be removed may well have already captured this detail. Data collection software storage adds a cost for practices but some already have these management systems in place, although not standardised.
There are two key issues here, the first around maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party (probably PHNs) QI provider. The second is broader intent which sees a likely shift towards a pay-for-performance scheme.
Maintaining clinical autonomy
Data control is, in fact, a real issue here. Maintaining data integrity given practices will be required to upload quarterly electronic data to a third-party QI provider is one clear risk. Although utilising the PHNs as a vehicle for change could be beneficial it will require a partnership approach. They will need to further engage with GPs to establish the required trust and make sure they don’t encroach on clinical autonomy. Broader organisations who already do evaluation well and are trusted by the profession should also be brought in. Overall, GPs must remain free, within the parameters of evidence-based care, to make decisions that affect the clinical care they provide, rather than having these decisions imposed upon them.
There seems a move here towards a pay-for-performance scheme which in itself is problematic. Combined with an added data task resulting in more paperwork for GPs these requirements will risk taking our focus from patient care. Most practices have clinical risk management systems in place to analyse weak points and improve patient care. The PIP redesign consultation paper states that there is emerging evidence around a need for regionally-based change management to embed a quality improvement culture in general practice. This implies that GPs are inactive in this area when in fact the profession values and drives many of its own quality improvement measures.
There are already measures in place to support practices in undertaking QI activities. The RACGP QI&PD services offer a wealth of quality improvement tools and guides including clinical audit mechanisms. The College has developed a set of 14 clinical indicators to deal exclusively with the safety and quality of clinical care provided by Australian general practices.
Important unmeasurable factors
It is important to recognise that not everything can be measured. While clinical and organisational measures can be captured, there are other aspects of care important for healthcare quality which prove more problematic. Continuity of care and ease of access to care are unlikely to be captured in a neat format for the PIP QI measure. While attractive to funders pay-for-performance programs may not improve health outcomes or improve system quality. They have the potential to worsen overall care quality as focusing just on measurable outcomes takes us away from holistic general practice.
There is a much larger shift which needs to occur here and it won’t be achieved through a pay-for-performance system. In transforming health, we need to shift from reactive to proactive and predictive care. Early identification is the only way we can control rising chronic disease rates but our system relies on patient contact when they present with noticeable symptoms. Often this is just too late. We need a system which can take us across the spectrum of preventive care - from healthy to chronically ill -and priority measures for what falls between - for those at risk - to allow us to intervene early enough.
Finding the right mix for payment reform might involve encompassing bundled payments alongside some capitation. The latter being voluntary. The fee-for-service payment system should remain the primary source of funding for general practice services. While very tempting for Government, stable controllable costs should not dictate here. It is the patient that should remain the focus. More measures addressing out of pocket costs for GP services are needed.
The paradigm shift from a reactive sick care system towards a proactive and predictive healthcare model still seems a distant hope. While we’ve started the transition to restrain the demand for acute services through more focus on preventive care, finding that balance of funding for both acute and preventive care is not easy. This shift will bring about payment reform which can drive significant change for a more sustainable health care system and provide for a healthier future.
A preventive care PIP could have been brought in as part of this latest redesign as a way to boost funding and encourage new ways of working, yet that opportunity has not been pursued. Regardless, the new proposed PIP QI measure should only be undertaken initially as a trial. This could occur alongside the Healthcare Homes’ voluntary trial. The PIP measure needs to be contained to a sample location to truly test its capacity to deliver what it claims, rather than bring unnecessary disruption to practices through national release.
 AHHA. Bundled payments: Their role in Australian primary health care. Australian Healthcare & Hospitals Association. 2015. Available at: https://ahha.asn.au/sites/default/files/docs/policy-issue/bundled_payments_role_in_australian_primary_health_care_0.pdf
 PHCAG. Better Outcomes for People with Chronic and Complex Health Conditions through Primary Health Care. Discussion Paper. 2015 Available at: https://www.health.gov.au/internet/main/publishing.nsf/Content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.pdf
 Duckett S. Opinion: Why it costs you so much to see a specialist — and what the Government should do about it. Grattan Institute. Published 14 August 2017. The Conversation Available at: http://www.abc.net.au/news/2017-08-14/why-it-costs-so-much-to-see-a-specialist-the-conversation/8803864
 RACGP. Standards for general practices (4th edition). Criterion 1.4.2 Clinical autonomy for general practitioners.Availableat:https://www.racgp.org.au/your-practice/standards/standards4thedition/practice-services/1-4/clinical-autonomy-for-general-practitioners/
 Australian Government Department of Health. Consultation Paper Redesigning the Practice Incentives Program. 2016.
 Wright M. Pay-for-performance programs. Do they improve the quality of primary care? AFP 2012;41:989-991. Available at: https://www.racgp.org.au/afp/2012/december/pay-for-performance-programs/
 MacIntosh E, Rajakulendran N, Khayat Z, Wise, N. MARS Blog: Transforming health: Shifting from reactive to proactive and predictive care. 2016. Available at: https://www.marsdd.com/news-and-insights/transforming-health-shifting-from-reactive-to-proactive-and-predictive-care/
6 October 2017
Dr Ayman Shenouda
A focus on palliative care
There was some great discussion generated from my recent blog on frailty and ICU outcomes. The importance of patient empowerment and preference towards care in the community resonated with many. Palliative care is an important extension to that discussion. This is an area, which we know is expanding with demand which is set to rise alongside disease rates and an ageing population. Despite a stronger national focus on palliative care, the patient’s preference for community care is not translating into policy.
Palliative care should improve the quality of life of patients with an active, progressive disease that has little or no prospect of a cure. More and more we’re seeing patients’ preference for palliative care in the home. We know that 70 percent of Australians would rather die at home than in hospital. Whatever the choice, the model of care must enable access to all patients facing a life-limiting illness. We know that those who would get the most benefit from palliative care often accessed it too late. There is still so much in this area that we need to fix. I think a good place to start is ensuring our patients’ preferences around dying at home.
Access and choice
In finding a way through the system to facilitate choice for more community-level care we are still a long way from enabling equitable access. Early access to palliative care services is an internationally recognised policy goal. However, it is clear that our shared policy goal is not being met in Australia when it comes to access and choice.
This highlights our first policy failure, which is around equity in access which of course stretches beyond just palliative care and can be persistent throughout life for some most in need.
Where you live and your socioeconomic status has some bearing on choice in terms of preference of setting in palliative care. AIHW 2014-15 data released early in the year showed that there is a higher proportion of palliative care-related hospitalisations (22.4%) in the lowest socioeconomic status areas. The rate of palliative care-related public hospitalisations was also highest for those living in these areas (30.9 per 10,000 population). Conversely, the rate of public palliative care-related hospitalisations was lowest for those living in the highest socioeconomic status areas (14.5 per 10,000).
Funding and policy context
Funding and policy context really matters here. This is because funding models clearly influence service provision and the development of palliative care services. Funding for palliative care involves a mixed system of public, private and charitable players. A mismatch between policy goals and palliative care funding mechanisms can compromise our shared aim in addressing need. 
This leads to the next policy failure which is around service planning and problematic due to care being split across levels of government.
Service planning relies on quality data and this is a key gap in palliative care. The sole Physician MBS item numbers map only a very small sample of service provision which really limits service planning, particularly in enabling patient choice to die at home.
This palliative medicine focus, while important, is limiting. It means that what is actually occurring at the community level in terms of GP-led palliative care is less likely to inform policy decisions. The undefined role of the general practitioner in palliative care across a range of settings is a contributing factor. While we are seeing more and more GPs with special clinical interests in palliative care meeting these needs in primary rather than secondary care, the system just doesn’t see them.
In the absence of item numbers, how can GP-led palliative care ever be fully measured? GPs play a critical role here. Chronic disease management and home visit item numbers are not sufficient in terms of planning for future demand or in capturing the complexity and non-clinical time involved in providing this care. The only available BEACH data shows that about 1 in 1,000 GP encounters in 2014-15 were palliative care-related, which equates to around 5 encounters per 1,000 population. This is most certainly an underestimate of the actual numbers given services delivered by GPs cannot be established from Medicare data.
Another key issue is that palliative care services have many individual providers both public and private. It is clear we need to get better at ensuring a more seamless service transition for the patient and family. Service integration prioritising multidisciplinary care at the local level relies on flexibility to facilitate the integration of funding streams. In rural areas, this can be particularly challenging even when there is a strong commitment by local service providers.
Service integration at the primary care level remains a key policy failing and much more effort is required to provide the necessary supports to enable a more integrated system.
General practice is the gateway for patients to the broader health system. We need new expanded funding measures specifically designed to enable service integration for palliative care in the community. Efficiencies can be found in community-based care, yet there is a reluctance to put the system supports in place to make it happen.
The recent $8.3 million announced in the Federal Budget will help boost the role that the PHNs have in coordinating end-of-life care. It is understood that the funding will support the provision of a facilitator which may help take the pressure off GP practices who are fulfilling much of this role already for their patients. But much more needs to be done in the area of facilitating greater access to GP-led palliative care services. Building local capacity to address increasing and future demand will require a significantly larger investment than we’ve seen to date.
Capturing broader perspectives
We know that demand for palliative care in Australia will grow. This, in turn, requires an expansion of home and community care in meeting patient preference. An important policy perspective needs to be captured from those receiving care and their caregivers. This will help us work through further how we can improve services to support dying at home.
A final additional focus therefore needs to be on the patient and caregiver if we are going to get this policy right.
A qualitative study of patient and family caregiver experiences of Hospice at Home care provides insights. It states that we need to focus on additional supports for older people and those living alone, recognised as high risk of being unable to receive this type of support. More targeted supports for older caregivers who are at a higher risk of caregiver burden are also required. The policy goal here has to be around promoting their quality of life with an emphasis on training for the full care team in the ethos of palliative care to ensure holistic care.
Where to now?
We know that GP-led community palliative care needs to be prioritised in policy. Yet there remains plenty of barriers limiting service expansion to facilitate this care from within the community and across settings.
Ensuring our system is more responsive to patient choice is of course what needs to drive all policy decisions. We know in this case that it is often a preference for care outside of the hospital setting. But when our system automatically preferences to tertiary care, it makes it harder to facilitate that care. This is unless of course you have well established and integrated service links and a significant local community commitment to make it work.
There’s a pattern emerging here and it’s about prioritising patient-centred healthcare in primary care. Access enabling choice, service planning and data capture, integration prioritising GP-led care and encompassing the patient and caregiver perspectives would bring us closer to a more responsive palliative care service system.
 AIHW. Web Report. Palliative care services in Australia. Last updated 24 May 2017. Available at: https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-in-general-practice
 Palliative Care Australia. National health statistics highlight inequitable access to palliative care. 24 May 2017. Available at: http://palliativecare.org.au/palliative-matters/national-health-statistics/
 Parliament of Victoria. Legislative Council Legal and Social Issues Committee. Inquiry into end of life choices Final Report. June 2016 PP No 174, Session 2014-16 (Document 1 of 2) ISBN 978 1 925458 38 1 (print version) 978 1 925458 39 8 (PDF version). Available at: https://www.parliament.vic.gov.au/lsic/article/2611
 Connor SR and Bermedo MCS. Global atlas of palliative care at the end of life (Worldwide palliative care alliance, World Health Organization), 2014, http://www.who.int/ nmh/Global_Atlas_of_Palliative_Care.pdf
 AIHW, op.cit. Profile of palliative care related hospitalisations.
 Groeneveld EI, Cassel JB, Bausewein C, et al. Funding models in palliative care: Lessons from international experience. McCaffrey N, Cassel JB, Coast J, eds. Palliative Medicine. 2017;31(4):296-305. doi:10.1177/0269216316689015.
 Australian Institute of Health and Welfare 2014. Palliative care services in Australia 2014. Cat. no. HWI 128. Canberra: AIHW.
 Palliative Care Australia. Budget offers new support to coordinate end-of-life care. 10 May 2017. Available at: http://palliativecare.org.au/palliative-matters/budget-phns/
 Jack B.A., Mitchell T.K., Cope L.C. & O'Brien M.R. (2016) Supporting older people with cancer and life-limiting conditions dying at home: a qualitative study of patient and family caregiver experiences of Hospice at Home care. Journal of Advanced Nursing 72(9), 2162–2172. doi: 10.1111/jan.12983
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.