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
21 October 2017
Dr Ayman Shenouda
Health Education Accreditation
No case for change
Australia enjoys an enviable reputation as a provider of high-quality medical education and training. We have built a strong reputation for excellence and quality through a system of Australian Medical Council (AMC) led accreditation standards. A system that upholds patient safety and quality of care through high-level and targeted policy whereby accreditation indicators can be applied consistently has been key to our success. Yet the recent consultation with the release of a discussion paper as part of a Government-commissioned review into the accreditation systems suggests we have a system in need of strong repair.
The key shift proposed in the draft report involves the formation of more centralised control through a new Health Education Accreditation Board with an equally strong remit.
These would include:
The need to pursue such significant change at this time has confused many from within the sector. The specialist medical colleges through the Council of Presidents of Medical Colleges (CPMC) released a response early in the consultation. The Australian Doctors Federation (ADF) and Australian Medical Association (AMA) followed with strong resistance to such significant change to a system which is working well. All seem to agree that the key shift proposed in this paper would see the AMC’s role weakened leading to a dilution of standards and patient care. It would most certainly see unnecessary controls imposed on the specialist medical colleges.
Alignment or more bureaucracy
Major reviews usually share some common factors and this one is certainly not unique. These include the need for strengthened systems to improve outcomes and in driving efficiencies. It is a need for streamlining and alignment that make their way into most of these discussions. This in turn almost always means more government control.
The Accreditation Systems Review report states a need for alignment but then offers additional layers of bureaucracy to achieve it. It recommends increased government control over health professional education and training through the removal of the independence of the regulator. There is also a proposal to give the health ombudsman jurisdiction over specialist colleges particularly in relation to decisions around International Medical Graduates (IMGs).
Making a case for change
These key shifts are being floated as policy solutions ‘to ensure that the educational programs provide a sustainable registered health profession workforce that is flexible and responsive to the changing health needs of the Australian community’.
It is difficult to see how a large bureaucracy will drive system efficiencies and why you would seek more alignment beyond what already exists for medical education through the AMC. Specialty-specific requirements aligned towards patient need are key to determining quality outcomes. This expertise resides from within the specialist colleges and the AMC and will not be found through a bureaucracy-led board without any clinical discipline authority.
The draft paper seeks to introduce changes which really just stem out of a Productivity Commission Review undertaken more a decade ago. Given this review is being led by the same independent reviewer that’s not all that surprising. But it’s clear that much has happened since 2005 which gives, even more, reason for those ideas that were rejected once to be rejected now.
The draft report outlines the case for ‘Reforming governance – the overarching model’ presenting 3 options with their option 3 being the preferred model. Interestingly, all the recommendations within the chapter steer us toward this preferred option or model. It also includes a diagram of the model which does very little to clarify the role of the AMC in this new preferred structure.
It’s clear the discussion omits the fact that the AMC has led some significant reforms to provide a quality framework which delivers an outcomes-focussed approach to accreditation. This may be unintended but it is most relevant to many parts of the governance discussion.
In the last three years, the AMC committed itself to national and international review, to build on its strengths and develop and implement a range of new activities. Revised standards for specialist program accreditation were rolled out after a two-year review and consultation effort. Progressing the evaluation and deployment of a new accreditation management system that sees a more streamlined accreditation processes.  None of these get a mention yet they have been implemented to achieve many of the very aims outlined in this discussion. The fact is that the AMC has already implemented outcomes-based standards and it is working towards a more streamlined system.
Delivering a more responsive health workforce
Building on the recent AMC-led reforms through encouraging more inter-professional team-based learning is now key. Alignment can certainly be achieved through a stronger multidisciplinary approach and there remain plenty of barriers in the training system limiting us here. The report makes some good points around this issue. Ensuring our health workforce is more responsive to emerging health and social care issues and priorities through encompassing a stronger team-based approach is precisely where we need to focus our efforts now .
Driving key workforce priorities through our accreditation system through some of those key enablers identified throughout the report should be pursued. These include more use of simulation-based education and training in the delivery of programs of study as well as making mandatory the inclusion of inter-professional education in all accreditation standards. This more team-based approach to learning is most important enabling service alignment and it would be good to see it formalised in some way.
The other really important area for workforce policy is the requirement that clinical placements occur in a variety of settings, geographical locations and communities, with a focus on emerging workforce priorities and service reforms. This is particularly important to rural and remote communities and together with current workforce planning mechanisms will help ensure we can address unmet need. It will help build a rural GP generalist workforce prioritising essential rural advanced skill areas, procedural and non-procedural, in response to service and skill deficits. If planned appropriately – in prioritising skill need – then these shifts will help to rebalance training it current acute setting focus. This will help to prioritise funding to ensure more community-based exposure strengthening these service solutions over time which will bring about those required service reforms.
After deciding stakeholders needed a little longer to absorb the long draft report, an extension was granted with submissions having just closed (16 October). It will be interesting to see how this discussion evolves before a final report is considered by COAG Health Minister at their next Ministerial Council meeting in November. I think on many aspects this review failed to make the case for major reforms to governance particularly in light of the changes already implemented from a medical training perspective by the AMC. The real opportunity here is to build capacity from within the current structure to align skills to workforce need towards a more integrated national training solution.
In prioritising what needs to be done it is important to realise that we have an accreditation system which is working well. There is good reason why the AMC is internationally recognised for its work. We have the highest possible standards of medical education, training and practice already in Australia. The specialist colleges are key to ensuring we keep it that way through the delivery of high-quality specialist training. They also play a vital role in providing national oversight and consistency to medical specialist training. More dialogue was most certainly warranted before presenting such significant shifts. I hope the discussion moving forward brings a more balanced perspective encompassing the many areas of reform already achieved to build on these areas in ensuring a future workforce responsive to need.
 CPMC. Media Release. Australian Medical Regulation Must Remain Independent. Council of Presidents of Medical Colleges 2017. Available at: https://cpmc.edu.au/media-release/australian-medical-regulation-must-remain-independent/
 AHMAC. Australia’s Health Workforce: strengthening the education foundation. Independent Review of Accreditation Systems within the National Registration and Accreditation Scheme for health professions.Draft Report September 2017. Australian Health Ministers’ Advisory Council 2017. Available at: http://www.coaghealthcouncil.gov.au/Portals/0/Accreditation%20Review%20Draft%20Report.pdf
 Productivity Commission 2005, Australia’s Health Workforce, Research Report, Canberra. Available at: http://www.pc.gov.au/inquiries/completed/health-workforce/report/healthworkforce.pdf
 AMC. Annual Report 2016. Australian Medical Council Limited. 2016. Available at: http://www.amc.org.au/files/656a1621bae0b8baaabca9e3ada8280a1dcbd38f_original.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
29 September 2017
Dr Ayman Shenouda
Cybersecurity in healthcare
The recent darknet Medicare breach came only a few months after the UK malware attack on the NHS locking its systems. You would expect the focus of authorities on potential threats to be high given the fallout from that. But we’re told the Government only became aware of the darknet issue from the media. And, that it had been there a while too: the data had been for sale on the darknet auction site for nearly nine months. So, while 75 Australians’ had their Medicare details sold, it appears neither the Department nor our security services were actively monitoring this posting.
We clearly need to get better at this. The Government had already demonstrated through the botched handling of the 2016 Census how unready it really was when it comes to predicting even the most predictable of attacks. The ABS website was crashed by a series of DDoS attacks which shut the census website down for nearly two days. Unfortunately, successive security and data breaches from government agencies like these only serve to undermine public trust.
Risks and benefits
Digitalisation of healthcare is a positive innovation but it comes with certain risks. It is a simple fact that the value of healthcare data makes our system more vulnerable to privacy breaches. You could say that publishing data of any kind potentially holds great risk to privacy. But certainly, the benefits in terms of service planning and health research outweigh those risks. It all comes down to how risks are managed so not to stifle policy or undermine public trust.
If we want to achieve a more integrated healthcare system then the only way forward is through enabling policies. The integration solution lies in policies such as those being pursued through the My Health Record.
We know the risk on our healthcare system and organisations through data theft attacks are becoming more common. As in health, prevention is always better than a cure and on this issue, the approach is the same. The focus here not only needs to be on how governments’ handle our personal information but how providers can be better supported to ensure organisational readiness.
My Health Record
There are a number of policy implications in terms of increased health information technology-based reforms. As the complexity of health services increase, the number of entities involved will increase and with that comes more risk around potential privacy breaches. We’re on the cusp of implementing long-awaited reform through the rollout of opt-out participation of the My Health Record system. It’s important to ask if this latest breach has shifted patients’ perceptions or altered their digital trust in moving forward on this policy.
We know that a Medicare card number alone is not enough to access a patient’s My Health Record. The official website reassures us that My Health Record is a secure online summary of a patient’s health information. That it is up to you what goes into it, and who is allowed to access it. While that last statement may be true, how well can this containment really be controlled?
Meanwhile, it seems take up in the pre-implementation phase of the opt-out My Health Record seems quite promising. The official stats show that almost 21 percent of Australians have already registered. The web page boasts that over 5 million people already have a My Health Record, with an average of 1 new record being created every 38 seconds. As with any good policy news, you can even follow progress with a helpful link provided: Keep up-to-date with the latest statistics on the My Health Record here.
Digital trust and implications for My Health Record
The Senate Finance and Public Administration References Committee Inquiry in August following the dark web breach has brought some new perspectives to the issue of digital trust. The 13 submissions provide some valuable insights, some of these I’ve summarised below.
The first cab off the rank, the Centre for Internet Safety, certainly didn’t hold back on the implementation of My Health Record. Stating that the shift to an opt-out system ‘has done little to quell public anxiety surrounding the placement of sensitive health details into the online world’. Critical also of the Government’s communication strategy which it says has not managed to convince on matters of security. This, combined with the constant reporting of breaches is all contributing to diminished trust, safety and confidence.
Their submission also states that the promotion of privacy issues and the importance of the protection of personal information is critical to the ongoing functioning of the online environment. To secure buy-in, it is important to create ‘benefit profiles’ alongside these new technology projects to truly test measures of ‘consumer trust, safety and confidence in the intended service delivery’. In terms of My Health Records, they warn uptake will be very slow unless the Department can adequately address the trust, safety and confidence benefits and competently communicate these to the public.
The Australian Information Commissioner’s input provided some useful guidance stating that ‘the use of personal information should be necessary, proportionate and reasonable to achieve the policy goals’. The Privacy Impact Assessment (PIA) is a policy tool designed to assist agencies to consider these matters measuring possible impacts on the privacy of individuals. The Commissioner stated that, in the case of the Medicare breach, a PIA would have highlighted privacy impacts associated with assessing Medicare care numbers through an online portal environment. Importantly, it would have identified any further proactive measures required to mitigate those impacts.
Both the RACGP and the AMA do not believe this latest breach will have any implications for the My Health Record roll-out. The University of Western Australia, while outlining the value of Medicare identification information to a criminal – identity fraud, prescriptions to obtain painkillers and possibly S8 medications as well as to divert Medicare rebate payments from a legitimate account to a false one - also state motivations to access to My Health Records or medical records of any kind as being less likely.
Importantly, the RACGP highlighted that even with preventative measures in place, real risks persist for any organisation in terms of internal or external data breaches in an interconnected world. There are College resources to support GPs to minimise risks including the RACGP Computer information security standards (CISS). It states that those practices implementing the cybersecurity and privacy guidance provided here are less vulnerable to a data breach.
Both the Department of Health and the System Operator of the My Health Record System, the Australian Digital Health Agency, state that is important to note that illegally obtained Medicare card numbers are not sufficient on their own to provide access to clinical records or an individual’s My Health Record.
The System Operator appropriately provides a detailed response to the impact on the rollout from the Medicare information breach. Reassuringly, it states that security and operation of the system protect against the unauthorised disclosure of health information from the My Health Records for individuals with access to Medicare numbers. Additional information is required to authenticate consumers and healthcare providers. But, despite these reassurances, it is clear in other submissions including those from the University of Melbourne, Deakin University and the University of Newcastle that concerns remain with the My Health Record system and its pending rollout. Future Wise give an excellent technical response to the issue as well as policy solutions in moving forward.
The policy lessons
It is important to see the risks in terms of potential implications to the rollout of the opt-out My Health Record system tested through this consultation. It will be interesting to see what recommendations are made in the Senate Finance and Public Administration References Committee Inquiry in its report due in October. Overall, I think more work needs to be done here with much more focus required on strategies to protect patient data in rebuilding trust.
From these consultations, mechanisms for overseeing and monitoring access seem lacking, so are the required assurances around data storage and controls and the system-wide capacity to provide the security controls to mitigate risks remain unconvincing. The collective wisdom provided in these submissions will help guide policy to safeguard from further threats in the future. As stated earlier, the success of important reforms including My Health Record comes down to how risks are managed so not to stifle policy or undermine public trust.
 Yaraghi N. Hackers, phishers, and disappearing thumb drives: Lessons learned from major health care data breaches. Centre for Technology Innovation at Brookings. May 2016. Available from: http://wikiurls.com/?https://www.brookings.edu/research/hackers-phishers-and-disappearing-thumb-drives-lessons-learned-from-major-health-care-data-breaches/
22 September 2017
Dr Ayman Shenouda
Influence or overload
We spend a lot of time trying to influence policy makers around what’s best for our patients. Advice which is always well-intentioned and usually offering the right policy fix, GPs work hard to influence and bring about positive sector change. We are passionate advocates for the patients and families we care for. Too often we see for ourselves the impact poor policy has on people’s lives. The solutions mostly lie in the evidence-based care that informs our everyday practice making us important policy participants.
a political perspective, it must be quite hard being on the receiving end of all this advice. Having to work through submissions from every health organisation in the country with their list on how best to fix it. Sifting through the detail trying to find some common ground against their own checklist of whose voice beckons their closest attention politically. Then trying to work through the conflicting areas of advice, where the bias may lurk, to find the most workable solution.
What’s really in the message?
The Political Alerts allow us all to participate in this spectacle checking online what each has had to say. If you’re like me you sit back and try to see if there is alignment in any of it. Next, comes the quick filter on who’s come up with the best response to the actual issue at hand.
The media too has its favorite. The go-to spokesperson on just about every health issue that impacts the sector. Not always the actual peak or expert on the issue either and for those at the grassroots the message sometimes seems a little apart. But then those real issues are just reduced to sound bites and random visuals if there is time around the spokesperson. In the end, the message is either oversimplified or reduced and likely to confuse.
Unfortunately, there will always be that competing tinges leaving an identifiable stain that prioritises first the organisation it represents. This almost always comes through and sometimes only subtlety but easy to spot for those within the system.
Finding common ground
Perhaps this could be made so much simpler – not only for the policy maker but in terms of outcomes – if we just came together as a united group and settled policy first.
This is not to say that collaboration doesn’t occur around issues. It does and usually at the highest levels. There are a number of unifying structures in place: The Council of Presidents of Medical Colleges, United General Practice Australia and of course on rural issues, the National Rural Health Alliance.
Often finding that common issue or cause is not all that hard. We already have it and it lies in patient centred care and that focus in primary care is what unites us. But this simple message becomes distilled when there are parts of the system vying for their space, sometimes even survival.
Primary care and collaboration
Primary care is just one of those areas where we can’t afford to lose focus.
It is a sector, which relies on teamwork. We already collaborate well by working together to share our expertise or to find ways to integrate for stronger outcomes but we can become easily undone by professional interests.
Over the past two decades, I have been involved or have been a director of a number of peak organisations involved in primary care. Obviously, an organisations first priority will always be to make sure it is able to achieve its own goals and aspirations. As a director, you learn to work within these boundaries. But these organisational-level priorities sometimes make collaboration more difficult.
Some strategies for collaboration
For collaboration to work, respect and trust are key.
Quite often it is the lack of trust among organisations in terms of intentions, which makes it so much harder to find common ground. We need to create a shared vision of the future and move towards it together. Have an agreed common goal and sign up to it.
It’s also important to look to the other influences that help us collaborate.
Take the time to build the relationships that support collaboration. This often means to value and embrace difference and healthy conflict. There can be great value from opposing points of view in terms of finding new solutions to tired problems.
We should also challenge the status quo together so no one has to face difficult change alone. And always strive for win-win outcomes where possible.
Finally, strong interpersonal skills among leaders are important to build the collaboration required to influence change.
More effort in bringing together the right mix of people to respond to issues impacting on our sector would support stronger outcomes. We have such a great diversity of talent within primary care which can be tapped into relatively easily bringing stronger depth to so many issues.
Sometimes referred to as coalition building it is about forming coalitions with those holding similar values, interests and goals to combine expertise and resources for a common purpose. In our case it is about having a ready-made alliance structured around targeted areas of expertise or the various issues our sector is likely to face.
It is well understood that a broad-based, grassroots coalition enhances credibility. Bringing together diverse participants with similarly diverse skillsets and access to target populations for stronger reach makes sense. Encouraging broad participation also ensures we can bring new ideas and fresh energy to an issue.
These types of strategies help bring a united voice to an issue. We should be supporting each other across issues that impact on primary care as a whole – at both the local and national levels. It would be great to start a discussion around this and we can start now. I’d be interested in your views around how we might be able to better facilitate these types of policy alliances in the future.
We’re better together
The whole is greater than the sum of its parts. It’s quite simple.
I think most working in primary care would consider that the whole is greater than the sum of its parts. First coined by the philosopher Aristotle, I love this phrase as it reminds us that we are better when we work together. And I really think that should guide our future policy contributions, particularly in primary care. It’s not always easy to implement but I think we need to get much better at it. It’s really just a case of an overcrowded agenda, which needs uniting or risk being overlooked. We most certainly need a united front in primary care.
Changing our healthcare system starts in the consulting room
15 September 2017
Dr Ayman Shenouda
There’s been a lot of discussion around empowering the patient more in their treatment decisions. That we need to shift our focus toward a system that empowers and facilitates choice. But undermining a shared decision-making model – one which has room to provide for both clinical choice and patient choice – is our healthcare system. We have a system which is based on a disease-based model of care which leaves little room to take into account the context of the patient's illness. A system that can allow us to refocus on the patient-centered, personal and unique experience of “illness” must be prioritised.
Patient experience in the health system is so vitally important and has to be valued. For me, changing our healthcare system really starts in the consulting room. It’s that doctor-patient relationship that I really value. And this often goes unnoticed by our decision makers – but it is here where lasting change can be realised. Discussions in general practice are of great value for helping patients take charge of their own health. A more focussed effort here not only helps to improve health but will support quality reform measures which can reduce costs.
Research shows us the benefits of a shared decision-making model approach. These include knowledge gain by patients, more confidence in decisions, and more active patient involvement. Studies have shown that, in many cases, informed patients elect for more conservative treatment options.
Preparing for the challenges ahead
The health system cannot cope with what it is facing. Health care demand on the system is reaching crisis point with public spending at unsustainable levels. Empowering patients is most certainly part of the solution if we are ever going to meet rising demand with an ageing population. But to do this, empowerment needs to be met with a system that can facilitate choice.
Recently I attended an event organised by the RACGP NSW Faculty delivered by an ICU Physician who led an impressive discussion around frailty. He spoke about the elderly intensive care unit (ICU) patient and poor outcomes. More specifically, the need to identify frail patients at high risk of poor outcomes and plan accordingly.
We were brought across a study which investigated the effects of frailty on clinical outcomes of patients in an ICU. It used a frailty index (FI) which was derived from comprehensive geriatric assessment parameters. It found that the use of a FI could be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs. Another study found frailty is common in patients admitted to ICU and is associated with worsened outcomes. It recommended that this vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans.
Identifying patients at high risk of poor outcomes is key here. But the system cannot identify what frail means, nor does it empower GP decision making at the cold face. Applying the FI is one way to ensure we’re not placing patients where there is no real benefit. But the culture within hospitals makes it hard to implement this tool. Enabling end-of-life discussions particularly at a point when there is a crisis situation is also a barrier.
Planning for end of life and putting in place an Advance Care Plan early is essential. GPs are very good at this. It should be undertaken as part of the Over-75 Health Check. and helps equip the patient, and their family, well for what lies ahead. It’s a good time to talk to the patient about prevention, maintaining functionality, minimising pain or complexity of disease as well as strategies to address them. It is also time to start the discussion around being frail and their expectations around that.
High price for poor outcomes
We know that more than 30 percent of patients admitted to intensive care units never make it out. Those that do rarely make it back to their own home. It costs around $4,000 per night in ICU . This spend can be better utilised if redirected to support patients in their own home.
I know from my own elderly patients’ experience that it is often hard for the patient not to end up in ICU. The system makes it hard to facilitate this care in the community. And it’s hard to take on the system during a crisis. It takes a strong family who is across their loved one's wishes.
Care in the community
I recall consulting at my surgery in The Rock some years ago and receiving an urgent phone call. It was the daughter of my 82-year-old patient and she needed my help in preventing the transfer of her mother from Wagga Base to Sydney. She told me the specialist was transferring her and that the family did not want her to go through this and that her mum didn’t want this either. They understood that their mum was in a critical condition but wanted her close to home.
I immediately made the call to the Specialist Respiratory Physician who explained she had a flouting clot in her pulmonary artery and needed an embolectomy and a filter in her IVC. The specialist had already discussed her case with the Cardiothoracic Surgeon in Sydney and organised the transfer. I explained that the family had called and that this was not what my patient, nor her family, wanted. I also explained that I was prepared to look after her in the community. Fortunately, the specialist at Wagga was comfortable provided she sign a discharge against medical advice.
This patient lived for a further five years. She was able to attend her grandson’s wedding in Sydney two years before she died peacefully at her home with her family around her. A testament to her strength and also that of her family. They ensured she stayed in Wagga to receive care an appropriate level of care in the community. They insisted that she was not transferred to a Sydney hospital where she was likely to end up in ICU and never to come home.
Making the system work
How can we ensure that the system can default to enable care in the community, rather than automatically preference for tertiary care? While there exists a frailty tool there’s reluctance to use it. There’s plenty of GPs happy to care for their patients in the community if that’s their choice. But rarely will the patient’s GP be consulted at that critical stage. There is also limited funding to facilitate this care.
A reality check is well-overdue in terms of outcomes particularly in dealing with the frail. We’re missing the point on where to focus care. This needs to be where there is the greater need and where the efficiencies can be found. And this is not on a system which is disease focussed and already crippled by expensive treatments. To prevent waste, more realistic expectations around outcomes can be achieved through person centred care enabling empowerment. One of the strengths of general practice is the unique relationship between patients and their GPs. Patient centred communication and shared decision making is the foundation on which our health system can be remodelled. Let’s prioritise it.
 Green AR, Carrillo JE, Betancourt JR. Why the disease-based model of medicine fails our patients. Western Journal of Medicine. 2002;176(2):141-143.
 Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner, M Llewellyn-Thomas, H Lyddiatt A, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2011;as well as(10):CD001431.
 Kizilarslanoglu, M.C., Civelek, R., Kilic, M.K. et al. Is frailty a prognostic factor for critically ill elderly patients? Aging Clin Exp Res (2017) 29: 247. https://doi.org/10.1007/s40520-016-0557-y
 Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Medicine (2017). 43: 1105.https://doi.org/10.1007/s00134-017-4867-0
Health sector reform: towards a sustainable system.
8 September 2017
Dr Ayman Shenouda
A decade of reform
We’ve had a multitude of reforms over the past decade or so with much of it stemming from the National Health and Hospitals Reform Commission (NHHRC). A strengthened consumer voice and empowerment was perhaps the most important shift in the reform discussion at that time. A shift which held great promise in realising change through a more patient-centred approach and one which prioritised primary care and its role in achieving the required shifts.
During the NHHRC years of review, significant structural reform was recommended including in terms of responsibility for primary health care services as well as a more transparent and equitable funding model for public hospitals. The latter has seen some sizeable shifts, particularly in the way we determine funding to public hospitals through the introduction of activity-based funding.
We’ve seen other changes too in formalising shared policy commitment in the form of National Partnership Agreements to help set and agree upon priorities and measure progress across a range of areas.
Structure reform requirements
It’s clear that much has been done to improve the performance of Australia’s health system. But after years of review and with policy fatigue well and truly set in are we any closer to a framework which will secure the future sustainability of Australia’s health system?
Key to realising patient-centred health policy lies in structural reform to promote more integrated care. Our past attempts haven’t brought us much closer to realising this clear requirement, noting we are still implementing much of it as many reforms are ongoing. Information Technology provides certain opportunity here. The My Health Record (formerly PCEHR), as one key measure, is still being implemented and yet to deliver on its promise. As it transitions towards the planned opt-out phase mid-2018 there is still much hope that it will succeed.
Organising primary care through a medical home model of care would also support integration and provide patients with continuous, accessible, high-quality and patient-centred care. Australian general practice encapsulates the medical home model, and a supported policy shift here, if funded appropriately, together with further incentives to promote integrated care across different care settings, would bring us closer to the level of reform required to address current and future demand.
But fragmentation in health care structure exists largely due to the primary and secondary care divide. Each which is then further complicated by its own arrangements through compartmentalised funding streams. This, of course, leaves little to no room to integrate at least not to the level we need to.
Complex governance structure
It’s clear that system complexities brought about by a governance structure with responsibilities falling between the Commonwealth and the states and territories have not served the health consumer well. It’s hard to navigate and even harder for patients with complex or multiple illness or disease.
Bringing the responsibility for acute and primary care together at one level of government is one clear solution. Devolving primary care to the states and territories might just help provide the structures and incentives needed to promote integration. A way forward might be in the form of a state-level trial to integrate local hospitals and health services with primary health networks piloting integrated models in one health service/local health district.
Integrated funding and management have been suggested before, many times in fact and it wasn’t that long ago that we had a serious discussion around it from former Prime Minister Rudd, although with a Commonwealth dominated role in mind.
More recent discussions lead to a similar conclusion, that a move to a single or pooled source of government funding would help to eliminate bureaucratic cost shifting and duplication. This alongside more private sector contributions and alignment to outcomes. Integrated funding and management is one of five central policy levers available to reform Australia’s health system. The other four are around consumer empowerment and responsibility; wellness and prevention; optimised care pathways; and information-enabled health networks. 
Making it better
It is important to acknowledge that Australia has a strong system of healthcare. A high-quality universal healthcare system with coverage through Medicare to the main components of care extending across public hospitals, medical services and pharmaceuticals. The Commonwealth remains the dominant policy maker, which is due to the simple fact that it generates most of the funding. There is a complex division of roles and responsibilities across levels of government with the involvement of both public and private sectors.
The financial dependency of the states on the Commonwealth makes it harder for them to lead in this area. The required focus on outcomes likely to become a bit blurred when it is confined to funding limits and controls imposed by it. While there may exist a shared policy objective - whether that is to help people sustain and improve their health or improving quality or even equity in access - in attaining those measurable outcomes compromise is always tied to the narrow confines of what has been negotiated.
It seems the way forward comes back to a question around who’s best positioned to lead? The current division of responsibilities and roles across levels of government impacts significantly. Devolution of responsibility and funding to one level should be tested to see if integrated funding translates to integrated delivery. If we can move beyond the control being where most of the funding is generated for one moment then we might get a little closer to fixing our fragmented system. This is where we remain stuck and unless tackled we will not move forward.
 The Royal Australian College of General Practitioners. What is General Practice? Melbourne: RACGP; 2012. Available at www.racgp.org.au/becomingagp/what-is-a-gp/what-is-general-practice
 Bartlett C, Butler S, Haines L. Reimaging Health Reform in Australia. Taking a systems approach to health and wellness. PwC; 2016 Australia. Available at: https://www.strategyand.pwc.com/reports/health-reform-australia
 OECD Health Policy Overview. Health Policy in Australia. OECD; 2015. Available at: http://www.oecd.org/australia/Health-Policy-in-Australia-December-2015.pdf
 PwC 2016, op. cit., p. 22.
 PwC 2016, op. cit., p. 8.
 The Commonwealth Fund. Health Care System and Health Policy in Australia. Available at: http://www.commonwealthfund.org/grants-and-fellowships/fellowships/australian-american-health-policy-fellowship/health-care-system-and-health-policy-in-australia
Let’s not lose another rural obstetrics service
1 September 2017 Dr Ayman Shenouda
Decline of rural obstetrics services
It was disappointing to see yet another decision without due consultation to downgrade rural maternity services recently and this one was particularly close to home for me. Temora Hospital’s maternity services will be reduced with patients requiring maternity surgery under general anaesthetic moved to other district hospitals. Only a month earlier, in July, it was Emerald in Queensland that was in the spotlight due to a maternity service closure. But none of this is really new, is it? Nationally we’ve seen more than 50% of small rural maternity units closed since 1995.
In this latest downgrade, we’re told Temora’s maternity services for low-risk pregnancies will continue but caesarean births and gynaecological surgery will now be relegated to Cootamundra and Young hospitals. This just shifts the costs in my view and is not a sustainable solution for this community and could see broader impacts on other services too if works are not prioritised and essential staff leave. Surely, part of the cost equation has to also look at the costs transferred to the patient as well as the skills lost and broader safety aspects of NOT having a locally accessible service?
The NSW Health Minister Hon. Brad Hazzard MP says he was kept in the dark on the decision by the Murrumbidgee Local Health District (MLHD) and wants the service retained. There is at least some hope for this community with the Minister making clear his views on the matter. But why do we need to get to this level in the first place? Local level planning and consultation should have occurred on such an important issue and well before it got to ministerial intervention level and preferably not debated through the media in this way.
Impacts for the local workforce
Putting aside the clear impacts of this decision - including higher risk birthing outcomes - for one moment. What now for the three obstetric providers who have been providing this service? One GP obstetrician in the town stated in the Harden Murrumburrah Express that she did not want to see Temora become a victim of bureaucracy.
We know that driving decisions to close or reduce rural maternity services is often around doctor shortages, safety concerns or funding constraints. This decision according to media reports comes down to physical infrastructure costs. The issue is the obstetrics theatre room was deemed unsafe for surgery following an audit by the Australian Council of Healthcare Services.
Rural patients need viable maternity and surgery services near to where they live. And doctors who invest in training to ensure a service for their community need some certainty around service continuity. They most certainly need to be involved in local service decision making which certainly seems not to have been the case in the Temora downgrade.
A strong focus on policy
This is a decision which seems contradictory to what we’ve seen from NSW HETI in terms of its rural generalist pathway. There has been an expansion of training positions this year with 40 positions being made available.
It is also contrary to the focus nationally which has seen committed action over an eight-year period. There has been a strong policy focus in the form of a Maternity Services Review (2009), a National Maternity Service Plan (2010-2015) and the current development of a National Framework for Maternity Services.
We’ve seen such a strong policy response in recent years and it’s important that local level planning decisions work within these broader nationally set priorities. Both the National Maternity Services Plan (2010-2015) and new National Framework for Maternity Services (2017), which is still being finalised, have set specific priorities to secure more equitable outcomes for rural patients including in the areas of access and workforce.
Some great policy outcomes have resulted already including in terms of tools to inform planning and in areas of national data development.
The Australian Rural Birthing Index (ARBI) was a key outcome of the Plan which has provided an important index to help in the planning for maternity services in rural locations. The index can be downloaded here: http://ucrh.edu.au/wp-content/uploads/2015/07/ARBI_FINAL_PRINT.pdf .
While the AIHW-led National Maternity Data Development Project aims to enhance maternity data collection and reporting in Australia. Both are important national planning tools which aim to utilise a population based planning approach as the basis for demand driven evidence-based decision making.
Protecting rural services
Despite such a strong policy focus and commitment, it is evident that we still need to improve maternity services in rural and remote communities. There is clearly state-level support for the development of rural GP procedural skills. However, this needs to also extend to rebuilding rural hospital infrastructure when required to ensure service continuity. Here in NSW, we have a policy commitment to develop workforce capacity by expanding rural generalists being potentially compromised by a local level decision driven by infrastructure costs which have led to the downsizing of maternity services.
The critical role of procedural GPs – both GP obstetricians and GP anaesthetists – in providing maternity services in rural Australia is well understood. Decisions which see closures or a downgrade of services will have a direct impact on the long-term commitment of both current and future rural doctors. Let’s not lose another rural obstetrics service – operative obstetrics and gynaecological procedures are needed in Temora and funding should be found to upgrade the operating theatre.
 Rural Doctors Association of Australia. Maternity services for rural Australia. Manuka: Rural Doctors Association of Australian, 2006.
 The Daily Advertiser. Media Article: Minister ‘kept in the dark’. Published 22 August 2017.
 Harden Murrumburrah Express. Media Article: Temora Hospital theatre closure could see expectant mothers transferred to Cootamundra or Young Hospital. Published 21 August 2017. Available at: http://www.hardenexpress.com.au/story/4870112/obstetrics-theatre-room-closing-at-temora-hospital/
 Longman J, Pilcher J, Morgan G, Rolfe M, Donoghue DA, Kildea S, Kruske S, Grzybowski S, Kornelsen J, Oats J, Barclay L. (2015) ARBI Toolkit: A resource for planning maternity services in rural and remote Australia. University Centre for Rural Health North Coast, Lismore.
25 August 2017 Dr Ayman Shenouda
RECRUIT, TRAIN AND RETAIN
Getting the policy settings right
I don’t think there’s ever been a better time to secure the next generation of rural GPs. Now more than ever before we have the right policy settings in place. We need to seize this opportunity to ensure we select the right doctors for rural Australia.
Once we’ve overcome that first hurdle in getting them there, we need to then ensure those registrars who choose rural practice, that once secured, they remain there. But not only remain there that they continue to thrive. To do this we need to ensure the right supports are in place.
The policy momentum has been building for some time with the help of thousands of rural GP champions – possibly most now reading this blog – who have advocated for change over many years.
We now have the right set of policy conditions: an overall increase in medical school intake with quarantined placements for rural; a rural emphasis and exposure with a focus on generalism as a priority in the training; and, of course, the regional training hubs which will soon be in place to help link the various stages of training.
We finally have the makings of an integrated rural medical training pathway. This includes a priority on rural community internships – a clear gap which needed fixing – and soon with the regional hubs, training can be structured in a more coordinated facilitated way.
The hubs, in particular, will strengthen the efforts of the Rural Clinical Schools’ and help build the facilities and infrastructure and teaching capacity needed to make this work. For the trainee, it will help to provide the navigational supports that have been so lacking in the past from medical school to rural practice. Importantly, we have a focus on non-coercive strategies in securing the next generation of rural GPs.
Why enter, why stay, why leave?
We know that many factors influence rural intention and that it is getting those supports right and across the full training continuum that counts.
Ruralising the curriculum is a key one. Embedding more primary care early into the medical curriculum is essential and this has certainly been said often enough. But other simple things like placing a rural scenario in the exam would also help to formalise assessment to enforce primary care and emphasise the important role of the generalist.
Getting them in early and interact as often as possible is another key requirement. Nurturing your registrars once there requires a whole of community effort.
I think it is instilling that sense of belonging that is vital at this point so the emphasis then needs to be multifactorial. Positive exposure offering a mix of rural experiences including clinical and nonclinical competencies and of the latter leadership being a key one here, the ability to lead and work in teams cannot be emphasised enough.
Trainees want broad exposure and the opportunity for multiple levels of clinical learning through blended placements. Trainees need to be empowered to make informed career decisions and to obtain the skills they need in the local setting. A community with the right structures and partnerships in place can facilitate this well.
Next is community connection and engagement and getting that right. This really gets to the heart of the issue – this is why they stay – that sense of place and identity. Ensuring a strong rural connection is hard work in training terms but worth the effort in the long run.
This is all part of developing a professional identity and mentoring plays a key role here. Longer-term placements in and around the same community also help to build those lasting relationships.
While I think an intrinsic characteristic of most GPs is their altruism there are also limits. We need to formalise that mentoring point – and at every learning stage – so that rural GPs and broader teaching staff are able to commit their focus towards mentoring.
More funding for mentoring has to be part of the suite of incentives in support of rural intention. Formalising succession planning in this way would help to ease the pressure on those nearing retirement too. That’s the ‘gracious exit’ part that often gets forgotten but just as vital as ‘easy entry’ for rural.
A rural pipeline functioning well can support these broader retention outcomes in terms of supplementing supply over time through a constant stream of new entrants. This would help make rural practice even more attractive as it provides an exit strategy for rural GPs without having to make that lifetime commitment. Rural GPs could stay for a shorter period, up to five years, without causing the workforce disruption that currently occurs upon exiting. Rural practice could become a standard part of the GP journey with supportive policy offering more flexibility and opportunity to spend at least part of your career within a rural community.
Now finally, getting to the hardest bit. Once you have them, then the focus then shifts to keeping them there. And getting to the bottom of that is a whole new set of questions which tend to include broader impacts including those on family.
Factors including an adequate income, appropriate workload, locum provision, access to specialists’ advice and continuing education, spouse career opportunities and children education all come in to play. Again, it takes a whole community to help make this work.
Bringing it all together
Piecing it all together there are a lot of factors that need to come together to get rural recruitment, training and retention right. Ensuring we have the right set of incentives in place for those making the commitment is key to policy success including rewarding advanced skills, procedural and non-procedural.
In understanding intentions to practice rurally, we know that rural origin plus a rural clinical school placement is a significant predictor. But there are many ways to get there and we should keep an open mind as many get there by accident. I think I fit that last category having only come to rural practice at the age of 35 after commencing in a completely different specialty to being with.
In securing strong rural outcomes, it comes down to nurturing those with an interest and being able to bundle those known influences. We’ve certainly come a long way in securing the right supports and focus to realise a fully integrated rural training pathway. It’s a multitude of factors including supportive policy and a strong local commitment from each and every one of us, but not least the trainee to secure the next generation of rural GPs.
 RACGP. New approaches to integrated rural training for medical practitioners. Royal Australian College of General Practitioners. 2014. Available at: http://www.racgp.org.au/download/Documents/Rural/nrffinalreport.pdf
 Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med. 2017 Aug 1. doi: 10.1097/ACM.0000000000001839. [Epub ahead of print]Availablat: http://journals.lww.com/academicmedicine/Abstract/publishahead/The_Road_to_Rural_Primary_Care___A_Narrative.98154.aspx
 RACGP 2014, op. cit. p.65.
 Humphreys J, Jones J, Jones M, et al. A critical review of rural medical workforce retention in Australia. Aust Health Rev 2001;24:91-102. [PubMed]
 Walker JH, DeWitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural Remote Health. 2012;12:1908.PubMed
18 August 2017
Dr Ayman Shenouda
Most will agree that high quality care in general practice relies on effective teamwork. There are some good studies providing insights into the key features of effective primary health care teams confirming a strong correlation between a good team climate within the practice and a range of aspects of high quality care. [i] A stronger focus on research within general practice, in my view, would provide more quantitative studies detailing the effects of integrated multidisciplinary teams from within the practice setting for differing health populations and geographic regions.
From a broader health system perspective, there is currently strong interest on the efficiencies of multidisciplinary teams and their effectiveness in improving health outcomes and lowering costs. The role of the team in supporting integration between services and in enabling a shift from episodic to continuous care at a whole of system level. Driving this interest is also the need to develop new models of care in addressing increased demands associated with an ageing population and as the disease burden increases.
The multidisciplinary team is best defined by Cohen and Bailey (1997) as ‘a collection of individuals who are independent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’.[ii] Therefore, ‘teamwork’, in this context, is the product of interactions between healthcare professionals in a team.[iii]
Teamwork starts at the practice level
My focus here is in establishing structures to support effective team interactions within your own practice first, providing ways to evaluate or measure success, which can then build toward broader integration aims.
In measuring practice-level performance, teamwork in the primary care setting is often determined through a focus on a specific disease area such as effectiveness in terms of management of chronic diseases. Organisational capacity within general practice can also be tested through quality improvement measures such as through clinical audit.[iv] In my experience, clinical audit provides an effective way to measure the effectiveness of multidisciplinary teams in a value driven hole practice approach that aims to deliver quality patient care with clear achievable outcomes. Its participatory structure also allows you to ensure involvement from the full team in finding practical solutions.
We know a much broader funding focus is required in terms of driving more effective ways to manage the increased complexities and costs associated with the new patient norm of multiple comorbidities and chronic diseases. Structural and system supports are required to enable coordination and collaboration across boundaries – primary, secondary and tertiary care. In order to truly tackle and address fragmentation and achieve a more seamless service for patients throughout their disease trajectory much more focus is required on ensuring the required supports at the practice level.
Effective team characteristics
Collaborative teamwork provides a link between efficient organisational practice and high-quality patient care.[v] A large cross-sectional study of Australian general practices undertaken in 2007 showed that team climate was important for patient and staff satisfaction. Interestingly, this study also found that in terms of large general practices, that separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.[vi]
But how much do we know around the qualitative aspects of what makes for a well-functioning multidisciplinary team in the practice setting?
One key study identified 10 characteristics underpinning effective interdisciplinary team work which is useful in terms of guiding a practice redesign. [vii]
The 10 underlying characteristics of an effective team.
I agree that all these aspects are important to a well-designed and high functioning team. From my own practice perspective, I would attribute the most reliant performance factors around good practice governance and business management systems including clinical information systems in supporting integration. But a great deal of focus for us also lies in providing a supportive team environment and in strengthening the capacity of the team.
Role utilisation and supports
A practice can make a significant difference for its patient population by using the team to their full capacity. Greater use of the primary care practice nurse through nurse-led clinics has provided significant benefits in my own practices. Our nurse-led diabetes clinic is proving very effective in delivering this care. As are our COPD and other chronic disease nurse-led clinics through offering enhanced patient management of chronic and complex conditions by helping patients in managing their conditions.
Nurse-led clinics not only lead to improved health care but can lead to patient empowerment as well as nurse empowerment. These models do not impact on continuity of care and instead provide a sustainable practice model enabling constant monitoring and management. Time intensive tasks such as data extraction, data management and patient recall systems in coordinating aspects of care are just a few examples which can be shared across the team.
Exposure to the full workings of the multidisciplinary team can enhance the training experience for the medical student, prevocational doctor or registrar in the general practice environment. A culture of teamwork needs to be instilled early and can only enhance the learning experience for the trainee. They need to be immersed in this structure and fully exposed to the workings of the multidisciplinary team. It helps to improve their understanding of others’ roles and builds respect and understanding.
Broader benefits for the entire patient population are achieved through stronger utilisation of the full practice team. Time efficiencies and cost benefits can be realised through increased throughput of patients. Patient booking can be made for both doctor and nurse, each with their own specific caseload and role but with a shared focus on enhanced patient care. The GP can then be better utilised in their specialist capacity to focus their expertise on more complex areas of care.
Primary care service delivery models that optimise the performance of the full multidisciplinary team should underpin future funding decisions. This is a key requirement to shifting care to the more cost-effective sector of primary care and out of hospitals. Increased costs in addressing demand must be met through flexible funding solutions to help meet the additional cost burden for private practices. The effective use of skills to optimise the full practice team is key to providing patient centred collaborative care but the funding must now follow.
[i] Campbell S M, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study BMJ 2001; 323 :784
[ii] Cohen, SG and Bailey, DR (1997). What makes teams work: group effectiveness research from the shop floor to the executive suite. Journal of Management 23: 238–90, DOI: https://doi.org/10.1177/014920639702300303
[iii] Van Dijk-de Vries AN, Duimel-Peeters IGP, Muris JW, Wesseling GJ, Beusmans GHMI, Vrijhoef HJ. Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care. 2016;16(1):9. DOI: http://doi.org/10.5334/ijic.2454
[iv] Amoroso C, Proudfoot J, Bubner T, Swan E, Espinel P, Barton C et al. Quality improvement activities associated with organisational capacity in general practice. Australian Family Physician Vol. 36, No. 1/2, January/February 2007 8-84.
[v] Mickan S, Rodger S. The organisational context for teamwork: comparing health care and business literature. Aust Health Rev 2000;23:179–92.
[vi] Proudfoot J, Jayasinghe UW, Holton C, Grimm J, Bubner T, Amoroso C, Beilby J, Harris MF. Team climate for innovation: what difference does it make in general practice? International Journal for Quality Health Care. 2007 Jun;19(3):164-9. Epub 2007 Mar 2.
[vii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
[viii] Nancarrow SA, Booth A, Ariss S, Smith T, Enderby P, Roots A. Ten principles of good interdisciplinary team work. Human Resources for Health. 2013;11:19. doi:10.1186/1478-4491-11-19.
11 August 2017
Dr Ayman Shenouda
Developing a skill set around your community’s needs.
Just like lifelong learning, community needs assessment is a continual process that helps us to ensure our community has the best possible service mix. Health needs assessment is developmental and has to be added to or adjusted over time as the community’s needs change. It is alongside that process that we commit to continual learning, to adjust our skills over time to ensure these needs are met.
For a rural community, where resources and infrastructure are scarce, needs assessment is a critical process. It helps you to prioritise where you can make the biggest impact, to plan and deliver the most effective care against those areas of critical need. It enables you to work collaboratively with the local community to develop the infrastructure required. Most of all it becomes a partnership as people centred health relies on community participation and through this process, you find yourself fully immersed in community life.
When I arrived in Wagga Wagga 17 years ago, I was armed with some advanced surgical skills acquired while working as a surgical registrar in Egypt, then further honed in Tasmania during my initial few years in Australia. Naturally, my fellow GPs in the practice referred to me patients with surgical skin conditions. This was great as it allowed me to utilise my skills, on the other hand, though patient expectations increased as they were under the impression that I was a Dermatologist!
In all honesty, my dermatology skills weren’t all that flash and it was clear the local service gap in Dermatology needed fixing. I subsequently completed a Diploma of Dermatology in 2003 through the University of Wales in Cardiff. I became very popular and started to have referrals from other practices in town, as without a local area specialist that role continued to fall to me. It was out of unmet need that this became a necessity of course but it really was the community driving that decision to upskill.
Now the Wagga community has access to dermatology services I am adjusting again but to a new requirement in palliative care. This is demonstrative of lifelong learning in practice – The good GP never stops learning – in providing lifelong care there relies a commitment to lifelong learning to adapting your skills to meet changing needs.
For those looking for more inspiration, there were some great rural stories produced some years ago. During 2012, the RACGP rural faculty celebrated its 20th anniversary and as part of our commemorating that milestone we produced a series of inspiring stories “Getting to know our rural GPs”. These stories were truly demonstrative of just how diverse the profession is and the depth of skills needed in supporting the often-complex needs of rural communities, while also highlighting the unique nature and rewards of living and working in rural general practice.
Applying a lifelong learning framework
In applying a lifelong learning framework, we already have the key structures to facilitate this. The Fellowship of the Royal Australian College of General Practitioners (FRACGP) signifies that a GP has been assessed as competent across the core skills of general practice enabling him or her to practice safely, unsupervised, anywhere in Australia.
The FARGP is a qualification awarded by the RACGP in addition to the vocational Fellowship (FRACGP). Providing a dedicated pathway for both general practice registrars and experienced practising GPs, the FARGP aims to develop advanced rural skills and broaden options for safe, accessible and comprehensive care for Australia’s rural, remote and very remote communities.
The FARGP is unique here in terms of using a population health approach to plan and execute health service needs for a community. The community-focussed project is undertaken over a six-month period and enables you to get to know your community and engage with them to improve health. This important requirement equips the candidate with essential planning tools and establishes leadership in a community.
Skill development in policy
For trainees, key to ensuring broad skill exposure is the need to map the training process to ensure a wide variety of experiences can be provided. Needs analysis is again critical here and this level of planning is something we should be doing more of at both the state and national levels. This level of planning provides a comprehensive training program and a way to ensure skills learned are transferrable to their practice after the completion of training posts in building a resilient workforce.
After all, it is these trainees that will provide vital services in the future. Ensuring broad exposure and allocating placements according to specific learning needs and against community need at this early stage makes perfect sense in planning a future generalist workforce. The new regional training hubs should help to support this needs assessment to tailor a training package which provides for the level of flexibility required to truly immerse in the community as well as ensure relevant clinical exposure.
Just as vital is the requirement for a skill-acquisition pathway for practising rural GPs acknowledging the lifelong learning requirement and addressing unmet need. A stronger focus is required at both the state and national levels in terms of providing that structure or mechanism in the current arrangements to facilitate training for those who wish to go back and retrain to meet a skill need in their community.
The Commonwealth’s Rural Procedural Grants Program is vital in supporting skill maintenance in some key hospital-based skill areas. Applying a population health needs assessment in terms of skill acquisition requirements should guide decisions at the policy level. This process would see an expansion of the procedural grants program to include essential non-procedural advanced skills. Policy planning needs to factor and be responsive to current and future need just as the GP does in responding to the changing health needs of their community over a lifetime.
5 August 2017
Dr Ayman Shenouda
Often a really good policy solution will in turn place more pressure on a part of the health system it relies. This isn’t necessarily a bad thing and is usually indicative of good policy spend. It is sometimes an outcome of optimal policy coverage as is the case for disease screening measures. The National Bowel Cancer Screening program, introduced in 2006, is an example of a policy working well.
We know that one in 12 Australians will develop bowel cancer by the age of 85 which makes it the second most common cause of cancer-related death in Australia after lung cancer. But, if detected and treated early the cure rate is around 90% which makes policy intervention through prevention and in this case, through screening measures, so vitally important. [i]
The is a great policy intervention which we’ve seen expanded under successive governments with broad coverage now currently available to Australians aged 50, 55, 60,64, 70, 72 and 74. Once fully implemented by 2020, all Australians aged 50 to 74 will be able to be screened every two years.[ii]
But as a result of this policy, we’ve seen demand increase for lower gastrointestinal endoscopies. This growth in demand means there is a need for the endoscopic workforce in Australia to be well planned in order to cope with future demand associated with expanded cancer screening, particularly with an ageing population. Service solutions to address current demand including nurse endoscopists are now being rolled out in Queensland and Victoria. But is this the right workforce response for Australia or is it more of a temporary fix to a growing system issue?
Here’s the policy background to the issue. The policy response to limited endoscopy capacity a few years ago saw the now defunct Health Workforce Australia (HWA) invest in a project to train nurses to perform endoscopic procedures. Expanding the scope of practice of health professionals was a typical policy response being keenly pursued at that time by HWA. This particular decision though saw unprecedented action with a policy preference to train non-medical endoscopists and build capacity from within nursing.
At the time, the medical press reported that doctors were calling for a moratorium on nurse endoscopy.[iii] From a resource perspective, it is important to also note that this was a decision undertaken within the broader context of increased medical graduates coming through and claims of impending oversupply.
The Advanced Practice in Endoscopy Nursing (APEN) program was modelled on approaches elsewhere including in the UK where the nurse endoscopist was well established. Although nurse endoscopy training and delivery of endoscopic services is not a new policy response: the first report of nurse endoscopy in the US was more than 35 years ago for flexible sigmoidoscopy.[iv] But I think it is important to work through policy alternatives for Australia particularly if one solution has limitations both in terms of efficacy and coverage.
The University of Wollongong evaluation of the HWA-funded APEN sub-project in 2014 highlighted some key points in terms of the validity of a nurse-led model as a workforce solution.
Firstly, it stated that one of the main drivers for the program was the need to respond to growing demand for lower gastrointestinal endoscopies arising from bowel screening. However, it also stated that only about a quarter of same-day colonoscopies are performed in public hospitals. A key detail that severely limits the ability of nurse endoscopists to meet this growing demand. The evaluation also stated that given full implementation was not achieved, that relative advantage in terms of effectiveness and cost effectiveness of the model could not be evaluated and could only be measured after trainees were qualified and working at full capacity. [v]
The Australian Medical Association of Queensland (AMAQ) in commenting on the Queensland roll out of nurse model to Cairns and Townsville, stated that medical endoscopists were more cost effective than nurses as surgery could be performed at the time of procedure.[vi]
Cost-effectiveness of the nurse-led model as a workforce solution has also been challenged in a study published in the World Journal of Gastroenterology in 2015. The study examined the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. The study concluded that the empirical evidence that supports non-physician endoscopists is limited to strictly supervised roles in larger metropolitan settings and mainly flexible sigmoidoscopy and upper endoscopy for asymptomatic or low complexity patients. [vii]
This same study also stated that contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. It stated that studies measuring cognitive competency were limited and providing endoscopic services is more than mastering the technical skills required to safely advance the scope. Further, that making clinical decisions in the context of the patient’s full clinical picture is critical to delivering efficient and meaningful services.[viii]
In finding an effective solution, the most obvious question for me in terms of utilising the available workforce is around why we are not looking to general practice to address excess demand? Some of the pressure placed on endoscopy units in managing this increased demand can certainly be addressed by general practitioners.
General practice offers a particularly viable solution for rural communities in endoscopy. Keeping trained procedural GPs in rural areas should be made a priority and this is a good example of where support is needed to sustain local solutions where rural GPs fill a service gap like this. Access to diagnostic endoscopy is limited in rural and remote areas and service expansion by GPs provides significant patient benefits in terms of time and costs.
While savings including around reduced costly patient transfers are obvious to most, the investment in GP procedural practice where it offers a sustainable service model should be sufficient for policy makers. It would help to reduce the demand placed on regional tertiary services and could help make GP procedural practice more viable in the smaller towns. We know that rural GP proceduralists must be supported to consolidate their skills in the communities they serve and this is one service solution which can help realise this aim. It is a workforce solution that needs to be considered.
[i] Cancer Council Australia. Position Statement. Bowel Cancer. Available from: http://www.cancer.org.au/policy-and-advocacy/position-statements/bowel-cancer.html
[iii] Australian Doctor. Doctors call for moratorium on nurse endoscopy. 30 January, 2015. Available from: https://www.australiandoctor.com.au/news/latest-news/nurses-expand-scope-into-endoscopy
[iv] Spencer RJ, Ready RL. Utilization of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum. 1977;20:94–96. Available from: https://www.ncbi.nlm.nih.gov/pubmed/844404
[v] Thompson C, Williams K, Morris D, Lago L, Quinsey K, Kobel C, Andersen P, Eckermann S, Gordon R and Masso (2014) HWA Expanded Scopes of Practice Program Evaluation: Advanced Practice in Endoscopy Nursing Sub-Project Final Report. Centre for Health Service Development, Australian Health Services Research Institute, University of Wollongong. Available from: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1384&context=ahsri
[vi] ABC News. More gastroenterologists needed rather than using nurse endoscopists in hsopitals, AMAQ says. 18 Apr 2016. Available from: http://www.abc.net.au/news/2016-04-18/amaq-more-gastroenterologists-rather-than-nurse-endoscopists-qld/7336202
[vii] Stephens M, Hourigan LF, Appleyard M, et al. Non-physician endoscopists: A systematic review. World Journal of Gastroenterology : WJG. 2015;21(16):5056-5071. doi:10.3748/wjg.v21.i16.5056. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408481/
In overcoming significant disadvantage, it is the capacity of the general practice workforce that will provide the biggest impacts in realising improved health outcomes over time. General practice is by far the most efficient and cost-effective part of the healthcare system. GPs are often relied on the most, particularly by those most in need and with complex and chronic conditions.
General practice is already an efficient part of the healthcare system. GPs also have a very large remit. In any given year, almost all Australians – or 85 per cent – will visit a GP at least once. Yet government expenditure on general practice is relatively low at around $6.8 billion, under 5 per cent, of total recurrent health spending.[i] When compared to the significant cost to the sector for hospital services - expenditure on public hospital services is at around $61 billion – general practice offers value for money.[ii]
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. The findings captured by Starfield for one make a convincing case for primary care investment and are not new, but so do so many studies that have followed it.[iii] [iv]
A broader population health policy framework that recognises the role of primary care and general practitioners in addressing health disparities makes really good policy sense. But how do we convince our policy makers – firmly fixed within their short-term electoral cycles and need for quick wins - that a strong investment now will provide real and significant returns for a healthier future?
It’s clear that policy makers are not short on evidence around the benefits of prioritising these areas. These are critical funding decisions that impact quality, access, and coordination of health service delivery.
There is significant unmet need with access to primary health care still one of the main barriers to achieving equitable health outcomes. This is the case for many disadvantaged Australians and certainly for Aboriginal and Torres Strait Islander communities. National studies have shown that health outcomes improve with improved access to GPs in areas with relatively high predicted need for primary health care.[v] But we are not seeing anywhere near the level of investment needed to make the shifts required in supporting those most in need.
Embedding more preventative health interventions in the primary health care setting also needs focus. Primary care and preventative health go hand in hand. A rising disease burden requires a stronger emphasis on preventative health and GPs are key in terms of delivery. We clearly need to be prioritising both areas and with the level of investment warranted to secure strong health outcomes. We need investment in both prevention and primary care with recognition through funding of the important role general practice has in delivering both aims.
While preventative health requires a whole of community focus and an effort from each and every one of us, much of the service responsibility again falls to general practice. The GP has the lead role in ensuring their patients remain healthy over a lifetime and preventing illness, identifying risk and offering early intervention is already a large part of what we do.
I know firsthand that our patients most certainly value general practice and understand well the need for prevention and for real investments around that beyond just a health message. Research Australia’s annual Health and Medical Research public opinion poll ranked preventative health as one of the nation’s key health priorities. More than 75 per cent of Australians ranked preventative health as a key priority in 2016.
In determining health priorities, that role now falls to the Primary Health Networks and their focus in six priority areas: Aboriginal health, aged care, e-health, mental health, population health and health workforce.[vi] However, we know that issues around equity and social determinants of health is key to shifting entrenched disadvantage. The much broader set of objectives in our National Primary Care Framework (April 2013) should be revisited. Clear aims to drive our funding decisions which included a focus on addressing inequity in keeping all Australians healthy, preventing illness as well as reduce unnecessary hospital presentations and making improvements in the management of complex and chronic conditions.[vii]
To drive the level of change general practice needs to be better resourced. Investment needs to prioritise general practice and build upon existing services and arrangements. An investment which will lead to improved health outcomes, better management of chronic disease, a stronger focus on prevention and lower rates of unnecessary hospital admissions. A strong investment in general practice is what is needed to secure a healthier future for all Australians. The lift of the freeze, albeit slowly, is welcomed, but this only puts us back where we were at in 2013 before it was introduced. Let’s get the full discussion back on track. Let’s pick up where we were at nearly a decade ago when we were on the cusp of significant reform in Australia. A reform which saw a priority on general practice and its role in prevention and primary care.
[i] Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2014–15. General practice series no. 38. Sydney: Sydney University Press, 2015. Available at http://hdl.handle.net/2123/13765
[ii] AIHW 2017. Australia's hospitals at a glance 2015–16. Health services series no 77. Cat. no. HSE 189. Canberra: AIHW.
[iii] Starfield, B., Shi, L. and Macinko, J. (2005), Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 83: 457–502. doi: 10.1111/j.1468-0009.2005.00409.x
[iv] Harris MF, Harris E. Facing the challenges: general practice in 2020. Med J Aust 2006; 185: 122-124.
[v] Australian Institute of Health and Welfare. 2014. Access to primary health care relative to need for Indigenous Australians. Cat. no. IHW 128. Canberra: AIHW.http://www.aihw.gov.au/publication-detail/?id=60129547987
[vi] The Department of Health. Primary Health Networks (PHNs). Available from http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Background
[vii]Commonwealth ofAustralia.NationalPrimaryHealthCareStrategicFramework.2013.Availableat: http://www.health.gov.au/internet/main/publishing.nsf/Content/6084A04118674329CA257BF0001A349E/$File/NPHCframe.pdf
Broad skill depth is what makes general practice unique and so central to addressing patient need. An essential part of that skill mix and key to addressing an aging population with more complex health care needs are non-procedural advanced skills.
The development of specialist clinical interests by GPs has always been a key feature of general practice. These are often the skills needed to meet identified patient need and provide an effective way to address access constraints, particularly for rural areas.
It makes sense then that in order to provide training to match demand that we don’t over emphasise or value certain skills over others. It’s also important to value the workforce you have as well as prioritise policy to support the next generation of GPs. This is the case for both urban and rural GPs we need to provide more opportunities in those extended skills or advanced skill areas identified and prioritised by the profession.
This is particularly important for practising rural GPs who need flexible training options so that they can acquire new skills to address unmet service need. And in meeting this need this requires an equal focus on both non-procedural and procedural skill acquisition.
We need an equal focus on both recruitment and retention strategies which in turn means factoring into the policy design both learning stage and time in career. To achieve this, we need targeted strategies to support both the existing workforce and those at an earlier learning and career stage.
Funding not only needs to be prioritised for skill acquisition but also for maintenance. Skill certainty is also crucial so that the GP can utilise the skills they’ve acquired to support their community. The return on investment is substantial and means that patients get the services they need and deserve.
Research led by RACGP Rural in 2013 helped to clarify the extent of advanced skills used and needed by GPs in rural and remote Australia. Not surprisingly the number of advanced skills acquired and used across most areas increased with rurality.
Mental health came out in front as the most commonly practised advanced skill in the study, followed closely by emergency medicine and chronic disease management. Of those skills GPs would seek to acquire to meet a community need, emergency medicine was the most prevalent, but this was followed by palliative care, paediatrics, and mental health.
Skills in emergency medicine were expectedly prominent with approximately 60% of respondents indicating that emergency medicine was relevant in rural general practice. However, only 38.7% had acquired it and 33.6% were currently using it. More broadly though, of those who had acquired an advanced skill, most were continuing to use that skill which was most reassuring.
The most important policy points from the study had to be the high prevalence of non-procedural advance skills as well as the continued reliance on emergency medicine in addressing need. There would be no surprises here particularly for those rural GPs currently overstretched to keep providing emergency and in-patient services. But also to those struggling to meet an increasing need in palliative care, paediatrics and mental health which extend to psycho-geriatric skillsets.
The policy requirement extends beyond providing training opportunity with a need to address system constraints which act as deterrents to working outside of the practice setting. Increased training opportunities need to be delivered in a supportive framework which enables skill utilisation facilitating service continuity otherwise it’s like doing half the job.
Capturing service complexity and rewarding GPs working across settings or in targeted areas of need offers a service solution in these areas. Investment in these skill-specific solutions based on need with a focus on GP-led models of care offer real solutions for health service viability.
We need to focus on enhancing health system interfaces where those non-procedural advanced skills factor strongly. In managing demand at the interface between primary and acute health care settings or various stages of illness – in palliative care or those with multiple chronic conditions for example – requires much more focus and across the full multidisciplinary team.
We need clear referral pathways which promote continuity of care for patients moving in and out of primary and tertiary care. The type of coordinated care planning made possible by that initial skill investment to enable an expanded role, but which is then further invested in terms of ensuring continued skill use across settings to provide for the required continuity of care.
15 July 2017 Dr Ayman Shenouda
The Federal Government’s $54.4 million investment to create 26 regional training hub sites nationally sees yet another significant rural health reform realised. Providing a more seamless transition from undergraduate training into rural practice, I believe the hubs measure is one of the most important reforms since the establishment of the Rural Clinical Schools nationally in 2000.
Having this policy realised is also a proud moment for me knowing that RACGP Rural was at the forefront of this reform having developed rural medical training pathway options for the Commonwealth through a major study undertaken in 2013.
What we now have with this policy is the level of integration we called for with the hubs being our highest ask. It’s also clear that other aspects of the full pipeline investment were informed by this study, which was one of the largest member-led rural consultations ever undertaken. Collectively these initiatives represent a significant rural training investment and it’s a great achievement for the sector.
It’s a substantial package, the three-part integrated rural pipeline package provides just short of $94 million over four years with the regional training hubs forming a key policy component. It also includes a rural junior doctor innovation fund and further investment to expand the rural specialist training program. Three new University Departments of Rural Health have also been committed for strategic sites across WA, NSW, and Queensland.
We’re also seeing some policy shifts here which are significant. Particularly in those key areas where we’ve been calling for change in order to address the policy gaps which impede integration. These are those junctions which occur from student to intern and intern to registrar which offer real opportunity in terms of being critical rural commitment points.
Firstly, in this policy, we see a clear focus on embedding more primary care earlier into the training. A new strategy to provide more internships that include rotations in general practice addresses a really significant problem where the lack of exposure to rural practice at this critical time impacts our recruitment goals. Factoring rural primary care rotations for rurally based first-year interns ensures this exposure across multiple settings. It doesn’t minimise the required hospital exposure but ensures essential exposure to community-based rural general practice.
While the early linkage of intern positions with specialist training positions is also evident through providing up to 100 new rural training places. We need to ensure our next generation of rural doctors are nurtured and supported once captured. This investment will go a long way towards supporting that aim by ensuring there is the capacity to provide high-quality rural placements.
We know there is a link between where a student ends up and where they completed their post-graduate studies. But even with the strongest rural interest and the best intentions, not everyone is suited and it takes a substantial personal commitment to make it work and stay.
We now have more capacity through this pipeline initiative to get those supportive elements right in order to provide a stable learning environment to equip trainees with the skillset they will need. Even more importantly it helps to ensure support can be sustained long enough to provide trainees with the skills and confidence required which makes staying much more likely.
The hubs provide for the right set of supports that will help us capture for rural the increasing domestic graduates coming through. It enables the university-hospital-community partnerships we need to set the right conditions to encourage more doctors to practise in rural areas.
This model facilitates a level of integration that will allow adequate clinical exposure in a rural area across all training stages. Most of all it provides a way to maintain a link to a specific rural community and to facilitate longer terms in rural areas.
What also needs to be emphasised here is a program of complete immersion. The step beyond rural exposure and a commitment towards longer placements. Community connectedness can only be achieved through longer placements in the same community throughout the full training continuum.
More cohesive and tailored training options will result. A more varied training experience will be able to occur, one which is appropriate to the learning stage but also flexible enough to be in line with community health needs.
Longer placements with multiple levels of learning are more effective allowing for the required immersion. It connects the trainee to the key players in the community, developing a network and connection to community through mentorship. Importantly they learn the value of rural general practice on their way through.
Policy success will, of course, be determined by improvements in the rural retention rate over time but I have no doubt the pipeline investment will work to build the right supports to make rural training a much more viable option.
These measures provide for the supportive and coordination factors as well as some much-needed infrastructure to make rural training work. It helps to formalise the networks needed to provide a pathway continuum for medical education and training from medical school to rural practice. All this combined provides a comprehensive policy solution which will translate into rural recruitment success and workforce retention over time.
Further reading: RACGP Rural developed a Position Statement to support policy implementation of the Regional Training Hubs.
The passing of legislation during the last sitting days in June to establish a new National Rural Health Commissioner is a significant step forward toward achieving a more equitable healthcare service nationally.
A new champion for rural patients, the role offers a new opportunity to ensure our collective voice is heard bringing to focus the important work we do. Through this key role, rural patients finally get the focus they deserve and we know that lasting change will require a broad policy lens encompassing all disciplines.
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.
A focus on the full multidisciplinary team is key to providing more integrated and improved patient-care strategies. Strategies which work to address access constraints in the context of diminished rural resources require supportive policy to enable integration. It is in developing these service solutions, through policy advancement, to support viable rural models of care that we can work together to address disparities.
One of the first tasks for the new Commissioner will be to work with stakeholders to develop a National Rural Generalist Pathway. In maximising workforce outcomes, the ‘generalist’ role has long been the basis of rural medical practice enabling strong patient reach across settings to address access constraints.
It is clear that rural GPs in utilising their broad scope to provide services across the continuum of care in a range of settings have always offered, and remain, a key solution to addressing rural patient need. But we are not working alone and this same level of focus is warranted across all disciplines to work to the level of service integration required.
It’s reassuring that a much broader remit is envisaged by Dr Gillespie for the new Commissioner role. We all understand that addressing workforce and services issues to provide more effective, comprehensive healthcare is much broader than medicine.
A focus encompassing nursing, dental health, Indigenous health, mental health, midwifery and allied health alongside medicine is required. The patient must also be given a strong voice and reaching out to the health consumer through collaborative community-led engagement will be important.
To realise strong reform, a needs-based approach which can allow for flexibility is required. But it’s a hard sell. A community-led model or approach doesn’t always fit current funding models and our system does not always allow for the required integration.
It is by working through the service mix required, both private and public, which are specific to local need and achievable against available resources, that communities can find the solutions they need. Removing barriers to enable multidisciplinary healthcare teams to deliver comprehensive patient care across rural settings is key to making this work.
How to address increasing local demand for palliative care services, for example, needs a significant local commitment and many disciplines to make this happen. Working through to address poor service integration such as fragmentation which can sometimes occur due to policy barriers which limit the participation of allied health in aged and community care is another key example.
We know what’s needed and what works well in rural. We’ve had years of review and it’s time to implement. Lasting change can only be realised through enabling more community-initiated solutions, adding flexibility to enable service integration.
Finding local solutions in addressing need takes local leadership and time for critical planning which often needs to occur outside of practice hours. Support for this type of action can and will lead to improved skill utilisation and solutions which can work.
It really takes a whole community - involvement by all sectors of the health community – to drive this level of change.
In my own town of Wagga Wagga we certainly strive toward this level of engagement but in implementing new solutions our collective voice is not always loud enough. There is renewed hope that the new National Rural Health Commissioner can help us raise the volume enough for our community-led action to lead to change.
A big part of securing the next generation of rural GPs is around ensuring there remains a positive focus on general practice.
Rural practice is challenging which in turn makes it very rewarding, enabling you to develop a breadth of skills to build resilience in addressing need. Providing that insight for future doctors in a supportive way during those early learning years is so vitally important.
Sitting with a registrar recently, I was surprised to learn that he considered himself a rural generalist, and not a rural GP. This is despite the fact that he was training to a curriculum which is general practice: the endpoint in training for a rural generalist is of course a general practice Fellowship.
Let’s be very clear: rural generalists are rural GPs.
General practitioners are generalists by definition. The term ‘rural generalist’ describes a rural general practitioner working to the full scope of their practice with skill sets that are informed by the needs of the community they serve. These skill sets may encompass both advanced procedural and non-procedural skills working across primary and secondary care contexts with an emphasis on emergency medicine.
It’s about ensuring the right skill mix against demand.
The Federal Assistant Minister for Health, Dr David Gillespie MP, certainly knows this requirement well and his own definition is fitting: “A rural generalist is a doctor who’s trained as a general practitioner but has extra skills so that they can operate in a hospital setting as well as a community setting. That involves not just being a jack of all trades, but being a well-qualified doctor who can cope with the extra problems, clinical, public health, and hospital skills that you need to look after a regional town.”
It is the context that matters most and is key to getting health rural workforce policy right. The general (core) and advanced (specific) skills required in addressing patient need depend on the health needs and context of the community.
That is why it is important we align training investment to service need. In developing a rural generalist pathway nationally, this, therefore, must also be broad. We need a national pathway that equips general practitioners with a full range of competencies enabling them to deliver patient care closer to home in the primary and secondary care contexts.
We know that developing skills around the ongoing care considerations are the areas that best serve the community. We also know that dedicated and clear pathways for rural GPs to acquire advanced skills and utilise them in a way that is valued and recognised are important workforce factors.
Supportive strategies like these are vital in attracting and retaining a skilled rural workforce that is responsive to need. Most of all it’s about valuing the contribution to the healthcare system of quality general practice and its essential and enduring role in supporting rural communities.
 Gillespie transcript. 29 March 2017. RDAA Poli Breakfast. Dr David Gillespie MP Federal Assistant Minister for Health. Canberra.
General Practice has faced many challenges over recent years –Medicare rebate freeze, new PHNs structure and recent changes in training delivery. All of these are impacting on the future of our profession. I believe General practice continues to evolve to meet the current and future challenges facing the Australian health system. However the College of GP’s has a pivotal role to support general practice to deliver an effective and sustainable healthcare for the communities they serve. This article is an attempt to explore and answer the question. How can the RACGP Add Value to General Practice?
As general practice expands to meet the new environment and future challenges it is imperative to have a systemic approach backed by a solid business model that underpins quality care. There is also a need to support the creation of new models of care delivery as many of the RACGP members are either seeking the opportunity to open new practices or refine existing practices. I believe that the College can play an important role in supporting the business of general practice this will in turn support a sustainable and viable small business models regardless of whether you work in, or own it.
The Australian health system ranks as one of the bests in the world I believe the strength of our health system lies in its reliance on general practice and the pivotal role of the general practitioner. I believe that it is essential that the solution for current and future challenges needs to come from within the profession by utilising the wealth of knowledge and expertise that exists within the College and its membership. This can position the RACGP as a leading voice in writing health policies and creating solutions alongside government.
We also need to continue to actively promote and celebrate the role of GPs as highly trained medical specialists that offer solutions to address future complex health issues. We need to continue lobbying government and advocating for change to the funding models to close the gap between specialist and GP rebates.
The strength of the College can only be realised by strong representation and engagement of its members. We need to create communication channels, which allow members to input ideas and concerns on key issues and provide a forum for expression of new ideas. Similarly, communication between the faculties and council needs to be enhanced. The College is privileged to have developed 9 faculties, each of which contributes important information and feedback on specialised aspects of general practice. Links between the colleges and sharing of information and practices can only serve to strengthen the workings of the College.
To cope with the increasing complexity of issues and constantly changing primary care environment there is an urgent need to build leadership, which harnesses the individual and collective talents of primary health, teams. This requires proper engagement with college members by recognising potential leaders and fostering their talents through specific training pathways and mentorship.
Research is the cornerstone of an academic college and the key to shaping our future practice. The general practitioner is in an ideal position to engage in research in primary care and help in the translation of new ideas and evaluation of interventions to the general public. There is a wealth of knowledge and research experience amongst our professorial members and Deans of General Practice, which can be utilised by the College. Our General Practices are a rich source for data collection, audit and real world experiences, which we need to encourage our College members as scientists to explore record and publish.
Imparting the art of general practice is part of our responsibility in passing the baton to the next generation and instilling in future doctors a passion for the profession of general practice. Promoting career pathways in general practice in both rural and metropolitan settings is a key role for the College. We need to support training, education and innovative thinking through a wide variety of programs to enhance skill development at all stages of training.
These are some of what I consider to be the key issues that the RACGP needs to engage with and I believe I have the experience in my past and present roles and the vision to lead the RACGP in the future to work alongside Council to add value to general practice.