And don't tell me what to do
Don't tell me what to say
And please, when I go round with you
Don't put me on display 'cause
You don't own me
Don't try to change me in any way
You don't own me
Don't tie me down 'cause I'd never stay
You Don’t Own Me 1963, Lesley Gore
Vaccination for Contrarians
The Social Services Legislation Amendment (No Jab, No Pay) Bill of 2015 has brought about an increase in childhood vaccination rates around the country and also on the North Coast. The essence of the Amendment was to remove conscientious objection to vaccination as an exemption from the requirement of children to be fully age appropriate vaccinated to be eligible for child care subsidies and Family Tax Benefit A.
Vaccination rates have risen to 93% nationally and are approaching the 95% level recommended for herd immunity. All Primary Health Networks (PHNs) reported rates of greater than 90%. However, rates can vary widely within PHNs and in this issue we report on the 1867 North Coast kids who are unimmunised. Recent Department of Health Data have shown shown that less than 50% of Mullumbimby two year olds are fully vaccinated; the lowest in the country.
To improve the levels and to counter last year’s anti-vaccination film, Vaxxed: From Cover-Up to Catastrophe, the Department of Health has launched a 5.5 million dollar campaign targeting areas of low vaccination.
Most North Coast general practitioners will have experienced long consultations with a parent debating the risks and benefits of vaccination for their child. Thankfully, these are less frequent now the conscientious objection exemption has been removed. Teasing out the science and the pseudo-science in these encounters is a long, labour intensive and often futile activity and not viable in a busy general practice.
As Dr Tony Lembke has recently noted on Radio National we must help our patients understand the full ramifications of their decisions. There has been some recent discussion about how best to achieve this.
Personal stories cut through. Older GPs may recall North Coast cases of the relatively common complication, Dawson’s encephalitis, the progressive neurological deterioration and early death from infantile measles.
Measles is rare now but has not been eradicated from Australia as once claimed. However, whooping cough remains very prevalent locally. Toni and David McCaffery of Lennox Head, parents of Dana who died in 2009 at the age of one from this disease, graciously appear in one of the Department of Health videos.
Telling an anti-vaxxer that their views are wrong has been shown to be counter-productive and, in fact, is more likely to strengthen their opinions. Recent research has suggested that highlighting the dangers of childhood infections is more effective than debating vaccination adverse reactions.
As GPs, we need to make our patients aware that the risks are high for all those unvaccinated children living in the viral culture medium of the North Coast hinterland.
Access and Cost
Australians have some of the highest out-of-pocket medical expenses in the OECD, surpassed only by Switzerland. Some 12 per cent of Australians’ health expenditure comes out of the patient’s pocket, with dental care, private hospital charges and medical specialist fees making up the bulk of the expenditure.
Although private health insurance can go some way to covering such costs, out-of-pocket expenses can still be quite significant, and vary depending on a patient’s location – witness the recent media coverage of disparate fees charged by surgeons for the same procedures.
Moreover, despite having paid for private cover, large, additional out-of-pocket costs for specialist in-hospital treatment cause some patients to opt for public hospital care.
The public hospital system is not averse to taking private patients. Charging health funds for in-patient treatment is deemed a much needed source of income by public health administrators. Similarly, getting GP referrals for outpatient specialist services brings in further revenue. The reason for the cost shifting from the State to the Commonwealth for self limited conditions escapes most patients and annoys them and GPs alike.
Private health insurers are placing restrictions on the services they provide and increasing their flag fall charges for each item of care. It is reported that private hospitals are feeling the pinch.
The current government is very keen on market forces in all aspects of Australian economic life, including medicine. Currently the Senate Community Affairs References Committee is reviewing the Value And Affordability Of Private Health Insurance And Out Of Pocket Medical Costs. It is due to report on 27 November, 2017.
Some are campaigning for an increased transparency in medical costs so that market forces can be brought to bear. The government has nearly all the required information to do this from the Medicare data it already holds, and it is not beyond the realms of possibility that it could publish a “Doctors’ Fees Watch” website. However, this may prove more difficult than anticipated, given the history from 2008 of Kevin Rudd's ill-fated Grocery Watch website.
It has also been suggested that a Medicare rebate be denied when the fee charged exceeds that recommended by the AMA. This seems somewhat fanciful given it would be directly counter to a free market philosophy. It may also be determined that the regulation of fees is unconstitutional. We shall await the Senate Committee’s report.
Nationally the rates of bulk billing are much higher for general practitioners than for specialists and the rate has stayed fairly constant, much to the chagrin of the Treasurer, despite four years of the Medicare freeze.
This issue of GPSpeak (page 23) reports on a study done locally on the availability of North Coast general practices to provide a same day appointment for a new patient. The study found just under half of North Coast practices could accommodate the patient that day, that bulk billing was only available in 20 per cent of practices and the mean out-of-pocket costs were close to $30.00.
The study, approved by the Southern Cross University Human Research Ethics Committee and the North Coast Primary Health Network, used a secret shopper methodology. The researcher posed as a relative of a 60 year old woman, new to the North Coast, suffering abdominal pain. The data sought by the study was whether the patient could get a same day appointment, preferably with a female GP and have the consultation bulk billed. If bulk billing was not available, the out-of-pocket costs were sought.
It's hard to know what GPs will make of this study. The implication that they should do more for less will be very familiar but any change will have to come at the national level and given the current environment this is unlikely.
Mental Health
Following last issue’s report on the mental health issues facing doctors, Tweed Heads anaesthetist, Dr Ian McPhee details some of his experiences as a health professional suffering from depression. He also reports on his and others’ work in advocating against mandatory reporting of mental health issues. GPSpeak congratulates him on his efforts in helping bring about the recent move by the Health Ministers of the Council Of Australian Governments to reverse mandatory reporting.
Exercise in Cancer and Arthritis
On page 12 Dr Ric Milner also gives a personal account of his experiences, this time in prostate cancer. Ric focuses on the role of exercise in advanced cancer and on page 9 he reviews the studies of the various aspects of exercise in cancer patients. While noting it is not a cure, he advocates strongly for its role in improving this last stage of one’s life journey.
Exercise also seems to be useful in making our back, hips and knees last a little longer. Professor David Hunter, rheumatologist from the Department of Medicine, Sydney University argues for a biopsychosocial approach to chronic arthritic pain and has recommendations for GPs to consider other treatments somewhere between the pills and the knife.
Join a club, make new friends and explore the world. Those with a little cartilage left in their knees may be inspired by Dr Kim Kerr’s recent trip with a Northern Rivers group to China to run the Great Wall Marathon (page 11).
Integration
Following a government directive, the North Coast Primary Health Network ceased to be a support organisation for primary health practitioners on 1 July 2016. The current focus is on commissioning, integration and primary healthcare quality. Working in partnership with the Northern New South Wales Local Health District there has been steady progress in a number of areas.
While far from perfect the last 12 months has seen improvements in the timeliness and quality of discharge summaries. In particular, the efforts of the Mental Health Unit should be acknowledged in this area.
Equally there has been an improvement in the quality of general practitioners’ Shared Health Summaries, partly brought about by the My Health Record financial incentives. The summaries are increasingly sought, and hopefully used, by the Emergency Departments and outpatient clinics.
Preoperative blood management has made significant progress in the Northern Rivers over the last two years and the Northern Rivers General Practice Network congratulates the NNSW LHD on what has been achieved and appreciates their ongoing support in providing in-house training for practices contemplating surgery based intravenous iron transfusion (page 27).
Innovation is not easy and there are many missteps along the way. The work being done on the Medical Home and the Winter Strategy is to be supported and the learnings from the mistakes will shape the future direction.
Communication is the key and despite the technical problems, information technology will drive improvements in our healthcare system. Adding pathology and later radiology to the My Health Record will bring both advantages and challenges to be managed. Changes in this area along with the electronic reporting of BreastScreen data (page 24) are expected in the next two years.
In p4$$W0rd (page 21) we offer some advice on staying safe in this electronic world. Security can be a hassle but nothing is worse than a system compromised and held to ransom.
It looks like the future is bright for innovators and those trying to make the North Coast medical world a little better. If we to tap into the zeitgeist, we might say, “blessed are the fruitful, the geek and the #woke”.
