What does the future hold for Australia's aged? - AMA WA

80 Pages·2013·22.57 MB·English

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WESTERN AciaUSTRALIA WESTERN AUSTRALIA
tio Journal of the Australian Medical Association WA | September 2013 Volume 53 / Issue 8 | amawa.com.au
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Council
President
September 2013
Dr Richard Choong
Immediate Past President
A/Prof David Mountain
Vice Presidents
Dr Michael Gannon C o n tE n t S
Dr Andrew Miller
Honorary Secretary
Dr Omar Khorshid
Assistant Honorary Secretary
Dr Janice Bell
Honorary Treasurer
Professor Bernard Pearn-Rowe
Councillors
Division of General Practice (WA)
Prof Bernard Pearn-Rowe
A/Prof Rosanna Capolingua
Division of Specialty Practice
Dr Tony Ryan
Prof Mark Khangure 46
Division of Salaried and State
Government Service 22
Dr Cassandra Host
Dr Daniel Heredia
Dr Dror Maor
Ordinary Members Profile: Dr John van Bockxmeer
Prof Gary Geelhoed The face behind Fair Game
Dr Stuart Salfinger Cover Story:
Dr Marcus Tan We were the young country
Co-opted Members
What does the future hold for Australia’s aged?
Dr Steve Wilson
A/Prof Frank Jones
A/Prof Peter Maguire
Prof Geoff Dobb
Dr Cassandra Host
Dr Melita Cirillo
Dr Ian Jenkins
Prof Ian Puddey
Prof Gavin Frost
Dr Alexandra Welborn 35
Ms Lee Fairhead
Ms Tahira Bhatti 38
AMA (WA) Office
Executive Director
Mr Paul Boyatzis Friend or Foe?
Director: Industrial & Legal
Ms Marcia Kuhne Cancer Screening deserves Beyond Borders:
Executive Officers careful thought MSF’s Somalia situation
Mr Michael Prendergast
Ms Christine Kane
Ms Clare Francis FEatU rES
Mr Gary Bucknall
14 Stirling Highway
Nedlands WA 6009
[phone] 04 Sinking in debt, yet spending 44 Crisis point
[email protected] unwisely A look at Russia’s
www.amawa.com.au
AMA (WA) Vice President, healthcare system
Medicus Dr Michael Gannon on the State Budget
60 When a window opens
Editor and Director of 06
Communications PCEHR: Moving forward How medical scientists came
Mr Robert Reid The legal issues and contractual flaws to understand the digestion
Deputy Editor
process
Ms Janine Martin
Advertising Inquiries rEGUL arS
Phone Mr Des Michael [phone]
Copy Submissions
Phone Ms Janine Martin [phone]
or [email protected]
02 President’s Desk 42 Opinion 62 Travel
Services 03 From the Editor 49 Dr YES 64 Food
Business Services Manager 50 Opinion 66 Wine
Ms Noelle Jones 09 Industrial
Financial Services Manager 53 AMA in the Media 67 P hotography
10 News
Mr John Gerrard 54 Soapbox 68 M ember Benefits
Medical Products Manager 18 AMA (WA) Clinical
Mr Anthony Boyatzis 55 Snippet & On the Town
Conference
Health Training 56 Feature: 70 Classifieds
Australia Manager 22 Cover Story:
Mr Geoff Jones The Olden Years The Fracking Feud Professional Appointments
59 Gardening & Positions Vacant
31 Opinion
The publication of an advertisement,
61 Drive
article or inclusion of an insert does not 41 For the Record:
imply endorsement by the AMA (WA) of
Dr Lachlan Henderson
the views, service or product in question,
and neither the AMA (WA) nor its agents
will have any liability for any information
contained therein. September MEDICUS 1
PRESIDENT’S DESK
It’s difficult to put simply
by Dr Richard Choong
AMA (WA) President
For some months now I have heard a continuous message in no other doctors, where the nearest hospital is miles away or worse
some sections of the media. I have been forced to hear this still, when you’re in a town on your own, is as appealing as lancing
message ad nauseum – that there is an undersupply of general a boil.
practitioners in Western Australia. Having a strong, supportive framework is a serious
Some, both in the media and the medical profession have consideration that faces a number of small rural towns that are
even misused my own comments on a quite complicated issue to trying to attract a doctor. The town may be some distance from a
support their own views on this matter. hospital, and medically isolated with no peer support. Remember,
Rarely is an issue as simple as it seems at first blush. attracting a doctor is not the same as attracting any tradesman –
Incredibly, some very intelligent academics have used the most we really do need to work in a supportive environment.
simplistic data to support their simplistic argument that WA is As a result of all these conflicting forces, very few new clinics get
short of doctors. established. Rather, doctors will move to established, functioning
This dangerous and carte-blanche use of data sometimes practices. The issue facing so many people who move into new
reminds me of a drunk man using a light pole to stay upright. areas is the lack of medical services. Usually the establishment of
Simplistically, there is shortage of GPs. WA has the second general practices may trail behind the development of the areas by
lowest GP numbers per capita of any state or territory in the years, if not decades.
country. But we are not alone. As Australia’s population ages and
However this is complicated by a host of issues such as the the complexity of comorbidities increases proportionately, the
maldistribution of doctors, both in the city and in regional and problems facing healthcare delivery to the elderly, the delivery of
rural areas. There are areas within the city which have as poor a aged care services and residential aged care facilities (RACF) are
doctor-patient ratio as regional areas. compounded.
Then there are suburbs such as Balga, which continue to Certainly, there has not been the required growth in RACFs to
struggle to attract any doctors at all – and this suburb is just 14km meet the needs of this growing and ageing segment. This is simply
from the Perth CBD. an issue of economics – there are insufficient margins for a large
But there are reasons for this which should be closely examined company to invest in the development, construction and operation
and if possible fixed. of a residential facility.
It has been decades since GPs would go out and set up their The government needs to focus on this area by boosting
shingles anywhere they wished. Today, new practices are not being funding and support to this segment of healthcare.
opened in any great number. It’s even less if you take out those Look around you, there are so many patients who are currently
practices that are established by large corporate entities or those living alone or with an equally aged partner who is unable to cope
doctors who are setting up practices in an area where they already when ill health strikes. The available services fill rapidly and the
work, thereby not actually increasing the overall doctor ratio in that end result is that patients queue in hospitals, exacerbating our
vicinity. overcrowding issue.
First in a long line of tasks, is acquiring council approval to These are people who don’t need to be in hospital, yet they do
establish a practice in a specific location. Keep in mind, this need more care than what can be safely delivered at home. This is
location is often determined by the council and may not always be where the government needs to focus its energies. Yet in the two
in an attractive or affordable spot. elections we have recently been through, there was little focus on
Once location is identified, set-up cost rears health, and none whatsoever on aged care.
its head. Establishing a general practice to So once again I return to stating the obvious. The
comply with the RACGP standards is a elderly with the complex comorbidities find themselves in
very expensive process – one that could crowded hospitals, they can’t go home, they can’t find a
be considered out of reach of many young nursing home and they can’t find a GP. Life just isn’t
doctors. very bright as you grow older. ■
Additionally, as we have all experienced, a new
practice does not always translate into instant patient
flow. Those of us who have established practices will
remember the days of sitting and waiting for patients to walk
through the door, knowing that the bills still needed to be paid. It
takes considerable time and effort to establish a large, sustainable
cohort of regular patients at any new practice.
Finally there is the issue of support. Moving into an area with
2 MEDICUS September
FroM tHE EDItor
Debates inject some punch
into lack-lustre campaign
By the time you read these words, the results of the 2013 The Australian experience is slightly different. Here debates
Federal Election will be well known. Depending on your are seen by leaders as something that have to be tolerated rather
view, government is now in the hands of a responsible political than celebrated.
majority with plans for our future, or in the hands of usurpers There were three ‘debates’ during the 2013 Australian Federal
who only have themselves and their supporters in mind. Election. The first was generally viewed as one of the most boring
Which party fits which description, of course, relies on your known to mankind, and was criticised for being similar to a joint
particular approach. press conference of two men who were trying to ignore each
But one of the disappointing aspects of the federal campaign other.
has been the lack of emphasis on health in the release of party The second and third ‘debates’ were based on the town
policies. This is in much the same way as the earlier 2013 Western meeting idea, where 100 or so ordinary, average Australians get to
Australian State Election campaign. ask the leaders questions about the issues that affect them rather
As one sage political observer said: “Health took a back seat than having questions asked on their behalf by mainly Canberra-
in the 2013 campaign and we are weaker as a community as a based journalists.
result.” These were far more productive and have, this writer suspects,
No costed policies of Indigenous health, no discussion about set the scene as future election highlights.
increasing the rebate and no real investigation into the future It was during the second debate that health was raised, and
labour force needs in the medical professions. Tony Abbott pledged that a coalition government would not
In fact about the only time that health took the forefront, albeit close any Medicare Locals. This was immediately portrayed as a
briefly, was during the second debate, or political forum, when reversal of his previous refusal to NOT undertake to close any of
Opposition Leader Tony Abbott was seen to back away from his the Labor government initiative.
previous promise relating to Medicare Locals. But woven into this 2013 campaign change is another, far
One of the interesting aspects of any Australian election more extensive and potentially important alternation in the way
campaign, state or federal, is the impact of debates between the elections are being fought and voters are being influenced – the
major party leaders on the election outcome. decline of the political journalist and the rise of new media.
Despite many predictions by psephologists, election debates This is the start of a tectonic shift in Australian politics,
actually played a role in the 2013 Federal Election campaign, when citizen journalists and private citizens can turn an
providing one of the few highlights for watchers of political election campaign. With little more than a smart mobile phone,
battles. individuals can tweet their support or disgust, make comments
Election debates have for some centuries played a part in about candidates or policies or put questions to candidates
election battles, sometimes importantly so. hundreds of times a day if they wish, make professional ads
The 1858 debates between Abraham Lincoln, then standing available via YouTube. As the citizen journalist becomes more
for the Illinois Senate and incumbent Stephen Douglas, involved important, the might of the editor and media owner is reduced.
nine extended meetings across the State. While Lincoln failed to No longer do we rely on ‘senior journalists’ in the Canberra
win the election, the wide attention they had attracted, along with press gallery who seem to believe the supposition that they have
a book of transcripts, made him a national figure of some stature a greater insight into important issues merely because of their
and helped assure his election as US President in 1860. senior years.
Election debates died until they began on radio in the 1930s Change is always around us but one of the greatest changes
and 1940s, and in the 1960s moved to television with the meeting was seen in the just completed election campaign, when
of John F. Kennedy and Richard M. Nixon in three debates. journalists seemed to become less important and private citizens
Prepared with every fact and figure about the economy of the more important. This is a change worth celebrating.
US and the Cold War, Nixon was universally acknowledged as One thing that won’t change however is the strength and
the victor of the first and most viewed one – on radio. determination of the AMA (WA) to represent the medical
Unprepared for the importance of TV however, John Kennedy, profession and public health as a whole.
who had spent the week in the Florida sun, easily won the A whole new crop of members and senators in Federal
televised version of the debate and the election a few weeks later. Parliament means more education, more advocacy and more
Since then, US presidential election debates have been a membership activity.
mainstay of campaigns – both primary and presidential. More A new party taking over the government benches in Federal
than a handful have influenced the eventual result and there Parliament will mean intense activity by the AMA to ensure that
is now a Presidential Debates Commission that organises the health receives the attention it deserves and General Practice in
debates themselves. particular receives the assistance it so badly needs. ■
September MEDICUS 3
anaLYSIS
Sinking in debt,
yet spending unwisely
by Dr Michael Gannon
AMA (WA) Vice President
Early last month, the Hon. Troy Buswell MLA handed upset with the loss of rebates for the power their solar
down the State Budget. His speech to the House talked panels return to the grid. Charging those colleagues of
of how another 50,000 people were expected to move to ours here on 457 Visas $4000 to educate their children in
Western Australia over the next 12 months and the pressure public schools has been described as mean. The delay in
already felt by services and infrastructure across the State. commencing clinical services at Fiona Stanley Hospital is
“The demand for hospital and health services is being expensive and embarrassing.
driven by a rapidly growing and ageing population, rising Positive aspects of the budget include the ongoing
community expectations, and an increasing number of commitment to improve hospital facilities in Midland,
people in the community with chronic illnesses requiring Busselton and Kalgoorlie, as well as replicating the
regular access to health services and high cost medical successful Southern Inland Health Initiative (SIHI) in the
technologies,” the Treasurer said. north of the state.
So has health in WA benefited from the State Budget, or I have some sympathy for Messrs Buswell, Barnett and
has it taken a battering? Hames. We all want more cargo. We can all think of the
The AMA was disappointed with cuts to the modest things we like. For example, I look forward to seeing more
promise previously made of $30 million for medical research. affordable housing for the poorest in our community, light
The Royal Perth Hospital Protection bill lies dormant on rail heading north up Alexander Drive and a 21st century
the floor of the Parliament and substantive funding for its sporting stadium in Burswood.
redevelopment has been deferred for three years. But state debt is headed for $28 billion. How do we pay
There was no mention of the extra beds required to ‘future for it all?
proof’ the sub-optimally planned New Children’s Hospital in The states lost the right to independently collect income
Nedlands. tax in 1942. The change in policy, instituted as a temporary
Many readers might have been measure to fund the war effort, was never reversed. Since
then the states have been dependent on block funding
grants and a series of flimsy inefficient taxes such as
petrol excise, state sales tax and payroll tax to fund
their activities.
The introduction of the GST in 2000 was
meant to make the states self-sufficient. But the
controversial Commonwealth Grants Commission
process creates major disparities between donor and
mendicant states.
WA’s share of the GST falls year by year. Next year we
are projected to receive back 45c for every dollar raised
and according to State Treasury’s estimates, we will
only be getting 7c by 2016-17. This is a large part of
the $15 billion that leaves WA each year bound for our
poor cousins to the east. I get angry every time I hear
that the NYMBY’s and Greenies in Tasmania have
beaten another attempt to support industry, create jobs
and perhaps stop another crop of their youngest and
brightest heading for the acrid, less sweet smelling air of
Melbourne or London.
For us Sandgropers, we must be thankful for at least
another 45 years of royalties from hematite iron.
But if we cannot have a debate in Australia about the
need to urgently recalibrate federal-state taxation power, the
states will not be able to afford the world-class public health
and education systems Australian taxpayers deserve.
Prior to his first election to prime ministership, ‘Kevin07’
promised to set about ‘fixing the Federation’. Despite
anaLYSIS
having eight Labor Premiers and Chief Ministers around should be instituted without a serious professional cost-
the Council of Australian Governments (COAG) table benefit analysis and meaningful consultation with relevant
in 2007-08, he as became his signature, talked a lot and stakeholders, such as those in health and the medical
produced a great deal less. ‘Kevin13’ promised last week to profession.
‘fix the Federation’. I am fairly sure it’s the same guy. When Rudd, Gillard, Roxon, Swan, Wong et al took
Liberal leader Tony Abbott talks the talk of a centralist office, Australia was debt free with money in the Future
a bit too much for my liking. Further concentration of Fund. Unless you have a very low seizure threshold, log
taxation power and decision making in Canberra, remote on and have a look at the live Australian Debt Clock as
from where health services are delivered, is no recipe for it hurtles toward $300 billion. No blame game fixed, a
success. cynically drawn up mud-map of Super Clinics, Medicare
So what should the AMA do? Locals desperately looking for relevance, ideologically-
Well, lobbying senators to fulfill their responsibility to based attacks on private medicine, tens of thousands more
their constituents in the States’ House is a waste of time. bureaucrats in Canberra and olive brown fag packets.
Long ago they collectively showed that their first loyalty is We can help the State Government. They need to ask
to Party, not to their State. for more help to make sure that Fiona Stanley is no white
We need to convince the Premier that enrolling a medical elephant. We can tell them why another medical school
student at university does not equate to producing a GP who won’t necessarily put another GP in Goomalling or another
wants to work in the bush. If there is money in the kitty for a Gynae in Mandurah. We can help with NEATs and NESTs,
new medical school, it might be better spent on career paths and getting value for money in health.
for doctors at RMO and Registrar levels. Over the past two More good news for the WA Government is that
years, we have eventually found jobs for interns, but only to Tasmania, New South Wales and South Australia will go
create a bottleneck 2-3 years downstream. broke before we do – creating the imperative to fix federal-
Perhaps we need to think twice before supporting state relations.
massive, heavily-bureaucratised, remotely-controlled But whatever we do – individually and collectively – we
schemes such as DisabilityCare and the PCEHR. They are have to stop wasting, spending on the never-never and learn
no doubt potentially worthy but no new spending measures to live within our means. ■
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September MEDICUS 5
GP MattE rS
The PCEHR
Moving forward
by Dr Edwin Kruys, GP
“I can confirm that the Government is not going to build a massive It seems like informed consent is missing here.
data repository. We don’t believe it would deliver any additional
CONTRACTUAL FLAWS
benefits to clinicians or patients – and it creates unnecessary risks”
Combine this with certain clauses in the one-sided
(~Nicola Roxon)
participation agreement and you’ll forgive me for thinking that
I’ve studied the PCEHR but I’m still not sure what the
the government, contrary to Roxon’s reassuring words, has
government has built and for what purposes. I was always under
built a massive data repository
the impression that the PCEHR was designed to assist clinicians
Once clinicians sign the agreement, they grant the
to improve patient care through better data flow. But this
Department of Health and Ageing a perpetual, irrevocable,
may not be the case. The recent resignation of NEHTA’s top
royalty-free and license-fee free, worldwide, non-exclusive
National Clinical Leads is an ominous sign. If the Department
license (including a right to sub-license) to use all material
of Health does not start sharing ownership of the PCEHR soon
they have uploaded to the PCEHR.
and improve governance of the system, the PCEHR will fail.
Those who think that you can always opt out are mistaken.
Here’s a quick rundown of the issues and how to move forward.
Even if healthcare organisations or practices cancel the
LEGAL ISSUES participation agreement, seven of the 14 clauses survive
A first glance at the PCEHR Act 2012 seems to confirm that the termination, including clauses regarding liability. It is good to
PCEHR is built for clinicians, as its four purposes are clinical in know that the government will continue to use the information
nature: after cancellation by a clinician or consumer for up to 130
• To help overcome fragmentation of health information years.
• To improve the availability and quality of health Another concern is the fact that the Minister may make or
information change PCEHR rules without legislation, and the Department
• To reduce the occurrence of adverse medical events and the of Health can change the participation agreement at any time
duplication of treatment without the need for input from clinicians. We thought the
• To improve the coordination and quality of healthcare After-Hours and PIP contracts by Medicare Locals were a
provided to consumers by different healthcare providers. disaster, but this agreement is possibly worse.
So far so good. But the Act is 93 pages long and I could find at
OTHER PROBLEMS
least five other ‘non-official’ purposes of the PCEHR spread out
By now it is obvious that Clinical Leads and professional
throughout the Act:
organisations have not been involved in many important
• Law enforcement purposes
decisions. There is a range of other issues, which I won’t
• Health provider indemnity insurance cover purposes
discuss here in detail, including technical software glitches, the
• Research
absence of MBS item numbers and lack of indemnity
• Public health purposes
insurance cover for the fines related to
• Other purposes authorised
the PCEHR. Under the PCEHR
by law.
Act 2012, all clinicians are seen as
employees, which could be a problem as many
doctors may be employed as contractors for various
reasons.
And this is where the concerns begin. These ‘non-official’
MOVING FORWARD
purposes are not directly related to the care doctors provide to
If the PCEHR can be used for data mining, legal purposes,
their patients. In general, one would say
insurance purposes, public health purposes etc., then that is
that patients and clinicians have to
fine. But I would strongly advise the profession to stay clear
give informed consent before their
from it. If however we agree, that the PCEHR is a ‘clinical
health information can be used
tool’, then clinicians must be involved in all decisions.
for research or other
What we need first of all is an open, well-informed
purposes.
discussion about the purposes of the PCEHR. What are
consumers and clinicians exactly saying yes to
when they sign up? A proper, transparent,
‘independent’ governance structure with
specific executive authority should be
formed.
66 MMEEDDIICCUUSS SSeepptteemmbbeerr
GP MattE rS
This PCEHR Board should include members from stakeholders. Clinicians own the rights of the data
professional and consumer organisations and act as a they create and upload, there is no need to grant the
watchdog over the PCEHR. Any changes to the rules government a perpetual irrevocable licence to use this
require a consultative process with the AMA and RACGP data.
before the Board can sign off. The current PCEHR The PCEHR Act 2012 and the participation contract
Advisory Committee and Council are not fulfilling these must both be reviewed and made 100 per cent acceptable
criteria at the moment. to clinicians. Appropriate indemnity insurance cover is
Consumers should know exactly what happens with a must, and 100 per cent opt-out must be possible for
their data after they have visited a healthcare professional clinicians and consumers at all times.
and who has access to their information. The purposes This will take time, but if we don’t start now there is no
of the PCEHR must be clear and agreed upon by all hope for the PCEHR.
THE 2013 PCEHR QUIZ FOR CLINICIANS AND MANAGERS
by Dr Edwin Kruys
How good is your knowledge of the national eHealth time by the government. What happens if a practice
records system? Are you aware of the pitfalls and or healthcare organisation does not agree to these
risks? Do the 2013 PCEHR Quiz to test yourself. changes?
a. The government will not change the contract unless
1. Who has access to the data in the PCEHR?
both parties agree
a. The consumer and their clinician(s)
b. The PCEHR registration of the organisation will be
b. The consumer, their clinician(s), the system operator,
suspended or cancelled
health care organisations, repository operators, portal
c. An independent mediator will be engaged to resolve
operators and contracted service operators
the conflict
c. The consumer, their clinician(s), and the system
operator in case of emergencies 7. The PCEHR is opt-in. If consumers or healthcare
organisations change their mind after they have signed
2. The PCEHR Act 2012 allows secondary use of
up, is opt-out possible?
PCEHR data for the following purposes:
a. Yes
a. Public health emergencies
b. No
b. Statistical analysis of de-identified health data
c. Law enforcement purposes, health provider indemnity 8. Once clinicians upload information to the PCEHR,
insurance cover purposes, research, public health the government owns the rights and grants all other
purposes, and any other purpose authorised by law participants the right to use the data. Do clinicians get
their data rights back if they cancel the participation
3. Once practices or healthcare organisations have
contract?
signed the participation agreement, their clinicians
a. Yes
become liable for unauthorised access and data breach
b. No
penalties. Are these penalties covered by all medical
indemnity insurances? 9. What happens if practices or healthcare organisations
a. Yes cancel the participation agreement?
b. No a. Seven of the 14 clauses survive termination of the
agreement
4. If a clinician accidentally uploads information to the
b. Nothing in the agreement is valid anymore
PCEHR (against a patient’s advice), what civil penalty is
c. The uploaded patient data will become inaccessible
applicable?
a. $2,400 10. How long will the information in the PCEHR be
b. $12,400 accessible after cancellation or death?
c. $20,400 a. Up to 130 years
b. Up to 10 years
5. A clinician who has contravened a civil penalty
c. 28 days
provision may need to pay the government a pecuniary
penalty of up to: Answers: 1B, 2C, 3B, 4C, 5C, 6B, 7B*, 8B, 9A, 10A.
a. $20,400
*You can cancel but you don’t get your data (rights) back and you
b. $52,000
remain liable for what has been uploaded etc (see Q9)
c. $102,000
6. The participation contract can be varied at any Disclaimer: As with any contract, get independent legal advice. ■
SSeepptteemmbbeerr MMEEDDIICCUUSS 77
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