It’s often been said, the Australian My Health Record is not a finished project. It is evolving and has, indeed, lots of potential to improve and streamline patient care. Sadly, the privacy issues that have haunted the project for years still seem to be unresolved. And when it comes to secondary use of patient data, there’s more to come from a different direction.
Back in 2013 I wrote this in a blog post about the My Health Record, then called the Personally Controlled Electronic Health Record or PCEHR:
“The PCEHR Act 2012 states that the data in the PCEHR can be used for law enforcement purposes, indemnity insurance purposes for health care providers, research, public health purposes and ‘other purposes authorised by law’. This is far from reassuring. There are many grey areas and unanswered questions. There are too many agendas. The PCEHR should first be a useful clinical tool to improve patient care.”
Five years later and there are still ambiguities about when, how and for what reason law enforcement agencies and other non-medical parties can access the national My Health Record system. This should have been crystal clear by now. Here’s is what I posted in 2015:
“(…) at the moment the information in the PCEHR may be used by the Government for data mining, law enforcement purposes and ‘other purposes authorised by law’, for up to 130 years, even after a patient or provider has opted out. (…) The legal framework should be reviewed, and any changes must be agreed upon by consumers and clinicians.”
When asked about this issue at yesterday’s Press Club AMA president Dr Tony Bartone indicated that he is prepared to push for legislative amendments to improve the confidence of Australians in the My Health Record.
I was glad to hear this. I’m all for amendments of the My Health Record legislation but at the same time the Department of Health is on a journey to get its hands on GP patient data – and this is unlikely to change.
For example, the Department of Health is preparing a new data extraction scheme, to be introduced in May 2019. To remain eligible for practice incentive payments GP clinics have to agree that de-identified patient data will be extracted from their clinical software by, perhaps, Primary Health Networks. From there the data may flow to, possibly, the Australian Institute of Health and Welfare, the organisation responsible for the secondary use of data in the My Health Record.
If this scheme goes ahead, government organisations will begin to take over data and quality control of general practice. The argument will be that it is in the interest of the health of the nation. Perhaps it’s my well-worn tin foil hat, but I have a sneaking suspicion what I will be blogging about in the years to come.
Community pharmacy groups are lobbying for pharmacy prescribing, a topic that has been on the wish list for a long time. Medical groups are concerned about patient safety and fragmentation and are pushing back. Is this Australian conflict model what we want or is there a better way forward?
Some pharmacists want to be able to write prescriptions as they believe it is in the scope of practice of a pharmacist and more convenient for patients.
Examples from abroad are used as an argument why Australia must follow suit. A ‘collaborative prescribing pilot’ is underway and the pharmacy sector is looking forward to the soon-to-be released results.
Pharmacists expect that their proposal will be cost-saving as people will not need to see the family doctor for prescriptions.
Not surprisingly, medical groups are upset and believe the proposal is not helpful and not in the best interest of patients.
Doctors are concerned that soon the head doesn’t know what the tail is doing or, in other words, that more prescribers will lead to more fragmentation and adverse health outcomes.
Concerns have been raised that warning signs or significant (mental) health conditions will be missed and screening opportunities lost. Some have also argued that pharmacists prescribing and selling medications at the same time creates commercial conflicts of interest.
As a result there will likely be pushback from medical groups. It is to be expected that when the debate heats up some unpleasant words will be said in the media before the Health Minister of the day makes a decision based on evidence, opinion or political expedience.
Then there will be a loser (usually not the Health Minister) and a winner, and the relationship between pharmacists and doctors remains sour at the expense of patient care.
A better way
This series of events has become a familiar scenario in Australian healthcare. What’s missing is of course a joint strategy or a solution that would benefit both parties as well as our patients (a win-win-win solution).
Community pharmacists play an essential role within primary care teams. The pharmacy sector is under pressure and is attempting to implement strategies to remain viable into the future, such as introducing services currently provided by doctors, nurses and others.
An obvious way forward would be for pharmacists and doctors to explore models that are not competitive but complement each other. This is a joint process that requires broad support from both parties.
We desperately need genuine collaborative models of care, such as pharmacists working in general practice, but there may be other models too.
This is of course easier said than done. It is, however, time to leave the Machiavellian era of Australian healthcare behind. Who’s going to take the first step?
I joined Twitter back in 2011. In those days, the social media platform felt like taking a leisurely stroll around the old village, stopping along the way to have a friendly chat with locals.
We had Sunday night Twitter chats, discussing anything to do with social media and healthcare in Australia and New Zealand. There were patients, doctors, nurses, midwives, pharmacists and others happily chatting with each other, sharing information and offering support, following professional codes of conduct and rules of courtesy.
It was an inspiring place, there at the Twitter village square.
In recent years, however, social media has become a ubiquitous part of the mainstream. As a result of the rapid growth of various platforms and the number of users and networks, it now feels like driving at high speed on a five-lane freeway.
I still occasionally see the locals from the village in their fast cars, but there’s no time to chat. I usually get distracted by the billboards or the other drivers, overtaking, blowing the horn and, not seldom, making angry gestures.
Interestingly, we all seem to be copying each other’s behaviors on the social media highways. And, somehow, I often end up in the lane for doctors. There is also a lane for patients, pharmacists, midwives and so on.
Although the doctors in my lane don’t always see eye to eye, we often agree on things like the abominable road conditions or the dangers of a fast-approaching storm. And, not infrequently, we get frustrated about the drivers in the other lanes, especially when they cross the double white unbroken dividing line or, heaven forbid, end up in our lane.
On the other hand, social media still has a lot to offer. There are many amazing, inspiring and funny people out there.
I was asked to write about the do’s and don’ts of social media, but I’m not the highway patrol. I have instead listed six simple things to remind myself of what I should already know when I’m participating in the traffic on Twitter, Facebook, LinkedIn or any other social media network.
Would you visit a doctor who has, next to his or her name in the public register, a mention of a court proceeding or tribunal hearing?
Or would you prefer to see another doctor, even if the small print on the register stated ‘allegations not proven’?
I often find the legalese speak on AHPRA’s website difficult to understand. A recent report recommended that the register should include web links to published disciplinary decisions and court rulings – which AHPRA has been implementing.
However, and this is not immediately clear from the explanation on the website, apparently proceedings will also be published when a doctor or other health practitioner was found not guilty.
Complaints that have been dismissed in a tribunal as without merit will still be listed with a link to the relevant court or tribunal ruling, according to this article on DoctorPortal. The issue was also flagged at the national AMA Conference last month.
This measure is meant to ‘build trust between doctors and patients’. I’m not sure it is protecting the public but I can imagine that publishing complaints that have been dismissed is confusing for the public – and can also be misinterpreted.
It has the potential to not only affect the reputation of health professionals unfairly, but also their mental health and general wellbeing.
We need to have another long hard look at this.
“The Medical Board of Australia (the Board) has decided to publish links to serious disciplinary decisions by courts and tribunals on the public register of practitioners only when there has been an adverse finding against the doctor.
The Board will not publish links from an individual doctor’s entry on the register to public court and tribunal decisions when no adverse finding against the doctor has been made.
The Board has removed links to tribunal decisions in which there was no adverse finding about the doctor that had been published on the register since March 2018.”
Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?
My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.
She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.
The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.
Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.
Tribes & organisations
Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.
Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.
However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.
We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.
5 tribal cultures
In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.
Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.
People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.
There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.
Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.
Let’s have a closer look at the most common culture, stage three.
I’m great (and you’re not)
The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.
One of the earliest examples I could find is this well known Rembrandt paintingtitled, ‘The anatomy lesson of Dr Nicolaes Tulp.’
Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.
You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.
Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.
They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.
The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.
How to upgrade
People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.
There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.
Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.
So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:
Focus your team on tribal success instead of personal success
Point out the superior results of stage four tribal cultures
Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
Encourage transparency and sharing of knowledge & information as much as possible.
There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.
Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.
‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.
People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.
More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.
We always talk about leadership but effective followership is just as important.
Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.
What the medical profession needs is people who build bridges.
I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.
Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.
This is an adaptation of a presentation given at GPDU18.
Consent for secondary use is implied if consumers don’t opt out of the MyHR. In other words, people need to take action if they don’t want their health data to be used for purposes other than direct clinical care.
To stop information flowing to third parties, consumers will have to press the ‘withdraw participation button’.
Another hot topic is the use of the data by commercial organisations which, interestingly, is permitted under the framework, provided it is ‘in the public interest’.
And, as expected, one of the main purposes of secondary use is the monitoring of outcomes of care. It remains to be seen what this will mean for the interaction and relationship between consumers and health providers.
The release of data is expected to commence from 2020.
A ‘My Health Record secondary use of data governance board’ will assess applications for access to MyHR data ‘based on the use of data, not the user’.
Any Australian-based entity, except insurance companies, can apply to get access to the data. The board will take a ‘case and precedent’ approach to determining what uses will be permitted and not permitted for secondary use.
Although information in the MyHR cannot be used for commercial purposes, such as direct marketing to consumers, data may be released to commercial organisations if they can demonstrate that the use is consistent with ‘research and public health purposes’ and is likely to be ‘in the public interest’.
I suspect that this backdoor will be in high demand by third parties such as the pharmaceutical industry.
The board can permit the linkage of myHR data with other data sources once the applicant’s use is assessed to be of public benefit. In an example provided in the framework, researchers link MyHR information to a database of clinical trial participants to investigate hospitalisations, morbidity and mortality.
Data may also be linked to other datasets such as hospitals, MBS, PBS and registry data.
The framework gives examples of the use of health data for secondary purposes, including:
Evaluation of health interventions and health programs (e.g. determine if an intervention or service is generating outcomes/benefits consistent with funding approvals)
Examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level
Construction of clinical registries (e.g. create or supplement data in clinical registries to evaluate the effectiveness of interventions)
Improvement of existing health services and development of new services
Enhancing post-market surveillance insights for new products
Improvements to patient pathways research
Increased visibility and insights into population health matters
Development of government health policy
Develop/enable technology innovations
Preparation of publications
Recruitment to clinical trials (e.g. identify people who may be suitable for a new product/service)
Development of clinical decision support systems (e.g. link data on individual’s health with best practice to influence treatment choices)
Health services research relevant to public health (e.g. examine the health service utilisation patterns for potentially avoidable hospitalisations; research that leads to changes in other government policies, such as welfare, and ultimately reduces impact on the health system).
A review will be performed after two years, which may identify additional uses.
The following uses of MyHR data are not permitted:
Determination of funds allocation for a health service (e.g. set the level of funds allocated to an individual community health service)
Remuneration of individual clinicians (e.g. to make/modify payments)
Individual clinician audit (note: this does not exclude examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level).
Direct marketing to consumers
Assessment of insurance premiums and/or claims
Assessment of eligibility for benefits (e.g. use by Centrelink and/or the Australian Taxation Office to make determinations relating to an individual)
Criminal and/or national security investigations, except as required by law (e.g. use to investigate the interactions of individuals with the health system as part of assessing their behaviour).
Data that has been removed or classified by consumers as ‘restricted access’ will not be retrieved for secondary use purposes. Similarly, when people cancel their MyHR record, the data will no longer be used.
Consumers can stop their data being used for secondary purposes by clicking on the ‘withdraw participation button’. It is expected that a dynamic consent model will be introduced later, which allows consumers to give consent for secondary use on a case-by-case basis (which would also open the door for the use of identified data).
In the light of the recent Facebook Cambridge Analytica Scandal I suspect that many consumers will press the button – or will be advised by health professionals to do so.
If the community pharmacy sector wants to work better with other healthcare providers, something has to change.
Health Minister Greg Hunt recently announced that the Federal Government rejected many of the proposals in the King review of the community pharmacy sector.
This means for example that pharmacies will not be required to separate alternative remedies, including homeopathic products, from evidence-based medicines.
Community pharmacy owners want to be taken seriously as healthcare providers yet, at the same time, they continue to behave like a commercial interest group.
Recent actions of the sector, such as the pro-codeine lobby, raised many eyebrows. Political donations and backdoor lobbying are still the norm in this industry.
Chemist shop model
“The Guild looks forward to continuing our close dialogue with the Government on all matters to do with the sector and community pharmacy’s role,” said Pharmacy Guild President George Tambassis in response to the announcement by Minister Hunt.
And the Guild’s David Quilty stated: “When it comes to pharmacy, the Federal Government has taken the very reasonable approach that when something works very well, why tinker unnecessarily with it?”
These responses speak for themselves.
The question is, does the chemist shop model work ‘very well’, or is it relying on lotions and potions, anti-competitive regulation and protection, lobbying and political donations to stay afloat?
In the Financial Review Stephen Duckett commented, “Once again, the power of sectoral interest groups in Australian health policy is exposed.” And, “Once again, the public interest has lost out.”
I couldn’t agree more.
I’m looking forward to the day the community pharmacy sector shakes its retail sales focus – we need more team players and collaboration.
The Practice Incentive Program is shrinking but the government expects new quality improvement systems and general practice data.
Most GPs were underwhelmed, to say the least, when they heard about the changes (read: cuts) to the Practice Incentive Program (PIP). Cutting the funding for nursing home visits is a hard sell for the Department of Health and the Federal Health Minister.
This is the wrong message at a time when there are more elderly people with complex chronic health problems in need of appropriate medical care, preferably in the community.
I have heard about various ‘fixes’, including improvements to the Medicare Benefits Schedule (MBS) schedule (good idea) and introducing nurse practitioners (not necessarily a good idea) – but nothing has been confirmed and it all sounds a bit like policy on the run, not a planned and coordinated strategy.
The scrapped incentives, including the aged care service incentive payment (SIP), will be used to set up a quality incentive payment system (QI–PIP) in GP practices. There are certainly arguments for supporting an enhanced quality improvement system in general practice, but was it the right decision to sacrifice the aged care payments?
We need practice data to review and improve patient care. I agree with the RACGP position that the development of a QI–PIP should assist general practices to undertake quality improvement activities.
However, the RACGP has also indicated that it will not support measuring performance against key performance indicators (KPIs) or so-called ‘quality indicators’ in combination with performance payments. There is just not enough evidence that this will significantly improve care in the long-run, but there is evidence of harm, including detrimental effects on the doctor–patient relationship and practitioner burnout.
Although we have had verbal assurance from the Department of Health that the new QI–PIP – to be introduced in May next year – will not be a pay-for-performance system, the longer-term plans are unclear. This has raised many concerns and it will hinder business planning for general practices.
In return for the quality improvement payments, practices will be required to hand over their patient data to Primary Health Networks (PHNs) under the current proposal. From there, the data will flow to other agencies but – just like the My Health Record data – we have not yet heard for what purposes it will be used, and what the implications will be for individual GPs within practices. Many GPs have indicated that they are not prepared to hand over data to their PHN or the Government.
Another big issue is the eHealth Practice Incentive Payment (ePIP), which was originally introduced to strengthen practice IT systems, but is now used to make practices – often practice nurses – upload shared health summaries to the My Health Record. As we are moving to a My Health Record opt-out system later this year, the time may have come to review the ePIP and make it more meaningful for general practice.
Lastly, the practice incentive funding was introduced in the 1990s and has never been indexed. In 2016, $21 million was earmarked for removal and used to partially fund the Health Care Home trials.
It all sounds like another example of the Government wanting more for less. You can’t have your cake and eat it, too.
By the end of the year Australians will have an online digital health record, unless they opt out of the system. The details of the move towards opt-out will be released soon.
The Australian Digital Health Agency (ADHA) is ramping up its activities to prepare for the change to opt-out. The large-scale operation will involve extensive stakeholder engagement, a nation-wide communication and advertising campaign and increased support for consumers and clinicians.
For consumers who have not opted out at the end of the defined three-month period later this year, a My Health Record (myHR) will be created. The record will be activated when used for the first time by consumers or clinicians.
Staff levels of the call centre – transferred from the Department of Health to ADHA – will increase from thirty to two hundred and will operate around the clock during the opt-out period.
The record will initially be empty apart from two years worth of retrospective MBS and PBS data. Consumers have the option to remove this data.
Pathology and imaging reports are uploaded into the MyHR one week after the test date. Some sensitive tests, such as HIV, may not be automatically uploaded depending on the various State or Territory legislation.
Clinicians and consumers will have the opportunity to stop the upload of results and other reports if desired. Consumers can restrict access to or remove reports from their MyHR.
No stone left unturned
No stone has been left unturned in finding ways to make Australians aware of their right to opt out: a wide scale advertising campaign will use various media including radio, social media, billboards and cinemas.
Materials such as waiting room brochures, tear-off pamphlets and reception cards will be made available to providers. Medicare will be sending out brochures to Australians. Consumer organisations have been engaged to help with awareness.
It is expected that the adoption and active use of the MyHR will vary across Australia as a result of the availability of already existing digital health solutions in various states and regions.
For example, in areas where discharge summaries are not always easily made available by hospitals, the uptake of the MyHR may be higher.
Currently there are about twenty million Australians without a MyHR. Based on the trials it is expected that only a small percentage, about 2%, will opt-out.
It looks like the opt-out procedure will be relatively simple and can be done via an online self-service portal or by phone through the help desk. Hard copy opt-out and ‘election-to-not-be-registered’ forms will also be available through post-offices, and will be made available to hard-to-reach populations.
Although care has been taken to make sure there is no coercion not to opt-out, those who do will receive a notification that their medical information may not be accessible during emergencies. They will also be asked to give a reason after they have opted out.
The MyHR website will shortly contain information about the opt-out procedure. It is also expected that the FAQ section will be expanded to assist consumers in making a well-informed decision.
Risks and challenges
The MyHR offers clear benefits as clinicians will have increased access to information such as shared health summaries, discharge summaries, prescription and dispense records, pathology reports and diagnostic imaging reports.
However, every digital solution has its pros and cons. It has been decided that the risks associated with the MyHR will not be explicitly discussed on the website.
Behind the scenes however, risk mitigation has been one of the priorities of ADHA. This obviously includes the risk of cyber attacks and public confidence in the security of the data.
Another challenge for ADHA will be to manage expectations – before, during and after the opt-out period. The reality is that the MyHR is not a be-all and end-all, and is still on a development journey.
As a result of the troubled past of the digital record there is a large group of skeptics. It appears that so far ADHD nor the Department of Health have been able to get this group on board. The usual promotional material, touting benefits, is unlikely to change anything. A more effective approach would involve addressing the concerns, issues and perceived obstacles.
Primary Health Networks (PHNs) will assist in spreading the message. The PHNs involved in the opt-out trials reported high levels of success in engaging providers.
Other parties including the Royal Australian College of General Practitioners (RACGP) will provide peer-to-peer education, which may help to balance the message, address some of the concerns and manage expectations.
Edwin Kruys is a member of the My Health Record expansion program steering group.
The information in this blog post is intended for informational purposes only. It may not be complete and is subject to change. Please refer to offical ADHA sources for MyHR updates.
There’s a lot to say for high value care. High value care is healthcare that generates a large amount of benefit for patients and the community compared to the resources invested. But there are also concerns.
Value based healthcare links outcomes with costs: ‘Value’ is derived from measuring health outcomes against the cost of delivering these outcomes. Although it makes sense to fund care that gives us the greatest health benefits, some argue that ‘value’ is more than outcomes.
Dr Jan Kremer is a Dutch Professor in patient-centred innovation and has a passion for patient-focused quality and innovation. In a recent blog post he questioned value based healthcare, stating that value has a different meaning to different people – ranging from efficiency to solidarity, equity and quality of life.
The right things
In healthcare, he said, it is not just about doing things right, but also about doing the right things. The former can be measured, the latter is about decision-making which can’t always be quantified. After all, we can achieve the desired outcomes by doing the wrong thing.
Indeed, a focus on outcomes only tells part of the story. Care may have value for people even when the outcomes are not good.
It is impossible to capture the complexity of healthcare through linear mechanical quality systems, like measuring isolated single-disease parameters. As Goodhart’s law says: ‘When a measure becomes a target, it ceases to be a good measure’.
Models that focus on outcomes often result in only modest improvements, usually not long-lasting and sometimes reducing quality of care for health conditions that are not targeted.
These models can negatively affect the patient-doctor relationship and take away the passion and enthusiasm of care providers.
Everyone wants value in healthcare. Professor Kremer said we must be careful with anglo-saxon models that measure everything. But there are alternatives.
In the Netherlands, learning together based on shared values, and measuring less, has resulted in important successes. According to Professor Kremer outcome data has been helpful in the development of Dutch high value care models, but it never controlled the process.
Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice.
It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.
Doctors need time to listen and think. General practice’s inherent time pressures, interruptions and the need to record information on computers can be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.
This is not rocket science and has been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.
In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.
In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.
It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.
It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.
Health Care Homes
Is block funding such as proposed in the Federal Government’s Health Care Homes model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.
Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.
A while back I spoke with a politician who was very cross about the decision by the Therapeutic Goods Administration (TGA) to make codeine products no longer available without prescription. When I asked why, the answer was, “Codeine is great for jet lag, especially with a Scotch.”
Clearly there was some confusion here about the indication of (the painkiller) codeine, which can cause serious side effects, especially in combination with other drugs and alcohol.
An ‘indication’ is defined in the law as ‘the specific therapeutic use(s) of the goods.’ Confusion about indications of medications is common. For example, people often mistakenly believe that green snot is an indication for antibiotics or that back pain is an indication for diazepam (Valium).
And, just to be clear, codeine is not indicated for jet lag.
Dryness in the triple burner
Unfortunately the Australian Government has just muddled the water by passing two bills in the Senate that allow manufacturers of vitamins, supplements and herbal complementary medicines to use a range of odd claims, such as ‘expel damp-heat in the bladder’, ‘moisten intestines’ and ‘cool blood heat’.
RACGP President Bastian Seidel expressed concern about many of the indications. He said: “(…) phrases such as ‘moistens dryness in the triple burner’, ‘replenishes gate of vitality’ and ‘softens hardness’ have no place in any genuine healthcare situation. These types of claims are extremely misleading and could lead to significant harm for patients.”
The new process has been warmly welcomed by Complementary Medicines Australia (CMA), representing stakeholders in the complementary healthcare industry and the Australian Self Medication Industry (ASMI), the peak body for the non-prescription medicine industry.
The Australian complementary medicines sector has grown rapidly in recent years – and manufacturers have just received a pat on the back from the Senate. Unfortunately, many Australian health consumers will be just as confused as doctors about these claims.
There’s a Dutch theory called ‘De wet van de remmende voorsprong’ which, according to Wikipedia, translates as ‘The law of the handicap of a head start’. The theory suggests that an initial head start by an individual, group or company often results in stagnation due to lack of competition or growth stimuli. This may eventually lead to losing pole position.
General practice was one of the first fully digitalised, more or less paperless, medical disciplines in Australia. The question is, are GP software packages keeping up with the times or is the profession at risk of falling behind and being overtaking by others?
Overall I am satisfied with the desktop software I use to look after my patients. It does the basics very well such as recording patient demographics and medical history, medication management, printing scripts and investigation referrals.
It also checks if medications agree with each other and if the patient happens to be allergic to a new pill I am about to prescribe.
But compared to, let’s say, ten years ago there haven’t been any breakthrough innovations. Sure, we can now check the national My Health Record and upload a shared health summary, but there’s also a lot to wish for.
We’re still relying on the good old fax machine and over the years I have seen more and more third-party software solutions appear on our system to perform tasks the desktop software can’t. Occasionally these packages clash with each other or slow the practice system down.
The wish list
Here’s a list of 7 basic things that should be included in all GP desktop software. I believe it would improve patient care and satisfaction.
I’d love to have the option to communicate securely with patients and other providers, asynchronously or via video link.
Our patients should be able to send digital health data or electronic script requests via a secure connection.
An online appointments booking system.
GPs should be able to send scripts electronically to the pharmacy.
It would be really nice if the software would help us to write (and send) smart electronic referrals by automatically inserting the data required by the specialty or provider we are referring our patients to.
If we want to change bullying and abuse within the profession we have to move our tribal cultures to the next level.
The medical profession has come a long way in the past 25 years, but sadly seems to have difficulties eradicating issues of humiliation and abuse of colleagues and medical students.
One option to fix the problem is to make junior doctors and students more resilient, which seems like a good principle that is currently being applied by other organisations in other areas. Fore example, Beyond Blue has released a practice guide for professionals to help children deal with the adversities they experience early on to prevent mental health conditions later in life.
But teaching resilience alone is not enough.
Another option is to increase awareness and understanding among senior doctors and educate them about bullying, discrimination and sexual harassment. A good example is the mandatory education module, ‘operating with respect’, from the Royal Australian College of Surgeons (RACS).
Elephant in the room
The elephant in the room, however, is our culture – or at least certain aspects of it.
David Logan, a professor at the University of Southern California, said it a few years ago in his New York Times bestseller ‘Tribal leadership’: on the tribal culture scale of 1-5, most professionals around the world score a meagre three. This includes lawyers, doctors and professors.
According to Professor Logan and fellow authors John King and Halee Fischer-Wright, a stage-three culture or tribe is built around knowledge, personal accomplishments and individual expertise. The emphasis is often on winning. Although there may be talk of teamwork, the group interactions usually resemble those of a master-servant relationship.
The mantra of a stage-three culture is, ‘I’m great’. The language used is often along the lines of, “I’m good at my job,” “I try harder than most,” “Most people can’t match my work ethic,” and key pronouns used are ‘I,’ ‘me,’ and ‘my’.
This creates several problems. Professionals operating in this type of culture often feel unsupported, undervalued and frustrated, and those around them feel like a support cast.
Stage-three cultures cannot be fixed, but they can be abandoned. The answer is to upgrade the culture and move away from the ‘I’m great’ mantra to ‘We’re great.’
The next level
Instead of relying on personal achievements and expertise, at stage-four it becomes all about the accomplishments of the group. Partnerships, communication and transparency are recognised as essential ingredients for success. This is a healthier environment, in which people feel more valued and supported.
Professor Logan’s top level is stage-five. Highly functioning teams focus on maximising achievement – not in competition with other groups or tribes but with what’s possible. Stage-five teams can work with anyone.
Australian research has shown that hierarchical and stereotype behaviours largely dissolve when health professionals are working in a more collaborative, multidisciplinary environment.
Resilience training and anti-bullying education are essential, but if we really want to make a difference we have to move our tribal cultures to the next level.
Richard Branson said we should put our resolutions in black and white, because that helps us stick to it. Just in case he is right, I wrote down 3 professional & personal resolutions for the new year.
1. Learn a new skill
Rightly or wrongly, one of my fears is deskilling – at a personal level, but also at a macro level as a profession. As Dr Margaret McCartney wrote in the BMJ, the enterprise to streamline medicine by outsourcing certain tasks to protocol-driven non-doctors, runs the risk of deskilling generalist doctors.
There are probably other reasons for losing our skills, such as policy changes and the costs of consumables and maintaining skills. But we can’t always blame others for everything, so I have decided to learn at least one new skill every year.
2. Change prescribing habits
I have made a conscious effort over the years to reduce unnecessary antibiotic prescriptions. I am doing the same with opioid analgesics for chronic non-cancer pain, in line with new RACGP guidelines.
In the case of antibiotic prescribing I had to overcome a few hurdles, such as the fear of not meeting my patients’ expectations or leaving a serious infection untreated.
Talking to colleagues was helpful and I found that – after a careful history, examination and explanation – most patients accept a ‘watch & wait’ approach, with appropriate safety netting.
There are parallels when it comes to prescribing opiates. After the GP17 Conference in Sydney I took the RACGP’s 12-point challenge to GPs (see image) and found that I am now spending more time talking with patients about the pros and cons of opioids.
Yes, it is easy to slip up, especially under time pressure and just before lunch or closing time. However, by perseverance the snail reached the ark. I find every small successful dose reduction or non-pharmacological intervention satisfactory. I hope this will be a drive to continue the conversations with patients.
3. Spend less time behind screens
Excessive screen time for children may be linked to several adverse health outcomes, so at home we use an app to limit the recreational time our children spend on their devices – making sure they have opportunities to learn, create and connect in the digital space. This sounds great but in reality it is a never-ending balancing act. It also made me realise that I may not be the best role model here.
I was asked to address the Committee for Economic Development of Australia (CEDA) about how to place health consumers at the centre of future healthcare reform and the delivery of health services. ‘Less is more’ is the presentation I gave on 2 November in Brisbane.
I would like to take you with me this morning to my practice in the Sunshine Coast hinterlands and introduce two of my patients. For privacy reasons their names and details have been altered.
To refer or not to refer?
My first patient is Susan, age 24. Susan requests a referral letter to a plastic surgeon. When asked she explains that she thinks her breasts are too small, and that she wants a breast enlargement.
What would you do if you were in my shoes? Can I please see a show of hands: who would refer Susan? Who wouldn’t?
This is of course about shared decision-making. I noticed Susan was slightly uneasy, she clearly felt uncomfortable about something, so I decided to explore her request a bit further. During our conversation Susan broke down in tears and told me that it was actually her boyfriend who thought her breasts weren’t the right size.
Our conversation about relationships and body image went on for over 20 minutes. Susan decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.
Susan could also have gone online to an automated referral website.
This is a screenshot from a real Australian online referral service. Here, Susan would have had to fill out a brief online questionnaire, pay with her credit card and she would have received a referral instantly via email.
But Susan decided to make an appointment with me instead and left without a referral. She could have ended up with implants she didn’t really want or need – and a large bill.
Never just about a script
My next patient this morning is John. He comes for a repeat prescription for blood pressure pills. When he sits down the first thing he says is: “Doc, I can do my banking online, why can’t I just send an email to request my scripts?”
John has a blood pressure machine but hasn’t been able to use it recently as he has been overseas.
I take his blood pressure which is very high. I notice John has gained weight since his last visit. He tells me he has a new job and works overseas as a plant operator for a mining project– and hasn’t had much physical exercise. He suddenly also remembers that he needs boosters for his travel vaccinations. As I check the records I notice his blood tests are overdue.
Although John came in for a script it looks like there are several health issues he may want some help with. Email contact would have been more convenient for John – but some problems would have gone unnoticed if he hadn’t come in.
In my job it’s never just about a script or a referral. Opportunistic screening and preventive care are key elements that make general practice effective.
At the same time we must ofcourse find ways to increase the uptake of digital health solutions. Telehealth, video consultations and asynchronous consultations with the usual GP practice have many advantages including potentially reducing travel and waiting times for our patients.
Unfortunately, one of the main reasons for the low uptake is that Medicare currently subsidises face-to-face GP care only.
High value care
Good doctors know when not to ask for a test, when not to prescribe antibiotics or opiates, when not to refer and when not to operate.
There are some great initiatives appearing that promote ‘less is more’ healthcare such as ‘Choosing Wisely Australia’. This initiative brings consumers and health providers together to improve the quality of healthcare through reducing tests, treatments and procedures that provide no benefit or, in some cases, lead to harm.
On the other hand we are seeing more disruptive, commercial, mainly profit-driven healthcare: Competitive markets built around growth, turnover and profits, and as we all know corporate medicine can drive resources away from patient care to meet market priorities.
This chart shows what happened after the rapid expansion of after hours home visiting services operating outside the more traditional medical deputising approach.
The two bottom lines show the explosion of visits by after hours home visiting doctors, funded by Medicare, with no meaningful reduction of emergency department visits – the top line.
Although the service is convenient for patients, the question has rightly been asked: does it represent high value care?
Health Care Homes
A solution suggested a few years ago by the Royal Australian College of General Practitioners (RACGP) was the patient-centred medical home, which concentrates care and funding for a patient in one preferred general practice.
The model was meant to enhance patient-centered, holistic care. It included for example:
Support for coordination of care, to improve the patient-journey through the various parts of the healthcare system;
Support for practices providing a comprehensive range of services locally;
A complexity loading which would support practices to respond to socioeconomic and Aboriginal and Torres Strait Islander status, rural status and the age profile of their local community, and reduce health inequalities.
This concept was reviewed, adjusted, modified, tweaked and tuned but what the Department of Health eventually came up with was a very different model; a model that simply pays practices a capitated lump sum for patients with chronic health conditions, and removes the fee-for-service system for chronic care – without significant extra investment to keep Australians well and in the community.
The department’s version of the ‘healthcare home model,’ which doesn’t necessarily solve our main problems such as poorly integrated care, is being trialled but the profession is lukewarm at most.
What about performance indicators, targets and pay-for-performance? This seems to be a hot topic in Australia. It is tempting to pay doctors when their patient loses weight, has a lower blood pressure or improves sugar levels.
Pay-for-performance schemes have been tried elsewhere in the world but the results are disappointing.
For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:
only modest improvements in quality, often not long-lasting
decreased quality of care for conditions not prioritised by the pay-for-performance system
no reduction of premature mortality
loss of the patient-centeredness of care
reduced trust in the doctor-patient relationship
reduced access to GPs
decreased doctor morale, and
billions of pounds implementation costs
As Goodhart’s law says: “When a measure becomes a target, it ceases to be a good measure.”
Primary care is a complex system. Quality improvement processes that are traditionally applied to linear mechanical systems like isolated single-disease care, are not very useful for complex systems.
We know that countries with a strong primary care system have better health outcomes and more efficient health systems. An important ingredient is continuity of care by the same general practice team.
It involves empowering patients to drive their own care as well as improvements in the healthcare system. We need to listen to our patients. This may also mean that we need to slow down. Less is more.
The RACGP believes that when GPs can spend more time with their patients, this enhances continuity and quality of care and will result in less prescribing, less pathology tests, less referrals and, importantly, less hospital presentations.
This chart, based on data from the Australian Institute of Health and Welfare, shows that General Practice services represent less than 9% of total government recurrent expenditure on health. Less than 9%…
In comparison, expenditure for hospitals represent 46%. Are we really doing everything we can to keep people well, in the community and out of hospital?
4 take-home messages
I have four take-home messages for you today:
#1: Take the good, leave the bad
We need to test new models of care in the Australian context, but we must avoid making the mistakes others have made before us, such as the UK performance payment schemes.
#2: Slow down
Let’s slow down. Allow patients & doctors to spend time together when needed. High turnover or profit-driven healthcare is not healthy for patients, doctors and our health budget.
#3: Convenience ≠ high value
We have to find a balance between convenience and value. Convenience is important, but it is never just about getting a referral letter or a script.
#4: Keep people well in the community
If we want to make a difference we must strengthen healthcare in the community, when people are relatively well, not just in hospitals when they’re terribly unwell. Rechanneling funding from hospital to primary care would achieve this.
Data is like garbage, you’d better know what you are going to do with it before you collect it ~ Unknown
It took a while, but the Department of Health is now inviting submissions about the various ways digital health information in the national My Health Record (MyHR) should, and could, be used.
By law information in the MyHR can be collected, used and disclosed ‘for any purpose.’ This ‘secondary use’ of health data includes purposes other than the primary use of delivering healthcare to patients.
The consultation paper is not an easy-read and I wonder how many people will be able to make heads or tails of the document – but then again it is a complex subject.
Nevertheless, secondary use of health data seems to make sense in certain cases. As the paper states:
“Secondary use of health data has the potential to enhance future healthcare experiences for patients by enabling the expansion of knowledge about disease and appropriate treatments, strengthening the understanding about effectiveness and efficiency of service delivery, supporting public health and security goals, and assisting providers in meeting consumer needs
Risks and red flags
There are risks. For example, I would be concerned if insurance companies or the pharmaceutical industry would get access to the data or if the information would not be de-identified.
The consultation paper also mentions performance management of providers, and driving ‘more competitive markets’. These are red flags for many health providers because there is little evidence these purposes will benefit patient care.
For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:
only modest improvements in quality, often not long-lasting
decreased quality of care for conditions not part of the pay-for-performance system
no reduction of premature mortality
loss of the person-centeredness of care
reduced trust in the doctor-patient relationship
loss of continuity of care and less effective primary care
decreased doctors morale
billions of pounds implementation costs
According to the consultation paper it is ‘not the intention’ to use MyHR data to determine remuneration or the appropriateness of rebate claiming by healthcare providers.
Interestingly, a similar discussion is currently happening around the changes to the quality improvement incentive payments (PIP) to general practices and the proposed requirement to hand over patient data to Primary Health Networks without, at this stage, a clear data framework.
Research & public health
It seems reasonable to use the information in the MyHR for research or public health purposes with the aim to improve health outcomes. The access, release, usage and storage of the data should obviously be safeguarded by proper governance principles.
A good idea mentioned in the paper is a public register showing which organisations or researchers have requested data, for what purposes, what they have found by using the data and any subsequent publications.
I hope the MyHR health data will never be used for e.g.:
The My Health Record is far from perfect but still has much to offer. Unfortunately it has an image problem and its value proposition will need to be clearly communicated to health professionals. There are also several loose ends that need fixing, such as workflow challenges and the medicolegal issues around uploading and accessing of pathology and diagnostic imaging reports.
Knowing exactly what MyHR data will be used for and by whom will be an important factor for many in deciding whether to participate and at what level. ‘Where did our health data go?’ is a question health professionals and consumers should never have to ask.
You can complete the public survey here. Submissions must be received no later than midnight Friday 17th November, 2017.
A good example of the toxic interaction between academia and the media is the coverage of a recent study that claimed parents did not trust their GP. The research data clearly showed Australian parents have confidence in the family doctor – but that didn’t seem to matter.
The study and the uncritical, sensationalised media reports about its bizarre conclusions received a dishonourable mention in ABC’s Media Watch. In this blog post Professor Moyez Jiwa and I examine a worrisome trend in the reporting of academic research.
With an ageing and increasingly morbid demography, health care costs are rising exponentially and, therefore, health policy is under constant scrutiny. Each previous reform is considered and, in many cases, reversed by every new government. In this context, reports that suggest any cause for public concern about the performance of health practitioners or hospitals are seized upon by the media to promote stories that will draw an audience.
In the new era of plain speaking, it is now possible to level outrageous claims against the beleaguered health industry. It is open season on doctors and their employers who may be perceived as a weakened, divided and defensive target. With each claim and counter claim the media chant “fight” and the protagonists oblige.
At the same time, the tertiary education sector is under similar pressure, having long participated in the competition for “most cited research”. The key performance indicators for academics are to grow academic outputs in peer reviewed journals. More than ever, it is a case of publish or perish, and sometimes this comes at the expense of quality.
The temptation to frame the performance of health practitioners in less than flattering terms may be hard for the media to resist, and poorly designed academic research provides opportunities for them to harvest dubious results. Data to draft sensational stories are ever more readily available, as algorithms capture everything that can be measured and very little of what really matters.
“… data science is a technology advance with trade-offs. It can see things as never before, but also can be a blunt instrument, missing context and nuance.
Editors of the burgeoning academic journals now vying for higher citations are also tempted to publish articles that can create a media storm and draw attention to their offering among the plethora of me-too rags, many of which derive income from advertisements targeting health practitioners.
Misrepresentation & spin
Exaggerations, simplifications and misrepresentations of research findings are often fuelled by the wording of abstracts and the use of spin in press releases from universities. This self-sustaining race to the bottom can damage health systems as well as grassroots health practitioners working in it and, worse, it may affect health outcomes.
It is time to pause for reflection. There are several elements in the eye of this perfect storm:
a sensitised and dissatisfied public;
electronic data that are ever more readily available;
a government with an eye on its dwindling coffers;
a squeezed and competitive tertiary education sector competing for ‘best’ university status based on research outputs rather than teaching excellence;
an academic culture encouraging quantity instead of quality of research;
media hungry for market share and advertising income;
a tolerance for sensational statements because of the trend to behave as if we all live on the set of a soap opera.
Doctors sometimes get things wrong. However, it is also very hard to draw conclusions from “data” without a great deal of the context in which the information was gathered. Data can be manipulated; it can be misleading, if not aberrant. Scientific methods can be flawed and the peer review process can be, and often is, faulty.
Journals publish what sells and the media report bad news because that’s what the public seems to buy. Finally, sound bites and 140-character sentences are now accepted as the way to communicate about complex issues. That includes issues that defy simple explanation.
Stop the rot
What is at stake, however, is our health. Every outrageous comment from an academic with a barrow to push and job to protect heaps more pressure on the very professionals who must prevent, diagnose and manage our illnesses. The results of poor research — badly designed, widely publicised, seemingly endorsed by peer review and poorly understood by a manipulated public — reduce trust.
Many academic institutions, researchers, journals and journalists work to high and ethical standards. However, our hope against the tsunami of chronic and complex conditions is the men and women who commit to the care of people, and we need to stop the rot before it sets in. The responsibility for reversing this state of affairs rests on many, but especially on the shoulders of the tertiary care sector, which needs to call out bad behaviour.
Professor Moyez Jiwa is Associate Dean of the Melbourne Clinical School at the University of Notre Dame. Dr Edwin Kruys is vice-president of the Royal Australian College of General Practitioners. This article originally appeared in MJA Insight.
It is concerning that those who have been given responsibility to look after the health of Australians take decisions influenced by commercial interests instead of sound evidence and common sense.
As I have said before we have an opiate problem in Australia and it is the responsibility of doctors, pharmacists, consumers and governments to solve it.
One of the opiates that are harmful is codeine. Codeine is closely related to morphine and can cause dependence, addiction, poisoning and, in high doses or in combination with other drugs, death. That’s why in many countries this painkiller, like other opiates, is only available via a doctor’s prescription.
The independent Therapeutic Goods Administration (TGA) has decided to do the same in Australia after extensive consultations with stakeholders including doctors, pharmacy groups and state health departments.
From 1 February 2018, medicines containing codeine will no longer be available without prescription in pharmacies. There will still be safe and equally effective alternatives available through the pharmacy without a script.
Unfortunately some of the stakeholders are undermining this process, putting patients at risk.
Wheeling and dealing
Publicly the Pharmacy Guild of Australia states that it is not seeking to overturn the decision by the TGA. It has, in fact cashed in a large sum of money from the federal government to develop and deliver education, information and communications for community pharmacies and patients to enable a smooth transition to the upscheduling of codeine.
However, behind the scenes it seems other things are happening.
For example, shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro, he made the following statement: “(…) the Nationals are calling on the Federal Government to reverse their decision in relation to the way customers can access codeine products over the counter.”
The Guild’s approach was clever: They picked a pharmacy in a town with no doctor, invited Barilaro, took a picture with him and issued a press release thanking the Deputy Premier for his support of the Guild’s ‘common sense’ proposal to allow pharmacists to continue to supply codeine, stating: “What are patients with headache, toothache or period pain meant to do in Harden when there is no doctor within a hundred kilometres for a week at a time? The AMA has no answer.”
The AMA reiterated the concerns around codeine, including that 75 per cent of recent painkiller or opioid misusers reported misusing an over the counter codeine product in the previous 12 months and that these products were even more likely to be misused by teenagers.
The AMA also expressed concern about the Guild’s lobbying of State and Territory Governments to undermine the independent TGA ruling.
The Guild immediately responded on social media saying this was ‘overblown self-serving nonsense from the AMA’.
President of the Royal Australian College of General Practitioners (RACGP) Dr Bastian Seidel reminded Guild representatives that opiate painkillers including codeine are not normally recommended for tension-type headaches.
Sales of codeine-containing medications without script represent a revenue of $150 million per year for pharmacies.
The Guild has been busy lobbying State Health Ministers – successfully, it seems.
This weekend the Australian newspaper reported that all State Health Ministers, except for South Australia, have written to Federal Health Minister Greg Hunt “relaying unnamed stakeholder concerns about the unintended consequences of requiring a script” for codeine. NSW Health Minister Brad Hazzard was one of the signatories on the letter according to the Australian.
Here’s a screenshot of (part of) the letter to Minister Hunt in which the State Health Ministers explain why they are worried about the upscheduling of codeine:
If it is true that people in regional areas are indeed “managing chronic conditions with codeine medications” bought from a pharmacy than that is of course a concern as codeine should not be used for this purpose.
The State Health Ministers seem to implicate in the letter that it is preferable to treat chronic conditions by self medicating with over the counter codeine purchased from pharmacies instead of going to a doctor to get appropriate treatment.
This would indicate a lower standard of care for people in rural and regional areas. The upscheduling decision by the TGA could actually help regional patients receive more appropriate treatment via a doctor and cut out-of-pocket medicine costs.
Cash for access unethical
The Australian also revealed that Queensland Health Minister Cameron Dick, who also signed the letter, failed to disclose seven cash-for-access meetings with Labor donors. One of the donors was the Pharmacy Guild of Australia.
Queensland’s Premier Ms Annastacia Palaszczuk had earlier announced she had a moral responsibility to ban certain donations.
The Guild gets high level access to politicians in all states via significant donations. Their political donations are on the rise (see graph). Concerns have been raised for a while now that the Pharmacy Guild is able to influence healthcare decisions based on commercial principles instead of sound evidence.
The Guild regularly negotiates a massive agreement with the Australian Government to the value of $19 billion for dispensing PBS medicines. This begs the question how ethical it is that the Guild, at the same time, transfers money into the bank accounts of the political parties it is negotiating with.
The Guild’s solution is weak
The Pharmacy Guild said on their website: “When we put our solution to the politicians they think it makes sense, particularly when we explain how up-scheduling alone will mean a loss of convenience and higher costs for patients, as well as the clogging up of GP practices.”
Although the medical profession and health consumer organisations can see through this rhetoric, it appears some politicians have more difficulties and I don’t blame them – at first glance the arguments by the Guild sound convincing.
The recent Health of the Nation report showed that most Australians can see their GP when they need to and are able to get an appointment for urgent medical care within four hours. The argument of ‘clogging up GP practices’ as a reason for over the counter opiates is deceptive and it is probably not the Guild’s place to comment on this.
So let’s look at the Pharmacy Guild’s preferred solution. They believe that pharmacists should continue to sell codeine without a script for acute pain and state pharmacies would monitor misuse via their real-time monitoring software called ‘MedsASSIST’. The Guild continues to remind everyone that they are the only one with this pharmacy software package.
The problem here is first of all that medications issued without a script in a pharmacy must be substantially safe and without risk of misuse.
Clearly codeine is not safe and there is unambiguous international evidence of harm and misuse. So it makes no sense for codeine to be freely available in the pharmacy on the one hand but on the other be subject to real-time monitoring.
There are also serious problems with MedsASSIST. It is not an independent tool but owned by the Guild. Not all pharmacies use it so it is easy to get around for those who use codeine for the wrong purposes.
The Therapeutic Goods Administration has considered the evidence around MedsASSIST and found that it did not lead to a significant number of people being denied codeine medications in the pharmacy.
The TGA mentioned an example where an individual was able to receive 660 codeine tablets in one month despite their purchasing behaviour being tracked by the software. This raises questions about the efficacy and safety of the Guild’s preferred solution. Is it just smoke and mirrors?
The Guild continues to accuse others that they have done nothing to monitor the use of drugs of dependence. This is also incorrect as many groups, including the AMA, RACGP and coroners have repeatedly asked for an effective national real-time prescription monitoring system, accessible by doctors and pharmacists.
What do consumers say?
The Consumers Health Forum has raised concerns about the Guild’s solution and said in their press release: “We do not support the proposal from the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia to allow pharmacists to dispense codeine products without a prescription for people with one-off acute pain under certain conditions.”
“CHF supports the role of TGA as the regulator; we believe overall it does an excellent job of ensuring Australians have access to safety and high-quality medicines. We also note that this decision brings Australia into line with most other developed countries. As recently as July 2017 France has moved to make codeine products prescription only. The evidence for harm from codeine and other opioids is growing and their efficacy in assisting with pain management is coming under more and more scrutiny.”
Other groups also expressed concerns about the Guild’s undermining of the TGA. Pain Australia, the RACGP and the RACP have issued a joint press release. Painaustralia CEO Carol Bennett said:
“Chronic pain is a major health issue in Australia – we need to do much better than offering medications that are often both ineffective and potentially harmful in responding to chronic pain. Providing appropriate pain management should be a much higher priority, particularly in rural locations where reliance on opioids is a significant issue.”
“Painaustralia supports a co-ordinated, whole of sector strategy to address the issue of access to optimal pain management, including public and clinical education programs, linkages between rural health care clinicians via Telehealth with specialist city based services.”
And addiction specialists?
Last month, addiction specialists from the Royal Australasian College of Physicians (RACP) reaffirmed their support to make codeine-based medications available only with a prescription because of the many reports about misuse, addiction, and secondary harm.
The RACP said in a press release: “Addiction is a serious medical condition which should be avoided at all costs. (…) Addiction alters life choices, life chances and life trajectory. Addiction specialists have seen the number of patients with addiction to over the counter codeine grow at an alarming rate.”
“People with persistent pain should talk to their doctor to develop an appropriate treatment plan. This may include a referral to see a pain specialist or pain management clinic to manage their condition on an ongoing basis.”
The response from the Pharmacy Guild: “doctors are missing the point on codeine.”
Protection of the Pharmacy Guild’s significant commercial interests seems to drive behaviour that is not always in the interest of the health of Australians. Sadly, feedback or criticism is met with aggressive counter punches. Working with the community pharmacy sector is becoming difficult for other health groups.
It is sad to see because the Guild represents a respectable profession. It appears that the Australian healthcare system, which makes pharmacies dependent on commercial activities, is partly to blame for this situation. I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look. Political donations and cash-for-access programs also seem highly inappropriate, especially in the healthcare sector. We desperately need more collaboration.
During my medical training in Amsterdam I witnessed many of the effects of the Dutch liberal policies such as the legalised practice of euthanasia and their model on cannabis. The Netherlands was also the first country in the world to legalise same-sex marriage over 15 years ago.
When it comes to same-sex marriage I support this. Not so much because of health reasons but simply because I believe it is fair.
I acknowledge that LGBTIQ communities (Lesbian, Gay, Bisexual, Transgender, Intersex and Questioning) have had a lot to endure. I also respect that there will be people who disagree with me here and may have other opinions.
In Australia we now have the odd situation of the voluntary Australian Marriage Law Postal Vote, where we are asked to vote on the question: Should the law be changed to allow same-sex couples to marry?
The RACGP position
The postal vote has created healthy debate but also vigorous campaigns by the ‘yes’ and ‘no’ camps. Organisations and businesses are being asked by their members and customers to take side and the health sector is no exception.
Unfortunately there have been inappropriate and hurtful comments on social media and elsewhere. It seems to me that these unintended consequences of the postal vote are doing more harm than good.
The Royal Australian College of General Practitioners (RACGP) has a diverse membership of more than 35,000 GPs with a range of views. The RACGP Council believes that members should make their own, personal decision about marriage equality.
This position does not imply that the RACGP is against same-sex marriage, or for, and it does not mean that the College or general practitioners do not acknowledge the many challenges facing the LGBTIQ community.
It also does not mean that the RACGP president is personally neutral on this topic – I know that he supports same-sex marriage.
To better understand the position of the RACGP Council it is good to look at the history and the role of the College. For many years the organisation has mainly focused on training, education and quality standards. In recent years the RACGP has moved into advocacy to improve support of and recognition for the provision of quality general practice care.
The RACGP has invested heavily in a large database of guidelines, standards, policies and position statements driving general practice care. However, there has not been a demand from members to advocate on public policy issues such as climate change, sugar tax, alcohol sale, refugees or marriage equality – as a result the College has not developed a position on many of these topics.
The RACGP recently sent out a poll asking members if they would like the RACGP to advocate on a wider range of public policy issues, and one of the examples given was marriage equality. The response: One hundred members participated and one third stated that they did not think this was a role for the College.
This is only a very small sample and clearly more debate is required. The direction of the College will ultimately depend on what the membership wants. Traditionally the Australian Medical Association (AMA) has been doing this kind of advocacy very well, but perhaps there is a role for the Colleges?
An important argument for change is that it would increase the College’s social responsibility. As family doctors we come in contact with all of life’s challenges so we may as well participate in the various debates.
On the other hand, it will be difficult for the College to be everything to everyone. It may create more disputes.
Lastly, various RACGP sources including the Standards for General Practices affirm and underline respectful and culturally appropriate patient care and, in accordance with the law, strongly condemn discriminatory treatment of people based on their personal characteristics.
I’d urge everyone to be kind and considerate and show respect for others in this important debate.
Addendum 02/10/2017: RACGP Council has issued a statement in support of marriage equality.
At the time of writing Edwin Kruys was vice-president of the Royal Australian College of General Practitioners (RACGP).